Editor’s Note: Commentaries by P. Reynolds and E. Rich appear on pages 1648 and 1651.
The landmark Patient Protection and Affordable Care Act (ACA) of 2010 is expected to expand health insurance coverage to 32 million uninsured Americans.1 However, this expansion of coverage will further strain a health care workforce that is already struggling to meet demand for primary care services and for providers to practice in underserved areas. Even before the ACA was enacted, the United States faced a projected shortage of more than 35,000 primary care physicians by 2025.2,3 These provider shortages have special implications for underserved populations: In 2008, the National Association of Community Health Centers estimated that 15,000 additional primary care providers would be needed to meet its goal of expanding access to 30 million patients by 2015,4 an objective that has become increasingly relevant with the expansion of the community health centers (CHCs) program in the ACA.
The ACA includes a number of provisions intended to strengthen the health care workforce, particularly the primary care workforce, in order to improve access. Among these provisions is the Teaching Health Center Graduate Medical Education (THCGME) program, a funding program designed to increase the number of primary care residents training in community-based settings.5 In this article, we begin by considering the challenges of funding graduate medical education (GME) in nonhospital settings and in primary care. We then describe the characteristics of the first designated teaching health centers (THCs), including their common features, planned educational initiatives, the challenges they have addressed, and their plans for evaluating outcomes. The work of the inaugural THCs has implications for primary care residency training, GME financing and training at large, and future policies aimed at strengthening the health care workforce.
The GME Challenge
The U.S. GME system is a critical determinant of the supply, specialty composition, and distribution of the nation’s physician workforce. The array of available positions at accredited residency training programs ultimately determines the number and specialties of physicians trained. Evidence suggests that residency program characteristics can influence physicians’ future specialization and geographic location choices. For example, studies have shown that residents trained in CHCs or in rural settings are more likely than those trained in other settings to practice in rural or urban underserved areas.6–8 Similarly, residents trained in internal medicine and pediatric primary care tracks are more likely to remain in primary care fields than are those trained in more traditional tracks.9,10
To support residency training, Medicare provides teaching hospitals approximately $10 billion annually.11 These subsidies are provided with few requirements regarding training programs’ products, in terms of graduates’ specialty choices or practice locations. Medicare’s GME payment formulas for direct medical education (DME) and indirect medical education (IME) expenses largely tie funding to the hospital-based, inpatient setting. Although nonhospital settings can receive DME payments, IME payments—which are twofold greater—are calculated as add-ons to Medicare’s inpatient reimbursement system.12 As a result, Medicare’s formulas effectively limit the amount of GME funding that community-based ambulatory care sites can receive for residency training programs and act as a disincentive for nonhospital sites to establish residency programs.
The primary care workforce is doubly disadvantaged in this situation. The lack of requirements concerning specialties trained has led hospitals to increasingly shift resident positions from primary care to non-primary-care specialties in an environment that incentivizes specialty care.13 As a result, there has been little growth in the number of primary care resident positions in the last decade, and there have been decreases in specialties such as family medicine.14 Further, training focused on the inpatient setting is unlikely to optimally prepare primary care physicians for patient care that will occur largely in community-based and ambulatory care settings. In 2010, the Medicare Payment Advisory Commission noted these long-standing inconsistencies in Medicare’s GME policy and called for greater accountability for GME payments to hospitals.15
An inadequate primary care workforce has implications for the quality and cost of health care. Evidence shows that health care systems with a strong primary care base are associated with better outcomes16,17 and lower costs.18,19 These findings suggest that strengthening the primary care workforce and increasing accountability in GME funding are critical to establishing an accessible, high-quality, and cost-efficient health care system in the United States.
A Legislative Solution
The ACA offers a legislative solution for increasing primary care training in nonhospital settings by funding the THCGME program at $230 million across five years (fiscal years 2011–2015). In this program, payments are provided directly to the THC, as a “community based, ambulatory patient care center” that “operates a primary care residency program.”5 Eligible health centers are those that expand existing or establish new accredited residency programs in primary care fields, which the act defines as family medicine, internal medicine, pediatrics, internal medicine–pediatrics, obstetrics–gynecology, psychiatry, geriatrics, and general and pediatric dentistry.
