The United States’ physician shortage is growing more critical every year.
The main reason, health care leaders say, is a lack of residency programs. While enrollment in medical schools has increased, the number of residency slots has not kept pace.
In the Pikes Peak region, Peak Vista Community Health Centers has created a family medicine residency program to help alleviate the shortage of primary care physicians, which is particularly acute.
Those efforts are a start, but residency programs are expensive to create and run. They’re dependent on federal financing, and subject to complicated regulations that dissuade hospitals and health systems from launching new residency programs.
“We’ve been sounding the alarm for many years,” said Dr. Erik Wallace, associate dean for the Colorado Springs branch of the University of Colorado School of Medicine. “There’s been lobbying efforts by many medical organizations to get Congress to change the rules around that. They’ve really struggled to get anything through.”
Legislation was introduced in both houses of Congress last year to fund 1,000 additional residency positions, but those would focus on opioid addiction and pain management and would do little to address the shortfall of primary care and specialty physicians.
A study released by the American Association of Medical Colleges predicted that by 2030, the United States will see a shortage of up to 121,000 physicians, including both primary care practitioners and specialists.
In Colorado, “we’re not producing enough physicians to meet the current need or the need in the future,” Wallace said.
While the physician shortage is also due in part to the aging population and retirement of older physicians, most health care experts trace the root of the problem to a 1997 effort to balance the federal budget by reducing Medicare spending.
Medical residencies — the graduate medical education physicians must complete after finishing medical school — are funded largely through Medicare.
The 1997 Balanced Budget Act, signed into law by former President Bill Clinton, tightened Medicare payments to health care providers and health plans and capped Medicare spending on graduate medical education.
“There was actually at that time a concern that we would end up with a surplus of physicians,” said Dr. Lisa Ramey, chief medical and dental officer at Peak Vista. “The overall goal was to decrease the amount of residency spots. … Unfortunately, over time, that pendulum has swung in the other direction. So that has got us to a situation where now, we do not have enough physicians to treat all of our patients — and our complexity of medical needs for these patients has also increased.”
The physician shortage is “significant” in both primary care and specialty areas, Ramey said.
In Colorado Springs, “there are some specialty areas that we do not have enough resources in the community for our patients who need more complex referrals,” Ramey said. Those include endocrinology, some orthopedic specialties and pediatrics.
The shortage of primary care practitioners contributes to escalating health care costs because patients who can’t get appointments tend to seek care in emergency rooms, Ramey said.
“Or they may forgo care, and because of that, their complexity or their health care situation is impacted and becomes more expensive to treat,” she said. “So instead of doing preventive care, we’re doing a lot after the fact.”
PEAK VISTA’S RESIDENCIES
To address the physician shortage, Peak Vista established a family medicine residency program in 2016, President and CEO Pam McManus said. Peak Vista also created an advanced practice registered nurse primary care fellowship in 2015.
“Both of those took a great amount of time to put in place at a quality level,” McManus said.
The family medicine residency is a three-year, accredited program that provides training in primary care clinical areas from outpatient pediatric and family medicine to gynecology and geriatric care.
The residents work with Peak Vista providers and also get training in inpatient services through Peak Vista’s partnerships with Penrose Hospital, Penrose-St. Francis Medical Center, UCHealth Memorial and Children’s Hospital in Denver.
The first cohort of eight residents graduated in June 2019.
The Advanced Practice Registered Nurse fellowship trains participants in classroom and clinical settings and rotates them through Peak Vista’s health centers during the latter part of the program.
The program accepts nurse practitioners, who often work alongside the family medicine residents.
“So they have a pretty extensive, interdisciplinary training within Peak Vista, focusing on our primary care and family practice,” Ramey said.
Six students currently are enrolled in the fellowship class.
One of the goals of both programs was to fulfill Peak Vista’s own needs for practitioners.
“This is really about long-term solutions for Peak Vista and being there for the community,” McManus said.
Of the first eight family medicine residents to graduate, five chose to stay in the Springs and one is a full-time provider at Peak Vista.
“For every resident that stays in our community, there is $1.2 million of economic growth that they generate,” McManus said.
And having residency programs is key to keeping physicians in a community.
“Seventy percent of residents stay in practice within 50 miles of where they graduated residency,” she said.
Ramey added that 80 percent of physicians who have trained within a community health center choose to work in a community health center at some point in their careers.
FILLING THE PHYSICIAN GAP
Penrose-St. Francis Health Services, a part of the Centura Health system, offers a four-year residency in anatomic and clinical pathology.
According to the Centura Health website, training occurs almost exclusively at Penrose Hospital.
Centura Health also has general surgery and pharmacy residency programs in Centura facilities in other areas, and family medicine residencies at St. Anthony North Health Campus in Westminster and St. Mary-Corwin Medical Center in Pueblo.
UCHealth Memorial Hospital is currently developing a general surgery residency in conjunction with the surgery group at the University of Colorado School of Medicine in Aurora, Wallace said.
The federal funding formula for residency programs is extremely complicated, and it’s not the only road block making it difficult for hospitals to create new programs.
“To start up a new program, you have to be a health care system that has never had residents come through your system prior to that time,” he said. “And then you basically state that, ‘OK, we’re going to set up X number of training programs and these specific specialties with this number of slots.’ And then you have basically five years to set up all of those slots.”
Once the five-year period expires, “the ability to create the slots is over, in terms of getting federal funding,” he said.
When that funding source dries up, health systems have to fund residency programs themselves or find another funding source.
And at a cost of more than $100,000 per resident per year, plus administrative support to run the program, many hospitals and health systems aren’t willing to do that.
Wallace said some states have sought to address the physician shortage by providing partial funding for new residencies and training programs.
“Georgia is one of those states where over the years they’ve set up additional residencies and training programs, and part of that funding has come from the state — but Colorado has not,” Wallace said.
Educational institutions in Colorado have, however, stepped up by increasing training opportunities for nurse practitioners and physician assistants.
At UCCS, for example, nurses who have completed a bachelor’s or master’s degree in nursing can take programs to earn a doctorate of nursing practice.
“Nurse practitioners can practice independently,” Ramey said. Physician assistants, on the other hand, can practice only under the supervision of a physician.
“However, I think that you will see across the state that nurse practitioners and physician assistants are seeing more complex patients that have more complex medical needs,” she said. “Sometimes a patient may need to be transferred to a physician due to complex needs of that patient. But I do not feel that that is a luxury, as it was 10 or 15 years ago.”
In the long term, the medical profession also needs to look at the pipeline for future physicians, McManus said.
“It’s really important that we’re even looking at elementary kids and middle school kids getting STEM programs and letting them know what kind of careers are available in health care and start that interest back then,” she said, “because this is not anything that we can solve in one or two years.”