Graduate medical education funding crisis. (Health Policy Update).

There are more than 1,000 teaching hospitals in the United States. These hospitals have an important role in the health care system, providing the vast majority of clinical research, ensuring care for 44 percent of the poor, and training more than 75 percent of the nation's physicians and numerous other health care professionals.' They are frequently cited as being responsible for maintaining both high quality of care and technological innovation.

Since 1965 Medicare has explicitly contributed to the costs of graduate medical education (GME). Initially, these payments were included under a costbased system, which paid extra for the higher costs of teaching, research, covering the uninsured, a sicker case mix, and special care units such as trauma, transplant, and critical care.

In 1984 the system was changed and payments were based on diagnostic-related groups (DRGs). This created two distinct funding streams: (1) direct medical education (DME), which paid for the costs of running training programs, such as resident and staff salaries, teaching expenses, and office space, and (2) indirect medical education (IME), which covered the cost differential of caring for a sicker patient population. In 1999 teaching hospitals were paid almost $6 billion through the DME ($2.2 billion) and IME ($3.7 billion). (2)

Funding academic medicine

Some U.S. policymakers question the appropriateness of Medicare paying for GME and believe the system needs to change. In the Balanced Budget Act of 1997, Congress approved a series of funding cuts to teaching hospitals by reducing prospective payments. The Association of American Medical Colleges estimates that 40 percent of teaching hospitals stand to loose up to $15 billion by 2002. (3) This change in funding represents the biggest threat to the GME system.

Commercial payers have historically paid more than the actual health care delivery costs at teaching hospitals to help pay for teaching, as well as the disproportionately higher rates of uncompensated care. Recently, these insurers have started to reduce their participation for social goods such as uncompensated care and GME as a component of their premium costs, This is particularly true of managed care programs. In addition, managed care has dramatically reduced costs in non-teaching hospitals, making teaching hospitals a less competitive option for many nonspecialized services and may result in fewer patient visits. These reductions are threatening the viability of the U.S. teaching hospital system.

Medicaid programs have historically contributed more than $2.3 billion for GME. Another $200 million of state tax dollars supports these programs. As states move to managed care contracts, the full value of these dollars is often not passed on to the teaching hospitals, further straining funding. Some state Medicaid programs are looking at the portion of dollars that they contributed to OME and have begun to carve them out of the capitated payments to managed care organizations. These funds are then paid to teaching hospitals directly. (4)

Some teaching hospitals receive federal funds for uncompensated care, paid through the 'disproportionate share hospital funding" (DSH). It, like the other funding sources, is under scrutiny and may be reduced. Additional funding support comes from research grants and gifts, but these are not enough to offset planned cuts.

Policy options

The first Balanced Budget Act passed by Congress In 1995 and later vetoed by President Clinton included language to allow for a trust fund or GME pool-this was an early attempt to address Congress' concerns. In 1996, the U.S. House of Representatives' Ways and Means Committee asked the Institute of Medicine (IOM) of the National Academy of Sciences to look "for a new model to preserve the missions of these institutions and revamp Medicare's role in funding." (5) Congress wanted the IOM to develop a methodology to create a GME trust fund--the IOM made its recommendations on how such a fund could be constructed and financed.

In 1997, Congress asked the Medicare Payment Advisory Commission (MedPAC) to study how Medicare funded GME and could better address workforce issues, as well as ways to change the system. This summer MedPAC presented their proposal to combine the indirect and direct medical payments and to pay only for direct patient care, not teaching. Payments would be made under a DRG per case system and adjusted for severity of illness. MedPAC also suggested that Medicare funding should not be used to address workforce issues--historically, it has been used to manage the scope and size of GME programs. (6)

This shift in ideology changes the debate from funding teaching to paying for services. The American Medical Association and the Association of American Medical Colleges disagree with this approach because it changes Medicare's explicit role in paying for GME. (2) There is also the fear that other payers would more rapidly follow Medicare's lead, resulting in the collapse of funding support.

Health care is entering a new age with dramatic increases in the availability of new and marvelous technologies. America's health care policies must prepare our medical workforce to make optimum use of these tools. The GME debate will reshape our medical system. Some of the important questions that must be addressed include:

* Where and how will we fund the training of physicians?

* How will we cover the uninsured?

* Who should pay for clinical research and cutting-edge technology?

* How much should the private sector pay?

* How should managed care contribute?

Conclusion

Changes in Medicare funding for GME will have profound affects on the viability of academic medicine and teaching hospitals. No consensus has been developed on how to achieve national objectives of conducting quality research, treating the uninsured, and maintaining a well-trained medical workforce. The policy implications of this debate are broad and will affect the full range of medical practice. Transforming Medicare's historic role must be done carefully to avoid destroying one of our most valuable assets: the best training programs in the world.

Note

The stated views are those of the author and do not represent those of the State of Maryland or the Department of Health and Mental Hygiene.

References

(1.) Associated Press, Teaching Hospitals Threatened by Crisis in Funding. Baltimore Sun, April, 4. 1999.

(2.) Greene, Jay. MedPAC Advises Ending GME Training Payments, American Medical News, Vol. 42. No. 32, August 23/30, 1999.

(3.) Association of American Medical Colleges, 1999.

(4.) National Governors Association Center for Best Practices. State Graduate Medical Education Financing Reform Efforts, StateLine. August 31, 1999.

(5.) Institute of Medicine, 'On Implementing a National Graduate Medical Education Trust Fund,' Washington. DC: National Academy Press. 1997.

(6.) Cummingham. Robert (Editor). MedPAC Rethinks GME: Conceptual High Ground Atop A Slippery Slope. Medicine & Health Perspectives. September 6, 1999.

Georges Benjamin, MD, FACP, is the Secretary of the Department of Health and Mental Hygiene in Maryland, Baltimore. He can be reached by calling 410/767-6505 or via email at [e-mail].