Newton, Warren MD, MPH; Arndt, Jane E. MA
Policy support for primary care has been declining for almost a decade despite increasing evidence of the major contribution of primary care, both to the health of the population1–5 and to the quality and cost-effectiveness of health care.6–10 Despite this decreasing support, during the last five years a remarkable renaissance of interest in new models of primary care11–23 has occurred, along with both a rethinking of our federal research enterprise to support translation of innovations outside of academic health centers (AHCs)24,25 and an increase in proposals for financing care that supports a medical home with primary care as the center.26,27 At both the state and federal levels, there is more interest in health care reform—now with a focus on a personal medical home—than at any other time in the last 15 years. In this context, considering a federal role in strengthening primary care to improve the health of the population is more appropriate than ever. The experience of the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program can teach the academic medicine community important lessons about how it should help formulate future policy.
This article briefly answers three related questions: (1) What Title VII grant programs were available to family medicine, and what were their goals? (2) How did Title VII change the discipline? and (3) What impact did Title VII family medicine programs have outside the discipline? We focus on the four grant programs intended directly for family medicine—(1) grants to departments of family medicine (currently called Academic Administrative Units in Primary Care grants), and grants for primary care programs in (2) residency training, (3) predoctoral training, and (4) faculty development—although Title VII programs have supported many other primary care educational programs (e.g., geriatrics) as well as minorities in health professions. Our data sources include available historical records, grant guidelines and agency reviews, Health Resources and Services Administration (HRSA) Advisory Committee reports, published evaluations, unpublished working documents, and direct query of department chairs and leaders with experience with Title VII. We should underscore, however, that changes in administration policy have limited the availability of many key documents and that full evaluation of the impact of Title VII awaits review of many individual grants in their institutional contexts. Finally, one must exercise caution in attributing outcomes solely to Title VII; throughout its history, Title VII has been one of many influences, working in concert with medical school leaders, professional societies, certifying boards, and political activists, especially at the state level.
What Title VII Grant Programs Were Available to Family Medicine? What Were Their Goals?
Academic family medicine has had a unique relationship with Title VII. Since becoming a recognized medical specialty in 1969, funds designed to meet national primary care health workforce needs have provided substantial benefit to family medicine. After the new specialty began, the federal government allocated funds in 1976 to increase the total number of physicians in order to prevent a projected physician shortage. During the next three and a half decades, academic family medicine matured in parallel with the evolution of the Title VII grant program. During the 1970s and 1980s, the broad goals and flexible resources of Title VII played a crucial role in promoting the development of the growing discipline and supporting its emphasis on educational innovation. In the past 15 years (1993–2008), these federal grant programs have become more sharply focused on meeting specific national workforce objectives, such as improving care for underserved and vulnerable populations and increasing diversity in the health professions. Although these objectives are, in principle, congruent with the values of family medicine, their implementation has produced tensions between the changing needs and priorities of the discipline and the policy-driven requirements of Title VII. Nonetheless, Title VII grants have maintained their vital support for the continued development of academic family medicine.
Early federal initiatives
Before discussing the impact of this support both within family medicine and on academic medicine more broadly, it is necessary to understand the history of Title VII. This section briefly highlights some of the major legislative landmarks and then discusses specific grant programs that have influenced the development of family medicine. The Family Practice of Medicine Act of 1970 (Public Law [PL] 91-696) first recognized the training needs of the newly established specialty of family medicine; this act authorized grants for separate departments of family medicine and for training programs in family medicine for medical students, residents, and practicing physicians.28 However, Congress never implemented the act because procedural questions created uncertainty about its legal status, and eventually the appropriated funds were transferred to other Title VII programs supporting family medicine.
The Health Professions Assistance Act of 1976 (PL 94-484), generally seen as the start of the current Title VII program,29 defined primary care and included support for residency training in family medicine, general internal medicine, and general pediatrics. Because family medicine was a newly created specialty in greater need of support during its initial development, it received special consideration, with explicit priority given in legislation to family medicine residency training. This favored status (including also support for predoctoral training and faculty development, which was limited only to family medicine) continued until 1981, when faculty development grants were first made available for the disciplines of general internal medicine and pediatrics.29
The same act also authorized funds to support, as its name “Grants for Establishment of Departments of Family Medicine” suggests, the establishment of new family medicine departments in allopathic and osteopathic schools of medicine. This grant program, which eventually became the current Academic Administrative Units (AAU) program, played a key role in the development of the discipline of academic family medicine. After these new departments were formed, they were expected to develop educational capacity; Title VII federal support provided funds to strengthen fledgling departments so that they could interact on equal footing with other disciplines. A program guide from that period illustrates this quest for parity: “Grant-supported projects are to assist in establishing, maintaining, or improving family medicine academic administrative units which are comparable in status, faculty, and curriculum to those of other clinical units at the applying schools” [emphasis added].30
Establishment grants were very flexible, supporting a wide range of activities including “comprehensive planning, development, administration, coordination, and evaluation of family medicine activities at all levels of the educational continuum (i.e., predoctoral, residency, faculty development, scholarly activities in family medicine).”30 The program guide did not provide definitions or examples of these broad categories, which allowed applicants to interpret them in ways that suited their proposed projects. Another permissible use of these grants was for planning and pilot testing of model curricula that might lead to future support from the programmatic grants for predoctoral training, residency training, or faculty development. No data are available on whether this actually happened. This flexibility encouraged a focus on education and curricular experimentation that has become a hallmark of academic family medicine.
Establishment/AAU grants provided a broad base of financial support for medical-school-based departments of family medicine. Between 1980 and 2005, 125 U.S. allopathic and osteopathic medical schools received grants totaling more than $245 million.31 During this period, most recipients received multiple grants, often providing a source of funds for initiation, development, and expansion efforts that spanned decades. At our institution, for example, Title VII funding across various programs supported the establishment of a new, required, statewide, community-practice-based clerkship; a teaching guide for that clerkship, which became a textbook; preceptor development; and the development and implementation of novel curricula in disparities and cultural competency.
In fiscal year (FY) 2000, 20 years after HRSA awarded the first Title VII Grants for Establishment of Departments of Family Medicine, the agency renamed the grant program “Academic Administrative Units in Primary Care.” While retaining some aspects of the prior program, the new program was more focused. Despite the gains of the previous 25 years, primary care was not adequately represented at all medical schools. Further, even in well-established departments, research competence was underdeveloped. Therefore, the FY2000 program guide for the new AAU grants identified three “program purposes: (1) establishment of an academic unit; (2) expansion of an academic unit; and (3) research infrastructure development within the academic unit.”32 The encouragement of “collaborative projects between two or more disciplines from primary care academic units” illustrated the agency’s move toward a broader primary care focus.32 Although there were no content restrictions on such projects, agency guidelines clearly promoted equal partnerships between family medicine, general internal medicine, and general pediatrics and encouraged “joint decision making, shared faculty, shared academic appointments, shared administrative staff, and shared evaluation activities.”32
The more focused programmatic grants available to family medicine complemented the broad scope of the earlier establishment grants and extended their influence to a wider audience. Although the agency restricted establishment/AAU grants and predoctoral training grants to medical schools, it made residency training grants available to a broad range of organizations, such as community-based residency programs, that might not otherwise have been able to engage in educational innovation. Residency and predoctoral training grants supported development of curricula and instructional materials, which recipients were encouraged to disseminate beyond the local institution. These local curricula complemented HRSA’s separate contracts to the Society of Teachers of Family Medicine and other organizations to develop national curricula in areas of particular educational need (e.g., genetics). Faculty development grants helped build the required skills of many faculty members in areas such as evidence-based medicine, quality improvement, and cultural competency, so they could be successful in the new discipline, and the grants drew educators both from within family medicine and from interdisciplinary medical education organizations.
Like the establishment grants, these programmatic grants reflected the evolving needs of the discipline. HRSA aided early efforts to build family medicine through direct support for developing clinical experiences in residency training and predoctoral training (e.g., ambulatory or rural clerkships and preceptorships) that were intended to influence specialty choice or attract and prepare trainees for clinical practice in new geographic areas. As more family medicine departments gained parity with established clinical disciplines, a required family medicine clerkship became a prerequisite for receiving either establishment or programmatic predoctoral training grant funding. Similarly, in response to the rapid initial growth of the discipline, the early faculty development grants were designed “to increase the supply of physician faculty available to teach in family medicine programs and to enhance the pedagogical skills of faculty currently teaching in family medicine.”33 This dual emphasis on faculty recruitment/retention and skill building has continued to be relevant as family medicine has become more established.
