Allen, Suzanne M. MD, MPH; Ballweg, Ruth A. MPA, PA-C; Cosgrove, Ellen M. MD; Engle, Kellie A.; Robinson, Lawrence R. MD; Rosenblatt, Roger A. MD, MPH, MFR; Skillman, Susan M. MS; Wenrich, Marjorie D. MPH
In order for a rural provider to be successful, you’ve got to find a way to get affiliated with a larger, regional player…. If you don’t do that, you’re a dinosaur. You’re going to go away. That’s true of any rural hospital in the state of Washington. It’s going to take a while but that’s where we’re going.
—Ben Hufnagel, hospital CEO1
Building a sustainable rural health workforce has long dominated the efforts of a substantial number of medical educators.2 Nineteen percent of the American population live in rural locations on 90% of the land.3 Few rural communities achieve an adequate supply of health professionals.4 The Patient Protection and Affordable Care Act (ACA)5 introduces a new factor to the effort to increase that supply. Nationally, many hospitals are positioning to become integrated health systems to better meet ACA goals of maximizing quality and efficiency while reducing cost; many are aligning and purchasing physician practices, leaving fewer independent hospitals and physicians. Some plan to become or align with accountable care organizations (ACOs)—the defining organizational structure under the ACA, designed to reduce cost while improving quality, safety, and efficiency. Rural practices and hospitals are preparing for change.
While a full understanding of the ACA’s challenges and opportunities will emerge gradually, some effects can be anticipated for building and sustaining an adequate rural primary care workforce. Any substantial shift in American health care directly influences health professions education at all levels: who is trained, how, and for what purposes. Community-based clinics, hospitals, and practices are vital settings for training medical students, residents, and other health professionals and, in particular, for training rural health professionals; the impact of the ACA on these institutions will influence the training that students and residents receive.
In this article, we examine a large medical education program in the U.S. Northwest that focuses on building the primary care workforce for its largely rural region, and discuss the ACA’s potential impact on this and other rural health training programs. The Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) program is one of the nation’s most successful models for rural health training. Analyzing the potential impact of the ACA and ACOs on WWAMI provides a national paradigm for addressing rural health workforce needs under the new health care agenda.
WWAMI’s Historical Commitment to Build a Primary Care Workforce for the Northwest
WWAMI serves a large, predominantly rural, resource-constrained region covering approximately 27% of the U.S. land mass and containing only 3.5% of the U.S. population.3 The 42-year-old WWAMI program was established by the University of Washington School of Medicine (UWSOM) to address the region’s rural health workforce needs.6–8 WWAMI’s founding goals for the region were to expand medical education, offer accessible training for health professionals, increase the number of primary care physicians, and address physician maldistribution.6–8
WWAMI’s approach to strengthening the regional workforce has built on factors that influence practice and specialty site. The state or region in which a physician practices is strongly correlated with the geographic location of the physician’s preadulthood, medical school, and residency.9 Premedical school factors such as rural upbringing may be most strongly correlated with recruitment of primary care physicians to rural areas, and training factors—such as commitment to rural curricula and rotations, especially during residency—may be most strongly correlated with rural retention.10 Residency training location is a strong predictor of practice location, and the combination of medical school location and residency location may have the largest impact.11,12
At the program’s inception, only one of the five states had a medical school: UWSOM. The WAMI partnership, as it was then called (Wyoming joined in 1996), avoided typical medical school start-up infrastructure labor and costs and optimized resources by using existing state universities for basic science training, community physicians’ practices and hospitals for clinical training, and existing UWSOM faculty and staff for sharing knowledge and teaching. As WWAMI was forming, a physician assistant (PA) training program, MEDEX Northwest, also started at UWSOM with a similar decentralized model. Although MEDEX Northwest is not formally part of the WWAMI program, it is closely aligned and works in tandem with the WWAMI program.
Medical school program
The UWSOM program accepts, trains, and graduates students from the five-state WWAMI region. Medical students are admitted from each state; their numbers are predetermined by legislative funding. The admission policy has a special focus on students who are likely to return to practice in their home states. Students complete their first year at their home state’s partner university. All students spend their second year in Seattle. For clinical training, students can choose from 180 locations across the five states. Each student completes at least 24 of 42 weeks of required rotations away from Seattle. In 2012–2013, 220 students were trained for each of the four medical school classes (120 students outside Seattle for the first-year class). From 1975 until 2013, 6,512 students have graduated.
