Meeting Coverage > AMA
AMA Delegates: No GME Funds for Non-Physicians
— In new turf fight, docs seek to keep NPs, PAs from getting federal training dollars
by Joyce Frieden, Washington Editor, MedPage Today November 16, 2020
The American Medical Association (AMA) must protect physicians' scope of practice by making sure federal funding for graduate medical education (GME) does not go to non-physicians, several members of the AMA's House of Delegates said Sunday.
"I've had the privilege of training mid-level [providers] and medical students for many years," said Ramin Manshadi, MD, a delegate from Stockton, California, speaking for himself at the virtual special meeting of the House of Delegates, adding that the difference in knowledge between the two groups "is quite vast."
The goal of nurse practitioner and physician assistant programs "is to take over the practice of medicine," he continued. "We need to be proactive and adapt by first increasing the funding for GME and systematically increase the number of medical schools. We need to uphold the integrity of our profession and deliver the best care possible for our patients. This resolution is appropriate and timely, and we need to support it."
"Scope of practice is what keeps me invigorated and coming to AMA every year for the last 30 years," said Alan Klitzke, MD, of Buffalo, New York, a delegate for the American College of Nuclear Medicine who was speaking for himself. "The failure to maintain scope of practice is one of the biggest threats to quality healthcare in our country."
Concerns About GAO Report
The delegates were speaking at a meeting of the AMA's Reference Committee on Medical Education, where they were discussing a resolution from the Michigan delegation urging the association to "work with the Liaison Committee on Medical Education, the Accreditation Council for Graduate Medical Education, and other interested stakeholders to encourage the Government Accountability Office (GAO) to oppose and refrain from further consideration of the diversion of direct and indirect graduate medical education funding to non-physicians."
The resolution noted that a December 2019 GAO report "contains potential errors that may adversely influence legislative decisions" about using GME funding for advanced practice professionals (APPs) such as nurse practitioners and physician assistants.
Elisa Choi, MD, of Boston, who was speaking for the American College of Physicians, said the U.S. is "facing a dire physician shortage ... The diversion of GME funding to non-physicians will only exacerbate this crisis."
APPs, "who are valued members of our clinical team, have a shorter training period than physicians and have no requirement for a residency," Choi said. "With an aging population with increased medical complexity and chronic diseases, it's especially important that patients have access to physicians who are specifically trained in comprehensive primary and team-based care for adults. The number of Medicare-funded GME positions at institutions is currently capped at 1996 levels, and this has prevented increased GME training physician numbers to offset the predicted physician shortages."
Most of the delegates who spoke at the meeting favored the resolution, but a few did not. John Williams, MD, a delegate from Gibsonia, Pennsylvania, and a member of the Council on Medical Education, spoke for the council and said that while the council was in "strong support of the intent of the resolution," it "appears to be reaffirmation of our [existing policy] to support training of the healthcare workforce, and we'd recommend reaffirmation."
The AMA already has policy supporting use of graduate medical education funding only for physicians, said John Williams, MD, of the AMA's Council on Medical Education. (Photo courtesy AMA livestream)
Drayton Harvey, MD, of Los Angeles, speaking for the Council on Legislation, disagreed, noting that the AMA was the only organization the GAO reached out to when writing its report. "The passage of this policy would allow AMA to work with partners to ensure ... that GME funding is not diverted" to non-physicians "and that we do not stand alone in our conversation with GAO on this issue," he said.
Dave Cundiff, MD, of Ilwaco, Washington, a delegate for the American Association of Public Health Physicians, who was speaking for himself, agreed with Harvey, saying that the resolution was a "directive to take action" and not a reaffirmation of existing policy. "I think the will of the House is clear, and we should take action," he said.
Supporting Displaced Trainees
Another issue before the committee was how to address the displacement of medical trainees that occurs when a hospital merges or closes. A report from the AMA's Council on Medical Education referenced the fall 2019 closure of Hahnemann University Hospital in Philadelphia, which "left more than 550 resident and fellow physicians ... without a program accredited by the Accreditation Council for Graduate Medical Education (ACGME) in which to continue their medical education."
