Growing community-based doctors

Medical white-coat ceremonies don't usually get much media attention. But when the Billings (Mont.) Clinic held its white-coat ceremony this past July to welcome its inaugural class of 12 internal medicine residents, “our mayor was there, our board was there, all the papers, radio and TV stations were there,” said Dr. Roger Bush, the program's director. “That doesn't happen in Boston.”

The ceremony was an important occasion for Billings, an integrated health system that includes a 240-physician group practice, a 285-bed hospital, a network of rural clinics and a nursing home. For the residents' first year, they'll spend most of their time close to the mother ship in Billings. But second- and third-year residents will spend more time at rural affiliates including a satellite clinic in Miles City, a farming community about 150 miles east.

The program aims to train new doctors to practice medicine in rural areas, using telehealth tools combined with a do-it-yourself attitude. It requires a different approach from urban academic medical centers, where residents tend to refer patients to subspecialists for basic treatment. “Our program is specifically designed and structured to train primary-care doctors how to practice in this region,” Bush said.

Dr. Clint Seger, Billings Clinic's director of regional medicine, said the Miles City facility has six full-time primary-care physicians supported by other clinicians, including nurse practitioners and physician assistants. Physician specialists from Billings drop by regularly. Patients come from a 60-mile radius, and the facility has one of the few infusion centers and CT scanners in the region. Scans are analyzed remotely by radiologists in Billings.

The Billings program is a model of the type of community-based training recommended in the Institute of Medicine's controversial report released in July on graduate medical education, Graduate Medical Education That Meets the Nation's Health Needs. The report triggered sharp criticism from the academic medical establishment for its recommendations to substantially change how the federal government funds physician training. The report suggested that the problem isn't an overall shortage of doctors, but rather a maldistribution of doctors by geographic area and specialty.

Around the country, a number of graduate medical education programs are training young doctors in community-based medicine, in the hope that they'll either stay where they are trained or relocate to other underserved communities. The Patient Protection and Affordable Care Act provided a modest amount of funding to address the maldistribution and train more young doctors in community-based and rural settings. But experts say there are too few such programs, and funding from the federal government and other sources is limited and precarious. In addition, some say the academic medical establishment has resisted this approach.

The report by the IOM committee, co-chaired by former Medicare chiefs Gail Wilensky and Dr. Don Berwick, recommended establishing an HHS policy council for graduate medical education that would develop policy for geographic distribution and specialty configuration of the physician workforce. It also recommended moving more programs out of academic medical centers and into community clinic settings. “There is a striking mismatch between the sites where residents are trained compared with the sites where they are likely to spend most of their careers,” the IOM report stated.

The report's proposals and its skepticism about a doctor shortage were quickly condemned by the American Hospital Association and the Association of American Medical Colleges. The Greater New York Hospital Association said the report's “radical recommendations” would “severely weaken America's teaching hospitals and their ability to train tomorrow's physicians.” Given this opposition, efforts to shift at least some GME funding away from traditional teaching hospitals will face an uphill battle.

But the Billings Clinic's Bush said the IOM report “was a statement of the stunningly obvious.” He added that “what may not be apparent in Philadelphia and Boston is readily apparent to the rest of society.”

The IOM report said the current hospital-based system of training new physicians does not prepare doctors well for outpatient practice. It cited a 2011 Health Affairs article reporting that Kaiser Permanente department chiefs saw that newly trained doctors lacked the skills to perform simple outpatient procedures and struggled to treat minor depression, headaches and minor chronic pain, certain acute musculoskeletal problems, and basic dermatological conditions.

“Particularly concerning is the evidence that recent GME graduates do not have some of the essential skills for office-based practice, where most of them will spend their careers,” the IOM report said. “This is likely due, in part, to the overwhelming emphasis of current GME programs on training physicians in hospitals rather than community settings.”

Two provisions in the Affordable Care Act have helped a little to move residency training out into communities and more rural areas. One is Section 5503, which benefited the Billings Clinic and resulted in the redistribution of 1,354 unfilled residency slots to rural or designated health professional shortage areas in 2011. The other is Section 5508, which created the Teaching Health Center GME program.

Bush said the idea of a rural residency program had been discussed for years, but it was finally realized when the healthcare reform law provisions were enacted to redistribute unfilled residency positions. “When Obamacare passed, we went into high gear,” he said. “It was an incredible opportunity to do an initial design for a program where there was a dire need.” Billings was eventually allocated the equivalent of 18 residents.

The federal Teaching Health Center program is spending $83.4 million this academic year to support 550 residency positions, at $150,000 apiece, that provide training in family medicine, geriatrics, internal medicine, obstetrics and gynecology, pediatrics, psychiatry and general dentistry. The residents are spread among 60 programs in 24 states.

Settings include rural areas such as Toppenish, Wash., inside the Yakama Indian Reservation, where general dentistry and family medicine residents train at the Yakima Valley Farm Workers Clinic; urban locations such as the Erie Family Health Center in Chicago's Humboldt Park neighborhood, which has a large Puerto Rican population and where family medicine residents affiliated with Northwestern University train; and suburban areas such as Conroe, Texas, where family medicine residents train at the Lone Star Community Health Center.

The ACA allocated a total of $230 million for residency training under the Teaching Health Center program. But the law's funding for that program will run out next September unless the program is renewed by Congress, which currently looks doubtful.

