Physician Workforce: Locations and Types of Graduate Training Were Largely Unchanged, and Federal Efforts May Not Be Sufficient to Meet Needs
Released: 2017-06-26T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: A well-trained physician workforce adequately distributed across the country is essential for providing Americans with access to quality health care services. While studies have reached different conclusions about the nature and extent of physician shortages, the federal government has reported shortages in rural areas and projects a deficit of over 20,000 primary care physicians by 2025. GME training is a key factor affecting the supply and distribution of physicians. Federal funding for this training is significant, more than $15 billion per year, according to the Institute of Medicine. Given the federal investment and concerns about physician supply, GAO was asked to review aspects of GME training.

This report describes (1) changes in number of residents in GME training by location and type of training from academic years 2005 through 2015, (2) federal efforts intended to increase GME training in rural areas, and (3) federal efforts intended to increase GME training in primary care. To determine changes in the locations and types of residents in GME training, GAO analyzed resident data from the accrediting bodies overseeing GME training. To identify and describe relevant federal efforts, GAO also reviewed federal laws, reports, and data, and interviewed agency officials.

section_title: What GAO Found
paragraphs: The locations and types of physicians in graduate medical education (GME) training—known as residents—generally remained unchanged from 2005 through 2015, but there was notable growth in certain areas. As shown in the table below, residents in GME training remained concentrated in the Northeast. At the same time, the number of residents grew more quickly in other regions, though this was somewhat tempered by regional population growth. Residents also remained concentrated in urban areas, which continued to account for 99 percent of residents, despite some growth in rural areas. From 2005 through 2015, over 80 percent of residents were receiving training in a medical specialty, which is required for initial board certification. In 2015, nearly half of these residents were in a primary care specialty (internal medicine, family medicine, and pediatrics), versus other specialties, such as anesthesiology. While this represented a slight increase from 2010, research has shown that many primary care residents will go on to receive additional GME training in order to subspecialize, rather than practice in primary care. Subspecialty training accounted for less than 20 percent of residents from 2005 through 2015, though the number of residents in subspecialties grew twice as fast as for specialties.

GAO found that the primary federal efforts intended to increase GME training in rural areas were incentives within the Medicare program that can provide hospitals with higher payments for such training. However, hospitals' use of these incentives was often limited, and certain Medicare GME payment requirements could present barriers to greater use.

GAO identified four federal efforts intended to increase primary care GME training. Each effort added new primary care residents and provided funding in areas of the country with disproportionally low numbers of residents or physicians, though to varying degrees. The four efforts accounted for a relatively small percentage of primary care residents and overall federal GME funding, about 3 percent and less than 1 percent, respectively. In addition, the extent to which the residents added by these efforts will be maintained or continue to grow is uncertain, in part because federal funding for some of the efforts has ended. As a result, the efforts may not be sufficient to meet projected primary care workforce needs. Further, GAO recommended in 2015 that the Department of Health and Human Services (HHS) develop a comprehensive and coordinated plan for its health care workforce programs, which is critical to identifying any other efforts necessary to meet these needs, and has not yet been implemented.

section_title: What GAO Recommends
paragraphs: GAO continues to believe that action is needed on a 2015 recommendation for HHS to develop a plan to guide its health care workforce programs. HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.

section_title: Letter
paragraphs: A well-trained physician workforce that is adequately distributed across  the country is essential for providing Americans with access to quality  health care services. The federal government has reported physician  shortages in some areas of the country, including in rural areas, as well  as in the primary care specialties of family medicine, internal medicine,  and pediatrics. Additionally, some experts contend that physician  shortages could be exacerbated in the future by such factors as an aging  population, population growth, and increased access to insurance. At the  same time, experts have also noted a number of factors that could  mitigate these shortages, including increasing or better targeting the  supply of physicians and greater use of nurse practitioners and physician  assistants.

While a number of factors affect the supply and distribution of physicians,  graduate medical education (GME)—commonly known as residency  training—is a significant determinant. Through medical school, students earn a medical degree and become physicians, but they are required to  undergo GME training to be able to practice independently. Physicians in  GME training are known as residents and must complete a GME program  in a specific medical specialty. Specialty GME programs generally last 3  to 5 years, after which physicians are eligible for medical licensure and  initial board certification to practice medicine. Some physicians may  choose to subspecialize and undergo additional GME training—also  referred to as fellowships. The percentage of residents that subspecialize  varies by specialty type. For example, family medicine residents are more  likely to remain in primary care than internal medicine or pediatric  residents, who research has shown tend to subspecialize at greater  rates.

GME training is funded through public and private sources. While GME  programs are generally established by hospitals or academic institutions  that may provide funding, the federal government also spends a  significant amount on GME training each year. Specifically, in 2014, the  Institute of Medicine reported that federal funding for GME training totaled  more than $15 billion per year, most of which was provided by the  Department of Health and Human Services (HHS). The vast majority of  HHS funding is distributed by the Centers for Medicare & Medicaid  Services (CMS), mostly through the Medicare program. Other, smaller  sources of federal GME funding include HHS grants, such as from the  Health Resources and Services Administration (HRSA), and from GME  training that occurs at Department of Veterans Affairs (VA) and  Department of Defense medical facilities.

Over time, experts have raised a number of concerns about the ability of  the current GME system to meet physician workforce needs. For  example, some are concerned that the system may not be producing  enough primary care physicians. According to one study, while the total  number of residents increased by 13.6 percent from 2001 to 2010, the  number expected to enter primary care decreased by 6.3 percent.  Additionally, Medicare GME funding is generally not targeted to specific  areas of workforce need, and the number of slots eligible for Medicare  GME funding was capped at 1996 levels for many hospitals by the  Balanced Budget Act of 1997. As a result of these and other factors,  stakeholders have long raised concerns that there is an uneven  distribution of residents across the country, with most concentrating in  certain urban centers where GME programs have historically been  located. The appropriate distribution of residents is particularly important  given evidence that physicians may practice in geographic areas similar  to those where they complete their GME training. To address physician  shortage concerns, the federal government has undertaken some efforts  to better target GME funding, including encouraging the training of  physicians in rural areas and in primary care specialties.

