Abstract
In this article, we examine the financing mechanisms for graduate medical education (GME) in the United States. In so doing, we identify Medicare as the single largest contributor to GME and the most important barrier to producing a physician workforce that is appropriately sized, balanced, and skilled. Until passage of the 1997 Budget Reconciliation Agreement, the structure of Medicare payments promoted overproduction and skewed production toward training specialists in tertiary settings. We then examine the various reform proposals put forward by major health care organizations and policy bodies. These organizations generally agree on seven policy objectives: Remove incentives that promote expanded resident production; Base the GME subsidy on actual costs and distribute it more uniformly; Focus reductions on specialty residency positions; Provide GME payments for training provided in ambulatory, community, and managed care sites; Decouple Medicare GME reimbursement from payments to health maintenance organizations for patient care; Require all health insurers to contribute to GME; and Ensure that reductions in the GME subsidy do not reduce access to care for low-income persons. A myriad of different mechanisms for achieving these objectives have been recommended, many of which could be melded together to form a comprehensive approach to GME reform. The prospects for meaningful GME reform are dim in the absence of broader Medicare reform. The costs to stake-holders are too concentrated while the benefits to the public are too diffuse for GME reform to stand alone. But the political imperative to deal with the federal budget's short-term deficit and Medicare's long-term solvency will likely create an opportunity for GME reform. An addendum has been added that shows how the 1997 Budget Reconciliation Agreement addresses most of the major reform objectives identified but that several important issues remain unresolved.
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Selected References
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- Anderson G. F. What does not explain the variation in the direct costs of graduate medical education. Acad Med. 1996 Feb;71(2):164–169. doi: 10.1097/00001888-199602000-00024. [DOI] [PubMed] [Google Scholar]
- Eisenberg J. M. Financing ambulatory care education in internal medicine. J Gen Intern Med. 1990 Jan-Feb;5(1 Suppl):S70–S80. doi: 10.1007/BF02600440. [DOI] [PubMed] [Google Scholar]
- Fuchs V. R. The supply of surgeons and the demand for operations. J Hum Resour. 1978;13 (Suppl):35–56. [PubMed] [Google Scholar]
- Iglehart J. K. The quandary over graduates of foreign medical schools in the United States. N Engl J Med. 1996 Jun 20;334(25):1679–1683. doi: 10.1056/NEJM199606203342521. [DOI] [PubMed] [Google Scholar]
- Mullan F. Powerful hands: making the most of graduate medical education. Health Aff (Millwood) 1996 Summer;15(2):250–253. doi: 10.1377/hlthaff.15.2.250. [DOI] [PubMed] [Google Scholar]
- Mullan F. The National Health Service Corps and inner-city hospitals. N Engl J Med. 1997 May 29;336(22):1601–1604. doi: 10.1056/NEJM199705293362212. [DOI] [PubMed] [Google Scholar]
- Reuter J., Gaskin D. Academic health centers in competitive markets. Health Aff (Millwood) 1997 Jul-Aug;16(4):242–252. doi: 10.1377/hlthaff.16.4.242. [DOI] [PubMed] [Google Scholar]
- Rice T. Physician-induced demand for medical care: new evidence from the Medicare program. Adv Health Econ Health Serv Res. 1984;5:129–160. [PubMed] [Google Scholar]
- Rivo M. L., Kindig D. A. A report card on the physician work force in the United States. N Engl J Med. 1996 Apr 4;334(14):892–896. doi: 10.1056/NEJM199604043341405. [DOI] [PubMed] [Google Scholar]
- Whitcomb M. E., Miller R. S. Participation of international medical graduates in graduate medical education and hospital care for the poor. JAMA. 1995 Sep 6;274(9):696–699. [PubMed] [Google Scholar]
- Woodward R. S., Warren-Boulton F. Considering the effects of financial incentives and professional ethics on 'appropriate' medical care. J Health Econ. 1984 Dec;3(3):223–237. doi: 10.1016/0167-6296(84)90012-2. [DOI] [PubMed] [Google Scholar]