Transcript GME Funding “Reform” and Outpatient Resident Education

Policy update: Graduate Medical
Education funding
Jeffrey R. Jaeger, MD, FACP
University of Pennsylvania Health
System
Outline
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How is GME funded?
What’s wrong with this picture
Supercommittee Primer
Potential scenarios
Advocacy opportunities
Graduate Medical Education (GME)
funding
• GME is funded through Medicare (CMS)
• Since 1980’s: 2 “funding streams”: Indirect and Direct
• Indirect Medical Education expenses:
– Factored in as an adjustment to Medicare billings:
• Varies based on resident/bed ratio, capped at 5.5% add on
• Example: If usual Medicare DRG is $10000, we get $10550
– Intended to cover:
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Sicker patients
More complex patients
More advanced diagnostic and therapeutic modalities
Longer lengths of stay and additional testing
GME Funding (cont.)
• Direct Medical Education expenses:
– Intended to cover salaries, benefits, administrative
costs, overhead, malpractice, faculty teaching time
– Hospital-specific per-resident amount (PRA) based on
costs to educate residents in 1983
• PRA adjusted for inflation but not work hours reform,
competencies, oversight rules
– Hospitals’ DME reimbursement = (# of residents*) x
(PRA**) x (% of hospital’s business attributable to
Medicare)
*Capped at 1997 numbers of residents
** Large variations between hospitals
GME Funding (cont.)
• IME > DME for most hospitals treating adult
patients*
• DME + IME = $9 billion+ annually for 100000+
residents and fellows nationally
• Estimates are that current funding just about
covers costs (Steinmann, Annals, 2011)
* Pediatrics has a separate funding stream also through Medicare
What’s wrong with this picture?
• From Washington:
– 2010 Deficit Commission: Charged with making
proposals to address the debt / deficit
• Recommendation 3.3.5: “Reduce excess payments to
hospitals for medical education”
• There’s a sense that someone other than CMS / taxpayers
(profession, hospitals, other insurers) should be funding
training
• Proposal: Fix DME at 120% of salary and cut IME to 2.2% =
$6 billion a year saved
– Did not gain enough consensus to make it to Congress
What’s wrong with this picture? (2)
• From multiple sources (lay press, academia,
politicians):
– If GME is going to be publicly funded, then public
priorities should inform GME
– Might we structure GME funding to achieve some
agreed-upon policy goals?
• Impact workforce?
• Bend the cost curve?
• Speed changes in healthcare delivery?
Supercommittee Primer
• Joint Select Committee on Deficit Reduction
• 12 Congressmen and –women
– 6 Senate, 6 House; 6 Dems, 6 GOP
– Must come to consensus on cutting $1.2 trillion
over 10 years or automatic cuts go into effect for
things near and dear to both parties
• GME again in the crosshairs with this group
Impact of GME cuts
• Some hospitals will fold their residencies
• Those that do not:
– Most will have to find alternative ways to fund
resident education
– Many will make cuts:
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Administration
Teaching supplements
Benefits
Numbers of residents?
Impact of GME cuts (cont.)
• Fewer residents means fewer man-hours
available for inpatient care
– Hospitals will need to hire more extenders or shift
rotations from elective/outpatient to inpatient
• But… Internal Medicine (IM) residents need to
spend 1/3 of their time in outpatient, and 130
half-days in continuity clinic
– Will the ACGME change the rules for the health of
hospitals?
– Or will they stand pat?
What about a legislative fix?
• What might we see?
– No change?
– All-payer funding of GME?
– $$$ shifted to programs training PCP’s?
• It’s already in Healthcare Reform law (PPACA)
• Will it include IM?
• Who would pay to train specialists?
– Support for development of new specialties?
What does it mean in the medium
term? Anyone’s guess…
• AMC’s and hospitals positioned to compete
for funding directed at primary care education
will be in better shape
• AMC’s and hospitals positioned to find
internal funding for GME will be in better
shape
• ACGME and ABIM may be under pressure to
create paths to practice that more reliably
produce the docs the nation thinks it needs
Pathways to advocacy
• Call your Representative and/or Senators and
ask to speak to the staffer for health care or
education
• Find contact information at
http://www.usa.gov/Contact/Elected.shtml
• Especially important if your Congressman or –
woman is on the Supercommittee
Supercommittee Membership
• House of Representatives:
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Rep. Jim Clyburn (D-S.C.)
Rep. Xavier Becerra (D-Calif.)
Rep. Chris Van Hollen (D-Md.)
Rep. Jeb Hensarling (R-Texas)
Rep. Dave Camp (R-Mich.)
Rep. Fred Upton (R-Mich.)
• Senate:
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Sen. Max Baucus (D-Mont.)
Sen. John Kerry (D-Mass.)
Sen. Patty Murray (D-Wash.)
Sen. Jon Kyl (R-Ariz.)
Sen. Pat Toomey (R-Pa.)
Sen. Rob Portman (R-Ohio)
Advocacy (cont.)
• ACP Capwiz has links facilitating advocacy on
GME: http://capwiz.com/acponline/home/
When you write or call
• Make it clear that you are a physician, caring
for patients on Medicare, and that you
support preserving funding for Graduate
Medical Education
• Personalized letters with stories about
patients are the best
• It’s important to acknowledge the reality that
everyone is going to have to pitch in
Summary
• GME funded mainly through CMS
• Current solution to debt/deficit presents likely
cuts to GME funding
• Outcomes and impact remain unclear
• Advocacy from academic medicine and from
actual residents is critical