The Geography Of Graduate Medical Education: Imbalances Signal Need For New Distribution Policies

Abstract

Graduate medical education (GME) defines the overall number, specialty make-up and geographic distribution of the U.S. physician workforce. Medicare GME payments represent the largest single public investment in health workforce development but it is an inflexible system that is drawing scrutiny for its rationale, effectiveness and balance. We analyzed Medicare hospital cost reports for teaching hospitals and found large state level differences in the number of Medicare sponsored residents per population, total Medicare GME payments, payments per person (ranging from $1.94 to $103.63 per person in Montana and New York, respectively), and average payments per trainee (ranging from $63,811 to $155,135 per trainee in Louisiana and Connecticut, respectively). Options to address these imbalances include ensuring those states that receive less Medicare GME are prioritized or protected in the case of increases or decreases in funding and the re-examination of the Medicare GME formulas. The state level variation highlights that the GME system badly needs flexibility and the capability to deliberate and make policy about public investments in graduate medical education.

Is Training in a Primary Care Internal Medicine Residency Associated with a Career in Primary Care Medicine?

“…It is therefore essential to determine which educational efforts ultimately promote careers in primary care amongst future physicians. Calls have been made for a re-evaluation of Graduate Medical Education (GME) funding, 40 and accountability measures will likely grow increasingly important. 7,[41][42][43] Our study has attempted to evaluate the outcomes of primary care residencies, and our results suggest that more work may be needed to improve the existing primary care training experiences.…”

Teaching Health Center Graduate Medical Education Locations Predominantly Located in Federally Designated Underserved Areas

“…Forty sites are designated as both HPSA and MUA/P. Of the 109 sites, 57% are located in states that fall into the 4 lower quintiles of Centers for Medicare & Medicaid Services-funded resident-to-population ratio states, 8 including 3 of 8 in the lowest quintile, with only 1.6 to 13.84 residency slots per 100 000 population (FIGURE).…”

“…The THCGME residency positions in primary care and oral health have the potential to ameliorate the geographic maldistribution of primary care physicians nationally by locating training in underserved sites. 8 Statute suggests, but does not require, that THCGME programs be located in underserved areas. Until now the location of clinical continuity training sites has not been available.…”

Establishing the First Residency Program in a New Sponsoring Institution: Addressing Regional Physician Workforce Needs

“…3 According to the Institute of Medicine, 4 ''under the current terms of GME financing, there is a striking absence of transparency and accountability for producing the types of physicians that today's health care system requires.' ' The 20th century saw American medicine evolving from generalist to specialist care, and from community-to hospital-based physicians.…”

“…In 2011, Medicare cost reports from teaching hospitals found large state-level differences in Medicare-sponsored residents per 100 000 population (1.63 in Montana to 77.13 in New York); total Medicare GME payments ($1.64 million in Wyoming to $2 billion in New York); payments per person ($1.94 in Montana to $103.63 in New York); and average funding per resident ($63,811 in Louisiana to $155,135 in Connecticut). 3 Proposals to address these imbalances are conceptually straightforward, but politically arduous. 2 Primary care and community-based training models represent a small minority of GME positions; yet primary care physicians generally perform better in domains of value, hospitalization rates, and patientcenteredness.…”