THE IMPACT OF GRADUATE MEDICAL-EDUCATION FINANCING POLICIES ON PEDIATRIC RESIDENCY TRAINING

Objective. To review special issues related to pediatric residency tra ining in managed care organizations, the effects of the changing healt h care system on the demand for pediatricians and the potential impact on financial support for residency training, current methods of finan cing graduate medical education (GME), possible future approaches to f inancing GME, and policy directions to support training of pediatricia ns well prepared for future practice. Methods. We reviewed current inf ormation on residency education in managed care settings, including th e rationale for training in such settings and the realities of such ed ucational experiences. We then assessed the evidence concerning the su pply and demand for pediatricians in the present health care marketpla ce, with its evolution to managed systems of health care. We summarize d current approaches to financing GME through Medicare, Medicaid, priv ate insurers and purchasers, and direct federal and state support, wit h emphasis on the financing of ambulatory training which could occur i n managed care settings. Lastly, we described factors influencing the upcoming revolution in GME financing and outlined possible new policy directions for the financing of relevant GME training experiences. Res ults. Appropriate training experiences in managed care organizations m ay be a valuable strategy to address the current disconnect between th e traditional hospital-based education of pediatricians and the expand ed competencies necessary to practice in intensively managed, integrat ed and accountable health systems. Present pediatrician supply appears to be in relative balance with health maintenance organization staffi ng patterns and with needs-based requirements estimates. However, the pediatrician-to-child population ratio is predicted to increase rapidl y over the next decade, leading to an oversupply of pediatricians unde r likely future health care delivery system scenarios. Medicare is the largest explicit payer of GME training costs, historically directing reimbursement primarily for hospital-based education. Numerous innovat ive financing strategies are being considered to facilitate funding of GME training in ambulatory settings and to open up funding to greater public scrutiny and accountability. Conclusions. Although reforms in federal GME financing have been limited to date and other significant changes have been largely state-based, it is likely in the future that explicit funds will be targeted to specialties in demand that prepare physicians well for future practice. Pediatricians and medical educat ors must intensify their voices in the financing debate to ensure a pr oductive future for quality pediatric residency training.