1. Teaching Health Centers and the Uncertain Future of GME
Frederick Chen, MD, MPH
University of Washington

2. Overview The role of research to inform and implement health policy
HRSA’s Teaching Health Centers
Update on Graduate Medical Education (GME) policy and politics

3. Generic health policy graph

4. Number of community health center patients

5. Workforce shortage in HCs
However this expansion has led to a worsening of the preexisting workforce problem within CHCs.
In fact, a survey of all CHCs reported in JAMA by Rosenblatt et al, also at the University of Washington, revealed shortages of staff and providers for CHCs
The most pronounced shortage was for family physicians which represent 60% of all providers in CHCs
CHCs reported 400 current family physician vacancies and 40% of these vacancies had been open for over 7 months.
This represents a need unlikely to be met by the current family physician training environment and in fact…
JAMA March 1, 2006-Vol 295(9):

6. Health Center physician vacancies
Over 400 FP positions open in Health Centers and over 13 months to fill a position
Majority of HC primary care physicians are family physicians

7. Exploring partnerships with HCs
WWAMI family medicine residency network
UW Department of Family Medicine
Region VIII/X Health Centers
NWRPCA (Region X)
Commissioned multi-method research, collaboration and outreach to promote linkages between residencies and HCs

8. Study questions
Do physicians who train in Health Centers go on to work in HCs?
How many programs currently train physicians in HCs?
What are the characteristics of existing HC-FMR partnerships?
What are the barriers and strengths of existing HC-FMR partnerships?

9. Survey Methods
Cross-sectional survey of family physicians who trained in WAMI residency programs
70% response rate (919/1312)
72 CHC-Trained grads at 6 HC-FMR sites
9 Non-HC affiliated residencies
Let me briefly review our methods. This was a cross-sectional study of graduates of the WWAMI FMRN from which includes all the FM residencies in WAMI at the time of the survey dispersal. WWAMI FMRN is a network of all the FM residencies within the five state area. At the time of the survey, Wyoming had yet to join the Network and is therefore not included in our results. Exclusion criteria were non-board certified respondents and respondents working less than 50% FTE.

10. Graduates working in any underserved setting p<0.01
CHC and Non CHC-trained cohorts were compared for differences between the training cohorts using chi-square analysis.
The above figure indicates the % of graduates working in underserved areas. The yellow represents non-chc graduates and the green the chc-trained grads.
As you can see the difference is quite large. 64% CHC vs. 37% of non-chc trained grads were working in underserved areas at the time of survey response, a statistically significant difference <.001in the two populations and an approximate doubling in the underserved workforce rate. p<0.001
Morris, Johnson, Kim and Chen. Fam Med 2008; 40:271-6.

11. Percent Working in Specific Underserved Settings * p<0.05
After looking at graduates working in any underserved area we wanted to get at the specifics so we analyzed graduates according to whether or not they were working in specific underserved areas. Again, yellow is non-chc and green is chc.
Furthest left on the graph is Migrant Health Center (8.3%, 3.3%, p<0.03), OR 2.2 (.8, 5.6) Indian Health Service (IHS) (9.7%, 3.8%, p<0.02) OR 2.4 (1.2,4.8), Rural Health Clinic (18.1%, 6.4%, p<0.001) OR 2.4 (1.2, 4.8), Medically Underserved Area (20.8%, 9.0%, p<0.001) OR 2.2 (1.2,4.2), FQHC (28.3%, 7.0%, p<0.001) OR 3.7(1.8, 7.5), HPSA (18%, 9%, p>0.05) OR 1.07 (.4, 2.8), National Health Service Corps (4.2%, 3.9%, p>0.05) OR 0.8 (.2, 2.8) Chi squared test.
This is a different type of analysis, each with important contributions to understanding the data. I would present the bivariate analysis to help them understand the relationship and then the multivariate analysis to show that even when controlling for traditional challenges to underserved workforce areas, specifically years from graduation (ie retention), the relationship still holds.

12. Summary
HC-trained physicians 3.4 times more likely to work in a HC (controlling for years from training, gender, FTE)
2.7 times more likely to work in underserved setting
No difference in training preparation for practice, spectrum of practice, and practice satisfaction
To summarize
There was similar responses between CHC and Non CHC-trained family physicians regarding satisfaction, practice characteristics and training. Both cohorts of graduates tended to be very satisfied with the aspects of their job/profession, practicing similar broad scope of practice, and felt their traiing prepared them adequately for their practice.
The workforce issues regarding recruitment to underserved areas showed remarkable differences. Bivariate comparative analysis demonstrated an approximate doubling in the family physicians working in underserved areas overall and a 2-4 times difference amongst the individual areas studied.
Multivariate analysis showed us that CHC graduates were 2.7x more likely to work in underserved areas, and 3.7x more likely to work in CHCs following graduation. This relationship, however, can not be evaluated beyond three years from graduation.
As a result we conclude that for the first three years following graduation, CHC-trained family physicians are filling the health workforce needs of underserved areas at rates approximately double those of their Non CHC-trained counterparts. And, it appears the recruitment advantage most benefits CHCs.

13. US Senators usually do not worry about selection bias.
Health policy lesson #1
US Senators usually do not worry about selection bias.

14. How common are HC-FMR partnerships?
National survey of Family Medicine Residencies
80% response rate (354/439)
23% (83) report some HC training
9% (32) with main continuity clinic in HC
5% (17) with satellite continuity clinic
Our group has performed a number of studies to investigate this relationship.
Share the results
Better understand the natural history, importance, areas for future development.
Informs policy
Morris, Lesko, Andrilla and Chen, Acad Med 2010; 85:594-8.

15. Training residents in HCs: Qualitative Methods
19 key informants
1 interviewer
2 coders
60 minutes semi-structured interviews
Audio-taped/transcribed
Thematically coded (Atlas Ti 5.0)
Thematic analysis
20 codes
8 themes
Major and minor themes

16. Training residents in HCs: Major Themes
Mission
Shared mission of Service AND Training
Money
Underfunded to start with
Increased administrative costs
Leadership
HC board, CEO, Residency Director
Quality
Patient care AND residency education
Morris and Chen, Ann Fam Med 2009; 7:

17. Summary: HC-FMR partnerships
Not a new idea, but a good idea
Produces physicians for HCs and underserved populations
High quality training
Lack of growth
Less than 10% of residency programs
Lots of challenges
In summary, our results demonstrate that FQHC trained family physicians have high training and job satisfaction ratings, a scope of practice similar to their non FQHC-trained counterparts, and are meeting the health workforce needs of underserved areas.
In light of the continued increase in the numbers of uninsured and the anticipated doubling in physician workforce needs in FQHCs, the results of our regional work suggest that part of the answer for the provision of heath providers to underserved areas comes from those residency programs based in FQHCs. .
Policy
Suport innnovation
the success of FQHC-FMR affiliation, as described in our work, argues for further collaboration between educational institutions, government, and community-based programs.
Innovative programs, like EHCs, combine community-based training, mission driven patient care, and enhanced governmental reimbursement strategies to better train family medicine physicians to serve the needs of the underserved.
Collaboration
Opportunity for academic, community, and government partnerships through the continued development and expansion of FQHC-FMR affiliations to meet the training and workforce needs of the underserved.

18. Health policy lesson #2
Your research becomes more useful when it supports what lawmakers want to do.

20. Affordable Care Act
Sec of Patient Protection and Affordable Care Act, “Increasing Teaching Capacity”
Section 340H (Title III), “Payments to Qualified Teaching Health Centers”

21. What is a Teaching Health Center?
Community based, ambulatory patient care center that operates a primary care residency program.
Payments for direct and indirect expenses to qualified teaching health centers that are listed as sponsoring institutions by the relevant accrediting body for expansion of existing or establishment of new approved graduate medical residency training programs.

22. HRSA Teaching Health Centers

23. Lessons Learned Accreditation requirement
Strong medical student interest
New model of GME with payments directly to the residency and community health center

24. “Don’t let the perfect be the enemy of the good”
Health policy lesson #3
“Don’t let the perfect be the enemy of the good”

25. Health policy lesson #3a
Sometimes this leads to imperfect legislation.

26. Medicare GME Since 1965, Medicare supports GME costs
Remains largest supporter of GME
GME goes directly to hospitals, not residency training programs
DME – direct medical education expenses related to care of Medicare patients (1/3)
IME – adjustment for added patient-care costs associated with training (2/3)

27. Medicare GME $9.5 billion supporting 111,000 residents $3 billion DME
$6.5 billion IME
– hospitals opened 13,000 new resident slots
Nearly 90% were specialty

28. High income specialties have increased training slots

29. Payments Medicare GME averages $100k but varies widely
Average Total GME Per Resident $33,445 in LA
to $143,644 in RI
Within California Family Medicine Programs Approximately $50,000 to>$170,000/Res
One NY Program over $215,000/Res
Childrens GME $80k
VA GME $120k

31. Costs How much does it really cost to train a resident?
$130k – 650k per resident per year
Net costs $37k
No standard accounting
‘We are at a loss to explain much of anything’
Lesko, Fitch and Pauwels, Fam Med 2011; 43:543-50

32. GME policy debate Where are we now?
Recognition of ‘Public Good’
Quality of residency training
Concerns about workforce distribution and specialty mix
Lots of questions about accountability

33. GME policy debate Where are we now?
COGME 19th Report
Greater accountability
Flexibility in programs and sites
2011 ACP ‘Aligning GME policy with the nation’s health care workforce needs’
Incentivize primary care
Greater flexibility

34. GME policy debate Where are we now?
2010 MEDPAC recommendation to ‘redirect’ half IME into incentive payments for performance
Increase transparency, annual reporting of hospital payments
Align GME with workforce needs

35. GME policy debate Where are we now?
2011 Macy Foundation calls for
Greater accountability
Flexibility in training sites
Competency-based training
Independent external review

37. Proposed Solutions
IOM Study to assess current GME and recommend modifications
All-payer fund
GME payments to follow trainees
Reallocation of GME slots
Residency tuition?
Reductions in programs? How will hospitals respond?

39. Health policy lesson #4
Never doubt that a small group of well-financed lobbyists can change the world.

40. Health policy lesson #5
Understand
Advocate
Represent

43. Generic health policy graph

44. National Health Expenditures and Their Share of Gross Domestic Product, 1960-2008
Dollars in Billions:
5.2% 7.2% % % 13.5% 13.5% 13.6% 14.3% 15.1% 15.6% 15.6% 15.7% 15.8% 15.9% 16.2%
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at (see Historical; NHE summary including share of GDP, CY ; file nhegdp08.zip).