Graduate Medical Education That
Meets the Nation’s Health Needs
Understanding the IOM Recommendations
WEBINAR
Gail R. Wilensky, Ph.D., Project HOPE
Debra Weinstein, M.D., Partners Healthcare System, Inc.
Deborah E. Powell, M.D., University of Minnesota Medical School
Webinar Agenda
Welcome
Jill Eden, M.B.A., M.P.H., Institute of Medicine
Study Overview
Gail Wilensky, Ph.D., Project HOPE
GME Financing
Debra Weinstein, M.D., Partners Healthcare System, Inc.
GME Governance
Deborah E. Powell, M.D., University of Minnesota Medical School
Q&A and Discussion
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Study Overview
Gail Wilensky, Ph.D., Project HOPE
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Current Health Care Context
• Mismatch between the health needs of the population and specialty
make-up of the physician workforce
• Persistent geographic maldistribution of physicians
• Insufficient diversity in the physician population
• Gap between new physicians’ knowledge and skills and the competencies
required for current medical practice
• Lack of fiscal transparency
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Study Origin
Broad support for the study—12 sponsors and 11 U.S. senators
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Charge to the Committee
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Composition of Committee
21 members, including experts in
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GME financing
Residency training (allopathic and osteopathic)
Undergraduate medical education
Nursing and PA education
Health care systems management
Physician training in teaching hospitals and health centers, large
academic medical centers, VA facilities, rural areas, safety-net
institutions
• Medicare and Medicaid
• Health and labor economics
• Accreditation and licensure
For complete committee list, visit www.iom.edu/GME
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Approach to the Study
To what extent is the current GME system producing an appropriately
balanced physician workforce ready to provide high-quality, patientcentered, and affordable health care?
• Justification and rationale for continuing to fund GME through Medicare or
other federal sources
• Economist’s perspective that residents, not teaching sites, bear the cost of
training
• GME system is a powerful influence over the makeup, skills, and knowledge
of the physician workforce
• Focus on Medicare: maximize leverage of federal support and minimize
barriers to progress
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Key Findings: Physician Workforce
• Forecasts of future physician shortages
― Vary in magnitude; historically unreliable
•
number of physicians won’t resolve imp. workforce issues
― Particularly with respect to specialty and geography
•
number of trained physicians not dependent on
― Residencies
•
ing Medicare funds
17.5% 2003-2012 despite cap on Medicare-funded spots
ingly specialized workforce being trained
• Newly trained physicians lack needed office-based skills
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Recommendations
Recommendation 1:
“Invest strategically”: maintain DME plus IME funding; move to a performancebased system
Recommendation 2:
Build a GME policy and financing infrastructure: including a policy council in HHS
and a GME Center in CMS
Recommendation 3:
Create one Medicare GME fund with two subsidiary funds: operational fund and
transformation fund
Recommendation 4:
Modernize Medicare GME payment methodology: move to a single per resident
payment (geographically adjusted) made to the sponsoring organization
Recommendation 5:
Medicaid GME funding as discretionary but with similar accountability/transparency
requirement
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GME Financing
Debra Weinstein, M.D., Partners Healthcare System, Inc.
