September 17, 2003, Bethesda, Maryland
The Council on Graduate Medical Education (COGME) convened in the Versailles Room I in the Holiday Inn Select, 8120 Wisconsin Avenue, Bethesda, Maryland, at 8:00 a.m., Dr. Carl J. Getto, Chairman, presiding. Originally scheduled to meet the next day, September 18, COGME adjourned following the conclusion of the current meeting because of the advent of extremely inclement weather conditions.
Carl J. Getto, M.D., Chair
Robert L. Johnson, M.D., Vice Chair
Regina M. Benjamin, M.D., M.B.A, Member
Laurinda L. Calongne, Member
William Ching, Member
Allen Irwin Hyman, M.D., FCCM 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
Jerry Alan Royer, M.D., M.B.A., Member
Susan Schooley, M.D., Member
Humphrey Taylor, Member
Donald C. Thomas III, M.D., 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
Stephanie H. Pincus, M.D., M.B.A., Designee of the Department of Veterans Affairs
Jerald M. Katzoff, Acting Deputy Executive Secretary
Howard Davis, Ph.D.
Helen Lotsikas, M.S.
Welcome and Announcements
Dr. Getto welcomed both new and old members and stated that since there is no pending legislation to reauthorize COGME, he wanted to accomplish as much as possible at this meeting. He stated that the agenda would be altered because of pending inclement weather to allow the workforce paper to be considered in the afternoon rather than the next day.
After introducing the new members to COGME, the Chair presented Dr. Stan Bastacky a plaque in recognition for his dedicated service as Acting Executive Secretary to COGME. Dr. Getto noted that Dr. Bastacky had been reassigned to the National Health Service Corps, Ready Responder Program. Dr. Bastacky responded with comments about his service with COGME, noting the many significant accomplishments during his tenure.
Elizabeth M. Duke, Ph.D., HRSA Administrator, after recognizing Dr. Bastacky's contribution to COGME, explained changes occurring in HRSA. She noted the advent of the Ready Responder Corps. She commented on the strong expansion of health centers, one of the important initiatives of the President as well as the number of excellent applications HRSA received for health centers during the first cycle funding in FY2003. She stated that those applications not able to be funded during the first cycle will be funded during FY2004 and noted that the establishment of new health centers was ahead of schedule. Dr. Duke remarked that the National Health Service Corps, another important initiative of the President, was well supported during FY2003 and hoped that the full complement of authorized 3,600 slots could be filled in FY2004. She noted the high retention rate of National Health Service Corps physicians.
Dr. Duke explained that the goal of the Ready Responder Corps was both to serve the underserved and to assist underserved areas to compete better for the National Health Service Corps and other providers. The Corps will also be mobilized to combat bioterrorism. She explained that the programNational Hospital Bioterrorism Preparedness Program is State administered and each State has submitted a preparedness program. Overcoming several obstacles, the States are beginning to implement the program. Dr. Duke concluded by stating that HRSA is preparing to do more with current resources. She also explained the procedures used to improve the grant making process and noted that the FY2004 grant preview programHRSA Grant Preview is in placeavailable.
Kerry Nessler, R.N., M.S., Associate Administrator for the Bureau of Health Professions, welcomed new members and announced staff changes in BHPr: Ms. Nessler acknowledged the following personnel: David Rutstein , Deputy DirectorAssociate Administrator for Health Professions; Carol Bazell, Director, Division of Medicine and Dentistry and instrumental in COGME; Roger Straw, Acting Branch Chief, Dental and Special Projects Branch; Jerry Katzoff, Acting Deputy Executive Secretary, COGME. She thanked Stan Bastacky for his service to COGME.
Ms. Nessler described the outcomeoutcomes of the International Workforce Conference in Oxford, England held November 4th and 5th. Issues discussed at the conference included physician supply and demand and hours worked by residents. Participants discussed methods to develop common data elements in order to improve reporting on physician workforce data. She and Carl Getto were among the attendees. She described the steps involved in the Bureau's strategic planning process, including inviting fifty outside organizations to the Bureau to provide input into the planning process.
