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Minutes of Meeting, April 30-May 1, 2007

The Council of Graduate Medical Education (COGME) convened in the Hilton Washington D.C. Rockville Executive Meeting Center at 8:30 am both April 30 and May 1, 2007.

Members Present

Russell G. Robertson, M.D., Chair
Denise Cora-Bramble, M.D., M.B.A, Member
Joseph Hobbs, M.D., Member
Mark A. Kelly, M.D., Member
Rebecca M. Minter, M.D., Member
Angela D. Nossett, M.S., Member
Robert L. Phillips, Jr., M.D., M.S.P.H., Vice Chair
Earl J. Reisdorff, M.D., Member
Vicki L. Seltzer, M.D., Member
Jason C. Shu, M.D., Member
William L. Thomas, M.D., F.A.C.P., Member
Leana S. Wen, M.S., B.S., Member
Barbara J, Chang, M.D., M.A., Designee of the Department of Veterans Affairs
Renate Rockwell representing Tzvi M. Hefter, Designee of the Administrator, Centers for
Medicare and Medicaid Services, DHHS
Anand Parekh, Designee of the Assistant Secretary for Health, DHHS

Members Absent

Thomas J. Nasca, M.D., M.A.C.P., Member
Kendall Reed, D.O., F.A.C.S., Member

Staff

Dennis Williams, Deputy Administrator, Health Resources and Services Administration (HRSA)
Michelle Snyder, Director, Bureau of Health Professions (BHPr)
Marilyn Biviano, Ph.D., Director, Division of Medicine and Dentistry, BHPr
Jerald M. Katzoff, Executive Secretary
Eva Stone

Welcome

Dr. Robertson, Chair, welcomed the COGME members.  He introduced Anand Parekh, M.D., Designee of the Assistant Secretary for Health, DHHS

Opening Remarks

Dennis Williams, Deputy Administrator, Health Resources and Services Administration, and Michelle Snyder, Director, Bureau of Health Professions, each gave welcoming remarks. Both noted the importance of the Council’s recent work and the emerging recommendations of the two reports under development.  In describing current activities of both HRSA and BHPr, both Dr. Williams and Ms. Snyder noted how the Council’s work has complemented the Agency’s and Bureau’s activities and goals over the past several years. Ms. Snyder noted recent changes in senior management at the Bureau. Of direct impact on the Council is the recent appointment of Dr. Marilyn Biviano to head the Bureau’s Division of Medicine and Dentistry, which, among its activities, provides oversight to COGME and two other advisory committees.

Executive Secretary’s Report

Mr. Katzoff discussed the COGME letter that was sent to the Secretary and Congress  in March 2007 concerning proposed Medicare changes in definitions for GME reimbursement and asked Dr. Robert Phillips to elaborate on the issue.  Mr. Katzoff then discussed the solicitation process for appointing new members to the Council. He indicated that four members of the Council will be ending their terms on September 30, 2007. Mr. Katzoff noted that the Council’s charter permits all retiring members to continue in their posts after their terms have expired, until a new member has officially been appointed to the Council.

Presentations to the Council on its Two Emerging Reports

From mid morning until noon, Dr. Barbara Chang, chair of COGME’s writing group on Enhancing GME Flexibility, led the discussions and review on each of the draft recommendations and accompanying narrative of the emerging report. Following lunch, Dr. Earl Reisdorff, Chair of COGME’s writing group on New Paradigms for Physician Training in Improving Access to Healthcare, led the discussions and review on each of the draft recommendations and accompanying narrative of that emerging report.

The first day’s plenary session ended at 3 pm.

Breakout of Council Members into Two Writing Groups

At 3:15 PM , the two writing groups convened to further revise each of their two reports in light of the discussions held earlier that day.

Report to Council on Draft Recommendations of the Two Reports

In the morning of the second day of the plenary session, the chairs of each writing group reported to the plenary meeting the new revised wording of each of the draft recommendations produced as a result of the previous day’s activities.

(Note that what follows are the revised draft recommendations contained in the most recent versions of the two draft reports dated mid-June 2007).

