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Workforce Workforce Graduate Medical Graduate Medical Education Education Brian Wells Brian Wells

Workforce Graduate Medical Education

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Page 1: Workforce Graduate Medical Education

Workforce Workforce Graduate Graduate Medical Medical

EducationEducationBrian WellsBrian Wells

Page 2: Workforce Graduate Medical Education

Shi l. & Singh, D.( 2001). Delivering Healthcare in America. Aspen

Publications: MD.

The US healthcare delivery system is The US healthcare delivery system is characterized by:characterized by:

Imbalance between primary and specialty care servicesImbalance between primary and specialty care services

An imbalance in the ratio of generalists to specialistsAn imbalance in the ratio of generalists to specialists

A geographic maldistribution of practitionersA geographic maldistribution of practitioners

A vast array of different types of healthcare professionalsA vast array of different types of healthcare professionals

Increasing growth in the use and prominence Nonphysician Increasing growth in the use and prominence Nonphysician CliniciansClinicians

**In Sum, a unique and intricate workforce **In Sum, a unique and intricate workforce dynamic in the health professionsdynamic in the health professions

- -

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PhysiciansPhysicians

Education and training of the Education and training of the physician workforce is divided physician workforce is divided into 4 major phases:into 4 major phases:

1. Premedical education1. Premedical education 2. Medical school2. Medical school 3. Graduate Medical Education (GME)3. Graduate Medical Education (GME) 4. Continuing Medical Education 4. Continuing Medical Education (Miller et al, 1999)(Miller et al, 1999)

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More on the GMEMore on the GME

Graduate Medical Education Graduate Medical Education Programs: Programs:

are entered by a physician after they are entered by a physician after they graduate from medical school and graduate from medical school and determines the area of specialty the determines the area of specialty the physician will pursue and practice physician will pursue and practice throughout their lifetime.throughout their lifetime.

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It is estimated that 16,000 It is estimated that 16,000 physicians enter GME programs physicians enter GME programs

each year. (1999)each year. (1999)(Miller et al 1999)(Miller et al 1999)

““GME as a societal good”GME as a societal good”- Residency or GME has been accepted in most part - Residency or GME has been accepted in most part

of society as an essential part of maintaining of society as an essential part of maintaining high quality physician workforce. After earning a high quality physician workforce. After earning a medical degree, US physicians are required by medical degree, US physicians are required by law in every state to complete an additional 1 to law in every state to complete an additional 1 to 3 years of GME before receiving a license to 3 years of GME before receiving a license to practice medicine practice medicine (AMA Graduate Medical Directory 1999-(AMA Graduate Medical Directory 1999-2000)2000)

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Entrance into GMEEntrance into GME

Despite this number of physicians Despite this number of physicians entering GME’s:-entering GME’s:-

there is no systematic programs to there is no systematic programs to ensure the appropriate number, ensure the appropriate number, distribution, and balance of distribution, and balance of specialties represented in the health specialties represented in the health care systemcare system (Miller et al 1999)(Miller et al 1999)

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Understanding the Understanding the Workforce DynamicWorkforce Dynamic

GME transition into the workforceGME transition into the workforce

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Physicians vs. Non-Physicians vs. Non-Physician Clinicians Physician Clinicians

(NPC’s)(NPC’s) In 1966 the Commission On Graduate In 1966 the Commission On Graduate

Medical Education (COGME) declared that, Medical Education (COGME) declared that, “ the primary physician will serve as the “ the primary physician will serve as the primary medical resource” primary medical resource”

A Physician has a licensure in the state A Physician has a licensure in the state which they are practicing in addition to a which they are practicing in addition to a degree (MD, DO) from an accredited degree (MD, DO) from an accredited medical schoolmedical school

Today Nonphysician Clinicians are playing a Today Nonphysician Clinicians are playing a more integral role in the healthcare systemmore integral role in the healthcare system

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NPC’sNPC’s Three Broad Categories of NPC Three Broad Categories of NPC

practice that overlaps with practice that overlaps with physicians physicians (many are required to have state (many are required to have state licensures)licensures)

1.1. Physician Assistant’s and Nurse PractitionersPhysician Assistant’s and Nurse Practitioners

2.2. Other traditional clinicians: nurse anesthetists, Other traditional clinicians: nurse anesthetists, midwives, psychologists, podiatrists, and midwives, psychologists, podiatrists, and optometristsoptometrists

3.3. Alternative clinicians: chiropractors, naturopaths, Alternative clinicians: chiropractors, naturopaths, and practitioners of oriental medicineand practitioners of oriental medicine

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Conflict between Physician’s and Conflict between Physician’s and NPC’sNPC’s

It has been estimated that NPC’s will It has been estimated that NPC’s will double in number from 1994-2010double in number from 1994-2010(85 per 100,000 – 143 per 100,000) (85 per 100,000 – 143 per 100,000) (Cooper, (Cooper, JAMA 1995)JAMA 1995)

** With this increase of NPC’s an increase in With this increase of NPC’s an increase in their authority to deliver health services their authority to deliver health services may also evolve and have implications may also evolve and have implications (Cooper, JAMA 1995)(Cooper, JAMA 1995)

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Competition?Competition?

Is there a capacity to absorb the increasing Is there a capacity to absorb the increasing number of Physicians and NPC’s?number of Physicians and NPC’s?

“ “ Heightened competition between physicians and Heightened competition between physicians and NPC’s seem virtually inevitable in a system that NPC’s seem virtually inevitable in a system that already has an abundant supply of physicians already has an abundant supply of physicians and is intent on overall cost containment” and is intent on overall cost containment” (Editorial, 1998, JAMA 280, 9 pp. 825). (This an (Editorial, 1998, JAMA 280, 9 pp. 825). (This an opinion from the AMA)opinion from the AMA)

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(JAMA 1998, Cooper et al, 734)

What will be the impact of What will be the impact of additional NPC’s on Physician additional NPC’s on Physician

Demand?Demand? This is a complex question influenced by This is a complex question influenced by

many parameters that requires a better many parameters that requires a better understanding of Physician Services that understanding of Physician Services that NPC’s may undertake:NPC’s may undertake:

1.1. Further assessment of scope of practiceFurther assessment of scope of practice

2.2. Prescription privilegesPrescription privileges

3.3. AutonomyAutonomy

4.4. Roles and Responsibilities in Clinical Roles and Responsibilities in Clinical PracticePractice

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(JAMA Editorials vol 280 (9) p. 746).

