Statement to The Subcommittee on Labor, Health and Human Services, Education, and Related Agencies House Committee on Appropriations concerning Family Practice Training Programs and Research
April 11, 2000

On behalf of
The Society of Teachers of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, and the North American Primary Care Research Group

Mr. Chairman, on behalf of faculty, researchers, program directors, and chairs of departments of family medicine, the Organizations of Academic Family Medicine are grateful for this opportunity to provide input regarding funding for two programs under your jurisdiction that are of great importance to our organizations and the nation. We wish to highlight the need for increased FY2001 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 Healthcare Research and Quality. We recommend a FY2001 appropriation for Section 747, the Primary Care Medicine and Dentistry Cluster, of $136 million, of which $87 million is needed for family medicine training. We support a budget allocation of $300 million for AHRQ, of which at least $25 million should be directed to the Center for Primary Care Research. This supplemental funding, with direction from Congress, will instruct AHRQ to devote increased attention to primary care issues.

We understand the difficult decisions you face yet again this year. We intend that this statement will provide the information you need to continue supporting these programs as you have so generously done in the past.

Primary Care Medicine and Dentistry Cluster (Including Family Medicine Training)
As we know the world is changing rapidly. Advances in computer technology and informatics, along with biomedical advances from the National Institutes of Health in the areas of genetics and applied molecular biology, have opened up new avenues for the practice of medicine. In just those three areas, genetics, applied molecular biology and informatics, a large amount of work needs to be done regarding its applications in the primary care arena. Departments of family medicine and other primary care divisions in medical schools and residencies need to develop both the infrastructure and the curricula to train physicians in these new areas of endeavor. A corollary investment is needed. The Primary Care Medicine and Dentistry Cluster of the health professions budget is uniquely able to use such an investment wisely, and leverage the funds expended into successful programs. We are concerned that once again, the President's FY 2001 budget recommends zero funding for the Section 747 Primary Care and Dentistry cluster. These departments and residencies do not have the ability to fund their own investment in the future. Congress was right when it reauthorized these programs, recognizing that a federal role is still important and necessary for meeting areas of critical need. We ask that Congress continue its support for these valuable programs.

Today we provide evidence that these programs are effective and affirm the importance of your continued and enhanced support.

Success in Meeting Congressionally Mandated Goals
The Congressionally stipulated goals of 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 4 program areas have been extremely successful in these regards. Specifically, in FY99, the latest year for which we have data, 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. Of these faculty, 76% 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 post-rescission level of $49.3 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 in developing both the quality and the capacity of our much needed family medicine training programs. Here are just a few examples from the field:
· The State University of New York at Buffalo department of family medicine has used Title VII family medicine graduate training funds to start a Rural Training Track (RTT) in Olean, NY. There are now 7 family doctors serving rural communities in New York state and Ohio that graduated from the program. As a side effect, our faculty has decreased the peri-natal mortality rate in Cattauragus County by 30% using improved and stabilized primary care obstetrical services by connecting to a network that includes advanced, high risk university-based care when appropriate. The model has now been duplicated in 22 rural communities across the United States. Our publications evaluating the outcomes of these RTTs nationally show 76% of the graduates are serving in underserved rural communities.

· At the University of Maryland the Title VII family medicine funding has been instrumental in allowing us to completely change the mix of our faculty (then residents). In the early 1990's our full time faculty was 80% male and only 7% minority. With the assistance of the Title VII funds we consciously sought more minority residents and women residents. We also used funds to encourage more minority and women faculty to join the faculty and mentor their careers. In FY2000, we are now 40% male and 47% minority faculty. Of our 39 residents, 30 are women and 18 are minority. We anticipate that with successful additional funding we will be able to add three more junior minority women faculty in FY01. We have the highest percentage of minority family medicine faculty of any non-minority medical school.

· Outcomes from the University of Southern California Family Medicine department are also successful. Due to our Family Medicine Department expansion grant, we have efforts underway in a remote region within the northeast corner of California, at the city of Alturas in Modoc County. We have identified a critical need for a Primary Care physician, especially one with advanced obstetrics training. Through the Title VII grant we recently received, just such a physician has been identified and efforts to support her through electronic record keeping and videoconference capability are under way. This electronic tether will link to our 24 hour Healthcare Consultation Center to provide "after hours" urgent care for patients and thereby give relief to the practitioner. As we continue to work with Modoc County, some special needs were identified such as the lack of regular routine visits by Veterans Administration (VA) patients in this remote county and to facilitate specialty care referral. The closest VA facility for these residents is 4 hours away by car, with no bus or train service. This gap will be bridged by electronic means via link-up with the VA Medical Facility in Reno, Nevada. This organized "Rural Access Program" (RAP) has been recognized by the State of California as seminal to its efforts in rescuing distressed rural facilities.