Graduate medical education
The WWAMI program incorporates graduate medical education (GME) through rural resident rotations within Seattle-based training programs, regionally based residency programs, and a network of residency programs. The Family Medicine Residency Network consists of 24 independent training programs. All are accredited by the Accreditation Council for Graduate Medical Education (ACGME). Twelve are in communities serving, or committed to serving, rural underserved populations; three are rural training tracks. Overall, the network programs train 537 residents per year.
Several other residency programs that are accredited by the ACGME are affiliated with UWSOM in other specialties that provide exposure to medicine outside urban metropolitan areas. These programs are the UW Internal Medicine Boise, Spokane Internal Medicine, UW/Idaho Psychiatry Track, and the new UW/Seattle Children’s Pediatric Residency Alaska Track. A new internal medicine residency program was recently accredited and will accept the first class of residents in July 2014.
Regular rotations in the WWAMI region within existing UWSOM programs are offered in three specialties: internal medicine, WWAMI-wide; pediatrics, WWAMI-wide; and obstetrics–gynecology, in Yakima, Washington.
The MEDEX Northwest program, which started in 1969, has four decentralized classroom sites: Seattle, Spokane, and Tacoma (which opened in the fall of 2013), all located in Washington, and Anchorage, Alaska. Based in the UWSOM’s Department of Family Medicine, MEDEX Northwest works closely with the School of Medicine in curricular efforts. The program has also begun to train the equivalent of PAs in the dental field. Of 1,888 graduates by 2012, more than 70% remained in the WWAMI region, and approximately 35% of these have been identified as working in a rural or medically underserved setting.
Support for community partners
Multiple programs have been developed to assist WWAMI’s rural health professionals. The WWAMI Rural Health Research Center, started in 1985, provides a foundation for studies on rural health care needs and provision of rural health care services nationally as well as in WWAMI rural populations. Throughout WWAMI’s history, UWSOM faculty have traveled to regional practice sites to provide faculty development, often in conjunction with trips to remote clinical training sites.
The Medcon program, in place since 1975, provides consultative education by telephone on clinical problems from UWSOM experts to physicians throughout the region.
Through Project ECHO (Extension for Community Healthcare Outcomes), a telemedicine program initiated in New Mexico, community-based primary care practitioners present their challenging clinical cases to a panel of experts while other regional practitioners observe and learn from the case discussion. Through a pilot funded by the Robert Wood Johnson Foundation, the program extended to a hepatitis C treatment module in Washington State. Subsequent funding from a Center for Medicare and Medicaid Innovations grant has expanded the program, including a Northwest component to the five-state WWAMI region. Additional focus areas are HIV/AIDS, pain management, and integrated addiction and psychiatry, with attention to other diseases and conditions planned.13
Impact of WWAMI on the rural workforce
Table 1 shows return rates of UWSOM graduates to their home states to practice, and return rates for students from any WWAMI state to a WWAMI state (i.e., the individual remains in the area but not necessarily in the home state) cumulatively through 2007. The percentage of students entering primary care has typically been higher than the national average. In 2013, 53% of 223 UWSOM students (representing all WWAMI students) entered a primary care specialty compared with a national average of 41.9%.14 Data from the Association of American Medical Colleges Graduation Questionnaire15 indicate the strong intention of many graduating UWSOM students to practice in rural and underserved areas. Compared with a national average of 30.9%, 58.4% of UWSOM senior students in 2012 said they plan to practice in an underserved area. Of those, 47.5% cited rural communities as their likely location compared with a national mean of 30.2%. Nearly 50% of UWSOM graduating seniors said they plan to care primarily for an underserved population compared with 27.8% among students nationally.
