Can the state shift the balance of power in GME?

Should medical schools that receive state support for residency training be expected to produce the kinds of physicians Texas needs to ensure a cost-effective, high-quality, well-coordinated, more equitable health care delivery system? That’s the policy question posed by a Texas Tribune news article from March 10, 2011, “Budget Rider Would Emphasize Primary Care.”

The budget rider in question would concentrate state support for graduate medical education by paying for only the first three years of residency training, rather than supporting training in years four through seven, some part of which are required for subspecialties. The idea is controversial, and of course opposed by many academic health centers and by the Texas Medical Association, but it’s exactly the kind of reform to medical education that’s gathering momentum across the country.

The recently published 20th report of the Council on Graduate Medical Education proposes that a major culprit behind the declining interest in primary care among medical students is the “hidden curriculum” found in academic health centers that favors specialty care provided in the hospital setting over primary care. How did this “hidden curriculum” come to be? Because GME programs at large teaching hospitals have evolved to meet the needs of the academic health center rather than the general population.

Here’s what the COGME report has to say:

“Although Medicare capped its funded GME slots in 1997, accredited GME positions have grown 6.3 percent from 2003-2006, virtually all of which are self-funded by the hospitals. Despite this increase, a rise in subspecialty rates led to fewer physicians pursuing generalist careers. Like student choices, this build-out of residency training positions is highly correlated with specialty income. Teaching hospitals invest in lucrative services in order to support their bottom line and residents and fellows are an inexpensive way to support those services. Increasing options for subspecialization has both direct and indirect effects on primary care production, first by closing primary care positions to be used for subspecialty training, and second by giving would-be primary care physicians options to subspecialize. The net effect is a substantial reduction in primary care production from GME, now at about 29 percent or less compared to 32 percent from 2003 to 2008. In bending BME to service their financial bottom line, the needs of the population are not best served.”

Texas is spending somewhere between $75 million and $79 million on GME formula funding in the current biennium, and the proposed budgets in the House and the Senate would drop that to between $53 million and $57 million. The money is doled out based on how many residents are in training at residencies affiliated with the schools, so the amounts for each vary widely. The University of North Texas Health Science Center at Fort Worth would get around $1.6 million while the University of Texas Southwestern Medical Center at Dallas would get about $13 million.

But that’s not where the schools get most of their GME funding. The bulk of GME funding comes from Medicare in the form of Direct Medical Education payments and Indirect Medical Education funding. Both streams are calculated with methodologies based on the number of residents in training at a teaching hospital, and the payments go to those hospitals. What’s more, Medicare only reimburses teaching hospitals for the time residents spend in the hospital, which is fine for most specialties, but detrimental to primary care. For family medicine residents, the most important classroom is the outpatient clinic, and unless that clinic is attached to the teaching hospital, residency administrators have to fight tooth and nail to secure resident stipends from their training hospitals.

For a teaching hospital, having subspecialty residents is good for the bottom line for three reasons. As COGME points out, they’re cheap labor for expensive procedures, so the revenue attributed to the practice plan goes up while the costs are held in check. Secondly, the more residents you have training in the hospital, the more Medicare GME dollars you can draw down. And thirdly, having a robust subspecialty GME program makes you a prime candidate for lucrative research grants from the National Institutes for Health.

A study published in the Annals of Internal Medicine last year ranked the nation’s medical schools by the amount of primary care physicians they produced. The authors found that research funding often warps the mission of academic health centers away from primary care. 

“The level of NIH support that medical schools received was inversely associated with their output of primary care physicians and physicians practicing in underserved areas. High levels of research funding clearly indicate an institutional commitment to research and probably indicate missions that value technical medicine and specialization rather than training in primary care and practice in underserved areas.”

In January of last year, TAFP published an article in Texas Family Physician examining the reasons behind the closure of the Baylor College of Medicine Kelsey-Seybold Clinic Family Medicine Residency Program. Among the events leading to the program’s termination was the decision by its main teaching hospital, St. Luke’s Episcopal Hospital, to reduce the stipends it paid for family medicine residents. I asked Steve Spann, M.D., senior vice president and dean of clinical affairs at Baylor College of Medicine, for his perspective on that decision by St. Luke’s. Here’s his response as quoted in the article:

“They did that unilaterally and despite some pretty strong protest from us, but they felt it was more to their benefit to put those stipends into neurosurgery.”

So here we are, after the passage of health care reform, trying to prepare at the state level for the implementation of its various components, yet still confronted by a fragmented, fractured delivery system without enough primary care physicians to make it all work. The COGME report makes a compelling argument that if we are to change the ratio of primary care physicians to specialty physicians in America, we must implement strategies to “improve GME and modify incentives so that they foster interest in primary care education and careers.” Seems to me this GME formula funding budget rider might be the right strategy at exactly the right time.


One Response to “Can the state shift the balance of power in GME?”

  • St. Luke’s also made a unilateral decision to keep back GME funding in 1987 rather than passing it on to those training family physicians, just a few months after I joined the department of family medicine. A promise to Rakel for 21 FTE by Baylor got to about 15 before shrinking substantially. Not surprisingly there are new calls to examine teaching hospital GME funding decisions.

    Mayo in Arizona recently converted family medicine to subspecialty positions.

    State cuts prevented me from becoming a teaching family physicians in the state of Texas as my job suddenly disappeared.

    A good friend and top FM doc also boarded in Ob-Gyn was prevented from becoming a teaching Texas doc by the licensure situation where weeks of missing data from facilities that no longer exist outgun double boards and stellar contributions.

    US MD schools have only 4% of full time faculty as family physicians (Barzansky, JAMA). About 2 – 5% is the range for the 1000 zip codes with top physician concentrations that have 50% of the US workforce and 11% of the population in 1% of the land area. Fortunately these exclusions keep family physicians at 30 per 100,000 across all populations in need until family physicians are the only remaining workforce at 20 per 100,000 in the smallest locations.

    By the way, teaching hospitals are responsible for tens of thousands of primary care nurse practitioners and physician assistants being converted to hospital care. This was one consequence of resident work hours restrictions.

    Hospitalist workforce also stole about 20,000 internists and now hospitalist train substantial internal medicine and pediatric residency graduates – forcing new influences into “primary care” training that Keirns in Academic Medicine already noted as dysfunctional and responsible for driving medical students and residents away from primary care.

    Non-primary care designs have basically doubled the number of DO, MD, NP, and PA numbers result each 15 years from 1965 and until at least 2030 if not longer. Primary care numbers doubled only 1965 to 1980 and have remained stagnant despite generic expansions that train more but retain less in primary care. It is actually not possible to resolve primary care deficits under the current generic designs as these designs require too many graduates.

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