Turning that once-in-a-generation offering into a true gift, however, is up to CMS, keeper of the batteries. And what we’re seeing in a proposed rule on how to distribute those residencies — while smartly engineered in some important ways — falls short of the Energizer Bunny mark.

First, the good stuff. The proposed rule — Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2022 Rates — signals the agency’s awareness of the primary care crunch we’ve long discussed and would take real strides toward closing related health equity gaps. That’s obviously welcome, and the Academy offered appropriate applause in detailed comments we submitted ahead of a June 28 deadline. (Since the December residency appropriation, in fact, we’ve been busy advocating for its most effective use.)

But there’s an even better way to address that shortage and close those gaps than what this rule proposes, and it involves a few refinements we’ve called on CMS to make.

The proposed rule prioritizes applications for residency programs located in the geographic health professional shortage areas where more than 30 million Americans live. Funneling more physicians in training to HPSAs is an AAFP policy goal, and it seems also to be what CMS has in mind here. But the methodology needs some tweaking. In our June 7 letter, as well as in comments sent to CMS in conjunction with several other groups this month, we’ve offered specific guidance on how to better shape the rule.

At the heart of this guidance, the Academy is urging CMS to invest in residency programs that train physicians who ultimately go on to practice in HPSAs. There’s no question the proposed use of existing HPSA scores is going to help award residency slots to programs ready to treat underserved patients. But we want the agency to take one logical step further and consider which hospitals and programs send the most trainees into HPSAs long term. Our letter refers to this as an “impact factor,” and if the agency incorporated it into the final rule, we’re confident that more family medicine residents would go on to care for underserved populations throughout their careers, not just during their training. Hence, impact. Layering this impact factor atop the rule as drafted now, CMS could address physician shortages and maldistribution while improving disparate access to care in many parts of the country. Again: impact.

The Academy is also asking CMS to add two criteria when determining which hospitals can apply for the new residency slots. As written, the proposed rule says applicants must be over their cap (that is, have more residency slots than the number set by the federal government in 1997), rural, within a geographic HPSA and/or in a state with a new medical school or branch campus.

We believe this part of the rule is another spot where a little tweaking would accomplish a great deal. Expanding the criteria to include hospitals with fewer than 250 beds and hospitals with only one residency program (where GME budgets often are forbiddingly small) could ensure permanent, badly needed physician residency slots at small facilities such as community hospitals. Places like this have made the news a lot over the past year, thanks to the pandemic. For the AAFP, they’re never not crucial. A nod to them in this rule would be a critical lifeline — one that, again, also would strengthen health equity.

CMS has the discretionary authority to do this. The platitude that comes to mind is “leveling the playing field.” But, especially after 2020, analogies centered on fun and games are inadequate. The consequences of continuing to underserve or ignore large swaths of Americans are too grim not to consider this targeted yet potentially comprehensive solution.

In conjunction with these asks, we’re also strongly recommending that CMS allow existing rural training track sites to increase the number of physicians they’re allowed to take. Such sites are already doing a big thing: training physicians where the need is most dire. It’s a clear case of an investment that is paying off and is ripe for reinvestment and expansion.

Despite the clear physician-workforce and patient-outcome wins we believe would result from these modifications to the proposed rule, we expect some friction from organizations that benefit from the system as it is, with its advantaging of large academic hospitals. The fact that we’re dealing with a limited number of new residency slots sets up what can appear to be a zero-sum proposition. The thing is, though, we’ve operated under this setup for a long time, and we’re not getting where we need to go. Not in terms of workforce and not in terms of health equity. For instance, the status quo is clearly not helping U.S. maternal mortality rates.

To get us where we need to go — to meaningfully fortify the primary care pipeline while advancing health equity — CMS needs to think a little bigger and define its terms a little more broadly by investing in programs with a demonstrated commitment to caring for the underserved and training physicians eager to do the same across their careers. These residency slots are the scaffolding for an improved and more sustainable health care workforce, one that can place family physicians where they’re most needed and root them there. The Academy is determined to make the most of this generational opportunity.

Stephanie Quinn is senior vice president of advocacy, practice advancement and policy.