Graduate medical education (GME) funding is linked with better patient outcomes and resident academic performance but did not boost hospitals’ bottom line, according to an analysis involving 1298 academic hospitals.
Critics have questioned both how hospitals are using the $10 billion a year in subsidies from the federal government and the accounting of the money, lead author Radoslav Zinoviev, MD, MBA, a cardiology fellow at the Cleveland Clinic in Ohio, and colleagues write.
While some critics have suggested that the money is padding hospitals’ bottom line, this work suggests that the investments are paying off and “hospitals are not getting richer,” Zinoviev told Medscape Medical News.
Zinoviev, who was affiliated with the internal medicine department at Yale New Haven Hospital in Connecticut during the study, and colleagues published their findings January 28 in JAMA Open Network.
While the findings counter some of the major criticisms of the funding, the researchers did find that transparency is lacking and distribution is not equitable.
But the link between funding and patient outcomes was clear with this analysis, which drew statistics from the Hospital Compare database, Zinoviev said.
Zinoviev explained that GME funding started after World War II as an incentive for hospitals to train residents by helping cover the costs the facilities would incur.
Currently, the federal government is the primary GME funder, through Medicare, Medicaid, the Veterans Health Administration, and other smaller sources.
Growth in the 1980s and 1990s in residency program meant that hospitals with large training programs were getting larger and larger payments allotted for their group of residents.
But backlash began to build in the 2000s, Zinoviev said, with arguments that hospitals were already getting cheap labor from the residents, in a sense generating their own revenue, so why did hospitals need so much extra money to offset the training costs? Calls to cut GME funding have been ever-present since then.
Hospitals counter that the money is needed because the costs associated with resident training are increasing. The money covers not only the salary and benefits of the resident, but teaching and administrative costs, malpractice coverage, and overhead as well.
More Funding Tied to Lower Death Risk
To find out more about how the money is being used and if it affects outcomes, the researchers analyzed data from the 1298 hospitals that received GME funds in 2017. The facilities had a median of 265 beds and 32 residents per training site. The hospitals received a median of $2.64 million per site (interquartile range [IQR], $0.49 – $8.39), with a median IQR of $100,500 ($58 000 – $134,700) per trainee.
Every additional $1 million in GME funding was linked with lower 30-day death risk from myocardial infarction (–2.34%; 95% confidence interval [CI], –3.59% to –1.08%, P < .001), heart failure (–2.59%; 95% CI, –3.93% to –1.24%, P < .001), pneumonia (–2.20%; 95% CI, –3.99% to –0.40%, P = .02), chronic obstructive pulmonary disease (–1.20%; 95% CI, –2.35% to –0.05%, P = .04), and stroke (–3.40%; 95% CI, –5.46% to –1.33%, P = .001).
“All 5 associations remained significant after Holm-Bonferroni correction for multiple tests of significance,” the authors write. “There was no significant association between GME funding and 30-day readmission rates.”
Zinoviev and colleagues also found a significant association between GME funding over the prior 5 years and resident success as measured by board certified examination pass rates.
However, GME funds did not guarantee financial health for the hospitals. Researchers found that hospitals with larger residency programs had higher revenues, but the amount of GME funding for hospitals was negatively correlated with hospitals’ financial standing (β = –7.9; 95% CI, –10.9 to –4.8; P = .001), even after adjusting for the confounders such as hospital size and type and size of residency program.
To determine financial standing, researchers used the Yale Hospital Financial Score, which includes both revenue and debt of an organization and ranks the hospitals accordingly.
Zinoviev acknowledged they were not able to explain why the correlation was negative in this study. However, he theorized it could come from large academic centers treating fewer people with private insurance and treating often sicker patients, though they did try to adjust for those potential confounders.
Darlene Tad-y, MD, associate professor of medicine and director of quality and safety for GME at the University of Colorado School of Medicine in Aurora, told Medscape Medical News that the results are “something we always suspected. We thought that the more we invest into the quality and robustness of our educational programs that we would in fact achieve better patient outcomes. This, I thought, really made that association apparent.”
“It also highlights that our trainees do have a hand in the quality and safety of care of our patients,” she said.
She said that critics sometimes misunderstand the costs for others to train the residents, research-associated costs, and administrative costs that GME funding supports. Those costs have increased partly in light of the caps on duty hours residents work as gaps have needed to be filled with more providers, she said.
She also noted that cost needs vary by specialty. “A psychiatry program will need something different than a surgical program so you need to have different people looking after those residents or trainees,” she said.
Tad-y does agree with the critics that there needs to be more transparency on how the funds are distributed and used.
Zinoviev said he hopes this study slows the momentum of calls to cut GME funding.
“We want to be clear,” he said. “We fully agree with the research of the past 20 years — that GME funding is not fairly distributed, that it is not going to small programs that may even need it more, not going to primary care programs. It is being directed to large, mostly coastal, hospitals.
“I certainly believe it should be reformed, but I think that’s the operative word — reformed — not eliminated,” he said.
JAMA Net. Open. Published online January 28, 2021. Full text
Zinoviev and Tad-y declared no relevant financial relationships.
A coauthor reported personal fees from UnitedHealth, IBM Watson Health, Element Science, Aetna, Facebook, Siegfried & Jensen law firm, Arnold & Porter law firm, Martin/Baughman law firm, the National Center for Cardiovascular Diseases of China, and F-Prime; serving as cofounder of Hugo Health, a personal health information platform; serving as cofounder of Refactor Health, an enterprise healthcare AI-augmented data management company; receiving contracts from Centers for Medicare & Medicaid Services, through Yale New Haven Hospital, to develop and maintain measures of hospital performance; and receiving grants from Medtronic and the US Food and Drug Administration, Medtronic and Johnson & Johnson, and Shenzhen Center for Health Information outside the submitted work.
Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and Nurse.com, and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.