Testimony to the Institute of Medicine Committee on Governance and Financing of Graduate Medical Education H. David Reines, MD FACS Professor of Surgery, Virginia Commonwealth University Vice Chair Surgery InovaFairfax Hospital Vice Chair, COGME December 19, 2012 12/19/12 Council on Graduate Medical Education 1
Charter-Public Law 92-463(1986) Description of Duties Provide advice and make policy recommendations to the Secretary of Health and Human Services, the Committee on Health, Education, Labor and Pensions of the Senate, and the Committee on Energy and Commerce of the House of Representatives, with respect to: (A) (B) (C) the supply, and distribution of physicians in the United States. current and future shortages or over supply of physicians in medical and surgical specialties and subspecialties. issues relating to foreign medical school graduates. (D) appropriate federal policies with respect to the matters specified in subparagraphs (A), (B), and (C), including policies concerning changes in the financing of undergraduate and graduate medical education programs and changes in the types of medical education training in graduate medical education programs. 12/19/12 Council on Graduate Medical Education 2
Charter Description of Duties - Continued (E) (F) appropriate efforts to be carried out by hospitals, schools of medicine, schools of osteopathic medicine, and accrediting bodies with respect to the matters specified in subparagraphs (A), (B), and (C), including efforts for changes in undergraduate and graduate medical education programs. deficiencies in, and needs for improvements in, existing data bases concerning the supply and distribution of, and postgraduate training programs for, physicians in the United States and steps that should be taken to eliminate those deficiencies. Under the ACA, we have also been given oversight in other areas of GME in HHS, including Public Health Training Centers (PHTC) and Public Health Traineeships. 12/19/12 Council on Graduate Medical Education 3
Membership David C. Goodman, MD, MS, Chair Geisel School of Medicine at Dartmouth H. David Reines, MD, Vice Chair Virginia Commonwealth University Kirk Aquilla Calhoun, MD The University of Texas Health Science Center Carol Carraccio, MD, MA The American Board Of Pediatrics Michael Core, MD University of Southern California Erin Corriveau, MD University of New Mexico Mary Ellen Rimsza, MD, FAAP University of Arizona Keya Sau, PhD University of Arizona Kenneth Shine, MD The University of Texas System Gamini S. Sooriyaarachchi, MD, MBA Nebraska Cancer Specialist David Squire University of Utah School of Dentistry Donald Keith Watson, DO Ohio University College of Osteopathic Medicine Daniel J Winn, MD Care First BlueCross BlueShield J. Nadine Gracia, MD Office of the Assistant Secretary of Health Judy Brannen, MD Richmond Veteran Affairs Medical Center Tzvi M. Hefter Centers for Medicare and Medicaid Services 12/19/12 Council on Graduate Medical Education 4
Previous Reports 16 th Report on Physicians Workforce Policy Guidelines for the US 2000-2020 17 th Report on Minorities in Medicine An Ethnic and Cultural Challenge for Physician Training 18 th Report on New Paradigms for Physician Training for Improving Access to Health Care 19 th Report on Enhancing Flexibility in GME 20 th Report on Advancing Primary care 12/19/12 Council on Graduate Medical Education 5
20 th Report on Advancing Primary Care A) Recommendation to raise the percentage of primary care physicians to 40% using financial incentives. B) Medical schools and academic health centers should allocate resources to address primary care and reform admission processes to increase students, including underrepresented minorities, who are more likely to choose a primary care specialty. C) Medical schools, academic health centers, and licensing agencies should reform the continuum of medical education to impart general competencies most efficiently. D) Significantly expand Title VII program to increase primary care and community based training E) Congress, the Administration, Department of HHS, and accrediting agencies should change regulations to support more training in out-patient settings and increase training in underserved areas. F) Ensure funding of the National Health Services Corps at $1.5 billion to recruit more primary care physicians, including general surgery. 12/19/12 Council on Graduate Medical Education 6
November 2011 Letter to Congress and Sect. HHS Recommendation 1: We recommend the preservation of the current level of GME funding. The Council on Graduate Medical Education (COGME) is aware that there are several proposals with the intent of reducing graduate medical education funding. COGME believes strongly that current levels of graduate medical education funding must be preserved commensurate with the imminent increase in demand for health care and in recognition of the implications of the Affordable Care Act. 12/19/12 Council on Graduate Medical Education 7
November 2011 Letter Recommendation 2: We recommend that both COGME's 19th Report (Enhancing Flexibility in Graduate Medical Education: September 2007) and 20th Report (Enhancing Primary Care: December 2010) be operationalized. These recommendations include creating 3,000 new entry-level graduate medical education positions which will lead to completion of training programs in alignment with societal needs. Specifically, shortages have been identified in the following medical specialties: Family Medicine Geriatrics General Internal Medicine General Surgery Pediatric Subspecialties Psychiatry Future recommendations by COGME may include newly identified shortages in other specialty areas. 12/19/12 Council on Graduate Medical Education 8
