Graduate Medical Education Payments Research Articles

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.

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

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

Comparison of the Financial and Operational Characteristics of For-Profit and Nonprofit Hospitals Receiving Federal Graduate Medical Education Payments, 2011-2020

This study compares graduate medical education (GME) payments between nonprofit and for-profit hospitals between 2011 and 2020 to assess how hospitals value GME.

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.

Medicare Support for Dental and Podiatry Graduate Medical Education Programs

Oral health care faces ongoing workforce challenges that affect patient access and outcomes. While the Medicare program provides an estimated $14.6 billion annually in graduate medical education (GME) payments to teaching hospitals, including explicit support for dental and podiatry programs, little is known about the level or distribution of this public investment in the oral health and podiatry workforce. To examine Medicare GME payments to teaching hospitals for dental and podiatry residents from 1998 to 2018, as well as the distribution of federal support among states, territories, and the District of Columbia. This cross-sectional study was conducted using data from 1252 US teaching hospitals. Data were analyzed from May through August 2020. Dental and podiatry residency training. Medicare dental and podiatry GME payments were examined. Among 1252 teaching hospitals, Medicare provided nearly $730 million in dental and podiatry GME payments in 2018. From 1998 to 2018, the number of residents supported more than doubled, increasing from 2340 residents to 4856 residents, for a 2.1-fold increase, while Medicare payments for dental and podiatry GME increased from $279 950 531 to $729 277 090, for a 2.6-fold increase. In 2018, an estimated 3504 of 4856 supported positions (72.2%) were dental. Medicare GME payments varied widely among states, territories, and the District of Columbia, with per capita payments by state, territory, and district population ranging from $0.05 in Puerto Rico to $14.24 in New York, while 6 states received no support for dental or podiatry residency programs. These findings suggest that dental and podiatry GME represents a substantial public investment, and deliberate policy decisions are needed to target this nearly $730 million and growing investment to address the nation's priority oral and podiatry health needs.

Addiction Medicine After COVID-19: The Imperative of a Trained Workforce

Addiction Medicine After COVID-19: The Imperative of a Trained Workforce

Children's Hospitals Graduate Medical Education Payment Program (HRSA)

Federal Grants & ContractsVolume 44, Issue 13 p. 7-7 Grant Alerts Children's Hospitals Graduate Medical Education Payment Program (HRSA) First published: 01 June 2020 https://doi.org/10.1002/fgc.31121Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume44, Issue134 June 2020Pages 7-7 RelatedInformation

Changes and Variation in Medicare Graduate Medical Education Payments

This study examines the growth of Medicare graduate medical education payments per resident full-time equivalent, variation in payment rates between hospitals, and potential savings from capping these payments.

Proposed Performance-Based Metrics for the Future Funding of Graduate Medical Education: Starting the Conversation.

Graduate medical education (GME) in the United States is financed by contributions from both federal and state entities that total over $15 billion annually. Within institutions, these funds are distributed with limited transparency to achieve ill-defined outcomes. To address this, the Institute of Medicine convened a committee on the governance and financing of GME to recommend finance reform that would promote a physician training system that meets society's current and future needs. The resulting report provided several recommendations regarding the oversight and mechanisms of GME funding, including implementation of performance-based GME payments, but did not provide specific details about the content and development of metrics for these payments. To initiate a national conversation about performance-based GME funding, the authors asked: What should GME be held accountable for in exchange for public funding? In answer to this question, the authors propose 17 potential performance-based metrics for GME funding that could inform future funding decisions. Eight of the metrics are described as exemplars to add context and to help readers obtain a deeper understanding of the inherent complexities of performance-based GME funding. The authors also describe considerations and precautions for metric implementation.