Given the significant amount of federal funds spent on GME training, as  well as concerns about physician shortages, you asked us to review  aspects of this training in the United States. In this report, we describe:  1.  changes in the number of residents in GME training by location and  type of training from 2005 through 2015,  2.  federal efforts intended to increase GME training in rural areas, and  3.  federal efforts intended to increase GME training in primary care.

To describe changes in the number of residents in GME training by  location and type of training from 2005 through 2015, we reviewed data  on GME programs and residents within the 50 states and the District of  Columbia from the two main GME accrediting bodies—the Accreditation  Council for Graduate Medical Education (ACGME) and the American  Osteopathic Association (AOA). From each, we obtained data for three  points in time—2005, 2010, and 2015. We used these data to examine  the geographic distribution of residents. To do this, we identified the  location of residents by the location of their primary training site and  compared these data to Census Bureau geographic regions and  population estimates. We also used Rural-Urban Commuting Area  codes to identify the location of residents’ primary training sites as being  either urban or rural. To compare the location of residents’ primary  training sites with physician workforce needs, we used HRSA  designations of areas identified as having a shortage of primary care  physicians—known as Health Professional Shortage Areas (HPSAs). A  HPSA may be a geographic area with a shortage of primary care  physicians (known as a geographic HPSA). Alternatively, an area could  be designated as a population HPSA if a population within the area, such  as a migrant farmworker population, is found to be underserved by  primary care physicians, even if the area as a whole is not underserved.  While we previously identified shortcomings with HRSA’s methodology for  designating HPSAs, we used HPSAs in this analysis because they  continue to be a primary way the federal government identifies physician  shortage areas. We also examined the distribution of residents across  primary care and other specialties, compared with subspecialty training.  Some residents train in a GME program called internal medicine- pediatrics that allows them to practice both internal medicine and  pediatrics, and we included those residents in our analysis of primary  care residents along with internal medicine, family medicine, and  pediatrics residents. Finally, we compared the distribution of residents in  ACGME-accredited programs with those in AOA-accredited programs.  We assessed the reliability of the ACGME, AOA, Census Bureau, and  HRSA data by reviewing documentation, discussing the data with  knowledgeable officials, and performing data reliability checks, such as  examining the data for missing values and obvious errors to test the  internal consistency and reliability of the data. The addresses for 52 GME  programs accounting for 483 residents ultimately could not be matched to  Census data, and, therefore, those programs were excluded from our  analysis. Further, our analysis of primary care specialties was limited to  2010 and 2015 because comparable data were not available for 2005.  After taking these steps, we determined the data from each of these four  sources were sufficiently reliable for the purposes of our reporting  objectives.

To describe federal efforts intended to increase GME training in rural  areas, we first identified relevant federal efforts. To do this, we reviewed  government and nongovernmental reports on funding for health care  workforce training, relevant federal laws, and interviewed federal officials.  We limited our selection to efforts that provided funding directly to GME  programs within the civilian health care system as of January 2016. As  such, we excluded efforts that provided payments directly to individual  residents, including loan repayment and scholarship programs, as well as  efforts funded by the Department of Defense. We also excluded efforts  that were not primarily focused on increasing the number of residents in  clinical training. For example, we excluded efforts that focused primarily  on curriculum enhancement for existing GME programs or GME training  for leadership, management, and research skills. Based on our selection  criteria, we determined that certain Medicare hospital payment incentives  administered by CMS were the primary federal efforts intended to  increase GME training in rural areas. Where available, we analyzed  Medicare hospital cost report data from fiscal year 2013—the most recent  year with reliable data—to determine the extent to which hospitals located within the 50 states and the District of Columbia used these incentives.  We assessed the reliability of the cost report data by reviewing  documentation, discussing the data with knowledgeable officials, and  performing data reliability checks, such as examining the data for missing  values and obvious errors to test the internal consistency and reliability of  the data. After taking these steps, we determined the data were  sufficiently reliable for the purposes of our reporting objectives. To further  describe these incentives, we reviewed relevant agency documentation  and interviewed CMS officials as well as officials that worked on a HRSA- funded technical assistance program related to one of the incentives.

To describe federal efforts intended to increase GME training in primary  care, we first identified the relevant federal efforts using the same  selection process as for the rural efforts we identified in our second  objective. Based on our selection criteria, we identified four relevant  federal efforts—HRSA’s Primary Care Residency Expansion program,  HRSA’s Teaching Health Center GME program, CMS’s Medicare GME  redistribution, each authorized by the Patient Protection and Affordable  Care Act (PPACA), and VA’s GME expansion required by the Veterans  Access, Choice, and Accountability Act of 2014, as amended. For each  effort, we obtained and analyzed available HRSA, CMS, and VA data on  funding levels and the number, type, and location of funded residents for  recipients located within the 50 states and the District of Columbia. We  assessed the reliability of the HRSA, CMS, and VA data by reviewing  documentation, discussing the data with knowledgeable officials, and  performing data reliability checks, such as examining the data for missing  values and obvious errors to test the internal consistency and reliability of  the data. After taking these steps, we determined the data from each of  these four sources were sufficiently reliable for the purposes of our  reporting objectives. For the Medicare GME redistribution, we also  analyzed fiscal year 2013 Medicare hospital cost report data previously  mentioned. To characterize the location of funded residents, we  compared data from the efforts to Census Bureau geographic regions and  Rural-Urban Commuting Area codes, as well as to HRSA’s HPSA  designations, using the same methodology we used for our first research  objective. To further describe the efforts, we also reviewed relevant  agency documentation, such as HRSA annual reports, and interviewed  HRSA, CMS, and VA officials.

We conducted this performance audit from November 2015 to May 2017  in accordance with generally accepted government auditing standards.  These standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: GME Training
paragraphs: Prior to entering GME training, students complete medical school under  one of two broad educational philosophies—allopathic or osteopathic.  Allopathic physicians represent the majority of physicians and have a  Doctor of Medicine (known as an M.D.). In contrast, osteopathic  physicians have a Doctor of Osteopathic Medicine (known as a D.O.).  Osteopathic medicine is based on a philosophy that emphasizes a  “whole-person approach,” and physicians receive specific training in  manipulating the musculoskeletal system.

