profession
Primary care work force: Grants target perennial plea for more residencies
■ HHS funds are a step in the right direction in meeting future primary care demands, but more is needed to stem doctor shortages, experts say.
By Carolyne Krupa — Posted Dec. 6, 2010
- WITH THIS STORY:
- » Related content
New funding to create an additional 889 primary care residency positions nationwide is an important step toward meeting growing demand for health care, graduate medical education experts say.
The money from the Health Resources and Services Administration comes amid years of calls for more residency funding from physician organizations and others concerned about projected physician shortages.
While the new positions are just a portion of what's needed long-term, they are a good start, said Perry A. Pugno, MD, MPH, director of medical education for the American Academy of Family Physicians.
"The real advantage to this is the fact that it's a recognition that we have a problem and that they're trying to make a difference," he said.
Eighty-two residency programs nationwide will benefit from $167.3 million in HRSA Primary Care Residency Expansion grants. The five-year grants will help create residency slots in pediatrics, internal medicine and family medicine, and were part of $320 million in awards the Health and Human Services Dept. announced Sept. 27 aimed at boosting the primary care work force.
Increased demand for care for an aging population and expansion of coverage to an estimated 32 million uninsured Americans under health system reform are expected to propel nationwide doctor shortages to 91,500 physicians by 2020. That figure includes 45,000 primary care doctors, according to the Assn. of American Medical Colleges. Meanwhile, HHS estimates that in the next decade, physician supply will increase by just 7%, one-third of practicing physicians will retire, and the number of Americans age 65 and older will grow 36%.
Expanding the primary care work force is a priority for HRSA and HHS in light of existing shortages and growing demand under health system reform, said Janet Heinrich, DrPH, RN, associate administrator for health professions at HRSA. There are about 110,000 residents nationwide, including 40,000 in primary care, according to data in the Sept. 15 issue of The Journal of the American Medical Association.
In addition to increasing slots, the grants support community-based training programs viewed as strong motivators for young physicians to choose a primary care career, Heinrich said. On Nov. 29, HRSA issued a call for applicants for another $230 million that will go toward increasing training opportunities for primary care residents and dentists in community-based ambulatory care centers.
The Reading Hospital and Medical Center in Reading, Pa., will receive $2.9 million over five years as part of the $320 million in expansion grants. The money will allow the center to expand from seven to 10 residents per class starting in July, said David L. George, MD, the hospital's vice president of academic affairs and chief academic officer.
The hospital's residency curriculum also is changing. Starting next year, residents will have a large portion of their training in a local community-based primary care practice.
Some residents who completed their elective training at ambulatory practices have gone into primary care as a result. "This offered an opportunity for them to see practice in the ambulatory setting in a more positive light," Dr. George said.
Rising demand
There is no guarantee that the grants will be renewed after five years. Recipients must commit to maintaining the added positions on their own past the grant period.
At Children's Hospital and Research Center in Oakland, Calif., grant money will enable expansion of the pediatric residency program next summer from 26 to 30 residents per class. It's the first growth in a decade of a program that gets more than 600 applicants annually from medical school graduates, said James Wright, MD, pediatrician and director of Children's pediatric residency program.
Many areas of the country already are seeing more demand for primary care services. At least 22 states and 15 medical specialties had reported physician shortages as of June.
"Our hospital has over 115,000 visits to our emergency department per year, and many of those are ones we anticipate should be and could be managed by primary care practices," Dr. George said.
Nationally, the opening of new medical schools and expansion of existing schools has led to a steady rise in overall enrollment of about 2% annually in the last six years. But residency programs aren't keeping pace, said Christiane Mitchell, AAMC director of federal affairs.
Medicare -- the largest funding source for residency programs -- has been capped at about 100,000 positions since the Balanced Budget Act of 1997. And joint state and federal GME funding through Medicaid -- the second-largest funding source -- is tenuous as states look to cut costs in the face of budget troubles and a sour economy.
An AAMC survey in 2009 found that 41 states provide GME Medicaid funding, seven less than in the previous survey in 2005. Nine of the 41 states were considering cutting GME Medicaid funding, Mitchell said.
"Those dollars are very much at risk," she said.
At its Annual Meeting in June, the American Medical Association House of Delegates adopted policies calling for more GME funding from a variety of sources and promotion of community-based training to encourage more people to become primary care physicians.
The Patient Protection and Affordable Care Act calls for the redistribution in July 2011 of residency positions that have gone unfilled for at least three years to train primary care and general surgery physicians. That is expected to amount to about 1,000 slots that will be redistributed largely to hospitals in medically under-served communities.
That still will not be enough, Mitchell said.
The AAMC is advocating for a 15% increase in Medicare GME funding over 10 years, which would produce another 4,000 physicians by 2020.
"When you're facing a physician shortage, any way to increase the number of physicians is a step forward," Mitchell said. "We really need to take some larger steps."