Graduate Medical Education Funding Does Not Flow to Primary Care Physician Production.

Graduate medical education (GME) funding consists of more than $10 billion annual subsidies awarded to academic hospitals to offset the cost of resident training. Critics have questioned the utility of these subsidies and accountability of recipient hospitals. To determine the association of GME funding with hospital performance by examining 3 domains of hospital operations: financial standing, clinical outcomes, and resident academic performance. This study is an economic evaluation of all academic centers that received GME funding in 2017. GME funding data were acquired from the Hospital Compare Database. Statistical analysis was performed from May 2016 to April 2020. GME funding. This study assessed the association between GME funding and each aspect of hospital operations. Publicly available hospital financial data were used to calculate a financial performance score from 0 to 100 for each hospital. Clinical outcomes were defined as 30-day mortality, readmission, and complication rates for a set of predefined conditions. Resident academic performance was determined by Board Certification Examination (BCE) pass rates at 0, 2, and 5 years after GME funding was awarded. Confounder-adjusted linear regression models were used to test association between GME funding data and a hospital's financial standing, clinical outcomes, and resident academic performance. The sample consisted of 1298 GME-funded hospitals, with a median (IQR) of 265 (168-415) beds and 32 (10-101) residents per training site. GME funding was negatively correlated with hospitals' financial scores (β = -7.9; 95% CI, -10.9 to -4.8, P = .001). Each additional $1 million in GME funding was associated with lower 30-day mortality from myocardial infarction (-2.34%; 95% CI, -3.59% to -1.08%, P < .001), heart failure (-2.59%; 95% CI, -3.93% to -1.24%, P < .001), pneumonia (-2.20%; 95% CI, -3.99% to -0.40%, P = .02), chronic obstructive pulmonary disease ( -1.20%; 95% CI, -2.35% to -0.05%, P = .04), and stroke (-3.40%; 95% CI, -5.46% to -1.33%, P = .001). There was no association between GME funding and readmission rates. There was an association between higher GME funding and higher internal medicine BCE pass rates (0.066% [95% CI, 0.033% to 0.099%] per $1 million in GME funding; P < .001). This study found a negative linear correlation between GME funding and patient mortality and a positive correlation between GME funding and resident BCE pass rates in adjusted regression models. The findings also suggest that hospitals that receive more GME funding are not more financially stable.

GME financing reform: the saga continues.

Although recent estimates predict a large impending shortage of plastic surgeons, graduate medical education funding through the Centers for Medicare and Medicaid Services remains capped by the 1997 Balanced Budget Act. The authors' aim was to develop a plan to stimulate legislative action. The authors reviewed responses of the American Society of Plastic Surgeons, American College of Surgeons, and American Medical Association from January of 2015 to a House Energy & Commerce Committee request for input on graduate medical education funding. In addition, all program directors in plastic surgery were surveyed through the American Council of Academic Plastic Surgeons to determine their graduate medical education funding sources. All three organizations agree that current graduate medical education funding is inadequate to meet workforce needs, and this has a significant impact on specialty selection and distribution for residency training. All agreed that funding should be tied to the resident rather than to the institution, but disagreed on whether funds should be divided between direct (allocated to residency training) and indirect (allocated to patient care) pools, as is currently practiced. Program directors' survey responses indicated that only 38 percent of graduate medical education funds comes from the Centers for Medicare and Medicaid Services. Organized medicine is at risk of losing critically needed graduate medical education funding. Specific legislation to support additional graduate medical education positions and funding (House Resolutions 1180 and 4282) has been proposed but has not been universally endorsed, in part because of a lack of collaboration in organized medicine. Collaboration among major organizations can reinvigorate these measures and implement real change in funding.