New Paradigms for Physician Training Writing Group

1. Access to health care must improve.  The expansion of existing programs and the creation of new models of training should focus on delivering care in areas of high medical need.  An incentive-based, non-mandatory structure should be created for medical school and residency graduates to practice in such practice settings.   
2. Federal- and state-based loan repayment programs should be increased.  Programs through the National Health Service Corps, the Department of Defense, Department of Veteran’s Affairs, and state repayment programs offer an opportunity to attenuate the indebtedness of medical students while placing physicians in under-served areas.
3. Incentives should be created to encourage medical schools to recruit and prepare physicians for clinical practice in under-served areas. 
4. A National Medical School (or system of medical schools) should be established.  This college of medicine would be unique in its emphasis to prepare physicians for clinical practice in underserved areas, public health issues, epidemiology, and emergency preparedness and response.  This newly-formed public medical school would offer free tuition to students in exchange for a mandatory service requirement after (and possibly during) residency training.
5. There must be increased targeted funding for physician training that creates a clinical physician workforce that serves populations in areas of limited access to medical care.  For example, reinvigoration of Title VII funding should be considered.       

Graduate Medical Education Flexibility Writing Group

Recommendation 1:   Align GME with future healthcare needs

1. Increase funded GME positions by a minimum of 15%, through funding directed towards innovative training models which address community needs and which reflect emerging,  evolving, and contemporary  models of healthcare delivery [See also Recommendation 3.].

Recommendation 2:  Broaden the definition of “training venue” (beyond traditional training sites) 

1. Decentralize training sites
2. Create flexibility within the system which allows for exploration of new training venues while enhancing the quality of training for residents [See also Recommendation 3.]

Recommendation 3:  Remove regulatory barriers to executing flexible GME training programs and expanding training venues

1. Address several of the limitations that currently exist within the Centers for Medicare and Medicaid Services (CMS) rules for expanding application of Medicare GME funds to other sites of care.
2. Invite CMS to use its Demonstration authority to fund innovative GME demonstration projects with the goal of preparing the next generation of physicians to achieve identified quality and patient safety outcomes by promoting training venues that follow the IOM’s model of care delivery.
3. COGME and others should work with Congress and CMS to re-evaluate and rewrite GME policies to provide flexibility in emergency situations with appropriate statutory and regulatory relief:
• To ensure the continued training of displaced residents (e.g., post-Katrina or sudden hospital closures);and,
• To permit 5-year affiliation agreements (as opposed to the current 3-year) in the case of abrupt hospital closure to permit sufficient time for damaged hospitals to be repaired; and,
• To require review of the impact of the loss of training positions on the community (i.e., to consider how best to preserve, sustain, or reconstitute local/regional physician workforce) in situations where a hospital is not able to resume training at previous levels due to natural disasters or unforeseen circumstances which result in the abrupt interruption, closure, or discontinuation of training programs, and the transfer of positions made permanent; and,
• To provide Hospitals receiving residents due to emergency closure of another hospital a temporary FTE cap adjustment and be allowed to exempt displaced residents from the three-year rolling average.  To clearly define “displaced resident” and who is eligible for reimbursement under this new rule, so there is no ambiguity.

Recommendation 4:  Make accountability for the public’s health the driving force for graduate medical education (GME)

1. Develop mechanisms by which local/regional or national groups can determine workforce needs, assign accountability, allocate funding, and develop innovative models of training which meet the needs of the community and of trainees
2. Link continued funding to meeting pre-determined performance goals
3. Alter Title VII in order to revitalize support for graduate medical education

Next Steps for Producing the Reports

In afternoon discussions, COGME members endorsed sending the two draft reports to about 15 organizations for review and comment prior to the reports’ transmittal to the Secretary, Congress, and the general public. The 15 organizations that COGME identified were thought to have strong expertise and interest in the issues and draft recommendations included in the two reports. The Council also endorsed inviting a small, select group of these organizations to present their comments to COGME on the first day of its two day plenary session scheduled for September 18-19, 2007.

Components of September Agenda

In discussions concerning the recommendations for enhancing GME flexibility, COGME expressed interest in learning the extent of state and regional engagement in GME and physician workforce planning. It therefore endorsed inviting selected states to discuss this issue at the September meeting, with the possibility that this issue will from the basis of the4 next report and /or a conference to be sponsored by COGME on state physician workforce/GME advisory panel activities.

In addition, the members agreed to send to Mr. Katzoff by early August their ideas for possible new topics as candidates for a new report. These items would then be discussed in the September meeting.

Public Comment

In public comments given on both days, Ms. Sunny Yoder of the Association of American Medical Colleges, Dr. Steven Shannon of the Association of American Colleges of Osteopathic Medicine, and Dr. Paul Rockey of the American Medical Association each welcomed COGME efforts in taking up the issues embedded in its two emerging reports.

Adjournment

The Council adjourned May 1, at 11 A.M.