Family Medicine Groups Press CMS to Expand Rural Training

June 27, 2016 11:19 am News Staff

In light of the great demand for rural physicians around the country, the AAFP recently joined with four other family medicine organizations to spur changes in a proposed CMS rule( that could help expand the ranks of primary care physicians where they are severely needed.

[Young physicians talking and working with a laptop at desk]

In a June 16 letter(5 page PDF) to CMS Acting Administrator Andy Slavitt, the groups outlined the suggested changes, which aim to provide greater support for rural training. CMS continues "to take an unduly cramped reading of its statutory authority," the groups contend -- specifically, its authority to create special rules to support such training. In addition to the AAFP, the letter was signed by the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors and the North American Primary Care Research Group.

"The production of primary care physicians, especially family physicians, is a key area where we believe CMS can and should do more to remove barriers to increased production," says the letter. "We hope CMS will provide special consideration for underserved rural areas under statutory authority given to CMS for that specific purpose."

Story Highlights
  • The AAFP joined with four other family medicine organizations to urge CMS to change a proposed rule on graduate medical education to better meet the demand for physicians in rural areas.
  • The organizations wrote that CMS is not using the statutory authority it has to promote the training of rural physicians.
  • Seventy percent of residents who train in a rural area continue to practice in the same setting.

The volume of medical residents who become rural physicians remains very low. A study published in Academic Medicine( in 2013 found that only 4.8 percent of all graduates of 759 teaching institutions chose to practice in rural areas, and 198 of these institutions produced no rural physicians at all.

Even though 70 percent of residents who train in a rural area continue to practice in rural settings, most rural training programs do not receive sufficient federal funding for their residents. According to the organizations, CMS should be doing more to promote training of rural physicians.

"We are concerned that CMS, in its rulemaking, has not sufficiently considered its authority to encourage the production of rural physicians," the letter reads.

For instance, urban hospitals should be permitted to launch more than one rural training track at any time, but current CMS rules make such a move cost prohibitive. If an urban hospital opens an additional rural training track in the same specialty in a new rural site, the program would be considered an expansion of a current residency and, therefore, ineligible for federal funding.

The Balanced Budget Act of 1997 limits the number of residency slots teaching hospitals can offer as a control on the growth of Medicare graduate medical education spending. However, the law included an exception for expanding residency slots in rural areas.

The letter asks CMS to use its authority to "allow the establishment of new training tracks by the same urban hospital, in the same specialty, at any time -- and provide for an increase in that urban hospital's cap" so it can establish a new rural training site.

The method CMS currently uses to calculate residency slots discourages urban hospitals from opening new rural training track programs. Residents who spend one year at the urban facility and two years training in a new rural site are still counted as residents of the urban hospital for the first year. A hospital that wants to begin a rural residency has the option of opening two or more separate sites of the same specialty simultaneously or it must establish the programs in different specialties, another obstacle to rural program expansion.

Current rules also prevent rural hospitals from increasing their cap on residency slots after a new program commences. The hospital can increase its residency slots only by opening a new program in another specialty.

CMS even applies limits on residency slots for hospitals that do not have an official teaching function. Hospitals that allow residents to use their facilities for brief rotations are designated as teaching hospitals even when that is not their core function.

"We ask that CMS revise its definition of a teaching hospital," the letter states. "If a hospital makes no claims for the training of residents in that hospital and is not the institutional sponsor of an accredited, or approved, graduate medical residency program, we ask that it not be considered a teaching hospital and, therefore, have no cap."

Related AAFP News Coverage
AAFP Urges More Federal Funding for Key Primary Care Programs

Reports Highlight Importance of Residency Training in Underserved Areas