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Video-1: youtube.com/watch?v=tcXKjfdlyuY

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Everyone, great to see everyone. Many people in person today, but welcome to those who are joining virtually. Uh, I'd like to go ahead and call the Graduate Medical Education Board meeting to uh calling to order. And Lucas, do you mind taking role?

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Yes. All right. Uh, Dr. Jennifer Choy. Hi. Dr. Becker, here. Dr. Knight here. pending. Dr. Shockley

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here. Angie Zagel here. Dr. Gy Mcccleen. Yes. Dr. G here. Dr. Hearn here. Then Kelly Collic

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here. Right. And Eric Davis here. Corum. Okay. All right. Welcome. We have some public members. I'll just mention that I have a resident working with me this month on a on a leadership elective. Alisi is here third year

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resident from Dr. Chap's program. Uh so it's good to have you. All right. Well, let's go ahead and uh so we're at forum. You said wonderful. And then let's go ahead and review the minutes from our last meeting January 24th. If there's any corrections or additions

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u clarifications, let us know. If not, we'll entertain our motion amend. Second. All right. All in favor of approving the minutes say I. I. We oppose. All right. The minutes are approved from

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our prior meeting. Well, we have a great meeting today. Uh we're going to have a lot of uh great discussion. We're thrilled to have some guests here from the Bowen Center. I'll introduce them in a second. And then we have a couple of grants to score. and uh you know I think we'll have a lively discussion probably

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around just the overall climate and the uh legislative updates and the things that are occurring um from that front as well and how that impacts our direction as a board. Um so really uh looking forward to today's meeting but uh first off I want to welcome um Ahana Maxi the

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director of the Bowen Center for Health Workforce Research and Policy at the IU School of Medicine and she has a presentation to share with us today uh from her and her team around the pipeline of physicians in Indiana and I think will be enlightening for our work as a board if we collaborate and work together going forward.

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Wonderful. Great. Um if if it's okay, I'll stand up because that way I can like see everyone in the room. Um I am excited to be here with you today. I don't want to assume that everybody knows what the Bowen Center is. So I want to take one minute um and just make sure you're aware of it. We are a

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academic research center that is housed within the school of medicine in the department of family medicine. Now you may have heard of the Bowen Research Center that's been around since the '9s. obviously named in honor of um uh you know our late uh beloved doctor um and

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former governor um Odo Bowen. Um but in 2015 the Bowen Research Center was formally renamed and approved by the dean to become the Bowen Center for Health Workforce Research and Policy. Our center as it is now the Boeing

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center works very closely with state government providing expert technical assistance for healthc care workforce data collection reporting analysis policy research um technical assistance. We work across executive branch agencies

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providing technical assistance and support um and we take ad hoc requests from the legislature as well. Um in addition to all of our work with state government, we do external projects and we have um uh you know a number of research grants and sponsored projects

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all of which are focused on healthc care workforce evaluations or policy related research. Um so really excited to be here with you today. The study that I'll be sharing with you all was a study that we did for the state of Indiana um

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specifically for the department of health and the health workforce council there. Uh we have Burke Mullen, executive director of that council here with us today as well. So, um, the Bowen Center was requested to do an analysis

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of Indiana's medical education pipeline to practice, um, to inform discussions that were going on specifically related to, um, certain specialties that we generally would consider primary care if we use the federal government's

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definition. So, those were family medicine, pediatrics, general pediatrics, and obstetrics, gynecology. So um uh and I you guys are the experts but I just did want to set up upfront the results that I'm going to be sharing

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with you today and and kind of the policy research. It is focused when we say medical education pipeline to practice. This study did include looking at our undergraduate medical education environment and our instate retention of

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our medical graduate talent. and then as a second phase looked at our instate retention of our medical resident talent in the state of Indiana. Um obviously looking at the ultimate outcome being practicing physicians in the state of

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Indiana. So the study originally was very focused on family medicine uh pedes and obgyn um and you may have seen we're happy to make sure you get the links you may have seen the full technical report where we lay out the methodologies the

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data sources and we did a deep dive into family medicine um uh pediatrics and obgyn that we did in partnership with Marian and um Indiana University School of Medicine um and we also O actually did key can informant interviews with

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every residency program director or team that was willing to connect. We sent invitations to all residency programs in the state for those specialty areas as part of the large um scale summary and those are all found in the technical report. So the technical report very

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focused on those specialties. Um in policy discussions once we started translating our findings right from what we found from our deep dive into family medicine obsessed the question came back to us well okay that's nice but how do we compare

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because where do we where are we falling behind where are we ahead to help inform policy decision- makingaking. So that led us to prepare a companion report that was Indiana's um physician pipeline to practice in context. That report is

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um broad. So it isn't the deep dive into family medicine. It isn't the deep dive into specialties. It looks more broadly at our pipeline to practice for physicians and how we compare to our neighboring states and to the nation.

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with regards to um our pipeline. Um most recently uh to make sure that there was really quick information available especially to inform discussions during the legislative session as we were nearing close our team put together a one-pager which I believe was shared

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with you all or should be in front of you. Um and that was just a quick snapshot of the findings from these reports um to make sure that there was some objective information that was available and documented um to individuals that were having policy related discussions.

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So I am going to spend only one slide talking about our very deep dive into um family medicine pediatrics and obgyn because I really want to spend the majority of the time sharing the results on the in context how we compare. Okay.

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Um this slide is looking at our um residency positions in the state of Indiana. So these are the bars and I apologize I know in the back it's probably small. This is looking at 2019, 2020, 21 all the way to 2024

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and it is looking at the first bar is family medicine. The middle is OBGYN and um the farthest one in each uh year is pediatrics. You don't need to be able to read the um legend at the bottom. The dark blue at

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the bottom are residency slots that were filled with Indiana medical graduates, either IU or Marian. The light blue are filled with students from other other programs, okay? Not Indiana. The gray

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are um slots that were not matched at match day. Okay. So, um you can see basically the trends, but the takeaway is from what we found if every single

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medical graduate medical student that graduates that goes into family medicine uh from both Marian and IU stayed here in state in Indiana, we would not even fill all of our family medicine slots as a state. Um and so you can see here um

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what the distribution is and what share Indiana medical graduates account for in matching to our slots here at the state. Um obgyn impedes. You can see um those ratios there. Very relatively very few.

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These are count data. relatively very few of our um OBGYN or pediatric residents were our Indiana medical grads. So we are retaining them into those restaurants. Yes. Um this is just

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a high level. I would encourage you if you are interested to please read the report. It goes in detail um into a lot of different things but I wanted to make sure that we had a lot of time for the discussion on it in context. Do you all have any questions about these data

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before we go on? Okay, one quick question. So for 2024 in family medicine, did those positions remain unfilled after the SOAP process? No, they were filled after SOAP, but

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this was looking at the match, which is why I was wanted to make sure I said this was at match. Yes. Any idea on the lighter blue group? How many of those are people that went to school out of state but are from Indiana? No, that would be a really

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great um data point to be able to explore, but that that is not something that we had access to. And I do want to share um that we are very grateful for collaboration and partnership from both Marian and IU um because they both collaborated and provided data to help

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support this. Okay. So, now we're going to switch gears and we're going to talk about the in context. Okay. And this is going to now we're we're switching everything I was talking about before was Indiana based data. We worked with our Indiana institutions um to get specific data

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points on specialties. But now what we're going to talk about is more nationally reported data because we want to see how we compare. Um and so we need to look to the data sources like WMC and RMP that are available across the board so that we can understand our

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environment in context to the national um environment. So number one when we're talking about uh undergraduate medical education um and I you guys you guys are the experts so I'm just going to share with you. I know that upfront. Um the first thing

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when we're looking in context is how many actual medical programs or schools do we have as a state? What do our contiguous states look like? And so I mean obviously we know Indiana we only have two. We are very small with number of programs. Um as compared to our uh

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neighboring states um so uh then we need to look at enrollment. How do we actually um compare looking at the number enrollment number of medical students? Um so even though we have only

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two medical programs at the state level, we actually do have a large they're larger programs as the IU program is very large. So um although we fall behind Kentucky with our schools or medical colleges, we are ahead. We still

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however fall very far behind enrollment in our other neighboring states with the exception of Kentucky. Now this is not sufficient to actually be able to compare our standing to the national or

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to um our neighbors. So what we've done is we've adjusted medical student enrollment to population across the states and nationally. And so this is the number of medical students

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adjusted per population using 100,000 population very common workforce um uh ratio metric that's used. And you can see that we uh still fall even though we do have IU which is a very large uh

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medical school with a large enrollment count. we still fall um very far behind the majority of our other states and behind the national average medical student per population with the exception of Kentucky. So, um this is

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putting our undergraduate capacity in context. Never fear, it is not all doom and gloom though because um if we train them, we can apparently retain them. And so what

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you're looking at is doubleAMCA reported uh data on the percent of physicians retained from medical school. And so you can see here, this is Indiana, our neighboring states, and the national

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average. Um in Indiana in 2023 um reported that we actually retained approximately 50% of the physicians that we trained in our medical programs. So um this is

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actually higher than all of our neighboring states um and significantly higher than the national average. So, this suggests that when we have students that come here um from wherever or we um raise them and they go into our medical

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schools that we are better at keeping them in Indiana. Um so, that is really great news and we're actually doing better at that than um our neighbors and than the national average. So, those are the findings in context for undergraduate medical education. I want

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to switch gears and talk about GME which is what you are all here to talk about today and we're going to put this into context. Um so graduate medical education um this again now we're looking at just the raw number of

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residency training programs. Okay. And so you can see here Indiana has 151 um residency programs. We fall behind all of our contiguous states including the state of Kentucky in the number of

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residency programs that we have at the state level. Um we want to again though look at the total number of residents because programs don't necessarily equate to the realized capacity. And so when we look at our actual number of

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medical residents, um you can see yes, we are very far behind everyone um except Kentucky. And we've been neckand-neck with Kentucky, but you'll note that we've actually started to increase above Kentucky over the last few years. And I would argue that's

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probably some of our investments that we've made into GME expansion. But regardless, we fall very far behind. Um, so now let's go ahead and adjust that per population. Okay. Because I I think that is important. Yes.

