MedPAC Cites Concerns with GME Structure, Urges Focus on Out-of-Hospital Settings

Today's graduate medical education (GME) system needs to do more to prepare physicians to make a mark on delivery and payment system reform and to increase the value of healthcare, the Medicare Payment Advisory Commission (MedPAC) suggests in its 2010 Report to the Congress: Aligning Incentives to Medicare released Tuesday.

"The Commission does think that the current graduate medical education system produces superb physicians . . .  but that there are concerns with the current structure," said MedPAC Executive Director Mark Miller, PhD, at a briefing.

Ongoing MedPAC research has raised questions about the ability of the medical education system to "produce a mix of medical professionals that will lead change in health delivery—lead that change from a focus on fee-for-service medicine to focusing on quality, coordination, and restraint of costs," Miller said.

Many current curriculums with residency programs examined by MedPAC failed to look at working with multidisciplinary teams, using quality metrics, and employing information technology. "The training systems tended to be highly focused on inpatient care—and less on out-of-hospital types of care," Miller said.

To change this, MedPAC is recommending that Medicare reallocate some of the $9 billion of subsidies allotted for GME annually. Specifically, it called for $3.5 billion to be allocated only to sponsoring education programs that "meet these higher criteria" such as working on teams and coordinating care, Miller said.

These programs also should have "stronger out-of-hospital" training as well, with focuses on such areas as nursing homes, clinics, or physician settings, Miller said. "That's not to abandon hospital care, which is clearly important for training, but to have a stronger focus on [outpatient care]."

MedPAC also suggested for GME that:

• A workforce analysis be considered by the Health and Human Services secretary to determine the number of residency positions needed in the U.S. by total and by specialty. This analysis also would examine the optimal level of other health professionals.
• Strategies be examined for increasing the diversity of the health professional workforce (e.g., increasing the shares from underrepresented rural, lower income, and minority communities). "There's never been a systematic evaluation of what works and what doesn't," Miller said.

In the annual report, MedPAC also took a closer look at the in-office ancillary services exception that permits physicians to deliver health services under the Stark law. In staff studies, it found that outpatient therapy was "rarely provided on the same day as a related evaluation and management or consultation office visit"—which was one of the "key rationales" for the exception, the report said.

Overall, less than half of advanced imaging, ultrasound, and clinical lab tests were performed on the same day as an office visit, with about half of standard imaging studies performed on the same day as an office visit. Outpatient therapy services were not generally associated with a related office visit at all.

Pulling up short of making recommendations, MedPAC instead suggested that several options should be examined for these services:

• Exclude therapeutic services such as physical therapy and radiation therapy from the IOAS exception.
• Limit the in-office exception to physician practices that are clinically integrated.
• Exclude from the exception diagnostic tests that are not usually provided during an office visit.
• Reduce payment rates for diagnostic tests performed under the exception.

MedPAC also suggested that legislation be considered to give Medicare more flexibility with "innovative purchasing policies" to improve the delivery of healthcare services. Medicare currently has legislative limits that prohibit it from adopting such policies quickly, Miller said.

As one example, MedPAC found Medicare's ability to use policies such as reference pricing—in which a new item or service is paid at the same payment rate as clinically comparable items of services—has been limited due to lack of clear legal authority.

Also, in Medicare, no basic authority exists that says 'you can pay differentially on the basis of performance," Miller said. "Again, there are exceptions ... but there is not a broad authority that says Medicare's payment should vary on the basis of quality, outcomes."