States may hold key to work force shortage solutions

This article is part of an ongoing series from the American Association of Clinical Urologists (AACU), based on a partnership between the AACU and Urology Times. Articles are designed to provide updates on legislative processes and issues affecting urologists. We welcome your comments and suggestions about topics for future articles. Contact the AACU government affairs office at 847-517-1050 or info@aacuweb.org for more information.

Sequester summer has arrived! Across-the-board spending cuts began their 10-year rollout Jan. 1, launched agency by agency and program by program. When Medicare cut health care provider payments 2% and the National Institutes of Health announced 700 fewer medical research grants would be awarded because of sequestration, the public barely noticed. Based on the quick reversal of air traffic control cuts, it would seem as though alleviating flight delays is more important than alleviating the impact of chronic disease.

In meetings with federal policymakers, the medical community has warned that Medicare cuts will restrict access to care just as millions of Americans enter the health insurance marketplace in January 2014. Uncertainty will also be heaped upon Medicare's contribution to graduate medical education (GME) as the urologic work force shortage reaches a crisis level.

Medicare currently funds 170 of 278 urology residency positions, according to a 2012 study of Society of University Urologists members. The relatively high percentage of non-Medicare residency slots is a blessing in disguise, perhaps, since mechanisms for alternative funding already exist. While advocacy on behalf of pending legislation to add 15,000 Medicare-funded residencies over 5 years remains a worthwhile endeavor, experts believe the most that can be hoped for is maintenance of the status quo as it relates to federal support for GME.

There is little doubt that the federal government will continue to play an important role subsidizing the training of physicians. However, given the immediate medical education and work force crisis, states will likely be the source of temporary and long-term solutions.

State Medicaid programs in 42 states and the District of Columbia contributed $3.87 billion to GME in 2012. Although this funding stream has been stable in recent years, its ongoing viability is tenuous, at best, because states are under no obligation to fund GME. Indeed, as recently as 2005, 47 states and DC supported GME via Medicaid. States also provide direct appropriations outside of Medicaid to fund physician training positions. The Texas legislature authorized $6,600 per resident payments to hospitals in 2006. That subsidy was cut to $4,000 in 2012, along with a significant reduction to the state's physician loan repayment program (from $23.3 million to $5.6 million).

Recognizing the increasing discrepancy between the number of medical school graduates and residency slots in Florida, Gov. Rick Scott (R) allocated $80 million in his 2014 budget to fund an additional 700 training positions. New Jersey Gov. Chris Christie's (R) proposed 2014 budget proposed an 11% increase for graduate medical education to fund salaries and facility expenses at the state's 71 hospitals. The medical community may call upon state policymakers to boost GME funding to address the immediate shortage of urologic training positions, but in the long run, non-governmental sources must be tapped.

So-called "all-payer systems" provide the most consistent and equitable funding for GME, although such models are utilized in very few states. Maryland's unique (thankfully) Health Services Cost Review Commission sets reimbursement rates for all hospitals. The commission takes GME into account when establishing payment schedules and the state distributes funds based on a per-resident formula.

A Professional Education Pool collects and distributes funds in New York that are generated by a "covered lives assessment" ostensibly paid by all private insurers. An increasing amount of the money generated by this assessment ($1.05 billion in FY 2012) has been allotted to general fund purposes, at the expense of GME. California lawmakers are considering a similar assessment during their 2013 legislative session. AB 1176 calls for a $5-per-covered-life fee paid by health insurers to generate $100 million a year for physician training programs. The legislation stalled in mid-May, after receiving favorable consideration by two committees.

These are just a few programs that might be reimagined in other states to address the medical education component of the urology work force crisis. Addressing an anticipated shortage of as many as 8,500 urologists by 2020 will also depend on the integration of medical technologies that enhance efficiency, telehealth, and non-physician provider scope of practice-public policies that are determined at the state level.

Urologist-led campaigns facilitated by the AACU have resulted in victories in capitals from Tallahassee to Olympia. Maintaining membership in such organizations and taking action when called upon will ensure future access to high-quality, physician-led urologic care.UT

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