Fixing the way the federal government funds America's graduate medical education (GME) has long been an AAFP priority, and a recent letter(15 page PDF) to the House Energy and Commerce Committee is further evidence of that concern.
The Jan. 5 correspondence was in response to the committee's Dec. 6, 2014, request for comment on GME reform.
The AAFP and the Council of Academic Family Medicine (CAFM) -- which comprises the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors and the North American Primary Care Research Group -- recognized that the call for public comment signaled a willingness by the House committee members to evaluate national policy on the structure and financing of the U.S. GME system.
The organizations collaborated to refine a response to seven questions the committee posed.
The joint letter pointed out some of the more pressing concerns with a GME payment system that requires no accountability from academic health centers for the nearly $9 billion in taxpayer money they receive annually. It asked that GME funding better support community-based training and argued that institutions receiving federal GME money have an obligation to prove they are producing enough primary care physicians.
- Graduate medical education funding should better support community-based training and help alleviate the nation's shortage of primary care physicians, the AAFP and the Council of Academic Family Medicine wrote in response to a call for comment from the House Energy and Commerce Committee.
- The current system encourages the wrong mix of specialty training, the organizations wrote.
- The organizations referred legislators to a proposal to align resources and increase accountability that the AAFP published last year.
Breaking Down Funding
The House committee asked how the GME financing system could become efficient, effective and stable. The AAFP and CAFM responded by reflecting on the current system's failure to produce "an appropriate physician workforce" to care for the country's population.
"This system lacks accountability and transparency. It rewards a select few states while other states and regions struggle to produce a physician workforce for their residents," said the letter. "The most important GME reforms the committee should pursue are those that would decouple GME financing from the hospital payment system."
The letter pointed committee members to a comprehensive GME proposal(7 page PDF) released by the AAFP in September 2014 that addressed possible changes to GME financing, as well as other issues. The proposal's five-point plan recommended ways to align resources(2 page PDF) and increase accountability.(1 page PDF)
The letter restated those recommendations, including a requirement that all sponsoring institutions and teaching hospitals seeking new Medicare- and/or Medicaid-financed GME positions meet minimum primary care training thresholds as a condition of their expansion.
The organizations acknowledged that the country's need for physicians went beyond just primary care, but said the need for primary care was "most acute."
"An appropriately sized primary care workforce will reduce the growth in health care expenditures and increase quality outcomes," they said.
The two organizations agreed with the committee's suggestion to make federally funded GME training opportunities available in both rural and urban areas. They noted that the geographic distribution of Medicare-funded GME training slots was "essentially frozen based on the location of residencies in 1996" and offered solutions including the reauthorization of "teaching health center" grant awards overseen by the Health Resources and Services Administration.
The letter noted the success of the Teaching Health Center Graduate Medical Education (THCGME) program since its inception in 2011 and pointed to the increase since then in the number of physicians trained in primary care specialties.
"Currently there are 60 THCGME programs operating in 24 states and training more than 550 primary care physicians and dentists in the most needed shortage specialties," said the letter. It noted the uncertainty surrounding future funding of the program that is undermining confidence among potential applicants to the program.
Assessing Workforce Needs
The AAFP and CAFM responded with a resounding "No" when asked whether the current GME financing structure met the current and future needs of the health care workforce, saying the system was "too closely aligned with hospital-based care and services." They cited long-standing research that showed physician training was centralized in the care sites least sought by patients -- hospital clinics and academic health centers.
"More importantly, why do we provide financial incentives to those sites least used by our population?" they asked. "Despite these facts, GME dollars continue to flow through hospitals."
The AAFP and CAFM suggested that the nation's physician training system "should be more closely aligned with our delivery system, which is no longer hospital-centric." They backed the assertion with comments from the Institute of Medicine (IOM) and the Council on Graduate Medical Education as well as with articles published in the journals Archives of Internal Medicine and Academic Medicine.
Citing the IOM report, the letter added, "By giving the 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 care settings."
The letter recommended three major reforms to the financing structure: allocating at least 33 percent of institutions' full-time equivalent slots to primary care, limiting federal support to first-certificate training programs (or the 25 primary specialties that make up the 150 unique disciplines in medicine), and requiring that sponsoring institutions and teaching hospitals seeking new Medicare- and/or Medicaid-financed GME positions "meet minimum primary care training thresholds as a condition of their expansion."
The AAFP and CAFM argued that the issue at hand was not the quality of existing training programs but the wrong mix of specialty training that the system incentivizes. With GME payment focused on hospital-based physician training, the emphasis remained on acute hospital care, noted the letter. Community-based specialties such as family medicine and geriatrics encompass training beyond the hospital setting and include priorities such as chronic disease management and preventive health. Those specialties deserve support, the letter added.
The organizations praised IOM suggestions calling for a single Medicare GME fund with two subsidiary funds and eliminating federal funding for fellowships in subspecialties.
Serving Patients First
The letter also noted that the current system of allocating and paying for residency slots does not meet the needs of the population but, instead, excels at "preparing highly trained subspecialists and physician researchers." Meanwhile, the AAFP and CAFM said, the nation faces a shortage of primary care physicians and a maldistribution of physicians that causes acute shortages in some rural and underserved areas.
"Family medicine recommends that Congress address both sides of the primary care physician shortage," said the letter. It urged holding training institutions accountable for producing a portion of primary care physicians, ensuring that federal GME funding includes residency programs outside of large academic hospitals and focusing on team-based primary care in underserved areas.
Finally, the letter advocated a continuation of strong state roles in defining the nation's health care workforce and agreed with an IOM report calling for states to maintain their control of Medicaid GME funding.
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