The Medical Education Futures Study Blog

A recent research brief examining Community Health Centers (CHCs) in Indiana indicates financial investment in CHCs will ultimately result in savings for health care systems – totaling $473 million for Indiana in 2007.  These savings come from the lower cost of health care in ambulatory settings and reduced spending on preventable emergency room visits and hospital admissions.

These savings offer a glimmer of hope in the current health care reform discussions and there is every indication that Congress plans to capitalize on this system by increasing funding to expand Community Health Centers.  The House Tri-Committee bill entitled America’s Affordable Health Choice Act increases CHC funding from the FY09 $2.19 billion authorization to $6.4 billion in FY19.

But these investments often ignore one critical issue – health centers are already struggling to recruit and retain the necessary primary care physicians to provide the health care services that increase access and lead to cost savings.  In fact, primary care is struggling across the practice spectrum.  Medical student interest in Family Medicine is at an all time low and more and more Internal Medicine residents are choosing to specialize rather than go into primary care.

Thankfully, Congress hasn’t been blind on this issue.  In the House Tri-Committee Bill, there are a number of pieces to strengthen primary care – including primary care bonus payments, expansion of primary care focused medical home demonstration projects, increased funding for primary care training programs, and the creation of a new Medicare Teaching Health Centers (THCs) project.  The THC model brings together components which will both strengthen the current CHC system and build the future primary care workforce.  

THCs would increase residency training in community-based ambulatory settings by directly funding health centers to run residency programs.  The current model of Federal support for residency training directs Medicare Graduate Medical Education (GME) payments to hospitals, who sponsor residency programs which are heavily weighted towards the needs and specialty-based culture of most hospitals.  Providing funds directly to health centers would promote the establishment and support of residency programs focused on the community-based primary care culture of most health centers.

Placing residency programs in health centers would immediately augment the current workforce as residents provide service.  Teaching increases buy in and retention for health center physicians and THC graduates are much more likely to continue practicing in health centers and in primary care.  THCs also have an added benefit when located in CHCs which provide care to the uninsured pre-Medicare population – without health care these individuals will ultimately cost Medicare much more than if their medical conditions were well treated prior to Medicare entry.

All in all, an investment in Teaching Health Centers will lead to a more robust Community Health Center system, cost savings for the entire health care system and a primary care workforce that will be needed to care for the growing and aging American population.

The total number of PGY-1 residency positions offered and filled increased again this year, with 400 (1.9%) more PGY-1 positions filled.  However, despite a promising increase in family medicine position filled last year, the number of positions offered and filled is down again this year - 100 fewer positions were offered and there were 75 fewer positions filled (Figure).

Figure. Results of the NRMP, 1997-2009, for Family Medicine Positions Offered and Filled (Source: AAFP)

The number of internal medicine and pediatric positions offered and filled rose incrementally, but increases in these PGY-1 positions will not necessarily equate to more primary care as more and more of these residents are choosing to further specialize after their initial “primary care” residencies.

Congress is increasingly recognizing the physician workforce and medical student specialty choices as critical components to developing a health care system in the U.S. that is equitable, accessible and cost-effective.  But the 2009 Match is another step in the wrong direction and hopefully it sends a message.  The time to act is now.  

While much of the primary care stimulus funding was cut out in the Senate version of the Stimulus package, it was restored in a modified form in conference and signed into law by President Obama on February 17.  The final law gives a significant boost to community health centers - $500 million for services provided at CHCs and $1.5 billion for construction, renovation, equipment, and health information technology systems - and to the National Health Service Corps - $300 million for recruitment and field activities.  Primary care training funding received a modest boost of $200 million for Title VII and Title VIII of the Public Health Service Act and grants to training programs for equipment.

While increased support for CHCs and the NHSC are critical steps towards increasing care and access to underserved / uninsured communities, the relative levels of funding for these programs in comparison to the funding levels of the primary care training programs indicates a denial of what is and will be a core problem in providing health care to these communities and the nation.  Ultimately the question is - who will provide the health care that is funded through these programs?

