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Congressional Testimony
March 21, 2000, Tuesday
SECTION: CAPITOL HILL HEARING TESTIMONY
LENGTH: 4147 words
HEADLINE:
TESTIMONY March 21, 2000 BRUCE BAGLEY PRESIDENT AMERICAN ACADEMY OF FAMILY
PHYSICIANS HOUSE APPROPRIATIONS LABOR, HEALTH AND HUMAN
SERVICES, AND EDUCATION LABOR HHS APPROPRIATIONS
BODY:
Statement of the American Academy of Family Physicians Concerning Title VII
Family Medicine Programs, AHRQ, and Rural Health Programs Presented by Bruce
Bagley, M.D. President March 21, 2000 I am Bruce Bagley, a practicing family
physician from Latham, New York, and President of the 89,000 member American
Academy of Family Physicians. I am delighted to appear before you to discuss
three issues of critical importance to family physicians in the US: funding for
family medicine training in Section 747 of the Public Health Service Act;
funding for the Agency for Healthcare Research and Quality (AHRQ); and funding
for rural health programs. Before I begin, I want to particularly thank you for
your strong support for health professions programs over the years. Without
Subcommittee advocacy -for these programs, funding levels would be far lower
than they are currently, and the actual existence of family medicine training
programs would be threatened. While the Academy has consistently sought higher
funding levels from the White House, Office of Management and Budget and the
Congress, we realize that without your help, the program might well not have
survived. FAMILY MEDICINE TRAINING PROGRAMS Recommendation The American Academy
of Family Physicians supports appropriations of $136 million for Section 747 of
Title VI I of the Public Health Service Act, Section 747 authorizes the Primary
Care and Dentistry cluster, which includes support for family medicine, general
internal medicine and general pediatrics, physician assistants and general and
pediatric dentistry. This figure includes $87 million for family medicine
programs. Section 747 is the only program at the federal level that provides
support for four family medicine training programs at both the undergraduate and
graduate level (residency training; academic departments; predoctoral programs
and faculty development). Section 747 is crucial to training the physicians that
America needs most; it is the engine that powers the growth of this nation's
supply of family physicians. It is also crucial seed money for grant recipients
to use for innovative programs such as those involving information technology.
President's FY 2001 Budget Proposal As you know, the President's FY 2001 budget
recommends zero funding for the Section 747 Primary Care and Dentistry cluster.
This is especially disturbing since Section 747 was reauthorized recently under
P.L. 105-392, and, in a bipartisan move, the law contains fewer categorical
programs, a focus on the disadvantaged and more flexible administration. The
Primary Care and Dentistry Cluster received $ 78.3 million in FY 2000 after a 2%
rescission, which was disproportionately larger than cuts many other Health
Professions programs received. The final spending bill had mandated an across-
the- board cut of .04 percent. Turning Around the Shortage of Family Physicians
There is a shortage of family physicians and other primary care physicians
(general internists and general pediatricians) in the US. Numerous experts,
including the Physician Payment Review Commission; the Council on
Graduate Medical Education; the Robert Wood Johnson Foundation;
the Pew Health Professions Commission; the American Medical Association and the
Association of American Medical Colleges have called for increasing the supply
of primary care physicians for quality, access and cost reasons. Most experts
believe a physician workforce with a 50/50 ratio between primary care physicians
and subspecialists would best meet America's health care needs; the ratio is
currently approximately 30/70. Physicians Section 747 family medicine grants
have helped establish an infrastructure throughout the country that has reversed
the downward trend in primary care. While at one time, the US physician
workforce was comprised of more than 50 percent primary care physicians, it
declined after World War 11 to approximately 30 percent today. The Section 747
family medicine training programs provided funds to establish family medicine
departments in medical schools; to increase the number of faculty to both teach
and act as role models, and to set up new residencies throughout the country.
