Want to Build Primary Care Physician Workforce? Expand Residency Training with Permanent Funding
FOR IMMEDIATE RELEASE: Wednesday, July 15, 2015
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WASHINGTON — Growth in primary care residency positions will likely backslide if the expansion depends on seed money from time-limited grants. That’s the conclusion by researchers who reviewed the outcomes of the U.S. Health Resources and Services Administration’s Primary Care Residency Expansion Program. The grants were designed to sustainably increase the number of primary care physicians.
The research, “Are Time-Limited Grants Likely to Stimulate Sustained Growth in Primary Care Residency Training? A Study of the Primary Care Residency Expansion Program(journals.lww.com),” was published online ahead of print in Academic Medicine.
“This study suggests an approach to primary care residency training expansion that relies on time-limited grants is unlikely to produce sustainable growth of the primary care pipeline,” write researcher Rossan Chen, MD, and her colleagues at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. “Policymakers should instead implement systemic reform of graduate medical education financing and designate reliable sources of funding, such as Medicare and Medicaid GME funds, for new primary care residency positions.”
Chen and her coauthors reviewed 62 primary care residency programs that received PCRE grants to determine whether they had secured continued funding after the program ends. Twenty-eight or 45 percent said they were unlikely, very unlikely or not planning to continue expanded positions when their grants expired. Only 14 or 22 percent reported they had secured full funding to support the expanded positions when support dries up.
The findings point to the inadequacy of short-term solutions to the primary care physician shortage, according to Chen. The Council on Graduate Medical Education has recommended that four in 10 graduating residents become primary care physicians. Currently only one in four go on to provide primary medical care.
Research has identified part of the issue: academic health centers that increasingly rely on revenue generated by subspecialty residents have added subspecialty training positions at the expense of primary care. As a result – despite a $15 billion annual investment of taxpayer dollars in training U.S. physicians – the graduate medical education system doesn’t produce enough family physicians, general internists and general pediatricians, the specialties most needed by American patients.
Legislation supporting a redistribution of Medicare funds to support residency training positions has also failed. In response, federal policymakers instituted short-term funding – such as the five-year PCRE grants – to provide seed money for expanding the number of primary care residency positions. The initiative was expected to add 900 primary care physicians to the workforce.
That approach, according to Chen’s research, has failed as well. Although the PCRE program relies on residency programs’ ability to secure funding when the grants expire, her research found few options are available.
“Although HRSA encouraged applicants to consider strategies for sustainable expansion, our results suggest that the majority of residency programs that received PCRE awards lack a solid financial plan to support the expanded positions,” she writes. “Most residency programs that received PCRE grants are based at training institutions that are already above their Medicare GME cap. Based on teaching hospitals’ recent track record of prioritizing specialty over primary care residency positions, we consider it unlikely that many of these institutions would voluntarily redistribute Medicare GME funding from specialty positions to primary care positions.”
Moreover, Medicaid is an unlikely source of support for the additional positions. Six states reduced their Medicaid GME payments and an additional five reported they might end Medicaid GME funding completely. Although the Affordable Care Act would have provided federal matching funds that could have been used for Medicaid GME funding, nearly half of states are not participating in Medicaid expansion.
“The PCRE program was developed to increase primary care physician production,” she writes. “Our findings suggest, however, that many of the residency positions gained through the PCRE program are in peril of being lost after the grants expire in 2015. Although HRSA encouraged applicants to consider strategies for sustainable expansion, our results suggest that the majority of residency programs that received PCRE awards lack a solid financial plan to support the expanded positions.”
Chen and her colleagues recommend reforms to Medicare GME as a better solution. “Our results suggest that an approach to primary care residency training expansion that relies on time-limited HRSA grants is unlikely to produce sustainable growth of the primary care pipeline,” she writes. “…Without a plan for systematic reform of GME financing – such as the plans proposed by the IOM committee, MedPAC, and COGME – the positive impacts of the PCRE program and similar time-limited training grant programs are likely to be modest at best.”
About the Robert Graham Center
The Robert Graham Center for Policy Studies in Family Medicine and Primary Care works to improve individual and population health by enhancing the delivery of primary care. The Center staff generates and analyzes evidence that brings a family medicine and primary care perspective to health policy deliberations at local, state, and national levels.
Founded in 1999, the Robert Graham Center is an independent research unit affiliated with the American Academy of Family Physicians (AAFP). The information and opinions contained in research from the Center do not necessarily reflect the views or policy of the AAFP.