American Urological Association initiative seeks boost in graduate medical education funding

Despite the continuing pressure in Washington to slash federal spending, efforts are under way to prevent cuts, and to even support increases, in graduate medical education funding in order to prevent serious shortages of physicians at a time when increased numbers of patients will be seeking care.

Washington-Despite the continuing pressure in Washington to slash federal spending, efforts are under way to prevent cuts, and to even support increases, in graduate medical education (GME) funding in order to prevent serious shortages of physicians at a time when increased numbers of patients will be seeking care.

For urology, this is especially important, according to Christopher M. Gonzalez, MD, MBA, vice chair of the AUA’s Health Policy Council. A professor of urology at Northwestern University’s Feinberg School of Medicine in Chicago, Dr. Gonzalez is leading an AUA initiative to boost GME funding for urology, warning that a critical work force shortage lies ahead.

According to the Association of American Medical Colleges (AAMC), the current physician shortage will exceed 130,000 doctors by 2025, including all specialties, even as the Medicare population grows by 36% over just the next 10 years. During that period, one in three physicians is expected to retire.

But for urology, Dr. Gonzalez warned, the situation is even more dire, noting that in 2009 there were only 3.18 urologists per 100,000 population, a 30-year low compounded by the fact that urology has the second oldest surgical subspecialty work force. The average age of urologists is 52.5 years, and more than 18% of those urologists are age 65 or older.

Making matters worse, Dr. Gonzalez said, is the fact that the academic urology work force is suffering a similar decrease, with more than 369 faculty positions needing to be filled over the next 5 years. That, he said, suggests that a shortage of academic urologists, the prime educators of urology GME, “may be more profound than that of independent practice.”

“The current system of GME funding for urology residency programs requires fundamental change,” as the shortage in the supply of urologists becomes more severe, Dr. Gonzalez said. An ad hoc Institute of Medicine committee has been assembled to study the situation, but that report is not expected until March 2014.

“Urologic care has already been compromised by this shortage of physicians, and it is going to be compromised even more,” Dr. Gonzalez warned, noting that the situation is especially serious in rural areas as urologists, in a 7:1 ratio, are drawn to urban areas, leaving many counties in the U.S. without urology services.

Making matters worse has been the pressure in Washington to reduce GME support as part of the continuing budget negotiations. The Simpson-Bowles Commission, which developed a framework for balancing the federal budget last year, proposed a 60%, or $60 billion, cut in GME spending. The Obama administration proposed a 10%, $9 billion reduction, while others offered up 20%/$20 billion.

According to AAMC, the impact of the worst-case scenario (Simpson-Bowles) cuts would be staff layoffs of up to 73,000, closure of training services, and elimination of services that operate at a loss-including those unavailable elsewhere in the community. AAMC said such reductions would result in the training of fewer physicians, nurses, and other health professionals, which would directly impact access to health care.

“The beneficiaries of Medicare and Medicaid are going to suffer unless an adequate solution is found,” Dr. Gonzalez cautioned. “We need to provide more training for residents. We need more funding for residency slots. If the number one issue for Congress is access to care, then they need to address this situation.”

Legislative efforts languish

There have been discussions on Capitol Hill and legislative proposals initiated to increase the number of training slots through Medicare and Medicaid, as lawmakers have come to realize that as the Affordable Care Act kicks in and more patients have health care coverage, it won’t do these patients much good if there are insufficient numbers of physicians to treat them.

In 2011, Sens. Bill Nelson (D-FL), Charles Schumer (D-NY), and Senate Majority Leader Harry Reid (D-NV) introduced the Resident Physician Shortage Reduction Act of 2011 (S.1627), which would increase by 15,000 the number of Medicare GME slots and would require the National Health Care Workforce Commission to submit a report to Congress identifying physician shortage specialties. That report would be used to target GME slots-at least 1,500 yearly-to shortage specialty residency programs.

Unfortunately, that bill-despite the firepower of its sponsors-languished in the Senate Finance Committee and died.

Similar bills were introduced late in 2012. H.R. 6352, the Resident Physician Shortage Reduction and Graduate Medical Education Accountability and Transparency Act, sponsored by Rep. Aaron Schock (R-IL), would increase resident limits for qualifying hospitals, providing for 3,000 new slots per year. Introduced in August, it languished in committee until Congress adjourned. A second, similar bill, H.R. 6562, was introduced on Sept. 25 by Rep. Joseph Crowley (D-NY) but also died in committee.

Once the dust settles from the fiscal cliff negotiations and decisions, this is an issue that needs to be addressed by Congress. As Dr. Gonzalez so accurately pointed out, it’s great to provide the previously uninsured with the ability to obtain health care. But it’s not so great if physicians are not available to provide the treatment they need.

And according to all the available signs, that is exactly where we are headed.

Fast Facts

Graduate medical education funding:

  • is the subject of an AUA effort aimed at heading off a critical work force shortage in urology

  • is necessary to maintain the urology work force in the face of increasing numbers of patients

  • has been targeted for cuts by the Simpson-Bowles Commission, the Obama administration, and others

  • was included in several failed pieces of legislation designed to increase residency slots

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