Since the first Institute of Medicine (IOM) Report recommending reform of graduate medical education (GME) in 1989, its funding and governance have been debated extensively. The long awaited IOM GME Report issued July 2014 recommends major reforms, producing further heated debate and controversy among stakeholders.
GME priorities must respond to the current transformation of our health care system, insurance coverage, and the need for training physicians with new competencies. The House Energy and Commerce Committee Subcommittee on Health recently requested input regarding the 2014 IOM Report. The intensity of stakeholder debate reflected in the responses to date underscores the challenge faced by Congress in legislating reform.
There is an opportunity, however, to immediately initiate a reform agenda with minimal change to existing appropriations, and only slight modification of current statutes, by targeting GME expansion through the existing Teaching Health Center GME program (THCGME), and by rejuvenating the Council on Graduate Medical Education (COGME).
Sixty THCGME programs in 24 states are currently training over 550 residents in primary care, psychiatry and dentistry that have been supported by $230 million over five years. Without the recently enacted “Medicare Access and CHIP Reauthorization Act of 2015″ (MACRA), funding for these programs would have expired this year. We propose bipartisan legislation that enhances the THCGME program, with increased and more sustainable support.
Enhancements include increasing the number of positions, with an emphasis on rural and urban underserved areas, and curricular modifications, including the integration of behavioral medicine into primary care graduate medical education, as described in the accompanying post. We describe examples of current or proposed programs which illustrate the potential of these modifications.
Need for Immediate Targeted GME Expansion in Primary Care
There is broad agreement on the need for adequate numbers of physicians prepared to work in primary care, geriatrics and psychiatry in urban and rural underserved areas. A 12,000-31,000 shortage over current primary care physician supply in the next ten years is anticipated, depending on modeling considerations such as physician retirement rates and entrance of advanced practice nurses to take up some of the duties physicians currently perform. Regional and state level supply and demand varies greatly: demand could exceed baseline supply in some areas by more than 10 percent.
Advantages of THC Primary Care Training
Several legislative GME expansion proposals have been circulated, but none have gained support among most stakeholders, in part because they do not adequately target primary care. Expansion and modification of the THCGME program addresses the consensus issues that major stakeholders — including the Accreditation Council for Graduate Medical Education (ACGME), American Medical Association (AMA), and Council of Medical Specialty Societies (CMSS) — agree are needed, including primary care training and physician distribution issues.
In its 22nd report (2014), COGME reiterated its call for expanding the proportion of resident training time spent in ambulatory and community settings incorporating new competencies needed for modern practice. This includes education in a variety of clinical settings and locations, including THCs. COGME identified an increasing need for “an emphasis on population health, team-based care, and greater use of technology in patient care to prepare residents for the future health care system.” COGME specifically recommended that THCGME funding should be stabilized with dedicated ongoing support that is distributed directly to the sites and programs where the education and training takes place.
Since THCs are generally located in Community Health Centers (CHCs), Rural Health Clinics, and other safety net settings that serve a large percentage of Medicaid and uninsured patients, they provide residency training in needed specialties for the underserved in many geographic areas. THCGME leadership surveys reinforce prior evidence that those who train in such settings are likely to remain and practice in them. Even with the enactment of MACRA, without an immediate increase in Congressional funding, the THCGME program will not continue to meet the GME targets the program already has demonstrated.
Current Achievements of THCGME Program
The THCGME program was authorized by the Affordable Care Act (ACA) in 2010. It began with 11 programs and 63 residents in 2011 and has grown to its current enrollment in three years. Early evidence suggests THCGME is producing the physicians it was designed to deliver, with over 90 percent of graduates intending to work in primary care, and more than three out of four in underserved communities. THCGME graduates are taking positions in rural settings at almost three times the rate of traditional graduates, 21 percent compared to 8 percent. Patient-centered medical home (PCMH) curricular innovations inspired by program expansion quickly and consistently have improved the knowledge, attitudes and skills of internal medicine residents, as documented by one large program.
