 |
 | |
        | |
Archives 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 John Dickinson, MD
10:00 a.m. On
behalf of Mr. Chairman, I am John Dickinson, MD, Chairman of the Department of Family Medicine at the University of Rochester School of Medicine & Dentistry, and President of the Association of Departments of Family Medicine. I am grateful for this opportunity to discuss funding for two programs under your jurisdiction that are of great importance to the Organizations of Academic Family Medicine. I wish to highlight the need for increased FY2000 appropriations for Health Professions Training, specifically the Primary Care Medicine and Dentistry Cluster under Title VII of the Public Health Service Act, and for the Agency for Health Care Policy and Research. We recommend a FY2000 appropriation for Section 747, the Primary Care Medicine and Dentistry Cluster, of $133 million, of which $87 million is needed for family medicine training. We support a budget allocation of $225 million for ACHPR, of which at least an additional $25 million should be directed to the Center for Primary Care Research. We understand the difficult decisions you face this year, given the restrictions on spending included in the budget resolution. We intend that this testimony will provide the information you need to continue supporting these programs as you have so generously done in the past. Title VII, Primary Care Medicine and Dentistry Cluster (Including Family Medicine Training) Mr. Chairman, health professions training programs were reauthorized just last year - unanimously in the Senate. Their new and more efficient format is the result of a major effort over several years to streamline and refocus the many programs included in Titles VII and VIII. Instead of over 40 line items, the programs are now clustered into several related groups. To assure successful implementation of this new authorization, the Health Resources and Services Administration (HRSA) and the Division of Medicine (DoM) have engaged our organizations to help craft project criteria and implementation strategies that are responsive to current national priorities and pertinent to our health care system. We are concerned that the President's FY 2000 budget recommends zero funding for the Section 747 Primary Care and Dentistry cluster. Congress was right when it reauthorized these programs, recognizing the need for a continued federal role. This testimony provides evidence that these programs are effective and affirms the importance of your continued and enhanced support. Success in Meeting Congressionally Mandated Goals The goals stipulated by Congress that emphasize both the delivery of health services to underserved populations and the geographic distribution of health professionals to underserved, particularly rural, areas are fully addressed by these programs. For family medicine, all four program areas have been extremely successful in these regards. Specifically, in FY99, ALL residency training programs that were funded under this program met the underserved preference criteria. Unfortunately, only one-third of those who met the criteria could be funded. Another 44 applications that met the underserved preference could not be awarded due to lack of funds. Outcome data from the Division of Medicine for FY99 reveal that 42% of graduates of family medicine programs funded under Title VII enter practice in medically underserved communities. That number is three to four times greater than the percentage of those who enter practice in medically underserved communities from all health professions. As for departments, in recent years, Title VII projects have greatly influenced the establishment of departments of family medicine in approximately a dozen medical schools. As a direct result, only eight of 115 schools of medicine are currently without departments of family medicine. Predoctoral training grants have provided critical leverage in the struggle to create meaningful family medicine clerkships in our nation's medical schools. Currently there remain only two dozen schools that do not require a family medicine clerkship or rotation. Faculty development project grants have been successful in providing essential teaching, administrative, and leadership competence necessary to creating skilled faculty and encouraging their retention. A 1997 study of three part-time faculty development fellowship programs that received Title VII funds demonstrated their success in training and retaining new faculty in family medicine. Seventy-six percent of these faculty remained in their academic positions and half were teaching in medically underserved settings. Another Congressional priority is to enhance the diversity of our medical workforce. In 1978, the first year for which we have data, the number of minority persons in training in family practice residency programs was 9.5%. By 1997, that rate had increased to 24%. Why is a Continued and Enhanced Federal Role Necessary? We request an increase in support for the Primary Care Medicine and Dentistry Cluster from the current level of $80 million to $133 million. Of this total, $87 million will be needed to address the challenges that continue to face family medicine training, an increase from the current level of $50.5 million. Is this money well spent? Two General Accounting Office (GAO) reports have addressed the return on our investment in these programs. One 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..." (emphasis added). A second report states that "students who attended schools with family practice departments were 57 percent more likely to pursue primary care." In addition, this report concludes 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. Title VII has been a powerful catalyst to grow both the quality and the capacity of our much needed family medicine training programs. Here are just two examples from my own institution that illustrate the importance of these programs. At the University of Rochester, our current family medicine department grant was a vital stimulus for our growing research infrastructure. The grant enabled our department to develop capacity to focus research in two areas that are distinctly primary care/family practice in flavor. One is to explain the widely recognized differences in health status (for example, higher perinatal mortality) between impoverished populations and those with means. A second is to identify those characteristics of families - structure, relationships - that influence health and healing. As a direct result of this effort, our faculty have increased their production of original research by nearly 30% in three years. A second grant for predoctoral training has given us the leverage we needed to change our medical school's core curriculum and to establish a required third year clerkship in family medicine. Our clerkship is an immersion experience in the offices of family physicians throughout the region. Over the last two years, 70% of our clerkship students spent this time among rural and underserved populations. Why are additional resources