The council recommended that the AMA ask the Centers for Medicare & Medicaid Services (CMS) to stipulate in its regulations that residency slots are not assets that belong to the teaching institution, and encourage the Association of American Medical Colleges and National Resident Matching Program to develop a process that could be used in the event of a sudden teaching institution or program closure.
The council also recommended that the AMA "encourage the [ACGME] to specify in its Institutional Requirements that sponsoring institutions are to provide residents and residency applicants information regarding the financial health of the institution, such as its credit rating, or if it has recently been part of an acquisition or merger."
Derek Baughman, MD, a PGY-2 family medicine resident speaking in support of the report and speaking on behalf of the Pennsylvania Academy of Family Physicians and several other delegate groups, read from a letter that a group of former Hahnemann medical residents wrote in support: "'We found out the hospital was being dismantled through an article in the Philadelphia Inquirer; rumors of financial instability had been floating around for years,'" the letter read. "'Many paid exorbitant fees to break their leases ... Our residency positions were essentially sold, and it took a long time for that to register ... Although teaching institutions pay trainees with funding provided by CMS, our last paycheck amounted to $1.25 per hour.'"
Testimony on the report was overwhelmingly positive. Louito Edje, MD, of Maumee, Ohio, speaking for the Great Lakes Coalition, offered "strong support of the very well-written report."
The coalition also supported an amendment offered by Luke Selby, MD, of Columbus, Ohio, speaking for the Resident Fellows Section. "We're asking for some specificity, which we see as the floor and not the ceiling for the kind of information institutions should have to provide to prospective applicants -- reports from the Better Business Bureau and other publicly available financial data," he said. "And as soon as it's revealed that an institution is part of a pending merger or acquisition, we believe that applicants should be provided that information."
Suja Mathew, MD, of Chicago, who spoke on behalf of the American College of Physicians, supported most of the report except for the provision requiring financial disclosures. "The disclosure of financial viability might unfairly disadvantage safety net hospitals that chronically function at marginal financial stability, and reported financials may only be loosely related to the risk of closure," she said.
But Hans Arora, MD, of Cleveland, Ohio, a delegate from the American Urological Association, who was speaking for himself, disagreed. "Regarding safety net hospitals, maybe it'll disadvantage them and maybe not, but trainees and trainees-to-be deserve to know; that's what this is about," said Arora, the main author of an earlier resolution that led to the council's report.
Criticism for the Clinical Skills Exam
Delegates also discussed a resolution from the North Dakota, South Dakota, and Iowa delegations calling for the AMA to encourage the relevant certification boards to "eliminate centralized clinical skills examinations used as a part of state licensure, including the USMLE [United States Medical Licensing Examination] Step 2 CS [Clinical Skills] Exam and the COMLEX Level 2 PE [Performance Evaluation] Exam" and advocate that "a replacement examination process be administered within the medical schools that verifies each medical student's competence in key clinical skills required to be a physician."
Without a standardized clinical skills exam, it will be hard to evaluate medical students from different schools, said Kim Templeton, MD, an AMA delegate from the American Association of Orthopedic Surgeons. (Photo courtesy AMA livestream)
The resolution received mixed reviews. "Despite being non-profit, the USMLE makes over $35 million annually for this exam," said Dayna Isaacs, MD, an alternate delegate from El Dorado Hills, California, who spoke for herself in support; she was referring to the CS2 exam. "The cost disproportionately affects low-income students and students in Hawaii and Alaska, who are required to fly to the mainland" to take the test, she said. "Second, this exam has not been proven to enhance patient safety, clinical outcomes, or clinical skills."
Kim Templeton, MD, of Leawood, Kansas, a delegate from the American Academy of Orthopedic Surgeons, who spoke on behalf of the Orthopedic Section Council, disagreed. "While we understand the concerns, especially during the pandemic, with cost and travel, we do worry about issues of objectivity," she said. "If similar exams are given in a medical school, with medical school faculty examining their own students, that may raise questions about how objective and valid the evaluations are."
"The other concern that we have is a lack of standardized metrics," she added. "How are we supposed to be able to evaluate the quality of medical students across schools if we don't have a standardized quality metric?"
Joyce Frieden oversees MedPage Today's Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy. Follow