Direct Graduate Medical Education Research Articles

The Influence of Anti-LGBTQIA+ Legislation on Graduate Medical Education

The Influence of Anti-LGBTQIA+ Legislation on Graduate Medical Education

Rural Residency Training as a Strategy to Address Rural Health Disparities: Barriers to Expansion and Possible Solutions.

Rural Residency Training as a Strategy to Address Rural Health Disparities: Barriers to Expansion and Possible Solutions.

The Value of Surgical Graduate Medical Education (GME) Programs Within An Integrated Health Care System

Surgical graduate medical education (GME) programs add both significant cost and complexity to the mission of teaching hospitals. While expenses tied directly to surgical training programs are well tracked, overall cost-benefit accounting has not been performed. In this study, we attempt to better define the costs and benefits of maintaining surgical GME programs within a large integrated health system. We examined the costs, in 2018 US dollars, associated with the surgical training programs within a single health system. Total health system expenses were calculated using actual and estimated direct GME expenses (salary, benefits, supplies, overhead, and teaching expenses) as well as indirect medical education (IME) expenses. IME expenses for each training program were estimated by using both Medicare percentages and the Medicare Payment Advisor Commission study. The projected cost to replace surgical trainees with advanced practitioners or hospitalists was obtained through interviews with program directors and administrators and was validated by our system's business office. A physician lead, integrated, rural health system consisting of 8 hospitals, a medical school and a health insurance company. GME surgical training programs within a single health system's department of surgery. Our health system's department of surgery supports 8 surgical GME programs (2 general surgery residencies along with residencies in otolaryngology, ophthalmology, oral-maxillofacial surgery, urology, pediatric dentistry, and vascular surgery), encompassing 89 trainees. Trainees work an average of 64.4 hours per week. Total health system cost per resident ranged from $249,657 to $516,783 based on specialty as well as method of calculating IME expenses. After averaging program costs and excluding IME and overhead expenses, we estimated the average annual cost per trainee to be $84,171. We projected that replacing our surgical trainees would require hiring 145 additional advanced practitioners at a cost of $166,500 each per year, or 97 hospitalists at a cost of $346,500 each per year. Excluding overhead, teaching and IME expenses, these replacements would cost the health system an estimated additional $16,651,281 or $26,119,281 per year, respectively. Surgical education is an integral part of our health system and ending surgical GME programs would require large expansion of human resources and significant additional fiscal capital.

Envisioning a Future Governance and Funding System for Undergraduate and Graduate Medical Education.

Funding for graduate medical education (GME) and undergraduate medical education (UME) in the United States is being debated and challenged at the national and state levels as policy makers and educators question whether the multibillion dollar investment in medical education is succeeding in meeting the nation's health care needs. To address these concerns, the authors propose a novel all-payer system for GME and UME funding that equitably distributes medical education costs among all stakeholders, including those who benefit most from medical education. Through a "Medical Education Workforce (MEW) trust fund," indirect and direct GME dollars would be replaced with a funds-flow mechanism using fees paid for services by all payers (Medicaid, Medicare, private insurers, others) while providing direct compensation to physicians and institutions that actively engage medical learners in providing clinical care. The accountability of those receiving MEW funds would be improved by linking their funding levels to their ability to meet predetermined institutional, program, faculty, and learner benchmarks. Additionally, the MEW fund would cover learners' UME tuition, potentially eliminating their UME debt, in return for their provision of health care services (after completing GME training) in an underserved area or specialty. This proposed model attempts to increase transparency and enhance accountability in medical education by linking funding to the development of a physician workforce that is able to excel in the evolving health delivery system. Achieving this vision requires physician educators, leaders of academic health centers, policy makers, insurers, and patients to muster the courage to embrace transformational change.

