Institute of Medicine

Transcription

1 Institute of Medicine Governance and Financing of Graduate Medical Education Utah Medical Education Council Richard Campbell Executive Director Phone: (801) Please visit our web page for more information

2 Environment Leading Up To The Creation Of The UMEC

3 COGME, 1994 Third party payers should explicitly pay for GME GME largely funded by teaching hospitals from patient care Accounting of GME funds remains unclear and are poorly coupled with physician workforce requirements Teaching hospitals increasingly compete with non-teaching hospitals Funding of GME may become increasingly difficult to maintain the flow into teaching hospitals Source: COGME 4th report

4 Utah 1997 Physician shortage (44th of 50 states) Federal GME funding capped GME pipeline insufficient for needs 442 residents 25 training programs 9 hospitals 4 sponsoring institutions 73 fellows in 26 programs No alignment with workforce needs

5 Utah 1997 Medicare DME and IME payments varied vastly among Utah hospitals (~$28,000 - $70,000) HCA began due diligence to purchase the University of Utah Hospital (sponsor of 85% of all GME in the state) PEHP hospital abruptly ceased their GME sponsorship

6 Utah Prior to the state fiscal year 2000, Utah had not paid for GME training with state funds. In 2000, the state legislature approved $500,000 to stabilize a family practice training program. In 2001, for the first time the University of Utah School of Medicine sought $16 million from the state legislature.

7 The UMEC

8 Utah Medical Education Council Quasi-governmental body Established 1997 Broad representation appointed by Governor Sponsoring institutions (4) Insurance industry Public School of Medicine Dean

9 Why A Quasi Agency Data can be collected under the public benefit or Greater Public Good powers of state government Enhanced ability to collect & analyze proprietary and confidential information Balance the for-profit & not-for-profit, public & private interests for good of state Support of Attorney General & State Treasurer Exempt from State personnel system & Money Management Act, & All funds non-lapsing. Rulemaking authority Exempt GME pass through funds from legislative review

10 Utah Medical Education Council (continued) Core Responsibilities Health Care Workforce Assess supply and demand Advise/develop policy Seek and disburse Graduate Medical Education (GME) funds Facilitate training in rural locations Manage Utah s GME demonstration project awarded by the Center for Medicare & Medicaid Services (CMS)

11 Utah Medical Education Council (continued) Products Partnerships public/private Reports health care workforce Models workforce and financial Program(s) expansion rural and urban Funds management privately funded programs expansion, Medicaid GME, rural training sites expansion, and Medicare demonstration

12 CMS Waiver

13 CMS Waiver Applied for in 1997 Required reapplication Extensive effort to address many complicated financial and logistical issues Finally approved in 2003 for five years Renewed once Ended June 30, 2010

14 CMS Waiver Application Federal GME funding flowed to hospitals Per resident funding varied between hospitals based upon historical nuances Financial incentives for hospitals to train ancillary-intensive specialists No incentive to coordinate GME efforts Waiver was required to change Federal GME funds flow

15 CMS Waiver Goals Allocate resources based on workforce needs Track workforce needs to determine GME funding priorities Establish an independent body to coordinate workforce and educational objectives Manage residency positions on a statewide basis Direct funds to the individual programs with the greatest impact on the workforce needs Hold each program accountable

16 CMS Waiver Goals (Continued) Payments to training programs only Payments to be the same across training programs regardless of training location Delivered through contract in conjunction with state workforce objectives Payments to last the full training cycle Create incentives for programs to meet desired outcomes

17 Challenges in Approval State consensus All institutions had to agree Pooled DME funds Excluded IME funds Withhold funding if needed Federal issues Accounting Payment policies (fiscal intermediary) Cost neutrality

18 Impact of Initial Waiver Established a neutral public body Legal safe haven for discussion Promoted collaboration Collected workforce and cost data Established statewide goals Developed methodology for resource distribution to meet the goals Aligned state needs with program size Expanded number of residents Allocated new positions based on need

19 Success

20 Funding for Resident Expansion Retrospective accounting identified eligible positions under the CMS cap for continued funding Facilitated Medicaid matching funds to cover salaries and benefits of all residents in 2002 Negotiated new position support with two major hospital systems

21 Workforce Coordination Survey physician workforce to identify needs (in 1998, 2003 and 2008) Established 1998 baseline In 2003 shortage of all specialists could not recommend shifting fund between programs In 2008 surplus were identified in some specialties started the process of shifting funds between programs Developed methodology to distribute new funds based upon workforce needs

22 Workforce Coordination Worked with programs to encourage graduates to practice in Utah Portion of funding at risk Programs could develop their own initiatives Annual accountability Job board Job fair Rural training opportunities Stakeholder committee Existing positions

23 New Rural Training Family Medicine General Surgery Internal Medicine Pediatrics Psychiatry

24 900 Medical Education Council: Utah GME Growth UMEC Formed Residents 36% growth Fellows 120% growth Total National Residency Growth , ~8% Utah Residency Growth , ~36% 2008 American Medical Association.JAMA, September 10, 2008 Vol 300, No.10.US Residency Training Before and After the 1997 Balanced Budget Act. p.1176

25 RETENTION MEASURE

26 Failures

27 Some UMEC Failures Inability to address the full range of GME with CMS Unable to make demonstration permanent Failure to generate more state funding

28 Final Thoughts

29 UMEC Capabilities React quickly to program changes Reallocation of funds if contract terms not met Redirect unfilled positions Targeted certain specialties for expansion Minimize impact on Federal payment policies

30 Results Training programs and teaching hospitals now accountable for the use of the GME funds Medicaid funds are used to reimburse their fair share of GME training costs Links GME funds to workforce objectives

31 Pending Questions Has alignment of funding and needs changed the specialty mix in Utah? Has emphasis on rural experiences improved rural physician recruitment?

32 Thank You Questions?

33 My contact information: David Squire Assistant Dean, Finance University of Utah School of Dentistry 26 South 2000 East, Suite 5900 Salt Lake City, Utah