As noted in a prior post, the Consolidated Appropriations Act, 2021 (CAA), enacted on December 27, 2020, included three provisions that impact graduate medical education (GME). Since enactment, the U.S. Centers for Medicare & Medicaid Services (CMS) proposed new rules to implement these changes through the Fiscal Year (FY) 2022 Inpatient Prospective Payment System Proposed Rule. These changes, if finalized, may have significant impacts on the future of the primary care physician workforce—particularly in rural and underserved areas.

Key Proposals Impacting GME

Pursuant to the CAA, CMS has proposed multiple regulations that would provide meaningful changes to the GME program, including:

  • Awarding 200 GME slots per fiscal year for five years beginning in FY 2023—totaling 1,000 new slots, with at least 10 percent of total positions going to hospitals in rural areas and hospitals that serve health professional shortage areas (HPSAs);
  • Promoting rural hospital GME funding opportunities by providing flexibility through a GME cap adjustment for hospitals with rural training track programs (RTTs); and
  • Allowing certain hospitals to “reset” their GME Per Resident Amount (PRA) or receive a full-time equivalent (FTE) cap adjustment.

Overall, these changes as proposed by CMS could provide meaningful improvements in addressing the current primary care physician shortage. CMS proposes to prioritize the distribution of FTE slots based on HPSA Score—a measure of the severity of a primary care or mental health provider shortage in a geographic area. This focus on HPSAs is meaningful, as nearly 60 percent of the 7,200 HPSA regions are rural.1

In addition, the flexibility for RTTs and for certain hospitals to establish new programs or reset their PRAs would likely support a greater inflow of residents in rural and underserved areas. Evidence suggests that exposing residents to rural health care leads to more young professionals practicing in rural areas.2

While all of these changes are likely to lead to increased support of the primary care physician workforce, more must be done to address the significant shortage we face of between 21,400 and 55,200 by 2033.3

Prioritizing Primary Care

The proposed policy changes will undoubtedly grow the physician workforce but should be more targeted to support primary care physicians. The benefit of increased access to primary care services is well-documented and unquestioned, and primary care physicians in rural and underserved areas often serve as the primary source of care an individual will need in his or her lifetime, including mental health services. The mental health crisis that existed long before—and has worsened during—the COVID-19 pandemic is an important area that must be addressed. While there certainly is a shortage of mental health professionals, primary care physicians have provided and continue to provide these services to patients across the country.

On July 23, ACOFP submitted comments in response to the proposed changes urging CMS to specifically prioritize primary care geographic HPSAs and to require that the additional GME slots go toward primary care residents. This would help improve access to primary care services in areas where they are most needed. In addition, ACOFP continues to advocate for additional funding and support for primary care physicians to ensure continued patient access to family medicine services.

The final rule is expected to be released by November 1. ACOFP will review the final rule for any additional changes to these GME proposals and continue to advance policies that grow the primary care physician workforce.

  1. Kayt Sukel. Dealing with the shortage of rural physicians. Medical Economics Journal. September 10, 2019 edition. Volume 96, issue 17. Accessible here:
  2. Ian MacQueen, Et. Al., Recruiting Rural Healthcare Providers Today: A Systematic Review of Training Program Success and Determinants of Geographic Choices. November 2017. Journal of General Internal Medicine. Accessible here:
  3. Stuart Heiser. “New AAMC Report Confirms Growing Physician Shortage.” Association of American Medical Colleges. June 26, 2020. Available at

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