The Institute of Medicine’s recent report on graduate medical education jarred the U.S. health care community by calling out the lack of transparency in federally funded graduate medical education spending. In 2012, Medicare and Medicaid provided nearly $14 billion to support GME programs and hospitals, the report states, yet residency programs are not required to account for how they use much of the money.
Barbara Ross-Lee, DO, the sole osteopathic physician on the IOM’s 21-member committee that wrote the report, says this lack of clarity is the most troubling problem facing the GME system.
“The fact that there is inadequate accountability and transparency creates an environment in which the GME system is not aligned with the direction that American health care is going,” says Dr. Ross-Lee, who is the vice president of health sciences and medical affairs at the New York Institute of Technology in Old Westbury, the parent school of the NYIT College of Osteopathic Medicine.
The report made several recommendations on reforming the GME system, which include freezing Medicare’s GME support at its current amount, diverting a small portion of funds to establish innovative GME programs, and creating a governing group charged with ensuring transparency in spending.
In this edited interview, Dr. Ross-Lee explains the reasoning behind these recommendations and how they fit in the greater scheme of medical education.
How does the lack of transparency in Medicare- and Medicaid-funded GME hurt health care?
Without transparency, there’s no accountability, and that’s the fundamental issue. If you don’t know how the money’s being used, then you can’t hold programs accountable for using public funds to deliver a GME system that meets the needs of the nation.
The report mentions the importance of training physicians in community health settings. Why is community-based training so important?
Most health care is delivered in the community. So training physicians to deliver care in community settings makes sense. Our current GME system trains students to deliver care in hospitals, not in the community, and community health care requires an different set of skills and competencies as well as a focus on the culture and health demographics of the communities themselves.
Also, if you train students in large teaching hospitals, most of which are not located in rural communities, the students will tend to stay in those areas. The students have minimal incentives to go to community settings in which they were not trained.
Our health care system rewards the specialties much more than the generalist disciplines. Students with high debt loads who are trained in hospitals are going to choose hospital specialties that are procedure-based.
The GME system is not organized to deliver the kinds of physicians that we need. And right now, there’s no transparency or accountability in the funding that would propel the system in a different direction.
The report suggests cutting out a portion of the dollars that are not well-justified and using those dollars to fund innovative models of education that address our current health system. We need to establish residency programs in communities and develop incentives for students to stay in these communities and to go into the generalist disciplines of family medicine, pediatrics and general internal medicine.
Physician associations, including the AOA, have repeatedly called for lifting the 1997 spending cap on Medicare GME. This report calls for keeping it as is and possibly finding other sources of funding. Was there much deliberation among the committee on making a recommendation that would go against what physician groups have long been advocating? How was the decision to make this recommendation reached?
Financing was, of course, a major charge that took up a lot of the committee’s time and effort. To examine the finances, we did a lot of in-depth study of publications and data to try and see exactly how the Medicare GME funding is being spent right now. We were confronted with a systemwide lack of transparency and accountability.
So we decided to take a portion of the existing dollars and recommend that they be used to develop some innovative ways to train physicians that will better serve the needs of the country and align with the direction in which health care is going. The positions developed through these new models will then be incorporated as newly funded residency slots.
More than two-thirds of Medicare GME funding is spent on indirect support, which means that money goes directly to the hospitals based on how many Medicare patients they treat. Of the $9.6 billion Medicare paid to teaching hospitals in 2010, nearly $7 billion was indirect support. Direct support, which pays for the direct educational expenses of residents, such as salaries, faculty and insurance, accounted for less than $3 billion.
So most of the money is unaccounted for in relation to education and does not support residency slots. This has been going on for 50 years, and it’s almost become an entitlement. The way the funds are distributed is no longer as relevant to the health care system as it was in 1965.
So we carved out some of the money that is not well-justified, and we recommend using it to develop some alternative models for GME. As these models are assessed, their trainees will be folded into the system. So the committee’s recommendations would increase residency slots. They just won’t do it in the traditional way of just giving more money to current sponsoring hospitals. We’re inviting the health care community to come up with new models to train physicians that are better aligned with the health needs of the nation.
Let’s fast-forward 10 years. Congress has gone ahead and enacted all of the report’s recommendations. What does the GME landscape look like? How does it better serve the nation?
We have more residency training slots. We have more slots that produce family physicians and generalists. We have developed programs and processes in underserved regions and underserved states across the country. The new programs allow these states and regions the flexibility of directing their workforce needs as opposed to forcing them to depend on large metropolitan areas to train their physicians.
I expect that we’ll see a lot more generalists and that we’ll see improvement in the health status of populations all across the country. Ten years is a short period of time in workforce development, but at least we will have some models in 10 years, if all of this is enacted, so we can determine whether we are going in the right direction.
