Chicago Deans Champion GME Reform

CMS rallies with the academic community on Capital Hill
By Elizabeth Sidney

In a show of solidarity, academic leaders and the Chicago Medical Society (CMS) united in Washington on March 4-5 to rally for a strong physician workforce. The CMS-organized delegation of medical school deans and governmental affairs staff urged prompt passage of a bill that would expand graduate medical education. The group met with House Ways and Means Committee members, who oversee Medicare, followed by Illinois lawmakers, culminating with Senate Finance Committee leaders. CMS President Robert W. Panton, MD, and the Illinois State Medical Society, represented by Board Chairman Steven M. Malkin, MD, rounded out the delegation.

Commanding the spotlight, Loyola University’s Dean Linda Brubaker, MD, and the University of Illinois’ Dean Dimitri Azar, MD, minced no words when they warned that teaching programs will be unable to train the next generation of doctors without immediate action to address the looming physician shortages. The two deans pressed lawmakers to pass HR 1201, “Training Tomorrow’s Doctors Today Act,” legislation cosponsored by Reps. Aaron Schock of Peoria (R-Ill.) and Allyson Schwartz (D-Penn.) that would increase the 1997 caps on Medicare-supported residency positions. The bill would add 15,000 new Medicare-supported GME slots over five years at a cost of approximately $10 billion over ten years.

Under the GME transparency provisions in the Schock-Schwartz proposal, teaching hospitals would report the mission-related costs associated with operating medical residency programs, such as the cost of stand-by services, trauma centers, burn units, and conducting medical research. The bill also requires the Government Accountability Office to report on specialties with physician shortages, recommending ways to increase diversity in the health care workforce, review the competency of doctors who serve seniors, as well as recommend improvements to geriatric care.

Relentless Focus on GME

Since taking office in June 2013, Dr. Panton has made GME advocacy the capstone project of his presidential year. Legislative grand rounds have been a major component of this campaign. CMS also unified the state’s eight teaching institutions into a coalition that blanketed Congress with joint letters, signed by each dean. Meanwhile, physician foot soldiers continue to meet individually with legislators in their home districts, and hold breakfast meetings at hospitals. That seven Illinois representatives have co-signed HR 1201, for a total of 63 cosponsors, is testament to CMS’ strong advocacy program.

Support for GME funding will continue under President-elect Kenneth G. Busch, MD, as CMS enlists medical students to share their concerns about debt and fear of not landing a residency spot.

Obama Budget Outrage

In addition to making legislative rounds, the CMS delegation was in Washington for the American Medical Association’s National Advocacy Conference, and for the release of President Obama’s fiscal year 2015 budget proposal. The budget has academic leaders up in arms because it would slash nearly $15 billion in Medicare Indirect Medical Education (IME) funding. (See sidebar.)

Reaction to the budget release was swift. “IME funding is critical to the Chicago College of Osteopathic Medicine of Midwestern University and the students we educate,” said Dean Karen J. Nichols, DO. Dr. Nichols, who was part of the CMS delegation, said that, “While I understand the need for Congress to deal with a growing federal deficit, cutting GME and limiting support for physicians in training and the patients they serve is not the answer. The GME system must be strengthened, not reduced.”

On the same note, the University of Chicago’s Benjamin Gibson warned that, “Further GME cuts would go to the heart of the South Side hospital’s ability to respond to the demand for services.” The cuts come at a time when the Association of American Medical Colleges (AAMC) estimates a shortage of 90,000 physicians by 2020—split evenly between primary care and specialty doctors.

Giimmer of Hope?

To support new primary care residency positions, the budget redirects $5.23 billion of the Medicare IME cuts to a competitive new grant program run by the HRSA. Under this plan, teaching hospitals, children’s hospitals, and community-based partnerships could apply for grants to support new residency spots in primary care or high-need specialties. But the GME grant program would fund only 13,000 new residency slots over the next 10 years. While the AAMC expressed appreciation over the Administration’s willingness to address the physician shortage, it has serious concerns about redirecting Medicare funds to providers that don’t actually care for Medicare beneficiaries. As a grant program, the stability of the funding source and the new positions would be a perennial challenge, the AAMC notes.

The National Health Service Corps (NHSC) would see a $505 million boost above the $305 million provided by the Affordable Care Act. In requesting $810 million for the NHSC, the Administration hopes to encourage 15,400 primary care clinicians to enter practice in underserved areas across the nation.

Yet academic and teaching centers remain skeptical that funding for the NHSC and GME grant program would not come at the expense of existing programs. Teaching hospitals already support nearly 10,000 residents per year above the Medicare caps, at a cost of more than $1 billion annually, the AAMC points out. It’s no coincidence that the President’s budget proposes new investments in GME and primary care equivalent to the exact amount the Administration is proposing to remove from IME.

Reform a Long Winding Road

Back in March, Rep. Schock, co-sponsor of HR 1201, expressed hope that once Congress passed a long-term solution to the flawed SGR formula, lawmakers would be able to focus on the critical issue of medical residency funding. Congress came tantalizingly close but missed an historic opportunity to repeal the SGR formula before the March 31 deadline. Like the GME cap, the SGR formula was established under the 1997 Balanced Budget Act.

Despite strong bipartisan consensus on the need to expand GME, the dearth of funding and disagreement over funding approaches all suggest continued stalemate. Even with some new primary care funding, other cuts and slashes in IME mean “there really isn’t any new money coming into this process,” explains the AAMC’s Leonard Marquez. The director of government relations says, “They’re just sort of shuffling the deck chairs.”