Editors Note: The Institute of Medicine released a report on graduate medical education on July 29th. As with all posts on this blog, this viewpoint represents the opinion of the author and not necessarily the University of Utah Family Medicine Residency. More information about the report can be found here.
The changing face of health care delivery is accelerating as never before. Increased reliance on team-based care, with inclusion of auxiliary members who have not traditionally been part of the a health care team, larger emphasis on population management, increased scrutiny on the value of care through both improved quality and decreased cost, have become the main drivers of reform. Yet despite these transformations, graduate medical education remains largely unchanged over the last century. This is the focus of the recent report from the Institute of Medicine (IOM) Governance and Financing of Graduate Medical Education. While growing pains are expected with any remodeling, the recommendations of this report may help solve many of the pitfalls of our current graduate medical education (GME) system to better meet the needs of the nation.
The majority of funding for GME comes from federal Medicare funds, along with some state-based Medicaid funds, and little private funding. Despite these significant public resources, there is currently minimal on how the funds will provide for the nation’s health care needs. There is currently a high market demand for primary care and certain sub-specialists, specifically in rural areas, but as the Medicare Payment Advisory Commission Chair Glenn Hackbarth stated in 2009, “The training system is not producing what society needs. It doesn’t seem to be self-correcting; it cries out for intervention.”
It is for this reason that the ad hoc IOM committee was created to produce these recommendations. The committee, chaired by Donald Berwick and Gail Wilensky, provides 6 goals and multiple specific recommendations that surround improved governance, adjusted payment methodologies, and overall higher quality training, in order to update the current GME structure.
The report encourages the creation of a GME Policy Council under the US Department of Health and Human Services that will provide “research and policy development regarding the sufficiency, geographic distribution, and specialty configuration of the physician workforce.” It also recommends the establishment of a GME Center within the Centers for Medicare and Medicaid Services to manage and oversee the distribution and use of Medicare GME funds. If implemented, this would allow an agile response to societal needs, such as an increased channeling of funds to support the training of more primary care providers in rural settings.
Adjusted Payment Methodology
While using the same amount of funds as currently dedicated to GME (and adjusting for inflation), a modernization of payment methods would be implemented to improve accountability and incentivize innovation. The current monies would be divided into two funds: an Operational Fund and Transformation Fund. These would be used for ongoing support of residency training and financing of innovative GME programs, respectively. Operational funds would be distributed directly to the sponsoring organizations instead of coupling the payments to patient loads and hospitals in which the residents train. Transformation funds will be used to provide for pilot programs and performance based payments to improve the quality of the training experience.
The increased governance structure and altered funding mechanisms allows publicly-funded GME to be accountable to those providing the financial support through research and policy. This also frees the organizations sponsoring the GME to train at sites where it is deemed most appropriate instead of being strictly hospital-based. This provides education to be better directed towards the changing face of medicine, and allowing for innovative techniques and settings instead of continuing to support a system that is unable to respond to fluctuating need.
There has understandably been concern from those who are heavily invested in the current model, such as hospital systems and some specialist organizations. As with any change, there will always be resistance. But the truth is that continuing to train physicians to work in an unsustainable health care system only contributes to the perpetuation of that system. In order to improve the value of health care, we need to train physicians to act in a system that appreciates quality and low cost care that also responds to patient’s needs. This includes a significantly greater emphasis on ambulatory training (without full exclusion of inpatient training), where the majority of care takes place; greater physician leadership in improving the quality and safety of care provided; and increased importance placed on leading teams to improve the management of patients with chronic conditions to optimize their health. The majority of clinicians are not currently trained in such an environment.
Many of the posts on Family Medicine Vital Signs illustrate the innovative education provided to Family Medicine residents at the University of Utah. These IOM proposed reforms would assist in supporting such culture of innovation at all GME programs.
Kyle Bradford Jones, MD is a Clinical Instructor at the University of Utah Family Medicine Residency. You can follow him on Twitter @kbjones11