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International Medical Graduates, the Physician Workforce, and GME Payment Reform March 1998
It has long been the position of the Council on Graduate Medical Education (COGME) that the United States has too many physicians and these physicians are not appropriately distributed across medical specialties and geographic locations. In recent years the growth of managed care organizations has reduced the demand for physicians' services and magnified the size of the projected physician oversupply. To achieve a better balance between physician supply and demand and more appropriate distributions across specialties and locations, COGME has advocated three broad policy goals: (1) reduce the number of first year GME positions from 140 percent of the number of graduates of accredited schools of medicine and osteopathy to 110 percent; (2) encourage half the residents completing their training each year to enter primary care specialties; and (3) continue support for residency programs that provide care to substantial numbers of underserved people.
7,227
4,329
2,173
9,383
11,556
* This category includes IMGs on J-1, J-2, and H-1 B visas
Despite these recommendations, there has been continued growth, especially since 1990, in the number of GME positions. Some experts believe that this growth has been driven by an increasing demand for residents by teaching hospitals, fueled in part by Medicare payments for residency training, and an ample supply of IMGs to fill those positions.
With a nearly fixed number of U.S. medical school graduates entering GME each year, the marked increases in recent years of graduates from schools outside the U.S. entering graduate training in this country has been a major contributor to the increased number of residents. As shown in Table 1, most of the increase in the number of total residents since the 1988-89 academic year has been due to a large increase in the number of foreign-born IMGS. Many IMGs remain in the U.S. because they are permanent residents. Likewise, while IMGs on temporary visas usually return home when their visas expire, many ultimately return to the United States to permanently add to the physician workforce.
The increase in the total number of IMGs has been generated for the most part by the large number of foreign-born IMGs entering residency programs with temporary J-1, J-2, and H-IB visas as shown in Table 2. Past data have suggested that a high percentage of J-1 exchange visitors have ultimately returned to the United States. H-lB visa holders may become eligible for conversion to permanent resident status, through family- or employment-based petition.
As a result of the observed growth in the number of IMGS, it has been suggested that policies designed to curtail the influx of these trainees could be used to reduce the number of first-year physicians entering the workforce, and thus move toward the objective of reducing the number of trainees to II0 percent of the number of graduates of U.S. medical schools. In its Seventh Report, COGME recommended reducing Medicare payments to teaching hospitals for IMGs by 75 percent over a 4-year period. Both the Council on Medical Education of the American Medical Association and the Institute of Medicine also have advocated focusing Medicare GME funding on the support of U.S. medical school graduates.
However, after further examination of potential policies that would begin to reduce the size of the pool of trainees, including policies relating to IMGS, COGME has come to believe that a policy that restricts Medicare GME funding to USMGs would be fraught with potential legal complexities if it discriminates against IMGs who are either naturalized U.S. citizens or permanent U.S. residents. As a result, COGME has reconsidered its prior recommendations with respect to IMGs and developed new recommendations to the Congress and the Secretary of Health and Human Services.
The new recommendations are designed around two basic concepts: (1) modifications to the exchange visitor program; and (2) changes in financial incentives that would encourage hospitals to reduce their training activities. COGME recommends that the United States should continue to sponsor exchange visitor training in accord with the original intent of this program to strengthen international relations and further mutual understanding through educational and cultural exchanges.
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