BHPR - Advisory Committee on Training in Primary Care Medicine and Dentistry

Advisory Committee on Training in Primary Care Medicine and Dentistry

Minutes of Meeting, November 17-18, 2008

Advisory Committee Members Present
Barbara Turner, MD, MSEd, Chair
Kevin Donly, DDS, MS, Vice Chair
Perri Morgan, PhD, PA-C, Vice Chair
Nathaniel Beers, MD, MPA
James Cawley, MPH., PA-C
Diego Chaves-Gnecco, MD, MPH
Mary Duke, MD
Katherine Flores, MD
Stephanie Janson, PA-C
Sheila Koh, DDS, RN
Dennis McTigue, DDS, MS
Eugene Mochan, DO, PhD
Lauren Patton, DDS
Stephen Shannon, DO, MPH
Harry Strothers III, MD, MMM
Raymond Tseng, DDS, PhD
James Thomas, PhD
Surendra Varma, MD

Others Present
Marcia Brand, PhD, Associate Administrator, Bureau of Health Professions
Jerilyn Glass, MD, PhD, Executive Secretary, Advisory Committee

Monday, November 17, 2008

The Advisory Committee on Training in Primary Care Medicine and Dentistry (Advisory Committee) convened its meeting at 8:30am ET at the Legacy Hotel, 1775 Rockville Pike, Rockville, MD 20852. Lauren Patton, DDS, Vice Chair, opened the meeting in the absence of Lolita McDavid, MD, Chair. She gave a brief overview of the Advisory Committee’s mission, key role, and responsibilities.

Dr. Patton introduced Dennis Williams, Deputy Administrator, Health Resources and Services Administration (HRSA), who made reference to the November 2008 issue of Academic Medicine which focused on the Federal Government’s 45-year investment in health professions and Title VII programs. Mr. Williams noted the accomplishments and activities of HRSA-supported community health centers within the past year. He provided data on the primary care clinics/centers supported and vulnerable patients reached. He also discussed plans for new initiatives for the National Health Service Corps.

Marcia Brand, PhD, Associate Administrator for the Bureau of Health Professions (BHPr), thanked the Advisory Committee for its public service. She mentioned the growing interest in reauthorizing Title VII legislation. She challenged the group to think about how it can foster interdisciplinary collaboration among the health professions.

The annual election for Advisory Committee officers was held with the election of Barbara Turner MD chair, Perri Morgan, PhD, PA-C vice chair, and Kevin Donly, DDS vice chair.

Guest speaker Tim Dall, a health economist and vice president of Lewin Group, described the Primary Care Workforce Projections Study. He focused on Lewin Group’s role in providing state level primary care supply and demand estimates. He described the Health Workforce Supply and Demand Model and how variations of this model were used in the Projections study. This model also will be used to forecast current and the future demand for clinicians.

Surenda Varma, MD led a discussion on the Residency Review and Redesign in Pediatrics (R3P) project. He said the redesign of pediatric residencies will maintain the six competencies of Accreditation Council for Graduate Medical Education (ACGME). However, there is debate about what should be required for maintenance of certification. Other important redesign considerations are the creation of a continuum of education aligned with learning, a review of current programs, and documentation of criteria that will close the gap between current and optimal health care outcomes.

Eugene Mochan, DO, PhD introduced the Wagner Chronic Care Model. He focused on the chronic care crisis in the U.S., the chronic care model, and how it fits with the medical home concept. He discussed the ineffectiveness of the current health care system and practice environment. Dr. Mochan proposed six ways to improve health care outcomes: 1) influence better behaviors of health professionals, 2) improve the use of non-physicians as team members, 3) enhance health information systems, 4) develop a better planning scheme for patients, 5) modernize self- management support and registries; and 6) incorporate special programs that provide care management for high risk-patients and those with multiple illnesses.

