Posts Tagged ‘family medicine residency program’

The super charge

Texas House Speaker Joe Straus, R-San Antonio, released the interim charges for the standing committees of the House of Representatives. As he said in the accompanying letter, these charges will set the stage for legislation considered during the 83rd Texas Legislature, which convenes in January 2013.

Of those that may affect family medicine, one assigned to the House Committee on Public Health stands out for its sheer immensity. It directs the committee to:

  • Examine the adequacy of the primary care workforce in Texas, especially considering: the projected increase in need (from an aging population and expanded coverage through federal health care reform), and cuts to workforce-building programs such as graduate medical education and physician loan repayment programs.
  • Study the potential impact of medical school innovations, new practice models, alternative reimbursement strategies, expanded roles for physician extenders, and greater utilization of telemedicine.
  • Make recommendations to increase patient access to primary care and address geographic disparities.

That about says it all, right?

Fortunately, TAFP is in a good position to positively influence the state health care reform discussion thanks to our members’ grassroots involvement through the TAFP Political Action Committee and the wise direction of big-picture strategists.

Because we’ve cultivated relationships with lawmakers, their staffs, and other capitol playmakers, they know the many benefits of primary care, family physicians’ concerns with the current system, and I’m convinced they even recognize the fonts and imagery on TAFP’s issue briefs. That means that we can actively work through the interim and the 2012 election cycle to proactively advance family medicine, and when the opening bell rings in January 2013, we’ll have laid the foundation to make substantial gains.

I invite you to use the comment section to give us your thoughts on any of the objectives above to give us direction as we move forward.

To the educators, what changes would you make to medical school curriculum that would provide the greatest benefit to the next generation of physicians?

To the innovators, actively experimenting with new practice models, what have you seen as the biggest barriers to controlling costs and providing the best care for patients?

To the rural physicians, what incentives are needed to draw more doctors to your area?

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Help wanted: Send us your ideas for the Primary Care Rescue Act

As a die-hard fan of the Texas Longhorns, I have no shame in telling you that after last year’s 5-7 record, I was glad the college football season was over. Even though I’m a self-admitted policy wonk and political news junkie, I was equally relieved—even somewhat jubilant—when the 82nd Texas Legislature finally closed up shop and went home. If you followed the frustrating struggle to balance the state budget without additional revenue, and witnessed the resulting cuts to higher education, public education, and health and human services, you might have been just as ready for it to end as I was. At least when they’re not in session, they can’t do any more damage, right? Now is not the time to bury our heads in the sand. In fact, the legislative interim is perhaps our best opportunity to formulate and articulate our most effective arguments for renewed investment in Texas’ primary care infrastructure. We can document the ill effects of the drastic reduction in state support for graduate medical education, especially in family medicine residency training, and we can illustrate the broken promise of access to primary care physicians for underserved communities made manifest by the 76-percent cut to the state’s Physician Education Loan Repayment Program.

And now is the time to begin preparations for a major initiative in the next legislative session. In the late ’80s, rural medicine in Texas was in terrible need of state investment. Health care organizations and advocates rallied around a broad set of goals encompassed in what was called the Omnibus Rural Healthcare Rescue Act, which the Legislature passed in 1989. The law created the Center for Rural Health Initiatives and the Office of Rural Health Care, and it contained tort reforms, benefits for rural hospitals, several reforms to strengthen the state’s trauma care infrastructure, and new recruitment and training programs for primary care physicians. Family medicine won funding for third-year clerkships, among other valuable reforms.

As our state demographics change, and following the decision of the 82nd Legislature to withdraw almost 80 percent of its investment in programs intended to increase the state’s primary care workforce, we believe primary care in Texas is in desperate need of something like that landmark omnibus package of reforms and initiatives. Let’s call it the Primary Care Rescue Act. Obviously we would want to include the restoration of state support for GME, especially the funds that go directly to family medicine residency programs through the Texas Higher Education Coordinating Board. Also we would include full restoration of funds for the Statewide Primary Care Preceptorship Program, and the Physician Education Loan Repayment Program. But what else should we include?

We wish to engage you—the membership of TAFP—in this endeavor from the very beginning. What state reforms would make your practice easier, more efficient, and provide better care for your patients? What kind of administrative simplification requests should we make in state programs? What about managed care reforms? Would a standardized pre-authorization process help? Standardized contracts? Real-time claims adjudication? What could the state do to make primary care more attractive to medical students?

