What lies ahead for emergency physicians?

An interview with
John C. Moorhead, MD
Professor of Emergency Medicine
Oregon Health Sciences University
Portland, OR

Editor's note: On the frontier for emergency medicine is what staffing will look like in a difficult payment environment. John C. Moorhead, MD, has devoted most of his career to workforce planning. The questions he's raised have been pertinent: Will the current workforce be sufficient to meet future demand? How will emergency medicine survive the shocks of reduced funding and falling reimbursement? How will this affect residency training? Aside from being a teacher and physician, Dr. Moorhead is president-elect of the American College of Emergency Physicians in Irving, TX. His milestone research on workforce planning in emergency medicine will be published this spring.

MCED: Your work has focused greatly on workforce planning in emergency medicine. Is it true that a shortage exists in the specialty?

Moorhead: On the supply side, there is a belief that emergency medicine is a shortage specialty. I think most of us believe that as a specialty we're doing quite well. We're attracting top-notch people. The literature and national surveys appear to bear this out. Repeatedly, they show that our residency programs are filling up at the highest levels of U. S. medical graduates.

But, when you go around the country, you get the feeling from talking to people in the field that things are tightening up a bit. It think it's a good idea to want to get ahead of that tightening-up process. It's one of the reasons we thought we'd study the data and draw some conclusions from them.

MCED: What's responsible for that perceived shortage?

Moorhead: We've expanded the number of residency programs and the number of residents training in emergency medicine at a faster pace than any other clinical specialty. Keep in mind, we've only been in existence as a specialty for about 20 years, and we've seen the number of graduates at entry-level positions expand at a rapid rate.

We've filled up an awful lot of metropolitan areas. Now, we're seeing that when graduates complete their residency training they're entering less populated areas. From the trend, we can conclude that residents are looking more broadly for opportunities. The research is trying to determine whether this pattern will continue, whether demand is in fact exceeding supply.

We know that most physicians entering the specialty today are coming directly from our training programs. In the past, physicians were grandfathered into the specialty. They trained in other specialties and migrated into emergency medicine. At this point at least, we know that the supply side is dominated by products of our training programs.

MCED: What role has managed care played in shaping this trend?

Moorhead: We've changed the focus of many residency program as the venue for the delivery of medical care has shifted from inpatient to outpatient. The areas of high penetration of managed care have been at the forefront of moving the focus of much of our training.

The vast source of revenue that supports graduate medical education comes from Medicare. With the transformation of a great deal of Medicare to managed care plans, the funding has undergone considerable change. Payments are now going wholesale directly to the plans, and the plans are negotiating what they will pay hospitals. It's become pretty clear that not all of the funding intended to support residency programs is getting through to the sites that were supporting that training.

The recent Balanced Budget Act of 1997 addresses that problem. If policy makers hold to their word, the funding for graduate medical education (GME) will be carved out in a mechanism that will ensure that the payments get through to the training sites.

Of course, we aren't assured of anything. But most people are pleased to see that the inclusion of language in the act was a realization that something had to be done.

MCED: Does managed care contribute to the problem of threatened funding for residency training?

Moorhead: I don't think we can make a blanket statement of that. But indirectly the answer is yes. There has been a failure by some managed care plans to recognize emergency medicine for the medical specialty that it provides and its potential to be cost-effective. Many of these plans are simply focused on the bottom line and seem preoccuppied with directing patients away from emergency departments (EDs).

That's unfortunate, because most people, including patients, feel that the care delivered in the ED is extremely efficient both from a time and cost standpoint. People look to emergency physicians knowing that the type of work they're involved in lends itself to providing a broad range of services. But few realize that public good that is derived from training programs and their cost. It's unfortunate that too many MCOs fail to see this.

MCED: Then should managed care shoulder part of the burden of subsidizing GME?

Moorhead: I believe it's very fair and appropriate to expect this. Health plans benefit directly from education. Therefore, they should contribute to the funding. But providers should remember that "He who pays the bills, calls the shots." If managed care plans are going to contribute to the funding of our training programs, they will and should demand some accountability for how those funds are expended. Providers need to consider the implications of this proposition before acting.

MCED: But is it realistic to get them involved when they're unwilling to cover a hospital's fixed costs?

Moorhead: No, it's very appropriate to get them involved in education funding. Physicians should at least put the issue on the table. The mechanism for doing so and what the health plan industry will expect in return will have to be carefully determined. On the other hand, I don't think it's fair for us as a society to ask that managed care do more than its share.

Health plans should contribute in a way that recognizes the benefit they derive from these training programs. But they shouldn't be asked to shoulder the entire burden of residency funding. It isn't right for Medicare to subsidize the enter system either.

MCED: Are there any efforts under way to do this?

Moorhead: Again, I think we can look at developments in Washington for these signs. The language of the Balanced Budget Act and the Medicare commission that's been set up to determine the future of the Medicare program has started to raise the point. I think we'll be seeing specific recommendations before long on the future of GME funding. Many of us are encouraged that these issues are being discussed.