By Rebecca Mayo, J.D.
An adequate, well-trained, and diverse physician workforce is essential for providing Americans with access to quality health care services. While a number of factors affect the supply and distribution of physicians, their graduate medical education (GME), also known as residency training, is a significant determinant. Since a significant portion of GME training funds come from federal programs and states, the GAO reviewed aspects of this spending and federal oversight and issued its report (GAO Report, No. GAO-18-240, March 29, 2018).
Spending. Most federal funding of GME training is provided through Medicare GME payments (direct and indirect), Medicaid GME payments, HHS’ Health Resources and Services Administration’s (HRSA) Children’s Hospitals GME Program (CHGME) and Teaching Health Center GME Program (THCGME), and the VA GME program. The THCGME program was created under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) to increase the number of primary care residents who trained in community-based, ambulatory patient settings. The CHGME was created to support pediatric and pediatric specialty GME training in freestanding children’s hospitals, and the VA GME program was designed to assist VA in the recruitment and retention of staff at its medical facilities.
In 2015, federal agencies and state Medicaid agencies spent over $16.3 billion on GME training. The federal government alone spent $14.5 billion through Medicare, Medicaid, VA, and the CHGME and THCGME programs. Seventy-one percent of federal GME training spending came from Medicare, with over $10.3 billion in payments to teaching hospitals. Medicaid spending accounted for 16 percent (or $2.4 billion) and matched an additional $1.8 billion that Medicaid agencies in 45 states spent on GME training.
Breakdown. These payments supported both direct and indirect costs associated with GME training. An estimated one-third of Medicare payments were made to cover the direct costs of GME training. HRSA also reported that one-third of CHGME payments were made to cover direct costs. The amount paid per full-time equivalent resident varied across programs, and the largest variation across recipients and regions was within Medicare. Over half of providers that participated in any of the five GME programs received payments from more than one federal program, which increases the risk of duplicate payments. Although the risk of duplication is reduced by the program’s designs as some of the programs are specifically designed to establish payments for hospitals or areas where there was not traditionally significant Medicare GME payments.
Data collection. The GAO found that there is no standard method or tool across teaching sites for identifying and capturing GME training costs. Factors specific to teaching sites, such as varying relationships and financial arrangements between the teaching sites and its faculty, may affect how they identify their training costs. Some GME training costs are difficult to accurately identify and measure for facilities across the board. For example faculty costs may be difficult to ascertain when the clinical supervisor is training residents while treating a patient. Other costs such as facility costs, indirect medical education costs and resident benefits for teaching sites costs and productivity are also difficult to determine.
Additionally, federal agencies do not systematically collect and standardize cost information at the national level. Agencies generally collect information to manage their respective programs, ensure the accuracy of payments, and reduce the potential for duplicative payments within or across federal programs that fund GME training. HHS however does not have sufficient information available to comprehensively evaluate the federal programs that fund GME training, identity gaps between federal GME programs’ results and physician workforce needs, and to make or recommend to Congress changes in order to improve the efficient and effective use of federal funds.
GAO recommendation. The GAO recommends that HHS coordinate with federal agencies to identify information needed to evaluate the performance and cost-effectiveness of federal programs that fund GME training, and to identify and implement opportunities to improve the quality and consistency of the information collected within and across federal programs.
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