text: Background Physician Shortages According to HRSA, the current demand for physicians in the United States will likely continue, with a projected shortage of 23,640 primary care physicians by 2025. While increasing physician supply is one way to reduce physician shortages, some experts have also suggested increasing the number of non-physician providers. For example, HRSA predicted that, with health care delivery changes that would allow for NPs and PAs to deliver a greater proportion of services than they do now, the projected shortage of 23,640 primary physicians in 2025 could be mitigated. According to the Bureau of Labor Statistics, in 2018, there were 756,800 physicians, over 189,100 NPs, and 118,800 PAs practicing in the United States. Graduate Training for Physicians, NPs, and PAs Physicians. Physician GME, also known as residency, provides the clinical training required for a physician to be eligible for licensure and board certification to practice medicine independently in the United States. Specifically, after completing medical school and receiving a medical degree, physicians enter a multi-year residency training program during which they complete their formal education as a physician, primarily in teaching hospitals. Completion of a residency can take from 3 to 7 years after graduation from medical school, depending on the specialty or subspecialty chosen by the physician. In some cases, physicians may choose to pursue additional training—referred to as fellowships—to become a subspecialist, such as a cardiologist. NPs and PAs. Since the first NP and PA training programs in the United States were founded in 1965, these professions and their educational requirements have evolved to allow them to furnish more care that was traditionally provided by physicians, such as diagnosing patients, prescribing medication, and performing certain procedures. The extent to which they can provide care independently from physician supervision varies by state. There are multiple pathways for students to become NPs. In general, after completion of a bachelor’s degree, a nurse may become an NP once he or she achieves a master’s or doctoral degree in nursing. Full-time master’s programs are generally 18 to 24 months and doctoral programs are generally 3 to 5 years. Both programs include classroom and clinical work. In addition, NP students may have varying amounts of hands-on nursing experience before entering an NP program. NP programs generally include the following focus areas: family practice, women’s health, acute care, adult/geriatric health, child health, neonatal health, and mental health. NPs are trained according to a nursing care model, which emphasizes providing comprehensive care for patients that encompasses their physical and other needs. After completion of a bachelor’s degree, students become PAs once they earn a master’s degree in physician assistant studies. The average full- time PA program takes about 27 months to complete, which includes classroom education followed by clinical work conducted through rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine, and behavioral medicine. In addition, PA students have varying amounts of hands-on work experience in health care before entering a PA program. PAs are trained to approach patient care according to a medical model focused on assessing, diagnosing, and treating disease. Both NP and PA students are required to complete clinical work as part of their graduate programs by providing care to patients under the supervision of a preceptor—an experienced and licensed health care provider who provides instruction and supervision to the student during their clinical rotations. Upon graduation and after passing a national certification exam and obtaining a license in the state in which they choose to work, both NPs and PAs can begin practicing. NPs and PAs may also complete an optional post-graduate residency training program, but unlike physicians, they are not required to do so in order to obtain a state license to practice. Figure 1 shows an example of education and training paths for physicians, NPs, and PAs. Federal Funding for Physician, NP, and PA Training Physicians. The vast majority of federal funding for physician GME training is distributed by HHS through CMS’s Medicare GME program. In our 2018 report on GME funding, we found that Medicare GME payments for physicians totaled more than $10.3 billion in 2015. CMS pays for a hospital’s costs associated with GME training through two mechanisms— direct graduate medical education and indirect medical education payments—both of which are formula-based payments set by statute. Direct payments are for costs that include, for example, residents’ salaries and benefits, compensation for faculty who supervise the residents, and overhead costs. Indirect payments are for costs including higher patient care costs that teaching sites are thought to incur as a result of training residents, such as increased diagnostic testing and procedures performed. Payments to hospitals may also include funds for training in nonhospital settings. Other sources of federal GME funding for physicians include the Medicaid program, which is jointly administered by CMS and the states, programs administered by HRSA, and other federal agencies outside of HHS. NPs and PAs. HHS funding is available to train NPs and PAs, primarily through HRSA grants authorized under titles VII and VIII of the Public Health Service Act. Specifically, according to HRSA officials, funding for programs that included NP and PA training totaled approximately $136.2 million in fiscal year 2019. (See table 2 for a description of these programs.) In recent years, CMS also provided funding for graduate training for advanced practice registered nurses, including NPs, from fiscal years 2012 through 2018 as part of the Graduate Nurse Education Demonstration. The Graduate Nurse Education Demonstration was established by the Patient Protection and Affordable Care Act to determine whether payments for clinical training provided to hospitals would increase the number of advanced practice registered nurses, including NPs, and whether these payments would affect the number of advanced practice registered nurses by specialty. Stakeholders Identified Benefits and Challenges of Expanding the Medicare GME Program to Include NP and PA Graduate Training Officials from the stakeholder organizations we interviewed identified the potential benefits and challenges of expanding the Medicare GME program to include NP and PA graduate training. Benefits of Expanding the Medicare