American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

GME and Workforce

ACS Letter in Response to the House Energy and Commerce Committee's Request for Information on GME Reform

On December 6, 2014 Members of the House Energy and Commerce committee sent out an open letter requesting information on Graduate Medical Education (GME). In response, ACS developed a set of principles on GME reform and used them to formulate a response to the seven questions in the letter. The response can be found here and was sent to the Committee on January 15, 2015. The DAHP plans to use the letter and the principles developed in its writing to contribute to ongoing congressional efforts to reform the way that gme is funded and administered.

Updates on Graduate Medical Education and Workforce

The Institutes of Medicine (IOM) report on the financing and governance of the nation’s graduate medical education (GME) system was issued this past summer to little fanfare. It was met with disappointment, and disregard, on Capitol Hill.

There has not been much movement since our last report in the workforce area. The Council on Graduate Medical Education (COGME) released its 21st report, “Improving Value in Graduate Medical Education.” In the report, the COGME recommends an increase in GME funding for high-priority specialties such as general surgery, family medicine, geriatrics, general internal medicine, high-priority pediatric subspecialties, and psychiatry. The COGME acknowledges there are many challenges facing GME such as poor geographic distribution of physicians in relation to population needs and increasing specialization, while primary care remains under-resourced. According to the COGME, part of the reason is that many teaching hospitals have not recognized the need for greater emphasis on primary care training, and curriculum is often inadequate in the areas of population health, care coordination, team-based practice, and other aspects of new systems of care. To address these and other challenges stated in the report, the COGME believes that GME must improve the value the public receives for its investment by increasing partnerships between training programs, teaching hospitals, accreditation organizations, state and federal governments, and other stakeholders to accelerate change. The COGME assumes that greater value in GME means a better targeting of public GME money and more effective training models.

There are several other active bills that ACS has supported, though there is little appetite to push the bills through Congress as they cost a significant amount of money and offsets are scarce.

  • S. 1557, the Children’s Hospital GME (CHGME) Support Reauthorization Act of 2013, reauthorizing the CHGME program, was introduced by Sen. Casey (D-PA) in the Senate. The full Senate then passed the bill by unanimous consent and referred it to the House Committee on Energy & Commerce. It is currently awaiting consideration in the House.
  • S. 577, the Resident Physician Shortage Reduction Act of 2013, which was introduced by Sens. Bill Nelson (D-FL), Charles Schumer (D-NY), and Senate Majority Leader Harry Reid (D-NV). S. 577 is a crucial piece of legislation that will address both short- and long-term workforce demands by increasing the number of Medicare-supported GME residency positions by roughly 15,000 over five years. Additionally, Reps. Joseph Crowley (D-NY) and Michael Grimm (R-NY) introduced H.R. 1180, similar legislation in the House. Both are supported by the ACS.
  • H.R. 1201, the Training Tomorrow’s Doctors Today Act, introduced by Reps. Aaron Schock (R-IL) and Allyson Schwartz (D-PA), increases the number of Medicare-supported residency positions by 15,000 over five years. In addition to increasing the number of residency positions, H.R. 1201 will establish Medicare GME accountability and transparency measures. The ACS sent a letter thanking them for continuing to push for more funding for GME and asking them to address concerns with some of the accountability and transparency provisions.
  • H.R. 702, the Access to Frontline Health Care Act, would create a new Frontline Providers Loan Repayment Program. Under this program, health care professionals, including general surgeons, would receive loan repayments from the U.S. Department of Health and Human Services in exchange for providing care for at least two years in a Health Professional Shortage Area or an area designated by a state as having a shortage of frontline care services. A frontline care service is defined as a health care service performed by a medical specialist or allied health professional in the fields of general surgery, ophthalmology, and otolaryngology, among others.

Also in workforce funding, the Patient Protection and Affordable Care Act authorized funding for loan repayments for pediatric subspecialists, including pediatric surgeons, who agree to practice in shortage areas for at least two years. The College sent a letter to appropriators asking that $5 million be included for the program. Unfortunately funding was not included in the omnibus appropriations act that funded the government for the remainder of the fiscal year. We also signed on to a coalition letter to the Office of Management and Budget (OMB) asking the Administration to ask that $5 million in funding be once again included within the Health Resources and Services Administration (HRSA). ACS will continue to push for the funds to be appropriated. The authorization of this program is set to expire after the current fiscal year and Congressman Joe Courtney of Connecticut has recently introduced legislation that would extend this authorization through fiscal year 2018. ACS supports this legislation.

Ensuring an Adequate Surgical Workforce

There is a growing body of evidence pointing to the current and worsening shortage of surgeons available to serve our nation's aging and increasing population. According to the Association of American Medical College's Center for Workforce Studies, there will be a shortage of 46,000 surgeons and medical specialists in the next decade. This is a startling and troubling statistic.

