Transforming Graduate Medical Education to Improve Health Care Value
N Engl J Med 2011; 364:693-695February 24, 2011DOI: 10.1056/NEJMp1012691
U.S. health care is too expensive, and its quality too inconsistent. To ensure that health care will be affordable for future generations and appropriate for our burgeoning geriatric population, its delivery and organization must change. Physicians should be in the vanguard of this change, and transforming medical education will be instrumental in preparing tomorrow's physicians to lead the way.
Swensen et al. have stated that U.S. physicians must shift from viewing themselves as “nonintegrated, dedicated artisans who eschew standardization” to become leaders of a system that values “wise standardization, meaningful measurement, and respectful reporting.”1 To manage this transition, physicians will need the requisite new perspectives and skills for evidence-based practice, effective use of information technology, quality measurement and improvement, cost awareness, care coordination, leadership of interdisciplinary teams, and shared decision making. Mastering the necessary skills and shifting one's perspective on what it means to be a good doctor will be a career-long endeavor that should begin during medical school and residency.
Because of the important role Medicare plays in financing residency training through payment to teaching hospitals for graduate medical education (GME), the Medicare Payment Advisory Commission (MedPAC) recently conducted a review of the U.S. GME system. This system is, in many ways, the envy of the world, annually producing thousands of new clinicians who are well trained in applying cutting-edge technology and techniques to aid severely ill or injured patients. Teaching hospitals also serve as linchpins of their local health care systems and contribute to stunning advances in medical science. Judged through this traditional frame of reference, the GME system is an extraordinary success. However, that success and frame of reference are no longer adequate. The GME system must join others in transforming the U.S. health care system into an economically sustainable enterprise that provides appropriate care for all Americans. Working with academic medicine and specialty boards, the Accreditation Council for Graduate Medical Education has taken important steps in reorienting its residency-program accreditation standards to support needed change. We applaud that progress, but it has been slower than MedPAC and some members of the GME community would like.
Medicare invested $9.5 billion in GME in 2009. It is the single largest payer for GME, but it establishes minimal accountability for achieving education and training goals. MedPAC has therefore recommended that Congress authorize Medicare to use this financial leverage to catalyze more rapid GME reform by linking about one third of its GME dollars to programs' performance on newly developed measures. In essence, MedPAC recommended that Congress stimulate GME reform by bringing new voices and new forces to the table.
To establish new performance measures that focus on the skills needed to improve our health care delivery system, MedPAC recommends that the secretary of health and human services create an expert advisory body. This group would include leaders from accrediting and certifying organizations and GME faculties, along with representatives of specialty boards, high-performing health care systems, public and private purchasers, and consumer and patient organizations. This advisory body should be given 3 years to develop new standards and a method for linking those standards to new payment incentives. The secretary's role would be not to develop the specific standards but rather to push the experts to be ambitious in addressing the problem.
Funding for the incentive payments should come from the $9.5 billion that Medicare contributes to GME. Because Medicare's current payments toward the indirect costs of GME (e.g., higher costs incurred for testing or longer hospital stays that are attributable to an institution's engagement in GME) exceed the estimated actual costs by about $3.5 billion,2 we recommend that this portion be reallocated to fund the incentive payments. All, some, or none of this amount could be paid out, depending on whether the advisory body successfully develops standards for increased accountability and on the extent to which GME programs meet those standards. MedPAC's goal is not to reduce Medicare outlays for GME: we would like to see programs receiving all $3.5 billion, because that would mean that new standards are in place and being met.
Recognizing the need for delivery-system reform and academic medicine's potential role in leading it, the Association of American Medical Colleges (AAMC) has proposed the creation of health innovation zones (HIZs). Academic medical centers would be the hubs of these zones, which would include other health care providers. If payment methods were changed within these zones (for example, through the institution of population-based capitated payments) and laws and regulations that are perceived as inhibiting collaboration and change were repealed or relaxed, the AAMC believes that HIZs could deliver more efficient care and become exemplars for the rest of the health care system. Because the HIZ concept entails major changes in financing, regulation, and organizational structures, the development and implementation of HIZs will raise complicated issues and take considerable time. MedPAC does not see HIZs as an alternative to our recommended performance standards; rather, the two proposals are potentially complementary. Indeed, GME programs that fare well under new performance standards should be well positioned to lead HIZs.
In addition, MedPAC recommended that Medicare publish information about how much it pays each teaching hospital for GME — information that is sometimes not available even to the residency-program directors and teaching-hospital faculty. Medicare's GME payments typically go into a hospital's general fund, which in some cases may be allocated as the institution's chief executive and board of directors see fit, without regard to the GME mission. This practice is not conducive to cooperative partnerships between GME programs and hospitals.
The AAMC and others have asked Congress to increase the number of GME positions funded by Medicare, arguing that we face a looming physician shortage. MedPAC believes that Congress should not fund additional GME slots, however, until it has reviewed a thorough assessment of those needs. That assessment must be based not on extrapolation from current patterns of care but rather on expectations about the workforce needed for a high-performing, sustainable health care system that includes a mix of physicians and other health care professionals. Simply funding more of the current mix of specialties could impede improvement of our health care delivery system. In the Patient Protection and Affordable Care Act, Congress established a National Health Care Workforce Commission charged with analyzing workforce needs.
MedPAC, like many others, is also concerned about the declining proportion of U.S. medical students choosing careers in primary care. GME programs could help to address this problem — for example, by expanding primary care programs and shrinking subspecialty programs or by investing sufficient resources in primary care programs to ensure that residents have high-quality experiences. GME sponsors should not be expected to carry the entire load, however. In fact, Medicare and private insurers may have control over the most important potential lever: the significant gap between the level of payments for primary care services and that for subspecialty procedures. Public and private insurers and the GME community all need to find ways to encourage careers in primary care.
The lessons learned and perspectives developed by physicians-in-training echo long into the future. One step toward a more effective and sustainable health care system is to match the content of training with anticipated needs. This is not a job for government, but for a partnership among GME faculties, residency-accreditation and physician-certifying organizations, insurers, and patient representatives. Government should serve as a catalyst, using its financing leverage to ensure that the necessary work is done and the proper parties are engaged.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
This article (10.1056/NEJMp1012691) was published on February 9, 2011, at NEJM.org.
From the Medicare Payment Advisory Commission, Washington, DC.
Report to the Congress: Medicare payment policy. Section 2A. Washington, DC: Medicare Payment Advisory Commission, March, 2010:39-66.
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