‘The problem with physician shortages is they hurt vulnerable people first’

Dr. Darrell Kirch, Earlier this month, president and CEO of the Association of American Medical Colleges, wrote to Congress about a bipartisan bill that aims to expand federal funding to pay for medical training for new physicians as a way to address the opioid crisis. The Opioid Workforce Act would create 1,000 new medical residency positions over the next five years. The AAMC has been lobbying Congress to find ways to address what’s expected to be a devastating physician shortage over the next decade. Kirch recently spoke to Modern Healthcare’s editorial board about that issue and others facing the next generation of physicians. The following is an edited transcript.

MH: How real is the physician shortage, and where are you seeing the greatest need?

Kirch: We see it in both primary care and specialty care. Where you see it is in wait times to get an appointment. Where you see it most acutely is in rural and urban underserved areas. It isn’t a hypothetical future event. It’s already occurring. I would argue it deepens every day. The mismatch is between the boomers aging and the physician workforce aging out, simultaneously converting physicians to patients. There’s a skew. You have critics who say it’s not going to happen because technology, artificial intelligence will take over all these functions, and it will be just fine.

But in our assessments, we’ve been factoring all of that in—technology, the use of nurse practitioners and physician assistants, which has expanded greatly. That’s part of the reason we give such broad ranges. We’ve been criticized because this year, we said basically it’s between 43,000 and 121,000 by 2030. That year is key, because that’s really when the effect of the boomers will be most fully felt. I think we have to say that hoping for the convergence of lots of future events is not a great strategy when it takes so long to build up the workforce.

MH: How much of this is a shortage, and how much of it is bad distribution?

Kirch: I would argue that there’s not a glut, in part because when you look at these cities that have the highest ratio of physicians to population, they’re interesting places. It’s a place like Lexington, Ky. Why is that? It’s because there’s the University of Kentucky Academic Health Center that pulls people in from all over the state. I don’t know of any areas where there’s such a glut that physicians aren’t fully occupied. The reality is the bad distribution. The problem with physician shortages is they hurt vulnerable people first. Poor people. People who are living more remotely. I think we need to see also that this isn’t just an economic issue. It’s a moral issue about who gets left out.

MH: What role did federal policy play in this situation?

Kirch: Around 1997, we went through a period where people believed that, if we managed care and got better at avoiding overutilization of services, we’d be just fine. But they didn’t really factor in the demographic wave of the baby boomers. We became convinced we had a good physician workforce and did not vigorously oppose a provision in the Balanced Budget Act that capped residency positions. That was intended to be temporary.

Well, we’re now 21 years past the Balanced Budget Act, and the pause is still in place. To the degree residency positions have expanded, it’s been selffunded by health systems, which, as their margins shrink, it’s hard for them to do.

The VA had a very modest expansion, and the Affordable Care Act took some steps to allow mild expansion. What we’ve proposed in the bills that are sitting in this Congress are modest expansions.

We need to build the physician workforce by modest expansion of residency positions, and we need to be relentless on deploying more efficient healthcare teams, on using technology better, on driving out overutilization.

MH: On another policy issue, bundled payments were made voluntary in this administration. Have your members largely been receptive to that move?

Kirch: As an organization, our position is that we do need more value in healthcare. We just had our meeting of the Council of Teaching Hospitals and Health Systems, the CEOs. I don’t see them changing their behavior. They know that a value-based system will probably yield better quality and outcomes and it will decrease their expense base. It’s the future. Medicare can lead what the private insurance sector does, but the private insurance sector can also demand value, and the expectation is that they will increasingly, as well as state Medicaid entities.

There was a governor I met with in a state I won’t name who said that these days, the job of a governor involves just three things: educate, mediate and incarcerate. He said, “If you look at my budget, those are the three main domains that we’re funding. With Medicaid costs rising, it hurts education. If you hurt education, you probably end up putting more people in the criminal justice track and the low employed track.” It’s a kind of vicious cycle. Whatever the CMS does, I don’t see any of our CEOs saying, “Oh, that value question is now off the table.”

MH: How can academic medical centers help lower healthcare spending?

Kirch: Historically, Vanderbilt was like any other academic health center. They were taking care of the poor and underserved in the immediate Nashville area. Jeff Balser, their CEO who also is dean of their medical school, has now developed Vanderbilt Health. His vision for the future is, there still needs to be a place that does these highly complex and more costly procedures, that has the cutting-edge technology, but it will relate not only to community hospitals, some of them in rural areas, and there will be primary care in the locations that are needed.

I was at Geisinger recently. You drive to Danville, and you drive through these small towns in rural Pennsylvania. There are these wonderful, well-staffed primary-care clinics in these towns. There might not be another one for 20 or 30 miles, but the way they staff them, they’re very focused on prevention and well-being. It really flips the notion of what an academic health center is—the academic health center that really does design everything to keep patients out of the hospital, ideally out of the clinic, at home.

Now, Geisinger did something that’s interesting. They didn’t have a medical school historically, but they essentially brought in the Commonwealth Medical School, a relatively new school in Scranton, because they understand it’s not just the system we design, but it’s how we train people to work in that system. That’s probably a good example of an educational curriculum that’s really designed to work in the future state.

MH: Are your members doing a good job of teaching physicians to work in this future state with technology and value-based care?

Kirch: Actually, I would say that that’s been one of the biggest shifts in medical education. If you go back 10 years, you really wouldn’t see curricular content in what schools now call healthcare-delivery science—that there’s a science of quality improvement, there’s a science of process improvement. Now you see that. Ten years ago, there was really no interprofessional education. Now virtually every campus has faculty who are dedicated to that. We’re a part of a group called the Interprofessional Education Collaborative. It started actually 11 years ago when pharmacy, nursing, our organization, the osteopathic medical schools, dental schools and public health schools, the six of us came together. Now there are about 30 members of the IPEC. It’s all about how do we, at the very beginning of health professions education, say, “You’re not going to be a solo, independent practitioner. You’re going to be a member of an interdependent team, and that requires a different skill set.”

I also think that today’s students are digital natives comfortable with electronic medical records or robotic surgery, and they outshine the faculty, many of whom are like me: digital immigrants. I think on all those fronts, there’s really been encouraging change. It shows up in interesting ways in academic health centers when those people become junior faculty, because when there are efforts like trying to improve the electronic health record, trying to build a better quality or safety program, often I’m struck by how it’s led by junior faculty, as opposed to senior faculty. That gives me extra hope for the future.

“More and more, it becomes clear that the hospitals that do best on the star ratings are the hospitals that don’t take care of the most complex cases.”

MH: The most recent CMS star ratings show that specialty hospitals have outperformed teaching hospitals. What are your thoughts on that?

Kirch: More and more, it becomes clear that the hospitals that do best on the star ratings are the hospitals that don’t take care of the most complex cases. They are the hospitals that aren’t dealing with people whose socioeconomic status creates problems in their health and their follow-up. The specialty hospitals can be very focused on slicing out a well-insured portion of patients with a certain disease, and doing very well with them. I wouldn’t dispute that they do well, but, for example, many of our member academic health centers don’t turn people away. Our member hospitals are such a small percentage of all the hospitals in the country, but we do a third of the charity care. Those are the patients who tend to be readmitted, not because the care was poor but because they had no car. They have no money for their prescription. No family support. I don’t see any movement on the CMS’ part in addressing that in star ratings.