Claude Earl Fox III, MD, MPH Administrator,
Health Resources and Services Administration
Discussants:
James R. Boex, MBA
Health of the Public Network
Howard K. Rabinowitz, MD
Generalist Physician Initiative
W. Donald Weston, MD
Community Partnerships for Health Profession Education Initiative
Good morning. Thank you for inviting me to open the meeting. I noticed that my invitation letter asked me to
discuss: "Are changes needed in organizational and public policy?" I toyed with the idea of just taking the
podium and saying: "Yes", and watching the discussants try to react to that. But I noticed that by the time the
program went to press, the question had changed to, "What changes are needed in organizational and public
policy?" So I guess change is no longer optional.
Curiously, that's exactly what I intend to say-and I don't expect to encounter any disagreement.
Health care is changing. Government is changing. Primary care education can either change along with them
or get trampled in the stampede of other programs rushing to change their approach.
But you already know that. The more pertinent question-and the more difficult answer-is how exactly do
organizational and public policy need to change? Rather unfortunately, I do not have that answer. If you do,
please see me at the close of this session. But I do have some ideas that could be part of that answer that I'd
like to share-and then we'll see what you and our discussants think.
Outcome
Before we can talk about needed change, we need to establish the outcome we want to achieve.
In the case of primary care education, from where I sit-at the helm of the federal agency that assures access
to care for underserved Americans-I see three clear and urgent needs.
* One, we need the right people-that is, individuals who are as racially and ethnically diverse as the
US population.
* Two, we need them to have the right skills-we have to train all kinds and levels of primary
care providers to work together, to work comfortably in the managed care environment, and to be
sensitive to the diversity of cultures that patients represent.
* Three, we need them working in the right places-because right now more than 43 million
Americans live in underserved areas. And in a nation that boasts the finest health care in the
world, that's just plain wrong.
To achieve those, we need clear, rational, and consistent organizational and public policies that continue to
move health professions training in the direction that these six national initiatives have pioneered.
Organizational Changes
At HRSA, we have three decades of experience in effecting organizational change in primary care education.
We know that even small adjustments in the policies of training institutions can have a big impact on the
students they attract, the skills they impart, and the practice patterns of their graduates.
Minority Recruitment
Training institutions can, for example, significantly increase their numbers of African-American, Hispanic,
American Indian, and Alaska Native students by reaching out to promising minority students while they're
16
still in high school or even middle school. And I think Don will reinforce that point-and show you what else
educators, States, and the private sector can do to increase the diversity of health professionals. Identifying
students while they're still years away from health professions training gives ample time to reinforce their
academic skills in science and expose them to the vast career options available to them within the primary
care disciplines. That's critical in a nation where under-represented minorities already comprise 24% of the
population-and are the fastest-growing demographic group-but only account for about 10% of current
primary care graduates. African-American, Hispanic, American Indian, and Alaska Native providers are far
more likely to treat both patients who share their minority heritage and patients who are low-income, unin-
sured, or insured by Medicaid. So the first change the primary care professions training enterprise can-and
should-make is to recruitment policies. They should look much more deeply and broadly at the pool of
potential applicants and make certain that their policies encourage under-represented minorities to apply for
and enter training.
Community-based Ambulatory Training
That will give us more of the right people. Now we need to make sure they have the right skills-that the
students who start out in primary care stay there-and that they can practice effectively in managed care
delivery systems as members of provider teams.
It should go without saying-and in this group, it probably could-we can't expect to produce adequate
numbers of generalists with a training system heavily weighted to favor specialty training. Yet that seems to be
what some individuals and institutions expect. We simply must make sure that our training institutions are
prepared to shift the emphasis of training into community-based ambulatory settings. HRSA supports a major
faculty development initiative with each of the three primary care disciplines to help educators and their
institutions make that transition.
Our programs are working with internal medicine, family practice, and general pediatrics to train faculty
leaders, junior faculty, and community-based providers to train primary care professionals in community-
based settings. Our entire Area Health Education Center program revolves around training students in commu-
nity-based ambulatory settings. And through these programs, we are achieving needed outcomes. Graduates of
HRSA programs are significantly more likely to stay in primary care and four times more likely than other
graduates to practice in medically underserved communities.
