A Presentation to the HRSA Advisory Committee on Training
in Primary Care Medicine and Dentistry Workgroup B

By
Carlos A. Moreno, MD, MSPH
And
Joseph E. Scherger, MD, MPH

On behalf of
American Academy of Family Physicians
Society of Teachers of Family Medicine
Association of Departments of Family Medicine
Association of Family Practice Residency Directors
North American Primary Care Research Group

Scenario 1, Title VII funding is eliminated

The effects of family medicine funding under Title VII are far broader than just the programs' effect on family medicine. This paper will address how Title VII funding supports family medicine in general, and what would happen to family medicine were the funding to go away. Secondly, it will look at how strong financial support for family medicine affects the production of primary care physicians in general, and the nation-wide distribution of physicians.

Documentation of what this money does in terms of production.

We can document the importance of strong financial support of family medicine.

The attached table shows increased numbers of family physicians if a school has a department of family medicine.
The General Accounting Office (GAO) in two reports in 1994, addressed the question of how do we know Title VII money is well spent? A July 1994 report, states that "the programs were important for funding innovative projects and providing 'seed money' for starting new programs. For example, Title VII was considered important in the creation and maintenance [emphasis added] of family medicine departments and divisions in medical schools."1
The GAO, in another report, states in October 1994 that "students who attended schools with family practice departments were 57 percent more likely to pursue primary care." In addition, the report goes on to say that "students attending medical schools with more highly funded family practice departments were 18 percent more likely to pursue primary care and students attending schools requiring a third-year family practice clerkship were [also] 18 percent more likely to pursue primary care." The money spent on Section 747 of Title VII is directly targeted in these areas.2
What type of physician does this funding help produce?

This funding provides flexibility to meet community and department needs. The funds permit:

innovation to cope with local needs
addressing of intractable social problems
flexibility for departments and residencies to support HRSA's mission and goals.
Without this funding what would happen? One of two things. Lack of success at finding alternative sources of funding, causing a decrease in strength and success of the department, particularly in the areas that HRSA and Congress are interested in - production of primary care providers and service to the underserved. Or, they would look to get funding from places such as NIH, not known for supporting primary care development. This avenue has the potential of changing the only departments whose total mission is in keeping with HRSA's mission, into mini-departments of internal medicine and pediatrics, thereby negating their intrinsic worth.

Loss of funding would cause tremendous impact on service to the underserved

Data show that if production of family physicians were to fall, the impact on the nation's underserved would be great. The fewer the number of family physicians produced, the greater the number of new HPSAs. This holds true even in comparison with the combined loss of internists, pediatricians and obstetrician/gynecologists. As one can see in the attached one-pager entitled "The United States relies on Family Physicians, Unlike any other Specialty," without family physicians, an additional 1332 of the United States' 3082 urban and rural counties would qualify for designation as primary care HPSAs. This contrasts with an additional 176 counties that would meet the criteria if all internists, pediatricians, and ob/gyns in aggregate were withdrawn."3

Evidence ties impact to Title VII funds specifically

Politzer, et al4 show that the Title VII funding is key. This funding has led to the time needed for HPSA elimination to decrease to 15 years. Doubling the funding for these programs would decrease the time for HPSA elimination to as little as 6 years.

According to the study, without this funding, not only would HPSAs not be eliminated, but the number of shortage areas would continue to grow. Moreover, success has been attained by an allocation of funds more favorable to family medicine that the other two primary care specialties.

Some anecdotes from the field

Kathryn M Andolsek MD MPH, Duke University residency faculty Reflecting on our curricular enhancements made possible from this program has been an interesting exercise. Many of these curricular areas seem "old" now, but were cutting edge at the time, including: a geriatrics curriculum; the development of a FM inpatient curriculum; AIDS curriculum that allowed us to care for HIV + patients at a time when no one else would provide this care in our community; family-centered obstetric care allowing family medicine faculty to supervise the residency ob (now incorporated as an expectation by our RRC);sports medicine (another one that allowed us to gain an early foothold in the institution, establishing credibility of our faculty and our curriculum.

Our most recent grant has allowed development of skills in evidence based medicine (which quickly necessitated enhanced teaching in medical computing ) and family violence. Both of these curricula have been developed, implemented, and are in the process of being posted to the Internet to continue their sustainability beyond the period of grant funding. They have also allowed us to participate collegially in multidisciplinary education with our colleagues in general medicine, pediatrics, and OB as well as our two affiliated residency programs.. We've been able to share these resources with many more house-staff (easily 4 to 5 times as many as) than those for whom it was "funded" as well as to be a "leader" in our institution for these types of curricular innovations.

