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What Can States Do For Graduate Medical Education?
Paul H. Rockey, MD, MPHScholar in Residence
Accreditation Council for Graduate Medical Education
ORGANIZATION OF STATE MEDICAL ASSOCIATION PRESIDENTSJune 6, 2014
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U.S. Spends $2.7 Trillion Per Year on Health Care
• $8,400 per person per year • Median household income $51K • Enough money to invest in the health-
care workforce, including physicians• How should we pay for GME?
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GME Funding Issues• Need more GME positions to keep up with
population growth, aging, chronic diseases and medical school expansion
• Need new training venues to meet community health needs
• Need GME positions in new models of health care (medical homes/chronic care models)
• Need to fund emerging costs (accreditation, technology, simulation, faculty, duty hours, etc.)
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Projected shortages of physicians, 2008 to 2020
58,000
91,500
7,40030,200
64,100
With ACA
Without ACA
Projections prepared by the Lewin Group for the AAMC.
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Medicare funding of Graduate Medical Education
• Medicare is funded by a payroll tax • Spends $525 Billion/year on medical services• Pays $9.5 Billion/year to teaching hospitals for
GME as part B (hospital revenue)• Less than 2% of Medicare is spent on GME • GME payments are tied to hospital beds
occupied by Medicare patients• Medicare funding of GME “capped” in 1997
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Explicit Payments for GME
• Total as much as $15 Billion from all sources: Medicare, Medicaid, VA, DOD, CHGME, HRSA, direct state support, other...
• GME spending is only 0.56 percent of the 2.7 Trillion spent on health care
• Fundamental to future medical workforce
What’s the problem?
• “Public good” vs. “subsidy to professional education”
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Projected U.S. Medical School Graduatesand First-Year GME
Approximately 7,000 IMGs also entered first-year GME in 2009.Projects 1% annual growth in number of first-year GME positions.Data compiled by AAMC Center for Workforce Studies, 7/2009 from 2008 AACOM and AAMC sources.
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Most GME funds go to teaching hospitals
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Most data on GME are national.
Why look at states?
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State Governments in the U.S. Control the Delivery of Health CareStates determine• who can deliver health care through
professional licensing boards and scope of practice legislation
• what services are paid for by Medicaid and private insurers through insurance regulations and legislated benefits
• how care is provided through regulations of health-care facilities
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States’ Roles are Expanding
• States fund public medical schools and several are funding new medical schools.
• The Affordable Care Act (ACA) strengthens States’ roles by vesting in them authority to expand Medicaid and/or to create state-based insurance exchanges.
• There is a high degree of variability among the States.
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Resident physicians per 100,000 state population
10 or fewer residents11 – 20 residents21 – 30 residents31 – 40 residents41 – 50 residents60 or more residents
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• Develop sustainable all payer funding
• Assess health care workforce regularly
• Train in settings accountable to populations
• Create new state-wide structures to allocate GME among specialties, geographies and sites
• Target GME expansion to high priority needs
What States Can Do
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What States Can Do
• Tap private insurance as a sustainable source for GME funding: – Bill in the California Assembly would levy an insurance
surcharge to fund $100 M/year for Graduate Medical Education
• Appropriate funds to initiate new (or expand existing) GME programs: – Georgia is creating new residency programs in “virgin”
hospitals that will qualify for Medicare funding– North Dakota, Florida and Wisconsin have appropriated
funds to expand residency training
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What States Can Do
• Award GME funds to teaching sites in non-hospital settings: – Kansas, Minnesota, Missouri, and West Virginia – States with large rural populations
• Target Medicaid GME funding toward State workforce needs: – Most States already fund residency training, either
through appropriations and/or Medicaid– GME funding by Medicaid totals nearly $4B per year– States could shape GME with their Medicaid funds
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Why Use Medicaid to finance GME?
• States control Medicaid expansion under the ACA• States could link health workforce training to
innovative models of care for Medicaid recipients, for example, in Teaching Health Centers (THCs)
• Medicaid has the advantage of Federal matching • 1115 Medicaid Waiver application:
– Illinois waiver would restore Medicaid GME, targeted to shortages and THCs
• Caution: Contracting Medicaid to for-profit insurance companies may exclude GME funds
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National “Game Changers”
• Institute of Medicine Report on the Governance and Financing of Graduate Medical Education– to be released June 19
• Single GME Accreditation System– ACGME and AOA have agreed to work together
• Congressional Action may still happen– Several Bills would lift Medicare cap on GME funding,
(with conditions)– For details, check out the AAMC website at:
www.aamc.org
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What Can States Do For Graduate Medical Education?
Paul H. Rockey, MD, MPHScholar in Residence
Accreditation Council for Graduate Medical Education
ORGANIZATION OF STATE MEDICAL ASSOCIATION PRESIDENTSJune 6, 2014