GME Program Predictability and stability of Medicare GME program funding. According to officials from five of the nine stakeholder organizations we interviewed—three NP and two PA organizations—a benefit of expanding the Medicare GME program is that it may create more predictability and stability for training funding for NPs and PAs. This would be beneficial by allowing NP and PA programs to do better long-range planning such as planning for the number of NP and PA students that can be admitted. Officials from two of these stakeholder organizations noted that a benefit of the Medicare GME program for physicians is that funding is historically more stable than the funding available to NPs and PAs through HRSA. Specifically, Medicare GME funding is mandatory, while funding for NP and PA training programs administered by HRSA is discretionary. During the annual appropriations process, Congress may choose to appropriate the amount requested by HRSA, to increase or decrease those levels, or to not appropriate any funds. For example, Congress appropriated $28.5 million in fiscal year 2018 for HRSA’s Nurse Faculty Loan Program, but then decreased this appropriation to $13.5 million in fiscal year 2019. Potential opportunity to pay preceptors. Officials from four of the nine stakeholder organizations—two NP and two PA organizations— noted that one benefit of expanding the Medicare GME program to include NP and PA graduate training is that funding could be used to pay preceptors as an incentive to supervise students. CMS and others have also reported that schools of nursing have faced significant challenges increasing enrollments, in part due to difficulty finding preceptors willing to supervise students. Similarly, officials from two PA organizations we interviewed noted that some programs may choose not to fill their available enrollment slots because they are concerned about finding enough preceptors to allow all their students to graduate. Officials from four of the stakeholder organizations we interviewed noted that supervising students can take time away from the preceptor’s productivity in seeing patients, and that some practices and health care systems do not allow their health care providers to serve as preceptors. Specifically, officials from two stakeholder organizations we interviewed said that, historically, these preceptors have volunteered as a way of “giving back” to their profession and have not been paid for their time. However, due to difficulties finding a sufficient number of volunteer preceptors, some graduate programs have begun reimbursing preceptors for their time in order to encourage their participation. CMS’s Graduate Nurse Education Demonstration also included funding for preceptors. Challenges of Expanding the Medicare GME Program Differences in training requirements. Officials from six of the nine stakeholder organizations—two NP, two PA, and two physician organizations—raised concerns about challenges that could occur because NP and PA clinical training requirements do not align with the current structure of the Medicare GME program. For example, officials from some of these organizations noted that the Medicare GME program is structured to fund physician residency training, which is required in order for physicians to practice, but NPs and PAs are not required to complete a residency after completing a graduate program in order to practice. Specifically, CMS makes GME payments to hospitals according to formulas outlined in statute based, in part, on the number of physician residency positions. Therefore, officials from some of these stakeholder organizations said that any change to Medicare GME to include NPs and PAs would need to consider how to allocate GME funding for NP and PA programs in light of these differences in training requirements between physicians, NPs, and PAs. Potential limitations on Medicare funding for physician training. Officials from seven of the nine stakeholder organizations we interviewed—four NP, one PA, and two physician organizations— expressed concern that expanding the Medicare GME program to increase the number of NPs and PAs without increasing overall funding may negatively impact the funding available for physician training. For example, officials from one stakeholder organization said that reallocating available Medicare GME dollars could be problematic and potentially diminish needed resources for others. An official from one of these stakeholder organizations said that there is currently not enough funding to provide residency training for all qualified physicians, and adding NPs and PAs to the existing pool of underfunded residency candidates would worsen the funding shortage. Officials from another stakeholder organization echoed this concern by noting that expanding the Medicare GME program could force NPs to compete with physician residents for patients and space. Available Estimates of NP and PA Training Costs Were Limited and Incomplete Through our review of the literature and our interviews with officials from stakeholder organizations, CMS, and HRSA, we identified two estimates of NP or PA graduate training costs. CMS’s evaluation of its Graduate Nurse Education Demonstration estimated the total cost of graduate clinical NP training to be about $47,000 per student, based on the funds paid to the demonstration sites from fiscal year 2012 through fiscal year 2018, and the Physician Assistant Education Association estimated the total cost of graduate PA training to be about $45,000 per student, based on the results of its 2018 survey. While these two estimates provide some information about the costs of training NPs and PAs, they provide limited and incomplete information on these costs. CMS Graduate Nurse Education Demonstration. CMS estimated NP graduate training costs totaling $47,172 per graduate according to its evaluation of the Graduate Nurse Education Demonstration, in which CMS funded graduate clinical training for advanced practice registered nurses—a category that includes NPs—over 6 years. This estimate represents the cost to CMS (defined as the total funds paid to the demonstration sites during the duration of the demonstration) for the clinical training of each graduating student. Part of the cost covered by the demonstration includes the costs of clinical preceptors. Congress appropriated a total of $200 million for the demonstration, which operated from fiscal years 2012 through 2018. The demonstration funded clinical training at five hospitals, which partnered with 19 schools of nursing, and multiple community- based care