Pieces of the Solution: Residencies

While there’s general acknowledgement that increasing the number of residencies in the state is key to addressing the shortage of physicians, the profession hasn’t always been eager to expand the ranks of physicians.

About 40 years ago, concerns about a doctor surplus spooked federal policymakers and the health care community. In 1980, the Graduate Medical Education National Advisory Committee — a panel convened by the U.S. Department of Health and Human Services — warned that the country would have 70,000 more doctors than it needed by 1990 and a surplus of 145,000 physicians by the year 2000. The panel, which predicted that HMOs and managed care would shrink the number of doctors needed and failed to recognize a growing demand for increasingly technologically sophisticated and intensive care, recommended that medical schools limit enrollment and that the federal government limit the entry of foreign medical graduates into the U.S. The report concluded that residency positions also would need adjustment.

The advisory committee’s conclusions — however wrong — became prevailing wisdom and led to moratoriums on new med schools. Medical schools also froze enrollment, says Robert Orr, a policy analyst at the Niskanen Center. Congress capped the number of Medicare-funded residency slots it pays and froze funding at 1996 levels.

Changing directions

Florida has since made notable efforts to break the logjam, with state lawmakers increasing spending for residency slots by using Medicaid dollars, amounting to $197.3 million annually. Last year, the state’s $97.3 million Medicaid Residency Program funded 6,431 residencies — an average of $15,130 per resident — and Florida’s Graduate Medical Education Startup Bonus Program funded 228 new residency positions at 15 hospitals at $100,000 apiece. The remaining $77.2 million from the $100 million of the Startup Bonus Program went toward 2,991 existing residency slots in high-need specialties.

All told, hospitals have roughly doubled the number of residency slots in the state over the last six to seven years — but they’ll need to pick up the pace to keep up with the flood of physician retirements.

“When you think about the number of years that a residency takes, and you think both about medical school and the people you would like to be a board-certified specialist in 2035 — those people are right now freshmen in college,” says Justin Senior, CEO of the Safety Net Hospital Alliance of Florida, which is advocating for a $38-million bump in Medicaid residency funding in the state. “You really have to think about expanding the offerings now, so that six or seven years from now, they’re going to have a residency spot when they graduate from medical school.”

In Polk County, home to Lakeland Regional Health, there’s only one primary care doctor for every 2,080 residents. By comparison, neighboring Hillsborough County has one primary care provider for every 1,210 people. The shortfall in Polk has contributed to Lakeland Regional Health Medical Center having one of the busiest emergency departments in the nation, with more than 190,000 patient visits annually.

Lakeland Regional, which operates a 864-bed hospital between Tampa and Orlando, plans to launch its first residency program next year. The program aims to top out at 190 residents within five years. “We already experience a severe physician shortage here in Polk County, and we felt that one way that we could address it was by allowing the organization to become a teaching hospital,” says Danielle Drummond, president and CEO of Lakeland Regional Health.

“We’re hopeful they’ll get to know our community and our organization and choose to stay local when they finish their training and hopefully establish here as practicing physicians once their time in their training program is complete,” says Drummond.

Lee Health — which operates four acute care hospitals and two specialty hospitals in Lee County — has achieved promising results with a family medicine residency program it launched in 2014. As of 2022, more than two-thirds of the physicians who graduated from the program (27 of 40) remained in Florida and 24 (60%) are practicing in Lee County.

To build on that success, Lee Health is launching an internal medicine residency program at its Cape Coral Hospital. Dr. Maja Delibasic, program director for the new residency program and an associate professor of clinical sciences at Florida State University College of Internal Medicine, says she was “very pleasantly surprised” with the response to the program. “We received more than 1,000 applications in 24 hours,” she says, and 250 candidates from the pool earned interviews for 12 slots.

Deep pockets

The biggest expansion in residency slots over the past decade has been at HCA Healthcare, which operates 49 hospital campuses and more than 450 sites of care in Florida. In 2012, the Nashville-based chain oversaw three residency programs in the state. This year, more than 2,000 residents are training in 122 Florida programs, and the for-profit company plans to have 170 residency and fellowship programs by 2029.

The new programs will bring total enrollment to 2,867 residents and fellows — “so that’s a lot of calculated and intentional effort to address the shortage,” says Dr. Monique Butler, chief medical officer for HCA Healthcare’s North Florida division.

The company’s deep pockets have helped. “Developing new residency programs requires hospital and financial resources, and HCA Healthcare has both,” Butler says. “Other health systems had capacity to increase the number of their residency programs, but only HCA Healthcare was positioned to increase graduate medical education residency slots on a large scale — adding thousands of residency positions for Florida. Our ability to scale and use the resources we have in place helps us with the cost.”

