5th WWAMI GME Summit - UW · PDF file• Multilevel, multivariable ... Rasoini R, Gensini...

©2017 Accreditation Council for Graduate Medical Education (ACGME)

5th WWAMI GME Summit

September 29, 2017

Mary Lieh-Lai, MD, FAAP, FCCPSenior Vice President for Medical Accreditation

ACGME


Disclosures

• No financial disclosures• Fully recovered:•Program Director•Designated Institutional Official

• Recovering:•Pediatric Intensivist•Faculty member


1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020

Evolution of the ACGME over 37 Years

First residency

First RRC

ACGMEestablished

ACGMEindependent

OutcomesProject

17 yearsSingle Accreditation

NAS

ACGME-I

CLER

MilestonesProject

JGME

2014 Duty Hours studies in Medicine and Surgery

2003 Duty Hours

2011 Duty Hours

CPRRevision

2017 Common Program Revisions: Phase I & II

SpecialtyPR Revisions


ACGME

• Not-for-profit organization• Accreditation of:• 800+ Sponsoring Institutions• 10,000 programs• 150+ specialties and subspecialties

• 133,000 residents and fellows• Accreditation of training programs• Does not provide individual certification:

purview of the specialty boards


ACGME Mission

“We improve health care and population health by assessing and

advancing the quality of resident physicians’ education through

accreditation.”


ACGME’s Public Trust Commitment The actions of the ACGME must fulfill the social contract, and must cause sponsors to maintain an educational environment that assures:• the safety and quality of care of the patients under the care

of residents today

• the safety and quality of care of the patients under the care of our graduates in their future practice

• the provision of a humanistic educational environment where residents are taught to manifest professionalism and effacement of self interest to meet the needs of their patients


Consider that the 32-year old resident training today has the potential to be

practicing beyond 2054


Why should residents be involved in QI?


What is the Role of the Resident?

“Residents can be empowered to improve the quality and value of care. Leaders of healthcare organizations need to stop thinking of residents (or residencies) as a problem, but rather think of them as part of the solution. Residents comprise a talented workforce that, when appropriately trained, deployed, and incented, can help achieve institutional goals to improve quality, safety and efficiency.”

George E. Thibault, MDSix Themes

Macy Regional Conferences on Innovations in GME


What is the Role of the Residency Programs?

“Residency programs will focus more on the importance of teamwork training and inter-professional collaboration. All physicians will work in teams throughout their careers, and more time in residency must be spent with learners and practitioners from other disciplines and professions with an explicit goal of developing team competencies.”

George E. Thibault, MDSix Themes

Macy Regional Conferences on Innovations in GME


Training matters….


JAMA, 2009: 302:1277• 4,906,169 deliveries• 4,124 physicians from 107

US OB residency programs• Program rankings from:

• FLEX• NBME Parts I, II, III• USMLE Steps 1, 2, 3

• Women treated by obstetricians in the bottom quintile had one third higher complication rates that those from the top quintile.

• The effect was durable through 15-17 years after residency


JAMA 2014; 312 (22): 2385

• Multilevel, multivariable analysis of 2011 Medicare claims data

• FM, IM residents 1992-2010• Hospital Referral Region

(HRR)• Low-• Average-• High-spending

• Associated with expenditures for subsequent care they provided

Physician Median Medicare Spending per Beneficiary Stratified by Residency Program Hospital Referral Region

vs Years in Clinical Practice

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

1 to 7 8 to 15 16 to 19

Low Training HRR Medium Training HRRHigh Training HRR

.02

<.001

.01

<.001.02

.19


JAMA Intern Med, 2014:174 910): 1640• Responses of 6,639 first-time takers of

ABIM certifying exam• Appropriately Conservative

Management (ACM) and Appropriately Aggressive Management (AAM) subscales

• Correct response represented the least or most aggressive management strategy

• Regardless of overall medical knowledge, internists trained at HRR with lower-intensity medical practice more likely to recognize when conservative management is appropriate and, more importantly, are capable of choosing an aggressive approach when indicated


Aligning Priorities

• While it is important to pay attention to• Medical knowledge• Patient Care• Systems-based practice• Interpersonal Communication Skills• Practice-based learning and improvement• Professionalism• Scholarship

• Educational and working environment• Physician Wellness


A Word about CLER

• Clinical Learning Environment Review• Six specific areas:• Patient safety• Health care quality• Care transitions• Supervision• Duty hours and fatigue management

and mitigation• Professionalism• Wellness


CLERhttp://www.acgme.org/Portals/0/PDFs/CLER/ACGME-CLER-ExecutiveSummary.pdf

• 297 initial visits• Who was interviewed?

