as being unique social benefits. Continuing federal support of some kind is generally seen as an indispensable factor in maintaining both of these benefits. Many groups expressed a wide variety of concerns including the inflexibility of the current funding system, but stressed that a payment system needs to be continued in a way that gives stability to the education industry, but that also lends flexibility to the industry to meet the changing requirements of the health care market.

CURRENT ISSUES OF GME

It is generally accepted that there is, or soon will be, a surplus of physicians in the United States. How much of a surplus there will be, in what regions or specialties, and what the role of the government should be in correcting this problem is a source of continuing debate. Many organizations voiced support for the Council on Graduate Medical Education (COGME) approach of limiting the number of Medicare-funded first-year resident slots to 110% of the size of the graduating class of U.S. medical schools and moving toward 50% of those slots devoted to primary care residencies (COGME, 1992, 1994). Some opposition was expressed to this policy, however, including questions regarding the rationale and support for using exactly 110%. Others claimed that there would be difficulty in implementing such a policy without controlling the denominator—medical school graduates.

Many of the organizations expressed concerns about currently proposed strategies that they feel may harm patients' access to their particular profession's services, in an attempt to correct work force problems that exist wholly in allopathic medicine. For example, representatives from both dental and podiatry programs submitted statistics and research that indicated that there is an undersupply of positions for their current graduates. In addition, podiatrists and nephrologists, as well as a few others, claim to serve the Medicare population more exclusively than other specialists; they believe that, at the very least, they should not be adversely affected by Medicare GME policy or prevented from responding to the growing need for their services, particularly among Medicare beneficiaries.

The inflexibility of the current GME funding structures in responding to changing market needs and direction was noted as a major concern. These needs included the desire for physicians with more ambulatory training, and for a different work force makeup, including more non-physician professionals like advanced practice nurses, physician assistants, and graduate level psychologists, to better serve all patients in a team-approach integrated environment, particularly in rural and large urban areas. Despite the need for flexibility in the funding system and the desire for change, almost all of the responders commented on the need for a system that offered stability for programs so that they could continue to train individuals in a high-quality environment throughout the term of their training.



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