Author + information
- John Gordon Harold, MD, MACC, President, American College of Cardiology∗ (, )
- Patrick T. O'Gara, MD, FACC, ACC President-Elect,
- Joseph A. Hill, MD, PhD, FACC, Co-Chair, ACC Academic Section Advisory Council and
- Marvin A. Konstam, MD, FACC, Co-Chair, ACC Academic Section Advisory Council
- ↵∗Address correspondence to:
John Gordon Harold, MD, MACC, American College of Cardiology, 2400 N Street NW, Washington, DC 20037
Cardiovascular medicine is experiencing a confluence of events that pose a significant threat to the future health of the nation. By 2030, it is predicted that more than 40% of adult Americans will have some form of cardiovascular disease. In addition, current projections indicate a 25% increase in the prevalence of both heart failure and stroke over the next 20 years—a result of an aging U.S. population (1). To make matters more complicated, an additional 30 million Americans will be seeking healthcare services beginning as early as next year as a result of the Affordable Care Act (2).
Meanwhile, according to the Association of American Medical Colleges (AAMC), a shortage of 62,900 physicians is expected in the United States by 2015, and this number is predicted to increase to 130,000 physicians across all specialties, including cardiology, by 2024 (3). The chances of reversing this negative workforce trend to meet the country’s growing health care demands are slim in the current environment, given what can be deemed as nothing less than a “perfect storm” of converging factors—draconian cuts in support for research, impending cuts in support for graduate medical education (GME), and declines in reimbursement for clinical activities. Not only are these factors slowing the pace of advances in medical science and healthcare delivery, but they are also limiting opportunities for the next generation of cardiologists and other health care professionals at a time when we need them the most.
The number of available residency training programs funded by Medicare is already capped as a result of the Balanced Budget Act of 1997, and an additional $11 billion in federal funding cuts over the next 10 years is included as part of the Obama administration’s proposed budget for the 2014 fiscal year. While several medical schools are expanding enrollment to meet future needs, these caps on Medicare GME funds and massive proposed cuts are leading us down a path where soon (i.e., by 2015) medical school graduates will exceed the number of available residence slots. This year alone, 528 U.S. medical graduates did not match into a residency program—more than double the number from 2012. According to the American Medical Association, this occurred “despite the fact that 99.4% of the available residency slots were filled—the highest percentage ever” (4).
Beyond the potential loss of Medicare’s direct support for GME, also threatened are indirect medical education payments (reimbursing teaching hospitals for providing unique and costly clinical services), disproportionate share hospital payments, and hospital outpatient department payments. The nation’s 300 major teaching hospitals not only provide the vast majority of GME, but also provide over one-third of all hospital charity care, and they house the vast majority of U.S. burn units and level 1 trauma centers. Yet, these academic centers, which account for >25% of Medicare spending, are at disproportionate risk for well over one-half of potential Medicare cuts (5). There can be no doubt that these cuts will decimate the nation’s medical education and academic research enterprise and place vulnerable populations at severe risk.
In a recent update on the state of academic medicine, the American College of Cardiology’s Academic Section Advisory Council said it best when they called this a crisis that is both urgent and complex. In addition to training the next generation of physicians, nurses, and other healthcare professionals; encouraging the world’s best and brightest students to enter into a medical career; and meeting the needs of a growing and aging population, teaching hospitals and their residents perform vital services to underserved communities and populations, as well as veterans and their families. In addition, on the global front, international graduates comprise nearly 27% of medical residents and fellows in the United States. Many of these residents are interested in much-needed primary care specialties and work in underserved communities within large cities or in rural areas.
Few recognize the full scope of the forces now colliding to threaten the survival of the academic medical enterprise. Without quick action, the future of medicine and the future of the ACC as a recognized leader of healthcare science and education are at stake. To that end, the College is working closely with the AAMC and the American Medical Association to support legislation in both the U.S. House of Representatives and the U.S. Senate that will help residency programs across the country train enough doctors to keep up with the expanding and aging Medicare population.
Both the bipartisan Training Tomorrow's Doctors Today Act (6) and the Resident Physician Shortage Reduction Act of 2013 (7) in the House, as well as the Resident Physician Shortage Reduction Act of 2013 (8) in the Senate, would lift the cap on the number of Medicare-supported residency positions. They would also increase the number of residency positions that receive support through Medicare GME payments by 15,000.
The College is also supporting the AAMC’s overarching workforce policy recommendations (9), which include:
• Increasing the number of federally supported GME training positions “by at least 4,000 new positions a year to meet the needs of a growing, aging population and to accommodate the additional graduates from accredited medical schools.”
• Continued federal investment in delivery system research and evidence-based innovations in healthcare delivery.
• Educating lawmakers about the need to not only expand support for GME, but also leverage clinical reimbursement and other mechanisms to achieve geographic distribution of physicians and influence specialty composition.
• Targeting funding for new residency positions based on “population growth, regional and state-specific needs, and evolving changes in delivery systems.”
The scope of the GME crisis is enormous, and the impacts if we do nothing are far reaching. Not only will patients be limited in their access to cardiovascular care, but our current and future trainees both nationally and abroad will be unable to move forward in a profession in which they are desperately needed. An entire generation of bright and ambitious physicians who wish to contribute to patient well-being through clinical care and discovery of new medical knowledge is gravely threatened.
We must act now and we must act together, both as a profession and as part of the broader medical community. Not only do our lawmakers need to hear from us about the very real impacts of continued cuts to the states and communities they represent, but we must also take a hard look at current processes in the new healthcare environment to see if there are opportunities to streamline education and training; better involve primary care physicians and other members of the care team; and/or organize the way teaching hospitals and residents conduct research and provide care. No one is immune to the problem, but thankfully, there are very real solutions if we choose to act together.
Note: Funding for graduate medical education is only one element of the “perfect storm” facing the house of medicine. Dramatically declining funding for medical research also poses significant threats to the prevention and treatment of cardiovascular disease. Stay tuned for a future President’s Page on this critical topic.
- American College of Cardiology Foundation
- Heidenreich P.A.,
- Trogdon J.G.,
- Khavjou O.A.,
- et al.
- ↵White House. FACT SHEET: The Affordable Care Act: Secure Health Coverage for the Middle Class. Available at: http://www.whitehouse.gov/the-press-office/2012/06/28/fact-sheet-affordable-care-act-secure-health-coverage-middle-class. Accessed August 27, 2013.
- AAMC Center for Workforce Studies I
- American Medical Association
- Umbach Tripp
- ↵Training Tomorrow's Doctors Today Act, H.R. 1201, 113th Cong. (2013).
- ↵Resident Physician Shortage Reduction Act of 2013, H.R. 1180, 113th Cong. (2013).
- ↵Physician Shortage Reduction Act of 2013, S. 577, 113th Cong. (2013).
- Association of American Medical Colleges