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The Council
on Graduate Medical Education JUNE 2002 available in PDF format (509 KB) COGME Reports
and Resource Papers
The Changing Nature of Health Care in America
Future Workforce Issues Requiring COGME Deliberative Study
Conclusion Vice Chair Regina M. Benjamin, M.D., M.B.A. William Ching Allen Irwin Hyman, M.D., FCCM Robert L. Johnson M.D. Ann Kempski Laurinda L. Merritt-Calongne,
LCSW-BACS Lucy Montalvo, M.D., M.P.H. Jerry Alan Royer, M.D., M.B.A. Susan Schooley, M.D. Humphrey Taylor Donald C. Thomas, III, M.D. Douglas L. Wood, D.O., Ph.D. Designee of the Assistant
Secretary for Health Designee of the Centers for
Medicare Designee of the Department Statutory Members Tom Scully Thomas L. Garthwaite, M.D. Former Member Contributing to
Report COGME Staff Stanford M. Bastacky, D.M.D.,
M.H.S.A. Jerilyn K. Glass, M.D., Ph.D. Richard Diamond, M.D., M.P.A. Jerald M. Katzoff Helen K. Lotsikas, M.A. Herbert Traxler, Ph.D. Eva M. Stone Anne Patterson COGME carries out its work by commissioning studies on emerging and high priority health workforce policy issues, debating the findings of its studies, obtaining the views of relevant outside groups, and submitting its conclusions and recommendations to Congress or the Secretary of DHHS on these important subjects. The state of the Nation’s health care workforce directly affects both the health of the American public and the economics of health care in the country. To the extent that the health workforce proves inadequate in numbers or geographic distribution to meet the needs of the public and the systems of health care in the country, then access to quality health care may be impeded, and overall health status adversely affected. To the extent that the workforce becomes unbalanced in relation to the public’s needs for specific types and numbers of health care practitioners, then the system becomes inefficient and suboptimal in the quality of its processes and outcomes. The basic issue of workforce size and composition occupied much of COGME’s deliberations. During the 1960s and 1970s, when the physician workforce was perceived to be in shortage, State and Federal policies and programs were enacted to counter those shortages. By 1986, the situation had changed, with overall surpluses projected, and shortages remaining only in some specialty areas. COGME examined this complex issue in several of its major reports, focusing on overall numbers; the balance between primary care and subspecialty care; the required balance of the physician workforce in terms of race, gender, and ethnic composition; and the role of IMGs in the overall supply system. COGME’s reports have helped to focus the attention of policy makers on the value of a physician workforce that reflects the gender, race, and ethnicity of the U.S. population. Achieving a balanced workforce is necessary to maintain the high quality care system expected by the population. COGME devoted considerable attention to the issue of physician distribution. Few problems have been as enduring as the inadequate numbers of physicians practicing in rural and inner-city areas. In its reports, the Council examined the reasons for physician reluctance to practice in underserved areas and pointed out programs, particularly the National Health Service Corps and those under Title VII of the Public Health Services Act, that have successfully trained primary care physicians who choose to practice in these areas. The Council has recommended curricular change in medical education, efforts to resolve the financial barriers to care in underserved areas, and an improved practice environment for physicians who work in these communities. While the Nation has become increasingly multi-ethnic, its physician workforce has yet to achieve the same diversity. Lack of academic preparation, encouragement, and financial resources were identified as contributing factors to the problem of low minority student enrollment in medical schools. The Council underscored the need for more effective recruitment of multi-ethnic faculty and student pools at all levels of the Nation’s educational system. Equally important is the development of cultural competence in all physicians. The focus should be on improved communication skills, an understanding of cultural-specific health beliefs, and an awareness of barriers to health care access. COGME returned several times to the complex issue of IMGs, their role in providing service to underserved regions, and their contribution to physician surpluses. While the original intent of the exchange visitor program was to permit graduates from other countries to obtain more advanced training than they would find in their own countries, more IMGs than expected found ways to remain legally in the U.S. after their training. Many have sought training in primary care specialties and subsequently elected to practice in U.S. shortage areas. In its recommendations, the Council focused on the costs and benefits of IMGS and their effects on workforce supply. Medical education feeds the physician workforce. COGME believes it to be imperative that undergraduate and graduate medical education continually monitor and improve itself if it is to provide training appropriate for future physicians. The Council’s publications have particularly focused on training that has high quality, community-based clinical opportunities and that develops the abilities of students and residents to respond to emerging public health needs. How to finance graduate medical education (GME) has been the subject of considerable discussion. COGME issued several reports providing a comprehensive view of key issues and alternatives in the on-going debate. The Council’s strongly held position is that a stable and equitable source of long-term financing for GME is vital, one in which all payers share the costs of physician training Future physician practice will require close collaboration among the health professions in order for the Nation to have high quality patient care. The Council issued two reports in partnership with the National Advisory Council on Nurse Education and Practice (NACNEP). The two councils explored the barriers to physician-nurse collaboration and suggested means to improve it. They and the Institute of Medicine are planning a June 2002 multidisciplinary summit in which health care leaders will develop a work plan to improve health professions education and practice. The Council expects that there will be at least as much change over the next 25 years as there has been over the past 25 years. Some of the issues now emerging are the role of genetics in health care, the aging of the population, continuing demographic changes, and the growing threat of terrorism around the world. These issues all create new challenges for the health care system and the education system that will provide the expanding pool future health care providers. Some of the issues now emerging are the role of genetics in future health care, the aging of the U.S. population, the continuing change in U.S. population demographics, and the growing threat of bioterrorism around the world. These issues all create new challenges to our health care system, and to the education and training systems that will provide us with the expanding pool of 21st century health care providers. New issues are certain to arise to challenge the current systems to an even greater degree than in the past. Congress and the Secretary of DHHS will continue to require objective, data-driven recommendations. COGME believes strongly that there will continue to be a need for a council on graduate medical education with the same structure and function as COGME following the expiration of COGME’s authorization on September 30, 2002. COGME also believes it has been successful in ensuring that vital issues affecting the health professions have received thorough analysis under its current structure and function and that options have been presented in a fashion that stimulated open, far-ranging discussion. COGME members, therefore, offer the following recommendations:
