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Gr raduate Meedical Educa ation That Meets s the Na t ation’s Hea Ne s alth eeds Com mmittee on the Govern nance and Financing of Gradua Medica Educatio g ate al on Board on He ealth Care Services Jill Eden, Don Berwi and Ga Wilensk Editors nald ick, ail ky, s PREPUBLICATION CO OPY: UNCOR RRECTED PR ROOFS

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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 Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate 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 Eastbay Community Foundation; 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; Contract No. 101053-0005 The Missouri Foundation for Health; Contract No. 101053-0004 Robert Wood Johnson Foundation; Contract No. 101053-0008 UnitedHealth Group; and Contract No. 101053-0011 U.S. Department of Veterans Affairs. Any opinions, findings, conclusions, 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 provided support for the project. Library of Congress Cataloging-in-Publication Data 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. PREPUBLICATION COPY: UNCORRECTED PROOFS

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PREPUBLICATION COPY: UNCOR RECTED PROOFS O R R

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The Nation Academy of Sciences is a private, nonpr nal o rofit, self-perpet tuating society of distinguished scholars enga d aged in scientific an engineering research, dedica nd ated to the furthherance of scien and technology and to the use for the g nce eir general welfare. Up the authority of the charter granted to it by the Congress in 1863, the Acad pon y g n demy has a man ndate that requir it to res advise the federal governme on scientific and technical matters. Dr. Ralp J. Cicerone is president of the National Acad f ent m ph s e demy of Sciences. The Nation Academy of Engineering was established in 1964, under t charter of th National Acad nal f w i the he demy of Science as a es, parallel orga anization of outs standing enginee It is autonom ers. mous in its admi inistration and in the selection o its members, s n of sharing with the National Academ of Sciences the responsibilit for advising the federal gov my t ty vernment. The National Acade emy of Engineering also sponsors engineering programs aimed at meeting natio g a onal needs, enc courages educat tion and researc and ch, recognizes the superior achi t ievements of eng gineers. Dr. C. D. Mote, Jr., is pr D resident of the N National Academ of Engineerin my ng. The Institu of Medicine was established in 1970 by th National Aca ute e he ademy of Scien nces to secure th services of e he eminent members of appropriate pro f ofessions in the examination of policy matters p e p pertaining to the health of the pu ublic. The Institu acts ute under the re esponsibility giv to the Nation Academy of Sciences by its congressional charter to be an adviser to the federal ven nal f s n government and, upon its own initiative, to identify issu of medical c t ues care, research, and education. Dr. Victor J. D Dzau is president of the Institute of Medicine. f The National Research Co ouncil was organ nized by the Nattional Academy of Sciences in 1 1916 to associate the broad com e mmunity of science and technology with the Aca y ademy’s purpose of furthering knowledge an advising the federal gover es g nd e rnment. Functioning in accordance with general po g olicies determine by the Acade ed emy, the Counc has become t principal op cil the perating agency of both the Nation Academy of Sciences and the National Ac b nal f cademy of Eng gineering in pro oviding services to the government the public, and the scientific and engineering communities. T Council is ad t, d a The dministered join by both Aca ntly ademies and the Institute of Medicin Dr. Ralph J. Cicerone and Dr C. D. Mote, Jr. are chair and v chair, respectively, of the N ne. C r. ., vice National Research Co ouncil. www.natio onal-academie es.org PREPUBLICATION CO OPY: UNCOR RRECTED PR ROOFS

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COMMITTEE ON THE GOVERNANCE AND FINANCING OF GRADUATE MEDICAL EDUCATION DONALD BERWICK (Cochair), Former President and CEO, Institute for Healthcare Improvement GAIL R. WILENSKY (Cochair), Senior Fellow, Project Hope BRIAN ALEXANDER, Director, Neuro-radiation Oncology, Brigham and Women’s Hospital and Dana- Farber Cancer Center 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 GAIL L. WARDEN, President Emeritus, Henry Ford Health System DEBRA WEINSTEIN, Vice President for GME, Partners Health 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) PREPUBLICATION COPY: UNCORRECTED PROOFS v