Following medical school, GME provides the clinical training required for  a physician to be eligible for licensure and board certification to practice  medicine independently in the United States. Residents in GME programs  train, usually in a hospital or clinic, under the direct or indirect supervision  of physician faculty members. Historically, ACGME has accredited GME  programs focused on allopathic training, and they are available to U.S. or  Canadian medical school graduates with a M.D., U.S. medical school  graduates with a D.O., and international medical graduates with the  equivalent of an M.D. degree from foreign medical schools. GME  programs focused on osteopathic training are accredited by AOA and  available only to U.S. medical school graduates with D.O. degrees. While  ACGME and AOA programs are accredited separately, ACGME and AOA  may also jointly accredit programs, and the organizations are in the  process of establishing a single accreditation system. On June 30,  2020, AOA is to cease accreditation activities and all GME programs are  to be accredited by ACGME, and physicians will be able to attend any  accredited program regardless of their type of degree.

Whether in ACGME or AOA programs, physicians may pursue GME  training within a variety of specialties or subspecialties. Initially,  physicians go through GME training for a specialty—such as internal  medicine, family medicine, pediatrics, anesthesiology, radiology, or  general surgery. Of the specialties, family medicine, internal medicine,  and pediatrics are considered primary care specialties, as they provide  comprehensive first contact and continuing care for persons with a broad  range of health concerns. Completion of training in one of these  specialties qualifies a physician to seek initial board certification to  practice medicine. Some residents, however, may choose to  subspecialize and seek additional GME training. For example, a physician  who completed an internal medicine GME program may decide to subspecialize in cardiology. (See fig.1.) The percentage of residents who  later subspecialize varies based on specialty type. For example,  according to a 2008 study, among the primary care specialties, 5 percent  of family medicine residents end up subspecializing, compared with 55  and 39 percent of internal medicine and pediatric residents,  respectively. Therefore, a resident training in a primary care specialty  may not ultimately practice as a primary care physician.

section_title: Physician Shortages
paragraphs: Studies of the physician workforce and associated shortages vary in the  assumptions they make about physician supply and demand, resulting in  different conclusions about the nature and extent of shortages.  However, there continue to be shortages of physicians, such as in  primary care, and studies have found that rural areas may be more likely  to experience shortages. For example, one study reported that while  there are about 80 primary care physicians per 100,000 people in the  United States, the average in rural areas is 68 per 100,000.

At the federal level, HRSA monitors the supply of and demand for health  care professionals and disseminates data about workforce needs and  priorities. With regard to primary care physician shortages, HRSA  identified 1,401 geographic and 1,485 population HPSAs across the  United States, as of January 2017. While these HPSAs were located in  nearly all 50 states and the District of Columbia, the South had the most  (42 percent), and the Northeast had the fewest (8 percent). According to  HRSA, 8,583 more primary care physicians would be needed to remove  these HPSA designations. In a November 2016 report, HRSA also  projected that the need for more primary care physicians is likely to  continue, with a shortage of up to 23,640 physicians by 2025 (while family  medicine and internal medicine had projected shortages, nationally,  pediatrics did not). HRSA projected primary care physician shortages in  all regions of the country, but noted that the South was expected to have  the largest shortage and the Northeast the smallest shortage. In addition  to shortages for primary care physicians, HRSA has also recently  projected shortages for other physicians, such as psychiatrists and those  in certain surgical specialties and internal medicine subspecialties.

While increasing physician supply through more GME training  opportunities is one way to prevent shortages, experts have also  suggested other options. For example, federal payment incentives have  been used to encourage physicians to practice in underserved areas, and  changes to physician payment could also encourage physicians to select  certain specialties. In addition, experts have suggested that access to  care could be increased through the greater use of telehealth and other  technology, as well as changing the pattern of practice, such as by  providing more team-based care or by eliminating care that is either  unnecessary or of limited value. Particularly with regard to primary care,  experts have also suggested that some health care needs may be filled  through the greater use of other types of providers, such as nurse  practitioners and physician assistants. (See app. I for a summary of  selected federal efforts related to nurse practitioner and physician  assistant training.)

section_title: Federal GME Funding
paragraphs: The federal government invests significantly in GME training. The vast  majority of federal funding is distributed by HHS through CMS’s Medicare  program, although HHS also provides GME funding through other  programs, such as CMS’s Medicaid program and grant programs  administered by HRSA. Other sources of federal funding include GME  training that occurs at VA and Department of Defense medical facilities.

With regard to Medicare, CMS makes GME payments to different types of  institutions, though hospitals paid through the inpatient prospective  payment system account for most of these payments. Medicare pays for  a hospital’s costs associated with GME training through two  mechanisms—direct graduate medical education (DGME) and indirect  medical education (IME) payments—both of which are formula-based  payments set by statute. DGME payments are made to cover the direct  costs of GME training, such as residents’ salaries. IME payments are  made to reflect the higher patient care costs hospitals with GME  programs may incur, because, for example, residents in training may  order more diagnostic tests and procedures than experienced clinicians  and take more time to interpret the results. The Balanced Budget Act of  1997 capped the number of residents that hospitals may count for DGME  and IME payment at the number of full-time equivalent (FTE) residents in  place in 1996. If a hospital did not have GME training in 1996, its resident  FTE caps are set 5 years after it begins training residents in its first new  program, based in part on the highest number of resident FTEs who train during that fifth year. While hospitals are free to add residents beyond  their caps, these generally do not result in additional Medicare payments.

With regard to VA, the agency estimated that in fiscal year 2015, more  than 44,000 residents rotated through a VA facility as part of their GME  training. Nearly all of the GME programs utilizing VA as a training site are  sponsored by an affiliated medical school or teaching hospital, rather than  by VA. VA provides payments to its medical centers for GME training and,  in turn, medical centers reimburse their academic affiliates for the time  residents spend training there.

