Minutes
of Meeting, July
28-29 , 2004
The Council on
Graduate Medical Education (COGME) convened in the Versailles Room
I in the Holiday Inn Select, 8120 Wisconsin Avenue, Bethesda, Maryland,
at 8:30am. on July 28-29, 2004, Dr. Carl J. Getto, Chairman, presiding.
Members Present
Carl J. Getto, M.D. (Chair)
Robert L. Johnson, M.D. (Vice Chair)
Laurinda L. Calongne (Member)
William Ching, Ph.D. (Member)
Rebecca M. Minter, M.D. (Member)
Lucy Montalvo, M.D., M.P.H. (Member)
Angela Dee Nossett, M.D., (Member)
Earl J. Reisdorff, M.D., (Member)
Russell G. Robertson, M.D., (Member)
Susan Schooley, M.D., (Member)
Humphrey Taylor, (Member)
Stephanie H. Pincus, M.D., M.B.A., Designee of the Department of Veterans
Affairs
Christina Beato, M.D., Acting Assistant Secretary for Health and Surgeon
General
Members Absent:
Allen Irwin Hyman, M.D., FCCM (Member)
Jerry Alan Royer, M.D., M.B.A. (Member)
Douglas L. Wood, D.O., Ph.D. (Member)
Howard Zucker, M.D. , Designee of the Deputy Assistant Secretary
for Health
Tzvi M. Hefter, Designee of the Centers for Medicare and Medicaid
Services
Staff:
Jerald M. Katzoff, Acting Deputy Executive Secretary
Howard Davis, Ph.D.
Eva Stone
Jaime Nguyen, M.D., M.P.H.
Welcome and
Announcements
Dr. Getto
welcomed the members of the Council and the public. Dr. Getto reviewed
the agenda for the day and introduced Captain Kerry Nesseler, R.N,
M.S., Associate Administrator for the Bureau of Health Professions.
Capt. Nesseler
provided a brief update on the Bureau and its continuing progress
towards developing and completing the strategic plans for the performance
and outcome measurements. The all grantee meeting is scheduled for
early June, 2005, in Washington, DC and all current Bureau of Health
Professions grantees will be invited to the meeting. Capt. Nesseler
also announced some personnel changes. Dr. Carol Bazell has taken
a new position at the Centers for Medicaid, Medicare Services (CMMS),
and Dr. Barbara Brookmyer is now at the Frederick County Health Department.
Capt. Nesseler introduced Tanya Pagan Raggio, M.D., a pediatricianboard
certified in pediatrics and preventive medicine and , as the new Division
of Medicine Director. Dr. Raggio will begin her appointment on August
22, 2004. Commander O’Neal Walker is the new Chief of Dentistry,
Psychology and Special Programs Branch in the Division of Medicine
and Dentistry. Captain Raymond Lala, D.D.S., has joined as a project
officer in the Division of Medicine and Dentistry.
Due to the absence
of Elizabeth Duke, Ph.D., at the meeting, David Rutstein,
M.D., was asked to read comments written by her. Dr. Duke gave
an overview of some of the programs currently in place at HRSA. She
also thanks the Council for its continuing dedication and efforts
in ensuring a strong and viable physician workforce in the future.
Review and
Discussion of Comments on the “Physician Workforce Policy Guidelines
for the U.S. 2000-2020” report:
A report of the
physician workforce was prepared by the Center for Health Workforce
Studies at the School of Public Health, University at Albany, State
University of New York by Edward Salsberg and Gaetano Forte.
This report forecasts future supply, demand, and need for physicians
based on the historical patterns of use of services by age, gender,
insurance status, type of area (urban, rural), and managed care penetration.
Included in the report are the results of the data analysis and a
description of the methodologies used to forecast supply, demand,
and need and the potential impact of changes in the factors that influence
each of those. The report also includes recommendations to assure
that the future supply better meets future demand and need.
Scenarios have
been constructed around the best understanding of changes occurring
in health care and in medicine. For each scenario, the report presents
a sensitivity analysis indicating the impact if change occurred to
a lesser or greater extent than current understanding portends. The
report concludes that the nation is likely to face a significant shortage
of physicians over the next 15 years and recommends an increase in
the number of new physicians being educated and trained in the U.S.
This marks a significant change from the Council’s earlier Reports
and is the first to call for an increase in U.S. medical school capacity.
COGME is no longer recommending that 50 percent of new physicians
be in generalist specialties but rather that the distribution by specialty
should be determined by marketplace demand. The report also strongly
endorses the need for additional data collection and research to guide
decisions on the size and mix of the physician workforce.
Prior to the meeting,
a draft of this report was sent to various organizations and institutions
for review and comments were requested. These remarks and comments
were compiled for all the members of the Council for their consideration.
After extensive
discussions and minor modifications, the Council approved the “Physician
Workforce Policy Guidelines for the U.S. for 2000-2020.” The
Council has endorsed the following revised recommendations to address
the likely shortage:
- In order to
meet the future physician workforce demand and need in the United
States, it is recommended that;
- The number
of physicians entering residency training each year be increased
from approximately 24,000 in 2002 to 27,000 in 2015;
- The distribution
between generalist and non-generalist physicians should reflect
on-going assessments of demand; a rigid national numerical target
is not recommended.
