Voices and Action - June 2020

 

Advocacy & Council of Academic Family Medicine: Policy Proposals to Combat COVID-19’s Harmful Impact on Primary Care Training

NAPCRG partners with allied organizations in family medicine to advocate on issues of mutual interest. This consortium is called the Council of Academic Family Medicine. The following is a summary of CAFM positions:

The COVID-19 pandemic has caused an unprecedented upheaval in our health system. New pressures and changes have required innovation and adaptation. CDC data show that among known COVID-19 patients, just over 80% remain in ambulatory care, and do not require hospitalization . The ambulatory care space has been deeply affected by COVID-19 and the impact on primary care and family medicine needs to be evaluated regarding new payment changes, training, care modalities and research. Below are four areas that we believe Congress should address in its next COVID-19 package to address both impact and recovery. These recommendations mainly relate to academic or training aspects of primary care practice.


Rural Hospital Bonus Payment to Help Retain Current Rural Training Programs

We propose a bonus payment to rural hospitals that maintain their current residency training programs. This will help rural hospitals struggling under COVID currently training residents who are likely to go into rural practice and who supply a significant portion of the future workforce serving those hospitals. The proposed payment is not a payment for ongoing graduate medical education (GME), rather it is an incentive payment to a rural hospital that commits to maintain their current training program(s) within the difficult COVID-19 environment. Although the payment is determined by the number of resident positions, it is not a payment for residency education. A rural hospital which serves as the primary location of training greater than 50 percent of residents’ time would receive the bonus payments upon agreeing to maintain its training program(s) for the next three academic years.


Provide Refundable Tax Credits for Primary Care Volunteer Community Preceptors

In order to help maintain primary care training in the community, we recommend providing a refundable tax credit to volunteer, or uncompensated preceptors, to help increase the ability of primary care physicians to provide appropriate, quality ambulatory experiences, especially in rural areas.


Primary Care/Ambulatory COVID-19 Research Funding

Provide additional $130 million in new funding for the Agency for Healthcare Research and Quality (AHRQ.) We request $80 million -- for Telehealth questions and general broad-based study on training needs (workforce). We also request $50 million -- on questions of deferred primary care, practice changes and training and supervision, physical and emotional burden on providers, patients, community; analyses regarding reduction in necessary versus unnecessary services, and to address the special needs for rural and underserved areas.


Workforce Needs Related to Primary Care under Title VII, Primary Care Training and Enhancement Program

Provide $125 million in new funding for Title VII, Section 747 (Primary Care Training and Enhancement.) This funding should be directed to both residencies and departments, to deal with issues related to faculty retention, public health competencies, recruitment, and retention of students into primary care. This funding would also develop new curriculum in this regard as well as other curriculum related to the pandemic and to address the segmented primary care workforce in an effort to reduce delivery system division.

I. Rural Hospital Bonus Payment to Help Retain Current Rural Training Programs:

Many primary care practices are experiencing tremendous financial hardship, and many are shutting their doors or laying off staff due to the impact of COVID-19 on the primary care workforce. Recent COVID-19 legislation helped some of these practices financially, but little attention was paid regarding the impact of training future primary care physicians, especially in rural America. Below is a new legislative proposal to aid in the retention of a meaningful training framework for rural primary care.

Background: Rural hospitals were under immense financial pressures prior to COVID-19. Over 100 rural hospitals have closed since 2013.

Current Medicare GME payments have not reimbursed rural hospitals adequately; consequently, hospitals need to subsidize these payments in order to support residency training. The data show that training in rural areas increases the likelihood of practice in rural areas. Training in rural settings is associated with a two- to three-fold increased likelihood of rural practice. COVID-19 has exacerbated these problems.

Given the economics of rural residency training, we are concerned that as rural hospitals face financial ruin, a residency program is convenient ballast – easily jettisoned to help the financial bottom line. Even hospitals that do not close, may, in the short term, choose to decrease or eliminate their residency due to its added costs.
Proposal: We propose a bonus payment to rural hospitals that maintain their current residency training programs. This will help rural hospitals currently training residents who are likely to go into rural practice and who supply a significant portion of the future workforce serving those hospitals. Data from a recent study of Family Medicine Rural Training Track graduates showed percentages ranging from 32.3% to 40.0%, with most above 35% in six of the seven post-graduate years. This compares very favorably to the current 9%of all physicians currently in rural practice.

The proposed payment is not a substitute GME payment, but rather is an incentive payment to a rural hospital connected to a commitment to maintaining the current training program(s) within the difficult COVID-19 environment. Although the payment is determined by the number of resident positions, it is not a payment for residency education. A rural hospital which serves as the primary location of training of greater than 50%of residents’ time, would receive the bonus payments upon agreeing to maintain its training program(s) for the next three academic years.

Total Cost: Our proposal would have a cost of approximately $88.35 million, supporting 90 rural hospitals across 39 states.

II. Provide Refundable Tax Credits for Primary Care Volunteer Community Preceptors:

Background: While most resident training occurs in hospital settings, one of the hallmarks of family medicine training is ambulatory training in non-hospital, community settings. This applies to both residents and medical student training. For medical students, their clinical rotations (clerkships) in family medicine and primary care are predominantly centered in community physicians’ offices. A preceptor is a physician or other clinical provider who provides a mentoring experience of several weeks, including a program of personalized instruction, training, and supervision at an ambulatory location to medical or other health professions students.
Providing this mentoring and supervision has costs associated with it; uniquely, this training has typically been accomplished by volunteer preceptors that choose to absorb costs because they like teaching and/or want to give back. However, as practices scramble to hold together their financial well-being given the impact of COVID-19 on their practices, it is increasingly more difficult to continue providing this free service. The medical student component is especially costly as the incorporation of students in the practice slows it down, reducing patient visit income. In normal times it is difficult for medical schools to identify enough community preceptors to provide quality ambulatory, community-based training. The pandemic has made this process even more difficult.

Proposal: In order to help maintain primary care training in the community, we recommend providing a refundable tax credit to volunteer, or uncompensated preceptors, to help increase the ability of primary care physicians to provide appropriate, quality ambulatory experiences, especially in rural areas.

III. Primary Care/Ambulatory COVID-19 Research Funding:

Proposal: Provide additional $130 million in new funding for the Agency for Healthcare Research and Quality (AHRQ.) We request $80 million -- for Telehealth questions and general broad-based study on training needs (workforce). We also request $50 million -- on questions of deferred primary care, practice changes and training and supervision, physical and emotional burden on providers, patients, community; analyses regarding reduction in necessary versus unnecessary services, and to address the special needs for rural and underserved areas. For more specific content of our requests, see below:

In AHRQ’s 1999 reauthorization, Congress stipulated that AHRQ’s Center for Primary Care Research “shall serve as the principal source of funding for primary care practice research in the Department of Health and Human Services.” The COVID-19 Public Health Emergency (PHE) has made visible many of the cracks in our health care system and our primary care infrastructure is in crisis. AHRQ is uniquely positioned to find answers to these questions with a proven track record of delivering timely results that identify what works – and what doesn’t – in health care delivery. We need AHRQ to address practice and questions that COVID-19 has brought to light and also those related to training primary care physicians for the future.

IV. Workforce Needs Related to Primary Care under Title VII, Primary Care Training and Enhancement Program:

Provide $125 million in additional, new funding for Title VII, Section 747 (Primary Care Training and Enhancement.) This funding should be directed to both residencies and departments, to deal with issues related to faculty retention, public health competencies, recruitment and retention of students into primary care, to develop new curriculum in this regard as well as other curriculum related to pandemic, and address the segmented primary care workforce in an effort to reduce delivery system division and increase full scope primary care providers. Specifically, funding is needed for the following:

  • Identify best practices to increase primary care’s ability to improve inpatient care capacity. Localities are currently using primary care providers to support over-burdened inpatient settings and new inpatient settings across the U.S. Additional Title VII, Section 747 funding could be used to identify appropriate training needs to retrain primary care providers to support our nation’s inpatient care needs.
  • Evaluate the highly segmented primary care physician workforce and make recommendations to reverse unnecessary delivery system division and increase full scope primary care providers.
  • Develop curricula that meets the needs of the pandemic, and for the future. Curriculum is needed in best practices for remote supervision of residents; caring for stable chronic disease patients and select acute care needs over the phone and virtually through Telehealth; training for crisis management; and conducting e-consults with specialists in both the inpatient and outpatient setting.

U.S. Health and Human Services -- Provider Relief Fund (PRF)

NAPCRG has participated with other family medicine organizations to urge the Department of Health and Human Services (HHS) to make an immediate, targeted allocation from the Provider Relief Fund (PRF) to primary care clinicians and/or practices in order to offset reduced revenue and increased costs associated with COVID-19. A targeted allocation for primary care must be:

disbursed immediately to primary care clinicians and practices to prevent them from closing in a matter of weeks;
sufficient to offset lost revenue and increased expenses related to COVID-19, after accounting for any disbursements such clinicians or practices may have already received from the PRF general allocations;
continued through the end of CY 2020.
Immediate relief is critical to support practices. A recent survey found that nearly half of primary care clinicians reported that they have laid off or furloughed staff; two-thirds report that less than half of the care they are providing is reimbursable; and 45% are unsure if they have the funds to stay open for the next four weeks.

Federal support has not been sufficient, and it has not reached everyone: most relief has gone to institutions and those who participate in Medicare, leaving behind primary care clinicians that primarily serve Medicaid, privately insured, and uninsured patients. More support is needed to help all primary care practices stay open through the pandemic and its aftermath.


National Summit on the Future of Residency Training – Call for Volunteers

In early 2020, the Accreditation Council for Graduate Medical Education (ACGME) announced a major revision of the residency requirements for Family Medicine. Major revisions are rare and important, happening about once a decade, and offer an opportunity for major changes in the structure and function of residency training. The residents trained under these new requirements will practice until 2050 and beyond.


AAFP and ABFM are collaborating with other family medicine organizations to consider core questions for residency training in late summer/early fall. This work will culminate in a national summit to be held virtually at the beginning of December.
In addition, the ACGME Review Committee for Family Medicine (RC-FM) will be conducting a future forecasting exercise.
Volunteer opportunities are available for both projects.

National Summit
Volunteers selected for the national summit will be asked to consider core questions, review background briefs, focus group summaries and drafts of commissioned papers, and attend the national summit. The summit will be virtual and is tentatively set for December 6-7, 2020.

ACGME RC-FM
ACGME will conduct a future planning exercise in November. Participants will imagine the future of family medicine and family medicine resident training in a number of very different but plausible future worlds.
Volunteers will join the ACGME writing committee for the exercise. Meetings will be in November and be virtual. Volunteers will be expected to review materials in advance and participate in a series of webinars.

Nominations
Self-nominations are welcome. Attendees will be broadly representative of the discipline and its stakeholders – practicing clinicians, residency directors and residency faculty, residents, students, major employers, DIOs and public members.
Diversity of perspective and expertise are critical. Please send a letter of interest and a biosketch inclusive of relevant experience to Mary Harwerth (mharwerth@aafp.org) by July 17, 2020.

Decisions will be made by early August.


Social Media