Washington Health Policy Week in Review
MedPAC Urges Changes in Doctor Training to Streamline Care

By John Reichard, CQ HealthBeat Editor

June 15, 2010 -- It didn't weigh in directly on the historic health care law, but the Medicare Payment Advisory Commission (MedPAC) had no small impact on the legislation, making recommendations that Democrats seized on to cut Medicare spending and help pay for coverage of the uninsured. Now the commission's impact could be felt once again—if Congress embraces its new recommendations to change the training of doctors.

MedPAC's advice on "GME in Medicare" may sound dry, but it's about producing a new breed of physician. Medicare's "graduate medical education" payments play a large role in financing the training of American doctors, and MedPAC says the program can help to transform the health care system.

"The current graduate medical education system produces superb physicians," but the commission is concerned about its current structure, MedPAC Executive Director Mark Miller said in briefing reporters Tuesday on this year's version of the panel's "June report." The document details the subjects the commission will focus on in coming months, along with making various recommendations.

Commissioners question whether current methods of training are able to produce a mix of medical professionals that will lead change in health care delivery from a focus on fee-for-service medicine to focusing on quality of care, better coordinated care and restraining costs.

"We found that curriculums we looked at in residency programs didn't focus on things like working in multidisciplinary teams, didn't use quality metrics . . . didn't focus on the use of IT — those types of skill sets," Miller explained.

The training systems "tended to be highly focused on inpatient care and less on out-of-hospital types of care."

Medicare spends $9 billion annually on financing graduate medical education, Miller said. "Our recommendation is to take $3.5 billion of that . . . and make it performance-based funding," he said. The money would go to programs that do emphasize team-based care, compliance with quality-based performance measures, better coordinated care and treatment outside of hospitals in primary care clinics and in nursing homes, for example.

"This is decidedly a shift in how this money is currently allocated."

The commission wants independent research on the numbers of and different types of health care professionals needed in a system that is better organized and more efficient. Current workforce projections are based on the needs of a less optimal system, Miller suggested.

The commission also wants research to better pinpoint how medical education should foster diversity in terms of seeking students from different races, income levels and geographic areas. And MedPAC wants more specifics on approaches that work best to bring health care professionals to medically underserved communities.

MedPAC also calls for a greater understanding of how individual institutions spend their GME dollars. The aim is to determine how much funding is needed to support high quality education. To reach that goal it urges HHS to "annually publish a report that shows Medicare medical education payments received by each hospitals and each hospital's associated costs."

Another theme of the report is how to make Medicare a more innovative purchaser of health care. MePAC wants to explore whether to urge adoption of "reference pricing," for example, in which a new item or service is paid at the same payment rate as an existing item that has comparable clinical benefit. Thus Medicare wouldn't pay any higher rates for a more expensive product that had the same clinical benefit as a less costly product. "We're going to continue to explore that idea," Miller said.

Miller also was asked about how the commission would work with the Independent Payment Advisory Board (IPAB) and whether the powers of the latter would make it more likely that MedPAC recommendations are actually put into practice.

"I think this generates more work for us," Miller responded. MedPAC is supposed to evaluate IPAB's ideas for streamlining Medicare, he noted.

"Whether it makes our stuff happen or not . . . is harder for me to say," Miller said. But "we're going to try to establish a strong working relationship with them," he added.


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