HRSA Administrator Describes Role of Family Physicians, PCMH in Health Care System

The Health Resources and Services Administration, or HRSA, serves as the home for primary care services in the United States. The agency, a $7.5 billion concern, administers such programs as community health centers and the National Health Service Corps, and in its current capacity, it provides care to 24 million medically underserved and uninsured people.

In February 2009, President Obama named Mary Wakefield, R.N., Ph.D., to the post of HRSA administrator. "As a nurse, a Ph.D. and a leading health care advocate, Mary Wakefield brings expertise that will be instrumental in expanding and improving services for those who are currently uninsured and underserved," said the president at the time.

Wakefield is considered an expert in rural health care, patient safety, Medicare payment policies and workforce issues. She has served on the Medicare Payment Advisory Commission and was director of the Center for Health Policy, Research and Ethics at George Mason University in Fairfax, Va. In the 1990s, she served as chief of staff for two Nebraska senators. Her husband is a family physician.

AAFP News Now recently interviewed Wakefield about the role of family physicians in the evolving health care system; the future of the patient-centered medical home, or PCMH; and workforce issues, among other topics.

Q. What role do you see for family physicians in the U.S. health care system?

A. Family physicians are critically important, of course. As you know, the (Patient Protection and) Affordable Care Act emphasizes quite strongly a focus on illness prevention, promoting health, and management of chronic conditions. All of these areas are core, from my perspective, to the work of family physicians. Family medicine makes major contributions in these areas.

As provisions in the Affordable Care Act are implemented and as we go forward, there is a very clear role and a need for the expertise that family medicine brings to the table.

Q. How will the additional resources the Advisory Committee on Training in Primary Care Medicine and Dentistry -- an agency of HRSA -- has called for (35-page PDF; About PDFs) affect the medical home model?

A. Obviously, the patient-centered medical home is a focus for the work of HRSA as we support the delivery of care to a variety of populations -- from mothers to infants to patients seen at community health centers to those served by Ryan White Clinics to patients seen in rural community health settings.

The patient-centered medical home is an important frame, if you will, for the services that are delivered to populations that we serve. In addition, you also will see attention being given to patient-centered medical homes through the advisory committee and the work of the Bureau of Health Professions. I would say its importance is systematic across much of what we are interested in focusing on both in terms of workforce training and the delivery of care using the examples I just gave you.

Q. What are your impressions of the recent Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health?

A. Of course, we are aware of the IOM's report, and we take all their recommendations seriously. I have asked my staff to review the report in detail. That being said, it is clear that nurses and nurse practitioners have essential roles in the delivery of high-quality, coordinated care. Care coordination is dependent on engaging an array of disciplines as part of care teams and is core to achieving high quality. There is no better illustration of this than (HHS) Secretary (Kathleen) Sebelius' recent announcement of more than $167 million for primary care residency expansion, as well more than $30 million for physician assistant training and $31 million for advanced nurse education expansion. The secretary said it best when she said, "Investing in our primary care workforce will strengthen the role that wellness and prevention play in our health care system."

Q. The IOM report on the future of nursing says Title VII dollars should be shifted toward nursing. How do you feel about that recommendation?

A. We always take what the IOM says seriously, and, as I said, I have asked my staff to review the report in detail, so I cannot comment on their specific recommendation. But what I can tell is we have seen an unprecedented investment in virtually all areas of the health care workforce from the president and this administration. The funding just mentioned and other funding, such as 2010 appropriations, the Affordable Care Act, and the (American) Recovery (and Reinvestment) Act, are the most comprehensive yet in addressing our nation's health care workforce supply. These funds will provide much-needed support for increasing primary care capacity by expanding training programs for primary care providers and increasing access to patient care clinics. They are vital to our future health care workforce.

Q. HHS recently released $727 million in construction dollars for community health centers. Does the release of this money mean you have a green light to start spending other parts of the $11 billion allocated under the health care reform law for community health centers?

