Institute of Medicine report falls short on primary care training

On July 31, the Institute of Medicine (IOM) released its report on governance and funding of graduate medical education (GME). The report calls for a restructuring of GME financing and a more accountable performance-based system of funding. However, it does not recognize the looming physician shortage, especially in primary care, declaring that there are “no credible data” to support such a claim.

A response of deep concern from organized medicine, including ACP, the American Medical Association, and the Association of American Medical Colleges, was immediate. Though the IOM is on target in its call for innovation, transformation, and accountability in how Medicare GME funding is used, ACP and others expressed concern that the report offers no recognition or recommendations to address the need for additional physicians trained in primary care and other specialties that face shortages in the years to come.

The IOM committee argues that new models of care using midlevel providers, innovative technology, and multidisciplinary teams will be sufficient to meet the health care needs of the near future, when a substantively expanded pool of patients seeking both primary and specialty care is expected. There is little disagreement about the report's claim that federal funding of GME should influence physician specialty selection, distribution, and location, or that everyone should have timely and adequate access to both primary and specialty care. But claiming there is no evidence of a physician shortage discounts reliable data and is based on huge assumptions about the needs and preferences of patients regarding how their care is administered. The report offers a presupposition as to how the health care work force will be identified and how primary care should be defined and deployed.

The IOM committee was co-chaired by Gail Wilensky, PhD, former administrator of the Health Care Financing Administration (now known as CMS) and Don Berwick, MD, former administrator of CMS, both recognized national leaders and experts in health policy. The 21-member committee comprised academicians, CEOs, GME program directors, health policy experts, and others. These are individuals who take their jobs seriously and are well respected and well versed in the challenges of health care and the complexities of GME.

The committee was charged by its funders (the Veterans Administration, the Health Resources and Services Administration, and several foundations) and by Congress with developing recommendations to improve GME and increase capacity in the physician workforce. It focused only on Medicare GME financing and governance. Medicare, the largest explicit source of funding for GME, contributes approximately $10 billion annually to fund an estimated 100,000 positions across the country. These funds are divided into Direct Graduate Medical Education (DGME) and Indirect Medical Education (IME) support. DGME funds are directed toward support of resident salaries and benefits as well as faculty costs. IME funds are directed toward support of teaching hospitals to defray the costs of treating more complex patients and providing services not available at other hospitals.

The report calls for continuing Medicare GME funding at the current level, adjusted for inflation over the next 10 years, but changing how funds are distributed and ultimately progressing to a performance-based payment system. Phase 1 of the changes combines DGME and IME into a single payment to sponsoring organizations based on a “national per-resident amount adjusted geographically” by regional differences in cost of living.

Funds would be divided into an operational fund to support existing programs and a transformation fund to encourage and support innovation, pilot alternative payment models, and fund training slots in targeted “priority disciplines” and geographic areas. Operational funding to existing programs would ultimately drop back to 70% of present levels, dedicating 30% to transformational efforts. After several years, operational funding would gradually drift back to 90% by the 10th year. Phase 2 would move the program to a performance-based payment method that would reward local, regional, and national workforce efforts.

ACP joins in the call for innovation and transformation in GME, including a greater emphasis on training in community-based settings. However, ACP is concerned that reducing GME payments to existing programs will have a devastating effect on many teaching hospitals and the patients they serve.

The report also does not recognize the need to fund more primary care training, a stance deeply concerning to ACP. The IOM committee did recognize a geographic imbalance in the physician work force and suggests that transformation would encourage realignment to underserved areas. This will be difficult without appropriate incentives, including payment reform and the availability of more training positions that will encourage students to choose primary care and more primary care physicians to stay in practice.

Congress has capped the number of residents eligible for Medicare GME support at 1996 levels. While the number of PGY-1 positions has continued to climb each year, the number of applicants for residency is rising at a much faster rate due to medical schools opening and expanding without commensurate expansion of GME slots. This bottleneck at the level of residency positions will only get worse if more GME positions are not created. The IOM committee claims this is not needed.

The AAMC recommends that positions be increased by at least 4,000 a year. This expansion is needed to meet the needs of millions of newly insured people and a growing and aging population, as well as to accommodate additional graduates each year. According to reliable studies, including those by Colwill and colleagues in the April 29, 2008, Health Affairs and Petterson and colleagues in the November/December 2012 Annals of Family Medicine, the U.S. will need 44,000 to 52,000 additional primary care physicians by 2025. These predictions take into account the increasing demand resulting from the 25 million Americans newly insured thanks to the Affordable Care Act, as well as population growth and aging.

The College has long supported the concept of team care and the patient-centered medical home (PCMH) model, the primary care model of the future. In the PCMH, multiple disciplines function as a team, each member working cohesively within the professional boundaries of his or her training and licensure. All members are uniquely qualified to take the lead where needed and indicated, the goal being to optimize outcomes, improve quality of life, and control cost. The intent of the PCMH is to enhance value in the care of patients. But in no scenario is the physician not central to that effort. Additionally, the care of a growing number of complex patients is transitioning from the hospital to the outpatient setting, and increasingly internists will be core participants in such care. We will need many more of them. The College strongly promotes the notion that all individuals deserve, indeed require, a personal physician whom they trust and rely on to coordinate high-value care. Nonphysician members of the team and innovative technologies are likewise needed but cannot replace physicians.

ACP appreciates the work of the IOM committee, but greater clarity is needed. The future of primary care is in crisis. It is critically important that those framing policy in response to the IOM report recognize that GME reform is necessary, but we must also provide adequate funding and support to expand training in primary care and other specialties facing shortages.