1. TRAIN AND SUPPORT
AMERICA’S PRIMARY CARE
WORKFORCE
Family Medicine’s Asks
Hope R. Wittenberg
CAFM Director, Government Relations
May 9, 2011

2. Training and Support Needed for America’s
Primary Care Workforce
Family Medicine’s Asks
#1) Appropriate $71 million for Primary Care Training and
Enhancement, a health professions program, for FY 2013
#2) Provide $300 million for the National Health Service Corps
for FY 2013 from the trust fund authorized by the Affordable
Care Act.
#2) Members of Congress should cosponsor HR 3667, our
Medicare GME pilot bill for primary care training. Senators
should consider cosponsoring a companion bill.

3. Ask #1: Primary Care Training and
Enhancement
Appropriate at least $71 million for Primary Care
Training and Enhancement authorized under
Title VII, Section 747 of the Public Health
Service Act in FY 2013.

4. Primary Care Training and
Enhancement
Context
• HRSA’s Primary Care Training program needs at
least $71 million, to avoid a second year in a row
without a competitive grant cycle.
• The nation needs new initiatives relating to
increased training in inter-professional care, the
patient-centered medical home, and other new
competencies required in our developing health
system.

5. Ask #1: Primary Care Training
• Enhanced funding is needed to help address
increased primary care needs.
• Current program prioritizes training in the new
competencies relevant to providing care within
patient-centered medical homes.
• Without a new competition we get further behind in
developing the innovative training needed for health
system improvement.

6. Ask #1 – Increased Funding for Primary Care
Training
Pushback #1: Too costly
Response:
• If we don’t modernize our primary care training now,
we will not be able to keep pace with the developing
health system.
• More primary care production will help address
increased health care costs and poorer health
outcomes.
• It’s not just “Invest now for future gains.” It’s “Don’t
allow primary care health training to languish in an
outmoded system.”

7. Ask #1 – Increase funding for Primary
Care Training
Don’t forget to add a personal story about
Title VII specifically or the need for more
primary care.

8. Ask #1 – Increase Funding for Primary Care Training
Pushback #2: These programs are ineffective
Response:
• The Institute of Medicine (IOM) pointed to the drastic
decline in Title VII funding and called these programs an
“undervalued asset.”
• The Congressional Research Service (CRS) found that
reduced funding to the primary care cluster negatively
impacted the programs at a time when more primary care
is needed.
• Personal story if you have one

9. Ask #2: Funding the National Health Service Corps
Provide $300 million for the National Health
Service Corps for FY 2013 from the trust
fund authorized by the Affordable Care Act.
Note: This is not an appropriations request,
per se – it is funded out of a trust fund;
however we don’t want Congress to delete
funding of the trust fund.

10. Ask #2: Funding the National Health Service
Corps
Pushback: Generally supported program – but
too costly and funded from “Obamacare,” the
Affordable Care Act.
Responses:
• In spite of a $5 m increase over last year, this funding
won’t be enough to keep up the current field strength.
• At this funding level, the field strength is projected to
drop by over 30%, from just over 10 thousand primary
care clinicians in FY 2011, to just over 7 thousand in FY
2013.
• Don’t throw the baby out with the bathwater – fund this
important program by whatever mechanism necessary.

11. Ask #3: Modernizing GME for Primary
Care Training
House Members: Cosponsor HR 3667, the
Primary Care Workforce Access
Improvement Act of 2011.
Senators: Consider introducing a companion
bill to HR 3667

12. Why is a Pilot Needed?
• Medicare GME is over 40 years old.
• It is hospital-based
• It is outmoded.
• Primary Care physicians need to train in the
community
• The education of primary care physicians must be
modernized
• More of the training should be in nonhospital settings
• Funding must be de-linked from inpatient hospital
services
• Costs and needs of training in the community setting
must be identified – and paid for by Medicare GME
• Entity whose primary mission is education should
have control of the funding and the training.

