“THE GME INITIATIVE” AND GME IN STATES

Family medicine struggles to fund graduate medical education (GME) due to antiquated Medicare rules that fund hospitals for GME. Medicare GME funding inadequately covers family medicine residencies, is inequitable with variation across the United States, and does not fill gaps in the cost of training.¹ Program leaders need to identify funding streams which include state initiatives, and learn to advocate for options to create sustainable residency infrastructures to produce needed workforce in their states. Having answers to key questions about state GME funding and collaborative partnership opportunities, and sharing best practices to advance these efforts will support advocates at state levels to optimize opportunities for meeting state and regional workforce needs.

The GME Initiative (GMEI) (http://www.gmeinitiative.org) is a grassroots, volunteer group of roughly 150 members representing approximately 35 states and is comprised of health care learners, educators, advocates, and leaders who are passionate about reforming GME through payment reform, partnerships, state initiatives, legislation, advocacy, and education at the state, regional, and national level. Beginning with a policy brief calling for GME Reform,² a GME Summit was held in 2015 (http://www.gmeinitiative.org/november-2015-summit/x0i4v). A key recommendation from this summit was to create a workgroup focused on state-based GME reform initiatives. The goal of the GMEI’s State Initiatives Workgroup is to track state initiatives, educate others about state GME activities, look at the finance, accountability, and governance of GME reform, and to host conference(s) on behalf of the GMEI. The first GMEI summit focusing on States was held January 2017 in Albuquerque New Mexico. (http://www.gmeinitiative.org/2017summitmaterials). Thirty-three states were represented at the Summit; since then more states have joined the GME Initiative and work of the States’ Workgroup.

In general, states that do support GME do it through Medicaid, through state general funds, taxes, special fees, or some combination of these. To better understand specific sources and availability of funds to support GME at the state level, the GMEI States’ Workgroup has developed a template for gathering key information across states. Key areas addressed in this template are: (1) state-specific goals for GME; (2) total annual amount of non-CMS federal dollars; (3) sources of funding—where does the money come from?; (4) strategies (legislative, financial) to expand GME within a state; (5) governance and accountability structures to ensure oversight over finances; and (6) barriers and challenges.

With pilot information from 9 states, the GMEI is beginning to learn about common strategies and common barriers/challenges. A key strategy for any GME activity is to engage stakeholders and legislators to educate them about what GME is and how targeted GME efforts support state workforce needs over time. A number of states are engaged in specific efforts targeting rural areas and often involve a coalition of multiple stakeholders (state Academy of Family Physicians, state medical association, state hospital association, medical school, and others). Barriers and challenges we are learning about include too many disparate stakeholders, administrative burdens related to oversight of funds, continual need to educate and reeducate legislators about what GME is and how long it takes to produce a physician workforce, and Medicare GME cap limits which prevent residency program expansion, especially in underserved areas.

Whatever the strategy or policy in play within a given state, what the GME States’ Workgroup strives to do is to “connect the dots” between the intent of a particular policy or strategy and the reality on the ground. An overriding inherent challenge in any state-supported GME effort is the time-limited nature of state funding. This is diametrically opposed to the hard-wired funding through Medicare from CMS which continues to flow with no accountability tied to those funds. State GME efforts require constant attention to data to demonstrate accountability while at the same time constant attention to ensuring that stakeholders continue to see the value.

There is much more to learn about GME at the state level. In a recent survey of Association of Departments of Family Medicine, more than one-half (54%) of the Departments are reportedly involved in formal regional or statewide efforts to address family physician workforce needs and workforce planning. What we have found through the GME Initiative is that there is much to be gained by learning from each other. For more information about the GME Initiative, and how one can join, contact Mannat Singh at mannat.singh{at}gmail.com.

• © 2018 Annals of Family Medicine, Inc.