SPECIAL ARTICLE
What the IOM Report on Graduate Medical Education Means for Physician Assistants James F. Cawley, MPH, PA-C Abstract Graduate medical education (GME) is funded by taxpayers through Medicare subsidies that pay for physician residency training, primarily to teaching hospitals. The Institute of Medicine (IOM) recently conducted a study of US GME and issued a series of recommendations for future
INTRODUCTION Graduate medical education (GME) represents a $15 billion taxpayer-funded system of subsidies for physician residency training. As a component of Medicare that pays teaching hospitals to train residents on a per-bed occupied basis, GME provides funding for postgraduate training of physicians within academic health centers and teaching hospitals. Critics have noted that despite the large sums involved, GME has failed to produce a physician workforce that meets the needs of the US health system.1 The physician workforce at present comprises a majority of specialists and subspecialists (over 70% of practicing physicians) and a consequent minority of physicians in primary care.2 The lack of public accountability has led to an imbalance in the types of physicians most needed in the health care system, namely physicians in the primary care specialties. Policy leaders have called for alteration in the structure and eligibility requirements of GME, which include the calls for reform from the chair of MedPAC, a key advisory group for the Medicare program. MedPAC noted that the way Medicare pays hospitals for training the nation’s future doctors is out of alignment with the agency’s goal of lowering costs while delivering higher quality care and calling for major reform of GME.2 Others have pointed out that teaching hospitals are not held accountable for creating and sustaining GME slots that meet the country’s workforce needs, that hospital’s business plans often depend on higher paying subspecialties for income, and that eligibility for training support through GME is typically restricted to physicians in certain medical and surgical specialties.3,4,5
KEY RECOMMENDATIONS As a result of mounting calls for reform, in 2013 the Institute of Medicine (IOM) undertook an extensive examination of GME and recently delivered its report with a broad set of recommendations.6 The recommended changes include taking steps that would initially maintain, but later restructure, existing GME J Physician Assist Educ 2015;26(2):86–87 Copyright ª 2015 Physician Assistant Education Association DOI 10.1097/JPA.0000000000000026
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policy reform. This commentary examines the major elements of proposed reforms for GME and offers analysis of those that may pertain specifically to physician assistant education now and in the future.
payments to teaching hospitals and would shift training pathways from the inpatient sector to community-based sites. It is important to bear in mind that these proposed changes would require Congressional action before they could be instituted. Recommendations include maintaining GME funding at the current level over the next decade but over time dividing total available funds between an Operational Fund to support existing GME programs and a new GME Transformation Fund to fund innovation as well as new GME programs in needed specialties and underserved areas. Also recommended is the creation of a national GME Policy Council, to be established in the Office of the Secretary within the US Department of Health and Human Services, to provide national leadership and guidance along with a GME Center, to be located in the Centers for Medicare and Medicaid Services, to administer the new system. The IOM report recommends ending the current system of basing GME payments on Medicare inpatient days, the resident-to-bed ratio, and other factors. What is proposed is a new basic per-resident amount (PRA) for each resident, with geographic adjustments. Such a system would spread existing GME dollars across more positions (with the Transformation Funds covering new GME positions and accredited positions not now funded) and would increase the amount available for actual training by combining the 2 current funding streams (Direct Graduate Medical Education and Indirect Medical Education). The 10-year time frame would allow teaching hospitals to adjust to new systems of GME payment policy. The new system recommended in the report would channel PRA funds to the institutions that are responsible for the actual delivery of GME, rather than just teaching hospitals, and would expand eligibility for funding to other entities such as educational institutions, community health centers, and GME consortia. A key operating principle put forth by the IOM Committee is to produce a physician workforce that is prepared to work in a delivery system that provides better patient care, improves population health, and does so at lower cost. The structure, location, and design of GME would be revised to achieve that desired physician workforce through increased transparency and accountability for achieving GME goals, more efficient use of public funds, and greater clarity in the planning and June 2015 Volume 26 Number 2
Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
SPECIAL ARTICLE oversight of GME policy, while mitigating any unwanted consequences of migrating to a new GME system.6
