Graduate Medical Education That Meets the Nation's Health Needs (2014) / Chapter Skim
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The United States has a robust GME system, one emulated by many other nations, with significant capacity to produce a high-quality physician workforce. Yet, in recent decades, the need for improvements to the GME system has been highlighted by blue ribbon panels, public- and privatesector commissions, provider groups, and Institute of Medicine (IOM)
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; nursing and BOX S–1 Charge to the IOM Committee on the Governance and Financing of Graduate Medical Education An ad hoc Institute of Medicine committee will develop a report with recommendations for policies to improve graduate medical education (GME) , with an emphasis on the training of physicians.
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The committee debated -- at great length -- the justification and rationale for federal funding of GME either through Medicare or other sources, given the lack of comparable federal financing for undergraduate medical education, other health care professions, or other areas important to society
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SOURCE: Adapted from Wynn, 2012 (Committee of Interns and Residents Policy and Education Initiative White Paper, "Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety")
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Specialties Accreditation Council for 70 Medical Continuing Licensing Medical Liaison Committee U.S. Medical Boards Education Medical College for Medical Licensing Admissions Test Education Examination Maintenance Licensure of Licensure Residency + Medical Premedical Medical School Fellowship Practice Certification American Commission Educational 14 Osteopathic Association on Osteopathic Commission for Licensing of Colleges of College Foreign Medical Boards Osteopathic Accreditation Graduates (for Medicine Entry by International Maintenance Medical Graduates)
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Thus, the committee decided to focus its recommendations on Medicare GME payment reforms (and their related governance) , rather than on a broader array of policy alternatives, such as an all-payer GME system or a wholly new federal GME program.
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These studies suggest that an expanded primary care role for physician assistants and advanced practice registered nurses, redesign of care delivery, and the use of other innovations, such as telehealth and electronic communication, may ultimately lessen the demand for physicians despite the added pressures of the aging population and coverage expansions. Some stakeholders and policy makers are pushing for significant increases in Medicare GME funding (via an increase in the cap on Medicarefunded residency positions)
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Unintended Consequences of Medicare GME Payment Methods The financial underpinnings of the GME enterprise are complex and largely undocumented. The committee found few informative data on GME financing and its outcomes.
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Both funding streams are directly tied to a hospital's volume of Medicare inpatients. In 2012, IME accounted for $6.8 billion, or 70.8 percent, of total Medicare GME payments to teaching hospitals.
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Transformational funds will support work to develop a foundation for a performance-based GME payment methodology, which represents a central aim of these recommendations. The committee acknowledges that repurposing and redesigning GME funding will be disruptive for teaching hospitals and other GME sponsors accustomed to receiving Medicare GME monies in roughly the same way for nearly 50 years.
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Department of Health and Human Services to take immediate steps to establish a twopart governance infrastructure for federal GME financing. Transforming Medicare GME financing will require an overarching policy-development and decision-making body and a separate operations center to administer GME payment reforms and solicit and manage demonstrations of new
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Department of Health and Human Services. Council members should be appointed by the Secretary and provided with sufficient funding, staff, and technical resources to fulfill the responsibilities listed below: • Development and oversight of a strategic plan for Medicare GME financing; • Research and policy development regarding the sufficiency, geographic distribution, and specialty configuration of the physician workforce; • Development of future federal policies concerning the dis tribution and use of Medicare GME funds; • Convening, coordinating, and promoting collaboration between and among federal agencies and private accredita tion and certification organizations; and • Provision of annual progress reports to Congress and the Executive Branch on the state of GME.
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, to create and maintain the new infrastructure, to ensure adequate technical support for new and existing GME sponsoring organizations, to sponsor develop ment of GME performance metrics, to solicit and fund large-scale GME payment demonstrations and innovation pilots, and to sup port other priorities identified by the GME Policy Council. RECOMMENDATION 3: Create one Medicare graduate medical edu cation (GME)
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Transformation Fund to finance demonstrations of innovative GME payment methods and other interventions to produce a physician workforce in sync with local, regional, and national health needs. All GME sponsor organizations should be eligible to compete for innovation grants.
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Maintaining separate IME and DGME funding streams would hamper efforts to collect and report standardized data, to link payments with program outcomes, to reduce geographic inequities in GME payments, and to minimize administrative burden. Separate funding streams create unnecessary complexity, and there is no ongoing rationale for linking GME funding to Medicare patient volume because GME trainees and graduates care for all population groups.
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In conclusion, the committee recommends that Medicare GME funding be leveraged toward the achievement of national health care objectives. Continued federal funding should be delivered by a system that ensures transparency and accountability for producing a workforce suited to the needs of the health care system.
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