Workforce Graduate Medical Education


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  • Direct quote from JAMA 1998, Cooper et al 734
  • JAMA editorials 1998 vol 280, 9 pp. 746
  • From CME Report 10-A-A-99 page 4
  • Medicare patient load” The hospital's Medicare patient load is the fraction of its total number of inpatient days that Medicare beneficiaries represent. Adjusted number of full-time-equivalent (FTE) residents The adjusted number of FTE residents is calculated by considering each resident in an approved training program based at the hospital, calculating the degree to which that resident is in the program full time, and then multiplying by an adjustment weight The weight equals 1.0 for residents who are in their "initial residency period" (IRP) and who have not been in training for more than five years.1 (Residents in geriatric fellowships may receive a weight of 1.0 for two additional years.) Other residents receive a weight of 0.5. Graduates of foreign medical schools must have passed a competency exam to be counted toward DME payments. Allowed amount per resident. The allowed per-resident amount differs among hospitals Based on the direct graduate medical education costs per resident incurred by the hospital in a period roughly corresponding to fiscal year 1984, increased by 1 percent and updated for changes in the consumer price index for urban consumers (CPI-U).
  • Under the formula, the hospital's payments increase with the resident-to-bed ratio (the ratio of the number of FTE residents in approved training programs who work in the hospital to the number of beds) A hospital receives approximately 7.7 percent more in payments for each 0.1 increase in the ratio of residents to beds The various provisions that reduce the weight of many residents in the calculation of DME payments do not apply to the count of FTEs that is used to calculate the indirect adjustment.
  • Allow more flexibility in the course of the Professional that appeared most relevant to them More competition for Professionals by Teaching Hospitals
  • That quicker response would address concerns that the market adjusts too slowly or that participants in the market lack the information needed for relying on the marketplace to allocate the number and types of physicians.
  • Workforce Graduate Medical Education

    1. 1. Workforce Graduate Medical Education Brian Wells
    2. 2. <ul><li>The US healthcare delivery system is characterized by: </li></ul><ul><li>Imbalance between primary and specialty care services </li></ul><ul><li>An imbalance in the ratio of generalists to specialists </li></ul><ul><li>A geographic maldistribution of practitioners </li></ul><ul><li>A vast array of different types of healthcare professionals </li></ul><ul><li>Increasing growth in the use and prominence Nonphysician Clinicians </li></ul><ul><li>**In Sum, a unique and intricate workforce dynamic in the health professions </li></ul><ul><li>- </li></ul>Shi l. & Singh, D.( 2001). Delivering Healthcare in America. Aspen Publications: MD.
    3. 3. Physicians <ul><li>Education and training of the physician workforce is divided into 4 major phases: </li></ul><ul><li>1. Premedical education </li></ul><ul><li>2. Medical school </li></ul><ul><li>3. Graduate Medical Education (GME) </li></ul><ul><li>4. Continuing Medical Education </li></ul><ul><li>(Miller et al, 1999) </li></ul>
    4. 4. More on the GME <ul><li>Graduate Medical Education Programs: </li></ul><ul><li>are entered by a physician after they graduate from medical school and determines the area of specialty the physician will pursue and practice throughout their lifetime. </li></ul>
    5. 5. It is estimated that 16,000 physicians enter GME programs each year. (1999) (Miller et al 1999) <ul><li>“ GME as a societal good” </li></ul><ul><li>- Residency or GME has been accepted in most part of society as an essential part of maintaining high quality physician workforce. After earning a medical degree, US physicians are required by law in every state to complete an additional 1 to 3 years of GME before receiving a license to practice medicine (AMA Graduate Medical Directory 1999-2000) </li></ul>
    6. 6. Entrance into GME <ul><li>Despite this number of physicians entering GME’s:- </li></ul><ul><li>there is no systematic programs to ensure the appropriate number, distribution, and balance of specialties represented in the health care system (Miller et al 1999) </li></ul>
    7. 7. Understanding the Workforce Dynamic <ul><li>GME transition into the workforce </li></ul>
    8. 8. Physicians vs. Non-Physician Clinicians (NPC’s) <ul><li>In 1966 the Commission On Graduate Medical Education (COGME) declared that, “ the primary physician will serve as the primary medical resource” </li></ul><ul><li>A Physician has a licensure in the state which they are practicing in addition to a degree (MD, DO) from an accredited medical school </li></ul><ul><li>Today Nonphysician Clinicians are playing a more integral role in the healthcare system </li></ul>
    9. 9. NPC’s <ul><li>Three Broad Categories of NPC practice that overlaps with physicians (many are required to have state licensures) </li></ul><ul><li>Physician Assistant’s and Nurse Practitioners </li></ul><ul><li>2. Other traditional clinicians: nurse anesthetists, midwives, psychologists, podiatrists, and optometrists </li></ul><ul><li>Alternative clinicians: chiropractors, naturopaths, and practitioners of oriental medicine </li></ul>
    10. 11. Conflict between Physician’s and NPC’s <ul><li>It has been estimated that NPC’s will double in number from 1994-2010 </li></ul><ul><li>(85 per 100,000 – 143 per 100,000) (Cooper, JAMA 1995) </li></ul><ul><li>* With this increase of NPC’s an increase in their authority to deliver health services may also evolve and have implications (Cooper, JAMA 1995) </li></ul>
    11. 12. Competition? <ul><li>Is there a capacity to absorb the increasing number of Physicians and NPC’s? </li></ul><ul><li>“ Heightened competition between physicians and NPC’s seem virtually inevitable in a system that already has an abundant supply of physicians and is intent on overall cost containment” (Editorial, 1998, JAMA 280, 9 pp. 825). (This an opinion from the AMA) </li></ul>
    12. 13. What will be the impact of additional NPC’s on Physician Demand? <ul><li>This is a complex question influenced by many parameters that requires a better understanding of Physician Services that NPC’s may undertake: </li></ul><ul><li>Further assessment of scope of practice </li></ul><ul><li>Prescription privileges </li></ul><ul><li>Autonomy </li></ul><ul><li>Roles and Responsibilities in Clinical Practice </li></ul>(JAMA 1998, Cooper et al, 734)
    13. 14. Will competition benefit the Public ? <ul><li>View 1: Costs may be driven down for physician and non-physician services, more options may become available </li></ul><ul><li>View 2: Regulatory bodies will develop more coordinated, uniform, and publicly accountable policies. This Pluralism could drive up the overall cost of healthcare </li></ul><ul><li>The trend in increasing NPC’s has been compared to the physician workforce growth that began 25 years ago </li></ul>(JAMA Editorials vol 280 (9) p. 746).
