By Wendy Biddle, J.D.
Although some data on costs was incomplete, the GAO completed their report on the pros and cons of expanding education funding beyond physicians to help with the healthcare shortage.
Because studies have shown that the United States faces a shortage of physicians which affects citizens’ access to healthcare, the Government Accountability Office (GAO), instructed by the Senate Committee on Appropriations, examined the potential of expanding the scope of the Medicare Graduate Medical Education (GME) program to include nurse practitioners (NP) and physician assistants (PA). The GAO found that funding the additional programs would provide more stable funding for NP and PA training compared to existing programs but the change would need to consider how to allocate GME funding because the training is different for PAs and NPs than for physicians (GAO Report, GAO-20-162, December 2019).
The federal government funds many education programs for health care providers, but most of the funding goes to support physician residency training through HHS’ Medicare graduate medical education program. Currently, the GME program does not fund any training for NP’s or PA’s who can perform many of the same services a physician can, like diagnosing patients and performing certain procedures.
During its investigation, the GAO estimated that for completing an NP program, it would cost about $47,000 per NP student, and for PA students, the cost was estimated at $45,000 per student. Training for NP students requires a master’s or doctoral degree in nursing and generally take between 18-24 months for master’s programs and 3-5 years for doctoral students. This time includes both classroom and clinical work. Students become PAs after they earn a master’s degree in physician assistant studies, which generally takes about 27 months to complete and includes classroom and clinical rotations. Both NPs and PAs can complete a post-graduate residency program but are optional, unlike physicians.
Benefits of expansion. HHS funding is currently available to train NPs and PAs through Health Resources and Services Administration (HRSA) grants. Those funds totaled $136.2 million in fiscal year 2019. Contrast that with the $10.3 billion in 2015 that was allocated to physician training through the GME program. The GAO found that the stakeholders who were interviewed stated that a benefit of expanding the GME program to include PAs and NPs is that it would create more stability and predictability for training funding for the NPs and PAs. This would allow those programs to do more long-range planning for student admissions. Because the GME funding is mandatory for physicians, it has typically been more stable than the grant-based, discretionary funding for PAs and NPs.
Another identified benefit of expanding the GME funding is that the funding could be used to pay preceptors as an incentive to supervise students. There have been reported challenges in finding preceptors and schools then chose not to fill all their available enrollment spots. Because supervising students can take time away from a preceptor’s productivity in seeing patients, some practices and health care systems do not allow their providers to serve as preceptors. That could change if the preceptors could be paid through the fund.
Challenges of expansion. A challenge the stakeholders noted was the training requirements for PAs and NPs do not align with the clinical training structure of the current Medicare GME program. The GME program is structured to fund the physician residency training, which is required for a doctor to practice medicine. But NPs and PAs are not required to complete a residency after their graduate program. Through the GME program, CMS pays hospitals according to formulas outside in statutes based on the number of residency positions. Including PAs and NPs would require a change to the GME program to account for the differences in training requirements between physicians, PAs, and NPs.
There was also concern that expanding the GME program would negatively impact the funding available to physician training. If the overall funding was not increased, and simply a reallocation of existing funds was put in place, there would not be enough funding to provide residency training for all qualified physicians.
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