Table 2 shows (1) the 2010 in-state retention rates for physicians who completed their ACGME-accredited residency in the WWAMI states, and (2) how those states rank nationally for retention of physicians in the states where they completed their GME. Although the programs are small, their retention rates exceed the national average for return, especially in Alaska and Montana.16 WWAMI states remain net importers of physicians.17,18
Potential Impact of the ACA and ACOs on the Rural Workforce
The ACA will have a rapid downstream impact on medical training in the WWAMI states and elsewhere. With expanded health care access for patients, primary care physicians, PAs, and nurse practitioners will be in even greater demand than in the past. A shortage of up to 91,500 physicians is expected nationally by 2020.19 Medical schools have been expanding their classes to meet the need. Since 2002–2003, the total number of students entering U.S. MD-granting medical schools has grown 18%.20 GME capacity, however, has not kept pace with the increase in medical students. The shortfall may have the strongest impact on rural locations, to which recruitment of physicians is already challenging.4
ACA funding mechanisms that affect rural practices in a positive way include expanded funding for community health centers, better prevention funding, increased investment in the National Health Service Corps, additional payments to hospitals in counties with the lowest Medicare spending, and a 1.0 floor on the wage index for frontier states.21,22 Rural physicians practicing in Health Professions Shortage Areas are eligible for both bonus payment and primary care incentive payment. Incentives to develop electronic health records also will help rural practices advance.
Factors critical to success under ACOs can be challenges for rural providers. Medicare ACOs require at least 5,000 fee-for-service beneficiaries assigned to them, based on the patients of primary care physicians. Few rural locations can achieve this volume without partnering with out-of-region health systems.23 New patients brought in by the ACA to critical access hospitals will most likely be Medicaid participants, with lower reimbursement rates.24 Other challenges are the need for sophisticated financial and information management systems, care coordination, and data analytics that require sophisticated staffing and investment. A successful ACO may initially lead to revenue decrease by reduced inpatient care, requiring a financial cushion for a transition phase.25 While joining an existing ACO or forming an out-of-region ACO may provide or increase needed resources, it also could threaten local control and result in out-of-area patient referrals, further draining local hospital and specialty service volumes.23,26
Case Study: WWAMI in an Era of the ACA and ACOs
In this section, we describe the potential impact of the ACA and its ACOs on the WWAMI program, as a case study of what the coming health reform may mean for medical education programs like WWAMI.
WWAMI health professions characteristics
The WWAMI states are diverse in their health professions profiles and national rankings (Table 3). Washington ranks 17th nationally for number of active physicians, whereas Idaho ranks 49th.27 Demographics vary considerably between eastern and western Washington. Based on 2009 data, approximately 20% of Washington physicians are in eastern Washington.16 Alaska has a relatively large number of PAs and nurse practitioners, and Wyoming has a relatively large number of nurse practitioners.
Addressing the region’s needs for primary care physicians
Tremendous efforts have gone into expanding the numbers of physicians in the five-state region through the WWAMI program, especially in primary care. These efforts have been successful; the number of physicians has increased substantially over the lifetime of the program. A comparison of the number of physicians per 100,000 people in 1970, directly before the WWAMI program began, with the 2009 number is shown in Table 4.28,29 Despite substantial improvement, only Washington achieves the national mean, and the rate is likely much lower for eastern Washington than for western Washington.
Under the ACA, Washington is expected to have an additional 800,000 insured patients, primarily through Medicaid; these patients will be cared for in patient-centered medical homes.30 Similar changes are likely in other states. UWSOM is expanding the number of medical students it trains throughout the WWAMI region to address increasing workforce needs. The Idaho legislature has approved 5 additional seats, and the Montana legislature has approved 10 additional seats. This will increase the class size from 220 to 235.
Careful attention has been directed to the specialty distribution of physicians to ensure the right mix of specialties region-wide. For example, thanks to WWAMI’s historical efforts, family physicians in the WWAMI states have distributed themselves more uniformly among urban, rural, and remote areas than have other physicians.31 Although the need for primary care professionals, and in particular family medicine physicians, remains paramount, other specialties are also important, and WWAMI has had success in providing training experiences that may attract physicians in specialties like general surgery.32
Increasing the numbers of medical students alone is not a viable approach to meeting these additional demands if comparable additional residency positions are not in place; students may be siphoned off to other states if WWAMI cannot increase residency positions available to them (see Table 5). The UWSOM and its WWAMI program are working to expand opportunities for medical students and regional GME opportunities for residents.
Despite this interest, the GME funding caps limit the ability of the WWAMI states to increase residency programs and positions. In 2011, the ACA partially ameliorated this by redistributing unused GME positions to produce more primary care physicians. In Idaho, 11.2 positions were added, and in Montana, 19.4 positions were added. Several positions were lost in Seattle or surrounding communities. The UWSOM and its WWAMI program are exploring ways to increase residency training programs and positions by seeking funding from a combination of primary care expansion grants, teaching health centers, Veterans Administration funding, redistribution, and other means.
