Graduate Medical Education Funding Research Articles

Goals, Structure and Financing of Surgical Residency Training: A Subcommittee Report of the Blue Ribbon Committee II.

As part of the Blue Ribbon Committee II, review current goals, structure and financing of surgical training in Graduate Medical Education (GME) and recommend needed changes. Surgical training has continually undergone major transitions with the 80-hour work week, earlier specialization (vascular, plastics and cardiovascular) and now entrustable professional activities (EPAs) as part of competency based medical education (CBME). Changes are needed to ensure the efficiencies of CBME are utilized, that stable graduate medical education funding is secured, and that support for surgeons who teach is made available. Convened subcommittee discussions to determine needed focus for recommendations. Five recommendations are offered for changes to GME financing, incorporation of CBME, and support for educators, students and residents in training. Changes in surgical training related to CBME offer opportunity for change and innovation. Our subcommittee has laid out a potential path forward for improvements in GME funding, training structure, compensation of surgical educators, and support of students and residents in training.

Graduate Medical Education Financing in the US Department of Veterans Affairs.

The US Department of Veterans Affairs (VA) partners with 250 sponsors of graduate medical education (GME), annually providing $850 million for 11,000 full-time equivalent resident positions that support veteran patient care and provide educational opportunities for trainees from affiliated academic programs. Knowledge of VA GME financing is vital to maintain these partnerships. In response to increased scrutiny from several federal oversight bodies, the VA revised its GME reimbursement policy and procedures, including implementing new resident tracking and auditing mechanisms. This article describes the VA GME reimbursement policies and procedures and, to facilitate understanding, compares GME financing policies of the VA and Centers for Medicare and Medicaid Services. Similarities include counting full-time equivalent positions for reimbursable resident activities (eg, patient care and didactics) and ensuring reimbursement is limited to 1 payment per resident. Differences include funding of resident salaries and benefits, indirect funding to support education, and the calculations to determine reimbursement. The VA continues to refine its GME financing policies and procedures to maintain compliance with laws and regulations, and to provide accurate reimbursement to academic affiliates. This endeavor is essential to support the vital GME partnerships between the VA and its affiliate institutions.

Lessons Learned From State-Based Efforts to Leverage Medicaid Funds for Graduate Medical Education.

Total Medicaid funds invested in graduate medical education (GME) increased from $3.78 billion in 2009 to $7.39 billion in 2022. States have flexibility in designing Medicaid GME payments to address population health needs. This study assessed states' impetus for using Medicaid funds for GME, structure of state Medicaid payments, composition and charge of advisory bodies that guide these investments, and degree of transparency and accountability to track whether Medicaid GME investments achieved desired workforce outcomes. Structured interviews were conducted in 2015 to 2016 and 2020 to 2021 with subject matter experts representing 10 states. Interview transcripts were analyzed and coded in 6 thematic areas: impetus for using Medicaid funds, the structure of state Medicaid payments, the composition of advisory bodies, the degree of transparency of Medicaid investments, accountability of Medicaid investments, and challenges and changes. States used Medicaid GME funding to address maldistribution of physicians by geography, setting, and specialty, respond to population growth and undergraduate medical education expansion, offset potential loss of teaching health center program funds, and launch new programs and sustain existing ones. States leveraged Medicaid funding by modifying state plan amendments and redesigning funding formulas to meet specific health workforce needs. Many states had advisory bodies to educate legislators, reach consensus on workforce needs, recommend how to disburse funds, and navigate competing stakeholder interests. States identified a need for improved data and analytic systems to understand workforce needs and monitor the outcomes of GME investments. Determining which accountability measures to use and implementing metrics were challenges. States have much to learn from each other about strategies to best leverage Medicaid funds to develop and sustain residency programs to meet population health needs. Learning collaboratives should be developed to provide a forum for states to share best practices and strategies for overcoming challenges.

Anesthesiologist shortage in the United States: A call for action

Anesthesiology is a vital component of modern healthcare. The United States is facing a shortage of anesthesiologists complicating the ability of hospitals and surgical specialties to meet the ever-growing demand. Recent local crises demand a reexamination of the issues. This shortage is complex and multifactorial, with causes on both supply and demand sides. The lack of sufficient graduate medical education funding for residency positions, changes in practice patterns and the aging and retiring workforce are limits to the supply. Increasing demand for surgical services will continue to rise by 2–3% per year over the next decade fueled by population growth, particularly among the elderly with the number of people 65 and older growing by 55% over the next decade. The problem of anesthesia supply and demand is complicated by the rapid expansion of private equity firms into the market. The effect is potentially increased cost and an alteration in the standards of care. While there are short-term solutions that can be adopted, such as hiring temporary help and expanding the role of mid-level providers, long-term solutions require a collaborative effort between healthcare providers, administrators, and policymakers to ensure that decisions are based on the best interests of patients and providers.