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And this is residents, not fellows. This is residents, not fellows. That is correct. Thank you. Um, so now we're going to again adjust that information for population. Okay. And so again, this is um now we're looking at the medical

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residence adjusted for population using it looking at the residents per 100,000 people. Okay. Um and uh basically we fall very far behind all of our neighboring states and

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extremely far behind also the national average with regards to our graduate medical education resident capacity for our population. This signals a dire need for additional

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and expanded and targeted investments. we are able to retain based on the data strategic and targeted investments at significant amounts are needed to grow the workforce. So again I shared it's

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not all doom and gloom. We train them, we retain them. This is now looking at the combination of position retention from residency and residency and medical school combined. Um I'm sorry again in the back that you cannot see these very

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clearly. Um but the national average for instate retention that's reported from the MC is is hovering around 48% of residents stay where they train or do residency. Um and then medical school and residency combined the national

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average is approximately 68% in state retention. Indiana falls above those um both of those metrics with 53% retention of our talent graduating from

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our residencies in state and 78% total retention from our pipeline and you can see that that is higher than all of our contiguous states. So um training the education pipeline is where we need to

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target a lot of our investment in order to build and grow our workforce. So um talking about investments I thought it would be a good idea uh since I was coming to you all today just to share what we have in the reports with

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regards to investments. We were um grateful for the collaboration with Lucas and the GME board um that they provided information and data from the investments that have been made by the board since board inception. Um, and I thought we'd take a moment. I know you

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all have celebrated that, but we have made some significant investment as a state in expanding our residency education capacity, specifically approximately $45 million since inception, leading to 592

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um contracted residents. So, we are working to build our um uh education pipeline through GME funding and investments. Um but we still fall very far behind the national average. Um and

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our states that are neighboring us that are competing for our talent, especially in the residency programs that um share uh borders with some of our neighboring states. So, what you're looking at now is um one

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of the things that we heard I shared with you that as part of our deep dive technical report um I got to meet with residency program directors from across the state and ask them what they're experiencing um what they think the opportunities are

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with with um expansion of programs and with retention of their residents post residency. One of the things that we heard from residency program directors, especially those whose programs were located in

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border counties to our neighboring states, that some of our top talent is getting cherrypicked by our neighbors because they are being enticed with significant incentives from across the border. And so, um, part of what our

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team did was a, uh, policy analysis and research into what do those investments look like from other states. Now, I want to share with you what is on this. There are two separate what we what we call loan repayment programs, incentive

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programs. Um, I and I apologize if you are all familiar with this. There is an opportunity for states to participate in a federal match loan repayment program that is called the national health service corps state loan repayment program. That program is competitive

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available to states. States are required to come up with matching funds to match the federal investment to run the program. Um, and so what you're looking at on the top is federal match for the National Health Service Core State Loan

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Repayment Program. Um, all of our neighboring states with the exception of Ohio currently operate a federal match loan repayment program. What I want to call attention to is that although it's a

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federal match and it must be run under federal guidelines, meaning only certain medical specialties qualify and individual um practitioners, clinicians, and physicians must be working in and

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practicing in specific communities under specific guidance such as they may not limit or restrict the number of Medicaid recipients that they serve. and they must offer a federally based sliding fee scale in order to qualify for this

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program. Um, but states have the opportunity within the program to do their own design to put proprietary I guess you know uh information and juice into it and how they design their

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program to make them more competitive. What I want to call attention to is in Indiana, our federal match program offers up to $80,000 over four years, 20,000 per year. Our

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max is 80,000 um in our federal match. Our neighbors offer significantly more. So um Illinois offers up to a 100,000 for four years or 25,000 per year. And when you go to

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Kentucky and Michigan, they offer $300,000 max in six years. Now, Indiana has the discretion to design this program and actually create the parameters for this program and the funding amounts. So, we

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fall far behind on the way we have designed and are administering our federal match program. In addition to federal match programs, many states develop state sovereign or fully state-run programs for incentives

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offering loan repayment. Um, and so that's what you're looking at on the the lower bar. These are stateun programs. These programs are developed in statute and are funded with either directed state appropriations or through funds

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that are established within the state where there may be state funds um uh deposited as well as philanthropic funds, employer funds, etc. to tap into these uh funds. Indiana does not

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currently have any state-run loan repayment program or initiative. All of our neighboring states have state-run programs. And when we're looking at those programs, all of them uh that all

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of those that are available for physicians are offering more than $100,000 max toward loan repayment. Um, and in some cases, uh, so for example, in Kentucky, it's, uh, $300,000

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for their state-run program in addition to their federal match. Now, their state-run program, they get to fully design and implement. Meaning, if they need to do general surgeons in rural communities, they can target

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general surgeons in rural communities. You cannot do that with the federal match program. So in the state of Indiana, we are behind on our federal match. We aren't competitive with our neighboring states that operate the federal match loan repayment. And we do

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not have any strategy at the state level or any investments at the state level to um target our own prioritization for physician workforce recruitment and investment. So, we thought that this was important to share with you all today

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because yes, if we train them, we can retain them, but we know that students are coming out with significant debt loads. And if you're training in St. Joe County up in Southbend, and you can quite simply work in Kalamazoo and you can get uh $300,000

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erased for six years in Kalamazoo versus 80,000 in Indiana. That's a hard cell to keep them here if they need to do that. Yeah. Now what body is uh coordinating that federal match program here in Indiana? That is the state office of primary care

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at the department of health. Okay. Y so I just have a few take homes um for you all and I think I am on time and on target. Obviously I've said all of these things. If we train them we can retain

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them. GME expansion. It It has to be a top priority for position workforce development in the state of Indiana. Opportunities exist right now to make our retention incentives more competitive. We we have the opportunity to make them more competitive right now. Um, but I think we also have the

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opportunity to discuss strategic development of our own incentives that could use state investment but could be strategically designed to enable employers to support those investments or philanthropic organizations as well.

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Um, I think you I know I'm preaching to the choir here, but strategic, intentional, and datadriven planning is needed to strengthen our medical education pipeline to practice. Um, and so I am going to open it up now. I'm

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happy to take any questions about the study, anything that you all would like to discuss. So, great information. Thank you. Questions? Yeah, Hannah online. Hi, can you hear me? We can hear you.

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Yeah. Hi, Hannah. This is Steve Becker. How are you? Great data. Um, very similar to 10 years ago, we had Trip Bumbach when we were starting down in Evansville do a similar sort of study for our state. Um, and really they found almost the exact same data. If we train

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them, we keep them. um at that time the only residency um spots per population that were even near the midpoint of the country was family medicine. Did you look at um or do you have this

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data in terms of the number of residency spots in different specialties comparing us to surrounding states and national average? um because as we try to figure out how we spend funds going forward, we're going to have to start targeting, I think, some some key areas that we

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need. So, I'm just curious if that data if you've if you have it or it doesn't look like you really looked at that particularly in this study. Thank you so much for asking. Uh and it's great to see you again, Dr. Becker. Um so uh this study was just to be very

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frank with you all this study was turned around in five months for the department of health. Um the Bowen Center has the capacity we would have access to the data to do a deep dive into specialty but obviously there are a lot of medical specialties and um so this study was

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basically the in context was limited to looking globally. um there would need to be probably a more targeted and longer duration study that would either or that would either prioritize other certain specialties or that would um be statewide for all specialties. I think

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to be quite frank I think that type of study is needed to really inform our investments. I'll just say actually the workforce data actually has it divided by specialty and so uh that's accessible and we're behind in literally every

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specialty. So if you look at us, we're 25 per 100,000 and Michigan is 75 per 100,000. You can only imagine that we're behind in and literally is from a time I'm sorry. Are you all right if we share these slides via email or on the website?

