Federal Agencies and State Medicaid Agencies Spent Over $16 Billion on GME Training in 2015 to Support Direct and Indirect Costs of Training

Federal agencies and state Medicaid agencies spent over $16.3 billion on  GME training in 2015 through five federal programs and 45 state  Medicaid agencies. Of this, the federal government spent $14.5 billion  through Medicare, Medicaid, VA, the CHGME program, and the THCGME  program. Providers in all 50 states and the District of Columbia received payments  for training GME residents, but some regions received a notably higher  amount compared to others. 1.) GME Training Costs Vary by Program Size, Type, Setting, Age, and Location

According to literature we reviewed and experts we interviewed, GME  training costs vary by residency program characteristic, and some costs,  such as faculty teaching time, are more prone to variation than others. Challenges Exist in Measuring and Comparing GME Training Costs and Little is Known about their Relationship to Federal GME Funding

We found that there is no standard method or tool across teaching sites  for identifying and capturing GME training costs. Factors specific to teaching sites may affect how they identify their  training costs. For example, program directors may  not have the financial experience needed to identify costs, and some  teaching sites may use outside consultants to identify costs. Information the Federal Government Collects to Manage Programs Is Not Sufficient to Comprehensively Understand Its Investment in GME Training

Agencies generally collect information to manage their respective  programs, ensure the accuracy of payments, and reduce the potential for  duplicative payments within or across federal programs that fund GME  training. However, HHS does not have sufficient information available to  comprehensively evaluate the federal programs that fund GME training,  identify gaps between federal GME programs’ results and physician  workforce needs, and make or recommend to Congress changes in order  to improve the efficient and effective use of federal funds. In addition, while CMS uses IRIS to collect  information on the number and type of residents and their number of  years completed in all types of GME training programs of residents  supported by Medicare GME payments, it does not use it to  understand the output of such spending or for health care workforce  planning. Further,  although HRSA collects data about the outcomes of its CHGME and  THCGME programs, this information is self-reported by funding  recipients. Because the information that agencies collect is not always complete or  consistent, HHS does not have sufficient information available to  comprehensively evaluate the federal programs that fund GME training. Recommendation for Executive Action

We are making the following two recommendations to HHS:  The Secretary of HHS should coordinate with federal agencies, including  VA, that fund GME training to identify information needed to evaluate the  performance of federal programs that fund GME training, including the  extent to which these programs are efficient and cost-effective and are  meeting the nation’s health care workforce needs. (Recommendation 1)
The Secretary of HHS should coordinate with federal agencies to identify  opportunities to improve the quality and consistency of the information  collected within and across federal programs, and implement these  improvements. At that time, we will send copies of this report to the  Secretary of Health and Human Services and the Secretary of Veterans  Affairs.
Why GAO Did This Study

An adequate, well-trained physician workforce is essential for providing access to quality health care. While a number of factors affect the supply and distribution of physicians, GME is a significant determinant. A significant portion of GME training funds come from federal programs and states.
This report (1) describes the amount and distribution of federal government and state Medicaid agency spending on GME; (2) describes what is known about GME costs; and (3) examines the extent to which the federal government collects information to understand its investment in GME. GAO reviewed reports, agency websites, and interviewed agency officials to identify federal programs that fund the clinical training of residents and were authorized through 2017. GAO analyzed 2015 data—the most recent data available at the time of GAO's analysis—including from a state survey. All 50 states and the District of Columbia responded to the survey. GAO reviewed literature, interviewed experts from seven organizations knowledgeable about GME costs, and analyzed Medicare data. GAO also reviewed documentation from HHS and the Department of Veterans Affairs (VA) and interviewed agency officials.

What GAO Found

Federal agencies and state Medicaid agencies spent over $16.3 billion in 2015 to fund graduate medical education (GME) training for physicians—commonly known as residency training. The federal government spent $14.5 billion through five programs, and 45 state Medicaid agencies spent $1.8 billion. About half of teaching sites that received funding—such as teaching hospitals—received funds from more than one of the five programs.
GME training costs vary due to the characteristics of teaching sites, such as the number of residents trained and their specialty, which can make it difficult to compare training costs across sites. Further, challenges exist in measuring training costs because some costs, such as faculty teaching time, are difficult to identify. Also, there is no standard method for identifying and capturing training costs, and each teaching site may vary in how it does so.
While federal agencies generally collect information needed to manage their individual programs, this information is not sufficient to comprehensively understand whether the federal investment in GME training meets national physician workforce needs. The information agencies collect is not always complete or consistent within or across programs. For example, national data on GME training costs are not systematically collected, and some agencies lacked data to understand the total amount spent, or the outcomes of their programs, such as where supported residents went on to practice. GAO recommended in 2015 that the Department of Health and Human Services (HHS) develop a comprehensive planning approach to identify and address areas of health care workforce need. HHS concurred and identified steps it could take. While HHS has yet to take these steps, the information currently available is also insufficient for such planning. Comprehensive information is needed to identify gaps between federal GME programs and national physician workforce needs—particularly the distribution of physicians geographically or across specialties—and to make or recommend to Congress changes to improve the efficient and effective use of federal funds to meet those needs.

What GAO Recommends

GAO recommends that HHS coordinate with federal agencies, including VA, to (1) identify information needed to evaluate federal GME programs, and (2) identify opportunities to improve the quality and consistency of information, and implement these improvements. HHS concurred with both recommendations.