Why GAO did this study. An adequate, well-trained health care provider workforce is essential to ensure Americans have access to quality health care services. However, studies have shown the United States faces a shortage of physicians, making it increasingly difficult for people to access needed health care. Experts have identified ways to address this shortage, such as through strategies that increase the number of other types of non-physician providers, including NPs and PAs. For example, members of Congress and others have questioned whether expanding the scope of the Medicare GME program to include NPs and PAs could help mitigate the effects of a physician shortage. A Senate Committee on Appropriations report included a provision for GAO to examine the potential of making GME payments under the Medicare program for NPs and PAs. This report describes: (1) stakeholder views on the potential benefits and challenges of expanding the Medicare GME program to include NP and PA graduate training; and (2) available information on the estimated costs of NP and PA graduate training. GAO reviewed literature and interviewed officials from nine professional associations with knowledge of NP, PA, and physician graduate training; and agency officials. Based on these interviews, GAO identified sources of information on estimated costs and reviewed those sources. What GAO found. The federal government funds many education programs for health care providers, but the vast majority of this funding—more than $10.3 billion in 2015— supports physician residency training through the Department of Health and Human Services’s (HHS) Medicare graduate medical education (GME) program. This program does not fund graduate training for nurse practitioners (NP) and physician assistants (PA) who deliver many of the same services as physicians, such as diagnosing patients and performing certain procedures. Instead, a smaller portion of federal funding—approximately $136 million in fiscal year 2019—is available to train them. Stakeholders GAO interviewed said that one benefit of expanding Medicare GME is that Medicare GME funding would provide more stable funding for NP and PA training, compared to existing programs. Stakeholders said one challenge of such an expansion is that clinical training requirements for NPs and PAs are different than physicians; therefore, any change to Medicare GME to include NPs and PAs would need to consider how to allocate GME funding in light of these differences. GAO identified two estimates of costs for completing an NP or PA graduate school program; while the estimates provide some information about these costs, they are limited and incomplete. The Centers for Medicare & Medicaid Services’ (CMS) evaluation of its Graduate Nurse Education Demonstration estimated the total costs over the 2012-2018 demonstration period to be about $47,000 per NP student. While clinical and classroom training are required for NP students, CMS’s demonstration only provided funding for clinical training, as specified by statute, and the estimate is not generalizable beyond the participating schools. The Physician Assistant Education Association estimated the total costs to be about $45,000 per PA student. The estimate is based on self-reported data from a 2018 survey of member PA programs and excludes in-kind contributions for clinical training. GAO received technical comments on this report from HHS and the professional associations interviewed and incorporated them as appropriate.
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