Lucy Loomis, MD, MSPH, is the director of Family Medicine at Denver Health.
A solid foundation in primary care is increasingly recognized as an essential component of meaningful health delivery system reform. However, the number of medical students choosing careers in primary care and in underserved communities has steadily declined over the last 15 years.
The Colorado Health Institute estimates that between 2005 and 2025 the primary care gap in Colorado, the difference between primary care supply and primary care demand, will grow by an additional 1,500-plus primary care physicians. That's on top of the current gap of about 1,000 primary care docs. Another 390 will be needed if federal health care reform results in nearly everyone having insurance. However, the number of nurse practitioners and physicians assistants who work in primary care influence this number.
The Colorado Community Health Network projects that to meet the needs of Colorado's uninsured population, the state's community health centers will need to double their capacity, hiring an additional 300 primary care providers over the next 10 years. The number of primary care graduates from Colorado residency programs won't be sufficient to meet this demand.
While factors such as rising medical student debt and relatively low salaries in primary care contribute to the shrinking proportion of graduates choosing primary care, the existing method of payment for graduate medical education (GME) also has contributed to this imbalance. Residency training has traditionally been hospital-based, and since being established in 1983 Medicare subsidies for residency training programs have gone to hospitals. The payment is based on a complex formula that includes the Medicare case mix at the teaching hospital, the number of residents, and historical payments.
The total number of positions funded by Medicare was capped in 1997, and any additional positions over a hospitals cap do not qualify for Medicare GME payment. Hospitals can cover more of the costs of specialty trainees with patient care revenue than they can for primary care trainees, with their requirement for non-hospital based clinic experience. As a result, the proportion of primary care positions has gradually decreased, and many hospitals are unwilling to add new primary care spots despite recent calls for more primary care graduates. This system of paying for residency has resulted in a workforce distribution that is driven more by the needs of the training hospitals than of the community.
In recognition of the importance of strengthening the primary care workforce pipeline, the 2010 Affordable Care Act contained a provision to "establish Teaching Health Centers that would be eligible for Medicare payment for the expenses associated with operating primary care residency programs."
Teaching Health Centers are defined in the bill as "an entity that is a community-based ambulatory patient care center and operates a primary care residency." The ACA also set aside funding of $230 million during the next five years to support expansion of primary care residency slots in programs meeting these criteria.
This is the first significant expansion in residency slots in more than a decade. It is unique in that the funding goes to Teaching Health Centers (rather than just teaching hospitals) and the funding only supports residents in primary care programs. Currently, no community health centers in Colorado are eligible for the program (though Denver Community Health Services is considering establishing a Teaching Health Center for its facility in Lowry). Since the federal funding is available only for new positions in programs sponsored directly by the health center (combined with the fact that the funding may expire after five years), many providers aren't certain whether it would make sense to apply.
Over the past 20 years, there have been many successful models of collaboration between primary care residencies and community health centers. Residents who complete their training in a health center environment are three-to-five times more likely than other residents to pursue a career working with underserved populations, and to work in health centers. Further expansion has been limited by the additional costs to a health center of running a residency.
Teaching Health Centers will provide additional funding to further develop and evaluate this promising model of producing a primary care workforce to meet the needs of our currently uninsured patient population.
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