Government and Regulations

Ever since 1997, when the federal Balanced Budget Act froze Medicare’s overall funding for graduate medical education, debates have flared regularly over whether and how the U.S. government should support medical resident training.

Discussions about the possible redistribution of billions of dollars are bound to make people nervous, but the controversy reached a fever pitch in 2014 when the Institute of Medicine released a report penned by a 21-member committee that recommended significant—and contentious—changes to the existing graduate medical education (GME) financing and governance structure to “address current deficiencies and better shape the physician workforce for the future.”

Should Medicare shake up the system to redistribute existing training slots to where they’re needed most, as the report recommends? Should it instead lift its funding cap to avert a potential bottleneck in the physician pipeline, as several medical associations have requested? One year later, the report has gained little traction amid a largely unchanged status quo that few experts believe is ultimately sustainable. The continuing debate, however, has prompted fresh questions about whether the current GME structure is adequately supporting the nation’s healthcare needs and has spurred widespread agreement on the need for greater transparency, accountability, and innovation.

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and one of the report’s co-authors, says she has seen firsthand the challenges arising from a lack of physicians in multiple specialties, especially in rural areas. “We believed that simply adding new money to a system that is outdated would not solve the issues in physician education and physician workforce,” she says.

Some HM leaders and other physicians’ groups have cautiously welcomed the report’s focus on better equipping doctors for a rapidly changing reality.

“It wasn’t wrong for them to look at this,” says Darlene B. Tad-y, MD, FHM, chair of the SHM Physicians in Training Committee and assistant professor of medicine at the University of Colorado in Denver. “And it’s probably not wrong for them to propose new ways to think about how we fund GME.”

In fact, she says, efforts to align such funding with healthcare funding in general could be timely in the face of added pressures like ensuring that new insurance beneficiaries have access to primary care.

Scott Sears, MD, FACP, MBA, chief clinical officer of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says healthcare is also moving rapidly toward managing populations as part of team-based care that increases quality while lowering costs. So why not better align GME with innovative Medicare initiatives like bundled payments, he asks, and then use the savings to reward those training programs that accept the risk and achieve results?

“Shifting some of our education to match what Medicare is trying to drive out in the real world, I think, is long overdue,” Dr. Sears says.

Other groups, such as the Association of American Medical Colleges, however, contend that the report’s prescriptions are far less helpful than its diagnoses. “Politically, there’s just stuff in there for everybody to hate,” says Atul Grover, MD, PhD, FACP, FCCP, the AAMC’s chief public policy officer. “I think [the IOM report] did a decent job of pointing out some of the things that we want to improve moving forward, but I’m not sure that the answers are quite right.”

An Uneven Funding Landscape

The strong opinions engendered by the topic underscore the high stakes involved in GME. Every year, the federal government doles out about $15 billion for residency training, including about $10 billion from Medicare coffers. Medicare’s share is divided into two main funding streams that flow primarily to academic medical centers: direct graduate medical education (DGME) and indirect medical education (IME) payments. The first covers training expenses, while the second reimburses teaching hospitals that care for Medicare patients while training residents.

Some skeptics have questioned whether the government should be funding medical education at all, noting that the arrangement is utterly unique to the field. Advocates have countered that the funding concept was embedded in the original Medicare legislation and that it correctly recognized the added cost of offering GME training while providing more complex Medicare beneficiaries with specialty services.

Nearly everyone acknowledges that there are still enough residency slots for all U.S. graduates, but Dr. Grover says residency programs aren’t growing nearly fast enough to keep pace with medical school enrollment, creating a growing mismatch and a looming bottleneck in the supply chain. Compared to medical school numbers in 2002, for example, the AAMC says enrollment is on track to expand 29% by 2019, while osteopathic schools are set to expand by 162% over the same timeframe.

It wasn’t wrong for the [Institute of Medicine] to look at this. And it’s probably not wrong for them to propose new ways to think about how we fund GME.

—Darlene B. Tad-y, MD, FHM, assistant professor of medicine, University of Colorado, Denver, chair, SHM Physicians in Training Committee

Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t. I think the challenge is that the devil’s in the details of how you do that.

—Vikas Parekh, MD, FACP, SFHM, associate director, hospitalist program, University of Michigan, Ann Arbor, chair, SHM Academic Hospitalist Committee

Despite the continued freeze in Medicare funding, many large medical institutions continue to add residency spots.

“We’ve been hundreds of residency positions over our cap for a very long time,” says Vikas Parekh, MD, FACP, SFHM, associate director of the hospitalist program at the University of Michigan in Ann Arbor. “The hospital funds them through hospital operating margin because in the net, they still view the investment as worthwhile.”

Alternatively, some non-university-based training programs have secured money from other sources to fund their residency positions, potentially creating new funding models for the future if the programs can demonstrate both quality and stability.

One key rationale for the IOM report’s proposed overhaul, however, is the longstanding and sizeable geographical disparity in Medicare’s per capita GME spending, which has skewed heavily toward the Northeast. A 2013 study, in fact, found that one-fifth of all DGME funding in 2010—an estimated $2 billion—went to New York State alone.¹ Florida, which recently overtook New York as the third most populous state, received only one-eighth as much money. And Mississippi—the state with the lowest doctor-to-patient ratio—received only $22 million, or about one-ninetieth as much.

The IOM report also suggests that the long-standing GME payment plan has yielded little data on whether it actually accomplishes what it was designed to do: help establish a well-prepared medical workforce in a cost-effective way. In response, one major IOM recommendation is to maintain the overall level of Medicare support but tie some of the payments to performance to ensure oversight and accountability, and provide new incentives for innovation in the content and financing of training programs.

As with other CMS initiatives, however, getting everyone to agree on which quality metrics to use in evaluating GME training could take awhile. For example, should Medicare judge the performance of the trainees, the GME programs, or even the sponsoring institutions? Despite the proliferation of performance-based carrots and sticks elsewhere in healthcare, Dr. Tad-y says, such incentives may work less well for GME.

“One thing that’s inherent with trainees is that they’re trainees,” she says. “They’re not as efficient or as effective as someone who’s an expert, right? That’s why it’s training.”

Dr. Parekh, who also serves as chair of the SHM Academic Hospitalist Committee, agrees that finding the right outcome measures could be tough. “It gets very dicey, because how do you define who’s a good doctor?” he says. Currently, residents often are assessed via the reputation and history of the training program. “People say, ‘I know that the people coming out of that program are good because they’ve always been good, and it’s a reputable program and has a big name.’ But it’s not objective data,” he says.

Dr. Sears, of Sound Physicians, notes that it’s also often difficult to attribute patients to specific providers.

“Many times in graduate medical education, patients are going in and out of the program or in and out of the hospital, and how do you attribute?” he says. “I think it becomes very complex.”

A New Take on Transformation

Another IOM recommendation would create a single GME fund with two subsidiaries: an operational fund for ongoing support and a transformation fund. The latter fund would finance four new initiatives to:

• Develop and evaluate innovative GME programs;
• Determine and validate appropriate performance measures;
• Establish pilot projects to test out alternative payment methods; and
• Award new training positions based on priority disciplines—such as primary care—and underserved geographic areas.