Elizabeth Burns, MD, University of Illinois, Chicago "I wonder if anyone [not involved] really understands what it takes (time and money wise) to develop curriculum. Especially when you are working with the community (you go to them and they are all over the place). Many departments don't have support for this (only 4 FTE's from the UIC department are supported on hard money from the dean--not enough even for combined pre-doctoral and residency requirements). Innovation costs something. The dean's don't seem to care anymore, so the feds better or in 15 years we will be back where we started."

Harold Williamson, Jr.,MD, Chair, University of Missouri-Columbia "Sad to say, but we'll do what it takes to get the money for our aspirations…We would NOT be doing many of the things the feds think are important because there is no place else to get money for those things. I think it's that simple."

Thomas Schwenk , MD, Chair, University of Michigan "Many marginal departments will go under, and the precarious nature of family medicine academic funding will be revealed, … this will certainly weaken the discipline considerably."

Marjorie Bowman, MD, Chair, University of Pennsylvania "The fact that we are not getting any Title VII money substantially inhibits our department's growth and the quality of education we can provide. The lack of funding affects the view of us within the school -- we are not seen as contributing an appropriate share, as less 'capable', etc. We are likely to be releasing at least one individual, and maybe two, because the funding we had we will no longer have."

Mark Johnson, MD, Chair, UMDNJ-New Jersey Medical School "Where else would we get the support for this kind of innovation? The lottery I suppose."

Jack Rodnick, MD, Chair, University of California, San Francisco "This money is different from other funds I have as a department chair. The funds are not available from the hospital or institution (which supports clinical work and/or ongoing required courses or residencies). They really provide the energy and time to build and expand depts. Other departments do this off of indirects from NIH grants or "profit" from well-paid procedures."

Scenario 2: Title VII funding remains level

The ramifications of this question are likewise multidimensional.

1. First of all, "level" funding is, in actuality, "declining" funding, as inflation consumes the purchasing power of grant dollars more each year.

Source: Bureau of Health Professions

The impact of that is, obviously, all of the aforementioned consequences of inadequate support for family medicine education.

2. The second impact of Title VII funding being level is already upon us -- namely, declining student interest in primary care (family practice) careers as evidenced by the 2000 NRMP Match statistics. Title VII has been central to the support for departments of family medicine and third-year clerkships, both shown to increase student interest in family medicine.1 While lack of increased funding cannot shoulder all the blame, we know that if more funds were directed toward departments of family medicine, the numbers of students going into primary care medicine would increase.1 Similarly, if more funds were directed toward community-based third-year clerkships, we can anticipate greater student interest in primary care careers.2 For a number of reasons, medical students have been for 3 years moving away from primary care in favor of careers in specialties offering either options for primary vs. subspecialty practice (transitional and preliminary medicine programs) or the combination of a predictable lifestyle and high income (anesthesiology, radiology, and emergency medicine programs).5

Source: Pugno PA, McPherson DS, et al. "Results of the 2000 National Resident Matching Program: Family Practice." Family Medicine 2000:32(8).

3. The third impact of level Title VII funding is the fact that the other current financial pressures affecting academic health centers and teaching community hospitals have narrowed operating margins and threatened the viability of both the teaching programs and even the institutions themselves.6 At a time of very tight budgets, little money is available for the development of new primary care initiatives or to respond affirmatively to the changing landscape of health care, including opportunities for programs in geriatrics, genetics, and informatics.

From a global perspective, two observations about Title VII and the current health care environment seem pertinent:

Currently funded programs are challenged by the continued decline in student interest in family medicine (and primary care), and level funding of Title VII may not provide sufficient support to overcome that trend.
There is no compelling evidence to support a change in the current distribution of Title VII funds among its various programs. The nation's physician workforce needs to match with the present manner in which Title VII funds are distributed, as evidenced by:
Family medicine's success in placing graduates in rural and other underserved areas - not just in percentages, but in raw numbers.7, 8
Family medicine grant applicants' success in meeting priority measures for Title VII funding.
Family medicine training's relevance to the future trends in medical practice, including an outpatient focus, prevention orientation, and evidence-based, cost-effective care.
Comments from family medicine educators regarding the importance of Title VII funding, and the need for its enhancement, are noted below:

David Swee, MD, UMDNJ-Robert Wood Johnson Medical School, New Jersey "Title VII continues to be the life blood of our department. It allows for creative development of new areas that have the potential for future growth and for which there is almost no other funding. While this is particularly true for medical education enterprises, whether at the predoctoral, residency, or faculty development/fellowship level, it is also true in the heart of scholarship, i.e., research."

Mark Johnson, MD - New Jersey Medical School-UMDNJ "This money has been a tremendous help in creating and expanding our position in the medical center. Most importantly, it has allowed us to leverage other sources of funding for our department. In sum, this grant program allows us to be creative and innovative…as well as educational and scholarly. It not only advances academic family medicine, but all of medical education."

