Transforming Health Care Through Evidence and Collaboration
Transforming Health Care Through Evidence and Collaboration

Other Approaches to GME Reform

The IOM is not alone in recommending significant changes to Medicare GME support. In contrast to our call to maintain current funding levels, the National Commission on Fis-cal Responsibility and Reform recommended reducing the currently legislated IME payment amounts by 60 percent and limiting the variation in DGME payments.2 The Medicare Pay-ment Advisory Commission (MedPAC) also recommended cutting IME payments by more than half (about $3.5 billion) and redirecting these funds to establish a performance-based incentive program.3 While this amount is similar to what the IOM recommended for the Transformation Fund, there would be sub-stantially less reallocation of funds under Med-PAC’s approach because they did not change the distribution of remaining GME funds.

Developments Since the IOM Report

The representatives of medical colleges (AAMC), organized medicine (AMA) and hospitals (AHA) responded to the IOM report immediately and more harshly than they had responded to previous reports recommending payment reductions and/or redistributions. Their key objections focused on the lack of agreement about a potential future physician shortage and its implied need for additional funding and on the refocusing of training opportunities away from the inpatient setting.

Other groups, including the Association of Academic Health Centers and several national and regional groups associated with primary care have been generally supportive of our work, applauding the report’s recognition of the mismatch between the increasing specialization in training and the needs of an aging population as well as the committee’s emphasis on training physicians to deliver patient-centered, value-oriented care.

Moving forward on the IOM recom-mendations will generally require Congres-sional legislation. Last De-cem-ber, a bipartisan group of eight repre-sentatives on the House Energy and Commerce committee asked stakeholders to comment on the IOM re-port and on other approaches to GME reform. Com-ments were due in mid-January of this year. The presumption is that the Energy and Com-merce committee will hold a hearing at some point and invite the stakeholders to discuss their submitted comments. No date for such a hearing has yet been announced though. Even less cer-tain is whether any funded legis-lation to modify GME payments will be put forth, or what that le-gislation might look like. Special interests are vocal and powerful on this contentious issue, and the recent passage of the “Doc Fix” legis-lation means that a legislative vehicle that might have contained GME reforms is no longer available.

Debates About Future MD Shortages

One area where the IOM parted ways with almost all of the medical groups is in its assessment of the likelihood of a future physician shortage. For example, recently updated estimates from the AAMC project a shortage of 46,000 to 90,000 physicians by 2025.4 GME stakeholders use such projections not only to argue against reductions in GME funding but also to press for more federally funded residency positions.

While the committee was not directed to consider this issue, assumptions about potential shortages or surpluses were part of our deliberations. We concluded that attempts to forecast physician supply and demand, both in the aggregate and by broad specialty types, have been singularly unsuccessful in the past. In fact, past projections have not always been even directionally correct. The biggest problem is that most models use existing physician-to-population ratios to project the number and type of physicians needed in the future. Implicitly this approach assumes that the current way of producing medical care is the only way to do so. Rarely a good assumption, it makes even less sense than usual in this era of rapid changes to how we are delivering and paying for care.

Furthermore, our supply of physicians has already been increasing rapidly, even without additional federal funding. Medical school enrollment rose 28 percent between 2003 and 2012 and the number of residents rose by about 20 percent despite the cap on Medicare funded positions.5 Increased numbers will not, however, automatically produce a better specialty or geographic mix of physicians.

In the end, leveraging a full decade of continued Medicare GME support (at upwards of $100 billion) as recommended by the IOM while figuring out how to introduce far more flexibility and deliberateness into training pro-grams will be more constructive than pro-ducing yet another round of shortage pro-jections that are far more likely to be incorrect than correct.

1 Institute of Medicine. Graduate Medical Education that Meets the Nation’s Health Needs. Washington, DC: The National Academies Press, July 2014.
2 National Commission on Fiscal Responsibility and Reform. The Moment of Truth: Report of the National Commission on Fiscal Responsibility and Reform. December 2010.
3 Medicare Payment Advisory Commission. Report to the Congress: Aligning Incentives in Medicare. June 2010.
4 IHS Inc., The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. Prepared for the AAMC. March 2015.
5 Chandra A, Khullar D, Wilensky GR. “The Economics of Graduate Medical Education.” New England Journal of Medicine, 370:2357-60. 2014.

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In this essay, Dr. Gail Wilensky, co-chair of that IOM committee, explains the recommendations and takes stock of the latest developments.