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Department of Health and Human Services
Council on Graduate Medical Education
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Minutes of Meeting

April 14-15, 1999, Washington, D.C.

The meeting was held in the Jefferson Room of the Washington Plaza Hotel, Washington, D.C. It began at 8:30 a.m., April 14 and work group meetings were held that afternoon. The Council reconvened at 8:30 a.m. and adjourned at 11:10 a.m., April 15. Dr. David N. Sundwall, Chair, presided.

Members Present:
David N. Sundwall, M.D., Chair
Lawrence U. Haspel, D.O., Vice Chair
Paul W. Ambrose, M.D., Member
Macaran A. Baird, M.D., Member
Regina M. Benjamin, M.D., M.B.A., Member
JudyAnn Bigby, M.D., Member
F. Marian Bishop, Ph.D., M.S.P.H., Member
Sergio A. Bustamante, M.D., Member
Ezra C. Davidson, Jr., M.D., Member
Carl J. Getto, M.D., Member (April 15 only)
Kylanne Green, Member
Ann Kempski, Member
Tzvi M. Hefter, Designee of the Health Care Finance Administration
David P. Stevens, M.D., Designee of the Department of Veteran Affairs

Others Present:
Stan Bastacky, D.M.D., M.H.S.A., Acting Executive Secretary
F. Lawrence Clare, M.D., M.P. H., Deputy Executive Secretary
Claude Earl Fox, M.D., M..P.H., Administrator, HRSA
Vincent C. Rogers, D.D.S., M.P.H., Associate Administrator for Health Professions

Welcome and Announcements:
Dr. Sundwall opened the meeting. Dr. Fox, Administrator, HRSA, extended greetings. He stated that presentations are to be videotaped, edited and made available to a variety of entities, such as DHHS regional offices, state health departments and others that might become more involved in looking at health workforce. Within HRSA and the Bureau of Health Professions there is a continuing effort to increase the interface on GME issues. He announced that the administration has proposed a GME plan in the 2000 budget which would provide $40 million to go to freestanding children's hospitals to compensate for their lack of reimbursement under Medicare. This will be the first time that HRSA has been involved in any administration of GME funds. HRSA is working with the National Academy of State Health Policy to look at state issues regarding Medicaid & GME. The Agency is developing a national center on workforce in order to build the data based that will provide an adequate information base on what is going on nationally as well as the state levels. He was pleased COGME and NACNEP are going to continue their interface.

Dr. Rogers welcomed Council members. He stated that the challenge for HRSA, the Bureau and COGME is the need for consistency, completeness, comparability and credibility of its data to support policy and workforce predictions and recommendations. One Bureau initiative is the development of the national center for health professions workforce information and analysis, which will function collaboratively with the Divisions in the Bureau as well as work closely with cross-cutting workforce issues of HRSAs other bureaus.

Dr. Bastacky welcomed Council members and made a few announcements. He touched upon the milestones since the last meeting. Both the 13th and 14th Reports have been published; COGME has a new web site; and the outline of the 15th Report is being developed. The "Bishop" report, a "snapshot" of COGMEs work, is now being developed. The first meeting of the contract with CMSS on medical specialties workforce studies was held in Baltimore. Paul Friedmann M.D., will provide an update at the Physician Workforce Work Group meeting in the afternoon.

Panel Presentations: The Changing GME Environment, and Accreditation and Certification
David C. Leach, M.D., Executive Director, Accreditation Council for Graduate Medical Education (ACGME), stated that the charge to ACGME is to define standards and judge programs independent of workforce and marketplace pressures. It has five sponsoring organizations. At the heart of the ACGME are the residency review committees which serve as a peer review mechanism that can both set standards and make judgments about programs in their disciplines. He stated that accrediting bodies are moving in general towards competency outcome measurements and are encouraging innovation. ACGME wants to become more data and evidence driven in order to objectify the process of accrediting residency programs. A recent ACGME draft report states that all physicians achieve competence in patient care, clinical science, practice-based learning and continuous quality improvement and working for an improvement model of accreditation through institutional review. He briefly described the goals of ACGME.

Stephen H. Miller, M.D., M.P.H., Executive Vice President, American Board of Medical Specialties (ABMS), stated that the ABMS is an umbrella organization for 24 medical specialty boards. Its mission is "to provide assurance to the public that a physician certified by a member board has the knowledge, skills and experience required to provide quality patient care in that specialty." Although the word "competencies" is not in the mission statement, all boards assess competencies. The goal is to develop the maintenance of competence to be demonstrated throughout the physician's career by evidence of life-long learning and continuous improvement of practice and ultimately the maintenance of competence within the broad field of healthcare delivery.

