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A Word From the President: A Better Blueprint for Improving GME

AAMC Reporter: September 2014

When the Institute of Medicine (IOM) released its long-awaited reform plan for graduate medical education (GME) at the end of July, it touched off renewed debate about the government’s role in helping to ensure our nation has enough physicians. As you may have seen in media coverage, the AAMC, the American Hospital Association, and other organizations expressed strong concerns about the impact the report’s recommendations would have on patient care and doctor training.

The IOM report recognized a number of areas where our current health care system and medical training need improvement, but missed the opportunity to offer meaningful solutions. Our system of financing and governing GME at teaching hospitals improves every day. Rather than focusing on changes that would provide better care to a growing and aging population, though, the IOM report seemed to prioritize the health of the nation’s economy over the health of its people. Setting up a new government bureaucracy to monitor GME, and funding it by drastically cutting federal support to teaching hospitals and doctor training, is simply not in the best interest of patients.

With a shortage of 130,600 physicians expected by 2025, federal support for GME must be increased, not cut, if we are to provide the care Americans will need in the future. While non-physician health providers can meet some of these needs, the recent delays at the VA should be all the proof we need that the danger of an undersupply of doctors is far greater than any risk of oversupply.

There is one point, however, on which we agree with the IOM: The nation’s residency training programs must demonstrate they have spent federal GME funds wisely and appropriately. But we believe a better approach exists in legislation pending in Congress that would establish a value-based payment system for teaching hospitals that receive Medicare indirect medical expense (IME) payments to help offset the higher costs associated with the unique and critical services they provide.

Under this proposed legislation, which addresses many of MedPAC’s June 2010 recommendations, institutions receiving IME payments would be required to report on all accountable items annually. Medical training programs not meeting basic performance benchmarks would have their IME funding reduced by up to 2 percent, while programs exceeding the goals would be rewarded.

To increase transparency, this legislation also would require teaching hospitals to report items that contribute to higher patient care costs, such as uncompensated expenses for clinical research, losses related to Medicaid patients, and the costs of trauma centers. Another provision would require the Government Accountability Office to identify physician-shortage specialties, including primary care, and award 1,000 or more newly available slots each year.

Between our work with congressional allies to pass this legislation and our members’ efforts to improve GME, the IOM report’s assertion that “there is a striking absence of transparency and accountability in the GME financing system for producing the types of physicians that the nation needs” was particularly surprising. This observation simply does not align with what I have seen during my many visits to your institutions. Unlike most IOM committee members, I have seen firsthand how hard our schools, hospitals, and faculty work to update their educational and training curricula to prepare physicians to meet changing societal needs. Your programs have made training in quality improvement, patient safety, and use of electronic health records, as well as working in interprofessional teams, an essential part of the educational process. In addition, more than 93 percent of all residents now spend some portion of their training in non-hospital settings, according to the Accreditation Council for Graduate Medical Education (ACGME).

The IOM report made scant mention of the stringent accountability standards and metrics enforced by the ACGME. Accountability is built into the accreditation process for residency training programs, and it is reviewed and modified regularly to address emerging health care needs or problem areas. Over the last few years, we have seen a comprehensive reform of the accreditation system. Along with the ACGME’s pioneering work in developing core competencies, the AAMC recently published guidelines of the core entrustable activities and competencies that every graduating medical student should be able to perform without supervision upon entering residency training.

In terms of transparency, it is worth pointing out that extensive information from institutions receiving GME funding already is public. Hospital cost reports on the Centers for Medicare & Medicaid Services website show the breakdown of direct graduate medical expenses (DGME) and IME payments for each teaching hospital. The website also posts each hospital’s Medicare caps and the number of residents training at the institution and in nonhospital training sites. Plus, the ACGME website offers a comprehensive overview of the data it collects.

We all share the goal of improving our nation’s GME system and strengthening teaching hospitals’ accountability and transparency. As I noted in my June column, the AAMC Board of Directors has made GME an issue of singular focus across the association’s membership for the next 12 to 18 months to catalyze efforts to improve our present system. But the federal government has an important role to play as well in ensuring our nation has an adequate supply of well-trained physicians. The IOM recommendations to cut vital funding that supports patient care and to create a new government bureaucracy will not get us there.

Working together, I know our community can do better for the millions of people who come through our doors. Whatever flaws exist, our nation’s GME system remains the best in the world. As we consider how to make it even better, we must not allow theoretical debates about an idealized health care system to take precedence over the real-world needs of the patients who depend on us.