Graduate Medical Education

That Meets the Nation’s Health Needs

Committee on the Governance and Financing of
Graduate Medical Education

Board on Health Care Services

Jill Eden, Donald Berwick, and Gail Wilensky, Editors

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

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Committee on the Governance and Financing of Graduate Medical Education Board on Health Care Services Jill Eden, Donald Berwick, and Gail Wilensky, Editors

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THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropri- ate balance. This study was supported by Contract No. 101053-0009 between the National Academy of Sciences and ABIM Foundation; Contract No. 101053-0013 Aetna Foundation; Contract No. 101053-0014 The California Endowment; Contract No. 101053-0002 California HealthCare Foundation; Contract No. 101053-0003 The Commonwealth Fund; Contract No. 101053-0012 East Bay Community Founda- tion; Contract No. 101053-0010 Health Resources and Services Administration; Contract No. 101053-0006 Jewish Healthcare Foundation; Contract No. 101053- 0001 Josiah Macy Jr. Foundation; Contract No. 101053-0007 Kaiser Permanente Institute for Health Policy; Contract No. 101053-0005 The Missouri Founda- tion for Health; Contract No. 101053-0004 Robert Wood Johnson Foundation; Contract No. 101053-0008 UnitedHealth Group Foundation; and Contract No. 101053-0011 U.S. Department of Veterans Affairs. Any opinions, findings, conclu- sions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that pro- vided support for the project. International Standard Book Number-13:  978-0-309-30355-2 International Standard Book Number-10:  0-309-30355-9 Library of Congress Control Number: 2014950457 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2014 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2014. Graduate medical education that meets the nation’s health needs. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Victor J. Dzau is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON THE GOVERNANCE AND FINANCING OF GRADUATE MEDICAL EDUCATION DONALD M. BERWICK (Co-chair), Former President and CEO, Institute for Healthcare Improvement GAIL R. WILENSKY (Co-chair), Senior Fellow, Project Hope BRIAN ALEXANDER, Director, Neuro-radiation Oncology, Dana-Farber/ Brigham and Women’s Cancer Center, Harvard Medical School DAVID A. ASCH, Executive Director, Penn Medicine Center for Health Care Innovation, University of Pennsylvania and Philadelphia VA Medical Center DAVID ASPREY, Professor and Chair, Department of Physician Assistant Studies; Assistant Dean, Office of Student Affairs and Curriculum, University of Iowa Carver College of Medicine ALFRED O. BERG, Professor, Department of Family Medicine, University of Washington School of Medicine PETER BUERHAUS, Valere Potter Distinguished Professor of Nursing and Director, Center for Interdisciplinary Health Workforce Studies, Institute for Medicine and Public Health, Vanderbilt University Medical Center AMITABH CHANDRA, Director of Health Policy Research, Kennedy School of Government, Harvard University DENICE CORA-BRAMBLE, Chief Medical Officer and Executive Vice President, Ambulatory and Community Health Services, Children’s National Health System MICHAEL J. DOWLING, President and CEO, North Shore–Long Island Jewish Health System KATHLEEN A. DRACUP, Dean Emeritus, University of California San Francisco School of Nursing ANTHONY E. KECK, Director, South Carolina Department of Health and Human Services OCTAVIO N. MARTINEZ, JR., Executive Director, Hogg Foundation for Mental Health FITZHUGH MULLAN, Murdock Head Professor of Medicine and Health Policy, Department of Health Policy, The George Washington University ROGER PLUMMER, Retired Telecommunications Industry Executive DEBORAH E. POWELL, Dean Emeritus and Professor of Laboratory Medicine and Pathology, University of Minnesota Medical School BARBARA ROSS-LEE, Vice President for Health Sciences and Medical Affairs, New York Institute of Technology GLENN D. STEELE, JR., President and CEO, Geisinger Health System v

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GAIL L. WARDEN, President Emeritus, Henry Ford Health System DEBRA WEINSTEIN, Vice President for GME, Partners Healthcare System BARBARA O. WYNN, Senior Policy Analyst, The RAND Corporation Study Staff JILL EDEN, Study Director CHERYL ULMER, Co-Study Director (through May 2013) STEPHANIE PINCUS, IOM Scholar-in-Residence CHELSEA FRAKES, Research Assistant (through April 2013) HANNAN BRAUN, Research Assistant (through June 2013) HANNAH DURING, Senior Program Assistant (starting June 2013) KAYLA WATKINS, Research Assistant (starting October 2013) SARA THARAKAN, Research Assistant (starting November 2013) ADAM SCHICKEDANZ, Chief Resident in Pediatrics, University of California San Francisco School of Medicine (July 2012) DOUG JACOBS, Medical Student, UCSF Pathways Explore Summer Fellow (2012) ROGER HERDMAN, Director, Board on Health Care Services (through June 2014) SHARYL NASS, Interim Director, Board on Health Care Services (starting June 2014) vi

