Rep. Phil Roe, M.D., R-Tenn., discusses his experience as a physician and the recent changes in health policy during the 2015 Family Medicine Congressional Conference.
Now that the onerous Medicare sustainable growth rate (SGR) formula has been permanently repealed, family physicians can set their sights on new issues for the coming year -- specifically, the primary care physician shortage.
One of the themes of the 2015 Family Medicine Congressional Conference (FMCC) last week was how to overcome that next hurdle now that the SGR is history. Several speakers focused on the lack of support in graduate medical education (GME) institutions for training the primary care workforce. As long as teaching hospitals dominate medical residency education, they said, there will be a continuing shortage of primary care physicians entering the field.
Even in Boston, an area with highly respected medical institutions, the city's major teaching hospitals are contributing to the primary care shortage. Joseph Gravel Jr., M.D., chief medical officer and director of the family medicine residency program at the Greater Lawrence Family Health Center, said the center sponsored its own residency because its community, just 25 minutes from Boston, was declared a health professional shortage area.
- Now that Congress has repealed the Medicare sustainable growth rate formula, family physicians can set their sights on other issues for the coming year, including possible solutions to the primary care physician shortage.
- As long as teaching hospitals dominate medical residency education, there will be a continuing shortage of primary care physicians entering the field, said several speakers at the Family Medicine Congressional Conference.
- Teaching health centers have become an important pipeline for training primary care residents.
The Lawrence facility is the second largest teaching health center (THC) in Massachusetts and trains family physicians to work locally and throughout the state. The program has 60 residents training in family medicine and other primary care specialties.
Overall, THCs are an important pipeline for training primary care residents. According to the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, in fact, more than 90 percent of residents who train in THCs enter primary care, compared to about 20 percent of all medical school graduates.
Gravel said the region's shortage of family physicians continues because the issue is not a priority for the three largest teaching hospitals in the state: Massachusetts General Hospital, Beth Israel Deaconess Medical Center and Brigham and Women's Hospital. Together, these three facilities receive $241 million annually from Medicare to train residents, yet they offered zero family medicine residency positions during the 2015 National Resident Matching Program, known as the Match.
Family medicine is the only specialty in the state considered to be in a supply-and-demand crisis, according to a Massachusetts Medical Society workforce study.(www.massmed.org) The entire state offered only 48 family medicine residency positions during the 2015 Match. By comparison, the state offered 114 slots in anesthesiology, 67 in radiology, 65 in neurology and 42 in pathology.
Two legislative aides at FMCC discussed the political obstacles that make it difficult to introduce changes in GME funding. Teaching hospitals receive an aggregate $10 billion annually from CMS for residency training, said Rodney Whitlock, Ph.D., M.A., health adviser to Sen. Chuck Grassley, R-Iowa, and some members of Congress believe the budget for GME should be cut. Whitlock said a better idea might be to identify ways to be more efficient with annual spending and allocate more for areas of need such as primary care.
Lisa Grabert, M.P.H., a staff member on the House Ways and Means Committee, explained that any proposed changes to GME funding or administration will encounter strong opposition from teaching hospitals. For instance, when a proposal arose for a General Accounting Office study of how training funds are spent, teaching hospitals responded by requesting more residency slots.
Training more primary care physicians is the first step to address many of the financial concerns about rising health costs. Kathleen Klink, M.D, medical director for the Robert Graham Center, discussed how states with a strong primary care foundation are able to keep overall costs lower. At the state level, there is a correlation between a higher concentration of primary care physicians in a specific population and lower costs per Medicare beneficiary, according to Graham Center research. The statistics accounted for the rural population.
But Klink said medical school graduates who enter family medicine residencies notice that the clinical settings where they train are often underfunded compared with those for subspecialties that are highly valued by teaching hospitals.
Family Caregiver Numbers Rise
Another FMCC speaker, Rep. Phil Roe, M.D., R-Tenn., noted that after years of work, bipartisan efforts to repeal SGR succeeded this year with passage of the Medicare Access and CHIP -- Children's Health Insurance Program -- Reauthorization Act (MACRA). He praised House Speaker John Boehner and Minority Leader Nancy Pelosi for working together on the act, which included elements both parties favored. That's in contrast to the political infighting that continues over the Patient Protection and Affordable Care Act, which passed without Republican support, Roe added.
Eventually, he predicted, a single payer system will take hold in the United States, similar to the environment in Britain and Canada.
In addition to the primary care shortage, another pressing issue that legislators are being asked to address is the rapid increase in the number of family caregivers. Rhonda Richards, a lobbyist for AARP, told FMCC attendees that an estimated 42 million people are providing unpaid care to elderly relatives. The value of that care is $450 billion, an amount higher than the 2012 Medicaid budget.
About 42 percent of workers have cared for a relative within the past five years, said Richards. The typical caregiver is a 49-year-old woman who takes care of her mother for roughly 20 hours per week.
The rise in ancillary care affects productivity because it requires many people to juggle work and family responsibilities. People who are caring for a relative need more flexibility in work hours or the option to work from home, Richards said.
FamMedPAC's Successes Highlighted
Physicians at FMCC heard how family medicine supports sitting legislators and legislative candidates through FamMedPAC, the AAFP's federal political action committee.
Mark Cribben, J.D., director of FamMedPAC, and Randy Wexler, M.D., the committee chair, provided an update on contributions to the committee. FamMedPAC received $930,000 in contributions for the 2013-2014 election cycle, a record high. During that cycle, FamMedPAC gave $783,000 to 124 candidates, 60 percent of them Democrats.
More than 84 percent of candidates who received support from FamMedPAC won their races, they said.
So far during the 2016 election cycle, $182,000 has gone to 51 candidates, 54 percent of them Democrats.
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