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Special Report |
1 From the American Board of Radiology, 5255 E Williams Circle, Ste 3200, Tucson, AZ 85711. Address reprint requests to M. Paul Capp, MD, Executive Director of the American Board of Radiology.
Index terms: Education • Radiology and radiologists • Special reports
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Introduction |
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 TOP Introduction KEYNOTE ADDRESSESABR CERTIFICATION EXAMINATIONSBREAK-OUT SESSION DISCUSSIONSAPPENDIX |
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The ABR, currently headquartered at 5255 East Williams Circle, Suite 3200, Tucson, AZ 85711, has issued approximately 42,000 certificates. To enter the field of radiology, an individual must have obtained a medical degree, followed by 1 year of direct patient care and 4 years in an approved program of graduate medical education in diagnostic radiology or radiation oncology. To become board certified, candidates must pass a comprehensive written examination in physics and clinical diagnostic radiology or radiation oncology. After successfully passing the written examination, candidates must undergo a 4-hour oral examination once their program director deems them "professionally qualified." Oral examinations are conducted by radiologists from the United States and Canada who have expertise in the examination process. Additional subspecialty examinations are given to those who have trained for a 6th year in nuclear radiology, neuroradiology, pediatric radiology, and vascular and interventional radiology. This certificate expires after 10 years.
To carry out its purpose, the ABR must have a great deal of interaction with its sponsoring organizations, as well as with medical specialty boards, specialty societies, medical societies, residency program directors, and hospital department chairs. Consequently, the ABR held its first seminar, "The Future of Graduate Medical Education in Radiology" on March 5 and 6, 1998, in Washington, DC, to encourage open dialogue between the organizations and to develop a strategy to ensure that radiology educational programs and certification programs can respond to the dramatic changes occurring in the health care system.
Attendance at the seminar was by invitation of the ABR and included representatives from the Residency Review Committees for both Diagnostic Radiology and Radiation Oncology, the American College of Radiology, the American Association of Physicists in Medicine (AAPM), the American Association of Academic Chief Residents in Radiology (A3CR2), the Association of Program Directors in Radiology (APDR), the Association of Residents in Radiation Oncology (ARRO), the Society of Chairmen of Academic Radiology Departments (SCARD), and the Society of Chairmen of Academic Radiation Oncology Programs (SCAROP). The approximately 95 radiologists and physicists who attended were a cross-section of both academic and private practice groups across the country.
Five keynote speakers established the tone of the seminar: Gail R. Wilensky, PhD, chair of the Medicare Payment Advisory Commission; Robert Dickler, senior vice-president for health care affairs of the Association of American Medical Colleges; Samuel O. Thier, MD, president and CEO of Partners HealthCare System, Inc; Howard Kessler, MD, medical director of Aetna/U.S. Healthcare; and Marc Hartstein, health insurance specialist from the Health Care Financing Administration. After a plenary session, seminar attendees were divided into small working groups, each of which was to focus on one of four areas: general radiology/community practice/primary care, academic radiology, subspecialization, or managed care. Each discussion group had representation from each of the other subgroups.
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KEYNOTE ADDRESSES |
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TOPIntroductionKEYNOTE ADDRESSESABR CERTIFICATION EXAMINATIONSBREAK-OUT SESSION DISCUSSIONSAPPENDIX |
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The future of graduate medical education is dependent on financing, on its size and scope, on its organizational structure, on its content and site, and on its quality and accreditation.
Financing
The training of physicians, given the amount of postgraduate work required and the intensity of the education within a clinical or delivery setting, is unique. In addition, the federal government's role in health care as the largest direct payer for health care services and the precedent setter for support and reimbursement methodology is also unique. Within the Medicare program, direct funding for graduate medical education provides support for resident stipends. The fund for indirect medical education was developed in the 1980s to address the differential costs between teaching and nonteaching hospitals.
Also, Medicare is not a source of full funding for direct graduate medical education costs. For example, if Medicare recipients make up one-third of the patients in a hospital, that hospital gets one-third of the total cost from Medicare for the education of residents. Payments for indirect educational expenses are linked to diagnosis-related groups, or DRGs, and specific patient episodes.
