Atul Grover, M.D., Ph.D.September 17, 2015

Medical Education: The Foundation of the Futureof Medicine

Future of Medicine Summit IXWest Palm Beach, FL

agrover@aamc.org@AtulGroverMD

AAMC: Med. Schools, Hospitals, MDs

• Membership includes: 144 U.S. medical schools (MD programs) Nearly 400 major teaching hospitals and health systems

Includes 51 VA medical centers Nearly 90 academic and scientific societies

• Over 300,000 “Voices:” 141,000 faculty members

Clinical and basic science (research) faculty Staff the physician practice groups and hospitals

83,000 medical students 115,000 residents

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Extraordinary clinical careCOTH hospitals comprise only 5% of all hospitals but account for:

37% of charity care 23% of all hospital care

24% of all Medicaid in-patient days 20% of all Medicare in-patient days

88,577 full-time MDs work in medical school clinical departments

Cutting edge researchOver half of NIH Extramural Research Awards go to an AAMC medical school and/or teaching hospital

Education and training74% of all residents train at an AAMC hospital

 

AAMC Hospitals’ 3 Missions Advance Health

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© 2015 AAMC. May not be reproduced without permission.

AMC Missions Rely on Multiple RevenueStreams; Revenue Cuts Mission Cuts

Clinical Revenue

IMEDSH

Residents,Students Research

Community Benefits

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© 2015 AAMC. May not be reproduced without permission.

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The Small “p” Politics of Medical Education: Adapting to Change

The Big “P” Politics of Medical Education: Advocating to Congress

© 2015 AAMC. May not be reproduced without permission.

Medical Education Enterprise: Numbers

830,000 doctors, including 750,00 in patient care• 32.6% = women; 24% = IMGs; 8.9% = minorities; 36% = age 55+

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144 MD schools and 30 DO schools• 80,000 MD students; 24,000 DO students

9,600 ACGME certified residency programs• 120,000 residents; 5,000 more in AOA certified programs

• 46.1% = women; 25.9% = IMGs; 10.5% = minorities

Society’s Changing Health Care Needs

Outcome Focused: Health care delivery, payment measured by quality, outcome metrics.• Volume or cost no longer drive payment.

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Cost Conscious: Health care designed to – • Maximize each health care team member’s contribution.

• Members include multiple different health professionals.

Population Health Focused: Emphasis on improving, maintaining health, not just treating illness.• Workforce size, distribution, demographic & specialty composition all

matter.

• Organization, financing of care matter, too.

© 2015 AAMC. May not be reproduced without permission.

What’s Changing:

How Medical Education Is Responding to Society’s Changing Needs

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Small “p” Politics of Medical EducationMajor Changes at Every Step in the Process

New MCAT + New Competencies to Demo + Life-long Learning

Achieving Competencies to Meet Society’s Changing Needs: Better Quality, Lower Cost, Population Health

The Match

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Core Competencies in Premedical Students

Resilience and AdaptabilityCapacity for ImprovementCritical ThinkingQuantitative ReasoningScientific InquiryWritten CommunicationKnowledge of Living SystemsKnowledge of Human Behavior

Service OrientationSocial SkillsCultural CompetenceTeamworkOral CommunicationEthical ResponsibilityReliability and DependabilityResilience and Adaptability

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www.AAMC.org/MCAT

A New MCAT Exam

In the first 14 hours, 14,000 applicants registered for the new MCAT

Diversity

Holistic Review

Pre-professional Readiness

Holistic Review

Academic Readiness

www.AAMC.org/admissions

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Enhancing Medical School

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Translating Competencies to Observable Behaviors

The Physician

Patient Care

Knowledge for Practice

Inter-professional Collaboration

Personal and Professional Development

Systems-based Practices

Practice-based Learning and Improvement

Professionalism

Interpersonal and

Communication Skills

Recommend and interpret

common diagnostic and screening

tests

Gather a history and perform

a physical examination13 Core Entrustable

Professional Activities

Prioritize a differential diagnosis

following a clinical encounter

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Refocusing Residency and Fellowships

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AAMC Vision for Optimizing GME

#2. Optimizing the Environment for Learning, Care, and

Discovery

#1. Investing in Future Physicians

#3. Preparing the Physician and Physician

Scientist for the 21st Century

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Optimizing GME: AAMC Priorities

1. Investing in Physicians:

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• Refine GME accountability metrics.

