Graduate Medical Education That Meets the Nation’s Health Needs Recommendations, Goals, and Next Steps
As the U.S. population ages and diversifies and the Affordable Care Act extends health coverage to more Americans than ever before, it has never been more critical for the nation’s graduate medical education (GME) system to produce a physician workforce that meets the evolving health needs of the population. Since the creation of the Medicare and Medicaid programs, the public has provided tens of billions of dollars to fund GME (residency training) in teaching hospitals and other educational institutions. Yet, under the current terms of GME financing, there is a striking absence of transparency and accountability for producing the types of physicians that today’s health care system requires. The committee recommends significant changes to GME financing and governance to address current deficiencies and better shape the physician workforce for the future.
The IOM committee’s complete recommendations appear below, as well as a table that relates these recommendations to goals and next steps suggested by the committee.
Recommendation 1: Maintain Medicare graduate medical education (GME) support at the current aggregate amount (i.e., the total of indirect medical education and direct graduate medical education expenditures in an agreed-on base year, adjusted annually for inflation) while taking essential steps to modernize GME payment methods based on performance, to ensure program oversight and accountability, and to incentivize innovation in the content and financing of GME. The current Medicare GME payment system should be phased out.
Recommendation 2: Build a graduate medical education (GME) policy and financing infrastructure.
2a. Create a GME Policy Council in the Office of the Secretary of the U.S. Department of Health and Human Services. Council members should be appointed by the Secretary and provided with sufficient funding, staff, and technical resources to fulfill the responsibilities listed below.
- Development and oversight of a strategic plan for Medicare GME financing;
- Research and policy development regarding the sufficiency, geographic distribution, and
- specialty configuration of the physician workforce;
- Development of future federal policies concerning the distribution and use of Medicare GME funds;
- Convening, coordinating, and promoting collaboration between and among federal agencies and private accreditation and certification organizations; and
- Provision of annual progress reports to Congress and the Executive Branch on the state of GME.
2b. Establish a GME Center within the Centers for Medicare & Medicaid Services with the following responsibilities in accordance with and fully responsive to the ongoing guidance of the GME Council:
- Management of the operational aspects of GME Medicare funding;
- Management of the GME Transformation Fund (see Recommendation 3), including solicitation and oversight of demonstrations; and
- Data collection and detailed reporting to ensure transparency in the distribution and use of Medicare GME funds.
Recommendation 3: Create one Medicare graduate medical education (GME) fund with two sub-sidiary funds
3a. A GME Operational Fund to distribute ongoing support for residency training positions that are currently approved and funded.
. A GME Transformation Fund to finance initiatives to develop and evaluate innovative GME programs, to determine and validate appropriate GME performance measures, to pilot alternative GME payment methods, and to award new Medicare-funded GME training positions in priority disciplines and geographic areas.
Recommendation 4: Modernize Medicare graduate medical education (GME) payment methodology.
. Replace the separate indirect medical education and direct GME funding streams with one payment to organizations sponsoring GME programs, based on a national per-resident amount (PRA) (with a geographic adjustment).
4b. Set the PRA to equal the total value of the GME Operational Fund divided by the current number of full-time equivalent Medicare-funded training slots.
4c. Redirect the funding stream so that GME operational funds are distributed directly to GME sponsoring organizations.
4d. Implement performance-based payments using information from Transformation Fund pilots.
: Medicaid graduate medical education (GME) funding should remain at the state’s discretion. However, Congress should mandate the same level of transparency and accountability in Medicaid GME as it will require under the changes in Medicare GME herein proposed.