Expanding interest in primary care and rural practice through selective admission and special programs
WWAMI’s approaches to expanding medical students’ interest in rural practice and primary care include (1) selective admission for students from rural and underserved backgrounds and with demonstrated backgrounds in primary care, and (2) special programs to attract and train students in primary care and rural practice. Current special programs are the Rural/Underserved Opportunities Program (R/UOP), a one-month, community-oriented, primary care experience33; the WWAMI Rural Integrated Training Experience (WRITE)6; the Targeted Rural Underserved Track (TRUST); and Track, where students complete all or most of their clerkships in a particular area. These programs and other WWAMI and related programs are listed and described in Appendix 1.
Roles of PAs
In the Pacific Northwest, PAs play an important role in primary care and increasing access to health care in geographically remote communities. The availability of PAs, as well as of nurse practitioners, has helped stabilize the practice of small-town specialists who need help but cannot necessarily justify the costly employment of another physician. In addition to the MEDEX Northwest program, two non-WWAMIPA programs serve Idaho and Montana.
The UWSOM is committed to supporting the training of PAs. A challenge is stemming PAs’ growing movement to specialty positions instead of sustaining their career interest in primary care, especially in rural regions.34 The ACA, with its focus on the patient-centered medical home, may offer more attractive opportunities to PAs in urban locales and in specialty areas, and this may detract from the ability to fill needed rural workforce needs. The WWAMI program is working to find ways to mitigate the siphoning of PAs from rural and generalist practices to urban, specialty practices. The opening of the new MEDEX Northwest PA program in Tacoma in fall 2013 brings the number of PA trainees to 140.
Support for community physicians
Although the Pacific Northwest has seen less growth of ACOs than other regions, trends suggest the number will increase. UW Medicine (an organization composed of four hospitals, the largest physician practice plan in the Northwest, a network of ambulatory clinics, a critical care air transport service, and UWSOM, the host of the WWAMI program) will become an ACO in 2014. WWAMI’s history of innovation and consultation to rural providers is a platform on which to expand assistance to rural areas struggling to address ACA-related issues. Historical regional collaborations through the WWAMI program have resulted in networks of health professionals working to find community-based solutions. This can be expected to accelerate under the ACA.
Addressing Challenges and Opportunities Introduced by the Convergence of Rural Medical Education and the ACA
After implementation of the ACA, ACOs are being built around the patient-centered medical home. In this model, primary care physicians and other health professionals are the nexus of health care for patients and focus on providing care that is patient-centered, comprehensive, team based, coordinated, accessible, safe, and of high quality. The increased need for more primary care physicians is resulting in expanded primary care programs nationally and a greater focus on primary care at regional campuses. Any anticipated increase in the choice of primary care by medical school graduates, however, will take time and will need to be accompanied by a similar increase in GME positions. Meanwhile, different pressures resulting from the ACA introduce challenges to training programs focused on rural and primary care medicine.
Medical education depends on quality clinical, community-based training experiences for medical students, residents, and other health professionals. Finding adequate numbers of clinical training sites is especially challenging for programs with a rural focus. Currently, the WWAMI program depends on approximately 5,000 physicians throughout the five-state region who volunteer to teach trainees within their practices, and more community training placements are needed to increase numbers of students in rural training. Special programs like R/UOP, WRITE, TRUST, and Track require community involvement. Unpublished surveys of WWAMI physicians completed every five years indicate a sustained interest by volunteer faculty in participating in WWAMI because of the stimulation and enjoyment students bring to their practices despite the decreased clinical productivity these physicians report.
As productivity demands increase, community and rural physicians may become reluctant to host students. In addition, as more physicians become employees of hospitals, clinics, and integrated systems, health systems may set productivity goals that reduce clinical training opportunities. Health systems may also set standards for teaching roles and for developing and maintaining clinical rotation opportunities. ACOs must budget for the real costs associated with having independent preceptors teach trainees. Medical schools must highlight the message to community health care constituents that an adequate workforce depends on providing training opportunities for the health professions, and that providing these opportunities helps with recruitment in the long term.
