Statement for the Record to the Senate Appropriations Subcommittee on Labor/HHS/Education on Title VII, AHRQ and Rural Programs

STATEMENT FOR THE RECORD


AMERICAN ACADEMY OF FAMILY PHYSICIANS


SENATE APPROPRIATIONS SUBCOMMITTEE ON
LABOR/HEALTH AND HUMAN SERVICES/EDUCATION


FY 2006 FUNDING LEVELS FOR
SECTION 747 PRIMARY CARE MEDICINE AND DENTISTRY CLUSTER
AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
RURAL HEALTH PROGRAMS


The 94,000-member American Academy of Family Physicians submits this statement for the record to the Senate Appropriations Subcommittee on Labor/Health and Human Services, Education and Related Agencies. Our statement is made in support of the Section 747 Primary Care Medicine and Dentistry Cluster. The Academy also supports the Agency for Healthcare Research and Quality (AHRQ) and rural health programs.

Section 747 is the only federal program that funds family physician training. The law requires the program to meet two goals: 1) increase the number of primary care physicians (family physicians, general internists and general pediatricians) and 2) boost the number of people to provide care to the underserved. Regarding family medicine specifically, Section 747 offers competitive grants for training programs in medical school and in residency programs.

The FY 2005 spending bill provided $89 million to Section 747, a figure that was $3 million below the FY 2003 levels, which is the highest figure the program has received in the last several years. Unfortunately, the President’s FY 2006 budget provided zero dollars for the program. In contrast, the congressionally established Advisory Committee on Training in Primary Care Medicine and Dentistry, which was set up solely to evaluate these programs, recommended significantly more funding: $198 million.

Family physicians are the specialists trained to provide comprehensive, coordinated and continuing care to patients of both genders and all ages and ethnicities, regardless of medical condition. These residency-trained, primary care physicians treat babies with ear infections, adolescents who are obese, adults with depression and seniors with multiple, chronic illnesses. And because they focus on prevention, primary care, and integrating care for patients, they are able to treat illnesses early and cost-effectively and when necessary, they help patients navigate our complex health system and find the right subspecialists.

In the last few years, there has been a great deal of interest in whether Section 747 actually meets its statutory goals, and specifically whether or not more physicians are practicing in rural and underserved areas as a result of the program. Due to this concern, the Robert Graham Center for Policy Studies studied medical schools receiving Section 747 family medicine funds and concluded that these programs met the law’s requirements. According to this research, the trainees exposed to Section 747 funding while in these schools were more likely to:

More specifically, according to this research, students with any exposure to Section 747 were 25 percent more likely to go into a primary care HPSA and 34 percent more likely to go to a rural county to practice. Moreover, the exposure of students to Section 747 funding between 1978-1993 was associated with nearly 4,000 additional primary care physicians in rural areas and 500 additional physicians in HPSAs than would have otherwise occurred. This research showed that Section 747, was, in fact, meeting the goals of the law.

Along a similar vein, another study by the Robert Graham Center looked at counties designated as HPSAs. The research showed that the US relies on family physicians more than any other medical specialty. For example, of the more than three thousand counties in the US, 784 are designated HPSAs. In a hypothetical exercise, the study removed all family physicians from the US counties and found that without these specialists, there would be 1,184 HPSAs - a 43 percent increase. Section 747 grants contribute to bringing health care to underserved areas.

Family physicians also play a major role in staffing the nation’s Community Health Centers (CHCs) and National Health Service Corps (NHSC). The Academy strongly supports the Administration’s commitment to funding increases for these programs. However, we believe that increasing funding for CHCs and the NHSC is only a partial solution. Without support for family physician training, there will be fewer physicians who work in these centers or practice in underserved areas. Thousands of family physicians will be needed if the necessary number of CHCs sites and NHSC staff is to be realized.

In fact, in 2003, Community Centers depended on primary care physicians for 95 percent of their physician staffing, over half of whom were family or general practice physicians. And, since 1971, the National Health Service Corps has placed more than 18,000 health care providers in underserved areas: almost half of the NHSC doctors were family physicians. Support for CHCs and the NHSC must go in tandem with funding for Section 747.