Jack Rodnick, MD - University of California, San Francisco "The funds allow us t take on the development of new educational projects, and to develop teaching at new clinical sites. The funds really benefit the whole school."

Joshua Freeman, MD - University of Texas Health Science Center San Antonio "Our predoctoral grant has been revolutionary, not only in the department, but in the medical school….Modules from our M3 clerkship, including community based teaching and cultural competency, have been successfully integrated into the M1 course, and will be picked up by other clerkships, such as pediatrics."

Scenario 3 and 4: Title VII increased to ideal funding level, and an ideal program for the future

There are two basic questions associated with this scenario:

What would an ideally funded Title VII program look like?
What level of funding would be needed to maximize the impact of the Title VII program?
However, before pursuing either question, it should be acknowledged that Title VII funding has indeed accomplished many of the objectives for which it was designed. Both of the GAO reports of 1994 address the effectiveness of Title VII funds in achieving the outcomes for which the program was designed:

Funding of innovative projects.
Providing "seed money" for the start-up of new projects.
The creation and maintenance of departments of family medicine in the nation's medical schools.
The development of 3rd year clerkships in family medicine.
The increase in students selecting primary care residencies from those schools with funded family medicine departments and 3rd year clerkships.
The increased rate of graduates from Title VII funded projects entering practice in medically underserved areas (MUAs), with a resultant reduction in the time required for Health Professions Shortage Area (HPSA) elimination.
Program Priorities for the Future

Using those observations, what should be the priorities for the Title VII programs of the future? We believe the health care priorities of import for the future should include:

The needs of our aging population (geriatrics).
Pragmatic applications of the rapidly advancing knowledge in genetics.
Medical informatics as well as other information control and management, especially with respect to new technologies that will arise quickly, as with the spread of the Internet, and new e-commerce or e-medicine.
Attention to the increased diversity of the nation, and the unique health care challenges associated with it.
Attention to the issue of health care access, specifically "who is going to be there to provide needed services?"
Innovation in health care delivery with attention to evidence-based medicine, practice-based quality improvement, resource distribution, universal access, health maintenance, and cost-effective care.
Support for the development of the research base upon which all these programs should be grounded.
The Bureau of Health Professions (BHP) is currently in the process of a critical assessment of its current programs, with the objective of identifying successful ones (like Title VII) and "changing only what needs to be changed."9 For example, with respect to the nation's population diversity, more students (3-4 times) coming out of BHP-supported programs are diverse and ultimately work in MUAs (4-5 times).9 Clearly, the programs of Title VII are on the right track toward meeting the health care challenges of the 21st century.

Funding Level

To address the second question of funding level, two different approaches could be taken: (1) to identify a target funding level based on a specific desired outcome grounded through experience, or (2) an evolving funding target based on the response of primary care to the challenge of addressing future needs. Some specific examples can be illustrative:

In Politzer's 1999 report in the Journal of Rural Health he notes: "In 1997, Title VII funded programs increased the rate of graduates entering HPSAs, resulting in 1357 providers, and reducing the time for HPSA elimination to 15 years. Doubling the funding for these programs would increase the number of Title VII funded generalist physicians entering MUAs, and could decrease the time for HPSA elimination to as little as 6 years."4 If that is indeed the case, then it would be reasonable to conclude that doubling current Title VII funding levels might indeed result in a greater than 50% reduction in HPSAs in as few as 6 years. Thus, specific multipliers applied to Title VII funding levels could be applied in accordance with time-specific programmatic objectives. We should also remember, however, that there are additional priorities at the heart of Title VII legislation, not limited to underserved and minority populations. The key issue is having enough primary care physicians to serve the nation's needs. In order to achieve these ends, such as through adequate support for departments of family medicine, an additional development fund should be created to come to grips with the general service needs of the nation.

Another approach to the determination of an ideal funding level for Title VII programs could be based upon current experience, but projected forward in response to the magnitude of proposals received that meet the funding criteria for each funding cycle. For example, in 2000, the Title VII program received a total of A proposals, of which B met the criteria for funding and were subsequently "approved." Available money, however, only permitted funding for C proposals, with an average award of $D. If we were to assume that the top 80% of approved projects merit funding, then the following formula could be applied:

B "approved" projects x 80% = E merit funding
E meritorious projects x the average award of $D results in a Title VII funding target of $F dollars.

As Title VII program priorities evolve, and the number of proposals which meet the funding criteria changes (presumably increase with the greater likelihood of actually being funded), then the target funding level for Title VII programs would similarly evolve to maximize the program's effectiveness.