Over time, a number of federal efforts have been created that provide  funding to increase GME training in rural areas and in primary care. For  example, the Medicare, Medicaid, and SCHIP Balanced Budget  Refinement Act of 1999 included provisions that could expand GME  training in rural areas by allowing certain qualified hospitals to increase  their resident FTEs above the 1996 caps. PPACA included several  provisions intended to increase primary care GME training. This included  two grant programs overseen by HRSA—the Teaching Health Center  program and Primary Care Residency Expansion program. In addition,  PPACA required that Medicare-funded resident FTEs not being used by  hospitals be redistributed to other hospitals meeting certain requirements.  Similarly, the Veterans Access, Choice, and Accountability Act of 2014  directed VA to expand its GME training, according to certain priorities,  including primary care. Some of the efforts focused on expanding primary  care also prioritized rural or underserved areas designated as HPSAs.  (See table 1 for additional information on these federal rural and primary  care efforts.)

section_title: Locations and Types of GME Training Were Largely Unchanged from 2005 through 2015, but Growth Was Notable in Certain Areas
subsections: section_title: Residents Remained Concentrated in Urban Areas and in the Northeast, Despite Growth in Other Parts of the Country
paragraphs: From 2005 through 2015, 99 percent of residents in GME programs  trained in urban areas, despite some growth in rural areas. Overall,  during this period, the number of residents grew by 22 percent—from  104,330 to 127,578. While there was growth in rural areas, urban areas  added a greater number of residents—almost 23,000 (from 103,526 to  126,355), compared with 419 for rural areas (from 804 to 1,223).

Residents in GME training were also concentrated in the Northeast,  although their rate of growth was higher in other regions of the country.  From 2005 through 2015, the largest percentage of residents (about 30  percent) trained in the Northeast, which also had the smallest percentage  of the U.S. population (about 18 percent). In 2015, the Northeast had 69  residents per 100,000 people. In comparison, the South also had about  30 percent of residents in 2015, but because it was the region with the  largest population (about 38 percent), it had only 31 residents per  100,000 people. While the Northeast maintained the highest  concentration of residents from 2005 through 2015, the resident growth  rate was higher in the other regions. Specifically, the number of residents  increased by 15 percent in the Northeast, compared with 24 percent or  more in each of the other regions. However, resident growth in the South  and West was somewhat tempered by the fact that these regions also  experienced higher population growth over the period, resulting in smaller  increases in the number of residents per 100,000 people compared with  the Midwest and Northeast. (See fig. 2.)

Within these broad regions, residents in GME training were further  concentrated in specific counties. Of the 3,143 counties in the United  States, in 2015, residents were located in 444 counties. However, about  half of residents were located in 31 counties. (See fig. 3.) These  counties accounted for 18 percent of the U.S. population and were  located in each of the four regions. In the Midwest, for example, 65  percent of the residents in that region trained in 11 counties. From 2005  through 2015, the overall number of counties with residents increased by  15 percent (387 to 444). While residents were no longer in 18 counties,  75 new counties gained residents. Of these 75 new counties, most were  located in the South (36) and the West (19).

GME training for some residents also occurred in HPSAs—areas of the  country designated as having a shortage of primary care physicians. For  example, in 2015, 33 percent (17,360) of all primary care residents  trained in a HPSA. The South had the highest percentage of its residents  in HPSAs (39 percent of 15,385 residents), and the Midwest and West  had the lowest (28 percent of 12,738 residents for the Midwest, and 28  percent of 8,348 residents for the West). In addition, 89 percent of the  residents in a HPSA trained in a population HPSA—an area designated  as having a shortage for a specific population—compared with 11 percent  who trained in a HPSA with a shortage in the entire geographic area.  Though many primary care residents trained in a HPSA, these residents  were located in less than 8 percent of the 2,685 HPSAs nationwide.

The trends presented here generally represent the location of GME  primary training sites and may not fully account for the clinical  experiences residents receive during their training. According to ACGME  officials, GME training must be based in areas that can support  requirements for accreditation, including adequate patient volume and  teaching quality. As a result, it tends to be primarily located in certain  areas, such as urban areas. However, officials said that residents training  in urban areas may rotate to participating sites in rural areas or treat  patients from surrounding rural areas at urban training sites. We were not  able capture such experiences, in part because neither ACGME nor AOA  collect data on the extent to which residents train at participating sites.

section_title: Most Residents Trained in Specialties, of Which Nearly Half Were in Primary Care, but Growth Was More than Twice as Fast for Residents in Subspecialties
paragraphs: From 2005 through 2015, most residents in GME programs were training  in one of the specialties that all residents are required to complete before  choosing whether to practice or subspecialize. For example, in 2015,  over 80 percent of all residents were training in a specialty, with the  remaining residents training in a subspecialty. Of the residents training in  a specialty, 45 percent trained in one of the primary care specialties.  More than half of these primary care residents trained in internal  medicine. As previously noted, research has shown that many primary  care residents who trained in internal medicine go on to subspecialize  rather than practice in primary care. (See fig. 4.)

Growth occurred for residents in GME specialty programs, but their  percentage of overall residents went down slightly (from 85 to 83  percent), as subspecialty growth was more than twice as fast.  Specifically, from 2005 through 2015, the number of residents in a  specialty grew by 19 percent (from 88,976 to 105,796) compared with 42  percent (from 15,354 to 21,782) for subspecialties. For both specialties  and subspecialties, the number of residents grew more in urban areas  than in rural areas, but the rate of growth was higher in rural areas,  particularly for specialties (53 percent compared with19 percent for  specialties, and 47 percent compared with 42 percent for subspecialties).  In 2015, residents in specialties accounted for about 90 percent (or 1,116)  of the 1,223 residents training in rural areas. The regional distribution of  residents in medical specialties and subspecialties reflected overall  trends, with both concentrated in the Northeast, but growing faster in  other regions from 2005 through 2015.

