December 1 - 2, 1999, Washington, D.C.
The December 1-2 meeting of the Council on Graduate Medical Education was held in the Presidential Room, Latham hotel, Washington, D.C. David N. Sundwall, M.D., Chair, presided. On the first day, the meeting began at 8:30 a.m. and was adjourned at 2:35 p.m., with participants convening in workgroup sessions for the remainder of the afternoon. The Council reconvened at 8:30 a.m. and was adjourned at 11:48 a.m. after which public comment was heard.
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
F. Marian Bishop, Ph.D., M.S.P.H., Member
Jo Ivey Boufford, M.D., Member
Sergio Bustamante, M.D., Member
William Ching , Member
Ezra C. Davidson, Jr., M.D., Member
Carl J. Getto, M.D., Member
Kylanne Green , Member
Ann Kempski, Member
Lucy Montalvo-Hicks, M.D., M.P.H., Member
Susan Schooley, M.D., Member
Donald. D. Thomas III, M.D., Member
Douglas L. Wood, D.O., Ph.D., Member
Tzvi M. Hefter, Designee of the Health Care Finance Administration
Gloria Holland, Ph.D., Designee of the Department of Veteran Affairs
Nicole Lurie, M.D., M.S.P.H., Designee of the Assistant Secretary of Health
Stan Bastacky, D.M.D., M.H.S.A., Acting Executive Secretary
F. Lawrence Clare, M.D., M.P.H., Deputy Executive Secretary
Neil Sampson, Deputy Director, BHPr
Welcome and Announcements:
Dr. Sundwall opened the meeting and welcomed the new Council members. Dr. Sundwall commented on the considerable current interest in graduate medical education (GME) and mentioned an analysis of recent legislation being done by the AAMC. Dr. Sundwall also mentioned his appearance on "60 Minutes" with Dr. Fitzhugh Mullan. At Dr. Sundwall's request, new COGME members introduced themselves, providing a short description of their current association, and professional position and activities. Later in the session, old members were asked to introduce themselves.
Jerry Katzoff was requested to give a remembrance for the professional contributions of the late Dr. Itzhak Jacoby. Mr. Neil Sampson, Deputy Associate Administrator, BHPr, extended a welcome. He gave a brief description of Bureau activities, particularly the role of the two new advisory groups: the Advisory Committee on Training in Primary Care Medicine and Dentistry and the Advisory Committee on Interdisciplinary, Community-Based Linkages, and information regarding new programs funded in the FY2000 budget: the children's hospitals graduate medical education project, and the Ricky Ray Hemophilia Relief Fund. He also cited the importance of the Cooperative Centers for Health Workforce Studies Program, National Center for Health Workforce Information and Analysis, funded by the Bureau, which contributes to the Bureau's role in collection, dissemination, and analysis of health workforce information.
Council of Medical Specialties Societies presentation
Dr. Sundwall introduced Dr. Paul Friedmann, Past President of the Council of Medical Specialty Societies (CMSS), and Dr. Richard A. Cooper, Director, Health Policy Institute, Medical College of Wisconsin. Drs. Friedmann and Cooper spoke on the Specialty Supply and Requirements Study being conducted by the CMSS. They described the process used to assess the methodology of various specialty manpower studies and discussed the difficulties imposed by the intricacies of specialty classification, the various facets affecting the estimation of the supply and demand of physicians, and the impact of increasing numbers of non-physician providers. Various models were portrayed that have been used in projections. Dr. Cooper explained the model developed for this project.
National Health Service Corps presentation
Dr. Sundwall introduced Donald L. Weaver, M.D., Director, Division of the National Health Service Corps (NHSC), Bureau of Primary Health Care (HRSA). Dr. Weaver noted the NHSC is up for reauthorization and the importance of emphasizing the role the NHSC plays in underserved communities. He gave the history and the current estimated strength (about 2,450) of the NHSC. Dr. Weaver stated that the NHSC meets, based upon the industry's standard of care, about 12 to 12.5 percent of the current need for clinicians in the designated shortage areas. Both requests from communities for clinicians and the number of applicants for scholarship and loan repayment programs exceed the resources NHSC can provide. Dr. Weaver related the strengths of the NHSC with respect to community responsiveness, cultural competence, and an interdisciplinary team approach to care. Thirty percent of the NHSC clinicians are underrepresented minorities.