COGME has been successful in ensuring that vital issues affecting the health professions, especially the physician workforce, have received thorough analysis and that options have been presented that stimulated wide discussion. The Council believes that a new council should have the same purpose, functions, and composition, as did COGME. A new council should have diverse categories of membership, which would provide a broad perspective from the multiple interests that comprise the health care system. COGME’s function of providing support to Congress and the Secretary of DHHS needs to continue in a new council in order to facilitate wise policy decisions. INTRODUCTION COGME’S Origins During that same year, the Department of Health, Education and Welfare (DHEW), now the Department of Health and Human Services (DHHS), established the Graduate Medical Education National Advisory Committee (GMENAC) to advise the Secretary of DHEW on the physician workforce. GMENAC projected that there would be an overall physician surplus by the 1990s, with shortages in a few medical specialties. The Committee also highlighted the uneven geographic distribution of physicians and the need to address medical education and training in the context of workforce needs. While its report was controversial, GMENAC provided workforce projections that were widely discussed and debated. Between GMENAC’s termination in 1980 and 1986, there was no public advisory body for physician workforce analyses and recommendations. By the mid-1980s, debate about the physician workforce had centered on several key issues:
In response to the continuing need for expert counsel, Congress (Title VII of the Public Health Service Act, Section 799 (H), P.L. 99-272) in 1986 authorized COGME to study health care workforce issues and advise Congress and the Secretary of DHHS on these matters. The statute specified that COGME members be chosen from broad and diverse categories representing distinct components and groups within the medical education and health care system. While the original statute called for COGME to terminate on September 30, 1996, the termination date was changed to September 30, 1995 (Title III, Health Professions Education Extension Amendments of 1992, Section 301, P.L. 102-408). By appropriations legislation, the Council’s life was extended through the end of fiscal year 1998. COGME was reauthorized with a termination date of September 30, 2002 when the Health Professions Education Partnerships Act of 1998 (P.L. 105-392) redesignated the Council on Graduate Medical Education as Section 762 [294o] of Title VII of the Public Health Service Act. No other public advisory body offers opinions formulated on these issues from the combined perspective of primary care and specialty care providers representing allopathic and osteopathic disciplines, medical educators, health professions students and trainees, international medical graduates, health care professional associations, public and private hospitals, business, labor, health insurers, and managed care organizations. In recent years, the health care system being examined by COGME has undergone major changes:
The challenge to medical schools is to prepare physicians for these changes and to respond to future challenges. COGME’s Advisory Process At the time of its earliest deliberations, COGME adopted a set of principles to guide its work, all related to its primary concern for the health of the American people:
Beginning with an initial report
to the Congress and the Secretary of DHHS in July 1988, COGME has issued 16
formal reports, two joint reports in collaboration with the National
Advisory Council on Nurse Education and Practice (NACNEP), and five resource
papers. These reports and papers have illuminated the most important health
care issues affecting the physician workforce. An appendix highlights the
dates of each COGME publication, together with a brief summary of the
changing context of issues and legislation affecting the physician workforce
and health care in general.
In responding to its Congressional charge, COGME has addressed the following issues. The Size and Mix of the
Physician Workforce Because of significant uncertainties that could change the assessment of aggregate supply, the Council recommended that the public and private sectors concentrate on the clearly identified problems of geographic maldistribution of physicians, continued underrepresentation of minorities in medicine, specialty shortages, and issues of quality of care. Health care expenditures in 1990 exceeded $650 billion, with costs projected to reach one trillion dollars by 1995. Despite these dramatic cost increases, inequalities in access to health care began to receive National attention. The number of medically uninsured Americans was expected to reach 37 million by 1995, and millions more faced non-financial barriers to basic health care. Furthermore, the Nation’s basic health status indicators, which are in some measure influenced by access to health care, lagged behind those in most economically developed countries. COGME recognized that health care reform to ensure access to basic care for all Americans is not possible without physician workforce reform. It was at this time that COGME issued a report arguing that physician workforce reform is a necessary part of reforming health care in order to assure access to basic care for all Americans. In COGME’s Third Report (1992), the Council posited that a series of deficiencies in physician supply was responsible for a mismatch between physician workforce and public need. In general, there were too few primary care physicians (family physicians, general internists, and general pediatricians) and too many specialists and subspecialists. Additionally, the geographic distribution of physicians was problematic, with growing access problems in inner city and rural areas. The 110:50/50 Concept In this recommendation, the “110” portion derives from the goal to correct the then perceived emerging oversupply of physicians by limiting first-year residency positions to ten percent more than the number of U.S. allopathic and osteopathic medical school graduates. COGME selected the year 1993 as the reference point for the additional ten percent. The recommendation to limit the number of physicians entering residency training to 110 percent of medical school graduates would have represented a sizable decrease from the 1993 figure of 140 percent. In concrete terms, COGME’s recommendation meant that first year residency positions in the U.S. would be reduced from 25,000 to approximately 19,600. Overall, physician supply excess was considered a contributing factor to increases in health care costs that were not accompanied by improvements in the health of the public at large. GME Consortia The Council (Fourth Report, 1994) recommended that the Nation develop a physician workforce plan. Within the context of health care reform, COGME recommended that GME consortia be established as the heart of the plan. Each consortium would be coordinated by a medical school, and the consortium would be accountable within the “110:50/50” framework for allocating the number and specialty mix of residency positions based on local, State, and regional health care needs and on broad National guidelines. Each consortium would include teaching hospitals, HMOs, and other institutions that train physicians, use their services, or represent the public. The consortia approach was designed to minimize State and Federal Government intrusion and maximize private sector involvement. Financial incentives provided by Medicare and other payers would have the goal of training more primary care physicians and assisting educational institutions to expand and improve the quality of primary care programs. Public funds would be used to support primary care practice in inner city and rural areas through (1) National Health Service Corps scholarships and loans, and (2) differential Medicare and Medicaid reimbursement provisions for physician practice in shortage areas. By the time of COGME’s Fourteenth Report (1999), the Council had seen a decade of changes in the American health care system that could significantly impact the Nation’s physician supply