When looking at primary care specialties specifically, from 2010 through  2015, the years for which we had comparable data, the number of  residents in a GME primary care specialty program increased slightly  more than all other specialties (11 percent vs. 9 percent). Among the  primary care specialties, residents in family medicine grew by 15 percent  (from 10,120 to 11,686), compared with 10 percent for internal medicine  (from 22,990 to 25,354) and 9 percent for pediatrics (from 8,106 to  8,814).

section_title: Most Residents Trained in ACGME Programs, but Residents in AOA Programs Increased Faster and Accounted for Most of the Growth in Rural Areas
paragraphs: The vast majority of residents trained in GME programs accredited by  ACGME, accounting for more than 90 percent of all residents from 2005  through 2015. As a result, residents in ACGME programs accounted for  84 percent of the growth in the number of residents over the time period.  However, there was a higher rate of growth for residents in AOA  programs. Specifically, the number of residents in ACGME programs  increased by 19 percent, from 100,918 to 120,497. In comparison, the  number of residents in AOA programs increased by 108 percent, from  3,412 to 7,081. As a result, the percentage of all residents in AOA  programs grew from 3 percent to 6 percent. (See fig. 5.)

Residents in ACGME and AOA programs both experienced growth in  areas with historically less GME training, though residents in AOA  programs were responsible for most of the growth in rural areas, as  summarized below.

While the largest number of residents in ACGME programs trained in  the Northeast from 2005 through 2015, the largest number of  residents in AOA programs trained in the Midwest. (See fig. 6.)  However, the South had the highest percentage of growth in residents  in ACGME programs over the time period, and the West had the  highest growth in residents in AOA programs.

From 2005 through 2015, almost all residents in ACGME and AOA  programs trained in urban areas, although both types of residents  experienced growth in rural areas. Despite their smaller number,  residents in AOA programs accounted for 70 percent of this growth.  Specifically, the number of residents in AOA programs in rural areas  increased by 291 (from 100 to 391), while number of residents in  ACGME programs increased by 128 (from 704 to 832).

From 2010 through 2015, the years for which we had comparable data,  the number of residents in primary care GME programs increased for  both ACGME and AOA. The number of residents in ACGME primary care  programs increased from 41,386 residents in 2010 to 44,563 residents in  2015. For residents in AOA primary care programs, the number increased  from 1,235 residents in 2010 to 2,747 residents in 2015.

section_title: Use of Federal Efforts Intended to Increase GME Training in Rural Areas Was Often Limited, and Officials Reported Challenges
paragraphs: Hospitals’ use of three Medicare payment incentives—the primary federal  efforts we identified intended to increase GME training in rural areas— was often limited. In part, this is because relatively few rural hospitals  reported having GME training—49 (7 percent) compared with 1,144 (26  percent) hospitals overall, in fiscal year 2013. For those rural hospitals  that did have GME training, there are two incentives that allow them to  expand the number of resident FTEs they can count for Medicare  payments, compared with what is allowed for urban hospitals. The first  incentive sets resident FTE caps for rural hospitals that had GME training  in 1996 at 130 percent of the resident FTEs at the hospital that year. Data  indicate that, where applicable, rural hospitals are likely to use this  incentive, as most of the 49 rural hospitals reported resident FTEs close  to or above their resident FTE caps. However, use of the second  incentive was more limited. Specifically, less than half of the 49 hospitals  reported data indicating that they used the incentive that allows them to  increase their resident FTE caps if they have a GME program in one  specialty, for example, family medicine, but start a new GME program in  another specialty, for example, internal medicine.

The third incentive encourages urban hospitals to start Rural Training  Track programs—where residents spend a portion of their GME training  in a rural area—by allowing a specific resident FTE cap adjustment for  that Rural Training Track if the program meets certain requirements.  While CMS was not able to provide information on the number of  hospitals that have used the incentive, evidence suggests it may be  limited. Specifically, one outside expert we spoke with said that based on  communications with Rural Training Track programs, only two urban  hospitals claimed an increase to their resident FTE caps for starting such  programs from 2000 through 2010.

In addition to the general challenges associated with offering GME  training in rural areas, CMS officials reported a number of challenges with  using Medicare funding to support rural GME training. For example,  officials told us that the way a hospital’s resident FTE caps are  established, as well as the amount it is paid per-resident for DGME, may  make rural hospitals hesitant to partner with urban hospitals to provide  GME training. Officials said some rural hospitals had their caps or per- resident amount set at low amounts because they served as a rotational  site for an urban hospital for a small amount of GME training, and then  later faced challenges in starting a full GME program, which is likely more  costly. CMS officials also identified challenges for urban hospitals  wanting to use the Medicare payment incentive for starting Rural Training  Track programs. For example, some urban hospitals have formed a GME  training program with rural hospitals that mirrors the structure of Rural  Training Track programs, but the program does not meet all the statutory  requirements for the Medicare payment incentive, such as being  separately accredited. Other urban hospitals have faced challenges if  they have started a Rural Training Track program with one rural site and  later wanted to expand the program to another rural site, as they are not  eligible to receive an additional increase to their caps for the expansion to  the second site.

section_title: Federal Efforts Intended to Increase Primary Care GME Training Were Relatively Small, and the Number of New Residents Added May Not Be Sustained
subsections: section_title: Efforts Funded Residents in Primary Care and Other Specialties, Many of Whom Trained in Underserved Areas
paragraphs: We identified four federal efforts intended to increase primary care GME  training. While all these efforts funded new primary care residents, some  also funded residents in other specialties or subspecialties, as  summarized below. (See table 2 for additional information on residents  funded by the four efforts.)

Residents funded under the Teaching Health Center program—which  provided GME payments to primary care medical and dental GME  programs in community-based settings—grew from 76 in 2012 to 600  in 2015. While the program included other specialties in its definition  of primary care, in a given year, about 90 percent of funded residents  were in family medicine, internal medicine and pediatrics. As of the  end of 2016, 384 residents funded through the program had  completed their GME training.

Residents under the Primary Care Residency Expansion program— which provided grants to primary care GME programs—increased  from 168 in 2012 to 500 in 2015. As of the end of 2016, 489 residents  funded through the program had completed their GME training.

The VA GME expansion—which aims to increase VA GME training by  up to 1,500 positions over 10 years—distributed 366 FTEs for new  residents to VA medical centers for 2016 and 2017. Of these, 163  were in primary care.