A related recommendation seeks to modernize the GME payment methodology. For example, the committee urged Medicare to combine the indirect and direct funding streams into one payment based on a national per-resident amount and adjusted according to each location. In addition, the report endorsed performance-based payments based on the results of pilots launched under the transformation fund.

Dr. Sears says he appreciates the report’s effort to address shortfalls in primary care providers relative to specialists. “That’s not to say that specialty medicine isn’t incredibly important, because it is,” he says. “But I think incentivizing or reallocating spots to ensure that we have adequate primary care physician coverage throughout the country will have tremendous impact on the ability to care for an aging population in the United States, at least.”

I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that. Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable. —Deborah Powell, MD, dean emerita, University of Minnesota Medical School, IOM committee member

Shifting some of our [medical] education to match what Medicare is trying to drive out in the real world, I think, is long overdue. —Scott Sears, MD, FACP, MBA, chief clinical officer, Sound Physicians, Tacoma, Wash.

Dr. Parekh agrees, at least in part.

“Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t,” he says. “I think the challenge is that the devil’s in the details of how you do that.”

A priority-based GME system, he continues, could potentially influence what type of physicians are trained.

“In my mind, it’s not irrational to think that if GME funding was more targeted around expanding slots in certain specialties and not expanding slots in other specialties, that there would be some ability to influence the workforce,” Dr. Parekh says. Influencing where residents go may be more difficult, though a growing mismatch between medical graduates and available residency slots might add a new wrinkle to that debate, as well.

Currently, U.S. medical graduates fill only about 60% of residency slots for specialties like internal medicine—a main conduit for hospital medicine—while foreign graduates make up the remainder.

“So who’s the first that’s going to be squeezed out? It will be foreign medical graduates,” Dr. Parekh says. Many of those graduates come to the U.S. on J-1 visas, which carry a payback requirement: practicing in underserved areas. “One worry is, will rural and underserved areas suffer from a physician shortage because U.S. grads won’t want to work there after you start squeezing out all of the foreign medical grads?” he asks.

Clear Line of Sight?

Dr. Parekh also supports efforts to establish a clearer connection between the funding’s intent and where the money actually goes. The IOM report’s proposal to do so, however, raises yet another controversy around the true purpose of IME funding. Teaching hospitals argue that the money should continue to be used to reimburse them for the added costs of providing comprehensive and specialized care like level I trauma centers to their more complex Medicare patient populations.

Number one, [the IOM] came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources. We found that problematic, given all the evidence we have of the growing, aging population. —Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer, Association of American Medical Colleges

A big part of the problem here is that people are free agents. If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists. —Daniel Brotman, MD, FACP, SFHM, chair, SHM Education Committee, director, hospitalist program, Johns Hopkins Hospital, Baltimore

Accordingly, the AAMC panned the report’s recommendation to replace separate IME funding with a single fund directed toward the GME sponsoring institution and subdivided instead into the operational and transformation funds. Dr. Grover says setting up a transformation fund with new money would make sense, but not as a carve-out from existing support.

“You’re removing those resources from the system and not replacing them, which is a challenge,” he says.

Medical schools are more inclined to want the money directed toward training goals, especially if they are to be held accountable for GME outcomes. “Right now, the hospital gets it, and it’s basically somewhere in the bottom line,” Dr. Parekh says. “No one really knows where that money goes. There’s very little accountability or clarity of purpose for that dollar.”

Amid the ongoing debate, the call for more transparency and accountability in GME seems to be gaining the most ground. “I don’t see tons of downside from it,” Dr. Parekh says. “I think it sheds light on the current funding environment and makes people have to justify a little bit more what they’re doing with that money.”

Dr. Tad-y puts it this way: “If you made your own budget at home, the first thing you’d do is try to figure out where all your money goes and what you’re spending your money on.” If Medicare is concerned that its GME money isn’t being spent wisely, then, the first step would be to do some accounting. “And that means a little bit of transparency,” she says. “I don’t think that’s a bad thing, to know exactly what we’re paying for; that makes sense. I mean, we do that for everything else.”

SHM and most other medical associations also agree on the necessary goal of increasing the nation’s primary care capacity, even if they differ on the details of how best to do so. In the long run, however, some observers say growing the workforce—whether that of primary care providers or of hospitalists—may depend less on the total number of residency spots and more on the enthusiasm of program leadership and the attractiveness of job conditions such as salary and workload.

“A big part of the problem here is that people are free agents,” says Daniel Brotman, MD, FACP, SFHM, chair of the SHM Education Committee and director of the hospitalist program at the Johns Hopkins Hospital in Baltimore. “If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists.”

Whatever happens, Dr. Parekh says hospitalists are well positioned to be integral parts of improving quality, accountability, and innovation in residency training programs.

“I think if more GME money is targeted toward the outcomes of the GME programs, hospitalists are going to be tapped to help with that work, in terms of training and broadening their skill sets,” he says. “So I think it’s a great opportunity.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Mullan F, Chen C, Steinmetz E. The geography of graduate medical education: imbalances signal need for new distribution policies. Health Aff. 2013;32(11):1914-1921.

Ever since 1997, when the federal Balanced Budget Act froze Medicare’s overall funding for graduate medical education, debates have flared regularly over whether and how the U.S. government should support medical resident training.

Discussions about the possible redistribution of billions of dollars are bound to make people nervous, but the controversy reached a fever pitch in 2014 when the Institute of Medicine released a report penned by a 21-member committee that recommended significant—and contentious—changes to the existing graduate medical education (GME) financing and governance structure to “address current deficiencies and better shape the physician workforce for the future.”

Should Medicare shake up the system to redistribute existing training slots to where they’re needed most, as the report recommends? Should it instead lift its funding cap to avert a potential bottleneck in the physician pipeline, as several medical associations have requested? One year later, the report has gained little traction amid a largely unchanged status quo that few experts believe is ultimately sustainable. The continuing debate, however, has prompted fresh questions about whether the current GME structure is adequately supporting the nation’s healthcare needs and has spurred widespread agreement on the need for greater transparency, accountability, and innovation.

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and one of the report’s co-authors, says she has seen firsthand the challenges arising from a lack of physicians in multiple specialties, especially in rural areas. “We believed that simply adding new money to a system that is outdated would not solve the issues in physician education and physician workforce,” she says.

Some HM leaders and other physicians’ groups have cautiously welcomed the report’s focus on better equipping doctors for a rapidly changing reality.

“It wasn’t wrong for them to look at this,” says Darlene B. Tad-y, MD, FHM, chair of the SHM Physicians in Training Committee and assistant professor of medicine at the University of Colorado in Denver. “And it’s probably not wrong for them to propose new ways to think about how we fund GME.”

In fact, she says, efforts to align such funding with healthcare funding in general could be timely in the face of added pressures like ensuring that new insurance beneficiaries have access to primary care.

Scott Sears, MD, FACP, MBA, chief clinical officer of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says healthcare is also moving rapidly toward managing populations as part of team-based care that increases quality while lowering costs. So why not better align GME with innovative Medicare initiatives like bundled payments, he asks, and then use the savings to reward those training programs that accept the risk and achieve results?

“Shifting some of our education to match what Medicare is trying to drive out in the real world, I think, is long overdue,” Dr. Sears says.

