GME funding must be targeted to Primary Care

Much of the cost of training physicians is currently borne by Medicare (and, to a lesser extent, Medicaid). This is known as Graduate Medical Education, or GME, funding, and it pays some, all, or more than all (depending upon the hospital and based upon a complicated formula discussed on May 25, 2009, Funding Graduate Medical Education) of the cost of training residents in the various specialties that comprise medicine. For those unfamiliar with medical education, graduation from medical school, while it confers the MD (or DO, Doctor of Osteopathy) degree and the title “doctor”, no longer permits practice in any of the US states. A least one, and in some states two, years of residency (“GME”) is required for licensure, and most doctors complete an entire residency of 3 or more years to make them eligible for certification as a specialist in a field (eg, family medicine, general surgery, internal medicine, psychiatry, etc.). Fellowship training is requires addition years beyond the core residency to become a sub-specialist – for example, those who complete an internal medicine residency can then do additional years to become a cardiologist, gastroenterologist, endocrinologist, etc.

Medicare augments its payments to institutions (usually hospitals, although there are a few consortia and federally-qualified health centers) with two types of payments, Direct GME which is intended to pay residents’ salaries and cost of teaching, and Indirect ME which is for the additional costs that training hospitals bear for a variety of reasons. (In addition to the piece linked above, see also Training rural family doctors, Nov 5 2010; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?, Apr 22,2010; Primary Care and Residency Expansion, Jan 7, 2010.) These payments have been the cornerstones for funding residency education. Because the amount is tied to the percent of Medicare patients in a hospital, rather than the total number of patients cared for in hospitals or outpatient settings, it could be (and has been) argued that funding GME should be done comprehensively and separately from Medicare. The most persuasive argument is that private insurers should also contribute to GME (they don’t, although Medicaid does in some, but not all, states). On the other side, many fear that uncoupling GME funds from Medicare would make it easier for a Congress looking at ways to cut the budget to cut GME than having it as part of Medicare.

Except this year, with exceptionally high pressure to cut the budget, Medicare is not even sacrosanct, although, as I have recently argued, (Medicare: A lifeline, not a Ponzi scheme, Dec 2, 2011) most of the proposals to cut it across the board by tactics such as raising the age of eligibility are poorly conceived. So there are now proposals to cut the funding from Medicare for GME. Unsurprisingly, this has created great anxiety in the community of academic health centers, and the Association of American Medical Colleges (AAMC), which has strongly supported expansion of GME residency slots, is quite alarmed (Preserve Medicare support for physician training, revised Oct 2, 2011). The Accreditation Council on Graduate Medical Education (ACGME), which accredits institutions that sponsor residency programs and, through its subsidiary Review Committees (RCs), each individual specialty and subspecialty, has done a study that shows that cuts in residency positions have already occurred and more major cuts are threatened if Medicare decreases its funding ("The Potential Impact of Reduction in Federal GME Funding in the United States: A Study of the Estimates of Designated Institutional Officials”). ACGME CEO Thomas Nasca, MD, is quoted by AAFP News Now as saying “We will actually reduce the number of physicians who are trained in the United States at a time when all workforce studies are demonstrating a mounting deficit of physicians….That will place us in a position where our physician-to-population ratio in 2020 and beyond is below (that of) most of the developed countries in the world." The study found that “With a 33 percent reduction in GME funding

• 68.3 percent of responders said they would reduce the number of core residency positions,
• 60.3 percent would reduce the number of subspecialty fellowship positions,
• 4.3 percent would close all core residency programs, and
• 7.8 percent would close all subspecialty programs.”

Because there are many more “core” residency positions than subspecialty fellowship positions, these would be disproportionately affected by across-the-board cuts. In addition, residency programs in primary care, which are not as profitable to the sponsoring institution, are even more likely to be cut despite the service that they provide to patients, especially those most in need. Perry Pugno, M.D., M.P.H., AAFP vice president for education, notes in that same article that "…any cuts to GME that go across the board are going to hurt primary care -- especially those of us who disproportionately take care of adults with chronic illnesses….In communities where primary care residency programs are present, those programs become the access point for the poor and disenfranchised of the area.” He says that it's not unusual for family medicine residency programs to see patients who live both in poverty and with numerous chronic illnesses. "The payment for taking care of those patients is so low that the local medical community often doesn't want to provide that care…But residency programs take all comers."

The key issue that Pugno is addressing is one that is very important issue and is not usually made explicit in national policy discussions: our current method of allocating Medicare GME funds to institutions (hospitals) rather than to individual residency programs tends to encourage funding the funding of positions in specialties that most profit those hospitals. The interests of the American people, in regard to the kinds of specialists they need, are not necessarily (and I would argue in fact are not) the same as the interests of the hospitals that sponsor residencies. Hospitals like to fund specialties whose trainees’ work enhances their revenue (e.g., cardiology fellows, who can increase the number of profitable procedures that are done) or at least decrease their loss (e.g., emergency medicine residents, who can fill gaps in seeing patients in emergency departments). Indeed, when hospitals can afford to, they often augment Medicare GME with their own funds to create more such positions. This is about their own financial interest, and does not take into account whether or not the US needs more cardiologists or ER docs, or more family physicians and general surgeons.