Recommendation 3: The Council on Graduate Medical Education November 2011 Letter COGME recommended that the Association of American of Medical Colleges (AAMC) and the American Association of Colleges of Osteopathic Medicine (AACOM) jointly convene: The appropriate accrediting agencies, representing the full continuum of medical education from undergraduate through graduate medical education The American Board of Medical Specialties The American Osteopathic Association-Bureau of Osteopathic Specialists The Federation of State Medical Licensing Boards The purpose of the convention was to propose a comprehensive review and development of new approaches for medical education and training in the United States: Streamlining of training for physicians Accelerating the time frame for the education of physicians Improving the quality of medical education Developing new strategies for competency-based evaluation Increasing the numbers of physicians being trained Developing new approaches to team based training 12/19/12 Council on Graduate Medical Education 9
21 st Report Draft The 21 st report s focus is Enhancing Value in an Era of Cost Constraints Graduate Medical Education should insure that practice environments of graduate medical education meet the Institute of Medicine s competencies of care, that are safe: timely, effective, efficient, equitable and patient-centered. The Accreditation Council for Graduate Medical Education should continue to evaluate implementation of strategies to improve patient centered care as part of institutional accreditation focused on the learning environment. 12/19/12 Council on Graduate Medical Education 10
21 st Report Draft The GME governing bodies, in conjunction with sponsoring institutions, must insure that graduate medical education targets the unique needs of the populations being served, by delivering culturally effective health care that addresses the needs of medically underserved and minority populations. Medical schools should recruit a diverse group of students using criteria for admissions that extend beyond traditional academic achievement to meet these needs. The Center for Medicare and Medicaid Services and other federal graduate medical education funding should create further incentives for medical schools and graduate medical education training programs to address these needs. This includes reconfiguring clinical assignments to more longitudinal time frames when these intersect with the goals of the specialty. 12/19/12 Council on Graduate Medical Education 11
21 st Report Draft A convocation of the leading regulatory bodies should jointly develop curricula that sequence learning experiences across the continuum of undergraduate, graduate and continuing medical education. The involved organizations should jointly develop a consistent set of competencies, not time based, that must be attained before trainees can transition from undergraduate to graduate medical education and from graduate medical education to fellowship training or practice. 12/19/12 Council on Graduate Medical Education 12
21 st Report Draft Accreditation and licensing organizations should consider flexibility in several area of clinical training in the fourth year of medical school. This training could be applied towards residency credit. Agencies that regulate undergraduate medical education could remove the barriers to obtaining licensure and achieving certification based on competencies. They should work with specialty communities and develop national tools to assess competence beyond medical knowledge utilizing new assessment models such as Milestones Project of the (Accreditation Council for Graduate Medical Education) ACGME. 12/19/12 Council on Graduate Medical Education 13
21 st Report Draft Institutional accreditation should include an evaluation of the faculty development program to ensure the ability of faculty to teach and assess the Accreditation Council for Graduate Medical Education competencies. 12/19/12 Council on Graduate Medical Education 14
21 st Report Draft Congress should consider increasing funding over the present cap established by the Balanced Budget Act of 1997 by at least 3,000 new residency positions: Family Medicine Geriatrics General Internal Medicine General Surgery Pediatric sub-specialties (medical and surgical) Psychiatry Increases in GME funding could be directed towards training programs which have a track record of trainees continuing to practice 1) in one of the above noted specialties 2) within HPSA (Health Professional Shortage Areas) designated by HRSA, 3) within regions with relatively lower per capita supply of physicians, or 4) serving populations of high need. Debt forgiveness and expansion of the National Health Service Corps could be utilized to attract physicians to areas where ratios are lower than acceptable. 12/19/12 Council on Graduate Medical Education 15
21 st Report Draft Congress should maintain overall funding for GME, and as noted above, and increase funding for additional positions. Funds provided for indirect medical education (IME), which is justified on the basis of higher utilization rates in teaching hospitals, require transparency in amount and allocation from the receiving institution to the targeted educational programs. A portion of these funds could be allocated for meeting objectives in training physicians who can practice effectively in the changing health care environment. 12/19/12 Council on Graduate Medical Education 16
21 st Report Draft Other points include : 1) A more efficient use of training funds through the elimination of transitional PGY positions and excess preliminary non-categorical positions. These should be reallocated to existing or new residency programs that meet the objectives outlined in the preceding recommendations. Because attrition from residency programs can approach 15%, some preliminary positions must be maintained to continue to feed the pipeline. 2) Examination of other sources of funding (global or all Payer ). The addition of up to 30,000,000 new patients to Medicaid under the Affordable Care Act will require new sources of GME monies to supplement training funds in the present Medicare commitment. 3) Funding Children s Hospital GME in an amount comparable to Medicare funding of non Children s Hospital GME by the federal government and through the same multiyear appropriation rather than an annual discretionary appropriations process 12/19/12 Council on Graduate Medical Education 17
Thank you 12/19/12 Council on Graduate Medical Education 18