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

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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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Top Ten Reasons for Future Subspecialist Physicians To Be Concerned

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This guest piece, by Robert Bowman, MD, of the AT Still School of Osteopathic Medicine in Mesa, AZ, can be considered to be a sequel to his guest blog from January 15, 2009, Ten Biggest Myths Regarding Primary Care in the Future. In that piece, Dr. Bowman discussed how, of the five primary care training “forms” (General Pediatrics, General Internal Medicine, Family Medicine, Nurse Practitioners and Physician assistant) only family physician provided enough “Standard Primary Care Years” per graduate, and distributed to the areas in which people live, to provide sufficient primary care. In this piece, he presents information on how the change in the workforce is likely to have an even greater impact on subspecialists.
I think that this is very timely. The idea that family physicians, or primary care doctors in general, will be “replaced” by nurse practitioners and/or physician’s assistants keeps rearing its ugly head despite evidence to the contrary. Dr. Bowman demonstrates that reimbursement policies that pay far more for “partialism” encourage both physicians and non-physicians to enter subspecialist practice. We still do and will need more primary care and it is not going to happen by magic. It is going to happen by changing reimbursement policies. (See, for example, Mary Carmichael's "The Doctor Won't See You Now", in Newsweek, Feb 26, 2010).

The first two graphics demonstrate trends in the number of primary care providers by "form" if there were not movement into subspecialism, and what the real trend will be.
The final graphic compares the retention in primary care, over time, for the different "forms" based on whether they are more "permanent choice" primary care (e.g., family medicine) or "flexible choice" (e.g., internal medicine).

10. “Midlevel” Growth: Nursing leaders have promised to deliver health access where it was most needed and received numerous concessions to move beyond nursing but have largely left health access behind along with basic nursing. Nursing leaders continue to promise primary care while nurse practitioners steadily depart primary care to become specialty workforce and appear poised to become “nurse doctors” (DNPs). There is every reason to believe that DNPs will be no more – and probably less – likely to practice in underserved or rural areas at greater rates than current NPs. Physician assistant leaders are likely to follow the independent "successes" of nursing. Future subspecialist physicians will face competition no other physician subspecialists have ever had to face.

9. Increasing NP, IM, Ped entry into subspecialties. About 40% more nurse practitioner, 50% more internal medicine, and 60% more pediatric graduates are entering specialty workforce compared to a 10 - 15 years ago, and specialization rates have continued to increase. In addition, more internists and nurse practitioners convert from primary care to specialty care in the years after graduation.

8. Increasing PA production, also entering subspecialties. Over 220% more new physician assistant graduates are entering the sub-specialty workforce, increasing from fewer than 1500 in 1998 to over 4600 in 2008. The percentages in emergency care, orthopedic, and surgical subspecialties are now greater than those in primary care. Physician assistants also are converting from primary care to specialty care after graduation. Only 28% of 2008 graduates entered primary care in AAPA surveys.

7. Postive Cost-Benefit ratio for “midlevel subspecialists. Nurse practitioner and physician assistant graduates have lower employment costs than subspecialist physicians. It is possible for 2 or 3 NP or PA subspecialists to generate more revenue than one subspecialist physician for less cost of salary, benefits, and other physician perks.

6. Increased “midlevels” in subspecialties decrease need for more subspecialist physicians. More and better nurses, assistants, and other health care team members are recruited to subspecialty workforce because the higher reimbursement for subspecialty services as compared to primary care allows these subspecialists to pay them more. Physician assistants and nurse practitioners are on track to increase to 450,000 that are more than 70% subspecialty care. The US is moving to a specialty workforce that can deliver more specialty care with fewer specialty physicians.

5.Increasing US graduates likely will further increase subspecialist production. US graduates deliver twice the workforce of non-citizen international medical graduates due to delays in entry and departures from the US workforce after graduation. Expansions of US medical schools are likely to replace more non-citizens with US origin graduates. This replacement results in twice the specialty workforce for each position transitioned from a non-citizen to a US origin graduate.

4. Increasing subspecialist production of US Medical Schools. The United States produces 40 - 50% more subspecialist workforce from each type of medical school compared to a decade ago. Currently no one can estimate just how much specialty workforce will be produced as the annual graduates entering the workforce continue to increase with higher percentages found entering specialty care in physicians and in non-physicians.