Paul Friedmann, M.D., Immediate Past President, Council of Medical Specialty Societies (CMSS) and Chairman of ACGME, focused on five points as they relate to the changing GME environment: the shift to ambulatory care; the impact of managed care; unionization efforts; reimbursement and funding; and the structural stability of the GME system. He also stated that the academic system, a complex adaptive system, will have to changed. One of the overwhelming concerns is the emergence of a competitive healthcare delivery marketplace which is forcing some changes. It is his view that the academic and the GME systems are unstable and could collapse. He predicts that "if the present trends continue, we are going to have a lot more trouble in the GME system than we have today."

Malathi Srinivasan, M.D., Chair, Resident and New Practicing Physician Group, Council of Medical Specialty Societies, outlined learning and teaching theories, infrastructural components, GME constructs and resident realities. She recommended the following: the highest standards in physician education; more stable GME funding sources; compensate teachers for care by buying out their time and cover costs for ancillary services; strengthen the oversight roles of the ACGME & ABMS; revise current HCFA documentation guidelines for attending physicians; and continue to involve residents in the deliberative process.

Panel: Physician Workforce Assessment Activities
Rebecca Hines, M.H.S., Acting Director, National Center for Health Workforce Information Analysis, summarized how the Center works with other agencies and associations to collect data either through negotiating the purchase or exchanging data. The Area Resource File pulls together in one place as much health-related and health professions data as possible. The Center has a series of physician supply and requirements models; an integrated requirements model, a physician aggregate requirements model; and a GME model. The Center is working with others in research projects and undertaking several projects to support the Bureau and Agency. The Center now has a web site is in process of updating it.

Fitzhugh Mullan, M.D., Clinical Professor of Pediatrics and Health Care Sciences, George Washington University School of Medicine, shared with Council information about the Third International Conference on the Physician Workforce held in Cambridge, England, by providing the historical prospective on this ongoing effort to begin to talk transnationally about issues relating to the physician and to some extent the healthcare workforce. The fourth conference is planned for this November in San Francisco. Dr. Mullan stated that "the M.D. is a passport for moving around the world today." He concluded by saying that COGME might well keep its eye on the international workforce activity which provides an interesting forum.

David A. Kindig, M.D., Ph.D., Professor of Preventive Medicine, University of Wisconsin, Madison, revisited the "110:50-50" with slides from the 8th Report that recommended the 110:50- 50. He identified factors that may stimulate revisiting the appropriateness of the COGME goal in the 8th Report that the future number of physicians entering residency be 110 percent of the number of graduates of allopathic and osteopathic schools in the US in 1993, and that of those graduates who complete training and enter practice as generalists should be 50 percent.

During the discussion, Dr. Mullan stated that attempts to persuade hospitals and policymakers to reduce the number of residents in residency programs had not been successful, in spite of a gap each year between 17,000 US medical school graduates (USMGs) and 24,000 first-year residents. The difference is primarily made up by international medical graduates (IMGs) of foreign medical schools. Dr. Mullan felt that the system was absorbing the larger number of residents, and the gap between USMG and IMG residents could be an indication that more than 17,000 USMGs are needed each year. He suggested an increased US medical school output to close the gap and increase opportunities for US citizens.

Panel: The Physician Public Health Workforce
Krstine M. Gebbie, Dr.P.H., R.N., Director, Center for Health Policy and Health Services Research, Columbia University, provided COGME with a comprehensive presentation of what public health is-- how people are defining public health and the public health workforce. She suggested that one focus on the balance (healthy people in healthy communities) that distinguishes people who have adopted public health as their focus from those focusing only on individual health.

Hugh H. Tilson, M.D., Dr.P.H., Clinical Professor of Epidemiology and Health Policy, school of Public Health, UNC-Chapel Hill; and Immediate Past President, American College of Preventive Medicine, stated that public health is important to physicians and training physicians about public health is critical. The pipeline is empty; there is probably a need for 3,000 -10,000 physicians trained in public health.

Dorothy S. Lane., M.D., M.P.H. Professor of Preventive Medicine and Program director, Residency in general preventive Medicine and Public health, state University of new York at Stony Brook; Chair, American Board of Preventive Medicine; Past President, Association of Teachers of Preventive Medicine; and President-elect, American College of Preventive Medicine, discussed the match between the preventive medicine specialty competencies and those identified in the COGME reports. For the past six years the number of residency programs in this specialty has been stable, but the number of residents has declined from 441 in 1993 to 420 in 1998. There is a shortage of preventive medicine specialists in health departments, inadequate numbers of faculty trained and certified in preventive medicine in medical schools and there is no stable source of funding for preventive medicine specialists. She reviewed some of the funding issues with COGME.

