Efforts to Downsize Residency Training Programs Get Technical Assistance
From 1997 to 2001, the Greater New York Hospital Foundation provided technical assistance to 17 New York teaching hospitals participating in a Robert Wood Johnson Foundation (RWJF) demonstration project to reduce the size of their residency training programs.
As reported to RWJF, project staff provided the following technical assistance:
- Surveyed 42 hospitals initially participating in the project to assess the specialty-specific reductions they made during the first year.
- Provided participants with reports that compared their residency program to others in the geographic region.
- Conducted a study of eight hospitals nationwide on their decision-making about residency program size.
- Convened eight educational seminars for staff at the demonstration hospitals.
- Provided consultation on various issues the hospitals faced as they reduced the size of their residency programs.
RWJF provided $498,675 in funding from June 1997 to November 2001 to support the project.
Teaching hospitals nationwide have experienced increasing financial and regulatory pressure due in part to reductions in Medicare GME payments, lower clinical reimbursement from all payors, and increased restrictions on resident working hours. As a result, a group of teaching hospitals in New York State agreed to participate in a federally sponsored demonstration project with a goal of reducing the overall size of their residency training programs by 20 to 25 percent over a five-year period.
In 1997, GNYHF began the New York Medicare GME Demonstration Project to help hospitals in the state achieve this reduction while maintaining or expanding primary care programs. HCFA (now known as the Centers for Medicare & Medicaid Services), the federal agency that administering administers Medicare and Medicaid, sponsored the demonstration project.
Participating hospitals indicated the need for technical assistance to reconfigure their training programs and address service delivery issues. One major question was which residency programs to reduce and by how much. Hospitals also had to grapple with a complex interrelationship among federal and state initiatives, such as New York State's "GME Incentive Pool" that made downsizing of non-primary care GME programs the main requirement for hospitals to receive awards from the state's $54 million annual pool; the New York State Department of Health's on-site surveys to determine compliance with the state's resident working hours and supervision regulations; and the federal Balanced Budget Act (BBA) of 1997, which included a less-stringent framework for downsizing residency programs than the New York GME project.
This grant allowed GNYHF, the education and research arm of the GNYHA, to provide technical assistance to 19 state teaching hospitals in the GME demonstration project. Of the 42 hospitals originally participating in the project, all but 19 dropped out (see below). Technical support encompassed broad issues of physician supply and demand, as well as specific institutional needs and goals in the area of education and service delivery.
The Center for Health Workforce Studies (CHWS), at the School of Public Health, SUNY-Albany, collaborated on the project, as did Hamilton HMC, a national consulting firm. All but 19 of the 42 hospitals originally in the project dropped out, with many citing HCFA's stringent requirements compared to the BBA's flexibility.
The project director reported that this hampered plans for technical assistance until it became clear which hospitals would continue and what their needs were. The program officer noted that RWJF had anticipated a high dropout rate and that it did not affect the essential elements of the project. (See the Appendix for participants.)
In reports to RWJF, the project director described the technical assistance provided the hospitals, including the following activities and products. (See the Bibliography for details.)
- Investigators surveyed the 42 hospitals initially participating in the project in August 1997 to assess the specialty-specific reductions each had made during the first year. With 34 hospitals responding, researchers found that the largest number of positions reduced was in internal medicine (83), but that the largest percentage cut (8 percent of the state's total) was in pathology positions. Investigators wrote and disseminated the survey findings as part of informational packets distributed at various meetings with participants. Project staff, when requested, helped individual hospitals develop a process for determining which residency positions to eliminate.
- Researchers provided participants with hospital-specific statistical reports that included a comparison of each hospital's residency program to others in the geographic region. Investigators used data from the AMA's Physician Masterfile and survey responses of 1,700 graduating residents to analyze regional and national physician supply and demand covering 27 core specialties. CHWS conducted a workshop on how to use this information, attended by 36 representatives from all 19 hospitals, and visited several hospitals to work with key staff.
