Toppling the Ivory Tower of Medicine

Last summer’s Institute of Medicine report on Graduate Medical Education (GME) raised vociferous concerns from stakeholders ranging from academic medicine (Association of American Medical Colleges), hospitals (American Hospital Association), and organized medicine (American Medical Association).

384px-UK-2014-Oxford-All_Souls_College_03In this Health Policy Report from the NEJM, the details of the IOM report are summarized and the salient issues surrounding the reform of GME are explained. Graduate medical education, the system by which we train our nation’s newest physicians, obtains its funding largely from public payers such as ($9.7 billion), Medicaid ($3.9 billion), the ($1.4 billion), and the Health Resources and Services Administration ($0.5 billion). Additional funds for GME come from the Department of Defense, individual states, and even foreign governments such as Saudi Arabia which fund educational opportunities for their citizens to train in the United States.

Ultimately, the bulk of the funding goes to hospitals in the form of indirect GME payments ($6.8 billion) which account for the extra costs affiliated with delivering health care provided by trainees. Only $2.8 billion of the total Medicare GME funding is directed toward paying the stipends for trainees and supervising physicians.

The IOM report recommends replacing the current payment model with two funds: an “operational fund” designed to provide payments to currently accredited GME programs based on a geographically-adjusted per-resident amount and a “transformation fund”  which would award new GME positions based on specialty and geographic priorities. There would be no change in the overall funding amount (approximately $10 billion).

First, If yes, is the optimal mechanism by lifting the cap on GME positions which has been in place since 1997? In my opinion GME positions should be targeted, as the IOM suggests, to account for the specific needs of communities. Under the current model, . Secondly, those venerable institutions comprising the Ivory Tower of Medicine would stand to loose billions by equalizing the distribution of funds among all currently accredited GME providers across America. Lastly,  hospitals would lose out to the actual providers of GME (i.e. educational institutions) under the IOM’s plans.

commentary by Cedric Dark, MD, MPH, FACEP

Excerpt

“For more than three decades, administrations from that of Republican Ronald Reagan (1981– 1989) to Democrat Barack Obama have proposed sharp reductions in the robust support by Medicare of graduate medical education (GME) programs. Teaching hospitals, the major recipients of an annual federal GME investment of more than $15 billion in 2012, have withstood most of these incursions because senior Democrats who chaired the congressional committees that oversaw Medicare and represented areas with heavy concentrations of training programs, such as New York, Massachusetts, and Illinois, strongly opposed these cuts. Their advocacy was reinforced by academic medical centers that house GME programs, conduct clinical research, provide complex care, and treat uninsured patients. But the continued growth of large entitlement programs, including Medicare (and its GME program), remain a target of budget cutters.” PMID 25607431

Inglehart, JK. NEJM 2015. 372 (4): 376-381.