A State-Based Strategy for Expanding Primary Care Residency

As the health care system looks to improve overall health and reduce unnecessary spending, primary care physicians become increasingly critical. The Affordable Care Act (ACA) recognizes that primary care clinicians have the potential to “bend the cost curve” through care coordination and preventive health care for our increasingly diverse and aging population. However, there aren’t enough primary care physicians to meet this need — especially in rural or poor urban areas. Current estimates predict that by 2035, our country will face a shortage of more than 44,000 primary care physicians.

As in many other states, the people of New Mexico are already experiencing this shortage. In 2014, the state had 96 primary care shortage areas, including areas in 32 of 33 counties in the state. At least 220 new physicians are needed immediately to meet the demand for basic medical care. The state has responded with an innovative and cooperative effort that led to legislation that is already expanding access to care for the state’s neediest residents.

The National Shortage Of Primary Care Residency Slots

While new medical schools are opening and established schools are increasing enrollment across the nation, there’s a residency bottleneck in the physician pipeline in many states, especially in primary care. Most of the funding for the country’s 100,000 residency slots comes from the federal government as part of Medicare spending.

However, the 1997 Balanced Budget Act placed a cap on such graduate medical education spending,effectively freezing it at 1997 levels and often locking in the ratio of primary care to specialty residency positions found at many academic teaching hospitals. Despite the ACA’s recognition of the importance of primary care, that emphasis has not been reflected in growth in primary care residency positions nationwide.

Within the present payment system, specialty care is more lucrative than primary care, and hospitals may depend on residents, rather than attending physicians, to deliver specialty services in order to recapture financial losses in other areas. Most residencies are based at tertiary care medical centers, which are dominated by subspecialty services and offer fewer opportunities for training in primary care.

The specialty-to-primary care ratio often more closely reflects teaching hospital service needs than of overall health workforce needs. This imbalance is exacerbated by the ability of more lucrative specialty departments to fund residency and fellowship positions outside the Medicare cap. To remedy current primary care shortages and avoid future shortfalls, the country needs to add another1,700 to 3,000 primary care residency slots.

Although federal legislation has been drafted to better align graduate medical education (GME) with state and national workforce needs, the proposed legislation has not made it through Congress. Nor has there been a sufficient, voluntary movement by academic medical centers to align publicly financed GME with the health goals of the nation.

Solutions are within reach: for example, a 2014 Institute of Medicine report outlines a mechanism for reforming GME payment while expanding public accountability for GME funding. However, policymakers and academic health center leaders have yet to act. Meanwhile the nation is experiencing a well-documented, publicized, and significant worsening of its primary care clinician shortages.

Finding A New Mexico Solution

New Mexico can’t afford to wait for Congress to address its primary care shortage. In 2013, a group of physicians, public health advocates, and legislators in the state of New Mexico set out to find a solution.

As part of a consortium of five universities in the Urban Universities for HEALTH program funded by the National Institutes of Health, the University of New Mexico is actively engaged in efforts to recruit more urban and minority students into the health sciences. The program has made important progress: through its changed admissions policies and its rural and minority-oriented BA/MD program, the ethnic composition of the medical school class now reflects the ethnic distribution of New Mexico. However, these steps may not go far enough if graduating physicians cannot obtain the necessary hands-on residency training, especially in primary care within New Mexico’s borders.

The New Mexico group looked at data that showed medical residents from minority and rural backgrounds were more likely to remain in New Mexico and to practice in underserved communities. They also considered a study that demonstrated that 70 percent of family medicine residents in New Mexico who trained for two or three years in rural areas of the state continued to practice in rural New Mexico.

These data are backed up by national statistics from The Robert Graham Center that show that 56 percent of residency graduates practice within 100 miles of where they completed training. Based on this analysis, the New Mexico group determined that increasing family medicine training in shortage areas provides the best chance to close the gap between supply and demand for primary care physicians.