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ROGER HERDMAN, Director, Board on Health Care Services (until June 2014) SHARYL NASS, Interim Director, Board on Health Care Services (from June 2014) PREPUBLICATION COPY: UNCORRECTED PROOFS 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, Executive Director, Physician Assistant Education Association PAUL BATALDEN, Professor of Pediatrics and Community and Family Medicine, Dartmouth Institute for Health Policy and Clinical Practice, Founding Director, Dartmouth-Hitchcock Leadership Preventive Medicine Residency Program, Dartmouth Medical School ELIZABETH BROWN, Robert Wood Johnson Clinical Scholar, The University of Pennsylvania Perelman School of Medicine DEBORAH WATKINS BRUNER, Robert W. Woodruff Professor of Nursing, Nell Hodgson Woodruff School of Nursing , Professor of Radiation Oncology, Associate Director for Outcomes Research, Winship Cancer Institute, Emory University BENJAMIN CHU, Group President, Kaiser Permanente Southern California and Hawaii, President, Kaiser Permanente Southern California Region TIMOTHY C. FLYNN, Senior Associate Dean for Clinical Affairs, University of Florida College of Medicine; Chief Medical Officer, UF Health Shands Hospital DAVID GOODMAN, Professor of Pediatrics, of Community and Family Medicine, and of the Dartmouth Institute, Co-Principal Investigator, Dartmouth Atlas of Health Care, The Dartmouth Institute for Health Policy and Clinical Practice Geisel Medical School at Dartmouth STUART GUTERMAN, Vice President, Medicare and Cost Control, The Commonwealth Fund RICHARD KNAPP, Retired Executive Vice President, American Association of Medical Colleges RALPH MULLER, Chief Executive Officer, University of Pennsylvania Health System KAREN J. NICHOLS, Professor of Internal Medicine, Dean, Chicago College of Osteopathic Medicine, Midwestern University ROBERT L. PHILLIPS, Vice President for Research and Policy, American Board of Family Medicine THOMAS C. RICKETTS, Professor of Health Policy and Administration and Social Medicine, Deputy Director, Cecil G. Sheps Center for Health Research, University of North Carolina Gillings School of Global Public Health DAVID SKLAR, Associate Dean of Graduate Medical Education, Professor of Emergency Medicine, University of New Mexico KATE WALSH, President and Chief Executive Officer, Boston Medical Center Although the reviewers listed above have provided many constructive 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 Association. 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 comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. PREPUBLICATION COPY: UNCORRECTED PROOFS vii

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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) system 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 critically, 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 graduate medical and other health professions education, academic health centers, clinical medicine, health care financing and administration, 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, Don 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, accountability, 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 Quality 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) PREPUBLICATION COPY: UNCORRECTED PROOFS ix

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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 individuals provided testimony to the committee: Jonathan Amiel, Assistant Dean for Curricular Affairs, Columbia University College of Physicians & Surgeons, Attending 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, The Dartmouth Institute, Geisel School of Medicine at Dartmouth 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 at the 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 of the Association of Faculties of Medicine of Canada Benjamin K. Chu, President, Kaiser Permanente Southern California Region 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 at the 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, The University of Pittsburgh Medical Center and 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 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 xi PREPUBLICATION COPY: UNCORRECTED PROOFS

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xii ACKNOWLEDGMENTS 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, The Josiah Macy Jr. Foundation Linda Thomas-Hemak, President and CEO, The 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 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 knowledge 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 PREPUBLICATION COPY: UNCORRECTED PROOFS

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ACKNOWLEDGMENTS xiii T. Michael Kashner, Research Professor of Medicine, 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 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 Stephanie Pincus, IOM Scholar-in-Residence 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 the ABIM Foundation, Aetna Foundation, California Endowment, California HealthCare Foundation, Commonwealth Fund, East Bay Community Fund, Health Resources and Services Administration, Jewish Healthcare Foundation, Josiah Macy Jr. Foundation, Kaiser Permanente Institute for Health Policy, 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. PREPUBLICATION COPY: UNCORRECTED PROOFS

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Contents Summary S-1 Approach to the Study, S-2 The Outcomes of Current GME Governance and Financing, S-4 Recommendations, S-8 1 Introduction 1-1 Scope of the Study, 1-3 Background, 1-4 Context for This Report, 1-9 Conceptual Approach to the Study, 1-10 Methods of the Study, 1-11 Orientation to the Organization of This Report, 1-12 References, 1-12 2 Background on the Pipeline to the Physician Workforce 2-1 Physician Supply, 2-2 The GME Pipeline – Medical School Enrollment, 2-4 GME Training Capacity, 2-6 Conclusions, 2-14 References, 2-15 3 GME Financing 3-1 Overview of GME Funding, 3-2 Medicare, 3-4 Medicaid, 3-15 Health Resources and Services Administration, 3-17 Veterans Administration, 3-21 Department of Defense, 3-23 The Black Box of GME Costs and Benefits, 3-23 Consequences and Conclusions, 3-33 References, 3-36 4 Governance 4-1 What Is Accountability?, 4-2 GME Accreditation and Certification, 4-9 Conclusion, 4-15 xv PREPUBLICATION COPY: UNCORRECTED PROOFS

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xvi CONTENTS References, 4-17 5 Recommendations for the Reform of GME Financing and Governance 5-1 Overview, 5-3 Recommendations for Reforming GME Governance and Financing, 5-12 Summary, 5-28 References, 5-28 Appendixes A Abbreviations and Acronyms, A-1 B U.S. Senate Letters, B-1 C Public Workshops Agendas, C-1 D GME Committee Member Biographies, D-1 E Data and Methods to Analyze Medicare GME Payments, E-1 F Illustrations of the Phase-in of the Committee’s Recommendations, F-1 PREPUBLICATION COPY: UNCORRECTED PROOFS