James Cawley, PA-C, and Dr. Morgan led a discussion on physician assistant (PA) specialty trends. Mr. Cawley said there are currently 73,000 practicing PAs. The percentages of PAs working in primary care are steadily decreasing and more PAs are working in specialty and subspecialty care. Mr. Cawley was concerned that the ACGME restriction in work hours for residents may possibly correlate to the decline of PAs entering primary care.

Dr. Morgan said that the number of practicing PAs has doubled in the past decade and tripled within the last 15-17 years. She stated that there is one PA for every 10 physicians, and one PA for every 33 pediatric physicians. She believes that factors that affect specialty choices of PAs and physicians are economics, debt, loan forgiveness, personal interest(s), control over lifestyle, and institutional and system culture. Dr. Morgan forecasted a likely shortage of physicians in the future, which will change the ratio of PAs to physicians.

The Advisory Committee deliberated on the recommendations for the eighth report. They discussed 1) needed changes in the practice environment; 2) the need for an increase in funding for Title VII, section 747 programs, 3) curriculum and infrastructure development, 4) and expanded authority to coordinate and support maintenance of medical certification. The Advisory Committee debated whether to advise Congress to grant expanded authority to HRSA for overseeing continuing medical education (CME) as it relates to training physicians to function within a medical-dental home.

During a working lunch, the Advisory Committee further deliberated on infrastructure development for the patient-centered medical-dental home and how funding could help health centers transition into the use of electronic medical records (EMR).

The Advisory Committee reconvened for small group reports. Dr. Strothers’ outline group suggested that the report provide a narrative of an ideal model. The group identified barriers to successful implementation of current primary care models, as well as possible solutions. The group would like to incorporate the concept that oral health significantly impacts systemic health. Dr. Strothers mentioned the Maternal and Child Health Bureau’s LEND model as a model to consider. The group suggested a recommendation that medical education be changed to support evolving primary care medical-dental home changes.

James Thomas, PhD reported back on the chronic care model and its intersection with the medical-dental home. The group concurred that a universal EMR is essential to the improvement of health care quality, efficiency, and cost effectiveness. Members suggested the medical-dental home model be introduced at the undergraduate level. The group suggested that telemedicine be used as another method of delivering care, that health care include psychological and mental health, and that an emphasis be placed on the team approach of physicians, nurses, dentists, PAs, etc.

Dr. Morgan represented the report recommendations group. She discussed the need for the redesign of primary health care. Her group focused on training innovations, creation of a U.S. workforce planning structure, and increased production of primary-care providers.

There was no public comment. The meeting adjourned at 4:00pm.

Tuesday, November 18, 2008

Dr. Turner began the session with a revision of the seventh report that reflected recent input from the members and staff aimed at making the recommendations more actionable. The Advisory Committee discussed the recommendation dealing with curriculum development in training programs for physicians, dentists, and physician assistants. The Committee made suggestions about the creation of training programs for post-graduate trainees and faculty clinician-educators who will become leaders in implementing the patient-centered medical-dental home concept. Further discussion centered on recommendations dealing with pilot projects in training programs, infrastructure development, and coordination of continuing medical and dental education. (See 7^th report recommendations at the end of these minutes.)

The agenda turned to the eight report, with Eric Moore, the contract writer, presenting ideas on effective report writing. He stressed the following: 1) statement of the problem and its relevance to stakeholders, 2) the objectives and the benefits of fulfilling the recommendations, 3) specific outputs and outcomes, 4) alternative approaches, and 5) a specific plan or roadmap.

Volunteers for the eighth report writing team were Dr. Morgan, Dr. Varma. Dr. Mochan, Katherine Flores, MD, Sheila Koh, DDS, William Curry, MD, Stephen Shannon, DO, and Harry Strothers III, MD. Dr. Morgan and Dr. Koh volunteered to serve as co-chairs on the Eight Report Writing Group. While absent, Dr. Curry was nominated to be a co-chair, too, so that each of the three disciplines on the Advisory Committee would be represented.

Advisory Committee members worked in three break-out groups on the following topics: innovation, training changes, and workforce.