Hospital Teaching Status and Medicare Expenditures for Complex Surgery

To evaluate the relationship between hospital teaching intensity, Medicare payments, and perioperative outcomes. Several emerging payment policies penalize hospitals for low-value healthcare. Teaching hospitals may be at a disadvantage given the perception that they deliver care less efficiently. Using Medicare Provider and Analysis Review files, we studied patients from age 65 to 100 years who underwent abdominal aortic aneurysm (AAA) repair (n = 71,422), pulmonary resection (n = 93,056), or colectomy (n = 277,619) from 2009 to 2012. Patients' hospitals were categorized into quintiles of teaching intensity (very major, major, minor, very minor, and nonteaching hospitals) based on the resident-to-bed ratio. Risk-adjusted 30-day Medicare payments were price-standardized to account for graduate medical education payments, disproportionate share costs, and regional wage-index adjustments. Risk-adjusted perioperative outcomes were also assessed. Comparing risk-adjusted Medicare payments per episode of surgery, very major teaching hospitals were $14,145 more expensive than nonteaching hospitals for AAA repair ($45,570 vs $31,426; P < 0.001), $9,812 more expensive for pulmonary resection ($39,550 vs $29,738; P < 0.001), and $19,147 more expensive for colectomy ($51,893 vs $32,746; P < 0.001). However, after accounting for social subsidies and regional variation in Medicare spending, risk-adjusted Medicare payments were not statistically different between very major teaching hospitals and nonteaching hospitals for AAA repair ($29,946 vs $27,993; P = 0.18) and pulmonary resection ($25,407 vs $26,813; P = 1.00); a statistically significant but attenuated difference persisted for colectomy ($34,949 vs $30,352; P < 0.001). Very major teaching hospitals generally had higher risk-adjusted rates of serious complications and readmissions, but lower risk-adjusted rates of failure to rescue and 30-day mortality than did nonteaching hospitals. After price-standardization to account for intended differences in Medicare spending, risk-adjusted Medicare payments for an episode of surgical care were similar at teaching hospitals and nonteaching hospitals for three complex inpatient operations.

A Survey Assessment of Perceived Importance and Methods of Maintenance of Critical Procedural Skills in Pediatric Emergency Medicine.

The aim of this study was to delineate pediatric emergency medicine provider opinions regarding the importance of, and to ascertain existing processes by which practitioners maintain, the following critical procedural skills: oral endotracheal intubation, intraosseous line placement, pharmacologic and electrical cardioversion, tube thoracostomy, and defibrillation. A customized survey was administered to all members of the Listserv for the American Academy of Pediatrics Section on Emergency Medicine. Perceived importance of maintaining critical pediatric procedural skills was measured using a 5-point Likert-type scale. Secondary outcomes included presence and type of mandatory training, availability of on-site backup, and perceived barriers to maintenance of skills. Two hundred sixty-two members (25%) responded representing 106 different institutions, 70% of freestanding children's hospitals that received graduate medical education payments in 2014, and 68% of pediatric emergency medicine fellowship programs. More than 90% of respondents felt it was either very or extremely important to maintain competency for 5 of the 6 critical procedures, but no more than 49% of respondents felt that clinical care alone provided opportunity to maintain skills. The proportion of respondents indicating no mandatory training for each critical procedural skill was as follows: oral endotracheal intubation (23%), intraosseous line placement (30%), pharmacologic cardioversion (32%), electrical cardioversion (32%), tube thoracostomy (40%), and defibrillation (32%). Critical procedural skills are perceived by emergency providers who care for children as extremely important to maintain. Direct care of pediatric patients likely does not provide sufficient opportunity to maintain these skills. There are widespread deficiencies relating to mandatory maintenance of critical procedural skill training.

In Reply to Rasouli and Willson.

In Reply to Rasouli and Willson.

