Advisory Committee on Training in Primary Care Medicine and Dentistry

Approved on August 3, 2007

Minutes of Meeting, May 17-18, 2007

Advisory Committee Members Present
Joseph A. Leming, MD, Chair
Sanford J. Fenton, DDS, MDS, Vice Chair (by phone)
Joseph F. Cawley, PA-C, MPH
Diego Chaves-Gnecco, MD, MPH
William Alton Curry, MD
Alan K. David, MD
Kevin J. Donly, DDS, MS
Katherine A. Flores, MD
Bonnie Head, MD
Lolita M. McDavid, MD, MPA
Eugene Mochan, DO, PhD
Charles P. Mouton, MD, MS
Joseph L. Price, PhD
Raymond J. Tseng, DDS, PhD
Barbara J. Turner, MD, MSEd
Surendra K. Varma, MD

Others Present
Stephen R. Smith, Senior Advisor, HRSA
A. Michelle Snyder, Associate Administrator, Bureau of Health Professions
Marilyn Biviano, PhD, Director, Division of Medicine and Dentistry
Jerilyn K. Glass, MD, PhD, Acting Executive Secretary, Advisory Committee

Thursday, May 17, 2007

The Advisory Committee on Training in Primary Care Medicine and Dentistry (Advisory Committee) convened its meeting at 8:33 a.m. at the Hilton Rockville Executive Meeting Center, 1750 Rockville Pike, Rockville, MD 20852.  Joseph A. Leming, MD, Chair, opened the meeting by introducing new advisory committee members and two administrators from the Health Resources and Services Administration (HRSA) who gave opening remarks.  Stephen R. Smith, HRSA Senior Advisor, presented Department of Health and Human Services (DHHS) certificates of appreciation to retiring members:  Eugene C. Rich, MD, Man Wai Ng, DDS, and Tina Cheng, MD.

Providing background, Mr. Smith said that HRSA works with about 80 different programs, most involving grants that support health care services, health professionals, and health care infrastructure.  He discussed the importance of Federal agencies getting informed recommendations from advisory committee members who have expertise in specific areas.  While agencies do not always control the ultimate output of the political process or the budgeting process, advisory committee recommendations are helpful in developing critical agency arguments for certain program directions.  For example, the Advisory Committee's fifth report on evaluating outcomes of Title VII, section 747 programs has been useful in discussions about the accomplishments of these programs and in internal budget presentations.

Mr. Smith pointed out that DHHS has about 215 advisory committees and often the Secretary will delegate requests to the specific agency.  Dr. Duke, acting on the Secretary's behalf, met with Dr. Leming in May about the Advisory Committee's letter to the Secretary and to two Congressional committees.  As a result of that meeting, the Bureau will provide money for a contract writer for the Advisory Committee's seventh report.  In the discussion following his remarks, Mr. Smith said that he believed that Title VII, section 747 programs, like the National Health Service Corps, were a means for the Federal Government to address primary care training.  There was discussion about collecting data to show cost effectiveness of these programs. 

A.Michelle Snyder, Associate Administrator for the Bureau of Health Professions, thanked Advisory Committee staff members.  She highlighted the importance not only of community health centers, but also health care professionals to staff the centers.  She pointed out that right now 64,000,000 Americans (about one in five of the population) live in an area with an inadequate level of access to primary health care.  Over 40,000,000 Americans, even if they can find a provider, do not have insurance to pay for care.  More than 16,000 primary care physicians and 9,000 dentists are needed currently in Federally-designated Health Professions Shortage Areas.  Ms. Snyder said that Title VII programs have encouraged students to practice in medically underserved areas, and one year after completing primary care training programs, graduates are more likely than other students to serve in those areas.  She reaffirmed the Bureau's support for Title VII, section 747 programs and the work of the Advisory Committee.

Sanford J. Fenton, DDS, MDS, Chair of the Writing Group for the sixth report, joined the meeting on speaker phone.  The Committee members discussed changes to the draft, and several members said they would send text changes to Katherine A. Flores, MD, Co-chair of the Writing Group.  The Committee decided to have the sixth report sent out for public comment.  The comments will be considered by the Writing Group in a future conference call, prior to the report going to an editor.

For the next report, the Advisory Committee discussed models of health care.  It was felt that the title of the seventh report should reflect an emphasis on a new view of an American health care system.  Professional societies in pediatrics, family medicine, and dentistry have endorsed the concept of a patient-centered medical and dental home as a way of explaining what primary care providers do.  The Committee decided the topic of the report would be a redefinition of primary care as providing a patient-centered medical and dental home within the health care system and its advantages in addressing vulnerable populations and health care disparities.  The report would focus on a rationale for implementing this concept and the educational needs for trainees to practice in this health care environment.