Will competition benefit the Will competition benefit the Public ?Public ?

View 1: Costs may be driven down for physician View 1: Costs may be driven down for physician and non-physician services, more options may and non-physician services, more options may become availablebecome available

View 2: Regulatory bodies will develop more View 2: Regulatory bodies will develop more coordinated, uniform, and publicly accountable coordinated, uniform, and publicly accountable policies. This Pluralism could drive up the overall policies. This Pluralism could drive up the overall cost of healthcarecost of healthcare

The trend in increasing NPC’s has been compared The trend in increasing NPC’s has been compared to the physician workforce growth that began 25 to the physician workforce growth that began 25 years agoyears ago

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Graduate Medical Graduate Medical Education FundingEducation Funding

Currently through federal and state sourcesCurrently through federal and state sources

Federal:Federal:Medicare is the largest funder approximated at $ Medicare is the largest funder approximated at $ 5.0 billion per year (5.0 billion per year (direct GME costs, residents salaries, direct GME costs, residents salaries, supervisory costs, overheard related to educational programs)supervisory costs, overheard related to educational programs)

(www.aapa.org/policy)-2003 (www.aapa.org/policy)-2003

Federal government- approximately $2.75 billion Federal government- approximately $2.75 billion through Medicaidthrough Medicaid

Department of Veteran’s Affairs- 700$ million Department of Veteran’s Affairs- 700$ million This supported residency training in programs affiliated with This supported residency training in programs affiliated with their institutionstheir institutions

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Graduate Medical Education Graduate Medical Education FundingFunding

-an introduction- -an introduction- State Funding:State Funding:Medicaid: Fee-for-Service medical Medicaid: Fee-for-Service medical

education education paymentspayments

Specific funds set aside by states for diverse Specific funds set aside by states for diverse training programs and departmentstraining programs and departments

States may also contribute public medical States may also contribute public medical schools to support faculty salaries that schools to support faculty salaries that benefit GME programsbenefit GME programs

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History of the Council of History of the Council of Graduate Medical Education Graduate Medical Education

(COGME(COGME)) Created in 1986 by Congress and was Created in 1986 by Congress and was

reauthorized through September 2002 to:reauthorized through September 2002 to:

1.1. provide an ongoing assessment of trends in the provide an ongoing assessment of trends in the nations physician workforcenations physician workforce

2.2. explore crucial issues related to training ofexplore crucial issues related to training of physicians and financing of GMEphysicians and financing of GME3. 3. advise and make recommendations on these advise and make recommendations on these

subjects to Congress and to the Secretary of subjects to Congress and to the Secretary of the Department of Health and Human Services the Department of Health and Human Services

(Adapted from Health resources and Services Administration, U.S. DHHS. (Adapted from Health resources and Services Administration, U.S. DHHS. http://www.hrsa.dhhs.gov/bhpr/dm/cogplans.htm.)http://www.hrsa.dhhs.gov/bhpr/dm/cogplans.htm.)

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COGME addressesCOGME addresses Various issues regarding the size and Various issues regarding the size and

makeup of the physician workforce and makeup of the physician workforce and the need to direct physician training to the need to direct physician training to meet diverse population needs in a rapidly meet diverse population needs in a rapidly changing healthcare environmentchanging healthcare environment

develops official reports and issue papers develops official reports and issue papers after consultation with leading experts in after consultation with leading experts in healthcare, medical education, and healthcare, medical education, and organizations that have similar interest in organizations that have similar interest in GME.GME.

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Major issues addressed Major issues addressed by the COGMEby the COGME

Size and mix of physician workforceSize and mix of physician workforce

Facilitating access to physician careFacilitating access to physician care

Financing physician trainingFinancing physician training

Role of International Medical Grads (IMG)Role of International Medical Grads (IMG)

Women in MedicineWomen in Medicine

Minorities in MedicineMinorities in Medicine

Educating physicians for future needsEducating physicians for future needs

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Introductory reviewIntroductory review

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Workforce GME: Workforce GME: Workforce Trends Workforce Trends and Supply and and Supply and

DemandDemand

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AssumptionsAssumptions Changes in federal policy toward Changes in federal policy toward

residency training affect the size and residency training affect the size and characteristics of the physician characteristics of the physician workforce.workforce.

Economic incentives also play a role in Economic incentives also play a role in the response of the supply of physicians the response of the supply of physicians (ex: the pattern of behavior observed (ex: the pattern of behavior observed during the late 1960s and the 1970s during the late 1960s and the 1970s after the introduction of Medicare, after the introduction of Medicare, Medicaid, and their precursor Medicaid, and their precursor programs).programs).

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Past Workforce Trends for Past Workforce Trends for Physicians and GME (i.e. Physicians and GME (i.e.

How did we get here?)How did we get here?) Can be broken down into five areas:Can be broken down into five areas:

Pre-1910Pre-1910 The Post-Flexner Era: 1910 – 1963The Post-Flexner Era: 1910 – 1963 The Epoch of Government Blank Checks: 1963 – The Epoch of Government Blank Checks: 1963 –

19901990 The Era of the Wholesale Market for Physician The Era of the Wholesale Market for Physician

Labor: 1990 – 2000Labor: 1990 – 2000 The Collapse of the Wholesale Market: 2000 – The Collapse of the Wholesale Market: 2000 –

PresentPresent

Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy. Health Aff

21(5):13-27, 2002. Available at: http://www.medscape.com/viewarticle/440692

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The Pre-1910 EraThe Pre-1910 Era

Pre-1910:Pre-1910: Closest the nation has come to a traditional free Closest the nation has come to a traditional free

market for physician servicesmarket for physician services A degree of physician-induced demand was in A degree of physician-induced demand was in

effecteffect Patients directly incurred the costs of most Patients directly incurred the costs of most

health care transactions.health care transactions. 160 medical schools, 25,000 medical students, 160 medical schools, 25,000 medical students,

approx. 175 physicians / 100,000 people. approx. 175 physicians / 100,000 people. Physician incomes were modest.Physician incomes were modest.

Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy. Health Aff 21(5):13-27, 2002

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The Post-Flexner EraThe Post-Flexner Era

The Post-Flexner Era: 1910 – 1963The Post-Flexner Era: 1910 – 1963 More than 30 medical schools closed during this More than 30 medical schools closed during this

period.period. 125 physicians / 100,000 U.S. population.125 physicians / 100,000 U.S. population. Anticompetitive market for physician labor Anticompetitive market for physician labor

under professionally dominated regulation.under professionally dominated regulation. ““They did business where business was good They did business where business was good

and avoided places where it was bad.”and avoided places where it was bad.” Planning commissions decided the nation Planning commissions decided the nation

needed more physicians to raise the level of needed more physicians to raise the level of supply in “below-average” communities.supply in “below-average” communities.

Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy. Health Aff 21(5):13-27, 2002

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The Epoch of Government The Epoch of Government Blank ChecksBlank Checks

The Epoch of Government Blank Checks: 1963 The Epoch of Government Blank Checks: 1963 – 1990– 1990 Rapid growth in physician supply due to heavy Rapid growth in physician supply due to heavy

investing in medical education by the U.S. Federal investing in medical education by the U.S. Federal Government.Government.

Employer-based insurance had become prevalent Employer-based insurance had become prevalent making consumers less price sensitivemaking consumers less price sensitive

1965 – 115 physicians / 100,000 U.S. population.1965 – 115 physicians / 100,000 U.S. population. By 1990, U.S. Fed. Gov. was spending more than By 1990, U.S. Fed. Gov. was spending more than

$6B/yr for GME with state gov’s giving additional $6B/yr for GME with state gov’s giving additional funds for state-supported medical schools.funds for state-supported medical schools.

Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy. Health Aff 21(5):13-27, 2002

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The Epoch of Government The Epoch of Government Blank ChecksBlank Checks

The Epoch of Government Blank Checks: 1963 – The Epoch of Government Blank Checks: 1963 – 19901990 U.S. spending on all health care services increased U.S. spending on all health care services increased

dramatically.dramatically. Contrary to market predictions, dramatic increase Contrary to market predictions, dramatic increase

could in fact coexist with rising physician incomes.could in fact coexist with rising physician incomes. Physicians lost atavistic fear of supply growth as a Physicians lost atavistic fear of supply growth as a

threat to earnings.threat to earnings. Medicare funding of GME revealed it was possible to Medicare funding of GME revealed it was possible to

obtain government financing without much obtain government financing without much government regulation.government regulation.

Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy. Health Aff 21(5):13-27, 2002

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The Epoch of Government The Epoch of Government Blank ChecksBlank Checks

The Epoch of Government Blank Checks: 1963 – The Epoch of Government Blank Checks: 1963 – 19901990 More directive federal approach to physician supply More directive federal approach to physician supply

planningplanning GMENAC undertook the nation’s most devoted effort GMENAC undertook the nation’s most devoted effort

to develop a needs-based physician workforce policy to develop a needs-based physician workforce policy producing detailed projections of required supply.producing detailed projections of required supply.

Programs (ex: National Health Service Corp) Programs (ex: National Health Service Corp) attempted to use incentives to induce physicians to attempted to use incentives to induce physicians to practice in communities with a meager supply of practice in communities with a meager supply of physicians.physicians.

1986 – Congress authorized the establishment of a new 1986 – Congress authorized the establishment of a new federal physician workforce planning group - COGMEfederal physician workforce planning group - COGME

GMENAC = Graduate Medical Education National Advisory CommitteeGMENAC = Graduate Medical Education National Advisory Committee

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The Wholesale Market EraThe Wholesale Market Era

The Era of the Wholesale Market for The Era of the Wholesale Market for Physician Labor: 1990 – 2000Physician Labor: 1990 – 2000 Attempted to transform the market for Attempted to transform the market for

physician labor from a retail to a wholesale physician labor from a retail to a wholesale market.market.

The managed care experiment intensifiesThe managed care experiment intensifies Rise of the wholesale market had the Rise of the wholesale market had the

potential to weaken the relative economic potential to weaken the relative economic strength of physicians.strength of physicians.

Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy. Health Aff 21(5):13-27, 2002

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The Wholesale Market EraThe Wholesale Market Era

The Era of the Wholesale Market for The Era of the Wholesale Market for Physician Labor: 1990 – 2000Physician Labor: 1990 – 2000 COGME’s initial activity was to synthesize COGME’s initial activity was to synthesize

information on physician supply requirements.information on physician supply requirements. Adopted an ecumenical approach.Adopted an ecumenical approach. COGME used wholesale-market, demand-based COGME used wholesale-market, demand-based

studies to arrive at physician estimates (GMENAC studies to arrive at physician estimates (GMENAC used needs-based estimates (paternalistic)).used needs-based estimates (paternalistic)).

1994 report by COGME endorsed implementation 1994 report by COGME endorsed implementation of a stronger system of federal financing and of a stronger system of federal financing and regulation of GME.regulation of GME.

Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy. Health Aff 21(5):13-27, 2002

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The Wholesale Market EraThe Wholesale Market Era

The Era of the Wholesale Market for The Era of the Wholesale Market for Physician Labor: 1990 – 2000Physician Labor: 1990 – 2000 1994 COGME recommendations were part of 1994 COGME recommendations were part of

the Clinton Health Plan.the Clinton Health Plan. Decreases in the number of U.S. MG selecting Decreases in the number of U.S. MG selecting

certain high-profile specialties.certain high-profile specialties. Market was changing the PC/Specialist supply Market was changing the PC/Specialist supply

balance, constraining physician’s incomes, and balance, constraining physician’s incomes, and possibly even dampening growth in overall possibly even dampening growth in overall physician supply.physician supply.

Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy. Health Aff 21(5):13-27, 2002

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The Collapse of the The Collapse of the Wholesale MarketWholesale Market

The Collapse of the Wholesale The Collapse of the Wholesale Market: 2000 – PresentMarket: 2000 – Present Managed Care has faltered.Managed Care has faltered. U.S. health care system may be headed U.S. health care system may be headed

back on a course of increasing back on a course of increasing specialization, rising physician incomes, specialization, rising physician incomes, and pressures to increase overall and pressures to increase overall physician supply.physician supply.

Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy. Health Aff 21(5):13-27, 2002

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Mix of Physicians in Mix of Physicians in Primary Care Versus Non-Primary Care Versus Non-Primary Care Specialists Primary Care Specialists

In 1965:In 1965: 51% of physicians involved in patient 51% of physicians involved in patient

care were in general practice, internal care were in general practice, internal medicine, and pediatrics.medicine, and pediatrics.

21% were in surgical specialties 21% were in surgical specialties (including general surgery)(including general surgery)

21% were other non-primary care 21% were other non-primary care specialties and subspecialties of internal specialties and subspecialties of internal medicine and pediatrics.medicine and pediatrics.

