A. Phase out over a 4-year period the granting of J-1 waivers for purely service reasons as a move toward restoring the exchange visitor program to its original purpose. At the same time, the policy of considering waivers for uniquely qualified researchers in nationally and internationally significant research efforts should be continued.
The four-year phase out of the service-based waivers would allow development of domestic program strategies to provide long-term, permanent solutions to alleviate physician maldistribution. On the other hand, waivers for researchers will encourage medical and health related research of an advanced technological nature that would produce benefits to both the Nation and the international community.
B. Increase the J-1 visa return-home period from 2 to 5 years for exchange visitor physicians.
A five-year minimum return home period allows J-1 visa holders sufficient time to contribute the benefits of U.S. training to their home country physician workforce and permits reasonable time for reacculturation. This should reduce the probability that J-1 visa holders will return to the U.S.
C. Eliminate use of the H-IB visa program for physician residency training.
The elimination of H- IB visa program would stop the use of the H-IB visa to circumvent the J-1 visa "return home" requirement.
IV. Enhance Primary Care Residency Training
A. Provide Medicare DME payments to a wide variety of ambulatory teaching settings, including managed care plans.
B. Include time spent in ambulatory settings outside the hospital in the calculation of Medicare IME payments to hospitals.
C. Make Medicare IME payments to ambulatory settings outside the hospital when ambulatory cost estimates have been developed.
D. Identify and remove the DME and IME components of the Average Adjusted Per Capita Cost (AAPCC) from Medicare capitation rates and utilize these funds specifically for GME purposes.
Practitioner competency is dependent upon training in appropriate settings such as in community-based ambulatory sites. Physicians trained to provide primary care in ambulatory settings can provide comprehensive, continuing, longitudinal care to patients. The policy of providing direct and indirect GME payments only for hospital-based residents or DME payments to residents rotating in hospital based ambulatory clinics has restrained appropriate training for all physicians, generalists in particular, to provide such care. Medicare IME payments to ambulatory settings would provide a strong incentive to initiate such training.
The AAPCC payment system for Medicare risk HMO contractors presents a difficulty in financing HMO residency training. AAPCC payments include equivalent amounts of DME and IME for a relevant geographic area, but these GME dollars are not identified in the AAPCC and are paid regardless of whether the HMO engages in residency training. As a result, Medicare GME funds are spread among all HMO contractors, without being focused on those that actually have teaching programs or necessarily use teaching hospitals for services.
These amounts should be removed from the AAPCC and made available for GME in a wide variety of teaching settings, including teaching hospitals and managed care organizations and HMOs with teaching programs, to help rectify possible inequities to teaching hospitals and eliminate the current disincentives to HMOs who wish to establish or expand residency training activities but do not currently receive explicit reimbursement for their efforts.
E. Support Public Health Service Act Title VII education programs, which have ultimate underserved practice as a goal.
Efforts need to be strengthened to encourage the domestic production of competent generalists who will serve in these areas. Most Title VII physician education programs operate under a statutory funding preference for applicants who demonstrate success in placing graduates in underserved communities.
F. Encourage new generalist residency programs by permitting exceptions to Medicare GME payment caps (as proposed in recommendation I.B.) for new primary care residency programs in geographic areas with shortages of physicians, including residents.
If Medicare GME payment caps are enacted, there should still be opportunities for Medicare DME and IME payments to encourage primary care residency programs in areas where relatively few or no programs exist. Residents frequently remain near the hospital where they received their residency training. The competency of primary care practitioners is dependent upon training in the proper settings such as in ambulatory sites in community-based hospitals. Promotion of new primary care residency programs can provide this type of training to physicians. These primary care physicians can offset the adverse impact of residency reduction and changes in the health service delivery environment by providing continuing, longitudinal, comprehensive general care to Medicare beneficiaries and vulnerable populations.
G. For DME, reinstate the 1994-1995 freeze on non-primary care per-resident amounts for a two-year period, while continuing the Consumer Price Index for Urban Areas (CPI-U) updates for primary care per-resident amounts.
Such a freeze has historical precedent. Freezing payments to non-primary care training programs while continuing for two years the CPI adjustment for primary care programs creates a payment differential in favor of primary care programs, carried forward as the CPI adjustments are resumed for both primary and non-primary care training programs payments. COGME believes that this differential in payments will motivate hospitals to shift the specialty training more in favor of primary care residency training or at least not reduce primary care training. This differential should be examined periodically for effectiveness.
It is COGME's intention that this freeze not adversely affect the recruitment and retention of minority residents in any specialty. COGME is on record as considering under represented minority participation and advancement in medicine as particularly critical for the Nation.
V. The United States Role in International Medical Education
A. Recommend to the World Health Organization that other countries engage to a greater degree in physician workforce analysis and planning.
B. The U.S. government should cease to support undergraduate medical education of U.S. students in foreign countries through loans.
Currently, the Department of Education is in the process of reviewing the credentialing requirements for medical schools in other countries. The purpose of this review is to ascertain if credentialing requirements are similar to those of the Liaison Committee for Medical Education (LCME). Eligibility of foreign medical schools to participate in the Federal Family Education Loan program for U.S. citizen medical students would be accorded only to those schools with LCME-like credentialing requirements. U.S. citizens who receive medical training in such schools would improve their likelihood of becoming ECFMG certified and accepted into a residency training program. Satisfaction of LCME-like requirements would reduce the number of foreign medical schools eligible to provide U.S. government funded support for U.S. citizen students.
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