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| Testimony
to the Subcommittee on Labor, Health and Human Services, Education, and Related
Agencies House Committee on Appropriations concerning Family Practice Training
Programs and Research Presented
by Joseph Hobbs, MD
10:00 a.m. On
behalf of Mr. Chairman, I am Joseph Hobbs, MD, Associate Dean for Primary Care at the Medical College of Georgia, and President of the Society of Teachers of Family Medicine. I appreciate the opportunity to be here today to speak on behalf of the listed academic family medicine organizations in support of critical funding of family medicine training programs and research. SECTION 747, FAMILY MEDICINE TRAINING Mr. Chairman, this committee has been very supportive of health professions training in general, and family medicine training in particular. We appreciate that support and hope that you will be able to sustain your efforts in the coming fiscal year. We ask that you continue to value the family medicine training programs under Title VII as federal funds targeted where they can do the most good. We believe that the small amount of funding spent on Section 747, family medicine training, is money well spent. It is money that achieves its purpose -- the production of generalist physicians, and ones who serve in rural and urban underserved areas. Moreover, this funding sows the seeds for a more cost-effective utilization of health care dollars in the future. The Organizations of Academic Family Medicine ask this committee to support these programs at a new authorized and appropriated level of $87 million for Section 747, family medicine training. Section 747 family medicine training funds are used to help develop and maintain an infrastructure for the production of family physicians. Funding is used for the establishment of departments of family medicine within medical schools, the development of third-year clerkships in family medicine for medical students, the training of family practice residents, and development of teaching and education skills for family medicine faculty. We believe there is good justification for this funding level. This funding has been remarkably successful in the past several years in establishing departments of family medicine in approximately a dozen medical schools - leaving nine without officially announced plans for a department of family medicine. Moreover, according to Association of American Medical Colleges (AAMC) data, some two dozen of the nation's medical schools have yet to implement required third-year clerkships in family medicine. Of the residency training grants last year, which provide critical and innovative funding, 45 of the 49 grants met the funding preference with respect to service to the underserved. In other words, the money is well spent in meeting Congressionally mandated goals. Our recommended funding level is the result of a strategic plan for the future needs of family medicine developed by the Academic Family Medicine Organizations, which is represented by all five family medicine organizations, to maintain the production of needed family physicians. We further recommend a combined authority of $306 million for all health professions programs, equivalent to the amount this subcommittee and the House passed last year. How Do We Know This Title VII Money Is Well Spent? Two General Accounting Office (GAO), reports have addressed the question of how do we know this 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 of family medicine departments and divisions in medical schools..."(GAO/HEHS-94-164). 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. (GAO/HEHS-95-9) Title VII has helped build much needed family medicine training capacity and quality. Here is just one example from my own institution that illustrates the importance of these programs. A number of years ago we were awarded an innovative residency curricula grant to develop academic community partnerships with a network of rural health clinics in a four county area - an area that was a Health Professional Shortage area, unable to keep private physicians, and economically depressed. The success of that grant is in the development of self-sustaining rural health clinics as teaching sites, with residents and students providing care under the auspices of a teaching physician. Physicians graduating from this program have subsequently been hired to direct these sites and have stayed for the long term providing continuity of care, and living in the community that they serve. Why is a continued and enhanced federal role necessary? Simply put, now is not the time to withdraw life-line funding from programs that are successfully meeting and achieving federal policy goals. America needs family physicians to provide care to all individuals, from cradle to grave, in all areas of the country, in a cost-effective, high-quality manner. The Consensus Statement on the Physician Workforce1 states that "It is likely that many traditionally underserved communities will continue to have an inadequate number of physicians, particularly generalist physicians [emphasis added], to meet the needs of the population." The statement goes on to request that federal funds be provided to increase medical school student experiences in rural and inner city communities, and to call for "federal incentives to encourage students to pursue careers as generalist physicians and to establish practices in these communities." Other expert bodies have also spoken to the need for increased production of generalist physicians, particularly to address service