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Tuesday Apr 26, 2016

Teaching Health Centers Key to Solving FP Shortage

March 18 was Match Day, which is when most fourth-year medical students receive confirmation of where they will conduct and hopefully complete their residency training.  

Overall, the 2016 Match continued an encouraging trend for family medicine and primary care. A record 3,105 allopathic medical students chose family medicine residency positions in the National Resident Matching Program. In addition, 2016 marked the seventh consecutive year that the number of medical students choosing careers in family medicine increased.  

Meanwhile, the American Osteopathic Association Intern/Resident Registration Program also produced encouraging results for family medicine with nearly one-fourth of participants choosing a family medicine position. The number of osteopathic medical students choosing careers in family medicine has nearly doubled since 2011.

The emphasis and priority placed on primary care by policy-makers and payers is influencing career choices of medical students. Primary care residencies had a fill rate of 96.1 percent, and family medicine increased its fill rate to 95.2 percent. This is a fairly remarkable number when you consider that less than a decade ago the fill rate for family medicine had dipped below 85 percent.

Overall, primary care positions accounted for 14.5 percent of all residency positions offered (4,053 of 27,860). With a primary care shortage knocking at the door, it is clear that more needs to be done to increase the pipeline for primary care specialties, which brings me to one of one of my all-time favorite policy issues -- teaching health centers (THCs).

The concept of teaching health centers is really quite simple. Instead of relying on the legacy graduate medical education system, which is focused on the academic medical center and other hospital settings, THCs use community-based settings such as federally qualified health centers (FQHCs), rural health clinics (RHCs), tribal clinics, and other settings to train residents. 

Most primary care services are provided in community-based settings, so this concept aligns quite nicely with the education and training model for family medicine residency programs. Additionally, unlike the legacy GME programs, the money for training flows directly to the practice and training site versus going directly into the overall budget of an academic health center or hospital.

Teaching health centers were established in 2010 under the Patient Protection and Affordable Care Act (ACA) and reauthorized in 2015 as part of the Medicare Access and CHIP Reauthorization Act (MACRA). Today, there are 690 residents being trained in 59 teaching health centers in 27 states and the District of Columbia. Of the 59 programs, an overwhelming majority of the residency positions are in family medicine. Yes, there are a few internal medicine, pediatrics, and obstetrics/gynecology positions, but the clear recipient of the majority of these positions is family medicine. And, these programs produce -- big time.

Besides producing large percentages of family physicians, the graduates of these programs have a strong commitment to providing care to vulnerable populations. The AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care recently published a one-pager(www.graham-center.org) that shows a stark difference between graduates of teaching health centers and those who completed their training in a legacy GME program. Specifically, the Graham Center found that 33 percent of THC graduates “planned to practice in a setting primarily associated with underserved populations (e.g. community health centers, rural health clinics, Indian Health Service, US Public Health Service).” By comparison, only 18 percent of graduates from non-THC programs planned to practice in underserved areas.

One of the primary reasons that I love THCs is this -- they are better positioned to address the geographic distribution problems that currently exist in the physician workforce. According to the Agency for Healthcare Research and Quality (AHRQ), 91 percent of all physicians practice in urban areas. This makes perfect sense, if you train in an academic health center or large hospital; it is highly unlikely -- if not improbable -- that you will migrate from Manhattan, New York, to Manhattan, Kansas. Training future physicians near desired practice locations is nothing new or novel. The de-centralization of GME has been a desired policy objective of academic leaders for decades. 

There is compelling data to support the de-centralization of physician training, especially in primary care. According to a 2015 Family Medicine study(www.stfm.org) entitled “Family Medicine Graduate Proximity to Their Site of Training,” 54.8 percent of family physicians practice within 100 miles of where they train, and 46 percent practice within 50 miles of their training location. When you look at those who have completed their training since 2000, the numbers are even more significant with 62.5 percent choosing practice locations within 100 miles of their training site.

The challenge historically was the lack of a program that allowed GME training to take place away from the hospital setting – until THCs. I'm not advocating for the elimination of all hospital-based GME because we need primary care programs in all settings. What I am an advocate for are policies that work, are scalable, and most importantly, achievable in our current political environment.

Upon his capture in 1934, FBI agents asked legendary bank robber Willie Sutton why he robbed banks. Sutton, who believed the question to be rhetorical, replied, dryly, "Because that's where the money is.(works.bepress.com)"

Why do I support THCs so strongly?  Because that’s where the opportunities are. There are more than 9,000 community health centers in the country serving more than 24 million patients annually. Fifty-seven have training programs. THCs are the hidden gem of workforce policy when they should be the Hope Diamond.  The AAFP has placed a priority on the continuation and appropriate funding of THCs. During the recent Family Medicine Congressional Conference (FMCC), participants advocated on behalf of THCs with their mnembers of Congress.  In addition to this work, the AAFP continues to pursue policies that extend the THC program and create a stable funding stream to ensure the continuation of this successful program.

Wonk Hard

The Partnership to Fight Chronic Disease has released a new report, “What is the Impact of Chronic Disease on America?(www.fightchronicdisease.org)” Two key takeaways from the report:

  • In 2015, 191 million people in America had at least 1 chronic disease, 75 million had 2 or more chronic diseases.
  • Chronic disease could cost the United States $2 trillion in medical costs and an extra $794 billion annually in lost employee productivity per year between now and 2030. The organization also has state-by-state impact analysis(www.fightchronicdisease.org) that you can review.

Posted at 07:00AM Apr 26, 2016 by Shawn Martin

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Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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