• 1,000 members of executive leadership• 8,755 residents and fellows• 7,740 core faculty members• 5,599 program directors• Thousands more: nurses, pharmacists and many others• (but not patients and families)

• Lessons learned• Resident participation in educational activities is variable• Degree of experiential learning and active engagement

varies significantly

http://www.acgme.org/Portals/0/PDFs/CLER/ACGME-CLER-ExecutiveSummary.pdf


CLER – Overarching Themes

Varied:• approach for addressing patient safety and

health care quality and the degree of resident/fellow engagement

• approach in implementing GME (usually independent of other areas of focus and strategic planning)

• extent in investing in education and training in the 6 areas

• degree in coordinating and implementing educational resources


Aligning Priorities• While it is important to pay attention to• Medical knowledge• Patient Care• Systems-based practice• Interpersonal Communication Skills• Practice-based learning and improvement• Professionalism• Scholarship

• Educational and working environment• Physician Wellness


0

10

20

30

40

50

60

70

25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64

Com

plet

ed S

uici

des

per 1

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Age Cohort

Incidence of Suicide Among White Male Physicians, Dentists, and General Population

Physician Dentist Population

Occup Med (Lond). 2008. 58 (1): 25-29.

Schernhammer E, Colditz G. Suicide Rates Among Physicians:Am J Psych. 2004. 161(12):2295-2302.

Male Physicians v General Population(not confined to USA)

Female physicians : age matched females in the general population

= 2.27Schernhammer E, Colditz G. Suicide Rates Among Physicians:

Am J Psych. 2004. 161(12):2295-2302.

Female Physicians vs General Population(not confined to USA)


The Iceberg

SuicideClinical Depression

Other Illness

Suicide

Physician Burnout

Occupational Hazard

Environmental/Cultural Mistreatment

EHR

Clinical Depression

Other Illness

Financial Issues


The Resident’s Work Day

Laundry

NeedRootCanal

Defer LoanPaymentsForms

Pay Bills

Family

DischargeNotes/Rx

EMR

Clinic

On Call

ReturnPatient Calls

Rounds

Conference Prep

Eat/Sleep

Clinical Work

Research

Attend Lectures

Simulation

Car broke down

Enter case logs


The Faculty Member’s Work Day

Laundry/Clean House

PersonalHealth appointments

Pay Bills

Family

Care forAgingParents

EMR

Clinic

On Call

AdministrativeWork

Rounds

Lectures

Eat/Sleep

Clinical Work

Research

Billing/RVUs

TeachingResidents


EMR has resulted in many positive outcomes, but….

• HITECH: Health Information Technology for Economic and Clinical Health Act of 2009

• Actually managed to accomplish a lot in a short time• 5000 hospitals• 500,000 physicians

• One sixth of gross domestic product

• Halamka JD, Tripathi M: The HITECH Era in Retrospect. Perspective, New Engl J Med, 2017, 307:907-909

“Along the way however, we lost the hearts and minds of clinicians. We overwhelmed them with confusing layers of regulations. We tried to drive cultural change with legislation. We expected interoperability without first building the enabling tools. In a sense, we gave clinicians sub-optimal cars, didn’t build roads, and then blamed them for not driving.”


Unintended Consequences of Machine Learning

• Cabitza F, Rasoini R, Gensini GF: Unintended consequences of machine-learning in medicine. Viewpoint, JAMA, published online July 20, 2017

• ML-DSS: Machine-learning based decision support systems

“It is likely that machine learning applications will soon transform some sectors of health care in ways that may be valuable but may have unintended consequences.”

“The quality of any ML-DSS and subsequent regulatory decisions about its adoption should not be grounded only in performance metrics, but rather should be subject to proof of clinically importantimprovements in relevant outcomes compared with usual care, along with the satisfaction of patients and physicians.”

“Simulated patients create simulated doctors”


Understand the Relationships

Program StructureResident Working

and Learning HoursFatigue

Professionalism

Physician/FacultyWell Being

in today’s andtomorrow’s

Clinical CareEnvironment

Patient Safetytoday, and in

future practiceof our graduates

Meaning

Autonomy, Mastery,and Purpose

Learning


Do not lose sight of the forest for the trees….


