Efforts to Assign More Doctor-Training Slots to Shortage Areas Have Failed, Study Finds

January 07, 2013

Recent efforts to redistribute doctor-training slots from specialty areas to primary care and rural health have failed, according to a new study that raises doubts about whether a similar shift will succeed under the nation's 2010 health-care overhaul.

The study, described in an article published on Monday in the journal Health Affairs, examined the outcome of a 2003 law that was supposed to shift nearly 3,000 residency positions into rural settings and primary-care slots. Both areas suffer severe shortages, in part because heavily indebted medical-school graduates can earn much more as specialists.

Despite the intent of the Medicare Modernization Act of 2003, only 12 of the 304 hospitals that received the extra residency slots were in rural locations, and they received just 3 percent of the additional positions, according to the article, by Candice Chen, an assistant research professor at George Washington University's School of Public Health and Health Services, and colleagues.

Many of the hospitals used the money that was intended for shortage areas to create new training positions for specialists, Dr. Chen found.

"Some hospitals even converted primary-care positions to specialty positions after receiving newly redistributed positions," the report says.

The number of residency training slots supported with federal funds has been capped since 1997. That has led to concerns that the growing number of medical-school graduates will face a bottleneck that will exacerbate physician shortages, especially in primary-care fields.

Some hospitals have unfilled positions, however, and both the 2003 and 2010 health-care laws called for those to be gathered up and redistributed to shortage areas.

But according to Dr. Chen, hospitals face "a snowball of incentives" to shift the money into even more specialty slots. Residents in fields like interventional cardiology can perform high-priced procedures that generate more money. And rural clinics that operate on slim margins may not have the time or resources to develop a training position that will meet accreditation requirements, she said in an interview.

Unless residency programs are held accountable for training residents to serve in shortage areas, the same thing is likely to occur under the Patient Protection and Affordable Care Act, otherwise known as Obamacare, she said, adding that the federal government pays hospitals nearly $13-billion each year for residency training.

The 2010 law, which was upheld by the U.S. Supreme Court in June, has a number of provisions designed to increase the number of doctors in primary care and rural medicine.

"It's a good start to say these areas are important," Dr. Chen said, "but we need to have a way to ensure that the training ends up where it's supposed to."