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Minutes of Meeting, September 18-19, 2007

The Council on Graduate Medical Education convened 8:30 a.m. on both September 18 and 19, 2007 at the Crowne Plaza, Silver Spring.

Members Present

Russell G. Robertson, M.D., Chair
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
Kendall Reed, D.O., F.A.C.S., Member
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
Tzvi M. Hefter, Designee of the Administrator, Centers for Medicare and Medicaid Services, DHHS

Members Absent

Denise Cora-Bramble, M.D., M.B.A, Member
Thomas J. Nasca, M.D., M.A.C.P., Member
Anand Parekh, M.D.,  Designee of the Assistant Secretary for Health, DHHS

Staff

Elizabeth Duke, Administrator, Health Resources and Services Administration (HRSA)
Marsha Brand, Ph.D., Director, Bureau of Health Professions (BHPr)
Marilyn Biviano, Ph.D., Director, Division of Medicine and Dentistry, BHPr
Jerald M. Katzoff, Executive Secretary

Welcome

Dr. Robertson, Chair, welcomed the COGME members

Opening Remarks

Elizabeth Duke, Administrator, Health Resources and Services Administration, and Marsha Brand, Ph.D., Director, Bureau of Health Professions, each gave welcoming remarks. Dr. Duke introduced Dr. Brand as the recently appointed Bureau director.   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 Drs. Duke and Brand noted how the Council’s work has complemented the Agency’s and Bureau’s activities and goals over the past several years.

Presentations to the Council (September 18)

Following Mr. Katzoff’s Executive Secretary’s report, Dr. Steven Shannon, President and CEO of the American Association of Colleges of Osteopathic Medicine, and Dr. Paul Rockey, Director of Undergraduate and Graduate Medical Education of the American Medical Association each presented to the Council their views and comments on the two draft reports of the Council, Enhancing GME Flexibility and New Paradigms for Physician Training in Improving Access to Healthcare. While both provided suggestions for the reports’ enhancements, they expressed support and approval for each of the reports and for virtually all of the reports’ recommendations.  They applauded the Council for its work, and expressed support for increased resources and staff for the council to further enhance the quality of its products.

Following the presentations and subsequent discussion, Dr. Robertson and Mr. Katzoff introduced Mr. Bryan Johnson and his colleague Dr. David Newman, recently commissioned to provide editorial and writing services to enhance the two drafts produced by the COGME members. The editors described the edits that they had made to the drafts over the five weeks that had elapsed since their commission.

Breakout of Council Members into Two Writing Groups

After lunch, the two writing groups convened to further discuss the revisions to be made on each of their two reports in light of the discussions held earlier that day and in light of all of the external comments received on the two drafts.  

Report to Council on Draft Recommendations of the Two Reports

Following the breakout sessions, Drs. Reisdorff and Chang, chairs of each writing group reported to the plenary meeting on the groups’ decisions of any changes to be made to the drafts and their recommendations

(Note that what follows are the revised draft recommendations contained in the most recent versions of the two draft reports prepared by Mr. Bryan Johnson and his colleague Dr. David Newman dated September 30 following the plenary session).

New Paradigms for Physician Training Writing Group

1. Existing programs should be expanded and new models of training developed that focus on delivering care in areas of high medical need. This should include an incentive-based, non-mandatory structure that encourages medical school and residency graduates to serve in such practice settings.
2. Federal loan programs through the National Health Service Corps (NHSC), the Department of Defense, the Department of Veterans Affairs, and state-based loan repayment programs should be enlarged to increase the number of physicians serving in underserved areas.
3. Incentives should be created that encourage medical schools to recruit and prepare physicians for clinical practice in underserved areas. 
4. A National Medical School (or system of medical schools)—the “United States Public Health Medical College” (USPHMC)—should be established. The USPHMC would be unique in its emphasis on service, public health issues, epidemiology, and emergency preparedness and response.
5. Funding targeted for physician training that creates a clinical physician workforce to serve populations in areas of limited access to medical care should be increased. 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%, directing support to innovative training models which address community needs and which reflect emerging, evolving, and contemporary models of healthcare delivery.

