Much of the cost of training physicians is currently borne by Medicare (and, to a lesser extent, Medicaid). This is known as Graduate Medical Education, or GME, funding, and it pays some, all, or more than all (depending upon the hospital and based upon a complicated formula discussed on May 25, 2009, Funding Graduate Medical Education) of the cost of training residents in the various specialties that comprise medicine. For those unfamiliar with medical education, graduation from medical school, while it confers the MD (or DO, Doctor of Osteopathy) degree and the title “doctor”, no longer permits practice in any of the US states. A least one, and in some states two, years of residency (“GME”) is required for licensure, and most doctors complete an entire residency of 3 or more years to make them eligible for certification as a specialist in a field (eg, family medicine, general surgery, internal medicine, psychiatry, etc.). Fellowship training is requires addition years beyond the core residency to become a sub-specialist – for example, those who complete an internal medicine residency can then do additional years to become a cardiologist, gastroenterologist, endocrinologist, etc.
Medicare augments its payments to institutions (usually hospitals, although there are a few consortia and federally-qualified health centers) with two types of payments, Direct GME which is intended to pay residents’ salaries and cost of teaching, and Indirect ME which is for the additional costs that training hospitals bear for a variety of reasons. (In addition to the piece linked above, see also Training rural family doctors, Nov 5 2010; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?, Apr 22,2010; Primary Care and Residency Expansion, Jan 7, 2010.) These payments have been the cornerstones for funding residency education. Because the amount is tied to the percent of Medicare patients in a hospital, rather than the total number of patients cared for in hospitals or outpatient settings, it could be (and has been) argued that funding GME should be done comprehensively and separately from Medicare. The most persuasive argument is that private insurers should also contribute to GME (they don’t, although Medicaid does in some, but not all, states). On the other side, many fear that uncoupling GME funds from Medicare would make it easier for a Congress looking at ways to cut the budget to cut GME than having it as part of Medicare.
Except this year, with exceptionally high pressure to cut the budget, Medicare is not even sacrosanct, although, as I have recently argued, (Medicare: A lifeline, not a Ponzi scheme, Dec 2, 2011) most of the proposals to cut it across the board by tactics such as raising the age of eligibility are poorly conceived. So there are now proposals to cut the funding from Medicare for GME. Unsurprisingly, this has created great anxiety in the community of academic health centers, and the Association of American Medical Colleges (AAMC), which has strongly supported expansion of GME residency slots, is quite alarmed (Preserve Medicare support for physician training, revised Oct 2, 2011). The Accreditation Council on Graduate Medical Education (ACGME), which accredits institutions that sponsor residency programs and, through its subsidiary Review Committees (RCs), each individual specialty and subspecialty, has done a study that shows that cuts in residency positions have already occurred and more major cuts are threatened if Medicare decreases its funding ("The Potential Impact of Reduction in Federal GME Funding in the United States: A Study of the Estimates of Designated Institutional Officials”). ACGME CEO Thomas Nasca, MD, is quoted by AAFP News Now as saying “We will actually reduce the number of physicians who are trained in the United States at a time when all workforce studies are demonstrating a mounting deficit of physicians….That will place us in a position where our physician-to-population ratio in 2020 and beyond is below (that of) most of the developed countries in the world." The study found that “With a 33 percent reduction in GME funding
- 68.3 percent of responders said they would reduce the number of core residency positions,
- 60.3 percent would reduce the number of subspecialty fellowship positions,
- 4.3 percent would close all core residency programs, and
- 7.8 percent would close all subspecialty programs.”
Because there are many more “core” residency positions than subspecialty fellowship positions, these would be disproportionately affected by across-the-board cuts. In addition, residency programs in primary care, which are not as profitable to the sponsoring institution, are even more likely to be cut despite the service that they provide to patients, especially those most in need. Perry Pugno, M.D., M.P.H., AAFP vice president for education, notes in that same article that "…any cuts to GME that go across the board are going to hurt primary care -- especially those of us who disproportionately take care of adults with chronic illnesses….In communities where primary care residency programs are present, those programs become the access point for the poor and disenfranchised of the area.” He says that it's not unusual for family medicine residency programs to see patients who live both in poverty and with numerous chronic illnesses. "The payment for taking care of those patients is so low that the local medical community often doesn't want to provide that care…But residency programs take all comers."
