IMG's and Workforce Policy: Steering or Drifting? By Herbert S. Sacks, M.D. APA President

Last year the federal government, after 30 years of supporting graduate medical education (GME), reduced Medicare's commitment to train new physicians by academic health centers. Many federal programs support GME, but Medicare is the largest source of these funds. Medicare provides direct medical education payments to hospitals that cover some of faculty salaries, residents' stipends, and administrative costs. Medicare also provides an indirect medical education sum that reflects added patient costs caused by teaching programs.

Hospitals have operated on the principle that the more residents there are, the greater the payments would be. In 1997 Congress changed the payment formula for indirect costs by providing less money to the hospitals and imposed a cap on the number of resident programs to be supported by both indirect and direct teaching payments. Why? From 1989 to 1996 there was an increase of residents in training of 26 percent, almost all reflective of an increase in international medical graduates (IMG's) entering U.S. training programs. In New York State, which trains the largest number of medical residents per capita in any state-15 percent to 20 percent of the nation's residents in all specialties-45 percent are IMG's; in New Jersey, 44 percent; in Connecticut, 30 percent; and in Illinois, 31 percent.

New York Demonstration Program

To stop further growth of GME, the Congress in 1997 capped the number of residents that Medicare would cover and found a new, strange way of counting residents to reduce the pain inherent in cutting positions. The statute gave teaching hospitals the opportunity to downsize residencies similar to the New York demonstration program recommended by the Greater New York Hospital Association to the Health Care Financing Administration (HCFA). In New York, hospitals participating will reduce the number of residents by 20 percent to 25 percent over five years, the bait being a declining percentage of reimbursements during the transition period. If after five years the hospital returns to the same number of the old positions, all the payments go back to Medicare. Please observe that in New York all third-party insurers paid $190,000 per resident, with Medicare alone exceeding $80,000 of that amount.

The New York demonstration program is silent on IMG training, but informed hospital administrations anticipated that more foreign than U.S. medical graduates would be affected by the reductions in numbers of residents. Many community hospitals, which can survive only with IMG residents, did not sign up with the project. Implementation of the demonstration program is so difficult that New York-Presbyterian and St. Vincent's hospitals have withdrawn from the program.

The program has come under attack by legislators in the Congress disagreeing that the U.S. had a physician surplus, claiming further that millions of Americans living in underserved areas would not receive adequate care. Repeal of HCFA's authority to continue the demonstration is in the Congressional winds.

New Federal Advisory Panel

A new federal advisory panel, the National Bipartisan Commission on the Future of Medicare, is going to review GME as part of preserving Medicare for the 76 million "baby boomers." Gail Wilensky, a HCFA administrator during the Reagan-Bush years and now chair of the Medicare Payment Advisory Commission (MEDPAC), points out that the government doesn't support graduate students in business, engineering, or the law.

Partisans and Proposals

The partisans in the workforce debate agree that there are too many physicians in the U.S., but many, including the AAMC, qualify that position by emphasizing the maldistribution problem. There is a range of proposals from different groups: The Institute of Medicine (IOM), the Council on Graduate Medical Education (COGME), the Pew Commission, the Kellogg Foundation, and the American Association of Medical Colleges (AAMC). The AAMC stated that there are not too many U.S. medical graduates, but that there are too many IMG's coming here for training. The AAMC has wanted to cut the available positions to 110 percent of U.S. medical graduates but is now awaiting the recommendations of Wilensky's MEDPAC, which will be a major determinant in U.S. medical graduate/IMG policy. The IOM report emphasized that the number of IMG's coming to the U.S. each year is equivalent to the graduating classes of 50 foreign medical schools, and 75 percent of those who come here for training remain here through marriage to U.S. citizens, naturalization, or being granted green cards.

To solve the alleged problem of too many medical specialists in this country, health policy wonks have supported a 50/50 ratio between primary care and specialists in training programs. But this assertion is based on German and U.K. projections for their own nations and were methodologically flawed, according to an article in the Journal of the American Medical Association 18 months ago.