Other groups, such as the Association of American Medical Colleges, however, contend that the report’s prescriptions are far less helpful than its diagnoses. “Politically, there’s just stuff in there for everybody to hate,” says Atul Grover, MD, PhD, FACP, FCCP, the AAMC’s chief public policy officer. “I think [the IOM report] did a decent job of pointing out some of the things that we want to improve moving forward, but I’m not sure that the answers are quite right.”

An Uneven Funding Landscape

The strong opinions engendered by the topic underscore the high stakes involved in GME. Every year, the federal government doles out about $15 billion for residency training, including about $10 billion from Medicare coffers. Medicare’s share is divided into two main funding streams that flow primarily to academic medical centers: direct graduate medical education (DGME) and indirect medical education (IME) payments. The first covers training expenses, while the second reimburses teaching hospitals that care for Medicare patients while training residents.

Some skeptics have questioned whether the government should be funding medical education at all, noting that the arrangement is utterly unique to the field. Advocates have countered that the funding concept was embedded in the original Medicare legislation and that it correctly recognized the added cost of offering GME training while providing more complex Medicare beneficiaries with specialty services.

Nearly everyone acknowledges that there are still enough residency slots for all U.S. graduates, but Dr. Grover says residency programs aren’t growing nearly fast enough to keep pace with medical school enrollment, creating a growing mismatch and a looming bottleneck in the supply chain. Compared to medical school numbers in 2002, for example, the AAMC says enrollment is on track to expand 29% by 2019, while osteopathic schools are set to expand by 162% over the same timeframe.

It wasn’t wrong for the [Institute of Medicine] to look at this. And it’s probably not wrong for them to propose new ways to think about how we fund GME.

—Darlene B. Tad-y, MD, FHM, assistant professor of medicine, University of Colorado, Denver, chair, SHM Physicians in Training Committee

Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t. I think the challenge is that the devil’s in the details of how you do that.

—Vikas Parekh, MD, FACP, SFHM, associate director, hospitalist program, University of Michigan, Ann Arbor, chair, SHM Academic Hospitalist Committee

Despite the continued freeze in Medicare funding, many large medical institutions continue to add residency spots.

“We’ve been hundreds of residency positions over our cap for a very long time,” says Vikas Parekh, MD, FACP, SFHM, associate director of the hospitalist program at the University of Michigan in Ann Arbor. “The hospital funds them through hospital operating margin because in the net, they still view the investment as worthwhile.”

Alternatively, some non-university-based training programs have secured money from other sources to fund their residency positions, potentially creating new funding models for the future if the programs can demonstrate both quality and stability.

One key rationale for the IOM report’s proposed overhaul, however, is the longstanding and sizeable geographical disparity in Medicare’s per capita GME spending, which has skewed heavily toward the Northeast. A 2013 study, in fact, found that one-fifth of all DGME funding in 2010—an estimated $2 billion—went to New York State alone.¹ Florida, which recently overtook New York as the third most populous state, received only one-eighth as much money. And Mississippi—the state with the lowest doctor-to-patient ratio—received only $22 million, or about one-ninetieth as much.

The IOM report also suggests that the long-standing GME payment plan has yielded little data on whether it actually accomplishes what it was designed to do: help establish a well-prepared medical workforce in a cost-effective way. In response, one major IOM recommendation is to maintain the overall level of Medicare support but tie some of the payments to performance to ensure oversight and accountability, and provide new incentives for innovation in the content and financing of training programs.

As with other CMS initiatives, however, getting everyone to agree on which quality metrics to use in evaluating GME training could take awhile. For example, should Medicare judge the performance of the trainees, the GME programs, or even the sponsoring institutions? Despite the proliferation of performance-based carrots and sticks elsewhere in healthcare, Dr. Tad-y says, such incentives may work less well for GME.

“One thing that’s inherent with trainees is that they’re trainees,” she says. “They’re not as efficient or as effective as someone who’s an expert, right? That’s why it’s training.”

Dr. Parekh, who also serves as chair of the SHM Academic Hospitalist Committee, agrees that finding the right outcome measures could be tough. “It gets very dicey, because how do you define who’s a good doctor?” he says. Currently, residents often are assessed via the reputation and history of the training program. “People say, ‘I know that the people coming out of that program are good because they’ve always been good, and it’s a reputable program and has a big name.’ But it’s not objective data,” he says.

Dr. Sears, of Sound Physicians, notes that it’s also often difficult to attribute patients to specific providers.

“Many times in graduate medical education, patients are going in and out of the program or in and out of the hospital, and how do you attribute?” he says. “I think it becomes very complex.”

A New Take on Transformation

Another IOM recommendation would create a single GME fund with two subsidiaries: an operational fund for ongoing support and a transformation fund. The latter fund would finance four new initiatives to:

• Develop and evaluate innovative GME programs;
• Determine and validate appropriate performance measures;
• Establish pilot projects to test out alternative payment methods; and
• Award new training positions based on priority disciplines—such as primary care—and underserved geographic areas.

A related recommendation seeks to modernize the GME payment methodology. For example, the committee urged Medicare to combine the indirect and direct funding streams into one payment based on a national per-resident amount and adjusted according to each location. In addition, the report endorsed performance-based payments based on the results of pilots launched under the transformation fund.

Dr. Sears says he appreciates the report’s effort to address shortfalls in primary care providers relative to specialists. “That’s not to say that specialty medicine isn’t incredibly important, because it is,” he says. “But I think incentivizing or reallocating spots to ensure that we have adequate primary care physician coverage throughout the country will have tremendous impact on the ability to care for an aging population in the United States, at least.”

I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that. Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable. —Deborah Powell, MD, dean emerita, University of Minnesota Medical School, IOM committee member

Shifting some of our [medical] education to match what Medicare is trying to drive out in the real world, I think, is long overdue. —Scott Sears, MD, FACP, MBA, chief clinical officer, Sound Physicians, Tacoma, Wash.

Dr. Parekh agrees, at least in part.

“Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t,” he says. “I think the challenge is that the devil’s in the details of how you do that.”

A priority-based GME system, he continues, could potentially influence what type of physicians are trained.

“In my mind, it’s not irrational to think that if GME funding was more targeted around expanding slots in certain specialties and not expanding slots in other specialties, that there would be some ability to influence the workforce,” Dr. Parekh says. Influencing where residents go may be more difficult, though a growing mismatch between medical graduates and available residency slots might add a new wrinkle to that debate, as well.

Currently, U.S. medical graduates fill only about 60% of residency slots for specialties like internal medicine—a main conduit for hospital medicine—while foreign graduates make up the remainder.

“So who’s the first that’s going to be squeezed out? It will be foreign medical graduates,” Dr. Parekh says. Many of those graduates come to the U.S. on J-1 visas, which carry a payback requirement: practicing in underserved areas. “One worry is, will rural and underserved areas suffer from a physician shortage because U.S. grads won’t want to work there after you start squeezing out all of the foreign medical grads?” he asks.

Clear Line of Sight?

Dr. Parekh also supports efforts to establish a clearer connection between the funding’s intent and where the money actually goes. The IOM report’s proposal to do so, however, raises yet another controversy around the true purpose of IME funding. Teaching hospitals argue that the money should continue to be used to reimburse them for the added costs of providing comprehensive and specialized care like level I trauma centers to their more complex Medicare patient populations.