6.5% were in obstetrics and gynecology.6.5% were in obstetrics and gynecology.

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Physicians per 100,000 Physicians per 100,000 peoplepeople

Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy. Health Aff 21(5):13-27, 2002. Available at: http://www.medscape.com/viewarticle/440692

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Physicians per 1,000 Physicians per 1,000 peoplepeople

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Progression of Physicians Progression of Physicians from 1965 to 1993from 1965 to 1993

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Past Workforce Trends for Past Workforce Trends for Nonphysician CliniciansNonphysician Clinicians

Between 1987 and 1997, the Between 1987 and 1997, the proportion of patients who saw a NPC proportion of patients who saw a NPC rose from 30.6% to 36.1%.rose from 30.6% to 36.1%.

Was a degree of differentiation Was a degree of differentiation between physicians and NPCs with between physicians and NPCs with respect to the services they provided respect to the services they provided but not with respect to the patients but not with respect to the patients they treated.they treated.

Source: Druss, Benjamin et al. Source: Druss, Benjamin et al. Trends in Care by Nonphysician Clinicians in the United Trends in Care by Nonphysician Clinicians in the United States,States, NEJM, Jan. 9 NEJM, Jan. 9thth, 2003, Vol. 348, pg. 130-137., 2003, Vol. 348, pg. 130-137.

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Past Workforce Trends for Past Workforce Trends for Nonphysician CliniciansNonphysician Clinicians

Traditional Nonphysician CliniciansTraditional Nonphysician Clinicians Nurse Practitioners – NPs Nurse Practitioners – NPs

1995 – 58,000 active NPs or double the 1995 – 58,000 active NPs or double the number in 1990number in 1990

1,500 NPs graduated in 19921,500 NPs graduated in 1992 7,500 NPs graduated in 19997,500 NPs graduated in 1999

Clinical Nurse SpecialistsClinical Nurse Specialists Slow, but steady growth – 11,000 in 1990 to Slow, but steady growth – 11,000 in 1990 to

15,000 in 199515,000 in 1995

Source: Cooper, Richard. Source: Cooper, Richard. Health Care Workforce for the 21Health Care Workforce for the 21stst Century: The Century: The Impact of Nonphysician Clinicians,Impact of Nonphysician Clinicians, Ann. Rev. Med., 2001, 52:51-61 Ann. Rev. Med., 2001, 52:51-61

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Past Workforce Trends for Past Workforce Trends for Nonphysician ClinicsNonphysician Clinics

Traditional Nonphysician CliniciansTraditional Nonphysician Clinicians Certified Nurse MidwivesCertified Nurse Midwives

3,000 in 19903,000 in 1990 5,000 in 19955,000 in 1995

Physician AssistantsPhysician Assistants 11,000 in 198011,000 in 1980 30,000 in 199830,000 in 1998

Source: Cooper, Richard. Source: Cooper, Richard. Health Care Workforce for the 21Health Care Workforce for the 21stst Century: The Impact Century: The Impact of Nonphysician Clinicians,of Nonphysician Clinicians, Ann. Rev. Med., 2001, 52:51-61 Ann. Rev. Med., 2001, 52:51-61

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Past Workforce Trends for Past Workforce Trends for Nonphysician CliniciansNonphysician Clinicians

Alternative Nonphysician CliniciansAlternative Nonphysician Clinicians ChiropractorsChiropractors

Modest increases during the 1990sModest increases during the 1990s 60,000 in 199860,000 in 1998

AcupuncturistsAcupuncturists 5,000 in 19905,000 in 1990 11,000 in 199711,000 in 1997

Source: Cooper, Richard. Source: Cooper, Richard. Health Care Workforce for the 21Health Care Workforce for the 21stst Century: The Century: The Impact of Nonphysician Clinicians,Impact of Nonphysician Clinicians, Ann. Rev. Med., 2001, 52:51-61 Ann. Rev. Med., 2001, 52:51-61

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Current Workforce Trends Current Workforce Trends for Physiciansfor Physicians

The number of medical residents in the The number of medical residents in the U.S. has generally been increasing U.S. has generally been increasing (however, there has been a slight decline (however, there has been a slight decline in the past few years).in the past few years).

83,000 in 1988 to 102,000 in 1993.83,000 in 1988 to 102,000 in 1993. However, there has not been a decline in However, there has not been a decline in

the number of programs to train these the number of programs to train these residents.residents.

Sources: CBO Study - Medicare and Graduate Medical Education - September Sources: CBO Study - Medicare and Graduate Medical Education - September 19951995

U.S. Graduate Medical Education, 2001-2002 – JAMA, September 4, 2002U.S. Graduate Medical Education, 2001-2002 – JAMA, September 4, 2002

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Current Workforce Trends Current Workforce Trends for Physiciansfor Physicians

The number of graduates of U.S. medical The number of graduates of U.S. medical schools has remained fairly constant.schools has remained fairly constant.

Much of the growth in the number of Much of the growth in the number of residents comes from foreign medical residents comes from foreign medical school graduates.school graduates.

The widely anticipated physician surplus The widely anticipated physician surplus did not materialize in 2000 (it was did not materialize in 2000 (it was thought that the surplus would increase thought that the surplus would increase to 145,000 or 22%).to 145,000 or 22%).

Page 43: Workforce Graduate Medical Education

Mix of Physicians in Mix of Physicians in Primary Care Versus Non-Primary Care Versus Non-Primary Care SpecialtiesPrimary Care Specialties

In 1995:In 1995: 34% were in general practice, family 34% were in general practice, family

practice, general internal medicine, and practice, general internal medicine, and general pediatrics.general pediatrics.

19% were in surgical specialties including 19% were in surgical specialties including general surgery.general surgery.

29% were in other non-primary care 29% were in other non-primary care specialties including anesthesiology and specialties including anesthesiology and radiologyradiology

11% were in subspecialties of internal 11% were in subspecialties of internal medicine and pediatricsmedicine and pediatrics

6.5% were in obstetrics and gynecology6.5% were in obstetrics and gynecology

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Current Workforce Trends Current Workforce Trends for Nonphysician Cliniciansfor Nonphysician Clinicians

Nonphysician clinicians (NPCs) are becoming Nonphysician clinicians (NPCs) are becoming increasingly prominent as health care increasingly prominent as health care providers.providers.