These costs have been funded from the patient-care dollar. As Medicare faces financial pressure, other methods of financing graduate medical education must be developed. The Association of American Medical Colleges supports all-payer funding. All-payer funding is rooted in the belief that HMOs and other health care insurance companies also have an obligation to support institutional costs. If all special funding was removed, studies suggest that a majority of teaching hospitals would operate in the red.
Size and Scope
Debate in this country has centered on whether too many physicians are being educated or if, at least, too many specialists and not enough generalists are being produced. These debates have pertained in particular to international medical graduates due to their increasing numbers.
One option is to let market forces prevail. Oversupply will lead to smaller incomes, making the field comparatively less attractive. A second option is to do nothing. A third option is to ban international medical graduates from coming to this country for training and/or staying when their training is complete. A fourth option is to regulate the number of people going into medicine; however, such a system would have to be incredibly complex, covering every training site at every level of training for every specialty.
Some legislators, especially those with constituents who do not have timely access to a physician, do not believe a critical oversupply of health care providers exists. In any case, regulation will lead to the creation of mechanisms that will be linked to grants.
Organizational Structure
Graduate medical education covers more than 100,000 residents and fellows in 7,300 hospital-based programs involving 1,600 sponsors. It has been suggested that graduate medical education either be consolidated into consortia to streamline the educational process or be forced to consolidate by shutting down low-quality programs. Others have suggested that responsibility for graduate medical education be given to local public organizations or that medical schools integrate graduate and undergraduate training.
Content and Site
Medical education should provide an understanding of managed care, health economics, population-based health care, and appropriate leadership roles for physicians. Also, more education should be offered outside the inpatient framework (for example, an HMO setting or a traditional ambulatory care setting). However, only a finite amount of time is available for education, and changes will affect the financing and nature of education.
Also, further consolidation of the health care system may lead to greater competition between medical schools and various educational sites. In other words, some faculty may be part of a delivery system that could put out of business the same physician groups they are dependent on for education.
Quality and Accreditation
Changes are already being made to improve the quality of graduate medical education. The Accreditation Council on Graduate Medical Education supports the use of outcome measures to determine the quality of residents' programs. Outcomes refer to determining whether an individual who finishes a training program is a good provider of health care. In addition, in the future programs will not be accredited if the sponsoring institution does not meet institutional requirements. Supporters of this change believe this will remove confusion between accreditation and certification, eliminate the proliferation of specialties, and tailor programs to local needs. Opponents believe this is counter to the development of medicine with its focus on specialties.
Role of Graduate Medical Education in an Integrated Health Care System
Samuel O. Thier, MD
Partners HealthCare System (hereinafter, Partners) developed approximately 5 years ago. As managed care penetration increased in Massachusetts, admissions to Boston hospitals were predicted to drop by up to 35%. Eventually, two of seven academic centers closed. In Worcester, Mass, over the past 10 years, the number of hospitals dropped from 11 to two. Partners was developed so patients could receive complete continuity in care. A network was organized to provide community-based primary care and community-based hospital care. Administrative and educational programs were consolidated.
With managed care, patients do not stay in hospitals for a long time. Instead, patients come in, are treated, and leave as soon as possible. This does not create a conducive teaching environment. Also, many specialists—nephrologists, endocrinologists, and rheumatologists, for example—do not carry out major work in a hospital, and many primary care practitioners do not involve themselves in educational endeavors.
Residents and fellows should be taught in a way that enhances an institution by improving productivity, attracting high-quality talent, raising the level of physician care, and broadening the spectrum of care. Therefore, institutional accreditation makes sense because it guarantees that all programs are meeting a predetermined standard.
Educational Promise of an Integrated System
In an integrated system, trainees gain experience with a variety of diseases and a broader range of patients from diverse socioeconomic backgrounds. It may also lead to curriculum expansion, giving trainees exposure to the continuum of care and to the managed-care system.
Generalists can be assigned to offices and community clinics. Trainees can also be sent to nontraditional sites, such as nursing homes, long-term care facilities, and rehabilitation facilities. Additionally, some primary-care practices may improve health care delivery with better integration between physicians, physician assistants, and nurse practitioners.
