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9 Family Medicine Residency Accreditation
55
scholarly activity and the RCFM may recommend that programs pay close attention to logging scholarly activity in
ADS for all the faculty listed on the ADS faculty roster, not
just core faculty. If logging is accurate, then the cumulative
volume of faculty scholarly activity for the program may be
low compared to other programs and it will be imperative for
the program to support faculty in achieving scholarly activity. Scholarly activity must be accomplished in at least three
of the domains listed in the program requirements (research,
peer-reviewed grants, quality improvement and/or patient
safety initiatives, peer-reviewed publications, creation of
educational tools or materials, contribution to professional
organizations, or innovations in education). Another common AFI is a deciency in the faculty and/or resident annual
survey results.
The RCFM votes upon nal citation(s) and AFIs and a
simple majority determines the decision.
The RCFM maintains an institutional memory bank of
accreditation decisions, citations and AFIs issued to all programs to help support consistency. Once citations are issued,
the program ADS submission is reviewed annually to determine whether the citations have been resolved and/or if new
citations are indicated. The quantity and severity of citations
may result in adverse accreditation decisions including
accreditation with warning or probationary status.
The RCFM chair and executive director present common
citation patterns at the annual AAFP Residency Leadership
Symposium and ACOFP program director meetings as well
as the ACGME Annual Education Conference. Attending at
least one of these annual presentations at a national meeting
can be exceptionally valuable for PDs, program coordinators
and faculty. The RCFM benets from feedback provided by
attendees at these meetings. Community feedback and citation trends are used by the RCFM when program requirements are due for revision or ADS is being updated.
Accreditation Status
The ACGME denes a number of accreditation status
options. After initial accreditation, most programs receive
Continued Accreditation. The RCFM may issue a program
Continued Accreditation with a warning if they determine
that the program has areas of requirement non-compliance
that are signicant enough to jeopardize the program’s future
accreditation status.
Probationary Accreditation means that after review of the
program, including a site visit, the RCFM determines that
the program has not demonstrated substantial compliance
with accreditation requirements. Probationary Accreditation
is considered an adverse decision. Programs with
Probationary Accreditation must be reviewed annually. The
RCFM may withdraw accreditation if the program’s lack of
substantial compliance with the accreditation requirements
is serious and widespread. In rare circumstances, accreditation may be withdrawn due to special circumstances such as
catastrophic loss of faculty or facilities.
Program Requirement Development
Historical Development ofProgram
Requirements
As mentioned earlier in the chapter, the rst edition of the
program requirements for family medicine were published in
1969 and consisted of two pages of general guidelines.
Several iterations of those requirements have since followed
and they have grown to over 60 pages. The increasing length
has been the subject of commentaries over the years, often
begging the question of whether the expanding details
required of programs for accreditation has, in the end, led to
the production of a more competent family physician. While
the ultimate quality of care provided by family medicine
residency graduates in the 1970s compared to the 2020s
would be nearly impossible to study, it is important to reect
on the broader purpose of accreditation requirements and
why the evolution to the current system has been necessary.
As graduate medical education has moved from being largely
an endeavor overseen by a subset of stakeholders from each
specialty who operated mostly in silos to one of an expanding single accreditation system built on a scaffolding of common program requirements, the process of creating specialty
specic requirements has changed [12].
Years ago, specialty specic program requirements were
entirely the purview of the AMA sub-committees for
Graduate Medical Education in a particular specialty. After
the formation of the ACGME, those requirements and their
revisions became the purview of the residency review committees and ACGME staff. The national debate around duty
hours and patient safety led to the conclusion that all specialties would need to be held accountable to certain standards in
the clinical learning environment which in turn led to the
multi-specialty process of oversight in the revision and creation of new requirements. After the adoption of the Common
Program Requirements (CPRs), the volume of requirements
expanded across all specialties. This did ensure that all specialties would be held accountable to certain expectations
around resources, faculty, scholarship, and administration
needed for resident education. At the same time, review committees were allowed to “further specify” requirements in
areas that were unique to the needs of training in a particular
specialty.
Previous iterations of the process to revise the family
medicine specialty specic requirements involved primarily
the RCFM and its members drafting a major revision and
56
G. S. Hoekzema et al.
subsequently releasing it to the family medicine GME community for review and comment. The review and comment
period were usually 45 days, after which, the RCFM was
required to respond to and address the comments received
and make any modications to the proposed revisions before
submitting the nal revised document to the ACGME Board
of Directors for approval. This process was used for the
major revisions in 2001 and 2011–13. Although this was a
more open and inclusive process than in the past, it was still
one which involved a relatively small group of individuals
working with the prior requirements as the primary starting
point and making changes based on the current medical education and practice environment. Some of the highlights of
these previous major revisions include the addition of
required clinical experiences, including dermatology, orthopedics and sports medicine, practice management, and gynecology. There was also a shift to a more proscriptive
accounting of clinical experiences, with minimum requirements for numbers of encounters, procedures or time-onservice for major areas such as adult inpatient medicine,
pediatrics, and maternity care. This move to specic minimal
requirements was in part due to a perception that the RCFM
arbitrarily issued citations for some programs and not others.
In order for the RCFM to have a more concrete minimum
standard, the requirements became more detailed and proscriptive. The impact of this shift in requirements was mixed.
