STS Health Policy Compendium Appendix D. Health Policy Compendium Graduate Medical Education

Transcription

1 STS Health Policy Compendium Appendix D Health Policy Compendium Graduate Medical Education

2 STS Health Policy Compendium 1 About STS Founded in 1964, The Society of Thoracic Surgeons is an international not-for-profit organization representing cardiothoracic surgeons, researchers, and other health care professionals who are part of the cardiothoracic surgery team. STS members are dedicated to ensuring the best possible outcomes for surgeries of the heart, lung, and esophagus, as well as other surgical procedures within the chest. STS has more than 6,600 members located in 85 countries. The Society s mission is to enhance the ability of cardiothoracic surgeons to provide the highest quality patient care through education, research, and advocacy. The STS National Database was established in 1989 as an initiative for quality improvement and patient safety among cardiothoracic surgeons. The STS National Database has three components Adult Cardiac, General Thoracic, and Congenital Heart Surgery, with the availability of anesthesiology participation within the Congenital Heart Surgery Database. STS also operates the STS/ACC TVT Registry in a joint effort with the American College of Cardiology (ACC). The STS Adult Cardiac Surgery Database is the world s premier clinical registry for cardiac surgery. The Database houses more than 4.7 million surgical records and gathers information from more than 95% of the ~1,100 groups that perform cardiac surgery in the United States. In 2012, the Database expanded to include its first two international participants: Brazil and Israel. In general, the STS National Database provides: A standardized format for examining the care of patients undergoing cardiothoracic operations; A tool that can be used to target specific areas for clinical practice improvement; The ability to obtain an accurate reflection of practice patterns; The ability to research the national aggregate data set; and The opportunity to participate in a national quality improvement effort for cardiothoracic surgery that has an impact at the local, regional, and national levels. The component Databases provide opportunities for quality improvement to their participants. The Society has developed quality performance measures in all three sub-specialties of surgery, and these measures have either been endorsed or are in the process of being considered for endorsement by the National Quality Forum. By collecting outcomes data for submission to the STS National Database, surgeons are committing to improving the quality of care that their cardiothoracic surgery patients receive. The Database has the corollary potential to be a powerful tool for clinical research. Since its inception, more than 100 publications have been derived from Database outcomes. These studies have been published in a variety of professional journals and textbooks and have significantly advanced knowledge in cardiothoracic surgery. Launched in 2011, the STS Research Center is a nationally recognized leader in outcomes research. The Center seeks to capitalize on the value of the STS National Database and other resources to provide scientific evidence and support cutting-edge research that ultimately helps cardiothoracic surgeons, government, industry, and other interested parties improve surgical outcomes and the quality of patient care.

3 STS Health Policy Compendium 2 The Database continues to expand with new initiatives. Launched in January 2011, STS Public Reporting Online enables Adult Cardiac Surgery Database participants to voluntarily report to the public their heart bypass surgery performance. Overall composite star ratings as well as their component ratings are listed on for more than 250 Database participants. With the success of participation nationally, STS launched in 2011 an initiative to accommodate Database participation worldwide by including international participants in the Adult Cardiac Surgery Database. Duke Clinical Research Institute (DCRI) is the data warehouse and analysis center for the STS National Database. The DCRI team brings the STS National Database a wealth of experience and knowledge in the area of outcomes management. On behalf of the STS, DCRI develops participant-specific reports that provide analysis of participants adult cardiac surgery outcomes. These reports benchmark each participant s data against regional and national outcomes displayed in both graphic and tabular format. Reports are available to participants in electronic web based format.

4 STS Health Policy Compendium 17 Graduate Medical Education Overview Funding Basics of Graduate Medical Education (GME) Medicare is the single largest payer of Graduate Medical Education (GME) in the United States. Medicare spent approximately $9.5 billion in 2009 on GME payments (MedPAC, 2010). Additional sources of GME funding include Medicaid, patient care revenues, private payers, Veterans Affairs/Department of Defense, Health Resources and Services Administration (for children s hospitals) and other state and federal programs. Medicare GME funding is divided into two areas; Direct Graduate Medical Education (DGME) and Indirect Graduate Medical Education (IGME). DGME Payments DGME includes costs that are directly related to educating residents/fellows (trainees): Trainee and faculty salaries/benefits Other overhead costs Basic Payment Formula: DGME payments are based on a base period per-resident amount (PRA) multiplied by the number of full-time equivalent (FTE) trainees the hospital staffed in the base period (i.e., 1 resident working in patient care activities full-time in one hospital = 1.0 FTE). The base period and PRA are typically based on the hospital s cost reporting period beginning in FY 1984 and the PRA is indexed for inflation each year. This is then multiplied by the hospital s ratio of Medicare inpatient days to total days to arrive at the DGME payment amount the hospital will receive from Medicare (the Medicare Share ). (PRA x FTE) x (Medicare inpatient days / total days) = Medicare DGME $ Per Trainee Example, Resident: ($85,000 x 1.0) x (212 / 365) = $49, Example, Fellow: ($85,000 x 0.5) x (212 / 365) = $24, Initial Residency Period: Trainees in their initial residency period (IRP) are counted as 1.0 FTE. Trainees who pursue training beyond the IRP or decide to retrain in another specialty are counted as 0.5 FTE. IRP examples include: General surgery = 5 years Internal Medicine = 3 years Obstetrics and gynecology = 4 years Since cardiothoracic trainees in traditional programs have already completed their general surgery residency and their IRP of five years, they are counted as 0.5 FTE for Medicare DGME payments. 6-year integrated program trainees will have 5 years at 1.0 FTE and one year at 0.5 FTE. IGME Payments

