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Comprehensive Graduate Medical Education Reform

The Council of Academic Family Medicine, and the American Board of Family Medicine joined with the American Academy of Family Physicians in developing the following new policy recommendations, relating to graduate medical education (GME). The following recommendations were released at a Summit on GME Reform in Washington, DC on September 15, 2014.

New Policy Recommendations

The organizations jointly requested that Congress:

  • Expand the number of residency positions for first-certificate residency positions, particularly in needed priority specialties, by limiting direct graduate medical education (DGME) and indirect medical education (IME) payments to the training for first-certificate residency programs, utilizing the savings for expansion.
  • Align financial resources with population health care needs through a 0.25% reduction in IME payments — from the current 5.5% to 5.25% — and allocate these resources to support innovation in graduate medical education, with emphasis on expansion to more states and communities, particularly for primary care and community-based education.
  • Fund the National Health Care Workforce Commission.
  • Require all sponsoring institutions and teaching hospitals seeking new Medicare- and/or Medicaid-financed GME positions to meet minimum primary care training thresholds as a condition of their expansion.
  • Demonstrate a commitment to primary care through the establishment of thresholds and maintenance-of-effort requirements applicable to all sponsoring institutions and teaching hospitals currently receiving Medicare and/or Medicaid GME financing.

Taken together, these policies allow for a budget neutral method of increasing innovation, right-sizing the physician workforce, promoting more ambulatory/community-based training and primary care production, and rationalizing the use of federal dollars to meet the nation’s health care needs.

Putting the Recommendations in Context

Family medicine has promoted the reform of Medicare GME for more than a decade, but the environment for change has not been sufficient for substantial success. With the recognition that graduate medical education is on every target list for deficit reduction, and the rising clamor for countervailing proposals to increase residency positions without safeguards to produce the right number and mix of physicians the country needs, we reexamined our GME reform policies last fall. Our perspective was to prevent large scale cuts to Medicare GME solely for deficit reduction purposes, while keeping intact our vision for the development of a more primary care-centric physician workforce. The work of the Robert Graham Center on the accountability of medical school and graduate medical education, data showing the rise in subspecialty production even without Medicare reimbursement for those residency positions, as well as calls from national advisory bodies for more accountability and transparency of Medicare GME, have informed our development of these policy recommendations.

Why Now?

With the July release of the IOM report on Governance and Financing of GME, there is now independent, nationally recognized data and expert opinion to support major changes to the way Medicare GME funding is distributed. Along with that, there is increasing acknowledgement that these public dollars should be accountable to the health care needs of the American public.

As with the recommendations of that IOM report, we know there will be individuals and institutions in academic medicine that will question or actively oppose these policies. As a result, we want to ensure that everyone in academic family medicine has background on the development of these proposals and talking points should colleagues in your institution raise questions about them. In addition, these policy recommendations will require Congressional action; they will be the foundation of our federal advocacy on Medicare GME for the foreseeable future.  

Learn More

To help fully digest the above policies, review this grid of our new policies, which includes the principles underpinning our recommendations, how they align with the recent IOM report on the governance and financing of graduate medical education, and talking points to help address some of your colleagues concerns. This press release describes our support for these changes to GME. In addition, here are two AAFP documents detailing more specificity of the policies.

We look forward to advancing needed reforms to improve the US health care system with a goal of achieving the triple aim: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.

For questions about CAFM’s position on GME reform, contact Hope Wittenberg at, 202-986-3309.

Copyright 2018 by Society of Teachers of Family Medicine