Commonwealth of Massachusetts
Executive Office of Health and Human Services

Special Commission on Graduate Medical Education

February 25, 2013

Meeting Agenda 

Administrative Tasks  
Overview of Commission 
Overview of Graduate Medical Education (GME)
Next steps

Administrative Tasks 

Open Meeting Law
Conflict of Interest

Overview of Commission

Statutory Charge

Section 277 of Chapter 224 of the Acts of 2012 creates a “special commission to examine the economic, social and educational value of graduate medical education in the commonwealth and to recommend a fair and sustainable model for the future funding of graduate medical education in the commonwealth”

Commission Members 

•	The Secretary of Health and Human Services or a designee, who shall serve as chair
•	The Secretary of Administration and Finance or a designee 
•	The Secretary of Labor and Workforce Development or a designee
•	The Commissioner of Public Health or a designee
•	A representative of the Massachusetts Hospital Association
•	A representative of the Massachusetts Medical Society
•	A representative of the Massachusetts League of Community Health Centers
•	4 representatives of the Commonwealth’s medical schools
•	A representative of the Conference of Boston Teaching Hospitals 
•	A resident in training at a Massachusetts hospital 

Purpose and Mission

Section 277 directs the commission to study and investigate the following issues: 

(1) the role of residents and medical faculty in the provision of health care in the commonwealth and throughout the United States

(2) the relationship of graduate medical education to the state's physician workforce and emerging models of delivery of care

(3) the current availability and adequacy of all sources of revenue to support graduate medical education and potential additional or alternate sources of funding for graduate medical education. Such review shall include the availability of federal graduate medical education funding to different types of sites where training takes place approaches taken by other states to fund graduate medical education through, including, but not limited to: (a) Medicaid programs, (b) the establishment of medical education trust funds and (c) efforts to link payments to state policy goals, including:
(i) increasing the number of high demand specialties or fellowships;
(ii) enhancing retention of physicians practicing in the commonwealth;
(iii) promoting practice in medically underserved areas of the state and reducing disparities in health care;
(iv) increasing the primary care workforce; 
(v) increasing the behavioral health care workforce; and
(vi) increasing racial and ethnic diversity within the physician workforce.  

Purpose and Mission

The commission shall file a report of its findings and recommendations, together with drafts of legislation, if any, necessary to carry out its recommendations, with the legislature not later than April 1, 2013. 

Overview of Graduate Medical Education

Graduate Medical Education 

•	Formal didactic and clinical training provided by an approved residency program to physicians who have received an MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine) degree

•	Period of training of three to seven years in which physicians are directly supervised in their learning in preparation for independent practice

•	In the United States, training programs must be accredited by the Accreditation Council for Graduate Medical Education (ACGME) or approved by the Commission on Osteopathic College Accreditation (COCA)

•	Teaching hospitals generally serve as the sponsors and main training sites for most residency programs, although training can occur in other inpatient and ambulatory settings in a variety of community-based settings.

Residency Statistics: U.S. and Massachusetts

U.S.  	
MA  	
 MA as % of U.S. 	

Total Population 	
315 million	
6.6 million	
2%	

Total Residents 	
115,293	
5,414	
5%	

Total Residency Programs 	
9,022	
402	
4%	

Source: ACGME Data Resource Book for the 2011-2012 Academic Year

MA Institutions Sponsoring More than One Program 

Hospital	City	Programs	Residents	
Brigham and Women’s Hospital	Boston	47	933	
Mass General Hospital	Boston	53	822	
Boston University Medical Center	Boston	43	588	
Beth Israel Deaconess Medical Center	Boston	40	566	
UMMS	Worcester	51	515	
Tufts Medical Center	Boston	45	444	
Children’s Hospital	Boston	37	368	
Baystate Medical Center	Springfield	24	317	
St. Elizabeth’s Medical Center	Boston	11	151	
Lahey Clinic	Burlington	14	130	
Cambridge Health Alliance	Cambridge	7	98	
St. Vincent Hospital	Worcester	5	97	
Berkshire Medical Center	Pittsfield	4	69	
Mount Auburn Hospital	Cambridge	2	60	
Steward Carney Hospital Inc	Boston	2	51	
Mass Eye and Ear	Boston	5	48	
Metrowest Medical Center – Framingham Union Hospital	Framingham	2	37	
Spaulding Rehabilitation Hospital	Boston	3	21	
Source: ACGME Data Resource Book for the 2011-2012 Academic Year

Specialties with largest number of NRMP listed residency positions – U.S.