5 STS Health Policy Compendium 18 IGME includes compensation for teaching hospitals for higher inpatient operating costs: Increased patient complexity (above MS-DRG payments) Lower productivity Standby capacity Basic Payment Formula: IGME payments are calculated as a percentage add-on to the hospital s Medicare per-case MS-DRG payments based on an intern and resident-to-bed ratio (IRB). The IRB is multiplied by a regional multiplier to calculate the IGME MS-DRG percentage increase. The Medicare multiplier since 2003 has been 1.35 and basically amounts to a 5.5% increase to MS-DRG payments for 10% increase in the IRB. Multiplier x ((1 + IRB) ) = IGME % Example: 1.35 x (( ) ) = 11% Example of impact on MS-DRG Payment MS-DRG 236; Coronary Bypass w/o Cardiac Catheterization w/o MCC= $21,240.74* Example: $21, x (1.11) = $23, Increased payment of $2, per case *Based on 2012 IPPS Medicare National rate Medicare Trainee Cap In the Balanced Budget Act of 1997, Congress placed a cap on the number of residency positions that Medicare would support. The law stipulated that Medicare would not pay for the allowable GME costs of residents in allopathic and osteopathic medicine beyond the costs of the number of residents who were training in a given teaching hospital as of December 31, 1996 (Iglehart, 2008). Any new trainee position created after this date is typically not federally funded, so the hospital is only compensated for DGME based on the maximum number of positions since this cap went into effect. Health Reform and GME The Patient Protection and Affordable Care Act (PPACA) of 2010 includes a provision, effective for portions of cost reporting periods occurring on or after July 1, 2011, which redistributes DGME and IGME payments for trainee FTE s from hospitals that had a resident amount lower than its cap. CMS was to take 65 percent of the DGME and IGME residency slots that went unused by a hospital for the past three years and redistribute them according to certain criteria. 70% of the redistributions are to go to hospitals with resident-to-population ratios in the lowest quartile and 30% to hospitals in health professional shortage areas (HPSA). This builds on a previous redistribution that was part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (CMS, 2010). On August 15, 2011, CMS posted a list of hospitals that would be either losing or gaining residency slots from their cap. 58 hospitals who applied received an increase in their cap while 276 hospitals saw reductions in their caps (CMS, 2012).

6 STS Health Policy Compendium 19 In addition, PPACA called for training positions from hospitals that closed on or after March 28, 2008 to be redistributed to other hospitals. Prior to this provision, DGME and IGME payments allocated to hospital systems that closed were not redistributed and simply vanished. Medicare Payment Advisory Commission (MedPAC) GME Reform Recommendations In their 2010 report to Congress, MedPAC recommended increasing accountability and transparency for Medicare GME payments through the creation of incentive-based payment programs measured by educational outcomes. They also called for healthcare workforce studies that could measure the impact of future specialty mixes on GME. The American Association of Medical Colleges (AAMC) and various hospital and specialty groups opposed these changes due to the potential impact on the healthcare system during current health reform requirements (AMA, 2010). STS and GME By 2020, the United States will face a projected shortage of both primary care and specialist physicians to care for an aging and growing population. According to the AAMC Center for Workforce Studies, there will be a shortage of over 90,000 physicians, including 46,000 surgeons and medical specialists, in the next decade. The shortfall in the number of physicians will affect everyone, but the impact will be most severe on vulnerable and underserved populations. These groups include the approximately 20 percent of Americans who live in rural or inner-city locations designated as health professional shortage areas. In addition to the 15 million patients who will become eligible for Medicare, 32 million younger Americans will become newly insured as a result of passage of the Affordable Care Act and thereby increasing the need for doctors and exacerbating an overall physician shortage. The U.S. Department of Health and Human Services estimates that the physician supply will increase by only 7 percent in the next 10 years. In some specialties, including cardiothoracic surgery, the overall supply of physicians will actually decrease. Medicare s support for physician residency training positions has been frozen since Unless the number of residency training positions expands, the United States will face a declining number of physicians per capita as the Medicare patient population grows (AAMC, 2010). In an article published in the journal Circulation, Grover, et al. (2009) reaffirm concerns of a severe shortage of cardiothoracic surgeons pending in the U.S. over the next 10 years. The article points out that with cardiovascular disease accounting for more than one-third of the deaths in the United States, and the Medicare-age population most frequently affected by cardiovascular disease expected to double by 2030, a shortage of cardiothoracic surgeons could have dire consequences. The number of practicing cardiothoracic surgeons is decreasing and that decline is expected to continue over the next decade as more than half of the current cardiothoracic surgeon workforce is 55 years and older (Grover, Gorman, & Dall, 2009). To compound the problem, the Medicare population is expected to grow nearly 44 percent by 2025 to an estimated 73.2 million Americans (CMS, 2012). Cardiothoracic surgeons

