In Reply to Rasouli and Willson.

Abstract

Letters to the Editor “unrealistic” and advocate “systematic reform of GME financing” instead. They also incorrectly contend, “Both the [Council on Graduate Medical Education] COGME and the Medicare Payment Advisory Commission (MedPAC) have proposed reallocating existing Medicare GME funds paid to teaching hospitals in order to support more primary care residency positions and fewer specialty residency positions.” While COGME 2 and MedPAC 3 cite the importance of strengthening primary care training, neither recommends reallocating GME funding from specialty to primary care. The COGME report cited by the authors recommends, “Congress should continue funding for current GME positions, while increasing funding for additional positions.” Further, “increases in GME funding should be directed toward … high priority specialties,” specifying both primary care and specialty disciplines. Likewise, MedPAC suggests a “rigorous, independent workforce analysis is imperative to inform the most efficient use of these funds,” without predetermining the outcome. We share the authors’ concern that a grant-based GME financing system would destabilize physician training, and that as financial pressures grow, hospitals’ ability to absorb training costs could shrink. We need a multifaceted strategy that includes expanded Medicare GME support and recognizes the unique value of targeted initiatives supported by the Health Resources and Services Administration (HRSA), like PCRE. The Association of American Medical Colleges supports HRSA’s workforce programs, including PCRE. The authors’ findings underscore that faced with physician shortages, we should increase investments in successful physician workforce development programs, including, but not limited to, HRSA-funded initiatives. Disclosures: None reported. Tannaz Rasouli, MPH Director, Government Relations, Association of American Medical Colleges, Washington, DC. Peters D. Willson, MPPM Senior Specialist, Policy and Constituency Issues, Association of American Medical Colleges, Washington, DC; pwillson@aamc.org. References 1 Chen RM, Petterson S, Bazemore A, Grumbach K. Are time-limited grants likely to stimulate sustained growth in primary care residency training? A study of the primary care residency expansion program. Acad Med. 2015;90:1278–1283. 2 Council on Graduate Medical Education. 21st report: Improving value in graduate medical education. Published August 2013. http://www. hrsa.gov/advisorycommittees/bhpradvisory/ cogme/Reports/twentyfirstreport.pdf. Accessed August 25, 2015. 3 Medicare Payment Advisory Commission. Chapter 4. Graduate medical education financing: Focusing on educational priorities. Published June 2010. http://www.medpac. gov/documents/reports/Jun10_Ch04. pdf?sfvrsn=0. Accessed August 25, 2015. In Reply to Rasouli and Willson: 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 report 1 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 Academic Medicine, Vol. 90, No. 12 / December 2015 funding toward primary care. The 20th COGME report 2 likewise promotes “implementing new methods of funding to include reallocation of existing GME funding” and “reallocating GME funding to primary care residencies.” Similarly, MedPAC 3 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. Disclosures: None reported. Rossan Melissa Chen, MD, MSc Associate physician, Kaiser Permanente Napa-Solano, Vallejo, California; rossan.m.chen@kp.org. Kevin Grumbach, MD Professor and chair, Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California. References 1 Council on Graduate Medical Education. 21st report: Improving value in graduate medical education. August 2013. http://www. hrsa.gov/advisorycommittees/bhpradvisory/ cogme/reports/twentyfirstreport.pdf. Accessed September 2, 2015. 2 Council on Graduate Medical Education. 20th report: Advancing primary care. December 2010. http://www.hrsa.gov/ advisorycommittees/bhpradvisory/cogme/ reports/twentiethreport.pdf. Accessed September 2, 2015. 3 Medicare Payment Advisory Commission. Chapter 4. Graduate medical education financing: Focusing on educational priorities. In: Report to the Congress: Aligning incentives in Medicare. June 2010. http://www.medpac.gov/documents/ reports/Jun10_Ch04.pdf?sfvrsn=0. Accessed September 2, 2015. Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.