Interdisciplinary Training
Any educational institution has a natural interest in the job market its graduates face. New primary care
professionals can, for the most part, count on a friendly-even hungry-market for their skills-an enviable
situation that is no longer true for either specialist physicians or nurses educated at less than the baccalaureate
degree level.
Yet we continue to produce inadequate numbers of primary care physicians, advanced practice nurses, and
physician assistants, particularly those who enter practice in medically underserved communities. Even with
50% of medical school graduates entering primary care residencies, only about 35% stay on the primary care
track. Less than a third of those destined for primary care end up practicing in medically underserved commu-
nities.
Why, with such strong market demand and severe public need? Why, with managed care expanding the scope
of primary care practice? Why, when technology is opening opportunities-and easing some of the burdens-
for primary care? Why are we unable to recruit and retain sufficient numbers for primary care and
underserved practice? It must be, at least partly, something about the way we teach and train.
All of HRSA's health professions training programs are geared to increasing the number of primary care
providers who are well prepared for practice with vulnerable populations. HRSA's total investment in health
professions training this fiscal year is close to $300 million. Our programs have been quite successful at
attracting promising students to enter primary care fields-and have validated the notion that where and how
you train students strongly influences where and how they will build their careers.
17
One of the more compelling models is the interdisciplinary generalist curriculum project, one of the six
initiatives sponsoring this conference. Carried out in 10 demonstration sites, the Interdisciplinary Generalist
Curriculum Project focused on first- and second-year medical students and featured direct supervised clinical
experience with generalist physician preceptors or mentors, preclinical curricula, and interdisciplinary teach-
ing and training by primary care physicians and their primary care colleagues. It supported the best learning
for the practice of primary care. Although the full evaluation is ongoing, we have seen strong evidence that
exposing students to interdisciplinary primary care education and practice early on can have a long-lasting
impact on their career choices.
We are expanding on the concept of instilling the right skills early on through our Undergraduate Medical
Education for the 21st Century Project. A total of 18 medical schools, in partnership with managed care
organizations or other integrated health care delivery systems, are full (8) or associate partners (10). They are
developing third- and fourth-year curricula and clinical experiences that include health systems-based care,
finance, economics, organization, delivery, ethics, population-based practice, and quality measurement and
improvement. Associate partners are focused on smaller projects.
Distance Learning
At the same time that we reach out to bring minority students into primary care and reach down and
strengthen primary care teaching in our health professions curricula, we also need to look at the training
infrastructure. Classroom education and hospital-based clinical training dominate today, but that, too is
changing-and changing in ways that further increase our ability to develop the primary care workforce we
need. We're seeing growing demand for primary care practitioners who can practice beyond the traditional
scope of primary care-who can manage patients with complicated chronic conditions-patients who would
have had to be referred to specialty care 5 years ago. We're also seeing growing demand for primary care
providers who are comfortable with technology. The World Wide Web gives consumers access to an abun-
dance of clinical information. Telehealth is becoming a reality as physicians "meet and treat" patients who are
hundreds of miles away.
Distance learning may be the most effective tool we have to keep practicing primary care providers ahead of
the curve-and to induce nontraditional students to enter primary care. HRSA supports 34 telemedicine
demonstration programs in rural regions and provides technical assistance to both health professions training
programs and to community health center and rural health clinic training sites. The HRSA-supported East
Carolina Area Health Education Center programs has a telehealth demonstration project that links faculty and
students at East Carolina Medical School with high school students in Greenville and addresses the students'
health concerns. We've found distance learning to be a viable option for underserved communities to "grow
their own" primary care providers. It enables local residents to be trained without ever leaving the commu-
nity-obviating the "how will we keep them down on the farm after they've seen Paree" question.
So those are some of the changes primary care training institutions need to make-recruit more diverse
students, expose them early and consistently to community-based, interdisciplinary primary care, and use
technology to reach and then train nontraditional students and to provide continuing education to practicing
providers. Some of them require the investment of funds-but many can be successfully implemented by
reallocating existing funds, under strict cost controls, and by recouping some of the costs from the ultimate
beneficiaries, including managed care organizations. I know that Howard has some thoughts on the compat-
ibility of community-based, ambulatory training and lower educational costs.
