The Affordable Care Act Medicaid Expansion, Social Disadvantage, and the Practice Location Choices of New General Internists.

BACKGROUND: A recent study found that states that expanded Medicaid under the Affordable Care Act (ACA) gained new general internists who were establishing their first practices, whereas nonexpansion states lost them. OBJECTIVE: The objective of this study was to examine the level of social disadvantage of the areas of expansion states that gained new physicians and the areas of nonexpansion states that lost them. RESEARCH DESIGN: We used American Community Survey data to classify commuting zones as high, medium, or low social disadvantage. Using 2009-2019 data from the AMA Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following the expansion to where they located during the 5 years preceding the expansion. SUBJECTS: A total of 32,102 new general internists. RESULTS: Compared with preexpansion patterns, new general internists were more likely to locate in expansion states after the expansion, a finding that held for high, medium, and low disadvantage areas. We estimated that, between 2014 and 2019, nonexpansion states lost 371 new general internists (95% confidence interval, 203-540) to expansion states. However, 62.5% of the physicians lost by nonexpansion states were lost from high disadvantage areas even though these areas only accounted for 17.9% of the population of nonexpansion states. CONCLUSIONS: States that opted not to expand Medicaid lost new general internists to expansion states. A highly disproportionate share of the physicians lost by nonexpansion states were lost from high disadvantage areas, potentially compromising access for all residents irrespective of insurance coverage.

Effects of the Affordable Care Act Medicaid Expansion on the Distribution of New General Internists Across States.

BACKGROUND: Some states expanded Medicaid under the Affordable Care Act, boosting their low-income residents' demand for health care, while other states opted not to expand. OBJECTIVE: The objective of this study was to determine whether the Medicaid expansion influenced the states selected by physicians just completing graduate medical education for establishing their first practices. RESEARCH DESIGN: Using 2009-2019 data from the American Medical Association Physician Masterfile and information on states' Medicaid expansion status, we estimated conditional logit models to compare where new physicians located during the 6 years following implementation of the expansion to where they located during the 5 years preceding implementation. SUBJECTS: The sample consisted of 160,842 physicians in 8 specialty groups. RESULTS: Thirty-three states and the District of Columbia expanded Medicaid by the end of the study period. Compared with preexpansion patterns, we found that physicians in one specialty group-general internal medicine-were increasingly likely to locate in expansion states with time after the expansion. The Medicaid expansion influenced the practice location choices of men and international medical graduates in general internal medicine; women and United States medical graduates did not alter their preexpansion location patterns. Simulations estimated that, between 2014 and 2019, nonexpansion states lost 310 general internists (95% confidence interval, 156-464) to expansion states. CONCLUSIONS: The Medicaid expansion influenced the practice location choices of new general internists. States that opted not to expand Medicaid under the Affordable Care Act lost general internists to expansion states, potentially affecting access to care for all their residents irrespective of insurance coverage.

Graduate Medical Education, 2022-2023.

This Appendix presents 2022 National GME Census data detailing the numbers and types of ACGME-accredited training programs and the residents and fellows in them.

Easing the Entry of Qualified International Medical Graduates to U.S. Medical Practice.

ABSTRACT: Almost one quarter of physicians and physicians-in-training in the United States are international medical graduates (IMGs), meaning they have graduated from a medical school not accredited in the United States. Some IMGs are U.S. citizens and others are foreign nationals. IMGs, many of whom have years of training and experience gained in their countries of origin, have long contributed to the U.S. health care system, especially by providing care to populations that have been historically underserved. Additionally, many IMGs contribute to the diversity of the health care workforce, which can enhance the health of the population. The diversity of the United States is increasing, and racial and ethnic concordance between a physician and a patient has been linked to improved health outcomes.IMGs must meet national- and state-level licensing and credentialing standards like any other U.S. physician. This assures the ongoing quality of the care provided by the medical workforce and protects the public. However, at the state level, variation in standards and standards that may be more challenging to meet than those for U.S. medical school graduates may hamper IMGs' contributions. IMGs who are not U.S. citizens also face visa and immigration barriers.In this article, the authors present insights gleaned from Minnesota's model IMG integration program as well as changes made in 2 states in response to the COVID-19 pandemic. Improving and streamlining processes for IMGs to be licensed and credentialed as well as the policies governing visas and immigration, where appropriate, can ensure that IMGs will be willing and able to continue to practice when and where they are needed. This, in turn, could increase the contribution of IMGs to addressing health care inequities, improving health care access through service in federally designated Health Professional Shortage Areas, and reducing the impact of potential physician shortages.

An increasing number of states filled Conrad 30 waivers for recruiting international medical graduates.

To address physician shortages in the United States, Congress created the Conrad 30 visa waiver program allowing non-citizen international medical graduates to obtain visas to practice medicine in underserved areas. There is little information on whether states have effectively used the program. To fill the gap, we examined the growth and distribution of Conrad physicians between 2001 and 2020. We found that the number of states filling all of their annual allocated Conrad slots increased over the last two decades, yet one-half of the states still did not fill their allowed slots in 2020. Our analysis also revealed substantial variations across states in the number of Conrad physicians by specialty (eg, primary care physicians and psychiatrists), geography (eg, rural vs urban areas and physician shortage vs non-shortage areas). Our findings suggest that states can better use the Conrad program to meet healthcare needs across specialties and geographic areas.

Beyond Training the Next Generation of Physicians: The Unmeasured Value Added by Residents to Teaching Hospitals and Communities.