and requirements. There had been a number of statutory and non-statutory changes related to GME, including the Balanced Budget Act in 1997. The Fourteenth Report was written to assess these changes related to the physician workforce and GME and the potential impact on the supply, demand, and training of physicians in coming years. While the rate of growth in the physician supply had moderated slightly, the Council still believed a physician oversupply was likely. With regard to the “110:50/50” goal, the Council found that only limited progress had been made in reducing the number of physicians in training. In 1997, the percentage of entrants into residency positions was 129 percent of the number of 1993 U.S. medical school graduates, a decline from 140 percent, but still short of the 110 percent goal. An increase in residency positions filled by exchange visitor international medical graduates (IMGs) caused some concern. A large number of IMGs were able to remain in the country, further adding to the U.S. physician workforce. In terms of primary care residencies, the Council found progress had been made. The number of entering residents likely to go into primary care practice had increased to two-fifths of the 129 percent. COGME concluded, however, that, while there were encouraging signs, the Nation was still producing too few generalists and too many specialists. Continued Need for a National
Health Workforce Plan The health care delivery system has undergone rapid and substantive changes since the Council introduced the “110:50/50” recommendations. COGME recognizes the need to re-examine these goals through new analyses. Some have suggested that the numbers of primary care physicians now may be adequate and shortages may exist in certain specialty areas. Further analyses are expected to be complex. Current physician workforce data make it difficult to assess the numbers of physicians who may be classified as subspecialists but function as primary care providers for at least some of their patients. A recent study commissioned by COGME suggests that in light of declines in IMGs and possible reductions in hours worked and other factors affecting productivity, limiting GME slots to 110 percent of 1993 U.S. medical graduates may produce shortages rather than assuring balance. A New York State resident exit survey conducted in 2000 found that the job market for graduates was considerably softer for primary care physicians than for specialists. U.S. medical schools are experiencing shifts in the population of students seeking admission to professional education in medicine. The number of women applicants has increased 62.3 percent over the past 20 years and represents 46.6 percent of the total academic year 2000 applicants. Entrants to graduate medical education programs have evolving professional expectations, increasing concerns and demands regarding the balance between professional and personal goals, and mounting education debt loads. According to the Association of American Medical Colleges, indebted medical school graduates owed an average of $90,745 in 1999, and 13.9 percent had educational debts exceeding $150,000. These and other factors affect specialty choice in residency training and the ultimate composition and behavior of the physician workforce. COGME recently broached the topic of specialty and subspecialty workforce methodology in its examination of the adequacy of physicians in specific specialty areas, Evaluation of Specialty Physician Workforce Methodologies (2000). The report provides a comprehensive review of the specialty literature, which underscores how complex and difficult these analyses are. The studies, largely conducted by various specialty and subspecialty groups, varied in purpose and design, and relied on different estimation models and data sources to project future workforce supply and demand. This variation prevented any conclusions about the size and adequacy of the specialist physician workforce. Moreover, the studies did not account for the complexity and elasticity of the physician workforce market, the broader medical and health care delivery marketplace, and the effects of population growth and technological change. The Council called for the development of valid and unambiguous models to guide the study of the specialty workforce. The Distribution of the
Physician Workforce
A close examination of career choices of U.S. medical school graduates indicates some important differences in patterns of practice choice. Physicians who enter primary care disciplines, especially those in family practice, are much more likely to practice in underserved areas than their peers who enter subspecialties. Some family medicine programs have two years of rural training. Financial interventions in the medical education system by both public and private sectors are credited with success in increasing the numbers of physicians practicing in underserved areas. Government programs authorized under Title VII of the Public Health Services Act, in particular, have a successful record of training primary care physicians who choose to practice in rural and underserved areas. Other programs that deliver care to the underserved and offer incentives to physicians who provide that care have made a difference, such as the National Health Service Corps, the Community and Migrant Health Center Program, and targeted incentives through Medicare and Medicaid. The scope of these programs, however, remains limited, and significant physician maldistribution remains. Entangled in the issue of geographic maldistribution is the issue of health insurance. From its earliest deliberations, the Council has proposed that the most direct and efficient means to improve access for underserved populations is to (1) assure they have health insurance coverage, and (2) establish focused programs that send health professionals to places with insufficient providers. In the absence of universal health insurance coverage, however, the Federal Government will need to increase its funding for disproportionate share coverage and for programs that make up America’s medical care safety net. COGME further recommended that managed care plans for Medicaid beneficiaries be required to enter into contracts with established community clinics and associated health care providers located in shortage areas. The Council also saw a continued role for preceptorship programs in shortage areas, loan repayment support to physicians in exchange for service, differential reimbursement incentives, and efforts to improve community support, all of which were recommended in COGME’s First Report (1988). Congress, in virtually all of its recent legislative initiatives [Balanced Budget Act of 1997; Balanced Budget Refinement Act of 1999; and Medicare, Medicaid, and State Children’s Health Insurance Program (SCHIP) Benefits Improvement and Protection Act of 2000], has incorporated provisions that provide exceptions or payment enhancements for hospitals training residents in rural areas. These provisions are consistent with COGME’s recommendations to increase the physician workforce in these areas. Data show that residents are more likely to practice in or near areas in which they receive their training. Physician maldistribution remains a severe and persistent problem in America, with no one effort likely to lead to the solution. Medical education can contribute through collaborative attempts at curricular change. The greater need is to resolve the substantial financial barriers to care in underserved areas and to find ways to improve the professional practice environment of physicians who work in underserved communities. Minority Representation in