Senate Committee Solicits Input on State of MH System

Back to table of contents Previous article Next article Government NewsFull AccessSenate Committee Solicits Input on State of MH SystemLeslie SinclairLeslie SinclairSearch for more papers by this authorPublished Online:15 Mar 2013https://doi.org/10.1176/appi.pn.2013.3b13AbstractExperts tell a Senate committee that the mental health system is overburdened, many patients don’t get needed help, and earlier and improved detection could change that reality.The Senate Health, Education, Labor, and Pensions (HELP) Committee, convened a meeting January 24 to discuss—for the first time in six years—the mental health of Americans. Prompted by the Newtown, Conn., school shooting and in anticipation of the changes the Affordable Care Act will bring about, committee members solicited input at the hearing they dubbed “Assessing the State of America’s Mental Health System.”“It seems to me that the questions before us are ‘who needs help’ and ‘who’s there to provide the help’,” said Sen. Lamar Alexander (R-Tenn.), the committee’s ranking member.Pamela Hyde, J.D., administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), was the first to provide testimony. “Behavioral health is a public-health issue, not a social issue, and it can be tackled and addressed with an effective public-health approach,” she said, while noting that SAMHSA’s National Survey on Drug Use and Health indicates that only 38 percent of adults with diagnosable mental health problems and only 11 percent of those with diagnosable substance use disorders receive treatment.“Prevention works, treatment is effective, and people do, in fact, recover,” she stressed, but obstacles including cost, access, and recognition of mental health disorders are the primary reasons treatment is not received by many who need it. Hyde pointed to upcoming changes associated with the Affordable Care Act that will extend the reach of mental health treatment to more Americans, saying “Medicaid is already the largest payer of mental health services, and the Affordable Care Act will extend Medicaid coverage to as many as 17 million hardworking Americans.”Thomas Insel, M.D., director of the National Institute of Mental Health (NIMH), also presented testimony and emphasized that most mental disorders begin early in life, yet patients often wait years for diagnosis and treatment. “The lesson we have learned from cancer and heart disease, diabetes and AIDS, is that the secret to having the best outcomes is early detection and early intervention…yet we don’t do that.” Moving forward, NIMH will support research on earlier diagnosis and quicker delivery of appropriate treatment, be it behavioral or pharmacological, he said. Medical Director James H. Scully Jr., M.D., submitted testimony on behalf of APA. “This hearing comes at a critical time when our leaders in government are faced with difficult choices about where to allocate limited resources,” he noted. “Nevertheless, I believe the current state of our nation’s mental health system is weak and demands immediate and significant attention by Congress and the administration.” Scully’s testimony presented five key areas through which the mental health system could be strengthened to ensure the mental health and well-being of all Americans:Mental Health Parity. APA urges issuance of a final rule on the Mental Health Parity and Addiction Equity Act of 2008. In the absence of a final rule, APA is concerned that access to critical mental health services will be jeopardized for millions of Americans. APA also supports reintroduction of the Medicare Mental Health Inpatient Equity Act, which would increase access to coverage for the most seriously mentally ill people. A Commission on Mental Health. APA supports the idea of a new commission—either presidential or congressional—to conceptualize how the nation’s mental health system can meet the needs of all Americans. Investing in Existing Mental Health System Components. APA supports investment in biomedical research, initiatives to develop and implement new treatments for addiction, and state block grants for mental health and substance use activities, suicide prevention, and jail-diversion programs for people with mental illness. Support for Graduate Medical Education. The ability of the U.S. mental health system to deliver high-quality care in a coordinated and cost-effective manner is dependent upon an appropriately trained workforce. As a physician specialty society, APA strongly supports the preservation of funding for both direct graduate medical education and indirect graduate medical education, programs that support 16,000 residencies each year. Early Intervention and Prevention Services for Youth. As a vulnerable population, children and adolescents are especially in need of early intervention and prevention services.Scully also brought to the committee’s attention the initiative APA launched through the American Psychiatric Foundation, called “Typical or Troubled?,” to train school personnel to make the distinction between students who are “just being adolescents” and students who demonstrate early signs of mental illness, saying “this program represents the type of early intervention and prevention strategy that could serve as a national model.” ■A video of the committee hearing as well as written testimony are posted at http://www.help.senate.gov/hearings/hearing/?id=b2048a10-5056-a032-529c-340d7ae5f237. Scully’s testimony is posted at http://www.psychiatry.org/advocacy--newsroom/advocacy/apa-submits-testimony-to-congress-on-the-state-of-americas-mental-health-system. ISSUES NewArchived

