Archive for March 2011
Should medical schools that receive state support for residency training be expected to produce the kinds of physicians Texas needs to ensure a cost-effective, high-quality, well-coordinated, more equitable health care delivery system? That’s the policy question posed by a Texas Tribune news article from March 10, 2011, “Budget Rider Would Emphasize Primary Care.”
The budget rider in question would concentrate state support for graduate medical education by paying for only the first three years of residency training, rather than supporting training in years four through seven, some part of which are required for subspecialties. The idea is controversial, and of course opposed by many academic health centers and by the Texas Medical Association, but it’s exactly the kind of reform to medical education that’s gathering momentum across the country.
The recently published 20th report of the Council on Graduate Medical Education proposes that a major culprit behind the declining interest in primary care among medical students is the “hidden curriculum” found in academic health centers that favors specialty care provided in the hospital setting over primary care. How did this “hidden curriculum” come to be? Because GME programs at large teaching hospitals have evolved to meet the needs of the academic health center rather than the general population.
Here’s what the COGME report has to say:
“Although Medicare capped its funded GME slots in 1997, accredited GME positions have grown 6.3 percent from 2003-2006, virtually all of which are self-funded by the hospitals. Despite this increase, a rise in subspecialty rates led to fewer physicians pursuing generalist careers. Like student choices, this build-out of residency training positions is highly correlated with specialty income. Teaching hospitals invest in lucrative services in order to support their bottom line and residents and fellows are an inexpensive way to support those services. Increasing options for subspecialization has both direct and indirect effects on primary care production, first by closing primary care positions to be used for subspecialty training, and second by giving would-be primary care physicians options to subspecialize. The net effect is a substantial reduction in primary care production from GME, now at about 29 percent or less compared to 32 percent from 2003 to 2008. In bending BME to service their financial bottom line, the needs of the population are not best served.”
Texas is spending somewhere between $75 million and $79 million on GME formula funding in the current biennium, and the proposed budgets in the House and the Senate would drop that to between $53 million and $57 million. The money is doled out based on how many residents are in training at residencies affiliated with the schools, so the amounts for each vary widely. The University of North Texas Health Science Center at Fort Worth would get around $1.6 million while the University of Texas Southwestern Medical Center at Dallas would get about $13 million.
But that’s not where the schools get most of their GME funding. The bulk of GME funding comes from Medicare in the form of Direct Medical Education payments and Indirect Medical Education funding. Both streams are calculated with methodologies based on the number of residents in training at a teaching hospital, and the payments go to those hospitals. What’s more, Medicare only reimburses teaching hospitals for the time residents spend in the hospital, which is fine for most specialties, but detrimental to primary care. For family medicine residents, the most important classroom is the outpatient clinic, and unless that clinic is attached to the teaching hospital, residency administrators have to fight tooth and nail to secure resident stipends from their training hospitals.
For a teaching hospital, having subspecialty residents is good for the bottom line for three reasons. As COGME points out, they’re cheap labor for expensive procedures, so the revenue attributed to the practice plan goes up while the costs are held in check. Secondly, the more residents you have training in the hospital, the more Medicare GME dollars you can draw down. And thirdly, having a robust subspecialty GME program makes you a prime candidate for lucrative research grants from the National Institutes for Health.
A study published in the Annals of Internal Medicine last year ranked the nation’s medical schools by the amount of primary care physicians they produced. The authors found that research funding often warps the mission of academic health centers away from primary care.
“The level of NIH support that medical schools received was inversely associated with their output of primary care physicians and physicians practicing in underserved areas. High levels of research funding clearly indicate an institutional commitment to research and probably indicate missions that value technical medicine and specialization rather than training in primary care and practice in underserved areas.”
In January of last year, TAFP published an article in Texas Family Physician examining the reasons behind the closure of the Baylor College of Medicine Kelsey-Seybold Clinic Family Medicine Residency Program. Among the events leading to the program’s termination was the decision by its main teaching hospital, St. Luke’s Episcopal Hospital, to reduce the stipends it paid for family medicine residents. I asked Steve Spann, M.D., senior vice president and dean of clinical affairs at Baylor College of Medicine, for his perspective on that decision by St. Luke’s. Here’s his response as quoted in the article:
“They did that unilaterally and despite some pretty strong protest from us, but they felt it was more to their benefit to put those stipends into neurosurgery.”
So here we are, after the passage of health care reform, trying to prepare at the state level for the implementation of its various components, yet still confronted by a fragmented, fractured delivery system without enough primary care physicians to make it all work. The COGME report makes a compelling argument that if we are to change the ratio of primary care physicians to specialty physicians in America, we must implement strategies to “improve GME and modify incentives so that they foster interest in primary care education and careers.” Seems to me this GME formula funding budget rider might be the right strategy at exactly the right time.