From broad support for primary care to targeted workforce development
These early Title VII grant programs, which coincided with the early years of academic family medicine, originated from a federally perceived need for production of more primary care physicians. After nearly two decades (1976–1992) of flexible support for primary care education, however, HRSA adopted a more targeted approach to meeting perceived workforce needs. Passage of the Health Professions Education Extension Amendments of 1992 (PL 102-408) authorized HRSA to adopt mechanisms for allocating funds to favor institutions whose performance was congruent with federal policy goals.28
This change marked a turning point for academic family medicine. The first report of HRSA’s Advisory Committee on Training in Primary Care Medicine and Dentistry in 2001 describes a deliberate change in agency strategy, from relatively unrestricted support for the development of a new discipline, to a much more targeted plan to “increase the pressure on academic institutions to become more aggressive in pursuing Federal policy goals.”34 Title VII grant programs became increasingly more restrictive as HRSA’s three-stage training strategy for meeting perceived workforce needs unfolded. The first of these overlapping stages, develop primary care training capacity, included the infrastructure-building efforts of the Grants for Establishment of Departments of Family Medicine and early primary care residency grant programs. Stage two, attract students into primary care, reflected broad efforts to increase parity between family medicine/primary care and more established clinical departments.
As HRSA’s strategy reached the more focused third stage, attract graduates to underserved areas, many academic family medicine organizations found that the previous flexibility they had enjoyed was curtailed substantially. The advisory committee report acknowledged this when describing “this system, which uses the power of the Federal purse to nudge health professions institutions into adopting Federal policy goals they might otherwise eschew.”34 As a result of this shift, family medicine departments and residency programs were no longer able to base their grant applications solely on the educational needs of their organizations; instead, they had to balance these needs with sometimes competing pressures to respond to federal policy goals.
HRSA developed several new grant mechanisms to “reward those institutions willing to build and operate the type of primary care training system most likely to attract and retain students in primary care tracks.”34 These mechanisms reflected HRSA’s view of the role of primary care training programs in meeting the changing needs of the population (e.g., by giving increased attention to geriatrics and to health disparities) and in producing a health care workforce that would respond to these needs (e.g., by producing more minority and rural physicians).
Two new mechanisms were used to modify peer reviewers’ assessments of proposal quality and to determine the degree to which a proposal met HRSA’s new goals. Statutory funding preferences provided first-in-line funding, in which qualifying proposals received grants ahead of other proposals, despite possibly higher peer review scores assigned to other grant applications and more innovative ideas found in other applications. Specifically, programs demonstrating that graduates practiced in medically underserved communities or those establishing or expanding administrative units received preference. Some applicants, especially those accustomed to the traditional National Institutes of Health (NIH) peer review process, have criticized this funding preference system—which continues today—because it seems to disregard the quality of both the ideas and the grant application itself. A high-scoring proposal that does not meet the funding preference can be denied funding, whereas a proposal with a much lower score might be funded instead. Some academic institutions that had come to rely on Title VII funding to support their educational programs are no longer able to compete because their organizational missions do not produce graduates who practice in underserved areas. Evolving preferences have set very high bars; for example, the latest preference for residency training requires 55% of recent graduates to be practicing in medically underserved communities. Of course, institutions achieving such goals merit support, but the preference mechanism with such high levels has sharply reduced the number of residencies applying for funds—and it has, thus, limited the potential impact of Title VII in transforming institutions.
In addition to preferences, funding priorities, realized through points added to a proposal’s final merit score, are given for the applicant’s record of producing primary care graduates and/or recruiting minority and disadvantaged students. Applicants may also receive additional points for increased numbers of academic units and for recorded collaborations between primary care disciplines, such as family medicine and general pediatrics, or family medicine and general internal medicine. Other funding priorities, such as development of research competence or infrastructure, have shaped the content of recent proposals.