This contrast between the interests of the hospital (what kind of residency positions are most beneficial to its bottom line) and the needs of the population, is, of course, a subset of the larger tension. We train doctors in highly-specialized tertiary care academic health centers, while they will mostly practice in the community. There are a number of reasons that this is not brought up more often. For the general lay public, including most members of Congress and their staffs, it seems like a subtle difference. For experts, such as the AAMC, the issue is that they represent the interests of the medical schools, and want to have those interests seen as also representing the interests of the US population. Of course, they do not always, especially the interests of the most rural, poor, minority and other underserved portions of that population.

I think we need to use every opportunity to make this issue more clear and open. While it is probably true that it is a mistake to decrease federal funding for GME, it is absolutely necessary to increase the support for primary care and, in particular family medicine. And this will only happen if GME funding is explicitly tied to requiring it to be spent on primary care programs, and “prevents substitutions”.

Primary Care and Residency Expansion

In discussing some of the things I liked in the bill that passed the Senate (December 23, 2009, Health Reform: The good, the bad, and the bigoted ) one of them was that the proposal to expand by 15,000 the number Medicare-supported residency (or Graduate Medical Education, GME) positions did not get included. The reason was that it did not explicitly require that these positions be used for primary care, which I believe is an essential requirement. I cited the strong arguments made by Shannon Brownlee and David Goodman in their New York Times op-ed of the same date, "Doctors no one needs". Most primary care, and particularly family medicine, groups were also unenthusiastic to opposed.

The Association of American Medical Colleges (AAMC) does not agree, unsurprisingly to those who are familiar with medical education, and was the biggest advocate for that provision. As AAMC President Darrell Kirch wrote in his December 21, 2009 communication “Leader to Leader” (not publicly available on the AAMC website), the news on the Senate bill “…was a great disappointment because we viewed this as a truly historic opportunity to make a positive impact on our future workforce.” In what many in the primary care community saw as a more combative statement, he went on to say “During this process we were deeply concerned that some members of the primary care community spoke out against the amendment, and argued that it would not support the expansion of the primary care workforce. Facing an extremely tight timetable, Senate staff clearly indicated to us that such opposition would discourage the leadership from moving forward on any GME language. The AAMC expressed strong concern that the vocal opposition of the family medicine community threatened to halt progress on GME legislation that did indeed benefit all training programs.”

In a recent letter to Senator Harry Reid, staking out the organization’s positions on what needs to be included (read “benefits academic medicine”) as the Senate and House move to reconcile their health bills in conference, Dr. Kirch writes that the GME expansion is critical, and that the AAMC is “…supporting the inclusion of this workforce expansion as part of provisions to strengthen primary care.” That sounds, good, making nice. However, other parts of the letter indicated that AAMC’s attack on primary care, and particularly family medicine, groups, for not supporting the its agenda of expanding (“benefit[ing] all training programs”) has progressed.

"The AAMC recognizes that primary care is an integral part of health care delivery. Primary care, however, may be provided by many types of physicians and other practitioners. We support defining primary care by the types of services provided and not by a specialty of the physician or other provider.”

What is the problem here? Surely the assertion above is reasonable, that defining primary care by services provided rather than the specialty of the provider makes sense. And the AAMC is saying it is supportive of primary care, and even including goals for more residents in the primary care specialties in the expansion of GME slots. It is a big step for the AAMC to be so supportive, publicly, of primary care, as they have not always been. And, in addition, there are other specialty areas (e.g., general surgery) that are also in great shortage. Indeed, the movement has been to sub-specialization and sub-sub-specialization, so we are seeing fewer physicians who are even generalists in their own sub-specialties (such as cardiology). The goal should definitely not be to increase slots only for primary care, but to target those specialties in which there is a mismatch between the number of doctors being trained and the number needed by the community.

Considering primary care, however, there are several problems with the current AAMC proposal.

1. The proposed bill is about expanding residency slots, not about defining the content of a primary care practice. Yes, there are subspecialists who provide comprehensive patient-centered care for their patients. Particularly in pediatrics, but also in adult internal medicine; people who have mainly one serious chronic disease (kidney failure, cancer, heart disease) sometimes receive most of their comprehensive care from nephrologists, oncologists, or cardiologists (more often in pediatrics because having only one chronic disease is the norm in children, but much less common in adults). Many of these subspecialists do not. In identifying practices as providing primary care for, say, increased reimbursement, looking at services provided is quite reasonable. However, in looking at a strategy for creating greater primary care capacity, what makes sense is to expand the residency programs in specialties that are particularly about training physicians to practice primary care, and whose graduates actually do so – family medicine, general pediatrics, and general internal medicine. This is especially true when looking at how we can provide comprehensive primary care to communities, not simply to selected individuals. To say “let’s just train more doctors altogether, and some will probably do some primary care" (radiologists? anesthesiologists? ophthalmologists?) is a nonsense strategy.

