Health Care Reform Law Calls for Reassigning Residency Slots to Benefit Primary Care

December 01, 2010 06:10 pm Barbara Bein

Part of the focus of the new health care reform law is training more physicians for a revamped, primary care-focused health care system, and one provision of the law could help. It specifies that hospitals' unused graduate medical education, or GME, slots be redistributed to hospitals in regions with health professional shortages that want to expand or establish primary care or general surgery residency programs.

According to Section 5503 of the Patient Protection and Affordable Care Act( if a hospital has residency positions that have been unfilled for three Medicare cost reporting periods, the hospital will be required to give up a proportion of those positions.

The HHS secretary will redistribute those slots -- which could number as many as 600, according to one analyst interviewed by AAFP News Now -- giving preference to hospitals located in states with a low resident physician-to-population ratio or with high numbers of people living in primary care health professional shortage areas, or HPSAs. Preference also will be given to urban hospitals that have accredited rural training tracks and to rural hospitals.

CMS' final rule( implementing GME redistribution was published Nov. 24 in the Federal Register and takes effect Jan. 1.

According to an analysis( of the rule by the Council of Academic Family Medicine, or CAFM, CMS has set up processes to determine

  • which hospitals are subject to reductions in their caps and how large those reductions will be,
  • how hospitals that want to obtain increases in their caps can apply to do so, and
  • what criteria will be used to determine which hospitals will receive increases.

To receive additional slots, hospitals first must demonstrate that they can fill the additional slots -- for example, because they're already exceeding their caps or they don't have room under their caps to start a new residency program or expand an existing one. Then, hospitals will be evaluated according to certain other criteria to determine their priority ranking order to receive the increases.

Expansion Program Will Pay Salaries, Benefits of Additional Primary Care Residents

In another initiative to increase primary care training, HHS has set up a program to pay for the salaries and benefits of additional primary care residents. Funding for the Primary Care Residency Expansion, or PCRE, program came from the Prevention and Public Health Trust Fund established by the Patient Protection and Affordable Care Act.

Five-year grants totaling about $168 million already have been awarded to 82 residencies in family medicine, general internal medicine and general pediatrics.

According to a Sept. 27 HHS news release(, by 2015, PCRE grants will support training for 889 more primary care residents than currently are being trained.

The grants, which are to be used solely to pay the salaries and benefits of these additional resident physicians, were made to public or nonprofit private hospitals, schools of medicine or osteopathic medicine, and public or private nonprofit entities( One such grantee is the University of Missouri-Kansas City, or UMKC, Family Medicine Residency in Lakewood, Mo.

In an Oct. 28 press release(, the residency announced that it had been awarded a $1.9 million grant to fund two new family medicine residency positions in collaboration with seven rural hospitals in Western Missouri.

The UMKC program, which currently has 36 residents, will grow to 42 residents by the end of three years, making it the largest family medicine training program in the state.

"This grant will begin what we plan to become a partial answer for the worsening accessibility to primary care in rural Missouri," said program director Todd Shaffer, M.D., M.B.A., in the press release. "We are committed to providing a primary care workforce trained to meet the needs of all populations but, particularly, both rural and urban underserved."

Family Medicine Residency of Idaho, Boise, also was awarded a $1.9 million grant. According to Ted Epperly, M.D., director of the Boise residency and an AAFP past president, one additional resident will be added to each of the program's two rural training tracks each year for three years, expanding the overall number of residents in the program from 39 to 45.

The analysis by the CAFM, which comprises 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, outlines the preference categories identified by CMS in descending order:

  • urban hospitals that have an accredited rural training track;
  • hospitals located in states, territories, etc., that have resident physician-to-population ratios in the lowest quartile;
  • hospitals located in states, territories, etc., that are among the top 10 in numbers of people living in primary care health professional shortage areas, or HPSAs; and
  • hospitals located in rural areas.

The analysis then further details the priority ranking order CMS will use to redistribute GME positions according to these preference categories.

