A growing body of evidence points to an ongoing and increasing shortage of surgeons available to serve the nation’s aging and growing population. According to the Association of American Medical Colleges’ Center for Workforce Studies, the U.S. will face a shortage of 46,000 surgeons and medical specialists in the next decade—a startling and troubling statistic for both surgeons and patients.1
Furthermore, this summer, the American College of Surgeons (ACS) Health Policy Research Institute (HPRI) at the University of North Carolina’s Cecil J. Sheps Center for Health Services Research released updated maps illustrating the distribution of general surgeons and surgeon specialists per 100,000 populations across the U.S. in 2006 and 2011. The maps contain data that are reflective of all 3,107 counties in the U.S. They indicate that in the timeframe studied, 181 counties lost all of their surgeons, whereas 161 gained at least one surgeon by 2011 after having none in 2006, and 680 counties and county-equivalent areas had no surgeons in either 2006 or 2011.2
The ACS is carefully monitoring legislation and activities that could affect the surgical profession and patient access to high-quality care and continues to advocate for policies that are designed to strengthen the surgical workforce.
GME policies and activities
As an example of these efforts, the ACS has endorsed and advocated for passage of the Resident Physician Shortage Reduction Act of 2011, S. 1627. This bill, introduced by Sen. Bill Nelson (D-FL), Sen. Charles Schumer (D-NY), and Senate Majority Leader Harry Reid (D-NV), seeks to bolster the U.S. surgical workforce and health care infrastructure by increasing the number of Medicare-supported residency positions. More specifically, S. 1627 would increase the number of residency slots nationally by 3,000 each year from 2013 through 2017, totaling 15,000 slots.3 In 1997, the Balanced Budget Act froze the number of residents for which a hospital could claim Medicare payment, based on the number of residents that each hospital trained in 1996.4 Although the College would prefer that Congress lift the present caps on graduate medical education (GME) funding entirely, the ACS supports S. 1627 for taking an important step toward addressing physician workforce shortages. Medicare-supported training slots are capped at roughly 80,000.
Under the Resident Physician Shortage Reduction Act, half of the new residency slots must be used for shortage specialty residency programs as defined by the Health Resources and Services Administration. The measure also directs the National Health Care Workforce Commission to study the physician workforce and identify specialties that are experiencing shortages. A report on the findings must be submitted to Congress by January 1, 2014. The proposed law also directs the U.S. Comptroller General to conduct a study on strategies for increasing the diversity of the health professional workforce. Results of the study must be made available to Congress no later than two years after the date of the bill’s enactment. At press time, S. 1627 was referred to the Senate Finance Committee for consideration.3
On May 17, Sens. Jack Reed (D-RI) and Jon Kyl (R-AZ) introduced another GME-related bill—the Graduate Medical Education Reform Act of 2012, S. 3201.3 This legislation applies to any hospital that receives Medicare indirect medical education (IME) payments. It directs the Secretary of the U.S. Department of Health and Human Services (HHS) to implement a budget-neutral Medicare IME performance adjustment program and requires that the HHS Secretary submit to Congress and the National Health Care Workforce Commission an annual report on Medicare GME payments.
The legislation aligns closely with the Medicare Payment Advisory Commission’s (MedPAC’s) proposal that teaching hospitals be held to a higher standard of accountability to ensure effective use of GME funding. The bill and MedPAC’s proposal do differ in some key ways, however. One such difference would limit the amount of IME funding placed at risk of being cut to 3 percent as opposed to the 50 percent identified by MedPAC. The IME adjustment pool included in the bill is budget neutral, which would enable high-performing teaching hospitals to earn back additional IME funding. The bill does not expand the current cap on Medicare GME support, as S. 1627 does. S. 3201 has also been referred to the Senate Finance Committee. At press time, the ACS Legislative Committee was reviewing this legislation.
Most recently, Reps. Aaron Schock (R-IL) and Allyson Schwartz (D-PA) introduced the Resident Physician Shortage Reduction and Graduate Medical Education Accountability and Transparency Act (H.R. 6352) on August 2.3 This legislation would expand the number of residency training positions supported by Medicare by 15,000 slots, and it would also establish transparency and accountability measures around GME. Essentially, this legislation combines the two Senate GME-related bills mentioned previously, the Resident Physician Shortage Reduction Act (S. 1627), which adds an additional 15,000 Medicare-supported residency slots, and the Graduate Medical Education Reform Act (S.3201), which incorporates accountability measures and transparency within the Medicare GME program. H.R. 6352 has been referred to the House Committee on Ways and Means and the Committee on Energy and Commerce for consideration. The ACS Legislative Committee was also reviewing the legislation at the time this article went to press.
The ACS also has been following the reactivation of the Congressional Academic Medicine Caucus, a bipartisan group that provides a forum for members to discuss the challenges and opportunities surrounding GME in the U.S, and to explore relevant policy approaches and solutions. Representatives Schwartz (D-PA) and Phil Roe, MD (R-TN), re-launched the caucus this past May. “America is on the cusp of a crisis in access to both specialty and primary care physicians due to a mounting physician shortage,” said Caucus co-chairs Schwartz and Roe in a joint statement. “Supporting our nation’s GME system will be pivotal to addressing this issue.”5 The ACS has reached out to the offices of Representatives Schwartz and Roe to express strong interest in partnering with the caucus as it works to address issues surrounding the development and supply of our future health care workforce.