CHCs and the NHSC rely heavily on primary care physicians to staff health centers and provide care in underserved areas.  But primary care is in crisis.  Medical students are entering primary care fields at all time low rates.  Yet the National Association of Community Health Centers (NACHC) report health centers currently need over 1,843 primary care providers and if they are to increase their reach, they will need over 15,000 additional primary care providers by 2015.

Solving the primary care problem in the U.S. will require changes in the physician payment system to reduce the income gap between primary care and specialist physicians and changes in the physician practice to maximize evidence based, quality care.  However, changes also need to happen in the primary care pipeline to ensure future medical students will choose to enter primary care fields and be ready to practice in the changing health system.  Many factors have been shown to promote primary care field choices - such as recruitment of students who intend to practice primary care, positive primary care experiences during medical school and strong primary care faculty - all of which are currently supported by Title VII grants.

Change needs to happen across the spectrum of the physician workforce - from practice and payment to recruitment and education.  It’s time to prioritize this issue and recognize the quick fix of funding CHCs and NHSC, without building the primary care workforce, will only lead to a future collapse of the system… to bright shiny health centers without the people to provide the health care within.

In 1954, Darrell Huff wrote a book entitled, “How to Lie with Statistics” which suggests the way statistical analyses are chosen and presented can bend the truth.  This month’s Health Affairs web exclusive suggests we could all use a review of this lesson.

On Dec. 4, Health Affairs released a package of web exclusives - a sort of point-counterpoint examining the relationship between physician supply, workforce composition and health care quality.  Buz Cooper’s article: States with More Physicians Have Better Quality of Health.  Baiker and Chandra’s response: Cooper’s Analysis is Incorrect.

For the non-statistician, Baiker and Chandra’s arguments are at times confusing and Cooper’s graphics appear compelling.  Cooper finds that states with more physicians per capita generally rank higher in state health care quality rankings.  He also finds that states with more specialists are associated with higher state incomes per capita. 

But, does this mean that more specialists result in better quality (Figure A) or does it mean that higher income results in better quality and incidentally more specialists (Figure B)?  Where is the true causal relationship?  Are more specialists only a representation of higher income and otherwise unrelated to quality?

In this case, income might be considered a “confounding factor” – in other words, income is related to both quality and the number of specialists, and the failure to control for income in the analysis may lead to an inaccurate conclusion that more specialists equals better quality.  These are hypothetical arguments.  I have not done the analysis either to support or negate Cooper’s arguments.  However, Baiker and Chandra find that when they compare areas with the same number of total physicians, areas with higher generalist to specialist ratios have better quality and lower costs.

On Nov. 10, the Wisconsin Council on Medical Education and Workforce released an update to its 2004 report Who Will Care for Our Patients?  The report is well researched and well thought out.  It concludes Wisconsin has a current maldistribution of physicians within the state and a current shortfall of 374 primary care physicians.  However, one of the report recommendations particularly struck me.  The recommendation -

     Attract physicians to Wisconsin and keep them here.

In fact, the physician workforce issue is a national issue.  In Oct. 2008, the AAMC reported on 22 state reports on physician shortages and 5 national studies on the physician workforce.  Simply pulling physicians to our own state of choice will not solve the problem.

Wisconsin is at the head of the class on the physician workforce issue.  The very existence of the Council on Medical Education and Workforce, a result of the 2004 report, is an indicator of the level of collaboration of both private and public organizations within the state to address this critical issue.  And it is appropriate to have state level organizations examining this issue, as physician workforce needs will vary depending on current state and local workforce compositions and needs for healthcare.  But the question is - if Wisconsin is successful, what happens to the workforce needs and the health status of the states they recruit from?

The Wisconsin recommendation points to the need for a national level “council” to develop a US physician workforce that meets the needs of all states and communities.  It is quickly becoming clear that a well thought out physician workforce will be a critical component to any kind of health care reform.  It’s time to make this issue a priority and develop a national level health care workforce institute with the funding and political will needed to provide the research, analysis and guidance to create this workforce.