Testimony to House Appropriations Subcommittee on Labor/HHS/Education on Title VII, AHRQ and Rural Health Programs

Chairman Regula and members of this subcommittee, thank you for your invitation to bring our concerns to your attention today. I am Warren A. Jones, from Ridgeland, Mississippi, and I chair the Board of Directors of the 94,300-member American Academy of Family Physicians. Family physicians conduct almost 200 million office visits each year - that is 73 million more visits than any other medical specialty. Family physicians are the backbone of the American health system. I would like to discuss three issues of importance to family physicians:

The Academy greatly appreciates the support that the Subcommittee has provided these programs throughout the years. Without your consistent help, Title VII Health Professions training, in particular, would not be funded at its current level. We strongly urge you to continue your active involvement with these programs - and offer you any assistance that we can provide. On behalf of America's family physicians, we thank you for your support.

Recommendation

The Academy continues to support a funding level of $169 million for Section 747 of Title VII of the Public Health Service Act for FY 2004. Section 747 authorizes the Primary Care and Dentistry cluster, which includes support for programs in family medicine, general internal medicine and general pediatrics, physician assistants and general and pediatric dentistry. This figure includes $96 million for family medicine programs and is the result of consultation between the organizations' members receiving funding under this cluster.

As you know, the President's budget would again eliminate all funding for the Section 747 Primary Care Medicine and Dentistry cluster. In addition, the Administration proposal includes only $11 million for all Title VII Health Professions programs, which is the same request made last year. FY 2003 spending levels for Title VII were $295 million, due, in large part, to this subcommittee's efforts. Under the President's plan, funding is directed only to "increasing diversity in the health professions and nursing workforce." The budget document asserts, "The FY 2004 budget continues the policy of not funding more general training efforts - primary care, interdisciplinary community projects, training for diversity and public health."

Primary care is that "care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern (the "undifferentiated" patient) not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis." In short, a family physician is trained to provide most of the care that most people need over a continuing period of time.

Section 747 is the only program at the federal level that supports family medicine training programs at both the undergraduate and graduate level. It is specifically designed to increase the number of primary care physicians and the number of individuals who will provide health care to the underserved. The following two studies indicate how it is succeeding in achieving its goals.

Section 747 funding has led thousands of physicians to go into primary care and family medicine and serve millions of patients. Specifically, a study by the Robert Graham Center for Policy Studies showed that medical schools that received Section 747 family medicine funds produced more medical students who ultimately:

The study showed that continued funding during the years of medical school training had more of a positive impact than intermittent funding.

Clearly, Section 747 funds have produced greater numbers of primary care physicians. In addition, another Graham Center study shows that family physicians are providing most of this primary care - and, that without them, counties around the US would not receive these services. Specifically, the study looked at counties designated as Primary Care Health Professions Shortage Areas. Of the 3142 counties in the United States, 1184 (38 percent) are designated full or partial county HPSAs, which translates to more than 41 million Americans. In a hypothetical exercise, the study removed all family physicians from the US counties. When this was done, that figure nearly doubles - the large majority of US counties became full or partial county HPSAs.

In addition, an article in The Journal of Rural Health also found that Title VII funding is key to ending HPSAs. According to the study, without this funding, the number of shortage areas would continue to grow. Moreover, the article states that Title VII funding has cut to 15 years the time needed to eliminate all HPSAs. Doubling the funding for these programs would cut the time to get rid of HPSAs to as little as 6 years (Robert M. Politzer, ScD, et al., Winter, 1999).

From these studies, it is clear that underserved populations, particularly in rural areas, depend on the care that Title VII supports.

In 1998, Congress established an Advisory Committee to review the Section 747 programs and to make recommendations. In its recent report, the Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD) released its recommendations to Congress and the Secretary of the Department of Health and Human Services. The first of six recommendations urged greatly expanding federal support for Section 747 to $198 million. The Committee also emphasized the growing need for primary care providers, as well as the success of Title VII funded programs.

The Office of Management and Budget recently established performance measures to gauge the effectiveness of these (and other federal) programs. In our view, the measures proposed for the Title VII programs are neither quantifiable nor appropriate, and lump all 21 programs together rather than assessing them individually. Consequently, conclusions based on these assessments are highly flawed.

