TED SIMONS: A new report was released today about the value of graduate medical education to Arizona's economy and its health care system. Here to talk about the report is Suzanne Taylor, executive director of the Arizona Chamber Foundation, Dr. Michael Grossman, associate Dean of graduate medical education at the U of A College of Medicine, Phoenix. He is also president of academic affairs for Maricopa Integrated Health System and Dr. Michael Whitcomb, a Flinn Foundation Medical Innovation Visiting Scholar at the University of Arizona. Good to have you all here. Thank you so much for joining us.
SUZANNE TAYLOR: Glad to be here.
TED SIMONS: Kind of at the bottom of all this is the fact that Arizona is behind the national average in terms of having fewer physicians and fewer residents. Why? What's going on out there?
SUZANNE TAYLOR: Well, that's right. Arizona's population has grown so quickly over the past several decades that we’ve really focused on attracting doctors from other states to come here as the primary means for building our physician work force. But more recently, our state realized that we need to focus on growing our own. So we have actually made some great progress in the last decade or so in terms of increasing the number of medical students at both our public and private universities. Where we still have a big gap is that next step in the training process, which is residencies or graduate medical education. And that's the area that we need to focus if we are going to get those physicians all the way through their training and have them practice here. The reason that's so important is because the location of a doctor's residency is one of the biggest indicators of where he or she will end up practicing medicine.
TED SIMONS: And the idea of Arizona having more physicians, having more residents just having more people in health care, it's important because we have an aging population, we have obesity, a lot of things are coming down the pike.
MICHAEL GROSSMAN: We have a tremendous amount of populations that are underserved at the present time. And there are multiple medical problems that exist in these populations that are not being addressed or answered. And I think one of the other issues that we haven't really paid a lot of attention to is the fact that our physician population is aging also. And even though we know what the ratio is of the numbers of doctors in Arizona compared to the--at per hundred thousand population compared to the national average and we are below the national average; not many doctors are working the full-time hours that they used to. Doctors work 60 to 70 hours a week. Many of them are not doing that anymore, so even though we have low numbers, we are also having lower office hours that are available.
TED SIMONS: Something else that's ahead is the affordable health care act and the stipulations therein. Primary care physicians would seem like a biggie because more cost effective. Is that correct?
MICHAEL WHITCOMB: Well, it depends on what's wrong with the patient in terms of who the physician ought to be, and what particular skills they ought to bring to the process of taking care of the patient. I think that there's a general trend in thinking that we need to change the healthcare delivery system in a way in which patients who go to a physician for their primary care with their initial contact, ongoing contact, simply aren't referred to a bunch of other physicians for the problems they have. And that tends to be a very common form of practice at the present time. So we need to increase the efficiency with which we are taking care of patients, and we need to be sure that we are training physicians who want to go into primary care practice in a way that they will continue to take care of patients with complex problems.
TED SIMONS: And when we talk about graduate medical education, define the term. Define the phrase.
SUZANNE TAYLOR: It's essentially synonymous with a residency program. So it is that next phase that a physician goes to after they have completed four years in undergraduate college, another four years in medical school. They select a specialty to go to so those residency programs can generally last anywhere between three and seven years.
TED SIMONS: And the idea of getting more money to help these particular residents it's there, it's pulled away, it comes, it goes. The report seems to suggest you need a dedicated funding stream here somehow.
MICHAEL GROSSMAN: That's very true. Particularly since our numbers are really below what they need to be for the numbers of people who are training. We are going to have to be able to be funding new spots in each of the residency training programs throughout the state and a dedicated stream of revenue to do this. It's an expensive proposition because it's not just the resident and a salary which is fairly low for them. It's the infrastructure that goes with the need for medical education. You need people who are teachers, you need resources, you need electronic resources. You need all kinds of materials for learning that the residents must have and the patient populations they deal with.
TED SIMONS: Has that requirement changed over the years? Because it seems as though we haven't heard a heck of a lot about graduate medical education being a problem until recently, and now the funding seems to be a big problem. What's happening?