Leveraging State Medicaid Funds And Federally Qualified Health Centers

While the federal government is the sole administrator of Medicare, the state-federal partnership inherent in Medicaid programs provides room for innovation. The New Mexico group, inspired by actions taken in Ohio to reallocate Medicaid GME spending to reflect local health workforce priorities, set out to formulate legislation to address the shortage of primary care residency positions in the state.

The model is made possible through the Community Health Center regulations governing “changes in scope of practice,” which are also allowed by CMS. Traditionally, a change in scope includes new services like oral health or behavioral health. In this case, it adds graduate medical education as an expanded scope of service. The approach is similar to the Health Resources and Services Administration (HRSA)-funded Teaching Community Health Center program. However, federal funding of these Centers in the current political climate can be vulnerable to federal budget cuts.

The budget language, which passed the New Mexico legislature easily in March 2014, redirected state Medicaid funds to help open up new primary residency slots in underserved areas of the state and builds on legislation that established financing for the New Mexico Primary Care Training Consortium in 2013, also through the Medicaid program. The Consortium is comprised of the four family medicine training programs in the state — two programs where the full three years is spent in Albuquerque and Las Cruces, and two “1 + 2” programs where the first year is spent in Albuquerque and the second and third years are spent in either Santa Fe or Silver City.

The New Mexico Human Services Department has agreed to include Federally Qualified Health Center (FQHC)-sponsored primary care residency development in the base Medicaid funding budget and FQHC payment system. Prior to the passage of this legislation, the cost of a specific number of primary care residency slots was a separate line item in the University of New Mexico budget and required further legislative appropriations to increase the number of slots. The new legislation streamlines the process by also allowing the addition of approved primary care training slots at FQHCs through this payment mechanism.

New Mexico is the first state to take this unique approach to funding GME expansion. While there are other states that use Medicaid funds for graduate medical education, only 10 states direct funds specifically toward primary care and none use the same approach as New Mexico. This model represents a critical shift in the paradigm for primary care training. It eliminates the concept of residency caps, other than state budget and program capacity limitations.

For example, if an FQHC wishes to begin or expand a primary care residency and receives approval for this from their Residency Review Committee, that FQHC applies for a change in scope of services to include incremental resident-related costs. If approved, Medicaid issues enhanced payments to the FQHC to cover the incremental costs of the residency program. The estimated cost per resident per year discussed in the initial legislation—approximately $150,000—was based upon the federal grant funding level initially established by HRSA in funding Teaching Community Health Centers in FQHCs.  Actual costs may vary.

In addition, while expansion of an existing residency program at an FQHC can be rapid once the expansion is ACGME-approved, it can take several years to create a new program in an FQHC. The state Medicaid program has agreed to pay any FQHC intending to start a new residency or expand an existing one an amount sufficient to cover the reasonable incremental costs associated with the resident month-long rotations on a pro-rated basis, depending upon the number of primary care resident month rotations at the FQHC. This is a natural way to develop resident education capacity.

An Effective, Replicable Solution

Within a year after legislative and administrative approval, the New Mexico Primary Care Training Consortium is already developing 10 primary care residency slots in four locations in some of the more needy parts of New Mexico, including Shiprock and Farmington, both in the heart of Navajo Country, and Las Cruces, on the border between the U.S. and Mexico.

With continuing legislative gridlock in the federal government, innovations in health services and in health workforce development are emerging from states. There, local solutions can grow from local needs and are often more appealing to state legislators who may be wary of federal policy. Although federal action is needed to address the nation’s primary care needs, New Mexico’s approach helps to swiftly increase access to care in the state. The model is replicable in other states because it relies on something all states have: state Medicaid dollars and FQHCs.