On the one hand, a clear minimum bar was set for all programs, which presumably would result in a more consistent
educational experience for residents across the varied landscape of FM residency training. On the other hand, numeric
requirements became a goal to achieve in order to avoid citations, rather than a minimum standard of quality. Independent
efforts to spur programs to exceed the requirements in the
pursuit of quality fell short. Most programs were satised
with nominally exceeding minimum expectations but showed
little desire to push clinical experiences further [13].
Scenario Planning: Development ofthe2023
Program Requirements
After the turmoil of the duty hours debate from 1999 to
2011, the ACGME embarked on the launch of the Next
Accreditation System (NAS), followed by the merger of the
osteopathic and allopathic GME communities into the
Single Accreditation System (SAS) starting in the year
2015. The result of all of this activity in rapid succession led
the ACGME Board of Directors to embark on a strategic
planning process. Recognizing the rapid state of change that
is constant in medicine and the need to have a plan that
would be adaptable in such an environment, the ACGME
utilized a process called scenario planning to help formulate
its new strategic plan. Scenario planning is a strategic process that is based on the premise that the best plans for the
future are those which will work and be adaptable under a
variety of future conditions, not just those of the current
state of affairs. As a result of the robust outcome of this
planning process, the ACGME Board of Directors determined that all specialties should undergo a similar strategic
scenario driven process to craft the next major revisions of
specialty specic requirements. This initiative would come
to be known as “Shaping GME: the Future of (insert specialty)” and it was launched with the major revisions for
Internal Medicine training in 2018, followed by Family
Medicine in 2020. Using a scenario planning process,
“Shaping GME: the Future of Family Medicine” produced
the most sweeping changes to the family medicine SPRs in
over a decade [4].
The major revisions for FM that went into effect July
2023 as a result of the “Shaping GME” process were the
product of a multi-stage process that involved many stakeholders in the FM GME community, as well as those from
other specialties, advanced practitioner organizations, regulatory bodies, and the public. A detailed description of the
process and lessons learned has been described elsewhere
[5]. In addition to the strategic scenario planning process,
which considered four potential future scenarios with very
different cultural and health system landscapes, the writing
group constructed several overarching themes that should
shape the specialty of FM over the next 15–20years. These
themes were then used as a scaffold to write the new requirements, with the mindset that they would be created on a
“clean slate” rather than by simply modifying the previous
requirements. A summary of the themes and the corresponding strategies needed in future training requirements is displayed in the accompanying table.
Summary of themes and strategies from family medicine review
committee scenario planning process
Community focused
population health
Holistic clinically competent
care
Lifelong adaptive learning Prepare for career-long adaptive
Relationship-based
communication
Establish and engage with
community council
Training for community-centric low
resource setting
Train in understanding of impact of
socioeconomic conditions impacting
health care
Training in applying population
health knowledge to scope of
practice
Comprehensive clinical care—
includes people, settings, disease
states, timescale
learning
Training for interpersonal
communication and relationship
building
(continued)
9 Family Medicine Residency Accreditation
57
Summary of themes and strategies from family medicine review
committee scenario planning process
Collaborative team-based
leadership
Technology integration Critical reasoning in use of
Values driven professionalism Recruit diverse, representative
Train in interprofessional leadership
and management skills
Train to be leaders, followers, and
educators of diverse teams
technology
Embrace educational technology
Technology in service to patientcentered care
residents, faculty, and staff
Understanding cultural humility and
diversity, equity, and inclusion
Look for family medicine values in
recruitment
Train to exemplify family medicine
values in independent practice
While in the end the requirements would have to conform
to the ACGME rubric as outlined in the CPRs, the writing
group did make substantial changes to the focus and content
of the requirements. The 2023 revisions place an increased
emphasis on the practice and community as the curriculum,
include fewer proscriptive and numerical requirements,
allow for more exibility and adaptability to the individual
programs’ mission and goals, and are a major shift toward
competency-based medical education (CBME) with the outcomes of training as the end in mind. The ultimate goal is to
produce a comprehensively trained, personal physician, who
is competent to provide care to any community they are
called to serve. In the end, the RCFM was ultimately responsible for responding to the public review and comments on
the proposed revisions, similar to the past and, as expected,
the FM GME community had wide ranging opinions on
these major shifts. The nal product was a robust document
that remained true to the themes that guided its writing and
poised FM training to be exible and adaptable to an uncertain future, while still being true to the denition of the specialty. The revisions were then sent on and approved by the
ACGME Committee on Requirements (COR).
When a review committee is allowed to “further specify,”
it must craft requirements within the guidelines and guardrails set by the CPRs. Any proposed specialty-specic
requirements (SPRs) must be peer reviewed by the
Committee on Requirements (COR), which is a standing
committee of the ACGME Board of Directors. The process is
akin to the editorial review of a manuscript submitted for
publication. The role of the COR is to ensure that all SPRs
conform to the intent of the CPRs. No one specialty is given
excessive latitude in the application of their SPRs with
regard to the clinical working and educational environment.
A good example of this was that when the CPR standards
around clinical and educational work hours changed in 2011,
some surgical specialties argued that there was educational
justication for allowing an extension of work hours beyond
the 80-hour limit set by the CPRs. Instead of allowing these
specialties to set their own hour limits, the COR was given
permission to grant up to a 10% time extension, provided the
Review Committee (RC) for a given specialty supplied a
detailed educational rationale. A more recent example of the
dialogue between specialty RCs and the COR, involved the
request by the RCFM to modify CPR requirements around
faculty teaching time [14]. In this case, the decision by the
COR to limit required core faculty time for administrative
and non-clinical teaching activity was met with signicant
FM GME community concerns, which were conveyed to the
RCFM.The RCFM, via its committee leadership, served as
an advocate for changes to restore the teaching time requirements to prior levels. This was a good example of the importance of open communication between the RCFM and its
GME constituents. The RCFM is in a unique position to
serve as both accreditor and advocate for the specialty.
