Convening and Leading Statewide Stakeholders to address Georgia’s Primary Care Shortages DENISE D. KORNEGAY, MSW

2008: Birth of the Summit In Spring of 2008, the Georgia Statewide Network Advisory Council prioritized its health workforce development focus on the shortage of primary care physicians in Georgia. Recent national reports also offered conclusive evidence that a major shortage was on the near horizon. The first Statewide AHEC Primary Care Summit was held in November 2008.

The Way We Were – cir. 2010 In 2010 Georgia: ◦ Ranked 39th among the 50 states in total residents per 100,000 population. ◦ Georgia had 20.8 residents per 100,000 ◦ US had 35.7 residents per 100,000

◦ To meet the national average of 35.7 residents per 100,000 population, Georgia would have to add a total of approximately 1,450 residency positions.

◦ Only one state surrounding Georgia (Florida at 17.9) had a resident to population ratio

lower than Georgia’s. ◦ To reach the Southeast average of 24.0 residents per 100,000 population, Georgia would

have to add a total of approximately 315 residency positions.

PC Physicians vs. All PC Providers: FOCUS

Recognized the value of all primary care providers

Recognized the complexity of the challenges and the scope of strategies needed

Chose to focus on Primary Care Physicians as the starting point, and in recognition that physicians’ education pipeline is the longest ◦ “Anyone can eat a bear- if they do it one bite at a time”

Primary Care Summit MISSION

To develop strategies to meet the

primary care physician workforce needs for the citizens of Georgia by 2020.

Primary Care Summit GOAL

50 Primary Care Physicians per 100,000 Population, by

2020

Annual Summits

Ground Rules • Invitation Only • Invitees were assumed to be experts in their respective fields • Presentations would be strictly limited • Pre-conference readings would be disseminated • Facilitators and Recorders would be used with every breakout group • Breakout groups would be given specific tasks to accomplish • It was to be a working meeting and not a conference • AHEC’s role was to convene, organize logistics, prepare advance materials,

send invitations, and develop the collaborative agenda based on the findings of the Summit

Developing the model: 2011 Preparing for the 2011 Primary Care Summit: ◦ the Statewide AHEC Network Primary Care Workgroup determined

that a model was needed to assist participants in addressing the complex issues and challenges involved with creating an appropriate Primary Care Medical Workforce for Georgia.

◦ It was agreed that the workforce would be addressed by each phase of its pipeline, thus allowing the participants to create balance across the pipeline through their recommendations.

Our model identifies four phases, the years covered by each, and the environment in which each phase occurs.

MEDICAL EDUCATION PIPELINE PHASE 1 PHASE 2 PHASE 3 PHASE 4 K-12 Education Undergraduate /

College Medical School GME / Residency

Training Years K-12 Years 13-16 Years 17-20 Years 23-28

ACTION UPDATES 2008-2016PRIMARY CARE SUMMIT POLICY AGENDA

2008-2016: Evolution of the Agenda Four major themes: ◦Community Based Faculty ◦Support of medical school expansions through increased focus on student barriers (housing, travel, admissions) ◦GME expansion and retention ◦State Governance / Guidance

Community Based Faculty Preceptors 2008- Explore methods to more effectively manage community based faculty resources needed to support expanded medical student pool

2011- Create incentives for community based faculty to provide clinical training for core medical student clerkships, to accommodate medical school class expansions; (Phase 3)

2012, 2013- Provide tax credits for primary care community based faculty providing uncompensated community based clinical training for 3rd and 4th year Georgia medical students.

2015, 2016 - Convert existing tax deduction to tax credits for primary care community based faculty physicians providing uncompensated clinical training to 3rd and 4th year Georgia medical students.

ACCOMPLISHMENTS: February 2012- Statewide AHEC launched the “Expert Preceptor Training Series”, providing six credit hours of CME. This free, on-line preceptor development initiative was designed to provide training for new and seasoned community based preceptors as an incentive to accept more students.

2014- Passed SB 391 creating the Georgia Preceptor Tax Incentive Program (GA-PTIP).

January- March 2015- First tax deduction letters certified and distributed.

2015- HB 463 introduced, expanding the definitions within the law, adding NP and PA preceptors to eligible recipients, and providing a vehicle for conversion to a tax credit.

