Graduate Medical Education That Meets the Nation’s Health Needs

1. Graduate Medical Education That Meets the Nation’s Health Needs Understanding the IOM RecommendationsWEBINAR Gail R. Wilensky, Ph.D., Project HOPEDebra Weinstein, M.D., Partners Healthcare System, Inc.Deborah E. Powell, M.D., University of Minnesota Medical School

2. Webinar Agenda Welcome Jill Eden, M.B.A., M.P.H., Institute of Medicine Study Overview Gail Wilensky, Ph.D., Project HOPE GME Financing Debra Weinstein, M.D., Partners Healthcare System, Inc. GME Governance Deborah E. Powell, M.D., University of Minnesota Medical School Q&A and Discussion 2

3. Study OverviewGail Wilensky, Ph.D., Project HOPE 3

4. Current Health Care Context • Mismatch between the health needs of the population and specialty make-up of the physician workforce • Persistent geographic maldistribution of physicians • Insufficient diversity in the physician population • Gap between new physicians’ knowledge and skills and the competencies required for current medical practice • Lack of fiscal transparency 4

5. Study Origin • Broad support for the study—12 sponsors and 11 U.S. senators 5

6. Charge to the Committee 6

7. Composition of Committee • 21 members, including experts in • GME financing • Residency training (allopathic and osteopathic) • Undergraduate medical education • Nursing and PA education • Health care systems management • Physician training in teaching hospitals and health centers, large academic medical centers, VA facilities, rural areas, safety-net institutions • Medicare and Medicaid • Health and labor economics • Accreditation and licensure • For complete committee list, visit www.iom.edu/GME 7

8. Approach to the Study • To what extent is the current GME system producing an appropriately balanced physician workforce ready to provide high-quality, patient-centered, and affordable health care? • Justification and rationale for continuing to fund GME through Medicare or other federal sources • Economist’s perspective that residents, not teaching sites, bear the cost of training • GME system is a powerful influence over the makeup, skills, and knowledge of the physician workforce • Focus on Medicare: maximize leverage of federal support and minimize barriers to progress 8

9. Key Findings: Physician Workforce • Forecasts of future physician shortages • Vary in magnitude; historically unreliable • number of physicians won’t resolve imp. workforce issues • Particularly with respect to specialty and geography • number of trained physicians not dependent on ing Medicare funds • Residencies 17.5% 2003-2012 despite cap on Medicare-funded spots • ingly specialized workforce being trained • Newly trained physicians lack needed office-based skills 9

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11. Recommendation 1: “Invest strategically”: maintain DME plus IME funding; move to a performance-based system Recommendation 2: Build a GME policy and financing infrastructure: including a policy council in HHS and a GME Center in CMS Recommendation 3: Create one Medicare GME fund with two subsidiary funds: operational fund and transformation fund Recommendation 4: Modernize Medicare GME payment methodology: move to a single per resident payment (geographically adjusted) made to the sponsoring organization Recommendation 5: Medicaid GME funding as discretionary but with similar accountability/transparency requirement Recommendations 11

12. GME FinancingDebra Weinstein, M.D., Partners Healthcare System, Inc. 12

13. Key Findings: GME Financing — An estimated $15B in federal funding 13

14. Medicare GME Payment Methods • Medicare GME payments are based on rigid, statutory formulas developed in an era when hospitals were the central site for physician training • Funds are distributed directly and primarily to teaching hospitals, with minimal reporting requirements • Two independent funding streams—direct graduate medical education (DGME) and indirect medical education (IME)—are each tied to a hospital’s volume of Medicare inpatients • Medicare-supported physician training slots are capped at each hospital’s resident census in 1996 • The financial impact of sponsoring residency programs is poorly understood 14

15. Key Findings: GME Financing • Medicare GME payments are • Inflexible – constrain funding for new programs and for training in non-hospital sites • Inequitable – payments tied to historical costs; subset of institutions and specialties excluded • Inscrutable – complicated formulas; confusion over purpose, flow and use of funds • Illogical – tied to volume of Medicare patients; funding directed only to PPS institutions 15

16. Recommendation 1 Invest Strategically • Maintain Medicare GME funding (sum of current DME & IME), adjusted for inflation • Phase-in an improved distribution methodology • Move to a performance-based system 16

17. Recommendation 3 Create one Medicare GME fund with two subsidiary funds • A GME Operational Fund to distribute ongoing support for residency training positions that are currently approved and funded • A GME Transformation Fund to finance initiatives to develop and evaluate innovative GME programs, to determine and validate appropriate GME performance measures, to pilot alternative GME payment methods, and to award new Medicare-funded GME training positions in priority disciplines and geographic areas 17

18. Combine IME and DME funding streams into a single payment • Distribute funds based on a national per-resident amount (PRA), with a geographic adjustment, where PRA = total value of the GME Operational Fund current # Medicare-funded training slots • Provide GME operational funds directly to sponsoring organizations • Utilize Transformation Fundto • Pilot new funding methodologies designed to achieve explicit outcomes • Explore new approaches to GME that will enhance efficiency and outcomes • Develop metrics needed for an outcomes-based payment system • Fund additional positions in needed areas Recommendation 4 Modernize Medicare GME payment methodology 18

19. Committee’sProposed MedicareGME Funding Flow 19

20. Allocation of Medicare GME Funds to the Operational and Transformation Funds Over Time 20

21. GME GovernanceDeborah E. Powell, M.D., University of Minnesota Medical School 21

22. Current GME Governance • No overarching system to guide GME funding in the interests of the nation’s health or local/regional workforce needs • CMS acts as passive conduit for distribution of funds to teaching hospitals • Program outcomes are neither measured nor reported • Only requirement is accreditation 22

23. Program Accreditation and Physician Certification and Licensure 23

24. Key Findings: Governance • Absence of transparency • No group accountable/responsible for producing needed specialty mix • Guaranteed financing as long as accredited • Accreditation is important but … • …doesn’t address local/national health priorities 24

25. Fundamental Questions About Medicare GME Program’s Outcomes and Effectiveness • What is the financial impact of residency programs? • Do these programs produce competent doctors? • How much funding does each institution receive annually? How much of this goes toward education? • What are the characteristics and specialties of residents supported by Medicare GME funds? • How many of these residents go on to practice in underserved specialties, locate in underserved areas, or accept Medicare/Medicaid patients? • What proportion of residents’ time is spent in hospital inpatient, outpatient, or community settings? 25

26. Minimum Requirements for Organizational Infrastructure for GME Financing • Robust resources with sufficient expert staff and the capacity to conduct or sponsor demonstrations of alternative payment methods • Regulatory authority to administer Medicare GME spending and oversee GME payment policies • Independence and objectivity with protections from conflicts of interest • A governing body selected with appropriate expertise • A mechanism to solicit input 26

27. Governance Models Considered by the Committee • National Health Care Workforce Commission • Private entity • Federal agencies—COGME, MedPAC 27

28. Recommendation 2 Build a GME policy and financing infrastructure • Create adequately resourced GME policy council in HHS OS • Develop a strategic plan for GME funding • Sponsor research re physician workforce sufficiency • Coordinate activities between fed agencies and accrediting/certifying organizations • Establish GME center within CMS • Manage and distribute funds consistent with policy council decisions 28

29. Recommendation 5 Medicaid GME • Medicaid-funded GME • Should remain at state’s discretion • Adopt same accountability/transparency standards as Medicare 29

30. Q&A and Discussion 30

31. Thank you! Visit www.iom.edu/GME to download the complete report and access related resources For more information: Jill Eden (jeden@nas.edu) 31