There are concerns that the United States is not producing enough primary care physicians to meet the nation’s need.1,2 The Council on Graduate Medical Education (COGME) has recommended that 40% of physicians completing residency training in the United States should enter primary care.3 Currently, however, only about 25% do so, a proportion that reflects a steady decrease over the past decade.4–6
Public funding of graduate medical education (GME), which is estimated at $15 billion annually, influences the supply, specialty composition, and geographic distribution of the physician workforce. The Institute of Medicine’s (IOM’s) Committee on the Governance and Financing of Graduate Medical Education is among the groups that have criticized this public investment in residency training for its lack of accountability and poor alignment with societal needs.7 Both the COGME and the Medicare Payment Advisory Commission (MedPAC) have proposed reallocating existing Medicare GME funds paid to teaching hospitals in order to support more primary care residency positions and fewer specialty residency positions.8,9
Organizations representing teaching hospitals have resisted such proposals; they have instead advocated removing the cap on Medicare-funded GME positions and increasing the numbers of both primary care and specialty residency positions funded by Medicare.10 Teaching hospitals have demonstrated their predilection for sponsoring specialty training by using discretionary funds or other, non-Medicare GME resources to add residency positions almost exclusively in non-primary care fields. In the decade after the Balanced Budget Act of 1997 capped Medicare-funded GME positions, teaching hospitals added 9,100 new Accreditation Council for Graduate Medical Education (ACGME)–accredited residency positions predominantly in specialty training programs, whereas the number of general internal medicine and first-year family medicine residency positions decreased by 1,255.11 Another example of favoring growth in specialty training positions over growth in primary care positions occurred following the enactment of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Although this law called for redistributing 3,000 Medicare-supported residency positions and gave priority to rural hospitals in doing so, twice as many new specialty positions as primary care positions were created, and only 3% of the new positions were added in rural areas.12
In the face of the political challenges to investing a greater share of Medicare GME funds in primary care residency positions, federal policy makers have adopted other strategies to attempt to boost primary care output.10 These alternative strategies have tended to rely on time-limited training grants, in contrast to Medicare GME funding, which is a formula-driven and ongoing source of revenue to teaching hospitals to compensate them for the expenses associated with training residents.
One recent example of the time-limited grant approach is the Primary Care Residency Expansion (PCRE) program. In 2010, the Health Resources and Services Administration (HRSA) issued five-year PCRE grants totaling $168 million, from the Prevention and Public Health Fund of the Patient Protection and Affordable Care Act (ACA), to residency programs to improve and expand the primary care workforce.13,14 Residency programs in family medicine, general internal medicine, and general pediatrics applied for an average of two new residency positions per year of training above their existing Medicare-funded GME cap. Priority was given to programs based in rural or community settings. The PCRE program’s five-year budget and project period was set as September 30, 2010, to September 29, 2015, with funding designated at $80,000 per new residency position per year. Eighty residency programs in 28 states received PCRE grants; two programs dropped out of the PCRE program after the first year. The PCRE program is projected to support the training of about 900 additional primary care residents in the expanded positions from July 2011 to June 2016, and 540 of these residents are expected to graduate during this five-year period.14,15
In developing the PCRE program, HRSA expressed an interest in residency programs sustaining the additional positions beyond the five-year grant period. HRSA asked applicants “to demonstrate how they will support residents in expanded positions that start in grant years four and five through the completion of their training without grant funds.”14 Moreover, HRSA indicated that “grantees are encouraged to sustain the expanded number of residents beyond the five years required by this award.”14 Absent congressional action to renew PCRE funding, after grants expire in September 2015 each residency program will be responsible for seeking its own funding to sustain the expanded positions, including those of first- and second-year residents who began their training in PCRE-supported positions in 2014 and 2015 and are expected to graduate in the outlying years of 2016 and 2017. Residency programs that are unable to secure alternative funding sources will need to eliminate the expanded positions. The PCRE program resembles another ACA initiative, the Teaching Health Center Graduate Medical Education program,16 which awards time-limited HRSA grants to fund community-based entities to start or expand primary care residency programs.
