The Patient Protection and Affordable Care Act (PPACA, or ACA), signed into law by President Barack Obama in 2010, will have a significant impact on the delivery of health care services in the United States. While some changes may pose threats to the physician-scientist workforce, others will create new opportunities.
Changes in reimbursement policies for the delivery of health care services under ACA will pose challenges for academic medical centers (AMCs), the traditional home of physician-scientists with a medical degree. These challenges include an increased number of patients with Medicaid, which traditionally has provided low reimbursement rates; a move away from fee-for-service medical care and a decrease in Medicare reimbursement for specialty services, both traditionally major sources of revenue and margin for AMCs; and threats to direct and indirect medical education payments, which fund costs of residents and faculty. As a result, AMCs will have fewer funds available internally to support physician-scientists and their research. Funding for physician-scientists in specialties such as surgery that have been relatively well compensated may be especially affected.
At the same time, new opportunities may arise for AMCs and physician-scientists. The emergence of population-health models, such as Accountable Care Organizations (ACOs), will create new opportunities for AMCs if they can master new organizational skills and re-position themselves in a competitive environment. Those AMCs that learn to manage costs successfully within population health risk models will earn profits that can help them invest in physician-scientists. Physician-scientists with expertise in areas such as clinical informatics, outcomes research, and economics will find important roles in AMCs responding to these new incentives, and new research funding sources, such as through the Patient Centered Outcomes Research Institute and the Centers for Medicare and Medicaid Innovation. Clinician scientists in diverse areas such as nursing, dentistry, and psychology may find their clinical and scientific skills increasingly valued by health systems that are increasingly responsible for patient outcomes and aware of the need for team approaches to care and research. Physicians in specialties that have historically been highly paid and anticipate declines in clinical earnings may be more likely to invest in training themselves for research and in maintaining research activity over their careers. Finally, at the Federal level, success in controlling costs could provide resources to increase investments in scientific research; the entire annual NIH budget is small compared to the increases in annual Medicare spending.
The increasing complexity and specialization of modern research methods has led many to suggest a growing need for team science approaches in biomedical research.13 Team science provides opportunities for MD physician-scientists, nurse-scientists, dentist-scientists and veterinary-scientists, along with non-clinician PhDs, to work side-by-side in addressing health challenges, with more diffused and/or shifting leadership roles.
This new approach enables clinicians to have varying levels of percent effort involvement in science and thereby play an important role, while also maintaining their clinical, teaching, and administrative commitments. If the current “all or none” approach whereby a scientist is defined as having an individual R01 is de-emphasized in the future, this could draw more clinicians interested in participating in clinical or translational research back into the scientific workforce. However, shifting to a team science approach will require a major cultural shift in the promotion and tenure process, which has long been oriented toward individual achievement. This means new investigators may be jeopardizing their career advancement opportunities if they serve as key personnel, rather than principal investigator, on a grant. In addition, funding opportunities and training in team science leadership roles would need to be developed.
Figure 2.3. A Brief Primer on NIH Support for Physician-Scientists
T32 Institutional Training Grants: supports predoctoral and postdoctoral research training programs since 1974. Research training activities can be in basic biomedical or clinical sciences.
T35 Short-Term Institutional Training Grants: supports intensive, short-term research training experiences for health professional students (medical students, dental students, and/or students in other health-professional programs) during the summer.
Medical Scientist Training Program (MSTP) (https://www.nigms.nih.gov/Training/InstPredoc/Pages/PredocOverview-MSTP.aspx):
Supports MD/PhD training programs at 43 institutions across the country, providing tuition and stipends to selected students for up to 6 years.
F32 Individual Postdoctoral Fellows: Applicants with a health professional doctoral degree may use the proposed postdoctoral training to satisfy a portion of the degree requirements for a master's degree, a research doctoral degree or any other advanced research degree program.
K08 Mentored Clinical Scientist Award: provides support and “protected time” to individuals with a clinical doctoral degree for an intensive, supervised research career development experience in the fields of biomedical and behavioral research, including translational research.
23 Mentored Patient-Oriented Research Award: supports the career development of individuals with a clinical doctoral degree who have made a commitment to focus their research endeavors on patient-oriented research via a supervised research career development experience.
K99/R00 Pathway to Independence Award: facilitates a timely transition of outstanding postdoctoral researchers from mentored, postdoctoral research positions to independent, tenure-track or equivalent faculty positions, and provides independent NIH research support during the transition that will help these individuals launch competitive, independent research careers.
Encourages outstanding health professionals to pursue careers in biomedical, behavioral, social, and clinical research by repaying $35,000 per year of student loan debt for up to 3 years for those employed in a research capacity.
13 Bennet, L.M., Gadlin, H. & Levine-Findley, S. (2010). Collaboration and team science: A field guide. https://ombudsman.nih.gov/collaborationTS.html