IOM Releases Report on Graduate Medical Education

On July 29 the Institute of Medicine (IOM) released a report on graduate medical education (GME) (1). This is the residency training that doctors complete after finishing medical school. This training is funded by about $15 billion annually from the Federal government with most of the monies coming from the Center for Medicare and Medicaid Services (CMS). The report calls for an end to providing the money directly to the teaching hospitals and to dramatically alter the way the funds are paid. Instead payments would be made to community clinics phased in over about 10 years. To administer the program, the report recommends the formation of two committees: 1. A GME Policy Council in the Office of the Secretary of the U.S. Department of Health; and 2. A GME Center within the Centers for Medicare & Medicaid Services to manage the operational aspects of GME CMS funding. The later committee would administer two funds: 1. A GME Operational Fund to distribute ongoing support for residency training positions that are currently approved and funded; and 2. A GME Transformation Fund to finance initiatives to develop and evaluate innovative GME programs, to determine and validate appropriate GME performance measures, to pilot alternative GME payment methods, and to award new Medicare-funded GME training positions in priority disciplines and geographic areas.

If adopted, the plan would end decades of attempts by CMS to coerce medical school graduates into primary care, especially in rural, underserved areas. By controlling funding for GME training, CMS would be able to dictate how physician training. Negative reaction was expected and swift from the American Hospital Association, the American Medical Association and the American Council on Graduate Medical Education, whose members would lose CMS money (2-4). Also expected, the proposal was supported by the American Academy of Family Physicians whose members who would gain under the proposal (5).

The IOM committee has a point. Despite a growing public investment in GME, there are persistent problems with uneven geographic distribution of physicians, too many specialists, not enough primary care providers, and a lack of cultural diversity in the physician workforce. Furthermore, according to the report "a variety of surveys indicate that recently trained physicians in some specialties cannot perform simple procedures often required in office-based practice.”

However, can a committee formed by CMS be expected to improve the health of America? Based on the composition of the committee and their past performance we think not. First, the committee was co-chaired by Don Berwick who was head of the Institute for Healthcare Improvement (IHI), CMS Administrator and presently a candidate for Massachusetts governor (6). During Berwick's tenure, the IHI proposed a number of non- or weakly evidence-based metrics. Many of these have been found to make no impact on patient-centered outcomes such as mortality, length of stay, readmission rates, morbidity, etc. (7). An example was the 18 month 100,000 Lives Campaign which according to Berwick prevented 122,300 avoidable deaths. However, the methodology, incomplete data and sloppy estimation of the number of deaths makes Berwick's claim dubious. Furthermore, when the campaign was expanded to the 5,000,000 Lives Campaign the "results" could not be reproduced. Also during Berwick's tenure, IHI prematurely championed tight control of blood sugar in the ICU, an intervention which resulted in a 14% increase in ICU mortality when properly studied (8). Undaunted, Berwick put many of these same meaningless metrics in place when he became administrator of CMS. One of these metrics, readmission rates, has been associated with a higher mortality (9). Now Berwick is running for Massachusetts governor. One wonders how politics might have affected the report.

Other members of the committee include the committee co-chair, Gail Wilensky, who was administrator of HCFA (the precursor of CMS), nurses, physician assistants, economists, a representative from industry and a number of academics. Missing were members of the large community of practicing physicians. It seems the IOM committee was assembled to produce a political rather than an evidence-based answer of how to solve patient care disparities. To paraphrase a well-known quote, the first casualty of politics is usually the truth. It seems likely that the proposed GME Center within CMS would have a similar composition to Berwick's present IOM committee and would likely offer political rhetoric rather than meaningful reform to GME. Similarly to those championed by Berwick at IHI and later CMS, we suspect that a series of meaningless metrics would be required that would do nothing other than add a paper burden to a medical system already drowning in paperwork. By removing local control, CMS will likely ignore local strengths. For example, the University of Colorado has an extremely strong pulmonary and critical care division. Although America needs this physician expertise, especially critical care, it seems likely that CMS might move these residency slots to family practice or general medicine. We believe that local control with appropriate incentives, is more likely to solve these problems than a centralized bureaucracy in Washington.

Lastly, a word about the report's claim graduates lack the skills to perform basic procedures. Our observations are similar and we are inclined to accept the claim. However, we point out that it was decisions of committees such as those proposed that required attending physicians to perform procedures in order to be reimbursed and that residents have fewer opportunities to perform procedures due to work hour restrictions. The committee's implication that somehow physician trainers are to blame seems quite disingenuous. Not identified in the report but crucial to physician development is developing skills to critically evaluate medical literature, rather than blindly follow the guidelines proposed by CMS, IHI or others of a similar ilk. 

