Just before Christmas in 2011, seven US senators wrote to the then president of the Institute of Medicine, Harvey Fineberg, requesting that the Institute of Medicine examine whether the current graduate medical education is meeting the nation’s requirements. After medical school, graduate medical training in a specialty lasts 3-7 years or longer. Because the GME is largely federally funded, they asked to examine if the payers for the GME are getting value for their money. Currently, the only condition for continued payment is that the GME programs maintain their accreditation. Six months later, the IOM received a formal request from the US Senate, and sponsorship from 12 private foundations including the Josiah Macy Jr. Foundation and the American Board of Internal Medicine foundation. A committee was formed, with Don Berwick of the Institute for Healthcare Improvement fame and Gail Wilensky at Project Hope as co-chairs.
The charge to the 21-member committee with diverse expertise was to study whether the current GME is meeting the nation’s needs for training physicians who can deliver excellent, efficient and high-value clinical care, whether the financing and governance is appropriate, and make recommendations on policies to reform the GME. The committee met over the next two years and the IOM published its report in late 2014. This post is a brief summary of the report.
Currently, the GME receives around 15 billion dollars in federal funding and a significant but unknown amount of private funding annually. Of the ~15 billion, 64.7% comes from Medicare, 26% from Medicaid, 9.6% from the Veterans Affairs system, and 3.1% from Health Resources and Services Administration. These are public tax dollars and overall, the committee acknowledges that the US GME is robust and produces high-quality physicians. There are more than one hundred and seventeen thousand residents in accredited GME programs at a given point in time. Increasing the number of residency slots is not necessarily dependent on federal funding, as is evidenced by a ~17% increase over last decade in spite of Medicare funding cap. A trend towards greater specialization has occurred with little strategic direction with respect to needs for balance between primary care physicians and specialists. The gaps in education are related to care coordination, team-based care, costs of care, health information technology, cultural competence and quality improvement. These competencies are essential to modern day clinical practice and the current payers of GME programs do not hold them accountable for these standards. There is not even a requirement that the physicians accept Medicare patients in their office practice. The committee noted that remarkably little is known about the individual, organizational and societal costs of residency training. Transparency and accountability are clearly needed.
The committee recommended that significant reforms are needed to ensure that the public’s investment in GME is aligned with the health needs of the nation. Rules governing the Medicare financing cannot occur without legislation. The recommendations are:
- Invest strategically. Maintain current GME support and modernize GME payment methods based on performance to ensure oversight and accountability. The committee urges data collection to inform better decision making.
- Establish a GME policy council to develop policies and strategic plan, and a GME center for managing financial aspects and ensure transparency in distribution of funds and accountability.
- Create a Medicare GME fund with two subsidiary funds, an operational fund for ongoing support of programs, and a transformation fund to finance investigator and program-initiated transformational initiatives and innovation directed at achieving the triple aim.
- Modernize Medicare GME payment methodology. Pay the organizations sponsoring GME programs directly, set a national per-resident amount and implement performance-based payments using Transformation Fund pilot payments.
- Continue state’s discretion regarding Medicaid GME funding while requiring similar levels of transparency and accountability as Medicare.
After reading the report, my own thoughts were that the recommendations are necessary next steps towards GME reform. The recommendations address federal funding and returns on investment for the public tax dollars. An overhaul of our GME requires more changes than those recommended in the report. The full report is available for download at www.iom.edu/GME