Sen. Patty Murray (D-Wash.) has introduced legislation to provide an additional $420 million to extend the Teaching Health Center program to 2019, but the measure has attracted no co-sponsors. In an August written statement, Murray echoed the IOM recommendations. “Currently, Medicare GME payments are designed primarily to reimburse teaching hospitals for the costs of physician training,” she said. “These hospitals are often located in large, urban areas. As a result, residents are not sufficiently exposed to the practice of primary care and are not trained in the community-based settings where most patients most often receive that care.”

If the Teaching Health Center program ends, Dr. Russell Maier, director of the Central Washington Family Residency program in Yakima, Wash., doesn't know what he and his residents will do. He currently trains 30 residents, 12 of whom are funded through the federal initiative. “If that funding goes away, most of those residents will go away—I don't have a viable Plan B,” he said. “I stay awake at nights and get up early some mornings thinking about this.”

Residents in Maier's program receive training at Yakima's two hospitals and at Community Health of Central Washington clinics in Yakima and Ellensburg. The program receives a mix of dollars from Medicare, Medicaid, the federal Health Resources and Services Administration, the state of Washington and the participating hospitals.

Maier said the residents train at clinics where they practice the full “cradle-to-grave” spectrum of family medicine. Both locations are recognized as patient-centered medical homes. In Ellensburg, there's a small clinic with three physicians and a nurse practitioner, serving lots of mainly Hispanic agricultural workers. Medical residents also are called to provide treatment at a nearby critical-access hospital if their patients are admitted or visit the emergency department.

Even with the federal funding, there are restrictions on moving more residency training into community-based settings.

According to Bush, the government money can be used only by the Billings Clinic for training provided at the clinic, not out in the community. “Our funding disappears when they get off our campus, and that's a huge problem,” he said. “We're going to have to have a bake sale to fund the salaries of people we send out.” Bush said he has sought grants from the state and from charitable foundations to fill that gap, but he's not optimistic.

Maier said his program has graduated two residents whose training was financed with Teaching Health Center program money. Both young doctors are going to practice at community health centers for lower-income patients, one in Yakima and one in Portland, Ore.

He agrees with the IOM report's recommendation to get more residents out of the inpatient setting, which he said his program has been doing since 1975. One reason that approach has been successful, he said, is because it allows physicians in training to build lasting relationships with patients and not just provide disconnected episodes of care.

“Many of our residents have taken care of patients through a pregnancy and are now taking care of the babies and the moms,” Maier said. “Academic medical centers are real important for education and research, but the fact is most physicians don't practice in that setting when they leave residency.”

Dr. Daniel Burke, director of the family medicine residency program at the University of Colorado Anschutz Medical Campus in Aurora, had urged one of his state's senators to ask the IOM to study the GME issue. Burke, a member of the Colorado Commission on Family Medicine, said he explored the feasibility of starting a three-year, six-person residency program for rural family medicine. But financing has been a challenge. Because of arcane Medicare funding mechanisms, the program was projected to lose almost $362,000 a year.

According to a financial analysis, he said, Medicare would pay $116,000 annually per resident for the proposed program's first year of residency training at the University of Colorado. But it would pay only $16,000 for second- and third-year residents training at the Colorado Plains Medical Center in Fort Morgan. The huge disparity in payment for the hospital-based and community-based parts of the program was largely because the university would receive indirect medical education funding to support a teaching hospital, while the Fort Morgan center would not get this indirect funding. “That's the way the convoluted rules come out,” Burke said. “So, to me, the IOM report was very encouraging.”

Burke added that his program would suffer because of the high rate of maternity cases in Fort Morgan, the area's generally low Medicare patient population and a low Medicare bed-day ratio. The IOM report noted the negative consequences of using these determinants of Medicare GME payment levels.

“The direct linkage of payments with Medicare patient volume also systematically disadvantages children's hospitals, safety net hospitals and other training sites that care for non-elderly patients,” the IOM panel wrote. “Nonclinical, population-based specialties, such as public health and preventive medicine, are similarly affected.”

But leaders at some traditional academic medical centers said they have long been doing what the IOM recommends. The Cambridge (Mass.) Health Alliance, an integrated safety net system affiliated with Harvard and Tufts, offers a variety of training environments in addition to its three-campus, 229-bed hospital. These include 15 community health centers, high school-based teen health centers and the city of Cambridge health department. “It gives us a richness of training sites to do GME training and medical student training that doesn't exist in other places,” said Dr. Richard Pels, the Cambridge Health Alliance's GME director.

Cambridge family and internal medicine residents are being trained to operate in new practice models such as patient-centered medical homes. Pels said his program's primary-care residents are given responsibility for managing the health of their patient populations, including taking care of patients' needs between visits and leading group visits for obese and diabetic patients every four to six weeks. “They're working collaboratively with a multidisciplinary team and are developing competence and a skill base that the IOM report is calling for,” he said.

Still, he acknowledged that Medicare's current GME financing formula creates barriers to community-based training. Beyond that problem, he said, GME educators must design primary-care training programs that demonstrate to young doctors that a career in community-based primary care can be rewarding.

“If you provide a training opportunity for residents where the care is innovative and excellent, that opportunity will have a huge impact, not only on their competency, but also in resident satisfaction,” he said. “Then they can see this as something where they want to spend their professional career.”

Follow Andis Robeznieks on Twitter: @MHARobeznieks