Thursday, October 7, 2010

Primary Care Grants from HRSA: not enough, not wisely done

In late September, the Health Resources Services Administration (HRSA), a branch of the federal Department of Health and Human Services (HHS) released the funding announcements for its grants support a variety of educational programs for academic year 2010-11. This was long anticipated news by those who had applied for them, since the time period that they cover began in July. The grants cover a wide variety of areas largely involving enhancement of the health professions workforce in primary care, oral health, physician’s assistants programs, minority health, geriatrics, pipeline development, and this year (with ARRA funds) $50 million for equipment. State-by-state funding (very important politically!) can be found here, broken down by state and category here, information on individual grants, by county, can be found here.

Virtually all of the programs supported by HRSA are in important areas that I have written about previously, but I will focus here on those I know best, the “Primary Care Cluster”, part of Title VII. These grants support program innovation in Residency Training, Medical Student (Predoctoral) Education, Faculty Development, and “Academic Administrative Units” (essentially departments of primary care). They have their roots in the development of Family Medicine as a discipline in the 1970s. The feds then, as now, saw primary care (family medicine) as an important need, but one which needed nurturance. Residency programs were being started and needed funding to develop and experiment with different curricula that would be most appropriate to create family doctors. There were no departments of Family Medicine in medical schools, or even academic faculty in the discipline, so the Academic Units grants were created to help support the creation of the former, and the Faculty Development grants the latter. Predoctoral grants helped develop the curriculum for educating medical students in family medicine.

These grants were successful, both in creating programs that trained more family doctors and doctors who went into practice in underserved communities, often through the National Health Service Corps (NHSC), another HRSA program. In addition, another (possibly unanticipated) outcome was that the formal training of family medicine faculty and fellows in educational skills, felt necessary because there were not existing physician educators in this field, created a core cadre of physician medical educators that was far more extensively and formally trained in areas such as teaching skills, curriculum development, implementation, and evaluation, and other education methodologies than faculty in other departments, revealing a large, previously unrecognized need in medical school and residency faculties. In the 1980s, the grants were expanded to a larger pool of primary care programs, primarily General Internal Medicine and General Pediatrics, and later Physician’s Assistants.[1] They became critical supports for innovation in the education of students, residents, and faculty.

While these programs were very successful, reported in numerous articles reporting on general internal medicine[2], general pediatrics, and family medicine (notably in a special issue of Academic Medicine, November 2008) and has been demonstrated to increase the number of physicians practicing in community health centers (Rittenhouse DR, 2008), and have actually enjoyed bipartisan support (after all, both Republican and Democratic legislators have underserved rural and urban areas in their districts), funding has always been threatened. For many years, Presidents of both parties would “zero out” funding for these programs in their budgets, only to have them restored by Congress after significant pressure from their constituents. Even then funding has often been cut; in 2006 there was just enough to fund the existing (usually 3-year) grants and no new ones were funded, and the years since have been marginal.

So there was great anticipation this year, with large (for a small program such as this, compared, say to the NIH funding of biomedical research in the tens of billions) increases from previous desert levels. Much of this was ARRA (stimulus) funding. And the results have been very disappointing. Like much of ARRA, emphasis was placed on projects that would programs that could show quick, tangible results so a good portion went to equipment grants. Some went to specific Congressional earmarks. ARRA funds supporting traditional Title VII Primary Care grants were for 5 years, and were all that was available to General Internal Medicine and General Pediatrics; the relatively small number of programs that were funded thus received relatively large grants. ARRA funds also supported a miniscule number (5) of new Academic Units Grants for Family Medicine. The pot for “regular” funds for grants was smaller than it has been in many other years, and large numbers of faculty development, residency, and medical student education grants that were highly-scored by the peer reviewers did not qualify for funding. The application of ARRA funds made this a particularly crazy year; in the Spring those with existing funding were told that they “might” have to submit new grants, in two weeks, so they wrote them before being told “never mind”. The grant reviews happened late and so funding was late. The staff at HRSA, a highly committed group, must have felt whipsawed by changes in rules from above and urgent questions from potential and current grantees.

So, life is tough. Not all grants get funded. Maybe only a small minority do – talk to those who apply for funds to NIH. And so the money came late – it came (to those who received it.) For grants other than those supporting faculty development fellowships, which would have needed to recruit fellows months before the end the academic year – this is not such a big problem. But with all the talk – justified – about the need to produce more primary care physicians for the US, this is a very small pool of funds to be divided up. Some family medicine leaders have given up on HRSA funding; one writes “Title VII is a dinosaur…it has not effectively funded new ideas for more than a decade…it is no better than a random lottery…” The rigid priority and preferences, good for some reasons, do tend to stifle innovation.

The other issue is the disposition of funds between the 3 primary care specialties, and especially the large 5-year grants to general internal medicine (the leader quoted above continues, “…although it doesn’t seem very random if all the AAU grants went to internal medicine.”) As has been noted on this blog before, the percent of graduates of 3-year IM residencies who enter primary care (general) internal medicine is vanishingly small; most go on to subspecialty fellowships, and most of the rest become hospitalists. The New England Journal of Medicine’s health policy writer, John Iglehart, describes this in the August 5, 2010 issue in an overview of the impact of the ACA law on residency training, “Health reform, primary care and graduate medical education”,[3] in which he indicates 10-20% of internal medicine residency graduates will enter primary care (I think 20% is dreaming; even 10% may be!) From one perspective, perhaps GIM needs a “jumpstart”, but there is little reason to believe HRSA grant funding will change the decisions (largely financial) for most IM graduates. On the other hand, Family Medicine residencies are producing primary care doctors in every study (Iglehart says 91%), so it could reasonably be argued that the funding should go with proven success.

Interestingly, one of the priority criteria for funding was that “90% of students entering ‘primary care’ specialties (FM, IM, Pediatrics) are in primary care practices 3 years later.” Given the large number entering IM, and the low % at almost all schools entering GIM, this is an extremely high bar, even though it generously uses 3 years rather than the 8 years post-graduation used in the study by Mullan and colleagues cited previously (A New Way of Ranking Medical Schools: Social Mission). The social mission of medical education: ranking the schools[4] used 8-year data to account for such things as a delay for a year or 2 between completing residency and entering a subspecialty fellowship as might occur for a 2-year NHSC commitment or a brief stint as a hospitalist to make money. My school, the University of Kansas, was ranked #5 nationally, mostly for its success in getting graduates into primary care and rural practice, but this was almost entirely due to family medicine; when the HRSA criteria are applied, only 70% of graduates of FM, GIM, and Peds were in primary care in 3 years, reflecting the fact that for KU graduates, as those from most institutions, the retention of internists in primary care is abysmal.

In any case, it is critically important to have significant federal funding for education and training in primary care if we are to meet our nation’s health needs, have physicians for rural areas, and staff our community health centers. The funding needs to be much greater, it needs to be reliable year-to-year, it should have consistent criteria, and it decisions should be made well before the start of the grant period. It is the least that Congress can do.

[1] Funds are also available to support nurse practitioner programs, but through a different stream, targeted to nursing.
[2] (Lipkin M, 2008)
[3] Iglehart JK, Health reform, primary care and graduate medical education, NEJM 5Aug2010;363(6):584-90.
[4] Mullan F et. al., The Social Mission of Medical Education: Ranking the Schools, Annals of Internal Medicine, 15Jun2010;152(12):804-10

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