Because of the ACA’s focus on patient safety, those who manage integrated systems may perceive that having trainees in clinical care settings introduces risk. Educational institutions must strive to address and alleviate these concerns. Simulation training may be a key tool, providing training in core skills and procedures before working with patients. At the UWSOM, the Institute for Simulation and Interprofessional Studies has borne this out through central venous line catheter training for residents that reduced the complication rate significantly and saved approximately $500,000 per year.35 Regional simulation centers may become important for distributed education settings; currently, for example, simulation is available in Boise, Anchorage, Billings, and Spokane. In addition, medical schools must build solid curricula that feature accountability—quality, safety, cost-effectiveness, and efficiency—for students and trainees at all levels.
The increased demand for primary care physicians puts a premium on physician recruitment and retention. Rural primary care practices are inherently at a disadvantage, with demanding practices and lower reimbursement. It is too early to tell whether financial incentives under the ACA will increase the numbers of medical students who choose primary care careers. The 2013 residency match shows an increase in students filling positions in internal medicine, pediatrics and family medicine, but this may partially reflect the increased numbers of positions.36 In addition, the pool of residents in internal medicine includes significant numbers of physicians who will subspecialize.37
Despite some indications that the decline in interest in primary care may be slowing somewhat,38 competition for primary care physicians in urban areas could undo some of the hard work undertaken to recruit rural providers. Sustaining and increasing financial incentives for primary care rural practice as the ACA matures will be vital to achieving workforce needs. Area Health Education Centers will continue to play a key role in rural recruitment and retention.
Federal control over numbers and types of residency positions is critical to the future physician supply. While the number of medical students has increased, GME positions remain relatively stagnant.20 Other avenues exist to build a larger GME workforce, such as using hospital and other nonfederal funding. However, these funding priorities compete in a constrained fiscal environment and may not be successful, resulting in a threatened bottleneck of medical students graduating without the ability to match into a residency program.20,38 Inevitably, this would do the greatest harm to primary care and rural workforces.
The ACA and the ACO model place a premium on interprofessional health care. A key to controlling cost and enhancing quality, efficiency, and safety is making optimal use of individual providers’ talents and expertise working in effective teams in the patient care medical home. This requires that all health care providers, clinics, facilities, and systems rapidly learn to work in well-functioning interprofessional teams. Strong leadership and ongoing change management are needed to develop these integrated health care teams. Learners can be an integral part of these transitions by bringing newly developed skills from the increased interprofessional focus in education occurring nationally. The WWAMI program and its host, the UWSOM, place a premium on advancing interprofessional education through initiatives to increase interprofessional training opportunities region-wide.
The development of ACOs in rural regions is inevitable. However, because rural locales may not have sufficient populations to sustain the numbers of patients needed to achieve bundling and other ACO components, rural providers may choose to partner with ACOs in other, more urban regions or with distributed ACOs. The consequence could change referral patterns, with increasing transfers to urban-based centers of patients who would normally seek care in small rural hospitals. Rural and small communities, however, may be uniquely positioned to transition to integrated systems and provide opportunities to train the next generation of health care professionals. Networking in and across locations is a more integral part of the rural environment than in the urban sphere. Existing rural networks provide fertile ground for the integration that characterizes an ACO environment and for helping to train the next generation of health care professionals. In the WWAMI region, the confluence of partnerships among the program’s participants—including physicians, state and local medical associations, health advocacy groups, and other health care organizations—will help to sustain and build these networks.
The upcoming era represents a time of challenge but also opportunity. At no time in the history of American health care has such a strong emphasis been placed on access, quality, safety, efficiency, and cost-effectiveness—all essential elements of successful health care. Although time and effort will be needed to fully incorporate these into training and practice settings, the transition is essential and positive. Care must be taken to ensure that training the next generation of physicians and other health professionals remains meaningful and integrated into health care settings. If students are relegated primarily to shadowing roles or do not have excellent apprentice experiences with interested teachers and mentors, future health professionals will lack the skills needed to provide safe, effective, high-quality care. Likewise, if the ACA is successful in its move to focus on an integrative role for primary care that ensures appropriate management and continuity, rural and other underserved locations must maintain a unique, special status. This must include provision of ongoing financial incentives for practicing in these more challenging settings in order to continue to attract and maintain quality providers. The development of GME primary care programs located in and serving rural locales will be important to ensure recruitment and retention of primary care physicians.
Clearly, the challenges associated with building and maintaining a rural primary care workforce have intensified, but overcoming these challenges remains vital to the future of American health care.
Acknowledgements: The authors wish to acknowledge the data contributions of Douglas Schaad, PhD, professor of biomedical informatics and medical education, University of Washington School of Medicine, Seattle, Washington.
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