    14. 15. Graduate Medical Education Funding <ul><li>Currently through federal and state sources </li></ul><ul><li>Federal: </li></ul><ul><li>Medicare is the largest funder approximated at $ 5.0 billion per year ( direct GME costs, residents salaries, supervisory costs, overheard related to educational programs) ( </li></ul><ul><li>Federal government- approximately $2.75 billion through Medicaid </li></ul><ul><li>Department of Veteran’s Affairs- 700$ million </li></ul><ul><li>This supported residency training in programs affiliated with their institutions </li></ul>
    15. 16. Graduate Medical Education Funding -an introduction- <ul><li>State Funding: </li></ul><ul><li>Medicaid: Fee-for-Service medical education payments </li></ul><ul><li>Specific funds set aside by states for diverse training programs and departments </li></ul><ul><li>States may also contribute public medical schools to support faculty salaries that benefit GME programs </li></ul>
    16. 17. History of the Council of Graduate Medical Education (COGME ) <ul><li>Created in 1986 by Congress and was reauthorized through September 2002 to: </li></ul><ul><li>1. provide an ongoing assessment of trends in the nations physician workforce </li></ul><ul><li>2. explore crucial issues related to training of </li></ul><ul><li>physicians and financing of GME </li></ul><ul><li>3. advise and make recommendations on these subjects to Congress and to the Secretary of the Department of Health and Human Services </li></ul><ul><li>(Adapted from Health resources and Services Administration, U.S. DHHS. </li></ul>
    17. 18. COGME addresses <ul><li>Various issues regarding the size and makeup of the physician workforce and the need to direct physician training to meet diverse population needs in a rapidly changing healthcare environment </li></ul><ul><li>develops official reports and issue papers after consultation with leading experts in healthcare, medical education, and organizations that have similar interest in GME. </li></ul>
    18. 19. Major issues addressed by the COGME <ul><li>Size and mix of physician workforce </li></ul><ul><li>Facilitating access to physician care </li></ul><ul><li>Financing physician training </li></ul><ul><li>Role of International Medical Grads (IMG) </li></ul><ul><li>Women in Medicine </li></ul><ul><li>Minorities in Medicine </li></ul><ul><li>Educating physicians for future needs </li></ul>
    19. 20. Introductory review
    20. 21. Workforce GME: Workforce Trends and Supply and Demand
    21. 22. Assumptions <ul><li>Changes in federal policy toward residency training affect the size and characteristics of the physician workforce. </li></ul><ul><li>Economic incentives also play a role in the response of the supply of physicians (ex: the pattern of behavior observed during the late 1960s and the 1970s after the introduction of Medicare, Medicaid, and their precursor programs). </li></ul>
    22. 23. Past Workforce Trends for Physicians and GME (i.e. How did we get here?) <ul><li>Can be broken down into five areas: </li></ul><ul><ul><li>Pre-1910 </li></ul></ul><ul><ul><li>The Post-Flexner Era: 1910 – 1963 </li></ul></ul><ul><ul><li>The Epoch of Government Blank Checks: 1963 – 1990 </li></ul></ul><ul><ul><li>The Era of the Wholesale Market for Physician Labor: 1990 – 2000 </li></ul></ul><ul><ul><li>The Collapse of the Wholesale Market: 2000 – Present </li></ul></ul><ul><li>Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy . Health Aff 21(5):13-27, 2002. Available at: </li></ul>
    23. 24. The Pre-1910 Era <ul><li>Pre-1910: </li></ul><ul><ul><li>Closest the nation has come to a traditional free market for physician services </li></ul></ul><ul><ul><li>A degree of physician-induced demand was in effect </li></ul></ul><ul><ul><li>Patients directly incurred the costs of most health care transactions. </li></ul></ul><ul><ul><li>160 medical schools, 25,000 medical students, approx. 175 physicians / 100,000 people. Physician incomes were modest. </li></ul></ul><ul><ul><li>Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy . Health Aff 21(5):13-27, 2002 </li></ul></ul>
    24. 25. The Post-Flexner Era <ul><li>The Post-Flexner Era: 1910 – 1963 </li></ul><ul><ul><li>More than 30 medical schools closed during this period. </li></ul></ul><ul><ul><li>125 physicians / 100,000 U.S. population. </li></ul></ul><ul><ul><li>Anticompetitive market for physician labor under professionally dominated regulation. </li></ul></ul><ul><ul><li>“ They did business where business was good and avoided places where it was bad.” </li></ul></ul><ul><ul><li>Planning commissions decided the nation needed more physicians to raise the level of supply in “below-average” communities. </li></ul></ul><ul><ul><li>Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy . Health Aff 21(5):13-27, 2002 </li></ul></ul>
