Mr. Chairman, we would like to thank you for the opportunity to provide this statement for the record on behalf of funding for family medicine training and second for the Agency for Health Care Research and Quality (AHRQ).

HEALTH PROFESSIONS: THE PRIMARY CARE MEDICINE AND DENTISTRY CLUSTER

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 FY2002 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 $169 million for FY 2003, of which $96 million is needed for family medicine.

This statement is designed to show the committee how its investment is paying off. This statement will discuss the success of these programs and include recommendations 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 statement 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.

President’s Budget Request for FY 2003 Zeros Out Primary Care Funding
The President’s budget zeroes out funding for the Primary Care Medicine and Dentistry cluster. In addition, the proposal includes only $94 million for all of the Health Professions programs, a sharp cut of 75 percent from the FY 2002 level of $378 million. The proposal emphasizes that the grants were developed in response to a physician shortage, as it did last year, although the document acknowledges a geographic maldistribution of doctors. The budget also claims, “most of the health professions grants have not proven effective because they do not accurately address current health professions problems.” According to several studies (see below), Title VII dollars have proven effective in addressing several major health professions problems.

Family Medicine Training Programs Are A Success
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:

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."

In another report, the GAO 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.

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:

Section 747 Advisory Committee Recommends Higher Funding
In 1998, Congress established an Advisory Committee to review and make recommendations on Section 747. The Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD) recently released their recommendations to Congress and the Secretary of the Department of Health and Human Services. The first of six recommendations urges greatly expanding federal support for Section 747 to $198 million. The Committee notes the growing need for primary care providers, as well as the success of Title VII funded programs.

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.

Future Funding Priorities
ACTPCMD’s report to Congress lays out priorities for training primary care providers. If additional funds are made available, Title VII dollars could enhance current training, allowing it to be even more effective at providing:

Primary Care Training Programs React Quickly to Emerging Health Challenges
Title VII dollars have created an infrastructure that allows educational programs to respond to contemporary health care issues. Specifically, the ACTPCMD report states that:

Mr. Chairman, 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, we 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). In it’s recent reauthorization, Congress established within the Agency a Center for Primary Care Research to “serve as the principal source of funding for primary care practice research in the Department of Health and Human Services.” The statute defined primary care research as research that “focuses on the first contact when illness or health concerns arise, the diagnosis, treatment or referral to specialty care, preventive care, and the relationship between the clinician and the patient in the context of the family and community.

Funding Request For AHRQ
We recommend appropriations of $390 million for the Agency for Healthcare, Research and Quality (AHRQ) in FY 2003. AHRQ conducts primary care and health services research geared to physician practices, health plans and policymakers that helps the American population as a whole.

President’s Budget Request for FY 2003 Cuts AHRQ Funding
The President’s budget includes $251 million for AHRQ, a cut of $49 million, or 16%, from the current funding level of $300 million. One unfortunate consequence of earlier earmarking of funds for the agency is that a cut of $50 million is felt disproportionately throughout the agency. A cut of this magnitude would result not only in the inability to provide new grants or contracts in FY2003, but would also mean a 46% cut in existing grants and a 31% cut in existing contracts. The budget also makes funding for the agency completely dependent on transfers from other agencies, rather than on a Congressional appropriation. This is a less secure funding method for this important agency.

What Does AHRQ Do?
AHRQ’s three goals are to 1) improve physician practice and Americans’ health outcomes, 2) improve the quality of health care (e.g., patient safety), and 3) improve the health care system (e.g., increase access and reduce costs). In brief, AHRQ “helps to improve the health and health care of the American people…” (AHRQ report, March, 2001).

How Does AHRQ Meet Its Goals?
AHRQ translates research findings from basic science entities like the National Institutes of Health into information that doctors can use every day in their practice with their patients. Another key function of the agency is to support research on the conditions that affect most Americans.

AHRQ Translates Research into Everyday Practice
Congress has provided billions of dollars to the National Institutes of Health, which has resulted in important insights in preventing and curing major diseases. AHRQ takes this basic science and produces information that physicians can use every day in their practices. AHRQ also distributes this information throughout the health care system. In short, AHRQ is the link between research and the patient care that Americans receive. An example of this link is basic science research showing that beta blockers reduce mortality. AHRQ supported research to help physicians determine which patients with heart attacks would benefit from this medication.

AHRQ Supports Research on Conditions Affecting Most Americans
Most typical Americans get their medical care in doctors’ offices and clinics. However, most medical research comes from the study of extremely ill patients in hospitals. AHRQ studies and supports research on the types of illness that trouble most people. AHRQ looks at the problems that bring people to their doctors every day – not the problems that send them to the hospital. For example, AHRQ supported research that found older antidepressant drugs are as effective as new antidepressant medications in treating depression, a condition that affects millions of Americans.

Institute of Medicine Recommends $1 Billion for AHRQ
The Institute of Medicine’s report, Crossing the Quality Chasm: A New Health System for the 21st Century (2001) recommended $1 billion a year for AHRQ to “develop strategies, goals, and actions plans for achieving substantial improvements in quality in the next 5 years…” The report looked at redesigning health care delivery in the United States. AHRQ is a linchpin in retooling the American health care system.

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: