Transforming the physician workforce through competitive graduate education funding

November 11, 2013

LEBANON, NH - Graduate Medical Education (GME) has fallen short in training physicians to meet changes in the U.S. population and health care delivery systems. But a new proposed funding mechanism coupled to a competitive peer-review process may be the best way to reform the process, according to an analysis and commentary in the November issue of Health Affairs.

Dr. David Goodman, professor at The Dartmouth Institute for Health Policy & Clinical Practice, and Dr. Russell G. Robertson, dean of the Chicago Medical School, note in their analysis that resistance to change is a long-standing problem in Graduate Medical Education. "The current system is remarkably inflexible - a place where good ideas for improving the physician workforce go to perish," they said.

Graduate Medical Education is the three-to-eleven-year period of physician training that follows medical school, commonly known as a residency or fellowship training. The number of training positions and the content of the graduate education determine the number, specialty mix, and competencies of physicians entering the workforce, for example cardiologists, pediatricians, radiologists.

"Progress by teaching hospitals, accreditation organizations, and Congress has been too slow to meet the workforce challenges of our changing and aging population and our health care delivery system," the authors said. "If teaching program performance is not linked to funding, recommendations to reform GME will likely remain in a state of inertia."

GME is primarily paid for with more than $13 billion in public money, with the bulk of it coming from Medicare through complex funding formulas. And, the funding mechanism is tied primarily to hospital-based services, ignoring the growing need for competencies that extend beyond acute patient care to improving clinical systems, team-based care, and longitudinal management of patients in the community.

Another deficiency in the funding mechanism is the "inflexible GME pipeline" that is anchored to the number of residents funded at the time of the passage of the Balanced Budget Act of 1997. Some expansion has occurred but mainly in subspecialties, ignoring the need for additional primary care physicians.

To improve the physician workforce, the authors recommend a new system of funding that is responsive to workforce needs, rewards innovation, and uses explicit outcome objectives to evaluate training programs. The funding would be publicly guided and awarded through competitive funding, similar to the process of awarding National Institute of Health peer-reviewed research grants.

"For the physician workforce to change and improve, there must be a trusted public entity that regularly sets overall goals for training direction and pipeline size," the authors said. The entity should be a federal advisory committee composed of the public, public health experts, health care systems, payers and medical educators.

These goals would guide the development of annual requests for funding proposals. Residency programs would be required to apply and compete for GME funding once every 10 years. This means that each year 10 percent of the nation's training programs would be reviewed. New programs would compete for funding. Existing programs that score poorly would receive reduced funding, while meritorious programs could grow. Awards would be for 10 years to enable teaching organization stability.

Applications would be reviewed through study sections. Programs would also need to report performance measures that include educational capacity, processes and outcomes. These measures would be available to the public including fourth year medical students who are choosing residency programs.

Funding would no longer be linked to residents' time caring for Medicare beneficiaries in acute care settings. "Indirect GME funding would no longer reward the very inefficiencies that health care reform is intended to remedy," the authors said.

This new funding mechanism would be an opportunity to transform the health care workforce by incentivizing innovation and a physician specialty mix that responds to the health care needs of the U.S. population. It would also provide financial and educational stability to graduate programs by instituting changes incrementally.
-end-
The full article may be found at Health Affairs at http://content.healthaffairs.org/content/32/11/1887.abstract

The Dartmouth Institute for Health Policy & Clinical Practice was founded in 1988 by Dr. John E. Wennberg as the Center for the Evaluative Clinical Sciences (CECS). Among its 25 years of accomplishments, it has established a new discipline and educational focus in the Evaluative Clinical Sciences, introduced and advanced the concept of shared decision-making for patients, demonstrated unwarranted variation in the practice and outcomes of medical treatment, developed the first comprehensive examination of US health care variations (The Dartmouth Atlas), and has shown that more health care is not necessarily better care.

Dartmouth-Hitchcock Medical Center

Related Health Care Articles from Brightsurf:

Study evaluates new World Health Organization Labor Care Guide for maternity care providers
The World Health Organization developed the new Labor Care Guide to support clinicians in providing good quality, women-centered care during labor and childbirth.

Six ways primary care "medical homes" are lowering health care spending
New analysis of 394 U.S. primary care practices identifies the aspects of care delivery that are associated with lower health care spending and lower utilization of emergency care and hospital admissions.

Modifiable health risks linked to more than $730 billion in US health care costs
Modifiable health risks, such as obesity, high blood pressure, and smoking, were linked to over $730 billion in health care spending in the US in 2016, according to a study published in The Lancet Public Health.

Spending on primary care vs. other US health care expenditures
National health care survey data were used to assess the amount of money spent on primary care relative to other areas of health care spending in the US from 2002 to 2016.

MU Health Care neurologist publishes guidance related to COVID-19 and stroke care
A University of Missouri Health Care neurologist has published more than 40 new recommendations for evaluating and treating stroke patients based on international research examining the link between stroke and novel coronavirus (COVID-19).

Large federal program aimed at providing better health care underfunds primary care
Despite a mandate to help patients make better-informed health care decisions, a ten-year research program established under the Affordable Care Act has funded a relatively small number of studies that examine primary care, the setting where the majority of patients in the US receive treatment.

International medical graduates care for Medicare patients with greater health care needs
A study by a Massachusetts General Hospital research team indicates that internal medicine physicians who are graduates of medical schools outside the US care for Medicare patients with more complex medical needs than those cared for by graduates of American medical schools.

The Lancet Global Health: Improved access to care not sufficient to improve health, as epidemic of poor quality care revealed
Of the 8.6 million deaths from conditions treatable by health care, poor-quality care is responsible for an estimated 5 million deaths per year -- more than deaths due to insufficient access to care (3.6 million) .

Under Affordable Care Act, Americans have had more preventive care for heart health
By reducing out-of-pocket costs for preventive treatment, the Affordable Care Act appears to have encouraged more people to have health screenings related to their cardiovascular health.

High-deductible health care plans curb both cost and usage, including preventive care
A team of researchers based at IUPUI has conducted the first systematic review of studies examining the relationship between high-deductible health care plans and the use of health care services.

Read More: Health Care News and Health Care Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.