When a national report recently declared that a shortage of primary care doctors is more about a system that neglects rural, underserved communities than a lack of physicians, Yakima Valley medical providers could only shake their heads.
They identified the problem years ago and have been trying to get policymakers to listen ever since.
“They’re not unique,” said Dr. Russell Maier, director of the Central Washington Family Medicine residency program at Community Health of Central Washington, referring to conclusions in a National Institute of Medicine report that’s drawn headlines around the country.
But the National Institute’s findings and the publicity it has generated might help tip the national debate toward action.
On the heels of the report, Sen. Patty Murray introduced legislation to create a permanent version of the Teaching Health Center pilot program that has successfully placed primary care residents in many small communities, including Yakima. Her bill would also reinvest certain dollars from the existing residency structure into increased training for primary care doctors.
Local medical leaders say Murray’s bill is a good start, but whatever happens, something needs to change in the way medical residencies are distributed and funded, or the doctor shortages in poor, rural communities are only going to get worse.
“Right now, it’s all focused on hospital-based training,” said Dr. Keith Watson, president of Pacific Northwest University of Health Sciences. “And most of the training in this country needs to shift to community-based care because that’s where most of the care actually occurs, and doctors need to learn how to do that.”
With a deadlocked Congress, however, it’s unclear if that change will come soon enough.
“We believe it has to be addressed by the end of this year,” Murray said by phone Thursday while traveling in Washington state. “This is Congress; it’s extremely challenging in Congress to get things done. But we’ve lined up support from groups all over the country, and we’re getting bipartisan support, which will help us.”
Murray’s bill strategically puts permanent funding for primary care residencies under Medicare, moving the community-based training programs — which have broad bipartisan support — out of the Affordable Care Act, which is poisonously partisan.
Residency slots are critical to producing more primary care doctors because medical school graduates must complete a residency program before they can become licensed, independent physicians. Most programs last three years, though grads who sub-specialize face more training. Without a residency, all they have is hundreds of thousands of dollars in debt and a fairly worthless “Doctor” title.
But even as medical schools nationwide have ramped up enrollment, the graduate medical education system, or GME, has not kept up with the need for more slots for residents to complete their training.
Space is particularly scarce in primary care disciplines: family practice, internal medicine, obstetrics, psychiatry and pediatrics. And that scarcity is most pronounced in rural areas like Central Washington, where it’s very difficult to persuade doctors to move and set up a long-term practice. Studies have consistently shown that doctors are more likely to settle where they’ve completed their residency. No residency programs, no new doctors.
GME money comes from Medicare, which helps explain why it’s so bogged down. Residency slots across the country were capped in 1997 as part of the Balanced Budget Act, so no one can expand their programs past what they had at that time. All GME-funded residencies are connected to teaching hospitals, which tend to be concentrated in urban areas and focus more on subspecialties than on primary care. If hospitals want to expand their residencies, they largely foot the bill, which leads them to expand into subspecialties that make money, not primary care.
Central Washington Family Medicine’s program is a joint effort between Community Health and Yakima’s two hospitals in order to access the GME dollars, and the residents complete required rotations at the hospitals.
The Affordable Care Act included a five-year pilot program for Teaching Health Centers, or THCs, that are community-based rather than hospital-based, which experts say should help get to the heart of the problem. The program is under the Health Resources and Services Administration. Locally, money from that program allowed Central Washington Family Medicine to expand from 18 residents (six per year) to 30 (10 per year) in 2012. Yakima Valley Farm Workers Clinic’s Sollus residency program in Grandview, which started last year and admits two residents per year, is funded entirely as a Teaching Health Center.
But that funding is set to expire at the end of this year, which would hurt local programs unless Murray’s bill passes.
“It would certainly be a blow for smaller communities like ours, because our hope was that we would expand this residency program into small, small communities like Othello and others,” said Farm Workers CEO Carlos Olivares.
“Our objective with this residency program, in partnership with PNWU, was that we would try to recruit kids that are from our area, and therefore would be more inclined to staying with us than leaving us,” he said.
Farm Workers’ pediatric dental residency program, for example, which receives GME dollars as part of the Lutheran Medical Center, has produced every single one of the pediatric dentists practicing in the Yakima area, Olivares said. Their Northwest Dental Residency, which is a Teaching Health Center, has had 80 percent of its primary care residents end up in an underserved community.
“Now, I would like to find GME-driven programs with that kind of track record,” Olivares said.
Murray’s bill, the Community-Based Medical Education Act of 2014, would first extend the THC program another five years, through 2019, which would allow the training of another 550 residents nationwide. She says that extension would cost $420 million.
Next, she proposes establishing a similar program, Primary Care Teaching Centers, but setting it up under the permanent auspices of Medicare as a new arm of GME, which would give it mandatory funding. It would create 1,500 new residency slots nationwide and be paid for by reallocating a small portion of current GME dollars from hospital-based training into the new community-based residencies. It would not require any new dollars.
Graduate medical education money comes in two forms: direct GME (which accounts for about a third of all GME dollars nationwide) and indirect GME (the other two-thirds). Direct GME must be used to pay for resident training, but indirect GME, which comes in the form of increased Medicare reimbursements to teaching hospitals, can be used on almost anything. Murray proposes siphoning off about 2 percent of those indirect GME payments to be reinvested in Primary Care Teaching Centers.
Her bill also includes directives to create more accountability within the GME system, which is a big concern in the Institute of Medicine’s report. Basically, the report said, even though most residents’ training is paid for in full by the federal government, programs are under no obligation to produce “the types of physicians that today’s health care system requires.”
Murray’s staff consulted with local health leaders at Community Health and PNWU on the language of the bill.
At Community Health, CEO Dr. Mike Maples said they are “perpetual optimists.”
“We really like Sen. Murray’s bill,” he said. “The step Sen. Murray’s bill is very consistent with what the IOM is suggesting. I see Sen. Murray’s bill as one of those baby steps. By the way, we also like the IOM report.”
If the Teaching Health Center program goes away, he said, the Central Washington Family Medicine residency has “a transition plan” with the two hospitals.
But he and Maier are hopeful for Murray’s bill, especially with the timing of legislation to reform the embattled Veterans’ Affairs health care system, which has won bipartisan support by highlighting some of the egregious byproducts of a doctor shortage.
“VA patients can’t get in; they primarily can’t access primary care, and they primarily can’t access primary care in what two areas? Rural areas of the country, and areas that are underserved by physicians,” Maier said. “If that wasn’t a canary in the coal mine, I don’t know what is. That’s a fairly objective outside crisis to support (this need). ... We do have a system in crisis, and it does take crisis for change.”
For PNWU, Watson said, Murray’s bill is important because without reform, there will be more and more medical school graduates who can’t find a residency. So far, the school’s three graduated classes have had 100 percent match rates for residencies, but Watson says that won’t last under the current paradigm.
“In the Northwest, we only have 2.6 percent of all the residency positions in the entire nation,” he said. “At some point, some of our students likely will not be able to find residencies, either.”
Olivares said if the THC program isn’t extended, Farm Workers’ Sollus program will continue through a partnership with Sunnyside Community Hospital and Kennewick General Hospital, but that’s not “the right way to go,” since it remains dependent on a hospital-based program.
Olivares hopes Murray’s bill moves forward.
“Let us continue to do this work. Don’t cut our legs in the middle of the race; let us finish.”