Advisory Committee on Training in Primary Care Medicine and Dentistry

Minutes of Meeting, April 20, 2009

Advisory Committee Members Present:
Barbara J. Turner, MD, MSEd, Chair
Kevin J. Donly, DDS, MS, Vice Chair
Perri Morgan, PhD, PA-C, Vice Chair
Nathaniel B. Savio Beers, MD, MPA
James F. Cawley, MPH, PA-C
Diego Chaves-Gnecco, MD, MPH
William Alton Curry, MD
Mary Burke Duke, MD
Katherine A. Flores, MD
Stephanie Janson, PA-C
Sheila Koh, DDS, RN
Desiree Lie, MD, MSEd
Lolita M. McDavid, MD, MPA
Dennis J. McTigue, DDS, MS
Eugene Mochan, DO, PhD
Charles Mouton, MD, MS
Stephen C. Shannon, DO, MPH
Harry S. Strothers III, MD, MMM
James Thomas, PhD
Raymond Tseng, DDS, PhD
Surendra K. Varma, MD

Others Present:
Jerilyn K. Glass, MD, PhD, Executive Secretary, Advisory Committee
Dan Mareck, MD, Director, Division of Medicine and Dentistry

Monday, April 20, 2009

The Advisory Committee on Training in Primary Care Medicine and Dentistry (Advisory Committee) convened its meeting at 8:33 am ET at the Doubletree Executive Meeting Center, 8120 Wisconsin Avenue, Bethesda, MD 20841. Barbara Turner, MD, Chair, began the meeting by welcoming Advisory Committee members and guests. She then invited Dan Mareck, MD, Director of HRSA’s Division of Medicine and Dentistry, to give remarks.   

Dr. Mareck summarized information regarding the additional funding within the 2009 omnibus bill for the Division’s primary care medicine and dentistry training program.  He stated that HRSA management has seen some preliminary numbers in the FY 2010 President’s budget and that preparations for the FY 2011 budget cycle were set to take place in coming months.

Ms. Brenda Williamson, Chief, Primary Care Medical Education Branch in the Division of Medicine and Dentistry, gave an update on the most recent Title VII, section 747 grant cycle.  She provided data on the number of grant applications received, the number that met eligibility requirements, the number that were funded by grant category, and the amount of money awarded.

Tannaz Rasouli, Senior Legislative Analyst, Association of American Medical Colleges (AAMC), provided a legislative update on Title VII, section 747. The AAMC coordinates the Health Professions and Nursing Education Coalition (HPNEC), a group of about 60 national organizations that come together to coordinate the AAMC’s advocacy on Title VII/Title VIII funding.  For FY 2010, HPNEC will be recommending $550 million for all of the programs that fall under Title VII/Title VIII.

Ms. Rasouli said the AAMC is working to get funding for Title VII restored to FY 2005 levels and recoup at least some of the funds lost since the FY 2006 cuts, due to inflation.  Some progress has been made.  The passage of the FY 2009 omnibus bill and the American Recovery Reinvestment Act, which included a total of $200 million for Title VII/Title VIII programs, provided a boost in funding.

Perri Morgan, PhD, PA-C, Co-Chair of the Eighth Report Writing Group, presented the Group’s work since the last meeting. She introduced the following guiding points: (1) efforts towards getting primary care training out of the hospital into the community; (2) guidelines to support the infrastructure of primary care training; (3) administrative recommendations for running the aforementioned training programs; (4) advocacy for changes in reimbursement strategies and Centers for Medicare and Medicaid Services (CMS) funding; and (5) development of a more structured healthcare workforce plan.

In response to the work presented by the Writing Group, Advisory Committee members convened in small groups to expand the recommendations into four main themes: community-based, primary care training; primary care systemic changes; Title VII; and workforce.

Raymond Tseng, DDS, PhD presented the following recommendations offered by the community-based, primary-care training group:

1. Funds, to include all-payer GME funding, should support costs associated with training medical, dental, PA students, and medical and dental residents. Such support should consist of stipends or loan-forgiveness programs for clinical preceptors and support for travel and temporary housing expenses for students and residents rotating through remote training centers.
2. Funds should be available for training in non-hospital training sites (community-based facilities).
3. Funds should be available to community health centers and other community-based, primary-care facilities that serve underserved populations.       
4. Primary-care facilities that receive these funds should have preventive services, systems for managing chronic conditions, electronic medical records, and training that centers on inter-professional collaboration.
5. Accrediting bodies should revise standards to promote community-based primary care training for medical and dental trainees at all levels.
6. Title VII, section 747 training grants should support community-based, primary care clinical training for physician assistant, medical, and dental students that recruits and supports community-based clinical preceptors.
7. BHPr should directly support community-based primary care clinical training by developing and disseminating materials and methods to assist educational programs with recruitment, training (including continuing medical and dental education), and support of preceptors.