The 1990s saw the following:The 1990s saw the following: rising numbers of graduates of training programs rising numbers of graduates of training programs

for NPCsfor NPCs Passage of legislation expanding their scope of Passage of legislation expanding their scope of

practicepractice A proliferation of managed care models that A proliferation of managed care models that

emphasized the use of these providers as a strategy emphasized the use of these providers as a strategy for containing health care costs.for containing health care costs.

Source: Trends in Care by Nonphysician Clinician in the U.S. - NEJM – Jan. 9Source: Trends in Care by Nonphysician Clinician in the U.S. - NEJM – Jan. 9thth, , 20032003

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Future Workforce Trends Future Workforce Trends for Physiciansfor Physicians

General apprehension about an impending General apprehension about an impending physician surplus (1995)physician surplus (1995)

This view was put forth by the Bureau of This view was put forth by the Bureau of Health Professions and the COGME in the Health Professions and the COGME in the 1990s and believed by many, including the 1990s and believed by many, including the AAMC.AAMC.

Controversial Trend Model suggesting an Controversial Trend Model suggesting an impending physician shortage (2002).impending physician shortage (2002).

General consensus that there is no evidence of General consensus that there is no evidence of a major impending surplus.a major impending surplus.

Sources: Cooper, Richard. Sources: Cooper, Richard. Perspectives on the Physician Workforce to the Year 2020,Perspectives on the Physician Workforce to the Year 2020, JAMA, Nov. 15 JAMA, Nov. 15thth, 1995, Vol. , 1995, Vol. 274, No. 19.274, No. 19.

Brotherton, Sarah et al. Brotherton, Sarah et al. U.S. Graduate Medical Education, 2001 – 2002,U.S. Graduate Medical Education, 2001 – 2002, JAMA, September 4 JAMA, September 4thth, 2002, Vol. 288, No. , 2002, Vol. 288, No. 9.9.

Cooper, Richard. Cooper, Richard. There’s a Shortage of Specialists. Is Anyone Listening?There’s a Shortage of Specialists. Is Anyone Listening?, Acad. Med., August, 2002, Vol. 77, No. , Acad. Med., August, 2002, Vol. 77, No. 88

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Future Workforce Trends Future Workforce Trends for Physiciansfor Physicians

Trend model relies on four trendsTrend model relies on four trends Economic expansionEconomic expansion Population growthPopulation growth Work effort of physiciansWork effort of physicians Services provided by nonphysician Services provided by nonphysician

cliniciansclinicians

Source: Cooper, Richard et al. Source: Cooper, Richard et al. Economic and Demographic Trends Signal An Economic and Demographic Trends Signal An Impending Physician ShortageImpending Physician Shortage, Health Aff., 2002, Vol. 21, No. 1, Health Aff., 2002, Vol. 21, No. 1

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Future Workforce Trends Future Workforce Trends for Physiciansfor Physicians

Source: Cooper, Richard et al. Economic and Demographic Trends Signal an Impending Physician Shortage, Health Aff., 2002, Vol. 21, No. 1

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Future Workforce Trends Future Workforce Trends for Nonphysician Cliniciansfor Nonphysician Clinicians

By 2005 it is expected that:By 2005 it is expected that: there will be more Chiropractors than general there will be more Chiropractors than general

internistsinternists there will be more PAs than general pediatriciansthere will be more PAs than general pediatricians the number of NPs in practice (>115,000) will the number of NPs in practice (>115,000) will

exceed the number of family physicians, and will exceed the number of family physicians, and will exceed by a factor of 2 the number that was exceed by a factor of 2 the number that was predicted to be required for that year by the predicted to be required for that year by the National Advisory Council on Nurse Education and National Advisory Council on Nurse Education and PracticePractice

Source: Source: Cooper et. al., Current and Projected Workforce of Nonphysician Clinicians, JAMA, September 2, 1998, Vol. 280, No. 9.

This slide originally appeared in a presentation by George Isham, M.D., Chief Health Officer for This slide originally appeared in a presentation by George Isham, M.D., Chief Health Officer for HealthPartners on May 16HealthPartners on May 16thth, 2001., 2001.

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Future Trends for Future Trends for Nonphysician CliniciansNonphysician Clinicians

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Future Trends for Future Trends for Nonphysician CliniciansNonphysician Clinicians

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Clinicians per 100,000 Clinicians per 100,000 populationpopulation

0 20 40 60 80 100 120

Primary CareNPCs

Primary CareMDs

Specialty NPCs

Specialty MDs

19952005

Primary Care MDs: FPs, Gen IM, Gen Peds, OB/GYNSpecialty MDs: All others except PsychPrimary Care NPCs: Prim Care NPs, Prim Care PAs, Cert Nurse Midwives, Chiros, Acupunct, NaturopathsSpec NPCs: Spec NPs, Spec PAs, Optometrists, Podiatrists, Cert, Reg Nurse Anesth, and Med and Surg CN Spec

Source: Cooper et. al., Current and Projected Workforce of Nonphysician Clinicians, JAMA, September 2, 1998, Vol. 280, No. 9.

This slide originally appeared in a presentation by George Isham, M.D., Chief Health Officer for HealthPartners on May 16th, This slide originally appeared in a presentation by George Isham, M.D., Chief Health Officer for HealthPartners on May 16th, 2001.2001.

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The Market for Resident The Market for Resident Physicians Supply and Physicians Supply and

DemandDemand Demand FactorsDemand Factors

Shaped by insurance and demographic Shaped by insurance and demographic characteristics (aging, for example) of the characteristics (aging, for example) of the patient populationpatient population

Epidemiological factorsEpidemiological factors Equipment and technologies available at Equipment and technologies available at

hospitalshospitals The reimbursement policies of private and The reimbursement policies of private and

government payers, goals of hospitalsgovernment payers, goals of hospitals Subsidies to hospitals for GMESubsidies to hospitals for GME

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The Market for Resident The Market for Resident Physicians Supply and Physicians Supply and

DemandDemand Supply factors:Supply factors:

The distribution of the supply of The distribution of the supply of resident physicians among specialties resident physicians among specialties responds to the incentives to enter the responds to the incentives to enter the various fields.various fields. Example: Salary, expected hours of work, Example: Salary, expected hours of work,

number of years in training, availability and number of years in training, availability and payment terms of loanspayment terms of loans

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The Market for Trained The Market for Trained Physicians Supply and Physicians Supply and

DemandDemand Demand factors:Demand factors:

Similar to demand factors of resident Similar to demand factors of resident physiciansphysicians

Shaped by the amount and type of Shaped by the amount and type of insurance coverage of the population and insurance coverage of the population and its demographic characteristicsits demographic characteristics

Epidemiological factorsEpidemiological factors Available technologyAvailable technology Reimbursement and coverage parametersReimbursement and coverage parameters

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The Market for Trained The Market for Trained Physicians Supply and Physicians Supply and

DemandDemand Supply factors:Supply factors:

Size and composition of existing pool of Size and composition of existing pool of trained physicianstrained physicians

Inflows of newly trained physicians and Inflows of newly trained physicians and immigrant physiciansimmigrant physicians

Outflows of retiring physicians (or Outflows of retiring physicians (or physicians moving to non-patient care physicians moving to non-patient care activities such as administration or activities such as administration or research).research).

