Abstract
This study analyzes data from the Centers for Medicare & Medicaid Services to identify whether new residency training slots went to rural and underserved areas with the greatest need.
In 2020, Medicare spent $16.2 billion on graduate medical education, but only 2% of Medicare-funded residency training occurred in rural areas.1,2 The lack of residency training in rural and underserved areas worsens the maldistribution of physicians because physicians who spend at least half of their residency training in rural and underserved areas have odds 5 times higher to practice in those areas after residency compared with those who trained elsewhere.3 To address this, Congress created 1000 new residency slots targeted toward training in rural and underserved areas.4
The Centers for Medicare & Medicaid Services (CMS) released data in February 2023 on the first 100 residency programs that received new residency slots. We analyzed these data to identify whether the new residency slots went to the areas of greatest need.
Methods
For each residency program that the CMS awarded new residency slots, we identified the specialty, the training site addresses, and the amount of time residents trained at each site by merging the Accreditation Council for Graduate Medical Education (ACGME) program codes published by the CMS with the ACGME Accreditation Data System and the American Medical Association residency databases. Training site addresses were geocoded using ArcGIS 10.8.2 (Esri).
For primary care and mental health, data from the CMS and the Health Resources and Services Administration were used to identify whether the training site was located in a rural health professional shortage area (HPSA), an urban HPSA, or neither. Geographically rural areas are defined by the CMS as counties outside metropolitan areas (vs urban areas with ≥50 000 people). The Health Resources and Services Administration5 defines HPSAs as population groups and areas experiencing a shortage of health professionals.
Results
The 100 residency programs that were awarded a total of 400 residency slots (200 direct and 200 indirect residency slots) appear in Table 1 by specialty. The residency programs with the specialties of family medicine (30.86%), internal medicine (19.64%), and psychiatry (11.11%) received the most residency slots (Table 1).
Table 1. Residency Programs Receiving New Residency Slots by Specialty.
Specialty | Awarded new residency slotsa | |
---|---|---|
Residency programs | Total slots, No. (%)b | |
Addiction medicine | 1 | 1.34 (0.34) |
Anesthesiology | 2 | 13.08 (3.27) |
Child and adolescent psychiatry | 4 | 6.94 (1.74) |
Dermatology | 1 | 2 (0.50) |
Emergency medicine | 4 | 12.16 (3.04) |
Family medicine | 28 | 123.45 (30.86) |
General surgery | 2 | 11.71 (2.93) |
Hematology and oncology | 1 | 5.84 (1.46) |
Internal medicine | 23 | 78.56 (19.64) |
Interventional radiology–integrated | 1 | 6.46 (1.62) |
Neurology | 3 | 12.98 (3.25) |
Obstetrics and gynecology | 5 | 22.76 (5.69) |
Orthopedic surgery | 2 | 15.6 (3.90) |
Pediatric emergency medicine | 1 | 1 (0.25) |
Pediatric rheumatology | 1 | 3 (0.75) |
Pediatrics | 5 | 16.53 (4.13) |
Psychiatry | 11 | 44.44 (11.11) |
Radiology–diagnostic | 2 | 10.43 (2.61) |
Surgery | 1 | 4.88 (1.22) |
Urology | 2 | 6.84 (1.71) |
The Centers for Medicare & Medicaid Services awarded 400 residency slots (200 direct and 200 indirect residency slots) to 100 residency programs.
The data are expressed in decimal places because some were partial slots.
The percentage of time spent training residents at training sites located in rural and urban primary care and mental health HPSAs appears in Table 2. Among the residency programs awarded new residency slots, 5% train their residents in rural primary care HPSAs for at least half (≥50%) of their residency, whereas 83% train their residents in urban primary care HPSAs for at least half of their training time (Table 2). For mental health HPSAs, 5% of residency programs train their residents at rural sites for at least half of their residency, whereas 73% train their residents at urban sites for at least half of their training time.
Table 2. Training Sites in Rural vs Urban Mental Health and Primary Care Health Professional Shortage Areas (HPSAs) Among the 100 Residency Programs With New Residency Slots.
Residency programs, No. (%)a | ||||
---|---|---|---|---|
Training sites in rural primary care HPSAs |
Training sites in urban primary care HPSAs |
Training sites in rural mental health HPSAs |
Training sites in urban mental health HPSAs |
|
Resident training time, % | ||||
0 | 88 (88) | 6 (6) | 88 (88) | 18 (18) |
1-9 | 6 (6) | 5 (5) | 6 (6) | 2 (2) |
10-49 | 1 (1) | 6 (6) | 1 (1) | 7 (7) |
≥50 | 5 (5) | 83 (83) | 5 (5) | 73 (73) |
Among the 100 programs that received new residency slots.
Discussion
This analysis shows that the first round of new residency slots primarily went to residency programs located in urban HPSAs. Residency programs with rurally located training sites may be encouraged to apply for new residency slots.
The allocation of residency slots underrepresents the rurality of the population living in HPSAs. Although 32.10% of people living in primary care HPSAs are in rural communities, only 5% of the programs receiving residency slots trained their residents for at least half (≥50%) of their residency in rural HPSAs.6
These findings suggest that the methods used by Congress for distributing residency slots ensured that more residency training occurs in urban HPSAs, but fell short of expanding training opportunities in rural HPSAs. Without a congressional mandate to evaluate residency slot distribution, policymakers may not know whether their distribution methods are achieving their policy goal.
The limitations of this study include reliance on data from residency programs’ current training sites to identify a program’s rural or urban HPSA status. The selected residency programs may have plans to train at new sites, which were not reflected in this analysis.
Future residency slot distribution could be improved by requiring a percentage of new slots to go to programs that train residents in rural locations for at least half their training time. In addition to changing the residency slot distribution methods, sustainable funding and technical assistance may be necessary to support residency programs in rural locations.
Section Editors: Jody W. Zylke, MD, Deputy Editor; Karen Lasser, MD, and Kristin Walter, MD, Senior Editors.
Data sharing statement
References
- 1.Congressional Research Service . Medicare graduate medical education payments: an overview. Published September 2022. Accessed May 1, 2023. https://crsreports.congress.gov/product/pdf/IF/IF10960
- 2.US Government Accountability Office . Graduate medical education: programs and residents increased during transition to single accreditor; distribution largely unchanged. Published April 2021. Accessed May 1, 2023. https://www.gao.gov/assets/gao-21-329.pdf
- 3.Russell DJ, Wilkinson E, Petterson S, Chen C, Bazemore A. Family medicine residencies: how rural training exposure in GME is associated with subsequent rural practice. J Grad Med Educ. 2022;14(4):441-450. doi: 10.4300/JGME-D-21-01143.1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Consolidated Appropriations Act, HR 133, 116th Cong (2021). Accessed May 1, 2023. https://www.congress.gov/bill/116th-congress/house-bill/133
- 5.Health Resources and Services Administration . What is shortage designation? Accessed July 5, 2023. https://bhw.hrsa.gov/workforce-shortage-areas/shortage-designation
- 6.Health Resources and Services Administration . Designated health professional shortage areas statistics. Accessed May 1, 2023. https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport
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