the Physician Workforce The problem of recruiting minority students into medical schools was seen as linked directly to poor early academic preparation, insufficient encouragement, and lack of financial resources. COGME recommended creative and vigorous efforts at the high school and college levels to encourage students to pursue careers in medicine. Specifically, consortia of medical schools, public schools, and community organizations should be established to work together to improve the educational pipeline. COGME made extensive recommendations including consideration of alternatives to the traditional use of standardized test scores and grade point averages for admission to medical schools and residency programs. In addition to recommending the availability of scholarships and loans, the Council urged partnerships with National and local media and advertising companies to produce media and materials aimed at minority children describing opportunities in science and health careers. The prohibitively high cost of a medical school education contributes to minority underrepresentation in the physician workforce. The Council urged that Federal funding priority be given to medical schools and teaching hospitals that have demonstrated success in recruiting and retaining underrepresented minority students. Financial assistance in the form of public and private sector scholarship and loan programs should be expanded to include all levels of medical education. The National Health Service Corps should be expanded to allow targeted opportunities for minority students. Of continued concern is the underrepresentation of minorities on the faculties of U.S. medical schools, resulting in few minority role models and mentors for minority students. Figures from the AAMC in the year 2000 indicate that only 6.2 percent of faculty in U.S. medical schools was Native American, Black, Hispanic, or Latino. The Council recommended that the Federal Government support programs that encourage minorities to pursue careers in academic medicine and provide incentives to medical schools that are successful in recruiting and retaining minority faculty. COGME Research on Minorities Minority populations are the fastest growing segments of the U.S. population. Current U.S. Census Bureau projections suggest that the percentage of minority groups will rise from the year 2000 Census figures of 28.6 percent to make up 32.7 percent of the population by the year 2010 and 47.2 percent by the year 2050. The Hispanic population, the fastest growing component of the population, is expected to increase from 11.9 percent in 2000 to 14.6 percent in 2010 and 24.3 percent in 2050. Minorities, particularly Black Americans, Mainland Puerto Ricans, Mexican Americans, and American Indians/Alaska Natives, also have among the poorest health status in the country. The Council emphasized that greater numbers of minority physicians need to be enlisted into the workforce because data indicate they are more likely than non-minority physicians to provide care to minority, poor, underinsured, and uninsured people. Recruiting more minorities into the health professions is seen as one way of decreasing the marked health disparity of minorities in this country. Cultural Competency In 1999, the Accreditation Council for Graduate Medical Education endorsed a professionalism competency for residents to demonstrate sensitivity to patients’ culture. . HRSA’s Bureau of Primary Health Care, in collaboration with other Government agencies, published a document directed to health professionals focusing on Hispanic culture. The document seeks to build physician-patient communication by using knowledge of culture to provide health care to Hispanic patients. Private and Public
Initiatives Since Project 3000 by 2000 began, medical schools have reversed the minority enrollment trend of previous years. Between 1991 and 1994, underrepresented minority applicants and matriculants to U.S. medical schools increased by 40 percent and 27 percent, respectively. Through HPPI, the AAMC collaborates with other health professions schools and graduate health science programs to increase minority representation. In addition to this important AAMC initiative, several influential documents have been published in recent years, including The Institute of Medicine’s Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions (1994), and the Pew Health Professions Commission’s Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century (1995). Congressional action on this subject also led to numerous Federal Government-sponsored initiatives to increase minority participation in health science and medical careers: Title VII, Section 740 programs in HRSA, and Title III, Section 338 programs in the National Institutes of Health. Many of these private and public efforts were addressed in COGME’s Twelfth Report (1998). While medical schools across the country continue their efforts to attract and retain minorities, their results have not been satisfactory. Out of an entering class of approximately 16,000 students, slightly more than 1,900 students from underrepresented racial/ethnic groups (less than 12 percent) were enrolled as first-year students in the academic year 2000-01. Given that underrepresented minorities comprise more than 20 percent of the Nation’s population, greater efforts are needed to address the disparity. International Medical
Graduates in the Physician Workforce Many IMGs are in the U.S. because they are permanent residents. Most of the increase in the total number of IMGs has been due to the large number of foreign-born IMGs entering residency programs with temporary J-1, J-2, and H-1B visas. A substantial number of IMGs participating in residency programs under the auspices of the exchange visitor program (temporary J-1 visa holders) are able to secure waivers to their “return home” requirement by agreeing to serve in health professionals shortage areas (HPSAs). A high percentage of J-1 exchange visitors who do return to their home country ultimately return to the U.S. As applied to an alien physician graduate of a foreign medical school, an H-1B visa allows admittance for temporary employment to perform medical services, contingent upon passing an examination. The alien physician must be sponsored by a U.S. employer and is limited to a three-year stay, renewable for an additional three years. Under this visa, the physician may petition for an adjustment to become a legal permanent resident, thereby increasing the ranks of the Nation’s physician workforce. Intent of Exchange Visitor
Program The waiver program, especially with the passage of the “Conrad Amendment,” provides a vehicle that allows the IMGs to remain. The number of service and research-related waivers granted for exchange visitor physicians, according to the Department of State, amounted to nearly 5,000 in the three years prior to 1999. The number of such waivers granted from 1991 through 1995 was 3,742. The large number of individuals who successfully obtain waivers has led to a concern that the U.S. may be depriving other countries of the benefits of the medical training and expertise acquired by these individuals during their education in this country. Reducing the Aggregate Total
of Physicians Entering the Workforce COGME recommended that Medicare GME payments be available only to those residents expected to become part of the U.S. physician workforce. Therefore, the Council called for eliminating both Medicare direct GME and indirect GME (IME) payments for new exchange visitor (J-1 visa) residents and using alternative funding sources such as home country financing or foreign aid. The Council recommended that the granting of J-1 waivers for purely service reasons be phased out over a four-year period in order to restore the exchange visitor program to its original purpose. After training, J-1 visa physicians should be required to live in their country of nationality or country of last residence for five years, instead of two years, before they could return to the U.S. The H-1B visa program for physician residency training should be eliminated because it has been used to circumvent the J-1 visa “return home” requirement. COGME further recommended that the Federal Government cease to provide loan support to U.S. students engaged in undergraduate medical education in foreign countries. Role of IMGs in Care to the
