Three notable and current topics in graduate medical education to follow

The funding and accreditation of graduate medical education (GME) programs is of critical importance to academic medical centers, hospitals and other organizations sponsoring GME programs, including the nearly 900 sponsors of GME programs accredited by the Accreditation Council for Graduate Medical Education (ACGME).¹ As we look further into 2024, we offer the following “GME Three”, topics which we consider particularly important for Sponsoring Institutions, programs and GME leaders to have on their radar.

The third round of applications for GME federal funding has opened

Section 126 of the Consolidated Appropriations Act, 2021, authorized the distribution of 1,000 additional Medicare-funded full-time equivalent residency cap slots to qualifying hospitals.² The slots are phased in at a rate of 200 per year, until all slots have been distributed. The first round of slots were distributed by the Centers for Medicare and Medicaid Services (CMS) for fiscal year 2023 on January 9, 2023, and the second round of awards were announced on November 15, 2023.

The next round of applications, for fiscal year, 2025, is currently open and will close March 31, 2024. The slots awarded for the third round will be announced by CMS by January 31, 2025 and will be effective July 1, 2025. The application can be accessed on the CMS Direct Graduate Medical Education page under the information for Section 126 distributions.  

To qualify for a cap increase under section 126, a hospital must demonstrate a likelihood of filling the requested slots within the first five training years after the effective date of the increase. In addition, the law mandates that at least 10 percent of the aggregate number of residency positions be distributed within each of the following four categories of hospitals:

• Category One: Hospitals located in rural areas or that are treated as being located in a rural area (pursuant to sections 1886(d)(2)(D) and 1886(d)(8)(E) of the Social Security Act).
• Category Two: Hospitals with a reference resident level greater than the otherwise applicable resident limit (e.g. hospitals training a number of residents in excess of their GME caps).
• Category Three: Hospitals in states with new medical schools or additional locations and branches of existing medical schools on or after January 1, 2000.
• Category Four: Hospitals that serve areas designated as Health Professional Shortage Areas (HPSAs).

There are limits on the number of slots a hospital can request and cap slots received under section 126 cannot be used to fund existing positions. Ninety-nine hospitals, with HPSA scores from 14-21 (based on a scale from 1-25) were awarded slots in round two. Psychiatry and Child and Adolescent Psychiatry programs represented 21 of the 99 hospitals/programs receiving additional slots, followed by programs associated with family medicine (18) and internal medicine (15).

The ACGME will not conduct 10-year accreditation site visits for programs—but programs still need to be prepared for site visits

The ACGME officially discontinued 10-Year Accreditation Site Visits for GME programs last October. Institutional 10-Year Site Visits have not been discontinued and GME programs are still required to complete the self-study process.

In addition, while programs will not undergo site visits associated the self-study process, the ACGME recently announced that it will be conducting site visits of GME programs with a status of Continued Accreditation.³ According to the ACGME, approximately one to two percent of programs with the status of Continued Accreditation will be selected through a random sampling process. Accreditation site visits of programs with Continued Accreditation status may also be scheduled at the discretion of the Review Committee.

Major program requirement changes anticipated for several specialties

Major revisions to the Specialty and Subspeciality Program Requirements were put forth by the applicable ACGME Review Committees in 2023 for the specialty of Pediatrics and for the Pathology and Psychiatric subspecialties. These major changes include a new definition of the applicable specialty (Pediatrics), integration of telehealth and electronic health records into patient treatment (Psychiatry subspecialties), greater emphasis on feedback to residents utilizing direct observation and competency based assessments (Pathology subspecialties) and other changes.

The final changes are anticipated to go into effect July 1, 2024 and have been closed to comment for several months. In the meantime, Impact Statements connected to the major revisions suggest that institutions may need to add resources to comply with certain of the proposed updated requirements. An expansion of required outpatient activities for Pediatric residents comes with an acknowledgement from the Review Committee for Pediatrics that some institutions may not have the appropriate facilities, quantity of facilities or personnel to meet the new requirements and proposed requirements within the Pathology subspecialties related to competency-based assessments may require additional faculty development per the Review Committee for Pathology.

Also on the horizon, are major changes to Surgery Program Requirements. Among the proposed changes is a new definition of a General Surgeon, the expansion of a restriction on where chief residents may be assigned, changes in the resources that programs - in partnership with Sponsoring Institutions - must ensure are in place for surgery resident education and an expansion of requirements related to surgical training using simulation. An additional proposed change is a requirement that programs offer clinical experiences in resource-limited environments, such as rural clinics, providing care in health care deserts and providing care on tribal lands. The proposed changes to the Program Requirements for Graduate Medical Education in General Surgery are open to comment until February 29, 2024. 

Revisions to the ACGME’s Institutional Requirements, which were last updated effective July 2022, are anticipated, but have yet to be published.

1 There were 886 sponsors of over 13,000 accredited residency and fellowship programs for the 2022-2023 academic year according to the ACGME. Accreditation Council for Graduate Medical Education, Data Resource Book, Academic Year 2022-2023 (2023).

2 These provisions were implemented in an Inpatient Prospective Payment System (IPPS) final rule with comment period, 86 Fed. Reg. 73416 (Dec. 27, 2021).

3 https://www.acgme.org/newsroom/e-communication/2024/january-8-2024/