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Key Findings: GME Financing
— An estimated $15B in federal funding
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Medicare GME Payment Methods
• Medicare GME payments are based on rigid, statutory formulas developed in
an era when hospitals were the central site for physician training
• Funds are distributed directly and primarily to teaching hospitals, with minimal
reporting requirements
• Two independent funding streams—direct graduate medical education
(DGME) and indirect medical education (IME)—are each tied to a hospital’s
volume of Medicare inpatients
• Medicare-supported physician training slots are capped at each hospital’s
resident census in 1996
• The financial impact of sponsoring residency programs is poorly understood
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Key Findings: GME Financing
• Medicare GME payments are
• Inflexible – constrain funding for new programs and for training in
non-hospital sites
• Inequitable – payments tied to historical costs; subset of institutions
and specialties excluded
• Inscrutable – complicated formulas; confusion over purpose, flow and
use of funds
• Illogical – tied to volume of Medicare patients; funding directed only
to PPS institutions
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Recommendation 1
Invest Strategically
• Maintain Medicare GME funding (sum of current DME & IME),
adjusted for inflation
• Phase-in an improved distribution methodology
• Move to a performance-based system
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Recommendation 3
Create one Medicare GME fund
with two subsidiary funds
• A GME Operational Fund to distribute ongoing support for residency training
positions that are currently approved and funded
• A GME Transformation Fund to finance initiatives to develop and evaluate
innovative GME programs, to determine and validate appropriate GME performance
measures, to pilot alternative GME payment methods, and to award new Medicarefunded GME training positions in priority disciplines and geographic areas
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Recommendation 4
Modernize Medicare GME payment methodology
• Combine IME and DME funding streams into a single payment
• Distribute funds based on a national per-resident amount (PRA), with a geographic
adjustment, where PRA = total value of the GME Operational Fund
current # Medicare-funded training slots
• Provide GME operational funds directly to sponsoring organizations
• Utilize Transformation Fund to
• Pilot new funding methodologies designed to achieve explicit outcomes
• Explore new approaches to GME that will enhance efficiency and outcomes
• Develop metrics needed for an outcomes-based payment system
• Fund additional positions in needed areas
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Committee’s
Proposed Medicare
GME Funding Flow
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Allocation of Medicare GME Funds to the
Operational and Transformation Funds Over Time
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GME Governance
Deborah E. Powell, M.D., University of Minnesota Medical School
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Current GME Governance
• No overarching system to guide GME funding in the interests of the nation’s
health or local/regional workforce needs
• CMS acts as passive conduit for distribution of funds to teaching hospitals
• Program outcomes are neither measured nor reported
• Only requirement is accreditation
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Program Accreditation and Physician
Certification and Licensure
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Key Findings: Governance
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Absence of transparency
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No group accountable/responsible for producing needed specialty mix
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Guaranteed financing as long as accredited
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Accreditation is important but …
…doesn’t address local/national health priorities
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Fundamental Questions About Medicare GME
Program’s Outcomes and Effectiveness
• What is the financial impact of residency programs?
• Do these programs produce competent doctors?
• How much funding does each institution receive annually? How much of this
goes toward education?
• What are the characteristics and specialties of residents supported by
Medicare GME funds?
• How many of these residents go on to practice in underserved specialties,
locate in underserved areas, or accept Medicare/Medicaid patients?
• What proportion of residents’ time is spent in hospital inpatient, outpatient,
or community settings?
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Minimum Requirements for Organizational
Infrastructure for GME Financing
• Robust resources with sufficient expert staff and the capacity to conduct or
sponsor demonstrations of alternative payment methods
• Regulatory authority to administer Medicare GME spending and oversee
GME payment policies
• Independence and objectivity with protections from conflicts of interest
• A governing body selected with appropriate expertise
• A mechanism to solicit input
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Governance Models Considered by the
Committee
• National Health Care Workforce Commission
• Private entity
• Federal agencies—COGME, MedPAC
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Recommendation 2
Build a GME policy and financing infrastructure
• Create adequately resourced GME policy council in HHS OS
― Develop a strategic plan for GME funding
― Sponsor research re physician workforce sufficiency
― Coordinate activities between fed agencies and accrediting/certifying organizations
• Establish GME center within CMS
― Manage and distribute funds consistent with policy council decisions
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Recommendation 5
Medicaid GME
• Medicaid-funded GME
― Should remain at state’s discretion
― Adopt same accountability/transparency standards as Medicare
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Q&A and
Discussion
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Thank you!
Visit
www.iom.edu/GME
to download the complete report
and access related resources
For more information:
Jill Eden (jeden@nas.edu)
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