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Department of Health and Human Services
Council on Graduate Medical Education

Minutes of Meeting

April 22, 2009, Bethesda, Maryland

 The Council of Graduate Medical Education (COGME) convened in the Doubletree Hotel and Executive Meeting Center at 8:41am April 22, 2009.

Members Present

Russell G. Robertson, M.D., Chairman
Robert L. Phillips, M.D., MSPH, Vice Chairman
Wendy Braund, M.D., M.P.H., M.S.Ed (ASH)
Denice Cora-Bramble, M.D., M.B.A.
Mary Dougherty (DVA)
Joseph Hobbs, M.D.
Mark A. Kelley, M.D.
Jerry Kruse, M.D., M.S.P.H.
Spencer G. Nabors, M.D. M.P.H., M.A.
Kendall Reed, D.O., F.A.C.O.S., F.A.C.S.
Sheldon M. Retchin, M.D., MSPH
Vicki Seltzer, M.D.
Jason C. Shu, M.D., D.O.M.
William L. Thomas, M
Leana Wen, M.A., B.S.

HRSA Staff Members:

Jerry Katzoff, Executive Secretary
Members Absent:
Tzvi Hefter (CMS)
Thomas E. Keane, M.D.

Welcome

Dr. Russell Robertson, Chair, called the meeting to order and welcomed the COGME members and guests. In his opening message, Dr. Robertson explained the importance of expediting the reporting process; announced his participation in upcoming meetings with the Medicare Payment Advisory Commission and the Brookings Institute; and detailed some of the activities within the agency that would be of interest to the COGME membership.

Executive Secretary’s Report

Mr. Katzoff gave his report introducing the Division of Medicine and Dentistry’s new director and staff members in attendance. Immediately following the report, Mr. Katzoff turned the meeting back over to Dr. Robertson.

Presentations to the Council

During the day, the Council members heard presentations given by Dr. Robert Phillips; Dr. Joseph W. Stubbs, President-Elect of the American College of Physicians (ACP); and Dr. Charles Roehrig and Ani Turner of the Altarum Institute.

Dr. Phillips’ presentation tracked the status of recommendations presented in COGME’s 16th Report on physician workforce policy guidelines. According to the 2005 report, COGME recommended that the Nation undertake a multi-pronged strategy to include: a modest increase in medical education and training capacity over the next decade; efforts to increase physician productivity; and increased tracking and assessments of the supply, demand, and need for physicians. Dr. Phillips found that while considerable progress has been made in increasing the production of medical students and the number of physicians entering residency training programs; there is still work to be done in the development of systems and studies to track and assess the supply, need, demand, and distribution of physicians in primary care.

It was also found that access to care for underserved populations and communities has greatly improved since the release of the 16th Report; and the promotion of workforce diversity has also increased significantly in the area of gender equality. Conversely, with the increase of patients receiving care in the underserved areas, the need for more practitioners has increased. In addition, while great strides have been made in gender equality for physicians, diversity in terms of race and ethnicity has not been tracked due to a lack of systems in place to collect such information.

Dr. Phillips concluded his presentation with the discussion of placing these recommendations along with others set forth by the Council in a proposed letter to Congress in response to the current talks on healthcare reform and the provider workforce. The purpose of the letter, as Dr. Phillips explained, would be to elevate the importance of the need to change the way graduate medical education is funded in order to produce the right workforce and avoid the consequences of not taking any action at all. The discussion culminated with Council members offering suggestions on how to effectively convey this message to Congress in order for immediate action to take place regarding the proposed recommendations.

Note: Subsequent to this meeting, a COGME letter was transmitted on May 5, 2009 to the HHS Secretary and Congress. It can be assessed through COGME's website.

The next presentation was given by Dr. Joseph W. Stubbs describing potential solutions to the challenges facing primary care. Dr. Stubbs reported that the key factors playing a role in why medical students are not entering into primary care are the high level of medical school debt, issues to exposure to training in the ambulatory setting, and the poor quality of practice life. In response to these issues, the ACP plans to release two papers offering recommendations on how to recruit and retain primary care physicians.

The first of these recommendations is to establish a national healthcare workforce policy that will educate and train the supply of healthcare professionals that meets the nation’s healthcare needs and ensures adequate supply of primary care physicians. Associated with that policy is the need to establish a national commission on healthcare workforce to ensure that the actions taken by the Department of Health and Human Services and Congress serve to meet or exceed the policies that are set out by the workforce policy.

The next recommendation offered by ACP is to increase funding for the National Health Service Corps scholarship program and Title VII scholarship and loan repayment awards for primary care physicians. The organization also feels that there should be a process of deferment of educational loans throughout the duration of the training in primary care residency programs. Furthermore, ACP recommends that more training is needed in the ambulatory care setting and an increase in Title VII funding that will go towards primary care training programs, curriculum development in academic medical centers, primary care mentorship programs, and developing materials to promote careers in primary care.

Lastly, the ACP recommends that the Federal Government should focus its efforts to restore primary care compensation to be competitive with other specialties. The organization advocates that more incentives be awarded for the value of the care provided and not solely for the volume of patient services being received. ACP believes that once the Government takes the lead on this issue, this will prompt the private sector to take notice and follow their lead.

The final presentation of the day was given by Dr. Charles Roehrig and Ani Turner of the Altarum Institute, updating the Council members on the modeling and analysis for determining supply of and demand for residency positions by specialty. It was reported that the proportion of physicians in the US in primary care has remained fairly stable at about one-third. Nearly 27% of the 2008 cohort will enter primary care with about 17% selecting this field as their first choice. Ultimately, it is projected that if recent expansions in non-primary care continue, primary care participation will trend toward 17%.