    25. 26. The Epoch of Government Blank Checks <ul><li>The Epoch of Government Blank Checks: 1963 – 1990 </li></ul><ul><ul><li>Rapid growth in physician supply due to heavy investing in medical education by the U.S. Federal Government. </li></ul></ul><ul><ul><li>Employer-based insurance had become prevalent making consumers less price sensitive </li></ul></ul><ul><ul><li>1965 – 115 physicians / 100,000 U.S. population. </li></ul></ul><ul><ul><li>By 1990, U.S. Fed. Gov. was spending more than $6B/yr for GME with state gov’s giving additional funds for state-supported medical schools. </li></ul></ul><ul><ul><li>Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy . Health Aff 21(5):13-27, 2002 </li></ul></ul>
    26. 27. The Epoch of Government Blank Checks <ul><li>The Epoch of Government Blank Checks: 1963 – 1990 </li></ul><ul><ul><li>U.S. spending on all health care services increased dramatically. </li></ul></ul><ul><ul><li>Contrary to market predictions, dramatic increase could in fact coexist with rising physician incomes. </li></ul></ul><ul><ul><li>Physicians lost atavistic fear of supply growth as a threat to earnings. </li></ul></ul><ul><ul><li>Medicare funding of GME revealed it was possible to obtain government financing without much government regulation. </li></ul></ul><ul><ul><li>Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy . Health Aff 21(5):13-27, 2002 </li></ul></ul>
    27. 28. The Epoch of Government Blank Checks <ul><li>The Epoch of Government Blank Checks: 1963 – 1990 </li></ul><ul><ul><li>More directive federal approach to physician supply planning </li></ul></ul><ul><ul><li>GMENAC undertook the nation’s most devoted effort to develop a needs-based physician workforce policy producing detailed projections of required supply. </li></ul></ul><ul><ul><li>Programs (ex: National Health Service Corp) attempted to use incentives to induce physicians to practice in communities with a meager supply of physicians. </li></ul></ul><ul><ul><li>1986 – Congress authorized the establishment of a new federal physician workforce planning group - COGME </li></ul></ul><ul><ul><li>GMENAC = Graduate Medical Education National Advisory Committee </li></ul></ul>
    28. 29. The Wholesale Market Era <ul><li>The Era of the Wholesale Market for Physician Labor: 1990 – 2000 </li></ul><ul><ul><li>Attempted to transform the market for physician labor from a retail to a wholesale market. </li></ul></ul><ul><ul><li>The managed care experiment intensifies </li></ul></ul><ul><ul><li>Rise of the wholesale market had the potential to weaken the relative economic strength of physicians. </li></ul></ul><ul><ul><li>Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy . Health Aff 21(5):13-27, 2002 </li></ul></ul>
    29. 30. The Wholesale Market Era <ul><li>The Era of the Wholesale Market for Physician Labor: 1990 – 2000 </li></ul><ul><ul><li>COGME’s initial activity was to synthesize information on physician supply requirements. </li></ul></ul><ul><ul><li>Adopted an ecumenical approach. </li></ul></ul><ul><ul><li>COGME used wholesale-market, demand-based studies to arrive at physician estimates (GMENAC used needs-based estimates (paternalistic)). </li></ul></ul><ul><ul><li>1994 report by COGME endorsed implementation of a stronger system of federal financing and regulation of GME. </li></ul></ul><ul><ul><li>Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy . Health Aff 21(5):13-27, 2002 </li></ul></ul>
    30. 31. The Wholesale Market Era <ul><li>The Era of the Wholesale Market for Physician Labor: 1990 – 2000 </li></ul><ul><ul><li>1994 COGME recommendations were part of the Clinton Health Plan. </li></ul></ul><ul><ul><li>Decreases in the number of U.S. MG selecting certain high-profile specialties. </li></ul></ul><ul><ul><li>Market was changing the PC/Specialist supply balance, constraining physician’s incomes, and possibly even dampening growth in overall physician supply. </li></ul></ul><ul><ul><li>Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy . Health Aff 21(5):13-27, 2002 </li></ul></ul>
    31. 32. The Collapse of the Wholesale Market <ul><li>The Collapse of the Wholesale Market: 2000 – Present </li></ul><ul><ul><li>Managed Care has faltered. </li></ul></ul><ul><ul><li>U.S. health care system may be headed back on a course of increasing specialization, rising physician incomes, and pressures to increase overall physician supply. </li></ul></ul><ul><ul><li>Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy . Health Aff 21(5):13-27, 2002 </li></ul></ul>
    32. 33. Mix of Physicians in Primary Care Versus Non-Primary Care Specialists <ul><li>In 1965: </li></ul><ul><ul><li>51% of physicians involved in patient care were in general practice, internal medicine, and pediatrics. </li></ul></ul><ul><ul><li>21% were in surgical specialties (including general surgery) </li></ul></ul><ul><ul><li>21% were other non-primary care specialties and subspecialties of internal medicine and pediatrics. </li></ul></ul><ul><ul><li>6.5% were in obstetrics and gynecology. </li></ul></ul>
    33. 34. Physicians per 100,000 people Source: Grumback, Kevin. Fighting Hand to Hand over Physician Workforce Policy. Health Aff 21(5):13-27, 2002. Available at:
