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4 The Role of Graduate Medical Education Consortia in the Postregulatory Era in New York State Benjamin K. Chu The year 1994 saw the confluence of a multiplicity of national and regional forces in New York State which created an atmosphere that held promise for radically changing the regulatory environment in the state. Those that had long advocated for the restructuring of graduate medical education in a state where training graduate medical residents was a highly subsidized activity saw a unique opportunity for reform. It was an opportunity brought about by the legislative expiration of the state regulatory authority, the increasing penetration of managed care, and the election of a Republican governor with a decidedly market-oriented bent. Many in New York had supported the concept of graduate medical education (GME) consortia as a better vehicle to meet overall state and regional workforce needs than relying on individual hospitals to reform the training of new physicians. As defined by the New York State Council on Graduate Medical Education (NYSCOGME), GME consortia are organizations convened around a medical school and embracing both hospital and nonhospital institutions engaged in training (New York State Council on Graduate Medical Education, 1988). The state's hospitals have opposed these changes in the past.
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This paper examines the year-long process of policy debate and formulation centered around establishing GME consortia as a centerpiece for workforce planning and funding in the postregulatory era in New York State and the role of information in this reform process. In the end, information played a necessary role in framing and focusing the debate, but it was more a combination of political and financial realities that proved to be the sufficient forces to move all sides to a brave new world for health care policy in New York. BACKGROUND Graduate medical education has always been an essential core component of the mission of New York's academic teaching hospitals. Over the course of the past two decades, the training of resident physicians also became a staple for service delivery for virtually all institutions serving inner-city poor populations in the state. Of 230 licensed acute care hospitals in New York State, 103 participate in teaching programs. Powerful financial incentives built into the Medicare hospital payment system combined with equally powerful incentives provided by five iterations of New York State's regulated all-payer hospital reimbursement system (New York Prospective Hospital Reimbursement Methodology [NYPHRM I to V]) create compelling fiscal pressures to train as many residents as possible to maximize reimbursement and service delivery capacity, regardless of workforce policy needs. It has been estimated that Medicare provides an average of $70,000 per year per resident nationwide (Mullan et al., 1993). In New York State, GME payments from all carriers total approximately $190,000 per resident per year, with reimbursement from Medicare exceeding an average of $80,000 per resident (New York State Department of Health, 1995). It was partially this big business aspect of GME that spurred New York State teaching hospitals' opposition to proposed workforce changes under the Clinton Health Care Reform Plan. It was also one of the reasons that the senior senator from the state, Senator Daniel Patrick Moynihan, painted these proposals to change funding to academic institutions as ''sins against the Holy Ghost" (U.S. Congress, 1994).
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Although New York hospitals certainly have perennially played a role in derailing national workforce reform proposals, considerable concern has been building within the state over the shortsighted hospital-oriented goal of holding onto the status quo. Reform was first proposed by a statewide commission in 1986 and was later adopted by the NYSCOGME, a statewide independent body created by the legislature to advise on matters concerning resident education in the state. The state commission and the council called for the tighter linkage between educational goals and statewide workforce policy goals for residency programs through the development of GME consortia. The council defines a GME consortium as "an organization of institutions, both teaching hospital and non-hospital sites, convened around a medical school, empowered to ensure the educational integrity of training programs and to serve as a vehicle to achieve policy goals and objectives with regard to workforce reform" (New York State Commission on Graduate Medical Education, 1986; New York State Council on Graduate Medical Education, 1988). The old system of GME reimbursement to the hospitals created a near entitlement to funding that encouraged the training of too many physicians in hospital-based specialties and in hospital settings without full regard to educational content, work-force needs, and societal goals. More balanced GME consortia, it was argued, could allow local interests