January 8, 1999

CoGME Addresses GME Financing

At its December meeting, the Council on Graduate Medical Education (CoGME) addressed graduate medical education (GME) financing. Two speakers raised, without answering, a series of questions about Medicare and GME that underscore the degree to which traditional financing methods are under scrutiny.

Jamie Reuter, Sc.D., director, Institute for Health Care Research and Policy, Georgetown University Medical Center, asked what are the policy objectives for federal financing? What training programs are to be supported and who will be accountable for their content and quality? How large should a federal commitment to GME be when there is no federal support for postgraduate education in other professions; e.g., law and engineering? If federal support continues, should it be targeted toward desired venues such as health maintenance organizations? What alternatives to federal funding might be used?

Judith Lave, Ph.D., professor of health economics and co-director, Center for Research on Health Care, University of Pittsburgh Graduate School of Public Health, (who also serves on the Medicare Payment Advisory Commission (MedPAC)) highlighted questions being raised about Medicare GME payments. Why do per resident costs vary tenfold among health care organizations? Why should Medicare subsidize residents who will earn a great deal relative to the general population that pays the Medicare tax? Should federal funds for GME continue to flow through patient care financing, or should the financing be separate and explicit? Are subsidies really needed? Why do managed care organizations not hire and train new doctors in the same way that IBM hires and trains its new people? And finally, how should education and service be organized in the future so that routine care in teaching institutions is not so expensive?

MedPAC Senior Analyst Craig K. Lisk briefed CoGME members on the commission's work on GME (see Washington Highlights, Dec. 4 and Dec. 18, 1998). In considering policy reform, MedPAC is examining the objectives of GME support from the perspective of the federal government as a prudent purchaser. What is Medicare buying when it pays for GME? How will the government assure accountability for federal funds? MedPAC will consider options and make recommendations on payment methods for GME:

• How much should be paid by the federal government?
  
• From where should the funds come?
  
• To where should they be paid?
  
• How should they be distributed?

Council members expressed their concern about unlinking GME financing from payments for patient care. They worried about potential impacts on uncompensated care generally and on safety net institutions particularly.

To inform the council's discussion of the financing of GME in ambulatory settings, a panel of three educators described efforts to expand ambulatory training for residents at their institutions: Malcolm Cox, M.D., professor of pedicine and associate dean for network and primary care education, University of Pennsylvania School of Medicine; Sheri A. Keitz, M.D., Ph.D., associate in medicine and director, Managed Care Learning Center, Department of Internal Medicine, Duke University School of Medicine, and director, PRIME Program, Durham VA Medical Center; and Joseph S. Scherger, M.D., chair of family medicine, and associate dean for clinical affairs, College of Medicine, University of California at Irvine. The panelists pointed to these requirements for overcoming barriers to GME in ambulatory and community care:

• change in the culture of academic medicine;
  
• introduction of the basic science of public health early in the medical curriculum;
• limited government involvement in prescribing supervision because its rules do not deal adequately with residents' increasing knowledge and skill during their training; and
  
• use of grants to enhance leverage, creativity, and credibility.

Council member Carl Getto, dean and provost, Southern Illinois University School of Medicine, reported on the work plan of COGME's working group on Financing GME. For the council's next (15th) report, the group will:

• scan the policy and health care environment;
  
• identify policy options for financing GME by the federal government, the states, and the private sector; and
  
• model the intended and unintended consequences of these options for at-risk populations and training in ambulatory settings.

Over the longer term, the group intends to look beyond short-term, budget-driven proposals and to address a rational payment system for GME, including objectives and evaluation criteria.

Information: Sunny Yoder, AAMC Division of Health Care Affairs, 202-828-0497.