- CHWS prepared a 40-page report tracking the results of a 1997 American Association of Medical Colleges (AAMC) study of nine US hospitals and their decision-making about resident program size. CHWS conducted follow-up interviews at eight of the nine institutions and found that, in general, the hospitals had trouble achieving cost-effective downsizing. Interview respondents also reported that many of the assumptions on which the downsizing decisions were based, such as a declining inpatient census, did not prove out. The CHWS report also contained a comprehensive literature review and bibliography on the general topic of alternatives to residents. The report is posted at the GYNHA Web site.
- Project staff convened eight seminars for staff at demonstration hospitals. The meetings and topics were as follows:
- GNYHF held a seminar on administration of the project and service delivery options for participating hospitals.
- GNYHF convened a meeting on the requirements of the Accreditation Council on Graduate Medical Education (ACGME) in the context of both residency reductions and expectations regarding notification and other procedures. The presentations included a report on the experiences of Henry Ford Hospital in Detroit, MI, in its residency reduction plan in internal medicine.
- Project staff convened a meeting to discuss AAMC research findings on the costs of replacing the service delivery component of resident activities and the approaches that had been taken by academic health centers nationwide to resize their configuration of residency programs.
- Project staff formed a work group of chairs of medical departments from the hospitals to exchange ideas and information on addressing the needs of a medical service adjusting to fewer residents. Participants discussed models used for residency reduction in their own institutions.
- At a meeting of 45 hospital administrators and staff members, Hamilton HMC presented the results of interviews conducted at six demonstration hospitals with 30 residency program directors, nursing staff, operations staff, and finance staff. The two-hour interviews focused on problems the hospitals were experiencing in carrying out the demonstration, particularly in the area of service delivery. HMC's presentation highlighted the role of residents in service delivery and potential areas for staff substitution and reconfiguration of services. Hamilton HMC produced an eight-page brochure highlighting their findings, distributed it to participating hospital staff, and posted it online.
- Project staff held two meetings during 1999-2000 on the use of performance indicators in assessing quality in residency training programs. Participants had requested information on assessment tools for residency training, and a total of approximately 125 hospital staff members attended, including administrators and physician leaders. The presentation reviewed new federal legislation and addressed the use of indicators by oversight bodies in determining educational areas needing special attention.
- CHWS produced a 104-page directory to assist hospitals in identifying recruitment opportunities for hiring mid-level practitioners to assume the service activities currently provided by residents. The directory lists physician assistant and nurse practitioner programs by specialties and by sponsoring institutions as well as information on the number of recent graduates and orientation to inpatient care.
- Project staff met with approximately 50 hospital representatives at various times during the grant period to clarify the Terms and Conditions of the demonstration project. The discussions included the implications of residency downsizing decisions in the context of federal and state regulations and national accreditation requirements.
- Project staff served as liaisons between demonstration hospitals and HCFA. Among their activities, project staff gained approval from HCFA to allow demonstration hospitals to revise the entire five-year plan for meeting the demonstration's Terms and Conditions. Project staff also assisted individual hospitals with writing special requests to HCFA.
The project director was a panelist at the AAMC's Group on Resident Affairs' 1998 Professional Development Meeting and gave a presentation at the 1998 annual meeting of the Association of Program Directors in Internal Medicine. Project staff also gave a presentation to the National Health Lawyers Association in Baltimore, Md. The ACGME Bulletin, distributed to 11,600 medical education and health care professionals, published an interview with the project director.
- The experiences of hospitals outside of New York State with downsizing residency programs were not very relevant to hospitals participating in the New York Medicare GME Demonstration Project. Hospitals in other states were self-directed, with the flexibility to determine their own timelines for downsizing and to decide the numbers of residents they would reduce based on programmatic needs. These options were unavailable to demonstration project hospitals, for whom failure to meet the Terms and Conditions would result in liability for all transition funds paid under the project.