Back to the Bedside


Avoid Bean Counting


Examples of QI Activities Led by Residents

• Vanderbilt University: reduce wasteful or unnecessary medical tests, treatments and procedures

• Grady Hospital: inventory on types of care transitions• U Va: patient satisfaction regarding physician communication• UCSF: institution-wide QI program (set goals and incentives)• UCSF: interprofessional collaboration for medication

reconciliation for inpatient admissions• Henry Ford Health System: interdisciplinary teams in clinics• Advocate Lutheran General Hospital: QI focused on specific

care objectives (e.g. diabetes management indicators)


QIPS Activities

• Does not have to be “fancy”• Important points:• Residents and faculty should not be “forced” to

do it:•Not for the sake of bean counting

• Purpose of QIPS activities•Develop an environment of quality improvement and patient safety•Turn this into a habit and lifelong practice


Consider this QI Activity• Studying EMR progress notes:

• The dangerous practice of cutting and pasting• Is the information current and accurate?• Is there a way to create a template for better progress notes or

synchronizing lab reports that are actually meaningful

Procedure note:Lumbar puncture attempted by three pricks. (Drs. Theodorou, Anderson and myself). 3rd prick successful, 3 tubes of CSF sent to lab for Gram stain, chemistry and cultures

Fecal fat not measured. Stoolspecimen clotted


Switching Gears…..


Actively Licensed Physicians - US 2016 (2010)

Counts PercentagesTotal 953,695 (850,085) 100%

DegreeDoctor of Medicine (MD) 870,312 (789,788) 91.3% (92.9%)

Doctor of Osteopathic Medicine (DO) 81,115 (58,329) 8.5% (6.9%)

Unknown 2,268 0.2%

Age< 30 years 18,023 (16,519) 1.9% (1.9%)

30-39 years 208,799 (184,120) 21.9% (21.7%)

40-49 years 227,953 (214,595) 23.9% (25.2%)

50-59 years 214,422 (215,541) 22.5% (25.4%)

60-69 years 183,870 (138,815) 19.3% (16.3%)

70+ years 94, 969 (75,627) 10% (10%)

Medical SchoolUS/Canadian (MD or DO) 724,640 (649,736) 76% (76.4%)

International Graduates 216,182 (188,598) 22.7% (22.2%)

Journal of Medical Regulation, 2017; 103(2): 1-21

30%

The Aging Physician Population?


US Medical Schools in the Pipeline

State/Province Medical Education Program City

California California University of Science and Medicine Colton

Nevada Roseman University of Health Sciences College of Medicine Las Vegas

Nevada University of Nevada, Las Vegas School of Medicine Las Vegas

New Jersey Seton Hall – Hackensack School of Medicine South Orange

Texas University of Texas Rio Grande Valley School of Medicine Edinburg

Virgin Islands University of the Virgin Islands School of Medicine St. Thomas

Virginia College of Henricopolis School of Medicine Martinsville

Virginia King School of Medicine and Health Science Center Abingdon


Projection to 2022TJ Nasca, MD

• Baseline matriculants in 2004: 16,648• Assume Allopathic Expansion achieves 30%

goal (growth from 2004) by 2022• Projected 2022 Allopathic matriculants 21,642 at

a minimum• Could be as high as 22,500 or more with

minimum 8 additional schools in pipeline (average class size 100-125)

• For analysis purposes, use 21,500 as estimate


Estimate (TJ Nasca)Total US Citizen Demand for US GME Pipeline Positions - 2022

US Allopathic Output 21,500 (+1,000)US Osteopathic Output 8,500 (+ 500)US IMG 3,500Total “Domestic” Demand 33,500 (+1,500)

“Desired” IMG Positions 2,000 (+1,500)

Total Demand 35,500 (+1,500)Assume 98% Efficiency 36,225 (+1,530)


Future Demand vs Future Supply(TJ Nasca)

• Allopathic pool seeking GME in 2022 21,500 (+1,020)• Osteopathic pool seeding GME in 2022 8,500 (+ 510)• International pool desired to be 5,500• Total desired pipeline positions 36,225 (+1,530)• Total projected pipeline positions (occupied) 31,500

• Currently short ~ 5,000 entry positions for estimated 2022 demand

• If growth is not accelerated, these dislocations will happen


Training Programs are not Cheap

• Idaho:• Increase from 9 to 21• $15 Million per year

• 1/3 State• 1/3 Programs• 1/3 Sponsoring institutions


GME Funding

• Major funding source:• Medicare: approximately $10 billion a year• Number of positions capped

• New medical schools, expanding existing schools• Other funding sources:• Medicaid (state and federal)• VA, HRSA• State government in underserved areas• Hospitals, health systems, communities


Sources of Funding(2013-2016)

• Medicare DME (2013) 3.4 Billion• Medicare IME (2013) 7.9 Billion• Medicare total (2013) 11.3 Billion

• Medicaid 4.3 Billion• VA (10% of residents) (2015) 1.5 Billion• Children’s Hospitals (2016) 295 Million• HRSA Teaching HC Centers (2016) 60 Million• Dept. of Defense (2012) 17 Million


Sources of Funding(Dollars/resident)

• Medicare total 137,000/resident• Medicaid Variable• VA (10% of residents) 146,000/resident• Children’s Hospitals 44,000/resident• HRSA Teaching HC Ctrs 95,000/resident


Direct (DME) and Indirect (IME) Funds

• Direct GME Payments (DGME or DME)• Pays Medicare’s share of residency education costs• Based on each hospital’s 1984 cost estimate • Reported on annual “hospital cost report”

• Indirect Medical Education (IME) Payments• Partially pays for higher patient care costs due to

presence of residents and “inefficiencies”• Paid through a higher inpatient DRG rate


How Much does your Hospital Get from CMS?