There are incentives for HCA and other systems with new residency programs to grow their training programs as quickly as they can. Hospitals without existing residency training programs are eligible for Medicare GME residency funding for as many slots as they create. But the clock starts ticking as soon as the first resident shows up for work, and Medicare will only pay for the number of residency slots the program has in place at the end of the program’s first five years, effectively capping the program at that number.

Those caps have made it harder for many of Florida’s traditional teaching hospitals to expand their training rosters, forcing them to pay for additional positions themselves or tapping into state funding. Florida’s Medicaid Residency Program, created in 2013, provides $97.3 million annually to help pay for residency slots at hospitals across the state, but as the Safety Net Alliance points out, the program has been a “victim of its own success” — with residency slots growing faster than funding for the program.

Hospitals creating new residency slots can also qualify for one-time grants of $100,000 per resident for each position they create in a high-need specialty area through the state’s Graduate Medical Education Startup Bonus Program. The state program has provided $400 million for 1,113 residency positions since 2017, according to FLORIDA TREND’S analysis of state records.

Graduate Medical Education

• 64% of the 8,962 individuals who completed residency training in Florida over the last decade are still practicing medicine in the Sunshine State.
• 3,255 of 10,695 physicians (30.4%) who completed a residency program in Florida over the past decade are practicing in medically underserved areas of the state.
• Florida has 34.9 medical residents per 100,000 people. New York has nearly three times (98 per 100,000) that amount.
• Florida had 7,608 residency and fellowship slots in 2020-21 — a 30% increase over the previous five years.

Public Support

• Together, Medicare and Medicaid account for roughly 90% of taxpayer funds spent on graduate medical education.

Residencies

The federal government doesn’t dictate the number of residency slots a hospital can have — but it does limit how many it will pay for through Medicare, and the program pays most teaching hospitals for the same number of slots they had in 1996. There are some exceptions to the caps: Rural hospitals can adjust the caps if they launch a resident training program, and urban hospitals can also adjust slots upward if they start new programs in rural settings. Hospitals with three or fewer residents can also grow their programs, and Medicare gives hospitals starting their first residency programs five years to grow before subjecting them to caps. In 2018, Medicare, the principal source of funding for the majority of the nation’s residency positions, provided $15 billion in residency funding to 1,319 teaching hospitals across the country — an average of $11 million per hospital and $171,000 per trainee (though it varies by hospital), according to a 2021 report from the Government Accountability Office. The report found that 70% of U.S. hospitals are training more residents than Medicare is funding.

Residency Funding — Fits and Starts

• 1997 — Based on inaccurate perceptions of an oversupply of physicians, Congress passes the Balanced Budget Act, capping the number and geographic distribution of Medicare-funded residencies as part of an effort to rein in health care spending.
• 2005 — Warning of an impending physician shortage, the Council on Graduate Medical Education recommends a 15% expansion in medical school enrollment by 2015. The following year, the Association of American Medical Colleges calls for a 30% increase in medical school enrollment by 2019.
• 2013 — Gov. Rick Scott and the Florida Legislature create and fund the Statewide Medicaid Residency Program, providing $80 million for residencies at hospitals with accredited residency programs.
• 2015 — The Florida Legislature appropriates $100 million for a new GME Startup Bonus Program, providing one-time grants (of $100,000 per resident) to qualified hospitals creating new residency positions in high-need specialties.
• 2017 — Rick Scott and the Legislature bump annual Medicaid Residency Program funding up to $97.3 million.
• 2020 — Congress passes legislation authorizing 1,000 new Medicare-supported medical residency positions — the first increase in 25 years. The new slots will be phased in at a rate of 200 per year beginning in 2023, with priority given to teaching hospitals in rural and underserved regions, hospitals in states with new medical schools and/or branch campuses established after Jan. 1, 2020, and hospitals training residents that are over their cap. The investment will total $1.8 billion over the next decade.
• 2021 — State funding remains static at $97.3 million for the Medicaid Residency Program and $100 million for the Startup Bonus Program.

Pieces of the Solution: Technology

The patient was ready for discharge, but the hospitalist was quarantined and couldn’t make it to the patient’s bedside — not in person, at least. Instead, a cart was rolled into the patient’s room, and the doctor examined the patient virtually. “There were no hiccups, no delays in that care, and they were able to still see their patient, do the follow-up and get them discharged sooner,” says Lauren Faison-Clark, administrator of regional development, population health and telemedicine at Tallahassee Memorial HealthCare.

Virtual rounding, as it’s called, has existed for a while but use of it skyrocketed during the pandemic. With a digital otoscope, doctors can peer into their patients’ ears. If doctors need to listen to a patient’s heart or lungs, they can pop in earbuds and listen to the beats and breaths that the digital stethoscope picks up.

