Fast Facts

Will there be enough doctors with the specialties people need in the places where people need them?

Multiple federal programs fund graduate medical education for physicians-in-training, known as residents. However, the government doesn't know if these dollars are helping to build the physician workforce that the nation needs.

The data collected don't provide all the information needed to fully understand

how much it costs to train physicians

how much the government spends

what the government gets for its money

We recommended improving the data to help ensure that the government's funds are being used effectively.

Average Payment from Medicare for Each Full-Time Medical Resident by State, 2015

A map showing that Medicare payments per medical resident are not evenly distributed across states.

A map showing that Medicare payments per medical resident are not evenly distributed across states.

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Highlights

What GAO Found

Federal agencies and state Medicaid agencies spent over $16.3 billion in 2015 to fund graduate medical education (GME) training for physicians—commonly known as residency training. The federal government spent $14.5 billion through five programs, and 45 state Medicaid agencies spent $1.8 billion. About half of teaching sites that received funding—such as teaching hospitals—received funds from more than one of the five programs.

Federal Spending on Graduate Medical Education (GME) Training, 2015

Program

Total GME spending (dollars in millions)

Percent of total spending (percent)

HHS programs

     Medicare

10,335

71

     Medicaid (federal share)

2,351

16

     Children's Hospital GME Payment Program

249

2

     Teaching Health Center GME Program

76

1

VA program

1,499

10

Total

14,509

100

Source: GAO analysis of Departments of Health and Human Services (HHS) and Veterans Affairs (VA) data; and GAO web-based survey administered to state Medicaid agencies. | GAO-18-240

GME training costs vary due to the characteristics of teaching sites, such as the number of residents trained and their specialty, which can make it difficult to compare training costs across sites. Further, challenges exist in measuring training costs because some costs, such as faculty teaching time, are difficult to identify. Also, there is no standard method for identifying and capturing training costs, and each teaching site may vary in how it does so.

While federal agencies generally collect information needed to manage their individual programs, this information is not sufficient to comprehensively understand whether the federal investment in GME training meets national physician workforce needs. The information agencies collect is not always complete or consistent within or across programs. For example, national data on GME training costs are not systematically collected, and some agencies lacked data to understand the total amount spent, or the outcomes of their programs, such as where supported residents went on to practice. GAO recommended in 2015 that the Department of Health and Human Services (HHS) develop a comprehensive planning approach to identify and address areas of health care workforce need. HHS concurred and identified steps it could take. While HHS has yet to take these steps, the information currently available is also insufficient for such planning. Comprehensive information is needed to identify gaps between federal GME programs and national physician workforce needs—particularly the distribution of physicians geographically or across specialties—and to make or recommend to Congress changes to improve the efficient and effective use of federal funds to meet those needs.

Why GAO Did This Study

An adequate, well-trained physician workforce is essential for providing access to quality health care. While a number of factors affect the supply and distribution of physicians, GME is a significant determinant. A significant portion of GME training funds come from federal programs and states.

This report (1) describes the amount and distribution of federal government and state Medicaid agency spending on GME; (2) describes what is known about GME costs; and (3) examines the extent to which the federal government collects information to understand its investment in GME. GAO reviewed reports, agency websites, and interviewed agency officials to identify federal programs that fund the clinical training of residents and were authorized through 2017. GAO analyzed 2015 data—the most recent data available at the time of GAO's analysis—including from a state survey. All 50 states and the District of Columbia responded to the survey. GAO reviewed literature, interviewed experts from seven organizations knowledgeable about GME costs, and analyzed Medicare data. GAO also reviewed documentation from HHS and the Department of Veterans Affairs (VA) and interviewed agency officials.

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Recommendations

GAO recommends that HHS coordinate with federal agencies, including VA, to (1) identify information needed to evaluate federal GME programs, and (2) identify opportunities to improve the quality and consistency of information, and implement these improvements. HHS concurred with both recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Health and Human Services The Secretary of HHS should coordinate with federal agencies, including VA, that fund GME training to identify information needed to evaluate the performance of federal programs that fund GME training, including the extent to which these programs are efficient and cost-effective and are meeting the nation's health care workforce needs. (Recommendation 1)
Open
Although the Department of Health and Human Services (HHS) concurred with GAO's March 2018 recommendation, as of April 2021 HHS had yet to identify information needed to evaluate the performance of federal programs that fund graduate medical education (GME) training. In December 2020, HHS noted that, as in years past, the President's fiscal year 2021 budget for HHS proposed consolidating federal spending into a single grant program for teaching hospitals, pulling together funding from (1) Medicare, (2) Medicaid, and (3) the Children's Hospitals Graduate Medical Education Payment Program. HHS indicated that this proposal would be an important first step toward putting in place improved expectations and information for monitoring performance. HHS did not indicate whether it had coordinated with federal agencies that fund GME training. As of August 2021, this proposal had not been adopted. Also in December 2020, HHS noted that the CARES Act directed the Secretary of HHS to develop a comprehensive and coordinated plan for health care workforce programs. This plan could include performance measures and the identification of gaps between the outcomes of such programs and relevant workforce projection needs. It was to be developed within one year of enactment of the CARES Act-that is, by March 26, 2021. However, HHS did not complete the plan by this date and requested an extension from Congress. Agency officials told us in August 2021 that they expect to publish a report related to the plan by September 7, 2021. Whether or not legislation is enacted to implement a consolidated federal GME grant program, HHS should take action to improve the information that agencies collect about how federal funding is used to support GME training. The health workforce plan required by the CARES Act also provides HHS with an opportunity to identify the needed information. Such actions are important for HHS to assess the cost-effectiveness of federal efforts to help meet the nation's health care workforce needs.
Department of Health and Human Services The Secretary of HHS should coordinate with federal agencies to identify opportunities to improve the quality and consistency of the information collected within and across federal programs, and implement these improvements. (Recommendation 2)
Open
Although the Department of Health and Human Services (HHS) concurred with GAO's March 2018 recommendation, as of April 2021 HHS had yet to identify opportunities to improve the quality and consistency of the information collected within and across federal programs that fund graduate medical education (GME) training. In December 2020, HHS noted that, as in years past, the President's fiscal year 2021 budget for HHS proposed consolidating federal spending into a single grant program for teaching hospitals, pulling together funding from (1) Medicare, (2) Medicaid, and (3) the Children's Hospitals Graduate Medical Education Payment Program. HHS indicated that this proposal would be an important first step toward putting in place improved expectations and information for monitoring performance. HHS did not indicate whether it had coordinated with federal agencies that fund GME training. As of August 2021, this proposal had not been adopted. Also in December 2020, HHS noted that the CARES Act directs the Secretary of HHS to develop a comprehensive and coordinated plan for health care workforce programs. This plan could include performance measures and the identification of gaps between the outcomes of such programs and relevant workforce projection needs. It was to be developed within one year of enactment of the CARES Act-that is, by March 26, 2021. However, HHS did not complete the plan by this date and requested an extension from Congress. Agency officials told us in August 2021 that they expect to publish a report related to the plan by September 7, 2021. Whether or not legislation is enacted to implement a consolidated federal GME grant program, HHS should take action to improve the quality and consistency of any information that agencies collect about how federal funding is used to support GME training. The health workforce plan required by the CARES Act also provides HHS with an opportunity to identify the needed information. Such actions are important for HHS to assess federal efforts to help meet the nation's health care workforce needs.

Full Report

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