Do you remember the wave of reality TV shows following plastic surgeons about 10 years ago? I went to medical school with one of those TV doctors. At the time, I was also doing research on Medicare graduate medical education (GME) payments and I wondered, how much did Medicare pay to support my classmate's residency training? I estimated, at the hospital's payment rate of $124,393 per resident per year for a 6-year program, Medicare provided $746,358 to support the training of that one plastic surgeon. That's a lot of tax dollars.
So where does the money go? Residents do increase the cost of clinical care due to losses in efficiency and a need for more resources and staffing but not to the degree that Medicare is paying. In fact, Medicare payments for these "indirect" costs of training are roughly two times the amount that can be justified by the data. Medicare GME incentivizes all the wrong things: hospital-centric, subspecialty care concentrated in New England. This has contributed to a physician workforce that is deficient in primary care and maldistributed across the U.S. The National Academy of Medicine has recommended a major overhaul of Medicare GME, including pulling back and redistributing a third of the $15 billion in annual payments to close the gaps in the physician workforce. Despite this, there has been little progress in reforming Medicare GME and now would be a difficult time to redirect funding to hospitals as they recover from COVID.
The Medicare GME system is just one of many factors in medical training and practice that has contributed to the doctor shortage. Let's explore some other efforts to fix key physician shortages that can have a greater impact.
The Affordable Care Act established the Teaching Health Center (THC) program to support a new model of primary care residency programs -- actually based in the primary care setting rather than in hospitals. These programs recruit residents from high need communities, where they also train. Because THC residents work in the very same communities in which they grew up, it's not surprising that they stay on to practice in these areas. Despite its success in supporting the primary care workforce, the THC program is funded at 0.8% the amount of Medicare GME and is facing a funding cliff later this year.
What about addressing medical school debt? Before they can even start their career, graduating medical students face a median debt of $200,000. The cost of medical school is a particularly significant barrier for those from disadvantaged backgrounds, who are more likely to choose primary care and underserved practices. Scholarship and loan repayment programs like the National Health Service Corps and pathway programs like the Health Careers Opportunity Program and the California Medical Scholars Program, a community college to medical school pathway program, can help mitigate barriers. These programs also help to address the long-standing lack of diversity in the physician workforce. But, like the THCs, the level of investment in these programs seems trivial compared to Medicare GME.
Practice side incentives are also important in driving specialty and practice decisions. On average per year, orthopedic surgeons and cardiologists earn $557,000 and $490,000, respectively, while family physicians earn $255,000. Sure, $255,000 doesn't sound so bad at face value, but remember that's the average income across a career, not the starting income when new physicians are also facing the reality of their medical school debt. The difference in income between different specialties is hard to ignore. Ultimately, if we want physicians in primary care and in underserved communities, we need to pay for it.
It's also important to recognize that the payment divide between specialties isn't just about income. It influences how physicians are able to practice too. Primary care has been likened to being a hamster on a wheel -- constantly running -- with 15-minute visits that aren't nearly enough time to provide high quality care. Placing this in the context of rising health worker burnout and moral injury across healthcare, we have a problem. The health workforce has been described as a leaky bucket and COVID punched a bunch of extra holes in our bucket, increasing the number of workers leaving their jobs. Strategies to address workforce shortages often focus on increasing production (e.g., putting more in the bucket) but we have to fix the bucket -- healthcare systems. Simply putting more in while more continue to leave is an expensive and losing proposition.
We also cannot concentrate on just one medical profession. As a primary care pediatrician, I know that my ability to provide care depends on a team of nurses, medical assistants, social workers, and many others. Recent shortages of direct care workers (who staff nursing homes) highlight the connectedness of the healthcare systems. When nursing homes are understaffed and can't accept patients, hospitals can't discharge them. This ripples all the way to the emergency room with increased boarding and overcrowding. Yet, the median hourly wage of a direct care worker is $14.27, less than Target's $15 per hour. Healthcare is truly a team effort and when any part of the team is suffering, when there is turnover or insufficient staffing, it affects everyone, including patients.
To fix the doctor shortage, we need to stop the bleeding and address burnout and moral injury. We need to pay for what communities need: primary care, mental health, and long-term care. And we need to invest in training that addresses the gaps in the physician and larger health workforce, and ultimately ensures access for all communities.
Candice Chen, MD, MPH, is an associate professor of Health Policy & Management in the Fitzhugh Mullan Institute for Health Workforce Equity at the George Washington University's Milken Institute School of Public Health.