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Letters to the Editor  |   July 2008
AOA is Strong Advocate for Debt Relief and Primary Care
Author Affiliations
  • John B. Crosby, JD
    American Osteopathic Association, Chicago, Ill
    Executive Director
Article Information
Medical Education / Practice Management / Graduate Medical Education
Letters to the Editor   |   July 2008
AOA is Strong Advocate for Debt Relief and Primary Care
The Journal of the American Osteopathic Association, July 2008, Vol. 108, 321-350. doi:10.7556/jaoa.2008.108.7.321
The Journal of the American Osteopathic Association, July 2008, Vol. 108, 321-350. doi:10.7556/jaoa.2008.108.7.321
To the Editor:  
As the number of osteopathic medical students increases, the burden of debt carried by these students likewise grows. The high cost of medical school education, osteopathic or otherwise, has gained increasing scrutiny over the past several years as annual tuition increases at medical schools escalate and Medicare and private-sector physician payment rates stagnate.1-3 
Ethan Wagner, DO,4 in his February 2008 letter to the editor, initiated impassioned profession-wide discussions5-8 about what the American Osteopathic Association (AOA) and the colleges of osteopathic medicine (COMs) can do to help lessen the burden of student debt and encourage responsible growth in the profession. As some AOA members wrote in the May 2008 issue of JAOA—The Journal of the American Osteopathic Association,5,6 high tuition is not a direct corollary with excellent education. 
The student debt problem is worsened by the reality that physician payment rates as established by Medicare, especially in primary care fields, are not certain and have not kept pace with inflation.9,10 This fact has raised warning flags for the medical profession at large, particularly for those primary care physicians who face tremendous debt loads after graduation without the assurance of high salaries. 
However, Dr Wagner4 makes some factual mistakes in his letter, such as his statement that “...the [COMs] and the [AOA] are directly responsible for the financial woes endured by many young osteopathic medical students and residents.” The truth is that the AOA has absolutely no jurisdiction over the amount of tuition a COM can charge. We could ask the COMs to charge less, but we have no authority to require compliance. 
In the letter by Chadd K. Kraus, MPH, OMS II,6 in the May 2008 JAOA, aspersions were cast against the AOA Commission on Osteopathic College Accreditation (AOA COCA) for authorizing branch campuses at osteopathic medical schools with high tuition rates. For those who are unaware, AOA COCA is not a business manager, and it cannot dictate how COMs conduct their governance. Similarly, if a COM applies for accreditation and/or expansion and meets all the required standards, AOA COCA must grant the application. Accreditation cannot be denied by AOA COCA solely for an arbitrary reason, such as a COM's for-profit status or tuition rates. 
The AOA can and will continue to advocate and educate state and federal policymakers, the public, and our own members regarding this important issue and the steps we all must take together to rectify the problem. As I discussed in my April 2008 “Executive Director's Desk” column in The DO,11 it is time for us to join such high-profile educational institutions as Harvard University, Yale University, and Massachusetts Institute of Technology in linking tuition rates to students' financial needs. These and other schools, including Cleveland Clinic Lerner College of Medicine Case Western Reserve University, recently set tuition at $0 or a greatly reduced rate for students who have the academic qualifications—but not the money—to attend their institutions.12,13 As I previously wrote,11 “Wouldn't it be great if we could add an osteopathic medical school to this list or reduce [students'] debt if they go into osteopathic primary care?” 
Advocating for payment incentives for physicians practicing in primary care is another way that the AOA actively addresses this problem. The AOA is a founding member of the Patient-Centered Primary Care Collaborative, a coalition of large employers, consumer groups, and major physician organizations that have joined together to develop and promote the patient-centered medical home model of care as the way to transform the US healthcare delivery system.14 By placing the primary care physician at the center of a healthcare team, the medical home model recognizes the crucial role that these physicians play in patient health. With a growing number of public and private entities signing on in support of this model, the AOA brings greater force to our advocacy for fair and equitable payment rates for primary care physicians. 