The sooner we can begin to craft a set of reforms to use during the election cycle, the more likely our success becomes. Remember, politics drives the process that sets policy. That’s why we want to hear your ideas for the Primary Care Rescue Act. Use this space, here on the blog, to comment with your ideas, and we’ll pay close attention to the discussion. If you’d rather send us your ideas individually, feel free to e-mail me, Jonathan Nelson, at jnelson@tafp.org. Or you can e-mail Tom Banning at tbanning@tafp.org, or Kate Alfano at kalfano@tafp.org. However you choose to share your ideas, we are eager to hear them. The legislative interim can be a time filled with promise and hope, and it’s the perfect time to lay the groundwork for big initiatives in the next session. Let’s take advantage of that opportunity.

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Without investing in physician training, health care bill creates aims without the means

An important piece of legislation designed to improve quality and lower costs in our fractured and inefficient health care system has received a second chance in the Special Session after dying in the House when time ran out on the 82nd Texas Legislature. However, because of other actions taken by our legislators that defund primary care residency training and other programs to bolster the physician workforce now and in the future, Senate Bill 8’s laudable goals are left without the means to achieve them.

The overarching goal of S.B. 8 is to reverse the negative trend in our health care system, to bend the cost curve by testing and implementing various performance-based payment methods that provide incentives for improved patient outcomes. It achieves this through two key mechanisms: the creation of health care collaboratives and the creation of the Texas Institute of Health Care Quality and Efficiency.

As envisioned in the bill, health care collaboratives clinically integrate physicians, hospitals, diagnostic labs, imaging centers, and other health care providers, aligning financial incentives to keep patients healthy and out of the hospital and emergency room. They are designed to move the delivery system away from a fee-for-service based system—where physicians and hospitals are paid for quantity of services over quality—to one in which doctors, hospitals, and other providers are accountable for the overall care of the patient and the total cost of the care provided.

Mounting evidence supports improved outcomes and lower costs achieved through this type of coordinated care. It works because patients receive care from a medical team, led by a primary care physician, that integrates all aspects of preventive, acute, and chronic needs using the best available evidence and appropriate technology to ensure patients receive the right care, at the right time, in the right place, at the right value.

Equally as important is the Texas Institute of Health Care Quality and Efficiency, which provides a safe harbor from antitrust laws for hospitals, insurers, and physicians to experiment with alternative payment and delivery systems.

A dedicated institute emphasizes experimentation at the state and community level, further encouraging the testing of health care provider collaboration, health care delivery models, and coordination of health care services to improve health care quality, accountability, education, and contain costs in Texas. Through regulation and rulemaking, our state and its agencies can ultimately shape how reform occurs, and this legislation provides the necessary medium for trial and error, adjustment and adaptation.

It is no secret that Texas faces a severe physician shortage, especially among the primary care physicians who are uniquely trained to address a variety of disorders and chronic diseases across multiple organ systems. By 2015, Texas will need more than 4,500 additional primary care physicians and other providers to care for the state’s underserved population.

Over the past few sessions, the Texas Legislature has put in place several provisions designed to increase the number of primary care physicians in our state and to draw those physicians to the rural and underserved areas of the state that need them most. Our elected officials expanded primary care graduate medical education and training, implemented education loan repayments for primary care physicians, and supported medical student primary care preceptorships—each proven to make a positive impact on increasing the primary care workforce.

How easily these gains can be reversed. The 82nd Legislature took a giant step backward when it chose to cut state support of medical residencies by 44 percent, from $106 million in funding for the current biennium to $59.6 million in 2012-2013; slash loan repayment programs, allocating $5.6 million to one repayment program for the first year only and zeroing out another program set up to meet the needs of Texas children; and completely eliminate the Statewide Primary Care Preceptorship Program.

Texas’ 28 family medicine residency programs prepare about 200 new family physicians each year for practice and these programs manage primary care clinics that deliver well-coordinated, cost-effective care to communities that need it. A significant portion of the care they provide is for Medicaid and CHIP patients, Medicare patients, and the uninsured. Many programs already operate at dangerously narrow margins, often teetering on the brink of closure, and proposed budget cuts could be the final nail in the coffin.

Cuts to the loan repayment programs alone could affect up to 1.1 million Texans, by the Texas Higher Education Coordinating Board’s estimate. Because of lack of funds to recruit new physicians to underserved areas, 750,000 patients could see diminished access to care, and the 426,000 currently served by 142 doctors in the program would likewise have difficulties finding a replacement physician to care for them.