    34. 35. Physicians per 1,000 people
    35. 36. Progression of Physicians from 1965 to 1993
    36. 37. Past Workforce Trends for Nonphysician Clinicians <ul><li>Between 1987 and 1997, the proportion of patients who saw a NPC rose from 30.6% to 36.1%. </li></ul><ul><li>Was a degree of differentiation between physicians and NPCs with respect to the services they provided but not with respect to the patients they treated. </li></ul><ul><li>Source: Druss, Benjamin et al. Trends in Care by Nonphysician Clinicians in the United States, NEJM, Jan. 9 th , 2003, Vol. 348, pg. 130-137. </li></ul>
    37. 38. Past Workforce Trends for Nonphysician Clinicians <ul><li>Traditional Nonphysician Clinicians </li></ul><ul><ul><li>Nurse Practitioners – NPs </li></ul></ul><ul><ul><ul><li>1995 – 58,000 active NPs or double the number in 1990 </li></ul></ul></ul><ul><ul><ul><li>1,500 NPs graduated in 1992 </li></ul></ul></ul><ul><ul><ul><li>7,500 NPs graduated in 1999 </li></ul></ul></ul><ul><ul><li>Clinical Nurse Specialists </li></ul></ul><ul><ul><ul><li>Slow, but steady growth – 11,000 in 1990 to 15,000 in 1995 </li></ul></ul></ul><ul><ul><ul><li>Source: Cooper, Richard. Health Care Workforce for the 21 st Century: The Impact of Nonphysician Clinicians, Ann. Rev. Med., 2001, 52:51-61 </li></ul></ul></ul>
    38. 39. Past Workforce Trends for Nonphysician Clinics <ul><li>Traditional Nonphysician Clinicians </li></ul><ul><ul><li>Certified Nurse Midwives </li></ul></ul><ul><ul><ul><li>3,000 in 1990 </li></ul></ul></ul><ul><ul><ul><li>5,000 in 1995 </li></ul></ul></ul><ul><ul><li>Physician Assistants </li></ul></ul><ul><ul><ul><li>11,000 in 1980 </li></ul></ul></ul><ul><ul><ul><li>30,000 in 1998 </li></ul></ul></ul><ul><ul><li>Source: Cooper, Richard. Health Care Workforce for the 21 st Century: The Impact of Nonphysician Clinicians, Ann. Rev. Med., 2001, 52:51-61 </li></ul></ul>
    39. 40. Past Workforce Trends for Nonphysician Clinicians <ul><li>Alternative Nonphysician Clinicians </li></ul><ul><ul><li>Chiropractors </li></ul></ul><ul><ul><ul><li>Modest increases during the 1990s </li></ul></ul></ul><ul><ul><ul><li>60,000 in 1998 </li></ul></ul></ul><ul><ul><li>Acupuncturists </li></ul></ul><ul><ul><ul><li>5,000 in 1990 </li></ul></ul></ul><ul><ul><ul><li>11,000 in 1997 </li></ul></ul></ul><ul><ul><ul><li>Source: Cooper, Richard. Health Care Workforce for the 21 st Century: The Impact of Nonphysician Clinicians, Ann. Rev. Med., 2001, 52:51-61 </li></ul></ul></ul>
    40. 41. Current Workforce Trends for Physicians <ul><li>The number of medical residents in the U.S. has generally been increasing (however, there has been a slight decline in the past few years). </li></ul><ul><li>83,000 in 1988 to 102,000 in 1993. </li></ul><ul><li>However, there has not been a decline in the number of programs to train these residents. </li></ul><ul><ul><li>Sources: CBO Study - Medicare and Graduate Medical Education - September 1995 </li></ul></ul><ul><ul><li>U.S. Graduate Medical Education, 2001-2002 – JAMA, September 4, 2002 </li></ul></ul>
    41. 42. Current Workforce Trends for Physicians <ul><li>The number of graduates of U.S. medical schools has remained fairly constant. </li></ul><ul><li>Much of the growth in the number of residents comes from foreign medical school graduates. </li></ul><ul><li>The widely anticipated physician surplus did not materialize in 2000 (it was thought that the surplus would increase to 145,000 or 22%). </li></ul>
    42. 43. Mix of Physicians in Primary Care Versus Non-Primary Care Specialties <ul><li>In 1995: </li></ul><ul><ul><li>34% were in general practice, family practice, general internal medicine, and general pediatrics. </li></ul></ul><ul><ul><li>19% were in surgical specialties including general surgery. </li></ul></ul><ul><ul><li>29% were in other non-primary care specialties including anesthesiology and radiology </li></ul></ul><ul><ul><li>11% were in subspecialties of internal medicine and pediatrics </li></ul></ul><ul><ul><li>6.5% were in obstetrics and gynecology </li></ul></ul>
    43. 44. Current Workforce Trends for Nonphysician Clinicians <ul><li>Nonphysician clinicians (NPCs) are becoming increasingly prominent as health care providers. </li></ul><ul><li>The 1990s saw the following: </li></ul><ul><ul><li>rising numbers of graduates of training programs for NPCs </li></ul></ul><ul><ul><li>Passage of legislation expanding their scope of practice </li></ul></ul><ul><ul><li>A proliferation of managed care models that emphasized the use of these providers as a strategy for containing health care costs. </li></ul></ul><ul><ul><li>Source: Trends in Care by Nonphysician Clinician in the U.S. - NEJM – Jan. 9 th , 2003 </li></ul></ul>