Cost Obstacle
Cost is one major obstacle to integrated graduate medical education. For example, training in ambulatory settings is more expensive than training in hospitals, where facilities and equipment are in place to handle residents and fellows. This might not be the case in the ambulatory setting. Another issue is, Who should pay? It will be difficult to decide whether a training program, medical school, teaching hospital, or practice should bear the cost of education. If funds were given directly to residents, rather than institutions, some bureaucracy and its associated expense might be eliminated. (Perhaps educational costs and other indirect expenses incurred by an academic center should be managed by putting the money in a trust fund.) Ultimately, funds should support education, not limit it.
So far, the managed-care industry has not considered educational support to be part of its responsibility, and the government is backing away from its responsibility. At Partners, we are addressing this in part by telling the managed-care companies we contract with that we expect them to support patient care, teaching, and research.
Facilities Obstacle
Many facilities are not built to train residents or house equipment for education. Overcoming this obstacle may be worthwhile in the long term, but many managed-care companies resist putting their patients in educational and research facilities.
Access Obstacle
If faculty members are pressured to meet stricter performance and productivity mandates, they will be less available for teaching and research. In fact, research shows that when the level of managed care increases in a given area, National Institutes of Health grant support decreases in clinical but not in basic science departments. In clinical departments, the number of published works by health care professionals also decreases. Managed-care companies do not invest in research because the people managing these companies have, in general, a short-term view and do not realize that without research and education the health care system will decay.
Faculty-Development Obstacle
In an integrated system, it is difficult to develop faculty from widely scattered trainees. Consequently, teleconferencing and an adequate patient-tracking information network are critical. To date, no such system has performed adequately in meeting these goals.
Overview
Many consider health care to be inefficient and expensive; consequently, the pressure is on to document effectiveness. Standardization would simplify such documentation, but it is difficult to standardize in a field where patients and diseases are not standardized. Outcomes can be measured adequately if based solely on patient mortality. But this simplistic method overlooks underlying conditions. Severity or risk adjustments do not adequately explain differences in death rates at various institutions. Still, quality differences among hospitals must be recognized. Partners has been more successful when evaluating care processes.
The health care system is too expensive, its objectives are not effectively prioritized, and methods to improve the system have not been aggressively examined. The people who are treated, the people who buy care, and the people who deliver care must talk together.
Graduate Medical Education as Viewed by the Insurance Industry
Howard Kessler, MD
The HMO Model
Aetna/U.S. Healthcare provides services for approximately 13.5 million members; of these, 3.8 million are covered under capitation. About 17% of HMO business in mature markets has evolved from traditional models to integrated delivery and risk-sharing models in which providers of care receive a percentage of the premium. This affects the way the industry can support radiology residents, fellows, and radiologists just out of training. In 1998, it is estimated that Aetna/U.S. Healthcare will spend about $1.06 billion on the delivery of radiology services, not including radiation oncology. Only board-certified radiologists or those with board-certified equivalency can perform radiologic studies according to the Aetna/U.S. Healthcare HMO model. Also, additional accreditation is expected. American College of Radiology accreditation for mammography and ultrasonography (US) accreditation have been incorporated into the HMO model.
In addition, an average primary care physician will allocate 1,200 RVUs (relative value units) of radiology service annually to the radiology community. In other words, radiology consumes resources, involves large expenditures, and is used frequently and continuously. New technologies are introduced; old technologies are being phased out. Consequently, Aetna/U.S. Healthcare is evaluating outcomes (ie, how radiologists perform tests and how their expertise or competency contributes to patient care).
Today, people coming out of training are unaware of the changing markets. Radiology has been hurt because radiologists were unaware of market changes.
The managed-care market is emerging because the public is demanding accountability and some standard in an industry where there has been none. Prevention and disease-management programs have improved quality of care. It is time academic institutions and payers see the potential for mutual benefit, work together to measure and improve care, and demand accountability.