The Medicare GME redistribution transferred 599 unused IME and  692 unused DGME resident FTEs to other hospitals, effective July 1,  2011. Hospitals that received increases to their resident FTE caps  were, for a 5-year period, required to use 75 percent of the  redistributed FTEs to support new primary care or general surgery  residents as well as meet a 3-year primary care average. In fiscal year  2013, data from 40 of the 55 hospitals that received cap increases  indicate that over 85 percent of the redistributed FTEs used were for  either primary care or general surgery residents.

The four federal efforts varied in the extent to which they funded family  medicine residents versus residents in other primary care specialties.  This could affect how many of the residents trained ultimately practice in  primary care, as family medicine residents are less likely to subspecialize.  In particular, while about half of the primary care residents funded through  the Teaching Health Center and Primary Care Residency Expansion  programs in 2015 were in family medicine, family medicine residents  accounted for 7 percent of the FTEs distributed through the VA GME  expansion in 2016 and 2017. VA officials told us that family medicine  GME programs have tended to focus their training in non-VA settings, in  part, because the VA has no pediatric patients and has historically  provided very little women’s health care, which is not aligned with some of  family medicine’s GME training requirements. However, VA is working to  build partnerships with family medicine programs as part of the GME  expansion.

To varying degrees, the four federal efforts funded residents in regions of  the country that have disproportionally low numbers of residents relative  to the population. All four efforts added residents outside of the  Northeast—where the resident-to-population ratios are the highest.  However, while the Medicare GME redistribution and VA GME expansion  efforts added over 90 percent of their FTEs to regions outside of the  Northeast, the regional distribution of residents funded by the Teaching  Health Center and Primary Care Residency Expansion programs in 2015  reflected national trends, with the most funded residents in the Northeast.  (See table 3.)

Though funding GME training in HPSAs and in rural areas was not a  priority across the four federal efforts, they did provide funding for  residents in such areas, and at greater rates than was the case for where  residents train overall. However, this varied depending on the effort, as  outlined below.

The percentage of residents funded in a HPSA ranged from 34  percent of all primary care FTEs distributed through the VA GME  expansion to nearly 60 percent of all FTEs transferred through the  Medicare GME redistribution; compared with the 33 percent of all  primary care residents that trained in a HPSA in 2015. Similar to  primary care GME training overall, residents funded by the efforts  were far more likely to train in a population HPSA than in a  geographic HPSA.

The percentage of residents funded in rural areas ranged from just  over 2 percent of residents funded through the Primary Care  Residency Expansion program to just over 5 percent of the residents  funded through the Teaching Health Center program, which was  higher than the 1 percent of all residents that trained in rural areas in  2015. The small number of funded residents training in rural areas  could in part be due to the number of rural GME programs or  providers that applied for funding. For example, based on our  analysis, just 3 rural hospitals applied for the Medicare GME  redistribution, each of which received new FTEs. Officials from CMS,  HRSA, and VA cited the challenges of increasing GME training in  rural areas. For example, HRSA officials said that rural areas may  have difficulty meeting accreditation requirements for certified faculty  members or volume of services, and CMS officials noted they may  face challenges attracting residents. HRSA officials also noted that it  may be hard for rural hospitals to fund the significant costs associated  with building infrastructure to start or expand GME training. VA  officials said that, partially in response to this challenge, the agency  awarded separate planning and infrastructure grants through the GME  expansion to help sites with very little or no prior GME training.  Officials noted that as the expansion is only in the first few years of its  10-year timeline, these grants are just being awarded and new  partnerships are just being formed. As a result, officials said that it will  take time for such investments to pay off and for new VA GME  programs to be built in rural and underserved areas.

While the four federal efforts are not all planning to report on whether  residents funded ultimately practice in primary care, or in a rural or  underserved area after completing GME training, evidence from the  Teaching Health Center and Primary Care Residency Expansion  programs suggests that many of their residents will. According to HRSA,  of the 47 Teaching Health Center residents completing training in 2014,  over 80 percent were practicing in primary care, 44 percent in a medically  underserved area, and 15 percent in a rural area. Additionally, among the  156 Primary Care Residency Expansion residents who completed training  in 2014, 67 percent intended to practice in a primary care setting, 46  percent intended to practice in a medically underserved area, and 17  percent intended to practice in a rural setting.

section_title: Efforts Represent a Relatively Small Investment in Primary Care GME Training, and New Positions May Not Continue in the Future
paragraphs: Despite increasing the number of primary care residents, the four federal  efforts still represent a relatively small investment in primary care GME  training when compared with overall federal GME spending and the  number of primary care residents nationally. Specifically, average annual  funding for the Teaching Health Center program, the Primary Care  Residency Expansion program, and the VA GME expansion accounted  for less than 1 percent of the more than $15 billion in estimated annual  federal spending on GME training, and the Medicare GME redistribution  accounted for less than 1 percent of the approximately 79,000 IME and  83,000 DGME FTEs that hospitals reported being able to claim for  Medicare payment in fiscal year 2013. In addition, we estimate that the  residents added through these efforts so far would have represented  about 3 percent of the nearly 50,000 primary care residents trained  across the country in 2015.

Moreover, some of the new primary care GME training added through the  federal efforts may not continue, in part because the Primary Care  Residency Expansion program and the Medicare GME redistribution were  one-time efforts that have ended. According to HRSA officials, just over  70 percent of the 74 Primary Care Residency Expansion awardees  responding to a request for information (a 96 percent response rate)  reported that they would continue to support all of the added primary care  resident positions after the grant period, and an additional 7 percent  planned to sustain at least some of the positions. However, for a variety  of reasons, including lack of funding, 19 percent of awardees planned to  revert to their prior number of residents and 3 percent were unsure of  their plans. IME and DGME FTEs received through the redistribution  became a permanent part of a hospital’s resident FTE caps. However, as  the requirement to use 75 percent of the redistributed FTEs for new  primary care or general care surgery residents expired in June 2016,  hospitals that added primary care residents as a result of the  redistribution may not continue to do so.

