Key Provisions related to GME in the healthcare reform bill

[exPCM]

Here is a good summary of our healthcare reform bill that was passed last month:
http://dpc.senate.gov/healthreformbill/healthbill52.pdf
Here are key provisions related to GME:

Increasing the Supply of Health Care Workers.

The federal student loan program will be modified to ease criteria for schools and students, shorten payback periods, and to make the primary care student loan program more attractive. The Nursing Student Loan Program will be expanded and updated. A loan repayment program is established for pediatric subspecialists and providers of mental and behavioral health services to children and adolescents who work in a Health Professional Shortage Area, a Medically Underserved Area, or with a Medically Underserved Population. Loan repayment will be offered to public health students and workers in exchange for working at least three years at a federal, state, local, or tribal public health agency. Loan repayment will be offered to allied health professionals employed at public health agencies or in health care settings located in Health

Professional Shortage Areas, Medically Underserved Areas, or with Medically Underserved Populations.

A mandatory fund for the National Health Service Corps scholarship and loan repayment program is created. A $50 million grant program will support nurse-managed health clinics. A Ready Reserve Corps within the Commissioned Corps is established for service in times of national emergency. Ready Reserve Corps members may be called to active duty to respond to national emergencies and public health crises and to fill critical public health positions left vacant by members of the Regular Corps who have been called to duty elsewhere.

Enhancing Health Care Workforce Education and Training.

New support for workforce training programs is established in these areas:
 Family medicine, general internal medicine, general pediatrics, and physician assistantship.
 Rural physicians.
 Direct care workers providing long-term care services and supports.
 General, pediatric, and public health dentistry.
 Alternative dental health care provider.
 Geriatric education and training for faculty in health professions schools and family caregivers.
 Mental and behavioral health education and training grants to schools for the development, expansion, or enhancement of training programs in social work, graduate psychology, professional training in child and adolescent mental health, and pre-service or in-service training to paraprofessionals in child and adolescent mental health.
 Cultural competency, prevention and public health and individuals with disabilities training.
 Advanced nursing education grants for accredited Nurse Midwifery programs.
 Nurse education, practice, and retention grants to nursing schools to strengthen nurse education and training programs and to improve nurse retention.
 Nurse practitioner training program in community health centers and nurse-managed health centers.
 Nurse faculty loan program for nurses who pursue careers in nurse education.
 Grants to promote the community health workforce to promote positive health behaviors and outcomes in medically underserved areas through use of community health workers.
 Fellowship training in public health to address workforce shortages in state and local health departments in applied public health epidemiology and public health laboratory science and informatics.
 A U.S. Public Health Sciences Track to train physicians, dentists, nurses, physician assistants, mental and behavior health specialists, and public health professionals emphasizing team-based service, public health, epidemiology, and emergency preparedness and response in affiliated institutions.

Supporting the Existing Health Care Workforce.

The Patient Protection and Affordable Care Act reauthorizes the Centers of Excellence program for minority applicants for health professions, expands scholarships for disadvantaged students who commit to work in medically underserved areas, and authorizes funding for Area Health Education Centers (AHECs) and Programs. A Primary Care Extension Program is established to educate and provide technical assistance to primary care providers about evidence-based therapies, preventive medicine, health promotion, chronic disease management, and mental health.

Strengthening Primary Care and Other Workforce Improvements.

Beginning in 2011, the HHS Secretary may redistribute unfilled residency positions, redirecting those slots for training of primary care physicians. A demonstration grant program is established to serve low-income persons including recipients of assistance under Temporary Assistance for Needy Families (TANF) programs to develop core training competencies and certification programs for personal and home care aides. Also, a grant program is established to provide grant funding and payments to teaching health centers that are focused on training primary care providers in the community. Medicare is also directed to test new models for improving the training of advance practice nurses.

My comment: Anyone see any trends in these provisions? Anyone really think there will be any significant increase or lifting of the residency cap to provide more money for residency slots?
What I see is "redistribution" to primary care and expansion of midlevels. Congratulations to all those pre-meds, med students, and residents out there who voted for this guy? Do you like what you see in these provisions?

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Members don't see this ad.

 

[yaah]

That's a good summary, thanks. What I see when I read it is a lot of attempt at cost-saving which will probably end up increasing costs.

Some of the provisions to supposedly increase the attractiveness of primary care I don't think are going to end up being that helpful.

I highly doubt there will be an increase in residency spots. I also see nothing about the rapid expansion of medical schools (especially expensive medical schools!) and how this will impact things. I tend to doubt these "primary care student loan programs" are going to come close to covering the cost of attending one of these schools.

