Teaching Health Centers - The Robert Graham Center
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Transcript Teaching Health Centers - The Robert Graham Center
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 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
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
What is a THC?
Old idea
Connecting
CHCs and FMRs
New legislation
Section 5508 of
Patient
Protection and
Affordable Care
Act (2010)
Why?
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
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”
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
Why such legislative success?
Strong community buy-in
Powerful local leaders
Provides concrete services
where they are needed
most
“Only two groups of
people…”
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
Supporting Programs
Federal Tort Claims Act (FTCA)
340B Drug discount program
Provides 20-50% in total savings
FQHC Look-alikes
Graduate Medical Education
(GME)
The other side of the THC coin
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)
Common Critiques of GME
Payments have limited
relationship to costs
Minimal Accountability
Financial incentives for inpatientbased and subspecialty
programs—since BBA:
46 FM programs closed
133 subspecialty
fellowships opened
Unable to match specialty mix
and geographic distribution with
population needs
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
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
Section 5508 of the PPACA
The first “Teaching Health Centers”
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
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
Survey Results
2012 Interviewees of THCs
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
Birth by State
Foreign
CA
NY
TX
WA
MA
PA
IL
MN
NJ
CO
OH
90
34
19
13
12
10
8
7
7
7
6
6
High School by State
Foreign
CA
NY
TX
WA
MA
PA
FL
IL
OH
MI
NJ
58
53
17
13
13
12
8
7
7
7
6
6
Race/Ethnicity
100%
12.00%
90%
White
80%
Axis Title
70%
Latino**
60%
10.00%
8.00%
Other
50%
40%
Pacific Islander
6.00%
Black
Latino**
30%
Black
20%
4.00%
Asian*
10%
2.00%
0%
Total
MS4s
(MD)
FM
Only
(MD)
Axis Title
THC
Only
(MD)
Native
American
0.00%
Total MS4s FM Only
(MD)
(MD)
THC Only
(MD)
U.S. Grads vs. FMGs
FMGs
71.39%
49.08%
47.94%
37.96%
29.63%
Total MS4s
(Applied)
Total MS4s
(Matched)
FM Only (Applied) FM Only (Matched)
THC Only
(Interviewed)
Public vs. Private Med School
Total MS4s
THC Only (MD)
Public
41%
Private
59%
Private
31%
Public
69%
Other Demographics
Average age: 29.8 years
High School: 74% public, 26% private
Marital Status: 52% single, 43% married, 3.5% domestic
partnership
Residency Selection Criteria
Residency Selection Criteria
Faculty
57.35%
Underserved setting or rotations
48.75%
Innovative Curriculum
48.75%
Proximity to Family
39.43%
Opportunities for significant other/spouse
27.60%
Teaching Health Center designation
25.81%
Rural setting or rotations
Income and benefits
Research opportunities
Proximity to social and cultural event
16.49%
12.19%
11.11%
10.04%
Residency Selection Criteria
MS4s vs. FM vs. THCs
70.00%
60.00%
Axis Title
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Faculty
Salary
Social/Recreation
Research
Total MS4s
42.00%
40.00%
26.00%
11.00%
FM Only
49.00%
41.00%
23.00%
2.00%
THC Only
57.35%
12.19%
10.04%
11.11%
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
Future Practice Plans
Underserved Area?
120.00%
100.00%
80.00%
No
60.00%
Undecided
Yes
40.00%
20.00%
0.00%
Total MS4s
THC Only (MD)
Future Practice cont.
Rural vs. Urban
70.00%
60.00%
50.00%
40.00%
Rural
Urban
30.00%
Other
20.00%
10.00%
0.00%
Total MS4s
THC Only (MD)
Future Practice Setting
Undecided or No Preference
20.83%
Rural/Unincorporated Area
Small Town(Population Less Than 2,500)
Town (Population 2,500 to 10,000—Other Than Suburb)
15.42%
8.33%
15.83%
Small City (Population 10,000 to 50,000—Other Than Suburb)
Suburb of a Moderate Size City
27.08%
17.92%
City of Moderate Size (Population 50,000 to 500,000)
Suburb of a Large City
Large city (population 500,000 or more)
31.25%
17.92%
27.50%
Determining Future Practice
80.00%
70.00%
60.00%
Percent
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
ALL
FM Only
THC Only
Birth
33.20%
40.89%
65.00%
Med School
37.99%
45.64%
63.00%
Residency
50.41%
60.98%
69.00%
Future Practice Criteria
Full-scope Family or Internal Medicine
53.60%
Underserved population
46.40%
Geographic location
42.09%
Proximity to family
33.45%
Opportunities for significant other/spouse
24.46%
Income and benefits
22.30%
Academic opportunities
21.94%
Federally Qualified Health Center (or look-alike)
National Health Service Loan Repayment site
Other Student Loan Repayment options
18.71%
15.11%
11.51%
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
Next Steps…
THCs have incredible potential
Possible impetus for GME restructuring
Institutionalized pipeline for CHC providers
What can THC residents do?
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
Thank you Robert Graham Center!
References
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1594-1604.
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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.
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2008;40:271-6.
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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 21 st 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.
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