The key issue that Pugno is addressing is one that is very important issue and is not usually made explicit in national policy discussions: our current method of allocating Medicare GME funds to institutions (hospitals) rather than to individual residency programs tends to encourage funding the funding of positions in specialties that most profit those hospitals. The interests of the American people, in regard to the kinds of specialists they need, are not necessarily (and I would argue in fact are not) the same as the interests of the hospitals that sponsor residencies. Hospitals like to fund specialties whose trainees’ work enhances their revenue (e.g., cardiology fellows, who can increase the number of profitable procedures that are done) or at least decrease their loss (e.g., emergency medicine residents, who can fill gaps in seeing patients in emergency departments). Indeed, when hospitals can afford to, they often augment Medicare GME with their own funds to create more such positions. This is about their own financial interest, and does not take into account whether or not the US needs more cardiologists or ER docs, or more family physicians and general surgeons.
This contrast between the interests of the hospital (what kind of residency positions are most beneficial to its bottom line) and the needs of the population, is, of course, a subset of the larger tension. We train doctors in highly-specialized tertiary care academic health centers, while they will mostly practice in the community. There are a number of reasons that this is not brought up more often. For the general lay public, including most members of Congress and their staffs, it seems like a subtle difference. For experts, such as the AAMC, the issue is that they represent the interests of the medical schools, and want to have those interests seen as also representing the interests of the US population. Of course, they do not always, especially the interests of the most rural, poor, minority and other underserved portions of that population.
I think we need to use every opportunity to make this issue more clear and open. While it is probably true that it is a mistake to decrease federal funding for GME, it is absolutely necessary to increase the support for primary care and, in particular family medicine. And this will only happen if GME funding is explicitly tied to requiring it to be spent on primary care programs, and “prevents substitutions”.
Debunking the Bunk
If the design for primary care was specific to primary care outcomes, the result of 13,000 annual graduates would be 13,000 for primary care.
This is a figure that would actually address the primary care needs of the United States.
But since the real output is just 5000 for primary care out of 13000 annual graduates, the US fails primary care by design.
If the design for primary care training was specific for needed health access result, then primary care training would be 100% found in zip codes in need of workforce, not just 12%. Primary care optimal for the elderly that are 65% found in 30,000 zip codes would be primary care 100% found in 30,000 zip codes where over 65% of those over age 65 are found.
Such a design would result in substantial primary care delivery where most needed by residents during training, by faculty, and by primary care team members. Those served by such a design would be most likely to be poor, near poor, rural, underserved, and disadvantaged - those most likely to be served by family physicians currently.
But since the design for primary care training adds more primary care where all workforce is concentrated (including primary care workforce), the design fails most Americans.
Also the new term “core residencies” is another deceptive term. The appropriate categories for primary care residencies are indicated by the outcome. The terminology should be flexible as compared to permanent in outcome. Family medicine is the last remaining permanent source of primary care. All other sources are flexible and depart primary care steadily during training, at graduation, and each year afterward.
Core residencies implies foundational. Flexible designs that can go either way are not suitable for building a health access foundation. Only permanent primary care deserves recognition as foundational. Only permanent can rebuild.
Internal medicine will be fortunate to have 1 FTE of primary care from each 8 residency graduates. This is over 85% not primary care. Pediatric expansions fail for the purpose of increasing primary care workforce as pediatric primary care is saturated in the locations where pediatricians choose to located. IM and PD are 70% crowded inside of top concentrations. Health access requires an entirely different result.
Any real choice for primary care and for health access result is a specific family medicine residency expansion forced 100% to 30,000 zip codes in need of primary care. If other sources fixed their flexibility problem, they could also participate.
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