Efforts to Bolster Rural Primary Care Residencies Fall Short

If the measure of success is intent and outcomes then the federal government's efforts under the Medicare Modernization Act of 2003 to train more physicians in primary care and to practice in rural areas have been a failure.

A study published this month in Health Affairs looked back on the mandate in the legislation to redistribute nearly 3,000 residency slots among the nation's hospitals. The researchers found that only 12 of the 304 hospitals that had received additional positions starting in 2005 were considered rural, and received only 3% of all positions redistributed.

And while primary care training had positive net growth after the redistribution, the growth of subspecialty training was twice as large and diverted would-be primary care physicians into subspecialty training.

Only 3% of rural hospitals got additional slots
"The really concerning thing is that the legislation specifically prioritized rural training so you would expect that the intent would be to significantly increase rural training. Only 12 rural hospitals received additional slots and that was only 3% of the total additional slots redistributed. Most of us would agree that that probably didn't meet the legislative intent," says Candice Chen, lead author of the study and an assistant research professor at the George Washington University School of Public Health and Health Services.

"The primary care issue is a little more complicated," Chen says. "We found that coming up to the redistribution a lot of the hospitals that got slots had been likely converting their primary care to non-primary care slots."

"Many of them increased their primary care training so in those hospitals where you had lost some primary care training you did manage to gain some back. But we saw a significantly larger increase in non-primary care training slots. And there was a subset of hospitals that received additional primary care slots and continued to convert them into non-primary care slots."

Chen says outcomes demonstrate the need for more coordination of medical workforce development on a national level.

"Each one of those GME programs is out there for individual organizations meeting their hospitals' and communities' needs and when you cobble them all together we are not getting what we need over all the country," she says.

"We need some more analyses and planning on a national level so we can start asking 'how can we get what we need out of this system as a whole? How do we build those requirements into the system so that in another 10 or 15 years, or even sooner than that,  people aren't scrambling to find a primary care provider.'"

Legislators lack "granular knowledge" of GME
Perry A. Pugno, MD, vice president for education with the American Academy of Family Physicians, says he is not surprised that the goals of the 2003 legislation were not attained.  

"When this first came out we contacted the people who were putting forward this legislation and said you really should have talked to us beforehand and we could have helped you write it so there were fewer loopholes that would allow the outcome that you got to occur," he says.

"The people who write this legislation see the problem, they are trying to make a difference, but they don't have the granular knowledge of the nuances for how GME functions and how trainees go through their training in enough detail to plug the holes from which these kinds of distributions occur."

"We knew small rural hospitals were probably not going to jump through all the hoops necessary to try to get some additional physicians and that the larger academic centers that train lots of specialists would eventually get their hands on many of these positions, which is exactly what happened."

Pugno says some of the shortcomings in the 2003 legislation could be alleviated under the Patient Protection and Affordable Care Act.

"There are provisions in the[PPACA]  that are trying to direct funding and support toward addressing rural training and the care of disenfranchised populations and things like that," he says.

Don't blame hospitals
"The conversation about redirecting money towards outcomes of training programs is probably the most effective. The caveat is that they need to be looking at the outcomes from people who are at least two years out from their residency training. One of the problems with these programs is there is a lot of talk about 'we are doing primary care training because we have all of these residents in internal medicine and pediatric residency programs.' But half of the pediatrics go into subspecialties and 90% of the internal medicine residents go into subspecialties."

Chen says it's not fair to lay all the blame on hospitals for skirting the intent of the legislation.

"People want to make hospitals the bad guys, but it's not as simple as that. Most hospitals are trying to meet a community need, particularly the smaller community hospitals," she says.

Much work to be done
"All the odds are stacked against them because of the way our payment systems are stacked up. They are incentivized to convert their primary care residency programs into specialty programs. They can generate more revenue that way and support some of the procedures and things that hospitals do that will bring in more revenue and make sure the bottom line is safe. I spend a lot of time looking at community-based hospitals that don't have a lot of margin. They are struggling and we don't want to see anything happen that would put those hospitals into even more jeopardy."

"The what-needs-to-be-done list is very long," she says. "A lot of people say it just can't be about GME or residency programs and we agree. We need changes in how we pay for care to strengthen the primary care workforce and incentivize people to go into primary care. We need payment and practice reforms. Primary care providers want to provide the best care, but when they feel like a hamster on a wheel they can't."

Even conceding payment and practice reforms, Chen says medical schools GME programs will still have a huge role in realigning the physician workforce. "It has to be done at the same time. If you don't, the educational system can hold back the reforms," she says.

"I would argue we have the best system in the world in terms of providing quality physicians. But there is no match in the kinds of physicians we are producing in terms of specialty and geographic distribution."

Poor distribution of physician placements
"How," asks Chen, "do we not only get the highest quality physicians but how do we get a workforce that matches the needs of the country and will support the payment and practice reforms that are aimed at getting us more comprehensive and cost efficient care?"

While the results from the 2003 legislation clearly fall short of the aspirations, Pugno says the mandate still raised the profile of primary care physicians.

"It's not a failure from the perspective that Congress is concerned about making the most of the money that they are putting into GME," he says.

"They fully recognize the need for more primary care. They fully recognize that we have maldistribution of physician placements and if we do more rural training we would have more physicians practicing in rural areas. So the basis from which they are coming and the things they are trying to fix are things we spent a decade trying to get them to recognize. So it is progress in the right direction. They just need to get some help tightening up how they write this legislation so they get the outcomes this legislation was designed to get."