settings. The cost estimate underreports the total cost of NP graduate training because, while both clinical and classroom training are required for NP students to graduate, CMS’s demonstration only provided funding for clinical training, as specified by the Patient Protection and Affordable Care Act. Specifically, CMS does not include the costs associated with classroom training, certification, and licensure of advanced practice registered nursing students. In addition, the demonstration targeted advanced practice registered nurses, which is a broader category that includes NPs in addition to other types of specialty nurses such as certified nurse-midwives and certified registered nurse anesthetists. However, according to CMS, the vast majority of advanced practice registered nursing students enroll in NP programs. CMS’s evaluation also noted that the cost estimates are not generalizable because they are only based on information from the schools that participated in the demonstration. (See table 3.) Physician Assistant Education Association survey data. The Physician Assistant Education Association, whose members are graduate PA programs, estimated PA graduate training costs totaling $45,309 per student—an estimate based on the results of a published annual survey of its members in 2018. This represents the average cost to the member PA programs for training a student in a 27-month PA graduate program, based on expense data reported by programs from the 2017-2018 fiscal year. The Physician Assistant Education Association’s data are self- reported by PA graduate programs. In addition, these data likely underreport the total costs of graduate PA training because they exclude in-kind contributions from clinical sites. These contributions, such as the donated time from volunteer preceptors, are necessary for clinical training. Officials estimated that paying for costs supported by these in-kind contributions—which the Physician Assistant Education Association estimated to be about $11,300 per student— would likely add an additional 25 percent to the total estimated cost to train PAs. (See table 4.) Agency Comments and Third-Party Views We provided a draft of this report to HHS for review and comment. The department provided technical comments, which we incorporated as appropriate. We also provided relevant draft portions of this report to the nine professional associations that we interviewed and they provided technical comments, which we incorporated as appropriate. We are sending copies of this report to the appropriate Congressional committees, the Secretary of Health and Human Services, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix I. Appendix I: GAO Contact and Staff Acknowledgments GAO Contact James Cosgrove, (202) 512-7114 or cosgrovej@gao.gov. Staff Acknowledgments In addition to the contact named above, Kelly DeMots (Assistant Director), Teresa Tam and Sarah-Lynn McGrath (Analysts-in-Charge), and Margaret Fisher made key contributions to this report. Also contributing were Leia Dickerson, Diona Martyn, Caitlin Scoville, Ethiene Salgado-Rodriguez, and Jennifer Whitworth.
target: An adequate, well-trained health care provider workforce is essential to ensure Americans have access to quality health care services. However, studies have shown the United States faces a shortage of physicians, making it increasingly difficult for people to access needed health care. Experts have identified ways to address this shortage, such as through strategies that increase the number of other types of non-physician providers, including NPs and PAs. For example, members of Congress and others have questioned whether expanding the scope of the Medicare GME program to include NPs and PAs could help mitigate the effects of a physician shortage. A Senate Committee on Appropriations report included a provision for GAO to examine the potential of making GME payments under the Medicare program for NPs and PAs. This report describes: (1) stakeholder views on the potential benefits and challenges of expanding the Medicare GME program to include NP and PA graduate training; and (2) available information on the estimated costs of NP and PA graduate training. GAO reviewed literature and interviewed officials from nine professional associations with knowledge of NP, PA, and physician graduate training; and agency officials. Based on these interviews, GAO identified sources of information on estimated costs and reviewed those sources. The federal government funds many education programs for health care providers, but the vast majority of this funding—more than $10.3 billion in 2015—supports physician residency training through the Department of Health and Human Services's (HHS) Medicare graduate medical education (GME) program. This program does not fund graduate training for nurse practitioners (NP) and physician assistants (PA) who deliver many of the same services as physicians, such as diagnosing patients and performing certain procedures. Instead, a smaller portion of federal funding—approximately $136 million in fiscal year 2019—is available to train them. Stakeholders GAO interviewed said that one benefit of expanding Medicare GME is that Medicare GME funding would provide more stable funding for NP and PA training, compared to existing programs. Stakeholders said one challenge of such an expansion is that clinical training requirements for NPs and PAs are different than physicians; therefore, any change to Medicare GME to include NPs and PAs would need to consider how to allocate GME funding in light of these differences. GAO identified two estimates of costs for completing an NP or PA graduate school program; while the estimates provide some information about these costs, they are limited and incomplete. The Centers for Medicare & Medicaid Services' (CMS) evaluation of its Graduate Nurse Education Demonstration estimated the total costs over the 2012-2018 demonstration period to be about $47,000 per NP student. While clinical and classroom training are required for NP students, CMS's demonstration only provided funding for clinical training, as specified by statute, and the estimate is not generalizable beyond the participating schools. The Physician Assistant Education Association estimated the total costs to be about $45,000 per PA student. The estimate is based on self-reported data from a 2018 survey of member PA programs and excludes in-kind contributions for clinical training. GAO received technical comments on this report from HHS and the professional associations interviewed and incorporated them as appropriate.