Renee Butkus, BA; Susan Lane, MD; Alwin F. Steinmann, MD; Kelly J. Caverzagie, MD; Thomas G. Tape, MD; Susan T. Hingle, MD; Darilyn V. Moyer, MD; and the Alliance for Academic Internal Medicine and American College of Physicians Graduate Medical Education Task Forces, for the Health and Public Policy Committee of the American College of Physicians (*)
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Dr. Lohr reports being a member of the ACP Board of Regents. Dr. Tape reports personal fees from ACP, UnitedHealthcare, and the University of Nebraska Medical Center outside the submitted work. Dr. Wallach reports stocks (Pfizer) outside of the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M15-2917.
Requests for Single Reprints: Renee Butkus, BA, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 2001; e-mail, RButkus@acponline.org.
Current Author Addresses: Ms. Butkus: American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 2001.
Dr. Lane: Stony Brook Medicine, 101 Nicolls Road, Stony Brook, NY 11794.
Dr. Steinmann: Saint Joseph Hospital, 1960 North Ogden Street, Suite 300, Denver, CO 80218.
Drs. Caverzagie and Tape: Department of Internal Medicine, University of Nebraska Medical Center, 42nd Street and Emile Street, Omaha, NE 68198.
Dr. Hingle: Southern Illinois University School of Medicine, 801 North Rutledge Street, Mail Code 9628, Springfield, IL 62794.
Dr. Moyer: Department of Medicine, Temple University, 3401 North Broad Street, 8 Parkinson Pavilion, Philadelphia, PA 19140.
Dr. Donnelly: Christiana Care Health System, John H. Ammon Medical Education Center, 4475 Ogletown-Stanton Road, Suite 2E70, Newark, DE 19718.
Dr. Jaeger: University of Pennsylvania, 3701 Market Street, 7th Floor, Suite 760, Philadelphia, PA 19104.
Dr. Laird-Flick: Michigan State University, 788 Service Road, B301 Clinical Center, East Lansing, MI 48824.
Dr. Moriarty: Yale–New Haven Hospital, 1450 Chapel Street, New Haven, CT 06511.
Dr. Sharma: Brigham and Women's Hospital, 75 Francis Street, Mail Code PBB-B416, Boston, MA 02115.
Dr. Wallach: St. Francis Medical Center, 601 Hamilton Avenue, Trenton, NJ 08629.
Dr. Wardrop: Department of Pediatrics, University of North Carolina, 260 MacNider Building, CB 7220, Chapel Hill, NC 27599.
Dr. Bronze: Department of Internal Medicine, University of Oklahoma Health Sciences Center, 920 Stanton Young Boulevard, PO Box 26901, WP1140, Oklahoma City, OK 73126.
Dr. Cooney: Department of Medicine, Oregon Health & Science University, Mail Code OP30, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239.
Dr. DeLong: Bassett Healthcare Network, 1 Atwell Road, Cooperstown, NY 13326.
Dr. Heudebert: University of Alabama at Birmingham School of Medicine, Faculty Office Tower Room 730, 510 20th Street South, Birmingham, AL 35294.
Dr. Kane: Thomas Jefferson University, Sidney Kimmel Medical College, 1025 Walnut Street, Philadelphia, PA 19107.
Dr. Levine: University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401.
Dr. Many: University of Alabama at Birmingham School of Medicine, 2119 East South Boulevard, Suite 304, Montgomery, AL 36116.
Dr. Smith: Northwell Health, 145 Community Drive, Great Neck, NY 11021.
Author Contributions: Conception and design: R. Butkus, K.J. Caverzagie, D.M. DeLong, G.R. Heudebert, S.T. Hingle, G.C. Kane, H.S. Laird-Fick, S.W. Lane, M.A. Levine, J.P. Moriarty, D.V. Moyer, N. Sharma, L.G. Smith, T.G. Tape.
Analysis and interpretation of the data: M.S. Bronze, R. Butkus, K.J. Caverzagie, T.G. Cooney, G.R. Heudebert, S.W. Lane, M.A. Levine, J.P. Moriarty, D.V. Moyer, S.L. Wallach.
Drafting of the article: R. Butkus, G.R. Heudebert, S.T. Hingle, G.C. Kane, H.S. Laird-Fick, S.W. Lane, M.A. Levine, J.P. Moriarty, D.V. Moyer, N. Sharma, L.G. Smith, A. Steinmann, T.G. Tape.
Critical revision for important intellectual content: R. Butkus, K.J. Caverzagie, T.G. Cooney, D.M. DeLong, G.R. Heudebert, S.T. Hingle, J.R. Jaeger, G.C. Kane, H.S. Laird-Fick, S.W. Lane, M.A. Levine, W.J. Many, J.P. Moriarty, D.V. Moyer, N. Sharma, T.G. Tape, S.L. Wallach, R.M. Wardrop.