While the number of medical students going into primary care increased in the
1990's, the percentage is still only one-third of all graduating medical
students. Market Demand for More Family Physicians In addition, the demand for
family physicians in the market is greater than our nation's current training
capacity. Medicare payment policies have contributed to the increase in
subspecialist physicians and have fundamentally skewed the market. These
policies have promoted training in the expensive inpatient specialties -- rather
than in family medicine and other primary care fields. Moreover, NIH grants,
totaling billions of dollars, go primarily to subspecialist research in the
nation's medical education complexes. In addition, managed care organizations
are preferentially recruiting family physicians. However, 43 percent of salaried
and 29 percent of capitated plans report that it takes one year or more to
recruit a new primary care physician. In community health centers, which rely
heavily on primary care physicians, 52 percent report difficulty recruiting
primary care physicians. Primary Care Doctors are Cost Effective Moreover,
numerous studies show that primary care physicians are more cost-effective due
to their prudent use of hospital services, tests and procedures. A September,
1995, study conducted by KPMG Peat Marwick, The Role of Primary Care Physicians
in Controlling Health Care Costs: Evidence and Effects, indicated that Medicare
spending could be cut by at least $48.9 billion and as much as $271.5 billion
over the next six years if primary care physicians were 50 percent of the total
physician workforce. Community Training Requires Support In contrast to other
specialties, 80 percent of family practice residencies are located in community
settings rather than in major tertiary care teaching hospitals. These
residencies provide more ambulatory training than any other residencies. As a
result, family practice programs do not have access to the considerable
resources that flow to teaching hospitals. Further, 25 percent of family
practice residencies are located in public hospitals. These hospitals receive a
low reimbursement for patient care services, and treat fewer Medicare patients.
As a result, they do not receive substantial Medicare graduate medical
education dollars. Acute Shortage of Faculty There is an acute shortage
of faculty for family medicine residency programs and family medicine
departments. The discipline has been successful at placing its graduates in
practice settings serving communities of need rather than in full-time faculty
positions. Without adequate funding, there is a risk that even the progress that
has been made so far will be compromised for lack of America faculty. Title VII
and Graduate Medical Education As you know, Title VI health
professions programs are separate and distinct from graduate medical
education (GME). Title VII is a Public Health Service program and
funding goes to medical schools, universities and residency
programs to develop a primary care infrastructure. Graduate medical
education is part of the Medicare program and funds go primarily to
hospitals to support residency training. The Academy has had a long-standing
interest in graduate medical education because of our
commitment to a rational physician workforce policy that both discourages an
oversupply of physicians, and encourages increased training of those physician
specialties in short supply. Our organization has produced and updated regularly
a number of policies on physician workforce issues, as well as specific GME
recommendations. In brief, absent a major overhaul of the physician workforce in
the United States that would address the primary care issues targeted by Title
VI I funding, we believe it is imperative to support these programs. Innovative
Programs Title VII funds are also used to support innovative new programs that
help training and teaching programs simply get better, a goal that often
involves new technologies. Innovative programs can include web-based
technologies to evaluate training programs, or even establish links to primary
care research networks. Grant recipients are using Title VII dollars to leverage
dollars not only to meet the traditional goals of diversity, outreach to the
underserved and rural populations, but also to new programs that use key
technologies. Outcomes Data There have also been several articles from well-
known entities that have specifically described the value of Title VII family
medicine programs. -An October, 1994 General Accounting Office (GAO) report
indicated that "students who attended medical schools with family medicine
departments were 57 percent more likely to pursue all three primary care
disciplines (italics added)." In addition, the 1994 GAO report indicated that
"students who attended schools requiring a third-year family practice clerkship
were 18 percent more likely to pursue primary care." -A November/December, 1997,
article in the Archives of Family Medicine found a strong relationship between
continued Title VII funding and the presence of family medicine departments,
which is associated with greater rates of primary care production. (The Impact
of Title VII Departmental and Predoctoral Support on the Production of
Generalist Physicians in Private Medical Schools, Robert M. Politzer, ScD, et.
