April 2021 GRADUATE MEDICAL EDUCATION Programs and Residents

Preparing to load PDF file. please wait...

0 of 0
100%
April 2021 GRADUATE MEDICAL EDUCATION Programs and Residents

Transcript Of April 2021 GRADUATE MEDICAL EDUCATION Programs and Residents

April 2021

United States Government Accountability Office
Report to Congressional Requesters
GRADUATE MEDICAL EDUCATION
Programs and Residents Increased during Transition to Single Accreditor; Distribution Largely Unchanged
Accessible Version

GAO-21-329

GAO Highlights
Highlights of GAO-21-329, a report to congressional requesters

April 2021
GRADUATE MEDICAL EDUCATION
Programs and Residents Increased during Transition to Single Accreditor; Distribution Largely Unchanged

Why GAO Did This Study
Physician GME provides the clinical education to practice medicine independently in the U.S. Agencies within the Department of Health and Human Services (HHS) fund GME, including over $15 billion from Medicare in 2018 (the latest year for which data were available).
To be eligible for federal funding, GME programs generally must be accredited. In 2014, the two primary accreditation organizations for physician GME—ACGME and AOA— announced plans for ACGME to serve as the nation’s single accreditor for these GME programs as of July 2020. The transition, which began in 2015, established a physician training framework to provide uniform, quality care to patients across the U.S.
GAO was asked to review the changes during the transition to a single GME accreditor. This report describes changes in the number, composition (e.g., specialty or subspecialty), and geographic distribution of GME programs and their residents.
GAO analyzed ACGME and AOA program and resident data for academic years 2014-2015 through 2019-2020. GAO also reviewed documents and interviewed officials from HHS agencies, ACGME, and AOA about HHS programs that fund GME, as well as changes in the number of programs and residents, their composition, and geographic distribution of their primary training sites during the transition to ACGME as the single accreditor.
GAO provided a draft of this report to HHS for comment. HHS provided technical comments, which GAO incorporated as appropriate.
View GAO-21-329. For more information, contact A. Nicole Clowers at (202) 512-7114 or [email protected]

What GAO Found
The number of programs that provide graduate medical education (GME) for physicians—commonly known as residency programs—and the number of residents in those programs increased during the transition to a single accreditor for GME programs. Between 2014-2015 and 2019-2020—the last academic year of the transition to the Accreditation Council for Graduate Medical Education (ACGME) as the single accreditor—the number of GME programs increased by 14 percent, from 10,608 to 12,117. Most (73 percent) of the 1,032 programs solely accredited by the American Osteopathic Association (AOA) in 2014-2015 applied for, and of these almost all were accredited by ACGME in 2019-2020; the remaining AOA-accredited programs chose to close. Overall, the number of residents training in GME programs increased by 13 percent.
Graduate Medical Education Residents by Program Accreditor, Academic Years 2014-2015 through 2019-2020

Data table for Graduate Medical Education Residents by Program Accreditor, Academic Years 2014-2015 through 2019-2020

ACGME Dual AOA

2014-2015 116.246 4.446 7.104

2015-2016 119.099 4.404 6.633

2016-2017 124.302 4.493 5.023

2017-2018 129.816 4.575 2.531

2018-2019 134.815 4.621 1.092

2019-2020 139.356 4.672 0.286

The composition of GME programs and residents—that is, whether they were in a specialty or subspecialty—did not change between 2014-2015 and 2019-2020. In both years, 83 percent of residents trained in a specialty program, such as internal medicine. Of the residents in a specialty program, nearly half trained in a primary care specialty (i.e., internal medicine, family medicine, or pediatrics). The remaining residents trained in a subspecialty, such as cardiovascular disease.
United States Government Accountability Office

The geographic distribution of programs and residents was largely unchanged between 2014-2015 and 2019-2020. In both years, most (about 60 percent) programs and residents were located in the South and Northeast, and nearly all (98 percent) programs and residents trained in urban areas. Of the 3,142 counties in the U.S., GME programs in 2014-2015 were located in 467 counties. By 2019-2020, the number of counties with programs increased to 525. While there was growth in the number of programs and residents in rural areas, growth in urban areas was greater.

Contents

GAO Highlights

2

Why GAO Did This Study

2

What GAO Found

2

Letter

1

Background

5

Number of Programs and Residents Increased during Transition

to Single Accreditor; Composition and Geographic Distribution

Were Largely Unchanged

8

Agency Comments

25

Appendix I: Accreditation Council for Graduate Medical Education Stages and Categories for Graduate Medical

Education during the Pandemic

28

Appendix II: Number of Graduate Medical Education Programs and Residents, by Specialty and Subspecialty,

Academic Year 2019-2020

31

Appendix III: GAO Contact and Staff Acknowledgments

36

GAO Contact

36

Staff Acknowledgments

36

Tables

Data table for Graduate Medical Education Residents by Program

Accreditor, Academic Years 2014-2015 through 2019-

2020 2

Table 1: CMS and HRSA Graduate Medical Education (GME)