A fundamental policy question is whether time-limited federal grant funding will in fact “prime the pump” of primary care residency training, with training institutions finding a way to maintain expanded residency positions once the federal start-up funding ends. HRSA awards in the 1960s and 1970s authorized by Title VII of the U.S. Public Health Service Act to support the establishment of new medical schools and new primary care residency programs did contribute to durable expansion of primary care physicians.4,17 However, it is not yet known whether time-limited residency expansion grants in the current era will produce similarly sustainable increases in training output.
Therefore, to evaluate the impact of the PCRE program and prospects for sustainability, we surveyed residency program directors whose programs received PCRE grants. The specific aims of this study were (1) to explore the perceived likelihood that residency programs will sustain the expanded positions after the end of the PCRE grant period in 2015, and (2) to identify the sources of funding that program directors have secured as well as plan to pursue to sustain the expanded positions after the PCRE grants end. We hypothesized that most residency programs receiving PCRE awards would not have secured ongoing funding for the expanded positions and that program directors would not be confident of sustaining the expanded positions.
Study participants and data collection
We contacted by e-mail the program directors of the 78 residency programs with an active PCRE grant to invite them to complete a confidential, self-administered online questionnaire hosted at Qualtrics.com (Qualtrics, Provo, Utah). We identified the residency program directors through the HRSA Data Warehouse. Nonrespondents received two follow-up e-mails and one telephone call. R.M.C. administered the survey by telephone to two program directors at their request. All data collection occurred between September and December 2013. Data were deidentified prior to analysis.
We drafted survey items and pilot-tested them among residency program directors at the University of California, San Francisco; the instrument was revised on the basis of their feedback. The final survey instrument ranged from three to eight questions, depending on the respondent’s answers.
Program directors were asked to provide the ZIP code of the principal ambulatory care training site for each expanded position and to indicate whether the training site was a federally designated facility serving underserved communities (Federally Qualified Health Center, Rural Health Clinic, or Critical Access Hospital). They were asked how many of the expanded positions their programs planned to sustain after the expiration of the grant. Those who reported plans to continue the positions were asked to rate their level of confidence that their programs will be able to continue the expanded positions beyond the expiration of the grant. Level of confidence was assessed as perceived likelihood of continuing the expanded residency positions and measured on a four-point scale, ranging from “Very unlikely to continue” to “Very likely to continue.”
We also asked about funding to support the expanded positions beyond the expiration of the PCRE grant. In these questions, we distinguished between the outlying years of 2016 and 2017, when the expanded positions will be partially supported by the PCRE grant, and the years after 2017, when the expanded positions will be completely unsupported by the PCRE grant. For each period, we asked program directors whether their program had secured full funding, partial funding, or no funding to sustain the expanded positions. For the years after 2017, we asked program directors who indicated that they had secured full or partial funding to indicate the sources of funding that had been secured. For those without secured funding for the years after 2017, we asked what funding sources they were planning to pursue. The response options for sources of funding were as follows: hope that the PCRE grant will be renewed; another HRSA grant; hospital funds (including Medicare GME); Medicaid GME funds; medical school or university funds including departmental funds; private health plans; resident-generated clinical income; medical group or physician hospital organization funding; state or county government funding; private philanthropy; and other.
Data management and analysis
Responses were extracted from the Qualtrics survey tool. We used the American Association for Public Opinion Research RR1 response rate definition.18 We explored potential nonresponse bias by examining the characteristics of responding and nonresponding programs using data on all PCRE-funded programs from the HRSA Data Warehouse; variables included primary care specialty, region of the country, number of expanded positions, and Health Professional Shortage Area (HPSA) designation. We calculated Pearson chi-square statistics to examine differences in characteristics between responding and nonresponding programs and differences in responses across program specialties. A P value < .05 was used to identify statistically significant results. All data analyses were performed using Stata version 13.1 (StataCorp LP, College Station, Texas).
This study was reviewed and deemed exempt by the University of California, San Francisco institutional review board. Informed consent was obtained at the beginning of the survey. There were no incentives offered for participation.
Of the 78 program directors of residency programs with active PCRE grants, 60 completed the online questionnaire and 2 completed a telephone interview (response rate = 79.5%). There were no statistically significant differences between the 62 responding programs and 16 nonresponding programs based on specialty, geographic region, program size, number of expanded positions per training year, or HPSA designation (Table 1).
