Graduate Medical Education (GME) Policy - Mark D Schwartz, MD NYU Grossman School of Medicine LEAHP Program 2021-6-2 - Society of General Internal ...

Graduate Medical Education
       (GME) Policy

        Mark D Schwartz, MD
  NYU Grossman School of Medicine
      LEAHP Program 2021-6-2

                                    https://www.nap.edu/read/18754/

Sunday, Dec 19, 2021

Congress Debates Federal Subsidies for
Graduate Education for Pre-K Teachers
  Need more teachers for universal pre-k
  for 3 and 4-year-olds recently passed in
  the American Families Act of 2021.

  • 0.25% increase in payroll tax
    proposed

http://savegme.org

GME policy is a microcosm of US health care policy…

  “…where professional associations, including the Association of
  American Medical Colleges, the American Hospital Association,
  and the Council of Teaching Hospitals, have lobbied Congress
  and state legislatures to use an outmoded formula to give $20
  billion annually to their members, leveraging national
  catastrophes into an opportunity to ask for more GME funding
  and raising the specter of “unintended consequences” to derail
  GME reform that would be in the public’s interest, including a
  reform proposal from the National Academy of Medicine.”

   Grischkan J, et. al. Moving the Financing of GME Into the 21st Century. JAMA 2020.

15.8% Increase
       20132018

Vs. 1997 BBA: GME cap (~100k)
• For each hospital at 1996 level
• Increased by ~30% since then

Chen C, et.al. JAMA Intern Med 2020;180(1):148–150.
doi:10.1001/jamainternmed.2019.4429

                            + 20%

Core Policy Questions
• Is GME a public good or a hospital cost?
  – Should American taxpayers subsidize the cost of GME?

• Should (How) Medicare GME shape the physician workforce?
  – If GME is a public good, what role should the public have in shaping
    the outcome?

US Graduate Medical Education
• GME in the US is the envy of the world, graduating >100,000
  new physicians for practice annually
• However, there is broad consensus* that current GME policy
  and practice are not well aligned with the needs of the US
  healthcare system in the 21st century

          *Inglehart JK. Financing Graduate Medical Education — Mounting
          Pressure for Reform. N Engl J Med 2012; 366:1562-1563.

GME Policy Problems
• Poor alignment of GME funding policy and US workforce needs
• Inadequate accountability by hospitals and GME programs for
  outcomes
• No transparency regarding use of funds by hospitals
• Inadequate curricular focus on competencies needed for
  healthcare reform

GME Policy History

• Pre 1965, GME was responsibility of hospitals
• Medicare’s founders debated its role in funding GME
   – Congress concluded that it was inappropriate to pay for
     these training costs with funds intended for health care

Reagan: “Nothing is as permanent as a
     temporary government program”
• Congress reluctantly and temporarily decided Medicare
  would pay its share
  – GME enhances value of patient care

• Subsequent commissions concluded:
  – “It is inappropriate to pay for GME through Medicare”

• Medicare GME funding is now securely ensconced in the
  Medicare trust fund and has grown
  – 1984: GME incorporated into Medicare’s Inpatient Prospective
    Payment System (IPPS)

• 1,100 (26%) teaching hospitals in the US
• 375 of the largest - Council of Teaching Hospitals and Health Systems (COTH)
    • Train about 75% of residents yearly and provide >40% of all hospital charity care
                                                                                          eHealth, 2019

JAMA. 2017;317(20):2105-2113.
doi:10.1001/jama.2017.5702

Sources of Public GME Financing
   Billions of Dollars (~$20B in 2018)

                       DoD, 0.02
   THC
Child GME
  Title 7            HRSA,
                      1.8
              VA, 1.8

            Medicaid, 4.2    Medicare, 12.5

                                              CRS Report, 2018

Follow the Money

        He K. Graduate medical education funding mechanisms,
        challenges, and solutions. Am J Surg. 2021;221(1):65-71.

Stewardship of Medical Education

Medicare GME Finance Policy: Direct and Indirect
• Since 1984, GME funding has been split into
  – Direct (DGME) and Indirect (IME) payments

• DGME:
  – Subsidizes costs of resident and faculty salary/benefits, and administrative
    costs

• IME:
  – percentage added on to the usual DRG payment to hospitals to account for
    the higher costs incurred by teaching hospitals that care for sicker patients
    and inefficiencies of care by trainees

https://fas.org/sgp/crs/misc/R44376.pdf

DGME = # Residents * PRA($) * Medicare Share
• # Residents based on 3-year rolling average/hospital
  – FTEs capped at 1996 levels