Obama 2015 Budget Would Extend Medicaid Pay Bump

Many physicians would continue to see higher payments through 2015 for treating Medicaid ­patients under President Obama's proposed budget for the upcoming fiscal year. The budget request submitted to Congress March 4 includes $5.4 ­billion to extend the Affordable Care Act (ACA) provisions that pay physicians at Medicare levels for certain primary care services to Medicaid patients. Otherwise, the increase will end this year. Under the budget proposal, nurse practitioners and physician assistants also would be eligible for the higher payment rates. “Allowing [the higher rates] to expire would result in a deep, across-the-board cut to primary care physicians who are taking care of the most vulnerable populations, at a time when millions more are becoming eligible for Medicaid,” Molly Cooke, MD, president of the American College of Physicians (ACP), said in a statement. The budget proposes $77.1 billion in discretionary spending for Health and Human Services (HHS), down $1.3 billion from 2014. This includes investments in the primary care workforce, expanded mental health services, and continued implementation of the ACA insurance marketplaces. The president's budget also calls for Medicare cuts of more than $400 billion over 10 years. Proposed in previous budgets, these include payment cuts for inpatient rehabilitation facilities, long-term care hospitals, and home health agencies; reduction in Medicare coverage of hospitals’ bad debts; reductions to indirect graduate medical education payments; and payment cuts to critical-access hospitals. In addition, the budget would introduce readmission penalties for skilled nursing facilities and strengthen the controversial Independent Payment Advisory Board (IPAB). The proposal would require the IPAB to recommend cost-cutting targets to Congress if the Medicare growth rate exceeds gross domestic product plus 0.5 percentage points. Current law sets that level at GDP plus 1 percentage point. The 2015 budget proposal would increase investment in the primary care workforce. It requests more than $5 billion over the next decade to train 13,000 new residents as part of a new competitive grant program available to teaching hospitals, children's hospitals, and community-based consortia of teaching hospitals or other health care institutions. The budget also beefs up funding for the National Health Service Corps. It includes nearly $4 billion in new funding over 6 years to increase the number of health providers in rural areas and federally funded health centers to 15,000. And it would invest $4.6 billion in community health centers in 2015 and another $8.1 billion for the next 3 years. For mental health services, the budget includes $55 million for Project AWARE, which encourages community and school officials to work together to keep schools safe, refer students to mental health services, and provide mental health “first aid” training so that teachers can detect early signs of mental illness. The budget request includes $50 million to train about 5,000 new mental health professionals, $20 million to help young adults aged 16-25 years navigate behavioral health services, and $5 million to change attitudes about people who have behavioral health needs in the workplace. The budget also provides funding for a demonstration project in Medicaid to help reduce the use of psychotropic medications prescribed to children in foster care by improving access to other mental health services. The release of the president's budget request came just weeks before the end of open enrollment in private health plans through the ACA's marketplaces. The budget includes $1.8 billion in funding for 2015 to cover the cost of running the federally facilitated marketplace. However, most of the funding – $1.2 billion – would be covered by user fees from health plans in the marketplaces. If Congress fails to provide the remaining funds, HHS officials said they could transfer monies from other agency accounts to cover marketplace costs.

The Geography Of Graduate Medical Education: Imbalances Signal Need For New Distribution Policies

Graduate medical education (GME) determines the overall number, specialization mix, and geographic distribution of the US physician workforce. Medicare GME payments-which represent the largest single public investment in health workforce development-are allocated based on an inflexible system whose rationale, effectiveness, and balance are increasingly being scrutinized. We analyzed Medicare cost reports from teaching hospitals and found large state-level differences in the number of Medicare-sponsored residents per 100,000 population (1.63 in Montana versus 77.13 in New York), total Medicare GME payments ($1.64million in Wyoming versus $2billion in New York), payments per person ($1.94 in Montana versus $103.63 in New York), and average payments per resident ($63,811 in Louisiana versus $155,135 in Connecticut). Ways to address these imbalances include revising Medicare's GME funding formulas and protecting those states that receive less Medicare GME support in case funding is decreased and making them a priority if it is increased. The GME system badly needs a coordinating body to deliberate and make policy about public investments in graduate medical education.