Following medical school, most newly graduated physicians enter residency training. This period of graduate medical education (GME) is critical to creating a physician workforce with the specialized skills needed to care for the population. Completing GME training is also a requirement for obtaining medical licensure in all 50 states. Yet, crucial federal and state funding for GME is capped, creating a bottleneck in training an adequate physician workforce to meet future patient care needs. Thus, additional GME funding is needed to train more physicians. When considering this additional GME funding, it is imperative to take into account not only the future physician workforce but also the value added by residents to teaching hospitals and communities during their training. Residents positively affect patient care and health care delivery, providing intrinsic and often unmeasured value to patients, the hospital, the local community, the research enterprise, and undergraduate medical education. This added value is often overlooked in decisions regarding GME funding allocation. In this article, the authors underscore the value provided by residents to their training institutions and communities, with a focus on current and recent events, including the global COVID-19 pandemic and teaching hospital closures.

A national survey of 'inactive' physicians in the United States of America: enticements to reentry.

BACKGROUND: Physicians leaving and reentering clinical practice can have significant medical workforce implications. We surveyed inactive physicians younger than typical retirement age to determine their reasons for clinical inactivity and what barriers, real or perceived, there were to reentry into the medical workforce. METHODS: A random sample of 4975 inactive physicians aged under 65 years was drawn from the Physician Masterfile of the American Medical Association in 2008. Physicians were mailed a survey about activity in medicine and perceived barriers to reentry. Chi-square statistics were used for significance tests of the association between categorical variables and t-tests were used to test differences between means. RESULTS: Our adjusted response rate was 36.1%. Respondents were fully retired (37.5%), not currently active in medicine (43.0%) or now active (reentered, 19.4%). Nearly half (49.5%) were in or had practiced primary care. Personal health was the top reason for leaving for fully retired physicians (37.8%) or those not currently active in medicine (37.8%) and the second highest reason for physicians who had reentered (28.8%). For reentered (47.8%) and inactive (51.5%) physicians, the primary reason for returning or considering returning to practice was the availability of part-time work or flexible scheduling. Retired and currently inactive physicians used similar strategies to explore reentry, and 83% of both groups thought it would be difficult; among those who had reentered practice, 35.9% reported it was difficult to reenter. Retraining was uncommon for this group (37.5%). CONCLUSION: Availability of part-time work and flexible scheduling have a strong influence on decisions to leave or reenter clinical practice. Lack of retraining before reentry raises questions about patient safety and the clinical competence of reentered physicians.

Attrition in residents entering US obstetrics and gynecology residencies: analysis of National GME Census data.

OBJECTIVE: We sought to identify risk factors for attrition among obstetrics and gynecology residents. STUDY DESIGN: We analyzed 2001-2006 American Medical Association Graduate Medical Education (GME) Census data for all residents who entered obstetrics and gynecology in 2001 to characterize residents who did not complete a 4-year training period in their initial programs ("attrition"). Multivariable logistic regression models identified predictors of attrition from among age, gender, race, Hispanic ethnicity, medical school type, and medical school graduation year. RESULTS: Of 1055 residents entering obstetrics and gynecology in 2001, 228 (21.6%) were in the "attrition" group (133 changed obstetrics and gynecology programs and/or completed training on atypical cycles; 75 changed specialty; 20 discontinued GME). Residents who were older, underrepresented minority race, Asian race, osteopathic- or international medical school graduates were more likely to be in the "attrition" group (each P < .05). CONCLUSION: Analysis of a national cohort of obstetrics and gynecology residents identified substantial attrition and demographic risk factors.

US residency training before and after the 1997 Balanced Budget Act.

CONTEXT: Graduate medical education (GME) determines the size and characteristics of the future workforce. The 1997 Balanced Budget Act (BBA) limited Medicare funding for additional trainees in GME. There has been concern that because Medicare is the primary source of GME funding, the BBA would discourage growth in GME. OBJECTIVE: To examine the number of residents in training before and after the BBA, as well as more recent changes in GME by specialty, sex, and type and location of education. DESIGN: Descriptive study using the American Medical Association/Association of American Medical Colleges National GME Census on physicians in Accreditation Council for Graduate Medical Education (ACGME)-accredited programs to examine changes in the number and characteristics of residents before and after the BBA. MAIN OUTCOME MEASURES: Differences in the number of physicians in ACGME-accredited training programs overall, by specialty, and by location and type of education. RESULTS: The number of residents and fellows changed little between academic year (AY) 1997 (n = 98,143) and AY 2002 (n = 98,258) but increased to 106,012 in AY 2007, a net increase of 7869 (8.0%) over the decade. The annual number of new entrants into GME increased by 7.6%, primarily because of increasing international medical graduates (IMGs). United States medical school graduates (MDs) comprised 44.0% of the overall growth from 2002 to 2007, followed by IMGs (39.2%) and osteopathic school graduates (18.8%). United States MD growth largely resulted from selection of specialties with longer training periods. From 2002 to 2007, US MDs training in primary care specialties decreased by 2641, while IMGs increased by 3286. However, increasing subspecialization rates led to fewer physicians entering generalist careers. CONCLUSION: After the 1997 BBA, there appears to have been a temporary halt in the growth of physicians training in ACGME programs; however, the number increased from 2002 to 2007.

Evaluation of the Conrad 30 Waiver Program's Success in Attracting International Medical Graduates to Underserved Areas.

This cross-sectional study evaluated the growth and distribution of physicians in the Conrad 30 Waiver program during the past 2 decades.