A. This is the first installment of that funding, and it is a substantial (investment). We are really excited because of the impact that this will have in both rural and urban areas in terms of construction and renovation, which was much needed in many health centers across the country.

There also was a call for proposals around school-based health centers. That also is part of the community health center program. You will continue to see through this year and into next year additional calls for proposals as we move forward to implement the provisions in the Affordable Care Act relating to community health centers.

Q. When will additional funds for community health centers be released?

A. Suffice it to say we are starting to map a plan about when different pieces of those 2011 dollars will be released. What we just released was money for new construction. We have set aside money for new access points. We are starting to do the background on the new access points because obviously the Affordable Care Act allocates resources for that, too. We have about $9.5 billion to create new sites in medically underserved areas. We are developing guidance consistent with the statute to expand access to preventive and primary health care.

Q. The health care reform law contains $1.5 billion in capital projects funding for the National Health Service Corps. What are your plans for deploying those funds?

A. I have to say I am really excited about that investment in the National Health Service Corps. The National Health Service Corps is a signature program when you think about ensuring that health care providers are placed in locations that need them the most, which includes family physicians and other primary care clinicians, as well.

In terms of the allocation of resources, the Affordable Care Act authorizes and appropriates that $1.5 billion between now and 2015. That means for fiscal year 2011 we will have $290 million that will flow. For fiscal year 2012, there will be $295 million. Each year there is an allocation that increases to basically allocate that $1.5 billion through 2015.

The great news there is we project that by the end of 2011, we will have more than 8,500 clinicians across the National Health Service Corps. That nearly doubles the number of National Health Service Corps clinicians between 2008 and the end of 2011. We are almost doubling the number of clinicians if you use 2008 as a base year. That means 9 million people served in those underserved communities.

Q. The health care reform law also creates teaching health centers to establish new or expanded primary care residency programs to help train primary care physicians. How do you envision those teaching health centers working?

A. The teaching health centers will establish new primary care residency programs in family medicine and a number of other specialties, as well. The resources also can be used to expand existing accredited primary care residency programs. The resources can flow either to those that already exist or to those that might be created.

An important feature of this teaching health center program is the emphasis on community-based training, which is important and quite consistent with a renewed focus on illness prevention and health promotion. Data show that if you educate folks in community settings, there is an increased likelihood that individuals will practice in community-based settings. It is important to give people exposure, not just in acute care facilities, but also to facilities that are community-based.

National Health Service Corps clinicians can be part of teaching health centers and can use some of their time to earn credit to pay off their loans if they are teaching in a teaching health center. The Affordable Care Act provides the flexibility to get up to 50 percent credit for teaching in future teaching health centers. Right now, (National Health Service) Corps clinicians can receive 20 percent service credit against their loan repayment for teaching in teaching health centers.

Q. What will be the role of Area Health Education Centers, or AHECs, in the future?

A. The Affordable Care Act also made changes to the Area Health Education Centers. In fiscal year 2010 funding, they are receiving about $10 million. We are certainly continuing investments in them.

I think they are really important because they focus on community-based training and interdisciplinary training programs. They really are designed to reach out to underserved communities, to disadvantaged students. If you think about the educational pipeline for the health care workforce, AHECs can be very important, with a focus on strengthening high school math and science or exposing students to health professions roles or reaching college students and using various strategies to encourage them to pursue health professions training programs. AHECs are an important program when you think about the workforce pipeline.

Q. What would you say to a medical school student who is considering a career in family medicine? What would be your advice?

A. Many of the investments that we are making right now mean nothing but opportunities for students who might choose family medicine as a specialty. This administration is focusing like a laser on promoting health, preventing illness and supporting innovation in health care delivery. I think that is family medicine. Family medicine is about engaging and leading new models of care, and family medicine also is about managing people with chronic illnesses, working as part of a team and coordinating care.

From HRSA's vantage point, given the investments we are making in community health centers, for example, the next generation of family physicians will have a lot more places to practice. I think it is a very exciting career specialty.