Graduate Medical Education

AAFP Proposal Presses for GME System Reform to Meet Nation's Primary Care Needs

September 17, 2014 12:11 pm Sheri Porter Washington –

The AAFP chose the U.S. Capitol here as the venue for a Sept. 15 press event during which AAFP leaders released a proposal that aims to strategically reform the nation's graduate medical education (GME) system.

After laying out the AAFP's plan for overhauling the country's graduate medical education system, AAFP Board Chair Jeff Cain, M.D., takes a question from the audience.

The Academy's recommendations(7 page PDF), which appear in a report titled Aligning Resources, Increasing Accountability and Delivering a Primary Care Physician Workforce for America, both affirmed and went beyond those made by authors of an Institute of Medicine (IOM) report( released July 29.

During Monday's press event, the AAFP unveiled a five-point plan that would, among other things, significantly change the way GME is financed.

Specifically, the proposal urges policymakers and stakeholders to take these actions:

  • Limit direct GME and indirect medical education payments to training for "first-certificate" residency programs -- that is, those that train physicians in one of 25 specialty areas such as family medicine, pediatrics, psychiatry, and internal medicine, and are foundational to additional subspecialty training.
  • Establish primary care thresholds and "maintenance of effort" requirements applicable to all sponsoring institutions and teaching hospitals that currently receive Medicare and/or Medicaid GME financing.
Story Highlights
  • The AAFP held a press event Sept. 15 at the Capitol to announce the release of a proposal that aims to reform the U.S. graduate medical education (GME) system.
  • The Academy's proposal builds on recommendations made by authors of an Institute of Medicine report released in July.
  • The AAFP's five-point plan would, among other things, significantly change the way GME is financed.
  • Require all sponsoring institutions and teaching hospitals seeking new Medicare- and Medicaid-financed GME positions to meet primary care training thresholds as a condition of expansion.
  • Align financial resources with population health care needs through a reduction in indirect medical education payments (money paid to hospitals to subsidize indirect expenses associated with resident training) and allocation of those resources to support innovation in GME.
  • Fund the National Health Care Workforce Commission.

Regarding the last item, the AAFP proposal notes that creation of the commission, a 15-member panel charged with reviewing current and projected health care workforce supply and demand, was mandated by the Patient Protection and Affordable Care Act but has not been funded by Congress.

According to the AAFP, the IOM and numerous other stakeholders, the United States currently is in the midst of a primary care crisis that most certainly will worsen in coming years.

"The United States not only faces a shortage but also a maldistribution of primary care physicians," the AAFP notes in the report. "This deficit is of particular concern given that access to health insurance is slated to increase substantially; the elderly population continues to grow; and many rural, poor and minority communities remain medically underserved."

Furthermore, "Fewer medical school graduates are choosing primary care as a specialty today than in the past."

AAFP Board Chair Jeff Cain, M.D., of Denver, was among the AAFP leaders on hand for the announcement.

Attendees at the AAFP's recent press event in Washington were anxious to discuss details concerning graduate medical education reform with AAFP President Reid Blackwelder, M.D., right foreground, and Kisha Davis, M.D., right background, the new physician member of the Board.

"We need to apply the same evidence-based principles we apply in medicine to medical education," Cain told the audience. He spoke of a "disconnect" between the current health care needs of the U.S. population and physician training. The solution can't simply be increasing the number of physicians when what the country needs is more primary care physicians, he said.

Cain noted a lack of accountability in outcomes from a 50-year old GME system that served the country well for decades but has not kept pace with demographic and population changes.

"The AAFP isn't suggesting that our nation's GME system has failed," Cain said in a related Academy news release. "We are suggesting that our GME system has excelled at what it was designed to promote, but it is time to change those incentives."

AAFP President Reid Blackwelder, M.D., Kingsport, Tenn., spoke to the enormity of the task at hand and said it required a "comprehensive approach." He reminded attendees that in January 2014, the Academy released its "four pillars" blueprint for primary care physician workforce reform.

That effort includes ongoing work on the physician pipeline, the medical education process, practice transformation and payment reform. "We've got to keep pushing for valued-based care" to ensure a solid base of primary care physicians in our health care system, said Blackwelder.

Kisha Davis, M.D., M.P.H., of Gaithersburg, Md., is a new-to-practice family physician who serves as the new physician member on the AAFP Board of Directors. With GME training in her not-so-distant past, Davis lent her voice to the AAFP's push for change.

She told an audience of more than 50 attendees that a knee-jerk response to the looming primary care physician shortage would be to increase the number of residency slots available. However, "Simply expanding the current GME financing system would produce more of the same and not resolve our current workforce situation," Davis cautioned.

She noted that 65 percent of medical residents and fellows train in just 12 states, and that academic health centers located in large metropolitan areas like to claim that they train physicians and then "export" them to states where they are most needed.

"In reality, this is simply not true," said Davis.

She said primary care residency training programs are at a distinct disadvantage when it comes to funding. "I've experienced this personally" said Davis, who watched primary care training slots in her academic training center decrease from 13 positions to 10 and then to eight in just a five-year period.

Davis also contended that the nation's "inadequate investment in primary care" was a leading cause of poor quality health outcomes and escalating costs. "Our training system should be more closely aligned with our delivery system," said Davis. "And our delivery system does not take place in hospitals."

The AAFP's proposal concludes by saying, "Our current GME system has become an enabler of our nation's high-cost health care system" by emphasizing fragmented care rather than continuous and comprehensive primary care.

"The AAFP believes that our nation has an obligation to use its limited resources to meet the health care needs of the citizens whose taxes finance our GME system."

In closing the one-hour presentation, Academy EVP and CEO Douglas Henley, M.D., underscored the AAFP's commitment to GME reform.

"There are eight deadly words in our vocabulary: 'We have always done it that way before.'

"We've been financing GME the same way for the last 50 years, and it's time to move beyond the status quo," said Henley. "We need to create a physician workforce with a primary care foundation because that's what the country needs."

Related AAFP News Coverage
IOM Report Calls for Restructuring of Nation's GME System
Overhaul Long Overdue, Says AAFP


More From AAFP
Fact Sheet: Increasing Accountability(1 page PDF)

Fact Sheet: Aligning Resources(2 page PDF)

Additional Resource
Journal of Contemporary Health Law & Policy: "Reforming Medicare-Financed Graduate Medical Education"(
(Aug. 1, 2014)