Although graduate medical education (GME) funded by Medicare typically is paid to hospitals, which then provide funds to residency programs for an array of specialties, that model has not always benefited family medicine.
Ted Epperly, M.D., speaks to a resident at the Family Medicine Residency of Idaho, Boise. Epperly was one of five residency directors who recently talked to AAFP News Now about teaching health centers and the future of family medicine training.
In response to a push from primary care organizations, including the AAFP, HHS, as directed by the Patient Protection and Affordable Care Act, recently implemented a new type of GME funding: the Teaching Health Center Graduate Medical Education (THCGME) program, a five-year, $230 million plan that provides funds directly to community-based teaching sites with a goal of producing more primary care physicians and dentists.
In July, HHS awarded $12 million to 32 THCs(www.hhs.gov) for the 2013-14 academic year. The funding will support more than 300 residents in a program that has expanded to 21 states.
AAFP News Now recently sat down with several directors of family medicine programs that have benefited from the THCGME funding. Participants in the roundtable were
- Richard English, M.D., program director of the Family Medicine Regional Network of the Wright Center for Primary Care, Kingston, Pa.;
- Ted Epperly, M.D., program director and CEO of the Family Medicine Residency of Idaho in Boise and a past-President of the AAFP;
- Joseph Gravel, M.D., chief medical officer and residency program director at Greater Lawrence Family Health Center in Lawrence, Mass.;
- Geoffrey Jones, M.D., program director at the Hendersonville Family Medicine Residency in Hendersonville, N.C.; and
- Francesco Leanza, M.D., residency director of the Harlem Residency in Family Medicine at the Institute for Family Health in New York.
Q: Some of our readers might not know exactly what a teaching health center is. How would you define it, and how is it different from a traditional residency program?
Joseph Gravel, M.D.
A: Joseph Gravel -- The major difference is the sponsoring institution is not necessarily a community hospital or tertiary medical center, but rather a community health center. The teaching health center program also has consortiums in the legislation, so it can be a combination of a community health center and another entity, which can be a hospital. But it's not the traditional model whereby the residency is a wholly owned subsidiary of the hospital.
The primary reason for the program is the need to get primary care physicians into traditionally underserved areas, whether urban or rural. There's a lot of literature that show the chances of a family physician ending up in an underserved community increases by three to four times if they train in a community health center versus a traditional hospital-based program.
Q: Because of accreditation requirements, family medicine residents are going to learn a lot of the same things, regardless of where they learn. But is the scope of practice going to be any different for a resident trained in a THC compared to a resident in a program in which a hospital receives federal payments for GME?
Geoffrey Jones, M.D.
A: Geoffrey Jones -- I think it depends on what the community health center is doing. Our community health center docs were not doing any inpatient or OB deliveries until we merged with them. Now they've hired faculty to do all those things, partly because they are going to have residents who depend on them. You could argue that having a residency is going to increase the scope of practice of the community health center as opposed to the other way around. Of course, we have a lot to gain from them in terms of caring for the underserved and maximizing resources.
Joseph Gravel -- We strive to train a comprehensive family physician because many of our graduates do end up in low-resource environments without ready access to subspecialists. Many of them end up in Indian Health Service sites and rural areas, even though we're in an urban community. We're always thinking in terms of making them as self-sufficient as we can and not make them dependent on subspecialists.
Ted Epperly, M.D.
Ted Epperly -- We've maintained full, broad scope -- a lot of OB, inpatient, pediatrics, ICU, etc. -- because we also train for rural. I think we are different from the typical family medicine residency program because we are really heavy with mental health training, a lot of drug and substance abuse training, and a lot of chronic pain training. We have a lot of integration of primary care and behavioral health and mental health.
Q: You mentioned integration. Is there more focus on team-based care in this model than in a typical residency program?
A: Joseph Gravel -- It's hard to make that comparison. I do think the community health center model greatly facilitates interdisciplinary care because we have mental health services, and we also have a vigorous community service department and other services in our health center. Non-community health center-based programs might not have access under one roof like that. We have a major focus on community health and population management.
Ted Epperly -- We're an NCQA (National Committee for Quality Assurance) Level 3 patient-centered medical home (PCMH). I think a lot of the THCs are on the cutting edge of pushing forward with patient-centered medical home activities. When you talk about focus on team-based care, that is the model of the patient-centered medical home. We offer interdisciplinary training with multiple types of individuals, including other types of physicians. There could be psychiatry residents, social workers, psychology, occupational therapy, physical therapy, dental hygienist, etc., in all of our training facilities.