THCGME and Medicare funding of GME differ in important ways. First, the THCGME program explicitly supports only primary care training programs centered in community settings. It is administered by the Health Resources and Services Administration (HRSA), and payments for both direct and indirect GME expenses are made directly to THCs.5 This is a significant departure from the Medicare GME funding formulas, which have generally supported payments to hospitals rather than to training programs or ambulatory sites.
Second, as THCGME funding is tied to specific health care workforce goals, THCs are held accountable for the payments they receive and for outcomes. The ACA5 requires that payment formulas be determined on the basis of training costs and includes specific annual reporting requirements for THCs, including the types of primary care training programs offered, the number of approved resident positions, and the number of residents who complete training and go on to care for vulnerable populations in underserved areas.
The Inaugural THCs
In January 2011, the first 11 THCs were awarded THCGME funding (Table 1). They filled all of the positions in their first classes through the 2011 National Resident Matching Program Main Residency Match or the American Osteopathic Association (AOA) Intern/Resident Registration Program, and they began training THCGME-funded residents in July 2011. Below, we describe these THCs’ organizational structures, including their sponsorship and leadership models and their partnerships with Federally Qualified Health Centers (FQHCs) and teaching hospitals; we also provide a first look at their primary care delivery models, their educational and curricular initiatives, and their plans for evaluating outcomes. (For an overview, refer to Table 2.) Details are drawn from our review of the applications these THCs submitted to the HRSA in 2010 (and also shared with us), from a meeting we convened of representatives from the inaugural THCs in Washington, DC, in May 2011, and from our dialogue with THC representatives through an ongoing voluntary network of the HRSA-funded THCs.
Creating and sustaining a successful primary care residency program in a community-based ambulatory care center is challenging.20–23 The health center must successfully marry its service and education missions while maintaining its financial stability, and it must develop administrative and governance structures that include educational systems. To be eligible for the THCGME program, health centers face additional regulatory challenges: The ACA5 requires that the institutional sponsor of record be the applicant health center or an educational consortium that includes a health center. Partnerships also play a role: Although THCs are not required to be FQHCs, many of the first THCs are partnerships between FQHCs and residency programs. Below, we describe the first THCs’ sponsorship models, leadership models, and partnerships with FQHCs, hospitals, and medical schools.
Sponsorship models. To meet the ACA’s requirements, the THC’s community-based training site must be the accredited institutional sponsor of the residency program, or it must be a central partner in a sponsoring GME consortium. In the latter case, HRSA specifies that the THCGME payments must directly support the ambulatory care site.24
Health center sponsor. Residency programs at 5 of the 11 THCs are directly sponsored by a health center. In one case, an existing residency program worked with the Accreditation Council for Graduate Medical Education to change its institutional sponsor to the health center in order to qualify for the THCGME program. An osteopathic residency program worked with the AOA, which accredits such GME programs, to change the AOA’s sponsorship requirements to allow health centers to act as sponsoring institutions. Previously, the AOA required institutional sponsors to be hospitals or osteopathic medical schools.
Consortium sponsor. Six of the 11 THCs qualified under the GME consortium model. In 4 of these, the THC entity is a not-for-profit, multi-institution corporation that operates the residency program and includes a health center. The other 2 consortia include independent, not-for-profit GME organizations affiliated with health centers. In 1 of these 2 consortia, the health center was the entity that applied for the THCGME program, whereas the GME foundation was the accredited institutional sponsor. In this case, the affiliation agreement required the health center to operate the residency program.
Leadership models. Most of the THCs integrate the residency program and health center leadership. At 6 of the 11 THCs, the residency program director also holds the position of health center CEO or chief medical officer or fills another clinical leadership role. One THC’s FQHC community board has oversight of resident education in addition to patient care and community service.
