Stephen C. Shannon, DO, MPH
Innovation: The Key to Solving the GME Dilemma
“Given the current concern over the federal deficit, the likelihood that Congress will remove the cap on Medicare’s GME support is nil. Indeed, holding on to existing GME support may be the best outcome medical educators can hope to achieve.”
So wrote John K. Iglehart, national correspondent for The New England Journal of Medicine, in the journal’s September 2011 issue. Since that article’s publication, serious threats to Medicare-funded graduate medical education (GME) have continued to surface in congressional negotiations, and in President Obama’s fiscal year 2013 budget proposal. And, AACOM continues to advocate for Mr. Iglehart’s best-case scenario—sustaining the $9.5 billion in federal support that currently constitutes the lion’s share of Medicare-funded GME.
But even if we and other advocates are successful in maintaining current GME funding levels, there will be insufficient funding available to provide residency training to the increasing numbers of physicians this country needs and medical schools are graduating. The growing population of aging Americans (many with chronic diseases) and the potential of adding more than 30 million individuals to the insured population under the Affordable Care Act (ACA) are just two of the factors driving the need to increase the nation’s physician workforce. And, while the number of osteopathic medical schools and enrollment in those schools is growing dramatically (enrollment is expected to have doubled between 2002 and 2015), if there are insufficient numbers of GME positions for graduating osteopathic physicians, our growth will be for naught.
With necessity being the mother of invention, I believe there are possible innovative solutions to our GME dilemma. What would happen, for example, if through expert planning and reform, the number and distribution of GME positions were tied directly to the number and type of positions needed, with an eye to geographic, demographic, and specialty need? What might happen if more programs were developed at hospitals that do not fall under the GME cap? Or if osteopathic medical colleges were to work with their Osteopathic Postgraduate Training Institutes (OPTIs) on creative development of more GME programs, in association with a variety of institutions and funding mechanisms? Or if the Teaching Health Center GME Program, which provides funds to establish or expand primary care residency training programs in community health centers, were expanded (or at least sustained) beyond the five-year trial basis funded by Congress as a part of the ACA?
Whatever the ultimate answers to these questions may be, I hope it is the medical education community and health care organizations that take the lead on closely examining them and suggesting reforms to our current GME system, rather than leaving scrutiny and decision making solely in the hands of our elected officials. I am heartened by the close attention being paid to GME examination and reform by groups ranging from the Josiah Macy Jr. Foundation (see Ensuring an Effective Physician Workforce for the United States: Recommendations for Graduate Medical Education to Meet the Needs of the Public) to the Council on Graduate Medical Education (see its November 2011 letter to Congress). And I am also hopeful that the Institute of Medicine, which currently is developing a special committee to examine the structure, funding and governance of GME, will put forth innovative and sustainable recommendations.
Innovation certainly will be the key to the success of any of these groups in effectuating positive, sustainable change. Thus, I hope my colleagues throughout the osteopathic medical education community and beyond will join with me in supporting and leading discussions around GME innovation. If we do not join together as vocal advocates, and instead leave it to others to define GME innovation, reforms may be implemented that are not in the interests of our students, or the patients they will serve.