Each year the U.S. government spends billions of dollars on graduate medical education (GME) at the nation’s hospitals to support postgraduate physician training. But a historically unequal distribution of those funds has prompted policymakers to rethink this funding and whether it benefits patients and students or simply boosts profits of wealthy hospitals.
A new study by Yale researchers published in the online medical journal JAMA Network Open finds that GME spending is associated with improved patient outcomes and better academic performance by medical residents, but does not improve the financial standing of hospitals.
In an analysis of the nearly 1,300 hospitals that received GME funding in 2017, the researchers found that every $1 million increase in spending was associated with a lower 30-day mortality rate for heart failure, acute myocardial infarction, pneumonia, stroke, and chronic obstructive pulmonary disease. When they looked at data from previous years, this trend held, the authors say.
They found no association, however, between subsidies received and hospital profitability.
“I thought we’d have a different result,” said Dr. Howard Forman, a professor at the School of Public Health, School of Management, and School of Medicine and co-author of the study. “I thought we’d find that these funds were fattening the pockets of rich hospitals.”
The study was led by Dr. Radoslav Zinoviev, an internist based in Baltimore who is affiliated with Yale New Haven Hospital and who first submitted the findings as an award-winning thesis at Yale five years ago.
Dr. Harlan Krumholz, the Harold H. Hines, Jr. Professor of Medicine at Yale School of Medicine, was also a co-author.
Created in 1944 to offset the cost of resident training, the GME subsidy is primarily funded as part of Medicare, Medicaid, the Veterans Health Administration, and other smaller programs.
Today more than $10 billion is spent annually to support the program. The 1,298 hospitals reviewed as part of the study received a median $2.64 million, with a median $100,500 for each trainee. The median number of residents per hospital was 32.
The researchers found a significant association between funds allocated to students and their internal medicine Board Certification Exam pass rates during the period studied.
Distribution of funds remains unequal, with larger teaching hospitals — particularly in the northeastern U.S. and on the coasts — receiving an inordinate share. However, the funding does not improve the profitability of these hospitals, the authors say. They speculate that in many cases the expenses of these academic hospitals — including the cost of training students — exceed the revenue benefit and leave these institutions less financially resilient.
It could be, Forman added, “that hospitals in cities like Boston, San Francisco, and New York City have a larger burden of costs for patients.”
The findings underscore the potential value of GME funding, and serve to enhance calls to more fairly distribute these dollars, Zinoviev said.
“We can’t be quick in dismissing GME funding, and the call to eliminate this subsidy is probably unjustified,” he said. “But we want to increase the transparency and increase the accountability in the way these funds are being used and improve the allocation across the country.”
