Will Teaching CHC Sites Deliver Health Access Result?

Teaching Community Health Center sites are a new innovation in graduate medical education (GME). Teaching CHCs have been set up to address failures in traditional GME in important health access areas - primary care needs, rural training, and the needs of states with fewer physicians. In general the states with highest concentrations of physicians have the most GME, the most specialized GME, the most clinicians of all types, and the highest spending on medical education and health care.

Teaching CHCs have been announced and it is possible to assess 65 sites with regard to future health access workforce impact. 

Will Teaching CHC Sites Deliver on their Promise of Needed Health Access Result?

Yes, but limited -The best answer is that the Teaching CHCs will have some small impact, but the full potential will not be realized. Changes should be specific to better site choices and greater focus upon graduates that will deliver health access where needed.

Local access improvement - All of the sites will add to care at the CHC sites and will have some influence regarding graduate choice of care where needed. Some sites are more likely to contribute care where needed for the United States due to the specialty trained, the county site of training, and the state location of training. 

Instate multiplier impact - Residency training has a profound impact upon instate practice location. Instate GME is a 20 to 40 times multiplier effect across US states when assessing 700,000 active physicians in databases controlling for origins (3 - 5 times instate effect) and medical school instate influences (4 - 6 times). Traditional GME concentrations in just a few states are a reason for failures in physician distribution for most states. Teaching CHC design should be specific to states (and counties) in need of workforce.

Residency Training Regional Impact - Research regarding residency training over the past 40 years has indicated that residency training location influences nearby practice. Training site graduates tend to fill up positions within a county and within nearby counties (within 60 miles). This effect may be stronger where no previous training exists and may be weaker when competing training exists. Traditional GME concentrates physicians where top concentrations exist. Teaching CHC training should be different. To accomplish this, Teaching CHCs should avoid locations where concentrations of physicians or clinicians are found. This is not the case for a substantial number of sites.

Specialty choice for training has significant impact. Only one source consistently and significantly multiplies care where needed. Family medicine training is the only training source with population based distribution. As other specialties melt away with lower local concentrations of physicians, family medicine remains about 30 per 100,000. With declining concentrations of physicians, family medicine becomes a greater proportion of local workforce. This translates to a 3 times multiplier for rural locations (RUCA), a 3 times multiplier for zip codes with fewer than 75 physicians (horizontal health access focus and outside of vertical concentrations), and a 3 times multiplier for counties lowest in physician workforce with less than 150 physicians per 100,000 or half of the national average or less. 

Population Based Distribution Is About Family Practice Positions Filled
by MD, DO, NP, or PA Only

No other source has population based distribution to locations in greater or greatest need. Population based can be determined by ratios of proportion of a specialty at a type of location compared to the population proportion. For example about 20.4% of active FM docs are found in rural locations with 19% of the US population for a ratio over 1.0 ratio. Because FM grads remain over 90% in FM and in primary care, their family practice positions filled influence population-based distribution for an entire career.

Only family practice positions filled by MD, DO, NP, and PA have population based distribution to locations where needed. Generic NP or PA graduates (just active clinicians with NPI) have lower concentrations or 0.62 ratios when considering counties in need of workforce - far less than the 1.0 population based ratio. Family practice positions filled by NP or PA have the family practice multiplier effect with twice or three times the distribution of sources not found in family practice. Unfortunately the NP or PA active family practice component is down to 25%. This is better than the 7% of MD or 17% of DO, but is far less than the 90% for family medicine trained physicians.

Teaching CHC designs should emphasize specialties found at Community Health Centers.

Generating a Ratio for CHC Distribution

A census of CHC workforce was assembled in 2004 and this can be compared to physicians in the 2005 American Medical Association Masterfile.

4.23 For All FM grads or 3084 out of 86,090 or 3.58% found in CHCs in 2004 (Rosenblatt census) compared to 0.85% of active US physicians in 2005 (Masterfile)

1.91 for PD training or 1247 out of 77,000 trained for 1.62%

1.64 for OB-Gyn or 525 out of 37,788 for 1.39%

1.09 for IM training or 1443 out of 156,761 trained for 0.92%

0.71 for Psychiatry or 197 out of 32,791 for 0.6%

Each of the 62 Teaching CHC sites was coded by county and by state location and by training specialty.

• Top Rated - 11 sites were top rated due to the triple combination of FM training, training in a state in greatest need, and training in a county lower to lowest in clinician concentrations.
• Higher Rated - 7 sites were higher rated with 2 out of 3 of a mix of FM training, county need, and state location need.
• Marginal - 29 sites were marginal with the main factor being FM training as the county and state locations did not reflect greater need.
• Lowest Rated - 18 sites were lowest rated as they were missing all 3. The sites were without FM training, without training in a state in greater need, and without training in a county of greatest need.

No Obligation - Since none of those trained at Teaching CHCs (or any program) acquire an obligation to serve where needed and none are required to stay instate or stay within their specialty of training, the results are limited. Again this translates to estimates based on specialty choice and training location influences. Specialty training choices other than FM are limited for reasons of primary care retention or poor distribution. 

• IM training is limited due to less than 20% remaining in primary care and even the student types favorable for primary care retention only have 30 - 35% office primary care result. 
• PD is down to 40% office primary care yield (COGME). 
• Psychiatry and geriatric graduates are poorly distributed where care is needed (Masterfile).

Again all Teaching CHCs will contribute locally and will have some small influence upon choice of underserved settings - but some sites are more likely to contribute to greater need.