Specialty	Number of Positions	
Internal Medicine	5,277	
Family Medicine	2,740	
Pediatrics (Categorical)	2,475	
Emergency Medicine	1,668	
Anesthesiology (PGY1 and PGY2)	1,476	
Obstetrics - Gynecology	1,240	
Surgery (Categorical)	1,146	
Psychiatry	1,118	
Radiology – Diagnostic (PGY1 and PGY2)	1,111 	
Orthopedic Surgery	682	

Source:  National Resident Matching Program, Results and Data: 2012 Main Residency Match (April 2012). Available at: http://www.nrmp.org/data/resultsanddata2012.pdf

Specialties with largest number of NRMP listed residency positions –Massachusetts

Specialty	Number of Positions	
Internal Medicine	450	
Surgery - General	106	
Anesthesiology (PGY1 and PGY2)	104	
Pediatrics (Categorical)	89	
Psychiatry	67	
Emergency Medicine	64	
Radiology - Diagnostic	62	
Family Medicine	45	
Neurology	42	
Obstetrics - Gynecology	37	

Source:  National Resident Matching Program, 2012 NRMP Main Residency Match: Match Rates by  Specialty and State (April 2012). Available at: http://www.nrmp.org/data/resultsbystate2012.pdf

Funding Sources for GME

Medicare
•	Largest funding source
•	$9.5 billion in funds

Medicaid
•	$3.8 billion in funds in 2009

Department of Veterans Affairs
•	Support about 9,000 residents 

Department of Defense
•	Educate and train about 3,000 residents 

Title VII health professions programs
•	$39 million in funds (2012)
•	Modest support for programs in primary care 

Children’s Hospitals GME Program
•	$300 million in funds 
•	Provides funds to freestanding children’s hospitals 

Teaching Health Center GME Program
•	$230 million, five-year initiative 
•	Supports primary care residents and dentists trained in community-based ambulatory patient care settings. 

Private Sources

Medicare Funding 

•	Direct Graduate Medical Education Payments (DGME)
o	resident stipends
o	faculty salaries
o	administrative costs
o	institutional overhead

•	Indirect Graduate Medical Education Payments (IGME)
o	adjustment intended to compensate teaching hospitals for:
•	the higher costs associated with teaching
•	the involvement of residents in patient care
•	the severity of illness of patients who require the specialized services that are available in teaching hospitals

Aligning GME Policies with Nation’s Health Care Workforce Needs, ACP Position Paper 2011

Direct Graduate Medical Education Payments 

•	Calculated by multiplying the base-period per resident amount (PRA) by the weighted number of full-time equivalent residents working in all areas of the hospital (and non-hospital sites, when applicable), and the hospital’s Medicare share of inpatient days

•	Each hospital has a predetermined federal cap on the number of FTEs set by the Balanced Budget Act (1997), readjusted in 2002 and 2005 on the basis of a national redistribution formula

•	Estimated payments of $3.2 billion in FY2011

Indirect Graduate Medical Education Payments 

•	Payment based on the IME adjustment factor, which reflects the hospital’s ratio of residents to beds and an IME multiplier (set by Congress) 

•	This measure is assumed to be correlated with academic activities, such as increased use of diagnostic or ancillary services and the availability of “state-of-the-art” treatment technologies

•	The formula translates into a 5.5 percent increase in IME payment for every 10 percent increase in the resident-to-bed ratio

