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Tuesday Sep 23, 2014

GME: IOM Report Shines a Light on a Flawed System

It has been well documented that our nation faces a shortage of physicians, especially primary care physicians. Although there is agreement that our nation needs more physicians, there is disagreement on how to best educate and train a physician workforce capable of meeting the health care needs of the nation. What is clear, in the opinion of the AAFP, is that any attempt to simply expand our current system of graduate medical education (GME), will only produce more of the same and do little to meet the health care needs of our citizens.  

Our nation has long recognized the value of supporting GME, and the first federal investment came in 1944 as part of the G.I. Bill. The most important step, however, occurred in 1965 when the United States committed to a stable source of funding for GME through Medicare. During the next 49 years, there have been legislative adjustments to our GME system, but until recently there had never been a comprehensive analysis of the program’s purpose and effectiveness. The good news is that this is starting to change as a result of efforts from the AAFP and like-minded organizations.

During the past three to five years, a national discussion about the current and future physician workforce and the process by which we train physicians began. The AAFP has been at the center of these discussions, which have led to an increased effort to research, analyze and ask some thought-provoking questions about the structure, governance and financing of our GME system.  These activities have come from the AAFP, the U.S. Congress, foundations, think tanks, health services researchers and government advisory bodies such as the Medicare Payment Advisory Commission, the Council on Graduate Medical Education(www.hrsa.gov), and most recently, the Institute of Medicine (IOM).

On July 29, the IOM released its long-awaited report “Graduate Medical Education That Meets the Nation’s Health Needs.”(www.iom.edu) This report was encouraged by several academic organizations, but a 2011 letter from seven senators requesting a study of GME and its financing was the catalyst to the IOM taking on this important issue.  

The IOM report focused much of its attention on the relationship between GME financing and hospitals' priorities in physician training. The report notes that “giving funds directly to teaching hospitals, the payment system discourages physician training in the clinical settings outside the hospital where most people seek care. Primary care residency programs are at a distinct disadvantage because of their emphasis on training in ambulatory settings. Hospitals’ control over the allocation of GME funds may also encourage the overproduction of specialists in disciplines that generate financial benefits for an individual institution rather than for the health care system overall.”  

The report also questions the validity of proposed policies that would expand the overall number of funded GME positions by stating that “the available evidence suggests that increasing the production of physicians is not dependent on additional federal funding.”

Finally, the IOM report discusses the inherent inequities in the geographic distribution of GME positions and funding. Today, 65 percent of the nation’s residents and fellows (74,195) are trained in 12 states, and 78 percent of all residents and fellows (88,736) are trained in a state east of the Mississippi River.

The IOM report includes five recommendations on how to improve the GME system:

  • Maintain Medicare GME support at the current aggregate amount while taking essential steps to modernize GME payment methods based on performance, to ensure program oversight and accountability, and to incentivize innovation in the content and financing of GME. The current Medicare GME payment system should be phased out.
  • Build a GME policy and financing infrastructure.
  • Create one Medicare GME fund with two subsidiary funds.
  • Modernize Medicare GME payment methodology.
  • Medicaid GME funding should remain at a state’s discretion. However, Congress should mandate the same level of transparency and accountability in Medicaid GME as it will require under the changes in Medicare GME herein proposed.

The report has been met with mixed reactions in the health care community. Many of the nation’s academic health centers, colleges of medicine and hospitals issued negative statements, essentially stating that the recommendations of the IOM would destroy our nation’s GME system. Of course, we must be mindful that most of those expressing the strongest opposition are the ones that benefit most from the status quo. Overall, the AAFP is pleased with the content and direction of the report. Although we would prefer more immediate actions, the IOM report closely aligns with the AAFP's view of what comprehensive GME reform should accomplish.  

As noted, the IOM report has opened communication channels, and a robust discussion on GME reform is occurring in Washington, D.C. The AAFP is seizing this opportunity, and on Sept. 15 we released “Aligning Resources, Increasing Accountability and Delivering a Primary Care Physician Workforce for America." You can read more about the Academy's proposal in a recent AAFP Leaders Voices Blog post by AAFP Board Chair Jeff Cain, M.D., and in AAFP News.

Although recent activities are encouraging and support the AAFP’s policy and advocacy objectives, change will not come independent of resistance. The American Hospital Association, in response to the IOM recommendations, stated that “cuts to GME funding would jeopardize the ability of teaching hospitals to train the next generation of physicians. They would limit the ability of teaching hospitals to offer state-of-the-art clinical and educational experiences.”  The association went on to state that “reductions in the IME adjustment would directly threaten the financial stability of teaching hospitals.”

At least they are honest. The key words in these sentences are “state-of-the-art” and “financial stability.” GME has been and continues to be a revenue stream for hospitals, not an education mission. We must shine a light on the shortcomings of our GME financing and governance structure, and the AAFP is just warming up its spotlight.

Posted at 09:00AM Sep 23, 2014 by Shawn Martin

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Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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