Redistribution of federal of workforce development funds fails to deliver primary care to underserved areas

February 7, 2013

Despite federal funding to increase the number of primary care providers, few new positions have been added, according to a new study.

Federal programs contributed more than $14 billion to develop the healthcare workforce over 2 years, yet little accountability exists for this spending, and a new study published in Health Affairs reveals that, despite funding to increase the number of primary care providers, few new positions have been added.

Graduate medical education (GME) payments are the largest public investment in healthcare workforce development, with Medicare paying teaching hospitals $9.7 billion, Medicaid paying $3.8 billion, and the Department of Veteran Affairs paying $800 million in 2008 and 2009. The Affordable Care Act requires training hospitals to redistribute positions funded by GME that are left vacant or unused as a result of cutbacks and mandates that 75% of positions must go to primary care or general surgery programs. Priority is given to hospitals in states experiencing primary care physician shortages, the study notes.

Yet, according to the study, out of 304 hospitals that received new positions under the redistribution, 140 decreased their primary care training by a total of 946.6 positions between 1998 and 2004. Seventy-six of those hospitals increased their total positions during that same period, which the study authors note suggests the hospitals converted primary care positions into non-primary care positions. A total of 494.8 positions were converted to non-primary care positions. Following redistribution efforts, 110 of the 140 hospitals that had decreased primary care again expanded their primary care residencies by 1,190.9 positions. In rural areas, only 12 hospitals received new GME-funded positions after redistribution for a total of 83 positions-less than 3% of all the positions redistributed-and one-third of the hospitals that received funds were in populated urban areas.

Overall, from 2004 to 2008, primary care positions increased by 1,585, but non-primary care positions increased by 3,433, the study notes. This trend reveals that redistribution efforts fell short of the GME program’s goal of expanding rural primary care training, study authors say.

“The relative growth of non-primary care training was twice as large and had a net negative effect on primary care production by diverting would-be primary care physicians to subspecialty training,” the study reveals. “In the end, the two legislative and regulatory priorities for the redistribution were not met, and the effort did not address key national healthcare workforce needs.”

Several hospitals decreased primary care training while increasing specialty training, even after receiving Medicare-funded positions, and redistribution efforts were preceded by a relative expansion of non-primary care training at the expense of primary care, the study adds.

Although redistribution added primary care positions overall, it did not prevent conversion of primary care positions to specialty positions, the authors note. They conclude that the Medicare GME payment system needs to be reassessed, and stronger safeguards are needed to maintain current levels of primary care training. Some suggestions from the study include introducing accountability requirements into the current system with sufficient penalties and incentives to truly make an impact, and instituting ongoing evaluations to ensure that desired outcomes are being met. Without such reforms, a complete overhaul of the current system may be necessary, including a re-evaluation of the formula system and potentially delinking payments from hospitals that don’t follow through on program requirements, the authors say.

 

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