Institute of Medicine Recommends Changes in Graduate Medical Education

Ms. Wilensky

Wilensky says the IOM report did not attempt to address the type or quality of physician training, but focused narrowly on the end results and how public funds achieve “policy goals reflecting the health needs of the nation.”

The report’s recommendations were:

• Maintain Medicare GME support at current levels, adjusted annually for inflation, while taking steps to modernize payment methods to ensure program oversight and accountability, and to incentivize innovation. In time, however, the current Medicare GME payment system should be phased out.
• Build a GME policy and financing structure, inclusive of new management and oversight structures.
• Create one Medicare GME fund with two subsidiary funds: an operational fund to distribute ongoing support for current residency training positions; and a transformation fund to develop and evaluate innovative programs, validate performance measures, pilot alternative payment methods and award new Medicare-funded GME training positions in priority disciplines and geographic areas.
• Modernize the GME payment methodology.
• Medicaid GME funding should remain at the state’s discretion, but Congress should mandate the same level of transparency and accountability.

“The training ought to produce a physician workforce that is focused on the triple aim of better care, lower cost and more population focused,” Wilensky says. “We recognize these are changes that CMS cannot do in itself [and] require legislative changes that are not administrative.”

The IOM report drew immediate response from advocates and adversaries alike. The Association of American Medical Colleges (AAMC), the American Hospital Association (AHA) and the American Medical Association (AMA) were quick to criticize the recommendations. According to a policy paper in the New England Journal of Medicine, the physician groups “were dismayed by the failure of the report to recommend an increase in the number of Medicare-funded GME positions, and by the fact that it rejected estimates of a growing national shortage of physicians.”²

Darrell Kirch, MD, CEO, of the AAMC, says the recommendation to redirect 35% of GME payments to the transformation would “slash funding for vital care and services available almost exclusively at teaching hospitals.”³

In a July 2014 article, the AMA agreed that changes to the GME system are needed to address impending workforce shortages, but doubled down on the theories that more funding and more training spots are a better way forward.⁴

“Despite the fact that workforce experts predict a shortage of more than 45,000 primary care and 46,000 specialty physicians in the U.S. by 2020, the [IOM] report provides no clear solution to increasing the overall number of graduate medical education positions to ensure there are enough physicians to meet actual workforce needs,” former AMA President Ardis Dee Hoven, MD, says. “The AMA believes the number of residency slots must be increased to produce an appropriately sized and geographically distributed physician workforce to accommodate our country’s future health care needs.”⁴

‘The cap system lacks flexibility &, thus, fails to address workforce projections,’ —Dr. Lohr.

According to the report, the AMA has lobbied Congress to support the Creating Access to Residency Education Act of 2014 (CARE Act), which would use federal monies for new residency positions, and supports “state legislation to increase funding to train more physicians to meet local workforce needs.”