There were 146 expanded residency positions created per year of training among the 62 responding programs. We estimated that 34 expanded positions per year of training were created among the 16 nonresponding programs, for a total of 180 new primary care residency positions per year of training across the 78 programs. At the 62 responding programs, half of the PCRE-supported residents (73/146; 50%) had their principal training site in a federally designated underserved setting (Table 2).
Twenty-eight respondents (45.1%; 95% CI 32.9%–57.9%) reported that their residency programs were unlikely to, very unlikely to, or not planning to continue any of their expanded positions after the PCRE grant expires (Table 3). These 28 programs account for 71 of the 146 (48.6%) new residents per training year among the respondents. The 34 program directors (54.9%) who indicated that their programs were likely or very likely to continue the expanded positions reported that they planned to sustain all their expanded positions. There were no statistically significant differences by specialty in the perceived likelihood of continuing the expanded positions.
Among the 52 respondents who reported at least a possibility of sustaining their expanded residency positions beyond the expiration of the PCRE grant (i.e., the respondents who selected any response option other than “Will not continue”), few reported having secured full funding. Less than half (25/52; 48.1%) reported that their programs had secured full funding for the expanded positions during the outlying years of 2016 and 2017 (Table 4). Approximately one-quarter (14/52; 26.9%) reported that their programs had secured full funding to sustain the expansion beyond 2017, when the expanded positions will be completely unsupported by PCRE grants.
Among the 34 respondents who reported that their programs were likely or very likely to continue all of the expanded positions, less than half (16; 47.1%) reported that full funding had been secured for the outlying years of 2016 and 2017, and about one-third (12; 35.3%) reported that full funding had been secured beyond 2017.
Overall, among all 62 respondents, less than one-quarter (14; 22.5%) reported that their programs had secured full funding to sustain their expanded positions beyond the outlying years of 2016 and 2017. Program directors of family medicine and pediatrics programs were significantly less likely than program directors of internal medicine programs to report that their residency programs had secured full funding for the outlying years of 2016 and 2017 (38.6% for family medicine and pediatrics programs combined versus 76.9% for internal medicine programs, P = .02). There was a similar though not statistically significant difference by specialty in having secured full funding for the years beyond 2017.
All 14 respondents who indicated that their programs had secured full funding for the years beyond the outlying years reported hospital funds (including Medicare GME) as a source of funding. Among the 38 respondents who had not yet secured funding and planned to pursue funding to continue the expanded positions beyond the outlying years, the most frequent funding sources identified were the hope that the PCRE grant would be renewed (34; 89.5%), hospital funds (25; 65.8%), medical school or university funds (14; 36.8%), and state Medicaid GME funds (14; 36.8%).
The PCRE program was developed to increase primary care physician production. Our findings suggest, however, that many of the residency positions gained through the PCRE program are in peril of being lost after the grants expire in 2015. Although HRSA encouraged applicants to consider strategies for sustainable expansion, our results suggest that the majority of residency programs that received PCRE awards lack a solid financial plan to support the expanded positions. Extrapolating our findings to all 78 residency programs with active PCRE grants, we conservatively estimate that nearly half of the expanded positions may be lost, representing a decrement of 88 primary care residency graduates annually (33 in internal medicine, 31 in family medicine, and 24 in pediatrics). As many as half of these at-risk positions are located in federally designated underserved settings. This figure may underestimate the future loss of expanded positions because few respondents reported that full funding had been secured to sustain the expanded positions after 2017. Our worst-case estimate is that 138 (77%) of the 180 expanded positions per training year may be lost once the PCRE grants end. Internal medicine residency programs appear to have better prospects for securing additional funding compared with family medicine and pediatrics programs, which may further blunt the ability of the PCRE grants to lead to sustained increases in primary care residency graduates entering primary care practice. Studies have shown that internal medicine residency graduates are less likely to pursue generalist careers than are graduates of family medicine or pediatrics programs.15,19
Many residency directors planned to pursue funding to sustain expanded positions from what we consider to be unrealistic potential funding sources, such as the hope that the PCRE grant will be renewed. The PCRE funding announcement stated that the grant was a one-time opportunity.14 Although President Obama, in his fiscal year 2015 budget, proposed spending $5.23 billion over the next 10 years to train 13,000 new primary care residents in high-need communities,20 to the best of our knowledge there are no congressional plans to reauthorize the PCRE grants or to appropriate the funds requested by the president. Another source that many program directors plan to pursue is hospital funding. However, most residency programs that received PCRE grants are based at training institutions that are already above their Medicare GME cap. On the basis of teaching hospitals’ recent track record of prioritizing specialty over primary care residency positions, we consider it unlikely that many of these institutions would voluntarily redistribute Medicare GME funding from specialty positions to primary care positions.1,10,21 In addition, some respondents planned to pursue Medicaid as a potential funder. In 2012, 42 states and the District of Columbia administered Medicaid GME programs; however, 6 states recently reduced Medicaid GME payments and 5 states reported that they had recently considered ending Medicaid GME payments altogether.22 Medicaid expansion under the ACA represents an opportunity for states to qualify for additional federal matching funds, which can be used for Medicaid GME programs. However, nearly half the states have chosen not to participate in Medicaid expansion, and the participating states face competing priorities for their Medicaid funds.