What insights were you able to contribute as the only DO on the committee? How did your unique perspective add value to the committee?
The committee was extremely impressed with osteopathic medicine. The members read the Blue Ribbon Commission report, which presented ideas to update osteopathic medical education. Although undergraduate medical education is outside the scope of the committee report, the members were interested in the Blue Ribbon Commission report’s recommendations on training and competencies. I remember someone on the committee saying, “The DOs are doing what we’re trying to get the rest of the system to do.”
We had lots of discussions about regional collaboratives and consortia, such as osteopathic postdoctoral training institutions. OPTIs bring together small community hospitals and other community health care groups to support GME.
OPTIs offer residents multiple placement locations. These sites might be federally qualified health centers, community health centers, rural health centers or migrant health centers. It’s a way of introducing residents in other institutions besides teaching hospitals. Ultimately, a consortia model allows you an opportunity to bring more clinical resources to bear for GME than just a single hospital. OPTIs stood out to the committee as an example of a consortia model that works.
In the public sessions, we heard testimony from collaboratives around the country. Collaboratives are groups of health institutions that come together to establish educational programs that address the health care needs of a specific region. Many of them struggled to sustain themselves because there was no continuous funding for their efforts.
So a lot of what osteopathic medicine has done was noted in the discussion and has made some of the recommendations feasible. Before the committee finished its deliberations, the discussion about the single GME accreditation system came up. If you look at the medical student flow diagram in the report, it becomes obvious that the governance is complicated and duplicative. Having parallel osteopathic and allopathic systems that are very convoluted doesn’t help us develop an efficient plan for GME.
The committee recommends better collaboration among agencies and groups that have some role in accreditation and governance. Single GME is an example of that. They thought it was a big move for the AOA, the American Association of Colleges of Osteopathic Medicine and the Accreditation Council for Graduate Medical Education. They applauded that decision.
The report notes that “a comprehensive review of the full arc of medical education is needed.” Do you see such a review—an examination of GME alongside continuing medical education and undergraduate medical education—taking place in the near future? What recommendations would you envision coming it?
I’d like to see the major health care foundations, such as the Josiah Macy Jr. Foundation, which helped fund the IOM GME report, and the Robert Wood Johnson Foundation, which also supported that report, immediately get started on reviews of undergraduate medical education and continuing medical education. Foundations have been a part of raising the questions and the issues that lead to reports such as the IOM GME report. The Macy foundation conducted preliminary research on GME before asking the IOM to prepare this report. The IOM should look now at undergraduate medical education and how it can better align with GME.
One of the major disincentives to generalist disciplines is the debt load of medical school. That’s the elephant in the room. Many graduates from medical school have debt loads in excess of $150,000. Why would you select a primary care discipline or a generalist specialty when you have so much debt and you would make much less money? Undergraduate medical education is extremely important to GME, and it’s time to study it as well.
Do you see future reports making recommendations on ways to reduce the debt load for medical students?
I’m hoping that somebody will be innovative in thinking about debt. Most of the states are strapped for dollars because of the economic downturn, and the private schools are tuition-dependent, particularly in osteopathic medicine. So we’re frozen in place right now. But I’m an eternal optimist. If you get some very bright, capable thinkers in a room, they should be able to come up with some really wonderful ideas on how we might be able to restructure undergraduate medical education so that we can get in control of the debt load and therefore not incentivize students to choose high-paid specialties.
What about continuing medical education?
We’re in a rapidly evolving world. What you learn today will be altogether different in five years or so. The CME system needs to better help physicians keep up with the new ways health care is delivered. Right now, CME is not organized or structured that way. There’s no clear direction on what CME should include to cover the changing needs of the population. And there’s no accountability for whether the education delivered through CME is actually applied or used. This stands in contrast to medical students, for instance, who are taking tests all the time, or residents, who take national exams at some regular interval. Continuing education doesn’t have the same requirement or mandate. And it’s not well-defined or aligned with the recertification of specialties.
Physicians focus on getting the number of hours they need to retain their licenses, but they have minimal focus or direction as to what they should be learning in a changing system.
Congress must enact the report’s recommendations in order for them to go into effect. What’s the likelihood that this will happen? Which recommendations do you think have the best chance of getting enacted?
Congress does not want to just add more money to Medicare because that does not address or solve the challenges of the health care workforce. They’ve been looking for a strategy to allow them to increase the workforce without increasing costs. All indications are that Congress will take this report seriously. It provides a roadmap. Congress will probably take action on the recommendations that are easiest to implement.
Which recommendations are the easiest to implement?
Congress will absolutely look at the funding stream and look at ways they can at least carve out some dollars for innovation. They may not do it in quite the way the IOM suggested, but they will do it. And I believe they will establish a policy-recommending group that will be charged with not only assessing accountability in Medicare GME funding, but also developing strategies to expand GME slots based on need.