In the Gulf, the US and globally, demand for healthcare is increasing while models for healthcare delivery are changing. On the demand side the world’s population is growing, aging, and acquiring more chronic diseases that require continuing care, and additionally, either through greater affluence or through the availability of more affordable insurance, the public is gaining greater access to healthcare systems. In the US affordable insurance was part of the Patient Protection and Affordable Care Act (ACA - also called "Obamacare").
ACA payment metrics depend not just on high quality in-patient care, but also on providing integrated high quality community care that optimizes patient outcomes. In reality, although hospital services remain essential, the burden of chronic disease, the need for greater emphasis on preventive care, and use of modern information technologies mean that the provision of care takes place increasingly in community settings. Thus, our global academic mission is to prepare our workforce in smarter, faster and cheaper ways to keep pace with increasing demand in an evolving healthcare system.
The projected physician shortage in the US has led to at least 17 new medical schools, aimed at increasing the number of graduates from about 16,000 to 20,000 per year. However, despite having more undergraduates, residency training (GME) has been capped at approximately 24,000 slots with no immediate Federal Government plan to expand GME funding. This year, for the first time in history, a significant number of US medical school graduates did not match to a residency training slot. Clearly this disconnect will do nothing to address a US physician workforce shortage.
To address this changing landscape, the Josiah Macy Foundation commissioned the Institute of Medicine to study and make recommendations regarding the future nature, scope and funding of GME in the US. The report was published July 29, 2014 and the recommendations could have significant implications for specialty training in the US and around the world. (1)
The IOM Report indicated that the majority of public financing for GME ($15 billion in 2012) comes from the Medicare program. Since its enactment into law 50 years ago, Medicare has provided secure funding for residency training. As the number of funded residency training slots has historically been greater than the number of US medical graduates, residency training has been available to international medical graduates (IMGs) who met the requirements of the Educational Commission for Foreign Medical Graduates (ECFMG). Many IMGs from the Middle East have taken advantage of this opportunity to train in the United States. The statutes governing GME financing date from 1965, a time when hospitals were the central site for physician training. Medicare GME payment rules continue to reflect that era such that the current payment system actually provides disincentives for physician training outside the hospital, where today the majority of healthcare is delivered.
The IOM Report identified 6 key goals for GME:
- Encourage production of a physician workforce better prepared to work in, help lead, and continually improve an evolving healthcare delivery system that can provide better individual care, better population health, and lower cost
- Encourage innovation in structures, locations, and designs of programs to better achieve Goal 1[e.g. training outside of hospitals]
- Provide transparency and accountability for stewardship of public funding and achievement of goals
- Strengthen public policy planning and oversight for use of public funds and achievement of goals
- Ensure rational, efficient, and effective use of public funds to maximize their value
- Mitigate unintended negative effects of planned transitions in funding methods
The Report recommended significant reforms and urges Congress to amend Medicare law to allow a transition to an accountable, performance-based system with a 10-year transition and implementation period. Specific recommendations include:
- Maintain Medicare GME funding at its current level, but modernize payment methods to reward performance, ensure accountability, and incentivize innovation in the content and financing of GME. Phase out the current Medicare GME payment system. [This will impact the largest academic medical centers receiving the majority of Medicare GME funding.]
- Establish a two-part governance infrastructure for federal GME financing. A GME Policy Council in the Office of the Secretary of the Department of Health and Human Services should oversee policy development and decision making. A GME Center within the Centers for Medicare & Medicaid Services should function as an operations center with the capacity to administer payment reforms and manage demonstrations of new payment models.
- Establish a two-part Medicare GME fund: Allocate Medicare GME funds to two distinct subsidiary funds—a GME Operational Fund to finance ongoing residency training activities and a Transformation Fund to finance development of new programs, infrastructure, performance methods, payment demonstrations, and other priorities identified by the GME Policy Council.
Should these recommendations be implemented, the impact on IMGs seeking US residency training could be considerable:
- As the number of federally funded residency training slots will not increase in the foreseeable future, competition for existing slots will increase as the number of US graduates rises over the next decade, disadvantaging international graduates.
- The number of highly specialized, hospital-based “interventional” training opportunities often desired by IMGs will decrease as more Medicare support is directed towards primary care training.
However, in the Gulf, the current strategy to strengthen regional indigenous postgraduate training using North American models to address the growing demand for a well-trained workforce will also reduce the reliance on specialty training in North America considerably.
- The presence in the Gulf of the Accreditation Council for Graduate Medical Education International (ACGME-I), which is the international arm of the entity that accredits residency training in the US, ensures that the standards for residency training here in the region is of an equivalent standard to that in the US and Canada. ACGME-I trainees receive a, rigorous standardized clinical experience where knowledge, skills and attitudes are objectively assessed and evaluated.
- It is anticipated that medical specialty board certification will be made available through a North American board certifying body in addition to the ACGME-I accreditation of the residency training. As in North America, board certification will be time-limited and require continuing professional development to maintain certification throughout a physician’s professional career.
Although the path is not easy, through strengthening education and training based on international standards, implementing a maintenance of licensure and certification strategy, and by only hiring those with internationally acceptable credentials, the Gulf region will ensure that the healthcare workforce will be using performance-based standards in tune with the evolving health system, and ensuring the best patient outcomes for its citizens.
References and Additional Readings :
- Chandra A, Khullar D, M.P.P., and Wilensky GR.The Economics of Graduate Medical Education. N Engl J Med 2014; 370:2357-2360. June 19, 2014DOI: 10.1056/NEJMp1402468
- Crisp N, and Chen L. Global Supply of Health Professionals N Engl J Med 2014; 370:950-957. March 6, 2014DOI: 10.1056/NEJMra111161
- Iglehart JK. The Uncertain Future of Medicare and Graduate Medical Education. N Engl J Med 2011; 365:1340-1345. October 6, 2011DOI: 10.1056/NEJMhpr1107519
Reviewed for October by
Robert K. Crone MD
Senior Advisor to the Dean on Academic Affairs
Weill Cornell Medical College in Qatar