Number one, [the IOM] came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources. We found that problematic, given all the evidence we have of the growing, aging population. —Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer, Association of American Medical Colleges

A big part of the problem here is that people are free agents. If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists. —Daniel Brotman, MD, FACP, SFHM, chair, SHM Education Committee, director, hospitalist program, Johns Hopkins Hospital, Baltimore

Accordingly, the AAMC panned the report’s recommendation to replace separate IME funding with a single fund directed toward the GME sponsoring institution and subdivided instead into the operational and transformation funds. Dr. Grover says setting up a transformation fund with new money would make sense, but not as a carve-out from existing support.

“You’re removing those resources from the system and not replacing them, which is a challenge,” he says.

Medical schools are more inclined to want the money directed toward training goals, especially if they are to be held accountable for GME outcomes. “Right now, the hospital gets it, and it’s basically somewhere in the bottom line,” Dr. Parekh says. “No one really knows where that money goes. There’s very little accountability or clarity of purpose for that dollar.”

Amid the ongoing debate, the call for more transparency and accountability in GME seems to be gaining the most ground. “I don’t see tons of downside from it,” Dr. Parekh says. “I think it sheds light on the current funding environment and makes people have to justify a little bit more what they’re doing with that money.”

Dr. Tad-y puts it this way: “If you made your own budget at home, the first thing you’d do is try to figure out where all your money goes and what you’re spending your money on.” If Medicare is concerned that its GME money isn’t being spent wisely, then, the first step would be to do some accounting. “And that means a little bit of transparency,” she says. “I don’t think that’s a bad thing, to know exactly what we’re paying for; that makes sense. I mean, we do that for everything else.”

SHM and most other medical associations also agree on the necessary goal of increasing the nation’s primary care capacity, even if they differ on the details of how best to do so. In the long run, however, some observers say growing the workforce—whether that of primary care providers or of hospitalists—may depend less on the total number of residency spots and more on the enthusiasm of program leadership and the attractiveness of job conditions such as salary and workload.

“A big part of the problem here is that people are free agents,” says Daniel Brotman, MD, FACP, SFHM, chair of the SHM Education Committee and director of the hospitalist program at the Johns Hopkins Hospital in Baltimore. “If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists.”

Whatever happens, Dr. Parekh says hospitalists are well positioned to be integral parts of improving quality, accountability, and innovation in residency training programs.

“I think if more GME money is targeted toward the outcomes of the GME programs, hospitalists are going to be tapped to help with that work, in terms of training and broadening their skill sets,” he says. “So I think it’s a great opportunity.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Mullan F, Chen C, Steinmetz E. The geography of graduate medical education: imbalances signal need for new distribution policies. Health Aff. 2013;32(11):1914-1921.

Ever since 1997, when the federal Balanced Budget Act froze Medicare’s overall funding for graduate medical education, debates have flared regularly over whether and how the U.S. government should support medical resident training.

Discussions about the possible redistribution of billions of dollars are bound to make people nervous, but the controversy reached a fever pitch in 2014 when the Institute of Medicine released a report penned by a 21-member committee that recommended significant—and contentious—changes to the existing graduate medical education (GME) financing and governance structure to “address current deficiencies and better shape the physician workforce for the future.”

Should Medicare shake up the system to redistribute existing training slots to where they’re needed most, as the report recommends? Should it instead lift its funding cap to avert a potential bottleneck in the physician pipeline, as several medical associations have requested? One year later, the report has gained little traction amid a largely unchanged status quo that few experts believe is ultimately sustainable. The continuing debate, however, has prompted fresh questions about whether the current GME structure is adequately supporting the nation’s healthcare needs and has spurred widespread agreement on the need for greater transparency, accountability, and innovation.

Deborah Powell, MD, dean emerita of the University of Minnesota Medical School and one of the report’s co-authors, says she has seen firsthand the challenges arising from a lack of physicians in multiple specialties, especially in rural areas. “We believed that simply adding new money to a system that is outdated would not solve the issues in physician education and physician workforce,” she says.

Some HM leaders and other physicians’ groups have cautiously welcomed the report’s focus on better equipping doctors for a rapidly changing reality.

“It wasn’t wrong for them to look at this,” says Darlene B. Tad-y, MD, FHM, chair of the SHM Physicians in Training Committee and assistant professor of medicine at the University of Colorado in Denver. “And it’s probably not wrong for them to propose new ways to think about how we fund GME.”

In fact, she says, efforts to align such funding with healthcare funding in general could be timely in the face of added pressures like ensuring that new insurance beneficiaries have access to primary care.

Scott Sears, MD, FACP, MBA, chief clinical officer of Tacoma, Wash.-based hospitalist management firm Sound Physicians, says healthcare is also moving rapidly toward managing populations as part of team-based care that increases quality while lowering costs. So why not better align GME with innovative Medicare initiatives like bundled payments, he asks, and then use the savings to reward those training programs that accept the risk and achieve results?

“Shifting some of our education to match what Medicare is trying to drive out in the real world, I think, is long overdue,” Dr. Sears says.

Other groups, such as the Association of American Medical Colleges, however, contend that the report’s prescriptions are far less helpful than its diagnoses. “Politically, there’s just stuff in there for everybody to hate,” says Atul Grover, MD, PhD, FACP, FCCP, the AAMC’s chief public policy officer. “I think [the IOM report] did a decent job of pointing out some of the things that we want to improve moving forward, but I’m not sure that the answers are quite right.”

An Uneven Funding Landscape

The strong opinions engendered by the topic underscore the high stakes involved in GME. Every year, the federal government doles out about $15 billion for residency training, including about $10 billion from Medicare coffers. Medicare’s share is divided into two main funding streams that flow primarily to academic medical centers: direct graduate medical education (DGME) and indirect medical education (IME) payments. The first covers training expenses, while the second reimburses teaching hospitals that care for Medicare patients while training residents.

Some skeptics have questioned whether the government should be funding medical education at all, noting that the arrangement is utterly unique to the field. Advocates have countered that the funding concept was embedded in the original Medicare legislation and that it correctly recognized the added cost of offering GME training while providing more complex Medicare beneficiaries with specialty services.

Nearly everyone acknowledges that there are still enough residency slots for all U.S. graduates, but Dr. Grover says residency programs aren’t growing nearly fast enough to keep pace with medical school enrollment, creating a growing mismatch and a looming bottleneck in the supply chain. Compared to medical school numbers in 2002, for example, the AAMC says enrollment is on track to expand 29% by 2019, while osteopathic schools are set to expand by 162% over the same timeframe.

It wasn’t wrong for the [Institute of Medicine] to look at this. And it’s probably not wrong for them to propose new ways to think about how we fund GME.

—Darlene B. Tad-y, MD, FHM, assistant professor of medicine, University of Colorado, Denver, chair, SHM Physicians in Training Committee

Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t. I think the challenge is that the devil’s in the details of how you do that.

—Vikas Parekh, MD, FACP, SFHM, associate director, hospitalist program, University of Michigan, Ann Arbor, chair, SHM Academic Hospitalist Committee

Despite the continued freeze in Medicare funding, many large medical institutions continue to add residency spots.

“We’ve been hundreds of residency positions over our cap for a very long time,” says Vikas Parekh, MD, FACP, SFHM, associate director of the hospitalist program at the University of Michigan in Ann Arbor. “The hospital funds them through hospital operating margin because in the net, they still view the investment as worthwhile.”

