Rich, Eugene C. MD; Mullan, Fitzhugh MD
Dr. Rich is Tenet Professor of Medicine, Creighton University School of Medicine, Omaha, Nebraska.
Dr. Mullan is Murdock Head Professor of Medicine and Health Policy, George Washington University School of Public Health and Health Services, Washington, DC.
Correspondence should be addressed to Dr. Rich, Department of Medicine, Creighton University School of Medicine, 601 N. 30th St., Omaha, NE 68131; e-mail: (firstname.lastname@example.org).
The Title VII primary care programs have been in place for over thirty years to improve Americans' access to primary care clinicians, especially physicians, through community based, primary care-focused education of students and residents, and preparation of faculty. Despite the long investment in these programs, however, U.S. medical students' interest in primary care has reached new lows. So it might seem obvious why the president's Office of Management and Budget (OMB) declared the Title VII primary care programs “ineffective;” But the OMB analysis aggregates these into an overall assessment of 40 separate Health Resources and Services Administration health professions programs. Furthermore the OMB evaluation of the Title VII primary care programs did not consider the outcomes most readily affected by these grants—those on the individual students, residents, faculty, and institutions. Accordingly, it does not reflect the important role of Title VII in building and sustaining primary care teaching over the years, an impact extensively documented in the accompanying articles. The Title VII primary care programs have struggled with diminishing levels of funding even as sources of support for specialized education have flooded into medical schools and teaching hospitals. What is most impressive about the successes of the Title VII primary care programs documented in the accompanying articles is not just the impressive record of accomplishment but that it occurred despite the powerful forces driving subspecialty care. Hopefully, the next generation of policy makers will use this important history to recommit to a national investment in primary care education.
This commentary is part of a theme issue of Academic Medicine on the Title VII health professions training programs.
The programs supported under Title VII, Section 747 of the Public Health Service Act (the Title VII primary care programs) have been in place for over thirty years. Dating back to the 1970s, these programs have focused on improving Americans' access to primary care clinicians, especially physicians, through community-based, primary care-focused education of students and residents, development of state-of the-art curricula addressing national priorities, and preparation of skillful and enthusiastic generalist faculty. Despite the three-decade investment in these programs, however, U.S. medical students' interest in primary care has reached new lows, with family medicine residency programs struggling to fill positions and the great majority of internal medicine residents choosing careers in medical subspecialties or hospital medicine.
Given these realities, it may seem easy to understand why the president's Office of Management and Budget (OMB) has declared that the Title VII primary care programs are “ineffective,” and why both Democratic and Republican Administrations have proposed to eliminate funding for them.1 Yet, the accompanying series of articles on the Title VII primary care programs document the successes of a variety of projects sponsored by these funds. How does one reconcile these stark differences in perspective? The problem arises in large part from the inherent challenges in evaluating the success of small and diminishing primary care training programs in an era of vastly expanded federal and commercial support for subspecialized training programs and practice.
Rather than conducting a separate evaluation of the Title VII primary care programs, the OMB report aggregated these in an overall assessment of 40 separate health professions programs administrated by the Health Resources and Services Administration (HRSA) in the Department of Health and Human Services Thus this evaluation encompassed not just the Title VII primary care programs but also the full range of health professions programs authorized under Titles VII and VIII, including such varied efforts as nursing training, nursing faculty loan repayment, separate geriatrics training grant programs for nurses and physicians, rural interdisciplinary training, rural and urban Area Health Education Centers, the Health Careers Opportunity Program, and the Center of Excellence programs to enhance the recruitment and success of underrepresented students and faculty. Given the breadth of these many very different HRSA programs it may not be surprising that OMB concluded the purpose of these programs to be diffuse, “subject to varying interpretations by interested parties,” and “not designed to have a significant impact on any one factor such as diversity, distribution, supply or quality of health professionals.”1 OMB further noted that these diverse health professions programs were not aligned with program goals in a way that made it easy to evaluate the impact of funding, policy and legislative changes. Whatever might be said about this methodological complaint by the OMB, their dismissive conclusions about the Title VII primary care programs are not reflective of those programs' importance in building and sustaining primary care teaching over the years, as the accompanying articles testify. Moreover, the Title VII primary care programs have struggled with diminishing levels of funding even as other sources of educational funding flooded into medical schools and teaching hospitals.