• PRA: Per-Resident Amount from 1984, updated annually by CPI
  – PRA weighted by
        – 1.0 FTE for initial residency period (IRP), usually first 3 years
        – 0.5 FTE beyond IRP (subspecialty fellowships)

• Medicare Share: % of Medicare inpatient days/Total inpatient
  days

IME = c * [(1 + IRB ratio) 0.405 -1]
• Percentage add-on to Medicare DRG payment to adjust for
  teaching intensity
   – IRB: intern/resident to bed ratio
   – C is a multiplier set by Congress (c=1.34)
       • 5.5% increase in IME adjustment for every 10% increase in IRB

• ~1,100 teaching hospitals get IME add-on to IPPS payments
   – Ranges from +1% to +48%
   – ~200 hospitals get 2/3 of the funds

• MedPAC estimates Medicare pays 2x the amount justified
   – i.e., a 10% increase in teaching intensity results in only a 2.7% increase
     in Medicare costs per discharge

Goals of GME Policy
• Align GME funding strategy with physician workforce needs
   – Geographic distribution – increase physician/population ratio in rural
      and inner city regions
   – Specialty distribution – increase PC physicians >40%
       • Increase GME grads in PC to 50%
   – Incentivize GME in competencies needed for reform
       • Ambulatory, team, evidence-based, coordination, cost-effective

• Increase transparency and accountability of hospitals and GME programs in
  their use and outcomes of GME funds

GME Advisors/Stakeholders
Advisory Organizations   Stakeholders
• MedPAC                 • AAMC & COTH
• HRSA                   • ACGME
  – COGME                • AHA and FAH
  – ACTPCMD

   Reform
    GME

MedPAC
• Hold back ½ of IME and pay out via pay for performance program
• HHS should collect data and publish annual report GME funding,
  costs, and use per institution
• Conduct workforce analysis number and mix of physicians needed
• HHS to report on financial impact of GME on institutions with focus
  on variable impact by specialty
• HHS to study strategies for increasing the diversity of our health
  professional workforce

                                         http://www.medpac.gov/-public-meetings-

AAMC
• We need more docs!
  • Lift the GME cap

• “Cuts to GME would jeopardize our ability to train physicians, nurses,
  and other health care providers, and limit critical services to the
  community”
• “Cutting physician training at a time when our nation faces a critical
  shortage of doctors would threaten the health of all Americans”

GME Policy Strategies
• Market-based approach – feds hands-off educational policy
  and workforce distribution

• Incentive-based approach – influence GME education and
  workforce via funding policy

• Regulatory approach – explicitly align support with educational
  and workforce outcomes

• Growing pressures to reduce deficit
• $4+B in empirically unjustified Indirect GME funding
• Physician shortage – desire to raise GME cap by hospital
  community
• Desire to increase accountability and transparency of GME
  by MedPAC, CMS, and policy-makers

•  trade increased GME funded positions for P4P

Resident Physician Shortage Reduction Bills
• 10th Congressional attempt to increase the GME funding cap!
  – 2007: First introduced by Sen Bill Nelson (D-FL)
• Most have bipartisan sponsorship in House and Senate
• All have died in Committee
  – 15,000 new slots  Cost > $20B over 10 years
  – Members loath to choose winners and losers
  – No political air cover of a non-partisan, expert estimate of workforce
    need
     • ACA’s National Health Professions Workforce Commission

Resident Physician Shortage Reduction Act of 2021

Resident Physician Shortage Reduction Act of 2021
• 2.3T spending bill Dec, 2020: 900B COVID relief + 1.4T Appropriation for FY21
   – Congress increased GME positions by 1,000 – the first increase since 1997

• New 2021 bill would increase GME positions by 14,000 over seven years,                   with
  >10% allotted to hospitals…
   –   in rural areas;
   –   training over their GME cap;
   –   in states with new medical schools or new branch campuses; and
   –   that serve areas designated as health professional shortage areas (HPSAs)

• Missing from prior versions
   – Allocate to hospitals training residents in outpatient sites and in shortage specialties

JGIM 2014

April 2017

Establish a GME Strategic Planning Committee
• Independent, ad hoc, non-partisan Committee within DHHS
• Work with, but independent of, the National Center for Health
  Workforce Analysis in HRSA’s Bureau of Health Workforce
• Independent, nonpartisan experts and representatives of the
  healthcare and the health services research communities

GME Strategic Planning Committee: Charge
• Educational methods consistent with society’s needs, including the
  sites of education and training such as inpatient and ambulatory
  locations;
• Develop strategies that address geographic maldistribution of
  medical specialists, workforce diversity;
• Recommend public and private funding options for GME; and
• Identify informational gaps and recommend methods for obtaining
  data.