and constituents to shape and modify GME programs on the basis of local and regional workforce needs. Consortia could be effective in creating a better balance between primary care and specialty programs, encouraging greater training in non-hospital ambulatory sites, fostering the training of underrepresented minorities, and stimulating rational consolidation and downsizing of program numbers and size to better reflect community needs. Before the debate described here, the success of calls for reform over the previous decade largely centered around marginal programs to boost indirect medical education funding for primary care residency programs, a loan repayment program to provide incentives for physicians to train and remain in underserved communities, and a series of state and legislative actions that provided the stimulus for the creation of six GME consortia around the state
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through a variety of pilot and grant programs (New York State Council on Graduate Medical Education, 1994). The most successful GME consortium in New York has been the Graduate Medical and Dental Education Consortium of Buffalo formed in 1983. In the years since its formation, it has successfully acted as the institution of record for all graduate medical programs sponsored by the nine affiliated teaching institutions of the State University of New York at Buffalo. Under an agreement with the state, the consortium's institutions have pooled GME funds to help centrally administer all residency programs and to develop programs to meet state training goals, particularly in primary care (New York State Council on Graduate Medical Education, 1991). The creation of a similar organization has been reported at the Medical College of Wisconsin (Kochar, 1996). Despite these examples and others identified in a Maine Medical Center/Association of Academic Medical Center survey in 1993 (Kelly et al., 1994), no GME consortia to date have served the wide-ranging role envisioned by NYSCOGME for rational planning and resource allocation on behalf of a range of programs sponsored by medical schools. Even without clear-cut successful models of GME consortia undertaking these expansive sets of responsibilities, the deans of the New York State medical schools had consistently endorsed the creation of consortia through its Graduate Medical Education Committee of the Associated Medical Schools of New York (Pardes, 1995, 1996). Soon after the demise of national health reform, a series of forces began to coalesce in New York State. These forces opened the door to major reform, even in the graduate medical education arena. The election of an upstate Republican governor with firm beliefs in market principles and a decreased role of government liquefied some of the bedrock foundation for the regulatory system in New York. The governor's spending cut and tax cut agenda required significant savings from the $23 billion a year Medicaid spending bill. Significant savings were sought through an accelerated push toward Medicaid managed care. With statewide managed care penetration approaching 25 percent (Greater New York Hospital Association Subsidiaries and Affiliates, 1995) and the rush to full enrollment in Medicaid managed care, hospitals faced the loss
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of GME funding. Funds paid to managed care organizations in the premiums for GME are often not reflected in the negotiated per diem rates; in addition, markedly decreased in-patient days decrease the funds paid via a per diem payment system. In this environment, hospitals sought a means to preserve nearly $3 billion in federal and state GME funds by pushing for federal and state carve-out pools devoted to GME and with monies largely passed on to hospitals in proportions roughly equal to the status quo (Greater New York Hospital Association, 1996a). However, with multiple high-profile groups including the national Council on Graduate Medical Education (1994), the Physician Payment Review Commission (1993), the Institute of Medicine (1996) and the Pew Health Professions Commission (1995), calling for fundamental restructuring of the training of the physician workforce to better reflect regional and national needs, New York hospitals faced an uphill battle in arguing to preserve the funding to train about 15,000 residents and fellows each year, many in specialties thought to be oversupplied both nationally and in the state. NYSCOGME and the state Department of Health renewed calls for reducing the number of residents trained and reallocating slots to better reflect the statewide need to increase the number of physicians with primary care training. These policy positions were supported with data compiled by the state Department of Health by using the American Medical Association's Medical Education and Research Database, coupled with profiling information obtained from an extensive survey of New York State physicians conducted as part of the 1994 physician licensure renewal process. This analysis highlighted the extraordinary numbers of residents being trained in specialties in which a clear oversupply existed according to a host of different workforce need methodologies. The analysis also highlighted the fact that nearly half of the graduate medical residents in New York State are international medical school graduates, precisely the pool of graduate trainees singled out for reductions by these national studies (Salsberg, 1996). A further layer of complexity in what is arguably an enormously overbedded hospital environment (Billings et al., 1996) has been the splintering of the hospital coalition along several major fault
