American Osteopathic Association

Advancing the distinctive philosophy and practice of osteopathic medicine

Rural Training Track Residency Programs

What is a Rural Training Track (RTT) program?

A rural training track (RTT) residency is a training program designed to prepare residents to practice rural primary care medicine. The most prevalent training model is a “1-2” RTT residency. In these programs the first year of training occurs in an urban setting, with the second and third years in a rural hospital(s) and/or rural nonhospital setting(s). Currently, most RTT programs are family medicine residencies. At present, there are 23 active 1-2 RTTs located across the nation, with more than a dozen in development.

Under the Balanced Budget Refinement Act of 1999 (BBRA), to qualify for Medicare graduate medical education (GME) payment incentives and an expansion in their GME caps, RTT programs must be separately accredited yet integrated with their larger, usually urban, parent residency programs and sponsoring institutions. All current RTTs have four or fewer residents per year and at least 20 months of shared training experiences.

Why are RTT programs important?

Rural areas suffer from significant shortages of primary care physicians. Of the nation’s 2,050 rural counties, 1,562 (77%) include primary care health professional shortage areas (HPSAs). Many of the physicians currently in practice in these areas are nearing retirement.

Research suggests that residents who train in rural areas and whose training emphasizes services necessary for rural practice are more likely to practice in rural areas. According to current data, 1-2 RTT programs have a success rate of 75% in placing physicians in rural practice, many of them in the same state where their training occurred. They also are more likely to practice in a HPSA, a community health center or a critical access hospital than residents in traditional programs.

RTTs are consistent with national efforts to create new models of physician training, including those that emphasize primary care, training in rural and underserved areas and in community-based ambulatory settings.

How do RTT programs differ from other programs?

At this time, the Accreditation Council on Graduate Medical Education (ACGME) is the only body that “separately accredits” RTT programs. In these ACGME programs, RTTs are separately accredited under existing specialty standards, though they are granted waivers from the minimum requirement of four residents per year for three years of training. Requirements for patient encounters are the same as for other programs in the same specialty. The curriculum may have many common months with the larger, urban parent program so long as the RTT residents have a minimum of 20 months of shared training experiences.

What Medicare incentives are available to hospitals that establish RTT programs?

The BBRA established certain GME payment incentives for RTTs and similar training programs to encourage training in rural areas. Inherent in this policy is Congress’ recognition that, for economic and/or Medicare payment reasons, it may be difficult for rural hospitals to start and maintain their own GME programs.

Under the BBRA, an urban hospital that has or establishes a separately accredited 1-2 RTT program or an accredited training program with an integrated rural track in a rural area may be eligible to increase its full-time equivalent (FTE) resident cap by its “rural track FTE limitation.” Although the term “integrated rural track” is not defined by statute, the Centers for Medicare and Medicaid Services (CMS) defines a rural track or integrated rural track as an approved medical residency training program established by an urban hospital in which residents train for a portion of the program at the urban hospital and then rotate to a rural hospital(s) or a rural nonhospital site(s).

Medicare regulations provide payment incentives to encourage urban hospitals to start RTT programs. If the residents spend more than one-half of their time training in rural areas, in hospital or nonhospital settings, the urban hospital may be eligible to count the residents for the time they spend training in the urban institution, even if it already is at its FTE resident cap. The rural hospital may be eligible to count the residents for the time they spend in the rural hospital.

Conversely, if the residents spend one-half or less of their training time in a rural hospital, the urban hospital will not be allowed to include the rural track residents in its cap. If the program is a new program, the rural hospital may be eligible to count the residents for the time they train the residents. If the residents spend one-half or less of their training time in a rural nonhospital setting(s), the urban hospital may count the residents if it pays the residents’ salaries and benefits for the time they spend training there.

What resources are available for those operating or starting an RTT program?

The Rural Training Track (RTT) Technical Assistance Program (Assistance Program) was established as part of the federal Improving Rural Health Care Initiative. A three-year demonstration program supported by the Health Resources and Services Administration’s Office of Rural Health Policy, the Assistance Program is a consortium of individuals and programs committed to sustaining RTT residency programs as a national strategy for training physicians for rural practice. Its objectives include improving fill rates of RTT programs, increasing the sustainability of existing RTT programs and helping new RTT programs get started. The Assistance Program facilitates information sharing about success factors for existing RTT programs, makes available technical assistance to support RTT development and expansion and helps participants understand the challenges of RTT programs. These challenges include Medicare GME financing issues, resident and faculty recruitment and isolation or lack of support from partner urban programs or sponsoring institutions.

Information on the Rural Training Track Technical Assistance Program can be found on the Program’s website. The website also includes links to a sample curriculum for a family medicine RTT program, an RTT budget template, an RTT Program Toolbox, an opportunity to request technical assistance or further information, a map of existing RTT programs, a list of key articles and a policy brief entitled “Training Physicians for Rural Practice: Capitalizing on Local Expertise to Strengthen Rural Primary Care.”