New Directions inAccreditation: Length
ofTraining, Advancing Innovations, and
Competency-Based Education
Length ofTraining: 3 or 4Years?
Current FM program requirements stipulate that training
programs must be 36months in duration, which has been the
length of training since the formation of the specialty.
However, beginning around the time of the last major revision of the requirements, a movement emerged that made the
case for extending the length of training to 4years. This was
largely driven by concerns around the changing scope of
practice and the imposition of work hour regulations during
residency training which effectively shortened clinical exposure in exchange for a safer work environment. Some programs recognized that what communities needed in the skills
of their family physicians was not able to be taught during
the standard 3-year curriculum. Whether this was in a traditional broad scope of skills, including hospital and maternity
care, or in more emerging advanced skills, such as addiction
medicine, advanced procedures, HIV treatment or high-risk
maternity care; a handful of programs embarked on an
experiment of 4years of FM training [15].
Eventually this movement was formalized into a pilot
project overseen by the ACGME and the RCFM, with input
from the ABFM, called the Length of Training Pilot (LOTP).
Beginning in 2012 and continuing for 10years, the LOTP
sought to enroll FM programs in a project to study the impact
and outcomes of 4years of training, using a variety of different curricular models. Initially there were 13 programs that
were included in the pilot but by the end of the 10years, only
four remained. Even with this small fraction of the total FM
58
G. S. Hoekzema et al.
programs in the country participating, the inuence of the
LOTP was substantial. With data that showed a broader
scope of practice among graduates as well as indications that
medical student recruitment did not suffer and residency
nancing hurdles for extending training could be overcome,
the larger FM community felt it would be worthwhile to consider ongoing study of the length of FM residency training as
part of the Shaping GME: Future of Family Medicine
requirement revisions and the Stareld Summit IV in
2020–2021 [16]. Hence the formation of the FM Advancing
Innovations in Residency Education (AIRE) project.
Advancing Innovations inResidency Education
(AIRE) Project
With changes at the ACGME over the 10years of the LOTP,
the appetite for innovation in GME had expanded, while at
the same time, the process for program requirement revision
and approval had become harmonized across specialties.
This convergence produced an environment in which FM
requirement revisions would need to conform to the convention of all other specialties, discouraging time variable training in favor of a set length of training for all residents in a
specialty. However, the ACGME had recognized that the
only means to determine the proper training sequence would
be to allow the study of innovative curricula. The ACGME
Advancing Innovation in Residency Education (AIRE) project was formed to allow a pathway to study innovative curricula which might require exemption from certain
accreditation requirements while still adhering to the majority of specialty training requirements.
The RCFM and ABFM, as part of the writing group process for the current major accreditation requirement revisions, determined that the AIRE program was the best
pathway for ongoing study on the optimal length of training
to acquire the competencies and skills needed to serve the
needs of diverse communities. Unlike the prior LOTP, which
largely included programs in which all enrolled residents
were required to complete 4years of training, the current FM
AIRE project opened the door to allow programs to tailor
their extended training pathways to some or all residents in a
program. The three primary streams of curricular innovation
are to include residents who receive an additional year of
training in an area of concentration, such as maternity care,
hospital medicine or advanced procedural care; or the integration of an ACGME/ABMS approved fellowship, such as
sports medicine or geriatrics, across a four-year program; or
a more robust comprehensive FM curriculum for 4 years
instead of three. The goal is to study the outcome of these
curricular innovations on graduate scope of practice, educational rigor, and patient care outcomes. The RCFM and
ABFM oversee this project which will include a robust and
thorough evaluation arm along with a collaborative learning
community comprised of the enrolled programs. An initial
target of 70–80 programs enrolled over a 2 to 3-year period
will be needed to produce a meaningful dataset of outcomes
[17].
Competency-Based Medical Education (CBME)
The debate around the appropriate length and scope of training in FM is part of a larger discussion around competencybased medical education (CBME). The traditional training
sequence in medicine is 4years of medical school followed
by a xed time in residency in a chosen area of specialty
training. For family medicine, this has been 3years. It has
been generally agreed that this length of time is adequate to
achieve the competencies needed for autonomous, unsupervised practice. However, it has also been recognized that not
all residents acquire the needed competencies at the same
pace. Some may need additional time to hone their skills or
remediate educational deciencies, while others may demonstrate competency for autonomous practice well before
36months of training is nished. Viewing time as a resource
instead of a predetermined educational outcome is one of
the tenets of CBME.However, CBME is more than just the
length of time needed to achieve competency; it is also an
educational process that demands the optimal sequencing
(arranging curricular elements in an order that allows the
resident to move from novice to mastery, building on prior
experiences) and assessment of the resident’s achievement
of the desired competencies required for meeting the needs
of the patients and community that the resident will serve
upon graduation. This process is heavily dependent on curricular exibility that provides an individual learning plan
(ILP) unique to each resident’s needs. Operationalizing this
type of educational system in the current GME environment
is challenging for virtually all specialties and FM is no
exception.
