Wednesday, May 27, 2015

The Future of Funding for HPM Physician Training

by Kyle Edmonds

Last year, the Institute of Medicine gave us the near-simultaneous release of two reports: Graduate Medical Education That Meets the Nation’s Health Needs and Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. These reports address two related aspects of reaching the IOM’s triple aims of better care, better health, and lower costs.

Even casual readers of this blog will know that there is a problem with the number of trained hospice and palliative medicine (HPM) physician specialists in the US – with an estimated 6,000-18,000 physician shortage in 2010 alone. According to the IOM Dying in America report, there were 6,400 physicians board-certified in HPM by ABMS between 2008 and 2012, though the practice styles of these physicians are unknown. Unfortunately, HPM is not individually monitored by HRSA National Center for Health Workforce Analysis (pdf), which monitors physician workforce. In these reports, HPM is contained in the “other patient care” category of physicians, which is one of the few projected to decrease in FTEs by 46% by 2025. It is no wonder, then, that the IOM Dying in America report highlighted the limited number of palliative specialist physicians (as well as nurses, social workers, spiritual counselors) as a major deficiency with regard to progress since the previous IOM Approaching Death report in 1997.

Back in 2010, the AAHPM Workforce Task Force laid out a model for physician workforce need to staff hospice and hospital-based palliative care and concluded that “the annual need for new physicians [leaving fellowship] just to keep pace would be about 269 physicians for the middle estimate and about 472 physicians for the high estimate. More will be needed to prepare for growth and aging of the population. Training capacity thus needs to expand considerably.” Since that time, we have seen disruptive changes in the financing of health care, robust growth in community-based palliative care and the closure of one of the country’s largest HPM training programs.

When it comes to workforce projections, however, the IOM GME report warns: “Concerns that the nation faces a looming physician shortage, particularly in primary care specialties, are common. The committee did not find credible evidence to support such claims. Too many projections of physician shortages build on questionable provider–patient ratios, fail to consider the marked geographic differences in physician supply, and ignore recent evidence of the impacts of more effective organization, new technology, and deployment of health personnel other than physicians…” Near-simultaneously, the IOM Dying in America report stated: “…entities such as health care delivery organizations, academic medical centers, and teaching hospitals that sponsor specialty-level training positions should commit institutional resources to increasing the number of available training positions for specialty-level palliative care.”

A Primer on Graduate Medical Education (GME)

Physician education is divided into two major phases: undergraduate (medical school) and GME (internship, residency, fellowship). Medical school is paid for in a traditional sense via scholarships, personal investment and loans. In contrast, graduate medical education has been publically funded since the mid-1960s. This funding was approximately $15B in 2012, with 90% of the funding being provided by Medicare and Medicaid. Presently, we publically fund 1 FTE per trainee for initial certification period GME programs (first residency programs) and 0.5 FTE per trainee for those in advanced training, such as a hospice and palliative medicine fellowship. These funding systems are highly complex and laid out well in the IOM’s report. Suffice it to say that healthcare delivery has changed somewhat since the 1960s and the priorities of the present funding structure are out of alignment. In their review, the IOM committee found a marked lack of transparency, variation in funding levels and misaligned priorities in this system of funding. This led them to provide several recommendations for change to achieve the Committee’s goals to (emphasis mine):

  1. “Encourage production of a physician work¬force better prepared to work in, help lead, and continually improve an evolving health care delivery system that can provide better individual care, better population health, and lower cost.
  2. Encourage innovation in the structures, locations, and designs of GME programs to better achieve Goal 1.
  3. Provide transparency and accountability of GME programs, with respect to the stewardship of public funding and the achievement of GME goals.
  4. Clarify and strengthen public policy planning and oversight of GME with respect to the use of public funds and the achievement of goals for the investment of those funds.
  5. Ensure rational, efficient, and effective use of public funds for GME in order to maximize the value of this public investment.
  6. Mitigate unwanted and unintended negative effects of planned transitions in GME funding methods.”  
Alternative Plans

In August 2013, "Improving Value in Graduate Medical Education" from the the Council on Graduate Medical Education emphasized that “Increases in GME funding should prioritize training programs that have a particular emphasis on new competencies needed to meet the changing health care system…to accelerate physician workforce alignment with population and health delivery needs.” They ask that particular attention be paid to specialties which prioritize “1) training in a variety of community settings, 2) treating diverse populations, and 3) emphasizing team-based care, care coordination, telemedicine, and efficient care provision.” Unfortunately, following this description of some of the key aims of HPM, they proceeded to omit HPM from their “high priority” specialty list.

Next Steps

There is obviously tremendous work going on with regard to GME and it is intendant upon those of us in HPM to be proactive. GME needs to be more transparent, more population-based, more focused on quality “patient-centered and family-oriented care” and HPM will need to play a role to achieve those aims. As the IOM GME, COGME and AAFP reports demonstrate, however, HPM is not on the radar of those making the policy recommendations. As a field we need to brainstorm an approach to moving forward to raise our profile and ensure we are in a position to play that role. In order to fulfill the charge of the Dying in America report, do we need to:

  1. Revisit and expand the concept of the “academic hospice” in the context of a push for community-based GME?
  2. Develop another HPM workforce study given the drastic changes in the field since 2010?
  3. Partner with other organizations to create a comprehensive workforce strategy for interdisciplinary, specialty palliative care & hospice?

I look forward to hearing your thoughts. Kyle P. Edmonds, MD is a palliative physician with a special interest in social media, health system reform and clinical bioethics.

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