Proposed Performance-Based Metrics for the Future Funding of Graduate Medical Education: Starting the Conversation

Abstract

Graduate medical education (GME) in the United States is financed by contributions from both federal and state entities that total over $15 billion annually. Within institutions, these funds are distributed with limited transparency to achieve ill-defined outcomes. To address this, the Institute of Medicine convened a committee on the governance and financing of GME to recommend finance reform that would promote a physician training system that meets society's current and future needs. The resulting report provided several recommendations regarding the oversight and mechanisms of GME funding, including implementation of performance-based GME payments, but did not provide specific details about the content and development of metrics for these payments. To initiate a national conversation about performance-based GME funding, the authors asked: What should GME be held accountable for in exchange for public funding? In answer to this question, the authors propose 17 potential performance-based metrics for GME funding that could inform future funding decisions. Eight of the metrics are described as exemplars to add context and to help readers obtain a deeper understanding of the inherent complexities of performance-based GME funding. The authors also describe considerations and precautions for metric implementation.

Graduate medical education funding mechanisms, challenges, and solutions: A narrative review

“…Some of the strategies proposed to improve both GME funding and resident compensation include creation of an all-payer system for graduate and undergraduate medical education; institution of a "tuition-for-service" program to eliminate medical student debt for those who work in underserved areas and specialties following residency training 19 ; billing private insurance for unsupervised minor procedures performed by trainees 20 ; and institution of performance-based GME payments on metrics such as value of care, access, and physician wellbeing. 11,21 Importantly, these changes should not occur without rigorous research and input from multiple stakeholders, including physicians in training. Therefore, future research should address the impact of these proposed interventions and develop other innovative solutions to improve both GME funding and resident compensation.…”

“…The AAIM and ACP remain cautious that these changes should not occur without rigorous research and input from multiple stakeholders, including physicians in training. 11,21 Resident Salary and debt New physicians graduate medical school at a time when their peers in other fields may have already been working and accruing wealth for four years. In contrast, 73% of medical students in 2019 graduated with debt, with a median educational debt of $200,000.…”

Breaking Down Silos Between Medical Education and Health Systems: Creating an Integrated Multilevel Data Model to Advance the Systems-Based Practice Competency

“…The goals and outcomes should focus on patient health as well as on health system efficiency and effectiveness for patient populations. 39,40 Proposing an Integrated Multilevel Data Model for SBP (5) apply to multiple settings of care, especially for outpatient vs inpatient-based GME programs; and (6) be relevant to the local community and society. 1,13,20,[39][40][41] In consideration of these factors while applying Nelson's levels from the macrosystem level down to the individual level, we developed a schematic diagram of an integrated multilevel data model (Figure 1).…”

“…To advance SBP performance, health systems and GME must work together to define the goals and outcomes at each level and the interactions and shared work by which they are achieved, and to measure them. The goals and outcomes should focus on patient health as well as on health system efficiency and effectiveness for patient populations 39,40 …”

Responsiveness to societal needs in postgraduate medical education: the role of accreditation

“…Suggestions for broader interventions have generally been made at the conceptual level, such as proposals in the United States to reallocate funding for graduate medical education to incentivize programs that meet social accountability aims [32], and some commentators have recommended metrics to be used in the allocation of funds [33]. In Canada, the report of a consortium of organizations that addressed the future of postgraduate medical education emphasized the social accountability of physicians to the public they serve [34].…”