Report of the Work Groups
The report of the discussions held in the Ambulatory Programs and Financing Work Group on Wednesday was given by Larry Haspel, M.D. The work group believed that the financing report should be in the context of looking at the aggregate supply of physicians, the distribution and mix of physicians, both on a specialty and on a geographic level; and the need to recognize the diversity issues. The focus is on moving training into ambulatory settings and finding a stable financing method to move planning forward. The work group stated that in addition to a contractor, an advisory panel should be formed with expertise to assist the contractor, and a more realistic time table should be developed.

David Sundwall, M.D. reported on the Physician Workforce Work Group meeting. The work group is in the process of revisiting COGME assumptions of 110:50-50. This is being accomplished through a series of studies, three of which are ongoing.

Dr. Friedmann, CMSS, Immediate Past President shared the progress being made on the CMSS contract. The first Advisory Committee meeting was held in Baltimore April 9-10. A template is being developed by which the specialty workforce studies for period 1992-1998 will be measured and assessed.

Dr. Colwill shared with the group via telephone his two-track project. First, he is looking at the number of generalists that we are training to the year 2020, including family physicians, pediatricians and internists. The second track is to study access to health care in rural America, realizing that family physicians and osteopathic physicians tend to settle in rural, underserved areas.

Dr. Kindig presented his study of the number of physicians needed for the safety net to serve under- served areas. He hopes to come up with numbers of physicians needed to serve in underserved areas about the time the National Health Service Corps comes up for reauthorization.

Update on MedPAC Activities: Craig Lisk, senior analyst with the Medicare Payment Advisory Commission (MedPAC), discussed the March meeting of the Commission. He reviewed its discussion concerning Medicare's GME payments and the indirect medical education adjustment. He presented several basic issues the Commission will consider as it discusses how Medicare GME payment might be changed and the broad options that can be considered for Medicare's direct GME and possible modifications.

State GME Financing Activities: Tim H. Henderson, M.S.P.H., Director, Primary Care Resource Center, National Conference of State Legislatures shared with Council what states are doing to finance GME. States are concerned about specialty mix and common concerns in recent years are whether or not there are too many specialists and not enough primary care physicians. He presented findings from the AAMC study that was being released, which is an update of an AAMC study conducted four years ago (the 1995 study was the first effort to look at how states are paying for GME under the Medicaid program). About 42 states and D.C. have implemented some kind of capitated managed care. There are great variations in strategies states are using to pay for graduate medical education or medical education generally. States are paying about $3 billion to support medical education, including an estimated $200 million for family practice residency training.

Proposed Children's Hospital GME Support Legislation: Karen Davenport, Legislative Assistant for Senator Bob Kerrey, spoke about Senator Kerry's proposal on GME for children's hospitals. The purpose of the bill is to provide some measure of federal support commensurate with Medicare support to other teaching hospitals. This bill uses new money; it is a guaranteed time limited fund (FY2000 through 2003). The Administration proposal is more appropriations-based and for direct funding only. She stated that the independent children's hospitals train somewhere between 25-30 percent of all pediatricians in the country.

Administration Proposal for Children's Hospital GME Support: F. Lawrence Clare, M.D., M.P.H., Deputy Executive Secretary, COGME, provided information on the Administration's proposal for children's hospital support, a high priority initiative that HRSA received at the beginning of this year. This includes a $40 million appropriation in the President's budget for FY2000 to be placed under Title VII of the Public Health Service Act. Eligible hospitals will be children's hospitals as defined under Medicare. The bill will provide for a formula grant based on applications by hospitals to the Secretary. He discussed both the challenges and opportunities.

Dr. Sundwall asked Council whether or not it should consider doing some analysis of the current burden and unintended effect of the documentation requirements on graduate medical education. It was suggested that COGME convene a group and develop a white paper that identifies the nature of the problem, its impact and changes recommended.

The minutes from the last meeting were approved.

Public Comment: Hope Wittenberg with the Organizations of Academic Family Medicine, stated that family medicine is having major difficulties with support for preceptors because HCFA does not recognize students for Medicare Payment purposes. She suggested that COGME look at this major issue within family medicine and ambulatory training.

The meeting was concluded at 11:10 a.m.