HRSA’s strategies—for attracting graduates to underserved areas and for training primary care clinicians to provide higher-quality care to vulnerable and disadvantaged populations—also specified topics that applicants should address. HRSA leadership identified topics based on sources such as the HRSA Advisory Committee, U.S. Public Health Service documents (e.g., Healthy People 2010 and reports from the surgeon general), and Institute of Medicine reports, and, thus, topics varied from year to year. For example, for FY2003, HRSA required proposals to address the relevance of their project to Healthy People 2010 goals and, if possible, to address geriatrics, genetics, underserved populations, distance learning, and/or participation in Kids Into Health Careers through linkages with primary and secondary schools.35 A year later, the list included oral health, mental health, public health, distance learning, and/or cultural competence.36 In FY2005, the special consideration list expanded to include professionalism, patient safety, quality improvement, health literacy, cultural competency, mental health, oral health, and genetics.37 These strategies to enlist academic institutions in pursuing federal policy goals continued to create tensions as family medicine departments struggled to balance these goals against educational priorities set by the discipline itself—and, indeed, earlier years’ priorities. For example, the Future of Family Medicine initiative,13 the discipline’s major effort to develop and disseminate a new model of care and education, placed only minimally in Title VII priorities—and in only some years.
In addition, a further constraint on grant applicants came with the legislation that reauthorized Title VII in 1998, which included statutory language that mandated attention to special populations at increased risk of adverse health outcomes or limited access to care. Thus, the agency encouraged applicants to propose projects “which prepare practitioners to care for underserved populations and other high risk groups such as the elderly, individuals with HIV-AIDS, substance abusers, people who are homeless, and victims of domestic violence.”32
How Did Title VII Change the Discipline?
A major federal goal of Title VII was to develop academic units or departments of family medicine. Analysis of the data clearly demonstrates that this goal has been and continues to be achieved. In 2007, family medicine departments existed in nearly every U.S. medical school; in fact, only 11 medical schools are now without departments of family medicine, and three of these have family medicine divisions. Further, the Liaison Committee on Medical Education now requires clinical experiences in family medicine for all medical students,38 and the vast majority of medical schools have required core clerkships in family medicine. By 2007, approximately 500 family medicine residencies had been established, the U.S. family medicine workforce numbered almost 100,000, and family physicians had more patient visits annually than surgeons, obstetrician–gynecologists, and pediatricians combined.13 Large majorities of patients with each of the most common and costly chronic diseases identify a family physician as their usual source of care.13 Although it is impossible to isolate the specific historical forces, it is clear that Title VII has been stunningly successful, working in concert with state and federal initiatives and with professional and educational organizations, to achieve these and other outcomes.
Within these academic units, moreover, the Title VII grant program has helped develop the educational endoskeleton of these departments. Seventy-seven percent of departments have received Title VII support for predoctoral education, both for clinical clerkships and for preclinical curriculum, and 82% of university residencies have received Title VII support at least once.39 Beyond the total amount of federal dollars, we underscore the educational significance and innovation of Title VII contributions. For example, at Southern Illinois University and East Carolina University (now Brody School of Medicine), Title VII grants in the 1980s funded the first efforts nationally to develop simulated patients and objective structured clinical examinations, two innovations now embedded permanently in the United States Medical Licensing Examination as Part 2B. More recently, Title VII grants have also supported development of some of the first uses of online and CD technology, such as the Medical University of South Carolina’s online and CD quality-improvement curriculum. Moreover, at the University of North Carolina and Oregon Health & Science University, Title VII-funded curriculum initiatives yielded two leading textbooks of family medicine,40,41 and recent Title VII grants have supported the development of innovative curricula in important areas such as HIV/AIDS, genetics, patient safety, cultural competence, and health disparities. The discipline of family medicine has led medical schools in developing physicians from the community to be faculty for substantial components of both preclinical and clinical curricula. Finally, Title VII grants have supported preceptor development as well as expansion of community teaching sites at many schools, including Baylor College of Medicine, Medical University of South Carolina, and the University of Massachusetts.
In addition to supporting the development of new courses and curricula, family medicine faculty have used Title VII grant funds to support development of clinical innovations in evidence-based medicine, community-oriented primary care, prevention, and quality improvement. Academic medicine widely accepts the critical value of these areas for contemporary primary care but understands less the essential role that Title VII funding has played in the spread of these ideas and educational innovations. It is important for the community to remember that there have been few other funders for this kind of intellectual research and development unrelated to basic science, medications, or devices.
