Geiger Gibson / RCHN Community Health Foundation Research Collaborative, issuing body.
Geiger Gibson Program in Community Health Policy, issuing body.
George Washington University, issuing body.
Milken Institute School of Public Health. Department of Health Policy and Management, issuing body.
[Washington, D.C.] : Milken Institute School of Public Health, George Washington University, March 10, 2015
About 50 million Americans have difficulty accessing timely medical care--even if they have health insurance--because they live in rural, urban or suburban areas without enough primary care physicians. The shortage in the number of primary care physicians, such as family physicians or internists, is expected to deepen. As a result, there is renewed interest in innovative approaches to training primary care physicians that encourage them to practice in underserved communities with the greatest needs. The Institute of Medicine, an arm of the National Academy of Sciences, recently called for major reforms in the way that the United States provides graduate medical education, the training of medical residents after they graduate from medical school before they go into independent practice. One of the most innovative alternatives--the Teaching Health Centers (THC) model--began development and testing in 2011, but is now jeopardized by the loss of federal funding. By 2014, more than 550 residents were being trained in 60 THC programs across 27 states and the District of Columbia (see Figure 1 and Appendix at the end). After completion of their training, they are expected to provide care for almost one million patients per year. Three-quarters of the THC residency programs are sponsored by nonprofit community health centers and the rest are at similar community-based settings. Most residency training today is hospital-based. Most residents spend little time in ambulatory care clinics and even less in community-based primary care settings. Yet, it is in the community--and not in the hospital--where the vast majority of patient care takes place. A principal cause of this mismatch is Medicare graduate medical education (GME) policy, which was designed 30 years ago. Medicare GME funds flow to hospitals based on complex formulas, provided that the residents work in those institutions. In fact, funding is reduced when residents spend time in community settings away from the hospital. Moreover, there is a hospital bias in favor of specialty training because most specialty residencies are more lucrative for hospitals than are primary care residencies. Specialty diagnostics and procedures are much more remunerative to hospitals than are the charges for generalist care. The Institute of Medicine found that current GME policies are not well-attuned to America's current and future health or social needs. For example, too few residents enter primary care and relatively few go on to practice in rural or underserved communities where the needs are highest. In contrast, the THC model offers clinical training at centers of excellence in community-based ambulatory care, such as nonprofit community health centers (CHCs) or community-based training consortia. These are settings in which residents can learn to practice efficient and effective primary care for patients in underserved communities both during, and for many years after, their residencies. It is too early for a full assessment of the THC program. Because the program began in 2011 and three years are usually needed to complete a residency, only a small share of the total number of residents have had the time to complete their training (two classes that completed in 2013 and 11 classes that completed in 2014). A more comprehensive evaluation is in progress. However, preliminary results demonstrate positive and promising results and signal why this innovative model of graduate medical education should continue to be developed and tested.
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