Support of medical school expansions 2008- Place community based faculty members on medical school admissions committees, specifically to recommend students for primary care or rural tracks

2008- Develop a more structured strategy to identify potential medical school applicants from rural communities

2011, 2013- Increase housing resources available to support community based training of medical students completing 3rd and 4th year medical school core clerkships and rural/primary care electives

2008, 2011, 2012- Expand the Pathways to Medicine program from southwest Georgia to other AHEC regions to increase early commitment to primary care medicine

ACCOMPLISHMENTS

FY 12- $693,750 added to Statewide AHEC Network contract to support expanded housing for students

FY 15- $300,000 added to the Statewide AHEC Network contract to support expanded housing for students

Summer of 2015: Pathways to Medicine offered by Foothills AHEC in addition to SOWEGA AHEC (the developer of the program)

GME Expansion- Slots 2011, 2012, 2013, 2014- Provide funding to create 400 new primary care Graduate Medical Education (GME) slots in Georgia

2011, 2012- Create a revolving fund to support new GME Program Start-Up and to support pairing of hospitals / programs to expand or establish primary care residency slots

2011, 2012, 2014- Create incentives for Georgia Medical School Graduates to select Georgia Primary Care Residency Programs for training

2013- Address the existing and worsening deficit of GME faculty to support expanded residency slots by providing funding for accelerated learning and for recruitment

2014- Support the Georgia Board for Physician Workforce proposal to increase primary care residency capitation funds for new and expansion positions

ACCOMPLISHMENTS: 2015- Board of Regents projects 400+ new residency slots identified and in development or already opened.

2013- Support new GME Program Start-Up and pairing of hospitals / programs to expand or establish primary care residency slots. $985,895 appropriated in FY 13.

2014- First Mini-Summit hosted on the topic of GME Faculty Deficits

FY15- Increase in the GBPW FY 15 budget for residency capitation grants by $498,168; most of these dollars qualified for federal match

FY16- Increased funds for 20 new residency slots (capitation) ($172,168)

FY 16- Increased capitation for residency grants ($799,981 state)

FY 16- MUSM received funds for the expansion of the 3 year FM Accelerated Track Program ($1,020,000)

GME Progress to date

Number of Programs Minimum Number of Residents

Maximum Number of Residents

Specialty

Internal Medicine 6 180 189

Family Medicine 5 63 84

OB/GYN 2 28 32

General Surgery 2 35 35

Emergency Medicine 1 24 30

Psychiatry 1 12 12

Transitional Year 4 22 40

Total 19 359 422

Progress to date As of July 1, 2015, Georgia had 26 new GME slots filled

Strong Georgia focus seen in background of these residents ◦ Gwinnett Family Medicine ◦ PGY1 – 5 from Georgia ◦ PGY2 – 4 from Georgia; The other has strong family ties to Georgia (partner

from GA.) ◦ Gwinnett Internal Medicine ◦ PGY1 – 3 from Georgia; 1 from Chattanooga ◦ PGY 2 is from Georgia

◦ St. Mary’s Internal Medicine ◦ PGY1 - 6 from Georgia (academic or family ties); 2 from the Southeast

GME – RETENTION 2008- Advocate more flexible loan repayment for primary care residents, including assistance during residency, resident stipends, 50/50 matches with communities, etc.

2011, 2012, 2013, 2014- Increase primary care loan forgiveness programs to be competitive with National Health Service Corps and with contiguous states to a minimum of $30,000 per year with a service commitment

2011- Develop incentives for primary care GME residency graduates to remain in Georgia to practice

2015, 2016- Create capacity to award provisional loan forgiveness based on completion of primary care specialty selection for residency training

2014, 2015, 2016- Continue to expand primary care loan forgiveness resources to allow more students to be offered these awards.

ACCOMPLISHMENTS: FY 15- GBPW funding increased to provide 10 additional GME loan forgiveness awards at the $20,000/year level (total awards increased from 16 to 26)

FY 16- GME Loan Forgiveness Awards increased to $25,000 / year

FY 16- Funding provided to reinstate a rural dentistry loan forgiveness program ($200,000)

2014- White paper developed on creating capacity to award provisional loan forgiveness based on completion of primary care specialty selection for residency training in a Georgia program; issues still under exploration

State Governance / Guidance 2011- Establish a joint legislative committee to develop and recommend incentives for primary care practice, for rural practice, and to address payment obstacles for primary care

2013- Educate policy leaders about impact of failure to act

2013- Request the Governor and General Assembly to appoint a Joint Legislative Committee on the GME crisis in Georgia

2013- Address the existing and worsening deficit of GME faculty

2014- Host a mini-summit that brings together primary care physicians, nurse practitioners, and physician assistants to define common barriers to producing primary care practitioners and to identify strategies to address these barriers

2014- Educate and Motivate the Georgia Congressional Delegation to become more active and proactive in seeking federal solutions to the challenges facing the primary care workforce, to include GME slot distribution, federal funding of GME, and primary care payment differentials

ACCOMPLISHMENTS: 2011-2015: Presentations of the annual Primary Care Summit recommendations were delivered to approximately 25 legislative committees, numerous professional and membership organizations, and several national meetings; work was incorporated into federal testimony related to medical education debt and impact on primary care choices.

