Are U.S. Trained Residents Ready for 21 st Century Care Systems?

1. Are U.S. Trained Residents Ready for 21st Century Care Systems? AHR Policy Briefing November 15, 2010 Francis J. Crosson, MDSenior Fellow, Kaiser Permanente Institute for Health Policy

2. MedPAC — Medicare Payment Advisory Commission • Independent federal body created by BBA ’97 to advise Congress on issues affecting Medicare • Successor to PPRC and ProPAC • 17 members, appointed by G.A.O. • Meets 8 times/year • Two major annual reports • March — payment policies and updates • June — other policy issues • Proceedings available at www.medpac.gov

3. MedPAC Provides Advice to Congress • Regarding payment updates to providers of Medicare services (March Report) • Regarding potential changes to the Medicare program as a whole (June Report) • The June, 2010 Report to Congress covered MedPAC findings and recommendations about Graduate Medical Education (GME) in the U.S.

4. MedPAC Graduate Medical Education Discussions, 2003-2010 • Does the Medicare program and the U.S. receive appropriate value for Medicare GME payments to hospitals? • 1,100 hospitals receive payments • DGME- $3.0 B; IME- $6.5 B • IME at 5.5% per 10% resident/bed increment (approximately 2X the “empirically justified amount”

5. Areas of Concern • Depletion of adult primary care physicians • Site of training; role models • Preparation for “21st Century Medicine” - team-based care/coordination - function within care systems - EMR “meaningful use” - affordability of care

6. MedPAC Findingsat April 1 Public Meeting (unofficial summary) • The U.S. GME system is, in some respects the envy of the world- especially in cutting edge technology preparation. • ACGME shift to “competencies” was good • However, the specialty mix of physicians coming through the GME pipeline is not well matched to the needs of an efficient, high, quality, high value delivery system.

7. MedPAC Findingsat April 1 Public Meeting (unofficial summary) • The GME system should embrace a more systematic effort to instill the skills and perspectives needed to accelerate the development of a high-quality, high value, and efficient delivery system, including (but not limited to) evidence-based medicine, team-based care, care coordination, and shared decision making.

8. MedPAC Recommendation in June, 2010 Report • Recommendation 1 Congress should authorize the Secretary to change Medicare’s funding of GME: • After consultation with appropriate groups- • Create standards committee • Payment tied to performance on standards • In 3 years IME payments above the empirically justified amount will be used to fund the new performance-based payment system

9. TPMG Chiefs Survey – Summer, 2010 • Are there any training gaps in newly hired residents in: - knowledge - skills - professionalism

10. Results- 7 Categories • Office based care competencies • Care coordination • Continuity of care • Clinical information technology • Leadership and management skills • Systems thinking • Certain procedural skills

11. Policy Implications • Urge support of MedPAC recommendation • Need for broad input into setting of standards (if Congress acts) • Coordination with the work of the ACA National Workforce Commission