In 1996-97 we had 1,221 PGY-1 psychiatry residents, of whom 44 percent were IMG's. With a 50 percent cut, we would have about 610 funded positions in psychiatry, which would drastically reduce the number of residency slots, close departments, and slash APA's membership rolls. Currently 25 percent of APA's members are IMG's.

IMG's Serve the Underserved

We have drifted into policy stances without adequate study and reflection. IMG's in psychiatry serve America in rural areas, inner cities, state hospitals and community clinics, and the corrections system. Can they be replaced by physician extenders, telemedicine, or generous loan-forgiveness programs designed for U.S. medical graduates in return for working in underserved areas? The workforce problems of psychiatry are no less in pediatrics and internal medicine, whose newsletters are redolent of these concerns.

Demographic Trends

Demographers predict, if the present trajectory holds, that the U.S. will cease to be a predominantly white nation. In March 1996 the Census Bureau indicated that by the year 2000, 70 percent of the American population will be white. By the year 2050, however, whites will account for barely 50 percent of the population, Hispanics 20 percent, African Americans 15 percent, and Asians 10 percent. Many Hispanic Americans are white, so these Census Bureau projections relate to a mix of racial and national origin groups.

On February 13 the National Center for Health Statistics reported that the numbers of babies born to Hispanic women in the U.S. rose to 18 percent of the total number of births, while currently Hispanic residents make up 10.3 percent of the population. More than 70 percent of babies born to Hispanic women in 1995 were born to Mexican Americans. As a result of high levels of immigration and a high birth rate, people of Mexican heritage are poised to become major economic, political, and cultural forces in the nation. Mexican Americans and indeed all Hispanic Americans need health care by doctors who are culturally sensitive and fluent in Spanish. The demographic tide, combined with APA's successful experiences with our Canadian district branches, has led us to explore the feasibility of a Mexican district branch.

African American and Hispanic physicians, notes a May 1996 New England Journal of Medicine article, have unique roles in caring for poor African American and Hispanic patients in California. Dismantling affirmative action programs will threaten health care for the poor and the minorities. An AAMC report suggested that IMG's do not commit to working in underserved rural areas or inner cities any more frequently than U.S. medical graduates.

IMG's in the Training Pipeline

The United States has a moral obligation to assist those foreign medical graduates in the pipeline of graduate medical education to complete their training in settings that provide opportunity to learn quality patient care and to avoid penalizing those currently practicing in the system.

APA recommends that for new entrants into the system, we provide an enhanced training process to deal with language and cultural barriers (cultural competence). At the same time, we underscore the need to evaluate the clinical skills of entering trainees. The Educational Commission on Foreign Medical Graduates (ECFMG) has developed a Clinical Skills Assessment (CSA) examination as a measure of clinical and interpersonal abilities, including spoken English, utilizing standardized patients (actors). The examinations will be given in Philadelphia beginning in July at a cost of $1,200. The debate has heated up with charges of discrimination (Psychiatric News, March 6). It is likely that the CSA will diminish the IMG pool available for residency training.

The New England Journal of Medicine in December 1995 ran a series of letters addressing the affirmative action and meritocracy arguments. The general view was that residency programs should admit the best qualified candidates for available positions to supply the public with the finest doctors possible. Indeed some U.S. medical graduates might be displaced if this view was widely accepted.

With our present system of psychiatric health care delivery inclusive of training, financing, and distributional considerations, U.S. psychiatry will always need IMG's. Remember, those IMG's in practice, in academe, and in the pipeline of training are colleagues, good friends, teachers, students, and researchers. Discrimination based upon race, gender, ethnicity, religion, and national origins is abhorrent to us. However, do we have the same responsibility for every medical graduate of the more than 1,300 medical schools in the world that we have to all physicians being trained here or who are practicing here? I think not. What do you think? Fax me at APA at (202) 682-0432.

Given the swift workforce developments, APA has an obligation to expeditiously examine and refine our policy positions so that they are responsive to the unique psychiatric needs of our people and become more consonant with those of the other 23 medical specialties. We must steer; we cannot afford to drift or hasty planning will become disintegrative, our collegial relations will become fractured, educational programs will be eliminated helter-skelter, service delivery will be compromised, and our highly vaunted research establishment will be gradually disarticulated.