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

1. Decentralize training sites
2. Create flexibility within the system of GME which allows for new training venues while enhancing the quality of training for residents.

Recommendation 3:  Remove regulatory barriers limiting flexible GME training programs and training venues

1. Revise current Centers for Medicare & Medicaid Services (CMS) rules that restrict the application of Medicare GME funds to limited sites of care
2. Use CMS's demonstration authority to fund innovative GME 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 Institute of Medicine's (IOM) model of care delivery
3. Assess and rewrite statutes and regulations that constrain flexible GME policies to respond to emergency situations and situations involving institutional and program closure.

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.

Presentations to the Council (September 18)

On the morning of September 19, Dr. Fitzhugh Mullan, Murdock Head Professor of Medicine and Health Policy at the George Washington University, presented to the Council. He described a two year, $750,000 study awarded to the University from the Josiah Macy Jr. Foundation. Directed by Dr. Mullan, the study, titled “The Medical Education Futures Study,” will examine medical education and training in Primary Care and Generalism, enrollment of minorities into medical schools, and the geographic distribution of physicians. The study will include analysis of past legislative and education initiatives, current expansion activities, and institutional, state, and local policies pertinent to the social mission of medical education.

Following this presentation and discussion was a panel presentation on the roles and activities of the Bureau of Health Profession’s three other advisory committees.  Presenting were Dr. Joseph Leming, past chair of the Advisory Committee on Primary Care Medicine and Dentistry, Dr. Hugh Bonner, Vice Chair of the Advisory Committee on Interdisciplinary, Community-Based Linkages, and Dr. Annette Debisette, Chair of the National Advisory Council on Nurse Education and Practice.

Included in the presentations and discussions was the recommendation initially put forth by the Advisory Committee on Primary Care Medicine and Dentistry for HRSA to convene a collaborative conference in the Spring of 2008 of the four Advisory committees to align work products along themes common to each of the groups.

In the late morning was a presentation by Tim Henderson, Acting Deputy Director of the Center for Health Policy Research and Studies at George Mason University. Mr. Henderson presented on recent and ongoing activities within states on medical education financing and physician workforce and GME planning.  Presently, eleven states link their Medicaid payments to health professions workforce goals, particularly for primary care training. However, Mr. Henderson could identify only three or four states that have a comprehensive program to link workforce analytics, GME policy goals, and GME policy implementation.

Recommendation for Collaborative Conference

As an outgrowth of the discussions of the Council concerning the recommendation initially put forth by the Advisory Committee on Primary Care Medicine and Dentistry for HRSA to convene a collaborative conference in the Spring of 2008 of the four Advisory committees to align work products along themes common to each of the groups, the Council approved the following recommendation:

The Council on Graduate Medical Education recommends that HRSA convene a collaborative conference of the four Title VII and Title VIII Bureau advisory committees in the Spring of 2008 for alignment of work products along common themes such as health professions workforce, health professions training, access to care, and workforce diversification.  The Council asks the leadership and lead staff of the four advisory committees to dialogue in advance of the meeting in order to set joint priorities for the meeting agenda.

Identification of New Issues for the Council’s Next Report

In discussions of the last topic of its agenda for the day, to identify an issue for its next report, the Council agreed on the report’s working theme or title--The Impact of Reimbursement on Physician Training Choice. While the focus of the proposed study will be to assess the impact of payer reimbursement on specialty choice, the proposed project analytics will include the general pool of influences on specialty training choice, and will look at factors influencing both the supply of and demand for GME positions. 

The proposed project is expected to culminate in a “numbered” report to include findings and policy recommendations.

The Council will invite collaboration with external groups such as the Institute of Medicine, the CMS and MedPAC.  For the initial development of material, staff will investigate the use of resources to develop “white papers” similar to the six papers developed for its two current projects. In addition, it is expected that “contract writer resources” similar to that utilized in the final preparation of our existing draft reports will be available to the Council.  These resources may be useful in working with COGME members to synthesize the papers, provide appropriate analysis, and draft a report.

Adjournment

The Council adjourned September 19, at 1:30 P.M.