- Hospitals undergoing a significant change in operations may have very different needs as a result of the varying levels of in-house management expertise available for implementing the change. The project director reported that developing technical assistance useful to the maximum number of hospitals was a challenge. Furthermore, the project director reported that project staff had to devote much more time than anticipated to obtain basic information about the residency programs and develop ways of making comparisons. (Project Director)
GRANT DETAILS & CONTACT INFORMATION
Technical Support for the New York Medicare Graduate Medical Education Demonstration Project
Greater New York Hospital Foundation (New York, NY)
Dates: June 1997 to November 2001
New York Medicare Graduate Medical Education Demonstration Project
Bronx-Lebanon Hospital Center
Brooklyn Hospital Center
- Buffalo General Hospital
- Children's Hospital of Buffalo
- Erie County Medical Center
- Mercy Hospital
- Millard Fillmore Hospital
- Niagara Falls Memorial Hospital
- Roswell Park Cancer Institute
- Sisters Hospital
Harlem Hospital Center
New York, N.Y.
Interfaith Medical Center
Lincoln Medical and Mental Health Center
Jacobi Medical Center; North Central Bronx Hospital (Joint participants)
Metropolitan Hospital Center
New York, N.Y.
Mount Vernon Hospital
Mount Vernon, N.Y.
New York Eye and Ear Infirmary
New York, N.Y.
Queens Hospital Center
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Physician Workforce Data for GME Planning, 42 hospital-specific reports, Albany, N.Y.: Center for Health Workforce Studies, 1997. 84 copies, two to each hospital, distributed in January 1998.
Directory of Nurse Practitioner and Physician Assistant Programs in New York State. Albany, N.Y.: Center for Health Workforce Studies, 1998. 200 copies distributed to chairpersons, demonstration hospital staff, and human resources executives.
Salsberg, E, Schreiber, S. Recent Efforts in GME Rightsizing: A Status Report and Literature Review. Albany, N.Y.: Center for Health Workforce Studies, 1999. Also appears online. Approximately 200 copies distributed to date.
"Survey of Year 1 FTE [Full-time Equivalent] Reductions in Medicare GME Demonstration Hospitals." Greater New York Hospital Association, fielded August 1997.
"Survey of Graduating Residents in New York Residency Programs." Center for Health Workforce Studies, fielded spring 1998.
Brochures and Fact Sheets
"Assessment of Residency Training Programs." Kurt Salmon Associates (formerly Hamilton HMC). December 2000. Also appears online.
"Project Administration and Service Delivery Options for Hospitals in the HCFA GME Demonstration." November 13, 1997, New York, N.Y. Attended by 45 people from 30 demonstration hospitals.
"ACGME Residency Reduction Issues and Experiences with Downsizing a Medicine Program," December 2, 1997, New York, N.Y. Attended by 63 individuals from 31 demonstration hospitals.
"Using Physician Workforce Data for GME Planning," January 13, 1998, New York, N.Y. Attended by 36 people from 19 demonstration hospitals.
"Clinical Reengineering Strategies for Residency Program Downsizing," February 3, 1998, New York, N.Y. Attended by 36 people from 20 demonstration hospitals.
"Preliminary Project Report on the New York Medicare Graduate Medical Education Demonstration Project." May 1998, New York, N.Y. Attended by 6 demonstration hospital staff members to review the work plan for the survey of performance indicators.
"The Use of Performance Indicators in Assessing Quality in Residency Trainee Programs." November 18, 1999, New York, N.Y. Attended by 45 representatives from 19 demonstration hospitals. Also on May 19, 2000, New York, N.Y. Attended by 70 representatives from 14 demonstration hospitals.
Report prepared by: Janet Spencer King
Reviewed by: Jan Hempel
Reviewed by: Marian Bass
Program Officer: Beth Stevens
Program Officer: Susan B. Hassmiller