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Yes, absolutely. From a timing perspective on completion of this, were you able to share this with the legislators and with administration? Yes, we were. So the original Yeah. feedback. Um I so let me just share with you we

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shared these through dissemination. Um there uh and I I'm just going to speak very frankly our my personal engagement with the legislature is generally only at the request of legislators who are requesting

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information. This was a study that we prepared for the department of health and we disseminated it broadly with these resources being available to any that might need to advocate. Um I do personally engage in educating legislators but I was not requested to

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do any education with legislators on this topic during this legislative cycle. It it was shared um with legislators. In fact, that was kind of the impetus for the one pager was we needed this to be really fast and really concise. I'm sure

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Greg will talk about it. It was just a gnarly last month. So, just uh from the perspective of the students that we retain from Indiana and from a way that we talk about it, I guess I just want to emphasize it's not

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all bad that we don't keep all I Indiana students. Um, and some of that kind of came out was like we only had this number of students from Indiana and that's actually not a bad thing. I think it's important for us to recruit some from Indiana. Not all of our IU and

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married students actually want to stay in Indiana for one thing. Uh, but also it's important for us to get some ideas from outside and some blood from outside and and bring in some mix. I think it is important that we retain our graduates and even our students that go out. We

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want new ideas to come back to Indiana. Uh, and so we want them to go out and come back. And we also see that that happens. I think that some of our state um data might show that as well. Some of our lenture data and some things. So at IU, we're working to actually collect

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information about when our when our residents come uh where did you go to high school? Uh what was your county of high school? Like where do you claim to be from? um just so we can get that and figuring out where people are going afterwards. So, we have a better sense of it. I think some of it we don't actually know where our graduates are

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going and where exactly we're losing our people too. Uh it looks like we're losing them potentially around the state, but even in our specialty care areas, it's hard to know exactly where we're um also we don't know people are coming back after maybe fellowships and things like that. I do think people do

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recognize Indiana as a really good state to practice in. So uh they do establish relationships and things like that and we do have a lot of connections back to where their families are. So we also find if we can marry them we have two places where their families

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might exist and they might pretend. So uh you know so I think that's important but just from a context standpoint as we present the data uh I think it's important that number one the match does what the match does not all Indiana students want to stay here and uh and we

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need to have an influx of last so I will share one of the things that is in the technical report I obviously didn't have time to go through all of the findings uh we worked with the professional licensing agency on an exploration of using the uh basically

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medical inter the residency permits um and matching that to full medical practice licenses and tracking those resident permits all the way out for over a decade [clears throat] into ongoing practice and self-reported actual active medical practice in the

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state of Indiana versus just maintaining a medical license. Um when we looked at that there were many limitations. We are still exploring um the use of that secondary data to develop actually an ongoing tracking system for how many

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residents we actually are actively retaining um into practice but the number was lower than um some of the other data that are reported. So you can stay tuned for that. Um we are trying to

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see if that can kind of be we have to remove fellows you know fellowship you have to remove individuals that are in a residency program somewhere else but are coming here for a rotation or a certain part of their training but there are existing data within our state data

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warehouses. Um and because residents require regulatory uh permit and lensure to practice, we can actually track that as a state as long as we can um start earmarking it at the time that the uh credential or the license is

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administered appropriately. That is all outlined in the technical report and the use of that data. Um the other thing I wanted to share is something that I've um actually only more recently become aware of because I have been involved as just a research expert in national

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conversations is regarding um NRMP exemptions. And so it appears that some states when they are looking at expanding their GME capacity, they're actually um specifically seeking MR NRMP exemption,

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so match exemption for specific slots in specific areas. So letting students actually apparently just uh decide that they would like to pursue that. Yeah. And so some states including Wisconsin are using that

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strategy and offering if a graduate would like to stay that they can stay there. So I didn't know if that's something that you all have ever talked about. They be part of the rural track program in Wisconsin. I know they have a really active rural uh pro some rural track

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programs and both specialties even. Um I don't know enough about the difference between the exemptions and the all-in policy. So the NRP has a very strict all-in policy. So I don't know where they differentiate that. Sometimes you can designate a track. So, uh, you know,

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if internal medicine has a RO track, you separated out two spots, the RO track position and you might get applicants to that almost a year guarantee, but I don't know that you can know how you guarantee that students

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have any other ideas on that. I do not have any experience. That gives me imagine if we hadn't done the work that we've done here over the last few years how much even I mean it was dire looking

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we hadn't added the numbers that we had had you know this would have been beyond words [laughter] um but how I mean we all are aware of the tightness of budget what happened this in the legislative process, the huge $2 billion shortfall. How do we, as

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Dr. Becker said, to target this, get strategic? I mean, we have to be be strategic in this. And our budget is not expanding. And I don't I I think it's a we're lucky we have what we have, but that's not going to be enough to fix

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this problem. What What do we do strategically? It has to be strategic in what we do. Then to the other thing that I mentioned earlier about knowing where people are from. I know for family medicine we do a

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graduate exit survey center does that for us. I don't know if that's all specialty that's that's done for. But are there questions within that? I think there are to ask where you're from to at least be to get a

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little more data about That's good to know. But I do agree we do need some crosspollination of ideas. We're just all right. 100% retention is not the goal. Um, but

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yeah, this is a good question and the comment you're making about the the climate, we're going to get into that. I think it's going to be a robust discussion around that today. It's really difficult right now. Um there's a lot of headwinds but we but and this is super important and we're so far behind

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other states that we must be continuing to try all all avenues. Dr. N. Yeah, a couple of things. First, thanks for pointing out the retention aspect of this because I think that we [clears throat] Yeah, we talk a lot about building new training, but retention and from that family medicine

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study, I believe we've seen retention within family medicine rough like 72% to 55% over the last 10 years. So, um so retention is showing um an issue. Um the other thing we need to just to take a

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step back and look at why GMBB is important, right? To address workforce issues and then again identify which specialties in Indiana we do need to be focusing upon. I worry if we say like the one slide talks about well we've got

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more family medicine slots than there is student interest in family medicine but if the data shows we need more family physicians. I don't feel like we should back off of that strategy because there's student interest then we need to continue to figure out how you

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generate more student interest in going into the specialties that we really need and not say well we're not going to train this many because there isn't interest in it. If we did that, then we'd be trained a whole lot of orthopedic surgeons, dermatologists, plastic surgeons, which there's shortage

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of those as well. But it feels like taking a step back and just um maybe again looking at my specialty in Indiana, what do we need so that as we are adding more GMBB, it's to address those specific specialties. that I don't

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receive recently, but I know I'm sure it's special. Yeah, if you go to the workforce uh is physician workforce data dashboard [clears throat]

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and I'm really intrigued by the loan repayment and so forth because primary care, you know, the guy that goes in third and the guy that goes into family bed comes out with the same amount of loans probably from medical school

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because they were at the same spot. And so that primary care guy needs for pain and maybe that's at least a royalt primary care guy. We need all of it. I mean we need we need that briefing. So,

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and I guess what I would suggest is what's missing from this that directly ties to what you're talking about is actually the assessment of our current position workforce to actually say these are explicitly our gaps and this is where we need to invest because our

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pipeline data is our pipeline data. That's who we're developing. What we really need to have is a very solid picture of what specific specialties do we need? where do we explicitly need them? Where are we currently training?

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Where are the gaps? And then fill those gaps. And so that wasn't the purpose of this exercise, but that's actually not and that is not something that's something we do have here at the state level. That's literally what the Bowen Center has been reporting on. Um and we

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have dashboards that are available to the GME board where you can look by specialty across the counties. um see the capacity in the FTE. We really need to have a statewide physician workforce assessment by specialty to identify what are our very targeted physician

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workforce needs within local communities so that then our education investments are aligning with that. Yeah. Just a quick question on those incentive programs. What's the scale of those? because although they're impact, you know, they they describe really

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wonderful program packages for these uh residents who are graduating and going in. Frank, if they're they're only funding, you know, 20 people, is that, you know, is that really what the barrier is or do we have other barriers that are more important for us to tackle? So,

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I can tell you that currently, um, and I I'm sorry, I do not remember the number exactly, but it is in the 20s. So that our program that ID that we are doing student loan repayment is a cohort of like twice for our state for our but for the other states the impacts you don't know how big their

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programs are how far reaching they are and I mean that's something that we could drill into but that was outside of the scope to understand like because it may be a small fra you know fraction of the physicians in those states who

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are getting learned attracted by those packages and and our program at IDO that is this is those federal match programs it's not just physician it's I mean mental health professionals it's RS it's various like

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it's kind of all so you say 20 not even what occurs in our hospitals are forced at the state of Indiana to negotiate within on the contract yeah those type of repayments significantly higher than what others perhaps because they're getting some state support getting done and so that makes it even

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more difficult from competitive standpoint for hospitals in the state of Indiana especially rural hospitals competitive enough to crack that out of town so it's it's a slow stand without some help

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oh thanks sorry didn't see your hand go ahead I was just going to say uh a great great report to share I'm going to dive deeper into the data. Um, we as a FQHC, we do use the National Health Service Corps

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student loan repayment system. It's not appearing to be very attractive as we're trying to recruit for medical doctors. Um, I do think if there's an area that we could focus on, that would be great to see if and it might gain some

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traction. you know, our our association, we've kind of heard that um there's a few professions that Governor Brun loves, and one of them is doctors. So, I think getting um this this message could be, you know, something wellreceived by the the current administration. I know

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he's got issues with the health care system, but but apparently doctors is one of his um uh favorite professions. And so uh talking about especially if you align uh you know the re the student loan payment programs for his desire to

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go into the OB deserts. I I think that's something that might be um easier to advocate for than what might first seem at this point because the data shows if we if there's opportunities for us to retain even

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more. But but just so you know, like for us that National Health Service Corps works for the dental community. Like I'm able to hire dentists from it, but the number is not big enough for us to attract the medical docs. I love to see us closer to the other

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states. And and so um my colleague, Mike Taylor, who's with me today, just pulled up Michigan. Michigan reports um funding hundreds of positions under their loan repayment program that's sovereign to their state at $300,000 for six years.

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So I think we're not talking about $5 million of investment. We're talking about many millions of dollars of investment to retain. Uh which is why our residency program directors up in northern Indiana are saying we are losing talent straight up

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into Michigan. They're getting sucked up in Michigan. So, I think Are there any other questions? But I know you need to move on. Yeah, we're Yeah, we're around time. Any any last questions and or comments? And um anything that Oh, go ahead. I just going to say loan repayment may

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become more attractive right now as public service loan forgiveness gets very shaky on the national national level. And so, I think students are going to be scrambling for things. I have residents right now that are in complete awful lipo right now of calling

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every two months to get their forbearance as their interest is accumulating. It is not ready for residents right now. And this is I'm I know I'm out of time. Loan repayment is only one type of incentive. There are other strategies

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that states can implement. So depending on what happens to plus loans, yeah, it may become much of a good deal. Yeah. If the plus loan limits are lowered significantly. Yes. Oh, go ahead. Go ahead, Angie. The other

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thing I was going to add if if I'm thinking about the barriers um and why it's not as attractive is because um even with the National Health Service Corp, we can't guarantee the student loan repayment will be there at the time we're trying to sign a physician. So, if

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there's a way for the the the residents to have some guarantee um of a state program, that would be very helpful. And uh Dr. Maxi, just from your perspective, is there things that you need from the GME board or how can we

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partner on this better or do you know what do you have the ability to move forward with that further investigation that we would be happy to support the GM board. We have a ton of data and resources that are already public and available. So I think it would probably

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be a great first step for the board and maybe that's another discussion and presentation is an overview of all of the actual physician workforce already practicing workforce data that are accessible and available to the board. Um we work with agencies um uh executive

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branch agencies, commissions and councils on an ad hoc basis when there is a need for a deep dive investigation. So if the GME board would like a very deep detailed analysis, we would be hap we would be happy to support and discuss that. Um our resources through the

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department of health are limited. So when we work with other agencies or commission, we generally do have to have some resources to do very targeted analysis. Okay, that's helpful. Thank you. Well, we really appreciate your pre being here today and the presentation and yes, very insightful and hope to

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continue the conversation for sure. Thank you. Thank you everyone. a good segue into our next topic. Um, I think you know, uh, it it was a very interesting uh, legislative session, very many challenges. I think there was a a lot of work done to try to do a fair

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amount of advocacy where we we could within scope. Um, you know, we wanted some of the board members appreciate any board member and who was trying to get out there. Uh Julie Reed from the ISMA was a great partner in trying to help open doors and get us into certain uh

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rooms. Dr. Knight and I had an opportunity to present [laughter] a a rural caucus um uh you know and try to advocate on GME funding and there were other conversations happening. It was just yeah as as we spoke to just a really challenging session. So, um I'd

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like to turn it over to to Greg and uh Lucas to talk a little bit about the overall um legislative session, the impact on us, and then um you know, some budget updates as we start to think about awarding these grants moving forward and how we're going to handle some of the strengths we are facing. So,

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Greg, yeah, thank you, Chair, and members of the board. I'm going to speak briefly about the budget. I know that that uh most if not everyone in the room is is pretty familiar with uh the economic climate um in which we are currently in. So just wanted to provide

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a little bit of commentary allow you know time for for questions if there are any and then hand it over to Lucas um to kind of um set the stage for the presentation about uh the budget that that he's going to give. So the um

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general assembly uh did adjourn signing die in in the early morning hours of April 25th um finishing a few days early for what is statutory statutoily mandated on April 29th. uh the uh budget bill. It you know I I

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think you know there are a lot of people holding their breath that that you know things might uh with the the revenue forecast on April 16th um you know be be uh positive and allow for some some um wiggle room and and and and other things

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um during the last few weeks of session that did not happen. Um and so the forecast was um you know a little you know quite a bit different even than what we uh saw during the previous one which occurred in December of 2024. So um it was known that the revenue would

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would flatline towards the end of the 20 2527 benidium. Um what we saw was was that being a little bit more pronounced and then actually um um some of that uh occurring um in the fiscal year in which we are currently in fiscal year 25. So

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um someone a minute ago mentioned the uh over $2 billion uh shortfall about 400 million of that is in the current fiscal year and then it's about 1 and 1 billion um during fiscal years 26 and 27. So want to give credit to um Governor Brun

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and his team and the Indiana General Assembly for um navigating you know the challenges um um of that and um really the approach that was taken falls into three different buckets. So, one um a a tobacco and cigarette tax was introduced

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um which you know is projected to generate about $800 million over the course of the next benium. Um second to that is that uh the general assembly did responsibly dip into Indiana's reserves. So, we're fortunate that we do have um

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uh had fiscal responsibility uh for quite some time and had that available. And then the third prong is um um cuts that were made uh throughout most of state government. So most state agencies saw at least a 5% operating reduction. Um programs you know across the board

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also saw that as well. Um so I I do want to highlight um while you know the result um you know maybe isn't exactly what what uh the board was uh pursuing as we we entered the the budget year I think it is a testament to the return on

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investment and strong work that has been done um since this body's inception in 2015 um you know and so having funding 7 million across each year of of the upcoming bianium um is is a success even

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though it may not seem that way to be um celebrated. So find funding does remain flat um from the last benium. But um yeah, I'll kind of pause there and just see if there are any questions, but wanted to provide kind of that holistic outlook before Lucas starts um getting

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into uh things with a bit more detail. Okay. Well, hearing none, sorry. Has there been any um discussion internally around looking at opportunities to amplify the state funds through federal

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managing matching grants through Medicaid? We've had talked a little bit about that in January. I know that the legislature eclipsed everything over the last couple months, but um but again, you know, other states are doing that very effectively to multiply the amount

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the states investing. Um has there been any discussion with with Medicaid about that? no discussion that that I'm aware of. I I I Dr. Matt, I think that that option still could be on the table. Um however, I do want to um point out there was kind

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of an omnibus um fiscal integrity and and contract accountability bill, Senate World Act 5, uh which got passed. One of the provisions there about eight of them in the bill focus on federal funding requests. And so depending on the nature of of what would be entailed in that

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request, there are some additional steps now that are needed. Namely, if if a state match is required um to participate in new federal funds, new permanent MT um um employees are added

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or other conditions um that the state would be expected to meet. Um there are reportedly reports now that go to the state budget committee and so if one of those um three kick in it would be um something in which state budget committee would have to repeat that

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report before anything could be pursued. So I'd be interested in what next steps are to initiate the process with Medicaid. My understanding is that [clears throat] for other states it occurs at the Medicaid level that state funding goes to Medicaid and it goes

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through um departmental transfer through the feds comes back and then it's distributed from Medicaid would then be distributed to this board to go out as grants. But but it sounds like

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the office of Medicaid has to sort of I always isiate that. Yeah, I was going to say I think that there's there's some some layers that we're we're glad to do a little bit of research on, but I think you know with our partners at the Department of Health and um you know, Secretary Ro and his team overseeing

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Medicaid, it would be a process that would obviously not just include the the mission, but definitely I think could get some um intelligence on that and just detail what the steps would be if players would be involved in that, what possible, you know, routes would be for

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pursuing Yeah. Is that something that hospital systems have any to explore? Like who does that exploration and figure that out? I think it's the opposite. Medicate

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from talking to other states who've done it, right? So I think if if yeah, either Lucas or Greg or whoever you think is appropriate could just even I guess open up the conversation. Is it other state same thing to be doing this? And is this something or not that we could have

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potentially have as a vehicle to get the state saying we're only going to put seven million in [clears throat] a lot but if the state say you know that they're already doing 7 million so this potentially wouldn't cost any more than the 7 million but it could come back sounds like most

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states are getting two to three times back from the feds. Um because this is a question that I've been asked a couple of times when I've done presentations outside of Indiana about what we're doing on the GV board. They're saying how much are you getting from federal ranching funds for this because it

