The system of federally funding physician training is inadequate to meet current and future healthcare workforce needs, various medical groups recently told the U.S. House Energy and Commerce Committee. The committee last month had asked the medical community (PDF) to weigh in on the topic.
Among suggestions for improving the system were adding at least 4,000 more federally financed GME positions and leveraging clinical reimbursement to influence geographic distribution and specialty composition.
The current system of graduate medical education lacks accountability and transparency, “rewards a select few states” and has not created the number of doctors the nation needs, said the 115,900-member American Academy of Family Physicians.
“It is our assertion that our current system—both in construct and financing—is contributing to the problem, not solving it,” AAFP Board Chairman Dr. Reid Blackwelder wrote in a letter (PDF) to the committee. “Stated more explicitly, we believe that simply expanding our current system will only exacerbate our current problems, not ameliorate them.”
The letter also was signed by leaders of the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group and the Society of Teachers of Family Medicine.
It goes on to cite several areas where the AAFP agrees with last summer's Institute of Medicine report, Graduate Medical Education That Meets the Nation's Health Needs, which was written by a panel chaired by former CMS administrators Dr. Donald Berwick and Gail Wilensky.
The report was criticized for its suggestion that the current financing system led to uneven geographic distribution of physicians and an unbalanced mix of too few primary-care doctors and too many specialists.
The 47,000-member American College of Cardiology acknowledged in its letter (PDF) to the committee that improving accountability and transparency of the GME system “is warranted,” as is taking a look at more training in outpatient-based settings. But it noted that the organization had several sharp disagreements with some of the IOM report's recommendations.
The number of federally financed GME residency training positions has been essentially frozen since 1997, but money from other sources has allowed the system to grow by 17.5% since the 2003-2004 academic year, so there are now roughly 118,000 residency slots.
The federal government contributed $15.5 billion toward GME in 2012, with $9.7 billion coming from Medicare, $3.9 billion coming from Medicaid, $1.4 billion from the Veterans Affairs Department and $500 million from HHS' Health Resources and Services Administration.
“Radically overhauling support for GME and diverting even more funding from specialty training in the midst of a projected cardiovascular workforce shortage could pose threats to the quality, high-value care of increasing numbers of patients with cardiovascular disease most at risk who need both primary- and specialty-care services,” ACC President Dr. Patrick O'Gara wrote.
The letter suggested adding at least 4,000 more federally financed GME positions, leveraging clinical reimbursement to influence geographic distribution and specialty composition, and basing the funding of new positions on population growth and state-specific needs.
The Association of American Medical Colleges, which represents 141 medical schools and 400 teaching hospitals, was among the IOM report's major critics and warned the committee in its letter (PDF) that the report's recommendations could have unintended consequences for medical education and access to care.
The letter noted that “there is a clear need to improve the distribution of the physician workforce,” but it added that creating new training opportunities in underserved areas will not be enough to “remedy non-educational obstacles.”
Rather than diverting Medicare dollars toward training programs that serve younger patients, the AAMC recommended that the committee explore ways that states could provide more support to local programs via Medicaid.
“The AAMC unequivocally believes that preserving Medicare's contributions to physician training is not only appropriate, but also is essential to securing access to high-quality healthcare services for the aging population,” wrote AAMC President and CEO Dr. Darrell Kirch. “Providing new incentives for states to invest already scarce state dollars in physician training through their Medicaid programs could help bolster support to community health centers, but would not undermine similar investments in facilities serving higher numbers of Medicare beneficiaries.”
The Energy and Commerce committee noted in its letter that it was preparing to review the IOM recommendations, but it didn't state when that review would take place. Its Subcommittee on Health is holding a hearing this week on replacing Medicare's sustainable growth-rate physician payment formula.
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