Graduate Medical Education That Meets the Nation's Health Needs (2014) / Chapter Skim
Currently Skimming:
5 Recommendations for the Reform of GME Financing and Governance
5 Recommendations for the Reform of GME Financing and Governance
Pages 131-168
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The committee strongly urges Congress to amend Medicare law and regulation, as outlined in this chapter, to enable the beginning of the transition in this very important investment in the nation's future physician workforce. Since the creation of the Medicare and Medicaid programs, the public has provided tens of billions of dollars to fund graduate medical education 131
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As Chapter 3 notes, although the VHA does not sponsor residency programs, VHA hospitals train a substantial portion of the nation's physicians through affiliation agreements with medical schools and other sponsoring organizations. VHA GME funding comes solely from the agency's annual appropriations.
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, including solicitation and oversight of demonstrations; and • Data collection and detailed reporting to ensure transparency in the distribution and use of Medicare GME funds. RECOMMENDATION 3: Create one Medicare graduate medical education (GME)
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4a. Replace the separate indirect medical education and direct graduate medical education funding streams with one payment to organizations sponsoring GME programs, based on a national per-resident amount (PRA)
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The committee considered a range of potential GME funding sources, including maintaining or modifying current Medicare support, an all-payer approach that would require both private and public payers to contribute to GME financing, a dedicated federal GME program independent of the Medicare and Medicaid programs, a significant expansion in Title VII health professions funding directed to physician education, and even the possibility of requiring residents to pay tuition. It quickly became clear that funding GME through an entitlement program -- such as Medicare -- provides a level of stability that enables sponsoring institutions to make the commitments to the trainees, faculty, and facilities that GME needs.
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BOX 5–2 IOM Committee's Goals for Developing Graduate Medical Education (GME) Policy Recommendations 1.
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. The number of subspecialty programs accredited by the Accreditation for Graduate Medical Education
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For example, GME funds might be used to finance new incentives for choosing a primary care career. The incentives might focus on the individual trainee by offering medical school loan repayment in exchange for a long-term commitment to primary care practice -- on a greater scale than currently provided by HRSA -- or else provide incentives to educational institutions that sponsor priority residency programs by paying a substantially higher per-resident amount (PRA)
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direct graduate medical education (DGME) payments to cover the salaries and benefits of residents and faculty and certain other costs, and (2)
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Moving to a uniform, single PRA payment will simplify administration and facilitate program oversight, transparency, and evaluation. The committee also recommends that a portion of current GME funding be preserved for the developmental work described above and also for new training slots (where needed)
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These include, for example, questions regarding the bottom-line financial impact of residency training programs on teaching institutions, how GME public funds are used for educational purposes, the extent to which residents are trained in community-based settings, the specialties and demographic characteristics of funded trainees, the practice locations of recent trainees, whether recent trainees accept Medicare and Medicaid patients once they enter practice, and the quality of care delivered by these physicians. As Chapter 3 reported, teaching hospitals are asked only to report the data elements that are needed to calculate Medicare IME and DGME payments.
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The relevant federal advisory groups and research centers -- most notably the Council on Graduate Medical Education (COGME) , MedPAC, and the CMS Center for Medicare & Medicaid Innovation (CMMI)
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As noted in the above review of Goal #1, the committee recommends that a portion of current GME funds be redirected to demonstrations of GME payment models that will realign the incentives in GME financing toward the production of a physician workforce that meets the nation's health needs. Table 5-1 provides a brief summary of recommended next steps.
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Create one unified GME fund to replace the separate Indirect Medical Education and achieve Goal #1. Direct Graduate Medical Education funding streams.
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Goal #6 1. The GME Policy Council should develop a strategic plan -- in consultation with the CMS Mitigate unwanted and unintended negative GME Center and GME stakeholders -- that allows for a careful phase-in of the reforms.
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RECOMMENDATIONS FOR REFORMING GME GOVERNANCE AND FINANCING Significant reforms are needed to ensure value in the public's sizeable investment in graduate medical education. These recommended reforms, presented below, cannot occur without legislative action.
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The current Medicare GME payment system should be phased out. The committee debated -- at great length -- the justification and rationale for federal GME funding either through the Medicare program or through other avenues of funding, given the lack of comparable federal funding for other areas of health care education such as undergraduate medical education, for other health care professionals, or for other areas important to society and in shortage.