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qualifies for that and my answer is always zero right now. The hospital association, House Bill 104 had language that was kept in it that related to moving from a what is the hospital assessment fee now which creates a match

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31 feds to a state direct and payment program which was going to even bring more dramatically or 800 million more in matching funds at the fed level. They are supposed to be working with MSRO as of yesterday to at least get a timeline

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on what that would look like. And I think that's where you start. I think you start there because the hospital association and the hospitals across the state of Indiana wanted to to at least have that included as much as it felt like was taken that that's the one thing really needed to have in there to allow

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for federal match. There's some anxiety over the Trump administration and how much of that match is going to be there at the end of the day through the end of the year because of the desire to take some of those funds and and and allow them to fund the permanent tax

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cuts. But there's still regardless of what they do at that stage, there are still significant federal mass monies both at the hospital level and at the champion level. And I I think you're absolutely right. need to make sure that

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as MRO is working on the hospital federal matching state directed payment program that portion of that allows us to do the same thing at the GME levels [clears throat] are going to be absolutely necessary. So it is in the works and I recognize as we sit here

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today we have $7 million to be here for the next two years. So that's what we need to focus on what we do that. But at the same time, um I don't think we're I think what I sort of took away from this most recent session is no matter how much the legislators like this cuz

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everybody we talked to loved it at the end, we didn't get any more. At least we didn't get lose any but we didn't get more. So I don't think we can assume two years from now we're going to get more when this when the budget comes around from you know get more from the state. So the question is, yeah, how do we how

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do we maximize this? How do we maximize this through federal opportunities? Yeah. So, okay, great. Um, on to start just to review from last

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July, just the last, you know, application voting. Um, the board carries over $1,525 uh in uninterrupted funds. So really captured in cash until the second appropriation hits. Uh this is a review on the lefth hand side. I think a nice

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common denominator to think about the programs is the annual expense the single year expense because you know we do deal with the variable of you know is it a three or a fiveyear program. So just to kind of set a level playing field you'll see one feasibility study two program development grants and eight

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residency expansions were approved in 2024. Uh the only outlier on this slide, you'll see um each of those expansion grants were approved at a two-year term except for Marian Health that was voted on earlier. Originally, they applied for program development and the board

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decided they were more on track to residency expansion. So that program was approved for three years. So that's the one difference you'll see on this slide. So just some contrast, these are the annual expenses that you see. Um on the lefth hand side you'll

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see the average for these eight grants. It's around $311,000. Um an important thing to consider is that you know this is just for last year's grants that were approved. If you were to look at all the residency expansion grants that were approved, uh the cost comes down to more around

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$275,000 average. Right? So I think a big part of that is the internal medicine programs that were approved, larger rosters, larger PGY classes. So that's a big driver of that. Um, and then you know something else to consider, um, there

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are four programs that are currently receiving residency expansion funds that did not reapply for last year. So those are still involved with GME, but they're just not showing up in this graphic. Um, and then the other part of that is that Dr. Choy shared with us last time there

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are two IU programs that are on track um to apply for these applications um in July of next year 2026 and they've been delayed for one year. So when we look at you know not this fiscal year but upcoming there's another six or so

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programs that could appear that might change that average. Any questions about this slide? This is pretty baseline but make sure we're all on the same page. Okay. Um, so what funds will we begin

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with come July 1st? That $11,000 carries over. We will receive an appropriation of 7 million. The finance department here at the commission uh recommends, you know, reserving $100,000 for staff expenses that might be supplies, salary, things like that internally at the

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commission, which will leave the board with $6,911,525 to use between July 1st and June 30, 2026. Right? So, an important thing to consider, the feasibility and program development grants that are discussed today will not be signed until July 1st.

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So, um, all of the previously awarded grants that all that money has been encumbered and it's already outside of this. So, this 7 million is truly new money to use. Okay. Thanks. Yes.

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So, you know, kind of looking back at the last 10 years or so, the board has reached a point of maturation. It's reached it one decade since inception. A lot of great work has happened in terms of outreach, networking, and you know, ensuring that there is still a bias for

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action in our state for this workforce shortage. Um, as Greg shared, the appropriation will frame flat from previous years. And so, kind of looking at what will the discussion in July look at as well as going into, you know, next spring. I would anticipate receiving at

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least one more feasibility study application and at least one more program development grant application. um if we reached out to within the last month that those would be coming. So something to factor in. I would drop that down. 75 million is pretty aggressive for [laughter]

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I was going to volunteer to be the application. [laughter] Well, thank you for pointing that out. Yeah, that would be kind of crazy, huh? Um 75,000. Uh so the board if they were to approve program development grant and

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a feasibility grant um which might be the grants we discussed today there would be 6,336,525 to use for residency expansion. So that's kind of the number to remember 6.3 million. And so I think, you know, part of the

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reason why I brought up that annual expense is kind of how can we break that down if we were to use last year's average around $300,000 per program per year. Um, this would fund about 20 years, individual years, right? If we're

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working on uh $7 million, I think this just gives us idea of which specialties the board would want to focus. Is it a three-year program or a 5-year program? and what can the board realistically, you know, support and fund with guarantees. So, um, that is kind of, you know, a

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high level of our budget review. I'm happy to take any questions clear, but yeah, we funded two years for approved by the do we also eventually need to go back and cut that third year out of this funding.

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So there was a clause um in that grant or the contracts that said you know if sufficient funding were provided in the upcoming bium those contracts be amended um judging by this amount we would not edit those contracts we wouldn't make any amendments so they would stay two

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years but we could choose to make them a little more at three years staff would recommend um amending those contracts so they would need to apply to get additional

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Um, and yeah, I'm anticipating the applicants from last July to apply again this upcoming July. I've been in contact with each of them. My understanding is that that's the plan. Yeah. I think what Dr. Sh is asking is are we

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fun spending to continue what we sort of have funded last time or are we just like doing the new cycle of the next upcoming class of these same programs? That's what I'm trying to to learn as I've gone through is that the

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question I think so yeah as I've gone through this forecast I've gone with the approach of the latter you know starting new with the starting years so some people so they would have some unfunded years yeah for those programs we did the two years one has two year several years not

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funded but yeah but they could apply to get that third year funded no big now it would be a new class starting for the upcoming class that's coming and you're going to have to deal with the gap in that subsequent years of those programs if I'm understanding

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correct those but those sponsoring institutions they knew that yeah but it it's sort of the first time we've been unable to fully fulfill the the uh that verbiage was explicit in the

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communications when we those contracts were signed so there are no surprises with this Yeah, but we were hoping we would have had more and then we could all move and fill it and you know make a make a home. And the reality is we can't because with all the upcoming expansion

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grants we expect in July we're going to be starting over and we're going to have enough for them. We don't expect having enough for those that we're expecting. I not that these other new programs come along. Right. Correct. not to not to sponsor all of

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those programs for the full term. Um, you know, if you were to go back and look at these programs and you know, follow that same model last year, they would come out to a little above 7 million, right? So, now I think a big part of this

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discussion today is, you know, part of what the Bowen Center brought forth is which which specialties are a priority for the workforce shortage in Indiana right now. Um, and so that's kind of why I want to bring us to that overall, you know, the program has around 20

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individual years of funding that they can do. So whether that's a fiveyear program, you do four or five year programs or you did however many three-year programs. That is kind of the area staff would recommend. Yeah. And I think you know it kind of

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gets to what I see as a fork in the road like when in July is either we couple kind of I mean what we sort of bandated it last year I'll call it but this two-year approach you know maybe we only would be able to do one year I don't

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even know what or we actually start using a scoring rubric as the way to discern who's getting which response because we're going to fully fun programs for the amount of time they're asking for. Is that am I so

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that's kind of the fork what I think we're going to be in in July. Dr. We also choose to reduce the yearly amount that we give and so take that what would have been two years to three years and say okay you're getting a

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smaller amount. we'll fund you three years, but it's effectively a smaller amount. So that there's maybe not, oh, you're funded year one, two, three, boom, got I don't say we just have less

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and I just want to that's tough and I want to keep it in the discussion, but isn't it really tough for the smaller hospitals to get funded funded? Not fun. That sounds really awful. But because the funded funded nothing results in a lot of reduction.

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So right I think the the dialogue is going to end up being on if legislators legislature decided 7 million's all you could get. I don't know how you grow programs and maintain

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the existing. So you could grow the new programs by cutting this in half or by cutting it to zero for the existing ones. They're going to drop and you're going to add new somewhere else. It's a net watch. But then they're going to drop in a few years and they'll do the exact same thing. I

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mean, I think so. Yeah. I think I mean and we don't know, right? I mean, we don't know if programs will truly close based on the losing this grant money. We don't that's a that's a hypothesis, right? I mean, they may the sponsoring institutions may see

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the investment as worthwhile. That's one possibility. The other possibility is some programs do close if we started out funding. Um or yeah, I I mean this is tough. We have limited resources. So, we're going to

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have to as a board come up with the best barest best use of the funds and we think is you know our our responsibility and our ability to serve. But it's this there's going to be some tough. We are July is going to be Last July was tough. This

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July is super tough. Yeah. So I guess I'm just trying to make sure I'm thinking about this right. Um shouldn't we decide whether we actually develop new programs or just support the ones we have? Is that a decision we need to make?