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Other supply and Other supply and demand factorsdemand factors

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What is the Appropriate What is the Appropriate Number of Physicians?Number of Physicians?

There is currently no consensus on this.There is currently no consensus on this. However, consensus has been reached However, consensus has been reached

that there is currently a more than that there is currently a more than adequate supply of physicians.adequate supply of physicians.

Increases in the number of physicians in Increases in the number of physicians in highly specialized fields should be highly specialized fields should be curtailed (1995).curtailed (1995).

Trend model suggest there may be an Trend model suggest there may be an impending shortage of specialists (2002).impending shortage of specialists (2002).

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What is the Appropriate What is the Appropriate Number of Physicians?Number of Physicians?

Major determinate of overall physician Major determinate of overall physician surpluses in the future will be the extent to surpluses in the future will be the extent to which patients continue to seek physicians for which patients continue to seek physicians for services that will also be offered by services that will also be offered by nonphysician clinicians. nonphysician clinicians.

The CBO determined that any surplus that does The CBO determined that any surplus that does arise should be self-correcting over time.arise should be self-correcting over time.

The CBO believes that if the number of The CBO believes that if the number of physicians were to become excessive, the physicians were to become excessive, the relative fees and incomes of doctors would fall, relative fees and incomes of doctors would fall, the medical profession would become less the medical profession would become less desirable, and the excess would be eliminated desirable, and the excess would be eliminated over time.over time.

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Problems with Problems with forecasting trendsforecasting trends

Many limitations with forecasting supply and Many limitations with forecasting supply and demand.demand.

Supply estimates are limited by predictions Supply estimates are limited by predictions concerning the future number of USMGs and concerning the future number of USMGs and IMGs.IMGs.

Demand estimates are limited by predictions Demand estimates are limited by predictions of technology impact and errors or oversights of technology impact and errors or oversights in HMO utilization data.in HMO utilization data.

Elasticity of physician work effort tends to Elasticity of physician work effort tends to reduce general level of effort among reduce general level of effort among physicians thus masking any true surplus.physicians thus masking any true surplus.

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Where are we going?Where are we going?

Increasing number of NPCs putting Increasing number of NPCs putting pressure on physicianspressure on physicians

Conflicting models of physician Conflicting models of physician supply/demand due to problems with supply/demand due to problems with forecasting.forecasting.

However, one thing is for certain:However, one thing is for certain: We are going to Angelique’s portion of We are going to Angelique’s portion of

the presentation.the presentation.

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Graduate Graduate Medical Medical

EducationEducationReformReform

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The Role of Medicaid in State The Role of Medicaid in State FundingFunding

There is no statutory requirement for There is no statutory requirement for payment into GME, it is purely voluntarypayment into GME, it is purely voluntary

Nearly all states still have contributed Nearly all states still have contributed under fee-for-service Medicaid programsunder fee-for-service Medicaid programs

Five states and Puerto Rico do NOT use Five states and Puerto Rico do NOT use funding for GMEfunding for GME

Of those, 3 (Alaska, Idaho, and Montana) Of those, 3 (Alaska, Idaho, and Montana) do not have medical schoolsdo not have medical schools

Funding ranges between 1% - 20% Funding ranges between 1% - 20% inpatient hospital paymentsinpatient hospital payments

The State Average is about 7%The State Average is about 7%

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Fair Share of Medical Fair Share of Medical Education CostsEducation Costs

Each state has the right to Each state has the right to decide whether or not to fund decide whether or not to fund GMEGME Become familiar with their own Become familiar with their own

workforce needsworkforce needs Using the money to target those Using the money to target those

groups who will be most neededgroups who will be most needed Identify GME costs and revenuesIdentify GME costs and revenues

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Fair Share of Medical Fair Share of Medical Education CostsEducation Costs

Consider the link between Consider the link between Medicaid GME and patient careMedicaid GME and patient care

Consider the link between Consider the link between Medicaid GME payments and Medicaid GME payments and Medicaid servicesMedicaid servicesShould Medicaid funds be used to Should Medicaid funds be used to support GME in institutions that do support GME in institutions that do no service a significant amount of no service a significant amount of Medicaid patients?Medicaid patients?

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Fair Share of Medical Fair Share of Medical Education CostsEducation Costs

Compare funding sourcesCompare funding sources Instill payment efficiencyInstill payment efficiency

Getting the most out of each dollarGetting the most out of each dollar Changing the processChanging the process

Ensure that funding is held accountable Ensure that funding is held accountable to meeting the needs of the state and to meeting the needs of the state and penalize those who do notpenalize those who do not

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Disjoint Funding Disjoint Funding StrategyStrategy

In Florida:In Florida: A large state health service corps A large state health service corps

program was created to expand loan program was created to expand loan repayment and scholarship activitiesrepayment and scholarship activities

While at the same timeWhile at the same time Another state policy was reducing Another state policy was reducing

payments for graduate medical payments for graduate medical educationeducation

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Innovations at the State Innovations at the State LevelLevel

TennesseeTennesseeMinnesotaMinnesotaMichiganMichigan

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TennesseeTennessee

In 1995, Tennessee implemented the In 1995, Tennessee implemented the Medicaid Managed CareMedicaid Managed Care TennCareTennCare

They stopped payment for GME in They stopped payment for GME in order to channel resources to order to channel resources to expand Medicaid enrollment to expand Medicaid enrollment to cover large portions of the poverty cover large portions of the poverty populationpopulation

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Tennessee, Con’tTennessee, Con’t

In 1996, TennCare restored GME In 1996, TennCare restored GME paymentspayments Funds went directly to medical schools, not Funds went directly to medical schools, not

hospitalshospitals Payments weighted heavily toward primary Payments weighted heavily toward primary

care teachingcare teaching Noncompliance penalties for non Noncompliance penalties for non

adherence to primary care priorities and adherence to primary care priorities and services directly towards Medicaid patientsservices directly towards Medicaid patients