• Align residency training with societal needs, students’ aspirations & desires.

• Make case for public funding of GME.

Optimizing GME: AAMC Priorities

2. Optimizing the Environment for Learning, Care, and Discovery:

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• Define, foster optimal learning environments.

• Improve environment for teaching faculty.

Optimizing GME: AAMC Priorities

3. Preparing the physician & physician scientist for the 21st Century

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• Elevate performance of entering

residents & new practitioners.

• Develop models, demonstrate ways to optimize duration of education and training.

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What Hasn’t Changed:

The Match Is Increasingly a Big Squeeze

Match 2015:

1,093* US MDs without a position before SOAP

606** US MDs without a position after SOAP

27,293*PGY1 Positions

18,025*US MD Seniors =

Applicants

Match

Data from the 2015 Match and 2015 SOAP

16,932 Matched US MDs*

Match DayMarch 20, 2015

21 Data: Results and Data 2015 Main Residency Match, NRMP, & NRMP CEO Presentation to April 2015 Group on Student Affairs

Primary Care Continues to Over Shadow Specialties in Match: 2015 Picture

This year, 27,293 residencies offered nationally. Potential primary care residencies = 46.3%.• Family medicine: 3,195

• Internal medicine: 6,770

• Pediatrics: 2,668

Total: 12,633 = potential primary care = 46.3% of all residencies offered

In contrast:*• Child neurology – 104 residencies offered = 0.38% of all offered

• Thoracic surgery – 35 residencies offered = 0.13% of all offered

• Dermatology – 22 residencies offered = 0.08% of all offeredSource: NRMP * = PGY-1 positions

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Why Is the Supply of Slots on Match Day so Tight?

The Big “P” Politics of GME

Two Points of ContentionIs there a physician shortage?

• Many, including AAMC, believe nation faces serious shortage by 2025

• Not all agree – e.g., IOM committee

Should Medicare fund more residency slots?

• In 1997, Congress capped # of residents for which Medicare pays GME at 1996 #. Virtually no change in cap in 18 years. But med school grads up nearly 30%.

Result = bottleneck.

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In 1997, Congress Capped # Residents Eligible for Medicare GME at 1996 LevelsNumber of applicants exceeds cap; big loss of $

25 Source: NRMP, Results and Data: 2014 Main Residency Match

The Big “P” Politics of GME: What Challenges Face the Physician Workforce

Projected shortages.• Significant shortages in primary & specialty care.

Growing health professionals workforces.• Rapid increases in NPs, PAs.

• Team-based delivery of care.

Political obstacles to lift Medicare GME cap.• $10 billion/10 years cost to add 3,000 resident slots/year.

• Some want to use GME $ for other purposes.

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New Workforce Projections Look at Multiple Scenarios: Shortages in AllScenarios run for AAMC: Demographic Changes: Growth, aging. Insurance Status Changes: ACA impact. Physician Behavior Changes: Work hrs, yrs. Staffing Pattern Changes: NPs Health Care Organization Changes: ACOs.

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New Projection Findings: What the Graphs Will Show You

Time

Ph

ys

icia

ns

DemandSolid line = Demand

Dotted line = Supply

Supply

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Supply Versus Demand: All Physicians

700,000

750,000

800,000

850,000

900,000

950,000

2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Full

Tim

e Eq

uiva

lent

Phy

sici

ans

Year

Demand (ACA + MC)

Demand (ACA)

Demand (ACA + RetailClinics)Demand (Demographics)

Demand (APRN Moderate)

Demand (APRN High)

Supply (Retire Later +2)

Supply (GME Growth)

Supply (Status Quo)

Supply (Millennial Hours)

Supply (Retire Earlier -2)

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All Physicians: Continued Shortages in 2025

New Projections for 2025:46,100 – 90,400 Shortage

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Primary Care: Cont’d. Shortages in 2025

New Projections for 2025:12,500 – 31,100 Shortage

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New Projections for 2025: 28,200 – 63,700 Shortage

“Med/Surg Specialties:” Cont’d. Shortages

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Why a Physician Shortage? Demand Is Growing Faster than Supply

• Many factors, but demographics = biggest

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• Population = growing larger, older

Elderly have greater health care needs 46% projected growth in elderly; 5% for young Medicine keeps people alive but with more illnesses Next 20 years: 36 million people added to Medicare

• Even best prevention delays disease, does not eliminate it.