Public Policy Changes
Of course health professions training is not carried out in a vacuum. Government has a special and appropriate
interest in medical education and, because an under-supply of health professionals substantially harms the
public, government underwrites much of the cost of graduate medical education. To date, the government
most concerned with medical education has been the federal government and I don't foresee any impending
crises that could jeopardize federal support for GME. HRSA supports more than 40 health professions train-
ing programs. Our sister agency, the Health Care Financing Administration (HCFA), funds graduate medical
education through Medicare-paying teaching institutions more than $7 billion last year-and contributing
another $1.75 billion through Medicaid.
18
I do see some shift in the policies that govern how those Medicare and Medicaid funds are spent. Historically,
the lion's share of Medicare and Medicaid GME funding has gone to traditional teaching hospitals that
emphasize specialty training, but policy shifts are opening the way for community-based ambulatory training
programs to receive a greater share.
HRSA is working more closely with HCFA than ever before-and as federal policy related to GME evolves,
we expect to see an increasing proportion of funds directed to ambulatory training sites and to primary care.
HCFA last year launched a major GME demonstration in New York to help participating institutions reduce
their overall number of residents while substantially increasing their proportion of primary care trainees.
We're all watching the program closely and hope it will prove to be one more way to address the conundrum
of medical education: overall oversupply, but ongoing shortfalls in diversity, in primary care, and in
underserved areas.
Last year's Balanced Budget Act initiated other changes in federal GME policy that also further HRSA's
workforce goals. Now direct payments may be made to qualified non-hospital providers, including HRSA's
community health centers and rural health clinics, if costs of approved residency programs are incurred.
It also establishes residency caps, but:
* enables non-hospital residency programs to be created without being subject to the caps;
* lets rural programs apply for exceptions to the caps; and
* authorizes a demonstration project to make direct medical education payments to consortia.
Clearly, federal policy is beginning to be more consistent and to more firmly support HRSA's and primary
care's shared goals.
HRSA is committed to further encouraging the development of unified federal policy on GME consistent with
the needs of the nation. We are monitoring the situation as it unfolds and provide feedback to HCFA, the
training institutions, the public, and others. But increasingly, federal policy is only one aspect of the public
policy equation. States, too, are recognizing an obligation to assure that their need for primary care profes-
sionals is met.
HRSA is partnering with states to bolster their capacity to develop workforce policy. We know that providers
have a tendency to practice in the states where they are trained. We are working with state legislators, health
departments, and others to help them assess their workforce needs and create policies that are friendly to
primary care education, training, and practice. We have had great interest from the states for technical assis-
tance to help them apply national analytical methods and modeling at the state, regional, and local levels-
where inadequacies in the health professions workforce are felt most acutely.
HRSA is working with them to adapt our Integrated Requirements Model so that in the near future, we will be
able to make state-level forecasts of primary care provider needs and supply.
I strongly encourage everyone involved in primary care training, likewise, to work within their own states to
educate policy makers and shape policy. Jim, I believe will shortly share his ideas on the principles that should
guide GME policy making.
Conclusion
After years of debate, I think there is general consensus that the goals HRSA and the primary care health
professions have long endorsed and worked toward-more emphasis on primary care, more providers caring
for underserved people and working in underserved areas, greater racial and ethnic diversity among provid-
ers-are both worthy and achievable.
The door is open. Now we need to step across the threshold.
19
Government-at the federal and state levels-has to continue to adopt policies that support those goals in the
context of the health care marketplace. Health professions training institutions, for their part, have to create
programs that train providers to meet the long-term needs of the nation and to fill a niche in the marketplace.
This symposium-where we will look at lessons learned by six national initiatives that represent 37 collective
years of innovation and evaluation-is an important step in the right direction.
It falls to each of us to act on these discussions and work together to create the sustainable and substantial
changes in both organizational and public policy that will yield the health professions workforce we need to
meet the challenges of the next century.
I look forward to the discussion.