Jeffrey S. Stroup, PharmD, James D. Hess, Ed.D.
Oklahoma State University - Center for Health Sciences
Context: Graduate medical education (GME) programs in the United States (US) are responsible for developing the future physician workforce. While GME funding remains a critical aspect of physician training, it is being considered as an area that can be potentially targeted for cuts by the federal government to solve budgetary issues. To better understand physician knowledge of GME funding overall in our region, we surveyed GME program directors of an osteopathic GME consortium to assess their knowledge level of GME funding.
Methods: The sample size for this study consisted of 25 program directors of either residency or fellowship programs in the Osteopathic Medical Education Consortium of Oklahoma (OMECO). Assessment of the program directors was through a survey-based tracking tool.
Results: A total of 12 responses were received for the survey. The most notable and significant finding of the survey was the general lack of knowledge regarding GME programs. With respect to DGME (direct graduate medical education) funding, 83% of respondents were unaware of the amount of funding the program received for resident stipends. Additionally, none of the respondents were aware how much funding was received for faculty programming.
Conclusions: GME funding is critical to the advancement of medicine in the US. The knowledge of GME funding must be enhanced at the program director level to ensure that those ground leaders of GME can take the funding message to a higher level.
Graduate medical education (GME) programs in the United States (US) are responsible for developing the future physician workforce which includes a strong primary care training arena. The goal of Affordable Care Act (ACA) was to improve access to healthcare and embrace population health through the primary care workforce. Public support for GME programs is estimated to be over $13 billion per year, funded primarily by Medicare through two payment mechanisms. 1 Direct graduate medical education (DGME) funds pay for resident salaries and faculty supervisor compensation.1,2 Indirect graduate medical education (IME) funds are allocated to compensate teaching hospitals for the increased costs associated with hosting these training programs. IME funds were initiated by Medicare due to the following assumptions: 1) patients tend to be sicker, 2) staff productivity can be lower, and 3) costs can be greater due to higher diagnostic utilization associated with training programs. 1,2 IME funds are supplemented to the inpatient Medicare payment rate for institutions with GME programs. Thus, IME payments are tied to inpatient volume, case mix, and residency size based on the IME cap set by Medicare.
GME program funding was introduced in 1965 with the establishment of Medicare. 3 At that time, hospitals were able to add GME costs to their medical bills as usual and customary charges. In 1997, the Balanced Budget Act capped the number of training programs that Medicare would fund primarily due to concerns of increased costs in physician training. 3 DGME payments are based on a hospital-specific per resident payment amount that was determined in 1984 and is updated for inflation. Since 1997, IME payment adjustments have decreased, and in 2010 the Medicare Payment Advisory Commission (MedPAC) recommended that a portion of IME payments be made contingent upon reaching desired educational outcomes and objectives. 2 Despite the cap put in place in 1997, over 15,000 new residency slots have been added that are “over cap.” 3,4 These residency programs are not funded through Medicare and in fact are
In addition to Medicare, state Medicaid programs have paid over $3.78 billion to support GME programs. 5 Veterans Affairs (VA) hospitals have also contributed to GME funding as over one third of all residents rotate through VA facilities during their training. 6 Several states also support GME through different legislative initiatives. In Oklahoma, the legislature has appropriated funds in years past to support rural residency program development across the state. 7
While GME funding remains a critical aspect of physician training, it is being considered as an area that can be potentially targeted for cuts by the federal government to solve budgetary issues. 1,2 In order to successfully advocate for continued federal support, it is important that each GME program and program director understand the components and funding mechanisms of the GME programs.
In 2008, the Association of Program Directors in Internal Medicine (APDIM) performed a survey to assess program director knowledge of GME funding.8 As a follow-up to that study and to better understand GME funding overall in our region, we surveyed GME program directors of an osteopathic GME consortium to assess their knowledge level of GME funding.
The primary purpose of this study was to assess by survey the knowledge of residency program directors as it relates to GME funding. The sample size for this study consisted of 25 program directors of either residency or fellowship programs in the Osteopathic Medical Education Consortium of Oklahoma (OMECO). The questions for the program director survey (figure 1) were uploaded by the Oklahoma State University (OSU) Center for Health Sciences Office of Educational Development (OED) and entered into the SurveyTracker program.
The OED designee emailed the survey to the identified OMECO program directors for completion. After approval by the OSU Institutional Review Board (IRB), the survey was launched on October 1, 2013 and concluded on December 1, 2013. Reminders were emailed to all program directors every two weeks to complete the survey. All reminder emails were approved by the OSU IRB.
Participation in the study was voluntary, and the survey program utilized was set-up in an anonymous mode. Therefore, all responses to this survey were confidential. All survey results were reviewed by the authors and all study data was kept confidential.
A total of 12 responses were received for the survey (figure 2).
All of the responses were from program directors of residency programs. In general, the majority of respondents (83%) were less than 50 years old, had been in practice less than 20 years (83%), had been a program director for less than 10 years (93%), and were faculty members (93%).
The most notable and significant finding of the survey was the general lack of knowledge regarding GME programs. With respect to DGME funding, 83% of respondents were unaware of the amount of funding the program received for resident stipends. Additionally, none of the respondents were aware how much funding was received for faculty programming. Despite this acknowledged gap in awareness, only 50% of respondents ever attempted to find out through any source how much DGME funding was received. Moreover, none of the respondents were aware of the amount of IME funds received. Despite being aware of the residency caps set by the Centers for Medicare and Medicaid Services (CMS) and unsubsidized residents employed at the institution, general funding knowledge of GME programs appeared to be lacking.