2. The significant impact on the health of the population that is related to increased primary care capacity only occurs with more primary care doctors. It does not occur with just more doctors, some of whom might do some primary care. (This is the point of the Brownlee and Goodman piece cited above.) These results have been documented repeatedly, in a variety of geographic areas and populations. Yes, there is also a contribution made by “non-physician” primary care providers including nurse practitioners and physician’s assistants, but they are not the concern of the AAMC, and, moreover, are increasing not practicing primary care. (See “myths” 2 & 3 in Dr. Bowman’s guest blog of January 15, 2009, Ten Biggest Myths Regarding Primary Care in the Future.) I addressed the issue of specialty choice in More Primary Care Doctors or Just More Doctors? (April 3, 2009). Of note, Dr. Richard Cooper, whose positions I criticize in that piece, has more recently been advocating for the needs of poor and minority communities, a good thing. His main point is that the Dartmouth Atlas data on geographic variation do not account for socioeconomic differences (debatable, certainly); however, I have not seen any retraction of his AAMC-type support for “more doctors” rather than more primary care doctors.

3. There are not enough students currently interested in entering primary care to fill currently existing positions. Thus, even if a greater priority were given to family medicine and other primary care residency positions, the new positions would, barring a major change – that would, as discussed in many previous pieces, have to be systemic and involve large, not simply cosmetic, changes in reimbursement – also be unfilled, at least by US graduates. Then, of course, the teaching hospitals and medical schools would use them for other specialties. Indeed, a big reason even more students do not enter the “ROAD” specialties described by Pauline Chen (“Primary Care’s Image Problem”, New York Times November 12, 2009, and discussed in this blog November 17, 2009, as Primary Care’s Image: A Problem?) is the limited number of slots; increasing slots without increasing the attractiveness of primary care as a career option will just increase the mismatch between the proportion of primary care doctors needed by the society and that being produced by medical schools. To the extent that primary care residency positions are filled by international medical graduates, it continues to contribute to the “brain drain”, where third-world countries bear the cost of educating physicians to provide care to first-world citizens.

The only way an increase in the number of GME slots could be beneficial is not only if a majority are targeted at primary care, but are required to be primary care, or they don’t happen. And that only specifically primary care internal medicine residencies count, and that the slots are withdrawn if, after 5 years, more than 25% of graduates have entered subspecialty training.

In greater detail, Patrick Dowling, chair of family medicine at UCLA, comments on the AAMC letter:

“Granted these are complex issues but in the end I read this as: ‘give us more of the same—we need more doctors, more funding for academic centers and we need to get reimbursed better!’ I think the AAMC would have much more credibility if they stepped up to the plate and said:

‘The US health care delivery system is terribly flawed and we are a significant part of the problem. We have terrible geographic and specialty maldistribution of physicians, our costs continue to be way out of line compared to any other industrialized country and we have unacceptable racial and ethnic disparities in outcomes of care.

‘Moreover, because the graduates of our medical schools have overwhelming chosen to practice subspecialty medicine in green leafy suburbs we must import international physicians, to staff our inner cities and rural towns in exchange for visas. Although we are fortunate to have someone to send, these docs face overwhelming linguistic and cultural barriers, especially in the provision of care to low income minority populations. And in some instances they represent a “brain drain” in from the donor countries

‘Further, as the baby boomers begin to hit age 65 at the rate of 5,000 per day on Jan 1, 2011, the epidemic of chronic diseases linked to aging will soar. We would propose the following new innovative steps to insure that we have a geographically dispersed physician workforce that delivers cost effect, high quality care with a physician workforce that is optimally balanced by specialty.

‘If you provide $X billion in extra funding for Academic Medical Centers (AMCs), enhanced funding for NIH budgets and thousands of more Medicare funded GME spots we will insure that the number of HPSAs will be reduced by X, that the actual number of USMGs choosing bona fide primary care specialties will increase by Y number which will result in a primary care to specialty ration of A to B, a ratio which works very well in other industrialized democracies.

‘Finally, if we are funded we promise to bend the unacceptable curve of increasing costs so that average yearly increases are less than X% of CPI. If we fail to meet these objectives we agree to decreased funding over the following years of $Z billion.’

“If I was in the US Congress,” Dr. Dowling concludes, “I would tell the AAMC that rather than stuffing their pockets it is time to put some skin in the game and actually become the leaders in the science of health care delivery and solve these problems.”

Hear, hear.
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