ACP: Governmental Affairs and Public Policy - ACP's comments on the Council on Graduate Medical Education's (CoGME) draft report entitled Reassessing Physician Workforce Policy Guidelines for the U.S. 2000-2020

Advocacy

ACP's comments on the Council on Graduate Medical Education's (CoGME) draft report entitled Reassessing Physician Workforce Policy Guidelines for the U.S. 2000-2020

May 25, 2004

Jerry Katzoff
Acting Executive Secretary
Council on Graduate Medical Education
Parklawn Building, Room 9A-27
5600 Fishers Lane
Rockville, MD 20857

Dear Mr. Katzoff:

The American College of Physicians (ACP), representing more than 115,000 internal medicine physicians and medical students, is pleased to offer comments on the Council on Graduate Medical Education (CoGME) November 2003 draft report on Reassessing Physician Workforce Policy Guidelines for the United States 2000-2020. Our membership includes faculty and administrators of teaching programs, physicians in internal medicine training, physicians specializing in the practice of internal medicine and its subspecialties, researchers, and medical students. Internal medicine has experienced declining student interest in the specialty, along with early retirements from practice and new self-limited practice arrangements by current physicians, all while more patients with complex chronic diseases continue to require care. The ACP recognizes that an adequate supply and distribution of physicians in the United States is essential and applauds CoGME for re-examining the issue.

Recommendation #1 to increase the number of physicians entering residency training from approximately 24,000 in 2002 to 27,000 in 2015 appears reasonable in order to meet the future demand and need for the physicians workforce. ACP agrees that the distribution between generalists and non-generalists will require ongoing assessments of need. We encourage CoGME to adopt the recommendation not to establish rigid national targets.

The ACP also agrees with the need to increase the number students enrolled in U.S. medical schools by 15% by 2015 (Recommendation #2). While we appreciate CoGME's desire to have the growth in medical school enrollment concentrated in existing shortage areas or expected areas of shortage, the abilities that existing training programs have in alleviating the physician supply shortage should not be overlooked. Enhanced efforts to recruit students from under-represented populations and from under-served areas would increase the future supply of physicians most likely to serve under-served populations. In addition, it is essential that federal programs such as the Health Resources and Services Administration, Department of Veterans Affairs, and Centers for Medicare and Medicaid Services send a clear signal that additional physicians are needed in the United States. There should also be recognition of the nation's future needs for an adequate supply of physician researchers and teachers.

The ACP supports Recommendation #3 to phase-in an increase in the number of residency and fellowship positions eligible for funding from Medicare to parallel the increase in U.S. medical school graduates. ACP strongly agrees with removing the existing cap on the number of residents and fellowships eligible for Medicare reimbursement. Increasing funding for residency training will likely be the most immediate and favorable remedy for the physician supply shortage. However the value of International Medical Graduates (IMGs) should not be overlooked, as they tend to provide a large portion of the care to medically underserved populations. Expansion of the J-1 visa waiver and Conrad 30 programs will also help to alleviate the workforce shortage. ACP urges CoGME to specifically recommend an increase in J-1 visa waiver and Conrad 30 programs to address the shortage of physicians in the most critically underserved areas. While both programs are currently designed to provide visa waivers to primary care physicians, we feel that it would also be beneficial to expand them to include waivers for sub-specialists. These increases in the physician supply should be in conjunction with efforts to increase the number of U.S. medical graduates from under-represented minority and disadvantaged groups.

The ACP strongly agrees that there is a need for regular and consistent monitoring and assessment of physician supply, demand, need and distribution trends in the United States (Recommendation #4). However, we urge CoGME not to delay taking immediate policy steps to address the physician supply shortage. Although we must continue to collect data on the physician supply shortage, the data that currently exists is persuasive enough to warrant immediate action. In addition, while we agree that common methodologies for measuring specialty specific supply and demand needs have yet to be established, existing research related to specialty-specific shortages should not be ignored. ACP also agrees that specialty-specific studies are needed to better determine specialty-specific needs (Recommendation #5).

The College is very supportive of efforts to positively encourage physicians to invest in new technologies that will improve quality and enhance productivity (Recommendation #6). We appreciate the recognition of the multiple barriers that currently deter many physicians from making such investments and we support changes in reimbursement policies to facilitate implementation of new technologies, such as those required to implement electronic health records. ACP favors development of systems of performance measurement that reward physicians for productivity enhancements and the provision of high quality health care.

Finally, ACP is very supportive of Recommendation #7 regarding expansion of the National Health Service Corps (NHSC) and other programs under Title VII of the Public Health Service Act. The Minority and Disadvantaged Health Professions training programs under Title VII, which are designed to improve health care access in medically underserved areas and to indigent populations by increasing minority representation in the health professions, is an extremely valuable program. This program should be expanded, and other programs to recruit more minorities into the health professions and provide scholarships and loan programs should be developed, as studies indicate that minority physicians are more likely to practice in underserved areas with high percentages of minority populations. The Indian Health Service (IHS) Loan Repayment Program and United States Armed Forces Health Professions Loan Repayment and Scholarship Programs should also be expanded. We urge CoGME to also consider means to encourage physicians who complete their service obligations in programs such as the NHSC and the HIS to remain and practice in underserved areas. Means should be explored for enhancing practice opportunities in both urban and rural underserved areas.

ACP also supports the use of low-interest loans with service obligations to encourage medical graduates to pursue careers in primary care and serve in health professional shortage areas. Furthermore, ACP favors allowing the deferment, or tax-deductibility, of interest and principal payments on medical student loans until after completion of residency training. By deferring payment of interest and principal on medical student loans until after completion of post-graduate training, residents will have increased funds necessary for professional development and more of an opportunity for a reasonable lifestyle. Additionally, given the rising cost of medical education and the need to train more physicians, ACP strongly supports efforts to develop innovative solutions involving alternative financing of both undergraduate and graduate medical education training so that incurrence of large educational debts can be avoided. We urge CoGME to specifically include a recommendation to research front-end solutions for alternative financing of medical education in its report.

The ACP appreciates the opportunity to offer comments on CoGME's physician workforce policy guidelines. We recognize that the issue of physician workforce is extremely important, and look forward to working with CoGME to ensure an adequate supply and distribution of physicians in the United States. If you have any questions regarding our comments, please do not hesitate to contact Renee Zerehi, Associate, Health Policy and Council Activities at 202-261-4555.

Sincerely,

Charles K. Francis, MD, FACP
President

Page posted: 6/1/2004