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Teaching Health Centers

Teaching Health Centers. A pilot reform of the graduate medical education system. Introductions. MS4 at Loyola Stritch School of Medicine in Chicago Inspired by Community Health Center (CHC) experience in 3 rd year

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Teaching Health Centers

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  1. Teaching Health Centers A pilot reform of the graduate medical education system

  2. Introductions • MS4 at Loyola Stritch School of Medicine in Chicago • Inspired by Community Health Center (CHC) experience in 3rd year • When looking for CHC-connected Family Medicine Residencies (FMRs), came across the term “Teaching Health Center” (THC) • Subsequently matched at one of the “Original 11” • In addition, survey of THC applicants had recently been completed, but not yet analyzed

  3. Objectives • Describe the complex history of THCs • Present the survey results of 2012 applicants • Utilize the expertise in the room • Refine survey analysis • Discuss possible THC action items

  4. What is a THC? • Old idea • Connecting CHCs and FMRs • New legislation • Section 5508 of Patient Protection and Affordable Care Act (2010) • Why?

  5. Origins of the CHC Movement • Originated in apartheid South Africa with John Cassel and Sidney Kark • Brought to the US by Jack Geiger and Count Gibson • First two U.S. CHCs in Massachusetts and Mississippi delta in the 1960s

  6. CHC Principles • Fusion of primary care and public health • Community-based and community-driven • “Epidemiological assessment of demographically defined communities, prioritization, planned interventions and evaluation” • “Their commonsense holistic philosophy came from an understanding that good health is impossible if you have to choose between food, rent and medicine”

  7. Brief Political History of CHCs • Initial federal adoption as a result of Ted Kennedy visiting the CHC in Boston • Started under institutional partnerships, but these broke down as local communities pressed for local control • Community-based board regulations enacted over presidential veto in 1975 • Block grant legislation under Reagan in 1981 • Reversed the legislation despite presidential veto in 1985 • Largest growth under the two Bush administrations

  8. Why such legislative success? • Strong community buy-in • Powerful local leaders • Provides concrete services where they are needed most • “Only two groups of people…”

  9. CHCs Today • Federal Funding of 2.6 billion annually • 2 billion more from the stimulus bill and another 11 billion in PPACA • 1,131 Centers with 8,000 sites serving 18 million people • 70% below poverty line, another 20 % near poor • 63% Minorities and 40% uninsured • Studies show despite more complex and sicker patients, outcomes are better, hospital admissions lower and ER visits less

  10. Supporting Programs • Federal Tort Claims Act (FTCA) • 340B Drug discount program • Provides 20-50% in total savings • FQHC Look-alikes

  11. Graduate Medical Education (GME) The other side of the THC coin

  12. Quick Summary of GME in the U.S. • First connected to Medicare in 1965 • Has since become backbone of GME funding • Especially for centers who lack substantial NIH support • Based upon direct and indirect costs estimates • Indirect being tied to inpatient care provided to Medicare recipients • Positions capped per the balanced budget act (BBA) in 1977 • Fiscal Year (FY) 2009 Fund distribution • 9.5 billion from Medicare • 3.2 billion from Medicaid • 800 million from Veteran’s Affairs (VA)

  13. Common Critiques of GME • Payments have limited relationship to costs • Minimal Accountability • Financial incentives for inpatient-based and subspecialty programs—since BBA: • 46 FM programs closed • 133 subspecialty fellowships opened • Unable to match specialty mix and geographic distribution with population needs

  14. Who Loses?Connecting GME back to CHCs • Since 1996, a 52.6% decrease in US Med students going into Family Medicine • Currently, 31% of total MDs practice primary care • And only 25% of grads are planning to do it • National Association of Community Health Centers (NACHC) projects an additional 15,000 providers will be needed to cover their patients by 2015 • In perspective—for 2011: • 25,020 residents matched, with 2,555 in FM

  15. CHC-FMR Partnerships: A Possible Solution? • Not a new idea at all (original CHCs had visiting residents) • But, has been formalized and institutionalized with mixed results • Natural partnership • Common commitments, increased sustainability, strong educational environment, and improved patient outcomes • But, significant challenges • Contrasting missions, chronic underfunding of both parties, and asynchronous governing bodies with vastly different oversight regulations

