Reforming GME to Train More Primary Care Physicians Will Require Enforcement

A new report (abstract) on an analysis conducted by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care and funded by the Josiah Macy Jr. Foundation indicates that redistribution of graduate medical education (GME) positions to produce more primary care physicians, which was called for in a 2003 law, was essentially a failure because monitoring systems were not in place and medical schools had a strong financial incentive to train more subspecialists.

The report in the January issue of Health Affairs studied the effects of a 2003 law designed to train more residents in primary care and in rural areas. The Graham Center analysis found that the legislation, known as the Medicare Prescription Drug Improvement and Modernization Act of 2003, largely failed to achieve those two goals primarily because monitoring and enforcement tools did not exist to implement the true intent of the law.

"If you increase GME positions, you had better be very specific about the intent for those positions -- what they should produce," said Robert Phillips Jr., M.D., M.S.P.H., one of the authors of the study and former director of the Robert Graham Center. "We need to have a watchdog or mechanism in place to make sure the law is carried out."

GME payments, the bulk of which come from Medicare, encompass a large public investment in health care workforce development, said the report authors; GME payments total about $13 billion a year. "Despite this sizeable annual investment, the supply and distribution of the physician workforce remains problematic. Although there is debate about the sufficiency of the overall number of physicians, most agree that specific specialties and geographic locations face significant shortages, limiting access to health care services."

The need for primary care physicians and services will become even more acute as the Patient Protection and Affordable Care Act extends health care coverage to millions more people during the next few years, Phillips said.

The Medicare Modernization Act of 2003 sought to address the ongoing shortage of primary care physicians by training more residents in primary care and in rural areas largely through the redistribution of unused GME slots. The Graham Center study assessed GME training levels before, during and after the redistribution process, relying on hospital cost reports to determine hospitals' primary care and nonprimary care resident counts during the three timeframes.

The act went into effect in 2004 and led to an increase of 1,585 primary care GME slots between 2004 and 2008, according to the study. But at the same time, the number of nonprimary care GME slots increased by 3,433 positions, more than twice the number of primary care GME slots gained.

"Closer inspection reveals that 48 hospitals decreased their primary care training while increasing (sub)specialty training -- after receiving additional Medicare funded positions," said the study's authors. "Our analysis also found that the redistribution was preceded by a relative expansion of nonprimary care training at the expense of primary care, and the redistribution maintained the momentum of this pattern of behavior on the part of hospitals."

Consequently, the redistribution "had a net negative effect on primary care production by diverting would-be primary care physicians to subspecialty training," said the study.

In an interview with AAFP News Now, Phillips pointed out that physicians who train in rural or underserved areas are three to four times more likely to stay in these areas after residency, which was one of the goals of the Modernization Act of 2003. The study found, however, that very few rural hospitals benefited from the redistribution.

"Out of 304 hospitals receiving additional positions, only 12 were rural hospitals," the study noted. "These hospitals received only 83 additional positions, less than 3 percent of all positions redistributed."

However, said study authors, there may be a "silver lining" in the report's findings. A secondary priority of the legislation was limiting the number of redistributed slots in urban hospitals -- a goal that was partially met. More than 60 percent of teaching hospitals are located in urban areas, but only 36 percent of the redistributed positions went to these hospitals, the report said.

Study authors reached a number of conclusions based on their analysis. For example, they noted that prioritization language apparently is insufficient to redirect the GME system.

The authors also called for stronger safeguards to maintain current levels of primary care training and larger reforms to "move the GME system to address the priority physician workforce needs of the nation."

Phillips, who now serves as vice president for research and policy at the American Board of Family Medicine, stressed the importance of putting in place enforcement mechanisms to hold teaching hospitals accountable for creating and sustaining GME slots that meet the country's workforce needs. This would entail tracking the outcomes of residency training programs on an annual basis and shifting money and resources away from or to teaching hospitals based on whether they are producing the workforce the nation needs, said Phillips.

"CMS could be the agency that handles the (enforcement), but Congress may have to create legislation to create the (enforcement) mechanism," Phillips said.

He described teaching hospitals as a "powerful force," saying that most of them don't want to be held accountable for their GME funding. "They have had a free pass and $13 billion to spend -- why would they want to change?" Phillips asked.

According to him, hospitals allocate and use GME positions based on their bottom line, and it is more profitable for them to fund subspecialty positions. Without an enforcement mechanism, this trend will continue, further weakening the U.S. health care system.

"It is self-serving, but it is not malintent on the part of hospitals," Phillips said. "Hospitals are going to staff up the services that make them the most money. Policy and oversight are needed to balance the fiscal incentives that currently govern their decisions."