Varies for each hospitalExample Resident Fellow/2nd Resident1/3 DME $ 40,000 $ 20,000*2/3 IME $ 80,000 $ 80,000Total $120,000 $100,000

*Fellows/2nd Resident get ½ of the DME *Most hospitals only pay for resident salary/benefits and not faculty salary (mostly generated by practice plans routed through the medical school)


What Are DME Payments Intended to Cover?

• For costs directly related to educating residents:

• Residents’ stipends/fringe benefits• Faculty Salaries/fringe benefits• Other direct costs• Allocated overhead costs

• Residents must be in ACGME approved program or pre-requisite for ABMS certification

• Residents/Fellows cannot bill


Medicare Pays Its “Share” of Resident “Costs”

= Medicare % X $ Per Resident Amount

1. Primary care example:40% x $100,000 per resident= $40,000/y

2. Non-primary care example:40% x $90,000 per resident= $36,000/y

3. Fellow or second residency example:40% x $90,000 per fellow ÷ 2 = $18,000/y(For fellows and those who go into a second residency, Medicare only reimburses hospitals for 50%)


Indirect Medical Education (IME)

• Compensates teaching hospitals for higher inpatient operating costs due to:• Unmeasured patient complexity not captured

by DRG system• Other operating costs associated with being a

teaching hospital (lower productivity, standby


What Happens to the CMS money?

• Hospitals get about $30,000 DME and $60,000 IME per resident

• Hospitals often pay resident salary and stipend, make sure they cover vacation

• Hospitals resist paying faculty/PD costs• Hospitals may or may not pay Program

Coordinator• Hospitals can hire on-site Program Coordinator

for you


What is the Resident Cap?

• The number of FTE allopathic and osteopathic residents that a hospital may count for DME and IME payments is limited to hospital 1996 Medicare cost report count, • 1997 Balanced Budget Act • (P.L. 105-33 Sections 4621 and 4623)

• Limits may be different for DME and IME• 78,000 nationally out of 117,000 total positions


MedPAC Recommendations to Congress

1. Secretary of Health and Human Services (HHS) to establish a "performance based" GME program with $3.5 billion in IME above 2.2 percent; (cut from the current 5.5 percent). HHS should establish standards for distributing these funds after consultation with various groups, including accrediting organizations, training programs and health care organizations, as well as patients and purchasers.

The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional agency established by the Balanced Budget Act of 1997


MedPAC Recommendations on GME

2. The Secretary should annually publish a report that shows: DME and IME payments received by each hospital, the number of residents trained, and Medicare's share of the associated costs incurred by the hospital.

3. The Secretary should conduct workforce analyses to determine the number of residency positions needed in the U.S by total and by specialty.


MedPAC Recommendations on GME

4. The Secretary should report to Congress on how residency programs affect the financial performance of sponsoring institutions and whether all residency programs should be supported equally by the Medicare program.

5. The Secretary should study strategies for increasing the diversity of the health professional workforce (e.g., increasing the shares of underrepresented, rural, lower-income and minority communities) and report on what strategies are most effective.


Source: GME Community through ACGME Accreditation Data SystemACGME Data Resource Book 2015-2016. Figure E3

Slide courtesy of Dr. T. Nasca


Source: GME Community through ACGME Accreditation Data SystemACGME Data Resource Book 2015-2016



Why are all these numbers important???


68% of Residents Practice Where They Trained


Government Accountability Office

• May 2017 Physician Workforce Report• “Locations and types of graduate training were largely

unchanged from 2005 to 2015, and federal efforts may not be sufficient to meet needs.”

• “A well-trained physician workforce adequately distributed across the country is essential for providing Americans with access to quality health care services. The federal government has reported shortages in rural areas and projects a deficit of over 20,000 primary care physicians by 2025. GME training is a key factor affecting the supply and distribution of physicians.


Key Points

• Training matters• Residents and fellows are

essential for QIPS improvement

• Pay attention to:• Community needs when

formulating residency programs

• Emphasize interprofessional team-based care


“Quality is not an act,It is a habit”

Aristotle


Thank you

5th WWAMI GME Summit - UW · PDF file• Multilevel, multivariable ... Rasoini R, Gensini...

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