Seven New York hospitals have dropped out of a federal reimbursement experiment that would have paid participants to train fewer doctors.
The defection is another blow to a plan designed to cut the nation's glut of physicians and save government money.
The teaching hospitals join seven others that have bailed out of Medicare's graduate medical education demonstration. Of the latest defectors, six hospitals are members of the Graduate Medical Education Consortium of Rochester, and the seventh is New York City's 1,234-bed Beth Israel Medical Center (Oct. 19, p. 3).
"Like any experiment, you don't know what the result is going to be until you start," said Edward Hundert, M.D., senior associate dean for medical education at the University of Rochester, a member of the consortium. Ultimately, consortium members were forced to make "unreasonable trade-offs" that didn't justify the money they would have received for reducing residency slots, he said.
New York state's voluntary GME demonstration project gained national attention because hospitals were to be paid for not training residents.
HCFA estimated it would spend $400 million to subsidize demonstration project participants that agreed to shrink residency slots by 20% to 25% over six years. Eventually, HCFA said, Medicare would save $200 million to $300 million annually as the number of residents declined.
In announcing their decision last week, consortium leaders cited some problems:
The 1996 base year used to calculate reductions was unusual because several slots were not filled that year. Under the demonstration project, the consortium's focus shifted "from creating the best possible educational experience to hitting reduction targets."
A mandate on maintaining the current 50-50 primary-care-to-specialist ratio inhibited local growth in subspecialties-pediatric cardiology, for example. Creating a new fellowship or residency meant downsizing current specialities.
The state cracked down on enforcing limitations on the number of hours residents work (Aug. 24, p. 20; June 1, p. 28). In some programs, residency reductions "could result in an inevitable increase in on-call demands," consortium leaders said.
Rochester participants had managed to slash 5% of available residency positions since late 1997. But they concluded that the goal of reducing residency slots "can best be achieved working outside of the demonstration project's rigid guidelines."
Many of the dropouts found the program to be too restrictive and administratively cumbersome. Beth Israel shared those concerns.
With the Rochester hospitals and Beth Israel dropping out, 35 hospitals remain in the demonstration project.
A HCFA spokeswoman conceded that a number of hospitals have found the demonstration inflexible and the reduction targets ambitious. It's not surprising that some are dropping out, she said.
"But one of the goals of the demonstration was to get folks to focus on the number of residents that are being trained," she said. Now the issue is clearly on their radar screens, she said.