7 STS Health Policy Compendium 20 predominantly care for patients in the Medicare population; more than two-thirds of Americans over age 65 are currently diagnosed with cardiovascular disease (AAMC, 2008). In addition, according to an AAMC study, there are 4,820 cardiothoracic surgeons nationwide which equates to one cardiothoracic surgeon per 62,577 people. From 1996 to 2006, cardiothoracic surgery saw a decline in practitioners of 0.8 percent (AAMC, 2008). This trend, combined with the lowest number of first year residents in 2007 and a long training time (eight years after the completion of medical school), is leading to a significant workforce shortage problem with the real potential of impacting access to needed lifesaving cardiothoracic surgical care. Further evidence is contained in a May 2009 General Accounting Office (GAO) report. The report demonstrates a 40 percent reduction in the number of applications for cardiothoracic residency positions from 2004 to More troubling is the 67 percent fill rate in 2008 compared to 2004 (94 percent). In 2010, 84 slots filled out of 116 available (72 percent) (Government Accountability Office). As a result of a 28% reduction from in the number of coronary artery bypass graft (CABG) operations and the rise in interventional cardiology procedures, open positions for cardiothoracic surgeons dropped as the need for new surgeons was seen as diminishing. However, as evident in Grover, et al., the need for cardiothoracic surgeons to perform non-cabg procedures is actually increasing. Cardiothoracic discharges increased for valve procedures (28%), other open heart procedures (24%), and lobectomies or pneumonectomies (11%) over the last decade. The authors conclude that the demand for cardiothoracic surgeons will increase over the next two decades (Government Accountability Office). Ensuring an adequate workforce, including the supply of skilled surgical specialists, will be crucial to successful health care reform implementation. A system that best serves all Americans should reflect current and future health care needs. STS Position on GME Policy In addressing this issue, STS is pursuing the following professional and public policy options that may make cardiothoracic thoracic surgery training more attractive to medical students. Specifically, STS is pursuing a number of avenues including new ways to develop and enrich the cardiothoracic surgery training curriculum. Among the concepts being considered are: Work to prevent the permanent loss of unused thoracic surgery training positions to primary care or other specialties. Assuming that the current reallocation policy imposed under the PPACA results in the loss of thoracic training slots, the STS proposes that a certain number of the aggregated unused GME slots be reallocated to thoracic surgery training if an institution can demonstrate that it can fill and sustain a new thoracic surgery training position. Urge Congress to raise the cap on Medicare-supported residency positions. Medicare must continue supporting training costs by supporting at least a 15 percent increase in GME positions, allowing teaching hospitals to prepare another 4,000 physicians a year to meet the needs of 2020 and beyond. Urge Congress to develop incentives that could include loan forgiveness programs and a longer loan deferment period for repayment to reduce the economic barriers for medical

8 STS Health Policy Compendium 21 students opting for specialties with long training periods like cardiothoracic surgery. Currently, it is not uncommon for a cardiothoracic surgery resident to be required to begin repaying student loans prior to finishing training and to graduate with significant student loan debt. Urge Congress to pass legislation supporting development of medical simulation technologies to augment training in cardiothoracic training programs. Medical simulation clinical skills training allows physicians to train and improve techniques without any risk or harm, resulting in reduced errors and improved outcomes for patients while ultimately reducing costs. Investigate options and benefits for expanding integrated six-year training pathways where residents will be selected out of medical school. Currently, the average 8 years of training for cardiothoracic surgery after medical school includes five years or more of general surgery training and two to three years of cardiothoracic training. There are currently 17 integrated cardiothoracic residency programs in the U.S. Address policy proposals calling for federal regulation of Resident Work Hours. Investigate geographical and economic factors leading to the lack of fill in cardiothoracic residency positions including a redistribution of residency positions within cardiothoracic surgery programs, pathways of unmatched cardiothoracic surgery applicants and options for increasing cardiothoracic surgery programs in underserved areas. Approved: January 27, 2013 (STS Board of Directors)