Studies of the preceptorship programs in Texas indicate that exposing medical students to primary care clinical experience early in their training, like that provided by the Texas Statewide Preceptorship Program, is an effective method of increasing the number of primary care physicians and expanding access to primary care in underserved populations. Not funding this program further deteriorates our state’s ability to produce the next generation of primary care physicians.

In addition to patient care, physicians contribute to the state economy, which can be of particular benefit to rural and underserved communities. A March 2011 study by the American Medical Association revealed that through supporting jobs, purchasing goods and services, and generating tax revenue, office-based physicians contributed $1.4 trillion in economic activity and supported 4 million jobs nationwide. And the study found that office-based physicians are unique in the health care system in that they almost always contribute more to state economies than hospitals, nursing homes, and home health agencies.

Without investing in an adequate primary care base our state will not have the network of physicians it needs to care for a population ballooning at both ends of the age spectrum, and health care costs will inevitably continue their unsustainable march higher.

All is not lost. Texas has a narrow window of opportunity to identify state-based strategies that will trigger dramatic improvements in our health care delivery system, empower patients to better understand their health care choices and responsibilities, increase competition in the insurance market, and lower overall costs.

Should S.B. 8 pass during the Special Session, its goals can be achieved eventually; the bill lays the foundation to re-engineer the fractured health care system to one that serves patients and bends the cost curve to make the system sustainable long term.

The 82nd Legislature fumbled on ensuring we have an adequate workforce to make these goals a reality, but we hope that future legislatures will recommit to primary care for the sake of Texans’ future. Because without the primary care physician workforce, the potential achievements of Senate Bill 8 are just hollow promises.

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BCM on the closing of Kelsey-Seybold FMRP: “They just didn’t want to be in the education business”

The Senate Finance Committee has held hearings for the past two weeks on every section of the budget, and because so many primary care programs suffered cuts (as did most other programs), many interesting exchanges have come to light. In all the discussions, though, both lawmakers and those testifying agree that primary care is of the utmost importance to ensuring Texans’ access to care.

Because residency programs play such a large role in producing the primary care physician workforce, here enters Paul Klotman, M.D., president and CEO of Baylor College of Medicine. He testified during the Feb. 8 hearing of the Senate Finance Committee, and Sen. Bob Deuell of Greenville questioned him on the closing of the Baylor College of Medicine Kelsey-Seybold Family Medicine Residency Program. Here’s their exchange.

Sen. Deuell: A family medicine program closed. What’s your take on that?

Dr. Klotman: Our family medicine program is doing fine. [Person in audience speaks]. Oh, are you talking about Kelsey-Seybold?

Deuell: Yes.

Klotman: My understanding is they just didn’t want to be in the education business, that they didn’t want to continue to have residents there.

Deuell: Was that because of finances?

Klotman: They’re driven by patient care, they’re at risk now, they need efficiencies in their system. It’s hard. One of the challenges is working in the educational piece into efficient organizations, but I actually believe you can do that. It just needs to be done in an integrated way and I don’t think that’s their primary mission.

My understanding is they just didn’t want to be in the education business, that they didn’t want to continue to have residents there.

–Paul Klotman, M.D., President and CEO, Baylor College of Medicine

So why did the program close? It turns out that it was financial. As Jonathan Nelson writes in “On the Brink,” the cover story of the first-quarter 2009 issue of Texas Family Physician, it began in 2006 when the program’s primary teaching hospital, St. Luke’s Episcopal Hospital, cut support for the program in half.

That sent Baylor and Kelsey-Seybold FMRP scrambling to find new sources of funding, none of which were stable from year to year. By fall 2009, they agreed that the program was no longer financially sustainable. Kelsey-Seybold needed a subsidy from BCM of between $400,000 and $450,000 to keep the program viable. But Baylor, which has operated at a substantial deficit for the past several years, couldn’t save the program.

Baylor College of Medicine’s 2010-2011 appropriation for GME formula funding— money intended to support their affiliated residency programs—is $15.3 million. That’s $2.5 million more than they received in the previous biennium.

The program closing certainly wasn’t because of lack of interest from the faculty or the applicants. Again, from “On the Brink”: In an era when family medicine residencies only manage to fill 45 percent of available residency positions with U.S. medical school graduates, 97 percent of the recruitment classes at the Kelsey-Seybold program over the last three years graduated from U.S. medical schools. More than 600 physicians applied for the four open positions at the residency in 2009, and of the four chosen, two are from out of state. “I’m constantly bombarded with people that would just love to come to our program,” says Tricia Elliott, M.D., F.A.A.F.P., the residency’s program director.

Read the full article here.

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