Partnerships with FQHCs and teaching hospitals. All 11 THCs include FQHCs or FQHC Look-Alikes. In two cases, residency programs are partnering with new FQHC sites: One program that has existing arrangements with FQHCs is placing residents at more FQHC sites, and the other program has developed new partnerships with FQHCs. The additional clinical training sites are necessary for the expansion of these two residency programs, and health care access is expected to increase at the new sites.
All of the THCs report affiliations with at least one university or medical school. Each partners with a teaching hospital or academic medical center to provide its residents with training in the inpatient setting. Nine of the THCs receive direct financial support for their residency programs from the hospital or medical center, most often in the form of “pass-through” Medicare GME funding (i.e., funding provided to nonhospital sites by affiliated teaching hospitals that receive Medicare GME payments for preexisting resident positions).
Delivery models for primary care
To ensure that residents are prepared to deliver high-quality care and have the skills they need to practice in a primary care setting, THCs are implementing delivery models that support the provision of primary care services, including electronic health records (EHRs), interdisciplinary care teams, and management/leadership training.
EHRs. The 11 THCs have implemented EHR systems at their community-based training sites. In their THCGME program applications, 4 THCs discussed plans to train residents to use EHRs to support clinical decisions, provide patient education materials, track patient outcomes, and connect to other health centers and hospitals.
Interdisciplinary health care teams. All of the THCs use interdisciplinary health care teams, and residents will practice as part of these teams. Two THCs plan to evaluate residents on the basis of their ability to practice in teams.
Patient-centered medical homes. At the time of their initial applications for the THCGME program in 2010, six of the THCs had applied or were in the process of applying for National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) status. One THC achieved Level 3 NCQA status in 2009.
Management/leadership training. Five THCs offer residents training in practice management and leadership. Two of the five provide training in interprofessional team management. One of the five programs has created a leadership curriculum that includes training in managing teams, conflict resolution, negotiation skills, creation and management of an FQHC, health care reform, political advocacy, and safety-net hospital management. Each resident in that program will serve for two months as an “acting medical director” of the THC, working alongside the health center medical director.
Quality improvement. Ten of the 11 THCs are integrating quality improvement training and projects in their health centers and residency programs.
The THCs’ curricula include a number of educational initiatives that are relevant to primary care practice and will produce graduates who are well prepared to provide the array of needed primary care services:
* Community medicine (10 THCs): Most include community needs assessments and a focus on population health
* Cultural competency (10 THCs)
* Focused rural training (5 THCs): Rural training rotations at 2 THCs are supported through additional stipends for travel and housing
* Geriatrics training (3 THCs)
* Primary care mental health training (3 THCs)
In addition, one THC includes a module on resident mental health aimed at reducing resident and primary care physician burnout. This curriculum includes resident wellness assessment and planning guides, workshops on burnout and compassion fatigue, monthly support groups, and vouchers for complementary medicine services to promote wellness.
Plans for evaluation
All 11 THCs plan to survey their graduates to determine whether they are practicing in primary care and in underserved settings; most surveys are planned for one year and five years after graduation. Other planned evaluations of graduate outcomes include practice in interprofessional teams, patient outcomes, use of EHRs and PCMH models, teaching, scholarship, community activities, leadership, and board certification. One THC plans to survey graduates’ employers concerning its former residents’ demonstration of the critical knowledge, skills, and attitudes needed for effective practice.
All THCs have systems in place for evaluating resident performance. Residents generally are evaluated by faculty and in-training exams. Eight THCs also plan to evaluate residents’ quality of care or patient outcomes using chart reviews for application of national guidelines and outcomes, patient satisfaction surveys, and/or evidence that QI efforts improve care and outcomes. Three THCs plan to track the number of patients served to determine the effect of new or expanded residency training programs on access to health center clinical services.
