Re: OPEN LETTER REQUESTING INFORMATION ON GRADUATE MEDICAL EDUCATION

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1 20555 VICTOR PARKWAY LIVONIA, MI p trinity-health.org The Honorable Joseph R. Pitts Chairman U.S. House Committee on Energy and Commerce, Subcommittee on Health 2125 Rayburn House Office Building Washington, DC Re: OPEN LETTER REQUESTING INFORMATION ON GRADUATE MEDICAL EDUCATION Dear Chairman Pitts and Members of the Subcommittee on Health, In response to your correspondence dated December 6, 2014, regarding information on graduate medical education (GME), Trinity Health appreciates the opportunity to comment and respectfully submits our following comments. Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation. It serves people and communities in 21 states from coast to coast with 86 hospitals, 128 continuing care facilities and home health and hospice programs that provide nearly 2.8 million visits annually. Trinity Health employs more than 89,000 people, including 3,300 employed physicians. Trinity Health has 28 teaching hospitals with Graduate Medical Education programs providing training for 1720 residents and fellows in almost 200 programs. Committed to those who are poor and underserved in its communities, Trinity Health is known for its focus on the country's aging population. As a single, unified ministry, the organization is the innovator of Senior Emergency Departments, the largest not-for-profit provider of home health care services ranked by number of visits in the nation, as well as the nation s leading provider of PACE (Program of All Inclusive Care for the Elderly) based on the number of available programs. Trinity Health appreciates the opportunity to answer these questions, and we look forward to ongoing discussions with the Committee. Please do not hesitate to contact Tonya K. Wells at wellstk@trinityhealth.org or if we can be of further assistance.

2 Page 2 of 5 In direct response to your specific questions in the Open Letter Requesting Information on Graduate Medical Education, Trinity Health responds as follows: 1. What changes to the current GME financing system might be leveraged to improve its efficiency, effectiveness, and stability? While not perfect we support the current GME funding mechanism through the hospital cost reports. We are aware of other options, none of which offers the stability of funding necessary to provide consistent support for residency training programs that last 3-7 years, from our perspective as a very large Health System we have serious concerns about the ability of the current program to fund our future physician needs. Specifically we are currently aware of the difficulty of our Critical Access Hospitals in obtaining the physician services that they need, and the system as a whole lacks the numbers of primary care physicians and certain specialties, such as psychiatry. Although a number of proposals to adjust funding to meet projected physician workforce needs, in terms of total numbers and specialty mix, have been made, none have been implemented. The prevailing view seems to be that adjustments of this nature are too difficult to achieve, particularly if physician supply is linked to market demand. Given the substantial support from public funds through CMS funding directed to GME training programs, accountability in terms of the use of those funds to create a balance of physician workforce in terms of total numbers and specialty mix seems evident. In addition to the current funding through Medicare, Trinity Health supports the Teaching Health Center GME program, 5-year initiative created by the Affordable Care Act to increase the number of primary care residents and dentists trained in community-based settings. Studies show that physicians trained in health centers are more than three times as likely to work in a health center and more than twice as likely to work in an underserved area as those not trained at health centers. We agree with the position of the AAMC that funding residency training through unreliable annual appropriations (e.g., CHGME), eliminates the long-term stability necessary to train residents. Introducing additional stability for existing and expanded physician training efforts should be a top priority for the nation. Efforts to reform GME financing should supplement, rather than replace, existing funding sources. Eliminating existing funding streams risks diluting or forfeiting the targeted focus that each program was intended to address. In the meantime, it will be essential to expand existing support for physician education, as described in question #2, to resolve current and future shortages. 2. There have been numerous proposals put forward to reform the funding of the GME system in the United States. Are there any proposals or provisions of proposals you support and why? We agree with several of the proposed GME expansion bills that direct funding to shortage specialty programs). (Resident Physician Shortage Reduction Act S.577 and H.R. 1180, and Training Tomorrow's Doctors Today Act, H.R. 1201). H.R also includes provisions to

3 Page 3 of 5 establish accountability and transparency measures in accord with recommendations issued by MedPAC. Trinity Health is in agreement with all of these provisions, and support measures to increase funding for GME programs that encourage training in: A variety of clinical settings and systems; Multispecialty and interprofessional teams; The relevant cost and value of diagnostic and treatment options; The delivery of evaluation and management (versus procedural) services; Methods for identifying system-based errors and implementing system-based Solutions; and Other "patient care priorities." 3. Should federal funding for GME programs ensure training opportunities are available in both rural and urban areas? If so, what sorts of reforms are needed? We are aware of the Rural Track Training support mechanisms that fund expansion of rural hospital training programs and the available expansion of CAP for Urban hospitals that help meet the training requirements of these programs. We support continued funding of the rural track training programs, as well request funding for underserved urban areas. In fiscal year 2014, Trinity Health gave back over $847 million in community benefit, which includes the provision of free medical care to poor, vulnerable and medically underserved populations. Oftentimes, this care is delivered by residency clinics in urban areas. Expanded funding, would allow us to broaden these efforts, while also increasing the likelihood that we retain physicians in those underserved communities. 4. Is the current financing structure for GME appropriate to meet current and future healthcare workforce needs? a. Should it account for direct and indirect costs as separate payments? i. If not, how should it be restructured? ii. If so, are there improvements to the current formulas or structure that would increase the availability of additional training slots and be responsive to current and future workforce needs? Trinity Health supports the positions of the AAMC, and agrees that if policy were changed to consolidating the DGME and IME payments, it would risk forfeiting the targeted and distinct purpose that each of these funding streams was intended to address. Without an alternative methodology to sustain critical, specialized services, such action could jeopardize communities access to life-saving care. The effects would extend far beyond the locale of the recipient institution, since, in many cases, major teaching hospitals are regional referral centers that provide irreplaceable specialized services not found in surrounding states. Trinity Health does not support proposals to restructure GME payments to follow the resident and the not institution. This would not be financially feasible for any individual training program to support the type of infrastructure necessary to manage the training,