Author’s Note

The following people cooperated to draw up and implement the legislation that created new residency slots in the state of New Mexico:

  • John Andazola, program director, Southern New Mexico Family Medicine Residency, Las Cruces, NM
  • Darrick Nelson, program director, Hidalgo Medical Services Family Medicine Residency, Silver City, NM
  • Luis Rigales, program director, Christus St. Vincent’s Hospital- La Familia New Mexico Family Medicine Residency, Santa Fe, NM
  • Dan Waldman, program director, University of New Mexico Family Medicine Residency, Albuquerque, NM
  • Deborah Weiss, consultant to the New Mexico Primary Care Residency Consortium, Santa Fe, NM
  • State Senator Howie Morales, New Mexico State Legislature, District 28, Silver City, NM
  • State Senator Sue Wilson Beffort, New Mexico State Legislature, District 19, Albuquerque, NM
  • (Former) State Representative Rudolpho “Rudy” Martinez, New Mexico State Legislature, District 39, Las Cruces, NM
  • Brent Earnest, New Mexico Cabinet Secretary of the Human Services Department, Santa Fe, NM

Citation: Kaufman A, Alfero C. “A State-Based Strategy For Expanding Primary Care Residency”. Health Affairs Blog, 31 July, 2015.

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The Supremes and ACA: Is opposing coverage for the poor really just mean?

In the context of the historic and momentous Supreme Court decision legalizing gay marriage across the US, and its affirmation of the Fair Housing Act, the third of the “trifecta” of progressive decisions announced this week, the ruling against those who argued that the ACA forbid federal financial support of federally-sponsored rather than state-sponsored insurance exchanges, seems rather pedestrian. After all, it just decided that the intent of the ACA was to achieve what its intent was – greater insurance coverage for the American people – and this would not be invalidated by 4 poorly-chosen words in a 1,000 page bill. What is more worthy of note is that there were three Supreme Court Justices who voted against it, when it was clearly not a real issue of law but an end-run to get it invalidated on a technicality. The low point of the dissent was Justice Scalia’s juvenile characterization of the majority decision as “jiggery-pokery”, an archaic expression most recently used in the public domain in a Harry Potter movie. Of course, Scalia could make a fair Harry Potter villain; not the potent evil of Lord Voldemort, but more of a scowling, snarling Severus Snape.

Health Score vs Cost - Comm Fund 2014But the decision has real meaning. It means that millions of Americans in the 34 states that elected to not establish state-based exchanges and thus depend upon federal ones will not lose their health insurance. That is a good thing for those people, and it is a good thing for America. It does nothing for those people who were excluded by the SCOTUS decision 3 years ago (also written by Chief Justice Roberts) that, while validating ACA, precluded requiring states to expand Medicaid. This left millions more in the states that have not done so (like mine, Kansas) without insurance. It certainly does nothing for the millions of those without legal documentation who live here, or the many others who fall between the cracks of the law. It still leaves us without the moral, medical, social, and economic advantages that come from a truly universal health system such as any of those adopted by every other wealthy nation, which achieve better health for less cost (see graphic). But it does make us seem slightly less cruel and benighted.[/two_third_last]

Not that this will end the discussion. A small article in the New York Times of June 27, 2015 notes that “Legal challenges remain for health law”. These include a lawsuit by House Republicans led by Speaker John Boehner maintaining ACA is invalid because it spends money not appropriated by Congress, and a series of suits by religious organizations about the law’s requirement that they cover contraception. Indeed, the whole opposition to the law has becoming akin to a religion itself; according to its opponents (obviously also including all the Republican candidates for President) it is bad as a matter of faith, even though it does so much good. Yes, it does good in costly ways, ensuring that insurance companies make their profit; it does it in arcane ways; it does it in ways which in fact cost some people more than they might have otherwise paid. But it provides several million people the opportunity to not be the Donna Atkins or Tommy Davis of the future (see Dead Man Walking: People still die from lack of health insurance, November 17, 2013).