Becoming Active Participants
Health care benefits managers are saying that fewer dollars are being budgeted for health care benefits. General Motors reported that $1,100 to $1,200 from the sale of every car goes to health care benefits. This jeopardizes research and development in such companies. Consequently, residents and fellows must better understand and recognize the importance of medical outcomes. They should be taught to be consultants, not merely image readers who rely on technology and order numerous tests. They must understand the implications of excessive or inappropriate ordering. They must no longer be passive participants in the delivery of health care.
Training has to change. Those in a radiology department must understand outcomes, payment methodologies, and future trends. They should understand capitation, risk sharing, integrated delivery systems, and the importance of disease management. The future of graduate medical education will be based on collaborative efforts, not separate from the delivery systems. Academic institutions and managed-care organizations must cooperate. In 1996, the Academic Medicine and Managed Care Forum was started with a grant from the Aetna Foundation. Thirty-six academic institutions currently work together and vie for grants through this forum.
Residents and fellows should have the opportunity to work with managed-care organizations. All will benefit from a more cooperative relationship.
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ABR CERTIFICATION EXAMINATIONS |
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TOPIntroductionKEYNOTE ADDRESSESABR CERTIFICATION EXAMINATIONSBREAK-OUT SESSION DISCUSSIONSAPPENDIX |
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Board certification is critically important. It may not prove competence to practice radiology, but no physician can practice radiology easily without it.
Previously, at the beginning of the 4th year of residency, physicians took a written examination in diagnostic radiology, physics, and radiobiology. Starting in 1997, the physics and radiobiology portions of the examination were offered in the 2nd year of residency to decrease stress by passing an examination early and enabling residents to carry the principles of physics into later radiology training. Many have taken advantage of this change. Residents may also take the diagnostic test early if they prefer.
Recently, 2,500 new questions were generated for the written examination based on responses from about one-quarter of the 200 program directors. Also, more program directors are being asked to serve as examiners for the oral examination.
The oral examination comprises 10 sections of 30 minutes each. Over 4 days, 13,000 individual examinations are given, which requires much money, time, and effort. Also, the already crowded structure of the examination does not allow for the incorporation of new subjects. For example, cardiac radiology is now incorporated into the chest and pediatrics section.
In the short term, the time for the oral examination may need to be decreased by half, perhaps by assigning two examiners to a candidate and abolishing current categories, thus testing on the whole body of radiologic knowledge. In the longer term, some oral-examination questions should become written-examination questions. This can be carried out effectively with a computer-based examination, and ABR is actually investigating this process.
Radiation Oncology Update
Speaker: David H. Hussey, MD
Board certification in radiation oncology requires a candidate to pass a written examination and an oral examination. The written examination covers 13 different clinical areas. Questions are submitted by 36 item-writers. Each question is reviewed by other item-writers, the category chairpersons, the written examination committee, and American College Testing (the company that oversees the written examination) before it is used. Candidates must pass the written examination to be eligible to take the oral examination. The oral examination comprises eight 
-hour sessions, each covering a different clinical area.
Approximately 70% of candidates pass the written examination and 60% pass the oral examination. However, the performance of candidates taking the examination for the first time is better. In general, poor performers on the written examination are more likely to also do poorly on the oral examination.
All certificates issued by the ABR in radiation oncology since 1994 have been 10-year time-limited certificates. Consequently, radiation oncologists who have been certified recently must pass a recertification examination within 10 years to maintain their certification status. A recertification examination in radiation oncology was offered for the first time in September 1999. This is a written examination composed of 250 items. It was given in a paper format in six cities around the country and in a computer format in two cities (Tampa, Fla, and Tucson, Ariz). Diplomates who were certified before 1995 do not need to recertify, but they can take the recertification examination voluntarily if they need evidence of recent certification.
Radiation Physics Update
Speaker: Edward L. Chaney, MD
Since 1947, 2,200 physicists have been certified by the ABR. Areas of certification are diagnostic radiology physics, medical nuclear physics, and therapeutic radiology physics. The written examination is divided into a general physics and specialization section. A candidate must pass both parts to take the oral examination. The oral examination is composed of five five-question one-on-one sessions of hour each.
Beginning in 2001, physics will offer time-limited certificates. Examinations are being updated to take in new technologies and practice patterns. Work is being done to develop a computer-based written examination and to transfer part of the oral examination to a computer-based format.