Alternatively, some non-university-based training programs have secured money from other sources to fund their residency positions, potentially creating new funding models for the future if the programs can demonstrate both quality and stability.

One key rationale for the IOM report’s proposed overhaul, however, is the longstanding and sizeable geographical disparity in Medicare’s per capita GME spending, which has skewed heavily toward the Northeast. A 2013 study, in fact, found that one-fifth of all DGME funding in 2010—an estimated $2 billion—went to New York State alone.¹ Florida, which recently overtook New York as the third most populous state, received only one-eighth as much money. And Mississippi—the state with the lowest doctor-to-patient ratio—received only $22 million, or about one-ninetieth as much.

The IOM report also suggests that the long-standing GME payment plan has yielded little data on whether it actually accomplishes what it was designed to do: help establish a well-prepared medical workforce in a cost-effective way. In response, one major IOM recommendation is to maintain the overall level of Medicare support but tie some of the payments to performance to ensure oversight and accountability, and provide new incentives for innovation in the content and financing of training programs.

As with other CMS initiatives, however, getting everyone to agree on which quality metrics to use in evaluating GME training could take awhile. For example, should Medicare judge the performance of the trainees, the GME programs, or even the sponsoring institutions? Despite the proliferation of performance-based carrots and sticks elsewhere in healthcare, Dr. Tad-y says, such incentives may work less well for GME.

“One thing that’s inherent with trainees is that they’re trainees,” she says. “They’re not as efficient or as effective as someone who’s an expert, right? That’s why it’s training.”

Dr. Parekh, who also serves as chair of the SHM Academic Hospitalist Committee, agrees that finding the right outcome measures could be tough. “It gets very dicey, because how do you define who’s a good doctor?” he says. Currently, residents often are assessed via the reputation and history of the training program. “People say, ‘I know that the people coming out of that program are good because they’ve always been good, and it’s a reputable program and has a big name.’ But it’s not objective data,” he says.

Dr. Sears, of Sound Physicians, notes that it’s also often difficult to attribute patients to specific providers.

“Many times in graduate medical education, patients are going in and out of the program or in and out of the hospital, and how do you attribute?” he says. “I think it becomes very complex.”

A New Take on Transformation

Another IOM recommendation would create a single GME fund with two subsidiaries: an operational fund for ongoing support and a transformation fund. The latter fund would finance four new initiatives to:

• Develop and evaluate innovative GME programs;
• Determine and validate appropriate performance measures;
• Establish pilot projects to test out alternative payment methods; and
• Award new training positions based on priority disciplines—such as primary care—and underserved geographic areas.

A related recommendation seeks to modernize the GME payment methodology. For example, the committee urged Medicare to combine the indirect and direct funding streams into one payment based on a national per-resident amount and adjusted according to each location. In addition, the report endorsed performance-based payments based on the results of pilots launched under the transformation fund.

Dr. Sears says he appreciates the report’s effort to address shortfalls in primary care providers relative to specialists. “That’s not to say that specialty medicine isn’t incredibly important, because it is,” he says. “But I think incentivizing or reallocating spots to ensure that we have adequate primary care physician coverage throughout the country will have tremendous impact on the ability to care for an aging population in the United States, at least.”

I have had physicians tell me that they do not understand why our report said that there was not a physician shortage, and I try to point out that we did NOT say that. Rather, the report [and the committee] said that we could not find compelling evidence of an impending physician shortage and that physician workforce projections had been and are quite unreliable. —Deborah Powell, MD, dean emerita, University of Minnesota Medical School, IOM committee member

Shifting some of our [medical] education to match what Medicare is trying to drive out in the real world, I think, is long overdue. —Scott Sears, MD, FACP, MBA, chief clinical officer, Sound Physicians, Tacoma, Wash.

Dr. Parekh agrees, at least in part.

“Fundamentally, the idea is not a bad one, to say that programs that were more aligned with national needs and priorities in terms of how they train physicians would get more funding, and those that did not wouldn’t,” he says. “I think the challenge is that the devil’s in the details of how you do that.”

A priority-based GME system, he continues, could potentially influence what type of physicians are trained.

“In my mind, it’s not irrational to think that if GME funding was more targeted around expanding slots in certain specialties and not expanding slots in other specialties, that there would be some ability to influence the workforce,” Dr. Parekh says. Influencing where residents go may be more difficult, though a growing mismatch between medical graduates and available residency slots might add a new wrinkle to that debate, as well.

Currently, U.S. medical graduates fill only about 60% of residency slots for specialties like internal medicine—a main conduit for hospital medicine—while foreign graduates make up the remainder.

“So who’s the first that’s going to be squeezed out? It will be foreign medical graduates,” Dr. Parekh says. Many of those graduates come to the U.S. on J-1 visas, which carry a payback requirement: practicing in underserved areas. “One worry is, will rural and underserved areas suffer from a physician shortage because U.S. grads won’t want to work there after you start squeezing out all of the foreign medical grads?” he asks.

Clear Line of Sight?

Dr. Parekh also supports efforts to establish a clearer connection between the funding’s intent and where the money actually goes. The IOM report’s proposal to do so, however, raises yet another controversy around the true purpose of IME funding. Teaching hospitals argue that the money should continue to be used to reimburse them for the added costs of providing comprehensive and specialized care like level I trauma centers to their more complex Medicare patient populations.

Number one, [the IOM] came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources. We found that problematic, given all the evidence we have of the growing, aging population. —Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer, Association of American Medical Colleges

A big part of the problem here is that people are free agents. If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists. —Daniel Brotman, MD, FACP, SFHM, chair, SHM Education Committee, director, hospitalist program, Johns Hopkins Hospital, Baltimore

Accordingly, the AAMC panned the report’s recommendation to replace separate IME funding with a single fund directed toward the GME sponsoring institution and subdivided instead into the operational and transformation funds. Dr. Grover says setting up a transformation fund with new money would make sense, but not as a carve-out from existing support.

“You’re removing those resources from the system and not replacing them, which is a challenge,” he says.

Medical schools are more inclined to want the money directed toward training goals, especially if they are to be held accountable for GME outcomes. “Right now, the hospital gets it, and it’s basically somewhere in the bottom line,” Dr. Parekh says. “No one really knows where that money goes. There’s very little accountability or clarity of purpose for that dollar.”

Amid the ongoing debate, the call for more transparency and accountability in GME seems to be gaining the most ground. “I don’t see tons of downside from it,” Dr. Parekh says. “I think it sheds light on the current funding environment and makes people have to justify a little bit more what they’re doing with that money.”

Dr. Tad-y puts it this way: “If you made your own budget at home, the first thing you’d do is try to figure out where all your money goes and what you’re spending your money on.” If Medicare is concerned that its GME money isn’t being spent wisely, then, the first step would be to do some accounting. “And that means a little bit of transparency,” she says. “I don’t think that’s a bad thing, to know exactly what we’re paying for; that makes sense. I mean, we do that for everything else.”

SHM and most other medical associations also agree on the necessary goal of increasing the nation’s primary care capacity, even if they differ on the details of how best to do so. In the long run, however, some observers say growing the workforce—whether that of primary care providers or of hospitalists—may depend less on the total number of residency spots and more on the enthusiasm of program leadership and the attractiveness of job conditions such as salary and workload.