In response to a blog in which I posted a map that shows that the vast majority of those remaining uninsured are in the states of the former Confederacy and suggested that while Southern people might not be meaner than others, the impact of their policies was (Medicaid expansion and uncovered lives: are people meaner in the South?, February 8, 2015), Bobby Cohen wrote in a comment “If meanness doesn’t explain the rejection of Medicaid expansion by Southern states, what does?” Well, for many people, I suppose, it is ignorance, of the sort demonstrated by “Keep the government’s hands off my Medicare!” or what I have called the “Craig T. Nelson fallacy” (“I’ve been on food stamps and welfare. Anybody help me out? No. No.”!!). Or the beliefs of some of the people in southeast Kansas interviewed for Kai Wright’s excellent article “Life and Death in Brownback’s Kansas”, published in the June 22/29 issue of The Nation where it seems that “Everyone is convinced that someone else is getting a better deal, that somewhere a horde of Kansans are gaming the system and preventing the truly needy from getting help.” In a true “What’s the Matter with Kansas”[1] illustration, even the doctor at the community health clinic who is fighting hard to get care for her impoverished patients who would have otherwise had Medicaid is conflicted; Brownback, after all, is a strong anti-abortion advocate, as is she.

All of these may explain some of the position of the leaders of this movement, but a better explanation can be found in the answer to one of the questions in “Steven Pinker’s Mind Games”, a psychology quiz on the NY Times website: “the best liar is the one who believes his own lies”. But it is hard to look at, not to mention listen to or read, the hard-core right-wing justices on the Supreme Court (who, unlike the GOP’s many presidential candidates are not even running for office) without thinking that they are, essentially, mean. They are not only against helping people when it will cost them, not altruists (another Pinker question), but even when it will save them money (again, see graphic).

I do not claim to be a legal scholar of the status of any of the Supreme Court Justices, or indeed the President. I gained some understanding from “The elusive right to health care under US law”, by Prah Ruger, Ruger, and Annas in the June 25, 2015 issue of the New England Journal of Medicine, published before any of these SCOTUS decisions were announced.[2] It’s a good and readable article which helps medical people like me understand some of the logic of court decisions. One line I found of particular interest was “American constitutionalism has championed negative liberties more than positive rights.” The idea is that the Constitution says government should not be allowed to take away our individual liberties (e.g., our guns) but not so much that we have a right to things (e.g., health care).

And yet, as pointed out by Gail Collins in “Supremes hit a high note”, this Court has “…destroyed the nation’s campaign finance laws, limited workers’ rights to challenge wage discrimination and women’s rights to control their bodies. And basically disemboweled a 50-year-old Voting Rights Act that Congress had renewed by increasingly large margins on four different occasions.” These decisions, almost all of which came out differently from those of the last 2 days only by the “swing vote” of Justice Kennedy (Chief Justice Roberts did join the majority in the decision on ACA), do not always follow this logic. It is quite an extension of the idea of liberty to say that corporations are people (the founders certainly didn’t think so) or money is speech. It is quite opposite protecting individual liberty to have laws limiting the ability of women to obtain contraception or abortion (although they can sure have guns!). Whether put forward by ignorant bigots, self-serving politicians, or sanctimonious Supreme Court Justices, the concept is most consistently “people should be allowed to do whatever they want, as long as they want the same things I do, but not what I disapprove of”. Sometimes, particularly when describing the actions of the powerful, this is described as political. But I think Dr. Cohen is right; it is essentially mean.

A phrase we commonly hear is that “mean people suck”. They do, but more important, when they have positions of power, they can do a lot of damage to others.

[1] Thomas Frank. “What’s the matter with Kansas?”. Henry Holt. 2004 [interestingly, published in the UK and Australia under the title “What’s the matter with America?”!] ISBN 0-8050-7339-6.
[2] Jennifer Prah Ruger, Ph.D., M.S.L., Theodore W. Ruger, J.D., and George J. Annas, J.D., M.P.H., The Elusive Right to Health Care under U.S. Law, N Engl J Med 2015; 372:2558-2563June 25, 2015DOI: 10.1056/NEJMhle1412262.

Post by Josh Freeman; originally posted on http://www.medicinesocialjustice.blogspot.com/

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Racism and the Social Determinants of Equity: Camara Jones at 2015 Beyond Flexner

Conference speaker Josh Freeman shares his insights into plenary speaker Camara Jones’ allegories on racism and social determinants of health.

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Would Doctors Be Better If They Didn’t Have To Memorize?

Conference participant John Schumann, MD reflects on his time at Beyond Flexner and the transforming state of medical education and our health system.

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