The RCFM and ABFM, in concert with all the major FM
educational organizations, have begun the process to shift
residency education toward a CBME emphasis. The new
program requirements which went into effect in July of 2023
have signicantly reduced the number of requirements that
are based primarily on the length of specic rotations or the
number of clinical encounters in favor of more exible, less
proscriptive requirements which emphasize the attainment
of specic competencies in those curricular areas critical to
training a comprehensive family physician. Because the
RCFM has heavily relied on numerical data related to a resident’s clinical experience in its accreditation decisions, it
will now need to shift toward data collection that captures
the program’s ability to assess the competency of its trainees
and corresponding graduate outcomes. The upcoming
9 Family Medicine Residency Accreditation
59
changes in this approach to collecting data have been
described in more detail in the previous section on the annual
program review process. The RCFM will need to use the
information collected from programs adopting these changes
to make accreditation decisions and to guide future changes
as the specialty shifts toward a CBME approach to
GME. Combining the learnings from this endeavor with
those of the FM AIRE project, the RCFM will continue to
play a major role in shaping the training of the current and
future FM workforce.
Summary andConclusions
Residency education in family medicine in the USA has
been evolving ever since the creation of the specialty. From
the earliest years with the launching of family practice training programs as the structured replacement for the previous
pathway to general practice, to the current common and specialty requirements crafted by the ACGME and RCFM, the
goal has been the production of a robust, comprehensive,
personal physician workforce that will meet the majority of
the health needs of the American public.
Accreditation of postgraduate training in the specialty of
family medicine has served to ensure rigorous, standardized
training, that produces competent, trusted physicians, regardless of the institution or community in which that training
occurs. The process of accreditation relies on the expertise
and commitment of the ACGME and the Review Committee
for Family Medicine (RCFM). This body of peer-selected,
dedicated volunteers has guided the oversight of the accreditation process with delity to the founding principles of the
specialty over the last ve decades. Although its primary role
is to ensure the consistent and fair accreditation of FM residency programs, the RCFM has played a major role in shaping the specialty through the creation and implementation of
specialty-specic training requirements.
We have used this chapter to describe in depth the unfolding of the critical role of program accreditation on the past,
current, and future FM residency education and its inuence
on our specialty in the hopes that the reader will gain a
deeper appreciation and understanding of the accreditation
process.
References
1. AMA Green Books. ACGME. www.acgme.org/about/publications-
and- resources/ama- green- books. Accessed 14 Aug 2023.
2. Advanced Solutions International, Inc. Mission & History. www.
acofp.org/acofpimis/Acofporg/About_ACOFP/Mission_History/
Acofporg/About_ACOFP/Mission_History.aspx. Accessed 14 Aug
2023.
3. Nasca TJ, etal. The next GME accreditation system– rationale and
benets. NEJM. 2012;366(11):1051–6. https://doi.org/10.1056/
NEJMsr1200117.
4. ACGME Common Program Requirements. ACGME. www.
acgme.org/globalassets/pfassets/programrequirements/cprresidency_2023.pdf. Accessed 2 Feb 2024.
5. Potts S, et al. Shaping GME through scenario-based strategic planning: the future of family medicine residency training. J
Grad Med Educ. 2022;14(4):499–504. https://doi.org/10.4300/
jgme- d- 22- 00505.1.
6. Overview. ACGME. www.acgme.org/about/overview/. Accessed
14 Aug 2023.
7. Mission, Vision, and Values. ACGME. www.acgme.org/about/
overview/Mission- Vision- and- Values/. Accessed 14 Aug 2023.
8. Nasca TJ. The next GME accreditation system – rationale and
benets. NEJM. 2012;366(11):1051–6. https://doi.org/10.1056/
nejmsr1200117.
9. Annual Update Changes– 2023–2024– Help Center – ACGME.
acgmehelp.acgme.org/hc/en- us/categories/14177239190423Annual- Update- Changes- 2023- 2024. Accessed 15 Aug 2023.
10. Accreditation Council for Graduate Medical Education Glossary–
ACGME. www.acgme.org/globalassets/pdfs/ab_acgmeglossary.
pdf. Accessed 25 Aug 2023.
11. Carek P, Potts S. Ongoing self-review and continuous quality improvement among family medicine residencies.
Fam Med. 2021;53(7):626–31. https://doi.org/10.22454/
FamMed.2021.888193.
12. Nasca TJ, Thomas CW.Medicine in 2035: selected insights from
ACGME’s scenario planning. J Grad Med Educ. 2015;7(1):139–42.
https://doi.org/10.4300/JGME- D- 14- 00740.1.
13. Hoekzema GS, etal. Six years’ experience using specialty national
residency index: an early dashboard to document change over
time. Fam Med. 2021;53(1):39–47. https://doi.org/10.22454/
FamMed.2021.305900.
14. Newton, WP, et al. Dedicated time for education is essential to
the residency learning environment. American Board of Family
Medicine. 18 October 2022. www.jabfm.org/content/35/5/1035.
15. Carek PJ. The length of training pilot: does anyone really know
what time it takes? Fam Med. 2013;45(3):171–2.
16. Douglass AB.The case for the 4-year residency in family medicine. Fam Med. 2021;53(7):599–602. https://doi.org/10.22454/
FamMed.2021.750646.
17. Newton WP, Hoekzema G, Magill M, Fetter J, etal. The promise of
Aire. Ann Fam Med. 2022;20(4):389–91. https://doi.org/10.1370/
afm.2869.
Graduate Medical Education Funding
KentonI.Voorhees, DanielBurke, LouisSanner,
andAlanB.Douglass
10
Key Points
• Graduate medical education funding represents the
nation’s largest investment in the healthcare workforce.
