ment and, more importantly, would give states discretion in allocating funds for graduate medical education. • If the funds initially were aggregated at the state level, state government would have virtually complete control of their disbursement. The difficulty with this, and to some extent with a block grant program, is the possibility that state control of education funds would mean more support for residency training in state and municipal hospitals than in private academic health centers. The following option for distribution of funds is the choice of the Task Force. A voucher system should be developed to distribute graduate The Task Force believes that a voucher system would bring to the distribution of graduate medical education funds a combination of desirable elements not fully available in the disbursement options described above. Medical school graduates would be entitled to receive vouchers with which to purchase their graduate education. They could choose from among accredited residencies offered by hospitals on the basis of what the hospital wished to provide to match its service needs, faculty, patient mix and other considerations. Vouchers could be financed by a combination of Federal, state and private sector funds in the relative proportions that they now support the direct costs of graduate education. The money value of a voucher would be held approximately equal to the cost of resident stipends, fringe benefits and other direct education costs. Disbursements of vouchers could be accomplished through any number of arrangements ranging from purely governmental to a voluntary private sector organization. Whatever system is put in place, the Task Force emphasizes that contributions by the private sector are crucial for preservation of graduate medical education. Although Medicare is the single largest payer of health services, the entire Federal govemment accounted for less than one-third of expenditures for personal health care in 1982. Most of the remainder of those expenses were paid by insurers, by businesses, and directly by patients-all in the private sector. On the Issue of Size The number of vouchers for first-year positions in graduate the most recent year. This recommendation, when coupled to the three-year-or-first-board eligibility recommendation stated earlier, would limit voucher support to little more than three times the number of graduates in the index year from schools accredited by the Liaison Committee on Medical Education and schools of osteopathic medicine. On the basis of 1983 graduates (15,885), the total number of vouchers offered would be 47,655 (not counting the extra-time slots for surgery and other first-board eligibility periods of more than three years). This is significantly fewer than the 59,176 occupied by United States medical graduates in 1983. Also in 1983, another 13,221 positions were held by foreign medical graduates (FMGs). In the proposed system, vouchers would not go to FMGs, but they would be free to seek other funding sources for training in the United States. The Task Force rec ognizes that exclusion of FMGs from a voucher system could pose detrimental effects for some public hospitals that have traditionally relied on FMGs. One solution would be the allocation of some vouchers to those hospitals most affected by the loss of FMGs so that the hospitals could recruit residents to meet their service needs. On the Issue of Program Content Principle #4 summed up the Task Force's strong opinion that funds for graduate medical education should no longer tie a resident exclusively to the teaching hospital or hospital-based services. The tertiary care training received in the high-technology hospital does not match the majority of cases seen in typical practice. There are many ways in which the discrepancy could be reduced. Teaching hospitals could establish satellite clinics in the communities, thereby giving residents more ambulatory care experience and perhaps enlarging the hospital referral base. Or hospitals could affiliate with group practices at non-hospital sites. Or residents could be encouraged to accept rotations in offices of physicians in private or group practice, as the University of Iowa does in fanuly practice programs. However, these and other possibilities of more appropriate clinical experiences for residents depend on separating funding for education from payment for hospital care. On the Issue of Academic health centers must become engaged in efforts to slow and ultimately reverse the trend toward specialty maldistribution in the United States. One reason is that an oversupply of specialists logically has some connection with the functions of academic health centers, where most specialists are trained. Another reason is that academic health centers are positioned to encourage change in a system that oversupplies specialists by virtue of the cenlers' many memberships on bodies that accredit specialist training programs, bodies that certify specialists and organizations of national scope in medical education. A third reason is that academic health centers are discovering that an oversupply of specialists can become intense competitors against the centers' teaching hospitals. There are several direct actions that could be taken or encouraged by academic health centers. They could, for instance, subsidize the primary care specialties with funds taken from the professional and hospital fees of the higher-earning subspecialties and services. Residency review committees (RRCs) could limit the time spent by primary care trainees in hightech units, as the pediatric RRC has been doing. Conversely, RRCs could mandate that an appropriate number of hours be spent in ambulatory care settings. A change in the supply of specialists may be aided by market forces as prepaid health care plans increase. Such plans have greater need for primary care physicians than for subspecialists. However, the market forces may have to be speeded by the addition of reimbursement formulas biased toward primary care, such as making reimbursement neutral as between technological procedures and time-consuming activities like history-taking. CONCLUSION The mounting pressures on graduate medical education come at an opportune time for the future health of residency training. The system has undergone little in the way of basic alteration since shortly after World War II. Its principal change has been to produce greater numbers of physicians, more specialized than is warranted by the medical needs of U. S. citizens. The organizational structure of almost any human enterprise seldom goes seriously unchallenged for as long as half a century, and it is neither surprising nor unsettling that graduate medical education is now in possible need of revamping. The Task Force was formed to consider alternatives for policymakers and academic health centers to preserve the virtues of graduate medical education and yet accommodate the changing contexts of cost consciousness, physician supply and specialty distribution. The Task Force regards graduate medical education as a national resource and seeks to keep its proven benetits intact. The Task Force recognizes that GME's financing will become more explicit, its capacity will be reduced for the production of highly specialized physicians, its organizational framework must become more rational, and its base should be broadened beyond the traditional emphasis on exposure to hospital inpatients. No better opportunity is likely to present itself for graduate medical education to undergo the inevitable realignments that can help it move into the next century, continuing to produce future generations of physician practitioners, teachers and researchers. |