The proposals in the IOM report are a bad idea from a committee whose head has been rife with bad ideas. The committee's report is not the "New Flexner Report" but will be the coffin nail in the death of quality, caring physicians if adopted.

Richard A. Robbins, MD

Clement U. Singarajah, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ

References

1. Institute of Medicine. Graduate medical education that meets the nation's health needs. July 29, 2014. Available at: http://www.iom.edu/Reports/2014/Graduate-Medical-Education-That-Meets-the-Nations-Health-Needs.aspx (accessed 8/5/14).
2. American Hospital Association. IOM panel recommends new financing system for physician training. July 29, 2014. Available at: http://www.ahanews.com/ahanews/jsp/display.jsp?dcrpath=AHANEWS/AHANewsNowArticle/data/ann_072914_IOM&domain=AHANEWS (accessed 8/5/14).
3. Hoven AD. AMA urges continued support for adequate graduate medical education funding to meet future physician workforce needs. July 29, 2014. Available at: http://www.ama-assn.org/ama/pub/news/news/2014/2014-07-29-support-graduate-medical-education-funding.page (accessed 8/5/14).
4. Kirch DG. IOM’s vision of GME will not meet real-world patient needs. July 29, 2014. Available at: https://www.aamc.org/newsroom/newsreleases/381882/07292014.html (accessed 8/5/14).
5. Blackwelder R. Recommended GME overhaul will support a physician workforce to meet nation’s evolving health needs. July 29, 2014. Available at: http://www.aafp.org/media-center/releases-statements/all/2014/gme-physician-workforce.html (accessed 8/5/14).
6. About Don. Available at: http://www.berwickforgovernor.com/about-don (accessed 8/5/14).
7. Robbins RA. The unfulfilled promise of the quality movement. Southwest J Pulm Crit Care. 2014;8(1):50-63. [CrossRef]
8. NICE-SUGAR Study Investigators. Intensive versus conventional insulin therapy in critically ill patients. N Engl J Med 2009;360:1283-97. [CrossRef] [PubMed]

Reference as: Robbins RA, Singarajah CU. IOM releases report on graduate medical education. Southwest J Pulm Crit Care. 2014;9(2):123-5. doi: http://dx.doi.org/10.13175/swjpcc107-14 PDF

Getting the Best Care at the Lowest Price

“Computers make it easier to do a lot of things, but most of the things they make it easier to do don't need to be done.”- Andy Rooney

A recent report from the IOM Institute of Medicine (IOM) claims that $750 billion, or about 30% of healthcare expenditures is wasted each year (1). This attention-grabbing statistic is reminiscent of the oft-quoted figure of 44,000-98,000 deaths attributable to medical errors annually from the 2000 IOM report titled “To Err Is Human: Building a Safer Health System” (2). The IOM estimate of deaths was based on two studies that used the Harvard Medical Practice Study methodology (3-6). Nurses reviewed charts and using preset criteria cases referred charts to physicians who had undergone a short training course. The physicians judged whether the adverse event was due to a medical error and whether the error contributed to the patient’s death. The incidence of deaths from medical errors was double in New York compared to Utah and Colorado resulting in the IOM’s high and low estimate. I remember reading the studies and thinking that both had problems. The physician reviewers were often outside the specialty area involved (e.g., nonsurgeons reviewing surgical cases); the criteria for error and whether it contributed to death were not clearly defined; and the results were inconsistent (were physicians from New York really twice as negligent as those from Utah and Colorado?). My impression was that no one would believe these flawed studies. I was very wrong. The IOM report helped spark an ongoing campaign for patient safety resulting in a number of interventions. Most were focused on physicians, some were expensive, and to date, it is unclear whether they have improved outcomes or wasted resources.

Now the IOM has published that an inefficient, extraordinarily complex, and slow-to-change US healthcare system wastes huge amounts of money (Table 1) (1).

Table 1. IOM estimates of wasted healthcare dollars.

Although the validity of the estimates is uncertain, most in healthcare would agree that a large portion of healthcare dollars are wasted. The report implies much of this inefficiency is due to clinicians because they are slow-to-change, inefficient and unable to keep up with the explosion in healthcare knowledge. Because of these limitations, physicians often mismanage the patient resulting in the waste of dollars noted above. In the healthcare system envisioned by the IOM, electronic health records (EHRs) would bring the research contained in more than 750,000 journal articles published each year to the point of care. Since it would be impossible for a clinician to read all 750,000 articles these would be communicated to the clinicians as guidelines.

