#SaveGME to Save Primary Care...and Reform GME to Save our Healthcare System

As I wrote in my last post, graduate medical education (GME) funding is threatened by proposed cuts to Medicare funding.  This is because Medicare provides money to training hospital to pay for GME positions and, if Medicare funding is cut, then training hospitals will review the perceived value of these GME positions.  It is possible, or even likely, that this would result in drastic and harmful changes to GME training--and primary care training programs would likely be the hardest hit.  The Accreditation Council for Graduate Medical Education (ACGME) has listed possible outcomes if Medicare funding for GME is reduced (pdf).  These include closing residency programs (especially in those hospitals that have only one program) and re-purposing those GME slots to more profitable or more prestigious positions, seeking industry support (from PhRMA or medical device makers) to pay for programs, increasing the debt burden on students interested in primary care, etc.

This is absurd.  If these changes were to take place, then we would be threatening our nation's health care system for decades to come.  We already are facing a shortfall of nearly 33,000 primary care doctors in the next few years (pdf).  How would reducing GME funding to primary care training improve this situation?  We already know that students' debt burden can discourage them from pursuing primary care careers.  How would increasing this debt burden improve this situation?  There is increasing understanding that PhRMA and other industry contacts influence how physicians practice.  How would making GME dependent on industry funding improve this situation?

The answers, obviously, is that reducing federal funding for GME will not solve anything.  Instead, it will reduce the number of new physicians--and, more importantly, the number of primary care and family physicians--at the very moment we urgently need to be training MORE physicians.  In his Dr. Synonymous blog, Pat Jonas demonstrates just how bad the situation is, and how bad it could get.

The fact that the proposed Medicare cuts would disproportionately impact primary care and family medicine programs will cause much deeper and longer lasting harms than might be suspected: Barbara Starfield's work has shown that INCREASED primary care IMPROVES outcomes while DECREASING costs in health care systems.  This is exactly what we are supposedly aiming for.  Meanwhile, evidence continues to mount showing that increased use of subspecialty reduces care coordination and would stand to increase costs.  So, as we look to decrease funding to GME and as training programs cut or cancel family medicine and primary care training slots in favor of subspeciality positions, we will reduce our system's ability to provide coordinate, safe, and cost-effective care while increasing the costs and fragmentation of care.

There are a number of ways that this crisis could be addressed.  One of the easier answers would be to ask states to help support community-based family medicine and primary care training programs.  The problem is that states continue to face major budget shortfalls of their own, and most are in no position to help.  In Virginia, the state has actually been CUTTING the budget line item that supports community-based family medicine training programs...and the programs narrowly avoided more cuts in the last fiscal year.

So, we know that we need to produce more physicians overall and that we have a critical and urgen need to produce more primary care physicians.  We cannot expect states to step up...and we do not want industry to pay for GME training...and we cannot expect residents to pay tuition for their training.  Fortunately, there are other options, but we need to act:

1. Call on Congress and the White House to remove Medicare cuts from current budget discussions.  Although the current GME funding mechanisms are flawed, they are better than the alternatives.  Click here to find your Representative, click here to find your Senators, and click here to contact the White House.  Insist that Medicare funding be preserved as is, and that cuts to Medicare not used to make a political point.
2. If you are a member of the American Medical Association, push to get this organization to support preserving funding for primary care slots as a priority--not just preserving GME funding overall.  We don't need more dermatologists or radiologists right now.  We need more primary care internists and pediatricians...but mostly we need more family physicians.  The AMA has not stood by primary care in the past (as evidenced by the recent outcry against the AMA's RUC), but this is a time when the AMA's support for family medicine training needs to be clear, loud, and aggressive.  Dr. Kevin Bernstein, on the Future of Family Medicine blog, makes the case as to why we need to save family medicine GME training.
3. Once the threatened cuts are avoided, we need to change the way that community-based GME slots are funded.  We need to separate GME funding from hospitals, and provide funding directly to those institutions and residency programs providing accredited GME.  This funding should be separated from Medicare, so that our current situation does not recur.  Dr. Mike Sevilla makes this case on his Family Medicine Rocks blog--and points out how GME cuts would harm community physicians...and the communities and patients they care for.
4. We need to rethink how we fund GME overall.  We know we have a national shortage of primary care physicians, and that there is no shortage of a number of other procedure-based subspecialties.  Why, then, are we still funding programs that a) do not meet a national need and b) make money on their own?  If a hospital can bill for their cardiology fellow's cardiac catheterizations, and the fellows increase the number of catheterizations their facility can perform, does the hospital really need GME funds?  No doubt they like those funds, but do they need them?  In a time when we are required to make difficult decisions and reduce the costs associated with health care, one option could be to put money where it will have the most value.  Increased funding for primary care--including robust loan repayment or loan forgiveness programs and enhanced GME funding--could improve care, reduce care fragmentation and reduce costs by addressing our primary care workforce imbalance.

Ben Miller has written how much GME funding matters to our current healthcare system.   If GME funding for family medicine programs is cut, then the likely response will be to reduce the numbers of GME slots for family medicine training.  This will perpetuate--and, over time, worsen--the current crisis in our nation's primary care workforce.  We would be producing fewer primary care physicians than we do now...and what we do now is already grossly insufficient.  Instead, medical students will find GME training slots in subspecialty care, and we will train more high-tech subspecialists.  This will increase fragmentation of care, and will increase healthcare costs (and reduce efficiencies) over time.

If we do not save GME funding for primary care, we will weaken our healthcare system's foundations...and these foundations will continue to weaken as we move forward.  Eventually, when the foundation is riddled with enough holes, then the system will collapse.  We could sit and wait until that happens...but we must not.  We must address this issue now, to prevent short-term harms, and we can rework the system to make it sustainable heading forward.  Otherwise, we will find ourselves picking up the pieces after our healthcare system--already the most expensive among developed nations, while producing lackluster results--after it finally fails.