Currently, U.S. medical graduates fill only about 60% of residency slots for specialties like internal medicine—a main conduit for hospital medicine—while foreign graduates make up the remainder.
“So who’s the first that’s going to be squeezed out? It will be foreign medical graduates,” Dr. Parekh says. Many of those graduates come to the U.S. on J-1 visas, which carry a payback requirement: practicing in underserved areas. “One worry is, will rural and underserved areas suffer from a physician shortage because U.S. grads won’t want to work there after you start squeezing out all of the foreign medical grads?” he asks.
Clear Line of Sight?
Dr. Parekh also supports efforts to establish a clearer connection between the funding’s intent and where the money actually goes. The IOM report’s proposal to do so, however, raises yet another controversy around the true purpose of IME funding. Teaching hospitals argue that the money should continue to be used to reimburse them for the added costs of providing comprehensive and specialized care like level I trauma centers to their more complex Medicare patient populations.
Number one, [the IOM] came out and said, ‘We don’t know that there’s a shortage of physicians and we’re, if anything, going to remove money from the training system rather than putting in additional resources. We found that problematic, given all the evidence we have of the growing, aging population. —Atul Grover, MD, PhD, FACP, FCCP, chief public policy officer, Association of American Medical Colleges
A big part of the problem here is that people are free agents. If you make more residency spots, but the economics are such that people decide to become cardiologists because cardiologists make twice or more what hospitalists make, then you may have increased residency spots but [added only] a very small increment in the number of hospitalists. —Daniel Brotman, MD, FACP, SFHM, chair, SHM Education Committee, director, hospitalist program, Johns Hopkins Hospital, Baltimore
Accordingly, the AAMC panned the report’s recommendation to replace separate IME funding with a single fund directed toward the GME sponsoring institution and subdivided instead into the operational and transformation funds. Dr. Grover says setting up a transformation fund with new money would make sense, but not as a carve-out from existing support.
“You’re removing those resources from the system and not replacing them, which is a challenge,” he says.
Medical schools are more inclined to want the money directed toward training goals, especially if they are to be held accountable for GME outcomes. “Right now, the hospital gets it, and it’s basically somewhere in the bottom line,” Dr. Parekh says. “No one really knows where that money goes. There’s very little accountability or clarity of purpose for that dollar.”
Amid the ongoing debate, the call for more transparency and accountability in GME seems to be gaining the most ground. “I don’t see tons of downside from it,” Dr. Parekh says. “I think it sheds light on the current funding environment and makes people have to justify a little bit more what they’re doing with that money.”
Dr. Tad-y puts it this way: “If you made your own budget at home, the first thing you’d do is try to figure out where all your money goes and what you’re spending your money on.” If Medicare is concerned that its GME money isn’t being spent wisely, then, the first step would be to do some accounting. “And that means a little bit of transparency,” she says. “I don’t think that’s a bad thing, to know exactly what we’re paying for; that makes sense. I mean, we do that for everything else.”