MICHAEL WHITCOMB: Well, there are two things that are happening which really makes this a much, much more serious problem than in the past. The first is that the single largest source for funding for graduate medical education is the Medicare program. In 1997, the Congress established caps on the number of residents that they would fund so that if an institution, let's say, arbitrarily, had 100 residents in 1996, they could add residents if they wanted after 1997, but Medicare would not contribute to the cost of the additional residents. And so that cap has put a lot of pressure on teaching hospitals in terms of where do they get the money to help increase, increase the payment of the total cost of graduate medical education that might mention? The second thing though is that the country as a whole is facing a shortage of physicians--a significant shortage of physicians, projected it will be by 2025 well over 100,000 physicians, and therefore while the cap was not viewed as seriously 15 years ago, now that we are facing a shortage of physicians and the only way we can deal with that is to increase the number of residents, the cap now makes a huge difference in terms of the ability to meet that challenge.
TED SIMONS: You see that as well?
MICHAEL GROSSMAN: I absolutely do. And I think one of the things that Dr. Whitcomb pointed out is this incredible pool of physicians because we were a major importer from other states. Well, the shortage is nationwide. And so we are in competition with the states where the residents are training. So we are not getting those people coming here in the way we used to, so we really do have to do more in-state training.
TED SIMONS: To do more in-state training you need more money. Talk about ideas out there? I have read everything from the lottery, to aviation fuel taxes, providers, the whole nine yards, what's the thought process out there? What are you hearing and what's viable?
SUZANNE TAYLOR: That's right. A couple of things are important to think about: Any dollars that the state puts into this trigger $2 from the Federal government. Up until two years ago, Arizona was funding graduate medical education and receiving that double match. During the budget deficit, the State made difficult decisions. One of those was to completely eliminate that funding. So that's the other reason that's particularly critical to think about some other potentially more stable sources.
TED SIMONS: Give us an example. What could be potentially more stable?
SUZANNE TAYLOR: There's a number of possibilities. One that you threw out there was a provider assessment. That's a topic that's been discussed for some other pieces of our health care system. But that's essentially where hospitals would contribute the funds themselves in order to draw down those matching funds. So that is one possibility. There's several other ways to approach it as well. Another innovative idea that we found looking at some other states was to take the portion of the income tax that's generated by net new jobs in the health care field and dedicate that towards graduate medical education.
TED SIMONS: Are those ideas, though, viable with the particular legislature here in Arizona that may not be as open -- it took away the money to begin with--the matching funds to begin with, so the general fund is out there in the field all on its own. How viable are these ideas and how do you get the point across that something has to work eventually?
MICHAEL WHITCOMB: I think that's really one of the big, big, big challenges is that the individuals who are responsible for crafting legislation have a whole host of challenges to deal with. And to be quite frank, their understanding of the nature of this challenge and how to deal with it is not as good as it could be and should be. And part of what needs to be done is to educate them and to begin the process of getting people to understand this is a critically important issue as you look forward. I think that's one of the great, great, great values of the report that came out today. Members of the community, those of us in academic medicine and Mike, when we say things like this, it sort of sounds like self-interest. But when it comes from other organizations that aren't in that position, I think it gets a little bit more attention. And it should. It's very, very critically important.
TED SIMONS: Why isn't that message getting across?
MGG: That is a wonderful question. I think that it's kind of ethereal because it's all part of the training process, and people don't really understand what it takes to create this. They see a resident running around the hospital looking at patients, and they don't understand that there's a curriculum, that there are standards that must be met, that we really have to produce the end product, which is a physician capable of practicing a specialty without the need of supervision on their own and capable of making appropriate decisions. There's a lot of work that goes into that, so there's an expense that follows it. And it's very easy to overlook that. So I think this report that came out today could be the nidus of a real movement afoot to educate the public and educate our state legislators to the fact that this is something we have to deal with.
TED SIMONS: And last point here: let's be clear that there is an economic impact of having physicians and residents in the state, and there's also an economic impact in knowing that businesses transferring or thinking of relocating know that the health care system is up to snuff.
SUZANNE TAYLOR: That's right. That's one of the reasons as the State Chamber of Commerce representing businesses of all sorts, that we saw this as an important issue for business attraction and retention. Plus the fact that as a State, we are now on a recovery trajectory, and we are at a point when we can think a little more broadly about, what do we really need to build the future that we all want? And this is a part of it.
TED SIMONS: Well very good, it's good to have you all here. Good discussion. Thank you for joining us. We appreciate it.