needed? Simply put, too much remains to be done. Now is not the time to withdraw life-line funding from programs that are successfully meeting and exceeding federal policy goals of geographic distribution, diversity, and service to the disadvantaged. In fact, much more effort is needed. We know that primary care remains underdeveloped, but essential to meeting the health care needs of all our people. We must not only continue to address targeted policy goals but also push the discipline of family medicine into areas it has not historically been able to enter. We now have departments of family medicine in most medical schools. They are the only medical school departments that are devoted exclusively to primary care. Some are in their infancy, many in early adolescence. They require continued support to reach full maturity and citizenship. A critical next step for most is to develop a functional research infrastructure so that they might begin to address a host of unanswered questions about the delivery of primary care services: why do many patients want unnecessary antibiotics; what is the best way to manage intractable pain; which patients will respond to a particular program to stop smoking? Departments of family medicine need further development of: 1) adequate research infrastructure; and 2) data systems matched to the attributes and challenges of primary care. Both the faculty development and the department programs under Section 747 will help to accomplish this objective. Furthermore, the outcome will be relatively easy to monitor as research capacity and production. In the predoctoral arena, more needs to be done to bring family medicine into parity with other specialties in medical schools. While the curriculum of some other specialties routinely includes 10 or more weeks, family medicine, if required at all, is frequently only of four or six weeks duration. The addition of family medicine curriculum time to the medical school experience is key to improving the numbers of physicians choosing careers, not just in family medicine, but throughout primary care. Nationwide, hundreds of faculty positions in family medicine training programs remain unfilled. Faculty development programs are an effective means to encourage future faculty, to develop their teaching and research skills, and to prepare them for needed leadership in community-based settings, particularly those that are rural or otherwise underserved. In Title VII's faculty development area, a great deal of collaborative work among specialties is underway, now allowed and encouraged under the new authorization. The HRSA work group on faculty development has identified the need for four types of faculty development training. These include: "Primary Care Clinician Research Fellowships" to emphasize the development of primary care investigators; "Primary Care Master Educator Fellowships" for development of master teachers who can influence the educational process within medical schools; "Primary Care Faculty Leadership Development Fellowships" to train faculty for teaching and educational leadership roles in community-based training programs and departments; and lastly, "Community Preceptor Training" to develop locations and methods which encourage community preceptor participation. All of these program areas deserve continued and expanded support to meet Congressionally mandated goals, and to address the continued needs of primary care development. Agency for Health Care Policy Research (AHCPR) It is apparent that the key federal agency available to fund primary care research is the Agency for Health Care Policy and Research (AHCPR). AHCPR's mandate specifies clinical research that includes primary care and practice-oriented research. As departments of family medicine embark on efforts to develop capacity for primary care research within their institutions, we remain concerned that AHCPR has not been well funded over the years. We sincerely appreciate the efforts this committee made last year to increase AHCPR's budget by $25 million. This year even more needs to be done. The Friends of AHCPR recommend a FY2000 appropriation of $225 million for the Agency. This level of funding is needed for the Agency to fully carry out Congressional initiatives for improving health care quality, expanding the availability of health outcomes information, and evaluating the effectiveness of health care delivery. Furthermore, the availability of primary care research funding 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. At minimum, AHCPR should grow at the same rate as NIH. We also support the dedication of at least $25 million in funding to primary care research within the Agency for Health Care Policy and Research, with such monies targeted to the Center for Primary Care Research. This supplemental funding, with direction from Congress, will enable AHCPR to devote increased attention to primary care issues. It is estimated that approximately $18.6 million of the total federal investment in medical research is awarded to family medicine investigators. This figure compares with an NIH budget of over $15 billion dollars. Such limited funding 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 that arise from their own experience. Accordingly, a national primary care research agenda is crucial. If it is to thrive, primary care research requires a home within the mainstream of the federal scientific enterprise. The leadership of AHCPR has made a commitment to develop a Center for Primary Care Research within the agency. Such a center, if adequately financed, would provide an enormous stimulus to family physicians and other generalist investigators who conduct hundreds of millions of patient visits each year. Their research will address important questions, such as the following: 1) how 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; 2) how to help primary care providers and subspecialists to better coordinate their efforts and to provide a continuum of care to those patients with serious medical problems; 3) the development and assessment of clinical care guidelines that are designed to make the best use of this country's strained health care dollars. The new Center for Primary Care Research could ensure the future of much needed primary care research. If adequately funded, its programs will provide the nation with a great deal of information to help control health care costs and to 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 urge you to recognize the need for such a home by supporting 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 two main recommendations for the FY2000 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, the Primary Care Medicine and Dentistry Cluster, up to $133 million for FY 2000, of which $87 million is needed for family medicine. ·
In order to support critical practice-oriented primary care research, we are asking
that at least an additional $25 million be targeted to the Center for Primary
Care Research at the Agency for Health Care Policy and Research. We also ask that
the Agency be funded at $225 million.
| |