In addition, the AOA and the American Association of Colleges of Osteopathic Medicine were recently successful in urging the US Congress to keep intact, at least through the fall of 2008, the debt-to-income ratio (ie, “20/220 pathway”) provision for medical student loan deferment in the Higher Education Act.15 The reinstatement of this provision means that all fourth-year osteopathic medical students and current residents will continue to be eligible for hardship deferment during the next year. Further more, our advocacy to keep this pathway intact even longer will continue. 
Association of American Medical Colleges. Medical Student Tuition and Young Physician Indebtedness: An Update to the 2004 Report. Washington, DC: Association of American Medical Colleges; October 2007. Available at: https://services.aamc.org/Publications/showfile.cfm?file=version103.pdf&prd_id=212&prv_id=256&pdf_id=103. Accessed July 3, 2008.
Fuchs E. With debt on the rise, students and schools face an uphill battle. AAMC Reporter [serial online]. January 2008. Available at: http://www.aamc.org/newsroom/reporter/jan08/debt.htm. Accessed July 3, 2008.
Santana S. Paying the price to become a doctor: the impact of medical school debt. AAMC Reporter [serial online]. January 2002. Available at: http://www.aamc.org/newsroom/reporter/jan02/medschooldebt.htm. Accessed July 3, 2008.
Wagner E. Debt control for young DOs [letter]. JAm Osteopath Assoc. 2008;108:53,81. Available at: http://www.jaoa.org/cgi/content/full/108/2/53. Accessed July 3, 2008.
Andrews CK. Excessive tuition does not equal excellent education [letter]. J Am Osteopath Assoc. 2008;108:231. Available at: http://www.jaoa.org/cgi/content/full/108/5/231. Accessed July 3, 2008.
Kraus CK. Mortgaging our future, foreclosing our profession [letter]. J Am Osteopath Assoc. 2008;108:231-233. Available at: http://www.jaoa.org/cgi/content/full/108/5/231-a. Accessed July 3, 2008.
Goeppinger KH. Award-winning debt-management education [letter]. J Am Osteopath Assoc. 2008;108: 233,264. Available at: http://www.jaoa.org/cgi/content/full/108/5/233. Accessed July 3, 2008.
Shannon SC. Working to ease debt burdens [letter]. J Am Osteopath Assoc. 2008;108:264-265. Available at: http://www.jaoa.org/cgi/content/full/108/5/264. Accessed July 3, 2008.
2007 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Washington, DC: Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds; April 2007. Available at: http://www.cms.hhs.gov/reportstrustfunds/downloads/tr2007.pdf. Accessed July 3, 2008.
Iglehart JK. Medicare's declining payments to physicians. NEng JMed. 2002;346:1924-1930.
Crosby JB. The rites of spring for DOs: playing ball in the major leagues of medicine. The DO. April 2008:14-15. Available at: https://www.do-online.org/pdf/pub_do0408exec.pdf. Accessed July 3, 2008.
Wang SS. Cleveland Clinic's medical school to offer tuition-free education. The Wall Street Journal. May 15, 2008:D3. Available at: http://online.wsj.com/article/SB121081981994794319.html. Accessed July 3, 2008.
Woods A. Harvard offers free tuition for low income students. Collegiate Times [serial online]. October 2, 2007. Available at: http://www.collegiatetimes.com/stories/2007/10/02/harvard_offers_free_tuition_for_low_income_students. Accessed July 3, 2008.
Patient-Centered Primary Care Collaborative Web site. Available at: http://www.pcpcc.net/. Accessed July 3, 2008.
Role SE. AACOM action alert: contact Congress in support of reinstatement of debt-to-income ratio 20/220 pathway for economic hardship deferment; May 7, 2008. American Association of Colleges of Osteopathic Medicine Web site. Available at: http://www.aacom.org/advocacy/alerts/Pages/050708alert.aspx. Accessed July 3, 2008.