Dr. Flores reported that the innovation group recommended Congress appropriate funding for the training of health care innovations that focus on prevention and chronic disease management. They also propose behavioral interventions (e.g. motivational interviewing) within this approach.

Nathaniel Beers, MD gave the report on changes in training. The group emphasized lifelong learning as an important component of medical education and training. Funding is needed to support substantial training in longitudinal community-based primary care ambulatory settings. The group discussed: 1) changes in funding to allow training in community settings, 2) recruitment and training of community- based practices, 3) interdisciplinary training and team practice training; and 4) innovative models in primary care delivery.

Raymond Tseng, DDS, PhD gave the workforce group report. The group identified a hostile primary care environment as a major workforce issue. One objective would be to increase interest and feasibility in Title VII programs. Another suggestion was financial incentives, loan repayment, and debt relief for those who enter primary care. His group discussed the importance of recognizing nurse practitioners (under Title VIII) as a crucial part of the primary care workforce.

Dr. Glass discussed plans for the next Advisory Committee meeting on April 20, 2009. The meeting will be followed by the All-Advisory Committee meeting on April 21 which includes the membership of all four advisory committees in BHPr.

Ms. Hope Wittenberg, director of government relations for The Academic Family Medicine Advocacy Alliance, gave public comment. She urged inclusion of an abstract in the seventh report and stated that Congress prefers just one page of recommendations.

The committee discussed writing a joint committee letter to the new secretary of the U.S. Department of Health and Human Services (HHS). Dr. Turner volunteered to coordinate the letter writing effort.

The meeting adjourned at 1:02pm.

7^th Report: Coming Home: The Patient-Centered Medical-Dental Home in Primary Care Training

Recommendations:

Restore funding of Title VII, section 747 to the $215 million level requested previously in the 2006 Advisory Committee Report in order to support existing primary care programs and to fund, in part, the following initiatives to establish the educational environment for the PCM-DH.
Title VII, section 747 should give priority to commissioning 30 expert educator teams to develop and evaluate new curricula on the skills, attitudes, and knowledge base needed to practice effectively in the PCM-DH.
Title VII, section 747 should give priority to developing 25 non-degree, clinician-educator training programs for 160 primary care post-graduate fellows/trainees and faculty annually to become leaders in training clinicians in the unique skills, attitudes, and knowledge need to practice in the PCM-DH.

Title VII, section 747 should give priority to creating 20 clinician-researcher training programs for 100 primary care postgraduate fellows/trainees and faculty annually to acquire the research skills necessary to conduct evaluations of the PCM-DH in regard to patient, clinician, and societal outcomes.
Title VII, section 747 should give priority to supporting and evaluating 50 two-year pilot projects of the PCM-DH in diverse clinician training programs followed by the implementation of the most promising projects in 100 additional training settings.
Title VII, section 747 should be charged with insuring that all curricula and training programs prepare clinicians to provide culturally competent, quality care for vulnerable populations within the PCM-DH.
Congress should consider allocating additional resources to support Title VII, section 747 to become the key Federal resource for information about PCM-DH educational programs and support initiatives to establish a PCM-DH infrastructure in training programs. Congress should consider funding the basic infrastructure needed to implement the PCM-DH in training programs (medical, dental, and physician assistant).
Congress should expand the authority of Title VII, section 747 to serve as the Federal program charged with insuring that organizations meet expert-established standards for training in the PCM-DH in their continuing medical and dental education programs as well as their maintenance of certification programs.
To support the initiatives in recommendations 2, 3, and 4, Congress should allocate $20 million in addition to the restored budget of $215 million requested for Title VII, section 747 (recommendation 1).

Congress should expand the authority of Title VII, section 747 to address new programs described under recommendations 6 and 7 and provide $5 million for staff support for these programs.
Congress should commission a study by a respected external organization, such as the Institute of Medicine, to examine critical topics related to the success of primary care including Federal support for the PCM-DH, training to practice in the PCM-DH, and incentives to increase interest in primary care.