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

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

3 MedPAC Provides Advice to Congress Regarding payment updates to providers of Medicare services (March Report) Regarding payment updates to providers of Medicare services (March Report) Regarding potential changes to the Medicare program as a whole (June 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. 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, Does the Medicare program and the U.S. receive appropriate value for Medicare GME payments to hospitals? Does the Medicare program and the U.S. receive appropriate value for Medicare GME payments to hospitals? 1,100 hospitals receive payments 1,100 hospitals receive payments DGME- $3.0 B; IME- $6.5 B DGME- $3.0 B; IME- $6.5 B IME at 5.5% per 10% resident/bed increment (approximately 2X the empirically justified amount 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 Depletion of adult primary care physicians Site of training; role models Site of training; role models Preparation for 21 st Century Medicine Preparation for 21 st Century Medicine - team-based care/coordination - team-based care/coordination - function within care systems - function within care systems - EMR meaningful use - EMR meaningful use - affordability of care - affordability of care

6 MedPAC Findings at 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. 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 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. 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 Findings at 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. 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 Recommendation 1 Congress should authorize the Secretary to change Medicares 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: Are there any training gaps in newly hired residents in: - knowledge - knowledge - skills - skills - professionalism - professionalism

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

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