Roughly 1,000 DOs and osteopathic medical students from across the U.S. donned their white coats in the nation’s capital to meet with congressional offices March 14 for the AOA’s annual DO Day on Capitol Hill. This year, the physicians and students focused on encouraging lawmakers to repeal the Medicare sustainable growth rate (SGR) formula and increase funding for graduate medical education.
Introduced last month, the Medicare Physician Payment Innovation Act of 2013, or H.R. 574, addresses the SGR formula. Sponsored by Reps. Allyson Schwartz, D-Pa., and Joe Heck, DO, R-Nev., the bill would repeal the formula and undo the fee-for-service payment model over a 10-year period.
This year, the estimated cost of repealing the SGR formula is $138 billion according to the Congressional Budget Office. The cost fluctuates annually based on health care spending and $138 billion is a reduction from previous years—it was estimated to be $318 billion last year. The repeal is considered to be “on sale,” said Ray Quintero, the director of the AOA’s Department of Government Relations, noting that the move to permanently repeal the formula has gained momentum in Washington for the first time in 10 years because of its current low cost.
The Centers for Medicare and Medicaid Services has used the SGR since 1997 to control spending. CMS annually recommends a change in physician compensation based on recent spending levels to match the target SGR. In 2012, the formula would have cut physician compensation for Medicare services by 26.5% if it was not prevented. Since 2003, Congress has voted 15 times to prevent the SGR cut to physician compensation for Medicare services.
However, a complete repeal of the SGR formula must be offset by savings elsewhere. H.R. 574 doesn’t include a pay-for-it mechanism, Quintero said, noting that passing the act is crucial and details of pay can come later. Dr. Heck, the bill’s co-sponsor, expressed similar sentiments when he met with osteopathic medical students from Nevada in his office.
“Let’s get people to agree on the policy,” he told them. “Once we do that, we can figure out how to pay for it.”
Julie Brodfuehrer, OMS II, wondered how it would be possible to convince other Republican representatives to back the bill.
“It seems like anything that is going to cost money, they don’t want to do,” said Brodfuehrer, who attends the Touro University Nevada College of Osteopathic Medicine (TUNCOM) in Henderson. “So what should we say to convince them?”
“I don’t like doing things that cost money either, unless we can pay for it,” Dr. Heck said, noting that it’s sometimes necessary to spend money upfront that will yield greater savings later. “You can’t have that across-the-board mentality of cutting everything today and not worrying about what the cost is going to be 10 years down the road.”
Following the meeting, TUNCOM’s Denise Nicole Teh, OMS II, noted that graduate medical education is the issue that concerns her and her classmates most.
“Hearing that new medical schools are being built worries us because we are adding medical students without adding residency positions,” she said.
Funding for residency positions comes from Medicare, and in 1997, Congress placed caps on the number of residency positions in the U.S. by passing the Balanced Budget Act of 1997. But in 2014, an estimated 30 million Americans will become newly insured, and in 2020, the primary care physician shortage will surpass 45,000, according to the Association of American Medical Colleges.
Last week, Schwartz and Rep. Aaron Schock, R-Ill., introduced a bill that would amend the Social Security Act to increase residency positions by roughly 15,000. Meanwhile, DOs and osteopathic medical students educated lawmakers on the problems a shortage of residency positions creates for medical students—and why increasing residency positions would ultimately lead to better patient care.
“Graduation from medical school doesn’t create doctors,” said Aaron Arthur Olsen, OMS III, after meeting with Rep. Sean Duffy, JD, R-Wis., and aides for Rep. Tom Petri, JD, R-Wis., and Sen. Tammy Baldwin, JD, D-Wis., on Thursday. “Training in a residency program creates physicians. There have been great advances, especially in the osteopathic medical arena, when it comes to creating new medical schools and increasing class sizes. However, the medical students are then left short-handed because there hasn’t been an increase in residency programs.”
Otto Stronach Shill IV, OMS I, who like Olsen attends the Midwestern University/Arizona College of Osteopathic Medicine in Glendale, agrees.
“Right now, residency programs get their pick of residents because there are a very limited number of spots,” he said. “If we expand the number of residency spots, we can shift the market more to the students’ benefit, and the residency programs will want to innovate and try to deliver better programs as well as provide better care to the patients.”
Limited residency slots are particularly concerning to osteopathic medical students and DOs from Maine, who fear losing physicians to other states, they said when they met with Patrick O’Neil, a legislative assistant for Sen. Angus King, JD, I-Maine.
“Students may not be able to complete their training in Maine,” said Cortney Linville, DO. “So what happens? They go to Oregon, maybe they fall in love with Oregon, and they never come back to Maine.”
Maine DOs and students also emphasized H.R. 574 in the meeting. Leigh “Jack” Forbush, DO, noted that the low Medicare payment rate meant that many physicians in Maine see extra patients or work extra hours to make ends meet.
“I have two jobs,” he said. “I run a private practice, and I also worked an extra 12-hour ER shift last week to make payroll, so I could pay my staff.”
Joel A. Kase, DO, MPH, also chimed in that he had two jobs.
O’Neil thanked them for sharing their personal stories.
“We like hearing what the issues are from physicians, so we know about them and we can craft effective policy,” he said.
And while student loans was not officially on the day’s agenda, the issue remains a concern for students, DOs and lawmakers alike.
While talking with students, Dr. Heck mentioned his own personal experience with medical school debt.
“I’m still paying off my student loans,” he said. “So I understand the amount of debt you are graduating with. Unfortunately, in this economic climate I don’t necessarily see an increase in [debt forgiveness and loan repayment] programs, but we have to make sure the programs we have stay funded.”
In the meeting with O’Neil, Dr. Forbush asked students to raise their hands if they expected to be $350,000 in debt when they finished medical school. Two students did, including Joseph Michael Anderson, OMS I, of the University of New England College of Osteopathic Medicine in Biddeford, Maine. The exchange prompted a conversation about how debt can impact medical students’ career choices. Students also said they worried that the federal Public Service Loan Forgiveness program would be canceled before they complete it.
“I have six more years of education between medical school and residency, and then 10 years of payment beyond that,” Anderson said after the meeting. “We’re looking at 16 years from now. I can’t make decisions based on a program that I’m hoping will remain in place for 16 years.”
It’s also hard to know what the GME landscape will look like in the coming years, Anderson said.
“Medical schools have been increasing their enrollments for the past several years,” he says. “And while the problem is not so clear right now, the number of graduates each year is increasing significantly. So 3.5 years from now when I graduate, it’s going to start being worrisome in terms of what’s available for us.”
Concern about the future of medicine led Anderson to DO Day, and he was encouraged by the receptivity of representatives and staffers on Capitol Hill to his and his colleagues’ concerns.
“My classmates and I were talking about it last night, and this experience pushed us all to want to be involved more in advocacy,” he said. “I’ll be back next year for sure.”