Programs and 2018 Spending

7

Data table for Figure 2: Number of Graduate Medical Education

(GME) Residents by Program Accreditor, Academic Years

2014-2015 through 2019-2020

11

Data table for Figure 3: Status of AOA-Accredited Programs’

Applications for ACGME Accreditation, as of June 30,

202013

Data table for Figure 4: Graduate Medical Education (GME)

Specialty and Subspecialty Programs, Academic Year

2019-2020

16

Table 2: Number of Residents per Type of Graduate Medical

Education (GME) Program, Academic Year 2019-2020

17

Page i

GAO-21-329 Graduate Medical Education

Figures

Data table for Figure 5: Graduate Medical Education (GME)

Specialty and Subspecialty Residents, Academic Year

2019-2020

18

Data table for Figure 6: Regional Changes for Graduate Medical

Education (GME) Programs and Residents, Academic

Years 2014-2015 and 2019-2020

21

Table 3: Number of Programs and Residents by Specialty or

Subspecialty, Academic Year 2019-2020

31

Graduate Medical Education Residents by Program Accreditor,

Academic Years 2014-2015 through 2019-2020

2

Figure 1: Number of Graduate Medical Education (GME)

Programs by Accreditor, Academic Years 2014-2015

through 2019-2020

9

Data table for Figure 1: Number of Graduate Medical Education

(GME) Programs by Accreditor, Academic Years 2014-

2015 through 2019-2020

9

Figure 2: Number of Graduate Medical Education (GME)

Residents by Program Accreditor, Academic Years 2014-

2015 through 2019-2020

11

Figure 3: Status of AOA-Accredited Programs’ Applications for

ACGME Accreditation, as of June 30, 2020

13

Figure 4: Graduate Medical Education (GME) Specialty and

Subspecialty Programs, Academic Year 2019-2020

16

Figure 5: Graduate Medical Education (GME) Specialty and

Subspecialty Residents, Academic Year 2019-2020

18

Figure 6: Regional Changes for Graduate Medical Education

(GME) Programs and Residents, Academic Years 2014-

2015 and 2019-2020

20

Figure 7: Distribution of Graduate Medical Education (GME)

Residents by County, Academic Years 2014-2015 and

2019-2020

22

Figure 8: Distribution of Graduate Medical Education (GME)

Residents by Number of Residents per County,

Academic Year 2019-2020

24

Abbreviations

AAMC

Association of American Medical Colleges

ACGME

Accreditation Council for Graduate Medical Education

AOA

American Osteopathic Association

CMS

Centers for Medicare & Medicaid Services

Page ii

GAO-21-329 Graduate Medical Education

COVID-19 DO GME HHS HRSA MD

Coronavirus Disease 2019 doctor of osteopathic medicine graduate medical education Department of Health and Human Services Health Resources and Services Administration doctor of medicine

This is a work of the U.S. government and is not subject to copyright protection in the United States. The published product may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately.

Page iii

GAO-21-329 Graduate Medical Education

441 G St. N.W. Washington, DC 20548

Letter
April 13, 2021
Congressional Requesters
Physician graduate medical education (GME), also known as residency, provides clinical education and prepares a physician for the independent practice of medicine in the United States. Specifically, after completing medical school and receiving a medical degree, physicians enter a multiyear residency training program in teaching hospitals and health centers, health departments, private medical practices, and other sites, during which they complete their formal education as a physician. These physicians are known as residents and complete a GME program in a specific medical specialty, such as internal medicine. Some physicians may choose to subspecialize and undergo additional GME training—also referred to as fellowships—in areas such as cardiovascular disease.
Within the Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS) and the Health Resources and Services Administration (HRSA) fund GME, including over $15 billion from Medicare in 2018 (the latest year for which data were available). To receive this funding, residency programs generally must be accredited.
Historically, the two primary accreditation organizations for physician GME were the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA).1 In academic year 2014-2015, more than 90 percent of residents were trained in GME programs accredited by ACGME.2 The GME programs accredited by ACGME focused on an allopathic approach—a system which uses a science-based approach to treatment and care for patients using a wide range of modalities, including therapeutics, diagnostics, interventions, and physical therapy, according to ACGME officials.3 The GME programs accredited by AOA focused on an osteopathic approach—a philosophy that emphasizes the interrelationship between
1Graduates of allopathic medical schools are doctors of medicine (MD) and graduates of osteopathic medical schools are doctors of osteopathic medicine (DO). 2The 2014-2015 academic year was from July 1, 2014, through June 30, 2015. 3Prior to academic year 2014-2015, DO graduates of osteopathic medical schools were eligible for and had trained in residency programs accredited by ACGME.

