Rural Primary Care Physician Workforce Expansion: An Opportunity for Bipartisan Legislation

摘要

Introduction The primary care physician workforce crisis has eluded solution for many years. Concerns raised 5?years ago about nadir of interest in primary care careers by medical students are now realized, as the proportion of residency graduates from our nation's teaching hospitals entering primary care careers, particularly to underserved rural areas, has hit an all-time low.1,2 There is an estimated shortage of 16?000 primary care physicians (PCPs) necessary to meet today's needs; this deficit will grow to 52?000 in the next decade.3 An aging population, with an aging population of physicians themselves, will exacerbate this situation. When the Affordable Care Act (ACA) is fully implemented, more than 25 million newly insured Americans will rely not only on the existing deficient physician workforce but also on physicians currently in training. We believe that expansion of primary care graduate medical education (GME) to address this shortage is urgently needed, and represents an opportunity for bipartisan support of GME expansion legislation.;The Physician Workforce Policy Vacuum Linking ambulatory GME with care for the underserved in community health centers (CHCs) was proposed in 1986.4 An Institute of Medicine workshop and study5 published in 1989 included many recommendations that, if implemented, could have reduced the primary care access crisis. Legislation establishing the Council on Graduate Medical Education (COGME) was enacted in 1986, and for the past 27?years COGME has served as the principal advisor to Congress on physician workforce issues. COGME has issued 21 reports, most speaking to the shortage of PCPs and physician maldistribution, yet to date has had relatively little impact on GME policy. In 2010, the ACA authorized the creation of a Health Workforce Commission. However, this body remains without funding and has not met,2 and the physician workforce policy vacuum persists.;A New Model for Rural Teaching Health Centers In this article, we discuss the absence of workforce policy, despite more than 25?years of recommended initiatives to address physician shortages, especially for underserved populations. We (1) suggest that teaching health centers (THCs) should be a major component of physician workforce policy and GME expansion legislation; and (2) propose a modification and expansion of the current ACA-funded program of GME payments for THCs (the THCGME program) as an optimal approach to develop rural THCs and thereby expand the rural primary care physician workforce. As a model for consortia that would facilitate the development of rural THCs, we first propose utilization of a previously described consortium model6 that facilitates the creation of community health center and academic medicine partnerships called “CHAMP” THCs. Second, we propose rural THCs as a key component of primary care GME expansion. Finally, we recommend that CHAMP THC and rural THC residency positions should constitute a major percentage of new positions established under GME expansion.;An Opportunity for GME Accountability Interest in expanding GME funding via proposed legislation presents a new opportunity to train a substantially increased number of PCPs, and achieve greater GME accountability for meeting the nation's primary care workforce requirements. For more than a decade, the Balanced Budget Act of 1997 has frozen Medicare GME at 26?000 first-year positions.7 Recognition that this cap is no longer tenable, particularly in view of an estimated domestic output of 27?000 medical students annually in the next 5?years, has resulted in interest to expand GME via proposed legislation. Recent studies2,8,9 suggest that without more specific guidance from and accountability to Congress, this expansion may serve the needs of hospitals rather than those of patients and communities. The timing of proposed GME expansion efforts coincides with the potential expiration of an important ACA feature, the THCGME program. This program is bu