However, research he conducted in the 1980s suggested there was stronger evidence that residents were substituting for the attending physicians.

Brian Biles asked about the Medicare formula for indirect medical education. The goal for implementing it was to keep teaching hospitals financially solvent as the system moved to prospective payment. Is a more sophisticated formula required today? Dr. Anderson replied that more sophisticated formulas can indeed be developed, but the objective needs to be known so the formula can be designed.

Al Dobson commented that the formulas in place today were designed to meet a policy goal of ensuring access for Medicare and Medicaid beneficiaries in AHCs that have high costs and providing support for interns and residents. There may be more questions today, but those were the policy goals in 1983. Dr. Anderson agreed that the funds are flowing exactly according to the formulas developed. The question, however, is whether those are the right objectives today.

Jeff Goldsmith reiterated his view that there will be tremendous pressure on AHCs to expand the number of trainees in the next 10-15 years. Much of the discussion has focused on using cost as a basis for deciding how to subsidize various activities. The result has been wide variations in the amount of support provided to specific institutions. Dr. Goldsmith asked if this is a viable basis for policy going forward. Dr. Anderson responded that expanding training programs will require an assessment of what we want them to accomplish. NIH faces these questions annually when it has to decide how much spend on cancer or AIDS. Although the future cannot be predicted, we can say where we think the problems will be and allocate money accordingly. We know that the needs of the 21st century are going to be more oriented toward chronic care and will be less hospital focused. Even if projections are imprecise, the alternative is to let each AHC make its own decisions with the current set of economic incentives, which will continue to have an acute care, inpatient focus.

Larry Lewin challenged the statement that DSH and NIH funding mechanisms have more accountability built into them than GME funding does. He noted that DSH funding is imprecise, yet has a significant impact on the size of the safety net, where it is located and whether it is oriented to outpatient or inpatient services. Dr. Anderson replied that in his view, graduate medical education was the least accountable, but it may be true that accountability for DSH dollars could also be clarified.

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