Medical residency caps are a growing issue for academic medical centers

Sept. 25--The number of old people is steadily growing in the United States at the same time more Americans are gaining access to health insurance. Both trends are helping drive a need for physicians, and that's posing some challenges for policymakers.

Currently, the only way to become a practicing doctor in the U.S. is to complete a residency program after medical school. The problem is that for the past two decades there has been a cap on the number of residents funded by Medicare, which is the primary source of payment for residents.

That cap has limited the expansion of some residency programs, which play a significant role in ultimately shaping the medical workforce. Residents also are key to helping academic medical centers meet the need to treat the poor and uninsured.

Health care experts fear that the system is nearing a point where the country will have more medical school graduates than available first-year residency slots, said Len Marquez, director of government relations for the Association of American Medical Colleges.

"Without additional federal funding, we're not going to be able to continue to grow at the rate society needs us to grow," said Dr. Julie Gammack, associate dean for graduate medical education at St. Louis University.

Executives at Barnes-Jewish Hospital, the main teaching hospital of the BJC HealthCare system, say the caps are a big problem.

Currently, Barnes-Jewish is funding 146 residents without any federal help. It's unlikely they'll be able to add residents or make further investments in programs without an additional source of funding, said Dr. John Lynch, chief medical officer at Barnes-Jewish Hospital.

But it's not just a problem for the hospitals, said Steve Lipstein, chief executive officer of BJC HealthCare.

"Missouri has some real challenges in terms of physician manpower," Lipstein said. "Predominantly, the big trend that is worrisome is the aging of the physician workforce in key specialty areas."

More physicians are nearing retirement at the same time an aging population is adding demands on the health care system.

To address the problem, some health systems have turned to interesting ways to increase their lot of residents. In one local instance, a hospital recently inked a deal to effectively lease slots to another, larger academic medical center.

Lawmakers also are getting involved.

Sen. Claire McCaskill, D-Mo., last week said she is adding her name to a bill that would increase Medicare-funded residency slots for hospitals. The bill, the Resident Physician Shortage Reduction Act, would add 3,000 new slots each year from 2017 to 2021, for a total of 15,000 new slots.

"We've got to get more well-trained doctors into the workforce, in the specialties that need them most, and we can't do that without residency programs to train them," McCaskill said in a statement provided to the Post-Dispatch.

"Raising the caps on Medicare-backed residents means giving hospitals and health centers the tools to address looming shortages, lower wait times for patients, and harness a pipeline of qualified professionals to tackle serious public health emergencies like the growing opioid crisis."

However, Marquez said the legislation, sponsored by Sen. Bill Nelson, D-Fla., has been introduced before -- and because it requires more funding it faces a gridlock in Congress.

There are 105,341 residents training at hospitals across the country during the 2016-2017 school year, according to the Accreditation Council for Graduate Medical Education. Missouri has 2,288 residents, almost half of who train at Barnes-Jewish Hospital in partnership with Washington University and St. Louis Children's Hospital.

During the 1995-1996 school year, there were 98,035 residents, according to a previous report from Council on Graduate Medical Education.

The caps reflect how much Medicare is willing to help financially.

"You can train as many doctors as you want, but Medicare will only support a certain number at your hospital," Marquez said.

About 20 years ago, legislators decided to limit the number of residents Medicare helped subsidize to curb costs.

And the number of residents a hospital was teaching at the end of 1996 is the cap that a teaching hospital is limited by today.

Medicare is the largest source of funding for residents. That funding pays for the care provided and covers the salary and other overhead costs to teach residents. However, Medicare doesn't cover the entire cost to train new doctors; it just pays a portion.

"It's months and months before you can see a primary care physician and that's in the city; can you imagine in the rural areas?" said Dr. Joan Shaffer, chairman of graduate medical education for Mercy St. Louis. Shaffer said Mercy already train 10 residents per year over the cap, meaning they receive no federal funding to train those 10 residents.

Mercy would like to add more residents for primary care and more to start a palliative care training program. But that's not likely without more funding.

Leasing residency slots

Because of the long-standing caps there are some interesting ways area health systems have gone about increasing their lot.

For example, St. Alexius and SSM Health renewed a deal this summer that industry experts say is somewhat rare compared with their peers around the country.

St. Alexius has agreed to effectively lease its 74 residency slots to St. Louis University Hospital annually for $5.2 million for three years, according to St. Alexius Hospital CEO Michael Motte.

While it allows for St. Louis University medical students more training opportunities, it provides a lifeline for St. Alexius.

The hospital is able to invest in capital upgrades thanks to the funding from the deal. The hospital is currently replacing its roof and will soon upgrade the operating room.

And those St. Alexius residency slots were actually inherited from Forest Park Hospital when the two merged to operate under the same license in 2010. Forest Park later closed. Now St. Alexius sees the slots as a way to generate additional revenue, and, in a sense, have turned them into a commodity.

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Samantha Liss --314-340-8017

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sliss@post-dispatch.com

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