Letters to the Editor
Letters to the Editor Understanding GME Financing To the Editor: The recent article by Chen et al1 assigns rankings to teaching hospitals based on the outcomes of their graduate medical education (GME) programs in two specific dimensions: graduates practicing in underserved areas and graduates practicing in highneed specialties, namely primary care. The authors are critical of programs that rank low among producers of graduates practicing in underserved areas and high-need specialties because they argue that programs receiving federal funding should be accountable to the needs of the taxpayers. While producing adequate numbers of primary care physicians is an important goal of our medical education system overall, the authors present incomplete and misleading information about the nature of GME financing that requires clarification. Specifically, the authors have incorrectly included in the “per resident” amounts of GME funding two separate sources of federal support with distinct and different purposes. The first is direct GME funding from Medicare, which covers approximately 20% of total training costs (including resident stipends, benefits, and faculty time) and is heavily weighted towards the training of primary care physicians. An individual teaching hospital generally receives a perresident payment for a family medicine trainee that is twice the amount of the direct GME payment for a cardiologist in training. Direct GME support is also tied to the percentage of care delivered to Medicare beneficiaries. The second type is indirect medical education (IME) payments, which are made on a per-discharge basis—not a per-resident basis. IME payments reflect patient characteristics, not trainee characteristics. According to Congress, these payments are added to Medicare discharges because of the failure of claims data “to account fully for factors such as severity of illness of patients requiring the specialized services and treatment programs provided by teaching institutions.”2,3 Teaching hospitals that provide more complex care—for instance, trauma, burn, transplant—and
1788
have higher Medicare patient volumes receive larger aggregate IME payments for that specialized clinical care. Both direct and indirect GME payments are greatly affected by Medicare patient volume. If Medicare funding were to flow disproportionately to programs based on production of a particular specialty, Medicare dollars currently being used to treat Medicare patients would potentially be shifted to institutions even if they care for few beneficiaries. Ultimately, the missions of major teaching hospitals are diverse and sometimes focused on particular clinical needs (such as pediatric or cancer care) or training physician–scientists (who are often subspecialists). By focusing on part of only one mission, the authors appear to suggest that high-touch care should be provided at the expense of high-tech care. While a strong primary care system is vital, teaching hospitals must pursue varied missions to meet the evolving health care needs of patients and their communities.
Dr. Grover’s reference to Congress’s justification for the indirect payment (IME) is incomplete. Congress intended IME payments “to compensate teaching hospitals for their relatively higher costs attributable to the involvement of residents in patient care and the severity of illness of patients requiring specialized services available only in teaching hospitals”1 (emphasis ours). While Dr. Grover is correct that these payments “reflect patient characteristics, not trainee characteristics,” it does not follow that their purpose is unrelated to education because patient care payments are the vehicle for transferring IME funds. Absent GME, hospitals cannot tap this $13 billion funding stream. Consistent with the purpose of our study, a 2001 report by Dr. Grover and colleagues recommended, “Future policy decisions should rest … on clearer agreement about which personal services and public goods provided by teaching hospitals deserve governmental support.”2
1 Chen C, Petterson S, Phillips RL, Mullan F, Bazemore A, O’Donnell SD. Toward graduate medical education (GME) accountability: Measuring the outcomes of GME institutions. Acad Med. 2013;88:1267–1280. 2 House Ways and Means Committee Rept., No. 98-25, March 4, 1983. 3 Senate Finance Committee Rept, No. 98-23, March 11, 1983.
We agree teaching hospitals should be valued for varied missions. However, Congress and Medicare do not allocate this money to support individual institutional missions. Failure to be accountable to the overriding mission of meeting the nation’s most pressing workforce needs risks further reductions, as has happened three times in the past two decades.2 Teaching hospitals have the opportunity to declare and demonstrate a return for this public investment. Our study demonstrates it is possible to measure specific outcomes of this investment.
In Reply to Grover: In our study we demonstrated a strategy to track workforce outcomes of GME programs because there is increasing belief that these publicly funded programs should be accountable to the health care needs of the American people. Dr. Grover is correct in summarizing this intent, but we disagree that our description of the nature of GME funding was either “incomplete” or “misleading.” Our aim was not to explain the policy intricacies of how these funds are paid; they are paid because these hospitals sponsor GME programs. We focused on what they produce.
The AAMC identified 12 proposals in the last three years to make wholesale cuts to GME funding.3 Failure to demonstrate value may bring more. Coggeshall4 said as much in his 1965 report to the AAMC: “Those responsible for medical education … will, in decades ahead, need to devote careful attention to appraising the needs of society for health care and health personnel and to developing and implementing plans to meet those needs.” We propose GME funding cuts might best be prevented by demonstrating the production of a workforce that ensures high-quality, cost-effective, and accessible health care for all Americans.
Atul Grover, MD, PhD Chief public policy officer, Association of American Medical Colleges, Washington, DC; [email protected].