Federal funding for the Title VII primary care programs have declined a startling 10-fold in real dollars during the past 30 years, even before the recent and devastating shortfall in FY2006, when the remaining Title VII appropriations were cut in half. Accordingly, funds for discrete, targeted evaluation of these programs have been quite limited, as have resources for program directors to invest in new educational innovations. Even more important, these limited funds have declined relative to the resources available to support non-primary-care training in U.S. medical schools and teaching hospitals. During the past 30 years, funding from the National Institutes of Health has increased almost threefold in inflation-adjusted dollars, to $29 billion annually, and Medicare graduate medical education funding, currently more than $8 billion/year, has doubled in real dollars since its inception in 1985. These federal funding inequities relative to primary care training and evaluation are reinforced in medical practice, where Medicare reimbursement for clinical services has preferentially rewarded specialized practice, be it payments for procedural hospital services (e.g., orthopedic and cardiovascular)2 or mispriced specialized physician fees.3,4 As a result, funds available to support specialized programs at teaching institutions have increased exponentially relative to declining support for primary care teaching programs. In the face of this “storm surge” of federal programs supporting specialized care, perhaps what is most noteworthy about the Title VII primary care programs is not their limited impact, but rather the numerous and highly significant primary care-oriented initiatives they have promoted and sustained against the great pressures of numerous countervailing incentives.
There remain a variety of challenges to evaluating the true effectiveness of the Title VII primary care training programs. First is the burden that substantive assessments can place on the projects themselves. A recent report published by the HRSA Advisory Committee on Training in Primary Care Medicine and Dentistry highlighted the challenges to project directors posed by evaluation, including the cost, (e.g., money, time and effort) as well as the difficulties tracking former students and residents, and of developing and implementing appropriate project-specific outcome measures.1 The report identifies appropriate outcomes to be considered by policy makers in future evaluations of the Title VII primary care programs and notes that the outcomes most readily affected by these grants are those focused on (1) the students or residents (e.g., acquisition of knowledge and skills, satisfaction with curriculum, performance on standardized exams), (2) the curriculum (delivery of innovative material or of high-priority material such as training in cultural competence), and (3) the institution (e.g., improvements in faculty numbers or in curricular offerings). This extensive report offered the following recommendations regarding future evaluations of the effectiveness of Title VII primary care programs:
The outcome measures utilized to evaluate Title VII, Section 747 programs should reflect the program's statutory focus on health professional education and training.
Outcome measures should be identified that evaluate the synergistic role of Title VII, Section 747 programs with other Bureau of Health Professions (BHPr) programs, especially the National Health Service Corps (NHSC), as well as the Health Careers Opportunity Program (HCOP), Area Health Education Centers (AHECs), and Rural Interdisciplinary Training.
BHPr should develop procedures for data collection, analysis, and reporting of program outcome measures.
Additional financial resources should be made available to BHPr to implement effective evaluation processes for the programs in Title VII, Section 747.
The accompanying series of articles documents a wide variety of programs and curricula funded by HRSA's Title VII primary care training grants. Although the evaluation of the Title VII primary care programs could be improved, there is evidence of beneficial outcomes for learners at all levels, as well as for teaching institutions. HRSA Title VII primary care program grants have been the chief source of funds available to primary care physician training; therefore, few if any of the initiatives described in these articles would have occurred absent HRSA funding. In reflecting on the outcomes of the past 30 years of Title VII investments in primary care training, what is most impressive is not the record of success recorded in these articles but that these benefits have prevailed despite powerful forces driving students, residents, faculty, and institutions toward training in subspecialty care. One would hope that the next generation of policy makers will use this important history to recommit to a national investment in primary care education.
1 HRSA Advisory Committee on Training in Primary Care Medicine and Dentistry. Evaluating the Impact of the Title VII, Section 747 Programs; Fifth Annual Report to the Secretary of the U.S. Department of Health and Human Services and to Congress. Washington, DC: Health Resources and Services Administration; 2005.
2 Medicare Payment Advisory Commission. Report to Congress: Medicare Payment Policy. Washington, DC: Medicare Payment Advisory Commission; 2007.
3 Bodenheimer T, Berenson RA, Rudolf P. The primary care–specialty income gap: Why it matters. Ann Intern Med. 2007;146:301–306.
4 Medicare Payment Advisory Commission. Assessing Alternatives to the Sustainable Growth Rate System. Washington, DC: Medicare Payment Advisory Commission; 2007.