In our study we demonstrated a strategy to track workforce outcomes of GME programs because there is increasing belief that these publicly funded programs should be accountable to the health care needs of the American people. Dr. Grover is correct in summarizing this intent, but we disagree that our description of the nature of GME funding was either “incomplete” or “misleading.” Our aim was not to explain the policy intricacies of how these funds are paid; they are paid because these hospitals sponsor GME programs. We focused on what they produce.
Dr. Grover’s reference to Congress’s justification for the indirect payment (IME) is incomplete. Congress intended IME payments “to compensate teaching hospitals for their relatively higher costs attributable to the involvement of residents in patient care and the severity of illness of patients requiring specialized services available only in teaching hospitals”1 (emphasis ours). While Dr. Grover is correct that these payments “reflect patient characteristics, not trainee characteristics,” it does not follow that their purpose is unrelated to education because patient care payments are the vehicle for transferring IME funds. Absent GME, hospitals cannot tap this $13 billion funding stream. Consistent with the purpose of our study, a 2001 report by Dr. Grover and colleagues recommended, “Future policy decisions should rest … on clearer agreement about which personal services and public goods provided by teaching hospitals deserve governmental support.”2
We agree teaching hospitals should be valued for varied missions. However, Congress and Medicare do not allocate this money to support individual institutional missions. Failure to be accountable to the overriding mission of meeting the nation’s most pressing workforce needs risks further reductions, as has happened three times in the past two decades.2 Teaching hospitals have the opportunity to declare and demonstrate a return for this public investment. Our study demonstrates it is possible to measure specific outcomes of this investment.
The AAMC identified 12 proposals in the last three years to make wholesale cuts to GME funding.3 Failure to demonstrate value may bring more. Coggeshall4 said as much in his 1965 report to the AAMC: “Those responsible for medical education … will, in decades ahead, need to devote careful attention to appraising the needs of society for health care and health personnel and to developing and implementing plans to meet those needs.” We propose GME funding cuts might best be prevented by demonstrating the production of a workforce that ensures high-quality, cost-effective, and accessible health care for all Americans.
Candice Chen, MD, MPH
Assistant research professor, School of Public Health and Health Services, George Washington University, Washington, DC; firstname.lastname@example.org.
Robert Phillips, MD, MSPH
Vice president for research and policy, American Board of Family Medicine, Washington, DC.
Fitzhugh Mullan, MD
Murdock Head Professor of Medicine and Health Policy, School of Public Health and Health Services, George Washington University, Washington, DC.
Andrew Bazemore, MD, MPH
Director, Robert Graham Center, Washington, DC.
1. . U.S. Congress, House of Representatives, Committee on Ways and Means. Medicare and Health Care Chartbook. May 17, 1999 Washington, DC U.S. Government Printing Office
2. Oliver TR, Grover A, Lee PR. Variations in Medicare Payments for Graduate Medical Education. 2001 Oakland, Calif California HealthCare Foundation
4. Coggeshall LT. Planning for medical progress through education; a report submitted to the Executive Council of the Association of American Medical Colleges. 1965 Evanston, Ill Association of American Medical Colleges;