The incongruence between many residency program directors’ plans to sustain the expanded positions and their reports of not having secured funding may be explained by several factors. Residency programs had less than one month to apply for PCRE grants after the grant announcement was released, allowing little time for long-term strategic planning with other stakeholders. We suspect that many PCRE grant proposals were approached with an attitude of “apply for funding now, figure out the long-term plan later.” Applicants often approach grant programs opportunistically, focusing on short-term needs and goals; in this case, these may have included adding residents to help address clinical service coverage challenges stemming from the ACGME-mandated resident duty hours restrictions that went into effect around the time of the PCRE program announcement.
Our study has several limitations. We did not explore reasons other than funding shortfalls for not planning to sustain expanded residency positions. Other factors may influence plans to sustain positions, such as overall institutional financial position and state support of a primary care mission. Additionally, the nature of prospective, subjective inquiry and the two-year gap between this inquiry in 2013 and the end of PCRE funding in 2015 allow for the possibility that respondents’ predictions may not accurately reflect what will happen when the PCRE grants expire. Program directors may not be sufficiently informed of funding opportunities, and they do not have the fiscal authority to decide whether institutional funding will continue, so their perceptions may not be accurate predictors of future funding decisions. Respondents may have underestimated the likelihood of funding in the hope of pressuring policy makers and training institutions to provide sustained funding. However, the fact that many respondents seemed optimistic about funding sources that are unlikely to be available, such as another cycle of PCRE grants, suggests that our results may overestimate the chances that the expanded positions will be sustained. In addition, our findings may be subject to nonresponse bias; however, our survey had a high response rate, and there were no significant differences in the measured characteristics of responding and nonresponding programs. Further research on the PCRE program should be conducted at the conclusion of the funding period, when more definitive outcomes for the expanded positions will be known.
Implications and conclusions
Although the number of primary care residency positions at risk of being lost after expiration of the PCRE grants is relatively small compared with the total number of primary care residency positions in the United States, our findings have important implications for primary care residency training, GME financing reform, and future policies aimed at strengthening the health care workforce. Our results suggest that an approach to primary care residency training expansion that relies on time-limited HRSA grants is unlikely to produce sustainable growth of the primary care pipeline. The IOM’s Committee on the Governance and Financing of Graduate Medical Education observed that “secure and predictable funding” for GME requires funding through entitlement programs and concluded that “effective strategic investment is far less feasible in a federal program subject to annual discretionary funding.”7 Without a plan for systematic reform of GME financing—such as the plans proposed by the IOM committee,7 MedPAC,9 and COGME3,8—the positive impacts of the PCRE program and similar time-limited training grant programs are likely to be modest at best.
In summary, our study sounds a cautionary note about the ability of one-time grants to stimulate lasting changes in GME and primary care physician production. Our results suggest that once the PCRE grants end, substantial erosion of the gains achieved in primary care residency positions is likely. Rather than relying on a strategy of time-limited grants with the hope that training institutions will solve the sustainability issue on their own, policy makers should implement systemic reform of GME financing and designate reliable sources of funding, such as Medicare and Medicaid GME funds, for new primary care residency positions.
Acknowledgments: The authors would like to thank the residency program directors who participated in the survey as well as Dr. Shannon Bolon and Anthony Anyanwu of the Health Resources Services Administration and Jill Eden of the Institute of Medicine.
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