The Impact of Health Care Economics on Surgical Education

Just like the world economy in 2012, health care is in a state of flux. The current economic environment will impact not only current colorectal surgery residents, but also future generations of surgical trainees. To understand the economic impact of the current health care environment on colorectal surgery residencies, we need to know the basics of graduate medical education (GME) funding for all residents. Since the 1960s with the initiation of Medicare, the federal government through the Center for Medicare and Medicaid Services (CMS) has been the largest source of GME funding. There are two types of costs associated with GME. Direct GME (DME) funding covers costs directly attributed to the training of residents. These costs include residents' stipends, salaries, and benefits; cost of supervising faculty; direct program administration costs; overhead; and malpractice coverage. Indirect GME (IME) costs are payments to hospitals as an additional or add-on payment for the increased cost of care that is generally found in teaching hospitals. In 2010, President Barak Obama signed into law H.R. 3200, the Patient Protection and Affordable Care Act (PPACA). In 2011, the Supreme Court held that the majority of the PPACA is constitutional. Although the true impact of this bill is unknown, it will change the formula for Medicare GME reimbursement as well as shift unused residency positions to primary care.

Complexity and uncertainty in financing graduate medical education.

The current sources and structure of graduate medical education (GME) financing policies are being challenged. To foster understanding of these challenges, the author explains the current GME financing system and explores the impacts that various policy changes and legislation under consideration would have on residency programs and the health of already financially stressed teaching hospitals. Specifically, the wide variety of revenue sources (mostly third-party payers) are discussed, particularly the present Medicare direct graduate medical education (DGME) payments and indirect medical education (IME) adjustment payments, and their policy implications. The author concludes that a serious problem in advocating a new approach to the financing of GME (which would focus on changes in Medicare support) is the absence of a common vision, not only among policymakers but also within the academic medical community. Too much energy has been expended on how GME and the special missions of teaching hospitals should not be funded, and not enough attention focused on how to achieve a dependable source of revenue to help finance them. The public policy challenge is how to sustain Medicare's traditional support for GME in the face of intense pressure to "save" Medicare through fundamental reforms.

Teaching hospital costs: implications for academic missions in a competitive market.

As the managed care environment demands lower prices and a greater focus on primary care, the high cost of teaching hospitals may adversely affect their ability to carry out academic missions. To develop a national estimate of total inpatient hospital costs related to graduate medical education (GME). Using Medicare cost report data for fiscal year 1993, we developed a series of regression models to analyze the relationship between inpatient hospital costs per case and explanatory variables, such as case mix, wage levels, local market characteristics, and teaching intensity (the ratio of interns and residents to beds). A total of 4764 nonfederal, general acute care hospitals, including 1014 teaching hospitals. Actual direct GME hospital costs and estimated indirect GME-related hospital costs based on the statistical relationship between teaching intensity and inpatient costs per case. In 1993, academic medical center (AMC) costs per case were 82.9% higher than those for urban nonteaching hospitals (actual cost per case, $9901 vs $5412, respectively). Non-AMC teaching hospital costs per case were 22.5% higher than those for nonteaching hospitals (actual cost per differences in case, $6630 vs $5412, respectively). After adjustment for case mix, wage levels, and direct GME costs, AMCs were 44% more expensive and other teaching hospitals were 14% more costly than nonteaching hospitals. The majority of this difference is explained by teaching intensity. Total estimated US direct and indirect GME-related costs were between $18.1 billion and $22.8 billion in 1997. These estimates include some indirect costs, not directly educational in nature, related to clinical research activities and specialized service capacity. The cost of teaching hospitals relative to their nonteaching counterparts justifies concern about the potential financial impact of competitive markets on academic missions. The 1997 GME-related cost estimates provide a starting point as public funding mechanisms for academic missions are debated. The efficiency of residency programs, their consistency with national health workforce needs, financial benefits provided to teaching hospitals, and ability of AMCs to maintain higher payment rates are also important considerations in determining future levels of public financial support.

Factors contributing to the variability of direct costs for graduate medical education in teaching hospitals.

Medicare's support of graduate medical education includes funds allocated to the direct costs of graduate medical education: housestaff stipends and benefits, faculty costs, and related educational costs such as classroom space. As reimbursed through the mechanism called the direct graduate medical education (DGME) pass-through, these direct costs have been reported to vary widely from one teaching hospital to another, with little explanation for this variation being available. Based on a national survey of 69 teaching hospitals--principally affiliated community teaching hospitals--the author suggests that a major cause for the variation in these costs might be found in their faculty-expenses component. It is further suggested that economies of scale may provide some clue as to the variability of these costs. The author also reports lower DGME costs for the survey sample than for the national sample, and suggests that the fact that community teaching hospital faculties include a significant volunteer component may account for some of these savings.