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: TIMI AGAR BARWICK, Physician Assistant Education Association PAUL BATALDEN, Institute for Health Policy and Clinical Practice, Dartmouth College Geisel School of Medicine FLOYD E. BLOOM, Bloom Scientific Associates Inc. ELIZABETH BROWN, University of Pennsylvania Perelman School of Medicine DEBORAH WATKINS BRUNER, Nell Hodgson Woodruff School of Nursing and Winship Cancer Institute, Emory University BENJAMIN CHU, Kaiser Permanente Southern California and Hawaii Regions TIMOTHY C. FLYNN, University of Florida College of Medicine and UF Health Shands Hospital vii

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viii REVIEWERS DAVID GOODMAN, Center for Health Policy Research, Dartmouth Institute for Health Policy and Clinical Practice STUART GUTERMAN, The Commonwealth Fund RICHARD KNAPP, American Association of Medical Colleges (retired) RALPH MULLER, University of Pennsylvania Health System KAREN J. NICHOLS, Chicago College of Osteopathic Medicine, Midwestern University ROBERT L. PHILLIPS, American Board of Family Medicine THOMAS C. RICKETTS, University of North Carolina Gillings School of Global Public Health DAVID SKLAR, University of New Mexico KATE WALSH, Boston Medical Center Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Neal Vanselow, Chancellor-Emeritus, Tulane University Health Sciences Center, and Georges Benjamin, Executive Director, American Public Health Asso- ciation. Appointed by the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review com- ments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Foreword As the U.S. population ages and diversifies and the Affordable Care Act extends health coverage to more Americans than ever before, it has never been more critical for the nation’s graduate medical education (GME) sys- tem to produce a physician workforce that meets the evolving health needs of the population. For decades, Medicare has been the dominant funder of GME programs—contributing almost $10 billion in fiscal year 2012—and this funding, along with support from the Department of Veterans Affairs and the Health Resources and Services Administration, has been extremely valuable to the successful function of teaching hospitals across the country. However, many studies have shown that the current GME program does not produce adequate numbers of physicians prepared to work in needed specialties or geographic areas. Nor does it train physicians to practice in the community-based settings where most Americans seek care. Perhaps most critical, it lacks the oversight and infrastructure to track outcomes, reward performance, and respond nimbly to emerging challenges. In 2012, an Institute of Medicine (IOM) committee was formed—with the support of 12 private foundations and backing from 11 U.S. senators— to analyze the governance and financing of the GME system. The 21 members of the committee who authored this report brought a range of experience in GME and education for other health professions, academic health centers, clinical medicine, health care financing and administra- tion, and research, among others. I thank this eminent and diverse group of individuals for their contributions to this important task. In particular, on behalf of the IOM, I extend my gratitude to the committee co-chairs, ix

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x FOREWORD Donald Berwick and Gail Wilensky, and study director, Jill Eden, as well as her staff, for their leadership and dedication throughout the study process. The committee’s report, Graduate Medical Education That Meets the Nation’s Health Needs, proposes significant revisions to rectify current shortcomings and create a GME system with greater transparency, account- ability, strategic direction, and capacity to innovate. The report adds an important new dimension to the IOM’s previous calls to action to improve the health system—beginning with the publication of Crossing the Qual- ity Chasm in 2001. I hope it will provide useful and principled guidance for policy makers and program administrators alike as we work toward a GME system that better contributes to achieving the nation’s health goals. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine (July 2002-June 2014)

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Acknowledgments The committee and staff are indebted to a number of individuals and organizations for their contributions to this report. The following individu- als provided testimony to the committee: Jonathan Amiel, Assistant Dean for Curricular Affairs, Columbia University Co lege of Physicians & Surgeons; Attending l Psychiatrist, New York State Psychiatric Institute’s Washington Heights Community Service Karl Auerbach, President, American College of Occupational and Environmental Medicine Paul Batalden, Professor Emeritus of Pediatrics and Community and Family Medicine, Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College Geisel School of Medicine Nick Bath, Senior Policy Advisor for Health, Senate Health, Education, Labor, and Pensions Committee Lisa Bellini, Vice Chair for Education, Department of Medicine, Perelman School of Medicine, University of Pennsylvania; Chair of the Board, Alliance for Academic Internal Medicine Cybele Bjorklund, Minority Staff Director, House Ways and Means Subcommittee on Health Mark Boom, President and CEO of The Methodist Hospital System Boyd Buser, Vice President for Health Affairs and Dean, University of Pikeville–Kentucky College of Osteopathic Medicine Nick Busing, President and CEO, Association of Faculties of Medicine of Canada xi