Enhancing the social capital of family medicine
Beyond individual programs and grants, Title VII has contributed substantially to the social capital of the discipline. As a new discipline, many family medicine departments and residencies enjoyed neither senior faculty nor a tradition of writing grants. For many junior family medicine faculty, the Title VII grant program was their only vehicle for learning how to write grant proposals. Consequently, this vital experience helped lead many of these faculty, as they matured, to NIH and foundation grant programs that are critical to the long-term success of the discipline. It is no accident that almost all of the members of the board of directors of the Association of Departments of Family Medicine during the last five years have led at least one Title VII grant—as have many of the first generation of federally funded NIH researchers in the discipline. Similarly, the faculty development fellowships funded by Title VII have played a major role in training the leadership of the discipline. For example, from the Title VII-funded, part-time Faculty Development Fellowship at the University of North Carolina, more than 60 fellowship alumni have served as department chairs, and more than 80 have served as residency directors. Finally, for many faculty in departments of family medicine, Title VII projects provided both content area expertise and administrative experience to allow them to earn institutional leadership roles, especially in education. This has occurred in many institutions, including the University of Wisconsin, Oregon Health & Science University, University of Missouri at Columbia, and University of Washington.
In addition to these benefits, however, Title VII funding for family medicine has had some adverse effects. In the 1980s, Title VII grants, like NIH grants for departments of medicine, were relatively easy to obtain. That ease, combined with generous state funding in many settings, created what may, in retrospect, have been a disincentive for developing the clinical programs, the research programs, and the revenue critical to long-term excellence. The relative strength of education compared with other missions in departments of family medicine can be seen as a legacy of Title VII, symbolized by the organization of most departments in divisions reflecting the Title VII grant programs (e.g., medical students, residency, and research), as opposed to the more typical organization along clinical subspecialty lines. This organization, almost unique to family medicine among clinical specialties, also reflects the clinician–teacher ethos of the whole discipline, as well as the early success of the University of Washington organizational structure, which served as a model for many departments. Title VII programmatic funding greatly strengthened this trend. Although emphasis on education would seem fundamental to medical schools, currently the clinical and research missions more often drive AHCs. Family medicine’s emphasis on education may not match well with the challenges deans currently face (e.g., clinical and NIH revenue), as recent surveys of deans and chairs suggest.39,42
What Impact Did Title VII Family Medicine Programs Have Outside the Discipline?
The most obvious impact of Title VII outside the discipline is the presence of family medicine academic units themselves within AHCs. These departments often play key teaching roles across the curriculum; in many settings, they play key patient-care roles, especially with indigent populations,43–45 and these departments are active in research.46–48 The value of having a primary care organizational unit has become even clearer as the relative influence of divisions of general internal medicine and general pediatrics has decreased at many institutions. Consequently, without family medicine, most medical schools would have few primary care voices among their leadership. The importance of family medicine leadership is particularly impressive in geographic areas such as Boston, where the decline of medical student and resident interest in general internal medicine has made manifest the importance of the primary care pipeline through family medicine.
Title VII support for medical education in the ambulatory setting has also had a strategic importance for AHCs. Medical education placed a great deal of emphasis on hospital-based care and teaching 25 years ago; although some schools continue to live in that era, most have developed extensive teaching programs outside of the hospital throughout the four years of medical school.48–52 Title VII-supported family medicine programs have made a major contribution to this transformation. In many schools, the family medicine clerkship was the first significant ambulatory educational experience, and it set the mold for future teaching in that venue. Likewise, in the preclinical years, Title VII grants have funded the development and dissemination of new curriculum content in community medicine, prevention, public health, quality improvement, and patient safety. Title VII activities predated the Association of American Medical Colleges’ (AAMC’s) new strategic emphasis on improving the health of the population by many years.
Title VII’s impact on medical education has gone beyond support for new educational venues to the support of individual faculty and the development of important lines of work. For example, building on the foundation begun at Michigan State University (the power reading curriculum), Yale (formal clinical epidemiology), and especially McMaster University (applied clinical epidemiology and critical appraisal of the literature), Title VII supported further development of the curriculum now known as evidence-based medicine. Family medicine faculty supported by Title VII have contributed substantially to the development of the methodology of evidence-based medicine, underscoring the importance of patient-oriented outcomes, external validity, and practice change as key components of evidence. In addition, Title VII has supported the dissemination of best practices for teaching evidence-based medicine to medical students, residents, and fellows through many national workshops, publications, and textbooks. Thus, in evidence-based medicine, as in other areas, the role of Title VII has been to support individual faculty both as they developed their ideas and then as they disseminated these programs across residencies and medical student teaching programs.