• Federal and state governments spent an estimated $18.8
billion in 2020 supporting graduate medical education
and that annual amount continues to grow.
• The expenses to operate a graduate medical education
program include resident trainee salaries and benets, salary support for faculty and administrative personnel, and
a variety of operational expenses.
• The Medicare program is the largest funder of graduate
medical education and provides two funding streams:
Direct Graduate Medical Education (DGME, sometimes
called DME) and Indirect Medical Education (IME).
• About one-third of Medicare graduate medical education
payments are “direct” payments for costs such as resident, faculty, and administrative support salaries, educational materials, building space, and other operational
costs, while about two-thirds of the Medicare graduate
medical education payments are for “indirect” costs that
are calculated for each hospital based on the ratio of residents to Medicare inpatient beds.
• Each hospital has “caps” for the number of residents supported through Medicare direct graduate medical education payments and indirect graduate medical education
payments.
• The second largest proportion of payments for graduate
medical education is through state Medicaid programs;
each state has a different formula for making these
payments.
K. I. Voorhees (*) · D. Burke · A. B. Douglass
Department of Family Medicine, University of Colorado School of
Medicine, Aurora, CO, USA
e-mail: KENT.VOORHEES@CUANSCHUTZ.EDU
L. Sanner
Department of Family Medicine and Community Health,
University of Wisconsin School of Medicine and Public Health,
Madison, WI, USA
• The most recent federal change in graduate medical education funding is the Consolidated Appropriations Act of
2021.
• There have been many efforts to support rural hospital
graduate medical education, but the regulations are complex and nuanced.
• Though residency program directors should be well
versed in graduate medical education funding and its
many regulations and subtleties to avoid pitfalls that may
adversely affect their programs, consultation with funding experts may be necessary.
Introduction
This chapter is intended to provide foundational knowledge
in Graduate Medical Education (GME) nances for leaders
in Family Medicine and other specialties recognized as high
need, and healthcare policy leaders. Leaders of existing programs will benet from knowledge in this area so they can
effectively advocate with their sponsoring institutions for the
nancial health of their programs. Leaders wishing to expand
their programs or start new programs need to be well versed
in funding options available and be aware of the many
nuances that exist in GME funding to avoid pitfalls that
could lead to long-term adverse funding situations. Policy
leaders will also benet from an understanding of the GME
nancing “system.”
GME funding represents the nation’s largest investment
in the healthcare workforce. Federal and state governments
spent an estimated $18.8 billion in 2020 supporting GME
and that annual amount continues to grow [1]. This large sum
makes the nancing and governance of GME a signicant
lever in policy activities aimed at improving, or otherwise
controlling, our healthcare system.
GME is the training of physicians after they graduate
from medical school and before they become eligible for
board certication in their specialty or sub-specialty.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_10
61
62
K. I. Voorhees et al.
Residency training leads to board certication eligibility in a
specialty. Fellowship training occurs after residency and
leads to board certication eligibility in a subspecialty. The
residency training period varies depending on specialty with
Family Medicine, Internal Medicine, and Pediatrics being
3years, OB-Gyn 4years, and 5years for General Surgery.
Fellowship training leads to board certication eligibility in
a sub-specialty such as gastroenterology or rheumatology.
The Accreditation Council for Graduate Medical
Education (ACGME) accredits GME training programs and
institutions in the USA.In academic year 2022–2023, there
were 13,066 residency and fellowship programs at 886
sponsoring institutions in 182 specialties and subspecialties.
There were 158,079 residents and fellows in training which
represents 1 out of every 7 physicians in the United States [2].
This chapter uses the term “GME trainee” to refer to both
residents and fellows in accredited GME programs. Unless
otherwise noted, “resident” and “residency” are terms used
in this chapter—and in many regulations—to also include
fellows and accredited fellowship programs.
Residency Operating Costs
The expenses to operate a GME program include GME
trainee salaries and benets, salary support for administrative and leadership personnel, salary support for academic
time (non-clinical) for faculty, and operational expenses.
Resident salaries vary geographically and by year of graduate training. As of November 27, 2023, resident salaries typically fell between $51,831 and $64,860 and averaged
$58,185. Resident benets ranged between 20% and 35% of
the salary and averaged $26,006, bringing the total salary +
benets to an average of $84,191 per resident per year [3].
Administrative, leadership, faculty, and staff-associated
costs also vary by location. These positions include the
Program Director (PD), Associate Program Director(s)
(APD), core faculty, Program Coordinator (PC), and other
support staff. In terms of FTE for academic (non-clinical)
time, it is recommended to refer to the Residency Program
Solutions (RPS) Criteria for Excellence (CfE). https://www.
aafp.org/students- residents/residency- program- directors/
residency- program- solutions.html#cfe The CfE is updated
periodically, including when new ACGME accreditation
requirements are released. The CfE makes recommendations
that more clearly t with the support needed to start and
maintain an excellent residency. Operational costs include
such things as expenses for educational materials, events
such as graduation and resident wellness outings, support to
attend professional meetings, and for some programs support
for housing and transportation.
Although the total can vary across the country, programs,
and specialties, the academic cost (not including clinical
operations costs) for a family medicine residency is about
$150,000–$180,000 per resident per year. For Teaching
Health Center-funded residency training programs (discussed in greater detail below) [which are funded through
the Health Resources and Services Administration (HRSA)
and authorized by Congress], the cost, as of 2023 legislation,
was set at $160,000 per resident per year [4]. A study commissioned by HRSA that was published in The New England
Journal of Medicine in 2016 put the average cost of a residency at $157,602 per resident per year [5]. A study of
Pacic Northwest community-based family medicine programs published in 2018 put the median academic cost at
$180,000 per resident per year [6].