4 Page 4 of 5 documentation, quality and regulatory requirements that are currently administered by teaching hospitals. Allowing GME funds to follow the resident would reduce the ability of teaching hospitals to maintain the mandated infrastructure. We advocate funding that is linked to current and projected work force needs. Funding should fairly represent the cost of resident education in the sponsoring hospital. This is an acute issue for Trinity Health Osteopathic programs and programs that inadvertently triggered their CAP post Osteopathic programs will have to meet new standards of the ACGME that require increased teaching and administrative resources as of b. Does the financing structure impact the availability of specialty and primary designations currently? The current structure favors hospital-centric residency training programs. Should it moving forward? It has been noted by a wide range of stakeholders that factors other than CME financing are more powerful forces influencing the specialty mix of physicians. Trinity Health supports initiatives such as the National Health Service Corps (NHSC) and Title VII health professions programs, which have been successful in promoting primary care careers include two that Committee members have championed over the years, both administered by HRSA. Moving forward, Trinity Health agrees with the AAMC and also believes that prescribing the specialty composition of training positions in legislation would inhibit training efforts from adapting to changing workforce needs. Currently, projections indicate the nation faces significant shortages evenly spanning both primary and specialty care, but workforce needs fluctuate and change over time. Preserving workforce flexibility at the regional and local levels is the best way to ensure that organizations can continue to fulfill the multifaceted health needs of our aging nation, including, but not limited to, primary care. Instead of attempting to micromanage specialty composition by locking it into the GME financing structure, Trinity Health supports ongoing analysis of population growth, regional and state-specific needs, and evolving changes in delivery systems to guide current and future targeting of funding for new residency positions. The legislation referenced above (H.R. 1201/S. 577/H.R. 1180) follows a similar model, thereby allowing the training environment to adapt as demographics, delivery models, and health care needs change. 5. Does the current system incentivize high-quality training programs? If not, what reforms should Congress consider to improve program training, accountability, and quality? The most significant determinant of program quality is the quality of its faculty and the sponsoring institutions ability to fund time for supervision, evaluation, documentation and remediation, if necessary. The ACGME Accreditation System requirements, which have been extensively revised, measure quality and outcomes at a granular level. Increased reporting and tracking to comply with ACGME requirements results in increased costs to the training programs and therefore it is important to strike the proper balance. We also support the provisions in H.R. 1201, which further federal investment in GME to advance transparency

5 Page 5 of 5 and accountability. Trinity Health also believes that increased funding for faculty development and teaching time is required to improve the quality of the GME programs in our country. 6. Is the current system of residency slots appropriately meeting the nation's healthcare needs? If not, please describe any problems and potential solutions necessary to address these problems? Our aging population continues to put pressure on the existing physician workforce and we expect there to be growing physician shortages, particularly in primary care. More resources need to be found to expand and incentive physicians to train in primary care. Lifting the cap on Medicare-supported residency positions would enable teaching hospitals that are willing and prepared to train physicians to begin expanding their programs immediately. The legislation described in question #2 (H.R. 1201/H.R. 1180/S. 577) provides a responsible means to achieve these goals and will be critical to prevent disruptions in patient access to care. 7. Is there a role for states to play in defining our nation's healthcare workforce? Since the Trinity Health system spans 21 states, we are acutely aware of the complexities of providing care in a variety of environments, both rural and urban. A "one size fits all" solution to GME funding will not adequately provide for the differences from state to state. We therefore see a strong case for collaboration between the state and federal governments for providing GME training support. We recommend a federal program that engages states and large health systems in GME program planning linked to physician workforce needs. We support the AAMC position for diversity of funding for GME, and the exploration of new sources of funding by health insurances companies and pharmaceutical companies. In closing, Trinity Health again wishes to convey its appreciation for the opportunity to comment and thank you for your efforts to review the importance of graduate medical education. We stand ready and willing to participate in any way requested to forge good public policy. Thank you for your attention to this matter. Respectfully, Tonya K. Wells, ACC, CPA Vice President, Public Policy & Federal Advocacy tel cell wellstk@trinity-health.org