Underserved Workforce planning would certainly need to address the changing health care landscape in many major urban centers where a high proportion of IMGs provide primary care services. The most recent data available indicate that nearly 81 percent of IMGs are providing patient care. Of this group, 11.2 percent are in the specialty of family practice or general practice, 26.3 percent are in internal medicine, and 10.5 percent are in pediatrics. More precise data are needed, however, to indicate the exact number of IMGs serving in specific underserved areas and for what duration. Concern about IMGs in the physician workforce has diminished with the decline in number of exchange visitor J-1 physicians entering residency programs. In 2000, U.S. citizens and U.S. permanent residents constituted about 50 percent of PGY1 positions compared to 42 percent in 1993. The initiation in July 1998 of the clinical skills assessment examination (CSA) by the Educational Commission for Foreign Medical Graduates (ECFMG) was thought by some to be accelerating the decline in the number of exchange visitor physicians. The need to arrange to take the CSA in Philadelphia, Pennsylvania, the only site where it is administered, and the examination cost of $1,200 (in 2001) were viewed as constraints. Recent evidence suggests little or no adverse impact on the number of IMGs being certified by the ECFMG because of the implementation of the CSA. It is noteworthy that IMGs are willing to accept positions in the National Residency Match Program (NRMP) not filled by U.S. medical school graduates, many of them in primary care specialties. This acceptance is particularly evident in major primary care disciplines. U.S. medical school graduates matching in family practice peaked at 2,340 in 1997, and then progressively declined to 1,503 in the 2001 NRMP. Although the total match rate has declined appreciably since 1997, the approximately 36 percent of positions filled by IMGs entering family practice prevented an even greater erosion in the fill rate than otherwise would have occurred. Similarly, figures for the year 2001 indicate that IMGs comprise 36 percent of residents in general internal medicine. Women in Medicine In terms of specialty choice, women physicians tended to cluster in primary care disciplines. About 60 percent of all women practiced in five specialties: family practice, internal medicine, obstetrics-gynecology, pediatrics, and psychiatry. Rates of increase in representation of women within academic medicine have been much slower. When the Fifth Report was released in 1995, women represented only ten percent of full professors, four percent of department chairs, and three percent of medical school deans. As of December 2000, the percentage of new women faculty had risen to 37 percent from 32 percent in 1997. Women still represented only 12 percent of full professors, 7.5 percent of department chairs, and 3.25 percent of medical school deans. The Fifth Report made a number of recommendations to help assure that women physicians achieve their full potential in academic leadership positions and in all specialty areas. COGME emphasized the importance of women physicians having access to adequate childcare, alternatives to allow for childbearing and child rearing without penalty, and flexible education and work schedules. The Fifth Report also examined women’s health status and its implications for the training of physicians. The report noted that women’s overall health status is worse than for men in terms of disability, morbidity, and chronic disease. Physicians need to have a broad understanding of conditions affecting women and competency in caring for women as they move through cycles of health and illness that are different from men. The incomplete and poorly coordinated care that women often receive has been attributed to inadequate health insurance (women are twice as likely as men to be underinsured), fragmented delivery of primary care services, and deficiencies in physician training. The status of women’s health also will be influenced by demographic shifts. As the population of older Americans continues to grow, women will continue to outnumber men, and therefore, disproportionately face the illnesses and conditions specific to the elderly. Also, women in certain minority groups are known to have a lower life expectancy, more health problems, and poorer access to care than white women, which will require a significant response from the Nation’s health care system. National Medical Ambulatory Care Survey data indicate that women physicians can play an important role in addressing this problem, as they are more likely to treat larger percentages of women in their practice, and are practicing increasingly in obstetrics-gynecology. Improvements in Medical
Education In Preparing Learners for Practice in a Managed Care Environment (1997), COGME described needed changes in medical education to prepare future physicians for health care systems in which they are likely to practice. The paper, while specifically focusing on practice in managed care settings, identified physician competencies that are useful in a variety of practice settings. Noting that the curricula of undergraduate and graduate medical education should not be viewed in isolation, this report describes learner needs across the continuum from pre-medical education to residency training and to life-long learning. A central premise is that physicians need to understand populations and to care for patients within the context of the settings in which they function. Competencies described in the paper, along with appropriate teaching strategies, include health systems finance; economics; organization and delivery; evidence-based and epidemiologically-based medicine; ethics; development of patient-provider relationships; leadership in promoting teamwork and organizational change; quality measurement and improvement; medical informatics; and systems-based care. Training in Community
Settings Physicians and Public Health COGME’s recommendations and concerns are particularly timely in view of recent heightened national concerns about terrorism. It is clear that an effective, coordinated response to the threat of bioterrorism or the spread of emerging infections requires a strong public health infrastructure. Such a structure must be capable of communicating effectively with knowledgeable, practicing physicians, who must identify, report, and manage urgent public health problems affecting their individual patients. Educating Physicians for
Changing Roles As the patient population becomes more diverse, the education of physicians requires more attention to effective communication skills, cultural competency, patient advocacy, conflict management, and ethical decision-making. Future physicians need to learn how to work in teams and to communicate effectively with colleagues and administrators. As more learning experiences shift to the community, medical schools need to take advantage of distance learning techniques to deliver educational programs. The role of information technology and the implications of patients’ increased use of the Internet and e-health resources need to be explored. Accountability requires that programs evaluate both short- and long-term outcomes for learners, teachers, and educational programs. Assessment techniques must be valid and reliable across a variety of teaching environments. Given the rapidity of change in medical practice with new advances in knowledge and skills, future physicians need to practice evidence-based medicine using the most valid and timely information available. They also must learn how to learn. They must be prepared to assume the role of lifelong learners if they are to provide competent care throughout their years of practice. In fact, assurance that physicians are maintaining their knowledge and skills has been built into all medical boards that now require physicians to meet re-certification criteria. Financing Graduate Medical
Education Financing and Workforce
Planning COGME believes it is vital that a stable and equitable source of long-term financing for GME be established in which all payers share the costs of physician training. As early as the Third Report (1992), the Council urged an all-payer system to finance GME, which would spread equitably the costs of preparing a well-qualified physician workforce across all payers. Similarly, the Fourteenth Report (1999) underscored COGME’s belief that GME is a public good that benefits the whole Nation. The Council also expressed its concern about the increasing fiscal pressure placed on teaching hospitals and ambulatory sites by a competitive marketplace and the drive for managed care plans and other payers to cut their expenses. Fiscal Health of Teaching