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xii ACKNOWLEDGMENTS Benjamin K. Chu, Group President, Kaiser Permanente Southern California and Hawaii Malcolm Cox, Former Chief Academic Affiliations Officer, Veterans Health Administration Charles Cutler, Chair-Elect, Board of Regents, American College of Physicians Ralph G. Dacey, Jr., President, Society of Neurological Surgeons Arnold R. Eiser, Vice President, Medical Education, Mercy Health System SEPA; Professor of Medicine and Associate Dean, Drexel University College of Medicine Dan Elling, Majority Staff Director, House Ways and Means Subcommittee on Health Karen Fisher, Professional Staff, Senate Finance Committee Tim Garson, Jr., Director, Institute for Health Policy, University Professor and Professor of Public Health Sciences, University of Virginia Roland Goertz, CEO, Heart of Texas Community Health Center, Inc.; Vice Chair, Educational Health Center Task Force, National Association of Community Health Centers Christopher Gonzalez, Vice Chair of Health Policy, American Urological Association Fern Goodhart, Health/Education Legislative Assistant, Senator Tom Udall David Goodman, Director, Center for Health Policy Research, Dartmouth Institute for Health Policy and Clinical Practice Tiffany Groover, National Health Service Corps Scholar, PGY-3, Internal Medicine, Boston Medical Center Atul Grover, Chief Public Policy Officer, Association of American Medical Colleges Kristi Guillory, Senior Policy Analyst, American Cancer Society Action Network Marc Hartstein, Director, Hospital and Ambulatory Policy Group, Center for Medicare, Centers for Medicare & Medicaid Services Dianne Heffron, Director, Financial Management Group, Center for Medicaid and CHIP Services, Centers for Medicare & Medicaid Services David Hoyt, Executive Director, American College of Surgeons John Ingle, Fellow, Department of Otolaryngology, University of Pittsburgh Medical Center; President, Committee of Interns and Residents Tim Johnson, Senior Vice President and Executive Director of Finance and Graduate Medical Education, Greater New York Hospital Association

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ACKNOWLEDGMENTS xiii Jim Kaufman, Vice President of Public Policy, Children’s Hospital Association Frank R. Lewis, Executive Director, American Board of Surgery Raul Mirza, PGY-4, Walter Reed Army Institute of Research, Sequential Preventative Medicine and Occupational & Environmental Medicine Residency Tom Nasca, Executive Director and CEO, Accreditation Council for Graduate Medical Education James Pacala, President, American Geriatrics Society Richard Pan, California Assembly member speaking on behalf of the American Academy of Pediatrics Judy Pauwels, Associate Professor, University of Washington Department of Family Medicine Robert Petzel, Under Secretary for Health, U.S. Department of Veterans Affairs Anne Morris Reid, Senior Professional Staff Member, House Energy and Commerce Subcommittee on Health David Reines, Vice Chair, COGME; Clerkship Director of Surgery, VCU School of Medicine Inova Campus Tom Ricketts, Deputy Director, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill Steven M. Safyer, President and CEO of Montefiore Lewis Sandy, Senior Vice President for Clinical Advancement, UnitedHealth Group Eric Schoomaker, GEN (Ret.), Former Army Surgeon General, Scholar in Residence, Uniformed Services University of the Health Sciences Heidi Schumacher, PGY-3, Pediatrics, Children’s National Medical Center Manisha Sharma, PGY-3, Family Medicine, Montefiore Medical Center Susan E. Skochelak, Vice President, Medical Education, American Medical Association David Squire, Former Executive Director, Utah Medical Education Council Megan Taira, Legislative Assistant, Senator Charles Schumer George Thibault, President, Josiah Macy Jr. Foundation Linda Thomas-Hemak, President and CEO, Wright Center for Graduate Medical Education Mary Wakefield, Administrator, Health Resources and Services Administration Steven A. Wartman, President and CEO, Association of Academic Health Centers