Even in the face of a rapid increase in applicant interest, many potential THC programs have not applied because of long-term funding concerns (Personal communications with Paul James, immediate past president of the Association of Departments of Family Medicine). A recent survey of THC program leadership indicates most will not recruit this year without evidence of stable funding.
Proposed Modifications Of The THCGME Program
The THCGME program has been successfully initiated. Nevertheless, significant modifications could enhance its capacity to achieve its mission. Another Health Affairs Blog post describes the advantages of integrating behavioral medicine training with the primary care residency curriculum for pediatricians, general internists and family medicine.
This paradigm would also apply for integration of geriatric training in family medicine and general internal medicine (GIM) THC residencies. These curricular modifications, along with greater integration of preventive medicine, palliative care and population health training, would produce primary care physicians with greater capacity to address the challenges of 21st century practice.
Integrating geriatric training into the curriculum for family medicine and GIM residents is imperative, considering the aging of the American population and the current lukewarm interest in specializing in the field, which leaves 44 percent of fellowship slots unfilled. These modifications require a reduction in the current time spent in certain inpatient training settings, especially for internal medicine residency training programs where increased focus on ambulatory settings would prepare internists for general practice and collaborative practice with hospitalists.
Legislation Required for THCGME Viability
Implementation of the necessary additional funding for THCs above the $60 million per year for two years authorized by MACRA would require drafting legislative language that can be supported by both sides of the aisle, working with the appropriate House and Senate committees of jurisdiction. Adequate funding through MACRA would provide a level of stability that enables sponsoring institutions to establish high quality programs focused on current GME needs.
We propose funding a total of 900 residency positions for this three-year program in order to produce about 300 graduates entering the workforce annually once the program is fully implemented, keeping in mind most but not all programs are three years in duration. After full implementation, adequate MACRA funding would require an amount representing about a 1 percent increase per year in current Medicare support of GME, which has not increased for almost 20 years since imposition of training caps by the 1997 Balanced Budget Act. The return on investment by training cost-conscious primary care physicians who address the current needs of the population cannot be over emphasized.
Timing for Implementation of the New THCGME Program
With sustainable funding, and the described curricular innovations to produce the primary care workforce the nation needs, we anticipate a substantial increase in uptake by medical and dental training programs poised to implement and support this paradigm. There has been a great deal of student interest in the THCGME programs. The incentive of National Health Service Corps education debt repayment for practice in underserved areas is attractive to students, particularly those from economically disadvantaged backgrounds, a needed cohort in medical practice.
In order to sustain the current THCGME program and achieve the described expansion, legislation would need to be enacted by July of 2015. This would allow expansion of current programs in time to prepare for the 2016 National Residency Match Program and new programs to become accredited in preparation for academic year 2017-2018.
Administrative and Funding Logistics of the New THCGME Program
Administration of the THCGME program should be continued by HRSA’s Bureau of Health Workforce through an interagency agreement with the Centers for Medicare and Medicaid Services (CMS) to provide funding as provided by Congressional authority. This approach would assure program stability and growth, and would maintain the oversight and evaluation already in place.
Selection and support of new programs should favor those which feature modifications as described here. The mechanism for funding, which flows to the site of residency training via educational consortia, has been described previously.
A Currently Funded Inner-City THC Program With Integration of Psychology Faculty, A PCMH, And EHRs
The Erie/Northwestern THC program is a family medicine residency of the Northwestern/Feinberg School of Medicine in Chicago. The number of applicants for this program, practice location of its graduates, and educational consortium mechanism for funding all serve to substantiate the efficacy of the THC program.
A major focus of the program is on building team-based care; it integrates behavioral health providers into patient care at the point of care. The Integrated Behavioral Health Consultant (IBC) has “an open-door” policy where providers “flag” the IBC to initiate a warm handoff among the patients, primary care providers, and the IBC. Residents gain experience and confidence in shared responsibility in caring for patients with other skilled clinicians on the team. Integrated electronic medical records enable medical staff and behavioral health specialists, social workers, psychiatrists, and psychologists to share progress notes to assure communication among the team members.
