DocFlows 2.0: Exploring the Interstate Migration of Residents-in-Training and Practicing Physicians - Sheps Center (2024)

Investigators: Erin Fraher, PhD, MPP, Evan Galloway, MPS, Brianna Lombardi, PhD, MSW

DocFlows 2.0: Exploring the Interstate Migration of Residents-in-Training and Practicing Physicians - Sheps Center (1)Background. Federal efforts to reform Medicare-funded graduate medical education (GME) have not yielded any significant changes, spurring states to explore alternative ways to produce the physician workforce they need to meet population health needs. In our work on Medicaid GME,1 state stakeholders consistently voiced the need for better data to track their workforce needs and outcomes. States were specifically interested in data to help them understand the degree to which they are retaining residents trained in-state, as well as retaining their actively practicing physician workforce. In 2019, we released the DocFlows web appwhich met that need by allowing users to query, download and share maps/graphs of interstate moves by residents and actively practicing physicians in 35 specialties between 2009 and 2015. Between 2017-2022, DocFlows was accessed by 2,563 unique visitors. Although it has been an important resource for decision and policy makers, significant changes have occurred since DocFlows was released in 2019.

Domestic migration patterns (the movement of the population within the United States) changed during the pandemic and continue to change. There has been a large increase in the number of Americans moving south, especially to Texas and Florida, leaving urbanized states of California, New York and Illinois.2 These population shifts have exacerbated the existing misalignment between where the population lives and where Medicare GME funding flows. Medicare GME investments are concentrated in the northeast and Midwest and lower in the south and west.3

Another important development since we released DocFlows in 2019 is that new state and federal funding sources have emerged for GME program development that have likely influenced the number of physicians training in different states. States are increasingly turning to state appropriations and Medicaid funds to develop new residencies. In 2022, 44 states leveraged Medicaid funding for GME, representing an increase of 96% from $3.78 billion in 2009 to $7.39 billion in 2022.4 At the federal level, the Health Resources and Services Administration has invested significant funding in the growth of new residency training programs. Since 2019, HRSA has awarded $64M through the Rural Residency Planning and Development Program to 84 organizations across 38 states and 1 territory in six specialties (family medicine, internal medicine, preventive medicine, psychiatry, general surgery, obstetrics and gynecology).5 Since 2021, HRSA has awarded another $46.27M to 92 organizations across 36 states in eight medical and dental specialties (family medicine, internal medicine, pediatrics, obstetrics and gynecology, psychiatry, general dentistry, pediatric dentistry, geriatrics) through the Teaching Health Center Planning and Development Program.6

Aims. This study will update and replicate the analysis conducted for DocFlows version 1. We will identify moves that newly trained physicians make after graduating residency and actively practicing physicians made between 2015-2023 (or the latest AMA Masterfile data available) in 35 specialties. A data visualization will be developed that allows users to visualize, for both residents and actively practicing physicians, five measures of interstate migration:

  1. National trade balance—the number of residents/physicians a state imported from all other states minus number that it exported to all other states between 2015-2023
  2. State trade balance—the number of residents/physicians a state imported from each other state minus number that it exported to each other state between 2015-2023
  3. Retention—the number and percent of physicians and residents retained between 2015-2023 in each state
  4. Import—the percent of a state’s workforce in 2023 that was trained in other state (resident analysis) or moved from another state (actively practicing physician analysis)
  5. Export—the percent of residents and actively practicing physicians that left the state between 2015-2023

We will also assess if physician migration patterns changed between 2009-2015 (DocFlows version 1) and 2015-2023 (DocFlows version 2) by state and specialty and examine how the net change in physicians in a state compares to the net change in population in that state.

Data and Methods. We will use the 2015 and 2023 American Medical Association Masterfiles. We will first clean and merge the different versions of the data. Physicians who were in active practice in both years will be included in the analysis. Active refers to physicians in direct patient care, administration, or research. Physicians who are retired, semi-retired, temporarily not in practice, not active for other reasons, do not have information identifying the state they work in, or were age 80 or older in 2023 will be excluded. Residents-in-training in 2015 who were still in training in 2023 or who were not in active practice in 2023 will be excluded from the analysis. For the import and export calculations, we will aggregate physicians to larger specialty groups as in Docflows 1.0. Data will be reported separately for physicians and residents.

  1. Fraher EP, Rains JA, Bacon TJ, Spero J, Hawes E. Lessons learned from state-based efforts to leverage medicaid funds for graduate medical education. Acad Med. Published online October 16, 2023:10.1097/ACM.0000000000005678. doi:10.1097/ACM.0000000000005678
  2. Frey WH. New census estimates show a tepid rise in U.S. population growth, buoyed by immigration. Brookings Institution. January 4, 2023. Accessed August 8, 2024. https://www.brookings.edu/articles/new-census-estimates-show-a-tepid-rise-in-u-s-population-growth-buoyed-by-immigration/
  3. Mullan F, Chen C, Steinmetz E. The geography of graduate medical education: Imbalances signal need for new distribution policies. Health Aff (Millwood). 2013;32(11):1914-1921. doi:10.1377/hlthaff.2013.0545
  4. Henderson TH. Medicaid graduate medical education payments: Results from the 2022 50-state survey. Published online 2023. Accessed August 13, 2024. https://store.aamc.org/downloadable/download/sample/sample_id/590/
  5. Rural Residency Planning and Development (RRPD) Program. Health Resources and Services Administration. June 2024. Accessed August 13, 2024. https://www.hrsa.gov/rural-health/grants/rural-health-research-policy/rrpd
  6. Teaching Health Center Graduate Medical Education (THCGME): Expanding the primary care workforce. Health Resources and Services Administration: Bureau of Health Workforce. July 2024. Accessed August 13, 2024. https://bhw.hrsa.gov/funding/apply-grant/teaching-health-center-graduate-medical-education
DocFlows 2.0: Exploring the Interstate Migration of Residents-in-Training and Practicing Physicians - Sheps Center (2024)

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