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driver like are we really like if we took the how much are we asking where this go around 650,000 something would that be better used I guess with open RFPs we have to allow

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people to apply and we have scoring I don't know if we can make that do we have to decide as long repeat the specifics of that question. Well, I guess like if if we have $7

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million and it takes $7 million to support all of the programs that you guys already have. So, um then should we not be entertaining new development grants and new facilities? Yeah, I guess we could make a decision

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to close the RFP for new This is like we're not going to have enough money. This is part of the discussion. Dr. It was never the intention to fund these programs in perpetuility. Right. We talked about that.

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Yes. Right. And but at the end I think we're also seeing the realities of what health systems are facing now which maybe they always were but it's more intense I think right now that if you take away this much grant funding for a program that there is a risk of closure

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and then we risk all this investment and then it's deescalating the the the pipeline. That's I think what people are concerned about. But your point is fair Dr. Becky. It was not the intention at the beginning to fund in perpetuity and

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we had early discussions about this philosophically and how long and if we had enough funds we decided yes we we would fund them in now we're at the point we could not have and I worry like for a system like mine that we could set up programs proven

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that but um my system if I said okay we'll have funding to set it up for two years and then maybe two years of expansion and then we're going to have to figure it out they I don't think that they would approve it from from my hospital, right?

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I think that's the frustration at the legislative level for us to be able to make a decision as to okay, we're going to we're going to shut some down so the the older ones because it was never meant to be in perpetuity and we're going to add new ones impact. What we've done then is basically bail out the

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legislature by saying, "Okay, I'm going to give you 7 million. They'll figure a way and they'll figure a way to continue. They they this board they hospitals figure a way to continue to grow residency programs in the future on the same numbers that they gave us four or five years ago. That seems

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ridiculous. That that seems um blatantly wrong. And the reality is that if we continue to do that, then we've we've allowed the legislature to basically drive us into a hole and they still get

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to brag up. They still get to brag up that they've grown programs state. I I just don't think it's I I think I questions right. I think decision has to be made as to are you willing to continue to grow programs knowing that

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the budget has not been expanded or are you going to say because this is all you gave us we will continue with the number of programs that we have now additional ones until such time as the budget increases how you have to decide I I don't know

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which is right yeah I from my perspective as Uh when I first came on, I was kind of thinking, well, why are we funding for so long? And right now, now after being in my job for a year and a half, actually, I feel like uh the programs that we're funding

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right now are actually pretty fragile. And uh until they've been around for 10, 15 years, every dollar counts. uh and believe that I believe yeah uh but

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seeing my programs that are only 5 years old have been funded through this uh you know we still need really strong fat development in our period we still need a lot of a lot of inputs that um yeah

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it's just not enough and so five years not enough so what's the m what's the ideal amount of time I can't answer that question that a little I'm personally a little reluctant to transition people out completely at least whether we

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decrease funds or whatever but I I would be reluctant to transition transition out existing program correct at the expense of new and that would be at the expense right of not offering new development when we see this mass of data that shows we're

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like layers behind other states which is also a really hard thing to Nobody has money to fix that problem. Like my hospital does not have money to fix that. I hear none of them.

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Nobody does. Nobody does. Go ahead. Dr. I guess I step back and look at the code the code that that formed this board and it the focus there is developing new program. It doesn't talk about sustaining. So I think that's a question

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that I have as state almost is is our charge as a board to continue to look at development of new programs or support the programs and ideal again it would be both and if we got more

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money we could we would help for a few years we could um could get that additional money but I well and I think the climate's different than it was 10 years ago when that code was written too. I mean, at the time

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we I I think I know for being on the board at the very early time and Steve, you maybe you could show the people on the virtual room. Uh, Lucas, but Dr. Becker, you know, I think at that time we philosophically it was very clear at the beginning of the board discussions

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that it was not it was a startup process. It was it was that was our our general gault. Um, but you know, we always had this tension that we knew that was out there, but I think the environment and our job as a board to read the current environment for these

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GME programs is very different than it was 10 years ago. We're substantially different. What would you say, Steve, as you are? I actually I actually think the original intent was to try to expand the state

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with 500 additional spots to get us close to the national average, which was what was required. And therefore, the original bill was written to get to 22 million a year to support 45,000 long-term for all the new programs

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long-term. That was the original goal. And of course, they only funded a 2-year period, you know, at 3.5 million the first year. Um, so I actually think the initial working group and intent was to be long-term funding. Now, that's the

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the decision that we're going to have have to make right now. Um, I think one thing anyone applying for a development grant right now certainly has to understand that they can't rely on the 45,000. So I think the the the groups that have

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worked on scoring metrics I I think in general we have felt the 500,000 development grant was a very important um grant probably the most important of the three that we do because that's that's [snorts] a time at which you're

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you're starting to build the program you have no revenue coming in now having started multiple programs that is really true that's a big hit on a hospital to take a jump and invest all that money in the first two years when they're getting no CMS revenue back. Um so you know I

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think at the beginning the goal was to add 500 spots in the state to get us near the national average. Um and that this would happen over a you know a 10-year period. Um, now there's been other discussions at the board and new

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people have joined the board and you rightfully the question is what should we do if we don't have enough money? Do we continue to fund um or do we do we start new programs and hope that other programs don't drop? Obviously, for

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somebody who has started and been involved with starting programs, um, and I I know Jen and and Rob would would think the same way. It is a tough slog to get through that first five six years and even at that time you're not fully

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solidified. Um and I my own personal feeling is in some ways we have to protect what's been built so far. Um because it would be horrible to lose programs and then have to start all over somewhere else and have a 5 to 8year

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period to get to those being stable. Um but I think that's a discussion for you know July's meeting. One thing I would recommend I would I would like to get the doubleAMC data uh and see exactly where we are number of resident spots

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for the residencies we are we are um um willing to fund so that we can at least get an idea if we've had impact. I do know that family medicine back 8 10 years was the only one that was above 25th percentile in our state among all

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the other ones. At that time we had one psych residency in the whole state. So we need to look after these multiple psyches have started maybe that now is getting to where it might be sustainable for our numbers long term. So I think

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before we make a bunch of decisions in July, it would be nice to at least have that doubleAMC data which is should be reliable if how many spots do we have in each of the specialties and then obviously longer term getting really good workforce development from from the

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Bowen Center to try to make some longer term decisions about what the state needs. Um so I think the discussion is right on that everyone and I think everyone's point is good. it, you know, we're in this position. We're just going to have to make the best decision

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um that we can with the funds we're going to have. Madam Chair, yes. Um you know, should the board decide to not approve the program development grant today, um there are at least four program development grants um

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that are on track to metriculate um by 2027, you know, pending no other delays, right? So there are still things happening and moving beyond what is discussed today. So just something to consider. Oh, that's a big factor. Those are

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people waiting in the wings looking to start up programs. And I'm also trying to think strategically as a board. How do we how do we uh does one avenue versus another help us

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drive more impetus to get more funding? I mean I don't I don't know the answer to that. Right. So we had to say we have to close our program development grants because of lack of funding. Would that create

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more urgency in the next bianium that we need more money so we can now start getting them? You know what I mean? It's with that how would that versus

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money there. when they when they apply for a new program grant, do they know that they may not get the expansion? Is that very clear to them? I think I mean historically every program has up to now. So I don't know

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that if they're talking to colleagues and they're trying to figure it out, they they probably assume they're going to get it, right? uh because we haven't been explicit of saying giving out part of it the application be how are

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you going to fund this past you know I know I know in the application it talks about possible support well and I think it's also we didn't really know would we drop off these because if you drop off the longstanding programs

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and you start the funding then there is the funding Right. And if you there would be a youth expansion funding for them. If you would say the program has been around for six, seven years, we're going to stop money. There actually would be dollars for them. So we haven't

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been explicit yet because we haven't really made that just one point. Yeah, Madam Chair, I the the way in which these these hospitals are qualified are applied is through the commission's R&P process, which we do

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for all of our grant agreements and contracts. Um those clauses are laid down very explicitly. Now you know because of approvals you know uh the supply um being sufficient to meet

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demand of the past we can't influence you know one's perspective if they're thought oh you know we're going to get this but um do want to just provide that that um clarity for the board that that that language is very clear throughout um the

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R&D clear throughout that that that it is a competitive process um yeah you know for which they are applying and that um we can't prevent assumptions but that language is is very clear and explicit

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there were a couple of other development grants that were coming up through like those are ones that we've already approved and funded I didn't understand so that's not money that were they're new there had new votes They're just going to hit our

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they're ones we're expecting to become expansion grants become program. So that is one emergency medicine program, two family medicine, one internal medicine and one psychiatry. So

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it's five that are set to metriculate by 2027. Interesting. Okay. Well, July is going to be um for [laughter] a very complicated meeting. Um, and we're going to have to come. So, I think

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we're, you know, but I think this but I wanted to make sure we laid this foundation out before we voted today on these two grants because it it does, you know, we could make some I presume this we we could table some things or we could make some decisions, but if we

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vote on these, we are taking out and they get approved. we're taking out 600,000 of the roughly of the six million of three 6.9 million we have um for the next two years. So that I just wanted to have that context in place.