Title VII-funded projects have helped to launch or to strengthen institutional initiatives focusing on underserved and vulnerable populations, including explicit clinical and teaching linkages with community health centers. At many institutions, Title VII supported the initial development of specific pathways for medical students to train in rural or underserved settings; examples include the University of Washington’s Underserved Pathway and the new urban track for Jefferson Medical College’s well-known Physician Shortage Area Program. For many residencies, too, Title VII supported clinical and teaching outreach to vulnerable populations; examples include the use of free clinics as teaching sites at the University of California–San Diego, the development of teaching at community health centers at Baylor College of Medicine, the University of Massachusetts, the University of California–San Francisco, and others, and the extension of training to practitioners for underserved rural communities at, for example, the University of Washington’s Family Medicine Spokane Rural Track Program. Most ambitious are efforts to improve the health of larger vulnerable populations, such as Boston University’s HealthNet initiative, the University of North Carolina’s Carolina Healthnet project, or the University of New Mexico’s statewide Locum Tenens Program and Health Care Commons project. In many settings, these linkages and clinical networks have developed to the point that they have become centerpieces of their institution’s clinical or community engagement strategy.
A final key contribution of Title VII has been the development of research capacity, primarily through the establishment of critical infrastructure such as primary care research fellowships and practice-based research networks. For individual departments, the impact has been remarkable. For example, at Jefferson Medical College, Title VII faculty development grant funding supported the career development of three fellows who remained as faculty; their efforts, along with others in the department, led to that department’s first NIH grant award, with 25 funded grant applications and more than $8 million in funding across three years. From a national perspective, Title VII awards to family medicine have helped give institutions core infrastructure necessary for population-based or Type II translation research. At the University of Colorado, for example, Title VII has funded a research fellowship for all the primary care disciplines, and at the University of Texas at San Antonio, as well as in many other settings, Title VII support has been critical to the creation of successful, practice-based research networks, which are critical for population-based effectiveness research. As NIH launched the Clinical and Translational Science Awards (CTSA) initiative, unsurprisingly, family medicine departments with substantial prior support from Title VII have taken a major role in a majority of the institutions that won CTSA funding in the first round.
Adverse Effects of Title VII Funding for Medical Schools
Perhaps the most critical adverse effect is that Title VII funds have allowed medical schools to expand their educational mission to ambulatory and primary care settings without having to commit institutional resources as extensively as they otherwise would have. Although the grants did require explicit attention to program sustainability, many schools developed long-term strategies in which new programs depended explicitly on prior successes and, in some places, infrastructure. Consequently, some departments and schools viewed Title VII grants, at least in part, as operational funds, permitting less permanent institutional investment in the costs of ambulatory and community education. Given the current paucity of external funds available for medical education in particular, this strategy has put core medical student education programs, as well as educational innovation itself, at risk. Thus, the dramatic cuts in Title VII federal funds in FY2005 have rapidly translated to cuts in educational programs in many medical schools.
Learning From History
The development of family medicine and its academic arm has been supported by many influences beyond simple social and clinical need, including
* professional advocacy and education societies (at both the national and state levels),
* the certifying board that raised standards of practice and supported innovations in education and leadership, and
* state policy makers who allocated direct funding for family medicine training and academic units.
The Title VII grant program was another of these important, supporting influences. Given its initial goals and modest funding, Title VII has achieved extraordinary success: family medicine is an established academic department or program at almost every medical school, and many of these programs and departments offer excellent educational experiences and boast significant research capacity. Family medicine faculty and departments have led development of new curricula critical for primary care, and they are beginning to play a leadership role in education and research in many AHCs.