Fixing the Primary Care Pipeline: The Role of Teaching Health Centers

To determine whether changes in graduate medical education (GME) funding have had an impact on emergency medicine (EM) residency training programs. A 34-question survey was mailed to the program directors (PDs) of all 115 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs in the United States in the fall of 1998, requesting information concerning the impact of changes in GME funding on various aspects of the EM training. The results were then compared with a similar unpublished survey conducted in the fall of 1996. One hundred one completed surveys were returned (88% response rate). Seventy-one (70%) of the responding EM residency programs were PGY-I through PGY-III, compared with 55 (61%) of the responding programs in 1996. The number of PGY-II through PGY-IV programs decreased from 25 (28%) of responding programs in 1996 to 17 (16%). The number of PGY-I through PGY-IV programs increased slightly (13 vs 10); the number of EM residency positions remained relatively stable. Fifteen programs projected an increase in their number of training positions in the next two years, while only three predicted a decrease. Of the respondents, 56 programs reported reductions in non-EM residency positions and 35 programs reported elimination of fellowship positions at their institutions. Only four of these were EM fellowships. Forty-six respondents reported a reduction in the number of non-EM residents rotating through their EDs, and of these, 11 programs reported this had a moderate to significant effect on their ability to adequately staff the ED with resident physicians. Sixteen programs limited resident recruitment to only those eligible for the full three years of GME funding. Eighty-seven EM programs reported no change in faculty size due to funding issues. Sixty-two programs reported no change in the total number of hours of faculty coverage in the ED, while 34 programs reported an increase. Three EM programs reported recommendations being made to close their residency programs in the near future. Changes in GME funding have not caused a decrease in the number of existing EM residency and fellowship training positions, but may have had an impact in other areas, including: an increase in the number of EM programs structured in a PGY-I through PGY-III format (with a corresponding decrease in the number of PGY-II through PGY-IV programs); a decrease in the number of non-EM residents rotating through the ED; restriction of resident applicants who are ineligible for full GME funding from consideration by some EM training programs; and an increase in the total number of faculty clinical hours without an increase in faculty size.

Graduate medical education funding mechanisms, challenges, and solutions: A narrative review

As funding for graduate medical education continues to decline, finding sources of funding for orthopaedic resident education is a major issue for residency programs, health systems, the American Academy of Orthopaedic Surgeons (AAOS), and the American Orthopaedic Association (AOA). The majority of funding for orthopaedic residency programs in the United States includes federal funding from Medicare and Medicaid to the academic health center, funding from faculty and endowments, contributions from individual hospitals and institutions, and industry financial support of courses and the provision of other educational resources1-10. With the continued decrease in federal government funding for graduate medical education and the decrease in funding from industry secondary to concerns about conflicts of interest, many residency programs may need to evaluate other sources of funding to meet the educational needs of their residents. We conducted a survey of residency program directors and chairs to better understand the funding sources for their educational programs. In addition, we sought to define the role of industry funding in resident education. The AAOS staff and the AAOS Washington Health Policy Fellows designed a survey regarding funding for orthopaedic graduate medical education and the impact of industry support in funding graduate medical education activities (see Appendix). A web-based survey was developed and administered to orthopaedic residency program directors or chairs in the AAOS database. Questions were formatted and the data collection tool was developed by the Department of Research and Scientific Affairs of the AAOS to ensure proper survey format and to minimize response bias11-13. In August 2008, residency program directors or chairs were contacted to apprise them of the survey. One week after the announcement, the survey link was distributed to 149 residency program directors or chairs (one contact per residency program). Three reminder e-mails were subsequently …

Recent changes by the Health Care Financing Administration (HCFA) have resulted in decreased Medicare support for emergency medicine (EM) residencies. To determine the effects of reduced graduate medical education (GME) funding support on residency size, resident rotations, and support for a fourth postgraduate year (PGY) of training and for residents with previous training. A 36-question survey was developed by the Council of Emergency Medicine Residency Directors (CORD) committee on GME funding and sent to all 122 EM program directors (PDs). Responses were collected by the Society for Academic Emergency Medicine (SAEM) office and blinded with respect to the institution. Of 122 programs, 109 (89%) responded, of which 78 were PGY 1-3 programs, 19 were PGY 2-4, and 12 were PGY 1-4. The PDs were asked specifically whether there were changes in program size due to changes in Medicare reimbursement. Although few programs (12%) decreased their size or planned to decrease their size, 39% had discussions regarding decreasing their size. Thirty percent of the PDs responded that other programs at their institution had already decreased their size; 26% of the PDs had problems with financing outside rotations; and 24% had a decrease in off-service residents in their emergency departments (EDs). Only seven (6%) of programs paid residents from practice plan dollars, while most (82%) were fully supported by federal GME funding. Nearly all four-year programs (97%) received full resident salary support from their institutions and 77% of programs accept residents with previous training. Nearly all EM programs are fully supported by their institutions, including the fourth postgraduate year. Most programs take residents with previous training. Although few programs have reduced their size, many are discussing this. Many programs have had difficulty with funding off-service rotations and many have had decreased numbers of off-service residents in their EDs. Recent GME funding changes have had adverse effects on EM residency programs.

The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require "all-payer" support.