- Increase total
enrollment in U.S. medical schools by 15% from their 2002 levels
over the next decade.
- Phase in an
increase in the number of residency and fellowship positions eligible
for funding from Medicare to parallel the increase in U.S. medical
school graduates recommended above.
- Develop systems
to track the supply, demand, need, and distribution of physicians,
and undertake a comprehensive re-assessment within the next four
years to guide future decisions on medical education capacity.
- Additional
specialty specific studies are needed to understand physician workforce
needs better and to inform the medical education community and policy
makers of the nation’s specialty specific needs.
- Promote efforts
to increase the productivity of physicians. There are several steps
the nation should consider to promote productivity improvements.
These include:
- Funding to
evaluate the effectiveness and efficiency of alternative models
of care, and practice and organizational arrangements;
- Evaluation
of specific new technologies;
- Dissemination
of information to physicians on the effectiveness of alternative
models of care, new technologies, and other strategies to improve
productivity; and
- Introduction
of reimbursement policies to support implementation of productivity
enhancements.
- Expand programs
and develop policies that:
- Address geographic
maldistribution of physicians;
- Improve access
to care for underserved populations and communities;
- Promote appropriate
specialty distribution and deployment;
- Promote workforce
diversity; and
- Support analyses
of data related to these issues.
After the report
is submitted to the DHHS Secretary and to the appropriate members
of Congress, the Health Resources and Services Administration (HRSA)
expects to publish and disseminate the report in the upcoming months
as COGME’s 16th report.
Discussion
of Future Issues:
In the afternoon
session, David Sundwall, M.D., former chair of COGME, led the
discussion on future issues regarding: (1) the supply, distribution,
and adequacy of the physician workforce in training and practice;
(2) financing of medical education; and (3) federal policies and non-federal
efforts to ensure an appropriately trained physician workforce. After
the discussion, the following issues were compiled in order to assist
in directing future work and recommendations for COGME.
In regard to
the supply, distribution and adequacy of the physician workforce in
training and practice:
- Issues regarding
the physician workforce should be differentiated from concerning
those physicians in-training versus those already in practice.
- Those areas
with shortages in specialties and subspecialties need to be identified
and investigated, especially those areas that are beginning to experience
shortages.
- Should physicians
be trained to complement or accommodate the practice situations
that currently exist to serve the needs of the population?
- Other groups
or institutions, besides COGME, should look at how funding impacts
training.
- Although Accreditation
Council for Graduate Medical Education (ACGME) does not look at
workforce or the requirements for residency programs, COGME should
collaborate with ACGME to examine broader issues such as how health
professions are prepared and how that affects safety and quality.
- The supply
of the physician workforce should be analyzed in the context of
access.
- Unemployment
figures of physicians in medical specialties should be reviewed
in discussing physician shortages.
- “Demand” is
often being used when describing the needs of the U.S. population
for physicians and specialty care. This approach should be focused
on access and less on training of residents. Access to health care
is a vital issue, specifically the ability of physicians to provide
care in underserved communities and populations.
- Although mostly
anecdotal evidence, the perception of a growing trend of specialist
that are providing general or primary care along with specialty
care and the magnitude of that care needs to be explained. Are
more generalists providing more specialty care as a result of the
shortage of specialists? The Mendenhall Study, which was a large,
well-funded study done approximately 20 years ago, attempted to
define the extent of primary care specialists were performing.
- Coordination
should be done between COGME and HRSA to develop a model, similar
to the one already in place at HRSA. HRSA currently uses physician
supply and demand model, which basically looks at physician-to-population
ratios in different settings by demographic characteristics for
more than 18 specialties on the supply and demand side. The HRSA
model is a demographics-driven model and relies on existing information
about utilizations rates in different settings.
- How can we
train physicians to address geographic maldistribution? HRSA has
a national aggregate model to obtain local geographic information.
The data are limited to individual states and do not account for
the impact by other states.
- A clarification
is needed if access, geographic maldistribution, and specialty maldistribution
are affected by incentives and reimbursements. What role does COGME
have in these issues?
- Cost-effectiveness,
quality, and outcomes need to be defined in order to develop an
appropriate model.
- What is the
impact on the current model by non-physician providers? What is
the role of non-physician clinicians and their role in providing
primary care?
- Workplace
redesign and redesign of work performance as a method in addressing
the workforce shortage.
- International
Medical Graduates (IMGs) continue to play a significant role in
the physician workforce and what impact they will have in the future
needs review.
- Issues of
global access need to be addressed, especially in regard to insurance
model; the concept of “coverage” versus access; and the insured
versus MC/MA versus the uninsured.
For financing
of medical education:
- What is Medicare’s
and MEDPAC’s role in financing graduate medical education?