Panel presentation: State Centers for Health Workforce Studies
Dr. Sundwall introduced the participants: Janet Coffman, M.P.P., Center for Health Professions, University of California at San Francisco; Judith Cooksey, M.D., University of Illinois, Chicago; L. Gary Hart, Ph.D., WWAMI Workforce Center, University of Washington, Seattle; and Edward Salsberg, M.P.A., Center for Health Workforce Studies, State University of New York, Albany. Dr. Salsberg presented a brief historical background and noted that the purpose of the funding of these Centers by HRSA was to involve the States in workforce planning efforts. The participants reported on their respective research activities and findings. Ms. Coffman discussed the impact of the anti-affirmative action decisions upon minority enrollments in the University system medical schools and the subsequent coping efforts. Dr. Salsberg described his Center's projects, which included such activities as a re-registration practice survey, a survey of practice intentions and marketplace experience of residents completing training in New York, and the development of state profiles of physician attributes for New York, Texas, and California.
Dr. Hart explained his Center's efforts to develop small area analytical methods for assessing State health workforce needs. Dr. Cooksey discussed her Center's examination of workforce and training issues with respect to four categories of health professionals: physicians, nurses, dentists, and pharmacists.
Medicare Teaching Physician Payment Policy Issues: comments by Thomas Marciniak, M.D.
Dr. Sundwall introduced Thomas Marciniak, Medical Director, Plans and Providers Purchasing Policy Group, Health Care Financing Administration (HCFA). Dr. Marciniak explained the principles upon which HCFA reimburses teaching physicians for their services; reimbursement is predicated upon: do not pay twice; required presence of the teaching physician; and proper documentation. The interpretation by Medicare is that resident physician services are already included in the GME payments. He accentuated the importance of distinguishing the interaction of a teaching physician with the resident from the performance of independent services by the physician. Dr. Marciniak pointed out that the December '95 Final Rule requires, as a precondition of payment, that the presence of the teaching physician during the critical portion of the service be documented. He explained the evolution of the 1995 and 1997 guidelines for determining the level of evaluation and management established by HCFA.
COGME Brochure (Bishop Report)
Dr. Sundwall asked Dr. Marian Bishop to describe the COGME brochure (the "Bishop report"). After Dr. Bishop described the document and its anticipated appearance, Dr. Sundwall requested Council members review and comment on the brochure.
Report of Workgroups
Dr. Boufford reported on the Physician Workforce workgroup. The first agenda item dealt with the physician public health workforce. Dr. Jerrilyn Glass, of the COGME staff, and Arthur Elster, M.D., of the AMA, presented. Dr. Elster reported on a proposed AMA survey in January 2000 of 6,000 physicians from the AMA Master File list to categorize them either into public health or preventive medicine practice. The AMA is seeking to provide more membership support and service to the latter group. Suggestions were made to modify the survey to provide more workforce data. Data from this survey might be available for presentation at the April COGME meeting. Paul Pomrehn, M.D., of the ATPM, discussed a collaborative program between the ATPM and the AMA focusing on undergraduate medical education efforts in preventive medicine and population health. He noted that the AMA is planning to publish a set of competency objectives in population health for all undergraduate medical education programs. Dr. Joan Cioffi, Centers for Disease Control (CDC), reported on CDC and HRSA collaborative initiatives to standardize preparation, either through formal certification or other certification processes, for professionals working in the public health infrastructure.
Although recognizing that considerable ferment exists in this field of which COGME needs to be heedful, Workgroup members felt more focus is needed to develop recommendations. A subcommittee composed of Drs. Regina Benjamin, Paul Ambrose, Marian Bishop, and Jo Boufford will meet before the April meeting of COGME to examine the issues and develop a set of recommendations requiring possible next steps for the Workgroup in this topical area.
Dr. Carol Simon presented initial efforts to revisit the conceptional framework supporting COGME's "110/50-50" recommendations. The Workgroup expects to have from her by the end of January a draft framework for review and comment. Dr. Jack Colwill stated that the original 50-50 recommendation applied to the residency not the practitioner split.
The third presentation concerned exploration of the possibility of developing a joint COGME-NACNEP project dealing with the following topics: interdisciplinary education; recruitment and retention of the underserved; underrepresented minorities in the health professions; and revisiting the IRM assumptions. It was suggested that a joint COGME-NACNEP working group be formed. COGME volunteers for the joint working group were solicited. Kylanne Green, William Ching, and Dr. Douglas Wood volunteered.
