… care for a nation?

Among the things our health-care system does well, you would not list a nimble and efficient ability to respond to changing demand for new physicians. The oft-cited geographic maldistribution and preference for subspecialty practice at the expense of primary care were just two of the institutional shortcomings targeted by a recent task force of the National Academy of Science’s Institute of Medicine.

A controversial report from the IOM expert panel released last month describes a graduate medical education system that continues to operate on decades-old assumptions and predictions, to the detriment of both the nation’s health and to medical interns’ and residents’ preparedness to practice medicine in the 21st century. The report acknowledges that “Health care reimbursement and the organization of health care services, for example, are far more important than GME in determining the makeup and productivity of the physician supply.” Nonetheless, the panel suggests that the system by which the nation contributes $15 billion annually to GME through Medicare funding needs major changes.

In a press conference following the release of the report, the panel chairs listed five recommendations, whose net effect would move funding away from traditional, teaching-hospital-based residency funding and toward more community-based training that more closely reflects what new physicians will face in practice. The panel calls for spending the same overall funding from Medicare over the decade, adjusted for inflation. But it would be distributed much differently, with a declining share providing direct subsidies to teaching programs. An increasing share would go instead to a “GME transformation fund” that would finance new ways to provide and pay for training and fund training positions “in priority disciplines and geographic areas.”

The panel suggested that the changes would also address a longstanding absence of accountability in GME funding and an emphasis on outcomes, concepts that are becoming standard in every other area of health care.

Any of the proposed changes are subject to Congressional approval, and politically well-connected hospital groups and others representing medical colleges have already reacted harshly to the proposals.

Despite the best efforts of the best minds in the field, changing models of care and the rise of new technologies mean we don’t know and can’t predict with any assurance of accuracy, how many physicians we’ll need 10 years from now. Relying on market forces has not worked. Cranking out more graduates, by itself, is not a solution.

1. IOM (Institute of Medicine). 2014. Graduate medical education that meets the nation’s health needs. Washington, DC: The National Academies Press.