The geography of graduate medical education: imbalances signal need for new distribution policies.

Graduate medical education (GME) determines the overall number, specialization mix, and geographic distribution of the US physician workforce. Medicare GME payments-which represent the largest single public investment in health workforce development-are allocated based on an inflexible system whose rationale, effectiveness, and balance are increasingly being scrutinized. We analyzed Medicare cost reports from teaching hospitals and found large state-level differences in the number of Medicare-sponsored residents per 100,000 population (1.63 in Montana versus 77.13 in New York), total Medicare GME payments ($1.64 million in Wyoming versus $2 billion in New York), payments per person ($1.94 in Montana versus $103.63 in New York), and average payments per resident ($63,811 in Louisiana versus $155,135 in Connecticut). Ways to address these imbalances include revising Medicare's GME funding formulas and protecting those states that receive less Medicare GME support in case funding is decreased and making them a priority if it is increased. The GME system badly needs a coordinating body to deliberate and make policy about public investments in graduate medical education.