The technology also enables patients at rural hospitals that aren’t part of TMH to get virtual consults with TMH specialists, such as cardiologists or neurologists — saving time and money and getting patients critical care when and where they need it. “People want to be close to home when they’re in the hospital. They don’t want to be in Tallahassee if they live in Franklin County. They want to be close to their family and their friends and their faith. If we can be there by simply having a couple of virtual consults to (connect them with) the specialist they need, that’s better for everybody and ultimately lowers the cost of that care,” Faison-Clark says.

She believes similar collaborations might help address the looming doctor shortage. “By figuring out what clinical care (hospitals in shortage areas) have and what we can supplement and developing a partnership, it’s really better for everybody, including larger facilities, because many times we’re at capacity, and we can’t accept that patient transfer. You really have to depend on those relationships and creative models.”

Pieces of the Solution: Non-Physicians

Non-physician providers — such as nurse practitioners and physician assistants — could help offset doctor shortages over the next decade, especially with recent expansions to their scopes of practice. In 2020, the Legislature enacted a law allowing nurse practitioners to operate primary care practices without physician supervision. Last year, the Legislature increased the number of physician assistants a doctor can supervise from four to 10 and removed the requirement that a PA tell a patient they have a right to see a doctor prior to the PA prescribing or dispensing a medication, among other changes. And Florida’s certified registered nurse anesthetists are also pushing for fewer supervision requirements, sparking a turf battle with the state’s anesthesiologists. The good news — Florida’s supply of nurse practitioners will nearly double by 2035, according to data analysis firm IHS Markit’s report, creating an abundance of 10,765 professionals in primary care and non-primary care. The report predicts a 746 shortage of nurse anesthetists in 2035 and a 381 shortfall of nurse midwives.

Pieces of the Solution: Expanding the Pipeline

Already, about a third of all physicians in Florida are trained in overseas medical schools, and schools in the Caribbean islands have emerged as a major source of doctors for both Florida and the nation.

In 2021, for example, more than 120 graduates of St. George’s University, located on the island of Grenada, matched into residencies in Florida. The school, founded in 1976, has sent more doctors into U.S. residencies over the past 11 years than any other medical school, making it the largest source of new doctors for the U.S. Seventy-five percent of the school’s graduates go into primary care, and they’re twice as likely to practice in an underserved area and provide services to Medicaid patients.

Over the past five years, 533 graduates of Ross University School of Medicine in Barbados and American University of the Caribbean School of Medicine in Sint Maarten have landed residencies in Florida. More than 1,300 of Florida’s licensed physicians are graduates of the two schools.

The institutions often get a bad rap for having lower bars to entry, hefty price tags and high attrition rates. Quality can vary considerably among the 60 or so offshore schools that exist today. “Has there been a stigma against Caribbean medical schools? Absolutely, historically — but we’re trying to change that, and we want it to be an afterthought,” says Dr. John Danaher, president of the division of Adtalem Global Education that oversees Ross University and the American University of the Caribbean School of Medicine.

Danaher and others say that beyond simply adding to the overall numbers of doctors, schools such as St. George’s and Ross are producing exactly the sort of doctors the nation needs — primary care specialists willing to work in low-income and medically underserved areas.

Danaher says about 72% of U.S. medical schools graduate 10 or fewer African-American doctors each year, while his schools turn out more than 100. Nearly three-quarters of the schools’ graduates go into primary care.

“Don’t look to us to turn out the Palm Beach dermatologists,” Danaher says. “What we turn out are those physicians committed to underserved areas, urban and rural, who are focused on serving primarily low-income communities because, quite frankly, our students and our graduates often come from those communities themselves.”

Danaher says the schools are eager to help Florida grow its physician population and has the capacity to do so, but the effort depends ultimately on the availability of residency slots where med school grads complete their training.

Approximately 59% of the 5,295 U.S. citizens graduating from foreign medical schools were offered first-year residency slots in 2021, according to the National Resident Matching Program, which oversees the match process. By comparison, 92.8% of graduates of U.S. medical schools who applied landed a residency slot.

The match rates are higher at some of the better-known Caribbean medical schools. Ross University and American University of the Caribbean School of Medicine, for instance, both had a 92% residency placement rate in 2001, and St. George’s University says that 93% of its eligible U.S. graduates who applied for U.S. residencies obtained one upon graduation over the last three years.

“The more residency spots that get opened, the more they’re able to do clinical rotations, the more our students will get introduced to Florida — end of story,” says Danaher. “That’s the way we’ll play our role in addressing the upcoming physician shortages.”

Pieces of the Solution: Medical Schools

Three new medical schools have opened in Florida since 2006, bringing the total number to 10. The new schools include the University of Central Florida College of Medicine, founded in 2006; Florida Atlantic University’s Charles E. Schmidt College of Medicine, founded in 2010; and the Dr. Kiran C. Patel College of Allopathic Medicine, which opened at Nova Southeastern University in Davie in 2018. One year later, Nova Southeastern launched a new branch campus for its osteopathic medical school (also named after Patel) in Clearwater.

Data indicate about half of the graduates from Florida medical schools will end up practicing in the state. Together, the four new programs have added about 387 medical students per year to Florida’s student rosters.

Overall, Florida medical schools have graduated 7,635 students with M.D. degrees between 2009 and 2019. Florida’s osteopathic medical schools graduated 4,350 doctors over the same time period, according to the Kaiser Family Foundation.

Florida’s osteopathic medical schools graduated 423 doctors in 2019, according to the Kaiser Family Foundation. All told, Florida has eight allopathic medical schools — whose graduates are M.D.s — and two osteopathic (D.O.) medical schools, but more osteopathic schools are in the works. Robert Hasty, founding dean and chief academic officer of the Idaho College of Osteopathic Medicine, is seeking accreditation from the American Osteopathic Association for the Orlando College of Osteopathic Medicine in Horizon West, a fastgrowing section of west Orange County. Development plans submitted to Orange County describe a 136,194-sq.-ft. medical college on 25 acres. Orlando plastic surgeon John Choi is looking at opening an osteopathic medical school in Celebration after purchasing a 36,000-sq.-ft. building there that used to belong to Stetson University, according to a report in the Orlando Sentinel.

Allopathic vs. Osteopathic

In the U.S., there are two routes of training for doctors — allopathic medical schools, which graduate M.D.s, and osteopathic medical schools, which graduate D.O.s.

While both are fully licensed physicians, the D.O. (doctor of osteopathy) philosophy of care emphasizes a more holistic approach, including hands-on manipulative therapy to adjust joints and tissues. Osteopaths receive extra training in the musculoskeletal system.

Almost two-thirds of Florida medical students train at the conventional allopathic schools to earn their doctor of medicine (M.D.).

Pieces of the Solution: Importing Doctors

Projections of Florida’s doctor shortage include expectations that the state’s population growth over the next 20 years will include doctors from elsewhere. Indeed, 11,692 (17.7%) of physicians surveyed in the state’s 2021 physician workforce report are recent transplants — having relocated to Florida in the last five years. The majority (54.3%) said their job had brought them to Florida vs. 34.6% who came for to be closer to family and friends. Approximately 5% (2,464) reported they were planning to leave Florida in the next five years, with the major reasons cited for leaving as family (32.2%), financial (21.9%) or simply “looking for a change” (18.5).

Looking ahead, attracting doctors from out of state doesn’t involve an undue amount of bureaucracy. Getting licensed to practice in Florida costs less than $1,000 (including a $350 application fee, $355 initial license fee and a $250 assessment that all doctors pay to help reduce malpractice costs in birth injury cases) — and once the physician’s application is complete, the whole process takes about 45 to 90 days.

Opinions on how best to recruit physicians differ. HCA’s Monique Butler says the company has the ability to recruit physicians from its other facilities across the nation to Florida and plans to use the approach. But UF’s Marvin Dewar warns that attempting to woo M.D.s from other states with signing bonuses, for example, will deteriorate into a medical arms race. “That does happen when there are shortages — and we see that happening, and we all participate in that — but that’s a race to the bottom. It’s like a bubble. It’s not a financially sustainable model,” Dewar says.

However they proceed, hospitals will have to get creative, given the competition for talent. Sixty-six percent of finalyear medical residents got 51 or more recruiting offers, according to a 2019 survey by Merritt Hawkins.

Dr. Dean Watson, vice president and chief integration officer at Tallahassee Memorial HealthCare, says the doctors who are coming out of training today aren’t interested in 12-hour workdays but are “looking for that work-life balance.” As a result, the hospital is having to hire seven or eight physicians to do a job that might have previously been handled by five or six doctors, and it’s also having to hire more non-physician providers (such as nurse practitioners and physician assistants) to fill the gaps.

Other incentives, beyond regular pay, are on the rise. Olesea Azevedo, senior vice president and chief human resources officer for AdventHealth, says the company is piloting a number of programs, including student loan repayment programs, to help retain doctors as they finish their residencies. “As we get the results of those pilots, we’ll identify (what works best) and scale that system wide,” she told FLORIDA TREND.

Doctor Deserts

Residents of some parts of Florida already are feeling the pinch of a doctor shortage. Most Florida doctors (98%) practice in urban counties, leaving just 1,059 doctors to serve Florida’s rural counties. Nine counties in Florida had fewer than 10 practicing physicians last year — and 2021 data from the Kaiser Family Foundation identified 276 health provider “shortage areas” — encompassing 6.3 million people — where nearly 70% of medical needs aren’t being met. Kaiser says the state needs an additional 1,505 practitioners in those regions to meet demand.