Implications for the GME System
The ACA5 established the THCGME program to support increased primary care residency training to address critical national workforce needs. This first look at the inaugural 11 THCs shows that they are training additional primary care residents in relevant delivery models (e.g., interdisciplinary teams and PCMHs) and in quality improvement processes. They are partnering with FQHCs and implementing curricula with community medicine, cultural competency, and practice management components to prepare their graduates for careers in primary care, particularly in underserved areas.
These first THCs are also helping reshape U.S. health care delivery and GME systems to support community-based primary care residency training. The work of the initial THCs to expand the types of entities eligible for GME accreditation and funding may reduce future sponsorship-related barriers for other community-based settings that wish to establish residency training programs. Although balancing service and education missions is a challenge for health-center-based residency training programs, the organizational structures that the THCs have established offer examples of the successful integration of these two missions. Our review of the THC leadership structures suggests that balancing the leadership of the service and education programs is an important component of balancing the two missions. At most of the THCs, this has been addressed through dual leadership roles.
The THCGME program also introduces a new level of accountability into the GME funding system. The program’s payments target the achievement of a specific outcome: increasing the number of primary care providers who are well prepared and willing to practice in community-based, often-underserved, settings. Legislation5 requires the THCs receiving this funding to report the numbers and specialties of the residents trained and the number who go on to care for vulnerable populations. This level of evaluation does not currently exist in the Medicare GME payment system. In addition, the THCs plan to evaluate additional outcomes, such as the effect of residency training on patient care services, trainees’ patient outcomes during and after residency, primary care career choices, implementation of primary care delivery models in practice, and community and leadership activities.
Funding, however, continues to be a critical issue in establishing, expanding, and maintaining training programs in community-based settings. Whereas the THCGME program now provides support for successful applicants, the ACA guarantees funding for only five years5; in contrast, annual Medicare GME support is guaranteed as part of a federal entitlement program.12 The THCGME program’s limited funding period may act as a barrier for health centers that are considering expanding or establishing new primary care residency programs. Because the average length of a primary care residency is three years, at the end of the five-year period, THCs may have residents in the middle of their training without guaranteed GME payments to support them. Any additional funding, which will be critical to the continuation of this program, must be appropriated by Congress for fiscal years 2016 and beyond.
Start-up funds are also a limiting factor, particularly for health centers that would require funding for up-front costs (e.g., hiring new faculty and staff, developing curricula, obtaining accreditation) to start a new primary care residency program. Although the ACA authorized a THC development grant to complement the THCGME payment program and support these activities, it has not received funding.
In conclusion, the THCGME program offers a legislative solution for funding GME to better meet the nation’s health care workforce needs. This look at the inaugural 11 THCs suggests that these residency programs are training primary care providers in relevant delivery models and preparing them for practice in community-based, underserved settings. The THCs are developing organizational and funding structures to address barriers to community-based training, and they are working with existing organizations, such as accrediting bodies, to support training in this setting. The THCGME program is small and faces significant funding challenges, and its outcomes have yet to be evaluated over time. However, these first THCs show great promise, and further study of their efforts and outcomes has the potential to shape primary care training and the GME system at large.
Acknowledgments: The authors wish to thank the 11 inaugural teaching health centers for participating in this study and in the teaching health center conference held in May 2011. Dr. C. Chen would also like to thank Dr. Marion Danis in the Department of Clinical Bioethics in the Clinical Center of the National Institutes of Health for acting as her intramural mentor for her Disparities Research and Education Advancing Mission (DREAM) Career Transition Award.
Funding/Support: The Josiah Macy Jr. Foundation supported this work through the grant entitled “Assessing Graduate Medical Education: How Are Teaching Hospitals and Teaching Health Centers Meeting Society’s Needs?” Dr. C. Chen was supported through a DREAM Award by the National Institute of Minority Health and Health Disparities, National Institutes of Health.
Other disclosures: None.
Ethical approval: Not applicable.
Disclaimer: The views expressed are those of the authors and do not represent the views of the Department of Health and Human Services or the National Institutes of Health.
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