  • First-level priority category: The hospital is in a state, territory, etc., that has a resident physician-to-population ratio in the lowest quartile, and it is an urban hospital that has, or will have as of July 1, 2011, a rural training track.
  • Second-level priority category: The hospital is in a state, territory, etc., that has a resident physician-to-population ratio in the lowest quartile.
  • Third-level priority category: The hospital is in a state, territory, etc., that is in the top 10 in numbers of people living in primary care HPSAs, and it is an urban hospital that has, or will have, as of July 1, 2011, a rural training track.
  • Fourth-level priority category: The hospital is in a state, territory, etc., that is in the top 10 in numbers of people living in primary care HPSAs, or it is located in a rural area.

Seventy percent of the slots available for redistribution will go to first- and second-level priority category hospitals. A table included in the CMS rule lists, in rank order, the states and the territory in the lowest quartile -- namely, Montana, Idaho, Alaska, Wyoming, Nevada, South Dakota, North Dakota, Mississippi, Florida, Puerto Rico, Indiana, Arizona and Georgia.

The remaining 30 percent will be redistributed to third- and fourth-level priority category hospitals. CMS has identified these areas as Louisiana, Mississippi, Puerto Rico, New Mexico, South Dakota, District of Columbia, Montana, North Dakota, Wyoming and Alabama.

According to the CAFM, in addition to these geographically based preferences, CMS will give preference to hospitals that will use the additional slots to, among other things,

  • establish a new or expand an existing primary care program that has a demonstrated focus on training residents to pursue true primary care careers;
  • establish a new geriatric medicine program or add residents to an existing geriatrics program;
  • expand an existing program for which the hospital can demonstrate that more than 50 percent of residents completing it go on to practice in rural areas, primary care HPSAs, or federally designated medically underserved areas; or
  • expand an existing emergency medicine program in which residents train in primary care HPSAs.

Hope Wittenberg, director of government relations for the CAFM, said the redistribution of Medicare-funded GME slots is a step toward encouraging the training of more primary care physicians, but it's not a cure-all.

"It's a signal from Congress that there needs to be more primary care and general surgery physicians trained," she told AAFP News Now. "It helps maximize the money Medicare is allowed to spend on residency training by freeing up the funding for these unused slots for these specialties."

However, Wittenberg added, it's only one step. "It's an uneven distribution and many states aren't eligible."

Ardis Davis, M.S.W., executive director of the Association of Departments of Family Medicine, agreed, noting that the states given the highest priority for the slots are mostly in the West and South.

"For departments of family medicine, redistribution will likely be good for a few, but does not benefit the large majority," Davis told AAFP News Now. "Geographically, it's generally good for family medicine departments in the West and South, but not nationally."

Joseph Gravel, M.D., of Lawrence, Mass., is president of the Association of Family Medicine Residency Directors and program director of the Lawrence Family Medicine Residency, which is a federally qualified health center. Gravel told AAFP News Now that although the redistribution will benefit some family medicine residencies, he is concerned that the Medicare allotment might not be enough.

"Each program will have to do a careful analysis of whether they can financially swing adding new positions or not -- there are a lot of variables in play," he said. "It's all over the map, the level of Medicare funding that a residency gets."

Gravel also noted that getting medical students interested in family medicine and primary care remains a hurdle.

"There still needs to be work done to create student choice," he said. "We can create all the residency slots we want, but until medical student debt is more seriously addressed, and (as long as) there remain 300 percent and higher payment discrepancies (between physicians in primary care and nonprimary care specialties) it will be difficult to fill additional slots."

Although hospitals that are interested in increasing their caps must complete applications by January 2011, the specific timetable for the redistribution is not yet known.

Wittenberg said it's unlikely the additional positions will be available for the 2011 National Resident Matching Program, known as the Match, which occurs in March. Residency programs put in the number of positions they have available for the Match in January of each year, but CMS won't have the number of unused slots until May 2011.

"Even though the slots are technically available on July 1, 2011, they may not be distributed and filled until 2012 or later," she said.