Rasouli and Willson disagree with our interpretation of our findings and our presentation of previous policy recommendations issued by the Council on Graduate Medical Education (COGME) and by the Medicare Payment Advisory Commission (MedPAC). Rasouli and Willson suggest that our finding that 54.9% of expanded positions are projected to continue after expiration of the Primary Care Residency Expansion (PCRE) grants should be interpreted as a “glass half full” rather than “glass half empty” finding. Although we acknowledge that the PCRE program grants have resulted in some meaningful gains in primary care residency positions, our study findings suggest that the outcomes will fall well short of the program’s stated goal of sustaining all added positions to achieve long-term increases in the production of primary care physicians. We find it difficult to share Rasouli and Willson’s optimism about the sustainability of the expanded positions when 73.1% of responding programs lack full funding for the final year of training for their current intern class of expanded residents (Class of 2018). Rasouli and Willson assert that we misinterpreted the recommendations of COGME and MedPAC. In fact, the 21st COGME report1 recommends that transitional graduate medical education (GME) positions “should be reallocated to existing or new residency programs that meet the objectives outlined in the preceding recommendations.” The report’s preceding recommendations include prioritizing an increase in GME funding toward primary care. The 20th COGME report2 likewise promotes “implementing new methods of funding to include reallocation of existing GME funding” and “reallocating GME funding to primary care residencies.” Similarly, MedPAC3 advocates for “a more accountable GME payment system … [that] likely will result in redistribution of current Medicare GME payments.” The time-limited grants initiated by the Health Resources and Services Administration (HRSA) are an excellent starting point for developing innovative programs aimed at addressing the nation’s health needs. We agree with organizations such as the Association of American Medical Colleges on the importance of HRSA continuing to administer grant programs that enhance health workforce development. However, we stand by our conclusion that research evidence indicates that these types of grant programs are insufficient to solve the nation’s primary care physician shortage. Shifting a greater share of the entering physician workforce into primary care fields will require facing the politically challenging task of reforming the nation’s largest source of entitlement funding for residency training, Medicare GME. Rossan Melissa Chen, MD, MSc Associate physician, Kaiser Permanente Napa-Solano, Vallejo, California; [email protected] Kevin Grumbach, MD Professor and chair, Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California.

ACGME, Osteopaths Fail to Reach Deal on Accreditation: 18-Month Negotiations Collapse

Challenges Facing Academic Urology Training Programs: An Impending Crisis

As a result of the decisions made in the Summer of 2011 to increase the federal debt limit of the United States,1 the Joint Select Committee on Deficit Reduction (the “Super Committee”) was formed to recommend to the Congress by 12 2011 reductions in federal spending to be accomplished over the next 10 years. Among the entitlement program elements being examined by the Super Committee, Medicare reimbursement for Graduate Medical Education (GME), the primary source of GME funding in the United States, has been identified as an opportunity for spending reductions. Specifically, the Medicare Payment Advisory Commission (MedPAC) has indicated that approximately 50% of the Indirect GME Reimbursement is not “empirically justified” on the basis of current costs of teaching hospitals intended to be covered by that reimbursement.2 This is seen by many as an opportunity for reduction. Furthermore, the Simpson Bowles Commission recommended a reduction in total GME funding in excess of 50% ($60 billion over 10 years) as a component of a comprehensive strategy to reduce federal deficit spending.3 This discussion occurs in the context of a predicted physician shortage, a mounting surge in the number of domestic graduates of schools of allopathic and osteopathic medicine designed to remedy that anticipated physician shortage,4 and slow growth in GME output over the past decade.5 However, this increase in medical school output must be accompanied by an increase in Graduate Medical Education, which is the required final pathway to entry into the unsupervised practice of medicine in the United States. As the body charged by the public and the profession with accreditation oversight of the vast majority of the GME programs in the United States, and to measure the quality of educational opportunities for physicians as they seek to prepare to meet the needs of the American public, the Accreditation Council for Graduate Medical Education (ACGME) attempted to estimate the impact of reductions in GME funding of the magnitude under discussion in our nation's capital on the educational pipeline for physicians.

IN THE mid-1970s, US government officials and other health policymakers began expressing concerns about the impact of physician maldistribution, both by specialty and by location, on the provision of medical care. 1-3 Government committees were established to study the problem and determine how the organization and financing of the nation's graduate medical education (GME) system was a contributing factor. 4,5 Stimulated by the government's interest, professional organizations and foundations sponsored independent studies of the relation between physicians' choice of specialty and location and the organization of GME. In general, these groups concluded that the policymakers' concerns were legitimate and the imbalances could not be effectively redressed without changing the way GME is organized and financed. 6-8 Although many in the medical profession agree that the policymakers' concerns are legitimate, there is still no concensus within the profession as to how the GME system should be reformed to improve physician specialty

Residency redesign: much to do.