For example, the target set for the proportion of underrepresented minorities (URMs) and disadvantaged students in health professions funded programs is set at 40 percent for 2004. However, only 12.5 percent of current medical school graduates are URMs, and data on disadvantaged backgrounds is not routinely, or even accurately, collected. The concept of disadvantaged background varies based on income related to family size, or is based on a vague, non-quantifiable notion of persons growing up in environments that do not prepare them to enter health professions schools.

For all of the health professions, minority representation has risen from 8.3 percent in 1985 to 11.7 percent in 2000. Given this data, it is simply unrealistic to expect a health professions program to increase its minority representation in one year to 40 percent.

The Advisory Committee's report to Congress also laid out priorities for training primary care providers. If additional funds were made available, Title VII dollars could improve current training and allow programs to provide:

Finally, Title VII dollars have created a system that allows educational programs to respond to current health care issues. Specifically, the Advisory Committee's report states that:

Investment in education to provide primary care has effects that touch the largest number of people in the country. No other group of health care providers can exert such a broad influence on the kind and quality of health care in the United States. Primary care training programs are ideally positioned to react quickly to meet ever-changing health care needs and issues, whether they are related to HIV/AIDS, growing numbers of elderly with chronic illnesses, implications of the modern genetics revolution, the threat of bioterrorism, or other issues that will continue to emerge and demand rapid educational intervention. Thus, this infrastructure is uniquely able to play a pivotal role in bringing emerging issues in health care to the population at large.

With the advent of possible new epidemics, SARS being a recent example, and the potential for bioterrorism, Title VII primary care programs can play an important role in training health care providers who can handle new health challenges.

Recommendation

We recommend appropriations of $390 million for the Agency for Healthcare, Research and Quality (AHRQ) in FY 2004. AHRQ conducts primary care and health services research geared to physician practices, health plans and policymakers that helps the American population as a whole.

AHRQ has the following three goals:

In brief, AHRQ "helps to improve the health and health care of the American people…" (AHRQ report, March 2001).

The Agency for Healthcare Research and Quality receives only $279 million in the President's proposal; the current funding level is $299 million. Of this figure, $84 million is slated for patient safety efforts, which includes $50 million for activities related to information technology investments defined as computerized physician order entry, computer monitoring for potential adverse drug events and computerized patient records, among others. In addition, $10 million is targeted to "promoting and accelerating the development, adoption and diffusion of information technology in health care."

AHRQ translates basic science research findings like those of the National Institutes of Health into information that doctors can use every day in their practice. Another key function of the agency is to support research on the conditions that affect most Americans.

Congress has provided billions of dollars to the National Institutes of Health, which has resulted in important insights in preventing and curing major diseases. AHRQ takes this basic science and produces information that physicians can use every day in their practices. AHRQ also distributes this information throughout the health care system. In short, AHRQ is the link between research and the patient care that Americans receive.

For example, research shows that beta-blockers reduce mortality. AHRQ supported research to help physicians determine which patients with heart attacks would benefit from this medication.

Most typical Americans get their medical care in doctors' offices and clinics. However, most medical research comes from the study of extremely ill patients in hospitals. AHRQ studies and supports research on the types of illness that trouble most people. In brief, AHRQ looks at the problems that bring people to their doctors - not the problems that send them to the hospital.

For example, AHRQ supported research that found older, cheaper antidepressant drugs are as effective as new antidepressant medications in treating depression, a condition that affects millions of Americans.

The Institute of Medicine's report, Crossing the Quality Chasm: A New Health System for the 21st Century (2001) recommended $1 billion for AHRQ to "develop strategies, goals, and actions plans for achieving substantial improvements in quality in the next 5 years…" The report looked at redesigning health care delivery in the United States. AHRQ is a linchpin in retooling the American health care system.

Finally, the Academy supports continued funding for several rural health programs. In particular, we support the programs of the Federal Office of Rural Health Policy; Area Health Education Centers, two programs that are equally important to health care in rural areas and in our inner cities; the Community and Migrant Health Center Program; and the National Health Services Corps. State rural health offices, funded through the National Health Services Corps budget, help states implement these programs so that rural residents benefit as much as urban dwellers. Continued funding for these rural programs is vital if we wish to provide adequate health care services to America's rural citizens.