by Allan Joseph
David Goodman and Russell Robertson have a thought-provoking paper in the latest edition of Health Affairs (which is filled with great stuff) proposing a new system for graduate medical education (GME), which is the catch-all term for internships, residencies, and fellowships physicians complete as part of their training. Here’s the key part of the abstract:
This article … proposes a new funding mechanism coupled to a competitive peer-review process. The result would be to reward GME programs that are aligned with publicly set priorities for specialty numbers and training content. New teaching organizations and residency programs would compete on an equal footing with existing ones. Over a decade, all current programs would undergo peer review, with low review scores leading to partial, but meaningful, decreases in funding. This process would incentivize incremental and continual change in GME and would provide a mechanism for funding innovative training through special requests for proposals.
The current GME system is mostly based on Medicare and pays hospitals both for the teaching costs of GME and to compensate teaching hospitals for their overall lower efficiency and sicker patient population. There aren’t a whole lot of restrictions beyond accreditation on residency programs; since a 1997 limit on the number of federally-funded positions at each hospitals, residencies have basically stayed the same — including in their specialty distributions and teaching models. As the health system evolves in its needs — most notably, towards chronic care and away from the acute, hospital-based care that dominates medical education — GME is stagnating.
The proposal suggests converting some, but not all, of GME funding into a competitive review process, somewhat similar to how researchers win grants from the NIH. It wouldn’t immediately disrupt an important source of funding for teaching hospitals, who simply couldn’t function without sufficient numbers of residents. However, by allocating a noticeable portion (perhaps 20-30%) of GME funding based on desired characteristics (the authors identify teaching quality, community service, graduates’ practice locations, and curricular goals as examples) could incentivize residency and fellowship programs to innovate in ways that benefit the larger system. Ideally, this would allow for spillover effects beyond the reviewed funding as hospitals innovate throughout their training programs.
Would the proposal work? It sure looks like it, at least in some form. The central problem is figuring out how to incentivize GME to fit the future needs of the system while allowing room for the incentives to change based on changing needs, all while preventing massive upheaval in the current system. The Goodman-Robertson proposal does all three, putting enough at stake to incentivize change and innovation without making hospitals worry too much about losing all of their residents. In addition, since the reviewing body can change the selection criteria as needed, the proposal would allow the selection process to evolve as the long-term needs of the system change.
There are only a couple problems. Chief among them is the natural change-averseness of healthcare financing, but since that really has nothing to do with the proposal, we’ll just set it aside for the moment. Political opposition to the proposal will cluster in a few spots, though the authors have taken great care to keep their proposal flexible. The most central flashpoint will be the body actually conducting the competitive review: what gives it the authority to steer the healthcare system and set criteria for major funding decisions? There’s something to be said for the concerns over what would amount to a mild version of central planning in the physician workforce. While the proposal is also intended to incentivize new GME programs, if the criteria aren’t set properly, it’ll be nigh impossible for new and totally innovative programs to win any awards, especially with reviewers likely taken from status-quo institutions. Finally, the uncertainty over residency slots for programs under review could affect their ability to properly participate in the match process, though timing the process would probably mitigate that issue.
But really, the political process is going to be difficult regardless, and the proposal at least tries to give innovation a leg up. Those issues pale in comparison to the benefit of moving GME towards a system in which the incentives for individual programs actually line up with those of the system at large. There’s not a lot in healthcare you can say that about — but why don’t we start with GME and see where that takes us?
Allan Joseph is a first year medical student at the Warren Alpert Medical School of Brown University, where he is pursuing an MD/MPP. You can follow him on Twitter @allanmjoseph.