Whereas GME issues remain a strong focus on Capitol Hill, some members of Congress have requested that the Institute of Medicine (IOM) begin evaluating the nation’s GME system. In December 2011, the following senators sent a letter to the president of the IOM, Harvey Fineberg, MD, PhD, encouraging the institute to conduct an independent review of the nation’s GME system: Jeff Bingaman (D-NM), Mark Udall (D-CO), Jon Kyl (R-AZ), Tom Udall (D-NM), Chuck Grassley (R-IA), Michael Bennet (D-CO), and Mike Crapo (R-ID). In the letter, the senators note that the GME system is under increasing stress and that the projections for the health care workforce are of significant concern. Subsequently, the senators have requested an analysis of the governance and financing of GME and potential reforms. An IOM committee has been developed to study these issues with funding from the Josiah Macy Jr. Foundation and other public and private entities. (For more information about this study, go to http://www.iom.edu/Activities/Workforce/GMEGovFinance.aspx.)6
On the GME grassroots front, the ACS launched a unique program with members of its Massachusetts Chapter. The goal of this grassroots program is to develop strong local ties to each member of the Massachusetts congressional delegation. During their initial visit, Massachusetts Fellows will urge their congressional representatives to sign on to a GME funding letter supporting the College’s position. The letter requests that Senate and House leadership continue to support and protect Medicare GME funding and to fight against the recent legislative proposals to cut it. The letter summarizes the looming surgical shortage, and makes clear that the workforce crisis will be further exacerbated should reductions to crucial GME funding, such as those proposed by the Obama Administration and debated by the Joint Select Committee on Deficit Reduction, take effect.
ACS and EHRs
Earlier this year, representatives of the ACS and a number of other provider groups met with key congressional staff to discuss several concerns regarding the Centers for Medicare & Medicaid Services (CMS) proposed rule titled “Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2.” The proposed rule presents meaningful use objectives and measures that eligible professionals (EPs) must meet to ensure they qualify for financial incentives, and to avoid the penalties for noncompliance specified in the American Recovery and Reinvestment Act of 2009 (ARRA).7,8 The ARRA authorizes CMS to provide financial incentives for EPs who meaningfully use electronic health records (EHRs.) These incentive payments began in 2011. EPs who have not demonstrated they have met the incentive criteria will face payment reductions in their Medicare payments in 2015.
The ACS and the other provider groups noted that some health care professionals may retire early rather than face the significant costs of investing in an EHR system. Other EPs may decide to opt out of Medicare altogether to avoid the penalties. With the increasing health care needs of the American population, the nation cannot afford to lose experienced physicians.
The provider groups have asked members of Congress to consider introducing legislation to create an exception for those EPs who are either currently eligible or will be eligible for Social Security and retirement benefits by 2014. The ACS and other organizations maintain that this exception should be one year long, with eligibility to apply again in each subsequent year. The availability of the exception would sunset after three years to ensure that physicians who do plan to continue practicing past their Social Security retirement age are not entirely exempted from the program requirements. A copy of this letter is posted at the following website: http://www.facs.org/ahp/ehr/index.html.9
The push continues
In the months ahead, the ACS will continue to advocate that Congress work to address the looming surgical workforce shortage, to support critical funding for GME, and to pass S. 1627. In addition, at press time, the ACS HPRI was working to add surgical subspecialties to its maps that demonstrate the distribution of the surgical workforce and was updating the Surgery Workforce Atlas for future release. The Atlas is an interactive, Web-based set of maps that shows, county-by-county and state-by-state, where shortages of surgeons and other physicians threaten patient access to timely, safe, high-quality, and affordable care. Updated surgical maps and links to the current Atlas can be found at http://www.acshpri.org/maps.html.2
- Association of American Medical College’s Center for Workforce Studies. Physician shortages to worsen without increases in residency training. Available at: https://www.aamc.org/download/286592/data/physicianshortage.pdf. Accessed July 21, 2012.
- American College of Surgeons Health Policy Research Institute. Maps. Available at: http://www.acshpri.org/maps.html. Accessed July 22, 2012.
- The Library of Congress. “Thomas.” Bill summary and status. Available at: http://thomas.loc.gov. Accessed August 6, 2012.
- American College of Surgeons Division of Advocacy and Health Policy. Workforce. Available at: http://www.facs.org/ahp/workforce/. Accessed July 21, 2012.
- Allyson Y. Schwartz website. Press release. Schwartz and Roe promote medical education and training opportunities for the next generation of physicians. Available at: http://schwartz.house.gov/press-release/schwartz-and-roe-promote-medical-education-and-training-opportunities-next-generation. Accessed July 21, 2012.
- Institute of Medicine of the National Academies. Governance and financing of graduate medical education. Available at: http://www.iom.edu/Activities/Workforce/GMEGovFinance.aspx. Accessed July 22, 2012.
- Department of Health and Human Services. Centers for Medicare & Medicaid Services; Electronic Health Record Incentive Program—Stage 2. Federal Register. Available at: http://www.facs.org/ahp/ehr/federal-register-stage-2-proposed-rule.pdf. Accessed July 22, 2012.
- Centers for Medicare & Medicaid Services. EHR incentive programs. Eligibility hospital information. Available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Eligible_Hospital_Information.html. Accessed September 18, 2012.
- American College of Surgeons. Advocacy and health policy. Electronic health record. Available at: http://www.facs.org/ahp/ehr/index.html. Accessed July 22, 2012.