In addition, while the Teaching Health Center program and the VA GME  Expansion are ongoing, they may face challenges in sustaining funded  residents or adding more primary care GME training. Without  reauthorization, funding for the Teaching Health Center program will end  in fiscal year 2017. HRSA officials said that Teaching Health Center  awardees may have difficulty sustaining residents added without  continuation of the grant program, in a large part because they are  community health centers that do not have other revenue lines to support  GME training. For example, they said that a recent decrease in Teaching  Health Center funding resulted in awardees training fewer residents than  they originally projected, and some awardees reported they may not be  able to continue GME programs. For VA’s GME expansion, as of June  2016, about 12 percent of the 163 primary care FTEs distributed to VA  medical centers remained unoccupied, which VA officials said could be  because, for example, the GME training programs were not ready to use  them. Further, the percentage of primary care FTEs distributed through  the expansion fell from 51 in 2016 to 37 in 2017. VA officials said that the  drop could be because of pent-up demand in the first year of funding, but  also reported challenges forming new partnerships with academic  affiliates in primary care specialties, such as those in family medicine.  However, VA officials also noted that they are actively pursuing such  partnerships, and it could take 5 to 7 more years to determine the extent  to which they are successful at producing new resident positions.

Given that these four federal efforts represent a relatively small  investment in primary care GME training, and that most other federal  funding cannot be targeted to primary care, the efforts may not be  sufficient to meet projected primary care physician shortages. In  November 2016, HRSA projected a shortage of up to 23,640 primary care  physicians by 2025—although it indicated that changes in health care  delivery, such as greater use of nurse practitioners and physician  assistants, could affect the extent of that shortage. It also noted  substantial regional variation, with the South facing the largest shortage  and the Northeast having almost no shortage. HRSA officials told us  their projections did not account for the primary care efforts we identified.  When asked the extent to which the efforts might mitigate the shortages,  officials said that the efforts could help to lessen them, particularly if the  ongoing efforts are fully supported with sustainable, long-term funding.  For example, they said that if the Teaching Health Center program were  able to continue to support the same number of resident FTEs as are  currently approved, it would produce approximately 3,000 new primary  care physicians by 2025. However, officials acknowledged that the efforts  account for a small percentage of overall primary care residents being  added to the physician workforce. As most other federal GME funding  comes from Medicare, which HHS generally distributes according to  statutory formulas unrelated to workforce needs, it is unlikely that other  federal funding sources will add the additional primary care positions  needed to fill the gap.

In a 2015 report, we recommended that, to ensure that HHS workforce  efforts meet national needs, HHS should develop a comprehensive and  coordinated planning approach to guide its health care workforce  development programs. In making this recommendation we noted that, without such planning, HHS cannot fully identify the gaps between  existing programs and national needs as well as the actions needed to  address these gaps. In response, HHS concurred with our  recommendation and, among other things, noted that it could convene an  interagency group to assess such things as gaps in workforce programs  and potential requests to the Congress for modified or expanded  legislative authority. As of December 2016, HHS officials indicated that  the agency had not taken steps to convene this group, but said that it is  still considering doing so in the future. In light of the limited nature of  current federal efforts to increase primary care GME training, we continue  to believe that our recommendation should be implemented and agree  that an interagency group like the one proposed by HHS is an important  first step toward ensuring a more comprehensive and coordinated  approach to workforce planning.

section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS and VA for comment. HHS  provided technical comments, which we incorporated as appropriate. We  also received emailed comments from VA through an analyst in its Office  of Congressional and Legislative Affairs that reiterated our findings on the  number of GME primary care positions added under the Veterans  Access, Choice, and Accountability Act of 2014.

As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  Secretary of Health and Human Services and other interested parties. In  addition, the report will be available at no charge on GAO’s 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 at kingk@gao.gov. Contact points for our Office  of Congressional Relations and Office of Public Affairs can be found on  the last page of this report. Other major contributors to this report are  listed in appendix II.

section_title: Appendix I: Federal Efforts to Increase Nurse Practitioner and Physician Assistant Trainees in Primary Care or Rural Areas
paragraphs: With the projected shortage of primary care physicians and challenges of  recruiting physicians to rural areas, some experts have suggested that  providers other than physicians could help address gaps in care. Nurse  practitioners—one type of advanced practice registered nurse—and  physician assistants are two examples of such providers. Both have  completed graduate-level education and, depending on the specialty they  choose, are trained to deliver a wide range of care, including primary  care. While nurse practitioners and physician assistants can furnish some  of the care provided by physicians, the extent to which they can provide  this care independently varies based on state laws. For example,  according to information from the American Association of Nurse  Practitioners, state laws differ in how much they allow nurse practitioners  to provide patient services independently, with 22 states and the District  of Columbia allowing them to practice completely independently, and the  remaining 28 states imposing varying restrictions, such as supervision by  physicians when performing certain services. Physician assistants  traditionally practice under the supervision of physicians to some degree,  but according to a National Governors Association study, while most  states allow physicians to determine the medical tasks they delegate to  physician assistants and the appropriate level of supervision, some have  more explicit requirements.

In November 2016, the Department of Health and Human Services’  Health Resources and Services Administration (HRSA) reported that  although it projects a shortage of primary care physicians by 2025, under  current utilization rates, the national supply of primary care nurse  practitioners and physician assistants is expected to outpace demand.  HRSA also projected that these trends will vary by region, and it expects  an oversupply of these providers to be greatest in some of the regions  facing a shortage of primary care physicians, such as the South. HRSA  noted that more effective integration of nurse practitioners and physician  assistants into health care delivery could help mitigate physician  shortages in primary care.

Similar to how we identified and described federal efforts to increase  graduate medical education in primary care or rural areas, we also  identified federal efforts to increase the number of nurse practitioner and  physician assistant trainees in primary care—which we defined as family  medicine, internal medicine, and pediatrics—or in rural areas.  Specifically, we reviewed government and nongovernmental reports on  funding for health care workforce training and interviewed officials from  the Department of Health and Human Services and the Department of  Veterans Affairs (VA). We limited our selection to efforts that provided  funding directly to training programs within the civilian health care system  and that were ongoing as of January 2016. As such, we excluded efforts  that provided payments directly to individual trainees, including loan  repayment and scholarship programs. We also excluded efforts that were  not primarily focused on increasing the number of trainees in clinical  training. For example, we excluded efforts that focused primarily on  curriculum enhancement for existing training programs or training for  leadership, management, and research skills.