Final approval of the article: M.S. Bronze, R. Butkus, K.J. Caverzagie, T.G. Cooney, D.M. DeLong, J. Donnelly, G.R. Heudebert, S.T. Hingle, J.R. Jaeger, G.C. Kane, H.S. Laird-Fick, S.W. Lane, M.A. Levine, W.J. Many, J.P. Moriarty, D.V. Moyer, N. Sharma, L.G. Smith, A. Steinmann, T.G. Tape, S.L. Wallach, R.M. Wardrop.
Administrative, technical, or logistic support: R. Butkus.
Collection and assembly of data: M.S. Bronze, R. Butkus, S.T. Hingle, S.W. Lane, J.P. Moriarty, D.V. Moyer.
In this position paper, the Alliance for Academic Internal Medicine and the American College of Physicians examine the state of graduate medical education (GME) financing in the United States and recent proposals to reform GME funding. They make a series of recommendations to reform the current funding system to better align GME with the needs of the nation's health care workforce. These recommendations include using Medicare GME funds to meet policy goals and to ensure an adequate supply of physicians, a proper specialty mix, and appropriate training sites; spreading the costs of financing GME across the health care system; evaluating the true cost of training a resident and establishing a single per-resident amount; increasing transparency and innovation; and ensuring that primary care residents receive training in well-functioning ambulatory settings that are financially supported for their training roles.
Total Medicare GME funding in 2012.
DGME = direct graduate medical education; GME = graduate medical education; IME = indirect medical education.
Recommendation 1: Maintain Medicare graduate medical education (GME) support at the current aggregate amount (i.e., the total of indirect medical education and direct graduate medical education expenditures in an agreed-on base year, adjusted annually for inflation) while taking essential steps to modernize GME payment methods based on performance, to ensure program oversight and accountability, and to incentivize innovation in the content and financing of GME. The current Medicare GME payment system should be phased out.
Recommendation 2: Build a graduate medical education (GME) policy and financing infrastructure.
2a. Create a GME Policy Council in the Office of the Secretary of the U.S. Department of Health and Human Services. Council members should be appointed by the Secretary and provided with sufficient funding, staff, and technical resources to fulfill the responsibilities listed below.
• Development and oversight of a strategic plan for Medicare GME financing;
• Research and policy development regarding the sufficiency, geographic distribution, and specialty configuration of the physician workforce;
• Development of future federal policies concerning the distribution and use of Medicare GME funds;
• Convening, coordinating, and promoting collaboration between and among federal agencies and private accreditation and certification organizations; and
• Provision of annual progress reports to Congress and the Executive Branch on the state of GME.
2b. Establish a GME Center within the Centers for Medicare & Medicaid Services with the following responsibilities in accordance with and fully responsive to the ongoing guidance of the GME Council:
• Management of the operational aspects of GME Medicare funding;
• Management of the GME Transformation Fund (see Recommendation 3), including solicitation and oversight of demonstrations; and
• Data collection and detailed reporting to ensure transparency in the distribution and use of Medicare GME funds.
Recommendation 3: Create one Medicare graduate medical education (GME) fund with two subsidiary funds.
3a. A GME Operational Fund to distribute ongoing support for residency training positions that are currently approved and funded.
3b. A GME Transformation Fund to finance initiatives to develop and evaluate innovative GME programs, to determine and validate appropriate GME performance measures, to pilot alternative GME payment methods, and to award new Medicare-funded GME training positions in priority disciplines and geographic areas.
Recommendation 4: Modernize Medicare graduate medical education (GME) payment methodology.
4a. Replace the separate indirect medical education and direct GME funding streams with one payment to organizations sponsoring GME programs, based on a national per-resident amount (PRA) (with a geographic adjustment).
4b. Set the PRA to equal the total value of the GME Operational Fund divided by the current number of full-time equivalent Medicare-funded training slots.
4c. Redirect the funding stream so that GME operational funds are distributed directly to GME sponsoring organizations.
4d. Implement performance-based payments using information from Transformation Fund pilots.
Recommendation 5: Medicaid graduate medical education (GME) funding should remain at the state's discretion. However, Congress should mandate the same level of transparency and accountability in Medicaid GME as it will require under the changes in Medicare GME herein proposed. (2)
Appendix Table. 2015 Match Summary, Internal Medicine Subspecialties*
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Butkus R, Lane S, Steinmann AF, Caverzagie KJ, Tape TG, Hingle ST, et al. Financing U.S. Graduate Medical Education: A Policy Position Paper of the Alliance for Academic Internal Medicine and the American College of Physicians. Ann Intern Med. 2016;165:134-137. doi: 10.7326/M15-2917
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Published: Ann Intern Med. 2016;165(2):134-137.
Published at www.annals.org on 3 May 2016
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