1. Graduate Medical Education Failing Primary Care Bob Phillips, MD MSPH Vice Chair, COGME June 9, 2008

2. 2 Status check: Family Medicine Family Medicine Positions 2008 Filled by US Graduates

3. 3 LSU Family Medicine Baton Rouge CLOSED Just before Katrina

4. 4 Family Medicine Fill Rate

5. 5 Reliance on International Medical Graduates Source: JAMA Medical Education Issues, thanks to Ed Salsberg, AAMC Change in Number of IMGs in Training 2002-2006

6. 6 IM Resident declining interest in generalist careers Source: Internal Medicine In-Training Examination Thanks to Ed Salsberg, AAMC (ACP, APM, and APDIM), Ibrahim Generalist Hospitalist

7. 7 COGME 19 th Report: Enhancing Flexibility in Graduate Medical Education Recommendation 1: Align GME with future needs  Increase funded GME positions by a minimum of 15%, directing support to innovative training models which address community needs and which reflect emerging, evolving, and contemporary models of healthcare delivery Recommendation 2: Broaden the definition of “training venue” (beyond traditional training sites)  Decentralize training sites  Create flexibility--allow for new training venues while enhancing the quality of training for residents

8. 8 Recommendation 3: Remove regulatory barriers limiting flexible GME training programs and venues  Revise current rules that restrict the application of Medicare GME funds to limited sites of care  Use CMS's demonstration authority to fund innovative GME projects with the goal of preparing the next generation of physicians to achieve identified quality and patient safety outcomes by promoting training venues that follow the Institute of Medicine's (IOM) model of care delivery COGME 19 th Report: Enhancing Flexibility in Graduate Medical Education

9. 9 Recommendation 4: Make accountability for the public’s health the driving force for graduate medical education (GME)  Develop mechanisms by which local, regional or national groups can determine workforce needs, assign accountability, allocate funding, and develop innovative models of training which meet the needs of the community and of trainees  Link continued funding to meeting pre-determined performance goals COGME 19 th Report: Enhancing Flexibility in Graduate Medical Education

10. 10 COGME: Relationship Between Physician Reimbursement and Specialty Choice? Unintended Consequences of Resource Based- Relative Value Scale Reimbursement 1  “Medicine’s generalist base is disappearing as a consequence of the reimbursement system crafted to save it – the RVRBS”  “The US physician workforce is unique among developed economies of the world. Virtually all European countries have a broad generalist foundation comprising 70%-80% of all practicing physicians. The United States is the opposite”  1. Goodson JD. Unintended Consequences of Resource Based-Relative Value Scale Reimbursement. JAMA. 2007:298:19:2308-10

11. 11 The Primary Care – Specialty Income Gap: Why it Matters  “Incomes of primary care physicians are well below those of many specialists, and the primary care-specialty income gap is widening.”  “The volume of many procedures performed by specialists has increased more rapidly than office visits, at times in dramatic fashion, contributing to faster income growth of some specialists as compared with that of primary care physicians”  “The sustainable growth rate hurts primary care”  “Private insurer payments favor specialty care over primary care to a greater degree than does Medicare” Bodenheimer T, Berenson RA, Rudolf P. The Primary Care – Specialty Income Gap: Why it Matters. Annals of Internal Medicine. 2007;146(4):301-6. COGME: Relationship Between Physician Reimbursement and Specialty Choice?

12. 12 Primary Care income less than other Specialties Source: MGMA Physician Compensation and Production Survey, 2007

13. 13 COGME Will likely continue to expand its traditional scope in looking at influences and policy options of the education pipeline outcomes –Accountability Likely to be more direct in its advising of the Administration and the Congress –Traditional reports –Timely, topical letters –Meetings