The work of the primary care systemic changes group, as presented by Katherine A. Flores, MD, included the following recommendations:

1. Congress should instruct CMS and encourage other payers to work with primary care leadership organizations to develop strategies to redefine how primary care is delivered and reimbursed.  States need to be incentivized to reimburse primary care more equitably. 
2. Congress should expand funding for loan repayment and National Health Service Corps programs (NHSC) at levels that positively impact primary care workforce shortages. Scholarship loan repayment and loan forgiveness should be established under Section 747 and expanded.
3. Medical-dental home training demonstration projects should be developed with a focus on innovative funding strategies (reference Advisory Committee’s 7^th report).
4. New models of primary care practice in community training sites should be developed to demonstrate how to provide primary care services in the current fiscal environment.
5. CMS and other payers should provide financial incentives to medical and dental practices that are exemplary in preventive services, care and management of chronic disease, use of electronic medical records, and other components of the medical and dental home model. Special attention should be given to providers of underserved populations.
6. CMS and other payers should pilot and evaluate reimbursement strategies that compensate for non-traditional approaches to care such as group visits, telephone and electronic communication, care management, and incorporation of non-traditional provider types such as patient educators, patient navigators, and community-health workers.
7. A structure for evaluation of each proposed project should be designed and implemented.  HRSA should be funded to develop an expertise to guide the evaluation of Title VII, section 747 grants so as to better support grantees.

The work of the Title VII group, presented by James Thomas, PhD, offered the following recommendations:

1. Continue and maximize support for all Title VII, section 747 programs, at least at the level recommended in the 7^th annual report, with annual cost of inflation adjustments, and ongoing evaluations and increases to meet the programmatic primary care needs of the country.
   1. Support programmatic innovations at institutions prioritizing curriculum and training system changes to implement the medical-dental home chronic care model.
   2. Support Title VII, inter-professional education for team-based training.
   3. Fund faculty development.  
   4. Fund programs that will essentially increase diversity among physicians, physician assistants and dentists.
2. Fund programs, as referenced in the 7^th report, for infrastructure, to support the implementation of an IT infrastructure for primary care training venues, particularly as needed for implementation of the primary care medical and dental home model.   
3. Improve data reporting efficacy of Title VII programs by funding grants focusing on evaluation of one or more Title VII programs or making evaluation a key part of allocation for ongoing training grants. 

The workforce group, as presented by Charles Mouton, MD, offered:

1. Establish a supplemental grant mechanism to support Title VII, section 747 grantees in the evaluation and long-term tracking of trainees.
2. Provide funding to develop programs that focus on the interdisciplinary training of primary care residents.
3. Develop training programs that promote primary care subspecialty collaborations and patient management, emphasizing the medical-dental home.
4. Create IT infrastructure and training programs that promote the medical-dental home and chronic-care model through collaboration.
5. Develop strategies to increase recruitment and retention of medical and dental faculty.
6. Support/fund programs that provide language and cultural competencies for international medical graduates entering into primary-care training programs, emphasizing additional training to prepare them to serve in underserved communities.
7. Enlist the Secretary of HHS to direct the Department to develop a health care workforce planning mechanism, with an emphasis on short- and long-term goals.

Following the group presentations, Dr. Turner led a discussion on the textual material in a draft of a report on interprofessional education under development by the All-Advisory Committee.  Dr. Mouton addressed concerns that the report implied that primary care physicians were a thing of the past and that their work could be done by nurse practitioners and physician assistants. Committee members also observed a lack of sufficient data to support what was proposed in the report. Dr. Turner suggested that the Writing Group scale down the proposed recommendations and include more information that supports the concept of a primary care team working in tandem with other health care professionals to deliver the most efficient service and care for their patients.

The Advisory Committee discussed prospective topics for the Ninth Report:  1) more training opportunities outside of traditional academic medical centers and dental schools; 2) an increase in the number of educators needed to train medical and dental students in primary care; 3) encroachments on clinical educators in primary care education; 4) promotion of a positive environment for primary care training; and 5) the identification of strategies to enhance the viability of faculty in academic medical centers.

Ms. Hope Wittenberg, Director of Government Relations for the American Family Medicine Advocacy Alliance, gave public comment. She urged the Committee to make a clear statement to Congress that reauthorization of Section 747 is critical to health care reform. She also stated that a more comprehensive discussion on workforce should be included in any communication about the reauthorization of Title VII and its programs.

Perry Pugno, MD, Director of the Division of Medical Education for the American Academy of Family Physicians, also gave public comment. He suggested that the patient-centered medical home and the chronic model should be placed together as a single line item in the request for reauthorization. He also observed that in terms of minority medical students, interest and support for primary care has waned because the field has been negatively marketed by academic deans and journal advertisers targeting minority medical students. He stated that this negative portrayal of primary care could significantly impact workforce reform and urged the Committee to identify strategies to restore the image of the field to this audience.

The meeting adjourned at 4:30pm.