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lines. The usually monolithic group of hospitals in the state began to see the hodgepodge of cross subsidization and payment add-ons for GME, uncompensated care, and other rate adjustments in a competitive light; those benefiting from the add-ons argue both for their continuation and for such add-ons to be paid through special pooled funds, whereas those that do not benefit argue for their elimination, maintaining that such payments confer undue competitive advantages to the hospitals that receive them. The Hospital Association of New York State published a set of tables establishing the winners and losers under one reform proposal (Hospital Association of New York State, 1996). Upstate hospitals, particularly those in nonteaching environments, began to see the prospect of pooled dollars flowing from upstate premiums to downstate hospitals to fund the training of unwanted doctors and the care of the uninsured; nonteaching hospitals throughout the state could see their competitive price advantage with managed care companies eroded by these subsidies; and financially stable institutions could see continued "taxation" to support financially distressed hospitals in the face of eroding margins. To further complicate the political horizons, a Republican governor was proposing radical changes in the state system of cross subsidization, and he expected support from the Republican-led state senate, the usual source of political support for the hospital lobby. ROUND ONE: MANDATORY MEDICAID MANAGED CARE The first health care item on the agenda for the new Governor, George Pataki, elected in 1994, was the desire to pare back Medicaid spending in the state. The chosen route was an acceleration of a process that New York began in 1991 legislation to convert its Medicaid population to managed care. At the time, a 5-year target was set to enroll 50 percent of eligible enrollees into managed care plans. The Pataki Administration's plan called for accelerating this timetable and moving toward full enrollment to shave billions of dollars from the Medicaid bill. Hospitals, on the other hand, were intent on trying to recapture money paid in the premiums to man-
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aged care companies that were invented to cover GME costs but were absent from the per diem rates negotiated by the companies for care rendered at the hospitals. Early on, a decision was made to submit a Health Care Financing Administration waiver application under Section 1115 of the Medicaid law to develop and implement a mandatory Medicaid managed care program for New York. To facilitate the application process and to build a consensus on the waiver application, the state Department of Health convened a Medicaid Managed Care Advisory Committee in the spring of 1995. A subcommittee was convened to look at GME issues. A large proportion of the committee members were members of NYSCOGME. The subcommittee met several times over the spring and summer and issued a draft report in October 1995 calling for the establishment of discrete pools of funds to pay for "public goods." The training of graduate medical residents was considered a public good. It was a decision that would have been easy to predict given the composition of the committee. This conclusion was widely accepted by state policymakers, given the prominence that residency training played in New York State hospitals. The committee called for the highest level of funding raised over the broadest base to support GME. It was divided, however, on the mechanism for the distribution of these funds. Hospital representatives favored codifying the current system of channeling funds to hospitals engaged in training with some incentives to foster training reform, but council representatives favored distribution through consortia. A hybrid approach was also proposed. That approach would allow funding to flow through either mechanism but would tie funding to training reforms (Medicaid Managed Care Advisory Committee, 1995). To support the debate, NYSCOGME Subcommittee on Consortia developed a consensus paper outlining its position on the value of these entities in addressing state and regional policy goals for GME. The paper outlined specific goals and objectives for training in the state and proposed a mechanism for funding GME via consortia, with financial incentives proposed to be used to help phase in this method of payment over a 4-year period (New York State Council on Graduate Medical Education, 1995).
