Awesome post. This is where you may be mistaken however.
CMS (since you reference feds) actually are not happy with increased physicians. Yes, reimbursement is based on a mostly static formula with some regional variation based on supply relating to workforce however one of the biggest drivers of health care costs is utilization (you can google and see so many reports on this, some from the CDC, that I will not link. It is also self evident, more use = more costs; also there is only very limited cost reduction with scale - a hospital doing 100 hip surgeries versus 20, both still need OR investment, infection protocols, anesthesiologists, in patient beds, etc. It's not like a manufacturing center where if you start doing 10000 of something you can replace part of the work force with automated machines for parts... but I digress).
What then are the potential drivers of health care utilization? Well there are many, but one of the biggest factors is increased supply of services.
https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwihjqHqmLnRAhUE7oMKHTQPC4oQFggaMAA&url=https://www.cdc.gov/nchs/data/misc/healthcare.pdf&usg=AFQjCNHZR9kjrp-0cSrNXQDuh0dyXMTirA&sig2=ePcnCRXbYNlmeZOECICSHg&bvm=bv.143423383,d.amc
This is a report from the CDC, see chart 2.
So let's take radiation oncology from the perspective of medicare, who pays for some of these trainees.
1. The federal government is paying money to educate physicians in a specialty whose labor model projects a large oversupply over the next decade
2. The more radiation oncologists, the more utilization. More providers will find the extra bone met, the extra borderline DCIS, low risk prostate (and maybe correctly so). This will lead to more health costs and divert dollars away from needed programs.
3. Even with slightly lower reimbursement per provider, you cannot overcome 2 because as reimbursement goes down then there is an inverse response of trying to increase volume to make up the difference, which is a pan specialty response
I think you are correct in that ASTRO could care less about us. Senior attendings may care about job prospects only in so much as it affects reputation, and will often act in a protective manner if they are challenged by the hiring of younger faculty (because in some payment models, that would be money out of their pocket). So will private practice docs. The ARRO paper is a nice nod but this field needs to go down to 80 residents by next year. Remember that the labor forecast projects a 27% increased in work force and a 19% increase in demand. There is no way this environment supports a 19% increase in demand. Even since 2015 there has been decreased reimbursement, decreased referrals under new payment models, decreased indications, and increasing hypofractionation. So while the 27% work force is a number based on facts, the demand % is an estimate and it is going downwards. Who is going to bear the brunt of that? The guy who loaded up 200-300K debt and will never have a chance at the caliber of career most of these senior physicians have had.
So back to my point, the argument needs to be taken to CMS directly. I am crafting a letter to Dr. Price and to CMS that builds on this data and highlights how in this forgotten corner of medicine, radiation oncology may be abusing the system with willful expansion of slots in the face of evidence there is already an oversupply projected for 10 years and may be a ripe area to cut education funds without damage to society. Will it matter? Who knows - but it is a reasonable position to lobby CMS to cut off all medicare funding for a field that DOES NOT REQUIRE even close to the number of graduates they produce based on the fields' own published labor model. Let the programs self fund using the resident as a poor man's PA / physician extender and antiquated case log requirement roster as proof of 'education'.
The next step is to publish a paper examining in all the programs that expanded, the number of either new positions or new faculty track candidates they have taken. If the demand for radiation has grown so much, and the biggest centers have been absorbing satelites and thus patient loads, then there should be a concordant increase in positions year by year, and this could be retrieved by googling rosters and a bit of doximity digging. If there is not, and we then pair that with the evidence that private practice is now being absorbed into these centers at alarming rates, then how can any program director or chair justify the expansions? If the jobs aren't at those centers, they aren't out there in numbers proportional to how much this field expanded regardless of the smattering of jobs in remote areas that need targeting recruiting.
The bottom line is that with such obvious abuse of the residency system, thinking ASTRO will protect us does not appear to be realistic. But highlighting the data to education payers directly may have some merit. Or the field might go down in flames and get a real ugly and nasty divide between the older and younger generations. Hopefully you are all being honest with the medical students you come in contact with.