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

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

The ACGME Framework for Medically Underserved Areas and Populations and Graduate Medical Education

The ACGME Framework for Medically Underserved Areas and Populations and Graduate Medical Education

Policy Recommendations for Improving Rural Cancer Services in the United States.

Compared with urban residents, rural Americans have seen slower declines in cancer deaths, have lower incidence but higher death rates from cancers that can be prevented through screening, have lower screening rates, are more likely to present with later-stage cancers, and have poorer cancer outcomes and lower survival. Rural health provider shortages and lack of cancer services may explain some disparities. The literature was reviewed to identify factors contributing to rural health care capacity shortages and propose policy recommendations for improving rural cancer care. Uncompensated care, unfavorable payer mix, and low patient volume impede rural physician recruitment and retainment. Students from rural areas are more likely to practice there but are less likely to attend medical school because of lower graduation rates, grades, and Medical College Admission Test (MCAT) scores versus urban students. The cancer care infrastructure is costly and financially challenging in rural areas with high proportions of uninsured and publicly insured patients. A lack of data on oncology providers and equipment impedes coordinated efforts to address rural shortages. Graduate Medical Education funding greatly favors large, urban, tertiary care teaching hospitals over residency training in rural, critical access and community-based hospitals and clinics. Policies have the potential to transform rural health care. This includes increasing advanced practice provider postgraduate oncology training opportunities and expanding the scope of practice; improving health workforce and services data collection and aggregation; transforming graduate medical education subsidies to support rural student recruitment and rural training opportunities; and expanding federal and state financial incentives and payments to support the rural cancer infrastructure.

APA’s Government, Policy, and Advocacy Update (January 2022)

Back to table of contents Previous article Next article Government & LegalFull AccessAPA’s Government, Policy, and Advocacy Update (January 2022)Search for more papers by this authorPublished Online:23 Dec 2022https://doi.org/10.1176/appi.pn.2023.01.1.44APA, Partners Detail Year-End Requests to Congressional LeadershipIn December, APA and its partner organizations, collectively known as the Group of Six, sent a letter to House and Senate leaders requesting action on several proposals to ensure patients have access to quality and affordable health care. The letter was addressed to Reps. Nancy Pelosi (D-Calif.) and Kevin McCarthy (R-Calif.), and Sens. Chuck Schumer (D-N.Y.) and Mitch McConnell (R-Ky).The Group of Six includes APA, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American Osteopathic Association.The letter outlines numerous actions that the groups urged Congress to take, including the following:Avert cuts to Medicare physician payments.Senate passage of the Improving Seniors’ Timely Access to Care Act (HR 3173), which the House already passed. The legislation would standardize and streamline the prior authorization approval process in the Medicare Advantage program.Extend Medicare telehealth flexibilities through at least 2024, including coverage for audio-only services, to ensure Medicare beneficiaries can continue to access virtual care.Extend funding for the Teaching Health Centers Graduate Medical Education program.Additionally, the letter outlined numerous actions Congress should take to address the mental health and substance use disorder crisis. The Group of Six urged Congress to promote the integration of mental health services with primary care, strengthen the mental health workforce by increasing funding for graduate medical education, increase funding to community health and mental health centers to enhance prevention and early intervention, and enforce the federal mental health parity law.APA and its partner organizations’ letter to Congress Leadership. APA Sends Letter Supporting Bill To Address Children’s Mental HealthIn a letter, APA and its partner organizations expressed support for the Investing in Kids’ Mental Health Now Act (S. 4747), introduced by Sens. Robert Casey (D-Pa.) and Rob Portman (R-Ohio). The bill would incentivize states to increase Medicaid reimbursement for pediatric mental health and substance use disorder treatment services, providing direct support to the pediatric mental health workforce and improving access to children’s mental health care.“Medicaid is the single largest payer of children’s mental health services in the United States, yet states often struggle to maintain an adequate network due to lower reimbursement rates for pediatric mental and behavioral services and an ongoing shortage of pediatric mental health professionals,” the letter stated. “These longstanding issues translate to delayed access to mental health care for children covered by Medicaid across the country.” ■APA’s letter to Senators Robert Casey, and Robert Portman. ISSUES NewArchived

Infertility: A Hidden Cost of Medical Training.

