The Affordable Care Act includes several provisions to highlight the importance of primary care. Under one provision, section 5503 of the ACA, hospitals must give up a portion of their unused residency slots to go into a pool to be redistributed to primary care and general surgery residency programs, mostly in rural and physician-shortage areas. Certain hospitals (such as rural teaching hospitals with fewer than 250 beds) are exempted. The shift is slated for July.
Dr. Wendy Biggs, assistant director of the American Academy of Family Physicians' division of medical education, explains how residency programs – and the supply of primary care physicians – will be affected.
Dr. Biggs: It's difficult to quantify the exact number. The Balanced Budget Act of 1996 froze or capped the number of residency positions for hospitals. Most institutions have their resident count close to or over their cap. According to the Council on Graduate Medical Education (COGME) Twentieth Report, the number of residency slots in the United States grew 6.3% between 2003 and 2006. Hospitals do not receive federal graduate medical education money for positions over their cap. Because hospitals self-fund these resident positions, they tend to be in high income–generating subspecialty areas. The government is redistributing 65% of unused, federally subsidized residency slots. Therefore, the number of slots will likely be in the hundreds, whereas we need tens of thousands of primary care physicians to take care of the health needs of our population.
CN: Where will these residency slots likely go?
Dr. Biggs: The law allows hospitals to apply for more residency positions. Slots will be granted based on the hospital's likelihood of filling the positions within 2 years and whether it has an accredited rural-training track. Overall, 75% of the redistributed positions must go to primary care or general surgery, but the percentage of primary care vs. general surgery positions is not specified. Moreover, the law has no provision to ensure that any resident who begins a primary care program will in fact practice in primary care rather than subspecialize after the first year of training.
Geographically, the states with the lowest resident physician-to-population ratio will get 70% of the redistributed positions. States with a large number of residency programs, such as New York and California, are more likely to get the redistributed residency positions, since they also have the largest populations (making a lower ratio).
CN: Given lagging interest in primary care in recent years, will programs be able to fill additional positions?
Dr. Biggs: The government is functioning under the “if you build it, they will come” scenario. However, more primary care residency positions do not mean more U.S. graduate applicants for those positions. Recent years have seen the creation of new medical schools and increasing class sizes in existing medical schools. However, until we resolve factors discussed in the COGME report – including improved reimbursement, debt management, and decreased administrative burden – U.S. medical students may continue to choose specialties other than primary care.
CN: How much of a difference will this make in increasing the size of the primary care workforce?
Dr. Biggs: The impact likely will be minimal. The government is not making new resident slots; it is simply redistributing them. The COGME report recommends that 40% of physicians should practice primary care. Currently, we are at 32%. An additional 63,000 primary care physicians are required to raise the proportion of primary care physicians to 40%. The number of residency slots to be redistributed probably numbers in the hundreds. Although the intent of the legislation is good, the actual increase will be insufficient.
CN: What other changes are needed to get more physicians into primary care?
Dr. Biggs: First and foremost, we need payment reform. Primary care physicians must be recognized for their value to the health care system. The COGME report suggests that the average incomes of these physicians must achieve at least 70% of median incomes of all other physicians. We have the data from the Canadians who several years ago experienced a substantial drop in physicians entering primary care. They improved the reimbursement to family physicians and saw a surge in medical student interest and entry into family medicine.
We need to move away from systems that pay for episodic care and toward payment mechanisms that recognize the value of care coordination. We need to value the hallmarks of the Patient-Centered Medical Home: first-contact access, patient-focused care over time, comprehensive and coordinated care, family orientation, community orientation, and cultural competency.
The COGME report recommends that 40% of physicians should practice primary care. Currently, we are at 32%.