GME Outcomes

Tracking the output of Graduate Medical Education: How are Teaching Hospitals and Teaching Health Centers Meeting Society’s Needs?

A collaborative endeavor between the Robert Graham Center and the George Washington University Department of Health Policy

Even before heath reform, there was growing concern about the physician workforce, specifically primary care, general surgery, child psychiatry and other shortage specialties. With health reform, pent-up health care demands of millions of more Americans will make these shortages even more apparent. Graduate medical education (GME) is required for practice in the United States and is the determining step in both the overall size and the specialty distribution of the physician workforce.  GME also represents the largest federal and state investment in medical education, with Medicare contributing over $9 billion per year and Medicaid contributing over $3 billion per year in teaching hospital GME payments.  

Over the last two years, the Medicare Payment Advisory Commission and the Council on Graduate Medical Education have both signaled a need to increase accountability of teaching hospitals for producing the physicians that Americans need.   It is both timely and relevant to examine the state of our health professions workforce training system, evaluate what it produces and how it may need to evolve to be responsive to the future health care delivery system and the population it serves. It is also timely to examine potential policy options for helping that evolution, especially as MedPAC increases its calls for change and as the GAO establishes a newly mandated Health Care Workforce Commission modeled after MedPAC.

Today, there are more than 650,000 practicing physicians in the United States.  This number represents a steady increase over the last 50 years in both the number of physicians and the physician-to-population ratio.  However, the distribution of physicians in the United States and the declining number working in a number of specialties including primary care, general surgery, and pediatric psychiatry, to name a few. This maldistribution and specific shortages contribute to rising costs and a declining ability to reduce disparities in health outcomes. These focused shortages are chronic and growing problems for the delivery of healthy services, even as the over all numbers rise.  

Physicians practice locales have trended heavily towards urban and well-to-do areas.  Eleven percent of physicians practice in rural areas while 20% of the country’s population resides in these areas.   The problems with primary care are also well documented.  Evidence clearly shows primary care is associated with high quality, cost effective health care. Yet, American medicine is increasingly specialized.  Physicians reporting that they practice primarily as specialists comprise 68% of practitioners whereas those working in the primary care comprise only 32% of doctors in practice.   The situation in primary care, however, is more problematic than the numbers might suggest.  A number of factors are associated with dramatic reductions in interest in primary care and general surgery among U.S. medical graduates.   Between the mid-1990s and today, the number of training positions in family medicine has declined 20% and the percentage of the family medicine residency positions being selected by U.S. graduates has fallen from 72% to 44%.   General surgery has suffered a similar fate. Further, in keeping with the financial drivers of hospital business models, a recent study shows that subspecialty residency expansion and reductions in primary care training correlate strongly with the relative income of those specialties.

Health care reform efforts recognized the critical importance of the primary care workforce to establish a stable and cost effective healthcare system.  The law includes a redistribution of unused residency positions that favors primary care and general surgery. It also supports residency training in community health centers and outpatient settings, training of advanced practice nurses, and grants to support interdisciplinary training.  The Macy Foundation has a long history of supporting work in these areas including an Institute of Medicine report in 1989 and recent recommendations in 2009 and 2010.  We recognize an opportunity to develop evidence about the status of training, particularly in underserved settings, and increase the transparency about training physicians that are desperately needed by the nation

Over a 24 month project period, we propose examining two aspects of the medical workforce: 1) the physician output of all residency training institutions in regard to primary care, other shortage specialties, and practice in underserved areas, 2) the career choices and practice sites of residents trained in Teaching Health Centers.  We will compare our findings with recent surveys of community health centers (we will also capture rural health clinics) to see how sensitive this process is for future tracking. We will also explore whether we can use claims data to identify programs where trainees do brief rotations vs those with longitudinal experiences. Additionally, we would further develop our successful web platforms to enhance the capacity to serve as a resource for information and communication on GME issues.