A prestigious government advisory group is proposing changes to the way graduate physicians are trained that could open the door for states like Georgia and South Carolina to add positions where they have historically been shortchanged, the co-chairwoman said.
But the report from the Institute of Medicine on graduate medical education does not address overall underfunding and the need to diversify funding away from Medicare, said Dr. Peter Buckley, dean of Medical College of Georgia at Georgia Regents University.
The institute issued its massive report Tuesday, titled, “Graduate Medical Education That Meets the Nation’s Health Needs,” in which the group criticized the current system as being “opaque” with “rigid” funding formulas that are not tied to outcomes, said Dr. Gail Wilensky, co-chair of the study group and a former director of the Medicare and Medicaid programs, which principally fund graduate medical education in the U.S.
The group proposed taking the Medicare payments, about $10 billion of the $15 billion used to fund residencies, and splitting it into two funds, an operational fund that would pay for current residencies and a transformation fund that would pay for innovative pilot programs and test new ways of measuring outcomes that would better tie performance to funding.
That fund could also be used to address historic geographic and specialty disparities, Wilensky said. The Balanced Budget Act of 1997 capped residency slots, cementing historic disparities between federally-supported residency positions that heavily favor the Northeast, the report notes. Georgia currently ranks 40th in residents per population, at 21.8 per 100,000, compared to a national average of 36.6 per 100,000 and states like Massachusetts, which enjoys a 83.7 per 100,000, according to the 2013 Physician Workforce Data Book of the Association of American Medical Colleges.
“What you have had difficulty doing in Georgia and elsewhere is laying claim to public dollars because of the cap that has been put in place,” Wilensky said. “We are sympathetic to the peculiar distribution that currently exists because of historical reasons and recognize that while you can still add programs and residents and that has happened at a pretty robust clip since the funding was capped, we do want to make funds available to specialty and geographic areas that we think have had difficulty accessing public funds in the past and it would come out of the transformation fund.”
While that transformation fund would start off at a lesser amount, say 10 percent of funding, that could grow to 30 percent by the end of the 10-year transition period the group envisioned, “which is in today’s dollars about $3 billion, which is a substantial amount of the Medicare funding, potentially going in this area,” Wilensky said.
The medical school group AAMC immediately denounced the proposal and said it “will slash funding for vital care and services available almost exclusively at teaching hospitals, including Level 1 trauma centers, pediatric intensive care units, burn centers, and access to clinical trials,” according to a statement from CEO Darrell G. Kirch, a former dean of MCG.
Buckley, the current dean, said he appreciated the group taking a look at a system that needs change.
“The whole finance and payment and the governance is way outdated,” he said. “Maybe that’s a way of looking at fundamentally changing some of the anachronistic funding and distribution” of residency slots.
Those slots make a difference – states typically retain about half of the residents they train to practice in that state, the report said. That rises to two of three if the resident also attended medical school in that state, according to the report. Georgia does even better – last year it retained 80.9 percent of residents who graduated from a Georgia program and who also graduated from high school in Georgia, according to the Georgia Board for Physician Workforce.
But the committee whiffed when its overhaul did not recommend increasing the overall funding, Buckley said.
“We’re talking about how to redistribute what isn’t enough money to go around,” he said. “That to me seems problematic.”
And the proposed overhaul still left Medicare paying for most of the training instead of looking at pulling in other payors, such as commercial health insurance, Buckley said.
“Why is it that other insurance not chipping in, in some kind of way, to support that service because currently they are getting it as a free ride,” he said.
Whether the overhaul will ever be implemented is unclear at this point – all of it would have to be approved as legislation by Congress, Wilensky said.