As far as nurse-run clinics and such, there has to be some role for these things in current medical practice. There are just too many patients with chronic issues that suck up physicians time - medication management, diet management, things like that. I would like to think that these programs will focus on areas that can augment physician delivered care, but I tend to fear that instead there will just be an increase in midlevel participation in more profitable methods. But I don't really blame the government totally for that. In many ways doctors are doing this to themselves because the midlevel increases their own income - the problem is you can't have it both ways.

 

[MacchinaDaCaffe]

SEC. 747. PRIMARY CARE TRAINING AND ENHANCEMENT.

‘(a) Support and Development of Primary Care Training Programs-

‘(1) IN GENERAL- The Secretary may make grants to, or enter into contracts with, an accredited public or nonprofit private hospital, school of medicine or osteopathic medicine, academically affiliated physician assistant training program, or a public or private nonprofit entity which the Secretary has determined is capable of carrying out such grant or contract--

‘(A) to plan, develop, operate, or participate in an accredited professional training program, including an accredited residency or internship program in the field of family medicine, general internal medicine, or general pediatrics for medical students, interns, residents, or practicing physicians as defined by the Secretary;

‘(B) to provide need-based financial assistance in the form of traineeships and fellowships to medical students, interns, residents, practicing physicians, or other medical personnel, who are participants in any such program, and who plan to specialize or work in the practice of the fields defined in subparagraph (A);

‘(C) to plan, develop, and operate a program for the training of physicians who plan to teach in family medicine, general internal medicine, or general pediatrics training programs

‘(D) to plan, develop, and operate a program for the training of physicians teaching in community-based settings;

‘(E) to provide financial assistance in the form of traineeships and fellowships to physicians who are participants in any such programs and who plan to teach or conduct research in a family medicine, general internal medicine, or general pediatrics training program;

‘(F) to plan, develop, and operate a physician assistant education program, and for the training of individuals who will teach in programs to provide such training;

‘(G) to plan, develop, and operate a demonstration program that provides training in new competencies, as recommended by the Advisory Committee on Training in Primary Care Medicine and Dentistry and the National Health Care Workforce Commission established in section 5101 of the Patient Protection and Affordable Care Act, which may include--

‘(i) providing training to primary care physicians relevant to providing care through patient-centered medical homes (as defined by the Secretary for purposes of this section);

‘(ii) developing tools and curricula relevant to patient-centered medical homes; and

‘(iii) providing continuing education to primary care physicians relevant to patient-centered medical homes; and

‘(H) to plan, develop, and operate joint degree programs to provide interdisciplinary and interprofessional graduate training in public health and other health professions to provide training in environmental health, infectious disease control, disease prevention and health promotion, epidemiological studies and injury control.

‘(2) DURATION OF AWARDS- The period during which payments are made to an entity from an award of a grant or contract under this subsection shall be 5 years.




It does appear that there will be some funds directed towards increasing residency spots in primary care. It would be a disaster if they really implemented that redistribution of unfilled residency spots towards primary care thing (considering there is a shortage of physicians of all types).

However, the troubling aspects of the bill's language (bolded above) is that these funds appear to only be available for 5 years and the way they slyly slipped in that thing about physician assistant programs. What happens after 5 years? Do these residency spots just disappear? IMHO, 5 years of increased primary care residency spots is in no way sufficient to make up for the decades long decline in primary care physician numbers.

I think a good way to increase students entering primary care would be to extend the grace period for loan repayment through all 3 years of a primary care residency, and to extend that period even further if they end up settling down into a rural or underserved area.

 

[VA Hopeful Dr]

Strengthening Primary Care and Other Workforce Improvements.

Beginning in 2011, the HHS Secretary may redistribute unfilled residency positions, redirecting those slots for training of primary care physicians. A demonstration grant program is established to serve low-income persons including recipients of assistance under Temporary Assistance for Needy Families (TANF) programs to develop core training competencies and certification programs for personal and home care aides. Also, a grant program is established to provide grant funding and payments to teaching health centers that are focused on training primary care providers in the community. Medicare is also directed to test new models for improving the training of advance practice nurses.

My comment: Anyone see any trends in these provisions? Anyone really think there will be any significant increase or lifting of the residency cap to provide more money for residency slots?
What I see is "redistribution" to primary care and expansion of midlevels. Congratulations to all those pre-meds, med students, and residents out there who voted for this guy? Do you like what you see in these provisions?

Am I reading this right? It looks like the article is saying that if hospital A has an unfilled slot, say prelim surgery, that they can reassign that spot/money to a primary care position?

Second, if that's true... so what? Correct me if I'm wrong, but weren't there zero unfilled spots after the match this year?

 

[exPCM]

Am I reading this right? It looks like the article is saying that if hospital A has an unfilled slot, say prelim surgery, that they can reassign that spot/money to a primary care position?

