With regard to population need, states varied in the robustness of their primary care workforce. The median number of PCPs per 100,000 people in 2000 among all states was 63. PCGME trainee growth over the study decade in relation to the 2000 PCP-to-population ratio varied widely across states without an apparent pattern or trend (r = −0.06; Figure 2, panel A). Of the 15 states with a PCP-to-population ratio below the median, 7 had PCGME decreases > 10%, while 8 had PCGME growth > 10%.
The total number of annual medical school graduates increased nationally by 19.0% from 2002 to 2012, with a median state increase of 12.5%. In many states, large changes (increases or decreases) in UME graduates did not correlate with corresponding growth in PCGME (r = 0.17; Figure 2, panel B). More than half of states had ≥ 10% growth of UME graduates, yet the majority of these states had declines in PCGME trainees.
Between 2002 and 2012, the U.S. population grew by 9.7% with a median state population growth of 7.8%. All but one state (Michigan) had positive population growth, with 35 states having > 5% growth and 20 states having > 10% growth. However, among the 25 states accounting for 85% of PCGME production, no state had net growth of PCGME trainees once corrected for population growth (Figure 3). Once adjusted for population growth, the national PCGME decline was 15.3% (unadjusted decline = 7.1%), and the median state decline among all states was 9.7% (unadjusted decline = 2.7%).
Despite states’ critical role in addressing local physician workforce needs, our findings show little correlation at the state level between PCGME growth and ostensible indicators of population need, such as PCP-to-population ratio or UME expansion. Further, the rate of state-level PCGME expansion has been largely unable to keep pace with population growth. Despite a federal funding cap on new GME positions in existing teaching hospitals, these positions have continued to grow, principally among subspecialty training programs (i.e., fellowships). Toward the end of our analysis period, the Health Resources and Services Administration Primary Care Residency Expansion and Teaching Health Center (THC) programs established numerous PCGME positions, although not enough to gain net core primary care trainees. Since 2012, there has been a considerable increase in the number of THC trainees27; however, if subspecialty (i.e., fellowship) positions continue to grow and be filled at a rate similar to the rate of growth in this analysis, it is unlikely that the growth in THC trainees will be large enough to offset the overall declines in PCGME trainees. Furthermore, ongoing funding for these programs is tenuous,28,29 and this modest federal contribution has not yet shifted the GME system away from specialization to address local workforce needs or the current and predicted national deficit of PCPs.
That UME growth, funded in many states under the banner of primary care expansion,30 showed little correlation with growth or even stability of PCGME is concerning. UME total enrollment grew 49% between 2002 and 2014,11 which is much larger than the graduate growth of 19% between 2002 and 2012 seen in our study. The consistency of the GME trends over the decade studied suggests even more growth of subspecialty training positions and continued reduction in primary care output after our study period.15 It has already been shown that UME expansion has little correlation with population growth or other indicators of population need9 and that the state of GME completion is a better predictor of state retention than is state of UME completion.20 Thus, both UME and GME growth have been uncoordinated with each other and with population need. The goal of public funding for UME and GME is to produce physicians to meet local and national health care needs, and yet state efforts have not generally coordinated physician pipeline development with local need.
As proxies for population need, we found that PCGME growth was not correlated with PCP-to-population ratio in 2000 or population growth from 2000 to 2010. However, in considering a publicly funded system that is responsive to local need and how this relates to PCGME, the question of “what specialty distribution would meet population needs?” arises. This question is not easily answered. Populations do need access to a wide array of specialty services, but it is unclear what distribution of specialists leads to improved outcomes. Conversely, a strong, integrated primary care foundation has been shown to produce better overall population health and health outcomes.1,2 Our inclusion of fellowship-trained family physicians likely underestimates their primary care contributions based on limitations discussed in the Method section; however, our inclusion of hospitalists as PCGME trainees far overestimates the net primary care outcomes.
Within the constraints of the current primary care system, there have been various models of delivering primary care that affect population access. For example, some patient-centered medical home models have reduced panel sizes,31 and many clinicians have left traditional practice for direct primary care, which even further reduces panels.32 These panel contractions emphasize primary care need, a need that will only grow from the current GME system. Some have argued that shifting work to nonphysicians, such as nurse practitioners (NPs) and physician assistants (PAs), may improve this burden.33 The optimal use of these clinicians may not be as physician substitutes, although this is frequently their role. Further, although the NP and PA workforce in primary care continues to grow, the majority of both NPs and PAs are now going into subspecialty services.34
This analysis did not include two special subsets: trainees in osteopathic-only residency programs and graduates of international medical schools (IMGs). Nationally, there are approximately 675 PGY-1 primary care trainees in osteopathic-only programs per year.35 Regarding state investment, as a number of osteopathic schools employ an interstate educational model where preclinical education is held at centralized locations, followed by clinical training in different states, it is unclear how graduates of these schools should be counted. Further, in 2014, the American Osteopathic Association, AACOM, and ACGME agreed to a single accreditation system for GME training as of 2020.36 This venture will give osteopathic graduates greater access to subspecialty training, potentially further eroding PCGME trainees. With regard to IMGs, each year thousands are accepted into GME programs, often in primary care. These GME positions were included in our analysis, but represent an influx of medical school graduates not accounted for in the state-level analysis, which further highlights the lack of coordination between the UME and GME pipelines.
