Seeing is believing:

Teaching health centers

Winston Liaw, MD, MPH

April 18, 2016

Family Medicine Congressional Conference

Graduate medical education

related training issues

• 1) Patient care occurs in ambulatory care settings yet medical education occurs in inpatient hospital facilities

• 2) Hospital based training does not encourage trainees to go into / stay in primary care

• 3) The current GME system has not increased primary care production

• 4) Physicians are maldistributed

Green LA, Fryer GE, Dovey SM, Phillips RL. The contemporary ecology of US medical care confirms the importance of primary care. Am Fam Physician 2001;64:928.

1) Patient care occurs in ambulatory care settings yet medical education occurs in inpatient hospital facilities

1) Patient care occurs in ambulatory care settings yet medical education occurs in inpatient hospital facilities

2) Hospital based training does not encourage trainees to go into / stay in primary care

Specialty 2002 % of total

2012 % of total

2012-2002 % change

Pathology 11 2.5% 9 1.8% -2 -18.2%

Family medicine 70 15.9% 64 12.6% -6 -8.6%

Obstetrics and Gynecology 21 4.8% 21 4.1% 0 0.0%

Internal medicine - pediatrics 3 0.7% 3 0.6% 0 0.0%

Physical medicine and rehabilitation PGY-1 2 0.5% 2 0.4% 0 0.0%

Dermatology 2 0.5% 2 0.4% 0 0.0%

Internal medicine 102 23.2% 107 21.1% 5 4.9%

Physical medicine and rehabilitation PGY-2 10 2.3% 11 2.2% 1 10.0%

Anesthesiology PGY-1 16 3.6% 18 3.6% 2 12.5%

Radiology PGY-2 19 4.3% 22 4.3% 3 15.8%

Surgery 40 9.1% 49 9.7% 9 22.5%

Orthopaedic surgery 8 1.8% 10 2.0% 2 25.0%

Pediatrics 51 11.6% 64 12.6% 13 25.5%

Emergency medicine 24 5.5% 37 7.3% 13 54.2%

Psychiatry 18 4.1% 28 5.5% 10 55.6%

Plastic surgery PGY-1 1 0.2% 3 0.6% 2 200.0%

Radiation oncology 1 0.2% 6 1.2% 5 500.0%

Otolaryngology 0 0.0% 8 1.6% 8 N/A

Neurology PGY-1 0 0.0% 6 1.2% 6 N/A

Neurology PGY-2 0 0.0% 6 1.2% 6 N/A

Neurosurgery 0 0.0% 5 1.0% 5 N/A

Radiology PGY-1 0 0.0% 2 0.4% 2 N/A

Other 40 9.1% 24 4.7% -13 -32.5%

Total 439 507 68 15.5%

Results from the National Residency Match Program from 2002-2012 for Virginia Residencies

3) The current GME system has not increased primary care production

2006-2016 growth: Family medicine: 20% All others: 30%

Primary care physicians by rural/urban geography, 2010

Geography

U.S.

Population

All

Physicians

All Primary

Care

Physicians

Family

Medicine/General

Practice

General

Internal

Medicine

General

Pediatrics

Urban 80% 89.0% 84.9% 77.5% 89.8% 91.2%

Large

Rural 10% 7.1% 8.4% 11.1% 6.7% 6.2%

Small

Rural 5% 2.6% 4.3% 7.2% 2.4% 1.8%

Remote

Rural/

Frontier

5% 1.3% 2.4% 4.2% 1.1% 0.8%

4) Physicians are maldistributed

Morris CG, Johnson B, Kim S, Chen F. Training family physicians in community health centers: A health workforce solution. Fam Med 2008; 40(4): 271-6.

A Teaching Health Center is…

An entity that:

1. is a community-based, ambulatory patient

care center, and

2. operates a primary care residency

program

Teaching Health Center details

• Created by the Affordable Care Act in 2010

• 5 year authorization (ended in FY2015)

• Funded by HRSA, rather than CMS

• Direct and Indirect Medical Education Payments

• Funding goes directly to the sponsoring institution (FQHC, consortium, etc.)

• Reauthorized in 2015 by MACRA (Medicare Access and CHIP Reauthorization Act)

– $60 million in 2016 and $60 million in 2017

Teaching Health Centers are in

shortage areas

Demand is strong despite funding instability

• More than 100 applicants for every teaching health center residency slot

• Graham Center survey:

– 80% THC programs responded

– 2/3 reported that they are very unlikely or unlikely to be able to continue to support current residency positions without continued federal funding

– Would recruit at least 128 fewer first year residents if federal money is discontinued

Take home messages

• The current GME system contributes to

the maldistribution of physicians and the

primary care shortage

• Exposure is key. Training in underserved

settings is associated with practice in

underserved settings

• The teaching health center program works

but would benefit from predictable funding