Residency Review Committee, Diagnostic Radiology Update
Speaker: Katherine A. Shaffer, MD
Program requirements of abdominal radiology as a new subspecialty were turned down because of political issues and misunderstandings. The Endovascular Surgical Neuroradiology program, designed to allow neuroradiologists and neurosurgeons to enter subsubspecialty training in interventional neuroradiology, received negative comments from those in radiology.
New program requirements for general surgery require that residents have an opportunity to become familiar with diagnostic and therapeutic methods such as stereotactic breast biopsy, noninvasive diagnostic examinations of the vascular system, invasive vascular interventional techniques, and US of the head and neck, breast, and abdomen. This is not, however, a requirement to have experience with these modalities; therefore, surgery residents are not required to have a rotation in US, for example.
In the past 4 years, programs in diagnostic radiology have decreased slightly, while vascular and interventional radiology programs have increased. The number of other programs is stable. The number of training slots has decreased due to programs that have closed, merged, or cut back.
The Residency Review Committee has proposed that 42 of the 48 months in training be in the "parent" or integrated institutions, up from 40 months. The maximum training period in any subspecialty should be 12 months. Also, a program director should have 3 years of experience as a faculty member, and one full-time–equivalent physician faculty should be at the parent institution for each resident in the program.
The seven subspecialty areas in the program requirements have been changed to nine, in accord with examination sections. Abdominal radiology includes gastrointestinal and genitourinary radiology since finding qualified faculty to supervise in these separate areas is difficult. Faculty members are considered qualified to supervise the training in a subspecialty area if they have fellowship training or 3 years of practice in the subspecialty; membership in a subspecialty society; and publications, presentations, and continuing medical education in the subspecialty. No one is required to have all these, however.
In addition, a training program should have an average of 7,000 examinations per year per resident. Also, a resident should have 6 months of training in diagnostic radiology before being on-call, without supervision, in an emergency room. Images should be reviewed, and reports should be signed by faculty. Residents should be supervised. Finally, half a program's graduates should pass the ABR examinations on the first try. Only 19% of the academic programs fail to meet this criterion.
Residency Review Committee, Radiation Oncology Update
Speaker: David H. Hussey, MD
The Residency Review Committee reviews radiation oncology training programs every 3–5 years, or as often as yearly if the program is having difficulty meeting the Residency Review Committee requirements. A variety of criteria are used to evaluate a program, including the availability of clinical material, the quality of treatment and learning facilities, faculty performance, and resident board scores. Much of the assessment is based on information submitted by the program directors, but programs are also reviewed by a surveyor who interviews the medical school administrators, faculty, referring services, and residents. All residents keep logs, but they are occasionally poorly kept, so that it can be difficult to determine how many patients the average resident sees. There can be no more than 1 residents per faculty radiation oncologist. The Residency Review Committee changed the required length of radiation oncology training programs from 3 years to 4 years in 1996. Of this, 36 months must be in radiation oncology and no more than 6 months can be spent in research.
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BREAK-OUT SESSION DISCUSSIONS |
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TOPIntroductionKEYNOTE ADDRESSESABR CERTIFICATION EXAMINATIONSBREAK-OUT SESSION DISCUSSIONSAPPENDIX |
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Shortly after World War II, the Hill-Burton Act made it possible for communities to build and equip hospitals. By 1954, income used by employers for employee medical benefits was no longer taxed. In the 1960s, Medicare and Medicaid were established. At the same time, there were rapid developments in medicine. In radiology, specifically, expensive, high-risk procedures were replaced by expensive, low-risk procedures. Institutions did not want to transfer patients to competing facilities for a study, and the government provided disincentives to contain costs. Instead, there were incentives for overutilization of medical tests, primarily to protect against legal action. Radiology departments were profit centers in which charges for tests did not reflect actual costs. Soon, physicians set up radiographic equipment in their own offices. Nonradiologists demanded radiographic equipment in their hospital departments, duplicating machinery and effort.
