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Graduate
Medical Education Consortia - Continued, 9th Report
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Defining the Organizational Structure That Would Best Serve Educational & Workforce Goals
(Consortium Demonstration Projects)
If consortia are to be an integral element of the graduate medical education system, it follows that they must be structured in a fashion that will enhance their effectiveness. This should not be taken to imply that there is a single "correct" model against which all consortia should be measured or even that presently available information allows prediction of the "best" model. Nonetheless, there are certain characteristics that should be imbedded in any consortium, no matter how its developers intend to merge or restructure their individual organizations.
To justify public support, consortia demonstration projects must be committed to providing a cost- effective administrative framework within which education and workforce reform can occur. In return, all payers of health care services should provide the funds necessary to ensure successful completion of the project.
To delineate how consortia might best be structured to achieve national, regional and local educational and workforce goals in an accountable and cost-effective manner, COGME recommends that:
- Funds be provided for twelve consortium demonstration projects;
- In the absence of enactment of an "all- payer" fund for graduate medical education, the federal government provide these funds, but the states and private medical insurance sector be encouraged to provide matching support;
- Funds be awarded on the basis of a peer reviewed, competitive process;
- Four projects be initiated each year in fiscal years 1998, 1999 and 2000; and
- Each project be funded for an initial period of three years, with the opportunity for renewal for an additional two three-year periods, for a total of nine years.
To promote innovation, the financial risks inherent in these projects, especially in altering the size and composition of graduate medical education programs, should be reduced. Neither the consortium collectively, nor its individual partners, should stand to lose graduate medical education payments during the demonstration period. However, any "hold harmless" provision should be made contingent on the consortium agreeing to a "workforce contingency"; that is, agreeing to restructure its training programs in a defined fashion.
With these considerations in mind, COGME recommends that:
The consortium as a whole, and its individual members, be held "financially harmless" (Medicare direct and indirect graduate medical education payments, and if possible state and private sector graduate medical education payments as well, be guaranteed at their respective levels the year prior to the award) for the duration of the award, but only provided that the consortium agrees to predefined standards for changing the size and/or composition of its residency training programs.
Demonstration project funding could also contain incentives to ensure certain organizational structures (for example, the transfer of official sponsorship of residency programs from individual members to the consortium) and to promote physician workforce policy goals (for example, increasing the proportions of generalist, women and minority residents, increasing the number of graduates practicing in Health Professions Shortage Areas, and so on).
Promoting Educational Consortia
Determining how educational consortia might best be structured will likely prove a more simple task than promoting their widespread implementation. Consortia are still relatively rare. One reason for this is that, for the most part, policy makers have yet to devise financing methods that favor, or even use, consortia. To promote the development of consortia, federal and state policy makers will have to provide appropriate incentives
Incentives to promote the widespread development of consortia could be modeled after those established by the consortia demonstration projects. At a minimum, these should include financial incentives that would enhance the composition, geographic distribution and diversity of the physician workforce. In addition, these incentives ideally should have a "shared responsibility" mantra, including defined contributions from all payers of health care services: Medicare, Medicaid and the private insurance industry alike.
Accordingly, COGME recommends that:
- Federal and State governments develop health care reimbursement incentives for the organization of consortia that would achieve educational and physician workforce goals in an accountable and cost- effective manner;
- Reimbursement incentives include Medicare, Medicaid and private sector graduate medical education payments; and
- These incentives be phased in progressively over a period of 3 to 5 years.
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