While North Carolina continues to seek ways to fill medical provider voids across the state, government regulations block one partial solution.
Fred Jacobs, executive vice president at St. George’s University in the West Indies nation of Grenada, said a ready supply of international students is available. But students can’t get a medical residency needed for licensure, hospital privileges, and board certification.
The American Association of Medical Colleges largely blames a cap the Balanced Budget Act of 1997 imposed on the number of residencies. Also, residencies — formally known as graduate medical education — are mostly paid with Medicare funds. There are more medical school graduates than available positions, yet Congress has resisted raising the cap or the funding.
Fifteen percent of current North Carolina doctors earned their diplomas at international schools. International graduates are more likely than U.S. graduates to work in primary care specialties.
Shaivya Pathak of Goldsboro is an example. She is one of 14 St. George’s graduates who matched with a hospital in the state. Returning to eastern North Carolina to do her medical residency was a no-brainer for her.
“This was a state I loved. This is an area I love,” said Pathak, who graduated from the N.C. School of Science and Math and East Carolina University. “North Carolina made me who I am.”
Equally important to her roots, she said, is a heart for the people who live there. Health disparities can be life or death matters in places like Plymouth, Edenton, and other medically underserved parts of rural eastern North Carolina, Pathak said. Her parents sometimes wait months to get a medical appointment.
“The need is there, and I just want to be able to go back, and to help close the need” by eventually opening her own practice, Pathak said.
The 26-year-old native of India is one of 10 St. George’s graduates who matched with Vidant Medical Center at ECU. She starts training July 1 to become a primary care doctor.
St. George’s is the third largest provider of doctors to the U.S., but matches only 92 percent of its graduates. U.S. medical schools place 98 percent of graduates in residencies. Jacobs said hospitals are familiar with U.S. students, which skews competitive selections in their favor.
The vast majority of medical school graduates get a residency through the private, nonprofit National Resident Matching Plan. Its electronic application service ranks students, and hospitals make them an offer. North Carolina matched 792 graduates to its 835-resident quota this year through that method (Results on pages 99-101).
“We would of course like to have more students match into North Carolina because the quality of the programs are so good” at teaching hospitals like UNC and Duke, said Jacobs, former New Jersey commissioner of health, and ex-president of that state’s medical board of examiners that licenses doctors.
But with the cap on residency slots there is no place for them to train, and where a doctor trains is a strong determinant of where they will establish a career practice, Jacobs said. International medical school graduates practice at high rates in low-income, rural, and other underserved areas.
Bipartisan legislation known as the Resident Physician Shortage Reduction Act of 2019 has been introduced in both houses of Congress (H.R. 1763, S. 348). It would raise the residency ceiling and increase Medicare funding.
Jacobs supports adding a free-market component to the funding issue.
Private or personal funding can’t pay for a residency, even though he knows some medical school graduates could afford it.
“There are no residencies that are for sale,” Jacobs said. He added it’s probably a good policy given the current college admissions bribery scandal.
Teaching hospitals in some states fund 12,000 residency positions with clinical revenue instead of Medicare money, but those slots are in jeopardy because Medicare reimbursement cuts affected their finances.
St. George’s is working with some U.S. teaching hospitals to create new residency programs that would be exempt from the existing cap.
Creative funding to bolster the GME program could include insurance company contributions, Jacobs said. Insurers have no incentive to participate financially as long as government-funded Medicare pays for the program.
“The states are sovereign and independent. They could set up medical education programs that fund residencies,” Jacobs said. But even that would be subject to further government bureaucracy. State residency review committees must approve expanding the positions or else the program won’t get credit.
The Association of American Medical Colleges says medical school enrollment has increased by 30 percent since 2002. Yet its 2019 study found by 2032 the United States will have a shortage of up to nearly 122,000 physicians.
The association strongly supports the congressional legislation, which would add 15,000 Medicare-supported GME residency positions over five years.
The Senate bill is in the Finance Committee on which North Carolina Republican Sen. Richard Burr sits. His office referred questions to Sen. Bob Menendez, D-N.J., committee ranking member and the bill’s lead sponsor.
“There are currently no legislative hearings scheduled in the Finance Committee, but we are working to build support for the bill, and working to advance it,” a Menendez aide told Carolina Journal.
It is one of several bills targeting rural and community hospitals in medical professional shortage areas that exist in North Carolina and other states, the aide said.
The GME bill would award new positions to teaching hospitals using these priorities, in order:
1) Hospitals in states with new medical schools or new branch campuses.
2) Hospitals training above current GME slot caps.
3) Hospitals affiliated with Veterans Affairs medical centers.
4) Hospitals that emphasize training in community-based settings or hospital outpatient departments.
5) Hospitals not in a rural area, but operate an approved “rural track” program.
6) All other hospitals.