Initially,  physicians go through GME training for a specialty—such as internal  medicine, family medicine, pediatrics, anesthesiology, radiology, or  general surgery. Physician Shortages

Studies of the physician workforce and associated shortages vary in the  assumptions they make about physician supply and demand, resulting in  different conclusions about the nature and extent of shortages. Federal GME Funding

The federal government invests significantly in GME training. Over time, a number of federal efforts have been created that provide  funding to increase GME training in rural areas and in primary care. Locations and Types of GME Training Were Largely Unchanged from 2005 through 2015, but Growth Was Notable in Certain Areas

		Residents Remained Concentrated in Urban Areas and in the Northeast, Despite Growth in Other Parts of the Country

From 2005 through 2015, 99 percent of residents in GME programs  trained in urban areas, despite some growth in rural areas. While the Northeast maintained the highest  concentration of residents from 2005 through 2015, the resident growth  rate was higher in the other regions. 2.) 3.) Most Residents Trained in Specialties, of Which Nearly Half Were in Primary Care, but Growth Was More than Twice as Fast for Residents in Subspecialties

From 2005 through 2015, most residents in GME programs were training  in one of the specialties that all residents are required to complete before  choosing whether to practice or subspecialize. For example, in 2015,  over 80 percent of all residents were training in a specialty, with the  remaining residents training in a subspecialty. As previously noted, research has shown that many primary  care residents who trained in internal medicine go on to subspecialize  rather than practice in primary care. As a result, the percentage of all residents in AOA  programs grew from 3 percent to 6 percent. Use of Federal Efforts Intended to Increase GME Training in Rural Areas Was Often Limited, and Officials Reported Challenges

Hospitals’ use of three Medicare payment incentives—the primary federal  efforts we identified intended to increase GME training in rural areas— was often limited. Federal Efforts Intended to Increase Primary Care GME Training Were Relatively Small, and the Number of New Residents Added May Not Be Sustained

		Efforts Funded Residents in Primary Care and Other Specialties, Many of Whom Trained in Underserved Areas

We identified four federal efforts intended to increase primary care GME  training. To varying degrees, the four federal efforts funded residents in regions of  the country that have disproportionally low numbers of residents relative  to the population. Efforts Represent a Relatively Small Investment in Primary Care GME Training, and New Positions May Not Continue in the Future

Despite increasing the number of primary care residents, the four federal  efforts still represent a relatively small investment in primary care GME  training when compared with overall federal GME spending and the  number of primary care residents nationally. Specifically, average annual  funding for the Teaching Health Center program, the Primary Care  Residency Expansion program, and the VA GME expansion accounted  for less than 1 percent of the more than $15 billion in estimated annual  federal spending on GME training, and the Medicare GME redistribution  accounted for less than 1 percent of the approximately 79,000 IME and  83,000 DGME FTEs that hospitals reported being able to claim for  Medicare payment in fiscal year 2013. However, officials acknowledged that the efforts  account for a small percentage of overall primary care residents being  added to the physician workforce. In a 2015 report, we recommended that, to ensure that HHS workforce  efforts meet national needs, HHS should develop a comprehensive and  coordinated planning approach to guide its health care workforce  development programs. HHS  provided technical comments, which we incorporated as appropriate. While nurse practitioners and physician assistants can furnish some  of the care provided by physicians, the extent to which they can provide  this care independently varies based on state laws. Specifically, we reviewed government and nongovernmental reports on  funding for health care workforce training and interviewed officials from  the Department of Health and Human Services and the Department of  Veterans Affairs (VA).
Why GAO Did This Study

A well-trained physician workforce adequately distributed across the country is essential for providing Americans with access to quality health care services. While studies have reached different conclusions about the nature and extent of physician shortages, the federal government has reported shortages in rural areas and projects a deficit of over 20,000 primary care physicians by 2025. GME training is a key factor affecting the supply and distribution of physicians. Federal funding for this training is significant, more than $15 billion per year, according to the Institute of Medicine. Given the federal investment and concerns about physician supply, GAO was asked to review aspects of GME training.
This report describes (1) changes in number of residents in GME training by location and type of training from academic years 2005 through 2015, (2) federal efforts intended to increase GME training in rural areas, and (3) federal efforts intended to increase GME training in primary care. To determine changes in the locations and types of residents in GME training, GAO analyzed resident data from the accrediting bodies overseeing GME training. To identify and describe relevant federal efforts, GAO also reviewed federal laws, reports, and data, and interviewed agency officials.

What GAO Found

The locations and types of physicians in graduate medical education (GME) training—known as residents—generally remained unchanged from 2005 through 2015, but there was notable growth in certain areas. As shown in the table below, residents in GME training remained concentrated in the Northeast. At the same time, the number of residents grew more quickly in other regions, though this was somewhat tempered by regional population growth. Residents also remained concentrated in urban areas, which continued to account for 99 percent of residents, despite some growth in rural areas. From 2005 through 2015, over 80 percent of residents were receiving training in a medical specialty, which is required for initial board certification. In 2015, nearly half of these residents were in a primary care specialty (internal medicine, family medicine, and pediatrics), versus other specialties, such as anesthesiology. While this represented a slight increase from 2010, research has shown that many primary care residents will go on to receive additional GME training in order to subspecialize, rather than practice in primary care. Subspecialty training accounted for less than 20 percent of residents from 2005 through 2015, though the number of residents in subspecialties grew twice as fast as for specialties.
GAO found that the primary federal efforts intended to increase GME training in rural areas were incentives within the Medicare program that can provide hospitals with higher payments for such training. However, hospitals' use of these incentives was often limited, and certain Medicare GME payment requirements could present barriers to greater use.
GAO identified four federal efforts intended to increase primary care GME training. Each effort added new primary care residents and provided funding in areas of the country with disproportionally low numbers of residents or physicians, though to varying degrees. The four efforts accounted for a relatively small percentage of primary care residents and overall federal GME funding, about 3 percent and less than 1 percent, respectively. In addition, the extent to which the residents added by these efforts will be maintained or continue to grow is uncertain, in part because federal funding for some of the efforts has ended. As a result, the efforts may not be sufficient to meet projected primary care workforce needs. Further, GAO recommended in 2015 that the Department of Health and Human Services (HHS) develop a comprehensive and coordinated plan for its health care workforce programs, which is critical to identifying any other efforts necessary to meet these needs, and has not yet been implemented.

What GAO Recommends

GAO continues to believe that action is needed on a 2015 recommendation for HHS to develop a plan to guide its health care workforce programs. HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.