Our proxies for population need did not account for all possible indicators of need as determined by states; it may be that PCGME or specialty growth relates to an unmeasured but defined need. For example, we did not examine whether state retention was correlated with need, and states with high retention rates may have lower PCGME growth despite large medical school enrollment increases. Other states with large influxes of IMGs or trainees in osteopathic-only programs may also have reduced PCGME growth. Finally, our analysis examined only actual trainees. It may be that states have PGY-1 primary care positions that remain unfilled; however, this would also be true for specialty and subspecialty positions.
GME position growth is affected by caps on Medicare funding, causing reliance on funding from Medicaid, the U.S. Department of Veterans Affairs (VA), or private sources for new growth. Georgia, which experienced one of the largest declines in PCGME during our study period, recently began to incentivize GME development in needed specialties and locations using workforce data and short-term start-up funds.30 Conversely, Florida and Texas, which have added numerous medical schools yet experienced substantial declines in PCGME, are among the states citing the challenges of additional administrative expenses and recruiting teaching faculty support.37 If the GME system were able to create financial partnerships outside Medicare and their federal caps, it is possible that residency programs could sustainably establish the positions required to meet workforce needs and to absorb new medical school enrollees.
Creating state-level financial partnerships may help address local workforce challenges and support pipeline creation. More than $4 billion of Medicaid funds are currently invested in GME.12 States have flexibility in Medicaid GME payments as well as the ability to assess local workforce challenges and allocate funds accordingly. Thus, these state-level partnerships (e.g., with Medicaid) could ensure that changes in GME structure—with regard to access, distribution, and specialty needs—are better aligned. Although many states have invested Medicaid dollars into GME, states often follow Medicare GME funding procedures, missing the opportunity for strategic allocation and strengthened local accountability.38 Although Medicaid provides less GME funding than does Medicare, these funds have the potential to make meaningful differences in local GME reform by helping shape the physician workforce to meet state needs.
The VA also funds many GME positions.39 In 2014, the VA announced funding of 1,500 new residency positions, emphasizing primary care and mental health and targeting facilities with a shortage of physicians, in rural locations, or in Health Professional Shortage Areas. Physicians who train in rural and underserved areas are more likely to remain in similar settings for practice,17,40 and a majority of family medicine graduates remain close to their GME site after graduation.41 Thus, establishing PCGME in primary care shortage areas may help ameliorate physician maldistribution. As of the time of writing, these VA positions were in the process of being distributed. We believe they have the potential to have a large impact on local populations.
The creation of pipeline programming and use of public funds requires accountability to ensure that workforce targets are met and physician distribution is improved. Few states systematically collect data regarding workforce assessment, and those that do have no requirement to use these data to support GME expansion.30 We suggest that GME policies support state workforce needs and require continuous evaluation and feedback to inform decision making and ensure the effectiveness of these publicly funded investments.
Our measures of need were not intended to be comprehensive so much as exemplary and based on previous state-level assessment.9 Because of the known lag time of the AMA Physician Masterfile, we may be overcounting physicians who are no longer in practice or undercounting the total number of PCGME trainees. Because the Physician Masterfile relies on input from the ACGME for the number of filled residency positions, trainees in programs that did not submit data to the ACGME would be uncounted. Finally, as stated in the Method section, we did not account for those entering hospital medicine, a specialty that had large growth during our analysis period42 and thus exacerbates the decline in PCGME trainees.
Recent growth in PCGME trainees is not correlated with state need. It is not correlated with the number of PCPs per population, with increases in UME graduates, or with state population growth. Nationally, total PCGME trainees declined 7.1% (unadjusted for population growth) or 15.3% (adjusted for population growth) from 2002 to 2012. Most PCGME trainee growth occurred in fellowship trainees and had the net effect of eroding primary care output. Existing data are helpful in tracking population need, the impact of workforce policies, and institutional accountability. States should capitalize on opportunities to create explicit linkages between medical education, training, and population need, to strategically allocate Medicaid GME funds, and to monitor the impact of workforce policies and training institution outputs.
Acknowledgments: The authors wish to thank Susan Skillman for her help in obtaining data pertaining to state-level enrollment at the University of Washington School of Medicine.
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