Janessa Perez-Motlis, M.D., (left) and Anna Tenorio, M.D., are third-year family medicine residents at the University of Texas Health Science Center at San Antonio, which is offering advanced primary care and expanding the number of family medicine residencies through Medicaid waivers.
One medical school in Texas was able to fund advanced primary care initiatives and increase the number of family medicine residency positions without waiting for policy changes in Congress or the state legislature.
Instead of relying on increased federal funding for graduate medical education, which has been capped since 1997, or state expansion of Medicaid, which Texas rejected, the University of Texas Health Science Center at San Antonio (UTHSCSA) is using Medicaid waivers to fund both endeavors.
Part of the Social Security Act, the 1115 Medicaid waiver program(www.medicaid.gov) supports innovative approaches to expanding access to care for low-income patients. It can be used to expand Medicaid eligibility for individuals, as well as to fund services that Medicaid typically does not cover and new service delivery systems that improve care, increase efficiency and reduce costs. UTHSCSA obtained three waivers to hire health care professionals for population health and increase the number of family medicine residents from 13 to 15 annually, a change that is expected to be approved by summer 2016.
- A medical school in San Antonio obtained three Medicaid waivers to hire health care professionals for population health and expand family medicine residency slots.
- Part of the Social Security Act, the 1115 Medicaid waiver offers funding to support innovative approaches to expanding access to care for low-income patients.
- Expansion of family medicine residency slots inside university health centers is limited given the emphasis on surgical and other procedure-based specialties.
The health center used one waiver to hire two nurse care managers -- one dedicated entirely to patients with diabetes -- as well as three medical assistants for population health management and a health coach. Another waiver helped the health center hire additional faculty and pay the salaries of residents in the family medicine program. A third waiver covers the recruitment of 13 community health workers who will address residency clinic patient needs such as home visits, community resources, medication, transportation and language services.
"When you are transforming the residency program, it is about more than just increasing the number of residents," said Carlos Jaén, M.D., Ph.D., professor and chair of family and community medicine at UTHSCSA. "You are getting more resources to practice community health or hiring RN care managers who monitor ER visits and hospital discharges to optimize transitions of care."
Funding from the waivers will last five years, gradually rising from $1 million to $1.7 million, and Jaén hopes that with additional funding from local partners, the health center can extend the initiatives to seven years.
Jaén said the waivers enable the medical school to accelerate its transition to a comprehensive care model. The next step is persuading insurers to increase payment for greater coordination.
"Now that we have something in place, we can have a discussion with payers to demonstrate that we need to find ways to get paid differently," he said. "When you are making the transition, it's difficult to have a dialogue with insurers if you don't have anything to show for it."
Finding financial support for family residencies is vital given the cap on graduate medical education imposed by the 1997 Balanced Budget Act and the limited expansion of family residency slots at university health centers. Although the overall number of first-year residencies in Texas(www.tafp.org) increased steadily between 2000 and 2012, the number of family residencies during that time declined from 247 to 211. Since 2002, three family medicine residency programs have closed in the state, according to the Texas AFP.
Elsewhere in Texas, UTHSCSA is using another waiver to fund a new family medicine residency at Doctors Hospital at Renaissance in Edinburg -- an area with a high concentration of low-income residents -- and to help restructure one that was in jeopardy at McAllen Medical Center.
"A few years ago, the trend was that we were closing family medicine programs," Jaén said. "We're moving in the opposite direction now, which is exciting to see."
Jaén said the tide is turning in efforts to recruit medical students into family medicine residencies.
"We live in an academic health center that is still focused on specialist care," he said. "We're starting to see hopeful signs, particularly among older medical students who are learning to appreciate the totality of experience of whole-person care."