3. Threats to very high subspecialist reimbursement. To the extent that there is any decrease in subspecialist reimbursement, these physicians will face the possibility of longer hours, more services, less vacation, and more years of work per subspecialist physician.

2.Supply, demand, and cost of care. All physicians will be blamed for continued health care cost increases as all levels of government and all businesses and all of the US people pick up the tab. There is potential for even more costs with subspecialists increasing services to compensate for an oversupply of subspecialists.

1. And, finally, when the United States finally invests in sufficient primary care substantially fewer visits will be needed in specialty offices.

Add to this
· the steadily increasing disconnect between subspecialist physicians separated from their patients by additional assistants
· the admission patterns of medical schools favoring upper-income students leading to subspecialists with ever more exclusive origins who are less and less like lower and middle income Americans .

In other words, our medical education leaders and medical association leaders and subspecialists...
...will probably never see it coming.

Robert C. Bowman, M.D., rcbowman@atsu.edu

Only those unable, those unaware, or those with another agenda fail to understand that solutions for basic health access have worked for over one hundred years.

http://www.basichealthaccess.org/ http://www.physicianworkforcestudies.org/ http://www.ruralmedicaleducation.org/

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"War on Specialists?": Wall St. Journal defends the status quo!

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The Wall St. Journal, October 13, 2009, contains a “Review and Outlook” piece (editorial) titled “The War on Specialists”. The opinion piece decries the way that “ObamaCare” is going to try to save money by reallocating funds from subspecialists to primary care doctors. As an example, they talk about the proposed cuts to some of the “basic tools of heart specialists”, echocardiograms and cardiac catheterizations. They quote American College of Cardiology CEO Jack Lewin, MD, as saying that it will cause a “horrible disruption” that may make senior patients wait days for tests and services, because staff will have to be laid off. (Of course, it could lead to SHORTER waits if the cardiologists do more procedures per day to try to make up that income!) The WSJ correctly points out that the cuts don’t necessarily cut any spending; “…the RVUs merely redistribute it from one medical bucket to another.” That is, the cap on spending on medical care (called the Sustainable Growth Rate, or SGR, which I have previously addressed) would increase primary care doctors’ reimbursements while it cuts those of subspecialists.

But would these predicted disasters actually come to pass? Hard to know; but what we do know is that the reimbursement for subspecialists is many times that of primary care physicians, so much so that it is more and more difficult to convince medical students, graduating with large debt, to enter primary care. The assertions of the WSJ, and Dr. Lewin (who used to be director of Public Health for the state of Hawai’i, and an advocate for the public’s health, before taking this more highly-paid job) are simply assertions. Following the same pattern as the paper I discussed recently by Dr. Cooper (“’Uncomplicated’ Primary Care?”), and others, they ignore data that shows that there needs to be a balance between primary care and subspecialty care in order to achieve the best outcomes in the public’s health, and that the current ratio is way out of balance. I have cited, over and over again, the literature, from many places and many times, that demonstrates this. And is conveniently ignored in this piece, attacking this consistent data as “based on a flimsy survey” that HHS has done and that Secretary Sebelius and budget director Orszag will not discuss with poor Dr. Lewin. Why bother to look at the data when you can simply assert your beliefs?

The WSJ article ignores the fact that much of the care provided by, for example, cardiologists, is excessive; that supply generates demand. The work of the researchers at the Dartmouth Health Atlas show the dramatic differences in costs of care and frequency of expensive procedures by region – often based on the density of subspecialists – without appreciable differences in health outcomes. (Or, when there are differences, that the outcomes are better where there is less use of expensive technology!) It makes the key mistake of conflating “health” with “preventing death”. Of course, we all want to prevent our deaths when we see meaningful life ahead, but the extraordinary expenditures that often prevent death only by weeks, days or hours, would often be better spent on having a sufficient number of primary care doctors to be able to maintain health, control chronic disease, and do preventive care. [1]