As the only federal program aimed at producing more generalists, Section 747 plays a role in lowering our nation’s health care costs and increasing the quality of US health care. For example, an article in Health Affairs (April 2004) demonstrated that states that spent more on Medicare had lower quality of care. There were two reasons for this result: states’ expensive health care did not improve patient satisfaction, or, outcomes (e.g., people who were admitted to intensive care in the last 6 months of their life.)

The second reason was also important: the authors found the makeup of the health care workforce made a difference. In fact, more primary care doctors in a state meant higher quality care and lower cost. In contrast, more specialists and fewer generalists led to lower quality and higher costs. And, just a small increase in the number of generalists in a state was associated with a large boost in that state's quality ranking.

An article in a more recent edition of Health Affairs (March 2005), “The Effects of Specialist Supply on Populations’ Health: Assessing the Evidence” went even further. This piece stated that there is a “negative relationship between the supply of primary care physicians and death from stroke, infant mortality and low-birthweight, and all-cause mortality.” The article went on to say that just one more primary care physician per 10,000 people was associated with a decrease of 34.6 deaths per 100,000 population.

The article also cited breast cancer research for the state of Florida, which indicated that “each tenth-percentile increase in primary care physician supply is associated with a statistically significant 4 percent increase in odd of early-stage breast cancer. “ Statistics were similar for other types of cancers: there was a relationship between early identification and the supply of primary care physicians. Numerous other research was included in the Health Affairs article indicating that a higher ratio of primary care physicians to populations led to better health outcomes. These data support the need for additional funding for Section 747, the only federal program that produces primary care physicians.

In 2003, the Oklahoma Physician Manpower Training Commission studied the amount of income that comes into a community due to the presence of one family physician, and the additional jobs that result from his or her practice. Their research showed that the figure was approximately $1.2 million in rural areas and $0.9 million in urban areas.

Unlike all other developed countries, the US does not have a primary care-based health care system. While other developed countries have about equal numbers of primary care doctors and subspecialists, less than one-third of the US physician workforce is primary care doctors (including family physicians). As a result, about 2/3 of the US physician workforce is made up of subspecialists.

In addition, compared to those in other developed countries, the US spends the most per capita on healthcare -- but has the worst healthcare outcomes. More than 20 years of evidence have shown that a health system based on primary care produces greater health and economic benefits. Boosting support for Section 747, which funds training for family physicians and for other primary care disciplines, could improve the health of patients in the US to enjoy those benefits.

The Academy recommends $440 million for the Agency for Healthcare, Research and Quality (AHRQ). A major purpose of AHRQ is to conduct primary care and health services research geared to physician practices, health plans and policymakers. What this means is that the agency translates research findings from basic science entities like the National Institutes of Health (NIH) into information that doctors can use every day in their practices. Another key function of the agency is to support research on the conditions that affect most Americans.

More recently, AHRQ has become the lead federal agency for research on comparative clinical effectiveness; information technology; and patient safety. For example, the Medicare Modernization Act asked AHRQ to study the “clinical effectiveness and appropriateness of specified health services and treatments,” and to use this information to improve the quality and effectiveness of the costly Medicare, Medicaid and SCHIP programs. In FY 2005, $15 million was appropriated by Congress for this purpose, and the agency now has determined the top 10 conditions for initial research. This type of study on “what works” in clinical therapies is crucial in an era of skyrocketing health care costs and limited federal dollars.

Historically, however, AHRQ has been the lead agency to translate research into information for physicians and patients. Over the years, Congress has provided billions of dollars to the National Institutes of Health, which has resulted in important insights in preventing and curing major diseases. However, AHRQ’s role has been to take this basic science and produce understandable, practical materials for the entire healthcare system. In short, AHRQ is the link between research and the patient care that Americans receive.

In addition, AHRQ has long-supported research on conditions that affect most people. Most 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 every day – not the problems that send them to the hospital.

Continued funding for rural programs is vital to provide adequate health care services to America’s rural citizens. We support the Federal Office of Rural Health Policy; Area Health Education Centers; the Community and Migrant Health Center Program; and the NHSC. 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 patients.

The Academy urges Congress to increase funding for Section 747 family medicine training, at a minimum, to the FY 2003 level of $92 million; provide $440 million for AHRQ and support rural health programs. Federal funding for these initiatives is vital to sustain and improve America’s health care system.