Having learned of our efforts at Modoc and at Catalina Island, the Department has been contacted and asked to provide technical, clinical and administrative expertise to rural communities in Riverside and Imperial Counties. Both counties have an agricultural base and are U.S.-Mexican border corridor communities. The community groups have asked for our residents to be placed in their communities to help them, and we will further assist them by linking clinical sites together electronically to provide continuity of care for the migrant workers as they travel, especially the women and children. The exponential impact of the initial Title VII funds invested is beginning to take root.

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.

Second, in the predoctoral arena, more needs to be done to put family medicine on par with other specialties in medical schools. While time in the curriculum devoted to teaching some other specialties routinely includes 10 or more weeks, family medicine time is frequently only 4 to 6 weeks in duration, if it is required at all. The primary care doctor of the future must not only be able to communicate well with patients, but be able to synthesize the new achievements coming out of NIH, and use computers and informatics in new ways that will change the way medicine is practices. Support for the development of new curricula, including genetics and informatics is needed throughout the medical school experience, particularly in the predoctoral arena.

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. As the field of medicine changes, the areas of genetics, applied molecular biology and informatics will need a great deal of attention. Not only will a large amount of work need to be done regarding these applications in the primary care arena, but equipping the faculty with the expertise to teach in these areas is needed.

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 Healthcare Research and Quality (AHRQ)
It is apparent that the key federal agency available to fund primary care research is the Agency for Healthcare Research and Quality (AHRQ). AHRQ'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 AHRQ has not been well funded over the years. We thank this committee for its renewed support for the Agency and its appropriating increasing funds for it. The Friends of AHRQ support a budget allocation of $300 million for AHRQ. Of that we support at least $25 million to be directed to the Center for Primary Care Research. This level of funding is needed for the Agency to fully implement 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.

As you contemplate expanded levels of funding for the NIH, we ask that you include AHRQ in that support. At minimum, AHRQ 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 Healthcare Research and Quality, with such monies targeted to the Center for Primary Care Research. This supplemental funding, with direction from Congress, will enable AHRQ to devote increased attention to primary care issues.

It was estimated that less than $19 million of the total federal investment in medical research is awarded to family medicine investigators. This figure is in comparison to the over $17.8 billion NIH budget. This has impeded 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 all Americans and their family physicians, nor have there been adequate efforts to develop clinical applications in primary care from new basic science knowledge. Consequently, physicians in family practice, although they are the dominant providers of primary care services to the American people, have had little support in answering research questions arising from their own experience. It is for these reasons that we support greatly increased funding for AHRQ.

Congress has dramatically expanded NIH's budget in recent years, but other federal institutions, such as AHRQ, have not seen comparable growth rates. We believe this to be an oversight that must be corrected. NIH's research cannot be fully utilized if we do not know how, when, and why it applies to the everyday primary care patient. This is where AHRQ will make its contribution. Primary care is ripe for a period of discovery similar to what has been witnessed in genetics and molecular biology. AHRQ is the best place to fuel the linking of strong science to the further development of primary care. However, this cannot be accomplished without the necessary financial support.

Accordingly, a primary care research agenda is crucial. AHRQ is committed to its Center for Primary Care Research. The Center, when adequately financed, will provide new tools to family physicians and other generalists, who conduct hundreds of millions of patient visits each year. The agenda ahead includes 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. Research aimed at safe-guarding patients has become a national priority, and AHRQ is perfectly suited to carry out this task. Such research would also 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 guide day-to-day clinical decisions and 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. When 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. Now is the time to further the rapid growth of the Agency so that it may put research into practice, resolve the medical errors problem, advance medicine through informatics, and provide answers to questions that are so practical in everyday life for so many. 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 AHRQ.

Recommendations for Family Medicine Training and Research
The Organizations of Academic Family Medicine have two main recommendations for the FY2001 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 $136 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 Healthcare Research and Quality. We also ask that the Agency be funded at $300 million.