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xiv ACKNOWLEDGMENTS Sandra Wilkniss, Senior Legislative Counsel for Health Care, Senator Bingaman We also extend special thanks to the following individuals who were essential sources of information, generously giving their time and knowl- edge to further the committee’s efforts: Robert Baron, Professor of Medicine, Associate Dean for Graduate and Continuing Education, University of California, San Francisco David Battinelli, Senior Vice President for Academic Affairs, North Shore–Long Island Jewish Health System and Dean for Medical Education, Betsy Cushing Whitney Professor of Medicine, Hofstra North Shore–Long Island Jewish School of Medicine Andrew Bindman, Senior Advisor and Assistant Secretary for Planning and Evaluation, Office of Health Policy, U.S. Department of Health and Human Services Christine K. Cassel, President and CEO, National Quality Forum Barbara Chang, Director, Medical & Dental Education, Office of Academic Affiliations, Veterans Health Administration Renate Dombrowski, Health Insurance Specialist, Division of Acute Care, Centers for Medicare & Medicaid Services Linda Famiglio, Chief Academic Officer, Geisinger Health System Erin Fraher, Director, North Carolina Health Professions Data System, Cecil G. Sheps Center for Health Services Research Victor Fuchs, Henry J. Kaiser, Jr., Professor of Economics and of Health Research and Policy, Emeritus; FSI Senior Fellow and CHP/PCOR Core Faculty Member, Stanford University David Godfrey, State Medicaid Director, Minnesota Department of Human Services Marc Hahn, President and CEO, Kansas City University of Medicine and Biosciences Tim Henderson, Health Workforce Consultant Michael Johns, Professor of Medicine and Public Health, Emory University T. Michael Kashner, Research Professor of Medicine and Associate Vice Chair for Education Research, Department of Medicine, Loma Linda University School of Medicine, VA Healthcare System Mary Kauper, System Administrative Director of Medical Education, Henry Ford Health System Kathleen Klink, Former Director, Division of Medicine and Dentistry, Bureau of Health Professions, Health Resources and Services Administration

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ACKNOWLEDGMENTS xv Richard Kronick, Director, Agency for Healthcare Research and Quality Mark E. Miller, Executive Director, Medicare Payment Advisory Commission Cathryn Nation, Associate Vice President, Health Sciences University of California, Office of the President Robert Phillips, Vice President for Research and Policy, American Board of Family Medicine Marla Salmon, IOM Nurse Scholar-in-Residence Edward Salsberg, Former Director, National Center for Health Workforce Analysis, Health Resources and Services Administration Kenneth Shine, Former Executive Vice Chancellor for Health Affairs, University of Texas System Robert Young, Henry Ford Health System Funding for this study was provided by ABIM Foundation, Aetna Foundation, The California Endowment, California HealthCare Founda- tion, The Commonwealth Fund, East Bay Community Foundation, Health Resources and Services Administration, Jewish Healthcare Foundation, Josiah Macy Jr. Foundation, Kaiser Permanente Institute for Health Policy, The Missouri Foundation for Health, Robert Wood Johnson Foundation, UnitedHealth Group Foundation, and U.S. Department of Veterans Affairs. The committee appreciates the opportunity and support extended by the sponsors for the development of this report. Finally, many within the Institute of Medicine were helpful to the study staff. We would like to thank Clyde Behney, Laura DeStefano, Chelsea Aston Frakes, Molly Galvin, Greta Gorman, and Abbey Meltzer.

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Contents Summary 1 Approach to the Study, 3 The Outcomes of Current GME Governance and Financing, 7 Recommendations, 10 1 Introduction 17 Scope of the Study, 19 Background, 20 Context for This Report, 25 Conceptual Approach to the Study, 26 Goals of the Committee, 27 Methods of the Study, 28 Orientation to the Organization of This Report, 29 References, 30 2 Background on the Pipeline to the Physician Workforce 35 Physician Supply, 36 The GME Pipeline—Medical School Enrollment, 39 GME Training Capacity, 41 Conclusions, 51 References, 52 3 GME Financing 61 Overview of GME Funding, 62 Medicare, 65 xvii

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xviii CONTENTS Medicaid, 78 Health Resources and Services Administration, 80 Veterans Health Administration, 85 Department of Defense, 87 The Black Box of GME Costs and Benefits, 87 Consequences and Conclusions, 98 References, 102 4 Governance 107 What Is Accountability?, 108 GME Accreditation and Certification, 116 Conclusion, 123 References, 125 5 Recommendations for the Reform of GME Financing and Governance 131 Overview, 132  Recommendations for Reforming GME Governance and Financing, 146 Summary, 164 References, 164 Appendixes A Abbreviations and Acronyms 169 B U.S. Senate Letters 173 C Public Workshop Agendas 179 D Committee Member Biographies 185 E Data and Methods to Analyze Medicare GME Payments 197 F Illustrations of the Phase-In of the Committee’s Recommendations 203

