Medicare GME Policy Holds Wins, Opportunities for Family Medicine
Residency Boost a Landmark Success, but Academy Data Point to Greater Potential
March 10, 2022, 4:00 p.m. News Staff — As CMS last month finalized policy on the first increase of Medicare graduate medical education residency positions in almost 25 years, the Academy lauded its focus on health equity and geographic health professional shortage areas — but repeated a call for the agency to consider the AAFP’s guidance when next determining residency distributions.
“To more meaningfully address disparate access to care and physician maldistribution, we again recommend CMS implement our impact factor into future distributions of slots,” said the AAFP and the Council of Academic Family Medicine in a Feb. 24 letter. “Our impact factor considers what proportion of trainees ultimately go on to practice in shortage areas and will help invest in programs that have a proven track record of addressing physician shortages.”
The letter was sent to CMS Administrator Chiquita Brooks-LaSure in response to a rule published Dec. 27, 2021, in the Federal Register and finalized Feb. 25. The Council of Academic Family Medicine includes 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.
CMS lacks the authority to distribute new slots based on specialty. However, the Academy and its co-signatories recognized the final rule’s movement toward a key goal for which they’d advocated — aligning GME funding with communities’ primary care needs — and it directly reflects several recommendations the AAFP sent CMS last year. Among other wins for the Academy’s advocacy, the new policy will
- prioritize smaller hospitals as a tiebreaker when considering applications with equal Health Professional Shortage Area scores, as the AAFP suggested (that is, when insufficient GME slots remain to distribute to applicants with equal HPSA scores, CMS will select hospitals with fewer than 250 beds);
- include community-based training sites toward meeting the 50% training requirement to qualify (a result for which the AAFP advocated); and
- align hospital GME awards to their program lengths so that, for example, a hospital applying to train residents in a program in which the length of the program is three years, such as family medicine, can request up to three full-time-equivalent residents per fiscal year — increased from one FTEs in the proposed rule, a metric to which the AAFP had objected.
“This final policy provides a more appropriate level of financial support and certainty for hospitals, which will more effectively address ongoing physician shortages and maldistribution,” the Feb. 24 letter said.
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Impact Factor
The Academy last year urged CMS to invest in residency programs that train physicians who ultimately go on to practice in HPSAs. Specifically, the AAFP asked the agency to consider which hospitals and programs send the most trainees into HPSAs long term, calling this measurement an “impact factor.”
In the final rule, CMS acknowledged this recommendation and asked for further comment on how to best estimate and weigh such an impact factor “using appropriately comprehensive and transparent data sources across physician specialties.”
The Academy and the CAFM were prepared: “We have worked to refine the data and methodology used to develop our impact factor to be more easily reproducible,” they told CMS.
Using November 2021 AMA data, 2020 HPSA numbers from the Health Resources and Services Administration, and the 2020-21 Accreditation Council for Graduate Medical Education file, the Academy and the CAFM developed a sample set of 21,375 physicians who received residency training from 622 sponsoring institutions, starting in 2016.
“We then determined what proportion of physicians are practicing in primary care HPSAs in 2021 compared to the total number of residents that began training at each sponsoring institution in 2016,” the letter said. “For example, if a sponsoring institution had 15 physicians that began training in 2016 and five of them are practicing in primary care HPSAs in 2021, that sponsoring institution would have a proportion of 0.33. We then convert the proportions into a score than can be used alongside the HPSA score.”
CMS should combine that score — the impact factor — with a GME applicant’s HPSA score, weighing each equally, to better determine how to award future residency slots, the Academy said.
“We then conducted analyses to better understand the value of including the impact factor in a prioritization for new slots,” the letter added. “In our primary analysis, we compared HPSA scores with the impact factor to determine whether there was a significant difference in scores across sponsoring institutions.
“In conducting a head-to-head comparison, we found that 39% (242 out of the total 622) of the sponsoring institutions differ substantially across the two measures. There are also 31 institutions that have a medium HPSA score but a high impact factor score. Given the limited number of available slots, it is likely that these sponsoring institutions would not be awarded new slots under the methodology finalized by CMS. However, these institutions have a track record of training physicians who ultimately go on to practice in physician shortage areas and are therefore meaningfully addressing disparate access to care. These results indicate that the impact factor adds significant value and should be incorporated into future efforts to distribute new residency slots.”
The Academy and the CAFM illustrated these analyses with tables and laid out several scoring combinations. In all cases, the letter said, data showed that “CMS’ methodology alone does not fully address the maldistribution of physicians or mitigate ongoing shortages in rural and other underserved areas.
“We strongly recommend CMS consider implementing an impact factor score in the distribution of future residency slots.”