- Another issue
is that most of the teaching hospitals are providing uncompensated
care and having the federal government pay for medical education.
- More accountability
is needed regarding the funding for graduate medical education.
What is COGME’s role in recommending what the educational outputs
should be?
- Hospitals and
currently only two community health centers receive payments from
Medicare. What then are the roles of teaching hospitals and them
contributing to uncompensated care?
- Should COGME
become involved with recommending the number of specialists needed
in the physician workforce? In the past, COGME has always deferred
to the specialty societies to determine their respective number
of physicians. Further, MEDPAC has explicitly stated its lack of
interest in using financing as a means to influence workforce.
- What is the
impact of the increasing malpractice rate on graduate medical education,
especially the growing trend of malpractice suits against residents?
How does medical liability relate to the financing of medical education
and patient care?
- Should hospitals
receiving reimbursements also pay for ambulatory sites?
- The undergraduate
debt burden is affecting specialty choice and will impact the future
physician workforce.
- What is the
possibility and likelihood of having flexible or target funding
for graduate medical education to reflect environmental changes
and to direct funding to meet the population’s needs?
For federal
policies and non-federal efforts to ensure an appropriately trained
physician workforce:
- The federal
government has historically had a limited role in dictating the
physician workforce. Should the federal role be to ensure access
to health care and, more importantly, funding quality care, specifically
in training the physician workforce?
- The federal
government should be involved in guaranteeing high quality care
and access to care for the uninsured and underinsured.
- There should
be fewer restrictions on hospital’s opportunity to train physicians
and less regulation on graduate medical education. Graduate medical
education should be used to enhance the value and quality of health
care providers to patients.
- Adequate funding
should be provided for the development and research of the physician
workforce data.
- The federal
government needs to prepare the physician workforce for national
defense and homeland security.
- The federal
government should advocate for a program that mandates one or two
years of public or community service in areas of health care disparities
and physician maldistribution in exchange for debt reduction or
other incentives.
- The federal
government should articulate a set of workforce priorities and ensure
that the programs it supports adheres to those priorities.
- In order to
define the federal role in the physician workforce, the state role
has, thus far, been variable and needs to be defined.
- The Council
firmly recommends that the federal government establish an entity,
whether it be COGME or an independent, autonomous advisory committee,
that would continue to advise Congress and the Secretary on issues
related to the health workforce. This advisory body should analyze
the available data and invest resources into health services research.
The first day
of the meeting adjourned at 5:04pm.
Discussion
of update of COGME’s twelfth report – “Minorities in Medicine”:
The second day’s
deliberations included a presentation by Rhonda Ray, Ph.D.,
on a draft report developed on behalf of COGME to update on the report,
“Minorities in Medicine.” The original report was disseminated
as COGME’s Twelfth Report in 1998.
This current report
reviews the literature regarding the advancement of these goals since
the 1998 COGME recommendations, assesses the progress made through
2003, and notes key findings. It also recommends ways to support
the academic pipeline to facilitate minority entry into medical school,
strengthen upstream (institutional and policy) efforts in medical
training, and ensure cultural competence in medicine and medical education.
Research indicates
that the greatest barrier to underrepresented minorities (URMs) admission
to medical school is the low applicant pool of URM college graduates
resulting from high attrition rates in high school and low enrollment
in college. To increase the pool of URM medical school applicants,
the retention of URM students must be addressed, both at the high
school and undergraduate level. Increasing the number of URM physicians
is an important step for improving health care for minority and underserved
populations and, consequently, for decreasing health disparities,
one of the Nation’s leading health priorities.
The recommendations
made in the updated report addressed two main goals:
- Increase URMs
in medicine, and
- Strengthen
cultural competency of physicians.
Six main groups
of recommendations were made (number of recommendations made under
each group):
- Group 1: Strengthen
programs and resources required to facilitate minority entry into
medicine. (8 recommendations)
- Group 2: Enhance
cultural competence. (5 recommendations)
- Group 3: Ensure
minority medical career choice and entry into specialties. (4 recommendations)
- Group 4: Increase
access to health care for minority communities. (2 recommendations)
- Group 5: Seek
constitutional and legal efforts to increase minority entry into
medicine. (1 recommendation)
- Group 6: Track
minority participation in medicine. (1 recommendation)
The Council commended
Dr. Ray on her well-detailed and researched report and approved it
as COGME’s 17th report, “Update on Minorities in Medicine.”
After the report is submitted to the DHHS Secretary and to the appropriate
members of Congress, the report is expected to be distributed along
with a summary letter requesting comments and responses that will
be presented on COGME’s agenda for its next meeting. After considerable
discussion, the Council decided that due to the urgency of time, the
report will not be vetted by selected organizations for comment prior
to the report’s transmittal to the Secretary and Congress. Rather,
the Council directed that after the report is submitted to the DHHS
Secretary and to the appropriate members of Congress, the report will
be distributed to the public along with a summary letter requesting
comments and responses that will be presented on COGME’s agenda at
a subsequent meeting.
The meeting on
the second day adjourned at 10:24am.