“Markets,” the WSJ asserts, “are supposed to determine the composition of the workforce, not a command medical economy run out of Washington.” Perhaps, but the situation that exists today is far from a “free market”. In addition to the almost-unique ability of medical specialists to generate demand based on supply, as discussed above, the simple fact is that it is the “command economy”, not the market, that accounts for the current, inequitable state of reimbursement. The assignment of RVU values grossly overvalues procedures in comparison to time spent with the patient discussing their health, managing medical problems and planning treatment. It is the fact that Medicare (and thus other insurers, whose reimbursements are almost always tied to multiples of Medicare rates) and its current method of reimbursing fee-for-service by RVU values that have created this inequity. What is needed is to correct it, and this cause is not served by blatantly false assertions that it is a free market, rather than a stacked system, that has created the problem.

While Jack Lewin has become an embarrassment to public health, he is doing his job. The WSJ can advocate for “markets” but should not imply that the status quo is a result of the operation of free markets, rather than a reflection of the way the deck is currently stacked. The WSJ provides no service whatever when it tries to make a discussion about what best serves the health needs of the American people a partisan cause. It can disagree with me on the issues, it can even choose to trumpet its disregard for facts, but this is not, and should not be a Democratic / Republican issue. The health of our people is too important.

[1] For example, the most common outpatient medical visit, code 99213, taking about 20-30 minutes, in which I can address multiple chronic health problems as well as preventive services, is valued at 0.92 work RVUs. If I then clean the wax out of the person’s ear, I get another 0.61.

More Primary Care Doctors or Just More Doctors?

In a Health Affairs “Web exclusive”, Dr. Richard Cooper of the Wharton School at the University of Pennsylvania has two studies, “States with More Physicians Have Better-Quality Health Care,”[1] and “States With More Health Care Spending Have Better-Quality Health Care: Lessons About Medicare”[2], which have generated a great deal of discussion; in this article I will address the first of these.

Cooper’s study purports to refute a previous study published by Katherine Baicker and Amitabh Chandra previously cited on this blog, “Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care”[3], a widely quoted study that demonstrated that when states were ranked by either quality of care indicators or by Medicare spending, there was a large difference between those with higher numbers of specialists (costs up, quality down) and generalists (quality up, cost down). Cooper, a long-time advocate of increasing physician production -- but not with an emphasis on primary care or generalists (believing that market demand is an effective way of determining physician workforce) -- argues that increasing numbers of physicians increases quality of care, regardless of whether they are family physician/general practitioners (FP/GP) or specialists, and identifies what he sees as flaws with the statistical assumptions and analysis in the original Baicker and Chandra article. Cooper looks at regions, and notes that the South has low numbers of both specialists and generalists and low quality, the Northeast has high numbers of specialist and low numbers of generalists and pretty high quality, but that the Upper Midwest, Northwest, and Northern New England states, with high quality and high levels of FP/GPs are what creates this result (seeming as if more FP/GPs improve quality). He believes that this is because these states are relatively wealthy, have relatively low numbers of poor and minorities, and perhaps more progressive social policies demonstrated, for example, by the lower rates of incarceration. Some of these are good points; places that have a lot of resources, both in terms of money and social capital, do well; it does not address the issues of the incredibly higher cost of medical care in the Southern New England and Mid-Atlantic states compared to the three areas above, which are very probably the result of the high level of specialists compared to generalists. Cooper does not address cost at all.

Baicker and Chandra respond to this article in the same web issue of Health Affairs,[4] particularly addressing both Cooper’s misinterpretation of their data, and (in their assessment) poor use of statistics in his own study. (I will not try to summarize these issues, which involve the use of correlation, weighting and regression analysis; those of you who are expert enough in statistics can read the article.) They conclude that, properly analyzed, Cooper’s data (as opposed to his conclusions) supports their conclusions in the original 2004 study that higher numbers of FP/GP doctors improve quality measures and higher numbers of specialists do not. They take issue with his title and main theme, ““Quality is better in states with more physicians, both specialists and family physicians”, saying “A more careful statement would be, ‘Quality is better in states with more family physicians, but no significant association was found for specialists.’” They state, in pointing out that correlation shows direction but not in magnitude:

“The numbers of specialists and generalists per capita may have identical correlations with quality, but they have very different size effects on quality. Cooper’s own exhibits suggest that this is the case—and that generalists have a dramatically bigger effect on quality than specialists do....you would have to add roughly ten specialists per capita to move up ten spots in the quality ranking, but you would only have to add one generalist per capita to move up the same ten spots. And, apparently, even the small effect of additional specialists on quality is statistically insignificant.”

