If the measure of success is intent and outcomes then the federal government's efforts under the Medicare Modernization Act of 2003 to train more physicians in primary care and to practice in rural areas have been a failure.
A study published this month in Health Affairs looked back on the mandate in the legislation to redistribute nearly 3,000 residency slots among the nation's hospitals. The researchers found that only 12 of the 304 hospitals that had received additional positions starting in 2005 were considered rural, and received only 3% of all positions redistributed.
And while primary care training had positive net growth after the redistribution, the growth of subspecialty training was twice as large and diverted would-be primary care physicians into subspecialty training.
Only 3% of rural hospitals got additional slots
"The really concerning thing is that the legislation specifically prioritized rural training so you would expect that the intent would be to significantly increase rural training. Only 12 rural hospitals received additional slots and that was only 3% of the total additional slots redistributed. Most of us would agree that that probably didn't meet the legislative intent," says Candice Chen, lead author of the study and an assistant research professor at the George Washington University School of Public Health and Health Services.
"The primary care issue is a little more complicated," Chen says. "We found that coming up to the redistribution a lot of the hospitals that got slots had been likely converting their primary care to non-primary care slots."
"Many of them increased their primary care training so in those hospitals where you had lost some primary care training you did manage to gain some back. But we saw a significantly larger increase in non-primary care training slots. And there was a subset of hospitals that received additional primary care slots and continued to convert them into non-primary care slots."
Chen says outcomes demonstrate the need for more coordination of medical workforce development on a national level.
"Each one of those GME programs is out there for individual organizations meeting their hospitals' and communities' needs and when you cobble them all together we are not getting what we need over all the country," she says.
"We need some more analyses and planning on a national level so we can start asking 'how can we get what we need out of this system as a whole? How do we build those requirements into the system so that in another 10 or 15 years, or even sooner than that, people aren't scrambling to find a primary care provider.'"