“A big part of the problem here is that people are free agents,” says Daniel Brotman, MD, FACP, SFHM, chair of the SHM Education Committee and director of the hospitalist program at the Johns Hopkins Hospital in Baltimore. “If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists.”

Whatever happens, Dr. Parekh says hospitalists are well positioned to be integral parts of improving quality, accountability, and innovation in residency training programs.

“I think if more GME money is targeted toward the outcomes of the GME programs, hospitalists are going to be tapped to help with that work, in terms of training and broadening their skill sets,” he says. “So I think it’s a great opportunity.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Mullan F, Chen C, Steinmetz E. The geography of graduate medical education: imbalances signal need for new distribution policies. Health Aff. 2013;32(11):1914-1921.

The government’s push toward value-based care aims to fix a broken reimbursement system and improve quality of care for patients. But the new payment models also bring new legal risks for physicians, experts and anti-fraud officials warn.

“Novel payment methodologies may present new program integrity vulnerabilities,” Dr. Shantanu Agrawal, director of the Center for Program Integrity at the Centers for Medicare & Medicaid Services, said at a recent American Bar Association meeting. “As they assume financial risk, providers are also assuming program integrity risk. Without adequate controls, provider-run systems may be relatively vulnerable.”

Alicia Gallegos/Frontline Medical News

The Department of Health and Human Services plans to have 30% of Medicare payments in value-based payment structures by the end of 2016, and 50% by the end of 2018. The transition will be driven through investments in alternative payment models such as Accountable Care Organizations (ACOs), advanced primary care medical home models, bundled payments models, and integrated care demonstrations for Medicare and Medicaid patients.

At the end of 2014, value-based payments represented 20% of Medicare fee-for-service payments to providers, according to CMS data. The rate was fueled by government programs such as the Medicare Shared Savings Program (MSSP), Pioneer ACOs, the Bundled Payments for Care Improvement Initiative, and the Comprehensive Primary Care Initiative. Meanwhile, HHS is encouraging private payers, marketplace plans, Medicare Advantage plans, and state Medicaid programs to move in the same value-based direction.

With so many new regulations, mandates, and programs coming down the pipeline, physicians are likely not thinking about the legal dangers that may arise with alternative payment structures, said Mark S. Kopson, a health law attorney in Bloomfield Hills, Mich., and chair of the American Health Lawyers Association’s Payers, Plans and Managed Care Practice Group.

Alicia Gallegos/Frontline Medical News

Fee-for-service models can involve claims “about excess treatments and unnecessary services to drive up reimbursement,” Mr. Kopson said in an interview. “When you get into these [value-based] types of programs, it’s the exact opposite. The real threat is the withholding of necessary care in order to reduce expenses and therefore drive up those margins for the providers.”

To avoid such claims, physicians should ensure that their charts include the reasoning behind treatment decisions and a thorough record of why certain treatments were chosen and diagnoses were made, Mr. Kopson advised.

“Going forward, your charting better be completely accurate and detailed so that you don’t leave room for the government to make an argument that you should have provided this or that additional treatment,” he said.

Inaccurate reporting of enrollment data or financial information within new payment models could also land doctors in legal trouble, according to CMS officials.

Problematic reports, enrollee data, or other information physicians are required to submit to the government could be considered falsification and lead to False Claims Act violations.

“Providers are responsible for the information reported and should ensure that the appropriate checks and balances are in place that verify data is reported timely and accurately,” Tony A. Salters, a CMS spokesman, said in an interview. “For some models, providers must attest to the accuracy of this data. [To] report inaccurately could result in violations of federal laws.”

Physician-run payment models, such as doctor-led ACOs, may also draw legal scrutiny if physicians fail to prevent bad behavior by de facto partners. Physicians must ensure that all costs claimed by subcontractors, other providers, and suppliers who are paid from or authorized by the provider-run system, have been validated, Mr. Salters said.

“Doctors need to be aware that other entities who become new partners should hold themselves to the same high standards,” he said. “Providers should have basic financial mechanisms in place, with more sophisticated systems requiring more sophisticated methods,” to ensure validation.

CMS officials recommend doctors conduct independent audits of their accounts, manual validation of record system accuracy, and periodic verification of subcontractor claims to confirm the accuracy of claims and costs within new payment models.

These are “all routine steps that practitioners can take in their own offices but which are even more important when the doctor assumes responsibility for a larger scope of services,” Mr. Salters said.

Gaps in documentation surrounding bundled payments can be another legal land mine, Mr. Kopson noted. Adequate records of the care spectrum are essential to prevent accusations that care was not provided during a single episode of care, or over a specific period of time.

“You have to capture and document all the services you are delivering, and have accurate tracking in place for the entire continuum of care,” Mr. Kopson said.

CMS recommends that physicians establish a strong compliance program to assist with anti-fraud controls of new payment systems. When creating or updating a compliance program, government officials said providers should consider the unique characteristics of the model in which they participate.

[email protected]

On Twitter @legal_med

The government’s push toward value-based care aims to fix a broken reimbursement system and improve quality of care for patients. But the new payment models also bring new legal risks for physicians, experts and anti-fraud officials warn.

“Novel payment methodologies may present new program integrity vulnerabilities,” Dr. Shantanu Agrawal, director of the Center for Program Integrity at the Centers for Medicare & Medicaid Services, said at a recent American Bar Association meeting. “As they assume financial risk, providers are also assuming program integrity risk. Without adequate controls, provider-run systems may be relatively vulnerable.”

Alicia Gallegos/Frontline Medical News

The Department of Health and Human Services plans to have 30% of Medicare payments in value-based payment structures by the end of 2016, and 50% by the end of 2018. The transition will be driven through investments in alternative payment models such as Accountable Care Organizations (ACOs), advanced primary care medical home models, bundled payments models, and integrated care demonstrations for Medicare and Medicaid patients.

At the end of 2014, value-based payments represented 20% of Medicare fee-for-service payments to providers, according to CMS data. The rate was fueled by government programs such as the Medicare Shared Savings Program (MSSP), Pioneer ACOs, the Bundled Payments for Care Improvement Initiative, and the Comprehensive Primary Care Initiative. Meanwhile, HHS is encouraging private payers, marketplace plans, Medicare Advantage plans, and state Medicaid programs to move in the same value-based direction.

With so many new regulations, mandates, and programs coming down the pipeline, physicians are likely not thinking about the legal dangers that may arise with alternative payment structures, said Mark S. Kopson, a health law attorney in Bloomfield Hills, Mich., and chair of the American Health Lawyers Association’s Payers, Plans and Managed Care Practice Group.

Alicia Gallegos/Frontline Medical News

Fee-for-service models can involve claims “about excess treatments and unnecessary services to drive up reimbursement,” Mr. Kopson said in an interview. “When you get into these [value-based] types of programs, it’s the exact opposite. The real threat is the withholding of necessary care in order to reduce expenses and therefore drive up those margins for the providers.”

To avoid such claims, physicians should ensure that their charts include the reasoning behind treatment decisions and a thorough record of why certain treatments were chosen and diagnoses were made, Mr. Kopson advised.

“Going forward, your charting better be completely accurate and detailed so that you don’t leave room for the government to make an argument that you should have provided this or that additional treatment,” he said.