    44. 45. Future Workforce Trends for Physicians <ul><li>General apprehension about an impending physician surplus (1995) </li></ul><ul><li>This view was put forth by the Bureau of Health Professions and the COGME in the 1990s and believed by many, including the AAMC. </li></ul><ul><li>Controversial Trend Model suggesting an impending physician shortage (2002). </li></ul><ul><li>General consensus that there is no evidence of a major impending surplus. </li></ul><ul><li>Sources: Cooper, Richard. Perspectives on the Physician Workforce to the Year 2020, JAMA, Nov. 15 th , 1995, Vol. 274, No. 19. </li></ul><ul><li>Brotherton, Sarah et al. U.S. Graduate Medical Education, 2001 – 2002, JAMA, September 4 th , 2002, Vol. 288, No. 9. </li></ul><ul><li>Cooper, Richard. There’s a Shortage of Specialists. Is Anyone Listening? , Acad. Med., August, 2002, Vol. 77, No. 8 </li></ul>
    45. 46. Future Workforce Trends for Physicians <ul><li>Trend model relies on four trends </li></ul><ul><ul><li>Economic expansion </li></ul></ul><ul><ul><li>Population growth </li></ul></ul><ul><ul><li>Work effort of physicians </li></ul></ul><ul><ul><li>Services provided by nonphysician clinicians </li></ul></ul><ul><ul><li>Source: Cooper, Richard et al. Economic and Demographic Trends Signal An Impending Physician Shortage , Health Aff., 2002, Vol. 21, No. 1 </li></ul></ul>
    46. 47. Future Workforce Trends for Physicians Source: Cooper, Richard et al. Economic and Demographic Trends Signal an Impending Physician Shortage, Health Aff., 2002, Vol. 21, No. 1
    47. 48. Future Workforce Trends for Nonphysician Clinicians <ul><li>By 2005 it is expected that: </li></ul><ul><ul><li>there will be more Chiropractors than general internists </li></ul></ul><ul><ul><li>there will be more PAs than general pediatricians </li></ul></ul><ul><ul><li>the number of NPs in practice (>115,000) will exceed the number of family physicians, and will exceed by a factor of 2 the number that was predicted to be required for that year by the National Advisory Council on Nurse Education and Practice </li></ul></ul><ul><ul><li>Source: Cooper et. al., Current and Projected Workforce of Nonphysician Clinicians, JAMA, September 2, 1998, Vol. 280, No. 9. </li></ul></ul><ul><ul><li>This slide originally appeared in a presentation by George Isham, M.D., Chief Health Officer for HealthPartners on May 16 th , 2001. </li></ul></ul>
    48. 49. Future Trends for Nonphysician Clinicians
    49. 50. Future Trends for Nonphysician Clinicians
    50. 51. Clinicians per 100,000 population <ul><li>Primary Care MDs: FPs, Gen IM, Gen Peds, OB/GYN </li></ul><ul><li>Specialty MDs: All others except Psych </li></ul><ul><li>Primary Care NPCs: Prim Care NPs, Prim Care PAs, Cert Nurse Midwives, Chiros, Acupunct, Naturopaths </li></ul><ul><li>Spec NPCs: Spec NPs, Spec PAs, Optometrists, Podiatrists, Cert, Reg Nurse Anesth, and Med and Surg CN Spec </li></ul><ul><li>Source: Cooper et. al., Current and Projected Workforce of Nonphysician Clinicians, </li></ul><ul><li>JAMA, September 2, 1998, Vol. 280, No. 9. </li></ul><ul><ul><li>This slide originally appeared in a presentation by George Isham, M.D., Chief Health Officer for HealthPartners on May 16th, 2001. </li></ul></ul>
    51. 52. The Market for Resident Physicians Supply and Demand <ul><li>Demand Factors </li></ul><ul><ul><li>Shaped by insurance and demographic characteristics (aging, for example) of the patient population </li></ul></ul><ul><ul><li>Epidemiological factors </li></ul></ul><ul><ul><li>Equipment and technologies available at hospitals </li></ul></ul><ul><ul><li>The reimbursement policies of private and government payers, goals of hospitals </li></ul></ul><ul><ul><li>Subsidies to hospitals for GME </li></ul></ul>
    52. 53. The Market for Resident Physicians Supply and Demand <ul><li>Supply factors: </li></ul><ul><ul><li>The distribution of the supply of resident physicians among specialties responds to the incentives to enter the various fields. </li></ul></ul><ul><ul><ul><li>Example: Salary, expected hours of work, number of years in training, availability and payment terms of loans </li></ul></ul></ul>
    53. 54. The Market for Trained Physicians Supply and Demand <ul><li>Demand factors: </li></ul><ul><ul><li>Similar to demand factors of resident physicians </li></ul></ul><ul><ul><li>Shaped by the amount and type of insurance coverage of the population and its demographic characteristics </li></ul></ul><ul><ul><li>Epidemiological factors </li></ul></ul><ul><ul><li>Available technology </li></ul></ul><ul><ul><li>Reimbursement and coverage parameters </li></ul></ul>
    54. 55. The Market for Trained Physicians Supply and Demand <ul><li>Supply factors: </li></ul><ul><ul><li>Size and composition of existing pool of trained physicians </li></ul></ul><ul><ul><li>Inflows of newly trained physicians and immigrant physicians </li></ul></ul><ul><ul><li>Outflows of retiring physicians (or physicians moving to non-patient care activities such as administration or research). </li></ul></ul>
    55. 56. Other supply and demand factors