The Redistribution Of Graduate Medical Education Positions In 2005 Failed To Boost Primary Care Or Rural Training

Graduate medical education (GME), the system to train graduates of medical schools in their chosen specialties, costs the government nearly $13 billion annually, yet there is little accountability in the system for addressing critical physician shortages in specific specialties and geographic areas. Medicare provides the bulk of GME funds, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 redistributed nearly 3,000 residency positions among the nation's hospitals, largely in an effort to train more residents in primary care and in rural areas. However, when we analyzed the outcomes of this recent effort, we found that out of 304 hospitals receiving additional positions, only 12 were rural, and they received fewer than 3 percent of all positions redistributed. Although primary care training had net positive growth after redistribution, the relative growth of nonprimary care training was twice as large and diverted would-be primary care physicians to subspecialty training. Thus, the two legislative and regulatory priorities for the redistribution were not met. Future legislation should reevaluate the formulas that determine GME payments and potentially delink them from the hospital prospective payment system. Furthermore, better health care workforce data and analysis are needed to link GME payments to health care workforce needs.

Commentary

The primary-care-oriented Teaching Health Center Graduate Medical Education (THCGME) program funded by the Patient Protection and Affordable Care Act of 2010 offers opportunities to explore alternative solutions to such graduate medical education (GME) policy issues as institutional indirect educational costs, variations in trainee-related productivity gains, and the program costs of GME innovations. THCGME reporting requirements may also provide data on the impact of various educational innovations on career choice and clinical care as well as other information that could be useful in devising a more transparent and equitable system of support for GME.THCGME program advocates should, however, be cautious in applying any lessons learned to broader GME policy reform. Unlike the THCGME funding, Medicare GME payments are part of the Medicare entitlement, tied to provision of clinical services and financed outside the annual congressional appropriations process. Pressure on domestic discretionary spending makes substantially expanded appropriations for the THCGME program an unlikely path for widespread reform. Absent secure "all-payer financing" of GME, residency program sponsors lack sufficient Medicare funds to cover all GME costs and must favor investments in specialties that meet local concerns, not long-term national workforce priorities. Nonetheless, the THCGME program provides an exciting opportunity to improve and to study primary care GME. Furthermore, the organizational infrastructures established, program leaders developed, data collected, and lessons learned from the program can inform more fundamental change in U.S. GME payment policy.

Policy for an Aging Society

MEDICAL STUDENTS AND RESIDENTS ARE TAUGHT to perform a complete review of systems in a thorough patient workup. Through this process, patients may report less prominent concerns that may be meaningful to the physician’s evaluation. As a complement to the new series, Care of the Aging Patient: From Evidence to Action, in this issue of JAMA, a Commentary will provide a forum for discussion of a policy review of systems for the care of older adults. In the first article, Reuben brings into sharp relief the need for greater expertise and new approaches to caring for older patients as they face physical decline and advanced illness. Using the case of Mr Z, Reuben examines the patientcare encounter and the analytical and interpersonal processes that the physician must undertake. For most US physicians, both specialists and generalists, this story is likely unfamiliar, and physicians may hardly be able to imagine themselves or colleagues conducting the kind of extensive evaluation described. Patients would flock to this comprehensive yet individualized care. Although this approach is at the core of training in geriatric medicine, such specialists are rare, and fewer students are seeking careers in geriatrics or primary care. In each year from 2007 to 2009 fewer than 100 US medical graduates pursued postdoctoral training in geriatrics. The crisis represented by this shortage is made clear by imagining an alternate scenario: usual care rather than best case. In the usual care scenario, Mr Z would have been considered a healthy older man. His falls would not have been explored and his concerns would have been referred to specialists. He ultimately could have sustained a major fracture, requiring surgical intervention. During that hospitalization, he most likely would have become weak and had iatrogenic complications, such that even a very prolonged rehabilitation would not return him to his prior function. During this time, someone most likely would have discovered that his wife at home had Alzheimer disease and was unable to care for herself. Hopefully, a capable social worker would have helped husband and wife to be admitted to the same long-term care facility, but they might have been separated since he would be in rehabilitation and she in custodial care. Their complex health care could lead not only to poor patient care but to costly overuse of technologies and most importantly loss of the function, dignity, and personal values they would have chosen. Reuben’s careful analysis suggests that anticipating and addressing patients’ evolving short-term, midterm, and longterm issues provides better care in all metrics: quality, fewer errors, and reduced overuse of health care services. Everyone is better off. Why don’t patients have more access to this kind of care and what will it take to provide it? The 6 characteristics of optimal quality of care for a patient facing frailty are: (1) extensive knowledge of the aging process, of prognostic indicators, and the multiple geriatrics syndromes; (2) proactive and anticipatory care that is longitudinal; (3) a well-functioning practice structure with a multidisciplinary team or network, in which care is coordinated efficiently and effectively and linked to community resources; (4) personal interaction with the relationship grounded in good communication skills and a clear sense of the patient’s values, goals, and preferences; (5) practices that manage care across diverse settings to ensure safe transitions and continuity; and (6) health care institutions, especially hospitals, that incorporate acute care of the elderly units, early mobilization, careful attention to drug interactions, and other best practices to reduce the grave risk they currently pose to frail, older individuals. Several current US policy initiatives may have the potential to improve the situation. First, workforce support for primary care should always include explicit attention to geriatric medicine. Most geriatric specialists begin postgraduate training in family medicine or general internal medicine, the 2 largest and mostthreatened primary care specialties. Geriatric medicine is at even greater risk—less widely sought than primary care. As initiatives to reallocate residency positions under the graduate medical education (GME) limits are considered, geriatric medicine should be foremost on that list—a core discipline for Medicare and Medicare GME payment priorities. Incentives such as loan forgiveness or repayment may help bridge the gap until effective payment reform occurs.