Inaccurate reporting of enrollment data or financial information within new payment models could also land doctors in legal trouble, according to CMS officials.

Problematic reports, enrollee data, or other information physicians are required to submit to the government could be considered falsification and lead to False Claims Act violations.

“Providers are responsible for the information reported and should ensure that the appropriate checks and balances are in place that verify data is reported timely and accurately,” Tony A. Salters, a CMS spokesman, said in an interview. “For some models, providers must attest to the accuracy of this data. [To] report inaccurately could result in violations of federal laws.”

Physician-run payment models, such as doctor-led ACOs, may also draw legal scrutiny if physicians fail to prevent bad behavior by de facto partners. Physicians must ensure that all costs claimed by subcontractors, other providers, and suppliers who are paid from or authorized by the provider-run system, have been validated, Mr. Salters said.

“Doctors need to be aware that other entities who become new partners should hold themselves to the same high standards,” he said. “Providers should have basic financial mechanisms in place, with more sophisticated systems requiring more sophisticated methods,” to ensure validation.

CMS officials recommend doctors conduct independent audits of their accounts, manual validation of record system accuracy, and periodic verification of subcontractor claims to confirm the accuracy of claims and costs within new payment models.

These are “all routine steps that practitioners can take in their own offices but which are even more important when the doctor assumes responsibility for a larger scope of services,” Mr. Salters said.

Gaps in documentation surrounding bundled payments can be another legal land mine, Mr. Kopson noted. Adequate records of the care spectrum are essential to prevent accusations that care was not provided during a single episode of care, or over a specific period of time.

“You have to capture and document all the services you are delivering, and have accurate tracking in place for the entire continuum of care,” Mr. Kopson said.

CMS recommends that physicians establish a strong compliance program to assist with anti-fraud controls of new payment systems. When creating or updating a compliance program, government officials said providers should consider the unique characteristics of the model in which they participate.

[email protected]

On Twitter @legal_med

The government’s push toward value-based care aims to fix a broken reimbursement system and improve quality of care for patients. But the new payment models also bring new legal risks for physicians, experts and anti-fraud officials warn.

“Novel payment methodologies may present new program integrity vulnerabilities,” Dr. Shantanu Agrawal, director of the Center for Program Integrity at the Centers for Medicare & Medicaid Services, said at a recent American Bar Association meeting. “As they assume financial risk, providers are also assuming program integrity risk. Without adequate controls, provider-run systems may be relatively vulnerable.”

Alicia Gallegos/Frontline Medical News

The Department of Health and Human Services plans to have 30% of Medicare payments in value-based payment structures by the end of 2016, and 50% by the end of 2018. The transition will be driven through investments in alternative payment models such as Accountable Care Organizations (ACOs), advanced primary care medical home models, bundled payments models, and integrated care demonstrations for Medicare and Medicaid patients.

At the end of 2014, value-based payments represented 20% of Medicare fee-for-service payments to providers, according to CMS data. The rate was fueled by government programs such as the Medicare Shared Savings Program (MSSP), Pioneer ACOs, the Bundled Payments for Care Improvement Initiative, and the Comprehensive Primary Care Initiative. Meanwhile, HHS is encouraging private payers, marketplace plans, Medicare Advantage plans, and state Medicaid programs to move in the same value-based direction.

With so many new regulations, mandates, and programs coming down the pipeline, physicians are likely not thinking about the legal dangers that may arise with alternative payment structures, said Mark S. Kopson, a health law attorney in Bloomfield Hills, Mich., and chair of the American Health Lawyers Association’s Payers, Plans and Managed Care Practice Group.

Alicia Gallegos/Frontline Medical News

Fee-for-service models can involve claims “about excess treatments and unnecessary services to drive up reimbursement,” Mr. Kopson said in an interview. “When you get into these [value-based] types of programs, it’s the exact opposite. The real threat is the withholding of necessary care in order to reduce expenses and therefore drive up those margins for the providers.”

To avoid such claims, physicians should ensure that their charts include the reasoning behind treatment decisions and a thorough record of why certain treatments were chosen and diagnoses were made, Mr. Kopson advised.

“Going forward, your charting better be completely accurate and detailed so that you don’t leave room for the government to make an argument that you should have provided this or that additional treatment,” he said.

Inaccurate reporting of enrollment data or financial information within new payment models could also land doctors in legal trouble, according to CMS officials.

Problematic reports, enrollee data, or other information physicians are required to submit to the government could be considered falsification and lead to False Claims Act violations.

“Providers are responsible for the information reported and should ensure that the appropriate checks and balances are in place that verify data is reported timely and accurately,” Tony A. Salters, a CMS spokesman, said in an interview. “For some models, providers must attest to the accuracy of this data. [To] report inaccurately could result in violations of federal laws.”

Physician-run payment models, such as doctor-led ACOs, may also draw legal scrutiny if physicians fail to prevent bad behavior by de facto partners. Physicians must ensure that all costs claimed by subcontractors, other providers, and suppliers who are paid from or authorized by the provider-run system, have been validated, Mr. Salters said.

“Doctors need to be aware that other entities who become new partners should hold themselves to the same high standards,” he said. “Providers should have basic financial mechanisms in place, with more sophisticated systems requiring more sophisticated methods,” to ensure validation.

CMS officials recommend doctors conduct independent audits of their accounts, manual validation of record system accuracy, and periodic verification of subcontractor claims to confirm the accuracy of claims and costs within new payment models.

These are “all routine steps that practitioners can take in their own offices but which are even more important when the doctor assumes responsibility for a larger scope of services,” Mr. Salters said.

Gaps in documentation surrounding bundled payments can be another legal land mine, Mr. Kopson noted. Adequate records of the care spectrum are essential to prevent accusations that care was not provided during a single episode of care, or over a specific period of time.

“You have to capture and document all the services you are delivering, and have accurate tracking in place for the entire continuum of care,” Mr. Kopson said.

CMS recommends that physicians establish a strong compliance program to assist with anti-fraud controls of new payment systems. When creating or updating a compliance program, government officials said providers should consider the unique characteristics of the model in which they participate.

[email protected]

On Twitter @legal_med

Session: Let’s Measure Our Own Performance: Propose and Evaluate Pediatric Hospital Medicine Quality Indicators

Summary: During this workshop, a staff of multiple, nationally-recognized quality leaders led a group to review, help develop, and help validate quality measures. The workshop was facilitated via the use of interactive survey tools, didactic sessions, and small groups.

Presenters discussed why quality measures are important and relevant. These included:

1. Improved quality of care,
2. Demonstration of value,
3. Third-party pay for performance indicators,
4. Determining our own indicators (versus being chosen for us), and
5. Performance incentives.

As part of the introduction to the workshop, the various quality measure validation methods were reviewed. These consisted of methods such as UCLA/RAND and Delphi Panel, as a means to determine validation and feasibility.

Validation was discussed in terms of what is being measured is the true outcome that was hoped to be achieved. The feasibility component used to make sure that the data used for quality measures, or process to be implemented for improvement, can easily be acquired to determine adherence, and that data is free of error. Facilitators reviewed various examples of validity and feasibility of quality measures with direct examples and discussions with attendees.