A final element of consideration must be addressed if the target of "ideal" funding for Title VII is achievable. That is, funds over and above that level necessary to support targeted Title VII priorities must be considered. In other words, additional funds should be available to support new, innovative approaches to meeting the nation's health care needs. As noted in many of the previously cited comments from Title VII funding recipients, the option for flexibility in funding support for innovation is largely limited to the Title VII moneys. Such flexibility supports the capacity of residency programs and departments to "leverage" those funds into additional support from local resources.

This "multiplier effect" is potentially a very powerful tool for directing other funding resources into the sphere of Title VII priorities, and it should be supported robustly. An additional 50% development fund for innovative projects would permit the Title VII programs to truly promote creative approaches to meeting the nation's health care needs for the foreseeable future. Applying such a factor to the previously calculated $F level of proposed funding for "approved" projects would result in a recommended Title VII funding target for 2001 of $G. This amount would be defensible based on past experience with the successes of Title VII and reasonable projections for how its effectiveness could be maximized through appropriately targeted funding.

We should note however this formula has only discussed new competitive proposals. We would not want to ignore the current funding that is expended each year for continuing grants. This should be added to the target amount so that the previously calculated $G becomes a final target figure of $H. Lastly, although we have framed this formula on the basis of family medicine Title VII funding, there is no reason this formula could not apply for other specialties within the primary care cluster.

A few comments from prior Title VII funding recipients highlight key points of the above-noted discussion:

Mark Johnson, MD, UMDNJ-New Jersey Medical School "We have just been notified that we received a grant to enhance research infrastructure. This is the third "departmental" grant that we have received. The first I wrote before I even started here. The flexibility that it awarded me as a new chair was tremendous. Having access to those funds provided me with leverage to get other commitments. The initial growth of the department exceeded projections. The next grant was also for research. It allowed us to buy research services from other departments, including bio-statistical support, and translated it into out-of-the-department mentors. Also it gave us dedicated staff for research."

Jim Wilson, MD, East Tennessee State University "The grants enable us to address many of theses issues in family medicine which I think would not be addressed if not for additional resources. They also allow us to train more individuals at the fellowship level, which is essential because other resources, except for geriatrics, are just not available. To be able to train two additional fellows in an area of special interest has shown to be very important in family medicine."

Kathryn M Andolsek, MD, MPH - Duke University, Durham, NC "Clinical primary care operates at such a "margin" of profitability; traditional "coffers" are decreasing, academic medical centers are dissolving or undergoing stringent "belt tightening" and have no extra to put into learning/teaching. These moneys are more essential than they ever were in improving our teaching/learning and ultimately the care we provide to the patients in this country. We desperately need to find (and teach) better ways to work with the homeless, the marginalized, and the increasing cultural, ethnic diversity of patients for whom we provide care. We need ways to develop new tools: informatics, evidence-based medicine, and the age-old issue of helping patients with the significant behavior changes necessary for optimal health. We need to develop ways of implementing new knowledge in fields such as genetics. We need curriculum to develop ways of enhancing the quality of what we do, decreasing errors, and fulfilling our commitment to society of high-quality, affordable, accessible care."

Thomas Schwenk, MD University of Michigan "Many new innovative educational programs, more emphasis on education and research in era of declining patient care revenue, redefinition of academic departments of family medicine according to academic and teaching missions rather than specialty referrals and downstream revenue, more community outreach, more distance education, more emphasis on cultural competency and outreach, more emphasis on less remunerative aspects of care such as chronic disease and end-of-life care."

Works Cited
1. General Accounting Office. [HEHS 94-164] Health Professions Education: Role of Title VII/VIII Programs in Improving Access to Care Is Unclear. Washington: GPO, 1994.

2. General Accounting Office. [HEHS-95-9] Medical Education: Curriculum and Financing Strategies Need to Encourage Primary Care Training. Washington: GPO, 1994.

3. United States Relies on Family Physicians, Unlike any other Specialty, The. Center for Policy Studies in Family Practice and Primary Care, 2000.

4. Politzer, Robert M., Hardwick, Kevin S., et al. "Eliminating Primary Care Health Professional Shortage Areas: The Impact of Title VII Generalist Physician Education." The Journal of Rural Health Winter 1999: 11-20.

5. Pugno PA, McPherson DS, et al. "Results of the 2000 National Resident Matching Program: Family Practice." Family Medicine 2000:32(8).

6. Council on Graduate Medical Education. Financing Graduate Medical Education in a Changing Health Care Environment (draft). Washington: GPO, 2000.

7. Bureau of Health Professions. Area Resource File, 2000 ed. Washington: GPO, 2000.

8. American Academy of Family Physicians. Report 155-Z. 2000.

9. Shekar, Sam. Personal Communication. 13 July 2000.