Using $170,000 as an average of these estimates, a 6-6-6
program would have total annual academic expenses of
about $3.1 million (not corrected for ination).
Determining the contribution of patient care revenues
toward the cost of operating a training program has proven
elusive. The Institute of Medicine (IOM), which is now the
National Academy of Medicine (NAM), performed an
exhaustive evaluation of the GME system in 2014. They
noted that “teaching hospitals added nearly 17,000 new positions to accredited residency and fellowship programs
between 1997 and 2012, without any further subsidization
by Indirect Medical Education (IME) or Direct Graduate
Medical Education (DGME), which is also known as Direct
Medical Education (DME) funding. IME and DGME
together are often called GME (Graduate Medical Education)
funding.” The report goes on to observe: “If it is assumed
that hospitals would not add the direct and indirect expenses
of trainees unless those expenses are offset by gains (which
is debatable), such additions above the cap suggest that residents add value in excess of those costs—even with no subsidization” [7] IME, DGME, and the Cap will be discussed
in detail below. The point here is that, for many specialties
and subspecialties, (particularly procedurally oriented specialties) residents’ and fellows’ clinical work can be leveraged to increase clinical revenue sufciently to offset training
costs.
Family Medicine is among the specialties in which this
offset is less favorable. While many Family Medicine and
other primary care training programs do leverage clinical
revenues to support their educational mission, in general
they are much more reliant on government programs that
provide GME funding.
Overview ofGovernment Programs that
Provide Financial Support forGME
Public funding for GME represents a signicant investment
and involves a complex mixture of funding through Medicare,
Medicaid, the Veterans Administration, the Health Resources
10 Graduate Medical Education Funding
63
Table 10.1 Graduate medical education public funding, 2018–2020
Funding agency Amount (in billions), (year)
Federal
Medicare $11.218, (2019)
HRSA $0.450, (2019)
Teaching health centers $0.127
Children’s hospitals GME $0.323
VA $1.600,a (2020)
States (predominantly Medicaid) $5.580, (2018)
Total $18.848
Abbreviations: HRSA Health Resources & Services Administration,
GME graduate medical education, VA U.S. Department of Veterans
Affairs
Phillips etal. [1]. https://doi.org/10.1097/ACM.0000000000004592
a
The VA lists $837 million for scal year 2020 spent directly on GME
trainees but says that of the total educational training budget ($2.2 billion), GME physicians and residents account for “approximately 80%
of its budget, and non-GME trainees [account] for approximately 20%
of the budget”
and Services Administration, state government appropriations and grants. Data compiled by the Center for
Professionalism and Value in Healthcare (CPVHC) shown in
(Table10.1) estimate the total GME government funding for
academic costs in 2020 to be at least $18.8 billion [1]. It can
be difcult to get a snapshot at any one point in time of the
actual governmental expenditure for GME as there are many
entities involved with different reporting formats and reporting schedules. The CPVHC data shown in (Table10.1) were
published in May of 2022 and are already outdated. It shows
Medicare expenditure in 2019 of $11.2 billion, while the
Graham Center website, by adding DGME and IME totals,
for all hospitals puts Medicare’s GME expenditure for scal
year 2021 at 16.4 billion. https://www.graham- center.org/
maps- data- tools/gme- data- tables.html
HRSA and the Veteran’s Administration (VA) combined
contribute an additional $2 billion. At the state level, funding
is mainly through the Medicaid system and totaled $7.3 billion for all states in 2022 (Extracted from Table10.1). HRSA
Teaching Health Center (THC) GME funding for residencies
(known as THCGME) in entities such as Federally Qualied
Health Centers (FQHCs) was $155 million to 72 programs
during the 2022–2023 academic year [8]. Pediatric training
through Children’s Hospitals known as Children’s GME
(CHGME) was $375 million for FY 2022 [9].
Other sources of revenue may include grant funding (private or governmental), foundation support, and various programs to defray start-up costs. From time to time, government
agencies such as HRSA will provide educational grants to
support development of certain curricular areas such as
Behavioral Health and Primary Care Integration [10], Rural
Health Care Coordination [11], Medication Assisted Therapy
[12], and temporary funding for new positions (e.g., Primary
Care Training and Enhancement grants) [13]. However,
these represent minor and undependable sources of funding.
HRSA has also made residency development grants available to help produce more doctors in rural and underserved
areas. These include Rural Residency Program DevelopmentTechnical Assistance Center (RRPD-TAC) [14], and
Teaching Health Center Program Development-Technical
Assistance Center (THCPD-TAC) grants (See “HRSA
Residency Development Funding” below) [15].
Teaching Health Centers GME Funding (THCGME) is an
important non-Medicare federal GME funding source, which
began in 2010 as part of the Affordable Care Act. There are
important distinctions between THCGME and Medicare
GME funding. The recipient of revenues for a THC teaching
program must be a community-based organization such as a
Community Health Center, Tribal Health Center, or Rural
Health Clinic. THCGME funding is only for the following
specialties: Family Medicine, Internal Medicine, Pediatrics,
Internal Medicine-Pediatrics (Med-Peds), OB-Gyn,
Psychiatry, General Dentistry, Pediatric Dentistry, and
Geriatrics [4, 16]. Medicare funding, on the other hand, is
directed toward hospitals, and the specialties trained are
solely at the discretion of the teaching hospital. Another key
difference is that Medicare funding is an entitlement, meaning that every position that is under a hospital’s cap will be
paid as long as there is a resident or fellow in that position.
