TRAIN AND SUPPORT AMERICA’S PRIMARY CARE WORKFORCE Family Medicine’s Asks Hope R. WittenbergCAFM Director, Government Relations May 9, 2011
Training and Support Needed for America’s Primary Care Workforce Family Medicine’s Asks#1) Appropriate $71 million for Primary Care Training and Enhancement, a health professions program, for FY 2013#2) Provide $300 million for the National Health Service Corps for FY 2013 from the trust fund authorized by the Affordable Care Act.#2) Members of Congress should cosponsor HR 3667, our Medicare GME pilot bill for primary care training. Senators should consider cosponsoring a companion bill.
Ask #1: Primary Care Training and EnhancementAppropriate at least $71 million for Primary CareTraining and Enhancement authorized underTitle VII, Section 747 of the Public HealthService Act in FY 2013.
Primary Care Training and Enhancement Context• HRSA’s Primary Care Training program needs at least $71 million, to avoid a second year in a row without a competitive grant cycle.• The nation needs new initiatives relating to increased training in inter-professional care, the patient-centered medical home, and other new competencies required in our developing health system.
Ask #1: Primary Care Training• Enhanced funding is needed to help address increased primary care needs.• Current program prioritizes training in the new competencies relevant to providing care within patient-centered medical homes.• Without a new competition we get further behind in developing the innovative training needed for health system improvement.
Ask #1 – Increased Funding for Primary Care TrainingPushback #1: Too costlyResponse:• If we don’t modernize our primary care training now, we will not be able to keep pace with the developing health system.• More primary care production will help address increased health care costs and poorer health outcomes.• It’s not just “Invest now for future gains.” It’s “Don’t allow primary care health training to languish in an outmoded system.”
Ask #1 – Increase funding for Primary Care TrainingDon’t forget to add a personal story aboutTitle VII specifically or the need for more primary care.
Ask #1 – Increase Funding for Primary Care TrainingPushback #2: These programs are ineffectiveResponse:• The Institute of Medicine (IOM) pointed to the drastic decline in Title VII funding and called these programs an “undervalued asset.”• The Congressional Research Service (CRS) found that reduced funding to the primary care cluster negatively impacted the programs at a time when more primary care is needed.• Personal story if you have one
Ask #2: Funding the National Health Service CorpsProvide $300 million for the National Health Service Corps for FY 2013 from the trust fund authorized by the Affordable Care Act.Note: This is not an appropriations request, per se – it is funded out of a trust fund;however we don’t want Congress to deletefunding of the trust fund.
Ask #2: Funding the National Health Service CorpsPushback: Generally supported program – but too costly and funded from “Obamacare,” the Affordable Care Act.Responses:• In spite of a $5 m increase over last year, this funding won’t be enough to keep up the current field strength.• At this funding level, the field strength is projected to drop by over 30%, from just over 10 thousand primary care clinicians in FY 2011, to just over 7 thousand in FY 2013.• Don’t throw the baby out with the bathwater – fund this important program by whatever mechanism necessary.
Ask #3: Modernizing GME for Primary Care TrainingHouse Members: Cosponsor HR 3667, the Primary Care Workforce AccessImprovement Act of 2011.Senators: Consider introducing a companion bill to HR 3667
Why is a Pilot Needed?• Medicare GME is over 40 years old. • It is hospital-based • It is outmoded. • Primary Care physicians need to train in the community• The education of primary care physicians must be modernized • More of the training should be in nonhospital settings • Funding must be de-linked from inpatient hospital services • Costs and needs of training in the community setting must be identified – and paid for by Medicare GME • Entity whose primary mission is education should have control of the funding and the training.
Current Funding of Hospitals with GME Medicare Part A Trust Fund GME FundingOther communityambulatory sites $ $ Rural Locations Accredited $ Hospital ? Primary Care Physician’s Residency Offices Training program CHCs Nursing Accrediting Bodies Homes Program is accountable to
What would the pilot look like?● Budget neutral; five years● At least 4 organizational models tested (2 of each)● Robust payment amounts to accommodate: • High cost of training in the community; money would follow the resident • Provide incentives: - to medical students who choose a primary care - for training in underserved areas, - to increase participation by underrepresented minorities, and - to support hospitals in their staffing needs. • Provide accountability for the Medicare GME dollars• Endorsed by: National Rural Health Association, ACP, AOA, and American Geriatrics Society
Pushback #1 Won’t hospitals be harmed by this?Responses:• Inpatient training will still be necessary – and can be purchased by the program/entity in contract with a hospital.• Hospitals that have actually used their GME dollars for primary care training will actually gain income from the medical education entity.• We expect this budget neutral pilot will shift only about $50 million per year.• This is only a pilot – a test of new models. If they don’t work, no harm/no foul.
Pushback #2Why should Medicare pay for this kind of training? Medicare GME’s purpose is to aid hospitals with the increased costs of training residents. Medicare should only pay its share.Responses: – MedPAC and COGME believe we are not getting the product we need – both in numbers and in kind. – MedPAC Commission Chair, Glenn Hackbarth, “the training system is not producing what society needs. It doesn’t seem to be self-correcting; it cries out for intervention.” – With the advent of health care reform, we expect ~ 32 million new covered lives – all in need of primary care physicians.
Responses, cont. – Strengthening the primary care workforce will promote ambulatory and preventive care -- with the associated decreases in hospitalizations and ER use. – Better health for Medicare beneficiaries – and cost savings to Medicare Trust Fund – Primary care physicians are a critical piece of the physician workforce – key to caring for Medicare beneficiaries. The litmus test should not be how many Medicare patients they see in the hospital while training, but rather what patients will they be able to serve when they are out in practice. – Primary care training should not be given short-shrift in training funds just because the old formula hasn’t kept up with the times and changes in modes of training and patient care.
Pushback #3 Didn’t Health Care Reform take care of paying for training in the community setting?Responses:• We are very pleased with the legislative changes to count – Non-hospital training time – Didactic time – Vacation, sick and other leave• However, those only adjust the regulatory requirements in keeping with the Congressional intent established in 1997• The HCR bill did not modernize the way Medicare Graduate Medical Education system for primary care training
Pushback #4Isn’t the Teaching Health Center (THC) concept included in HCR a way to modernize primary care training?Responses:• We supported the THC, and in fact it fits in one of our models that our pilot would test.• However, it is not a Medicare modernization tool.• It is dependent on appropriated dollars, not Medicare.• It will not test other models that currently exist for primary care training.
Cuts to Medicare GME3. Fundamental position is don’t cut Medicare GME5. If cuts are needed: Keep Full GME/IME for core residencies – initial accreditation7. If more cuts needed: Keep Full GME/IME for primary care training, and other specialties in shortage
Training and Support Needed for America’s Primary Care Workforce Family Medicine’s Asks#1) Appropriate $71 million for Primary Care Training and Enhancement, a health professions program, for FY 2013#2) Provide $300 million for the National Health Service Corps for FY 2013 from the trust fund authorized by the Affordable Care Act.#3) Members of Congress should cosponsor HR 3667, our Medicare GME pilot bill for primary care training. Senators should consider cosponsoring a companion bill.#4) Protect Full GME/IME funding for primary care training.
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