Despite our best efforts to encourage program directors to complete the survey, only twelve responses were received out of the potential twenty five. These respondents did, however, give us a glimpse into the general thought patterns of the program directors. Our hope would be that on a national level, the osteopathic training leaders would develop a national survey to attain the thoughts of all program directors of osteopathic training programs. With that information in hand, a national working group could be convened to develop a pathway that could be applied to training institutions at the local level. On a final and ironic note, it is worth stating that prior to the survey the program directors attended a mandatory one-hour GME review session. In this session, a national osteopathic GME expert reviewed GME funding and its relevant mechanisms with all of the program directors. Despite this recent training session, it appears that the program directors still lacked the knowledge necessary to fully understand as well advocate for the GME funding issue. Perhaps program directors view the financing aspects of GME as uninteresting or “someone else’s job.” Or perhaps no one really cares about GME funding until a crisis is in full swing. From this we can only conclude that the road to GME financial literacy is a long and arduous one.
GME funding is critical to the advancement of medicine in the US. The knowledge of GME funding must be enhanced at the program director level to ensure that those ground leaders of GME can take the funding message to a higher level within their organizations and to state leaders to advocate for their training programs. A national review and reform of GME must be undertaken to ensure the program remains intact. While a national reform is needed, state and local leaders must convene to develop unique ideas to support GME funding.
1. Council of Graduate Medical Education. Twenty-first report: improving value in graduate medical education [Internet]. Rockville (MD): COGME; 2013 Aug [cited 2014 Feb 20]. Available from: http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/ twentyfirstreport.pdf
2. Medicare Payment Advisory Commission. 2010. Report to Congress: Aligning Incentives in Medicare. Washington, DC: MedPAC.
3. Iglehart JK. Financing Graduate Medical Education - Mounting Pressure for Reform. N Engl J Med. 2012; 366: 1562-1563.
4. Brotherton SE, et al. Brotherton SE, Etzel SI. Graduate medical education, 2011–2012. JAMA. 2012; 308: 2264–79.
5. Chen C, Petterson S, Phillips RL, Mullan F, Bazemore A, O’Donnell SD. Toward graduate medical education (GME) accountability: measuring the outcomes of GME institutions. Acad Med. 2013; 88: 1267-1280.
6. Goodman DC, Robertson RG. Accelerating physician workforce transformation through competitive graduate medical education funding. Health Aff (Millwood). 2013; 32: 1887-92.
7. Oklahoma Hospital Residency Training Program Act, HB 3058, Oklahoma Legislature (2012).
8. Chaudhry SI, Khanijo S, Halvorsen AJ, McDonald FS, Patel K. Accountability and transparency in graduate medical education expenditures. Am J Med. 2012; 125: 517-522
9. Salsberg E, Rockey PH, Rivers KL, Brotherton SE, Jackson GR. US residency training before and after the 1997 Balanced Budget Act. JAMA. 2008; 300: 1174–80.
10. National Commission on Fiscal Responsibility and Reform. The moment of truth: report of the National Commission on Fiscal Responsibility and Reform [Internet]. Washington (DC): White House; 2010 Dec [cited 2014 Feb 20]. Available from: http://www.fiscalcommission.gov/sites/fiscalcommission.gov/files/documents/TheMomentofTruth12_1_2010.pdf
11. Office of Management and Budget. Budget of the United States government, fiscal year 2014 [Internet]. Washington (DC): OMB; 2013 [cited 2014 Feb 20]. Available for download from: http://www.whitehouse.gov/omb/budget/Overview
12. Graves JA. Medicaid expansion opt-outs and uncompensated care. N Engl J Med. 2012; 367: 2365-2367.
13. Chatterjee P, Joynt KE, Orav EJ, Jha AK. Patient experience in safety net hospitals. Arch Intern Med. 2012; 172: 1204-1210.
14. Agrawal S, Brennan N, Budetti P. The sunshine act-effects on physicians. N Engl J Med. 2013; 368: 2054-2057.
15. Department of Health and Human Services. Modified policy on freedom of information act disclosure of amounts paid to individual physicians under the Medicare program. Fed Regist. 2014; 79: 3205-3206.
16. Iglehart JK. The residency mismatch. N Engl J Med. 2013; 369: 297-299.
17. Gomez PP, Willis RE, Jaramillo LA. Evaluation of a dedicated, surgery-oriented visiting international medical student program. J Surg Educ. 2013 [article in press].
18. Mullan F, Chen C, Steinmetz E. The geography of graduate medical education: imbalances signal need for new distribution policies. Health Aff (Millwood). 2013; 32: 1914-1921.
19. All-Payer Graduate Medical Education Act of 2001. H.R. 2178, 107th Cong. (2001).
20. Medical Education Trust Fund Act of 2001. S. 743, 107th Cong., (2001).
21. Shannon SC, Buser BR, Hahn MB, Crosby JB, Cymet T, Mintz JS, Nichols KJ. A new pathway for medical education. Health Aff (Millwood). 2013; 32: 1899-1905.
22. Florida Medicaid, SB 1646, Florida Legislature (2012).
23. Florida Medicaid Managed Care, SB 730, Florida Legislature (2012).
24. Spero JC, Fraher EP, Ricketts TC, Rockey PH. GME in the United States: a review of state initiatives. Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill. September 2013.