Despite these successes, a new Title VII is still necessary. Despite progress since 1969, the current environment is very challenging, with rapidly decreasing clinical reimbursement for primary care compared with most subspecialist clinical areas, increased strain on the financing of AHCs, decreased support of primary care by the AAMC and the Council on Graduate Medical Education, and sustained drops in student interest in family medicine and other primary care disciplines—all in addition to, and partly the result of, the traditional ambivalence of AHCs to primary care. More broadly, however, the IOM53 and others54–56 increasingly agree that AHCs must change dramatically across all missions to retain their relevance to our society. For example, in 2004, the IOM53 underscored priorities for change: (1) creating new ways of providing care across the continuum of care, from hospital to home health to community practices, (2) extending teaching to the community and expanding training to address new problems such as health disparities, and (3) developing a new approach to research in order to better extend innovations to communities and improve the health of populations. This is an ambitious agenda for change, but it is one that provides a clear and substantial role for family medicine.48
A national focus on improving the health of the population will require a variety of interventions, both in clinical practice and in shaping the evolution of AHCs. Key interventions include
* changing clinical reimbursement guidelines both by the Centers for Medicare and Medicaid Services (CMS) and by commercial insurers in support of the Patient Centered Medical Home,
* continuing the NIH roadmap and CTSA initiatives, with their emphases on improving the health of the public, and
* instituting pay-for-performance policies for the educational outcomes of AHCs in order to produce providers who contribute to improving the health of the population.
Within this broad mix of policy elements, however, the next generation of Title VII-type funding can play a very important role in catalyzing change across all missions. The experience of Title VII over the last generation can, thus, provide important lessons for how to structure new support.
Continue to support establishment of new academic units
The experiences at the University of Pennsylvania, Columbia University, and Boston University confirm the critical value of supporting new academic units. Given the rapid spread of regional campuses to meet workforce needs, support for these new regional campuses in development across the country is urgent in order to increase the probability that they will indeed meet the needs of society by producing primary care providers. Beyond new academic units, the medical education community should consider reframing establishment efforts to support centers of excellence which can catalyze clinical and academic change across their institutions.
Efforts to improve the health of the population through primary care merit substantial increased funding; although much can come from changes in priority at CMS and NIH, academic infrastructure in primary care is critical to progress in other domains. Given the dramatic impacts on the discipline and on academic centers, Title VII has proved very cost-effective. More funds will be necessary to achieve greater impact across more schools. A reasonable goal would be similar to the approximately $300 million in NIH support of workforce research through MD–PhD programs. Because the goal is an appropriate workforce across the United States, the target should be all medical schools and residencies, with an explicit effort to leverage funding with contributions by medical schools, hospitals, foundations, and community organizations.
Emphasize innovation and dissemination
The program grant guidance should insist that grantees disseminate their products in enduring forms and create closer linkage to clinical care delivery sites. One of the major lessons of Title VII is how much these programs have led to innovations in teaching. Strengthening that process through published articles and other enduring records is critical to the role of Title VII as a sparkplug for new ideas.
In addition, physicians in academic settings see many vulnerable patients, but they must contend with great barriers to change and quality improvement57; improving the care of these patients is a good in its own right. Key areas for improvement—and for education—include realizing the next generation of disease management, shaping the evolution of information systems, mitigating health disparities, and improving the health of the population in the communities served by AHCs.
Reframe outcomes assessment
The Title VII program should specify a set of outcomes appropriate to the methodology used in the grants, with formal revision of goals every five years. The logic model used for evaluation of the new program should more closely fit the possible outcomes of academic interventions.
Balance federal health policy with institutional needs
The explicit linkage of Title VII to specific federal policy has had mixed results. Too loose a connection does not hold institutions accountable for their social responsibility; too tight a connection sharply limits the number of schools that can benefit and can actually decrease the involvement of many schools that could otherwise help spread the message. The ultimate goal needs to be the improvement of the health of the population; this requires a focus on transforming all institutions while, at the same time, providing special support for organizations for which mitigating disparities and supporting vulnerable populations is a major part of their mission.
Support individual faculty and their career development
The rise of family physicians into leadership positions both within family medicine and in larger institutional and national roles has been one of the major outcomes of the Title VII program. Junior faculty development awards through NIH and Centers for Disease Control and Prevention have been very helpful for family medicine faculty, but almost all focus on specific diseases, and the structure is not ideal for generalist faculty. Faculty development under Title VII should continue to target both junior faculty and senior faculty and support the role of generalists in AHCs, with an emphasis on innovation, institutional change, and improvement of the health of the population.
Clearly, medicine and society face new and dramatic challenges, challenges that require significant changes in the system of medical care and its academic infrastructure. Patients are changing, what medicine can do is expanding, and public accountability is rising rapidly: the stakes are greater than ever before. Within that context, the potential contributions of family medicine are substantial. A new Title VII—strengthened, focused, and targeted at institutional reform and improving the health of the public—can help patients and communities directly, while requiring AHCs to meet their social responsibility.
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