Stephen C. Shannon, DO, MPH

Good News, Bad News and Uncertainty for Graduate Medical Education

As we head into a new year, one of the biggest challenges confronting medical educators is how to ensure that our graduates have sufficient access to residency slots, so that they can continue their education and prepare to join the future physician workforce. This is not a new challenge, but recent activity at the federal level spells a combination of good news, bad news and just plain uncertainty as we look ahead.

First, the good news: In November, The Health Resources and Services Administration (HRSA) released a funding opportunity for its Teaching Health Center Graduate Medical Education (THCGME) Program, which will provide payments for direct and indirect expenses to qualified Teaching Health Centers (THCs) for the costs of new residents in a newly established THC, or an expanded number of residents in a pre-existing THC.  This five-year program, authorized and appropriated for $230 million under the Affordable Care Act (ACA), supports an increased number of primary care residents and dentists to be trained in community-based ambulatory patient care settings, including (but not limited to) federally-qualified health centers; community mental health centers; rural health clinics and health centers operated by the Indian Health Service; Indian tribes or tribal organizations; and entities receiving funds under Title X of the Public Health Service Act. 

In addition, the U.S. Department of Veterans Affairs (VA) has since Academic Year 2007-2008 expanded its graduate medical education funding.  Now in the fifth year of this expansion, the VA Office of Academic Affiliations will provide funding for about 250 new, permanent resident positions nationwide in AY 2011-2012 (residents start July 1, 2011). For more information about the VA opportunities, visit here.

The THC funding program and VA expansion program are good news. They increase primary care GME opportunities, set a strong precedent for providing GME funding outside of the traditional Centers for Medicare and Medicaid Services (CMS) funding stream, and create new and innovative means of training medical residents outside of the traditional venue of the hospital. Whether such programs are a harbinger for a broader restructuring of how GME is funded remains to be seen.

One recent attack on Medicare-funded GME makes finding alternatives all the more important, and represents the bad news that may haunt us in 2011 and beyond. On December 1, the National Commission on Fiscal Responsibility and Reform released its final report, entitled "The Moment of Truth," with recommendations for reducing the nation’s deficit.  Established this year by Presidential Executive Order, the bipartisan Commission has worked for the past several months to develop recommendations aimed at improving the nation’s current fiscal situation and achieving long-term fiscal sustainability. While the final report was not approved by a sufficient Commission majority for it to be forwarded to Congress for consideration, some version of the report is expected to go forward, and members of Congress will be guided by at least some of the findings.  

As I noted in my recent press statement on the topic, the report includes a recommendation to severely cut the graduate medical education funding that CMS provides to hospitals with teaching programs for physician residents. These programs currently receive approximately $9.5 billion annually, which cover the costs of more than 100,000 residents. The Commission recommends cutting around 50 percent of this funding—an extraordinarily large proportion—to the tune of $60 billion over 10 years.  And that would be very bad news for GME indeed.

We all know that a variety of factors are driving the need for greater numbers of physicians to serve the nation’s public — current and projected physician workforce shortages; 32 million newly insured individuals resulting directly from the Affordable Care Act; an aging population and a concomitant rise in the incidence of chronic disease; the demographics of the current physician population (one-third of physicians are over age 55, and current trends point to more family medicine physicians retiring than entering the specialty for a number of years); and new models of care aimed at providing more accessible, more affordable care to more Americans.  If funding for GME were to be cut as recommended by the Commission, residency programs would be unable to continue educating their current number of residents, much less the additional graduates we are all working so hard to produce by establishing new schools and increasing class sizes.

All of which leads to the uncertainty regarding graduate medical education.  In their efforts to control costs and reduce the nation’s growing deficit, will policy makers whittle away at one of the nation’s most important funding sources for future physicians? Alternatively, will policy makers find ways to create new and innovative avenues for increasing GME funding, thereby recognizing the vital role GME plays in ensuring an adequate physician workforce? And, finally, will the nation finally come to terms with its traditional structure of GME financing and work to build a new and improved way of providing educational funding for new medical school graduates? Only time—and a concerted effort on the part of the entire medical education community—will tell.

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