Hospitals The Balanced Budget Act The BBA of 1997 sought to balance the Federal budget by 2002 and contained a number of provisions that affected GME. Since Medicare constitutes the largest Federal source of expenditures for GME, this legislation had the potential of profoundly affecting GME and the physician workforce. Provisions designed to achieve a balanced budget included one to control the continued growth of GME positions. This control was to be accomplished by: (1) capping the total number of residents in hospitals who were funded by Medicare, (2) reducing the IME intern/resident-to-bed ratio (IRB) adjustment factor, and (3) capping the IRB adjustment factor. The BBA also had an unintended adverse effect on the capability of family practice residency programs to increase the number of rural residency positions. The BBA of 1997 authorized the phased carve-out of GME dollars from Medicare payments for Medicare+Choice enrollees. The dollar value of this carve-out, according to estimates by the Health Care Financing Administration, would reach $2.6 billion for fiscal year 2002. In its Fourteenth Report (1999), COGME argued that the Medicare carve-out was an opportunity for the Nation to support health workforce priorities. Reference was also made to 19 States that carve out a GME portion of Medicaid managed care payments and distribute funds to teaching hospitals in order to achieve State workforce policy goals. The report recommended that the Federal Government collaborate with States in building the expertise and capacity for workforce planning and study. Teaching hospitals, specialty organizations, and rural health providers all made claims of adverse effects under the provisions of the BBA. Because of the many outcries, COGME commissioned a staff resource paper examining the GME provisions of the BBA and their consequences, The Effects of the Balanced Budget Act of 1997 on Graduate Medical Education: A COGME Review (2000). In its report, COGME noted that the BBA removed some incentives for continued growth in the number of residents and provided incentives for training in non-hospital settings. The legislation also produced unintended consequences that would financially hurt many teaching hospitals. In response to such criticism, the Balanced Budget Refinement Act of 1999 (BBRA) was passed to provide payment adjustments under Medicare for BBA relief. The BBRA revised the multi-year reductions of IME payments, slowing their reduction beginning in the year 2000. In addition to providing a measure of fiscal relief to teaching institutions, the BBRA accorded flexibility to rural and other areas. Provisions allowed hospitals to increase the number of primary care residents countable in the base year limit and permitted reclassification of certain hospitals as rural hospitals. Subsequent to the BBRA, further legislative relief was provided via the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). Because of the legislation, the reduction in the IME Medicare adjustment factor was moderated. Continued COGME Support for
GME Reform GME payment policies and alternative models for financing reform, especially in light of the increasing importance of ambulatory care educational experiences, are described in the Fifteenth Report. A central recommendation is the creation of a GME fund that would combine Federal funding with all-payer funds for GME in order to support high quality training of an appropriately sized physician workforce. IME accounts would pay hospitals and other clinical training sites for the indirect costs of educational activities. Direct GME accounts would pay program sponsors or their designees for the direct costs of GME, and a National average per resident payment would be established. The Council recommended the continuation, with some modifications, of the limits on resident numbers as set in the BBA. Caps would be applied to sponsoring institutions rather than hospitals. Residents in non-hospital settings would be included and adjustments would be allowed in the limits to improve physician workforce distribution. An account would be established for funding special programs directed at building high quality community-based training capacity or achieving specific workforce goals. Additional support would be provided for hospitals and community-based training sites that serve a disproportionate share of low-income patients. The Fifteenth Report also recommended that Medicare rules moderate the requirements for documentation of care expected of attending physicians. Because current methods of graduate medical training involve proctored viewing and guided manipulations, it is imperative that clinical attending physicians (attendings) spend as much time in the direct development of clinical skills in their trainees as possible. As attendings make rounds to see patients and review patient status with residents, they verify by their signature that charted information is correct and sufficient to be useful; this process, regularly subject to hospital audit, has been efficient and effective in transforming physician trainees into functional graduates. COGME was concerned that requiring attendings to write a separate note of findings is counterproductive to the GME process. Such excessive documentation detracts from the time that attendings have to teach the graduates and detracts from patient care. Assuring Public Debate on GME
Financing
In order to publicize the ideas expressed at the Stakeholders Meeting, COGME published the transcript, with minor editing, Proceedings of the GME Financing Stakeholders Meeting: Public Response to COGME’s Fifteenth Report (2001). Several States have been addressing ambulatory care financing issues (e.g., Michigan, Tennessee, New Mexico, Minnesota, West Virginia). Professional organizations, especially those involved in primary care (e.g., American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Society of Internal Medicine), have also indicated interest in the recommendations. THE CHANGING NATURE
OF HEALTH CARE IN AMERICA Aging of the U.S. Population Increasing Diversity of the
U.S. Population Rising Health Care Costs Shift of Care from Hospitals
to Ambulatory Settings The shift in care from the inpatient to the outpatient setting has had several impacts:
Unprecedented, Rapid Scientific and Technological Advances In the basic sciences:
In the applied sciences:
Continuing Changes in Health
Care Financing The New Marketing and
Consumerization of Health Care FUTURE WORKFORCE ISSUES
REQUIRING COGME DELIBERATIVE STUDY Physician Workforce In addition, the shifting demographics of the population needing health care services should receive scrutiny. Many attributes of the current demographics of our society, for example the increased numbers in the population of racial and ethnic minorities, need to be considered by educators and policy makers. In 1999, 28 percent of the U.S. population belonged to a racial/ethnic minority group. The U.S. Census Bureau projects that by 2020 this will increase to 40 percent of the U.S. population. Changes in the infant, child, adolescent, and young adult population have outstripped early projections, for example an increase in the Hispanic birth rate and an influx of minority children as a result of burgeoning immigration. The number of Hispanic children has increased from 9 percent of the child population in 1980 to 16 percent in 2000. By the year 2020, it is projected that more than one in five children in the U.S. will be of Hispanic origin. In addition to an increase in raw numbers, this population has also added to the numbers of underserved individuals. Demographics, unmet health care needs, language barriers, and patient and parental satisfaction with health care are but a few of the factors that call for an ongoing assessment of physician workforce needs. The aging of the population and the needs of the chronically ill are new factors to be considered. What is the optimum mix of providers to deliver efficient, cost-effective, high quality care to such patients? Current evidence addressing such questions is extremely limited and many alternative models for care exist. One model assumes that broadly educated primary care physicians with training in geriatric medicine will provide the bulk of care. It has been suggested by some experts that subspecialists with broad experience in each patient’s major chronic illness would be better able to provide high quality “primary care” for such patients. Answers to these questions must be pursued. The Specialty Physician
