Graduate Medical Education: Value-Based Reimbursement Models Heading Our Way?

Courtesy of the Institute of Medicine

Courtesy of the Institute of Medicine

As an educator, there are few things more rewarding than watching the transformation our new interns experience from the time they come into our programs on July 1st  until the day they finally graduate residency a number of years later. It is like an abbreviated version of watching your children grow up…many enjoyable memories that make you smile, a few challenging bumps in the road that remind you they are still young, and like all of us no matter how old we are, still have more learning yet to experience. But at the completion of that journey we share with our residents, we feel good about what they have accomplished and send them off on their own.

The purpose of graduate medical education (GME) in the United States is to do just that – to prepare medical school graduates for the independent and unsupervised practice of medicine. Over the last few years, there has been considerable debate on whether we have been meeting our GME mission. Many, including organizations like CMS and HRSA that help fund GME to the tune of around $9.1 billion a year, would not call it a debate but a fact that we have been failing. The competencies and skills necessary to provide safe, high quality care at good value are not ones found in most GME curricula of today. Healthcare continues to change dramatically and medical education has not kept pace. In December, 2008, the Institute of Medicine (IOM) issued a report titled “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety”. In the report, the IOM asserted that revisions to medical resident workload and duty hours are necessary to better protect patients against fatigue-related errors, and to improve the learning environment for doctors in training. While the report made recommendations on duty hours, patient care handovers and patient case loads, a significant portion of the report focused on current GME patient safety related deficiencies. Aligned with David Leach’s writings, the IOM recommended the use of near misses and unsafe conditions as opportunities for both resident education and institutional patient care improvement purposes.

The Accreditation Council for Graduate Medical Education (ACGME) responded quickly to these recommendations. Dr. Tom Nasca, the current CEO for the ACGME, sent a letter to all residency programs on June 23rd, 2010 in which he outlined a new cohesive and comprehensive package of interrelated standards that were designed to accomplish three goals:

  1. To assure the safety and quality of care rendered to patients in our teaching hospitals today;
  2. To assure the safety and quality of care rendered to patients of our current residents in their future independent clinical practice; and
  3. To assure the provision of a safe and humanistic educational environment for our residents to learn and demonstrate professionalism and effacement of self-interest.

On September 28, 2010, the ACGME Board of Directors approved new requirements for residency programs, including updated standards for resident duty hours, education, and supervision. ACGME’s press release at the time stated: “The standards are based on recommendations made by the IOM in 2008 and evidence collected during a 16-month review of the scientific literature on sleep issues, patient safety and resident training.” The new standards were implemented on July 1, 2011.

All of us in healthcare are experiencing the escalating demands for transparency of outcomes, greater accountability, and quality based reimbursement models as they relate to patient care. Many say, “It’s about time,” because this newer value-based model has finally garnered the attention of hospital boards and C-Suites. If the model has successfully created urgency around the provision of safe, high quality patient care, don’t look now but that same model might be just around the corner for the provision of safe, high quality GME where academic medical centers will be paid on value with penalties for lapses in safety and quality education. A reimbursement model based on Value-Based Education and HCAHPS for graduate medical education…is it déjà vu all over again?

More to come on these new ACGME standards…

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One Comment on “Graduate Medical Education: Value-Based Reimbursement Models Heading Our Way?”


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