2011-2015- Annual meetings with Governor’s (OPB), House and Senate budget staff and analyst to present and explain the PC Summit Recommendations

2014- Hosted mini Summit on GME Faculty Deficits

2014- HR 1722 creating the House Study Committee on Medical Education / GME was passed

2015- Hosted mini-Summit on Identifying Common Educational Barriers to Producing PC graduates, for Georgia NP, PA, MD, DO programs

KEY LEGISLATION Passed

Preceptor Tax Incentive Program: PTIP

This bill began as HB 922, then became SB 292, and then was amended to SB 391. It was the last legislation passed in the 2014 General Assembly. The Governor signed it into law in April. The Statewide AHEC has developed process and administrative work flow to support this expanded responsibility. MCG provided administrative dollars to the AHEC. Website is available at www.gru.edu/ahec/ptip. Georgia is the first state in the nation to pass such legislation.

History of the Preceptor Tax Deduction Legislation •2012 Primary Care Summit recommendation •First of its kind, nationally •Began as HB 922 sponsored by Rep. Ben Harbin; passed as SB 391 on Sen. Don Balfour’s Tri-Care Bill •Department of Revenue language negotiated for Tax Manuals for 2014

What need does it meet?

◦159 Counties: ◦6 without a Family Physician ◦31 without a General Internist ◦63 without a Pediatrician ◦79 without an OB/GYN ◦66 without a General Surgeon

Training Challenges: Community Based Training Sites to Support Education

MEDICAL STUDENTS: Each medical / osteopathic student has approximately 7 required core clerkship rotations in their third year (Family Medicine, Internal Medicine, Pediatrics, Emergency Medicine, OB/GYN, Psychiatry, and General Surgery). ◦ Each rotation lasts 4-6 weeks on average ◦ Approximately 40% of these required clerkship rotations occur in community based settings

with non-compensated volunteer faculty ◦ In 2012, there were approximately 594 3rd year Georgia medical students at five schools ◦ 594 x 7 required core clerkships = 4,158 rotations ◦ 4,158 x 40% in community settings = 1,663 rotations in non-compensated community sites ◦ In 2020 it is estimated that Georgia will have 803 3rd year medical students needing +/-3,212

off campus community based training with a CBF member

Solution: Provide tax incentives for primary care community based faculty precepting 3rd and 4th year Georgia medical students

•Off-shore and out-of-state medical schools are using Georgia CBF and paying them

•To not disadvantage NP and PA programs who used the same physicians they were included as eligible rotations as well

•The Tax Deduction is intended to assist Georgia programs (MD, DO, NP, and PA) with providing the community based educational resources needed to graduate students in primary care

Definitions: Preceptor A licensed Georgia Physician (either MD or DO) providing uncompensated community based training for medical, nurse practitioner, or physician assistant students matriculating at a Georgia program (public or private) for selected rotations

Definitions: Community Based Faculty “Community based faculty physician” means a non-compensated physician who provides a minimum of three and a maximum of ten clerkships within a calendar year. “Medical core clerkship”, “physician assistant core clerkship”, or “nurse practitioner core clerkship” means a clerkship for a student who is enrolled in a Georgia medical school, a Georgia physician assistant school, or a Georgia nurse practitioner school and who completes a minimum of 160 hours of community based instruction in family medicine, internal medicine, pediatrics, obstetrics and gynecology, emergency medicine, psychiatry, or general surgery under the guidance of a community based faculty physician.

Eligibility •Licensed physician in GA

•Cannot receive direct compensation for teaching medical, osteopathic, NP, or PA students

•Deduction only available for rotations supporting Georgia medical, osteopathic, NP, or PA programs •Must complete a minimum of three rotations to be eligible; deductions are provided retroactively once eligibility is established

•A maximum of 10 rotations may be claimed for deductions each calendar year

Eligibility-Continued

The only rotations available to receive the deductions are: ◦Family Medicine ◦General Internal Medicine (inpatient and ambulatory) ◦General Pediatrics ◦OB/GYN ◦Psychiatry ◦Emergency Medicine ◦General Surgery

Definitions: Rotations A rotation is defined as 160 hours of community based clinical training It can be accrued from multiple programs Hours do not have to occur within one student rotation

Eligible Programs: Physician •Emory University School of Medicine •Medical College of Georgia (Georgia Regents University) •Mercer University School of Medicine •Morehouse School of Medicine •Philadelphia College of Osteopathic Medicine, Georgia Campus

Eligible Programs: Physician Assistant •Emory University PA Program •Georgia Regents University PA Program •Mercer University PA Program •South University PA Program •PCOM-GA Campus PA Program

Eligible Programs: Nurse Practitioner Albany State University

Armstrong Atlantic University

Brenau University

Emory University

Georgia College and State University

Georgia Regents University

Georgia Southern University

Georgia State University

Kennesaw State University

Mercer University

University of North Georgia

Valdosta State University

Definitions: Certification The Statewide Area Health Education

Centers Program Office at Georgia Regents University shall administer the program and certify rotations for the

department.