    56. 57. What is the Appropriate Number of Physicians? <ul><li>There is currently no consensus on this. </li></ul><ul><li>However, consensus has been reached that there is currently a more than adequate supply of physicians. </li></ul><ul><li>Increases in the number of physicians in highly specialized fields should be curtailed (1995). </li></ul><ul><li>Trend model suggest there may be an impending shortage of specialists (2002). </li></ul>
    57. 58. What is the Appropriate Number of Physicians? <ul><li>Major determinate of overall physician surpluses in the future will be the extent to which patients continue to seek physicians for services that will also be offered by nonphysician clinicians. </li></ul><ul><li>The CBO determined that any surplus that does arise should be self-correcting over time. </li></ul><ul><li>The CBO believes that if the number of physicians were to become excessive, the relative fees and incomes of doctors would fall, the medical profession would become less desirable, and the excess would be eliminated over time. </li></ul>
    58. 59. Problems with forecasting trends <ul><li>Many limitations with forecasting supply and demand. </li></ul><ul><li>Supply estimates are limited by predictions concerning the future number of USMGs and IMGs. </li></ul><ul><li>Demand estimates are limited by predictions of technology impact and errors or oversights in HMO utilization data. </li></ul><ul><li>Elasticity of physician work effort tends to reduce general level of effort among physicians thus masking any true surplus. </li></ul>
    59. 60. Where are we going? <ul><li>Increasing number of NPCs putting pressure on physicians </li></ul><ul><li>Conflicting models of physician supply/demand due to problems with forecasting. </li></ul><ul><li>However, one thing is for certain: </li></ul><ul><ul><li>We are going to Angelique’s portion of the presentation. </li></ul></ul>
    60. 61. Graduate Medical Education Reform
    61. 62. The Role of Medicaid in State Funding <ul><li>There is no statutory requirement for payment into GME, it is purely voluntary </li></ul><ul><li>Nearly all states still have contributed under fee-for-service Medicaid programs </li></ul><ul><li>Five states and Puerto Rico do NOT use funding for GME </li></ul><ul><li>Of those, 3 (Alaska, Idaho, and Montana) do not have medical schools </li></ul><ul><li>Funding ranges between 1% - 20% inpatient hospital payments </li></ul><ul><li>The State Average is about 7% </li></ul>
    62. 63. Fair Share of Medical Education Costs <ul><li>Each state has the right to decide whether or not to fund GME </li></ul><ul><ul><li>Become familiar with their own workforce needs </li></ul></ul><ul><ul><ul><li>Using the money to target those groups who will be most needed </li></ul></ul></ul><ul><ul><li>Identify GME costs and revenues </li></ul></ul>
    63. 64. Fair Share of Medical Education Costs <ul><ul><li>Consider the link between Medicaid GME and patient care </li></ul></ul><ul><ul><li>Consider the link between Medicaid GME payments and Medicaid services </li></ul></ul><ul><ul><ul><li>Should Medicaid funds be used to support GME in institutions that do no service a significant amount of Medicaid patients? </li></ul></ul></ul>
    64. 65. Fair Share of Medical Education Costs <ul><ul><li>Compare funding sources </li></ul></ul><ul><ul><li>Instill payment efficiency </li></ul></ul><ul><ul><ul><li>Getting the most out of each dollar </li></ul></ul></ul><ul><ul><ul><li>Changing the process </li></ul></ul></ul><ul><ul><li>Ensure that funding is held accountable to meeting the needs of the state and penalize those who do not </li></ul></ul>
    65. 66. Disjoint Funding Strategy <ul><li>In Florida: </li></ul><ul><ul><ul><li>A large state health service corps program was created to expand loan repayment and scholarship activities </li></ul></ul></ul><ul><ul><li>While at the same time </li></ul></ul><ul><ul><ul><li>Another state policy was reducing payments for graduate medical education </li></ul></ul></ul>
    66. 67. Innovations at the State Level <ul><li>Tennessee </li></ul><ul><li>Minnesota </li></ul><ul><li>Michigan </li></ul>
    67. 68. Tennessee <ul><li>In 1995, Tennessee implemented the Medicaid Managed Care </li></ul><ul><ul><li>TennCare </li></ul></ul><ul><li>They stopped payment for GME in order to channel resources to expand Medicaid enrollment to cover large portions of the poverty population </li></ul>
    68. 69. Tennessee, Con’t <ul><li>In 1996, TennCare restored GME payments </li></ul><ul><ul><li>Funds went directly to medical schools, not hospitals </li></ul></ul><ul><ul><li>Payments weighted heavily toward primary care teaching </li></ul></ul><ul><ul><li>Noncompliance penalties for non adherence to primary care priorities and services directly towards Medicaid patients </li></ul></ul><ul><ul><li>Set-aside stipends for physicians who stay in the state </li></ul></ul>
    69. 70. Minnesota <ul><li>Established an all-payer pool for GME </li></ul><ul><ul><li>Only other state besides New York to implement </li></ul></ul><ul><li>Created in response to the predicted growth of managed care that would put academic medicine under siege </li></ul>