THCGME funding, on the other hand, is discretionary and it
made available through HRSA grants that require
Congressional appropriation every 5years or less. The reauthorization decision is often linked to other controversial
appropriation issues in Congress creating signicant uncertainty for training programs to plan for future residency
classes.
Medicaid represents the second largest funder of GME
after Medicare, accounting for 7.39 billion in 2022 [17].
Forty-three states, plus the District of Columbia, participate
in Medicaid GME. By complicated formulas discussed
below, federal dollars can be matched to state appropriations
to augment funding. States are not obligated to follow
Medicare GME rules in how or to whom funds are disbursed;
11 states have programs in which funds are directed to entities other than teaching hospitals such as medical schools
and community health centers. With this exibility, states are
able to use Medicaid GME funding to impact local workforce priorities.
In the sections below, the governmental programs that
fund GME will be discussed in more detail. For the Medicare
and THCGME sections, the rules will be described in the
context of starting a new training program. These are the
funding sources most commonly utilized by nascent Family
Medicine programs. Knowing the GME funding rules at the
inception of a program can help ensure that it will have the
maximum funding available for the coming years.
Many stakeholders through the years have expressed concern that the public investment in GME does not yield the
64
K. I. Voorhees et al.
dividends that the investment deserves; and that the workforce produced is not the one best suited to the needs of the
country. Medicare GME provides the largest government
contribution to GME, and the description of how it works—
and proposals for reform—represents the bulk of this
chapter.
Medicare GME Funding
Brief History ofMedicare GME Funding
The original legislation enacting the Medicare program in
1965 included provisions for payment to hospitals for the
services of medical interns and residents and was calculated
based on a hospital’s claimed GME costs. Medicare GME
was and is only paid to hospitals generally under Medicare
Part A (hospital care) and now also part C (Medicare
Advantage). The original support for GME included in the
1965 legislation referred to GME nancial support via
Medicare as a temporary situation until such time as the
country developed a more direct comprehensive approach to
funding GME.This has not yet occurred. So, we have been
left with an evolving set of rules that have attempted to provide GME funding largely via the Medicare program. Since
Medicare—and thus Medicare GME—is an “entitlement”
program, it is agnostic about the specialty training it funds
and does not evaluate funding in light of national workforce
needs. Modifying Medicare GME to better target or limit
funding has required specic legislation over the decades
since 1965.
The Social Security Amendments of 1983 (Public Law
98-21) had major effects on Medicare and other federal programs. In an attempt to curb rising health care costs, Medicare
shifted from cost-based reimbursement of hospitals to the
Inpatient Prospective Payment System (IPPS). The IPPS
pays hospitals based on the admitting diagnosis in a system
called Diagnostic Related Groups (DRGs). There are hundreds of DRGs that attempt to categorize every condition for
which a patient might be hospitalized. In this system, hospitals that are more efcient at managing the care of a patient
with a given DRG (e.g., pneumonia with a 3-day length of
stay) would do relatively better than ones who incurred more
costs for the same DRG (e.g., pneumonia with a 5-day hospital stay with more testing and more expensive medication).
Hospitals that participate in the Medicare DRG payment system are called Inpatient Prospective Payment System
Hospitals (IPPS Hospitals). The great majority of hospital
care in the USA is provided in IPPS hospitals. Unless otherwise noted we use the term “hospital” in this chapter to mean
IPPS hospital. There are also hospitals that aren’t IPPS hospitals including Veterans Administration (VA) hospitals,
military hospitals, Indian Health Service (HIS) hospitals,
Critical Access Hospitals (CAHs), and Rural Emergency
Hospitals (REHs). There are subtypes of IPPS hospitals that
are paid via the DRG system but have important differences
in how GME funding rules apply. These subtypes of IPPS
hospitals include Sole Community Hospitals (SCHs), Rural
Referral Centers (RRCs), and Medicare Dependent Hospitals
(MDHs) among others.
When the DRG payment system was developed two funding streams for GME support were instituted for IPPS hospitals: Direct Graduate Medical Education (DGME, sometimes
called DME) and Indirect Medical Education (IME). DME
represented the legacy of “cost-based” hospital reimbursement from the pre-PPS era and was intended to cover such
direct costs as resident salaries and benets, faculty compensation, medical liability insurance premiums, building space,
and other costs (Table10.2). The pre-1983 historical claimed
costs for residencies at each hospital were xed as a hospitalspecic Per Resident Amount (PRA) which varied widely
between hospitals and across the nation. Medicare paid their
share of each hospital’s direct costs based on the hospital’s
PRA multiplied by Medicare’s percent of hospital care.
Teaching hospitals successfully argued that DGME would
be insufcient to cover all the training costs because
physicians- in-training cause signicant cost increases in
patient care due to ordering additional diagnostic tests, using
more specialized services and technologies and requiring
longer time to interpret tests. IME was then instituted to
cover these “indirect costs” of more expensive patient care.
Using a complicated formula, IME adds a calculated percentage increase to every DRG payment that Medicare sends
to a hospital for all Medicare patients, including ones that are
not seen by residents or fellows. The remuneration from IME
proved quite favorable, and today approximately two-thirds
of the GME support paid to teaching hospitals is through the
IME revenue stream. Indeed, IME helps to cover the academic costs of a residency that are not covered by DGME
and make up for the fact that for many teaching hospitals,
there is no other payer that will cover direct GME costs
beyond Medicare’s share. More details on DME and IME
calculations are explained later in this chapter.