Richard English, M.D.
Richard English -- We're just getting our feet wet here. Just in the last six to eight months, we have moved from our for-profit sponsor, a big health care system, to back under the Wright Center. We have yet to see a lot of the benefits. But in terms of looking at what has been done so far at other parts of the Wright Center, they've invested. The internal medicine residency is a (NCQA) Level 3 PCMH. We're just Level 1. All their clinics are Level 3 homes, and the team-based care is a major part of what's going on. They've also been able to invest in care coordinators, which I think for Level 3 you really need. That was something that was not going to happen in the model we had been under.
Q: Many of the teaching health centers are in underserved areas. Are residents from these programs better positioned to practice culturally effective health care?
Francesco Leanza, M.D.
A: Francesco Leanza -- Cultural competence is an essential part of the fabric of family medicine and of federally qualified health centers (FQHCs). In our population, we have a lot of patients with Medicare or Medicaid and a high percentage of people who are medically underserved, underrepresented minorities, as well as those with limited English proficiency, mental health issues and/or chemical dependency. We've been able to focus teaching on the needs of population.
Ted Epperly -- I would say, absolutely, we’re all over culturally competent and effective care because of the nature of our population. Boise, Idaho, is a refugee relocation center for the U.S. State Department, so we have 43 languages spoken in our clinic. We had a project recently where each one of our second-year residents took one of the major populations and did an in-depth report for the rest of the program on culturally relevant issues to that population -- their languages and customs. It was a marvelous experience for all of us to learn more about the people we're serving.
Academy, Others Offer HRSA Insights on Teaching Health Centers
The Teaching Health Center Graduate Medical Education program was created by the Patient Protection and Affordable Care Act with the intent of increasing the nation's supply of primary care doctors who are prepared to practice in community settings, especially those with underserved populations. Now two years into the program, the Health Resources and Services Administration (HRSA) is evaluating how well teaching health centers (THCs) are meeting those goals.
The AAFP, along with the organizations that make up the Council of Academic Family Medicine -- the Society of Teachers of Family Medicine, Association of Departments of Family Medicine, Association of Family Medicine Residency Directors and North American Primary Care Research Group -- recently provided comments to two related items HRSA posted in the Federal Register.
On Aug. 8, the family medicine organizations submitted a letter voicing support for THCs in general and specifically applauding HRSA's plan to work with researchers at George Washington University to evaluate the "training, administrative and organizational structures; clinical service; challenges; innovations; costs associated with training; and outcomes of teaching health centers." The letter urged HRSA to evaluate the program, which is funded through 2015, on an annual basis.
"The evaluation of this program is critical to understanding the significance of the teaching health center model," the letter said. "This feedback will be useful for a wide range of stakeholders and funders. We believe HRSA will need several years of data to completely understand the benefits of the program."
In a letter dated Aug. 29, the same five organizations voiced support for HRSA's intention to evaluate a chart the agency uses to determine the number of residents in each THC, the programs' growth and plans for expansion. The letter, however, urged HRSA to modify the chart to accommodate five-year residency programs and to track information on residents leaving programs to determine if they actually go on to practice primary care.
Geoffrey Jones -- We partner with our FQHC, which is called Blue Ridge. It's the oldest migrant health center in the country. We have 50 percent Latino population there. Their outreach, compared to what we were able to do in the residency, is phenomenal. Now our residents are going out into the migrant camps and doing health screenings. That was one of our resident projects. The mandate that migrant health centers and other community types of health centers have to provide opens a new opportunity for us that my hospital-owned practice -- until we became a FQHC -- didn’t prioritize. Now it's an inherent part of who we are. I think the residents live that and breathe that, see the community activity going on and buy into that.
Q: Since teaching health centers are funded directly -- rather than having money funneled through a hospital system -- how does this affect your relationship with the hospitals with which you still work?
A: Ted Epperly -- In my community it isn't a problem at all. They're happy for us, and the reason they are is that THCGME funding means they pay us less. We were getting Medicare pass-through money, and they were keeping an amount of that. They were happy that they didn't have to continue to escalate their payments to us. I told them we would pass the savings on to them, meaning they wouldn't have to continue to pay us.
But when this money runs dry -- if it does in 2015 -- they are going to have to make us whole again. To their credit, they agreed to do that. What this has done in my community is made us more of an independent partner and less of a dependent stepchild. In many residency programs, finances are so limited, you can't really grow into your own being. It's been a really good thing to help us get to the next level of our evolution.
