The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require “all-payer” support.

Federal, state, and local health policies shape the landscape on which clinical decisions are made, sometimes in ways that are not apparent when those policies are formulated.1,2 Whether the decisions are about insurance coverage and benefits, payment models for care and resource allocation, health workforce issues, or mechanisms to improve health care quality, these policies affect what we do in clinical care, research, and education. Solutions to the myriad challenges that confront us and our patients daily often seem elusive. Discussion about these issues can become contentious, and sometimes appears to be driven by emotion rather than reason. In an ideal world these difficult decisions would be informed by evidence. The impact of new policies on access to, cost, quality, and outcomes of care would be formally evaluated. Critical examinations of the scientific basis for policy, empirical analyses of the impact of policies, and syntheses of the evidence underpinning policy challenges can be helpful to JGIM readers who want to understand how the health care system works. In this issue of JGIM, we introduce a new section entitled Health Policy, which will feature original policy-relevant research, scholarly reviews, and perspectives on health policy issues. Articles should place these issues in the context of their impact on practices, providers, patients, and populations. Articles that examine how alternative strategies foster or impede the delivery of high-quality primary care would be of special interest. We believe this section will fill a need for an outlet for articles that approach these issues from a primary care perspective and build on prior contributions of SGIM members in this area. As we examine these issues there is much that American readers can learn from other countries.3–5 By learning about different countries' experience with alternative strategies and approaches to similar challenges, we may gain new insights into old problems. Conversely, some nations are looking to American models of care for solutions.6 While the United States is unique in the industrialized world in having failed to achieve consensus on how to provide universal coverage, the United States faces many of the same dilemmas as other countries. One of the key policy questions in health systems in all developed countries, though they may differ on how they are organized and financed, is how to maintain quality of care while keeping costs under control. In the United States, managed care became a dominant model for cost control and many managed care plans chose a “gatekeeper” approach to contain costs while promoting coordination and continuity—important domains of primary care quality.7–9 Usually, this meant that a patient was expected to see his/her primary care physician (PCP) first for all nonemergency problems and see specialty physicians only on referral from the PCP. There were often strong financial incentives to make this happen, ranging from withholds from PCP payments to lack of insurance reimbursement for visits to the specialty physician and any tests and treatment that arose from that consultation. However, this gatekeeper system has become increasingly unpopular with patients, and there is pressure to eliminate it. Some large managed care organizations are now experimenting with dropping the gatekeeping requirement and allowing open access to specialty care.10 In this issue Himmel et al. assess the attitudes of German patients toward gatekeeping.11 Germany has a system of universal coverage in which most Germans (90%) receive health care through membership in a sickness fund that finances their medical care. The remainder is wealthy enough to purchase private insurance. The German system shares many features with traditional fee-for-service indemnity insurance in the United States. It has a majority of specialists, it pays physicians by fee-for-service, and patients may have their first contact with either a PCP or a specialist. In fact, Germans have much higher rates of ambulatory care utilization than Americans do. Pressures for cost containment are mounting and there is growing interest in the advantages of a primary care–centered delivery system. Himmel observes that most of the German people they surveyed were willing to accept their family physician as the entry point and coordinator of all other health services. However, the German respondents did not advocate a gatekeeper model. Himmel et al. did not ask the respondents whether they would support a system where patients who see a specialist physician without a referral would not be reimbursed for the visit. Rather, Himmel asked the softer questions about supporting a system where patients saw a family practitioner first and the family practitioner would arrange and coordinate specialty care when needed. There is evidence that Americans respond similarly. In a recent American survey assessing similar preferences, almost all patients valued the role of a PCP as a source of first-contact care (94%) and coordinator of referrals (89%). Depending on the specific medical problem, 75% to 91% of patients preferred to seek care initially from their PCPs rather than specialists.12 However, they did not want to experience barriers to specialty care. As in Germany, preferences were associated with patients' perceptions of the quality of the doctor-patient relationship and trust and confidence in their PCP. We are left with the challenge of defining the role of primary care within the current market environment. What policies will enable the development of quality primary care built upon sustained and constructive doctor-patient relationships? Is a system that controls costs, lets PCPs serve as patient advocates, serves patient needs, and preserves some choice possible?13 We hope this new section in JGIM will shed light on this and other pressing questions confronting PCPs. We hope to foster a greater understanding of the interactions among health policy, clinical practice, and health outcomes. Health policy is not just about federal and state legislation but is broadly defined to include decisions made by national, state, and local governments as well as decisions and initiatives led by professional organizations, academic health centers, insurers, and pharmaceutical companies. Topics of interest for the Health Policy section include but are not limited to: Analysis of evidence to inform policy alternatives: patient's rights proposals, Medicare pharmacy benefit proposals, and methods to assure patient safety Evaluation of the effects of prior policy on health care delivery Regulatory reform: proposed changes in financing of graduate medical education, and changes in Medicare payment policy Synthesis of evidence underlying reform proposals: analysis of alternative strategies to achieve universal access, alternative approaches to Medicare reform, state and local models of reorganizing the health care system Description of federal initiatives aimed at eliminating racial and ethnic health disparities: e.g., Department of Health and Human Services Race and Health Initiative, and Healthy People 2010 Impact of the market in practice: managed care, safety net providers, market instability, and continuity of care General concepts: risk adjustment for payment and quality measurement, performance measurement and reporting for high-risk populations, and dimensions of access to care International comparisons: What can we learn from other nations? How do other countries address challenges similar to the ones that we confront? We also encourage research papers that report the results of targeted interventions, natural experiments, or case reports that enhance our understanding of these issues. Submissions should be relevant to general internists and should help the JGIM reader understand more about health policy and its effects of patients, physicians, or medical institutions and our work as clinicians, researchers, and educators. We look forward to your submissions.