Jerald Katzoff, Acting Deputy Executive Secretary, Mr. Katzoff reviewed the agenda and briefing book materials and acknowledged staff.
Carl Getto noted Dr. Marvin Dunn's death, stating that Dr. Dunn and his words of wisdom will be greatly missed. Dr. Getto then introduced panel participants.
Presentations on the Physician Workforce
Elliott Fisher, M.D., M.P.H., Center for Evaluative Studies, Dartmouth Medical School. Dr. Fisher, discussed his research concerning the geographic variation in physician supply, explaining that he based his analysis on Hospital Referral Region data. He shared the findings which showed that the generalist physician supply grew modestly while the growth of specialist physician supply was much more rapid. He observed that there is no evidence that increases in the per capita supply of specialist physicians and the intensity of their services result in any difference in health status. Dr. Fisher considers that while more specialist physicians are not needed, current GME policies exacerbate the disparities in physician supply and may contribute to a poorer quality of care.
Jonathan Weiner, Dr. P.H., Professor of Health Policy and Management, The Johns Hopkins University's Bloomberg School of Public Health, discussed his continued research on managed care staffing patterns. Dr. Weiner noted the expected publication of his study on staffing patterns of prepaid group practices. He described the methodology used to derive physician staffing patterns in prepaid health delivery organizations, including trends in the staffing patterns of Kaiser Permanente. He compared the results with comparable data currently existing in the country. He noted that the demographics of the population served by these organizations are similar to the general population demographics. The proportion of primary care physicians ranges from 41% to 46% percent of the overall physician supply in these organizations. However, specialty care in these organizations increased at twice the rate (2.4% annually) as of the national rate (1.2%). National growth in the use of non-physician providers (NPP) exceeded the growth of NPP, used in Kaiser Permanente, which occurred mostly in NNP specialists. Dr. Weiner felt that efficient practice could support fewer physicians than currently exist with good quality outcomes.
Robert Butler, M.D., President and CEO, International Longevity Center, discussed the impact of an aging society on physician workforce requirements. The factors he noted that will influence the projected need for physicians to care for older persons are changes in demography, utilization patterns, and physician productivity. He noted the multiple, complexity, interactive physical and psychosocial pathologies of older persons, particularly those over the age of 75. This group is also subject to adverse reactions caused from the use of many different drugs. Dr. Butler stated that 17% of older patients in hospitals suffered adverse drug reactions. Since the current medical lexicon is not sensitive to aging and noting that the marked increase in the proportion of elderly expected between 2000 and 2050, Dr. Butler stressed the need for physicians that are trained (geriatricians) to provide appropriate care for this group of persons.
Impact of Residency Duty Hours Restrictions-Cost and Structural Adaptations
Danielle Carrier, Program Director for Operations Improvement, University Health System Consortium (UHC), described the results of the UHC Benchmarking Project survey. The Project goals were: 1) identify successful strategies to comply with the new resident work hour limitations; 2) determine the current level of compliance with the new ACGME standards; 3) focus on changes n the service delivery process; and 4) provide an opportunity for knowledge sharing among members. Survey respondents detailed compliance strategies, with scheduling cited as the most common. Based upon respondents cited cost figures, the medical costs were $170,000 per program or $4,834 per resident, primarily resulting from additional labor costs for additional FTEs.
Ms. Sunny Yoder, Association of American Medical Colleges (AAMC), conveyed the fact that the AAMC was actively involved in research and initiatives to help members develop coping strategies. The AAMC held an Educational Conference last September and is to hold one again during the latter part of this September on the topic dealing with implementing requirementACGME requirements for resident physician duty hours. She described some positive as well as adverse results from these restrictions. Ms. Yoder described possible adaptive responses that may evolve. She noted that finding a balance between regulatory-style enforcement and traditional accreditation processes will constitute a challenge.