    70. 71. Minnesota, Con’t <ul><ul><li>The legislature created in 1997 and then appropriated funds into a medical education/research trust fund </li></ul></ul><ul><ul><ul><li>Medical Education and Research Trust Cost Fund (MERC) </li></ul></ul></ul><ul><ul><ul><li>The fund created incentives to train multiple types of providers according to Minnesota’s population needs </li></ul></ul></ul><ul><ul><ul><li>Initially, supported by a tax on providers </li></ul></ul></ul><ul><ul><ul><li>Now a portion has been allocated from the Tobacco settlement </li></ul></ul></ul>
    71. 72. Michigan <ul><li>Changed dramatically in 1997 when the state aligned the payments according to three policy goals: </li></ul><ul><ul><li>To train the appropriate numbers of primary care providers </li></ul></ul><ul><ul><li>To enhance training in rural areas </li></ul></ul><ul><ul><li>To support education in ways of particular importance in the treatment of the Medicaid eligible population </li></ul></ul>
    72. 73. Michigan, Con’t <ul><ul><li>Primary care pool </li></ul></ul><ul><ul><ul><li>Based on the institution’s number of residents in primary care and its share of Medicaid residents </li></ul></ul></ul><ul><ul><ul><li>Weighted for Medicaid utilization and for performance factors </li></ul></ul></ul><ul><ul><ul><ul><li>Physicians that participate in Michigan’s Medicaid program after completing their residency </li></ul></ul></ul></ul>
    73. 74. Michigan, Con’t <ul><ul><ul><li>Must provide documentation to the state detailing how the funds are used to be reimbursed (meeting the goals mentioned before) </li></ul></ul></ul><ul><ul><ul><li>Encourages the education of young physicians in the primary care fields </li></ul></ul></ul><ul><ul><ul><ul><li>Family practice </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Preventative medicine </li></ul></ul></ul></ul>
    74. 75. Michigan, Con’t <ul><li>The Innovations in Health Professions Education Grant Fund </li></ul><ul><ul><li>Established with GME funds formally in capitation payments to MCOs to stimulated innovations in health profession education </li></ul></ul><ul><ul><li>Accelerate the pace of health care change in the state </li></ul></ul><ul><ul><li>Awarded on a competitive basis to programs that support the goals </li></ul></ul>
    75. 76. Do you think that the government should subsidize GME?
    76. 77. Subsidies <ul><li>Based on the size of their graduate medical education programs </li></ul><ul><ul><li>Direct graduate medical education (DME) payments </li></ul></ul><ul><ul><li>Indirect medical education (IME) adjustment. </li></ul></ul>
    77. 78. Direct Medical Education Payments <ul><li>For its DME payment, a teaching hospital receives an amount equal to the product of three factors </li></ul><ul><ul><li>&quot;Medicare patient load” </li></ul></ul><ul><ul><li>Adjusted number of full-time-equivalent (FTE) residents </li></ul></ul><ul><ul><li>Allowed amount per resident. </li></ul></ul>
    78. 79. Indirect Medical Education Adjustment <ul><li>The additional amount Medicare pays to a teaching hospital equals the hospital's total Medicare diagnosis-related group (DRG) payments for inpatient services multiplied by a factor that is calculated according to a specific mathematical formula </li></ul>
    79. 80. Federal Reform of GME Financing <ul><li>Modify the Current System </li></ul><ul><li>Restructure the System </li></ul><ul><li>End Federal Financing </li></ul>
    80. 81. Modify the Current System <ul><li>Reduce the IME Teaching Adjustment </li></ul><ul><ul><li>The Government's Prospective Payment Assessment Commission (ProPAC) has suggested that the current IME subsidy be reduced to reflect more accurately those increases in teaching hospitals' costs that are associated with larger resident-to-bed ratios </li></ul></ul><ul><ul><li>IME adjustment be reduced in phases from its current rate of about 7.7 percent to 4.5 percent, for a 0.1 increase in the resident-to-bed ratio of the hospital </li></ul></ul>
    81. 82. Reduce the IME Teaching Adjustment <ul><ul><li>A decrease in IME payments would be expected to lead to fewer residents than teaching hospitals would otherwise have trained </li></ul></ul><ul><ul><li>Teaching hospitals might also scale back some activities besides residency training </li></ul></ul>
    82. 83. Modify the Current System, Con’t <ul><li>Reduce or Eliminate GME Subsidies for Noncitizens </li></ul><ul><li>Approximately one-fourth of all current residents graduated from foreign medical schools </li></ul><ul><li>The majority of those foreign medical graduates are not U.S. citizens </li></ul><ul><ul><li>although most of them are expected to enter the trained U.S. physician workforce at some point </li></ul></ul>
