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Thibault: Don’t Cut Medicare Investment in Physician Training

Medicare payments to teaching hospitals are one of many options on the chopping block for budget negotiators eyeing ways to address the  debt ceiling crisis.

Cutting what Medicare spends to fund graduate medical education training may be an easy target. But it is shortsighted and not in the best interest of the American public. At a time when we need to address a serious shortage of physicians, policymakers should seize this opportunity to invest GME dollars more wisely, not scale them back to meet budgetary goals.

Many know that Medicare is the largest public health insurer in the country, covering 48 million elderly and disabled Americans. What most people don’t realize is that it also is the single largest payer for training interns and residents for practice.

Medicare spends nearly $10 billion annually on graduate medical education; Medicaid, the state-federal program for low-income people, pays an additional $3.5 billion. While it is a publicly financed good, the public has had little to say about how these dollars are spent.

The U.S. system for educating physicians is the envy of the world. But it has to change if we are to have a more robust, reliable and effective health care system.

The Medicare GME program is largely responsible for the composition of the physician workforce in this country. It helps determine the number and specialty mix of physicians who enter practice each year.

Payers that support residency training should work with the medical profession to make sure that the billions of dollars they are spending are producing physicians with the right skills and competencies, who get training in settings where most patients get care, and who represent the specialties we need.

Earlier this year, a workgroup made up of leaders in academic medicine and health care convened by the Josiah Macy Jr. Foundation and the Association of Academic Health Centers issued a set of recommendations for reforming GME policy.

Although they brought very different perspectives to the table, these leaders all agreed on one thing: that an impending shortage of physicians that could reach more than 100,000 by the middle of the next decade in mostly primary care and some specialty areas, as well as the need to better meet contemporary health needs, requires strong action now.

A top recommendation is determining how best to restructure the GME system to increase physician supply in the specialties where there are shortages. Over the past decade, the number of those training in subspecialties has grown at five times the rate of those training in core specialties.

To make sure we increase the number of physicians in the needed core specialties, we recommend an immediate, one-time increase of 3,000 entry level GME positions in adult primary care, general surgery and psychiatry. This would not require a new investment but rather would be funded by reallocating existing positions.

Congress should also charge the Institute of Medicine to conduct a review of the goals, governance and financing of GME to make sure the accreditation process for residency training programs is based on contemporary and future needs rather than past history.

A first step is making sure the Accreditation Council for Graduate Medical Education best serves the needs of the public, the training programs and the trainees. This review should facilitate decisions on the number of residency positions that are needed, what training sites should be used and what funding mechanisms are needed to support training.

While it might be desirable to increase the public investment in GME, growth in Medicare funds used to support residency training activities is out the question.

In fact, Medicare already has effectively frozen spending on GME since 1997 by capping the number of residency slots it would fund. This spending freeze has contributed to a shortage of physicians. A further reduction will only worsen the shortage and leave many Americans, including the growing number of elderly who are living with multiple chronic conditions, without the care they need.

We agree that the GME enterprise needs to be reformed. This same group will soon be releasing specific recommendations for changes in the site, content and duration of GME.

Rather than reducing the dollars we now spend, let’s work together to make sure we spend what we have to make the system for training the next generation of physicians more accountable and responsive to the public.

George Thibault, M.D., is president of the Josiah Macy Jr. Foundation, which supports medical and health professional education.

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