IMPLICATIONS FOR PHYSICIAN ASSISTANTS With the specifics of reform of Medicare GME on the table, it is important for the physician assistant (PA) profession and its educational community to be aware of the implications of a restructured GME system. PAs play an important role within a large number of US academic health centers and teaching hospitals where they work in what some call “physician substitute” roles. Although the number of PAs in these positions is not precisely known, it is estimated that at least several thousand PAs work in teaching services providing care in lieu of physician residents whose clinical hours are reduced by the 2004 Accreditation Council for Graduate Medical Education work hour limitation policies. Given the extent of the participation of PAs within US GME programs, there is a case to be made to expand GME to include PA students, who may go on to work in “PA house staff” roles. Furthermore, given the similarity of the disciplines and duties performed by both physician residents and PAs within GME programs, it makes sense that PAs would be included among the health professions whose training is subsidized by these public sources of funding. It is of interest that the committee debated at great length whether it is justifiable to continue government funding for GME, through either Medicare or other sources. It noted the lack of similar funding for undergraduate medical education and for other health care professions and nonmedical professions that are also important to society and whose workforce may also fall short of demand.7 The IOM Committee concluded that the size and stability of Medicare GME argued for its maintenance as the basis for federal contributions to residency training. The Committee recommended maintaining but capping the size of the fund (with cost of living adjustments) and uncapping the number of positions. The positions funded in the future should be directed toward more explicit GME goals, with a new system of performance-based accountability put in place through gradual steps. This latter concept, transition to a performance-based system, represents new thinking that holds promise for reframing the debate over GME funding.8 In addition, the need for an enhanced and expanded primary care workforce made up of teams of clinicians providing preventive services, acute care, and chronic disease management argues for new training models among education systems. These models may include GME-supported interdisciplinary primary care training opportunities for family medicine residents and PA students to learn together with the aim of growing future patient-centered medical home
June 2015 Volume 26 Number 2
practices. Graduate medical education involvement in demonstration projects where the 2 disciplines train together may positively impact practice opportunities and the specialty choices of graduating PA students. A number of the themes that run throughout the IOM report on GME—public accountability, team orientation, performance-based orientation—are values and characteristics that define PAs in the health care workforce. Physician assistants have been shown to practice in rural and medically underserved areas9 and to serve medically underserved populations in community health center settings10 to a greater degree than physicians. PAs continue to be responsive and adaptive members of the health workforce whose value will increase as the US health care system continues to evolve. James F. Cawley, MPH, PA-C, is a professor in the Department of Prevention and Community Health and for Physician Assistant Studies at The George Washington University. He is also a senior research fellow at the American Academy of Physician Assistants. Correspondence should be addressed to: James F. Cawley, MPH, PA-C, Department of Physician Assistant Studies, The GW University, 2175 K Street, Washington, DC 20037. Telephone: (202) 994-3573; Email: [email protected]
REFERENCES 1. Chen C, Petterson S, Phillips R, et al. Toward graduate medical education (GME) accountability: measuring the outcomes of GME institutions. Acad Med. 2013;88:1267–1280. 2. Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Aff (Millwood). 2008;27(3):w232–w241. 3. Hackbarth G, Boccuti C. Transforming graduate medical education to improve health care value. N Engl J Med. 2011;364:693–695. 4. Josiah Macy Jr. Foundation. Ensuring an Effective Physician Workforce for America: Recommendations for an Accountable Graduate Medical Education System. New York, NY: Josiah Macy Jr. Foundation; 2011. http://www.josiahmacyfoundation.org/docs/ macy_pubs/Effective_Physician_Workforce_Conf_Book.pdf. Accessed August 12, 2014. 5. Iglehart JK. Medicare, graduate medical education, and new policy directions. N Engl J Med. 2008;359(6):643–650. 6. Institute of Medicine. Graduate Medical Education that Meets the Nation’s Health Needs. Washington, DC: National Academies Press; 2014. 7. Wilensky G, Berwick D. Reforming the financing and governance of GME. N Engl J Med. 2014;371:792–793. 8. Salsberg E. The Institute of Medicine Graduate Medical Education Report: Better Aligning GME Funding With Health Workforce Needs. http://healthaffairs.org/blog/2014/07/31/iomgraduate-medical-education-report-better-aligning-gme-fundingwith-health-workforce-needs/. Accessed March 1, 2015. 9. Shaffer R, Zolnik E. The geographic distribution of physician assistants in the United States: clustering analysis and changes from 2001 to 2008. Appl Geogr. 2014;53:323–331. 10. Hing E, Hooker RS. Community Health Centers: Providers, Patients, and Content of Care. NCHS Data Brief #65; 2011. US Government National Center for Health Statistics: Hyattsville, Maryland.
