ARTICLE IN BRIEF
Academics involved with graduate medical education discuss the deleterious effects the recent round of sequestration cuts could have on neurology training and patient care.
It remains unclear whether the federal cuts, known as the sequester provisions, will have an impact on the number of neurology residency and fellowship training positions nationally. But most academics involved with graduate medical education (GME) agree that the 2 percent cut in Medicare reimbursements for GME — compounded by the 5 percent cut in funding for the National Institute of Neurological Disorders and Stroke (NINDS) — may jeopardize the ability of medical schools and teaching hospitals to conduct some cutting-edge research and train enough neurologists to care for an increasingly aging population.
Indeed, at a time when newly insured Americans receiving coverage under the Patient Protection and Affordable Care Act could flood neurologist offices, all concur that any potential reduction in training slots would compel neurology departments to re-examine their methods of delivering patient care.
PROGRAMS ARE ‘MAXED OUT’
Steven L. Lewis, MD, professor and associate chair of the neurological sciences department at Rush University Medical Center in Chicago, who directs the university's neurology residency program, said he suspects that “many, if not most, programs are already maxed out” in fulfilling service demands with their current allotments of residency positions, particularly given the higher acuity of patients hospitalized nowadays with neurological disorders.
Any decrease in residents would need to be offset by hiring nurse practitioners, physician assistants, and other physician extenders to maintain a balance between service and education, said Dr. Lewis, a member of the AAN Education Committee. Otherwise, he added, the result would be “a deleterious effect on residents' exposure to various other educationally important inpatient and outpatient clinical and even non-clinical experiences,” including electives.
The 2 percent cut in Medicare reimbursements from CMS [Centers for Medicare & Medicaid Services] adds “a real strain on the teaching hospitals' finances,” said Christiane A. Mitchell, director of federal affairs at the Association of American Medical Colleges (AAMC) in Washington. “We've already seen some large teaching hospitals look at whether or not they can afford the number of training programs they have in place right now.” Some teaching hospitals already have opted to eliminate an entire residency program in one or more specialties, she added.
THE EFFECT ON ACADEMIC RESEARCH
Susan E. Kirk, MD, associate dean for graduate medical education and designated institutional official at the University of Virginia Health System in Charlottesville, said the cuts to the NIH are especially worrisome. “Some of our residents and fellows are on training grants from the NIH, so there's a possibility that this may well be another direct cut to salaries and benefits,” Dr. Kirk told Neurology Today. “It's very unlikely that they will lose their jobs, but what may happen going forward is that those positions are closed.”
She noted that in anticipation of a physician shortage, new medical and osteopathic schools have opened, creating hundreds of additional slots for students to enroll in their programs. That's “the real big disconnect,” said Dr. Kirk, an associate professor of medicine and obstetrics and gynecology who is also trained in endocrinology.
“There will be fewer and fewer residency positions for those medical school graduates to train. It hasn't happened yet, but everyone predicts that the better students are the ones who will be hired into the available residencies, which will not be expanded with the looming cuts to funding,” she added. What would happen to the remainder of graduating medical students — those who end up without residency matches — is unknown at this time.
Henry J. Kaminski, MD, chairman of the neurology department at George Washington University in Washington, DC, said many departments are “already operating in the red or with significant subsidization from endowment support or directorships from hospitals.”
Cost-saving measures — in response to federal budget cuts over time (not just sequestration) — could include decreasing faculty pay, trimming staff, or turning away Medicare and Medicare patients. “The devil is going to be in the details of each program,” said Dr. Kaminski, president of the Association for University Professors of Neurology.
“Teaching hospitals may choose to support clinical specialties that contribute to margin,” he added. “Neurology is not considered a source of high revenue generation despite the numerous ancillary benefits for radiology, neurosurgery, etc. Therefore, if a teaching hospital decides to focus on service lines in orthopedics or cancer, it may consider reducing support for neurology and eliminating that educational program.”
Doing away with one, two, or three residency slots may not sufficiently compensate for cuts in funding. In addition to the cost of a neurology resident's salary along with fringe benefits — about $80,000 per year — there are other expenses associated with operating a training program. All programs are mandated to have a residency director to support education of the trainees, said Dr. Kaminski.
Allison Brashear, MD, professor and chair of the neurology department at Wake Forest University School of Medicine in Winston-Salem, NC, said that not being able to train enough neurologists to serve the aging population's anticipated needs is a big concern. “The volume of neurologists trained every year is insufficient to meet current needs, and decreasing the number of spots available will make it harder to train those interested if there are fewer positions.”
Thomas J. Nasca, MD, chief executive officer of the Chicago-based Accreditation Council for Graduate Medical Education (ACGME), surmises that some institutions may be more inclined to spare fellowship positions than residency positions. In the ACGME's 2011 study, fellowships were cut less frequently than residencies.
Neurology departments or their institutions often provide funding for fellowships “because they bring some special value in service delivery,” noted Dr. Nasca, who is board-certified in internal medicine and nephrology. For instance, stroke or epilepsy fellowship trainees could provide significant expertise to patients with particular afflictions. “Some of their funding may be in jeopardy for the research dimensions of their program.” A lot hinges, however, on a neurology department's or supervising clinical investigator's capability to compensate for the NIH cuts. “That would be an institutional decision,” he said. “It would not be in any way systematic, and so it is relatively unpredictable.”
What is predictable, according to Kapil D. Sethi, MD, director of the movement disorders program and professor of neurology at Georgia Health Sciences University in Augusta, is that a shrinking number of neurology residency positions would result in “fewer neurologists in the making.” While the competition for those scarce positions may become fierce, he said, attracting even better medical students, the overall impact would be negative. “There is already a shortage of neurologists in some areas,” he noted, and the quality of care would suffer if a neurologist is stretched thin while seeing more patients per day.
This is the third article in a series about the effect the sequestration cuts will have on neurology. Also see, “Sequestration Means Fewer Medicare Reimbursement Dollars for Neurologists: How to Lessen the Blow,” http://bit.ly/ZE9xZZ; and “Sequestration Cuts Threaten Federal Funding for Neurology Research,” http://bit.ly/PEdnS3.