    83. 84. Reduce or Eliminate GME Subsidies for Noncitizens <ul><li>A disadvantage of the policy is that it might lead to a two-tier residency system </li></ul><ul><ul><li>Increased movement of citizens into more prestigious programs </li></ul></ul><ul><ul><li>Foreign students having to enter into less prestigious programs </li></ul></ul><ul><li>The future supply of physicians in this country could probably be smaller than without such a policy </li></ul>
    84. 85. Restructure the System <ul><li>Open Up the Market for GME by Offering Vouchers </li></ul><ul><li>The doctor could transfer the voucher to a medical group or hospital as part of a contract in which the organization would provide training and a stipend to the resident in exchange for his or her services and payments from the federal government </li></ul><ul><li>Specialty boards might be reluctant to consider training at non-hospital sites </li></ul>
    85. 86. Restructure the System, Con’t <ul><li>Voucher system changes could be too slow to positively affect needed changes in the workforce </li></ul><ul><li>The federal government could inform medical or premedical students about trends and innovations in the market for physicians' services </li></ul>
    86. 87. Restructure the System, Con’t <ul><li>Provide vouchers of different values or vouchers only for particular specialties </li></ul><ul><li>Citizenship could be considered a potential requirement for receiving a GME voucher </li></ul><ul><ul><li>but not a requirement for receiving training </li></ul></ul>
    87. 88. End Federal Financing <ul><li>Estimates indicate that eliminating both DME and IME payments would reduce federal spending </li></ul><ul><ul><li>over $7.5 billion for fiscal year 2000 </li></ul></ul><ul><ul><li>over $8.5 billion for fiscal year 2002. </li></ul></ul><ul><li>Hospital’s would be bearing the true costs associated with having a residents </li></ul>
    88. 89. End Federal Financing, Con’t <ul><li>Medicare's payment rules for physicians' services could be loosened to allow residents to bill for beneficial medical services that they provide to Medicare patients </li></ul><ul><ul><li>That might introduce new questions about payment levels and qualification requirements for residents </li></ul></ul>
    89. 90. End Federal Financing, Con’t <ul><li>Could potentially eliminate the concern for having more physicians than appropriate </li></ul><ul><li>Many FMGs who would have done residencies in this country and who would probably have become part of the future U.S. workforce of fully trained physicians might choose not to do so </li></ul>
    90. 91. End Federal Financing, Con’t <ul><li>Significantly weakened incentives to hire residents and lower stipends </li></ul><ul><li>Medical schools would also be affected because of their ties to teaching hospitals </li></ul>
    91. 92. Which policy change do you think would be the best?
    92. 93. What do you think are some of the affects on the population if the policy changes on GME funding?
    93. 94. Policy Changes Effects <ul><li>Access to Care </li></ul><ul><li>Medicare Beneficiaries </li></ul><ul><li>The Uninsured and Indigent </li></ul>
    94. 95. Access to Care <ul><li>There are incentives for teaching hospitals to both provide more services to Medicare beneficiaries and hire more residents </li></ul><ul><ul><li>Changes in those might alter teaching hospitals' incentives to treat Medicare beneficiaries </li></ul></ul><ul><li>In the longer run, its impact on the future supply of physicians </li></ul>
    95. 96. Access to Care, Con’t <ul><li>In the shorter run, alter the available medical residents that care in communities in where a significant amount of hospital-based patient care is provided </li></ul><ul><li>Affect the revenues of teaching hospitals, where services for patients who are uninsured and indigent are provided </li></ul>
    96. 97. Medicare Beneficiaries <ul><li>The GME payments encourage teaching hospitals not only to employ more residents than they otherwise would but also to be more willing to provide services to Medicare beneficiaries </li></ul><ul><li>A hospital's DME payments increase with its Medicare caseload </li></ul>
    97. 98. Medicare Beneficiaries, Con’t <ul><li>A hospital's IME payments rise with its Medicare admissions </li></ul><ul><li>It follows that changes in the DME or IME formula would alter the incentive to admit and treat Medicare patients </li></ul>
    98. 99. The Uninsured and Indigent <ul><li>Access to care for uninsured, indigent people may be affected by the level of GME subsidies for two reasons </li></ul><ul><ul><li>Changing the amount of the subsidies would probably affect the amount of various services that teaching hospitals provide, including care for uninsured people </li></ul></ul><ul><ul><li>Affecting the number of residents available to provide care to this population </li></ul></ul>
    99. 100. Questions
    100. 101. Sources <ul><li> </li></ul><ul><li>Matherlee, Karen. 2002. “Federal and State Perspectives on GME Reform.” National Health Policy Forum. </li></ul><ul><li>O’Neil, June. 1995. “Medicare and Graduate Medical Education.” </li></ul>