  16. Section 5508 of the PPACA The first “Teaching Health Centers”

  17. Section 5508 at a Glance • 230 million for FY 2011-2015 • For primary care GME programs based out of a health center • Not required to be a FQHC or look-alike • First awards given in January 2011 to 11 of the 24 programs that applied • In 2012, 11 more recipients selected giving total of 22 THCs • Will not reach $230 million cap without significant further expansion • Central impact: GME funds given directly to outpatient site and with significantly increased accountability measures

  18. The “Original 11” • 9 FM, one IM, one Dentistry • 6 of 11 directors run CHC and FMR • 5 include rural training • All 11 use EMR and are either FQHC or FQHC-look alikes

  19. Survey Results 2012 Interviewees of THCs

  20. Methods • Population studied: • All applicants that received interviews a THC for 2012 • 549 surveys sent, with 282 responses • 51% response rate • Some items written to mirror other common survey results • Graduation Questionnaire (GQ) • ERAS and NMRP data

  21. Birth by State High School by State

  22. Race/Ethnicity

  23. U.S. Grads vs. FMGs

  24. Public vs. Private Med School

  25. Other Demographics • Average age: 29.8 years • High School: 74% public, 26% private • Marital Status: 52% single, 43% married, 3.5% domestic partnership

  26. Residency Selection Criteria

  27. Residency Selection cont. • Other specialties considered: • 23% IM • 15% Peds • 8% OB/GYN • Average total THC programs applied to: • 1.4 • Only 69.5% of interviewees had ever heard of THCs before interviewing

  28. Future Practice Plans

  29. Future Practice cont.

  30. Determining Future Practice

  31. Future Practice Criteria

  32. Results Summary • Possible challenge with diversity? • Significant interest in underserved and rural medicine • Looking for strong faculty and research opportunities • Significantly less interested in salary and social opportunities • Limited knowledge of THCs

  33. Next Steps… • THCs have incredible potential • Possible impetus for GME restructuring • Institutionalized pipeline for CHC providers • What can THC residents do?

  34. Suggested Action Items • Education • Re-distribute slides and reference list • Shared webinar of UDS mapper • Advocacy • Shared 2-pager • arrange site visits • Research • Select 2-3 best practices and scale up? • Communication • Blog • Exchange rotations? • Future? • THC Faculty Development Fellowship

  35. Thank you Robert Graham Center!

  36. References Blewett LA, Smith MA, Caldis TG. Measuring the Direct Costs of Graduate Medical Education Training in Minnesota. Acad Med. 2001; 65: 446-452. Covey AS, Friedlaender GE. Financing Graduate Medical Education: Sorting out the confusion. Journal of Bone and Joint Surgery. 2003; 85: 1594-1604. Fryer GE, Green LA, Dovey S, Phillips RL. Direct Graduate Medical Education Payments to Teaching Hospitals by Medicare: Unexplained Variation and Public Policy Contradictions. Acad Med. 2001; 76: 439-445. Geiger HJ. Community-Oriented Primary Care: A Path to Community Development. Amer J of Pub Health. 2002; 92: 1713-1716. Jones TF. The Cost of Outpatient Training of Residents in a Community Health Center. Fam Med. 1997;29:347-52. Jones TF, Culpepper L, Shea C. Analysis of the Cost of Training Residents in a Community Health Center. Acad Med. 1995; 70: 523-531. Lefkowitz B. The Health Center Story: Forty Years of Commitment. J Ambulatory Care Manage. 2005; 28: 295-303. Morris CG, Chen FM. Training Residents in Community Health Centers: Facilitators and Barriers. Ann Fam Med. 2009;7. Morris CG, Johnson B, Kim S, Chen F. Training Family Physicians in Community Health Centers: A Health Workforce Solution. Fam Med. 2008;40:271-6. Mullan F, Epstein L. Community-Oriented Primary Care: New Relevance in a Changing World. Amer J of Pub Health. 2002; 92: 1748-1755. National Association of Community Health Centers, Robert Graham Center, The George Washington University School of Public Health and Health Services. Access Transformed: Building a Primary Care Workforce for the 21st Century. Bethesda, MD; 2008. Patient Protection and Affordable Care Act, P.L. 111-148, 111th Congress, 2nd Session (2010). Phillips RL, Turner BJ. The Next Phase of Title VII Funding for Training Primary Care Physicians for America’s Health Care Needs. Ann Fam Med. 2012; 10: 163-168

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