GME programs are beset by troubles over funding cuts

Editor's note: After years of debating how best to put the brakes on runaway graduate medical education (GME) programs, the Health Care Financing Administration (HCFA) last year issued a spate of proposal that threaten to toughen standards and sharply curtail federal funding for medical residency programs. Many of these measure take effect this year. According to Steven Dronen, MD, associate head of emergency medicine at the University of Michigan in Ann Arbor, for emergency medicine the cuts could not come at a worse time.

As a specialty, emergency medicine is finally coming into its own, partly through a successful set of residency programs throughout the nation. Cutbacks and the growth of Medicare and Medicaid managed care will undoubtedly affect these programs. The Managed Care Emergency Department spoke with Dronen, immediate past president of the Society for Academic Emergency Medicine in Lansing, MI, about the probable effects of these trends.

MCED: How are proposed GME cuts going to affect emergency medicine residency programs?

Dronen: It's hard to predict. We are in a period of rapid expansion. Residency programs in emergency medicine have been growing at a rapid pace among universities and teaching hospitals across the country. It's been a long process. But it's paid off. GME in emergency medicine has come a long way. Now with the new federal government mandates that are capping the number of residents in each program, many of these programs have canceled a number of positions. Universities are following state guidelines regarding the number of positions they must keep in high-demand areas such as primary care and certain specialties.

So the universities have been left trying to figure how to shift their resources in the face of both threatened government cuts and state mandates for trained physician specialties. The big programs were largely in primary care and pediatrics. If a university is already at its cap for the number of its positions, the logical place to cut is in your largest programs. In most cases, that means primary care and pediatrics. But with state mandated percentages of slots that have to be filled coming from primary care you don't want to cut from there. You cut from other specialities such as emergency medicine.

MCED: What are the probable consequences when this happens?

Dronen: What I hope will happen is that institutions will centralize their residency decision-making policies. Traditionally, the number of positions that they have had, for example in surgery, was determined largely by their service needs, individual programs, and department chairs. No one really bothered to ask "what's the right number of residents we should turn out?"

I think what may be good for everyone is for institutions to centralize that process and say: "Let's not look at individual programs to determine how many residents we need let's look institutionally what's the right mix." If we do it that way, there's hope for emergency medicine. In an institutions that has a strong centralized system of GME, emergency medicine has a chance to win out.

MCED: But are we in fact turning out too many emergency physicians?

Dronen: We don't have enough statistical information to make any accurate statements. But it's my guess that we're pretty close to where we should be. What we really don't know is at what age do emergency physicians retire. Are we going to see a lot of them retire when they reach 55? Emergency medicine is said to be a young man's or woman's specialty due to the physical demands of the specialty, the long hours and night work. It's reasonable to assume then that most emergency physicians will retire a little earlier than other disciplines. If that's true, most manpower projections that I have seen lead me to believe that we are not turning out sufficient numbers of physicians in the specialty.

MCED: In view of the federal mandates, will the cutbacks encourage other specialties to enter the field?

Dronen: I don't think there will be cutbacks. Nobody really knows what the manpower needs are in emergency medicine. We do know what the supply is now. We are turning out roughly 1,000 graduates per year from programs across the country. That's a reasonable number of people. Is it the right number? Nobody knows. But I don't think we'll face a serious shortage for years to come in which we'll have to rely on people in other disciplines.

If anything, I think it'll be the reverse. People who don't have the formal training in emergency medicine have found it increasingly difficult to find jobs. I think this will certainly continue in urban areas. I don't know what will happen at rural hospitals. That is still up in the air. But there is a definite possibility that rural providers may experience a severe manpower shortage in the next few years. And they may be now the most vulnerable to the government's threatened cutbacks.

MCED: Some people say managed care organizations (MCOs) should foot part of the bill for GME. What do you think?

Dronen: There are several organizations that benefit immensely from the high-quality training of emergency physicians. But it remains unclear to me how we should go about measuring their investment according to the benefit they gain. The whole system for funding GME evolved it seems by accident. It got tagged on to the Medicare reimbursement almost like an afterthought. In some states such as Minnesota the Blue Cross plan or other insurers pay into GME.

But we've never come up with a good system. Managed care is essentially a for-profit entity. They have their goal, which is to maximize profits. Right now, they are clearly the beneficiaries of a tax supported system in the form of Medicare and Medicaid risk plans. But I don't know whether they should be held responsible for funding residency program even if the do benefit from these efforts. I have a problem with the for-profit sector directly underwriting public education programs.

Over time, however, we should look at all beneficiaries of residency programs and find a way to make them pay their fair share. A discussion should start at the federal level with significant input from educators over how we're going to do this. How do we set standards for a steady stream of high quality physicians? How do we make sure there isn't a random specialty mix that gets more funding while others get cut? And who's going to pay for this on a cost-benefit basis? The public really benefits from GME, so tax dollars going into training makes a great deal of sense.

MCED: Is money the only issue here?

Dronen: I think there's a real threat to quality. All GME programs are going to come under intense regulatory pressure over the next few years. One of the best examples of this is the entire clinical documentation issue. In general, the government's request that attending physicians be directly involved with supervising residents in training is an unreasonable request. What's going on in emergency medicine is that we're playing a paper game.

Even though we are the only specialty that has 24-hour a day supervision in teaching, we're playing this game in which we're having to document everything we do twice. It's creating a tremendous strain. Faculty members have to sit and document everything that went on involving residents on the previous shift just to comply with federal requirements.

The Health Care Financing Administration in Baltimore, MD, keeps ratcheting up these requirements. It used to be that the cumulative documentation was adequate. You could bill based on what the resident said in response to what the faculty said. Now they're changing it so you must bill based on what the faculty said. So even if the resident has documented everything necessary to bill at a certain level, the faculty must also document for billing. That just sounds like "let's try to decrease billing because the faculty isn't always present or able to document." That to me is one glaring example of the federal government trying to squeeze providers into lower reimbursements.

MCED: The government claims these efforts are designed to correct abuses.

Dronen: The government is probably right. A lot of GME programs have been under-supervised. You can walk into many teaching hospitals after five o'clock, and you're not going to see many residents there or much teaching going on. Yet there's plenty of care going on during those hours. In the past, there were lots of bills generated for that care. The government position is that they're paying residents for providing that care so they shouldn't be paying attending physicians for the same thing.

I don't disagree with that. But in emergency medicine, we came to an agreement long ago that we would do things differently from other disciplines. We tend to supervise residents very closely 24 hours per day as required to be accredited. The new federal regulations have been helpful in correcting past abuses.

MCED: Then these regulations have been a good thing.

Dronen: I don't think that correcting abuses was the government's agenda. If I thought that all the government wanted to do was increase supervision of residents I'd be behind them 100% But I don't think that's the idea. What they are seemingly trying to do is decrease funding for GME by making the documentation and supervision requirements so onerous that in the end you're left asking is it even worth having residents. Can you treat patients and do additional documentation for every patient charge just to get your reimbursement? Does it become economically feasible?

This appears to have nothing to do with increased quality or accountability. We work very hard on our shifts and then we have to spend hours filling out paper work. Sometimes it spills over into the next day, devoting time you should be spending in teaching or with patients. I'm not advocating going back to the old ways. but there has to be something reasonable in the requirements.