Set-aside stipends for physicians who stay Set-aside stipends for physicians who stay in the statein the state

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MinnesotaMinnesota

Established an all-payer pool for Established an all-payer pool for GMEGME Only other state besides New York to Only other state besides New York to

implementimplement Created in response to the predicted Created in response to the predicted

growth of managed care that would growth of managed care that would put academic medicine under siegeput academic medicine under siege

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Minnesota, Con’tMinnesota, Con’t The legislature created in 1997 and The legislature created in 1997 and

then appropriated funds into a medical then appropriated funds into a medical education/research trust fundeducation/research trust fund Medical Education and Research Trust Cost Medical Education and Research Trust Cost

Fund (MERC)Fund (MERC) The fund created incentives to train The fund created incentives to train

multiple types of providers according to multiple types of providers according to Minnesota’s population needsMinnesota’s population needs

Initially, supported by a tax on providersInitially, supported by a tax on providers Now a portion has been allocated from the Now a portion has been allocated from the

Tobacco settlementTobacco settlement

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MichiganMichigan

Changed dramatically in 1997 when Changed dramatically in 1997 when the state aligned the payments the state aligned the payments according to three policy goals:according to three policy goals: To train the appropriate numbers of To train the appropriate numbers of

primary care providersprimary care providers To enhance training in rural areasTo enhance training in rural areas To support education in ways of To support education in ways of

particular importance in the treatment particular importance in the treatment of the Medicaid eligible populationof the Medicaid eligible population

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Michigan, Con’tMichigan, Con’t

Primary care poolPrimary care poolBased on the institution’s number Based on the institution’s number of residents in primary care and of residents in primary care and its share of Medicaid residentsits share of Medicaid residents

Weighted for Medicaid utilization Weighted for Medicaid utilization and for performance factorsand for performance factors

Physicians that participate in Physicians that participate in Michigan’s Medicaid program after Michigan’s Medicaid program after completing their residencycompleting their residency

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Michigan, Con’tMichigan, Con’t

Must provide documentation to the Must provide documentation to the state detailing how the funds are state detailing how the funds are used to be reimbursed (meeting the used to be reimbursed (meeting the goals mentioned before)goals mentioned before)

Encourages the education of young Encourages the education of young physicians in the primary care physicians in the primary care fieldsfields

Family practiceFamily practice Preventative medicinePreventative medicine

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Michigan, Con’tMichigan, Con’t

The Innovations in Health Professions The Innovations in Health Professions Education Grant FundEducation Grant Fund Established with GME funds formally in Established with GME funds formally in

capitation payments to MCOs to stimulated capitation payments to MCOs to stimulated innovations in health profession educationinnovations in health profession education

Accelerate the pace of health care change in Accelerate the pace of health care change in the statethe state

Awarded on a competitive basis to programs Awarded on a competitive basis to programs that support the goalsthat support the goals

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Do you think that Do you think that the government the government should subsidize should subsidize

GME?GME?

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SubsidiesSubsidies

Based on the size of their Based on the size of their graduate medical education graduate medical education programsprograms

Direct graduate medical education Direct graduate medical education (DME) payments (DME) payments

Indirect medical education (IME) Indirect medical education (IME) adjustment.adjustment.

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Direct Medical Education Direct Medical Education PaymentsPayments

For its DME payment, a teaching For its DME payment, a teaching hospital receives an amount equal to hospital receives an amount equal to the product of three factorsthe product of three factors

"Medicare patient load”"Medicare patient load” Adjusted number of full-time-equivalent Adjusted number of full-time-equivalent

(FTE) residents(FTE) residents Allowed amount per resident. Allowed amount per resident.

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Indirect Medical Education Indirect Medical Education AdjustmentAdjustment

The additional amount Medicare The additional amount Medicare pays to a teaching hospital equals pays to a teaching hospital equals the hospital's total Medicare the hospital's total Medicare diagnosis-related group (DRG) diagnosis-related group (DRG) payments for inpatient services payments for inpatient services multiplied by a factor that is multiplied by a factor that is calculated according to a specific calculated according to a specific mathematical formulamathematical formula

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Federal Reform of GME Federal Reform of GME FinancingFinancing

Modify the Current SystemModify the Current System

Restructure the System Restructure the System

End Federal FinancingEnd Federal Financing

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Modify the Current Modify the Current SystemSystem

Reduce the IME Teaching Adjustment Reduce the IME Teaching Adjustment

The Government's Prospective Payment The Government's Prospective Payment Assessment Commission (ProPAC) has Assessment Commission (ProPAC) has suggested that the current IME subsidy be suggested that the current IME subsidy be reduced to reflect more accurately those reduced to reflect more accurately those increases in teaching hospitals' costs that are increases in teaching hospitals' costs that are associated with larger resident-to-bed ratiosassociated with larger resident-to-bed ratios

IME adjustment be reduced in phases from its IME adjustment be reduced in phases from its current rate of about 7.7 percent to 4.5 percent, current rate of about 7.7 percent to 4.5 percent, for a 0.1 increase in the resident-to-bed ratio of for a 0.1 increase in the resident-to-bed ratio of the hospitalthe hospital

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Reduce the IME Teaching Reduce the IME Teaching AdjustmentAdjustment

A decrease in IME payments A decrease in IME payments would be expected to lead to would be expected to lead to fewer residents than teaching fewer residents than teaching hospitals would otherwise have hospitals would otherwise have trainedtrained

Teaching hospitals might also Teaching hospitals might also scale back some activities scale back some activities besides residency trainingbesides residency training

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Modify the Current System, Modify the Current System, Con’tCon’t

Reduce or Eliminate GME Subsidies for Reduce or Eliminate GME Subsidies for Noncitizens Noncitizens

Approximately one-fourth of all current Approximately one-fourth of all current residents graduated from foreign medical residents graduated from foreign medical schoolsschools

The majority of those foreign medical The majority of those foreign medical graduates are not U.S. citizensgraduates are not U.S. citizens although most of them are expected to enter the although most of them are expected to enter the

trained U.S. physician workforce at some pointtrained U.S. physician workforce at some point

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Reduce or Eliminate GME Reduce or Eliminate GME Subsidies for Noncitizens Subsidies for Noncitizens