A check-and-balance system is necessary. Graduate medical education suffers when problems with the health care system exist. Managed care is part of the problem. It is not a health care system developed to provide good and affordable care. The purpose of managed care is profit. Money is saved at the expense of the patients.
Radiology exists at the hub of the demands from clinical specialists. It can become an essential part of health care that draws the many health care factions together.
A national vision is needed, not a patchwork revision to managed care. Health care must be structured on a foundation focusing on the needs of the patient.
Dealing with Managed Care
Managed-care companies are interested in outcomes and their relationship to value and cost. Managed-care systems do not want to get involved in education. Physicians, then, have an opportunity to become involved with developing standards of care. These standards will not be based on board certification.
Before Medicare, residents in radiology were trained with no government subsidy. If managed care does not support training, graduate medical education will not suddenly cease to exist. Therefore, the challenge to the ABR and the Residency Review Committee is to move their emphasis from certification to establishing requirements for practicing graduate radiologists.
Managed Care and Research
Because managed care has reduced payments, fewer funds are being used to support academic time and for research. Fewer departments of radiology are pursuing research. Consequently, some research will not be done; even large institutions will become choosier about their research projects. The ABR and Residency Review Committee must allow for greater flexibility for the training researcher. In particular, the field must allow dedicated research residents to undergo years of research training, with training in clinical radiology. Departments will expend their own resources to support research and go outside the department for research mentors. Cooperation between departments, the ABR, and the Residency Review Committee is essential. Research must pay for itself or be part of a large research service industry that includes corporations and the government.
In addition, the 21st century will be most involved with genetics and the effects of the environment on genetics. For radiology to remain a health care specialty, it must become more involved with molecular medicine.
The challenge today is to raise the profile of radiology in patient care and research. Perhaps radiology should shorten its core curriculum and the amount of general training required. This would involve a clear definition of what the core curriculum is. If dedicated to one type of practice, the imaging core curriculum could be limited to 24 months, allowing extra time for research training.
Training Modifications
Clinical experience is important and must remain part of training. Possibly, the core curriculum could be reduced to 3 years and deal with scientific research as it relates to medical imaging and informatics. Various training tracks could be devoted to diagnostic radiology or research, as well as subtracks in neuroradiology, cardiovascular and interventional radiology, pediatric radiology, and nuclear medicine. Another subtrack would involve practice outside the training institution. Learning the business side of medicine, as well as more familiarity with primary care, should also be part of training.
Because the public, through managed-care companies, is demanding accountability, resources and ways of continuously improving measures to quantify services, quality, and outcomes must be developed. Once a level of accountability is established, it must be applicable to all physicians.
Flexibility will be necessary; therefore, the generalist will remain valuable in community and academic practices. A generalist can be used more broadly than a specialist; this will result in cost-effective care.
Also, radiologists should be reimbursed for providing consultative services to primary-care physicians. Finally, health care premiums should be taxed to provide services for the indigent and underinsured.
Effect of Managed Care on Training
Graduate medical education should prepare future radiologists for the influence of managed care on their practice by emphasizing the relevance of direct patient care, relationships with referring physicians, and the business side of practice. Teaching should be less didactic and more "real world." A faculty can become more effective if it uses teaching opportunities on the Internet. Also, training programs should become more self-reliant because funding will probably not come from managed care. The ABR should gather information from various sources and determine the weaknesses of residents coming out of a radiology program.
State of Research
Mentors for research trainees are diminishing. Training in research methodology is lacking. The importance of research is not stressed. Trainees learn facts but do not become familiar with radiology as a lifelong learning process.
The subspecialty societies should network and support academic radiology and realize support is needed from outside radiology to understand the molecular and genetic aspects on which 21st century medicine will be based.
More funding is going to the National Institutes of Health and the National Cancer Institute. Otherwise, funding for research is diminishing to the point that new research centers are unlikely to develop. Consequently, the existing research centers of excellence must be coordinated. Training essentials in research methodology must be defined and incorporated in the ABR examination. Also, the teaching environment is threatened. Many do not have time to teach, and those who do are not justifiably appreciated. Trainees must be taught to teach. Therefore, two training tracks should be developed: one for the clinician-teacher and one for the investigative researcher.