al.) -Family physicians have deep roots in rural communities, where 25 percent
of all Americans live, About one-quarter of family physicians locate there, as
well. The February, 1998, Tenth Report of the Council on Graduate
Medical Education (COGME) stated that, "Programs authorized under Title
VI I of the Public Health Service Act support family medicine programs with a
successful record of training physicians who choose to practice in rural and
underserved areas. These efforts should be continued and increased." Moreover,
the goals stipulated by Congress in the Title VII reauthorization bill emphasize
both the delivery of health services to underserved populations and the
geographic distribution of health professionals to underserved, particularly
rural, areas. These congressionally mandated goals are fully addressed by the
Title VII programs, and for family medicine, all four program areas have been
extremely successful. In addition, another Congressional priority is to enhance
the diversity of our medical workforce. In 1978, the first year for which we
have data, the number of minority residents in training in family practice
residency programs was 9.5 percent. By 1997, that rate had increased to 24
percent. Finally, over 90 percent of physicians who complete family practice
residency programs work in direct primary patient care and are able to handle a
high percentage of their patient's problems. AGENCY FOR HEALTHCARE RESEARCH AND
QUALITY Recommendation The American Academy of Family Physicians recommends
appropriations of $300 million for the Agency for Healthcare Research and
Quality (ARHQ) in FY 2001. We strongly support the Agency because of its
emphasis on primary care and practice-oriented research. It is the only federal
agency with this charge. President's FY 2001 Budget The President's budget
proposed a funding level of $250 million for ARHQ in FY 2001; a boost of 22
percent above the current funding level of $204 million. What is Primary Care
Research? Primary care research includes 1) research on the conditions that
affect the majority of the population, and 2) translating biomedical research
into practice. Additional research is needed on conditions that affect most
Americans. Most medical care is provided in outpatient settings. However,
ambulatory medicine is the least researched mode of patient care. Over 95
percent of all medical conditions have been evaluated and treated outside of
hospitals over the last 30 years. -However, physicians are educated and trained
using research that has been derived mainly from hospitalized patients, or
patients with rare conditions. Primary care physicians who diagnose and treat
patients before they require hospital care operate without the level of research
available to their subspecialist colleagues. In addition, it is not enough to
develop new treatments; they must also be implemented and result in better
patient outcomes. American medicine is praised worldwide for its excellence in
biomedical research, and rightly so. However, while we have invested heavily in
new technologies, drugs and procedures, they are seen increasingly as costly
advances for potentially modest gains. Greater gains may be possible if we can
invest more heavily in finding ways to bring state-of-the art medicine to
community medical practices. Primary Care Research Agenda A primary care
research agenda should include at least six basic categories for study. (The
agenda is further described in the AHCPR report, Putting Research into Practice:
Report of the Task Force on Building Capacity in Primary Care, 1993.) Included
in this agenda should be research on: the origin of disease and the loss of
health; improvements in diagnostic accuracy; appropriate treatments;
improvements in the physician-patient relationship; improvements in health care
delivery; improvements in patient satisfaction. Examples of Primary Care
Research Needs Primary care research is needed to provide information to
physicians on the most effective treatment plans for patients with numerous,
serious conditions. An example of this situation is a single patient with
diabetes, hypertension, depression, low back pain and heart disease.
Traditional, disease-specific treatment is not useful in this situation;
treatment for one disease may exacerbate the other conditions. Research is also
needed on differentiating the common headache that affects 20 million Americans
from one with serious implications. While headaches afflict millions of
individuals, the primary care physician has little information on how to
identify the few who suffer from life- threatening illness. IOM Recommendation
on Funding Needed for Primary Care Research According to the 1996 Institute of
Medicine (IOM) report on primary care, Primary Care: America's Health in a New
Era, federal investments in primary care research today total between $15 and
$20 million annually. The IOM report recommended an immediate fourfold increase
in primary care research. RURAL HEALTH PROGRAMS Finally, the Academy supports
continued funding for several rural health programs. In particular, we support
the programs of the Federal Office of Rural Health Policy; Area Health Education
Centers, two programs that are equally important to health care in rural areas
and in our inner cities; the Community and Migrant Health Center Program and the
National Health Services Corps. State rural health offices, funded through the
National Health Services Corps budget, help states implement such programs so
that they benefit rural residents as much as urban dwellers. Continued funding
for these rural programs is vital if we wish to provide adequate health care
services to America's rural citizens. CONCLUSION Thank you for your
consideration of these important requests. I would be pleased to answer any
questions at this time.
LOAD-DATE: March 30, 2000,
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