Workforce Effect of Primary Care
Providers Other Than Physicians on Health Care Based on the 1995-1999 National Ambulatory Medical Care Survey data, about one-fourth of office-based primary care physicians used physician assistants or nurse practitioners for about 11 percent of visits. These latter practitioners, working under the supervision of a physician, provided primary care that was similar to care provided by physicians. Does this imply a lesser need for primary care physicians or does it forecast an increase in a two-tiered system of health care, wherein cost and access determine the availability and/or quality of services? More likely, the growth in the non-physician workforce calls for a reassessment of the “traditional” models of health care delivery. As outlined in the first joint report by COGME and NACNEP (1995), future assessment of needs for a primary care provider workforce must include consideration not only of physicians, but also of providers from other disciplines. This recommendation led to the development of an Integrated Requirements Model by the Bureau of Health Professions, Health Resources and Services Administration (HRSA), for its health workforce analyses. The roles of providers other
than physicians, and the degree to which they may substitute for or
supplement the services of physicians, must be defined in the context of the
quality and accessibility of care provided for patients with differing
problems. Analyses must also consider the legal scope of practice of these
other health care providers, which varies from State to State. Alternative
models for the organization of patient care are emerging. COGME plans to
examine these alternatives and address the effects of such emerging models
on quality of care, access to care for rural and urban underserved
populations and implications for primary care and specialty physician
workforce needs.
Graduate Medical Education
and Unionization While these concerns have existed for some time, several factors point to a rise in unionization of medical staff in coming years. While house staff at public teaching institutions has long been able to unionize and generally has done so, the far larger proportion at private institutions has not. The 1999 decision of the National Labor Relations Board to permit unionization at private teaching hospitals could result in a considerably larger proportion of unionized house staff. In addition, there has been a trend towards unionization of individual physicians in various practice systems, as they perceive a loss of control and/or income. These issues merit close study. Adequacy of Health Care
Workforce Data Care for the Underserved An important question is whether we should continue to depend upon international medical graduates to provide a major proportion of care for underserved populations. If not, what new steps will be necessary to reverse these and other worrisome trends? The population of uninsured and underinsured in the U.S. has risen since the 1970s. Assuring their access to care and the maintenance of the health care safety net will remain a crucial issue. Rising costs seem likely to place severe constraints on the resources available to address these problems. Changing Models of Insurance
and Physician Workforce Needs Collaboration Among Health
Professionals to Improve the Quality of Health Care The need to prevent errors in health care and improve patient safety prompted the second COGME-NACNEP collaboration. The need for action was spurred early in the year 2000 by a report of the Institute of Medicine. The IOM report cited research indicating that adverse events occurred in 2.9-3.7 percent of hospitalizations. Moreover, medical errors, estimated to be one of the ten leading causes of death in the U.S., surpassed yearly deaths attributable to motor vehicle accidents, breast cancer, or AIDS. Recommendations emphasized the need to enhance the knowledge base about errors, create an effective reporting system, raise standards and expectations for improvement, and create safety systems within health care organizations. Emphasis was placed on the careful application of information technology, improvements in medical and nursing education, and a multidisciplinary approach to care. Shortly thereafter, in January 2001, COGME and NACNEP issued a joint report entitled Collaborative Education to Ensure Patient Safety. The report noted that physicians and nurses most often practice independently, and concluded, “It is a myth that health care operates as a system.” The report highlighted the many points in the existing system that require but lack effective coordination. It noted that information systems must play a role in assisting collaborative health care teams to manage the inevitable shifts in care among patient care units, providers, and health care organizations for patients with complex illnesses. The report also noted that patients need to participate more actively in their own health care, which means that physicians and nurses have to adjust their own practice approaches to encourage patient education and participation. The report called for new standards, models, and incentives to achieve the necessary level of transformation needed for a unified system of patient care. Two of the recommendations by COGME and NACNEP have already been implemented in the form of new cooperative agreements awarded by HRSA:
The call by COGME and NACNEP for coordinated teamwork to improve health care quality was echoed and expanded in the IOM’s follow-up report on patient safety, Crossing the Quality Chasm: A New Health System for the 21st Century (2001). Rather than recommending specific organizational changes, the IOM Report broadly outlined a course for health care providers, the health care industry, insurers, Government, and the public at large to undertake. The IOM envisioned crucial roles for Government and the private sector in promoting broad-based analyses and discussion on needed changes that would be unlikely to occur if left to the marketplace. The lead recommendation was that: A multidisciplinary summit of leaders within the health professions should be held to discuss and develop strategies for (1) restructuring clinical education to be consistent with the principles of the 21st-century health system throughout the continuum of undergraduate, graduate, and continuing education for medical, nursing, and other professional training programs; and (2) assessing the implications of these changes for provider credentialing programs, funding, and sponsorship of education programs for health professionals. A Joint COGME-NACNEP Planning Group is collaborating currently with the IOM and several other Federal agencies and advisory committees to convene a multidisciplinary summit of leaders within the health professions in June 2002. The goal of the summit is to define a work plan for implementation of the changes needed in health professions education and practice to make fundamental improvements in the quality of the Nation’s health care. CONCLUSION
The ongoing rapid changes in the U.S. health care system and the crucial problems that it faces will make it necessary for Congress and the Secretary of DHHS to continue to make critical judgments. The function performed by COGME needs to be continued by a new council in order to ensure an ongoing and stable source of analysis, balanced advice, and productive public debate that facilitate wise policy decisions.