Through this review, we identified three efforts within HRSA that met our  criteria. One of these efforts was focused on physician assistants and the other two focused on nurse practitioners. (See table 4.) For each  effort, we obtained and analyzed HRSA data to determine funding and  trainee levels. To determine the reliability of the data we reviewed, we  interviewed agency officials and checked for outliers and obvious errors  to test the internal consistency and reliability of the data. After taking  these steps, we determined that the data were sufficiently reliable for the  purposes of our reporting objectives. We also interviewed HRSA officials  and reviewed agency annual reports for further information about the  efforts. In this appendix, references to years are to academic years  unless otherwise noted.

Overall, we found that the amount of funding and trainees funded per  awardee varied across the efforts. For example, the Expansion of  Physician Assistant Training and the Advanced Nursing Education  Expansion had a smaller number of applicants awarded funding and  trainees funded and a larger average amount of funding per awardee  than the Advanced Education Nurse Traineeship. (See table 5.)  According to HRSA, while the median traineeship award for the  Expansion of Physician Assistant Training and the Advanced Nursing  Education Expansion during 2014 was $22,000, the median award for the  Advanced Education Nursing Traineeship was $7,390.

As part of its annual reporting, HRSA examined the extent to which  graduates of these programs practiced in primary care, rural areas, or  medically underserved areas after completing their training. According  these reports, though the number of 2013 Expansion of Physician  Assistant Training graduates was smaller, they were more likely than  2013 graduates of the two nurse practitioner programs to be practicing in  primary care or rural or medically underserved areas one year after  graduating. (See table 6.)

HRSA reported that funding for trainees in the Expansion of Physician  Assistant Training and the Advanced Nursing Education Expansion  ended in 2016, while the Advanced Education Nursing Traineeship was  ongoing at the time of our review. When asked about the sustainability of  the efforts without federal funding, HRSA officials referenced a recent  study, which found that of 22 Expansion of Physician Assistant Training  grantees responding to a survey, 82 percent planned on maintaining all  expanded positions; 4 percent intended to maintain a portion of the  expanded positions; and 14 percent intended to revert to their previous  training levels. HRSA officials said that they would anticipate similar  levels of sustainability for the Advanced Nursing Education Expansion.

section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Acknowledgments
paragraphs: In addition to the contact named above, William Hadley, Assistant  Director; Rachel Svoboda, Analyst-in-Charge; Toni Harrison; and Daniel  Lee made key contributions to this report. Also contributing were Samuel  Amrhein, Emily Flores, Vikki Porter, and Jennifer Whitworth.

Fast facts: The federal government has reported physician shortages in rural areas; it also projects a deficit of over 20,000 primary care physicians by 2025. Residents in graduate medical education (GME) affect the supply of physicians. Federal GME spending is over $15 billion/year.

We found that, from 2005-15, residents were concentrated in the Northeast and in urban areas. And, while many trained in primary care, primary care residents often subspecialize in other fields. Federal efforts to increase GME in rural areas and primary care were limited. In 2015, we recommended HHS develop a plan for its health care workforce programs—it has yet to do so.

Question-summary annotations: questions: question: How did locations and types of physicians in GME change from 2005 to 2015?
answer: The locations and types of physicians in graduate medical education (GME) training—known as residents—generally remained unchanged from 2005 through 2015, but there was notable growth in certain areas.

question: What amount of residents were receiving training in a medical specialty?
answer: From 2005 through 2015, over 80 percent of residents were receiving training in a medical specialty, which is required for initial board certification.
child_questions: question: What amount were in a primary care specialty?
answer: In 2015, nearly half of these residents were in a primary care specialty (internal medicine, family medicine, and pediatrics), versus other specialties, such as anesthesiology.

question: What does research say about primary care residents?
answer: While this represented a slight increase from 2010, research has shown that many primary care residents will go on to receive additional GME training in order to subspecialize, rather than practice in primary care.

questions: question: What efforts did GAO identify?
answer: GAO identified four federal efforts intended to increase primary care GME training.
child_questions: question: What did each effort do?
answer: Each effort added new primary care residents and provided funding in areas of the country with disproportionally low numbers of residents or physicians, though to varying degrees.

question: Why is it uncertain whether these efforts will be maintained or continue to grow?
answer: In addition, the extent to which the residents added by these efforts will be maintained or continue to grow is uncertain, in part because federal funding for some of the efforts has ended.

question: What did GAO recommend in 2015 for HHS?
answer: Further, GAO recommended in 2015 that the Department of Health and Human Services (HHS) develop a comprehensive and coordinated plan for its health care workforce programs, which is critical to identifying any other efforts necessary to meet these needs, and has not yet been implemented.

questions: question: What is essential for providing Americans with access to quality health care services?
answer: A well-trained physician workforce adequately distributed across the country is essential for providing Americans with access to quality health care services.

question: What physician shortages exist?
answer: While studies have reached different conclusions about the nature and extent of physician shortages, the federal government has reported shortages in rural areas and projects a deficit of over 20,000 primary care physicians by 2025.

question: Why is GME training important?
answer: GME training is a key factor affecting the supply and distribution of physicians.
child_questions: question: How is GME training supported?
answer: Federal funding for this training is significant, more than $15 billion per year, according to the Institute of Medicine.

questions: question: What does this report describe?
answer: This report describes (1) changes in number of residents in GME training by location and type of training from academic years 2005 through 2015, (2) federal efforts intended to increase GME training in rural areas, and (3) federal efforts intended to increase GME training in primary care.
child_questions: question: How did GAO get information for this report?
answer: To determine changes in the locations and types of residents in GME training, GAO analyzed resident data from the accrediting bodies overseeing GME training.

question: How did GAO identify and describe relevant federal efforts?
answer: To identify and describe relevant federal efforts, GAO also reviewed federal laws, reports, and data, and interviewed agency officials.