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“ Compendium of Graduate Medical Education Initiatives”

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“ Compendium of Graduate Medical Education Initiatives” AMERICAN MEDICAL ASSOCIATION “ Compendium of graduate medical education initiatives” Table of contents Introduction . 1 Background . .1 Why reform GME? . 1 Current GME initiatives . .. 2 Federal legislation for GME expansion . 2 Institute of Medicine (IOM) . 3 American Medical Association . 4 Council on Graduate Medical Education (COGME) . .. 4 Association of American Medical Colleges (AAMC) . 5 American Academy of Family Physicians (AAFP) . .. 5 Heritage Foundation . .. 5 Program on Health Workforce Research and Policy at the . 5 Cecil G . Sheps Center for Health Services Research State initiatives . 6 Regional medical education: The WWAMI experiment . 6 International medical graduates . 6 Proposals for GME reform . 7 Part A: Considerations for GME reform . 7 Percentage of reimbursements and/or insurance plans . 7 for GME funding All-payer model . 7 Payments tied to quality measures or performance metrics . 8 “Grown Your Own” approach of Kaiser Permanente . .8 Teaching Health Center (THC) and Primary Care . .9 Residency Expansion (PCRE) Grants Governance board to decide needs . 9 Combine IME with DGME . 10 Per resident payment amount . 10 Tax breaks for hospitals that privately fund residency positions . 10 “Bed-tax”: A State provider tax/assessment/fee . 11 Increasing grant money to GME training . 11 Part B: Alternative routes for medical students who fail to match . 11 Assistant physicians . 11 Program-specific “5th year” or research + clinical programs . 12 for unmatched graduates American Medical Association “Compendium of graduate medical education initiatives” report ii Table of contents (continued) Master’s programs for non-matched medical students . 12 Increase number of “transitional years,” “traditional rotating . 12 internships” and “intern years” Appendix A: The IOM Report . 13 Appendix B: Relevant AMA policy . 14 Appendix C: The WWAMI . 21 Appendix D: State initiatives . 22 Appendix E: Comparison of assistant physician bills . 25 Copyright ©2016 American Medical Association . All rights reserved . 16-0067:5/16:PDF:df American Medical Association “Compendium of graduate medical education initiatives” report iii American Medical Association “Compendium of graduate medical education initiatives” report in Connecticut), or (c) the payments per state inhabitant Introduction ($1 .94 in Montana versus $103 .63 in New York) ”. 2 In addi- The American Medical Association Council on Legislation tion, salaries of residents have remained constant and have (COL) and the AMA Council on Medical Education (CME) diminished in purchasing power over the years due have long-focused on ways to improve graduate medical to inflation . education (GME) to ensure medical students have the opportunity to fulfill training requirements and become Why reform GME? practicing doctors . Recently, states have introduced legis- lation on Assistant Physicians, a unique role for unmatched The call for GME reform is two-fold . First, Congress devel- students, which generated numerous questions regarding oped the existing GME funding scheme several decades the governance, funding, and future of GME . To adequately ago in 1965 . Importantly, Congress intended this to be a address these concerns, this document seeks to provide temporary measure until a more suitable source of funding background regarding the challenges faced by the current could be found . A Congressional report at that time stated: GME system . It then outlines GME initiatives . These include “Educational activities enhance the quality of care in an AMA, private and state efforts, which we hope will inform institution, and it is intended, until the community under- future GME advocacy . takes to bear such education costs in some other way, that a part of the net cost of such activities (including stipends of trainees, as well as compensation of teachers and other Background costs) should be borne to an appropriate extent by the hos- GME refers to any type of formal medical education after pital insurance program ”. 