A disadvantage of the policy is that it A disadvantage of the policy is that it might lead to a two-tier residency might lead to a two-tier residency system system Increased movement of citizens into more Increased movement of citizens into more

prestigious programs prestigious programs Foreign students having to enter into less Foreign students having to enter into less

prestigious programs prestigious programs The future supply of physicians in this The future supply of physicians in this

country could probably be smaller than country could probably be smaller than without such a policy without such a policy

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Restructure the SystemRestructure the System

Open Up the Market for GME by Open Up the Market for GME by Offering VouchersOffering Vouchers

The doctor could transfer the voucher to a The doctor could transfer the voucher to a medical group or hospital as part of a medical group or hospital as part of a contract in which the organization would contract in which the organization would provide training and a stipend to the provide training and a stipend to the resident in exchange for his or her resident in exchange for his or her services and payments from the federal services and payments from the federal governmentgovernment

Specialty boards might be reluctant to Specialty boards might be reluctant to consider training at non-hospital sites consider training at non-hospital sites

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Restructure the System, Restructure the System, Con’tCon’t

Voucher system changes could be Voucher system changes could be too slow to positively affect needed too slow to positively affect needed changes in the workforce changes in the workforce

The federal government could The federal government could inform medical or premedical inform medical or premedical students about trends and students about trends and innovations in the market for innovations in the market for physicians' servicesphysicians' services

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Restructure the System, Restructure the System, Con’tCon’t

Provide vouchers of different values Provide vouchers of different values or vouchers only for particular or vouchers only for particular specialtiesspecialties

Citizenship could be considered a Citizenship could be considered a potential requirement for receiving a potential requirement for receiving a GME voucherGME voucher but not a requirement for receiving but not a requirement for receiving

trainingtraining

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End Federal FinancingEnd Federal Financing

Estimates indicate that eliminating Estimates indicate that eliminating both DME and IME payments both DME and IME payments would reduce federal spendingwould reduce federal spending over $7.5 billion for fiscal year 2000 over $7.5 billion for fiscal year 2000 over $8.5 billion for fiscal year 2002. over $8.5 billion for fiscal year 2002.

Hospital’s would be bearing the Hospital’s would be bearing the true costs associated with having a true costs associated with having a residentsresidents

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End Federal Financing, End Federal Financing, Con’tCon’t

Medicare's payment rules for Medicare's payment rules for physicians' services could be physicians' services could be loosened to allow residents to bill loosened to allow residents to bill for beneficial medical services that for beneficial medical services that they provide to Medicare patientsthey provide to Medicare patients That might introduce new questions That might introduce new questions

about payment levels and qualification about payment levels and qualification requirements for residentsrequirements for residents

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End Federal Financing, End Federal Financing, Con’tCon’t

Could potentially eliminate the Could potentially eliminate the concern for having more physicians concern for having more physicians than appropriatethan appropriate

Many FMGs who would have done Many FMGs who would have done residencies in this country and who residencies in this country and who would probably have become part of would probably have become part of the future U.S. workforce of fully the future U.S. workforce of fully trained physicians might choose not trained physicians might choose not to do soto do so

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End Federal Financing, End Federal Financing, Con’tCon’t

Significantly weakened incentives to Significantly weakened incentives to hire residents and lower stipendshire residents and lower stipends

Medical schools would also be Medical schools would also be affected because of their ties to affected because of their ties to teaching hospitalsteaching hospitals

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Which policy Which policy change do you change do you think would be think would be

the best?the best?

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What do you think What do you think are some of the are some of the affects on the affects on the

population if the population if the policy changes on policy changes on

GME funding?GME funding?

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Policy Changes EffectsPolicy Changes Effects

Access to CareAccess to Care Medicare Beneficiaries Medicare Beneficiaries The Uninsured and Indigent The Uninsured and Indigent

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Access to CareAccess to Care There are incentives for There are incentives for

teaching hospitals to both teaching hospitals to both provide more services to provide more services to Medicare beneficiaries and hire Medicare beneficiaries and hire more residentsmore residents Changes in those might alter Changes in those might alter

teaching hospitals' incentives teaching hospitals' incentives to treat Medicare beneficiariesto treat Medicare beneficiaries

In the longer run, its impact on In the longer run, its impact on the future supply of physiciansthe future supply of physicians

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Access to Care, Con’tAccess to Care, Con’t

In the shorter run, alter the In the shorter run, alter the available medical residents that care available medical residents that care in communities in where a in communities in where a significant amount of hospital-based significant amount of hospital-based patient care is providedpatient care is provided

Affect the revenues of teaching Affect the revenues of teaching hospitals, where services for hospitals, where services for patients who are uninsured and patients who are uninsured and indigent are providedindigent are provided

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Medicare BeneficiariesMedicare Beneficiaries

The GME payments encourage The GME payments encourage teaching hospitals not only to teaching hospitals not only to employ more residents than they employ more residents than they otherwise would but also to be more otherwise would but also to be more willing to provide services to willing to provide services to Medicare beneficiariesMedicare beneficiaries

A hospital's DME payments increase A hospital's DME payments increase with its Medicare caseloadwith its Medicare caseload

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Medicare Beneficiaries, Medicare Beneficiaries, Con’tCon’t

A hospital's IME payments A hospital's IME payments rise with its Medicare rise with its Medicare admissionsadmissions

It follows that changes in the It follows that changes in the DME or IME formula would DME or IME formula would alter the incentive to admit alter the incentive to admit and treat Medicare patients and treat Medicare patients

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The Uninsured and The Uninsured and IndigentIndigent

Access to care for uninsured, indigent Access to care for uninsured, indigent people may be affected by the level of people may be affected by the level of GME subsidies for two reasonsGME subsidies for two reasons Changing the amount of the subsidies would Changing the amount of the subsidies would

probably affect the amount of various services probably affect the amount of various services that teaching hospitals provide, including care that teaching hospitals provide, including care for uninsured peoplefor uninsured people

Affecting the number of residents available to Affecting the number of residents available to provide care to this population provide care to this population

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QuestionsQuestions

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SourcesSources

www.nyas.org/books/medicaled/www.nyas.org/books/medicaled/gme18hen.htmgme18hen.htm

Matherlee, Karen. 2002. “Federal and Matherlee, Karen. 2002. “Federal and State Perspectives on GME Reform.” State Perspectives on GME Reform.” National Health Policy Forum.National Health Policy Forum.

O’Neil, June. 1995. “Medicare and O’Neil, June. 1995. “Medicare and Graduate Medical Education.” Graduate Medical Education.” http://www.cbo.govhttp://www.cbo.gov