Anticipating Changes in States and Counties Regarding Need for Clinicians

Some situations are changing at the sites. For example increases in population and demographic changes in Texas or other states or certain counties will worsen their health access situation. 

In general the counties lower to lowest in workforce are increasing faster in population growth and have more elderly and more arising to insurance coverage. More with diabetes, obesity, smoking, poor health status, and preventable hospitalizations reside in counties short of workforce. Faster growth, higher complexity, and lesser workforce levels are likely to be associated for some time. Sadly penalties are also more likely with even lower reimbursement as Hong demonstrated in JAMA regarding CHC populations and Pay for Performance.

Stability of Recommendations

County deficits in the counties with lower to lowest concentrations and state deficits have been present for decades. Family medicine has been a consistent multiplier of distribution for its entire 44 year existence - but remains at 3000 annual graduates or the level first achieved 34 class years ago without much change since.

Will Training Interventions Improve Health Access?

For over 3 decades this answer has been an emphatic "NO!" 

Only from 1970 to 1980 has the United States improved health access workforce as seen with increases in primary care, workforce where needed, and distribution. The combination of specific training focus (FM, primary care) with funding for primary care training with increased Medicare and Medicaid spending illustrated the route to health access recovery. 

There is no guarantee that Teaching CHC contributions, even in family medicine, will increase FM graduates. The sites often have few graduates and some may not fill their residency positions. Expansions of residency positions outside of family medicine (generic expansion) may allow more medical students to bypass family medicine - another downside of Teaching CHC designs that are not specific to FM alone. Family medicine, internal medicine, and psychiatry are rather low on the priority list for medical students making career choices. Income and support and location advantages await those who specialize.

Some FM sites are found in states where FM programs have been terminated or downsized as traditional GME institutions find it to their advantage to convert FM GME positions to various other GME positions. The health access disadvantages of the current design are numerous.

Major design changes in FM could also decrease annual FM graduates and FM workforce. Some influential FM leaders have supported an increase in FM program length from 3 to 4 years. This can result in fewer slots offered and available in the match and fewer graduates. A program with 24 slots divided by 4 years would offer 6 slots rather than 24 divided by 3 years of GME for 8 slots. If FM goes to a 4 year training design this will effectively shrink FM annual graduates nationwide as 9000 divided by 3 is 3000 per year as compared to 9000 divided by 4 or 2250. Based on elective choices in some larger programs, about half of the residents have opted for 4 year training. This is still over 10% shrinkage of FM graduates. Other losses would be 3% fewer years in a career and lesser activity. Longer and more formal academic training for the past 50 years for FM, NP, and PA training has been associated with decreased distribution.

Shrinkage of the best source of primary care, primary care where needed, and workforce where needed would be a disaster for health access in the United States. It would seem that longer training, higher debt, lower income, and decreased life income would also be a disaster for medical students considering family medicine as well.

The Prospect for Health Access Recovery from Training Interventions

There is no guarantee that any training intervention will work because primary care spending support remains insufficient. Increases from 1300 to 16,000 annual NP graduates from 1980 to the present with increases from 1400 to 8000 annual PA graduates, two doublings of osteopathic graduates, numerous doublings of Caribbean graduates, and recent increases in MD graduates would be expected to have some impact. Unfortunately the health access impact has been limited and will remain limited due to limitations of primary care spending support. 

Expansions of graduates without more support have resulted in declines in the primary care result from training. The tripling of primary care capable graduates arising from six sources from 13,000 in 1980 to over 36,000 has been associated with a decline from over 60% serving in primary care to less than 30% - such is the serious consequence of payment inequities regarding primary care and basic services versus non-primary care and more specialized services. 

The expansions have involved the sources with the least primary care delivery (3 - 6 Standard Primary Care Years for NP, PA, IM) and have avoided the family medicine source with the most primary care delivery over a career (25 Standard Primary Care Years). Sources substantially not primary care in result over a career are not specific to health access recovery.

Spending specific to primary care continues to remain fixed and lower such that any training intervention for primary care may not result in greater primary care result. To deliver more care, the spending must be specific to the hiring and support of more clinicians and team members that deliver care. Spending diverted to non-primary care, administration, management of care, billing, dealing with insurance or government, consultants, health information technology, and personnel that do not deliver care results in less available for teams and clinicians that deliver care.

Recovery of health access requires payment and training interventions specific to health access – permanent family practice result, more spending on primary care delivery, more spending in counties in need of care, more core specialist result from core specialty training. In other words the US still needs broadest generalists and general specialties and better support for their work delivering basic services and primary care where most Americans have fallen behind by design.

Teaching Health Centers should bridge the gap that exists between the needs of most Americans and traditional training. Specific attention to this task is required.

Special funding for health access is scarce, and should be made most specific to interventions highest yield for health access. Hundreds of millions have been spent in recent years upon generic interventions that will result in less than one-third of graduates in primary care with even more limitations regarding service where needed.

Traditional GME funding must be made accountable and so must the funding of non-traditional health professional training. The accountability must be the same as for health access.

• Instate for most states in need of workforce
• Primary care result - permanent
• Workforce where needed

Family medicine training in states in need of workforce in counties in need of workforce is the solution. Not only should graduates complete residency in such locations, they should have preparation and medical education in such locations. Specific designs in favor of health access shape all influences possible to instate, primary care, and where needed.

Teaching CHCS need specific health access design.

Best of Basic Health Access

Robert C. Bowman, M.D.
www.basichealthaccess.blogspot.com 

World of Rural Medical Education at www.ruralmedicaleducation.org