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During the time of the deliberations, a development in Rochester, New York, provided some additional impetus to those trying to counter the argument that GME consortia could not serve as a vehicle for planning and funding residency training programs. In an attempt to trim costs, Kodak decided to move its retiree health benefits business to a managed care organization that specifically excluded Strong Memorial Hospital in Rochester from its panel of hospitals. Costs were higher at Strong primarily because of add-ons to cover GME. This decision by Kodak caused such an uproar that it galvanized the University of Rochester into proposing to Kodak and the Rochester Health Commission, a business council that has traditionally been very active in fostering community-wide health planning, the creation of a GME consortium to rationally plan and distribute pooled funds for training programs. In exchange for a commitment on the part of the business community to contribute a portion of the health premium to fund GME, the University of Rochester agreed to create a consortium inclusive of all institutions engaged in training in Rochester and with representation from key community groups and businesses to plan for and fund programs. Implicit in the arrangement was the agreement to reconfigure and reduce training programs so that they correlated more closely with the needs of the Rochester community. The consortium was to encompass institutions engaged in competitive networks and would have a heavy focus on the educational integrity of the programs. The intent of the consortium was to obtain similar commitments from the state Medicaid program and the federal Medicare program to carve out and similarly fund GME through this single vehicle. The consortium was formed in the summer of 1996. Funding through the consortium is planned for the academic year beginning in July, 1997 (Cohen, J., Senior Associate Dean for Medical Education, University of Rochester School of Medicine and Dentistry, personal communication). In the ensuing months, political jockeying to maximize the support in the state for the 1115 waiver resulted in a compromise. A GME pool was created from funds carved out of the premiums paid to managed care plans enrolling Medicaid recipients. Funds from this pool were distributed to hospitals through a system that shad-
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owed what would have happened under the rules of the Medicaid fee-for-service system. This temporary system allowed hospitals to recover GME funds lost in caring for more than 400,000 Medicaid managed care enrollees in the state. The Department of Health guaranteed this system for a 6-month period prior to the expiration of the NYPHRM V legislation. It postponed consideration of the use of GME consortia as the vehicle for rationally planning for workforce needs and channeling GME funds until the post-NYPHRM debate. ROUND TWO: THE GOVERNOR'S AD-HOC TASK FORCE ON NYPHRM With the debate shifting to defining the actual system that would replace the state's highly regulated reimbursement system, the governor convened a 20-member task force under the auspices of the Commissioner of Health to advise the governor on what he should propose for the post-NYPHRM period. Representation was broader than that in the Medicaid Advisory Committee. The task force included representatives from hospitals, managed care plans, health insurers, employers, and consumers. There was no representation from the NYSCOGME or from the Associated Medical Schools of New York. The council chairman and the chief advocate of GME consortia since the 1986 state commission were invited to testify before the task force but played no formal role in the task force's deliberations. The task force issued its report in December 1995. It called for the swift movement toward a market-driven system of negotiated hospital rates. Consistent with the earlier recommendations, the task force recognized the state's obligation to continue to fund two key public goods: uncompensated care and GME. It proposed $1.2 billion to $1.5 billion in expenditures to fund uncompensated care and to provide direct and indirect support for expansion of insurance programs for the uninsured and the creation of a $675 million pool to fund GME. This represented only a portion of the existing funding for GME. It was proposed that roughly $1 billion in additional funds could be successfully obtained through negotiations with the payers. Funding for public goods was to be derived
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from an assessment on payers for care that had been rendered. True to the previous recommendations, the task force acknowledged the possibility of channeling GME funds through GME consortia meeting public good priority goals for training (New York State Department of Health, 1995). Although most of the main health care constituents in the state were generally supportive of the direction of the report, they were wary of the funding levels and the proposed mechanism for financing the pools. Rather than establishing a fair and broad base of financial support for funding for public goods, the payer surcharges were seen as a tax on providers. The lobbying machinery began to gear up in anticipation of the governor's formal legislative proposal. ROUND THREE: THE GOVERNOR'S PROPOSED POST-NYPHRM LEGISLATION Despite promises that the proposed legislation would promptly follow the task force report and the governor's campaign pledge to eliminate the perennial delays in passing the state budget, the proposed New York Health Care Reform Act of 1996 was not issued until March 20, 1996. This was 11 days before the final state budget was to be enacted by law. The legislation followed the overall thrust of the task force report but deviated in some key essential details. The act created the pools of funds for uncompensated care and GME as called for by the task force. However, the total pool proposed for GME totaled only $295 million with another $394 million promised in the Medicaid fee-for-service rates. Furthermore, the act called for 43 percent of this pool to be distributed to upstate hospitals, reflecting the approximate percentage of distribution of the payer surcharges that would fund the pool. As a result, New York City teaching programs that ordinarily receive 80 percent of the GME dollars would receive only about a third of what they would normally get in direct medical education payments. An additional surcharge of approximately 5 percent was proposed for New York City payers. These funds would supplement the payments to New York City teaching hospitals but would have seriously affected the competitive positions of these institutions. Finally, the governor
