TY - JOUR
T1 - Medicare financing of graduate medical education
T2 - Intractable problems, elusive solutions
AU - Rich, Eugene C.
AU - Liebow, Mark
AU - Srinivasan, Malathi
AU - Parish, David
AU - Wolliscroft, James O.
AU - Fein, Oliver
AU - Blaser, Robert
N1 - Funding Information:
Arguments from traditional economics might suggest the public has no interest in or need to fund the direct cost of medical education.28 As this argument goes, residents are incompletely trained individuals who are seeking general training from hospitals and who pay for the cost of their education through their labor. Under this line of reasoning, if current public support for graduate medical education is inadequate, then residents will make up the difference through lower stipends, additional labor (either for the teaching hospital or through moonlighting) or personal loans. However, as Gbadebo and Reinhardt state, ``Thus, it might be argued ... that the complete self-financing of medical education with interest-bearing debt .. . would so commercialize the medical profession as to rob it of its traditional ethos to always put the interest of patients above its own. Indeed, it can be argued that even the current extent of partial financing of their education by medical students has so indebted them as to place the profession's traditional ethos in peril.''29 For faculty as well, inadequate GME funding has important effects on the work environment. As discussed previously, while DME payments are based on the hospital's historical estimate of training costs, hospitals are not required to demonstrate that they use these funds to support resident education. Not surprisingly, in many institutions, the financial support for education is not explicit and the critical work of resident training not directly supported. With declining clinical revenues and decreased funding of teaching hospitals, there is often increased pressure on faculty to concentrate on revenue-generating work rather than on teaching. Indeed, there may be negative incentives to devoting physician time to residency program administration, resident instruction, and faculty development. There can also be significant pressures to use residents to increase the financial productivity of the clinical services.
PY - 2002
Y1 - 2002
N2 - The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require "all-payer" support.
AB - The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require "all-payer" support.
KW - Graduate medical education
KW - Internship and residency
KW - Medicare
KW - Teaching costs
KW - Teaching hospitals
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U2 - 10.1046/j.1525-1497.2002.10804.x
DO - 10.1046/j.1525-1497.2002.10804.x
M3 - Review article
C2 - 11972725
AN - SCOPUS:0036231712
SN - 0884-8734
VL - 17
SP - 283
EP - 292
JO - Journal of general internal medicine
JF - Journal of general internal medicine
IS - 4
ER -