Short Takes On News & Events

Study Points To “Imbalance” In Spending On Doctor Training

By Phil Galewitz

November 4th, 2013, 5:39 PM

Florida and New York have roughly the same population, but New York has five times as many Medicare-sponsored residency training positions and seven times the Medicare funding graduate medical education.

The numbers give a glimpse into the “imbalance” in how Medicare distributes its $10 billion a year for graduate medical education (GME), according to a study by George Washington University researchers published Monday in Health Affairs.

New York state received 20 percent of all Medicare’s graduate medical education funding while 29 states, including places struggling with a severe shortage of physicians, got less than 1 percent, the study said. Other states at the top of the heap in funding are Massachusetts, Rhode Island, Pennsylvania, Michigan and Connecticut, the study found. Each of these states gets more than $71 in funding per each resident compared to $14 for Florida and $11.50 for Texas. At the bottom is Montana, which gets $1.94 per resident.

The distribution is important because while some medical residents move elsewhere after training, most practice near where they train. Doctors enter medical residency typically for three or more years after they graduate from medical school.

“Such imbalances play out across the country and can affect access to health care,” said lead author Fitzhugh Mullan,  a professor of medicine and health policy at GW.

New York received $2 billion in federal GME funding, according to the study. At the same time, the study found Florida received one tenth the GME funding ($268 million) and Mississippi, the state with the lowest ratio of doctors to patients in the country, received just $22 million in these federal payments.

The formula that determines how such dollars are distributed was set up decades ago and does not account for population growth, Mullan said.

“Due to the rigid formula that governs the GME system, a disproportionate share of this federal investment in the physician workforce goes to certain states mostly in the Northeast,” he said. “Unless the GME payment system is reformed, the skewed payments will continue to promote an imbalance in physician availability across the country.”

But changing that balance is politically difficult because states that have the largess in funding don’t want to give it up to help states with less money, he said. Hospitals count on the funding, Mullan said.

Dr. Atul Grover, chief public policy officer at the Association of American Medical Colleges, defended the existing formula and said his group, which represents teaching hospitals, wants Congress to increase funding overall. But at a time when the federal government is focused on cutting the deficit, he concedes that is unlikely to happen soon.

Grover says the GME money analyzed in the study is somewhat misleading because it includes funding for hospital burn centers, trauma centers and treating sicker patients.

Grover said growing states with fewer residency training positions will have a harder time keeping up with demand for physicians. He said some big states such as Florida and Texas don’t have enough residency slots to train all graduating medical students.

The Affordable Care Act does little to change how the residency positions are allocated, though the law called for reallocation of unused slots. Last year, about 50 of the more than 26,500 positions went unfilled.

Medicare funding makes up about two-thirds of the $15 billion spent on graduate medical training each year. The rest is largely paid for by hospitals.

6 Responses to “Study Points To “Imbalance” In Spending On Doctor Training”

  1. Pete says:

    Regarding how much states spend on doctor training, There’s a whole lot of truth to the old adage, “You get what you pay for”. My advice, if longevity is important to you, it might be wise for you to live in the northeast. Why would anyone live in Montana?

  2. Ronald Brimberry MD says:


    Just because the payment received by States varies from region to region does not mean that the quality of resident education is poorer than in those States which receive better funding. As a Family Medicine Residency educator for more than 30 years, in one of the States which receives the lowest amount of GME funding per capita, I can assure you that the distribution of these $10 billion Federal dollars is way off base. Our teaching hospitals do not deserve to be less well supported for GME funding than hospitals in the Northeast.

  3. Jessica says:

    Another thought is that the cost of living in the northeast, especially NYC is astronomically higher than Montana. They must pay their residents more because much of the money goes to pay for the cost of living. Although this article emphasizes the important issue of physician shortages in the west, and the need to improve GME funding, the issue is bigger than ‘just share the pot equally’.

  4. margie says:

    Pete’s right. Who in their right mind would risk living in rural red states. The fact that most rural patients are more inclined to opt to travel thousands of miles to urban hospital centers for treatment for their serious illnesses speaks to Ronald’s point. If you must have a certain type of sophisticated procedure, most patients want doctors with lots and lots of experience in that specific procedure. Take for instance robotic surgery or proton beam radiation therapy, when I think about doctors with multiple daily procedures using sophisticated radiological and robotic surgical systems, I don’t necessarily think of the doctors in Butte Montana.

  5. JLR says:

    I think you are all missing the meaning. The dollar amount is per state resident, not per resident in training. Furthermore, this spending doesn’t just affect specialized care. It means there are no family doctors available for millions of people. That’s why they end up having to travel far for care. Why should the Federal government give $2 billion to NY, a state already full of doctors? The entire idea behind Medicare funding of GME is to ensure there will be enough doctors to take care of Medicare patients. If there are not sufficient primary care doctors in rural states, it will cost all of us taxpayers because people will be sicker and they will end up costing more to Medicare. I live out West–should I be penalized because the system was set up decades ago to favor the Northeast? And are the Federal government and the taxpayer getting what they thought they were paying for?

  6. Kevin says:


    Do you think the governor of Texas and Texas legislators plan to make sure more Texans are insured and have access to a primary care doctor?