With this looming crisis in the surgical workforce, the American College of Surgeons (ACS) is concerned that focusing efforts only on specialties that fall under the broad rubric of primary care could have severe consequences for surgical patients. We support primary care, and know that it is a needed service for all patients. However, primary care is a service that can be provided by a spectrum of providers. In contrast, surgeons are uniquely qualified to provide necessary and life-saving procedures that no other professional can provide. The needed services of surgeons, which account for an essential part of our health care system, are under great stress because there are more limited numbers of these professionals who are qualified to provide important services to patients.

ACS' Division of Advocacy and Health Policy (DAHP) staff have been fighting to ensure that patients continue to have access to high-quality surgical care by supporting policies and initiatives, such as the ones listed below, that will strengthen the surgical workforce.

Access to Frontline Health Care Act

On July 22, 2013, the ACS sent a letter of support for the Access to Frontline Health Care Act that would create a new Frontline Providers Loan Repayment Program. Under this program health care professionals, including general surgeons, would receive loan repayments from the U.S. Department of Health and Human Services in exchange for providing care for at least two years in a Health Professional Shortage Area, or an area designated by a state as having a shortage of frontline care services. A frontline care service is defined as a health care service performed by a medical specialist or allied health professional in the fields of general surgery, ophthalmology, and otolaryngology, among others.

Pediatric Subspecialty and Mental Health Workforce Reauthorization Act

On July 22, 2013, the ACS sent a letter of support for the Pediatric Subspecialty and Mental Health Workforce Reauthorization Act that would extend authorization for the pediatric subspecialty loan repayment program through 2018. Under the current law, the program will expire in 2014. This program provides $35,000 per year for up to three years to pediatric surgeons or other pediatric medical and mental health specialists who agree to practice for at least two years in underserved areas. On July 11, the Senate Appropriations Committee passed a bill that, for the first time, included funding for the program at $5 million for fiscal year 2014.

ACS Supports the Conrad State 30 and Physician Access Act

ACS-supported legislation, to help address physician shortages, has been reintroduced in Congress. The Conrad State 30 and Physician Access Act (S.616), introduced by Sens. Amy Klobuchar (D-MN), Heidi Heitkamp (D-ND), Jerry Moran (R-KS), and Susan Collins (R-ME) on March 19, would expand and permanently reauthorize the Conrad 30 Program. Since 1994, the Conrad 30 program has worked to bring thousands of foreign physicians, trained in the U.S., to rural, inner-city, and other medically underserved communities.

Under current law, foreign physicians must return to their home countries for two years after completing residencies in the U.S. on J-1 visas. The Conrad 30 program allows these physicians to receive a waiver of requirement in exchange for three years of service in an underserved area. The "30" in the name of the program represents the maximum number of doctors each state can receive each year. The program has been reauthorized by Congress several times and used by every state in the country.

S. 616 would not only remove the sunset provision, but also would improve the functioning of the program and allow it to expand to better meet the needs of the country. The bill also makes other improvements to the immigration laws affecting physicians outside of the Conrad 30 program with the same goal of increasing access to medical professionals in underserved communities. For example, under current law, physicians may receive a National Interest Waiver green card under the EB-2 category if they serve for five years (three of which can be under the Conrad 30 program) in a medically underserved area or Veteran Affairs facility. Moreover, the legislation would exempt these physicians from the worldwide cap on employment-based green cards. The sponsors of the legislation are working to get it included in the Senate's comprehensive immigration reform proposal.

Read the Letter to Senators Klobuchar, Moran, Heitkamp, and Collins

ACS Supports Resident Physician Shortage Reduction Act

Read the Letter to Majority Leader Reid, Senator Nelson, and Senator Schumer

Read the Letter to Representatives Grimm and Crowley

ACS Training Tomorrow's Doctors Today Act

Read the Letter to Representatives Schwartz and Schock

CHGME Support Reauthorization Act

In January, Congress unanimously approved the Children's Hospital Graduate Medical Education Support Reauthorization Act (CHGME) that reauthorizes the much-needed CHGME program. CHGME hospitals currently train approximately 43 percent of pediatric specialists. Such hospitals are ineligible for traditional GME financial support through the Medicare program, making the reauthorization of the CHGME program vital to sustain the pediatric workforce and protect the health of children.

ACS sent a letter to Rep. Joe Pitts (R-PA) and Rep. Frank Pallone (D-NJ) thanking them for sponsoring the legislation, and for considering it in the first legislative meeting of the Energy and Commerce Committee in the 113th Congress.

Congressional Academic Medicine Caucus

In May 2012, Reps. Allyson Schwartz (D-PA) and Phil Roe MD (R-TN) relaunched the Congressional Academic Medicine Caucus. This bipartisan caucus provides a forum for members to engage in a constructive dialogue about the challenges and opportunities surrounding graduate medical education (GME) in the United States and explore relevant policy approaches and solutions. "America is on the cusp of a crisis in access to both specialty and primary care physicians due to a mounting physician shortage," said the caucus co-chairs, Schwartz and Roe. "Supporting our nation's GME system will be pivotal to addressing this issue." ACS advocacy and health policy staff will be closely following the work of the caucus and will provide updates when available.

Contact: Heather Smith