Internists Say GME Funding Undermines Primary Care

Marcia Frellick

May 04, 2016

The American College of Physicians (ACP) and the Alliance for Academic Internal Medicine (AAIM) are sending a joint message to Congress that the current system for funding graduate medical education (GME) does not work for a modern workforce.

"It's very clear to us that the current way we fund GME is very disconnected from the real-world facts that we need more primary care physicians at a time when the nation has expanded access to health insurance," ACP President Wayne Riley, MD, told Medscape Medical News. "The way we finance GME in many ways undermines efforts to expand primary care."

The message comes in a joint position paper, "Financing U.S. Graduate Medical Education," published online May 3 in the Annals of Internal Medicine.

The statement recommends several immediate changes. Among them is a single payment per resident that can follow the resident beyond a hospital. This is particularly relevant not just for primary care specialties but also for rural and underserved areas.

At this time, the payment, under Medicare rules, is tied to the hospital where the resident matches, so those who want to pursue training in a rural area will find it difficult because the GME payment will not follow.

That same formula also keeps people from pursuing training in ambulatory settings, even though "we know that most healthcare over the next quarter century is going to be delivered in outpatient settings," Dr Riley notes.

"The preponderance of the training occurs in the four walls of a big, tertiary care hospital where, in reality, the way they really practice will be more like what they experience in a community health center," he said.

Authors Say Insurers Should Pay

The authors also call for insurance carriers to contribute to the GME pool. "All payers benefit from better trained physicians who've gone through graduate medical education. Right now, they make no contribution at all," Dr Riley explained.

Under the current system, GME is funded through a combination of sources. The federal government provides GME funding (about $15 billion a year) through Medicare. States fund GME through Medicaid, but at widely different levels. Private payers pay higher rates to teaching hospitals compared with other hospitals to fund GME. GME also receives funding from hospitals and universities and through gifts or grants from industry.

"The fact that most of the onus falls on the American taxpayer vis-a-vis the Medicare trust fund we think is a perverse incentive," Dr Riley said.

According to authors from the AAIM and ACP, led by Renee Butkus, the current system of GME financing does not consider physician workforce needs on the local, regional, or national level.

The funding system has long been a source of controversy. AAIM and ACP separately called for an overhaul in 2010 and 2011. Now, joining forces, they hope to push through change.

"We're reaching a choke point," Dr Riley said. "We know over the past 20 years there have been 20 to 25 new medical schools producing new graduates, but we've been capped since 1996 by the Balanced Budget Act in terms of residency training slots."

Soon graduates will have difficulty finding primary care spots, and if they do "there may be a 6-month wait," Dr Riley said.

For now, the issue lies with Congress in relaxing or reforming the funding formula.

This position paper also suggest to Congress a way to favor primary care and give more funding to programs that produce primary care doctors, family physicians, internists, pediatricians, and obstetrician-gynecologists because those are areas facing significant shortages, Dr Riley said.

"The concept of a performance-based GME payment system is worth exploring," the authors write.

"That's one way, by defining this mechanism, you could reinvigorate primary care, by having a higher differential or close the gap between specialty residency payments. That will have an enormous steering effect," Dr Riley said.

A coauthor reports being a member of the American College of Physicians Board of Regents. Other coauthors report personal fees from the American College of Physicians, UnitedHealthcare, and the University of Nebraska Medical Center outside the work and holding Pfizer stock. No other financial relationships were disclosed.

Ann Intern Med. Published online May 3, 2016. Full text

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