Philip Musgrove, deputy editor of Health Affairs, who wrote the Introduction to Cooper’s article, makes this point in the most recent issue of Health Affairs, which contains a series of letters relating to these articles (including letters by both Cooper and Baicker and Chandra). In responding to a letter by John Frey (see below) that asserts that Cooper’s viewpoint is supported by Musgrove, the latter endorses the analysis of Baicker and Chandra, writing “Cooper’s analysis actually agrees with theirs [Baicker and Chandra’s], since his own results show that the presence of more specialists has a much smaller (about a tenth as large) effect on quality than the presence of GPs has.” [5] Of note, Cooper’s response contains no such acknowledgement.

The letter from Dr. Frey, a leading family physician and academic who is Professor and Chair Emeritus in the Department of Family Medicine at the University of Wisconsin, suggests that:

“To test Richard Cooper’s hypothesis that it is simply more doctors, not the mix of specialty/generalists, that makes a difference in access, quality, and cost, why not close down all generalist training programs (which are well on their way toward that goal anyway, with the choices made by U.S. medical students) and see what happens? Managing complex multiple comorbidities, managing urgent and unorganized health complaints, or providing primary and secondary preventive care to large populations of chronically ill patients would be done by an increasing cadre of subspecialty providers.”[6]

Implicit in Frey’s suggestion is that they (the subspecialists, sometimes, to distinguish them from generalists, called “partialists”) would not, and perhaps could not, do so. I absolutely agree. While I do not urge the adoption of such a plan (and I’m sure Dr. Frey really does not either) any more than I advocate closing volunteer safety net clinics to stop “bailing out” government and society from the consequences of their failure to act to meet the basic health needs of all our people, I have no question but that the results would be exactly what Dr. Frey implies. And I have no doubt that the subspecialists would overwhelmingly agree. The “Joint Principles of the Patient Centered Medical Home” developed collaboratively by the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP, representing internal medicine doctors), the American Academy of Pediatrics (AAP), and the American Osteopathic Association (AOA) and endorsed by the Patient Centered Primary Care Collaborative (PCPCC)[7], an industry-led coalition, never specify that these services must be provided by an identified primary care doctor, but it is very unlikely that there are many subspecialists who would choose to have to provide all these services.

However, Frey is correct about the fact that medical students are voting with their feet and running from primary care. Unquestionably, while there are many reasons that medical students might choose one specialty or another, the major issue in the dramatic change away from primary care in recent years ere is expected income combined with medical debt. As I have previously noted, much of this income differential is not “market” driven but simply reimbursement driven. If nothing is done to change the circumstances that have produced this movement, Frey’s ironic suggestion might become de facto true, and we will all suffer for it. Unfortunately, the work of scholars and policy people such as Cooper, advocating simply increase in the number of physicians without attention to the composition of the physicians workforce, may hasten rather than slow, this disastrous outcome.

[1] Cooper RA, “States with More Physicians Have Better-Quality Health Care,” Health Affairs 28, no. 1 (2009): w91–w102
[2] Cooper RA, “States With More Health Care Spending Have Better-Quality Health Care: Lessons About Medicare”, Health Affairs 28, no. 1 (2009): w103–w115
[3] Baicker K & Chandra A, “Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care”, Health Affairs, 7 Apr 2004;W4.184
[4] Baicker K & Chandra A, “Cooper’s analysis is incorrect”, Health Affairs 28, no. 1 (2009): w116–w118
[5] Musgrove P, “Primary/specialty care: an author responds”, Health Affairs Mar-Apr 2009;28(2):594-5.
[6] Frey JJ, “Test the primary/specialty care hypothesis”, letter, Health Affairs Mar-Apr 2009;28(2):594.
[7] “Joint Principles of the Patient Centered Medical Home”, February 2007, http://www.pcpcc.net/node/14