With the precarious state of the national economy, the future of graduate medical education (GME) seems to be hanging in the balance — and neurology residency programs, which are already small in number (126 to be exact), may feel the predicted cutbacks more than other specialties.
Federal funding for GME will be reduced, that much is apparent, said Neurology Today Editor-in-chief Steven P. Ringel, MD, professor of neurology and vice president for clinical effectiveness and patient safety at the University of Colorado-Denver in Aurora. “Just how they will do this is less clear, but likely they'll go after indirect medical education,” the additional payments that teaching hospitals receive to offset higher patient care costs relative to non-teaching hospitals, he said.
Dr. Ringel discussed the future of GME funding as part of a special forum organized by the Association for University Professors of Neurology at this year's annual meeting of the American Neurological Association. In telephone interviews with Neurology Today, Dr. Ringel and other neurologists involved with graduate education discussed the potential impact of GME cuts on neurology.
FEWER TRAINING AND FELLOWSHIP POSITIONS
“Most residency training programs have more hospital-paid resident positions than are reimbursed by GME funds — they may have 30 positions and GME funding pays for 20, so the deficit comes out of the hospital's bottom line,” Dr. Ringel told Neurology Today. “Because of the financial pressures on everybody [right now] it's likely that if GME money goes down, hospitals will reduce the number of positions.”
Steven T. DeKosky, MD, vice president and dean of the University of Virginia School of Medicine, who is also a neurologist, said the first positions that hospitals may look to eliminate are those that are paid out-of-pocket. “Most commonly those are fellowships — and may include neuromuscular disease fellowships, MS fellowships, behavioral neurology, and dementia fellowships — which are usually not high margin-gainers.”
At his own institution, Dr. Ringel predicted that the hospital would lose several million dollars even at the lowest recommended reduction. For a field that is already small, these proposed — and increasingly likely — budget cuts are especially scary, he said.
This is going to be a real problem for hospitals, Dr. DeKosky said. “On the one hand, the government says we are going to decrease the funding for residency slots but oh, by the way we'd like you to help preserve the primary care slots. On the other hand, the primary care slots don't help the high throughput of revenue or increase procedures. You want to save the transplant and the cardiac specialists for that,” he told Neurology Today. There are, of course, benefits to raising the number of primary care doctors, and they do channel more patients to neurologists and other specialists, he said, “so the hospitals are in a real pickle.”
FOCUS ON COST-EFFECTIVENESS
The cuts, combined with an intensified focus on keeping health care cost-effective, could signal staffing changes at academic medical centers, Dr. Ringel said. That has already begun to happen, for example, with increased demand for neurohospitalists.
“With neurohospitalists, you have a small group of doctors who are present [at the hospital] all the time. So they can do more [than residents]. The hospitals often subsidize those positions,” and they may decide that, “because the residency work hours are shorter, they get their money's worth — and more — by hiring hospitalists.” This may also mean employing more nurse practitioners and physician assistants because they can be cost-saving for the hospitals as well.
The idea of a “resident-focused” program has really shifted in recent years and faculty has become much more involved in direct care, Dr. Ringel told Neurology Today. But, ultimately, he said, “we are academic centers and we are obligated to train the next generation of doctors — so it's not black and white,” though hospitals will put this sort of pressure on teaching programs in coming years.
We can't forget that it's not a straightforward financial cost-benefit issue, Steven L. Lewis, MD, associate chair and professor in the department of neurological sciences at Rush University Medical Center in Chicago, said. “Having a neurology residency and fellowship training program is critical to the academic milieu and vitality of a neurology department and for the institution.” Dr. Lewis serves as the vice-chair of the AAN Neurology Residency Review Committee, but the opinions expressed in this article are his own.
KEEPING NEUROLOGY VISIBLE
The real fear, Dr. Ringel said, is that hospitals will start picking and choosing between specialties, and they may say, “We don't need neurology; we make more money when we have surgery positions because we can collect more money in procedural specialties.”
Once funds are cut, hospitals may also decide they are more interested in funding family doctors and less interested in “super-specialists” like neurologists, Dr. Ringel said. “That's a big fear, that we'll be considered super specialists,” he said. However, Drs. Lewis, Ringel, and DeKosky had a few suggestions on how to allay these concerns.
It's becoming more and more apparent, especially as the number of individuals with neurodegenerative and chronic diseases goes up, that neurologists don't serve a role of only supplying diagnosis. “We provide ongoing care,” Dr. Ringel said, and, as such, “we are trying to get ourselves classified as primary care physicians — so far unsuccessfully — by CMS [Centers for Medicare & Medicaid Services]. We feel that we provide a lot of principal care for chronic disease.” That's one of the arguments we have in defense of our specialty, he said.
