Primary Care Training: Follow the Money

Kenneth W. Lin, MD, MPH


August 07, 2015

Editorial Collaboration

Medscape &

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Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University School of Medicine and I blog at Common Sense Family Doctor. Today I'm going to talk about graduate medical education and, specifically, the funding of residency programs that produce future primary care physicians. Although practicing family doctors recognize that more medical students will want to do this work if salaries go up and work conditions improve, a potential bottleneck is the number of available training positions. 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%.[1]

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.[2] 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.[3,4]

So where else can money be found to support additional primary care residency positions? For years, the Centers for Medicare & Medicaid Services (CMS) has provided generous "no strings attached" funding to institutions that train all types of residents to offset the costs of resident and faculty salaries and extra patient care costs in teaching hospitals. In 2012, CMS alone doled out nearly $10 billion.

Last year, the Institute of Medicine published a report[5] 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!

We have a long way to go to get from here to there. An analysis of the outcomes of residency training found that the 20 institutions that produce the most primary care physicians received only about a third as many dollars from CMS as the 20 institutions that produced the least.[6] In other words, CMS mostly subsidizes graduate medical education in places that train mostly subspecialists.

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.

This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.


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