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Angie [clears throat] um so I agree this is actually laying out the case for the advocacy or the educational work that needs to be done as to why we need uh

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more funding. If we cut existing grantees and continue to expand and fund new programs, then the legislators will have no incentive. They the we figured out the the the we

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solved our problem, right? Um, and so, so I would say we we probably should use the I mean we we need to go to them and say this is the dilemma that we're in, you know, and make sure that, you know, they kind of do we need to go

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back to what that core document was as far as our marching orders because we don't want to we want to fulfill the obligation at hand. But I agree, we can fund new ones and the last thing we want to do is open up the newspaper and see a bunch of residencies wellestablished,

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you know, in the community um start to close their doors. That that makes no sense at all. Um my question is what's been it, you know, ha I know you guys probably don't have this off the top of your head, but I'm have we proved like

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99% of the grant applications that have come through are okay. So all these people that are currently planning are sort of it's been historically almost you know a guarantee that you you get the funding. Yes, we have had the

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funding. So, we have been able to award pretty much every grant with some applications. We've sent them back for some clarifications or some Oh, yeah. Maybe um it wasn't but they they weren't they didn't follow the the RFP requirement that it was that

326
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specialty because we never had PMR on them. Yeah. But generally, we have um to your point, Angie, we've been able to approve almost everything. So, I mean, I wonder even should there be some sort of statement issued by the

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office or the board to everybody that's in the process just letting them know that the funding was not increased and putting them on notice, but also that's a document that can be shared with the legislators as well as we start to

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advocate. Yeah, I want to add, Angie. I think that's a really good point. And I I think like for the development grants, those institutions need to know that at this point they're probably not going to be 45,000. So, but they are actually in

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the launchpad to build the program. So, they're going to make that decision right now that they're going forward with the program with the half a million dollar startup grant. So, in that way, that is a a strong um statement by that organization that they're willing to do

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this. So they're not going to count on the 45,000 to make it. Now, of course, the world can change in two years. Hospital revenues can fall through the, you know, so we can't control those things, but I think it would be good to let people specifically know the

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situation the board's in and that we don't want them starting a residency expecting to have the 45,000 a spot to make it run. Yeah. But, you know, and I I hear you,

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Steve, but with our current scoring rubric, it doesn't it's not going to direct the funds that way. Our current scoring rubric takes away points for people for long for the programs that are more well established.

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And so if that's a decision, so there's no we can't tell those programs in current state you can't apply and if they are given the scoring rubric as we've set it up they actually will get more points than

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the established programs and so right but they can't be guaranteed nobody can be guaranteed and unlike in the prior years it was sort of a guarantee because there was plenty of money. So, I'm just saying that whatever our scoring metrics is at the [clears throat] time we vote,

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that's what it is. But in reality, we we need to let people if they're applying for a development grant, it's not like it was three years ago where everybody was getting 45,000. It's it's fair to let those institutions know that. And that actually is part of the, you know,

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the need that we have to raise funds from the state or somewhere else. Yeah, go ahead. My other Go ahead, Angie. I'll Well, my other question was, if we choose to decrease funding for the

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existing grantee, how much notice I'm I'm still trying to wrap my head around the timing of everything, how much notice would they have of the funding change? It would be it would be contingent upon when that decision was made by the

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board. Yeah, Angie. So, uh, I I was this is I didn't want to interrupt this really good conversation, but if there are substantive changes that the board desires to be made prior to July 1st, that would require a vote, for example,

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uh, Dr. Becker, to your point, with the $45,000 per slot, uh, that I believe Lucas can correct me if I'm wrong, is explicitly stated in the RFP. And so there would be some really quick updates which we can do but they would need to be made done at the board's direction.

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And so that would require vote on on some of these different items. So I I think doc Dr. Hearn um I was planning to bring up that she mentioned it um with with the scoring. I mean that is the northstar in its present form and so if there are changes

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amendments that need produced on those um we're glad to take a look at those but that would need to get turned around soon. Yeah. If the you know unless Yeah. I mean the other option is for us to try I mean this would be a path

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forward is to live into the our scoring rubric. We've had it for a long time. We just had a couple of meetings of our scoring subcommittee to refine it, make it very objective. And so what we could do is just like live into that scoring rubric that we've made and then just

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recently refined and then see what happens in July because the rubric will drive we designed the rubric to drive what we thought we wanted as a board. We've agreed upon to develop new programs and maybe support them in their Yeah. and

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right versus like right now trying to change our rubric again is a little bit of a panic approach. It's not I understand we're feeling panic because it's we're right here. Um but we could just live into it and then see what happens and then based

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on that if we decide you know we need to modify we could I mean that is one down road for the for the following July as we see gosh this had anticipate I we didn't expect it to fall like this or we see that but the because our RFP and our

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rubric yeah is what we are supposed to follow. So the the the vision of this board was always to develop new programs. That was we we put priority on that not necessarily to support them. I mean ideally both said Steve said the

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vision was to start in support. So both it was to do both right choose which one it was. I guess I think we've had discussions over the course of the board's tenure. Yeah. that have has has

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led itself a little bit towards this fact that we knew it wouldn't be forever. That's like not a tenable thing to think just, you know, have these grant funds forever and and not, you know, at some point they they shift to newer programs that want to start up. We

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we we we've definitely discussed that a fair amount over the years, but I think ideally we've wanted to do we've also wanted to understand that supporting a program longer than 5 years is ideal and they do need this support infrastructure. So it's a both a

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chair. Yes, we need to edit or you know make amendments to that R&B. Um you know those applications are due by June 25th, Wednesday, June 25th. I would want those applicants to have at

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least one month with the RFP. So you know and all, you know, last deadline would be May 21st. Wednesday, May 21st. So it's just over three. So I guess yeah the thing I think I need to get gather from the board is do we

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want to just like live into our current scoring that we've modified or do we want to try to hedle a work group in the next couple weeks to do some modification such that we could then pivot and that would be a big change to do in a very short amount of time. But

353
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when you say live into our current score, that means that some programs in July might not get just to keep sight the agenda. Um there are three proposed recommendations in the agenda today. Yeah. So this is an appropriate time to talk

354
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about that language. Um but that is part of something that should be decided today. Right. Yeah. Yeah. I do want to be u Yeah. So, um I but I do want to get some feedback from the board about which direction to move in. If we want to just

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move forward with our current scoring rubric with the modifications that are about to be discussed from the scoring subcommittee or if there's a desire to try to very quickly create another subcommittee to do a deep dive and make some different recommendations.

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Would you like to vote on that? Someone would need to make a motion to to reconvene the subcommittee if if that's what we think that that's sort of direction we want. I mean, it would need a motion to But you you do we want to vote of our opinion? We get to

357
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share share our opinion. I mean, how many are in favor of living into our Can I just ask the group for their general? Yeah. um moving forward with our current rubric and living into that in the July meeting

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versus trying to create a very quick ad hoc group to three to make some modifications before the July meeting to our scoring group. Any in favor of that? I like that idea better, but I don't know that it's I mean, the question become, do you

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really have I think you can address some things that are a priority in the state of Indiana for this group to say, okay, these are the ones we're trying to protect as opposed to some that may have either deeper pockets or a safety net.

360
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But you got time. Yeah. Well, it seems like there's enough momentum to just like live into what we've done. And honestly, that's okay. You know, then we'll see what the what the uh ramifications are and then we'll be able to guide our board even better

361
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once we learn how those do shake out. I think that's it sounds like that's the direction we're going to go. So, why don't if it's okay for the sake of time, I know we're getting close to the end of our board meeting. Um let's talk about the updates to the scoring rubric, but thank you for this robust discussion because we this is really hard really

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hard stuff that we're facing right now. Just to clarify, my understanding is the board will postpone the focus on feasibility and program development today. I don't No, I don't think so. I think we're just deciding that in July we're going to live with our current scoring.

363
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Okay. That that was a decision we made. Correct. Yes. Yeah. Okay. And then we can still uh move forward. Yeah. Great. So, yeah, the recommendations

364
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there's nothing new here. Um this has all been previously discussed. There it is. So this is the current residency expansion uh you know scoring template. Um there are two areas for u evaluator discretion

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up to 20 points. Um the recommendations of the scoring subcommittee are to implement a tiered scoring system. See if I can read this bigger. So for uh involving a collaborative approach uh taking that from 20 points

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possible down to 15 and just listing out what those components are so the applicant can ultimately determine what that score is going to be prior to moving forward. Um so those eligible collaborations area health education center critical

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access hospital a federally qualified health center behavioral health provider and other um and so that is still to leave some discretion up to the evaluator. you know, if there's something that hasn't been discussed in that subcommittee, still opportunity for us.

