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Capitol Hill Briefing Focuses On Rural and Underserved Training Programs

Capitol Hill Briefing
May 6, 2015

Programs to encourage physician training and practice in rural and underserved areas were the focus of a May 6 Capitol Hill briefing titled “Strategies to Address Physician Shortages in Rural and Underserved Communities,” hosted by the Association of American Medical Colleges (AAMC) and the Congressional Academic Medicine Caucus. The briefing, moderated by Atul Grover, MD, PhD, AAMC chief public policy officer, focused on the Conrad 30 J-1 Visa Waiver Program, the National Health Service Corps (NHSC), the creation of new teaching hospitals, and the Medicare Rural Training Track (RTT) program.

Dr. Grover was joined on the panel by Michelle A. Nuss, MD, FACP, campus associate dean for graduate medical education and designated institutional official of the Georgia Regents University/University of Georgia (GRU/UGA) Medical Partnership Campus, and Connie Berry, MA, manager, Texas Primary Care Office at the Texas Department of State Health Services.

Opening the briefing, Dr. Grover discussed how a number of factors influence where a physician ultimately chooses to practice. He noted that 40 percent of physicians practice where they trained and 66 percent practice in the area where they trained if they also went to medical school there. If a physician goes to medical school and completes a residency program in the area where he or she is from, the likelihood of the physician also practicing in that area is 85 percent.

On the other hand, Dr. Grover noted that while training location may play some role, other influences—such as job opportunities for a spouse—also have an effect, and a number of states are able to retain only a small percentage of physicians that train in the state. Communities across the country benefit from investments made by institutions in a “donor” state like New York because many New York graduates practice in other states.

The panelists then discussed existing federal policies designed to support training opportunities in rural and underserved areas, as well as ways to incentivize doctors to practice in those communities.

Dr. Nuss explained how GRU/UGA has been working with non-teaching hospitals to begin residency programs that are eligible for Medicare support (despite caps imposed on existing training programs in 1997), with a focus on rural and underserved areas. She also discussed the roadblocks to doing so despite the availability of Medicare funding.

For example, she described the importance of ensuring that the medical staff is ready and willing to assume the additional responsibilities associated with operating a high-quality training program. Other roadblocks include the need for new equipment and faculty, and the change in culture. “It is a mission change for a hospital to become a teaching hospital,” Dr. Nuss said.

She also explained that new teaching hospitals require somewhere between $2 million and $8 million in start-up costs, but they do not receive any Medicare dollars until the first resident begins work. Georgia used state funding, along with a hospital match, to cover some of these costs.

Ms. Berry shared information on how states, through their primary care offices, designate underserved areas and recruit health professionals to work in those areas. To achieve this, they use a number of incentive programs, such as loan forgiveness and repayment, Title VII grants, the NHSC and similar state programs, as well as tax credits and foundation grants. Additionally, all 50 states use the Conrad 30 J-1 Visa Waiver Program, which allows international medical graduates to receive a waiver of the requirement to spend two years in their native country after completing residency in the United States if they spend three years working in an underserved area.

On the topic of the shortage of physicians in rural and underserved areas, Ms. Berry said, “Is it supply or distribution, or both? In Texas and in many other states, it’s supply and distribution.”

Dr. Grover wrapped up the panel discussion with a review of the issues, including current and projected physician shortages. He reiterated Ms. Berry’s point, adding, “We are facing a need for more doctors and more doctors in underserved and rural areas. Until we address the national physician shortage, we will continue to have shortages in underserved areas.”

He concluded with a review of potential ways to combat these shortages, emphasizing the need for a multipronged approach, including existing efforts supporting residency programs at critical access and rural hospitals, facilitating development of new teaching hospitals, developing innovative care delivery models, continuing to implement team-based care, and expanding programs that incentivize doctors to train and practice in rural and underserved communities. At the same time, Dr. Grover described the importance of a modest expansion of support for existing training programs across the country, highlighting recently introduced bills in the House (H.R. 2124) and Senate (S. 1148) that would add 15,000 new graduate medical education slots over five years.

Dr. Grover also discussed related AAMC publications such as Becoming a New Teaching Hospital: A Guide to Medicare Requirements and Rural Training Track Programs: A Guide to the Medicare Requirements.