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A Growing, Aging Population Matters

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HHS/HRSA The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand, December 2008 at http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf

Physician utilization/100,000 people by age

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Because of Growth/Aging: Supply Also Not Likely to Keep Pace with Demand

Number of physicians per capita = flat/decrease in next decade if we don’t train more.

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# of hours /week worked makes big difference. Older physicians work longer hours than younger

“Millennials” – Will that continue?

Age of retirement also a big factor. 36% of doctors now = age 55+. Most will retire in the next decade. But will they retire sooner or later Even a year or 2 delay makes affects future supply.

Indicators of Physician Shortages

Longer waiting times for an appointment Both primary care and specialists Most vulnerable – low income, complex patients

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Backlog of unfilled positions for doctors – e.g.: 19% of WY population lives in underserved area 31% of MS population

Classic examples: VA, Medicaid Long waiting times for veterans became big new MacPac reports difficulty getting specialist

appointments for Medicaid, CHIP recipients

Source: http://hrc.nwlc.org/status-indicators/people-medically-underserved-areas

Example: In July 2015, 67% of VA Physician Vacancies = Specialists

Source: AAMC Analysis of Job Postings from VA Physician Careers Website, as of July 2015http://www.vacareers.va.gov/careers/physicians/index.asp

30%

67%

Percent of VA Physician Vacancies

Prim. Care Specialists

Other

3%

Other = Non-Care Givers

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What Do Shortages Mean for Patient Care Delivery?

Increasing pressures for changes in care delivery: Non-physician providers Team delivery New technologies New reimbursement strategies Focus on outcomes, cost Population health promotion

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© 2015 AAMC. May not be reproduced without permission.

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The Power of Advocacy: Your Advocacy

Where Do We Go from Here? AAMC Advocates a Four-Pronged Strategy

No one tactic is enough. A multi-pronged strategy is needed to avoid a physician shortage.

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Advance health care delivery reform to achieve more cost-effective care. AMCs are leaders.

Champion accountability for GME – bipartisan bills.

Pass legislation to lift cap on number of residents for which Medicare will pay for GME – also bipartisan.

Strengthen federal investment in programs to address maldistribution, such as NHSC and Title VII.

We’re advocating for all of them. Please join us.

Reduce the Physician Shortage

Bill Nelson (D-FL)

Charles Schumer (D-NY)

Harry Reid (D-NV)

S. 1148: Resident Physician Shortage Reduction Act of 2015A bill to amend title XVIII of the Social Security Act to provide for the distribution of additional residency positions, and for other purposes114th Congress, 2015–2016. Sponsor and 12 cosponsors.

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© 2014 AAMC. May not be reproduced without permission.

Reduce the Physician Shortage

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Joe Crowley (D-NY)

Charles Boustany, M.D. (R-LA)

H.R. 2124 : Resident Physician Shortage Reduction Act of 2015A bill to amend title XVIII of the Social Security Act to provide for the distribution of additional residency positions, and for other purposes114th Congress, 2015–2016. Sponsor and 76 cosponsors.

© 2014 AAMC. May not be reproduced without permission.

Encourage Your Members of Congress

Please Thank:

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Sen. Bill Nelson for sponsoring the Senate bill.

Rep. Alcee Hastings for cosponsoring the House bill.

© 2014 AAMC. May not be reproduced without permission.

Encourage Your Members of Congress

Ask to Them Cosponsor GME Bills:

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Sen. Marco Rubio

Rep. Lois Frankel

Rep. Patrick Murphy

Grassroots Advocacy Is Essential

“Now more than ever the people are responsible for the character of their Congress. If that body be ignorant, reckless, and corrupt, it is because the people tolerate ignorance, recklessness, and corruption."

James Garfield, "A Century of Congress" published in Atlantic, July 1877

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What You Can Do: Join AAMC ActionPower AAMC’s Grassroots Advocacy

• Nearly 156,000 people are part of AAMC Action – over 10,000 new members in ‘15

• Over 29,000 responded to calls to action – 16+% of the community.

• Join the community at www.aamcaction.org

• Encourage friends, family, colleagues to do the same

www.aamcaction.org48