Monday, August 10, 2015

Primary care training: follow the money

Training any kind of doctor is time-consuming and expensive, but the way teaching hospitals are financed often means that it is more profitable to open a subspecialist residency program than one in primary care. In a previous post, I reviewed a Robert Graham Center study that concluded: "Medicare pays a disproportionate amount of its nearly $10 billion per year in subsidies to institutions that produce mostly subspecialists, even in specialties where supplies are plentiful, at the expense of training sorely needed family physicians and other generalists." I elaborated on the imperative to align public graduate medical education spending with population health outcomes in a recent Medscape video commentary. Here are some excerpts:

Researchers have estimated that in order to meet the projected US population need for primary care physicians in 2035, residency production will need to increase by 21%. For the past 5 years, a small grant program from the Health Resources and Services Administration (HRSA) has supported training about 900 additional residents in family medicine, internal medicine, and pediatrics. Of these, historical trends predict that about 600 will practice primary care. Although this is only a drop in the bucket compared with what is needed, the funding for these positions unfortunately will expire this year. Two surveys of program directors whose programs received one of these time-limited grants found that only 1 in 5 has secured funding to continue to support the expanded positions after 2017. ...

Last year, the Institute of Medicine published a report that called for reforming the allocation of taxpayer-supported residency funding to make teaching institutions accountable for producing a physician workforce that "can provide better individual care, better population health, and lower cost." My interpretation of this statement is: Provide financial incentives to train more family physicians! ...

The bottom line is that primary care physicians and our professional organizations need to push not only for reforms in how we are paid for patient care, but also reforms in how residency programs are funded in order to increase our numbers and produce a balanced workforce that meets the health needs of our nation.


  1. All of this lamentation about not having enough funding to provide residency training for physicians - thanks to Medicare. Did you ever stop to think that no such funding is available for a 'residency year or years' for nurses? Why is only one class of providers being subsidized in this manner?

  2. Fair question. Actually, the nursing education programs also receive funding from Medicare, but community-based programs are in much the same boat as primary care MD and DO programs - currently the law requires that Medicare funding for nursing education "pass through" a hospital. There is a bill pending in Congress that would correct this issue and allow funding to be dispersed separately:

    Rather than competing against each other, primary care physician and nursing (and nurse practitioner) organizations should work together to address the current disparity in public funding that overemphasizes hospital-based specialty programs over community-based primary care.