Dr. Roehrig discussed that in order to avert this outcome; primary care must be promoted in multiple dimensions including the creation of incentives to ensure an adequate supply of primary care training positions and avoiding excess expansion of non-primary care training positions.  If primary care preferences are not increased, the only way to maintain 30% or more in primary care is through the control of non-primary care positions offered. As a result, an essential component of increasing preferences is to increase primary care incomes relative to non-primary care incomes. Dr. Roehrig observed that increasing the average incomes of primary care physicians by 20% may keep primary care preferences at 30%.

However, Dr. Roehrig noted that incomes are only part of what needs to be done to attract more physicians into primary care. Additional strategies presented include: the modification of medical school selection criteria or recruiting applicants who are more likely to be interested in primary care; and increasing opportunities for undergraduate and graduate medical education training in quality outpatient and community settings.

He also noted that improving the primary care practice environment (i.e. reducing administrative burden) and improving perceptions of primary care practice environments and employment opportunities, are key strategies to increase primary care preference.

The presentations were followed by a discussion among Council members regarding the development of COGME’s 20th Report. During this discussion, several key points were identified and a list of draft/prospective recommendations were formulated (see below).The tentative recommendations were not discussed at length or approved. it is expected that the list will serve as a basis for further COGME discussion over the next several months. This list and its accompanying discussion as well as that from the November 2008 meeting will serve as the foundation for a draft for the 20th Report.  This draft will be available for discussion, review and revision by the November 2009 meeting.

Subsequent to this meeting, the recommendations formulated from the discussion were edited and compiled.

Included below are these recommendations: Series of Prospective Recommendations

  • The US ration of primary care physicians to specialty positions should be 50-50. 32-35% of US physicians are primary care physicians to date.  Best outcomes are when that is close to the 40-50% range.  Note, these vary over time and are based on needs and practice issues that should be related to this include healthcare, education, ancillary resources.  We should look to decrease costs, increase equity, increased access.  For example, in the current setting, breast and cervical cancer screening rates have declined.
  • Non-physician clinician positions committed to primary care should increase.  The percentage of primary care physicians should be at least 40% over the next 10 years.
  • Healthcare reform and access to care should be based on population needs and not market needs.
  • New recommendations regarding resident work hours should be taken into consideration when making physician workforce recommendations. Consider the role of resident work hours and whether or not this should be a factor in making GME recommendations.
  • New and innovative solutions towards eliminating medical school debt for physicians entering primary care ought to be considered. Eliminated all debt for students committed to entering primary care, whether this would be through scholarships or loans.
  • Primary care physician incomes should be at 60-70% of the incomes for all medical specialties.  Incomes for primary care should be increased to a threshold of 60 percent of non primary care specialists
  • Any net Increases in medical school class size or the number of new medical should produce new primary care physicians.
  • Primary care physicians’ pay should be reimbursed by innovative models, care coordination, pay for performance, and fee for service with the intent to a net doubling of primary care reimbursement.
  • Graduate medical education payments for the ambulatory component of primary care residency should be increased.
  • Programs should be developed that support ambulatory training sites such as federally qualified health centers and rural health centers, with the intent designed to reduce barriers and address needs of these communities.
  • Medical schools have a societal responsibility need to produce graduates in line with societal needs if they accept federal dollars.
  • Support current increases (quadrupling of National Health Service Corps scholarships).
  • Undergraduate medical education, specifically the M1 and M2 year, should require a mandatory six week block doing ambulatory care with quality preceptors who are well-reimbursed to care and teach.
  • Any incremental increase in the GME cap should be targeted toward primary care physicians or have strategiceffect on thehealth of the n population.
  • Policy changes must result in improved geographic distribution in rural and urban settings (partnerships with community health centers/federally qualified health centers; the CHCs and FQHCs should not bear the burden of the costs of the program).
  • Consideration of the Patient Centered Medical Home as the construct for GME funded ambulatory care training is recommended.
  • There should be a minimum of 20% increase in reimbursement for primary care physicians based on Medicare billing codes.
  • Any increases in medical school class size should be structured tracked to increasethe primary care physician production.
  • Endorse patient-centered medical home and preferred funding for health information technology and interprofessional care.
  • Request that specialty societies consider the availability of tracking to ambulatory care tracks.
  • Create financial incentives to encourage choosing primary care training and focus in non-hospital settings.
  • Any demonstration projects moving toward accountable care organizations should mandate inclusion of academic health centers.
  • Workforce recommendations  should be considered in the context of where the US is headed with healthcare reform.
  • Some analysis of what is working and not working presently should be undertaken.
  • Incentives to medical students for specific communities with a demonstrated needfor residency training in primary care should be considered.
  • Salaries for residents in primary care residencies should be higher than other specialties.
  • Increase income for primary care physicians.
  • Increase income for primary care residents as compared to other residents.
  • Medical schools should be mandated/incentivized to select a portion of students with a pre-disposition to primary care. 
  • Student selection at the level of med school: we should incentivize medical schools to provide high quality primary care experiences.
  • Graduate medical education should be better supported and reimbursed through CMS.
  • Reiterate the GME points from the 18th and 19th reports.
  • GME payments should bypass the hospital completely to the primary care programs, specifically family medicine.
  • There should be resident pay differentials for graduates who go into community-based practices/family medicine.
  • Current GME caps should remain in place except for primary care physicians or other specialty shortages.

Adjournment

The Council adjourned at 4:15pm.