Second, if that's true... so what? Correct me if I'm wrong, but weren't there zero unfilled spots after the match this year? No, there were 1060 unfilled PGY-1 spots

There were 1060 unfilled PGY-1 spots after the match.
461 of the unfilled PGY-1 spots after the match were in prelim surgery.
http://www.nrmp.org/data/advancedatatables2010.pdf

I have not seen any official data on how many unfilled spots there were after the scramble.

 

[Droopy Snoopy]

There were 1060 unfilled PGY-1 spots after the match.
461 of the unfilled PGY-1 spots after the match were in prelim surgery.
http://www.nrmp.org/data/advancedatatables2010.pdf

I have not seen any official data on how many unfilled spots there were after the scramble.

How exactly does one 're-distribute' a 1-yr prelim surgery spot into a 3-yr categorical FM position?

 

[Maybeknot]

Why exactly did the AMA endorse this bill?

 

[Slack3r]

Why exactly did the AMA endorse this bill?

Because they were told the SGR formula would be reworked and tort reform would be included. Neither was, the AMA withdrew their support but no one paid attention because all the politicians were already spouting the support of the AMA.

 

[lanzarlaluna]

Because they were told the SGR formula would be reworked and tort reform would be included. Neither was, the AMA withdrew their support but no one paid attention because all the politicians were already spouting the support of the AMA.

Then why did I receive something in the mail from the AMA expressing their happiness with the bill a week AFTER the bill passed?

 

[ArsenalEPL4Life]

What exactly is a prelim surgery spot? What does that mean? Is it where a medical student was unable to match into his/her choice of general, orthopedic, neuro, plastics, or urological surgery spot so they take a prelim surgery year and then get automatic acceptance into the spot they desired, or do they have to reapply after doing the prelim surgery? Also, if they have to reapply, will their chances be greatly increased since they have that prelim surgery under their belt? Thank you.

 

[BlazerMed]

What exactly is a prelim surgery spot? What does that mean? Is it where a medical student was unable to match into his/her choice of general, orthopedic, neuro, plastics, or urological surgery spot so they take a prelim surgery year and then get automatic acceptance into the spot they desired, or do they have to reapply after doing the prelim surgery? Also, if they have to reapply, will their chances be greatly increased since they have that prelim surgery under their belt? Thank you.

Prelim surgery is the same as prelim medicine, just rotating through the surgery department on their intern curriculum. It can be used as the prelim year for radiology/anesthesia/etc., and it doesn't guarantee a spot for future years though it can happen.

 

[Winged Scapula]

What exactly is a prelim surgery spot? What does that mean? Is it where a medical student was unable to match into his/her choice of general, orthopedic, neuro, plastics, or urological surgery spot so they take a prelim surgery year and then get automatic acceptance into the spot they desired, or do they have to reapply after doing the prelim surgery?

Absolutely not "automatic". The Prelim year is a year (or two in some places) only without any guarantee. They have to reapply.

Also, if they have to reapply, will their chances be greatly increased since they have that prelim surgery under their belt? Thank you.

Some say chances are greatly DECREASED (at least when compared to applying as a medical student). You are "used goods", its hard to keep up appearances for an entire year, you don't have the support of your medical school, its hard to get time off during a surgical intern year to interview etc. However, if you do well, you may be able to find a categorical position somewhere but should expect to repeat the intern year.

 

[Speculatrix]

Absolutely not "automatic". The Prelim year is a year (or two in some places) only without any guarantee. They have to reapply.



Some say chances are greatly DECREASED (at least when compared to applying as a medical student). You are "used goods", its hard to keep up appearances for an entire year, you don't have the support of your medical school, its hard to get time off during a surgical intern year to interview etc. However, if you do well, you may be able to find a categorical position somewhere but should expect to repeat the intern year.

Really interesting perspective, I had no idea just how dismal being an unmatched surgery prelim was. If you say to expect to repeat the intern year, I assume you mean that people escape the prelim surgery hole by matching into a cat-PGY1? Have surgery programs been known to "create" PGY2-cat positions, or is most of that availability just due to attrition? I am always surprised to see Caribbean students matching/scrambling into Mayo/JH/UCLA/NYP prelim surgery, but it's unclear what happens after even "prestigious" prelim surgery programs.

 

[Winged Scapula]

Really interesting perspective, I had no idea just how dismal being an unmatched surgery prelim was.

Yes, its reputed to be a special level of hell.

If you say to expect to repeat the intern year, I assume you mean that people escape the prelim surgery hole by matching into a cat-PGY1?

I mean that most who do a Prelim Surgery year should not assume that if they find a position for the following year that its for a PGY-2, that they may have to also apply for PGY1 spots.

Have surgery programs been known to "create" PGY2-cat positions, or is most of that availability just due to attrition?