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Boxes, Figures, and Tables BOXES S-1 Charge to the IOM Committee on the Governance and Financing of Graduate Medical Education, 2 S-2 IOM Committee’s Goals for Developing Graduate Medical Education (GME) Policy Recommendations, 6 S-3 Catalyzing Innovation in GME: Parameters for the Institute of Medicine (IOM) Committee’s Proposed Transformation Fund, 14 1-1 Study Sponsors, 19 1-2 Charge to the IOM Committee on the Governance and Financing of Graduate Medical Education, 20 1-3 Pipeline Specialties, 23 1-4 Primary Care Specialties, 24 3-1 Legislative Milestones in Medicare Financing of Graduate Medical Education (GME), 66 3-2 Insights from the Institute of Medicine (IOM) Case Studies, 88 3-3 Usual Components of the Direct Costs of Sponsoring GME Programs, 90 5-1 Recommendations, 133 5-2 IOM Committee’s Goals for Developing Graduate Medical Education (GME) Policy Recommendations, 136 xix

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xx BOXES, FIGURES, AND TABLES 5-3 Catalyzing Innovation in GME: Parameters for the Institute of Medicine (IOM) Committee’s Proposed Transformation Fund, 156 FIGURES S-1 Current flow of GME funds, 4 S-2 Program accreditation and physician certification and licensure, 5 1-1 Continuum of physician education from undergraduate medical education to clinical practice, 22 2-1 Physician supply: The complex reality, 37 2-2 Trends in the proportion of underrepresented racial minorities (URMs) among medical school graduates and the U.S. general population, 49 3-1 Current flow of GME funds, 63 3-2 Number of Medicare-funded training positions per 100,000 population, 2010, 73 4-1 Program accreditation and physician certification and licensure, 117 5-1 Proposed Medicare graduate medical education funding flow, 155 5-2 Allocation of Medicare graduate medical education funds to the Operational and Transformation Funds over time (by percentage), 157 TABLES 1-1 Selected GME Statistics, 21 2-1 Change in the Number of Medical Schools, Medical School Enrollment, and Applicants to GME Programs, 2002 to 2012, 40 2-2 Growth in ACGME-Accredited Programs and Residents, Academic Years 2003-2004 to 2012-2013, 42 2-3 Initial Residency Period and Subspecialty Certificates Issued by the American Board of Medical Specialties, Selected Years, 43 2-4 Selected Pipeline Specialties (Initial Residency Period) with Five or More Subspecialties, 44 3-1 Source and Estimated Amount of GME Funding, Selected Years, 64 3-2 Per-Resident Amounts and Medicare Share by Hospital Characteristic, 2008, 71

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BOXES, FIGURES, AND TABLES xxi 3-3 Number and Percentage of GME Sponsoring Institutions, by Institution Type, Multi-Program and Single-Program Sponsors, Academic Year 2012-2013, 76 3-4 CHGME Appropriations, 2000-2013, 82 3-5 Selected Data on Teaching Health Center (THC) Funding, Academic Years 2011-2013, 84 3-6 Residency Review Committee Faculty Staffing Requirements for Selected Specialties, 91 3-7 Mean Resident/Fellow Stipends by Region, Academic Year 2012-2013, 93 3-8 Direct GME Costs by Hospital Characteristics, 2008, 94 3-9 Relative Financial Impacts of Program Characteristics of Training Programs in Internal Medicine, Cardiology, Family Medicine, Dermatology, General Surgery, Urology, and Radiation Oncology, 99 3-10  nintended Consequences of Current Medicare GME Payment U Methods, 100 4-1 The Use of Accountability Mechanisms in Federal Graduate Medical Education (GME) Programs, 109 4-2 Current Federal Reporting Requirements for GME Programs, 115 4-3 Private Organizations That Have a Governance Role in GME, 118 4-4 GME Governance: Standard Setting, Accreditation, Certification, and Licensing Organizations, 120 5-1 Goals and Recommended Next Steps for Reforming Medicare Graduate Medical Education (GME) Governance and Financing, 144 5-2 Pros and Cons of Selected Organizational Options for Strengthening the Governance of Medicare Graduate Medical Education (GME) Funding, 150 5-3 Key Features, Advantages, and Impacts of the Proposed Graduate Medical Education (GME) Payment Methodology, 159 E-1  Number of Hospitals and Total Direct Graduate Medical Education (DGME) Unweighted Resident Count by Type of Hospital, 198 F-1 Example of Phased-In Allocation of GME Funding to Operational and Transformation Funds in Transition Years 1-5 ($ in Billions), 204 F-2 Illustration of Combined PRA Calculation, Before Inflation Adjustment, 206 F-3 Illustration of Impacts of Changing to Combined PRA, 208

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