needs in rural and other underserved areas. While we have historically supported a cap on the total number of resident slots, we have also advocated that 50 percent of those slots should be primary care. We have not yet reached that goal. Changes to Medicare do not support production of family physicians. We have found over the past year in our deliberations over funding for these programs that there seems to be a misunderstanding as to the relative use of Medicare graduate medical education funds (GME) and Title VII dollars. Some have made the argument that since Medicare funds residency training through GME there is no need for Title VII funding. I'd like to take a moment to discuss the difference between the aims and goals of the two programs. Medicare GME funding is money that is directed to hospitals to help defray the costs of having residents train in those institutions. Title VII dollars, for the most part, is money directed at medical schools and universities to help develop a primary care infrastructure within the medical school environment. Only about one-third of the nation's family practice residencies receive Title VII funding, and that money, unlike GME funds, goes to the program itself and is used to develop innovative curricula, linkages with community training opportunities, faculty development, and to maintain fiscal stability of departments of family medicine. Within the medical school environment, family medicine departments must compete with other departments without access to the same funding streams the others have. For example, the federal government has instituted conflicting incentives that have made it fiscally difficult to develop a family medicine infrastructure. Medicare reimbursement rates for procedural services, Medicare reimbursement for graduate medical education in a hospital setting, and the more than $13.5 billion a year spent on NIH research all serve to induce the academic medical environment to produce significantly more subspecialists than primary care physicians. Many of you may believe that the recent changes to Medicare graduate medical education funding, as passed in the Balanced Budget Act (BBA) of 1997, such as the capping of residency slots, will help reduce the nation's total production of physicians, while protecting the production of physicians who serve in rural areas. Unfortunately, this is not the case. While we wholeheartedly support the intent of the statutory changes, the implementation of some of them will have two unintended consequences: 1) penalizing family practice programs that have historically sent residents for training in non-hospital settings, including rural site rotations, while promoting such training for other specialties, and 2) restricting growth of all family practice programs, when 40 percent of their graduates serve in rural areas. These consequences are especially troubling since Congress intended support for production of rural physicians. The BBA recognizes and will pay for training in the ambulatory setting, if it is initiated after the 1996 cost reporting period. Any program, such as most primary care programs and particularly family practice, that had been sending residents out of the hospital for training, and had been bearing those costs themselves, will have to continue to do so without the help of GME funding. It is ironic that other specialty programs which now begin to train in ambulatory settings outside the hospitals will have those costs included in their GME funding. We believe this is an unintended consequence of the statute, but one that clearly penalizes family medicine training, where ambulatory training has been the hallmark of the specialty. Another change included in the BBA will restrict the growth of all family practice programs. We strongly support the statutory language that requires special consideration for the needs of underserved rural areas. We believe that those programs producing physicians who serve in rural areas, even though the program itself is not located in a rural area, should be supported and allowed to grow. There have been several recent expansions in family practice residency programs that include a rural training track, with residents located in outlying hospitals, or with satellite programs designed specifically to train residents to work with underserved populations. While these new programs or satellites required accrediting body approval, they are still definitely part of the "mother" residencies. As such, they are not technically new programs and hence are not exempt from the cap. We believe they should be allowed to grow. They are reasonable expansions, that given the current wording of the HCFA rule implementing the law, would not be allowed, but which would certainly meet the intent of the statute. Given these changes, it is even more apparent that the funding under Title VII of the Public Health Service Act is a critical factor supporting the production of family physicians. The infrastructure needed to produce them must be sustained, and funding directed at the production of physicians to serve in rural and underserved areas must be maintained. Title VII family practice training funds are directly targeted to those programs producing graduates to serve in rural and urban underserved areas. Why is Title VII so important to the production of rural physicians? Studies underway (Coltis, Colwill, personal communication) indicate that the ratio of rural physicians to population has been declining steadily over the past 50 years. Now, for the first time in half a century the ratio appears