In testimony before the House Public Health Committee on March 2, Dallas physician John Carlo, M.D., put forth his support for a statewide smoking ban that would prohibit smoking in public places and workplaces. Advocates tried to pass similar legislation last session and failed, for various reasons. Now as it comes up again as House Bill 670 by Rep. Myra Crownover, R-Lake Dallas, and Senate Bill 355 by Sen. Rodney Ellis, D-Houston, public health groups are gearing up for another push.
Dr. Carlo said that physicians and the public at large have known conclusively since 1986 that secondhand smoke is dangerous to children and adults, and that there is no risk-free level of exposure to secondhand smoke. As medical professionals, you understand the biological explanation why secondhand smoke exposure causes damage to blood vessels and the heart. Study after epidemiological study demonstrates an increase in cardiac disease and mortality with increasing exposure to secondhand smoke.
While 33 Texas municipalities have passed some type of smoking ban in public places, including the largest cities in the state, many rural communities haven’t. Some say a smoking ban is an infringement on an individual’s right to smoke; others say it will hurt local businesses like bars and restaurants (which, by the way, isn’t true according to a January 2011 survey by Baselice and Associates, Inc.).
A March 1 press conference held by Smoke Free Texas and the Texas Public Health Coalition—of which TAFP is one of 27 members—highlighted several bills, including the smoking ban bills. Representatives spoke about the economic damages caused by tobacco use—that the annual direct medical expenses of smoking, loss of workplace productivity, and premature death cost Texas more than $20 billion. A report prepared for the American Lung Association showed while the average retail price of a pack of cigarettes in 2010 was $5.52, the actual cost to the Texas economy was $21 per pack—a heavy price. Find coverage of the press conference at http://www.tafp.org/news/stories/11.03.03.1.asp.
What do the physicians say? You know your patients better than anyone else. As a rural physician, what steps do you take to encourage patients to quit? Do you meet resistance from these patients? We’ll continue to follow this issue as it progresses. Tell us what you think.
By Greg Sheff, M.D.
I was fortunate to be one in a group of primary care physicians who met with Lt. Gov. David Dewhurst this February to discuss possibilities of payment reform in Medicaid, the Children’s Health Insurance Program, and the private insurance market. This meeting comes on the heels of the introduction of two major pieces of legislation, Senate bills 7 and 8. These bills would implement a host of pilot projects to test bundled payments, payments based on episodes of care, and quality incentives. It continues the positive momentum the state needs to move us away from a fractured health care system into one that provides the right care for Texans.
The unrelenting march of increasing health care costs is unsustainable, both for Texas and for the nation. Payment reform that aligns physician and hospital incentives with our society’s goals—affordable, coordinated, evidence-based, quality-measured care—is critical to rein in health care costs. The patient-centered medical home, driven by a strong primary care workforce, is a proven cost-effective method for delivering this coordinated and integrated care.
Earlier this year, Austin Regional Clinic (ARC) joined a multi-year medical home pilot administered by Blue Cross and Blue Shield of Texas (BCBSTX). The pilot was initiated in large part in response to Texas legislation requiring the Employees Retirement System (ERS), the self-funded insurer for state employees, to experiment with alternate payment and delivery models in an attempt to reduce the state’s ever-increasing health care costs. We are one of five physician groups in the state participating. Our program serves roughly 45,000 patients, including both the ERS (whose health care benefits are administered by BCBSTX) and BCBSTX fully-insured populations.
As we have seen with our ARC Medical Home Program, there is a definite tipping-point phenomenon in getting providers to commit the resources necessary to proactively coordinate patient care. We have been approached by a number of payers investigating our capability to transform our care delivery model. However, not until we were approached with a payer as large as ERS were we able to make a compelling internal business case for investing the resources to transform our own workflows.
For me, this is the real pearl in the ERS Medical Home initiative: The Legislature, with control of Medicaid, CHIP, and ERS/Teacher Retirement System payments, has the opportunity to change—not by mandate but by example—the cost of care delivered across Texas.
However, a primary-care-led health care system cannot exist without actively nurturing and growing the primary care workforce. Since its inception, ARC has emphasized the importance of long-term doctor/patient relationships, coordination of care, and a strong primary care physician base—three major tenets of the medical home model. Drawing upon ARC’s 30 years of experience, I cannot overstate the importance of supporting initiatives to increase the number of medical school graduates choosing a career in primary care.
Payment and delivery system reform for ERS/TRS, Medicaid, and CHIP patients, coupled with an investment in growing our primary care workforce, helps not only the Texas budget in the short and long term, but provides the seeds to transform all care in Texas.
Gregory Sheff, M.D., is the medical director for the ARC Medical Home Program.