YEAR THE HEALTHCARE CONTEXT
COGME REPORT 1967 National Advisory Commission on Health Manpower Report on National Physician Shortage. 1968-1975 Expansion in and opening of new medical schools. 1970 National Health Service Corps began to address physician maldistribution [Critical Health Manpower Shortage Area designation created, later redefined as Health Professionals Shortage Areas (HPSAs)].Community and Migrant Health Centers established to improve access to care for underserved. 19711973 Initiation of funding support for family practice programsHealth Maintenance Organization (HMO) Act promoted creation of HMOs in rural areas and defined Medically Underserved Areas (MUAs). 1976 The Health Professions Educational Assistance Act acknowledged an end to overall physician shortage. The Act codified support for Family Medicine Programs and other policies to overcome primary care physician shortage and geographic maldistribution of physicians. 1977 Title VII legislation provided support for primary care training programs (particularly in Family Medicine) to increase physicians who will provide care for underserved. 1981 GMENAC reported§ Projected physician surplus by 1990s, shortages in some medical specialties and surpluses in others.§ Uneven geographic distribution of physicians; need to address medical education and training in context of workforce needs. YEAR THE HEALTHCARE CONTEXT
COGME REPORT 1984 General Professional Education of the Physician, report of the American Association of Medical Colleges (AAMC) asserted need for revising content and process of medical education to respond to projected needs of the population. 1985 Report of the Secretary's Task Force on Black and Minority Health reported that minorities have marked health disparities, including excess deaths due to cancer, cardiovascular disease, diabetes, infant mortality, substance abuse, violence, and other health problems.Consolidated Omnibus Budget Reconciliation Act changed GME financing by cutting indirect costs and overall payments, as well as direct costs paid per resident. Act limited GME payments to time required for board certification (5 yr. max.). Payments for IMGs only if passed examinations (FMGEMS, ECFMG, or VQE).COGME was created. 1988 Review of NIH research funding stated that not enough women are represented in many research studies affecting both genders. Report created outcry from Congressional Caucus for Women's Issues. First Report of the Council YEAR THE HEALTHCARE CONTEXT
COGME REPORT 1990 Immigration and Nationality
Act allowed non-U.S. physicians to enter U.S. and provide clinical services
if they meet licensure and H1B visa requirements (H1B convertible to
permanent visa through petition from family or employer).GAO Report noted
difficulties of States in determining quality of education of IMG physicians
and differences in licensing procedures for IMGs and U.S. medical graduates.
Scholar-In-Residence Report - Reform in Medical Education and Medical
Education in the Ambulatory Setting 1991 AAMC launched Project 3000 by 2000 to raise U.S. medical school minority enrollment.AMA discontinued its National Physician Credentials Verification Service as too costly. YEAR THE HEALTHCARE CONTEXT
COGME REPORT 1993 President Clinton proposed major health care system and insurance reform involving Government-supervised "managed competition."Legislation authorized DHHS to survey medical school curricula to determine how women's health issues were incorporated and, if inadequate, recommend changes.Number of IMG residents equal to approximately 40 percent U.S. medical graduates. YEAR THE HEALTHCARE CONTEXT
COGME REPORT YEAR THE HEALTHCARE CONTEXT
COGME REPORT YEAR THE HEALTHCARE CONTEXT
COGME REPORT 1997 Black, Hispanic, and American Indian/Alaskan Native Americans represented 23.6 percent of U.S. population, yet only 12.2 percent of enrollees in U.S. medical schools (7.1 percent drop in new minority enrollees since 1996).AAMC Survey reported 39.6 percent of U.S. medical school graduates plan primary care training and substantial increases in numbers of residents over past 10 years.Balanced Budget Act (BBA) - Provisions to be fully implemented by 2002:§ Hospital-specific cap on total residents and ratio of interns and residents to beds.§ Reduced IME funding.§ Provided measures to soften the impact of cutting residents on DME and IME payments.§ Carved out funds for teaching facilities from distributions to managed care (rising from 20 percent in 1998 to 100 percent in 2002).§ Financing for training in non-hospital settings.§ Transition payments to hospitals voluntarily cutting residents (³ 20 percent over 5 years).§ Federal study of overhead and DME on "inappropriate" variations in DME. Ninth Report - Graduate Medical Education Consortia: Changing the Governance of Graduate Medical Education to Achieve Physician Workforce ObjectivesResource Paper - Preparing Learners for Practice in a Managed Care EnvironmentTenth Report - Physician Distribution and Health Care: Challenges in Rural and Inner City AreasEleventh Report - International Medical Graduates, the Physician Workforce, and GME Payment Reform YEAR THE HEALTHCARE CONTEXT
COGME REPORT 2000 Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA) provided further legislative relief for reduced IME payments to teaching hospitals.Women represented 46 percent of entering US medical students, but only 12 percent of full professors, 7.5 percent of department chairs, and 3.25 percent of medical school deans. Resource Paper - The Effects of the Balanced Budget Act of 1997 on Graduate Medical EducationResource Paper Compendium - Update on the Physician WorkforceResource Paper - Evaluation of Specialty Physician Workforce MethodologiesFifteenth Report - Financing Graduate Medical Education in a Changing Health Care EnvironmentCouncil on Graduate Medical Education: What is it? What has it done? Where is it going? YEAR THE HEALTHCARE CONTEXT
COGME REPORT |
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Last Updated November 20, 2001
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