Well, they cannot create positions. Those are fixed. However, yes positions open either due to attrition (still around 20%) or at academic programs, movement in and out of the research years/labs.

I am always surprised to see Caribbean students matching/scrambling into Mayo/JH/UCLA/NYP prelim surgery, but it's unclear what happens after even "prestigious" prelim surgery programs.

Yes. It IS unclear although as I recall Mayo does (or has) published this in the past. However, the more prestigious programs do have a name brand that, if you do well, can serve you well in trying to find another position. But you'll also notice that these prelims almost never translate into staying at said prestigious program for PGY-2. Can be a double edged sword - prestigious program may have prestigious high caliber residents against whom you are competing. You might look slightly less impressive when compared than if you were at Podunk Surgery residency; whether the connections offset this I do not know, but I suspect it does carry some weight.

 

[Speculatrix]

WS: Please never leave SDN!! You are such a wonderful source of information and so helpful!

I mean that most who do a Prelim Surgery year should not assume that if they find a position for the following year that its for a PGY-2, that they may have to also apply for PGY1 spots.

Oh okay, just "apply broadly: you might get a PGY2 or a PGY1". Do programs ever apply for funding for or create some mysterious number of PGY(2-5) categorical positions, in anticipation that a bright prelim might join them and that way they can boost their categorical numbers?? Like, similar to Ophtho PGY2-4, Rads PGY2-5 (which all exist bc they need a prelim year), are there GS PGY2-5 positions guaranteeing categorical PGY2-5?? In addition to standard GS categorical PGY1-5 positions.

Well, they cannot create positions. Those are fixed. However, yes positions open either due to attrition (still around 20%) or at academic programs, movement in and out of the research years/labs.

So Polly Prelim can outgun Cathy Categorical, force Cathy to take a leave of absence for mental issues, encourage her to do research, drop out, have a baby, etc... and then take over Cathy's spot? This seems to create an environment where prelims can be vultures for their categorical classmates. Yikes! Is this common?

Yes. It IS unclear although as I recall Mayo does (or has) published this in the past. However, the more prestigious programs do have a name brand that, if you do well, can serve you well in trying to find another position. But you'll also notice that these prelims almost never translate into staying at said prestigious program for PGY-2. Can be a double edged sword - prestigious program may have prestigious high caliber residents against whom you are competing. You might look slightly less impressive when compared than if you were at Podunk Surgery residency; whether the connections offset this I do not know, but I suspect it does carry some weight.

Very interesting issue! I wonder what the Mayo said. Prestigious AMG categorical is likely a better intern than Carib-prelim, who's there just because she aced her boards... hence making the prelim look bad overall. Excellent point about Podunk Surgery: every prelim I know who's "traded up" to a categorical has been at Podunk State or Third-Tier U.

For next year's match:

Polly Prelim applies to Prestigious Universities, through connections. No luck, "no IMG's in our categorical program". Doesn't match, since the all-star program is filled with AMG categoricals and IMG's are for the prelim spots.

Polly's boss at Mayo doesn't know too many people at the Podunk level, but she still applies with her lukewarm letters because she looked less impressive alongside the AMG superstar. Podunk fills its categorical spots with its current prelims, who look great in comparison, because the other AMG's were not necessarily superstars.

Polly loses out after going to Mayo/JH for prelim surgery. No job for her, but 1 year of working in Rochester, MN.

Sad story. Is this plausible? I wonder if this has happened to anyone?

 

[VA Hopeful Dr]

There were 1060 unfilled PGY-1 spots after the match.
461 of the unfilled PGY-1 spots after the match were in prelim surgery.
http://www.nrmp.org/data/advancedatatables2010.pdf

I have not seen any official data on how many unfilled spots there were after the scramble.

I should have been more clear, I was talking about post-scramble. If this goes through, would they change any post-match pre-scramble slots of primary care then?

 

[NotAProgDirector]

Am I reading this right? It looks like the article is saying that if hospital A has an unfilled slot, say prelim surgery, that they can reassign that spot/money to a primary care position?

Second, if that's true... so what? Correct me if I'm wrong, but weren't there zero unfilled spots after the match this year?

Actually, this is not the way it works. The new health care bill does not reallocate unmatched spots in any way.

Here's what it does: Pre-1997, hospitals could simply increase the number of residents they had and be paid. Medicare saw spending spiraling out of control, and in 1997 congress passed the BBA which capped institutions. They would be paid for the number of spots present in 1997, but no more. (There is an exception -- if an institution starts a new program it can increase the number of funded slots, but simply increasing the size of existing programs does not).

Since 1997, some programs and institutions have closed. Those funded slots have disappeared. This law allows the HHS secretary to take those slots and redistribute them to existing programs for primary care fields only.