•	Estimated payments of  $6.3 billion in 2010

Changes to GME funding in the Affordable Care Act 

•	Distribution of Medicare GME positions: 	
o	65% of unused residency slots under cap to be redistributed in application process determined by the HHS Secretary 
o	75% of the redistributed positions must be for primary care or general surgery
o	Approximately 750 slots identified for redistribution

•	Graduate Medical Education Technical Changes:
o	Changes calculation for time spent training in nonhospital sites
o	Expands range of activities eligible for both DME and IME payments 

Next Steps

Proposed Commission Schedule
 
•	February Meeting
o	Overview of Graduate Medical Education in the Commonwealth, including overview of funding to support graduate medical education

•	March Meeting
o	Physician workforce and emerging models of care
o	Approaches taken by other states to fund graduate medical education 

•	April Meeting
o	Develop draft recommendations

•	May Meeting
o	Draft report

Discussion

•	Key questions the Commission should address, in light of time constraints
•	Experts or other presenters that the Commission would recommend inviting to present to the Commission, or that should be interviewed by Commission staff
•	Feedback to proposed schedule

Open Meeting Law

•	Notice must be posted for meetings
•	Meetings must be open to the public unless the public body enters into executive session
•	Minutes must be kept for both open and executive sessions

For more information:
•	http://www.mass.gov/ago/government-resources/open-meeting-law/video-trainings/ 
•	Office of the Attorney General’s Division of Open Government hotline: 617 963-2540, openmeeting@state.ma.us

Meeting definition

•	Definition - deliberation by a public body with respect to any matter within the body’s jurisdiction. If a quorum of the members of a public body expect to deliberate, they must hold a meeting and provide notice to the public. 

•	Exceptions:
o	On-site inspection
o	Attending an event or training
o	Attending a meeting of another public body
o	These exceptions only apply so long as the quorum of members do not discuss matters within the jurisdiction of the committee.

Deliberations

•	Definition - An oral or written communication through any medium, including electronic mail, between or among a quorum of a public body on any public business within its jurisdiction. 

•	A quorum is defined as a simple majority under the Open Meeting Law unless otherwise provided.

•	Fewer than a quorum of a body’s members can discuss matters within that body’s jurisdiction without that communication being a deliberation. 

Deliberations (cont’d)

•	Exceptions to deliberations
o	Members of a public body may distribute a meeting agenda, procedural or scheduling information.
o	Reports or documents to be discussed at a meeting may also be distributed to a quorum of the public body without constituting deliberations.
o	These exceptions only apply if the person distributing does not express any opinion on matters within the body’s jurisdiction (i.e. can email a report but cannot add a statement stating whether they agree with that report).

•	Avoid serial communications 
o	For example, 4 members of the committee (that are not a sub-committee) email each other discussing matters within the jurisdiction of the committee. One of these members then forwards the discussion to 3 more members. This is a deliberation as a quorum of members has been reached.

Open Meeting Documents

Materials to be distributed:
•	Open Meeting Law, G.L. c. 30A, §§18-25 
•	Open Meeting regulations, 940 CMR 29.00 
•	Guide to the Open Meeting Law published by the Attorney General 

The Guide has a form on the last page that must be signed and returned to EOHHS.

Conflict of Interest Law (M.G.L. c. 268A)

•	As a member of this Commission, you are regarded as a Special State Employee under the Conflict of Interest Law. 
•	As a special state employee, you are subject to all the provisions in the conflict of interest law that apply to "state employees" except where the statute specifically sets out less restrictive provisions for special state employees (in recognition of the need to avoid unduly restricting the ability of board and commission members to earn a living while serving the state).
•	You are prohibited from receiving gifts, bribes, etc and must disclose any financial interest in any organization that could conflict with your ability to perform your duties on this Commission.
•	The above description is intended to be general in an effort to help you gain a basic understanding of the Conflict of Interest Law. For specific questions it is important that you contact the State Ethics Commission at www.mass.gov/ethics or by calling (617) 371-9500, or by requesting written advice from the State Ethics Commission's Legal Division, One Ashburton Place, Room 619, Boston, MA 02108.  The legal advice received from the State Ethics Commission is free and confidential.