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Wednesday Sep 17, 2014

GME Reform: An AAFP Call to Action

Primary care is the foundation of high-performing health care systems throughout the world, but in the United States, we primary care physicians make up less than one-third of the physician workforce, and our numbers are dropping.

 I talked about the need to reform the graduate medical education system during a presentation Sept. 15 in Washington. Other speakers, from left, were pediatrician Fitzhugh Mullan, M.D.; Kisha Davis, M.D., M.P.H., the new physician member of the AAFP Board of Directors; AAFP President Reid Blackwelder, M.D.; and AAFP EVP and CEO Douglas Henley, M.D.

A growing number of organizations -- including the Association of American Medical Colleges, the Council on Graduate Medical Education (COGME), the Pew Health Professions Commission and the Robert Wood Johnson Foundation -- have stated that at least 40 percent of U.S. medical graduates need to enter primary care fields if we are to meet the needs of our nation's health care system. But our current GME system is failing to hit that mark because nearly 80 percent of new physicians are choosing subspecialty careers. We are rapidly falling behind.

A primary care physician shortage already exists, and it will only be exacerbated by our changing health care needs: a growing population, the increase in chronic disease seen in our aging population and expansion of health insurance coverage.

The calls for change are mounting. Last year, COGME -- which was created by Congress to provide assessments of physician workforce issues -- released a report that called for drastic changes in the GME system, including increased funding to support 3,000 more graduates per year and prioritized funding for high-priority specialties, including family medicine.

Just this July, the Institute of Medicine released its analysis of GME in the United States and found that the current system lacks transparency and accountability and is producing a physician workforce that doesn't meet the country's needs -- despite an annual $15 billion investment from U.S. taxpayers.

On analysis, it's not surprising that our current GME system produces the outcomes that it does, because funneling funds through hospitals leads to residency workforce decisions based on the financial needs of those local institutions and not on the overall needs of our health care system.

This week, I was pleased to join other AAFP leaders on Capitol Hill as we took things a step further, unveiling a new budget-neutral proposal that would address those issues of transparency and accountability while aligning funding resources with actual workforce needs. The Academy's proposal recommends that policymakers and legislators take the following steps:

  • Establish primary care thresholds and maintenance-of-effort requirements for all sponsoring institutions and teaching hospitals that currently receive Medicare and Medicaid GME financing.
  • Require all sponsoring institutions and teaching hospitals seeking new Medicare- and Medicaid-financed GME positions to allocate one-half of their new positions to primary care.
  • Limit direct GME and indirect medical education (IME) payments to training for "first-certificate" residency programs. Repurposing funding currently spent on fellowship training would be used to create more than 7,500 new first-certificate residency training positions.
  • Align financial resources with population health care needs through a 0.25 percent reduction in IME payments and reallocation of those resources to support community-based primary care training.
  • Fund the National Health Care Workforce Commission. The Patient Protection and Affordable Care Act created this panel to review health care workforce supply and demand, but Congress has failed to allocate funding for it.

Yet it is important to note that the current and future physician workforce cannot be corrected through GME reform alone.

Earlier this year, a task force created by the Council of Academic Family Medicine -- which comprises the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the Society of Teachers of Family Medicine and the North American Primary Care Research Group -- with support from the AAFP, the AAFP Foundation and the American Board of Family Medicine, created the "Four Pillars for Primary Care Workforce Reform" concept, a comprehensive approach that includes:

  • the medical school pipeline,
  • the process of medical education, 
  • improving the practice environment for a more rewarding professional setting and 
  • primary care payment reform.  

Even as we work on all of these comprehensive reforms, changing the GME system is one of the most important policy levers we can pull now because of the vast government investment in the program and the multiple recent national reports calling for reform. Our GME system is stale. It was created in 1965 -- a different time -- and for a different purpose. Now, it is one of the few areas of the health care system that has not experienced major disruption in composition, function or financing.

Please join me in engaging our nation's leaders in a conversation about why our GME system should be reformed. It is time for the investment our nation makes in GME to be transparent and accountable and to produce the physician workforce our country needs and deserves.

Jeff Cain, M.D., is board chair of the AAFP.

Posted at 09:36PM Sep 17, 2014 by Jeffrey Cain, M.D.

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