References
Academic Medicine, Vol. 88, No. 12 / December 2013
Letters to the Editor Understanding GME Financing To the Editor: The recent article by Chen et al1 assigns rankings to teaching hospitals based on the outcomes of their graduate medical education (GME) programs in two specific dimensions: graduates practicing in underserved areas and graduates practicing in highneed specialties, namely primary care. The authors are critical of programs that rank low among producers of graduates practicing in underserved areas and high-need specialties because they argue that programs receiving federal funding should be accountable to the needs of the taxpayers. While producing adequate numbers of primary care physicians is an important goal of our medical education system overall, the authors present incomplete and misleading information about the nature of GME financing that requires clarification. Specifically, the authors have incorrectly included in the “per resident” amounts of GME funding two separate sources of federal support with distinct and different purposes. The first is direct GME funding from Medicare, which covers approximately 20% of total training costs (including resident stipends, benefits, and faculty time) and is heavily weighted towards the training of primary care physicians. An individual teaching hospital generally receives a perresident payment for a family medicine trainee that is twice the amount of the direct GME payment for a cardiologist in training. Direct GME support is also tied to the percentage of care delivered to Medicare beneficiaries. The second type is indirect medical education (IME) payments, which are made on a per-discharge basis—not a per-resident basis. IME payments reflect patient characteristics, not trainee characteristics. According to Congress, these payments are added to Medicare discharges because of the failure of claims data “to account fully for factors such as severity of illness of patients requiring the specialized services and treatment programs provided by teaching institutions.”2,3 Teaching hospitals that provide more complex care—for instance, trauma, burn, transplant—and
1788
have higher Medicare patient volumes receive larger aggregate IME payments for that specialized clinical care. Both direct and indirect GME payments are greatly affected by Medicare patient volume. If Medicare funding were to flow disproportionately to programs based on production of a particular specialty, Medicare dollars currently being used to treat Medicare patients would potentially be shifted to institutions even if they care for few beneficiaries. Ultimately, the missions of major teaching hospitals are diverse and sometimes focused on particular clinical needs (such as pediatric or cancer care) or training physician–scientists (who are often subspecialists). By focusing on part of only one mission, the authors appear to suggest that high-touch care should be provided at the expense of high-tech care. While a strong primary care system is vital, teaching hospitals must pursue varied missions to meet the evolving health care needs of patients and their communities.
Dr. Grover’s reference to Congress’s justification for the indirect payment (IME) is incomplete. Congress intended IME payments “to compensate teaching hospitals for their relatively higher costs attributable to the involvement of residents in patient care and the severity of illness of patients requiring specialized services available only in teaching hospitals”1 (emphasis ours). While Dr. Grover is correct that these payments “reflect patient characteristics, not trainee characteristics,” it does not follow that their purpose is unrelated to education because patient care payments are the vehicle for transferring IME funds. Absent GME, hospitals cannot tap this $13 billion funding stream. Consistent with the purpose of our study, a 2001 report by Dr. Grover and colleagues recommended, “Future policy decisions should rest … on clearer agreement about which personal services and public goods provided by teaching hospitals deserve governmental support.”2
1 Chen C, Petterson S, Phillips RL, Mullan F, Bazemore A, O’Donnell SD. Toward graduate medical education (GME) accountability: Measuring the outcomes of GME institutions. Acad Med. 2013;88:1267–1280. 2 House Ways and Means Committee Rept., No. 98-25, March 4, 1983. 3 Senate Finance Committee Rept, No. 98-23, March 11, 1983.
We agree teaching hospitals should be valued for varied missions. However, Congress and Medicare do not allocate this money to support individual institutional missions. Failure to be accountable to the overriding mission of meeting the nation’s most pressing workforce needs risks further reductions, as has happened three times in the past two decades.2 Teaching hospitals have the opportunity to declare and demonstrate a return for this public investment. Our study demonstrates it is possible to measure specific outcomes of this investment.
In Reply to Grover: In our study we demonstrated a strategy to track workforce outcomes of GME programs because there is increasing belief that these publicly funded programs should be accountable to the health care needs of the American people. Dr. Grover is correct in summarizing this intent, but we disagree that our description of the nature of GME funding was either “incomplete” or “misleading.” Our aim was not to explain the policy intricacies of how these funds are paid; they are paid because these hospitals sponsor GME programs. We focused on what they produce.
The AAMC identified 12 proposals in the last three years to make wholesale cuts to GME funding.3 Failure to demonstrate value may bring more. Coggeshall4 said as much in his 1965 report to the AAMC: “Those responsible for medical education … will, in decades ahead, need to devote careful attention to appraising the needs of society for health care and health personnel and to developing and implementing plans to meet those needs.” We propose GME funding cuts might best be prevented by demonstrating the production of a workforce that ensures high-quality, cost-effective, and accessible health care for all Americans.
Atul Grover, MD, PhD Chief public policy officer, Association of American Medical Colleges, Washington, DC; [email protected].
References
Academic Medicine, Vol. 88, No. 12 / December 2013