13. Current Funding of Hospitals with GME
Medicare
Part A
Trust
Fund GME
Funding
Other community
ambulatory sites
$ $
Rural
Locations Accredited
$ Hospital ? Primary Care
Physician’s Residency
Offices
Training program
CHCs
Nursing Accrediting Bodies
Homes Program is accountable to

15. What would the pilot look like?
● Budget neutral; five years
● At least 4 organizational models tested (2 of each)
● Robust payment amounts to accommodate:
• High cost of training in the community; money would follow the
resident
• Provide incentives:
- to medical students who choose a primary care
- for training in underserved areas,
- to increase participation by underrepresented minorities, and
- to support hospitals in their staffing needs.
• Provide accountability for the Medicare GME dollars
• Endorsed by: National Rural Health Association, ACP,
AOA, and American Geriatrics Society

16. Pushback #1
Won’t hospitals be harmed by this?
Responses:
• Inpatient training will still be necessary – and can be
purchased by the program/entity in contract with a
hospital.
• Hospitals that have actually used their GME dollars for
primary care training will actually gain income from the
medical education entity.
• We expect this budget neutral pilot will shift only about
$50 million per year.
• This is only a pilot – a test of new models. If they don’t
work, no harm/no foul.

17. Pushback #2
Why should Medicare pay for this kind of training?
Medicare GME’s purpose is to aid hospitals with the
increased costs of training residents. Medicare
should only pay its share.
Responses:
– MedPAC and COGME believe we are not getting the product we
need – both in numbers and in kind.
– MedPAC Commission Chair, Glenn Hackbarth, “the training
system is not producing what society needs. It doesn’t seem to
be self-correcting; it cries out for intervention.”
– With the advent of health care reform, we expect ~ 32 million
new covered lives – all in need of primary care physicians.

18. Responses, cont.
– Strengthening the primary care workforce will promote
ambulatory and preventive care -- with the associated decreases
in hospitalizations and ER use.
– Better health for Medicare beneficiaries – and cost savings to
Medicare Trust Fund
– Primary care physicians are a critical piece of the physician
workforce – key to caring for Medicare beneficiaries. The litmus
test should not be how many Medicare patients they see in the
hospital while training, but rather what patients will they be able
to serve when they are out in practice.
– Primary care training should not be given short-shrift in training
funds just because the old formula hasn’t kept up with the times
and changes in modes of training and patient care.

19. Pushback #3
Didn’t Health Care Reform take care of paying for
training in the community setting?
Responses:
• We are very pleased with the legislative changes to count
– Non-hospital training time
– Didactic time
– Vacation, sick and other leave
• However, those only adjust the regulatory requirements in keeping
with the Congressional intent established in 1997
• The HCR bill did not modernize the way Medicare Graduate Medical
Education system for primary care training

20. Pushback #4
Isn’t the Teaching Health Center (THC) concept
included in HCR a way to modernize primary
care training?
Responses:
• We supported the THC, and in fact it fits in one
of our models that our pilot would test.
• However, it is not a Medicare modernization tool.
• It is dependent on appropriated dollars, not
Medicare.
• It will not test other models that currently exist
for primary care training.

21. Cuts to Medicare GME
3. Fundamental position is don’t cut Medicare
GME
5. If cuts are needed: Keep Full GME/IME for
core residencies – initial accreditation
7. If more cuts needed: Keep Full GME/IME for
primary care training, and other specialties in
shortage

22. Training and Support Needed for America’s
Primary Care Workforce
Family Medicine’s Asks
#1) Appropriate $71 million for Primary Care Training and
Enhancement, a health professions program, for FY 2013
#2) Provide $300 million for the National Health Service Corps
for FY 2013 from the trust fund authorized by the Affordable
Care Act.
#3) Members of Congress should cosponsor HR 3667, our
Medicare GME pilot bill for primary care training. Senators
should consider cosponsoring a companion bill.
#4) Protect Full GME/IME funding for primary care training.

23. What’s Next?
Please remember to fill out you evaluations and
leave them on the tables.
Breakout sessions begin promptly at 10:45,
following this break.