Joint Statement Opposing Expanding Graduate Medical Education Funding to Nurse Practitioners and Physician Assistants

Haig Aintablian, MD^a; Gabriel Stahl, MD^b; Gregory Jasani, MD^b; Hannah R. Hughes, MD, MBA^c; Allison Beaulieu, MD^d; Nehal Naik, MD ^e; Christina Hornack, DO^f

^aAmerican Academy of Emergency Medicine Resident and Student Association (AAEM/RSA), President
^bAmerican Academy of Emergency Medicine Resident and Student Association (AAEM/RSA), Member-at-Large
^cEmergency Medicine Residents’ Association, President
^dCouncil of Residency Directors in Emergency Medicine, Resident Member-at-Large
^eSociety for Academic Emergency Medicine Residents and Medical Students, President
^fAmerican College of Osteopathic Emergency Physicians Resident Student Organization (ACOEP-RSO), President

On December 18th, the Government Accountability Office (GAO) released a report considering the expansion of federal General Medical Education (GME) funding to include nurse-practitioners (NP’s) and physician assistants (PA’s).¹ All Emergency Medicine Resident Organizations and Students (AEROS) opposes the expansion of GME funding to include non-physician practitioners (NPP). The report was created to consider the utilization of NPP’s as an avenue to mitigate the anticipated primary care physician shortage as outlined by the Health Resources and Services Administration (HRSA) in 2016.² 

While NPP programs experience rapid expansion, the US physician pipeline faces persistent shortages. Any expansion of GME must prioritize the physician shortage.  There has been an increase in medical school enrollment (allopathic and osteopathic) by an average of 4% from 2005-2018 which far outpaces the 1% annual increase in residency positions per year since the Balanced Budget Act (BBA) was passed in 1997.^3,4 The BBA was created to avoid what was thought to be an impending physician surplus at the time. Based on the HRSA report from 2016, the surplus will never come to fruition. The restricted supply of GME positions results in medical students who are unmatched to GME training, delaying their entry into the physician workforce, and further exacerbating the physician shortage. While the physician shortage is growing, NPP programs have no limitation on training positions. According to the Health Resources and Services Association report from 2016, NP’s and PA’s are growing at a rate that will result in a 74% and 61% surplus by 2025 respectively.²  Even with the projected surplus, NPP’s receive  $41 million in annual funding from the Centers for Medicare & Medicaid Services (CMS).¹ The stark contrast in proliferation of new NPP’s to new physicians based on the current funding model, further supports the argument against the expansion of funding for NPP education.

GME funds a well developed and consistent model physician training. GME funding of NPP programs would fund an unstandardized curriculum with highly variable cost of training. Medical students accrue roughly 6,000 clinical hours in addition to the thousands of hours dedicated to independent study and lecture.⁵ Furthermore, prior to receiving funding from GME, physicians have completed three United States Medical Licensing Exams with a fourth to be completed in clinical training. Once residency begins, physicians take part in a time tested model of training with predictable budgets. The varied training pathways of NPP’s and lack of formal clinical training requirements results in “limited and incomplete” estimates of NPP training, as stated in the GAO report.¹ 

The GAO previously recommended that the Department of Health and Human Services (HHS) develop a comprehensive plan to address the physician shortage and noted the vast disparity in GME funding between rural and urban communities.^6,7In response, HHS has included efforts to redistribute physicians from densely populated areas to rural communities using multiple incentives, including distribution of CMS funds.⁸Of note, GAO addressed the use of non-physician practitioners to improve access to healthcare in rural areas.  However, according to the Agency for Healthcare Research and Quality (AHRQ), NPP’s remain far more concentrated in urban areas.⁹   With such measures already presented for federal funding to address the physician shortage and geographic distribution, expanding GME funds to include NPP’s only poses additional planning and costs without guaranteeing improving access and quality of primary care. 

AEROS steadfastly opposes the expansion of GME funding to NPP’s. GME funding of NPP training would lead to poorly vetted expenditures that would divert funds away from the unsolved physician shortage.  To address the unsolved physician shortage, as well as access to high quality and compassionate care, we need to focus our time and resources on training the next generation of physicians. 

REFERENCES

1. Government Accountability Office, Views on Expanding Medicare Graduate Medical Education Funding to Nurse Practitioners and Physician Assistants. (GAO Publication No. 20-162). Washington, D.C.: U.S. Government Printing Office.: December 2019. 
2. Health Resources and Services Administration, National and Regional Projections of Supply and Demand for Primary Care Practitioners: 2013-2025 (Rockville, Md.: November 2016).
3. AAMC: Results of the 2018 Medical School Enrollment Survey . AAMC. 2018,
   http://www.aamc.org/system/files/2019-08/results-2018-medical-school-enrollment-
   Survey.pdf . Accessed January 2020.
4. United States. Congress. House. Committee on the Budget. Balanced Budget Act Of 1997 : Report of the Committee on the Budget, House of Representatives, to Accompany H.R. 2015, a Bill to Provide for Reconciliation Pursuant to Subsections (b)(1) and (c) of Section 105 of the Concurrent Resolution on the Budget for Fiscal Year 1998, Together with Additional and Minority Views. Washington :U.S. G.P.O., 1997.
5. Coalition PC. Compare the Education Gaps Between Primary Care Physicians and Nurse Practitioners. Texas Academy of Family Physicians website. tafp.org/Media/Default/Downloads/advocacy/scope-education.pdf . Accessed January 2020.
6. US Government Accountability Office. Health care workforce: comprehensive planning by HHS needed to meet national needs. December 11, 2015. http://www.gao.gov/products/GAO-16-17. Accessed January 20, 2020.
7. US Department of Health and Human Services. HHS Strategic Plan FY 2018-2022 [Internet]. Washington (DC): US Department of Health and Human Services.: 2018 
8. Government Accountability Office, PHYSICIAN WORKFORCE: Locations and Types of Graduate Training Were Largely Unchanged, and Federal Efforts May Not Be Sufficient to Meet Needs. (GAO Publication No. 17-411). Washington, D.C.: U.S. Government Printing Office.: May 2017. 
9. Primary Care Workforce Facts and Stats. Content last reviewed July 2018. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/research/findings/factsheets/primary/pcworkforce/index.html. Accessed January 2020.