Clarification: Certifications Only the Statewide AHEC Program Office can certify

eligible rotations

Individual academic programs will report completed qualifying rotations to the Statewide AHEC Program

Office

GA-PTIP: MECHANICS

GA-PTIP Website: www.gru.edu/ahec/ptip Features two online reporting portals: ◦Physician Registration ◦Program Reporting

Provides FAQs, Eligibility Guidelines, Training Opportunities, Program Guidelines, News and Updates

Provider Portal •One time online registration through the new secured website portal •Will not need to renew annually but can edit if key information changes •Requires provision of the medical license number as a unique, but public, identifier

Program Portal Programs submit reports of eligible completed rotations through secure online portal

Statewide AHEC Program Office Will maintain website and portals Data will be summarized at the Statewide AHEC Program Office Tax Deduction Certification letters will be issued by the Program Office in January of each year for the last full calendar year Provide a report to the Legislature each year

2014 PTIP UPDATE

UTILIZATION •563 preceptors have registered

•326 qualified to receive deductions

•From the data reported by the programs, 983 preceptors were eligible to receive deductions but at least 490 preceptors did not register with the program •18 of 23 eligible academic programs provided rotation and training hour reports; five nurse practitioner programs did not submit data.

•$883,000 in deductions were certified by the Statewide AHEC for 2014 state income tax filings

UTILIZATION, continued •68% of the deductions were earned and awarded for MD/DO student support •Nurse practitioner students accounted for 11% of deductions earned •PA students accounted for 21% of earned deductions.

FY14 – PTIP Training Hours Reported by School/Program

UNIVERSITY MED/DO NP PA TOTAL Hours Albany State University 0 Armstrong Atlantic University 0 Brenau University 3,009 3,009 Emory University 27,452 6,945 20,276 54,673 Georgia College and State University 3,190 3,190

Georgia Regents University 134,913 18,720 153,633 Georgia Southern University 11,108 11,108 Georgia State University 1,566 1,566 Kennesaw State University 12,555 12,555 Mercer University 22,258 7,440 22,816 52,514 Morehouse University 5,866 5,866 Philadelphia College of Osteopathic Medicine

102,320 1,200 103,520

South University 32,200 32,200 University of North Georgia 4,778 4,778 Valdosta State University 0 Total Hours Reported 298,675 50,591 95,212 438,612 Total Programs Reporting Data 5 8 5 18 Total Programs Eligible to Report Data 5 14 5 24

ALL SCHOOLS: by Rotation TypeMD PA NP TOTAL %

EMER MED 109 30 12 151 5%FAMILY MED 895 83 218 1196 38%GENERAL SURGERY 248 117 37 402 13%INTERNAL MED 330 85 28 443 14%OB/GYN 193 64 69 326 10%PEDS 266 77 81 424 13%PSYCHIATRY 136 38 6 180 6%NON - SPECIFIED 0 0 19 19 1%

TOTAL 2177 494 470 3141 100%

2015 – 2016 Legislative, Budget, and Policy Collaborative Agenda WHAT IS NEXT FROM 2015 PRIMARY CARE SUMMIT?

Legislative and Budget Items: 2016 Convert the new tax deduction program into a tax credit ◦ HB 463 Introduced and will be acted on in the 2016 legislative session.

Create capacity to award loan forgiveness for Georgia medical school graduates choosing Georgia primary care (family medicine, general internal medicine, and general pediatrics) residency programs beginning PGY 1 ◦ Permission from the National Residency Review Committees to continue to develop this program has

been received.

Continue to expand the number and amount of GME loan forgiveness awards available to graduates of Georgia residency programs ◦ Amount increased to $25,000 in 2015 legislature. Ten new awards requested in the FY 17 budget as

well as New Awards created to support NP and PA graduates.

Support the Board of Regents request for funds to continue creation of new residency programs in the state, and to plan for redirection of these funds as the new slots are opened ◦ Funding continued in FY 17 budget

Support an increase in the primary care residency capitation program to provide increased funds to existing programs and to accommodate new programs coming on line ◦ Funding to support a $1500 / primary care resident and $500/non-primary care resident increase in

capitation funds achieved

Host a mini summit for Primary Care Residency Director to identify strategies to promote Georgia’s GME resource and to market them more successfully.

Special Thanks To the Medical College of Georgia @ Georgia Regents University for underwriting the administrative costs to provide this incentive for our valued community based physicians who are supporting our primary

care education pipeline.

Other Questions?

Contact information Denise D. Kornegay, MSW Associate Dean, AHEC Executive Director, Georgia Statewide AHEC Network Program Georgia Regents University

dkornega@gru.edu

(706) 721-8331