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BOXES, FIGURES, AND TABLES Summary Boxes S-1 Charge to the IOM Committee on the Governance and Financing of Graduate Medical Education, S-2 S-2 IOM Committee’s Goals for Developing Graduate Medical Education (GME) Policy Recommendations, S-3 S-3 Catalyzing Innovation in GME: Parameters for the Institute of Medicine (IOM) Committee’s Proposed Transformation Fund, S-12 Figures S-1 Current flow of GME funds, S-6 S-2 Program accreditation and physician certification and licensure, S-7 Chapter 1 Boxes 1-1 Study Sponsors, 1-2 1-2 Charge to the Committee on Governance and Financing of Graduate Medical Education, 1-3 1-3 Pipeline Specialties, 1-7 1-4 Primary Care Specialties, 1-8 Figure 1-1 Continuum of physician education from undergraduate medical education to clinical practice, 1-6 Table 1-1 Selected GME Statistics, 1-5 Chapter 2 Figures 2-1 Physician supply: The complex reality, 2-4 2-2 Trends in the proportion of underrepresented racial minorities (URMs) among medical school graduates and the U.S. general population, 2-13 Tables xvii PREPUBLICATION COPY: UNCORRECTED PROOFS

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xviii BOXES, FIGURES, AND TABLES 2-1 Change in the Number of Medical Schools, Medical School Enrollment, and Applicants to GME Programs, 2002 to 2012, 2-5 2-2 Growth in ACGME-Accredited Programs and Residents, Academic Years 2003-2004 to 2012-2013, 2-7 2-3 Initial Residency Period and Subspecialty Certificates Issued by the American Board of Medical Specialties, Selected Years, 2-8 2-4 Selected Pipeline Specialties (Initial Residency Period) with Five or More Subspecialties, 2-10 Chapter 3 Boxes 3-1 Legislative Milestones in Medicare Financing of Graduate Medical Education (GME), 3- 6 3-2 Insights from the Institute of Medicine (IOM) Case Studies, 3-24 3-3 Usual Components of the Direct Costs of Sponsoring GME Programs, 3-26 Figures 3-1 Current flow of GME funds, 3-3 3-2 Number of Medicare-funded training positions per 100,000 population, 2010, 3-13 Tables 3-1 Source and Estimated Amount of GME Funding, Selected Years, 3-4 3-2 Per-Resident Amounts and Medicare Share by Hospital Characteristic, 2008, 3-10 3-3 Number and Percent of GME Sponsoring Institutions, by Institution Type, Multi-Program and Single Program Sponsors, Academic Year 2012-2013, 3-14 3-4 CHGME Appropriations, 2000-2013, 3-19 3-5 Selected Data on Teaching Health Center (THC) Funding, Academic Years 2011-2013, 3-21 3-6 Residency Review Committee Faculty Staffing Requirements for Selected Specialties, 3- 27 3-7 Mean Resident/Fellow Stipends by Region, Academic Year 2012-2013, 3-28 3-8 Direct GME Costs by Hospital Characteristics, 2008, 3-29 3-9 Relative Financial Impacts of Program Characteristics of Training Programs in Internal Medicine, Cardiology, Family Medicine, Dermatology, General Surgery, Urology, and Radiation Oncology, 3-33 3-10 Unintended Consequences of Current Medicare GME Payment Methods, 3-35 PREPUBLICATION COPY: UNCORRECTED PROOFS

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BOXES, FIGURES, AND TABLES xix Chapter 4 Figure 4-1 Program Accreditation and Physicians Certification and Licensure, 4-10 Tables 4-1 The Use of Accountability Mechanisms in Federal Graduate Medical Education (GME) Programs, 4-3 4-2 Current Federal Reporting Requirements for GME Programs, 4-8 4-3 Private Organizations That Have a Governance Role in GME, 4-12 4-4 GME Governance: Standard Setting, Accreditation, Certification, and Licensing Organizations, 4-15 Chapter 5 Boxes 5-1 Recommendations, 5-2 5-2 IOM Committee’s Goals for Developing Graduate Medical Education (GME) Policy Recommendations, 5-5 5-3 Catalyzing Innovation in GME: Parameters for the Institute of Medicine (IOM) Committee’s Proposed Transformation Fund, 5-20 Figures 5-1 Proposed Medicare GME funding flow, 5-21 5-2 Allocation of Medicare graduate medical education funds to the operational and transformation funds over time (by percentage), 5-22 Tables 5-1 Goals and Recommended Next Steps for Reforming Medicare Graduate Medical Education (GME) Governance and Financing, 5-11 5-2 Pros and Cons of Selected Organizational Options for Strengthening the Governance of Medicare Graduate Medical Education (GME) Funding, 5-15 5-3 Key Features, Advantages, and Impacts of the Proposed Graduate Medical Education (GME) Payment Methodology, 5-24 Appendix E Table E-1 Number of Hospitals and Total Direct Graduate Medical Education (DGME) Unweighted Resident Count by Type of Hospital, E-1 PREPUBLICATION COPY: UNCORRECTED PROOFS

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xx BOXES, FIGURES, AND TABLES Appendix F Tables F-1 Example of Phased-In Allocation of GME Funding to Operational and Transformation Funds in Transition Years 1-5 ($ in Billions), F-2 F-2 Illustration of Combined PRA Calculation, Before Inflation Adjustment, F-3 F-3 Illustration of Impact Changing to Combined PRA, F-5 PREPUBLICATION COPY: UNCORRECTED PROOFS