Infertility: A Hidden Cost of Medical Training.

Competing Incentives: For-Profit Hospitals Add Complexity to Graduate Medical Education (Commentary).

Competing Incentives: For-Profit Hospitals Add Complexity to Graduate Medical Education (Commentary).

Payment strategies for behavioral health integration in hospital-affiliated and non-hospital-affiliated primary care practices.

Recent value-based payment reforms in the U.S. called for empirical data on how primary care practices of varying characteristics fund their integrated behavioral health services. To describe payment strategies used by U.S. primary care practices to fund behavioral health integration and compare strategies between practices with and without hospital affiliation.Baseline data were used and collected from 44 practices participating in a cluster-randomized, pragmatic trial of behavioral health integration. Data included practice characteristics and payment strategies-fee-for-service payment, pay-for-performance incentives, grants, and graduate medical education funds. Descriptive and comparative analyses using Fisher's exact tests and independent T-tests were conducted. The sample had 26 (59.1%) hospital-affiliated (hospital/health system-owned, academic medical centers and hospital-affiliated practices) and 18 (40.9%) non-hospital-affiliated practices (community health centers/federally qualified health centers and privately-owned practices). Most practices (88.6%) received payments through fee-for-service; 63.6% received pay-for-performance incentives; 31.8% received grant funds. Collaborative Care Management billing (CPT) codes were used in six (13.6%) practices. Over half (53.8%) of hospital-affiliated practices funded their behavioral health services through fee-for-service and pay-for-performance incentives only, as opposed to two-thirds (66.7%) of non-hospital-affiliated practices required additional support from grants and/or general medical education funds. Primary care practices support behavioral health integration through diverse payment strategies. More hospital-affiliated practices compared to non-hospital-affiliated practices funded integrated behavioral health services through fee-for-service and pay-for-performance incentives. Practices without hospital affiliation relied on multiple funding streams including grants and/or general medical education funds, suggesting their approach to financial sustainment may be more precarious or challenging, compared to hospital-affiliated practices.

Beyond Training the Next Generation of Physicians: The Unmeasured Value Added by Residents to Teaching Hospitals and Communities.

Following medical school, most newly graduated physicians enter residency training. This period of graduate medical education (GME) is critical to creating a physician workforce with the specialized skills needed to care for the population. Completing GME training is also a requirement for obtaining medical licensure in all 50 states. Yet, crucial federal and state funding for GME is capped, creating a bottleneck in training an adequate physician workforce to meet future patient care needs. Thus, additional GME funding is needed to train more physicians.When considering this additional GME funding, it is imperative to take into account not only the future physician workforce but also the value added by residents to teaching hospitals and communities during their training. Residents positively affect patient care and health care delivery, providing intrinsic and often unmeasured value to patients, the hospital, the local community, the research enterprise, and undergraduate medical education. This added value is often overlooked in decisions regarding GME funding allocation. In this article, the authors underscore the value provided by residents to their training institutions and communities, with a focus on current and recent events, including the global COVID-19 pandemic and teaching hospital closures.

New Opportunities for Expanding Rural Graduate Medical Education to Improve Rural Health Outcomes: Implications of the Consolidated Appropriations Act of 2021.

Evidence shows that those living in rural communities experience consistently worse health outcomes than their urban and suburban counterparts. One proven strategy to address this disparity is to increase the physician supply in rural areas through graduate medical education (GME) training. However, rural hospitals have faced challenges developing training programs in these underserved areas, largely due to inadequate federal funding for rural GME. The Consolidated Appropriations Act of 2021 (CAA) contains multiple provisions that seek to address disparities in Medicare funding for rural GME, including funding for an increase in rural GME positions or "slots" (Section 126), expansion of rural training opportunities (Section 127), and relief for hospitals that have very low resident payments and/or caps (Section 131). In this Invited Commentary, the authors describe historical factors that have impeded the growth of training programs in rural areas, summarize the implications of each CAA provision for rural GME, and provide guidance for institutions seeking to avail themselves of the opportunities presented by the CAA. These policy changes create new opportunities for rural hospitals and partnering urban medical centers to bolster rural GME training, and consequently the physician workforce in underserved communities.

Adult Neurology Rotations for Child Neurology Residents: A Survey of Program Directors.

