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. 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.) 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.) 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. 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). 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. 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. 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. 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. 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. 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. 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.

Summary: 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. 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. 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.