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proposed large financial incentives for hospitals to join a GME consortium. Hospitals could elect to remain outside a consortium and receive 100 percent of allocated funds in the first year. In the second year, this allocation would decrease to 50 percent. In the third year of the legislation, all funding would be removed unless the institution joined a qualified consortium. Each consortium would be charged with meeting a host of statewide policy objectives that would include reducing the numbers of residents, increasing the training of primary care residents, increasing the training in underserved areas, increasing the numbers of minorities in medicine, and improving the retention of graduates in New York State (Greater New York Hospital Association, 1996b). The governor proposed markedly reduced funding levels for GME and clearly took a stand on the imbalance in the flow of funds from upstate to downstate regions. Featuring GME consortia as the preferred vehicle for reform of GME in the state was a pleasant and welcome surprise to its advocates. However, the poison pill of reduced funding and potential regional conflicts dampened the enthusiasm. The sheer volume of so many other controversial issues addressed in the legislation raised the specter that funding through consortia would become one of a host of tradable issues in the final negotiations. A wave of criticism with regard to the lack of specificity in the bill for organizations that would direct hundreds of millions of dollars of GME funds prompted the Department of Health to ask the NYSCOGME to develop more detailed guidelines for consortia. The council responded with a second position paper outlining what it thought were the key essential ingredients for a successful consortium and setting forth a process for certification and clear outcomes measures consistent with overall state workforce goals (New York State Council on Graduate Medical Education, 1996). These guidelines were largely incorporated into the New York Senate version of the post-NYPHRM legislation with the concurrence of the Department of Health and the governor's office. INTO THE SAUSAGE MAKER The stage was set for a grueling debate on a crucial reform of
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the regulatory health care environment in New York State. However, the health care reform issue was only one of a host of major reform issues being proposed as part of the debate over the state budget. Health care reform, welfare reform, proposed changes in the workman's compensation system, school reform, and a bevy of other high-profile issues shared the limelight in this debate. Within the health care reform debate, the move to negotiated rates, funding for public goods, reform of the method of funding uncompensated care, continued support of 20 New York City-based financially distressed hospitals, equity issues between upstate and downstate hospitals, competitive issues surrounding pooled resources for GME and uncompensated care, and a myriad of health care initiatives to encourage expansion of insurance for the uninsured were among the host of issues crowding the discussion of the use of consortia to channel dedicated monies for GME. With a long history of contentious debates and late budgets, this was not going to be a smooth process. The entire legislature was up for reelection that year, creating an environment that warned lawmakers to take clear stock before making radical changes in the system. The budget battles proved to be every bit as controversial and cantankerous as promised. Moving toward a market-oriented system with the swirl of change sweeping the country heightened the sense of competition among the stakeholders. The usual monolithic hospital lobby showed many fault lines at several crucial junctures but survived the ensuing quakes. An upstate coalition of nonteaching hospitals argued against any pooled funding for teaching and uncompensated care. Financially solvent maverick elements within the hospital lobby attempted to splinter into a group calling itself the Coalition for Fair Funding to lobby against cross subsidies for financially distressed hospitals and those serving disproportionately higher volumes of uninsured individuals. Teaching hospitals and medical schools were unified in trying to obtain maximum funding for GME but were deeply divided on the incentives to channel funds through GME consortia. The Department of Health, supported by NYSCOGME, took a strong position in support of consortia as the strongest vehicle for fostering change in training programs. The
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department, with the support of the state Senate, first proposed differential payments to teaching programs participating in consortia and then an incentive pool that could be distributed to hospitals or consortia at the commissioner's discretion to support statewide goals. The hospital lobby opposed any system of financial incentives to join consortia. It called for only voluntary participation. Uncharacteristically, the hospital lobby's main champion in this debate was the democratic State Assembly, whose primary thrust was counter to many of the reform proposals offered by the governor. In the past, the Republican-controlled state Senate was the body more likely to carry water for the hospitals. The pitched battles and backroom trading finally resulted in a budget accord 104 days past the day it was supposed to have been enacted. The delay set a record for tardiness in the state. In the end, the New York Health Care Reform Act of 1996 was a grand set of compromises that preserved a good deal of the current system while charting new waters. By January 1997 a new system of negotiated rates would replace the old regulated system. Stable funding for uncompensated care and GME was secured through the creation of two funds with broad bases of revenue. The pool of funds for GME ended up with approximately 25 percent less money than what the current system provided. A critical dimension of the bill was the uncoupling of the funding in the next three years from the total numbers of graduate medical residents being trained. This allowed for rational decreases in training without financial penalties. Different contribution and distribution methodologies for Medicaid and non-Medicaid funds minimized the disruption in the flow of funds between upstate and downstate hospitals and between hospitals with different financial profiles. The methodology for funding uncompensated care better reflected true service to the poor. Special initiatives to expand health insurance would be funded. In the end, 10 percent of the $545 million non-Medicaid pool of funds for GME were set aside for distribution by the Commissioner of Health to consortia or teaching hospitals meeting the criteria for meeting statewide policies regarding workforce training. Overall, this represented a pool of approximately 4 percent of the total funds for GME to be used as an incentive for programs to join a GME consortium.
