Thursday, September 8, 2011

Is Graduate Medical Education Funding worth it?

Graduate Medical Education has for the most part escaped big budget cuts in the past, mainly because powerful lawmakers have aligned to protect funding for teaching hospitals in their own states and districts. Plus, the Association of American Medical Colleges, the American College of Physicians, hospital organizations, and many others long have made funding for GME a top legislative priority.

GME, though, could be on the chopping block as Congress’s new “Super Committee” comes up with recommendations to reduce the deficit by at least $1.2 trillion over the next decade. A report from the Congressional Budget Office of options to reduce the deficit to reduce the deficit suggests that $69.4 billion could be saved over the next decade by consolidating and reducing GME payments. Earlier this year, the bipartisan Fiscal Commission on Fiscal Responsibility and Reform also proposed trimming GME payments.

How then should those who believe that GME is a public good respond? One way is to circle the wagons and just fight like heck to stop the cuts. But that raises a basic question: is GME so sacrosanct that there shouldn’t be any discussion of its value and whether the current financing structure is effective and sustainable?

Another approach, the one taken by the ACP in a position paper released yesterday, is to acknowledge that GME financing needs to be aligned more strategically with the country’s workforce needs, and that the responsibility of paying for it should be shared among all payers, so the federal government’s share would gradually decline.

In its 26-page policy paper, ACP provides 11 recommendations to preserve sufficient funding to support GME in the United States while ensuring that such spending is used effectively, including policies to:

• Require that all payers (insurers) be required to contribute to GME financing.
• Strengthen transparencies, accountabilities and value, including aligning financing with an assessment of workforce needs,
• Weighting funding to support programs that train primary care physicians and other specialties facing shortages,
• and funding pilots of innovative models to train physicians in the specialties and with the skills needed to meet societal needs.

ACP notes that the recommendations are made with the perspective that the federal deficit is at an all-time high and that there is an increased commitment to fiscal responsibility.

GME, in ACP’s view, is a public good. GME is a public good— it benefits all of society, not just those who directly purchase or receive it. All payers depend on well-trained medical graduates, medical research, and technical advances from teaching hospitals to meet the nation’s demand for a high standard of care. ACP believes that all payers derive value from this system and should share the investment in education and research. All payers should be concerned about preserving the nation’s system of GME, maintaining high standards of quality for patient care services and that opportunities for entry into the medical profession are available to the best-qualified candidates. Accordingly, ACP calls for a mechanism to be established to require all payers to explicitly contribute to GME.

I anticipate that there will howls of protest from the health insurance industry about having to pay their fair share of GME; many Republican lawmakers are likely to resist imposing a GME “tax” on health plans, and many Democrats will be concerned about even opening the door to any reduction in the federal government’s contributions to GME. But if we all benefit from having well-trained doctors, shouldn’t we all chip in? Why should taxpayers—and seniors enrolled in Medicare—be expected to pay almost the full freight?

And shouldn’t taxpayers, and others who contribute directly or indirectly to GME, have the right to insist that GME funds be spent more strategically, based on an assessment of the workforce that the country actually needs and the success of programs in producing doctors with the right skills and training?

Today’s questions: Do you think GME is a public good? Should all payers be required to contribute so that the federal government’s share gradually declines? Should training programs be accountable in how they use GME funds?

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