Page 1

GAO-21-329 Graduate Medical Education

Letter

structure and function, and has an appreciation of the body’s ability to heal itself, among other things.
On February 26, 2014, ACGME, AOA, and the American Association of Colleges of Osteopathic Medicine announced a memorandum of understanding outlining a single GME accreditation system in the United States with ACGME as the single GME accreditor.4 Beginning July 1, 2015, GME programs previously accredited by AOA were able to apply for ACGME accreditation under the terms of the memorandum of understanding. Under the agreement, on June 30, 2020, AOA stopped accrediting GME programs and ACGME became the single GME accreditor for these GME programs.5
Prior to this agreement, GME programs exclusively accredited by ACGME did not include training in osteopathic principles. As part of the agreement, ACGME-accredited programs can now apply for osteopathic recognition, which provides an opportunity for physicians, including those who did not graduate from an accredited college of osteopathic medicine, to obtain GME training in osteopathic principles and practices, which they can apply to patient care. The single GME accreditation system will allow graduates of allopathic and osteopathic medical schools to complete their residency and fellowship education in any ACGME-accredited program. The system also established a physician training framework designed to provide uniform, quality care to patients across the United States.6
There have been questions about the extent to which programs that had been accredited by AOA would be able to achieve accreditation from ACGME and be able to continue training residents. You asked us to review the changes during the transition to a single accreditor. In this report, we describe changes in the number, composition (e.g., specialty

4The American Association of Colleges of Osteopathic Medicine was founded to lend support and assistance to the nation's osteopathic medical schools, and to serve as a unifying voice for osteopathic medical education.
5AOA stopped accreditation for GME programs on June 30, 2020, with the exception of select situations. In select situations, some GME programs accredited by AOA will continue for a limited time beyond June 30, 2020; for example, they will continue teaching their current residents before closing, but will not accept any new residents.
6Individuals enrolled in GME specialty (residency) programs are residents, while individuals enrolled in GME subspecialty (fellowship) programs are fellows. We refer to participants in all GME programs as residents.

Page 2

GAO-21-329 Graduate Medical Education

Letter
or subspecialty), and geographic distribution of GME programs and their residents.
To describe changes in the number of programs and residents in GME training overall, we reviewed annual data for academic years 2014-2015 through 2019-2020 on GME programs and residents within the 50 states and the District of Columbia from the two GME accrediting bodies— ACGME and AOA. Data for academic year 2019-2020 were the most recent data at the time of our review.
· To describe changes in programs and residents by composition (i.e., specialty of training) and geographic distribution between 2014-2015 and 2019-2020, we obtained data on programs and residents for 2014-2015 and 2019-2020. We examined the composition of programs and residents across primary care and other specialties, compared with subspecialty training programs.7 We defined primary care as the specialties of internal medicine, family medicine, and pediatrics.8
· We also analyzed the geographic distribution of programs and residents by identifying the Census Bureau geographic region and county of each GME program’s primary training site.9 We also used Rural-Urban Commuting Area codes to categorize the location of

7We grouped GME programs by specialties and subspecialties using ACGME and AOA categories.
8Some residents train in a combined GME program called internal medicine-pediatrics, which provides training in a combination of internal medicine and pediatrics. We considered those residents and programs to be primary care.
9We used the primary training site for these analyses. Residents may also train for more limited periods at participating sites, but data about the number of residents training in these locations were not available, because neither ACGME nor AOA collect data on the extent to which residents train at participating sites.
For the census regions, see U.S. Census Bureau, Geographic Terms and Definitions, accessed August 21, 2020, https://www.census.gov/programs-surveys/popest/about/glossary/geo-terms.html.

Page 3

GAO-21-329 Graduate Medical Education

Letter

programs and residents’ primary training sites as being either urban or rural.10
· In addition, we examined AOA data on programs and their residents that had been solely accredited by AOA in 2014-2015 (the last academic year before the transition) by their 2019-2020 ACGME accreditation status.
We assessed the reliability of ACGME, AOA, and geographic data by reviewing documentation, discussing the data with knowledgeable officials, and performing data reliability checks, such as examining the data for missing values and obvious errors, to test the internal consistency and reliability of the data. After taking these steps, we determined the data from each of these sources were sufficiently reliable for the purposes of our reporting objectives.
We also interviewed officials from ACGME and AOA about changes in the number of programs and residents, their composition, and geographic distribution of their primary training sites during the transition to ACGME as the single accreditor. Finally, we reviewed documents and interviewed CMS and HRSA officials regarding the programs they administer that fund GME and their agencies’ roles related to oversight of and involvement in physician GME accreditation.
We conducted this performance audit from March 2020 through April 2021 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

10Rural-Urban Commuting Area codes characterize all census tracts regarding their rural and urban status using Bureau of Census Urbanized Area and Urban Cluster definitions in combination with work commuting information. There are two current versions of the codes, one for census tracts and another for zip codes. We used the most recent zip code version, which is based on Census Bureau data from 2010, for both academic years in our analysis. See Economic Research Service, Rural-Urban Commuting Area Codes, accessed August 28, 2020 https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/. Addresses defined as urban core by code were grouped as urban and the remainder were grouped as rural.

Page 4

GAO-21-329 Graduate Medical Education
ResidentsProgramsEducationGraduateGme Programs