House Investigating the Match

[WildWing]

Antitrust probe into the residency match.

https://www.reuters.com/legal/government/us-house-panel-launches-antitrust-probe-medical-residency-system-2025-03-17/

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[Lost in Translation]

Too late for me but if this results in residents getting paid more then great. But I have no clue what this committee is bringing up as a gripe against the system.

 

[WildWing]

The article cites the physician shortage as the driver - that the Match artificially constrains supply.

 

[LucidSplash]

The article cites the physician shortage as the driver - that the Match artificially constrains supply.

Which is a little insane of a thought process. And shows that those initiating this don’t understand medical training pathways or their importance.

 

[RangerBob]

Which is a little insane of a thought process. And shows that those initiating this don’t understand medical training pathways or their importance.

I agree.

If Congress wanted to address the physician shortage, a good first step is indexing Medicare physician reimbursement rates to inflation, which are now 33% lower than they were in the early 2000's. Yet hospital reimbursement is tied to inflation.

It's a wonder that we still have any independent physician practices left over. Without changes, the only independent physicians we'll see in our lifetime will be hospital-based docs/groups (low overhead), high-grossing specialties/cash pay practices, and perhaps those who were savy enough to purchase the property their outpatient practice building sits on.

A lot of docs are just retiring early instead of selling their practice or put up with burnout.

While I didn't vote for Trump, I was hopeful that maybe Musk would make things more efficient/get rid of a lot of the regulations that also contribute to burnout. But instead he seems to just have started a large bonfire in the dumpster out back.

We at least got our act together to increase medical school seats. But as we all know, all that really results in is pushing out IMG/FMGs since the residency cap is the issue. So I guess perhaps that cap on residency funding should be the first thing to address. Medicare reimbursement second.

 

[LucidSplash]

I agree.

If Congress wanted to address the physician shortage, a good first step is indexing Medicare physician reimbursement rates to inflation, which are now 33% lower than they were in the early 2000's. Yet hospital reimbursement is tied to inflation.

It's a wonder that we still have any independent physician practices left over. Without changes, the only independent physicians we'll see in our lifetime will be hospital-based docs/groups (low overhead), high-grossing specialties/cash pay practices, and perhaps those who were savy enough to purchase the property their outpatient practice building sits on.

A lot of docs are just retiring early instead of selling their practice or put up with burnout.

While I didn't vote for Trump, I was hopeful that maybe Musk would make things more efficient/get rid of a lot of the regulations that also contribute to burnout. But instead he seems to just have started a large bonfire in the dumpster out back.

We at least got our act together to increase medical school seats. But as we all know, all that really results in is pushing out IMG/FMGs since the residency cap is the issue. So I guess perhaps that cap on residency funding should be the first thing to address. Medicare reimbursement second.

By extrapolation, I suspect residency funding is going to be cut like everything else, given the cuts to academic medical center research and ancillary funding. And then it will be suggested that the free market will take care of the physician shortage by paying residents even less.

 

[wysdoc]

The politician's premise “For years, resident wages have remained stagnant while doctor shortages have increased,” U.S. Representative Scott Fitzgerald, R-Wisconsin, said in a statement. “This harms medical students and hospital patients, and forces us to rely on foreign talent to fill the gap.”
is faulty - it's not low resident wages that are responsible for the doctor shortage, it's maldistribution of doctors because so many young doctors want to live in metro areas only. Residencies are the necessary step to train doctors to enter the community. Spending a bunch of money to "investigate price fixing of wages" is nonsense.

 

[RangerBob]

By extrapolation, I suspect residency funding is going to be cut like everything else, given the cuts to academic medical center research and ancillary funding. And then it will be suggested that the free market will take care of the physician shortage by paying residents even less.

I agree that's the likely outcome. Even if by miracle residency funding isn't cut, I'm sure medical centers will need to move funds around from somewhere.

Another possible outcome is to let residents bill just like PA/NPs. I could see hospitals lobbying for that if residency funds are cut. Whether that's actually a good thing for the resident is unclear, as I'm sure that would result in more exploitation of the resident and less focus on education (which some programs already do). And who knows if hospitals would actually pay the resident more.

Personally I think the current system is ''ok." But residents should be paid more--especially senior residents. If not, the government should go back to classifying residents as students and provide more lenient tax/loan benefits.

 

[NotAProgDirector]

The wheel of time turns, and ages come and pass. What was, will be again, and what is, will be again. Ages come and pass, leaving memories that become legend. Legend fades to myth, and even myth is long forgotten when the Age that gave it birth comes again.

This sounds like a re-hash of the initial lawsuit. It makes no sense at all.

The physician shortage has nothing to do with the match at all. Whether there is a shortage at all, vs a maldistribution, is debatable. And if the issue is "all the baby boomers retiring" -- well that may cause a surge of patients, but once they all pass on, we'd then have a glut of doctors. And whether we're training the right mix of generalists / specialists is anyone's guess. And last is the complex question of whether primary care should be delivered by physicians, or someone else.

The residency cap is often brought up as a block on more spots. But, if a community hospital opens a new residency program, that bypasses the cap and generates new funding. The cap prevents established programs from growing. But perhaps what we need, if we want more PCP's in underserved areas, is more training programs in those areas. And the cap doesn't impact that at all -- no new laws need to be passed.

The statement "physician salaries have been on the rise but residents have remained stagnant" is inaccurate. Resident salaries have certainly increased. As already mentioned, physician payments have decreased over time. Whether salaries have outpaced inflation I can't say.

And the match doesn't depress resident salaries. All programs must publish their salaries prior to the match, and residents are free to choose programs with higher salaries or better benefit packages if they wish. Even without a match, residents will not be in any position to try to demand higher pay "or I'll just go elsewhere".