The other argument would be to say: “Look, you want to perform aneurysm surgery and brain tumor surgery, first neurologists must diagnose those conditions and then refer them on to neurosurgeons. After the surgery, patients will require neuro-rehabilitation. As is the case for specialists in heart disease, neurologists should create a service line with neurosurgery, interventional neuroradiology and neuro-rehab. So, that's a strategy — creating a service line may give neurology greater influence,” Dr. Ringel said.
Dr. Lewis agreed, though he stressed that it would be impossible to guess the metrics individual institutions will use for deciding the allotment of residency programs. It would not be surprising for institutions to reward programs with large inpatient and outpatient volumes, he said.
For neurology programs, Dr. DeKosky said, “We bring increasing value to the hospital system, in infusion for neurological disorders, in stroke care, in telemedicine, in collaboration with neurorehabilitation and neurosurgery. These are all points to put before the hospital administration — to demonstrate our value and suggest that we'd like to partner with them in figuring things out, instead of, as many of us are wont to do, crossing our arms and just saying, ‘No, our intrinsic value should be obvious, and you should not touch us.”
Now it is all about being a system that works well and is patient-centered, Dr. DeKosky said. And neurology should not only be a collaborator in that, but also an organizer of system approaches to patient care. This, he said, will get the attention of the hospitals and put the neurology department and residency training programs at a much better position with respect to the hospital, when it comes to budget allocations.
We're a small number of people. Each specialty makes its own demand, and that's the problem, Dr. Ringel said. The more of you, the more you demand, and the more the cost goes up.
“Health policy analysts look at the numbers and they say, ‘We need more primary care. Neurologists should be consultants; maybe they shouldn't be doing disease management,'” Dr. Ringel said. For example, he added, some health maintenance organizations such as Kaiser Permanente design a reduced role for neurologists as long-term providers. “Their neurologists will do the initial evaluation of headache patients and then their primary care doctors will provide the follow-up care.” They partition it out so neurologists only perform the tasks that are unique to their specialty.
“The federal government will cut Medicare spending…and Medicaid will follow. That's most of the funding for GME,” Dr. Ringel said. As for the allocation for residency programs, there could be variation state by state: “Ultimately every hospital that creates these residency positions decides how many they want based on the competing demands,” Dr. Ringel said.
At this point, it's really uncertain what the potential funding changes will mean in terms of the actual allocation of residency positions nationwide — or even locally, Dr. Lewis said. “But I think it is important for neurology programs within our institutions to be very visible and clinically strong and active departments and to be highly involved in the education of medical students and residents — our own and throughout the institution.” I think that those programs with a strong clinical imprint on the institution will most likely fare the best in terms of allocation of GME funding within their institution, he said.
“What's the Chinese proverb: ‘May you live in interesting times'? I think we'll have to adapt,” Dr. Ringel said. •
A GLOBAL PERSPECTIVE: GME REDUCTIONS
In an Oct. 20 report published on its website — http://bit.ly/sluwOO — the Accreditation Council for Graduate Medical Education (ACGME), posted results from a survey of 306 institutional officials on three different funding scenarios: GME spending at the stable 2011 levels, a reduction by 33 percent, and a reduction by 50 percent.
At a projected 33 percent reduction, 4.3 percent of responding sponsors reported they would close all core residency programs and 7.8 percent would shut down all subspecialty programs. These sponsors represent 339 programs (102 core and 237 subspecialties) and 3934 positions (2783 core and 1151 subspecialty positions). At a 50 percent reduction, 14 percent of responding sponsors said they would close all core residency programs and 20.9 percent would close all subspecialty programs. These sponsors represent 538 programs (193 core and 345 subspecialties) and 6630 positions (5003 core and 1627 subspecialty positions).
Commenting on the study, Dr. Lewis said: “Based on the survey results, it seems that most DIOs feel that there will be a significant overall decrease in positions nationally with reduced funding for GME. Of course, it's difficult to know how such a funding change would actually translate into the real world, but this is a real concern. Some institutions that currently host residency programs may decide not to do so and those that do may perhaps decrease the number of positions.”
Though the numbers from this study are not specific to neurology, they do provide valuable insight into just what might happen to specialty and subspecialty programs if federal funds are to decline.
In September, the Journal of the American Medical Association published resident distribution data for 2010-2011 within the US, which showed that neurology residents make up a meager 1.7 percent of all residents (just over 1900 individuals). Any loss to the neurological community will surely reverberate far.