to be increasing. This increase is almost entirely a result of increased numbers of family physicians. Currently, half of U.S. rural counties are shortage areas. We have approximately 34 family physicians per 100,000 people in rural areas (1995 data). If our current level of production remains stable, by the year 2010, that number would increase to 42 family physicians per 100,000 individuals in rural America. This will go a long way toward alleviating current rural physician shortages, but is dependent upon future funding of family practice training programs. Title VII funding is critical to the continued support of family medicine training. Agency for Health Care Policy Research (AHCPR). Also of great concern to the academic family medicine community is funding for the Agency for Health Care Policy and Research (AHCPR). AHCPR's mandate specifies clinical practice research to include primary care and practice-oriented research. Research funding availability is an important factor in increasing the number of physicians who enter primary care medicine. We ask that as you contemplate expanded levels of support for the NIH, you include AHCPR in that support. We believe that AHCPR would be able to grow at the same rate as NIH. We support the dedication of at least $25 million in funding to primary care research within the Agency for Health Care Policy and Research. This money should be targeted to the newly established Center for Primary Care Research. This supplemental funding, with direction from Congress, will urge AHCPR to devote increased attention to primary care issues. It is estimated that less than $10 million of the total federal investment in medical research is awarded to family medicine investigators. This figure is in comparison to the over $13.5 billion dollar NIH budget. This has precluded family medicine researchers from developing vigorous investigational programs to guide family physicians and others in providing primary care. Consequently, while our country has invested in basic medical science research through NIH programs, there has been little support to answer questions of major concern to family physicians or to develop clinical applications from new basic science knowledge. As a consequence, physicians in family practice, although they provide the majority of care to the American people, have had little support in answering research questions arising from their own experience. Accordingly, a primary care research agenda is crucial. The AHCPR recently committed itself to establishing a Center for Primary Care Research within the agency. Such a center, if adequately financed, would provide new tools to family physicians and other generalists, who conduct hundreds of millions of patient visits each year. The agenda would include research to improve diagnostic accuracy and streamline the diagnostic process, while at the same time reducing inappropriate use of expensive, unnecessary or potentially dangerous medical tests. Such research also would help primary care providers and subspecialists to better coordinate their efforts to provide a continuum of care to those patients with serious medical problems. Finally, much of primary care research focuses on the development and assessment of protocols of care that are intended to make the best use of this country's strained health care dollars. One can look at primary care research as research into the best ways to implement the successes of biomedical research. In other words, how do we put the critical information derived from biomedical research to use in the population? This is the arena where research encounters the real person. This mandate to the agency has given hope that much needed primary care research would receive federal attention and support and be able to provide the nation with a great deal of information to help control costs of health care and improve, or reduce, morbidity and mortality. If we are ever to change the status quo in this country and examine the root causes of expensive and unnecessary medical care, research in family medicine and primary care is essential. This research has no home elsewhere in the federal government. We implore you to recognize the need for such a home and support the Center for Primary Care Research with dedicated funding within AHCPR. Recommendations for family medicine training and research. The Organizations of Academic Family Medicine have three main recommendations for the FY98 Labor/HHS Appropriations bill. They are as follows: · We ask that you continue your support for family medicine training, and bring the appropriations level for section 747 up to $87 million for FY 1999. · We ask the committee to express, in its report, the need for designated funding for family medicine training programs, even in light of a single authorization for primary care training programs. · In order to support critical practice-oriented primary care research we are asking that at least an additional $25 million be targeted to the new Center for Primary Care Research at the Agency for Health Care Policy and Research. We also ask that as you find ways to fund the critical biomedical research infrastructure within NIH, that you determine AHCPR to be critical to this nation's research infrastructure, and fund it in a like manner to NIH.
1
American Association of Colleges of Osteopathic Medicine, American Medical Association,
American Osteopathic Association, Association of Academic Health Centers, Association
of American Medical Colleges, National Medical Association.
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