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Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
What the IOM Report on Graduate Medical Education Means for Physician Assistants James F. Cawley, MPH, PA-C Abstract Graduate medical education (GME) is funded by taxpayers through Medicare subsidies that pay for physician residency training, primarily to teaching hospitals. The Institute of Medicine (IOM) recently conducted a study of US GME and issued a series of recommendations for future
INTRODUCTION Graduate medical education (GME) represents a $15 billion taxpayer-funded system of subsidies for physician residency training. As a component of Medicare that pays teaching hospitals to train residents on a per-bed occupied basis, GME provides funding for postgraduate training of physicians within academic health centers and teaching hospitals. Critics have noted that despite the large sums involved, GME has failed to produce a physician workforce that meets the needs of the US health system.1 The physician workforce at present comprises a majority of specialists and subspecialists (over 70% of practicing physicians) and a consequent minority of physicians in primary care.2 The lack of public accountability has led to an imbalance in the types of physicians most needed in the health care system, namely physicians in the primary care specialties. Policy leaders have called for alteration in the structure and eligibility requirements of GME, which include the calls for reform from the chair of MedPAC, a key advisory group for the Medicare program. MedPAC noted that the way Medicare pays hospitals for training the nation’s future doctors is out of alignment with the agency’s goal of lowering costs while delivering higher quality care and calling for major reform of GME.2 Others have pointed out that teaching hospitals are not held accountable for creating and sustaining GME slots that meet the country’s workforce needs, that hospital’s business plans often depend on higher paying subspecialties for income, and that eligibility for training support through GME is typically restricted to physicians in certain medical and surgical specialties.3,4,5
KEY RECOMMENDATIONS As a result of mounting calls for reform, in 2013 the Institute of Medicine (IOM) undertook an extensive examination of GME and recently delivered its report with a broad set of recommendations.6 The recommended changes include taking steps that would initially maintain, but later restructure, existing GME J Physician Assist Educ 2015;26(2):86–87 Copyright ª 2015 Physician Assistant Education Association DOI 10.1097/JPA.0000000000000026
86
policy reform. This commentary examines the major elements of proposed reforms for GME and offers analysis of those that may pertain specifically to physician assistant education now and in the future.
payments to teaching hospitals and would shift training pathways from the inpatient sector to community-based sites. It is important to bear in mind that these proposed changes would require Congressional action before they could be instituted. Recommendations include maintaining GME funding at the current level over the next decade but over time dividing total available funds between an Operational Fund to support existing GME programs and a new GME Transformation Fund to fund innovation as well as new GME programs in needed specialties and underserved areas. Also recommended is the creation of a national GME Policy Council, to be established in the Office of the Secretary within the US Department of Health and Human Services, to provide national leadership and guidance along with a GME Center, to be located in the Centers for Medicare and Medicaid Services, to administer the new system. The IOM report recommends ending the current system of basing GME payments on Medicare inpatient days, the resident-to-bed ratio, and other factors. What is proposed is a new basic per-resident amount (PRA) for each resident, with geographic adjustments. Such a system would spread existing GME dollars across more positions (with the Transformation Funds covering new GME positions and accredited positions not now funded) and would increase the amount available for actual training by combining the 2 current funding streams (Direct Graduate Medical Education and Indirect Medical Education). The 10-year time frame would allow teaching hospitals to adjust to new systems of GME payment policy. The new system recommended in the report would channel PRA funds to the institutions that are responsible for the actual delivery of GME, rather than just teaching hospitals, and would expand eligibility for funding to other entities such as educational institutions, community health centers, and GME consortia. A key operating principle put forth by the IOM Committee is to produce a physician workforce that is prepared to work in a delivery system that provides better patient care, improves population health, and does so at lower cost. The structure, location, and design of GME would be revised to achieve that desired physician workforce through increased transparency and accountability for achieving GME goals, more efficient use of public funds, and greater clarity in the planning and June 2015 Volume 26 Number 2
Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
SPECIAL ARTICLE oversight of GME policy, while mitigating any unwanted consequences of migrating to a new GME system.6
