Jeffrey A. Singer
Last weekend the American Medical Association House of Delegates passed a resolution tacitly claiming that the National Residency Matching Program (NRMP) is likely anti‐competitive and a violation of the Sherman Antitrust Act of 1890. The resolution concluded:
RESOLVED, That our American Medical Association study alternatives to the current residency and fellowship Match process which would be less restrictive on free market competition for applicants. (Directive to Take Action)
This is quite surprising, given that the AMA was a co‐defendant, along with the Association of American Medical Colleges (AAMC), the Accreditation Council for Graduate Medical Education (ACGME), the American Hospital Association (AHA), and several teaching hospitals in a 2002 antitrust class action lawsuit brought by Dr. Paul Jung (Jung v. AAMC) on behalf of current and former residents.
As Eastern Virginia Medical School Professor Bryan Carmody explains in his blog and this very well‐produced video, the NRMP system established in the 1950s has since been the only way that medical school graduates may seek positions in residency programs. The program was established by the AAMC and National Student Internship Committee and supported by the AMA. It provides a centralized application process that matches applicants with residency programs using a mathematical algorithm designed to maximize the preferences of both parties. The NRMP eliminated and replaced the process where medical school graduates negotiated residency positions and salaries at various institutions. The NRMP ended any negotiation process. Each residency program participating in the NRMP pays all its residents in all specialties the same salary. Medical school graduates have no other options for seeking residency positions outside the NRMP.
Dr. Jung and co‐plaintiffs argued that all this violates antitrust law. Many legal scholars believed the plaintiffs had a strong case as their lawsuit moved forward. As the defendants’ prospects of acquittal began to fade, the AMA and the NRMP engaged in a public relations campaign to “save the match.” Eventually, the AAMC, AHS, and the AMA lobbied successfully to get Congress to attach a last‐minute rider–without debate–to the 2004 Pension Funding Equity Act, co‐sponsored by Senators Edward Kennedy (D‑MA) and Judd Gregg (R‑NH). The rider, entitled “Confirmation of Antitrust Status of Graduate Medical Resident Matching Programs,” exempted the NRMP from the Sherman Antitrust Act:
It is the purpose of this section to—
(A) confirm that the antitrust laws do not prohibit sponsoring, conducting, or participating in a graduate medical education residency matching program, or agreeing to do so; and
(B) ensure that those who sponsor, conduct or participate in such matching programs are not subjected to the burden and expense of defending against litigation that challenges such matching programs under the antitrust laws.
Every state and the District of Columbia require medical school graduates to complete at least one year of a residency program (residency programs range from 3 to 7 years) and pass Step 3 of the standardized national licensing exam (USMLE for MDs and COMLEX for DOs) to get a license to practice as a general practitioner. As Cato Research Associate Spencer Pratt and I detail in our recent policy brief:
Since the early 1950s, hospitals and medical centers that offer postgraduate training (residency) programs have been participating in the National Resident Matching Program (NRMP), which matches graduating medical students with available residency programs. Many medical school graduates do not match with positions in accredited programs because the number of residency slots available has not increased at the same rate as the number of medical students. The graduates are stuck in limbo, unable to apply the knowledge and clinical skills acquired with their doctorate degrees to care for patients while also being unable to further hone and develop those clinical skills with postgraduate training. According to the American Medical Association, in 2021, roughly 7 percent of doctor of medicine graduates and 10 percent of doctor of osteopathy graduates found themselves in that state of limbo.
Our brief discusses how Missouri lawmakers addressed this problem by licensing a new category of health care practitioner called Assistant Physician (AP). Already having received their doctorates in medicine, these graduates are essentially apprentice physicians. They work under the supervision of collaborating licensed medical doctors. Missouri launched this innovation in 2017. Missouri allows APs to annually renew their licenses without limits.
Since then, several other states have followed Missouri’s lead by enabling APs to render primary care services to patients. Unfortunately, unlike Missouri, under intense lobbying from state chapters of the American Academy of Family Physicians (AAFP) and the American Medical Association, lawmakers in those states have limited the number of times an AP may renew a license. In some cases, such as Idaho, the AP license is only good for one year. The AAFP and AMA have convinced many state lawmakers that an AP should only serve as a “bridge year” to allow medical school graduates an opportunity to gain experience and income while waiting to enter the next year’s match. Idaho, for example, only grants a one‐year, non‐renewable license to APs.
The recent AMA resolution calls for the organization to study alternatives to the current matching system that “would be less restrictive on free market competition for applicants.”
We agree. In the “Recommendations” section of our policy brief, Spencer Pratt and I state:
State lawmakers should enable medical school graduates to use their experience as APs as an alternative pathway to unrestricted licensure as GPs. If one or two years of residency plus passing Step 3 of the USMLE qualifies physicians in most states to practice medicine as GPs, then three or more years of experience as an AP and passing the same exam should suffice as well.
The AP to GP alternative pathway could lead to innovations in how specialty boards certify clinicians. For example, GPs who wish to specialize nowadays apply to specialty residency training programs. When they complete residency training, they take standardized specialty examinations and seek certification from specialty boards such as the American Board of Internal Medicine, the American Board of Family Medicine, the American Board of Pediatrics, and the American Board of Obstetrics and Gynecology. Thus, increasing the number of GPs might incentivize some certifying organizations to develop alternative pathways to certification that place greater emphasis on real‐world experience. Certifying organizations might even develop various levels of certification based on applicants’ backgrounds and experience.
Increasing the supply of APs and, in turn, GPs, while promoting innovation in specialty certification would increase primary health care access and choice.
If the AMA seriously seeks redemption from its past anti‐competitive transgressions, supporting this alternative pathway would be a good place to start.