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So, no major changes, just clarity. And again, our subcommittee was just trying to make things much more objective because some of these scores were like 20 points if you collaborate and we wanted to provide a little more structure and objectivity to it.

369
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Yep. So, um hearing no questions, that is the first recommendation. The second recommendation, which it sounds like was in favor of everyone, is a 50-page limit on the applications. Uh, and so, you know, that will be me working pretty

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closely with those closely with those applicants just to ensure that they're not missing any key points of their application. But that's recommendation two. We love that one. They'll love it, too. I think so. And then three following that same that

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same vein for the first recommendation. So strength of application you know uh just kind of listing out different compon components that would make a full complete strong application including a faculty development plan letter from medical staff leadership letter from administrative leadership and then some

372
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form of community support. Right? Still a total points possible of 20. So those are the three you know the three recommendation areas and so ultimately a lot of this will be

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more formulated versus this is what I feel. Yeah Dr. Can I make a suggestion? It says letter to the state legislature. I think the intent was to legislate not.

374
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Yes, your local legislator. It would be very hard to get a letter. Yeah. Yeah. And the other uh the other scores remain the same which are based on density of positions in that area based

375
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on years from inception of the program and uh one other [clears throat] we have the initial collaboration. Yep. Uh so you have the

376
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population to primary care ratio um the county ranking collaborative approach year since establishment and strength of application. Yeah. Okay. So I'm happy to answer any questions about those recommendations.

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And if there's no further question to approve that to approve second. Okay. All in favor of approving our updated uh scoring rubric as outlined. I any opposed?

378
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Okay. So, that motion carries and this will be our new rubric effective with the next Yep. So, this will I'll start working on edits to the RFP at least with this. So, we'll aim to have this published. We'll we'll discuss the timeline that

379
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yeah, we'll start picking that up. Thanks for all your help. You guys a lot of work. Thank you. And thanks for the folks on the storm scoring subcommittee as well for their effort. Okay. Well, I want to keep us moving. Get us see if I can get us done on time.

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We're pretty darn close. So in the vein of what we just spoke about, I think we'll then move forward with scoring these grants because that's what we said, you know, and we just philosophically sort of agreed like let's just live into our funding and our scoring rubrics and our RFP process. And

381
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so we have two grants for consideration today. The first is a feasibility study that was um sent in from I think it's Beacon Health. Did I have that right? Beacon Health System up near South Bend. They were exploring multiple um different possible GME programs and

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they've applied for the $75,000 uh grant and hopefully you had a chance to review the application. Lucas, do you have scoring to share with the group? Yes. Um so the uh state or the county ranking was

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awarded 20. The population to physician ratio were awarded 10 points. the average for the involving a collaborative approach just under 18 points out of 25 right and then the naive specialty oops above that um comes

384
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out to just under 21 points so the score for that uh the feasibility grant is 60 68 out of 100 any questions or discussions about this grant application there since there we have had funds the

385
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score doesn't won't really dictate but we're just providing it for all right if there's no discussion on this grant application I'll enterain a motion to approve this uh feasibility grant for vegan house

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okay Dr. Choice Dr. Shley first Dr. Sure. Second. All in favor of approving the feasibility study from Beacon say I. I. Any opposed? Any opposed? Okay. The feasibility study for their for this will be approved. So

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we can let them know. Thank you, Lucas. Then um la uh la the second program uh grant we have to approve today is a program development grant from southwest for psychiatric the southwest consortium from psychiatry. I assume we have a couple of folks who may need to recuse

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themselves. Um but want to just uh again run through the scoring and open up any discussion on that grant application that questions or discussion points people might want to share. Okay. Um go ahead Lucas. Right. So this should u be located in Vanderberg County. Uh so

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receiving full points 20 points for the county ranking. The physician to population ratio received 10 points out of possible 25. Um this sheet that I'm showing you um takes out the people who claimed the

390
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conflict of interest. Um so 19.5 points out of possible 20 for a collaborative approach and then 19 points out of 20 for strength of application and then 90 specialty 16.5 out of 20. So

391
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this application received about 85 points out of the possible 105. Now if the board is interested if the scores of those who claimed the conflict of interest was included it's less than a point of difference. So the board is pretty on page with these applications.

392
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Yeah. Okay. Wonderful. Second. Yeah. All in favor of approving the Southwest K3 uh grant development grant say I. Any opposed? Okay. That also is approved. So good

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news. We got to share some good news [laughter] for now. They were in this very good mood. All right. Excellent. Um, okay. Well, thank you. This was a this was a complicated meeting and and July will be maybe even

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more so, but uh I appreciate everyone's effort to do the right thing. This is this is hard stuff. All right. Well, really thrilled that we've had our student members uh who've been a part of this board with us. It's just uh fantastic that I think you guys I think it's such a great learning opportunity

395
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first of all that you all get to be a part of this board to just listen and uh reflect a little bit. Um so I'm going to read the resolutions for each of our student members my glasses versus resolution for Eric Davis for his service to the graduate medical

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education board. Whereas Indiana currently has a shortage of over 800. Actually these are the same. Let me um I don't read twice. Is that a thing? Yeah. And also a resolution to recognize Kelly Pull. Um so let me read this. Yes. Uh

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whereas Indiana currently has a shortage of over 817 physicians. And whereas increasing the number of physicians especially in rural and underserved area improves the health and quality of life of who's your communities. And whereas the graduate medical education board was

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established in 2015 to expand graduate medical education in Indiana by funding new residency program slots at licensed hospitals and qualifying nonprofit organizations. And whereas the graduate medical education board is comprised of 10 ganatorial appointees representing

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key public health organizations and associations throughout the state. And whereas Eric David has represented the Marian University, Tom and Julie Wood College of Osteopathic Medicine as a student adviser of the graduate medical education board since 2023 and served

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the graduate medical education committee and in Indiana residents with distinction. And whereas Kelly Cole has represented the Indiana University School of Medicine as a student advisor of the GME board since 2024 and served the graduate medical education community

401
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and Indiana residents with distinction. Now there be resolved. The graduate medical education board expresses its deep appreciation to Kelly Pulock and Eric Davis as they conclude their terms of service and wish you both continued success.

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next and a little bit anything you want to say about your time on our board and what you I'll start off. It has been an incredible learning opportunity. So, thank you so much. I've had no idea the time, efforts, and funding it takes to start these programs. So, it really has

403
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kind of altered my perspective a bit. Definitely, you know, when you learn a little bit of something, you realize all that you don't know. And I think this has been a perfect fit for that. Um so thank you for having me here. Um I will be going to Mayo Clinic Florida for my neurology residency. Um and just along

404
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with that on being with the board I was really surprised not surprised I knew about it but during my application process you know I'm going to apply in Indiana has IU so incredible program you know a 10 spots and then you look at Ohio Illinois they all have 30 40 plus

405
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neurology positions. So it was just very startling to see you know kind of what the board was tackling like right in front of me. So um very thankful thank you all too. Yeah. I am like trained here from here. So I do intend to go to Florida as Dr.

406
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Troy said but probably I wouldn't be surprised if I came back. So I'm kind of that doesn't show something new out there. Yeah. Yeah. Wonderful. Thank you. I'm a similar position. So I imagine

407
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Christ Medical Center in Oklahoma the Chicago surrounding area for internal medicine. Um I also have a family here. So the Indiana like you said underlying come back is very real for them. But that being said I'm excited to carry on

408
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here. So I wanted to thank the board for you know allowing us to have this opportunity. Uh I went all around after my medical organizations during the board year and I got to spend one uh one month at a program that's funded by the board and so it was really neat to kind

409
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of see those areas and where the point is [clears throat] you know medical access to to so thanks to the board thank you to Dr. Knight University for me to have this position. Yeah. Well, we wish you both much

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success and we do hope we lure you back and [clears throat] uh we are so excited that I think both Dr. Kn made recommendations or uh for us to have new student members that'll join us at our next meeting. So um you know you your shoes will be filled with others in your

411
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same position and we're just thrilled uh for your connection to this board and and what you get to do moving forward in your career. Thank you. Um, all right. Any I'm going to pivot now. Think if we got through all of our agenda items. Um, any public testimony that we would want

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to anyone would want to share from the virtual org in the room? And just to note, uh, we received some public testimony um, following the previous meeting. Um, board members should have all received an email about that and it's also in your your packet your agenda packet um, in case you would

413
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like to look at it. Yeah, there was a fellow who had written us a letter and clear out a little bit of their recommendations. I thought that was nice to see them taking an interest. All right. Well, this was a very full meeting. Look forward to our meeting in

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July and really just seeing uh the fruits of our work and how it all plays out. Uh and just appreciate everyone's engagement today. So, we'll see you all. So, a motion to move adjourn our meeting today. I think there's no opposition. Okay. All right. All right. Seasoned and we will

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see you all in three three months of July.