A new analysis of the $10 billion a year that Medicare uses to support graduate medical education in the U.S. shows one state – New York – with 20 percent of the money while some states, including Georgia, get barely above 1 percent.
The rates have been locked in for at least the last 17 years and favor states that have programs already densely packed with the required residency trainings, which also greatly influence where the residents will practice once they complete training.
As states like Georgia try to address an increasing physician shortage by expanding medical school enrollment without the needed residencies, it could be effectively exporting doctors to those residency-rich states.
New York has nearly five times as many residency slots per capita than Georgia but receives seven times more per capita in funding than Georgia, an Augusta Chronicle analysis of the data found.
While some officials are begging for more residency funding overall, a more realistic approach would be redistributing more fairly the money already going out, the study’s lead author said.
In an analysis in the journal Health Affairs, researchers at George Washington University broke down the $10.1 billion that Medicare sends to teaching hospitals to support graduate medical education, which is required before medical school graduates can be licensed and helps prepare them for specialties. That funding is heavily concentrated in the Northeast, particularly in New York.
New York receives $103.63 per capita in residency funding compared to $14.114 for Georgia and $1.94 for Montana, according to the study. Georgia has 3.1 percent of the U.S. population, and 2.4 percent of U.S. medical students but gets only 1.36 percent of the total residency funding, said lead author aid Dr. Fitzhugh Mullan, Murdock Head Professor of Medicine and Health Policy at George Washington.
“That’s a pretty dramatic story,” he said.
The disparity is probably well known to those who work in the field or run teaching hospitals but they might not grasp the extent of it, Mullan said.
“They may not appreciate how unbalanced it is and how, depending upon where you are, how your state is doing very well or doing very poorly,” he said.
A big part of the problem is Medicare uses formulas to calculate the payments that were first established in 1983 and despite some adjustment in 2000 retain much of the disparities despite changes in population growth and changes in medical schools, Mullan said. And unfortunately, there is currently no one in a position to change it, he said.
“Because they are set up by formula, there is not currently the ability for either policymakers such as the Congress or medical education leaders to sit down and say, ‘We really should be investing more here and less there or we should be investing more in primary care and less in plastic surgery,’ ” Mullan said “That does not exist.”
And it could have implications beyond residency training – research shows there is a 50 percent chance a resident will stay to practice in that state, and that number rises to 66 percent if the student also went to medical school in that state.
“It clearly gives you a leg up,” Mullan said. “And if you are a state with relatively few residency positions you’re at a disadvantage. And you are certainly at a disadvantage if you are cranking up your medical schools because they will have to go elsewhere to get trained and the return rate will be diminished.”
Even when there was a redistribution of 1,345 unfilled but funded residency slots in 2011, Georgia lost out, said Dr. Peter Buckley, the dean of Medical College of Georgia at Georgia Regents University. Those positions went to the 11 neediest states – Georgia was considered 12th neediest and got none.
The Association of American Medical Colleges has called on Congress to appropriate another $1 billion to add residency slots to help keep up with a record number of medical students enrolled but Mullan said he doesn’t see that happening.
“We’re going to have to think about other ways of generating more residency positions because going back to the federal government time after time, particularly without any accountability, is not proving to be a very successful strategy if Congress does not allocate more positions,” he said.
The big question, Mullan said, is “could the current residencies and the current residency money, which is $10 billion, could that be reapportioned in a way that you’d get better and fairer outcomes?”
While that looks good to Georgia, “there’s not much talk about that,” Buckley said, and in the end is just redistributing the money.
A better way might be what Georgia is already attempting to do, which is find another way to fund positions, he said. Gov. Nathan Deal and the Legislature have pushed to create 400 new positions to meet the increasing medical school enrollment, Buckley said. GRU and University Hospital have also revived residency positions at University, Buckley said.
“It’s a partnership and, if you like, it’s a social contract between our two institutions on behalf of the people of Augusta to train doctors and train them in good systems with the intent that they will stay in our region and provide care in our region,” he said.
Staff Writer Sandy Hodson contributed to this report.