The Impact of Title VII on General and Pediatric Dental Education and Training

The authors describe the impact of the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program on the development, growth, and expansion of general and pediatric dentistry residency programs in the United States. They first briefly review the legislative history of the Title VII program as it pertains to dental education, followed by a historical overview of dental education in the United States, including a description of the differences between dental and medical education and the routes to professional practice. The authors then present an extensive assessment of the role of the Title VII grant program in building general and pediatric dental training capacity, diversifying the dental workforce, providing outreach and service to underserved and vulnerable populations, stimulating innovations in dental education, and engaging collaborative and interdisciplinary training with medicine. Finally, the authors call for broadening the scope of the Title VII program to allow for predoctoral training (dental student education) and faculty development in general and pediatric dentistry. In doing so, the Title VII program can more effectively address current and future challenges in dental education, dentist workforce, and disparities in oral health and access to care.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Redesigning Residency Training in Internal Medicine: The Consensus Report of the Alliance for Academic Internal Medicine Education Redesign Task Force

Because of numerous criticisms of the content and structure of residency training, redesigning graduate medical education (GME) has become a high priority for the internal medicine community. From 2005 to 2007, the leadership of the internal medicine community, working under the auspices of the Alliance for Academic Internal Medicine Education Redesign Task Force, developed six recommendations it will pursue to improve residency education: (1) focus education around a "core" of internal medicine, which provides the framework for both the structure and content of residents' educational experiences, (2) fully adopt competency-based evaluation and advancement, which will enhance training by focusing on individual learners' needs, (3) allow for increased, resident-centered education beyond the internal medicine core, because different types of practice require customized knowledge and skills, (4) improve ambulatory training by providing patient-centered longitudinal care that addresses the conflict between inpatient and outpatient responsibilities, (5) use new faculty models that emphasize the creation of a core faculty, and (6) align institutional and programmatic resources with the goals of redesign, balancing the clinical mission of the institution with the educational goals of residency training. Adoption of these recommendations will require significant efforts, including pilot projects, faculty development, changes in accreditation requirements, and modifications of GME funding systems. Opportunities are ample for individual programs to develop creative approaches based on the framework for educational redesign outlined in this article, and for these educational and clinical redesign initiatives to work hand-in-hand for the benefit of patients, faculty, trainees, and institutions.

Plan to End Medicaid Payments Threatens Teaching Hospitals

Plan to End Medicaid Payments Threatens Teaching Hospitals