Minutes
of Meeting, April
30-May 1, 2007
The Council of
Graduate Medical Education (COGME) convened in the Hilton Washington
D.C. Rockville Executive Meeting Center at 8:30 am both April 30 and
May 1, 2007.
Members Present
Russell G. Robertson,
M.D., Chair
Denise Cora-Bramble,
M.D., M.B.A, Member
Joseph Hobbs, M.D.,
Member
Mark A. Kelly,
M.D., Member
Rebecca M. Minter,
M.D., Member
Angela D. Nossett,
M.S., Member
Robert L. Phillips,
Jr., M.D., M.S.P.H., Vice Chair
Earl J. Reisdorff,
M.D., Member
Vicki L. Seltzer,
M.D., Member
Jason C. Shu, M.D.,
Member
William L. Thomas,
M.D., F.A.C.P., Member
Leana S. Wen, M.S.,
B.S., Member
Barbara J, Chang,
M.D., M.A., Designee of the Department of Veterans Affairs
Renate Rockwell
representing Tzvi M. Hefter, Designee of the Administrator, Centers
for
Medicare and Medicaid
Services, DHHS
Anand Parekh, Designee
of the Assistant Secretary for Health, DHHS
Members Absent
Thomas J. Nasca,
M.D., M.A.C.P., Member
Kendall Reed, D.O.,
F.A.C.S., Member
Staff
Dennis Williams,
Deputy Administrator, Health Resources and Services Administration
(HRSA)
Michelle Snyder,
Director, Bureau of Health Professions (BHPr)
Marilyn Biviano,
Ph.D., Director, Division of Medicine and Dentistry, BHPr
Jerald M. Katzoff,
Executive Secretary
Eva Stone
Welcome
Dr. Robertson,
Chair, welcomed the COGME members. He introduced Anand Parekh, M.D.,
Designee of the Assistant Secretary for Health, DHHS
Opening Remarks
Dennis Williams,
Deputy Administrator, Health Resources and Services Administration,
and Michelle Snyder, Director, Bureau of Health Professions, each
gave welcoming remarks. Both noted the importance of the Council’s
recent work and the emerging recommendations of the two reports under
development. In describing current activities of both HRSA and BHPr,
both Dr. Williams and Ms. Snyder noted how the Council’s work has
complemented the Agency’s and Bureau’s activities and goals over the
past several years. Ms. Snyder noted recent changes in senior management
at the Bureau. Of direct impact on the Council is the recent appointment
of Dr. Marilyn Biviano to head the Bureau’s Division of Medicine and
Dentistry, which, among its activities, provides oversight to COGME
and two other advisory committees.
Executive Secretary’s
Report
Mr. Katzoff discussed
the COGME letter that was sent to the Secretary and Congress in March
2007 concerning proposed Medicare changes in definitions for GME reimbursement
and asked Dr. Robert Phillips to elaborate on the issue. Mr. Katzoff
then discussed the solicitation process for appointing new members
to the Council. He indicated that four members of the Council will
be ending their terms on September 30, 2007. Mr. Katzoff noted that
the Council’s charter permits all retiring members to continue in
their posts after their terms have expired, until a new member has
officially been appointed to the Council.
Presentations to the
Council on its Two Emerging Reports
From mid morning
until noon, Dr. Barbara Chang, chair of COGME’s writing group on Enhancing
GME Flexibility, led the discussions and review on each of the
draft recommendations and accompanying narrative of the emerging report.
Following lunch, Dr. Earl Reisdorff, Chair of COGME’s writing group
on New Paradigms for Physician Training in Improving Access to
Healthcare, led the discussions and review on each of the draft
recommendations and accompanying narrative of that emerging report.
The first day’s
plenary session ended at 3 pm.
Breakout of Council
Members into Two Writing Groups
At 3:15 PM , the
two writing groups convened to further revise each of their two reports
in light of the discussions held earlier that day.
Report to Council on
Draft Recommendations of the Two Reports
In the morning
of the second day of the plenary session, the chairs of each writing
group reported to the plenary meeting the new revised wording of each
of the draft recommendations produced as a result of the previous
day’s activities.
(Note that what
follows are the revised draft recommendations contained in the most
recent versions of the two draft reports dated mid-June 2007).
New Paradigms
for Physician Training Writing Group
- Access to
health care must improve. The expansion of existing programs and
the creation of new models of training should focus on delivering
care in areas of high medical need. An incentive-based, non-mandatory
structure should be created for medical school and residency graduates
to practice in such practice settings.
- Federal- and
state-based loan repayment programs should be increased. Programs
through the National Health Service Corps, the Department of Defense,
Department of Veteran’s Affairs, and state repayment programs offer
an opportunity to attenuate the indebtedness of medical students
while placing physicians in under-served areas.