Thomas Whalen, M.D., Program Director, General Surgery, Robert Wood Johnson Medical School, described the accommodation his surgery program made to the duty hour restrictions. He expressed concern about the impact of duty hour restrictions on the training, particularly of surgical residents. He opined that duty hour limitations would cause residents to lose the opportunity to learn from their mistakes. A major problem lies in the availability of resources. Administrators will say, “It is your problem – run with it.”
Brett Robins, M.D., Program Director and Assistant Professor, Med/Peds, University of Rochester, considers that excessive duty hours disheartens students and causes them to be cynical. He expressed support for duty hour restrictions and wondered why there was such a long period before these restrictions were instituted.
Following the above panel discussion, Dr. Getto introduced Mrs. Ruth Bletzinger.
University of Michigan Supreme Court Case Ruling
Ms. Ruth Beer Bletzinger, Director, Division of Community and Minority Programs, AAMC, discussed the implications of the University of Michigan Supreme Court Case ruling for medical school admission criteria needed to achieve the goal of educating a diverse physician workforce.
Dr. Getto thanked Ms. Bletzinger for her discussion and then introduced Mr. Salsberg.
Report on the Physician Workforce
Edward Salsberg, Director of the Center for Health Workforce Studies, State University of New York, presented a draft copy of his report “Development of a Framework for Revised COGME Physician Workforce Goals.” The paper contained findings of probable projected shortages over the next 20 years in the physician workforce in both the primary and non-primary care sectors, and contained eight recommendations, which called for the need for (a) phased, modest increases in enrollments in both the undergraduate and graduate medical education, (b) modest increases in the number of non-physician providers, (c) systems to track the supply, demand, and need for physicians, and (d) expanded programs funded by the Public Health Service that canto help meet expected future physician workforce needs. The draft recommendations were leftprojected on thea screen for the benefit of COGME during its discussion.
During the discussion, Mr. Salsberg stated that he had tried to respond to the comments and concerns expressed at COGME's previous meeting held in April. He explained that this version of the paper explicated more clearly the underlying assumptions and included scenarios portraying different assumptions. He then proceeded to discuss the findings, background, methodology, and potential recommendations, reiterating previous caveats concerning the difficulties of forecasting.
The session was opened to discussion. Dr. Royer remarked on comments concerning the paper submitted by Jack Colwill, M.D., which contained two assertions: (1) the type of health care delivery system would affect the physician supplydemand; and a (2) a taut physician supply would restrain costs. Dr. Colwill further stipulated that COGME should still note its concern about the decline in the supply of primary care physicians.
COGME members discussed the basis and implications of assumptions and the rationale of the proposed recommendations. During Council deliberations, members expressed several concerns. Some of these concerns dealt with the tenuous nationsnature of the assumptions, the fact that the problem of physician maldistribution was not addressed, and the ineffectiveness of directing GME policy without addressing overall reimbursement issues.
Dr. Getto recognized Dr. Marilyn Biviano, Director of the National Center for Health Workforce Analysis (NCHWA) in the Bureau of Health Professions. Dr. Biviano explained that the NCHWA was currently preparing a physician manpower workforce report using their own as well as Mr. Salsberg's the Bureau's workforce models., but with differing assumptions about the future compared with Mr. Salsberg's analysis. She stated that since the report had not yet been cleared by HRSA, she could not share the report findings with Council members at this time. However, the NCHWA study will not indicate any long-term shortage physician shortage.
After considerable discussion, Dr. Getto achieved Council consensus by asking the contractor to incorporate several revisions into the report. Revisions included the need for re-writing one or more recommendations, deleting the recommendation calling for modest increases in the number of non-physician providers, and including a statement concerning the desirability of COGME's continued tracking of physician access in underserved areas
The Council gave preliminary approval to the findings and revised recommendations of the draft report, subject to approval of the final editing at a later date.
The meeting was adjourned at 4:52 p.m.