The next big step in the evolution of Medicare GME came
with the Balanced Budget Act (BBA) of 1997, the Balanced
Budget Renement Act (BBRA) of 1999, and the Benets
Improvement and Protection Act (BIPA) of 2000. These bills
passed in the era when there was a perception that there were
too many doctors and controlling health care costs meant
restricting the supply of new physicians though some exibility
was allowed for rural hospital GME training. The BBA capped
teaching hospital funding at the level of the number of residents
that a hospital was training at the end of 1996 [7]. Thereafter,
any expansion of resident or fellow training slots would typically need to be self-funded by the teaching hospital. Early on
there were important exceptions to the cap: GME naïve hospi-
10 Graduate Medical Education Funding
Table 10.2 Examples of direct and indirect graduate medical education costs that teaching sites may incur
Direct costs Indirect costs
Resident salaries and fringe benets
Faculty compensation
Payment for preceptors
Administrative staff compensation
Building space
GME ofce expenses
Infrastructure improvements (e.g., call rooms, library, lecture rooms, etc.)
Medical malpractice insurance premiums
Licensing and other professional fees
Accreditation fees
Resident recruitment costs
Faculty development
Program-funded conferences fees and travel costs
Subsidies for parking, housing, and meals
Education materials such as equipment, technology software, and
textbooks
Technology for faculty and residents
Other allocated hospital overhead
Adapted from “Table 10.2: Examples of Direct and Indirect Graduate Medical Education Costs that Teaching Sites May Incur” published in GAOReport to Congressional Requesters 18-240 “Physician Workforce: HHS Needs Better Information to Comprehensively Evaluate Graduate
Medical Education,” Mach 2018. www.gao.gov/assets/gao- 18- 240.pdf and from “Establishing a hospital’s Per Resident Amount: Be careful as the
result is permanent!” by Susan Banks and, Lori Mihalich-Levin published in “Dentons” April 7, 2016. https://www.dentons.com/en/insights/
newsletters/2016/april/6/gme- dentons/establishing- a- hospitals- per- resident- amount
Less efcient provision of services by residents in lieu of more
experienced clinicians
Additional diagnostic tests or procedures ordered by residents
Longer time for residents to interpret test results
Additional costs of resident supervision, especially during the
resident’s rst year of residency
Higher staff-to-patient ratios
Greater use of highly specialized or emerging technologies, such
as burn units or transplant units
Increased record keeping to maintain educational records for
residents
65
tals, rural hospitals starting new programs, and Rural Training
Tracks (RTTs). Legislation also provided a redistribution of
unused cap slots in 2006–2010. Additional legislation would be
required for any further slot redistribution.
As people tried to take advantage of these new program
funding avenues, a number of confounding rules emerged as
barriers. A few of these were addressed in the Consolidated
Appropriations Act that passed in late 2020 and implemented
in 2021 (CAA 2021).
CAA 2021 Section 126 provided 1000 new cap slots allocated over 5years via an annual application process for 200
slots per year. The application process involves meeting certain priorities that focus mainly on expanding training into
underserved areas [18]. Section 127 redened RTTs as Rural
Track Programs (RTPs) and removed the requirement for
separate accreditation from the home program. Section 127
also provided more exibility and funding opportunities for
RTPs and their associated rural hospitals. These are detailed
in the last paragraph in the section DGME (DME) and PRA
Setting discussing rolling averages, and the last sentence of
the section Rural Track Programs discussing opportunities
to increase the rural caps for these programs. Section 131
attempted to x an issue that developed in hospitals that had
very low PRAs and/or very low caps and provided some protection for GME-naïve hospitals to delay becoming teaching
hospitals until they trained >1.0 FTE residents. See the
“DGME (DME) and PRA Setting” section of this chapter for
details of how this works now.
Other legislation has passed that made less signicant
changes in Medicare GME rules. There have been many
unsuccessful attempts to craft and pass legislation that would
provide more comprehensive improvements in the Medicare
GME system or set up alternative funding mechanisms.
These are discussed at the end of this chapter.
DirectGME (DME) Paymentsand Per Resident
Amount (PRA) Setting
DGME is intended to pay Medicare’s share of the direct
costs of a GME program. The “direct” costs that DGME is
intended to cover are shown in Table10.2, and the equation
to derive the DGME payment is in Fig.10.1. The direct costs
in the tables are examples of expenses that can be paid and
claimed when a hospital is setting its PRA. As of 1983
Medicare ceased basing payments on actual residency program costs and shifted to a hospital-specic PRA, which was
initially set for each hospital using historical claims data.
Initial PRAs had wide variation from hospital to hospital.
Each year the baseline PRA is then adjusted for ination and
used to calculate the next year’s DGME payment. New
teaching hospitals that started making claims after 1997 had
their PRA set using a local/regional comparison PRA average. Once set, these new hospital-specic PRAs are also
adjusted for ination each year. There were a few years
where primary care PRAs were allowed to inate but nonprimary care PRAs were not, so there is a small current difference in primary care versus non-primary care PRAs for
those two different groups of GME trainees. The FY2018
national median PRA was $103,375 for primary care and
$101,830 for non-primary care. The average PRAs weighted
by FTEs were $116,198 for primary care and $112,190 for