- Incentives
should be created to encourage medical schools to recruit and prepare
physicians for clinical practice in under-served areas.
- A National
Medical School (or system of medical schools) should be established.
This college of medicine would be unique in its emphasis to prepare
physicians for clinical practice in underserved areas, public health
issues, epidemiology, and emergency preparedness and response.
This newly-formed public medical school would offer free tuition
to students in exchange for a mandatory service requirement after
(and possibly during) residency training.
- There must
be increased targeted funding for physician training that creates
a clinical physician workforce that serves populations in areas
of limited access to medical care. For example, reinvigoration
of Title VII funding should be considered.
Graduate Medical
Education Flexibility Writing Group
Recommendation
1: Align GME with future healthcare needs
- Increase
funded GME positions by a minimum of 15%, through funding directed
towards innovative training models which address community needs
and which reflect emerging, evolving, and contemporary models
of healthcare delivery [See also Recommendation 3.].
Recommendation
2: Broaden the definition of “training venue” (beyond traditional
training sites)
- Decentralize
training sites
- Create flexibility
within the system which allows for exploration of new training venues
while enhancing the quality of training for residents [See also
Recommendation 3.]
Recommendation
3: Remove regulatory barriers to executing flexible GME training
programs and expanding training venues
- Address
several of the limitations that currently exist within the Centers
for Medicare and Medicaid Services (CMS) rules for expanding
application of Medicare GME funds to other sites of care.
- Invite CMS
to use its Demonstration authority to fund innovative GME demonstration
projects with the goal of preparing the next generation of physicians
to achieve identified quality and patient safety outcomes by promoting
training venues that follow the IOM’s model of care delivery.
- COGME and
others should work with Congress and CMS to re-evaluate and rewrite
GME policies to provide flexibility in emergency situations with
appropriate statutory and regulatory relief:
- To ensure
the continued training of displaced residents (e.g., post-Katrina
or sudden hospital closures);and,
- To permit
5-year affiliation agreements (as opposed to the current 3-year)
in the case of abrupt hospital closure to permit sufficient time
for damaged hospitals to be repaired; and,
- To require
review of the impact of the loss of training positions on the
community (i.e., to consider how best to preserve, sustain, or
reconstitute local/regional physician workforce) in situations
where a hospital is not able to resume training at previous levels
due to natural disasters or unforeseen circumstances which result
in the abrupt interruption, closure, or discontinuation of training
programs, and the transfer of positions made permanent; and,
- To provide
Hospitals receiving residents due to emergency closure of another
hospital a temporary FTE cap adjustment and be allowed to exempt
displaced residents from the three-year rolling average. To clearly
define “displaced resident” and who is eligible for reimbursement
under this new rule, so there is no ambiguity.
Recommendation
4: Make accountability for the public’s health the driving force
for graduate medical education (GME)
- Develop
mechanisms by which local/regional or national groups can determine
workforce needs, assign accountability, allocate funding, and develop
innovative models of training which meet the needs of the community
and of trainees
- Link continued
funding to meeting pre-determined performance goals
- Alter Title
VII in order to revitalize support for graduate medical education
Next Steps for Producing
the Reports
In afternoon discussions,
COGME members endorsed sending the two draft reports to about 15 organizations
for review and comment prior to the reports’ transmittal to the Secretary,
Congress, and the general public. The 15 organizations that COGME
identified were thought to have strong expertise and interest in the
issues and draft recommendations included in the two reports. The
Council also endorsed inviting a small, select group of these organizations
to present their comments to COGME on the first day of its two day
plenary session scheduled for September 18-19, 2007.
Components of September
Agenda
In discussions
concerning the recommendations for enhancing GME flexibility, COGME
expressed interest in learning the extent of state and regional engagement
in GME and physician workforce planning. It therefore endorsed inviting
selected states to discuss this issue at the September meeting, with
the possibility that this issue will from the basis of the4 next report
and /or a conference to be sponsored by COGME on state physician workforce/GME
advisory panel activities.
In addition, the
members agreed to send to Mr. Katzoff by early August their ideas
for possible new topics as candidates for a new report. These items
would then be discussed in the September meeting.
Public Comment
In public comments
given on both days, Ms. Sunny Yoder of the Association of American
Medical Colleges, Dr. Steven Shannon of the Association of American
Colleges of Osteopathic Medicine, and Dr. Paul Rockey of the American
Medical Association each welcomed COGME efforts in taking up the issues
embedded in its two emerging reports.
Adjournment
The Council adjourned
May 1, at 11 A.M.