Impact of Title VII Training Programs on Community Health Center Staffing and National Health Service Corps Participation

The study by Rittenhouse et al establishes an important link between Primary Care Health Professions training grants under Title VII, Section 747 and the supply and distribution of physicians practicing in community health centers and in the National Health Service Corps’ (NHSC) Loan Repayment Programs, which involve practicing in medically underserved areas. These new findings add to earlier research demonstrating that a greater proportion of students exposed to Title VII grants in medical school pursue careers in primary care and practice in rural areas.1 While HRSA has received no funding for Workforce Information and Analysis under Title VII,2 it has demonstrated that its Title VII programs exceeded targets in the: 1) Percentage of graduates who are underrepresented minorities or from disadvantaged backgrounds, 2) Proportion of Title VII participants trained in medically underserved communities in 2007, and 3) Percentage of Title VII trained health professionals entering practice in underserved areas.3

Since 2006, funding for Title VII primary care training grants has been cut to just over half of its 2005 level, from $88 million in 2005 to a proposed $48 million in 2009. At the same time, there has been ongoing expansion of the number of community health centers under the Federal Health Center Growth Initiative. This expansion has potential to improve access to primary care for the underserved and reduce disparities in their receipt of recommended services. The number of patients coming to CHCs for their care has increased significantly in recent years, as have visit rates and the delivery of services in these settings.4 However, to realize the potential of the Initiative, a sufficient primary care workforce needs to be available to provide care in these new CHCs. The lack of sufficient numbers of primary care physicians risks the success of the Federal Health Center Growth Initiative and the health of the people it is intended to serve.5 Rittenhouse et al’s finding that physician trainees who attend Title VII funded medical schools or residencies are more likely to practice in CHCs and in the NHSC, suggest that enhanced federal support of Title VII training grants would be a step toward addressing this primary care workforce and distribution challenge.

1. Fryer GE, Meyers DS, Krol DM, et al. The association of Title VII funding to departments of family medicine with choice of physician specialty and practice location. Fam Med. 2002;34(6):436-440.

2. HRSA’s FY2009 Justification of Estimates for Appropriations Committees: House Labor HHS-Education Appropriations Subcommittee, Senate Appropriations Committee, Title VII Health Professions Programs FY 2009 Funding, available at http://www.aamc.org/advocacy/hpnec/fy09housesenate.pdf

3. HRSA Budget Justification available at, ftp://ftp.hrsa.gov/about/budgetjustification09.pdf

4. O’Malley AS, Forrest CB, Politzer RM, Wulu JT, Shi L. Health Center Trends, 1994-2001: What Do They Portend for the Federal Growth Initiative? Health Affairs. 2005;24(2):465-472.

5. Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers; implications for planned expansion. JAMA. 2006; 295(9): 1042-1049.

Competing interests:   None declared

In this era of limited funding, we must consider the most powerful levers to improve the critical shortage in family medicine and primary care. Title VII funding in 2003, $92.4 million as described by Rittenhouse et al, was dwarfed by the total 2003 GME budget of $18.7 billion.[1] GME is a much bigger hammer than Title VII and could more directly affect specialty choice, drive Community Health Center training, and improve staffing for other underserved populations. And yet, GME funds have traditionally not been used to direct physician specialty or practice location.

The Council on Graduate Medical Education (COGME) has recommended not only that Title VII funding be expanded, but that GME funds be used to lever workforce solutions: “Make accountability for the public’s health the driving force for GME.”[2] Controlling GME expansion (to coincide with the already occurring medical school expansion) in the direction of primary care would immediately and directly affect workforce composition. Even the Medicare Payment Advisory Commission (MedPAC) recently suggested, “Policymakers could consider ways to use some of these GME and IME subsidies toward promoting training in primary care.”[3]

Additionally, many states are already using state Medicaid GME (>$1.25 billion in 2003[1]) and other discretionary funds (such as tobacco settlements) to directly sponsor primary care specialty training and underserved training sites in order to achieve state workforce goals.[4]

However, the Association of American Medical Colleges (AAMC) workforce position expresses hesitation about any policy control of specialty choice:

“Individual medical students and physicians should be free to determine for themselves which area of medicine they wish to pursue and GME programs and teaching hospitals should be free to offer training in specialties they wish to offer if accredited by the ACGME…The AAMC should support efforts to promote a healthcare delivery and financing system that can better align marketplace demand for physicians with health care needs of the population.”[5]

As David Goodman recently commented in JAMA, this virtual absence of physician workforce public policy will only lead to more of the same workforce problems: “The expected argument against accountability is that it is wiser to allow market forces to decide the fundamental questions of workforce size and composition. However, doing so practically assures maintaining the status quo. It is unreasonable to expect that market forces will self-organize an effective health workforce. It is time to try public health workforce planning.”[6]

I wholeheartedly support Goodman’s proposal of a permanent health workforce commission that could mold a rational workforce agenda for the U.S. We must enable our large pool of federal GME funds to help create the workforce we so desperately need.

1. Wynn B, Guarino C, Morse L, and Cho M. “Alternative Ways of Financing Graduate Medical Education.” Report to the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, May 2006.

2. COGME 19th Report: Enhancing Flexibility in Graduate Medical Education, Sept. 2007 ftp://ftp.hrsa.gov/cogme/19thCOGME.pdf

3. MedPAC Report to Congress: Reforming the Delivery System, June 2008. http://www.medpac.gov/documents/Jun08_EntireReport.pdf

4. COGME Resource Paper: State and Managed Care Support for Graduate Medical Education: Innovations and Implications for Federal Policy, July 2004 http://www.cogme.gov/ManagedCare/ManagedCareReport.pdf

5. AAMC Statement on the Physician Workforce, June 2006. http://www.aamc.org/workforce/workforceposition.pdf

6. Goodman D. “Improving Accountability for the Public Investment in Health Professional Education: It’s Time to Try Health Workforce Planning.” JAMA. 2008;300(10):1205-1207.

Competing interests:   None declared

I want to congratulate the authors on a Herculean accomplishment: pulling together AMA, Medicare, PHS, and NHSC data in a compelling way takes more courage and dedication than cleaning out the Augean stables. As someone who has drowned in the unforgiving morass of data that these authors have confronted, I can only admire their fortitude.

Their results bolster the conclusion that investing in the training of primary care physicians improves the staffing of medical practices that provide care to our huge under-served population. The study almost certainly under-estimates the payoff from that investment, not only in the number of clinicians that are attracted to Community Health Centers and National Health Service Corps sites, but in the graduates who serve vulnerable populations in inner-city hospitals, prisons, and even suburban populations.

But the rationale for government attention to the production of primary care clinicians applies much more broadly. With the collapse of primary care in the United States, everyone is deprived of that most fundamental human service: a well-trained generalist who can provide long- term care in the context of family and community. Until we turn our current dysfunctional health care system on its head, we will squander our national resources without addressing the core of the problem. And funding such as that provided through Title VII is part of the solution.

Competing interests:   None declared

While support for Title VII is important to be able to have some means to an end, it is also important to understand the factors related to the end point of health access delivery. Family medicine is a most important end point as the remaining permanent form of primary care and health access.1

Funding can be provided for any number of interventions that would result in more family physicians. Logistic regression using underserved location outcomes can give some idea of where funds might be expended.2, 3

Underserved locations can be defined by locations with 19% of the zip code population in poverty or a location with a Community Health Center, a National Health Service Corps designation, or a whole county primary care shortage designation. These were captured from 2001 – 2003 data. About 21% of the nation’s population is found in underserved zip codes along with 7.6% of the 1987 – 1999 medical school graduates from all medical school sources as captured in the 2005 Masterfile. About 14.2% of this cohort was found in family medicine. About 56% can be tracked to a known city or county location with a medical school although about 70% of those born in the US and in other nations have this origin. About 17.4% attended the top 21 medical schools ranked by MCAT. Older graduates or those over age 29 at medical school graduation were 18% of the cohort. About 8.4% were born in rural areas in this group arising from both United States and international sources. About 20.5% were born in the highest income quartile counties in the United States.

Parameter Estimates for Underserved Locations, Rural or Urban Using SPSS 15 n = 295,256 Physicians Graduating from Medical School 1987 - 1999

Independent Variable in Equation . . . . . . .Sig. . . . . . . Odds Ratio . . . Low . . . . High 95% C.I.

Family Practice Physician Variable . . . . . . . 0 . . . . . . . . 2.284 . . . . . . 2.212 . . . . 2.358

Born in a County with a Med School . . . 9.86E-15 . . . . . 0.884 . . . . . .0.857 . . . . 0.912

Top 21 MCAT Medical School Grad . . . . 2.08E-71 . . . . . 0.672 . . . . . .0.644 . . . . 0.702

Older Age Medical School Graduate . . . . 1.54E-62 . . . . . .1.323 . . . . . .1.28 . . . . . 1.367

Rural Born Medical Student (RUCA) . . . . . 4.34E-26 . . . . . 1.274 . . . . . .1.218 . . . . 1.333

Top Quartile Income County Birth . . . . . . 6.19E-42 . . . . . .0.749 . . . . . .0.719 . . . . 0.781

Six other logistic regression equations were used to assess variables for foreign origin, US MD foreign born, lower quartile MCAT medical schools, and physicians born in lowest income quartile (1969 per capita income) counties.

The most important factor in physician distribution to underserved areas is family practice. Graduates who were older (1.3 times odds ratios), had rural origins (1.3), graduated from schools with lower MCAT averages (1.5), or had lower income quartile county birth origins (1.5) were more likely to be found in underserved locations. Odds ratios for family practice contributions increase beyond 3 times in rural, rural whole county primary care shortage areas, the lowest income rural areas, and isolated rural locations. Family practitioners also capture 61% of physician positions in rural Community Health Centers.4

Graduates from exclusive origins, exclusive schools, or medical school counties were less likely to be found in underserved areas. Even with other exclusive factors loaded, the medical schools ranking in the top as measured by Medical College Admission Test scores delivered the least health care in underserved areas.

Foreign born international graduates had higher contributions to underserved areas, but many of these graduates who completed international schools from 1987 - 1999 were still serving J-1 Visa obligations. Foreign born United States medical school graduates have increased to 14% and have lower underserved contributions (0.85 odds ratios) of underserved location and some of the lowest rural location rates of all graduates.

Family physicians maintain 15% underserved location or twice the national physician average. About 100 average family physicians deliver 2930 standard primary care years and 440 standard primary care years in underserved locations. At least 2500 graduates from the top 20 MCAT schools are needed to deliver the same underserved primary care as 100 family physicians. Schools that admit the most exclusive students, train medical students in top concentrations of physicians and specialists, graduate the most physicians found in zip codes with 200 or more physicians, produce the fewest family physicians, and retain the least primary care graduates in primary care are least likely to improve health care access.

The United States is graduating fewer family physicians, admitting more exclusive medical students,5, 6 tolerates health policy that destroys primary care,1, 7 and rewards the health professionals that provide the least health access.

Only policies that result in more family physicians are able to address current health access needs. More infrastructure is needed for family medicine training, but this will require much more than Title VII budget. More medical students need to gain family medicine experiences, but this will not happen in the medical school locations that have the lowest percentages of family practice physicians in the nation.2 More medical students need to be encouraged to choose and remain in primary care, but this will not happen in locations with dysfunctional primary care clinics.8 Medical school leadership also needs to be changed as even medical school deans in rural states focus on admissions of the most exclusive students and expand specialty training when the state needs to admit those most likely to chose family practice and graduate more family physicians. Ideally the state would complement medical education by funding the graduation of more family physicians and paying for medical school costs for those willing to maintain instate family practice careers for the first 10 – 15 years after graduation. This also forces other states that steal primary care to grow their own.

More medical students who are most likely to choose family medicine need to be returned to medical school admission. Admission of older medical students is also a good intervention and fortunately has gained favor, except in the most exclusive schools where the youngest graduates are the rule. Most of all the United States must give free medical education to physicians willing to choose family medicine and maintain 10 - 15 years as practicing family physicians. Since family physicians average 29.3 years of primary care delivery, this should not be a challenge. The nation should be warned however, that those who make the needed health access choices will also need reasonable physician salaries (not the lowest), sufficient support for the nurses and health care team members that optimize primary care (not the fewest and the least experienced), and rebuilding of the primary care facilities in the nation.

This also must preceded major health care finance interventions such as universal access. Premature implementation of expanded health care access would release decades of pent up health care demand that would overwhelm current primary care and health access capability. A steady hand to rapidly increase family practice graduates, support of primary care practitioners, and restore primary care infrastructure can then be coordinated with increased patient access to care. The nation accomplished this during the 1970s with a quadrupling of primary care production, rebuilding of health care infrastructure beyond existing concentrations, and restoration of financial access for patients left behind. The United States knows what to do. It does not take great vision or revision to accomplish the needed tasks. Mostly it takes common sense and leaders that stay in touch with each other and with the needs of most Americans.

References

1. Bowman RC. Measuring Primary Care: The Standard Primary Care Year. Rural and Remote Health. 2008;8.

2. Bowman RC. Physician Distribution By Concentration. Primary Care Research Methods and Statistics Conference. San Antonio, Texas; 2007.

3. Bowman RC. Logistic Regression and Rural Practice Location. In: Proceedings, Association of American Medical Colleges 2007 Workforce Conference; 2 May; Washington DC, 2007.

4. Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. Jama. Mar 1 2006;295(9):1042-1049.

5. Association of American Medical Colleges. Minority Students in Medical Education: Facts and Figures XI Available at https://services.aamc.org/Publications/showfile.cfm?file=version12.pdf&prd_id=89&prvid=87 Accessed April, 2003. Washington DC 1998.

6. Association of American Medical Colleges. Minority Students in Medical Education: Facts and Figures XIII Available at https://services.aamc.org/Publications/showfile.cfm?file=version53.pdf&prd_id=133&prv_id=154&pdf_id=53, Accessed July 2006. Washington DC 2005.

7. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med. Feb 20 2007;146(4):301-306.

8. Keirns CC, Bosk CL. Perspective: the unintended consequences of training residents in dysfunctional outpatient settings. Acad Med. May 2008;83(5):498-502.

Competing interests:   None declared