We aimed to identify how child neurology and neurodevelopmental disabilities residency program directors (PDs) implemented revised Accreditation Council for Graduate Medical Education requirements for adult neurology training for child neurology residents. Before 2014, the American Board of Psychiatry and Neurology certification for child neurology required an adult year, with no specified rotation requirements. At that point, programs scheduled a median of 10 months of adult neurology rotations during the third postgraduate year (PGY-3). In 2014, the adult neurology requirements were modified to include 6 months of hospital-based, 3 months of outpatient, and 3 months of other elective (may include neurophysiology, neuropathology, and/or neuroradiology) rotations. However, the effects of these changes on child neurology residency training nationally have not been characterized. A 16-item online survey was emailed to 79 PDs in the United States in September 2020. Survey responses were collected from September to October 2020. Descriptive statistics were calculated, and associations with departmental affiliation (pediatrics/neurology), graduate medical education (GME) funding source, and program size were compared using nonparametric tests. The response rate was 72% (53 pediatric neurology, 3 neurodevelopmental disabilities). The median adult months per year of training were as follows: 9 PGY-3, 2 PGY-4, and 1 PGY-5. Nearly all had both hospital inpatient and consult rotations with night and/or weekend shifts; 57% included neurocritical care and 36% epilepsy monitoring units. 48% of programs scheduled night and weekend shifts (including 25% that scheduled 24-hour calls) for residents on outpatient and elective rotations. Few programs required adult neurophysiology (20%), neuropathology (32%), or neuroradiology (25%). Programs with children's hospital GME funding (for either 2 or 3 years) tended to be larger (p = 0.008). Otherwise, departmental affiliation, funding source, and program size were not associated with rotation timing. Most child neurology residency programs still consolidate adult training in the PGY-3 year and often schedule additional hospital shifts during outpatient and elective months. However, there is a small shift toward adult neurology rotations occurring in the PGY-4 and PGY-5. Departmental affiliation, funding source, and program size do not consistently affect training practices. Few programs mandate adult neurophysiology, neuropathology, or neuroradiology rotations.

The 2020 Joseph W. St Geme, Jr. Leadership Award Address: On Leadership and the Joy of Pediatrics

The 2020 Joseph W. St Geme, Jr. Leadership Award Address: On Leadership and the Joy of Pediatrics

Graduate Medical Education Enhancement and the Consolidated Appropriations Act, 2021.

Graduate Medical Education Enhancement and the Consolidated Appropriations Act, 2021.

Preparing for the Future: Funding for Graduate Medical Education in Cardiothoracic Surgery

Although cardiothoracic surgeons are familiar with the importance of graduate medical education (GME), the nuances of GME funding may be less well understood. With the recent passage of the Consolidated Appropriations Act 2021, there will be an increase in the number of GME slots. This first expansion of GME funding since 1996 may start to alleviate the bottleneck in training the next-generation workforce.

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.

Is Resident-Driven Inpatient Care More Expensive? Challenging a Long-Held Assumption.

The financial impact of graduate medical education (GME) on teaching hospitals remains poorly understood, while calls for increased federal support continue alongside legislative threats to reduce funding. Despite studies suggesting that residents are more "economical" than alternative providers, GME is widely believed to be an expensive investment. Assumptions that residents increase the cost of patient care have persisted in the absence of convincing evidence to the contrary. Thus, the authors sought to examine resident influence on patient care costs by comparing costs between a resident-driven service (RS) and a nonresident-covered service (NRS), with attention to clinical outcomes and how potential cost differences relate to the utilization of resources, length of stay (LOS), and other factors. This prospective study compared costs and clinical outcomes of internal medicine patients admitted to an RS versus an NRS at Massachusetts General Hospital (July 1, 2016-June 30, 2017). Total variable direct costs of inpatient admission was the primary outcome measure. LOS; 30-day readmission rate; utilization related to diagnostic radiology, pharmaceuticals, and clinical labs; and other outcome measures were also compared. Linear regression models quantified the relationship between log-transformed variable direct costs and service. Baseline characteristics of 5,448 patients on the 2 services (3,250 on an RS and 2,198 on an NRS) were similar. On an RS, patient care costs were slightly less and LOS was slightly shorter than on an NRS, with no significant differences in hospital mortality or 30-day readmission rate detected. Resource utilization was comparable between the services. These findings undermine long-held assumptions that residents increase the cost of patient care. Though not generalizable to ambulatory settings or other specialties, this study can help inform hospital decision making around sponsorship of GME programs, especially if federal funding for GME remains capped or is subject to additional reductions.

How Accountable to the Public Is Funding for Graduate Medical Education? The Case for State Medicaid GME Payments.

How Accountable to the Public Is Funding for Graduate Medical Education? The Case for State Medicaid GME Payments.