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THE ROLE OF INFORMATION AND LESSONS LEARNED The attempt to reform a system of training graduate medical residents in a state with a preponderant financial stake in maintaining the status quo proved to be difficult but achievable. Attempts at reforming state policies and incentives are rendered more difficult by a federal system that heavily rewards teaching hospitals for staying the course. In the end, the inertia against change was overcome not so much by data and information pointing toward a more rational system but by huge changes in the health care marketplace, fiscal pressures on state coffers and hospital budgets, and the gathering momentum of consensus with regard to the irrational objective of training ever increasing numbers of physicians for a world that will in all likelihood require fewer. Information that pointed toward the imbalances in the New York system of training graduate physicians had been accumulating for years. Information was necessary for change, but the coalescence of key forces over 2 years was required to successfully push for fundamental reform. First and foremost among these forces was the ascendancy of a new state leadership with a political rhetoric predisposed to challenging the precepts of the old system. A new market environment with market rules emphasizing winners and losers and competition over limited funds further undermined these precepts. This new market environment coldly called into question the time-honored value that New York State put into support for research, teaching, and education, which were considered public goods. These extolled missions, generously supported in the past, became potential liabilities in a market-driven environment with its laser focus on costs. Academic medical centers and other teaching hospitals in New York recognized these changes and were compelled to consider heretofore unacceptable options to preserve financing for core public goods. In the end, information helped to frame the debate, but political and financial forces created the environment that forced all the stakeholders to take stock of their new positions before coming to the table. Where information pointed in the direction, these
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forces forged a compromise that could meet many stakeholders' need for a modicum of stability in a vastly changing world. The uncoupling of funding for GME to the numbers of graduate medical residents trained allowed the state to seek similar protections from the Medicare program to create the right environment to encourage the transition to a more rational base. The Medicare program responded by inviting the state to develop a full proposal to uncouple funding from the number of graduate medical residents with the goal of rationalizing the scope of New York State training programs (Greater New York Hospital Association, 1996c).* Although the financial incentives to participate in regional planning through consortia represent only a small portion of the total pool of funds, these incentives are sizable enough to make a difference to most institutions. It remains to be seen how successful these consortia will be in fostering cooperation among potentially competitive health care institutions. For its part, NYSCOGME played a key role in the decidedly uphill battle to create incentives for collective planning and funding for residency programs with a medical education perspective. As a statewide body with representatives from teaching hospitals, medical schools, community health organizations, managed care organizations, and the New York State Medical Society, forging a consensus through the development of council-endorsed position papers in support of consortia carried a good deal of weight with the Department of Health and with the state Senate. Clear and reasoned testimony, correspondence, and position papers enhanced its influence as an impartial body advocating for change. Some advocates for GME reform and for increasing the role of consortia in GME reform will be disappointed that the New York Health Care Reform Act of 1996 fell short of carving a dominant role for these organizations formed around a medical school. However, realists will recognize a significant victory for a largely un- * The New York Medicare Graduate Medical Education Demonstration began on July 1, 1997, and is under the responsibility of HCFA's Office of Payment and Delivery within the Office of Research and Demonstration.
