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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 Robert Schwartz, MD On
behalf of
Mr. Chairman, the Organizations of Academic Family Medicine would like to thank you for this committee's commitment to these programs. We appreciate the increased funding included in the FY2001 appropriations funding bill. Family medicine training programs are funded under Section 747, the Primary Care and Dentistry cluster, of Title VII of the Public Health Service Act. 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 $158 million for FY 2002, of which $96 million is needed for family medicine. I am here today to talk about how your investment is paying off. I would like to tell you about the success of these programs and about what still needs to be done. As you look at all the opportunities you have to fund domestic health programs you need to be able to make judgments about the value and utility of these programs. We have been asked in various venues to show proof that these funds actually do what they are intended to do. We must show that this money makes a difference. In this testimony we intend to do just that. In addition, we believe Congress also needs to understand what unmet needs exist in our nation - needs that these programs can successfully help address.
Let's take a first look at health professions training - specifically family medicine training. These programs are producing the outcomes that Congress has requested. In a current study, (currently submitted for peer reviewed publication), the Robert Graham Center For Policy Studies In Family Practice and Primary Care, has shown that federal funding through Title VII of family medicine departments, predoctoral programs, and faculty development has made a difference. The study shows that : " All three types of grants made a difference in producing more family physicians, and more primary care doctors. " Predoctoral and department development grants made a difference in producing more primary care doctors serving in rural areas, and more primary care doctors serving in primary care health professional shortage areas. " Sustained funding during the years of medical school training had more positive impact than intermittent funding. We must conclude from this data that this funding means that thousands of physicians are making different career choices, choices that positively affect millions of patients in underserved areas and in primary care. Moreover, if this money were to "go away" fewer students would be making these career choices. Other indicators of success The
federal government's independent General Accounting Office (GAO) has also shown
that this money works. The 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." Loss of funding for family medicine training would cause tremendous impact on service to the underserved Data show that if production of family physicians was 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 health professional shortage areas, or HPSAs. This holds true even in comparison with the combined loss of internists, pediatricians and obstetrician/gynecologists. 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. The bottom line is that without family physicians 1332 counties would qualify for primary care HPSA designation vs. 176 counties if others were withdrawn. WHAT IS THE UNMET NEED? WHY MUST WE CONTINUE TO FUND AND GROW THESE PROGRAMS? According to a study by Politzer, et al (The Journal of Rural Health,Winter,1999) Title VII funding is key to ending HPSAs. 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 than the other two primary care specialties. Title
VII funding has indeed accomplished many of the objectives for which it was designed: The training enterprise that does not value primary care either financially or otherwise is a key part of the problem. Title VII funds that support the infrastructure and stability of family medicine departments in medical schools have to be sustained in order to keep producing the current levels of primary care physicians and, more specifically, those who will practice in rural and other underserved areas. Clearly, the programs of Title VII are on the right track toward meeting the health care challenges of the 21st century. So, while we believe that current funding must be maintained, more needs to be done. Program Priorities for the Future 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: WHAT LEVEL OF FUNDING WOULD BE NEEDED TO MAXIMIZE THE IMPACT OF THE TITLE VII PROGRAM? The Organizations of Academic Family Medicine support funding for Section 747, the Primary Care Medicine and Dentistry Cluster of Title VII of the Public Health Service Act, at $158 million for FY2002. This allows for $96 million to fund family medicine training programs under this cluster. We also support the Health Professions and Nursing Education Coalition (HPNEC), which advocates continued support for the health professions and nursing education programs authorized under Title VII and VIII of the Public Health Service Act. HPNEC recommends at least $440 million for Title VII and Title VIII in FY 2002. This recommendation is the first stage of a two-year effort to increase funding to $550 million, which HPNEC has determined to be necessary for the programs to improve the quality, geographic distribution, and ethnic diversity of the health care workforce, particularly in underserved areas. These figures do not include funding for the children's hospitals graduate medical education program, an amount separate from Title VII and VIII funding. The family medicine organizations support an increase in funding of the primary care and dentistry cluster to $158 million to allow for $96 million for family medicine training. We attained this figure by adding current levels of funding to the additional funding needed to address new areas of unmet need. Basically, we looked at the level of approved but unfunded grants through these programs - and only took the top 80% to ensure that only especially high quality grants would be funded. We took that figure and added on funding for the aforementioned new areas that need to be addressed, including geriatrics, genetics, and informatics, to reach a figure that is based in the real needs of our nation. We know that this committee has to weigh the value of funding various programs against each other. We hope that the evidence we have presented here will bring the committee to the conclusion that funding spent on these programs would bring value for the money and would be money exceptionally well spent. FUNDING FOR THE AGENCY FOR HEALTH CARE RESEARCH AND QUALITY(AHRQ) Mr. Chairman, once again, I thank you and this committee for increasing funding for this important agency. 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 the capacity for primary care research within their institutions, we appreciate the increase in funding within the Agency in recent years. However, we remain concerned that the increases in funding for AHRQ have been targeted to specific areas of research and there has not been an equally needed increase in investigator-initiated research. The Friends of AHRQ support a budget allocation of $400 million for AHRQ. This includes funding for patient safety, translating research into practice, outcomes research, and 350 new investigator-initiated grants. 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 continue to support 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 is estimated that less than one-fifth of 1 percent (.16 percent; approximately $28.7 million) of the total federal investment in medical research is awarded to family medicine investigators. This figure is in comparison to the almost $18 billion NIH budget. This has impeded family medicine researchers from developing vigorous investigation 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. 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 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 in addition to resolving the medical errors problem, it may put research into practice, 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 FY2002 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 $158 million for FY 2002, of which $96 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 a
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