In response to a question, Marilyn Biviano, PhD, Director of the Division of Medicine and Dentistry, suggested the Advisory Committee consider what it is trying to impact, what it is trying to answer in terms of Title VII, section 747.  She said it is helpful to focus on tangible recommendations, supported with data.  The Advisory Committee discussed prevention and primary care, service to the underserved, the link of Title VII, section 747 outcomes with those of the National Health Service Corps, and cost effectiveness of primary care.  Outcomes may include the amount of training occurring in community health centers and the number of Medicaid or Medicare patients served.

There was discussion that radical change was needed in the current health care system, that community health centers are in fact medical/dental and sometimes psychiatric homes for patients, and that a medical/dental home is a model to address health care vulnerability, access, and services.  The question was raised as to whether there is an economic model that would justify increased funds for Title VII, section 747 based on benefits to the population.  Would Congress support public/private partnerships to help fund the training of health professionals to work in collaborative groups in medical/dental homes? Such partnerships would leverage Title VII, section 747 funds.    

The Advisory Committee began drafting initial recommendations for the seventh report.  The recommendations urge the Nation to embrace medical and dental homes as a model to address vulnerability and access for the population, with special emphasis on vulnerable groups.  Title VII, section 747 funds for the educational pipeline are critical.  The Title VII, section 747 grant program has a work product, that will advance the medical and dental home concept.  While in one sense the work product is deferred in its measurability and return, the services provided patients by students and residents within the programs are immediate.  A possible recommendation is to fund pilot projects that deploy, through an academic institution, a medical/dental home concept to geographic areas in need.  These projects may include public/private partnerships and involve matching funds.

One report suggestion was to include an appendix that lists for each Congressional district the number of uninsured, the number of primary care training programs, and the number of people served in these training programs.  Anecdotes backed with data, especially regarding the pediatric and geriatric populations may be helpful.  There was some discussion of the kind of data available from HRSA.  Dr. Biviano mentioned that health workforce data were available, including numbers, types, and distribution of practitioners, and numbers from the National Health Service Corps.  The Committee considered the idea of getting data from the private sector as well.

The Seventh Report Writing Group includes Surendra K. Varma, MD, William Alton Curry, MD, Alan K. David, MD, and Diego Chaves-Gnecco, MD, MPH.  The Co-chairs are Barbara J. Turner, MD, MSEd. Joseph F. Cawley, PA-C, MPH, and Kevin J. Donly, DDS, MS.

There was no public comment.  After the public portion of the meeting adjourned, ethics training was given to new members of the Advisory Committee in closed session.

Friday, May 18, 2007

The Advisory Committee discussed qualifications for a contract writer for the seventh report.  Skill in writing policy documents was primary and knowledge about the medical/dental home concept secondary.    

The Advisory Committee felt it would be helpful to have speakers for the September meeting who could address policy, economic, and practical issues related to the medical/dental home concept.  Suggestions were made about inviting experts from pediatrics, dentistry, and family medicine, specifically from the Graham Center.  Perhaps someone experienced in implementing the concept could be added.

A plan was made to invite constituent organizations to give public comment at the September meeting.  They would be asked to share their experiences with the medical home or dental home concept and provide clinical vignettes. The comment period would be limited to 5 minutes, and a two-page briefing paper provided to the membership in advance of the meeting.

The Advisory Committee broke into small groups to work on the seventh report; one group worked on an outline and the other worked on recommendations. 

Barbara J. Turner, MD, MSEd reported for the outline group.  The group felt that evidence should be gathered for the medical/dental home concept from both national and international models, emphasizing economic and other outcome measures.  The special topics of prevention, the complex patient, and reduction of health care disparities were included, as were training curricula and learner competencies.  The Advisory Committee emphasized that multidisciplinary medical/dental home is a model for the delivery of primary care and that funding was needed for innovative training.

Raymond J. Tseng, DDS, PhD reported for the recommendations group.  The group recommended giving priority to grant proposals that develop the concept of a medical/dental home within a redefined primary care delivery model.  Additional recommendations were made about curricula, faculty development, collaboration with Federally-funded programs, outcome measures, best practices, and funding sources.    

During the public comment period, Stephen C. Shannon, DO, President of the American Association of Colleges of Osteopathic Medicine (AACOM), suggested there be coordination and communication among the Advisory Committee, the Council on Graduate Medical Education, and the Advisory Committee on Interdisciplinary Community Based Linkages for a greater impact of the primary health care workforce message.

The Advisory Committee meeting adjourned at 11:30 a.m.