Information Trading How Information Influences the Health Policy Process (1997) / Chapter Skim
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2 Funding Graduate Medical Education in the Year of Health Care Refrom: A Case Study of a Health Issue on Capitol Hill
2 Funding Graduate Medical Education in the Year of Health Care Refrom: A Case Study of a Health Issue on Capitol Hill
Pages 27-48
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From page 27... ...
THE CLINTON HEALTH SECURITY ACT On January 3, 1994, when ~ started my Robert Good Johnson Health Policy fellowship in the Office of Senator George Mitchell, Democratic Senate Majority Leacler from Maine, ~ was handled a i,362-page document labeled S.1775 (the Clinton HSA)
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From page 28... ...
_ AS CONCEPUALIZED AS INTRODUCED AS AMENDED AFTER INSIDE AND OUTSIDE COMMITTEE HEARINGS CONGRESS AND MARKUP i~ ~ pi AS REWRITTEN BY MITCHELL STAFF ) t it_ AFTER SENATE DEBATE 1: WHAT WAS ACTUALLY AS REPORTED BY AS UNDERSTOOD BY NEEDED THE MEDIA THE PUBLIC FIGURE 2.1 SOURCE: Adapted by Oliver Fein from Arkansas Trial Lawyer Association.
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From page 29... ...
The Clinton HSA slid the following: · Created an all-payer fund for GME and academic health centers (AHCs) of $40 billion over 5 years by pooling GME funds from the Medicare trust fund with a new 1.5 percent assessment on private health insurance premiums (Tables 2.1 and 2.2~.
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From page 30... ...
· Made GME payments directly to "the approved physician training program." All four of these proposals were a major departure from existing · ~ pot fiches: · GME had only been supported by Medicare, not private insurance.
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From page 31... ...
(Association of American Medical Colleges, 1993~. · GME funds were distributed only to teaching hospitals, not to residency training programs.
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From page 32... ...
, the Clinton HSA proposed 55 percent primary care output, compared to COGME' s 50 percent. Rather than adopting COGME' s recommen
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From page 33... ...
FUNDING GRADUATE MEDICAL EDUCATION TABLE 2.4 Recommended Approaches to Workforce Reform 33 Expert Panels Support for 50% Primary Care Support for Reduction in Total No. of Residents Support for All-Payer Pool Council on Graduate Medical Education Physician Payment Review Commission Prospective Payment Assessment Commission X Pew Health Professions Commission Robert Wood Johnson Foundation Macy Foundation American Medical Association Association of American Medical Colleges American Academy of Family Physicians American Board of Internal Medicine American Osteopathic Association X X X X X X X X X X X X X X X X X X X X X X
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From page 34... ...
When ~ arrived in Senator Mitchell's office, the phrase payment to "the approved physician training program" was causing substantial agitation among teaching hospitals. It meant that Medicare direct GME payments wouIc3 be macle to training programs, which collie then negotiate with teaching hospitals, community health centers, and other sites as training locations.
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From page 35... ...
released a briefing memo entitled Academic Health Center and Workforce Policies. It laicl clown the rationale for all-payer GME financing in terms that sound quite familiar today: "Private insurers now pay major teaching hospitals 25% to 30% more than community hospitals.
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From page 36... ...
Debra Folkerts, a family nurse practitioner, represented the American Nurses Association, the American Association of Nursing Colleges, anc3 the National Nurse Practitioner Coalition. It was no coincidence that she came from Kansas, home of the Senate Minority Leacler, Robert Dole.
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From page 37... ...
About ~ month later, on April 14, the committee scheclulec3 the hearing to make the case against workforce reform anc3 primary care, entitled Academic Health Centers uncler Health Care Reform. Again, the witnesses refiectec3 a variety of constituencies, with a disproportionate number of witnesses from Chairman Moynihan's state of New York.
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From page 38... ...
Senator Kennedy was viewed as a friend of academic medicine anc3 had reported out a bill that was extremely favorable to academic health centers anc3 that specifically created a new funding pool for medical schools. The Labor anc3 Human Resources Committee bill proviclec3 more funds for GME anc3 AHCs than Clinton's HSA a total of $68 billion over 5 years, compared with Clinton's $41 billion (see Table 2.2~.
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From page 39... ...
So the Kennedy bill included the 55 percent goal for primary care and a national council to reduce the number of residency training slots without a specified target. The result of markup in Senator Moynihan' s Finance Committee was essentially identical to that in Senator Kennedy's Labor and Human Resources Committee with respect to GME funding levels, but there were no workforce goals for primary care or for reducing the number of residents.
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From page 40... ...
ProPAC had acivocatec3 reducing the indirect GME adjustment factor to 5.2 percent anc3 the Clinton HSA had reclucec3 it to 3.0 percent. Those preparing the Mitchell bill cleciclec3 not to buck Moynihan on GME financing anc3 accepted the Finance Committee's funding levels.
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From page 41... ...
How collie such a large government subsidy of GME and teaching hospitals be legislated without accountability for the outcome, particularly since many analysts ascribed a substantial part of medical inflation to the overproduction of doctors? The staff preparing the Mitchell bill, tried to craft a bill that still had workforce integrity, but that would phase in workforce goals more gradually and loosen the legislative constraints on any national commission in the fourth and fifth years, so that there could be flexibility to respond to the unintenclec3 consequences that might result from adherence to rigid percentages (see Figure 2.24.
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From page 42... ...
With this information Mitchell' s staff might have been better able to speak to Senator Moynihan's fears of an adverse impact on New York. It turned out, however, that these data were viewed as political dynamite by the Clinton Administration, because they showoff the wide disparity uncler existing Medicare formulas in the clistribution of GME funds between states (e.g., for every GME clolIar spent in North Dakota, $217 was spent in New York)
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From page 43... ...
There was also the weight of 20 years worth of information moIclers: private and government expert panels, the record of the other committees in the U.S. House of Representatives that hac3 reported out health reform legislation, and the opinions of multiple senators and representatives, all of whom favored workforce provisions, not to mention the political calculation that if academic medicine w ante c3 $70 billion worth of support (almost twice what it presently received from Meclicare)
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From page 44... ...
A group of moderate Republican and conservative Democratic senators that coalesced during the 1994 health care reform effort led by Republican Senators John Chafee of Rhode Island and David Durenberger of Minnesota, and Democratic Senators John Breaux of Louisiana and Ken Conrad of North Dakota. The Mainstream Coalition attempted to chart a programmatic course between the liberal Democrats and the conservative Republicans.
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From page 45... ...
The deans' Saturday Morning Working Group was able to take the opportunity of national health care reform and insert entirely new support for medical schools. The New York academic health centers were able to exert enormous influence to maintain the status quo, even if it jeopardized enhanced funding for the total enterprise.
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From page 46... ...
GME funding cuts were limited to $9.9 billion over 7 years and were taken only from indirect GME payments (by reducing the indirect medical education adjustment factor from 7.7 to 4.5 percent) , not from direct GME payments, which remained untouched.
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From page 47... ...
AAMC supported creation of a GME Trust Fund anc3 callecl for a "sharecl responsibility approach," another way of saying all-payer financing; limitation of Medicare GME to U.S. medical graduates; anc3 expansion beyond hospitals of the entities that may receive GME payments, such as meclical schools, multispecialty group practices, GME consortia, or other entities that incur the costs of training (but not training programs clirectly)
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From page 48... ...
1994. Academic Health Centers and Workforce Policies.
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