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Report: Simple Policy Change Could Solve U.S. Physician Shortages in 25 States

Authors call for equal licensure requirements for foreign-educated and U.S.-educated docs (Jan. 22)

According to a new study from the University of Virginia, half of the 50 states could end their primary care physician shortages, and save billions annually in health care costs, by a simple policy change: equalizing the licensure requirements for foreign-educated physicians and U.S.-educated physicians.

More than a quarter of physicians practicing today received their medical education outside of the U.S., and this dependence on foreign-trained physicians is poised to grow with the implementation of the Affordable Care Act and an aging population, the study notes.

All but a few states require graduates of non-U.S. medical schools to complete longer post-graduate residency training — generally 1 to 2 years longer — than graduates of U.S. medical schools before being eligible for a state license to practice medicine.

The additional requirements purportedly ensure that international medical graduates meet the same standards as American-trained doctors. But the study authors are skeptical of this rationale for a number of reasons.

First, in order to be eligible to apply for residency training in the U.S., international medical graduates must demonstrate that their qualifications are equivalent to U.S. medical graduates by passing three sections of the U.S. Medical Licensing Exam. The test is not easy; in 2008, only 43% of international medical graduates passed all three components of the test on their first try. This screening is effective, the authors note: post-licensure, there are few differences between U.S. and international medical graduates in patient health outcomes, or in the frequency of disciplinary actions by state medical boards.

According to the authors, the history of additional residency requirements suggests that they were created as a barrier to entry. Historically, states often prohibited non-citizens from obtaining medical licenses, regardless of where they were educated, until the U.S. Supreme Court ruled this practice unconstitutional in the 1970s.

As of 2009, the authors say, the five states with the worst physician shortages per million residents were New Mexico, Louisiana, Mississippi, Missouri, and North Dakota, four of which require international medical graduates to complete 3 years of residency training versus 1 year for U.S. medical school graduates. The exception is New Mexico, which requires 2 years for both domestic and international graduates.

The authors claim that lowering barriers to international medical graduates is an apt solution to address U.S. physician shortages — a problem in much of the U.S., especially in primary care — because those graduates are more likely than U.S.-trained medical graduates to become general practitioners, and are more likely to work in localities with physician shortages.

Using Department of Homeland Security records of the number of international medical graduates (those self-identifying as doctors) entering each state annually, the authors modeled the expected physician migration if state residency requirements were equalized for U.S.- and foreign-educated physicians over the 6-year period from 2004 to 2009.

The modeling found that 25 states would gain enough physicians to end their shortages.

Large states would be the biggest gainers, with California, New York, and Illinois gaining an estimated 3,321, 2,816, and 1,030 foreign-trained physicians, respectively, over 6 years. The sparsely populated Rocky Mountain states of Idaho, Wyoming, and Montana would each gain fewer than two physicians.

This policy change would also generate sizable savings in healthcare costs, the authors estimate. The average state, they found, would see an approximately $139 million decline in annual healthcare costs through fewer hospital visits alone.

“While equalizing residency requirements would not completely satisfy physician needs in half the states, it is a straightforward, practical policy change that can result in measurable improvements in social welfare,” said co-author Dr. Sonal Pandya.

Source: University of Virginia; January 22, 2013.

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