3 Stakeholders have since called the receipt of an M .D . or D .O . degree in the United States . for a restructuring of GME payment to reflect the changing This includes intern, residency, and fellowship training . health care landscape . The current system is primarily funded by two streams of Second, the current system limits the number of training Medicare dollars: Direct Graduate and Indirect Medical positions despite national and local needs . Undergraduate Education, or DGME and IME, respectively . DGME payments medical training has increased in both size and number . are meant to cover direct training costs, such as salary, Enrollment in United States medical schools alone has benefits, and administrative costs . IME, however, is provided increased by 23 .4 percent, with 17 new medical schools to counter the additional costs thought to be associated established between 2002 and 2014 .4 Additional expansions with sponsoring teaching programs and providing patient are expected to continue, with estimates that in the 2018- care in training centers . Beyond Medicare, there are addi- 2019 academic year, enrollment in medical school will tional, smaller funding streams, including: state payments, have increased by 30 percent from 2002 .5 In addition, more the Department of Veterans Affairs, and the Department international medical students are looking to train in the of Defense . Government funding of GME in 2012 was $15 U .S . While the number of medical students continues to billion with $9 .7 billion coming from Medicare, $3 .9 billion grow and the U .S . population continues to increase and from Medicaid, and $1 .4 billion from the VA 1. grow older, parallel expansion in residency training has Though Medicare and other government entities pay over not ensued to the same degree . This is primarily due to $15 billion annually for GME programs throughout the the cap on government-funded residency positions since country, this funding does not fully cover the cost of main- the Balanced Budget Act of 1997 . taining teaching programs (approximately $27 billion per The Balanced Budget Act of 1997 used data from 1996 to year) . Hospitals, training centers, and residency programs set and project what was intended to be another temporary are also not required to report use of these funds and very funding mechanism for GME . This funding structure has few, if any, have public data on how these GME payments been in place ever since, limiting the number and location are utilized . DGME and IME payments also “differ significant- of training programs that can receive federal GME dollars . ly by state (beyond cost of living or care differences), as seen This cap, however, has not prohibited academic centers by metrics such as (a) the number of Medicare-sponsored from funding their own residency positions in addition to residents per 100,000 population (77 in New York, 19 in the federally supported slots, leading to a modest increase California, 14 in Florida, 3 in Arkansas), (b) the average in the number of residency positions . Yet, these programs payment per resident ($63,811 in Louisiana versus $155,135 American Medical Association “Compendium of graduate medical education initiatives” report 1 admit that their GME expansion is not based on workforce The above systems encompass almost every residency assessments . The most common reasons cited “[were] to program in the United States . Exceptions to the above expand service lines that generate revenue . Other reasons match programs include: included recruitment of faculty or spouse, prestige, needing additional staff due to duty hours restrictions, and the local • Military Match: available to military personnel only . job market (for example, openings in nearby practices or the • Rural Scholars Program: students graduate medical development of a new hospital .)”6 Hence, the number of un- school in three years after committing to a primary care matched students continues to grow as residency positions training program at that school . fail to meet the demand of patients, local communities and • Family Medicine Accelerated Program: students medical graduates . This problem is reflected in the growing commit to Family Medicine and are channeled into number of unmatched medical students . The most recent that track in three years . number of U .S . senior students without a residency position, following the main residency match, totaled 606 in 2015 • Post-SOAP Positions: for applicants who match into alone, which does not include international medical gradu- PGY-2 positions, but fail to match into a PGY-1 position, ates, previous graduates, or other non-traditional applicants . preliminary positions can be created by programs after For those U .S . seniors who did not match this year and hope the SOAP concludes in order to bridge the applicant to to reapply next year, their probability of match success their match commitment . plummets from 96 percent to around only 40 percent .7 • Off-Cycle Appointments: positions that begin prior to February 1 can be offered outside of the match . These are Match Data, 2013-20158 oftentimes openings created by an unplanned absence of a trainee 10. Unmatched Unmatched Total U.S. U.S. Total unmatched allopathic osteopathic unmatched U.S. post- Year students students U.S. students SOAP Current GME initiatives 2013 1097 675 1772 591 Several stakeholders have offered potential GME reforms . 2014 975 611 1586 506 While these proposals differ, the following outlines key 2015 1093 610 1703 606 aspects
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