This outstanding program graduated its first class of eight residents in July 2013. All graduates practice in primary care and staff CHCs, with five remaining at Erie. All four resident classes to date have recruited outstanding medical school graduates. Of the 868 applicants for 2015, 323 were U.S. medical school graduates.
A Proposed Rural THC Program Emphasizing General Internal Medicine
The Family Health Center of Marshfield, Wisconsin is a CHC with an 11,579 square mile service area located within a 15-county region in North Central Wisconsin. This predominantly rural area is comprised of 302 municipalities, 66 percent of which are populated by less than 1,000 people. This rural CHC targets all individuals living at or below 200 percent of the Federal Poverty Level who experience access to care barriers, and individuals who encounter geographic and/or cultural/linguistic barriers. In most of the service area, access to dental and behavioral health care has been a major problem and public transportation is limited or nonexistent. Forty percent of the service area population reside in federally designated shortage areas.
Marshfield Clinic (MC) has been a state leader in training health care providers to practice in rural and underserved areas since 1927. MC, in partnership with Ministry Saint Joseph’s Hospital (MSJH), has successfully developed several GME programs, including internal medicine and pediatrics, since it commenced residency training in 1975. With that foundational framework, MC also became a designated campus of the University of Wisconsin School of Medicine and Public Health (UWSMPH) in 2007 and, subsequently, the inaugural site of its Wisconsin Academy for Rural Medicine (WARM) program in 2009. Specifically, WARM is dedicated to improving the supply of physicians in rural Wisconsin and improving the health of rural Wisconsin communities. WARM will have graduated over 25 MC-based students by May of 2015.
The MC/MSJH Internal Medicine Residency Program has trained many primary care and sub-specialist physicians for rural areas for many decades. It is well suited for expansion to meet the needs of the state of Wisconsin. Residents would train at the main campus at Marshfield and at regional MC CHC sites such as Park Falls or Minocqua. Unfortunately, the lack of sustainable funds obstructs this mission. The THCGME program would allow the MC/MSJH Internal Medicine Residency Program to expand from its current capacity of 24 trainees. Expansion of primary care internal medicine training in modified THCs recently has been proposed to rejuvenate interest in general internal medicine.
Long the backbone and centers for both undergraduate and graduate medical education in the U.S., our teaching hospitals have major investments and focus on research, complex care, and care for uninsured. Even in the face of controversy over GME payment formulas, they represent a superb educational model that has been a beacon to the world. Yet, the number and types of physicians trained through our current GME system do not align with the specialties and skills required in our rapidly transforming health sector. Also, GME funding, transparency and accountability are receiving increasing attention.
Because of the complexity of required GME reform, and the diversity of stakeholders input, phased implementation of GME reform has recently been recommended to the Energy and Commerce Committee. Legislation required to rejuvenate COGME should be enacted as soon as possible, thereby allowing phased GME reform to proceed under COGME leadership. Meanwhile, our proposal to ensure viability of the THCGME program should be implemented immediately, with a level of sustained support which encourages participation of some of our outstanding primary care residency programs. A more viable THCGME program would facilitate its future further expansion as its efficacy is increasingly documented.
Our proposed legislation is based on broad and deep stakeholder support of the need for primary care physicians who are prepared to care for urban and rural underserved populations, armed with the training and competencies required to deliver continuous, comprehensive, accessible patient-centered care. Behavioral health and geriatric care, as well as palliative, preventive, and population health medicine, must receive increased curricular emphasis, supported by enhanced faculty training and development.
The THCGME programs are positioned to carry out this vital mission and accomplish the triple aim of improving population health and patients’ experience of care, while managing costs by shifting care away from high volume in-patient care to high-value personalized care. The THCGME well-developed PCMH system of care, electronic medical records, and high percentage of graduates who practice in underserved areas strongly support its potential impact.
Thus, sustained Medicare funding for this targeted, non-controversial approach to GME reform is compelling as an immediate legislative initiative. This relatively simple, widely supported initiative can accelerate GME training to deliver a new generation of physicians prepared to provide the right care and services to patients when and where they are needed.
Authors’ note: The authors’ recommendations do not necessarily represent the position of their present or past affiliations.