April 25, 2008

1. Action Alert: Contact Your Senators to Extend the Moratorium on Cuts to Medicaid GME

2. COGME Recommends GME Expansion, Incentive Programs

1. Action Alert: Contact Your Senators to Extend the Moratorium on Cuts to Medicaid GME

The US House of Representatives passed (349-62) the Protecting the Medicaid Safety Net Act of 2008 (HR 5613) April 23, 2008. The bill would place a one-year moratorium on the Centers for Medicare & Medicaid Services regulation to eliminate federal Medicaid spending for graduate medical education. The challenge now will be to gain Senate support for the legislation to ensure it is passed before the existing moratorium ends May 23. The Alliance for Academic Internal Medicine (AAIM) urges you to contact your senators and encourage them to support extending the Medicaid moratorium. For contact information, please visit www.senate.gov.

In the Senate, the Economic Recovery in Health Care Act of 2008 (S 2819) will be the main vehicle for pushing Medicaid moratorium legislation forward. While slightly different from HR 5613, the Senate bill introduced by Senator John D. Rockefeller IV (D-WV) also asks for an extension of the Medicaid moratorium. When contacting your senators, please be sure to ask for support of both bills HR 5613 and S 2819. When discussing the possibility of cutting Medicaid matching funds for physician training, please be sure to explain how the change would affect your institution and state.

While the White House threatened to veto any legislation proposing a delay to the Medicaid regulations, the House bill received 75 more votes than the two-thirds necessary to override a veto. Some House Democrats have talked about adding the legislation to a war funding bill to ensure its passage; however, some Democrats do not agree with such a measure, so no decision has been made as of yet. Observers believe the overwhelmingly positive reception the bill received in the House has created enough momentum to move it through the Senate quickly.

While a number of Senate Republicans do not want to lose federal funding for physician training, others agree with President George W. Bush that the new Medicaid regulations are necessary to rein in overall Medicaid costs. According to a spokesperson from the US Department of Health and Human Services, the House vote “is a victory for budget gimmickry at the expense of US taxpayers…The legislation invites states to bill federal taxpayers for what are state responsibilities.”

On May 7, members of the Association of Program Directors in Internal Medicine (APDIM) from target states will participate in APDIM Hill Day. The purpose of Hill Day is to activate members and have them visit Capitol Hill to speak with representatives, senators, and key staff who influence medical education policy. This year, Hill Day participants will discuss AAIM’s “Signature Issue,” the extension of the moratorium on cuts to Medicaid GME.

AAIM encourages you to contact your senators to ask for support of HR 5613 and S 2819.

2. COGME Recommends GME Expansion, Incentive Programs

The Council on Graduate Medical Education (COGME) released two reports Wednesday, March 26, 2008, related to physician training and access to health care. The reports “New Paradigms for Physician Training for Improving Access to Health Care” and “Enhancing Flexibility in Graduate Medical Education” articulate recommendations that would create incentive programs to increase the number of physicians practicing medicine in underserved areas as well as expand graduate medical education (GME) programs. COGME is authorized to advise Congress on issues pertaining to GME and the supply and distribution of the physician workforce.

“New Paradigms for Physician Training for Improving Access to Health Care—Eighteenth Report” explores the problems caused by limited access to health care and suggests strategies that could be implemented to improve access in rural and urban settings. The five recommendations discussed in the report are:

• Increase access to health care using incentive-based models.
• Increase funding of federal and state loan repayment programs.
• Increase admission of students from underserved areas in medical schools.
• Create a national medical school.
• Expand strategic access funding, including reinvigoration of the Health Resources and Services Administration’s Title VII health professions training programs.

“Enhancing Flexibility in Graduate Medical Education—Nineteenth Report, expands upon previous COGME reports, that outline the shortfall of the current and future supply and demand of physicians. The report suggests addressing this shortage by:

• Aligning GME with future health care needs.
• Broadening the definition of “training venue” beyond traditional training sites.
• Removing regulatory barriers limiting flexibility in GME training programs and training venues.
• Making accountability for the public’s health the driving force behind GME.

COGME’s recommendation to increase GME positions aligns with its previous recommendations and those of the Association of American Medical Colleges to expand the number of graduating physicians by 15% and 30%, respectively. The report asserts that “if medical school graduates increase without a corresponding increase in GME positions, the result will be an increase in the number of US-trained physician residents without an increased production of independent physicians at the end of the medical education pipeline.” While Medicare funding restrictions on GME have made reform difficult, the report claims overall flexibility in GME curriculum, structure, funding, and accreditation may address the current shortcomings.

Despite the COGME and AAMC projections of a physician workforce crisis, not everyone within the medical community is convinced. In an article published April 17, 2008, in the New England Journal of Medicine (NEJM)—“Physician Workforce Crisis? Wrong Diagnosis, Wrong Prescription”— David C. Goodman, MD, and Elliott S. Fisher, MD, question the validity of these claims. Dr. Goodman and Dr. Fischer warn that greater numbers of more physicians does not necessarily translate into better health care. The authors also caution that an unrestricted expansion of GME could potentially undermine primary care and increase the number of physicians entering more specialized practices. However, another article appearing in the same issue, “Grassroots Activism and the Pursuit of an Expanded Physician Supply,” reiterates the challenges ahead for GME and physician workforce as noted by COGME and AAMC.

The Alliance for Academic Internal Medicine—the nation’s largest academically focused specialty organization—consists of the Association of Professors of Medicine, the Association of Program Directors in Internal Medicine, the Association of Subspecialty Professors, the Clerkship Directors in Internal Medicine, and the Administrators of Internal Medicine.

Please contact AAIM Vice President for Policy Charles P. Clayton (cclayton@im.org), AAIM Policy Coordinator Nicole V. Baptista (nbaptista@im.org), or AAIM Policy Assistant Jessica L. O'Hara (johara@im.org) at (202) 861-9351 with questions or comments about this week’s Merlin.