Specialists in Demand
Subspecialists will be in demand, and it is to their advantage to be accredited. Interspecialty training, such as between neuroradiology and neurology, was initially popular but required medical students to consider specialization early in their medical training. Of course, specialists must maintain good relationships with referring physicians.
Radiation Oncology
Not many facts support the adequacy of graduate medical education in radiation oncology. Data show there are not enough patients per resident. Also, training seems tradition-bound, leading to inflexible, rigid residents. And, as institutions become technologically complex, traditional skills may be deteriorating.
A radiation oncologist must be able to take care of patients and not rely on medical oncologists or interns if complications arise. Required training in community practice, away from the home institution, may address some of these issues. Consideration should also be given to teach values and end-of-life issues.
Managed Care and Radiation Oncology
So far, managed care has been an instrument of cost control in medicine. It has not increased access for patients to the health care system. Also, the decrease in cost of care has not meant an improved quality of care.
Anecdotally, managed care is blamed for denying care leading to exacerbation of the medical condition. Additionally, managed care is facing more government regulations and reimbursement reductions. Many HMOs are reporting financial losses.
The promise of cost control and a high quality of care is not flawed, but the managed-care industry must make some changes to survive. Patients must have increased access to specialists and information on quality of care, yet costs must still be controlled. Quality and outcomes can be measured, but can the ability of a trainee to apply book knowledge to a practice be measured?
In the future, the value of radiation oncology will be compared with the value of other therapies. Funding of technology will be considered with other priorities. Unless the technology is shown to improve clinical outcomes, the relationship between radiation oncology and technology will be threatened.
Future Strategies
To attract the best, more students should be exposed to radiation oncology in medical school. The visibility of the specialty should be increased at academic medical centers. Also, research opportunities in radiation oncology training programs should be improved.
Residents may become distracted from their academic endeavors by studying for the board examination. Perhaps the physics and biology portions can be taken earlier in training. In other words, emphasis on the board examinations should be decreased and new content should be taught. Special certification in pediatrics and brachytherapy must also be recognized.
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APPENDIX |
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TOPIntroductionKEYNOTE ADDRESSESABR CERTIFICATION EXAMINATIONSBREAK-OUT SESSION DISCUSSIONSAPPENDIX |
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GME Reform Goals
Medicare is reforming its support for physician training. Demonstration projects and new laws are designed to (a) curtail growth in the number of residents that Medicare helps train, (b) slow the rate of increase in spending, (c) encourage more training of primary care physicians, and (d) promote training in outpatient and managed care because services for Medicare beneficiaries increasingly are shifting to these settings.
Training Doctors at Teaching Hospitals
Medicare makes two types of GME payments to teaching hospitals.
Direct medical education payments cover administrative costs and salaries for medical residents and teaching faculty. These payments are based on the "base year" cost of a teaching hospital's GME programs in 1984, the number of residents and interns in the hospital now, defined by "full time equivalents," where two half-time residency slots equal one full-time equivalent, and the proportion of all care a hospital provides, defined by "inpatient days," to Medicare patients.
Indirect medical education payments are intended to cover the added costs of having care provided by physicians who are in training. For example, residents often order more tests than would be ordered in a nonteaching hospital. These payments are based on teaching intensity, defined by the ratio of residents and interns to beds.
New Changes
The Balanced Budget Act of 1997 makes important changes that will help achieve Medicare's GME reform goals. These reforms should save Medicare $12.2 billion over the next 5 years.
Residency cap.—Direct GME payments from now on will be based on the number of residents each hospital had in 1996, and a hospital will no longer get more direct GME money by adding new residency slots. There are exceptions to this cap for teaching hospitals that started new residency programs after January 1, 1995, for hospitals in rural underserved areas, and for dentistry and podiatry programs. This cap can be calculated on an aggregate basis for affiliated hospitals that share residents.
Indirect medical education.—These payments are being adjusted to match more closely the true costs they cover. The formula on which these payments are based—the "IME adjustment factor"—is dropping from its current 7.7% to 7.0% in FY 1998, 6.5% in FY 1999, 6.0% in FY 2000, and 5.5% in FY 2001 and thereafter. A new, hospital-specific cap on the resident-to-bed ratio will be used in calculating these payments.