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tested concept. The real test for the advocates will now be to translate the opportunity presented by the ability to channel significant funds into a workable model for rational planning. REFERENCES Billings, J., S. Kaplan, and T. Mijanovich. 1996. Projecting Hospital Utilization and Bed Need in New York City for the Year 2000. Health Research Program, Robert F. Wagner Graduate Program. March 18. Council on Graduate Medical Education. 1994. Recommendations to Improve Access to Health Care through Physician Workforce Reform, Fourth Report. Washington, D.C.: U.S. Department of Health and Human Services. Greater New York Hospital Association. 1996a. The Case for Preserving New York's Graduate Medical Education System. March 5. New York: Greater New York Hospital Association. Greater New York Hospital Association. 1996b. Summary of Governor Pataki's proposed post-NYPHRM legislation. Memorandum. April 2. New York: Greater New York Hospital Association. Greater New York Hospital Association. 1996c. Correspondence to the Greater New York Hospital Foundation, Inc., regarding a concept paper for a Medicare GME demonstration project to restructure the size, composition and focus of graduate medical education programs. July 1. New York: Greater New York Hospital Association. Greater New York Hospital Association Subsidiaries and Affiliates. 1995. Annual Report and Statistics. New York: Greater New York Hospital Association Subsidiaries and Affiliates. Hospital Association of New York State. 1996. Work Tables. New York: Hospital Association of New York State. Institute of Medicine. 1996. The Nation's Physician Workforce: Options for Balancing Supply and Requirements. Washington, D.C.: National Academy Press. Kelly, J. V., F. T. Larned, and H. L. Smits. 1994. Graduate medical education consortia: Expectations and experiences. Academic Medicine 69:931-942. Kochar, M. S. 1996. A medical school-based GME consortium in Milwaukee. Academic Medicine 71:238-242. Medicaid Managed Care Advisory Committee. 1995. Deliberations of the Graduate Medical Education Subcommittee. Considerations in Developing a Policy for the Financing of Graduate Medical Education in New York State. Draft report. October. Albany: Medicaid Managed Care Advisory Committee. Mullan, F., M. L. Rivo, and R. M. Politzer. 1993. Doctors, dollars and determination: Making physician work-force policy. Health Affairs 12(Suppl.): 138-151.
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New York State Commission on Graduate Medical Education. 1986. The Report of the New York State Commission on Graduate Medical Education. February. Albany: New York State Commission on Graduate Medical Education. New York State Council on Graduate Medical Education. 1988. Graduate Medical Education Consortia. First Annual Report. New York: New York State Council on Graduate Medical Education. New York State Council on Graduate Medical Education. 1991. Graduate Medical Education Consortia. Fourth Annual Report. New York: New York State Council on Graduate Medical Education. New York State Council on Graduate Medical Education. 1994. Graduate Medical Education Consortia. Fifth Annual Report. New York: New York State Council on Graduate Medical Education. New York State Council on Graduate Medical Education. 1995. Graduate medical education consortia: A model for reform. Position paper. December 18. New York: New York State Council on Graduate Medical Education. New York State Council on Graduate Medical Education. 1996. Graduate medical education consortia: Guidelines for certification. Position paper. March. New York: New York State Council on Graduate Medical Education. New York State Department of Health. 1995. New Directions for a Healthier New York: Reform of the Health Care Financing System: Findings and Recommendations of Governor George E. Pataki's Ad Hoc Task Force on New York's Prospective Hospital Reimbursement Methodology. December. Albany: New York State Department of Health. Pardes, H. 1995. Testimony Before the Ad Hoc Task Force on New York Prospective Hospital Reimbursement Methodology (NYPHRM). October 24. Pardes, H. 1996. Regarding the governor's Health Care Reform Act of 1996. New York: Associated Medical Schools of New York. Pew Health Professions Commission. 1995. Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century. The Third Report of the Pew Health Professions Commission. San Francisco: Pew Health Professions Commission. Physician Payment Review Commission. 1993. Annual Report to Congress. Washington, D.C.: Physician Payment Review Commission. Salsberg, S. 1996. Graduate Medical Education and the Supply and Distribution of Physicians in New York State. Presentation to the New York State Council on Graduate Medical Education Plenary Meeting, New York, March 25. U.S. Congress. 1994. Congressional Record 140(113):Sl1667. Washington, D.C.: U.S. Government Printing Office.
Representative terms from entire chapter: