TRAIN AND SUPPORT

AMERICA’S PRIMARY CARE WORKFORCE

Family Medicine’s Asks

Hope R. Wittenberg

CAFM Director, Government Relations

May 9, 2011

Training and Support Needed for America’s Primary Care Workforce

Family Medicine’s Asks

#1) Appropriate $71 million for Primary Care Training and Enhancement, a health professions program, for FY 2013

#2) Provide $300 million for the National Health Service Corps for FY 2013 from the trust fund authorized by the Affordable Care Act.

#2) Members of Congress should cosponsor HR 3667, our Medicare GME pilot bill for primary care training. Senators should consider cosponsoring a companion bill.

Ask #1: Primary Care Training and Enhancement

Appropriate at least $71 million for Primary Care Training and Enhancement authorized under Title VII, Section 747 of the Public Health Service Act in FY 2013.

Primary Care Training and Enhancement

Context

• HRSA’s Primary Care Training program needs at least $71 million, to avoid a second year in a row without a competitive grant cycle.

• The nation needs new initiatives relating to increased training in inter-professional care, the patient-centered medical home, and other new competencies required in our developing health system.

Ask #1: Primary Care Training• Enhanced funding is needed to help address

increased primary care needs. • Current program prioritizes training in the new

competencies relevant to providing care within patient-centered medical homes.

• Without a new competition we get further behind in developing the innovative training needed for health system improvement.

Ask #1 – Increased Funding for Primary Care Training

Pushback #1: Too costly Response:• If we don’t modernize our primary care training now,

we will not be able to keep pace with the developing health system.

• More primary care production will help address increased health care costs and poorer health outcomes.

• It’s not just “Invest now for future gains.” It’s “Don’t allow primary care health training to languish in an outmoded system.”

Ask #1 – Increase funding for Primary Care Training

Don’t forget to add a personal story about Title VII specifically or the need for more

primary care.

Ask #1 – Increase Funding for Primary Care Training

Pushback #2: These programs are ineffectiveResponse:

• The Institute of Medicine (IOM) pointed to the drastic decline in Title VII funding and called these programs an “undervalued asset.”

• The Congressional Research Service (CRS) found that reduced funding to the primary care cluster negatively impacted the programs at a time when more primary care is needed.

• Personal story if you have one

Ask #2: Funding the National Health Service Corps

Provide $300 million for the National Health Service Corps for FY 2013 from the trust fund authorized by the Affordable Care Act.

Note: This is not an appropriations request, per se – it is funded out of a trust fund; however we don’t want Congress to delete funding of the trust fund.

Ask #2: Funding the National Health Service Corps

Pushback: Generally supported program – but too costly and funded from “Obamacare,” the Affordable Care Act.

Responses:• In spite of a $5 m increase over last year, this funding

won’t be enough to keep up the current field strength.• At this funding level, the field strength is projected to

drop by over 30%, from just over 10 thousand primary care clinicians in FY 2011, to just over 7 thousand in FY 2013.

• Don’t throw the baby out with the bathwater – fund this important program by whatever mechanism necessary.

Ask #3: Modernizing GME for Primary Care Training

House Members: Cosponsor HR 3667, the Primary Care Workforce Access Improvement Act of 2011.

Senators: Consider introducing a companion bill to HR 3667

Why is a Pilot Needed?• Medicare GME is over 40 years old.

• It is hospital-based • It is outmoded. • Primary Care physicians need to train in the

community• The education of primary care physicians must be

modernized • More of the training should be in nonhospital settings • Funding must be de-linked from inpatient hospital

services• Costs and needs of training in the community setting

must be identified – and paid for by Medicare GME• Entity whose primary mission is education should

have control of the funding and the training.

Medicare Part A Trust Fund GME

Funding

Accredited Primary Care

Residency Training program

Hospital

$ $

?

Accrediting BodiesProgram is accountable to

Current Funding of Hospitals with GME

Rural Locations

CHCs

Physician’s Offices

Nursing Homes

Other community ambulatory sites

$

What would the pilot look like?● Budget neutral; five years● At least 4 organizational models tested (2 of each)● Robust payment amounts to accommodate:

• High cost of training in the community; money would follow the resident

• Provide incentives:- to medical students who choose a primary care- for training in underserved areas, - to increase participation by underrepresented minorities, and - to support hospitals in their staffing needs.

• Provide accountability for the Medicare GME dollars

• Endorsed by: National Rural Health Association, ACP, AOA, and American Geriatrics Society

Pushback #1Won’t hospitals be harmed by this?

Responses:• Inpatient training will still be necessary – and can be

purchased by the program/entity in contract with a hospital.

• Hospitals that have actually used their GME dollars for primary care training will actually gain income from the medical education entity.

• We expect this budget neutral pilot will shift only about $50 million per year.

• This is only a pilot – a test of new models. If they don’t work, no harm/no foul.

Pushback #2Why should Medicare pay for this kind of training?

Medicare GME’s purpose is to aid hospitals with the increased costs of training residents. Medicare should only pay its share.

Responses:– MedPAC and COGME believe we are not getting the product we

need – both in numbers and in kind.

– MedPAC Commission Chair, Glenn Hackbarth, “the training system is not producing what society needs. It doesn’t seem to be self-correcting; it cries out for intervention.”

– With the advent of health care reform, we expect ~ 32 million new covered lives – all in need of primary care physicians.

Responses, cont.

– Strengthening the primary care workforce will promote ambulatory and preventive care -- with the associated decreases in hospitalizations and ER use.

– Better health for Medicare beneficiaries – and cost savings to

Medicare Trust Fund

– Primary care physicians are a critical piece of the physician workforce – key to caring for Medicare beneficiaries. The litmus test should not be how many Medicare patients they see in the hospital while training, but rather what patients will they be able to serve when they are out in practice.

– Primary care training should not be given short-shrift in training funds just because the old formula hasn’t kept up with the times and changes in modes of training and patient care.

Pushback #3Didn’t Health Care Reform take care of paying for

training in the community setting?Responses:

• We are very pleased with the legislative changes to count– Non-hospital training time– Didactic time– Vacation, sick and other leave

• However, those only adjust the regulatory requirements in keeping with the Congressional intent established in 1997

• The HCR bill did not modernize the way Medicare Graduate Medical Education system for primary care training

Pushback #4Isn’t the Teaching Health Center (THC) concept

included in HCR a way to modernize primary care training?

Responses:• We supported the THC, and in fact it fits in one

of our models that our pilot would test.• However, it is not a Medicare modernization tool.• It is dependent on appropriated dollars, not

Medicare. • It will not test other models that currently exist

for primary care training.

Cuts to Medicare GME

1.Fundamental position is don’t cut Medicare GME

2. If cuts are needed: Keep Full GME/IME for core residencies – initial accreditation

3. If more cuts needed: Keep Full GME/IME for primary care training, and other specialties in shortage

Training and Support Needed for America’s Primary Care Workforce

Family Medicine’s Asks

#1) Appropriate $71 million for Primary Care Training and Enhancement, a health professions program, for FY 2013

#2) Provide $300 million for the National Health Service Corps for FY 2013 from the trust fund authorized by the Affordable Care Act.

#3) Members of Congress should cosponsor HR 3667, our Medicare GME pilot bill for primary care training. Senators should consider cosponsoring a companion bill.

#4) Protect Full GME/IME funding for primary care training.

What’s Next?

Please remember to fill out you evaluations and leave them on the tables.

Breakout sessions begin promptly at 10:45, following this break.