Three-year rolling average.—To cushion payment cuts for cutting the number of residents, GME payments be based on a rolling average average of the number of residents at a hospital over the last 3 years. This also will slow payment increases for any hospital that adds new residency slots that are not affected by the new residency cap.
Outpatient and managed care.—To encourage more education in outpatient facilities and managed care programs, residents working in these settings now may be included in a hospital's resident count for indirect GME payments if the hospital pays all or most of the costs of training. These residents were already included in direct GME payment calculations. For the first time, Medicare will make GME payments to nonhospital providers participating in an approved medical residency program. These could include Federally Qualified Health Centers, Rural Health Clinics, and Medicare+Choice organizations such as HMOs. Input from interested parties is now being gathered, and a regulation on how these payments will be made could be published as early as Spring 1998.
Managed care carve-out.—Another important change is known as the managed care carve-out. Medicare payment to managed care plans is based on the average cost of care for patients in the Medicare fee-for-service program. The formula to determine that average has included GME payments. Now, however, GME costs are being "carved out" of payments to managed care plans. Teaching hospitals will get GME payments directly for the Medicare managed care patients they treat, in much the same way as GME payments for Medicare fee-for-service patients are calculated. The carve-out is being phased in, so the formula for figuring these payments will be multiplied by an "applicable percentage" of 20% in 1998, 40% in 1999, 60% in 2000, 80% in 2001, and 100% in 2002. Teaching hospitals should get about $5.3 billion over the next 5 years through this carve-out.
The National Voluntary Residency Reduction Plan
The Balanced Budget Act includes important new incentives for hospitals to cut residency programs and increase primary care training. Congress is allowing teaching hospitals to voluntarily participate in a program that will ease payment reductions as residency programs are cut. Transition payments will be made to hospitals that reduce their program size by 20% to 25% over 5 years. The 20% reduction option requires a hospital to increase its number of primary care residents by 20%. The 25% reduction option requires a hospital to maintain its current proportion of primary care to total residents.
The transition payments will not be made for the first 5% of cuts in a residency program. For reductions beyond that, however, the hospital will get transition payments that will help the hospital shift to other employees work handled by residents but not directly related to their education. Thus, the residents' time will be more sharply focused on education, and care that can be provided by other workers will be delivered more efficiently and cost effectively.
The transition payments phase down over 5 years. In the 1st and 2nd year a hospital will get 100% of what it would have gotten if it had kept a residency slot; then 75% in the 3rd year, 50% in the 4th year, and 25% in the 5th year. After that, the payments phase out completely. These transition payments can begin in the 1998 academic year. Hospitals may apply for the payments, individually or in groups as consortia, until November 1999. A regulation detailing how this program will work should be published by early 1998.
Other GME Demonstration Projects
The Residency Reduction Program outlined above is based on a demonstration project initiated by Medicare in 1997. That demonstration is limited to New York State, which has the largest number of residents in the country and receives 20% of all Medicare GME payments. The demonstration's goals are the same as in the national program. The primary difference is that transition payments include the first 5% of residency cuts.
Medicare is working with Utah on a demonstration project to set up one centralized fund that will coordinate all financial support for GME from Medicare and all other payers. It will be administered by a state-level Medical Education Council.
Another demonstration authorized by the Balanced Budget Act will explore how direct medical education payments can be made to "consortia" of GME providers working together rather than to individual hospitals. That could promote more collaborative arrangements, particularly in nonhospital settings.
The National Commission and MedPAC
Further ideas on GME reform are likely to come from the new National Commission on the Future of Medicare and the Medicare Payment Advisory Commission (MedPAC). Both these groups are charged with looking at GME issues over the next 2 years and making policy recommendations.
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Footnotes |
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Abbreviations ABR = American Board of Radiology HMO = health maintenance organization
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  G. J. Becker 2000 RSNA Annual Oration in Diagnostic Radiology: The Future of Interventional Radiology Radiology, August 1, 2001; 220(2): 281 - 292. [Abstract] [Full Text] [PDF]
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