The final presentations dealt with the research projects of Dr. Jack Colwill and Drs. David Kindig and Don Libby. Dr. Colwill reported on the progress of his project to assess the generalist physician supply and needs to the year 2000 with implications for rural and urban shortage areas. The section on family medicine has been completed and the other section on general internal medicine, and general pediatrics will be completed by April. The Kindig-Libby paper "Estimation of Needs for Primary Care Physicians in Underserved Areas: Quantification of COGME's Tenth Report" was reviewed and suggestions were made to: (1) recalculate projections in view of the marked increase that has occurred in the number of non-physician providers; and (2) disaggregate the physician numbers to identify better areas of need within States. A discussion ensued concerning the use of the Kindig-Libby paper to support a COGME recommendation for the reauthorization of the NHSC.
Dr. Carl Getto reported on the GME Financing Workgroup. He said that the first draft of the report is under development. A major goal of the report will be to examine if the GME financing system supports moving training into settings other than traditional inpatient settings. The second part is to design models that might work better to fund the training of doctors to care for patients in the entire panoply of places in which people need to have health care provided. The workgroup does not intend, however, to discuss the sources of funding. He stated that Barbara Wynn is the contractor and the project advisory panel met on November 19. The draft paper of the effects of the Balanced Budget Act was reviewed and is expected to become a resource paper.
Osteopathic Medical Education and Workforce Issues
Dr. Larry Haspel introduced John Crosby, President, American Osteopathic Association. Dr. Crosby gave a brief description of the status of osteopathic medicine and emphasized the purpose is to develop a completely trained physician comfortable in primary care and family practice. He described the Osteopathic Post Training Institution (OPTI) model used to train their physicians. It is a consortium model that provides a seamless continuum of training that uses training settings other than the tertiary hospital. The OPTI also trains students in the managed care environment. He illustrated the application of the OPTI model at Michigan State University. The number of DOs is expected to increase from 44,000 currently to 82,000 to 87,000 in 20 years. The AOA is attempting to work with 26 States to establish new GME programs. There will be an insufficient number of future osteopathic residency positions for the anticipated number of graduates of DO programs.
Department of Defense GME Activities and Issues
Dr. Sundwall introduced Michael L. Cowan, M.D., Rear Admiral, MC, USN, Chief of Staff to the Assistant Secretary of Defense for Health Affairs. He spoke of the forces impinging on the United State military affecting its graduate medical education programs. He noted that military medicine has a dual obligation: to provide peacetime health care to its beneficiaries in military clinics, hospitals, and medical centers throughout the Country and world; and to provide care to military personnel during wartime. Military medicine and the attendant training needs face substantial challenges as the mission of the military to preserve national security has changed. He sees potential trouble in recruiting and retaining physicians in military medicine.
Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD)
Dr. Sundwall introduced Dr. Barbara Brookmyer as the Deputy Executive Secretary of the ACTPCMD. This new committee is authorized under the reauthorization of the Title 7 programs in the Public Health Service Act. It is composed of 23 public members representing the disciplines of family medicine, general internal medicine, general pediatrics, general dentistry, pediatric dentistry, and physician assistants. Dr. Brookmyer reported on the activities and deliberations of the committee during its meeting. She anticipates opportunities to collaborate with COGME.
Possible panel on the National Labor Relations Board's (NLRB) decision regarding residents
The National Labor Relations Board's (NLRB) decision regarding residents was brought forward for consideration by the Council. The suggestion was made that COGME should have a panel to discuss the role of labor unions in institutions providing GME. Mr. William Ching, Dr. Carl Getto, Ms. Ann Kempski, Dr. Donald Thomas and representatives from AAMC and NLRB will be asked for suggestions regarding participants and possible areas of discussion by a panel.
Vice Chair nominating committee
In a final action of business, Dr. Sundwall appointed a committee to nominate a new Vice Chair. The committee included Dr. Regina M. Benjamin, Ms. Ann Kempski, and Dr. Donald D. Thomas.
Dr. Marvin Dunn, of the Accreditation Committee for Graduate Medical Education, offered several recommendations, particularly with respect to the scheduling of public comments and making COGME material available to interested parties prior to Council sessions, the dissemination of which possibly could be accomplished through the COGME website.