The Lesson from Rural Health Course #101: GME reform must address the local shortages of practitioners faced by both rural and inner city communities.
 
"President's Message," Rural Health FYI, November/December, 1997
 
Tim Size, President, National Rural Health Association
 
 
Posturing is well underway regarding the reform of Graduate Medical Education (GME) structure and funding, the combatants engaged and once again rural interests are at risk of being trampled as an oversight. The Washington Post recently published a debate between two medical education heavy weights, the executive director of the Pew Health Professions Commission and the co-chairman of the Institute of Medicine Committee on U.S. Physician Supply. While taking opposing positions on whether or not medical schools should be closed, neither one as much as mentioned the ongoing maldistribution of physicians.
Given the editorial nature of this column I have chosen not to fully note the extensive professional credentials of the colleagues whose comments you will be reading; I am indebted for their assistance and intend no disrespect. In my first "President's Message," I referenced the need for NRHA to grow as a virtual, multi-place organization; hopefully this is an example of a "virtual editorial"--multiple voices identifying the rural facets of a complex issue:
 
"Rural America still cries for competent, technically appropriate professionals who have demonstrated knowledge and experience in rural/remote practice. The GME question of physician over supply is in reality a case of inappropriate training leading to physician maldistribution. Our funding streams and training programs have missed the mark by not mandating a set of skills that would lead toward rural competency, developed in parallel to efforts toward establishing cultural and technical competency. We Alaskans often refer to the 'Joel Fleishman' phenomenon (from Northern Exposure)--the urban-trained physician as a rural fish out of water." (Barbara Doty, MD, Alaska)
 
"Many accrediting bodies continue to severely limit programs wishing to use rural training sites. If we want to increase rural practices, we have to greatly increase the number and type of rural residency training experiences. Not only must GME funding be made available to ambulatory rural sites, federally qualified or not, various [specialty driven] Residency Review Committees must allow greater flexibility in location of training while still assuring educational quality. The recently enacted Balanced Budget Act (BBA) is really chipping at the edges of the GME problem from the point of view of rural practice. Allowing payment of GME direct costs for time spent in federally qualified sites is certainly good news, but the big dollars are elsewhere. There is very little in the BBA that will lead resident physicians out of urban teaching hospitals into rural communities." (Jim Norton, PhD, Kentucky)
 
The principle relevance of the Balanced Budget Act to GME is that it has charged the Medicare Payment Advisory Commission (MedPAC) to develop a report by August of 1999 on the "Long-Term Policies Regarding Teaching Hospitals And Graduate Medical Education." The preparation of this report will be a major forum for the growing debate about the future supply and distribution of both physicians and other practitioners. According to the BBA, MedPAC will examine and develop recommendations on whether and to what extent Medicare payment policies and other Federal policies regarding teaching hospitals and graduate medical education should be changed. MedPAC must make recommendations regarding:
 
· "Possible methodologies for making payments for graduate medical education and the selection of entities to receive such payments including whether and to what extent payments are being made (or should be made) for training in the nursing and other allied health professions,"
 
· "Federal policies regarding international medical graduates."
 
· "The dependence of schools of medicine on service-generated income."
 
· "Whether and to what extent the needs of the United States regarding the supply of physicians, in the aggregate and in different specialties, will change during the 10-year period beginning on October 1, 1997, and whether and to what extent any such changes will have significant financial effects on teaching hospitals."
 
· "Methods for promoting an appropriate number, mix, and geographical distribution of health professionals."
 
"It is important to divide components of the rationale for Medicare GME payments. Specifically we need to separate the needs of quaternary care hospitals for subsidies, from the need for educational support payments. We should pay for each separately, upon their own merits, to different recipients. We are at a point that we need to consider that federal support to hospitals for graduate medical education as narrowly defined (i.e. educational support payments) be discontinued. (Medicare subsidies could continue to quaternary care hospitals for indigent care, supra intensive care and research, if justified.) Divide the education money saved into (a) targeted grants to training programs which meet policy priorities and (b) targeted loan repayment programs for service in areas and for populations meeting policy priorities." (Wayne Meyers, MD, Kentucky)
 
"Medicare pass through money has been available to hospitals to be used for training physicians or nurses when the hospital runs the program. When there were many diploma nursing programs run by hospitals, these programs received some of this money to educate nurses. As most diploma nursing programs have closed, there have been very few nursing educational programs with access to any of this money. I support the recommendation that nurse practitioner programs be eligible for some of this pass through money since they are providing essential health services (often replacing residents) in hospitals and in primary care clinics. This change could be extremely helpful to rural areas since it could support the training of nurse practitioners, many of whom practice in rural areas." (Sarah Barger, DPA, RN, FAAN, Alabama )
 
"The great majority of discussion regarding GME centers around the training of physicians. While it's clear that many rural areas are in need of physicians to provide care, it's also clear, but not as widely discussed, that rural America also needs other trained health professionals to make the health care system work effectively. As recommendations are being developed by MedPAC regarding payment to entities for GME, there needs to be the inclusion of provisions to pay for the training of non-physician providers, such as physician assistants and mental health professionals. This would encourage those teaching hospitals to develop a more integrated, team approach to training health professionals and more comprehensively meet the needs of rural communities." (Jennifer Frary, PA-C, Wyoming)
 
"Reducing the overall supply of residents and ultimately physicians will require reductions in International Medical Graduate trainees if all US students get a residency slot. This could lead to additional geographic shortages in the short run if the number of insured individuals is not increased or if safety net programs like the National Health Service Core and Community Health Clinics are not increased. The Council on Graduate Medical Education strongly recommends that part of the GME dollars saved from training less residents be allocated to such purposes. Less than 1/2 of 1% of US physicians are in the National Health Service Core; increasing this to 2-3 percent would go a long way until universal coverage would allow market forces to operate. (David Kindig, MD, Wisconsin)"
 
"The most important changes in graduate medical education have been to encourage more and more training of residents in community settings. As clinical care, and therefore the place to train new doctors, has moved more and more into office and community based practice, the rationale for funding hospitals has gotten less defensible. Programs should be funded and hospitals which are important parts of those programs should be recognized as a part of but not the heart of residency training. The heart will remain the community based office, be that model teaching practice or, increasingly, new models which integrate graduate medical education into existing practices such as in rural training tracks. The future is to have the funding go directly to the training programs themselves which can then best negotiate their educational needs." (John Frey, MD, Wisconsin)
 
"Family medicine has provided thousands of physicians to underserved rural communities. The numbers choosing rural practice have remained at about 600 per year, despite increases in residencies and resident positions. Family practice is now in danger of becoming much like the other medical specialties: as the supply increases, there is increasing maldistribution of the specialty. The only exception to this rule is urban poverty practice where family practice graduates have posted major increases. If family medicine fails to address this location issue, it will soon face more than threats to it's funding. Without special efforts to increase the numbers of family medicine residents choosing rural locations, much of the political power of family medicine will be lost." (Robert Bowman, MD, Nebraska)
 
In summary, from our May, 1996 NRHA Issue Paper, Funding Of Graduate Medical Education: "The current mechanisms in place to fund GME primarily through Medicare are fundamentally flawed. They were created decades ago and designed to meet objectives that are no longer relevant. Public funding for GME has evolved into a system so arcane as to approach incomprehensibility. When we look at the current geographic distribution of physicians and their specialty mix, it is clear that the current system has not served the needs of rural communities well. NRHA believes that the Medicare payment system to support GME should be altered in ways that support national and regional work force needs."