Over the past decade, a remarkable number of laws, rules, regulations, and new ways of doing business have hit physicians (7). Each, when viewed alone, looks very reasonable, but, taken in aggregate, they are undermining the profession and medical care. Healthcare has become more expensive and physicians have shouldered this blame despite losing much of their autonomy. The IOM recommendations on computers may be another in the death by a thousand cuts that independently thinking physicians are receiving.

Although I’m resentful of the IOM report’s implications, bringing computers and EHRs to the clinic is a good idea. However, as a retired VA physician I have repeatedly heard how the “magic” of the computer can solve problems. The VA long ago installed an electronic health record with a set of guidelines that anyone could follow. Certainly improved efficiency and reduced costs would shortly follow. Unfortunately, this does not appear to be the case. When the VA EHR was instituted the numbers of physicians and nurses within the VA declined although the numbers of total employees increased (8). At least part of the increase was due to installation and maintenance of an EHR. At the same time an ever increasing number of guidelines were placed on the computer. Costs to ensure compliance and bonuses paid to administrators for compliance further escalated expenses. Furthermore, the guidelines caused a marked consumption of clinician time. According to one estimate, compliance with the source of many of the VA guidelines, the US Preventative Services Task Force, would require 4-7 hours of additional clinician time per day (9). Clearly, this was unsustainable so further money was allocated to hire healthcare technicians to comply with many of the guidelines. Compliance improved but efficiency, costs, morbidity or mortality did not (10). Furthermore, an unexpected increase in healthcare expenditures occurred outside the VA as a consequence of EHRs. A recent report from the Office of Inspector General of Health and Human Services notes an increase in higher level billing codes in Medicare patients (11). Experts say EHR technology resulted in the increase because of its super-charting capabilities (12). Therefore, it seems unlikely that EHRs as currently utilized will improve efficiency or lower costs.

Much to their credit, the IOM seems to recognize these limitations when they say, "Given such real-world impediments, initiatives that focus merely on incremental improvements and add to a clinician's daily workload are unlikely to succeed” (1). The report goes on to say that instead, the entire infrastructure and culture of healthcare must be reconfigured for significant change to occur. I would agree. Previous changes to improve healthcare have done nothing more than shift monies away from clinical care which will not improve patient outcomes (13). This occurred at the VA and will occur again if left unchecked. A meaningful partnership between clinicians and payers achieving and rewarding high-value care is needed. To do this physicians need considerable input, and perhaps more importantly, control of any EHR. Second, physicians need to be rewarded for good care which is centered on improved patient outcomes and not endless checklists that do little more than consume time. Failure to do so will result in inefficient and more costly care and not in the improvements promised by the IOM.

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Smith M, Saunders R, Stuckhardt L, McGinnis JM. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academy Press. 2000. Available at: http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx (accessed 9/8/12). 
2. Kohn LT, Corrigan JM, Donaldson MS.  To Err Is Human: Building A Safer Health System.  Washington, DC: National Academy Press. 2000. Available at: http://www.nap.edu/openbook.php?isbn=0309068371 (accessed 9/8/12). 
3. Hiatt HH, Barnes BA, Brennan TA, et al. A study of medical injury and medical malpractice. N Engl J Med 1989;321:480-4.
4. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6.
5. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84.
6. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, Howard KM, Weiler PC, Brennan TA. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-71.
7. Kellner KR. Physician killed by ducks. Chest 2005;127:695-6.
8. Robbins RA. Profiles in medical courage: of mice, maggots and Steve Klotz. Southwest J Pulm Crit Care 2012;4:71-7.
9. Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635-41.
10. Robbins RA, Gerkin R, Singarajah CU. Relationship between the Veterans Healthcare Administration hospital performance measures and outcomes. Southwest J Pulm Crit Care 2011;3:92-133.
11. Office of Inspector General. Coding trends of Medicare evaluation and management services. Available at: http://oig.hhs.gov/oei/reports/oei-04-10-00180.asp (accessed 9-8-12).
12. Lowes R. Are Physicians Coding Too Many 99214s? Medscape Medical News. Available at: http://www.medscape.com/viewarticle/767732 (accessed 9-8-12).
13. Robbins RA, Gerkin R, Singarajah CU. Correlation between patient outcomes and clinical costs in the VA healthcare system. Southwest J Pulm Crit Care 2012;4:94-100.

*The views expressed in this editorial are those of the author and do not necessarily represent the views of the Arizona or New Mexico Thoracic Societies.

Reference as: Robbins RA. Getting the best care at the lowest price. Southwest J Pulm Crit Care 2012;5:145-8. (Click here for a PDF version of the editorial)