IMPLICATIONS FOR PHYSICIAN ASSISTANTS With the specifics of reform of Medicare GME on the table, it is important for the physician assistant (PA) profession and its educational community to be aware of the implications of a restructured GME system. PAs play an important role within a large number of US academic health centers and teaching hospitals where they work in what some call “physician substitute” roles. Although the number of PAs in these positions is not precisely known, it is estimated that at least several thousand PAs work in teaching services providing care in lieu of physician residents whose clinical hours are reduced by the 2004 Accreditation Council for Graduate Medical Education work hour limitation policies. Given the extent of the participation of PAs within US GME programs, there is a case to be made to expand GME to include PA students, who may go on to work in “PA house staff” roles. Furthermore, given the similarity of the disciplines and duties performed by both physician residents and PAs within GME programs, it makes sense that PAs would be included among the health professions whose training is subsidized by these public sources of funding. It is of interest that the committee debated at great length whether it is justifiable to continue government funding for GME, through either Medicare or other sources. It noted the lack of similar funding for undergraduate medical education and for other health care professions and nonmedical professions that are also important to society and whose workforce may also fall short of demand.7 The IOM Committee concluded that the size and stability of Medicare GME argued for its maintenance as the basis for federal contributions to residency training. The Committee recommended maintaining but capping the size of the fund (with cost of living adjustments) and uncapping the number of positions. The positions funded in the future should be directed toward more explicit GME goals, with a new system of performance-based accountability put in place through gradual steps. This latter concept, transition to a performance-based system, represents new thinking that holds promise for reframing the debate over GME funding.8 In addition, the need for an enhanced and expanded primary care workforce made up of teams of clinicians providing preventive services, acute care, and chronic disease management argues for new training models among education systems. These models may include GME-supported interdisciplinary primary care training opportunities for family medicine residents and PA students to learn together with the aim of growing future patient-centered medical home
June 2015 Volume 26 Number 2
practices. Graduate medical education involvement in demonstration projects where the 2 disciplines train together may positively impact practice opportunities and the specialty choices of graduating PA students. A number of the themes that run throughout the IOM report on GME—public accountability, team orientation, performance-based orientation—are values and characteristics that define PAs in the health care workforce. Physician assistants have been shown to practice in rural and medically underserved areas9 and to serve medically underserved populations in community health center settings10 to a greater degree than physicians. PAs continue to be responsive and adaptive members of the health workforce whose value will increase as the US health care system continues to evolve. James F. Cawley, MPH, PA-C, is a professor in the Department of Prevention and Community Health and for Physician Assistant Studies at The George Washington University. He is also a senior research fellow at the American Academy of Physician Assistants. Correspondence should be addressed to: James F. Cawley, MPH, PA-C, Department of Physician Assistant Studies, The GW University, 2175 K Street, Washington, DC 20037. Telephone: (202) 994-3573; Email: [email protected]
REFERENCES 1. Chen C, Petterson S, Phillips R, et al. Toward graduate medical education (GME) accountability: measuring the outcomes of GME institutions. Acad Med. 2013;88:1267–1280. 2. Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Aff (Millwood). 2008;27(3):w232–w241. 3. Hackbarth G, Boccuti C. Transforming graduate medical education to improve health care value. N Engl J Med. 2011;364:693–695. 4. Josiah Macy Jr. Foundation. Ensuring an Effective Physician Workforce for America: Recommendations for an Accountable Graduate Medical Education System. New York, NY: Josiah Macy Jr. Foundation; 2011. http://www.josiahmacyfoundation.org/docs/ macy_pubs/Effective_Physician_Workforce_Conf_Book.pdf. Accessed August 12, 2014. 5. Iglehart JK. Medicare, graduate medical education, and new policy directions. N Engl J Med. 2008;359(6):643–650. 6. Institute of Medicine. Graduate Medical Education that Meets the Nation’s Health Needs. Washington, DC: National Academies Press; 2014. 7. Wilensky G, Berwick D. Reforming the financing and governance of GME. N Engl J Med. 2014;371:792–793. 8. Salsberg E. The Institute of Medicine Graduate Medical Education Report: Better Aligning GME Funding With Health Workforce Needs. http://healthaffairs.org/blog/2014/07/31/iomgraduate-medical-education-report-better-aligning-gme-fundingwith-health-workforce-needs/. Accessed March 1, 2015. 9. Shaffer R, Zolnik E. The geographic distribution of physician assistants in the United States: clustering analysis and changes from 2001 to 2008. Appl Geogr. 2014;53:323–331. 10. Hing E, Hooker RS. Community Health Centers: Providers, Patients, and Content of Care. NCHS Data Brief #65; 2011. US Government National Center for Health Statistics: Hyattsville, Maryland.
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Copyright Ó 2015 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