It remains an open question about whether resident salaries are too low. Some residents bring great value to their programs in the form of coverage, and often the costs of replacing those residents are used as a metric to assess whether their salary is fair or not. But in some programs that doesn't really hold true -- we have a 1 resident / 1 intern team with 10 patients, or a 1 resident / 2 intern team with 14-16 patients. Each team has a single faculty supervising. Should all those residents disappear, the faculty would just care for the patients alone. We already have non-teaching teams that are faculty only, so this wouldn't be any different than what we already do (although I certainly admit that working with residents is more fun than working on my own). Same with night coverage -- we have night floats at night, but also faculty and NP/PA's at night covering our non-teaching service, and the teaching service is much smaller than the non teaching service. And then our residnts have a good amount of elective time -- which generates no income for the hospital at all. So for sure there are some programs / institutions where resident services are critical to operations, and there are some where they are not. (All of this ignores the CMS payments, which certainly help hospital bottom lines).

Don't get me wrong - I strongly support residents and their well being. I'd love to have their pay increase. They do good work, and work hard. But resident salaries are more driven by the gatekeeping function of training (you can't get a job as a physician without completing a residency) and the difficulty in switching programs. These distort the free market - and I don't see an easy solution to address that. Other than some regulatory / central price fixing (which seems problematic), or allowing a national union for residents (which has it's own set of problems).

 

[comp1]

Has there ever been a time when Congress wasn't investigating the Match, since it started? Congress literally protected it from antitrust issues by law. I fully anticipate they have been appropriate remunerated to continue to do so.

 

[NotAProgDirector]

Just listened to the whole thing. Very interesting that the only witnesses listed on the announcement / website ended up all being anti-match, and then there was one poor guy from BWH who was pro-match. As expected, many times the hearing turned into "bash the other party" -- either dems bashing repubs for TRUMP, MAGA, cutting Medicaid, research funding, etc. Or repubs bashing dems mainly on DEI.

Lots of spun facts about how bad the match is:
Doctor shortage caused by match
8000+ unmatched candidates, a crime when there's a doctor shortage
Low resident salaries (won't be improved by removing the match)
Locks people into positions

There was this fun moment when the repubs were dunking on the ACGME for their DEI policies, and the LECOM guy said "well we got an email this week saying they ended that" and the repub was like "well, I guess that's good then".

The witnesses included:
Some guy from LECOM who seemed mostly angry at the ACGME for "closing down his programs". He talked about their ortho program getting closed. Presumably this was a casulty of the ACGME/AOA merger. His explanation made no sense -- that the ortho residents rotated at some other site and the ACGME didn't allow that -- which is nuts because of course you can set up a PLA (program letter of agreement) and have residents train at multiple sites. He also complained that an IM program got shut down, because the PD refused to get a COVID vaccine and it was an ACGME requirement. Which, as far as I can tell, is bogus -- there's no vaccine requirement that I know of.

Perhaps lost in all that noise was his actual point -- that the ACGME req's may be impossible in really small rural programs. I am not familiar with the FM req's, but the IM reqs require ICU time, and research, and a geriatrics experience, and exposure to all the subspecialties -- and I expect it would be very difficult to do that in a critical access hospital. So, would it be "right" to allow people to train at a site like that? Or should we have fully outpatient training sites? Sadly, these would have been the interesting questions to debate -- which did not happen (and has nothing to do with the match).

Then there was the lawyer who filed the original class action law suit. He droned on about how many people's careers had been ended by "the match". Which makes no sense. He made the usual points that somehow without a match residents would negotiate for their salaries and salaries would magically rise. He also went on this tangent that people who are terminated get blacklisted -- which has nothing to do with the match or the ACGME, but has some reality to it. Although certainly people resign from one field and get a spot in another. Honestly seemed to me that he's just looking for a big payday if he can get his lawsuit restarted.

Third was a policy wonk lawyer. He in many ways was the most interesting, as he was the most balanced. He was pretty clear that he didn't think the match should be removed, but perhaps reformed (but no details on how). Said to one question that he didn't think that ending the match would raise salaries. He was mostly focused on the barriers in getting medical licenses, and seemed to want IMG's to just directly get licenses and practice.

Last was the doc from BWH who supported the match. But spent a bunch of his "opening statement" time bashing the current admin. The first questioner beat him up over it, and honestly he deserved it. Regardless of whether cutting Medicaid and NIH funding is good or bad, it wasn't really what this hearing was primarily about.

Essentially, a waste of 1.5 hours of my time. Mostly grandstanding. Really sad, it could have actually been an interesting discussion. It is true that the match exemption was stuck in another must-pass bill with no discussion or debate. Although I agree with it, it was a slimy way to get it done which I don't agree with. If the exemption is removed, then it just ends up in court and perhaps a better review gets done there. Although I wonder if the exemption is removed whether the "better" plan is for the NRMP to just say "the match is over" and watch the chaos unfold, which then likely brings back a match.

 

[AlbinoHawk DO]

Perhaps lost in all that noise was his actual point -- that the ACGME req's may be impossible in really small rural programs. I am not familiar with the FM req's, but the IM reqs require ICU time, and research, and a geriatrics experience, and exposure to all the subspecialties -- and I expect it would be very difficult to do that in a critical access hospital. So, would it be "right" to allow people to train at a site like that? Or should we have fully outpatient training sites? Sadly, these would have been the interesting questions to debate -- which did not happen (and has nothing to do with the match).

I would not want an internal medicine doctor without exposure to ICU, geriatrics, and subspecialties. That's one of the most critical aspects of being an internist. The research component is very weak as it is. People can fulfill it with just a case report and doing an M&M.