Table 3.

Comparison of Major GME Reform Proposals

	Commonwealth Fund	MedPAC	Bipartisan Commission on the Future of Medicare	COGME	Medical Education Trust Fund (AAMC)
Major points	Calls for strong emphasis on social missions of teaching hospitals	Calls for improvement of case-mix measurement method to more accurately reflect illness severity/inpatient care cost relationship	Raises question of whether DME should be subject to appropriations process	Creates a GME fund that combines federal funding with all-payer funds	Amends Social Security Act to add new title (Title XXII) that would establish Medicare Education Trust Fund
	Urges that financing method should evenly distribute burden of payment		Acknowledges difficulty in differentiating IME costs between teaching and non-teaching hospitals, and so recommends that Congress continue current methodology	Calls for DME monies to be paid directly to program sponsors
	Recommends that financing should not contribute to regional oversupply or specialty imbalance among U.S. physicians	Recommends that developing workforce policy is not a role for Medicare		Would modify Medicare teaching physician rules to emphasize teaching physician's overall responsibility for patient care and to reduce importance of documentation	Calls for specific premium tax of 1.5% on health insurance premiums
		Urges refinement of DRG system
		Uses “teaching hospital adjustment” in place of DME payment system
Funding mechanism	All-payer	Use of current funding mechanism (PPS system)	Use of current funding mechanism, but raises question of whether DME should be subject to appropriations process	All-payer	All-payer
		Intended to be budget-neutral and to improve accuracy of GME payments
Unique characteristics	Emphasis on social missions	Only proposal calling for elimination of DME payments and use of “teaching hospital adjustment”	Only proposal to discuss possibility of subjecting DME to appropriations process	Only proposal to recommend paying DME monies directly to program sponsors	Only proposal to call for legislation amending IRS code, establishing 1.5% premium tax on all health insurance premiums
	Site-neutral distribution of trust fund payments
	Specific attention to safety net providers		Only proposal to recommend exploring funding IME and DSH payments outside of Medicare program	Only proposal to recommend modifying teaching physician rules to place additional emphasis on overall responsibility for patient care and less emphasis on documentation
			Unique level of influence due to standing of former Commission members in Congress
Potential to improve the current idiosyncratic variations across institutions in per resident payment amounts?	Yes	Yes	Unclear	Yes	Yes
Does the proposal in question allow for recalibration of teaching costs to reflect year 2002 realities?	Yes	No	Unclear	Yes	Yes
Authority over DME funds shifted to the professionals responsible for resident education?	No	No	No	No	No
Potential to improve the current problem that resident positions are variably underfunded by year of training and specialty?	Yes	Unclear	Unclear	Yes	Yes
DME payments tied to the institution's actual expenditures on resident education?	Unclear	No	Unclear	Yes	Unclear
Potential to improve the current problem that DME monies are earned without any accountability for program outcomes?	No	No	Unclear	Yes	No

GME, graduate medical education; MedPac, Medicare Payment Advisory Commission; COGME, Council on Graduate Medical Education; DRG, diagnosis-related group; DME, direct medical education; PPS, prospective payment system; IME, indirect medical education; DSH, disproportionate share hospital.