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could be used to leverage changes in physician residency training to produce a workforce more suited to achieving the triple aim. Build an Infrastructure to Facilitate Strategic Investment RECOMMENDATION 2: Build a graduate medical education (GME)
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to take immediate steps to establish a two-part governance infrastructure for federal GME financing. Transforming Medicare GME financing will require an overarching policy development and decisionmaking body and a separate operations center with the capacity to administer GME payment reforms and to solicit and manage demonstrations of new GME payment models.
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Services (HHS) • Also create a GME Center in CMS to • CMS has direct responsibility for implement changes in GME funding, Medicare policy and funds oversee pilots and demonstrations, distribution and the capacity and facilitate scaling up of to collect GME funding data successful pilots.
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agency GME reform efforts • Cannot be funded with Medicare GME funds. • Would require new funding source and be subject to annual changes in discretionary appropriations.
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In the longer term, the Council should be charged with prioritizing the allocation of GME funds across identified domains, such as specialty or subspecialty, geographic location, training site, or types of sponsoring organizations (e.g., teaching hospitals, hospital consortiums, educational institutions, clinics, teaching health centers [THCs] , or local or regional health care workforce agencies)
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As noted earlier, a number of topics should be explored by the Council and the Center in collaboration. These include, for example, the financial impact of residency training programs on teaching institutions, how GME public funds are used for educational purposes, the extent to which residents are trained in community-based settings, the specialties and demographic characteristics of funded trainees, the practice locations of recent trainees, whether recent trainees accept Medicare and Medicaid patients once they enter practice, and the quality of care delivered by these physicians.
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. As Figure 5-1 illustrates, this fund would finance ongoing residency training activities sponsored by teach ing hospitals, GME consortiums, medical schools and universities, freestanding children's hospitals, accountable care organizations, integrated health care delivery systems, community-based health centers, regional workforce consortiums, and other qualified enti ties that are accredited by the relevant organization.3 • A Transformation Fund to finance new training slots (including pediatric residents currently supported by the CHGME program and other priority slots identified by the GME Policy Council)
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compete for innovation grants and additional funding for new training positions. Allocations to the Operational and Transformation Funds Recommendation 1 specified that total Medicare GME funding should remain at the current level (in an agreed-on base year)
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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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These training positions should receive the same PRA as others. Figure 5-2 illustrates the committee's recommended allocation of Medicare GME monies to the Operational and Transformation Funds during the transition to the new payment system.
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4a. Replace the separate indirect medical education and direct GME funding streams with one payment to organizations sponsoring GME programs, based on a national per-resident amount (PRA)
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• Decrease in aggregate GME funding for some ing organizations institutions. Funds are distributed to • Provides a structure for accountability by linking • Disrupts funding arrangements for training sites that receive sponsoring organizations funding to authority for GME programs.
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The GME Policy Council should determine whether other types of training sites (e.g., cancer, psychiatric, and long-term care hospitals) should be folded into the program at a later date (with funds from the Transformation Fund)
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As Figure 5-2 shows, the committee recommends that, during the initial years of transition, an increasing portion of operational funds be transferred to the Transformation Fund for its developmental and innovation activities. Later in the 10-year period, as successful pilots are implemented on a broader scale and performance payment methods are in place, most of the transformation funds should be absorbed back into the Operational Fund.
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Developing and piloting of possible measures should be a high priority for both the GME Policy Council and CMS GME Center. The process should be objective and evidence based.
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Medicaid GME RECOMMENDATION 5: Medicaid graduate medical education (GME) funding should remain at the state's discretion.
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found that teaching hospitals were free to choose how to use Medicaid GME funds, and few states coordinate GME decisions regarding the number, location, or specialty of new residency positions. The committee suggests that the GME Policy Council consider the extent to which it might advise the CMS Center for Medicaid and CHIP Services4 and the state Medicaid programs on introducing transparency in their GME programs.
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2002. Accounting for graduate medical education funding in family practice training.
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1999. Report to the Congress: Rethink ing Medicare's payment policies for graduate medical education and teaching hospitals.
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A look at the costs and benefits of operating graduate medical education programs. Washington, DC: RAND Health.
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