Richard English -- We changed our sponsorship from a for-profit health care system, which is in the business of running hospitals and had divested itself from all the education that it had when it took over the system. I think they're happy that's been done. Being the good educator, I thought I could just go there, give them a PowerPoint, they would see my point and say, 'Hey, that's great, Rick,' and give me some money. But that didn't happen.
What's also interesting here in our community is the graduate medical education is a separate corporation. We have the new medical school -- the Commonwealth Medical School -- but rather than being under the medical school, the GME arm, which is the Wright Center, is independent and is financially independent. That raises eyebrows when we start talking to the for-profit folks because we're not walking around with our hands out. It's changing the relationship. From our side of it, I don't have to explain why something like going to Society of Teachers of Family Medicine conferences is a good idea. It's much better that way. It's changed the dynamic between hospital systems and GME. Graduate medical education grew up a little bit.
Geoffrey Jones -- It depends on whether you are starting a new program or expanding an existing one. We are an expanded program, so our teaching health center money covers additional spots, but we're still heavily related to the hospital, which owned my practice until they ceded control to the FQHC. We're still very engaged.
Q: As was mentioned, federal funding for teaching health centers is scheduled to stop in 2015. What happens then?
A: Francesco Leanza -- One has to believe that a program that has demonstrated the success that the THCGME program has shown through its very competitive recruitment of some of the best students in the country -- and the focus on producing the physicians our country needs the most -- that a program like that will be sustained through bipartisan support in Congress. Should it not be continued, our Harlem residency program will close because this is its only source of funding. And our affiliated rural training program in upstate New York would lose 12 of its 30 residents.
Although we all would like to see reform in Medicare’s mainstream funding of GME to focus on primary care, that has proven to be politically impossible to date. The THCGME program solves three problems at once: training more physicians, getting more physicians into primary care, and focusing on the training of physicians for rural and urban underserved areas.
Richard English -- We would shrink back to the CMS money. Right now, I have 17 in my first-year class -- up from seven -- spread out at different centers. We're really looking this year at how many we're going to recruit. We'd love to keep it at this size, but if that funding doesn't happen, we would drop back down to seven per class.
Geoffrey Jones -- Before the expansion, I had three per year, and now I have four. We have a ramp-down clause, so we would phase that additional spot out and go back to nine total residents instead of 12, which would make life difficult.
Ted Epperly -- We're at 16 residents per class, so 48 total. We have a core program in Boise and two rural training tracks. We have two per class in the three-program system -- six residents -- funded by the THCGME program. We've tried to work out an issue with the hospital, as I mentioned. My hope is the hospital would continue the funding so we won't have to cut back. If they default on that commitment, then we would have to cut our program size. That would be sad because Idaho ranks last in the United States in the number of primary care physicians per capita, and we're trying to help the state with a workforce issue.
Q: What have you learned so far about training physicians in this kind of system, and would you do it all over again? Has it been worth it?
A: Ted Epperly -- We're not going to change anything in medical education if we don’t change the model. This is exactly what we've needed. I'd do it again in a heartbeat, and I hope we can continue it.
Geoffrey Jones -- It's too soon after starting ours to know for sure how this will turn out. I think the residents are having a great experience. I think they really like the patient population and the culture of a community health center, but we're three months into our transition. It's changed so much of what we do and how we do it. Change is hard, but I'm hopeful it will work out.
Q: We've talked a lot about why this model is good for the residency. But if I'm a medical student looking at different options in the National Resident Matching Program, why would I want to come to your program instead of a traditional program? What is the difference to the resident?
A: Geoffrey Jones -- What we've found this year in interviewing, as we were starting our association with our community health center, is that community health centers are a big draw for any residency that has an affiliation, whether you are a teaching health center or not. We can offer them opportunities to care for the underserved and to really practice the kind of medicine that led them to choose family medicine in the first place.
Ted Epperly -- We have resident applicants from all over the country looking at our program for a multitude of reasons, one of which is because of the capability to treat the underserved. They want to be part of the solution to the U.S. health care miasma, and they see community health centers and teaching health centers as a model for that.
Q: Any final thoughts?
A: Joseph Gravel -- We had to move a residency eight years ago because money was being syphoned off for things like cafeterias. There is virtually no accountability for tax money that is sent to hospitals. (The THCGME program) is a clear way to make the system more accountable for what it is supposed to be producing.