Graduate Medical Education Failing Primary Care

Bob Phillips, MD MSPHVice Chair, COGME

June 9, 2008

2

Status check: Family Medicine

Family Medicine

Positions 2008

Filled by US Graduates

3

LSU Family

Medicine Baton Rouge

CLOSED Just

before K

atrina

4

Family Medicine Fill Rate

5

Reliance on International Medical Graduates

IM

Anesthesiology

Pediatrics

PsychiatryPhysical

MedPathology

General Surgery

IM Sub-specialties

OBGYN

Family Medicine

-1000

-500

0

500

1000

1500

2000

Source: JAMA Medical Education Issues, thanks to Ed Salsberg, AAMC

Change in Number of IMGs in Training 2002-2006

6

IM Resident declining interest in generalist careers

24%23%

19%

16%

3%5% 5%

7%

0%

5%

10%

15%

20%

25%

30%

2002 2003 2004 2005

Source: Internal Medicine In-Training Examination Thanks to Ed Salsberg, AAMC(ACP, APM, and APDIM), Ibrahim

Generalist

Hospitalist

7

COGME 19th Report: Enhancing Flexibility in Graduate Medical Education

Recommendation 1: Align GME with future needs

Increase funded GME positions by a minimum of 15%, directing support to innovative training models which address community needs and which reflect emerging, evolving, and contemporary models of healthcare delivery

Recommendation 2: Broaden the definition of “training venue” (beyond traditional training sites)

Decentralize training sites

Create flexibility--allow for new training venues while enhancing the quality of training for residents

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Recommendation 3: Remove regulatory barriers limiting flexible GME training programs and venues

Revise current rules that restrict the application of Medicare GME funds to limited sites of care

Use CMS's demonstration authority to fund innovative GME projects with the goal of preparing the next generation of physicians to achieve identified quality and patient safety outcomes by promoting training venues that follow the Institute of Medicine's (IOM) model of care delivery

COGME 19th Report: Enhancing Flexibility in Graduate Medical Education

9

Recommendation 4: Make accountability for the public’s health the driving force for graduate medical education (GME)

Develop mechanisms by which local, regional or national groups can determine workforce needs, assign accountability, allocate funding, and develop innovative models of training which meet the needs of the community and of trainees

Link continued funding to meeting pre-determined performance goals

COGME 19th Report: Enhancing Flexibility in Graduate Medical Education

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COGME: Relationship Between Physician Reimbursement and Specialty Choice?

Unintended Consequences of Resource Based-Relative Value Scale Reimbursement 1

“Medicine’s generalist base is disappearing as a consequence of the reimbursement system crafted to save it – the RVRBS”

“The US physician workforce is unique among developed economies of the world. Virtually all European countries have a broad generalist foundation comprising 70%-80% of all practicing physicians. The United States is the opposite”

1. Goodson JD. Unintended Consequences of Resource Based-Relative Value Scale Reimbursement. JAMA. 2007:298:19:2308-10

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The Primary Care – Specialty Income Gap: Why it Matters

“Incomes of primary care physicians are well below those of many specialists, and the primary care-specialty income gap is widening.”

“The volume of many procedures performed by specialists has increased more rapidly than office visits, at times in dramatic fashion, contributing to faster income growth of some specialists as compared with that of primary care physicians”

“The sustainable growth rate hurts primary care”

“Private insurer payments favor specialty care over primary care to a greater degree than does Medicare”

Bodenheimer T, Berenson RA, Rudolf P. The Primary Care – Specialty Income Gap:

Why it Matters. Annals of Internal Medicine. 2007;146(4):301-6.

COGME: Relationship Between Physician Reimbursement and Specialty Choice?

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Primary Care income less than other Specialties

Source: MGMA Physician Compensation and Production Survey, 2007

$50 $150 $250 $350 $450

Family Medicine/General Practice

General Pediatrics

General Internal Medicine

Psychiatry

Emergency Medicine

OB/GYN

Opthalmology

General Surgery

Otorhinolaryngology

Dermatology

Urology

Hematology/Oncology

Anesthesiology

Gastroenterology

Orthopedic Surgery

Diagnostic Radiology

Cardiology-Invasive

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COGME

• Will likely continue to expand its traditional scope in looking at influences and policy options of the education pipeline outcomes– Accountability

• Likely to be more direct in its advising of the Administration and the Congress– Traditional reports– Timely, topical letters– Meetings