During the first breakout session, the groups were separated into teams focused on 1. care transitions, 2. safety, and 3. clinical care. The groups were asked to determine three quality indicators per individual, discuss the top five indicators voted on by the group, and than to review and discuss as a group the validity and feasibility of the measures using a scoring tool of 1-3: Not Valid/Feasible, 4-6: Equivocal, 7-9: Valid/Feasible. At the end, a delegated group speaker was asked to discuss either the pros/cons of one of their measures in regards to validity and feasibility to the total audience. Facilitators assisted on clarifying the reasons of why validity and feasibility metrics were appropriate.

During the final parts of workshop, positive and negatives of quality metrics determination methodology were discussed. The attendees reflected on the process of how quality measures are determined along with how these may be used within their settings.

Key Takeaways

Clearly determining the validity and feasibility of quality metrics for pediatrics has become an important topic. It not only has significant ramifications to the value we provide to our patients, but also the financial sustainability of programs and institutions, especially with the current changes in payment models. The workshop gave a clear and concise way of how to come up with quality metrics and the facilitators greatly added to the understanding of how we can “raise the floor” and “raise the ceiling” of pediatric care. TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Session: Let’s Measure Our Own Performance: Propose and Evaluate Pediatric Hospital Medicine Quality Indicators

Summary: During this workshop, a staff of multiple, nationally-recognized quality leaders led a group to review, help develop, and help validate quality measures. The workshop was facilitated via the use of interactive survey tools, didactic sessions, and small groups.

Presenters discussed why quality measures are important and relevant. These included:

1. Improved quality of care,
2. Demonstration of value,
3. Third-party pay for performance indicators,
4. Determining our own indicators (versus being chosen for us), and
5. Performance incentives.

As part of the introduction to the workshop, the various quality measure validation methods were reviewed. These consisted of methods such as UCLA/RAND and Delphi Panel, as a means to determine validation and feasibility.

Validation was discussed in terms of what is being measured is the true outcome that was hoped to be achieved. The feasibility component used to make sure that the data used for quality measures, or process to be implemented for improvement, can easily be acquired to determine adherence, and that data is free of error. Facilitators reviewed various examples of validity and feasibility of quality measures with direct examples and discussions with attendees.

During the first breakout session, the groups were separated into teams focused on 1. care transitions, 2. safety, and 3. clinical care. The groups were asked to determine three quality indicators per individual, discuss the top five indicators voted on by the group, and than to review and discuss as a group the validity and feasibility of the measures using a scoring tool of 1-3: Not Valid/Feasible, 4-6: Equivocal, 7-9: Valid/Feasible. At the end, a delegated group speaker was asked to discuss either the pros/cons of one of their measures in regards to validity and feasibility to the total audience. Facilitators assisted on clarifying the reasons of why validity and feasibility metrics were appropriate.

During the final parts of workshop, positive and negatives of quality metrics determination methodology were discussed. The attendees reflected on the process of how quality measures are determined along with how these may be used within their settings.

Key Takeaways

Clearly determining the validity and feasibility of quality metrics for pediatrics has become an important topic. It not only has significant ramifications to the value we provide to our patients, but also the financial sustainability of programs and institutions, especially with the current changes in payment models. The workshop gave a clear and concise way of how to come up with quality metrics and the facilitators greatly added to the understanding of how we can “raise the floor” and “raise the ceiling” of pediatric care. TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Session: Let’s Measure Our Own Performance: Propose and Evaluate Pediatric Hospital Medicine Quality Indicators

Summary: During this workshop, a staff of multiple, nationally-recognized quality leaders led a group to review, help develop, and help validate quality measures. The workshop was facilitated via the use of interactive survey tools, didactic sessions, and small groups.

Presenters discussed why quality measures are important and relevant. These included:

1. Improved quality of care,
2. Demonstration of value,
3. Third-party pay for performance indicators,
4. Determining our own indicators (versus being chosen for us), and
5. Performance incentives.

As part of the introduction to the workshop, the various quality measure validation methods were reviewed. These consisted of methods such as UCLA/RAND and Delphi Panel, as a means to determine validation and feasibility.

Validation was discussed in terms of what is being measured is the true outcome that was hoped to be achieved. The feasibility component used to make sure that the data used for quality measures, or process to be implemented for improvement, can easily be acquired to determine adherence, and that data is free of error. Facilitators reviewed various examples of validity and feasibility of quality measures with direct examples and discussions with attendees.

During the first breakout session, the groups were separated into teams focused on 1. care transitions, 2. safety, and 3. clinical care. The groups were asked to determine three quality indicators per individual, discuss the top five indicators voted on by the group, and than to review and discuss as a group the validity and feasibility of the measures using a scoring tool of 1-3: Not Valid/Feasible, 4-6: Equivocal, 7-9: Valid/Feasible. At the end, a delegated group speaker was asked to discuss either the pros/cons of one of their measures in regards to validity and feasibility to the total audience. Facilitators assisted on clarifying the reasons of why validity and feasibility metrics were appropriate.

During the final parts of workshop, positive and negatives of quality metrics determination methodology were discussed. The attendees reflected on the process of how quality measures are determined along with how these may be used within their settings.

Key Takeaways

Clearly determining the validity and feasibility of quality metrics for pediatrics has become an important topic. It not only has significant ramifications to the value we provide to our patients, but also the financial sustainability of programs and institutions, especially with the current changes in payment models. The workshop gave a clear and concise way of how to come up with quality metrics and the facilitators greatly added to the understanding of how we can “raise the floor” and “raise the ceiling” of pediatric care. TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.

Pediatric Hospital Medicine 2015's keynote speaker, Rita Mangione-Smith, MD, MPH, reviewed quality measures being developed for medically complex patients by the Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN). As one of the most challenging groups to not only provide care but to determine if the management provided brings value, the importance of quality measures was emphasized.

Dr. Mangione-Smith, of Seattle Children’s Hospital, reviewed the need for quality measures, as well as the process of developing these measures. Quality measures help to quantify outcomes from care practices, stated Dr. Mangione-Smith, to compare similar settings, and also to set possible benchmarks. The processes range from identifying and prioritizing measures to how they are validated as true value added outcomes. Data sources, sample size, and reliability/validity of the measures are considered important components to ensure that answers or results acquired are applicable and relevant to the population. Another important component is to clearly define a child with medical complexity.

Some reasons why medically complex patients require this focus:

• The low amount of information about their quality of care, investment, and need for coordination;
• Lack of understanding of which care practices make the biggest differences on their outcomes; and
• Their high rate of resource utilization.

The objective was to see which areas of care, such as care coordination, have the highest benefit/improvement on outcomes so as to prioritize resources more effectively. Dr. Mangione-Smith also touched on some obstacles and challenges, such as lack of insurance coverage leading to use of emergency resources as their primary care and its effect on increasing resource utilization.

Measures were determined via a multi-component methodology. Surveys using a binary and linear mean scoring tool were used. This provided multiple types of information such as assessing family’s perception of care, their understanding of medical information and care plans, and their accessibility to medical care services or information about their child.

Currently there is very little evidence on which management methods have the most significant, or any, effect on children with medical complexity. The use of quality measures to help guide which practices may have the highest positive impact on their outcomes greatly adds to the challenging care of this population and can be “used to assess quality of care coordination over time.” TH

Dr. Alvarez is a pediatric hospitalist and medical director of community hospital services at Children’s National Health System in Washington, D.C.