An Opportunity to Update the Way We Think About Training Health Professionals
Catherine Dower, JD, is the associate director for research at the Center for the Health Professions at the University of California, San Francisco. Dower recently wrote a policy brief for Health Affairs about the state of graduate medical education funding. Read the brief on the Robert Wood Johnson Foundation website.
Human Capital Blog: What is graduate medical education (GME) and why is it important?
Catherine Dower: GME refers to the practical training doctors undergo after medical school, when they work for a few years as ‘residents’ – usually in hospitals – under more experienced physicians before they can practice on their own. As all doctors must go through GME before being licensed, it’s a big piece of their professional preparation. Also, the number of doctors who go through GME correlates directly with the number of doctors who can be newly licensed each year, affecting supply. The number of residencies has always been larger than the total number of U.S. medical school graduates, with the gap being filled by internationally-trained medical graduates, who often stay in the U.S. to practice. Importantly, residents play a big role in a hospital’s labor force and GME is expensive.
HCB: How is GME funded in the United States?
Dower: Hospitals participating in the GME program receive payments from multiple sources to cover GME costs. By far the largest contributions come from federal dollars, totaling about $9.5 billion from the Medicare program plus $2 billion in Medicaid dollars per year. Medicare support covers costs that are both ‘direct’ (resident salaries and supervising physician time) and ‘indirect’ (hospital expenses associated with running training programs, such as more tests and longer patient stays). The states also help pay for GME through Medicaid programs; and private insurers reportedly pay higher negotiated payments to teaching hospitals than they would to other hospitals. Payment formulas are complex and controversial. The Medicare Payment Advisory Commission (MedPAC) estimates that indirect GME payments may be $3.5 billion higher than actual indirect costs.
HCB: Is GME funding secure and adequate to meet current and emerging needs?
Dower: After several decades of growth and security, GME funding is looking less stable. State budget realities have resulted in reduced state GME support. And now calls are coming from President Obama’s administration and others to reconsider the substantial investment the federal government makes. At the same time, some are concerned that we need not only to stave off cuts but to expand GME to meet a recent expansion in the number of U.S. medical schools and medical students.
HCB: What impact does health reform have on demand for medical care and on GME funding to prepare the health workforce?
Dower: We can expect to see around 30+ million people newly insured as the Patient Protection and Affordable Care Act rolls out across the U.S. This will translate to a large number of individuals seeking care who haven’t had regular sources of care in the past and likely strain the current capacity of our health care system to absorb the demand. Primary care will be among the first needs and the biggest burden will be felt first by the safety net system, including the country’s community clinics and public hospitals.
The health care reform act itself did not call for any dramatic changes to GME, although modest efforts were included in it and in other recent federal action to increase support for primary care workforce generally—including expanded recognition for nurse practitioners and physician assistants as primary care providers—and through a new program called Teaching Health Centers GME, which trains residents in community-based ambulatory settings.
HCB: What are the central issues that have been raised in the debate over GME funds?
Dower: A key issue in the GME funding debate is the sheer size of government support. Medicare alone covers about $100,000 per year per resident; with multi-year residency programs and other public support, a single doctor’s GME totals half a million dollars or more. That’s a large investment to justify these days. Moreover, we don’t have any assurance that the doctors coming out of GME will practice in the locations or specialties where they are critically needed.
One of the country’s biggest challenges is maldistribution. The ratio of primary care doctors-to-population, for example, has been growing steadily for many years (declining interest among U.S. medical graduates in primary care is outweighed by increasing interest among Doctors of Osteopathic Medicine (DOs), and foreign-trained graduates). But doctors locate in well-served urban and suburban communities in higher concentrations than the general population. In many rural areas and inner-city neighborhoods, would-be patients cannot find providers. The gap between having plenty of providers in some places and not enough in others keeps growing.
Medicare GME funding also has no requirements about the quality of GME training, performance of residents, evaluation of the GME program or patient health care outcomes.
HCB: Should policy-makers and stakeholders be concerned about an emerging problem, or is this an opportunity to take a fresh look at how we educate and train health care professionals in the United States?
Dower: The current system for GME funding was established when Medicare was launched close to 50 years ago. It has undergone little if any fundamental change since then. From the research and policy work I do, I think we are now offered an opportunity to update the way we think about GME and the training of health professionals generally. From my perspective, we surely need to continue to train physicians, but public funds could be tied to outcomes and more focused on training those physicians who locate where needed and who choose the specialties most in demand. No less importantly, my view is that public funds spent on the education and training of health care workers could be seen in a bigger picture in which a number of professions all play roles in health care. While public support for graduate and clinical training of professions beyond medicine historically has been minimal to non-existent, I believe all could benefit from support for high quality and accountable preparation programs.