Impact of Title VII Funding on
Community Health Center Staffing
AcademyHealth
2007 Annual Research Meeting
Diane R. Rittenhouse, MD, MPH
Department of Family and Community Medicine
University of California, San Francisco
Collaborators
Kevin Grumbach, MD & Christine Nielsen, BA
• UCSF Department of Family & Community Medicine and
Center for California Health Workforce Studies
George E. Fryer, Jr., PhD & Thomas Miyoshi, MSW
• New York University, Center for Child Health Research
Robert L. Phillips, Jr., MD, MSPH
• The Robert Graham Center for Policy Studies in Family
Medicine and Primary Care
David C. Goodman, MD, MS
• Dartmouth Medical School, Department of Pediatrics
Community Health Centers
• Federally Qualified Health Centers (FQHCs)
are a critical component of the health care
safety net. (2004: 6,651 FTE physicians)
• President Bush’s Community Health Center
Initiative = MAJOR EXPANSION
• FQHCs are experiencing difficulty recruiting
physicians (2004: 809 vacancies).
Title VII Primary Care
Training Grants
• HRSA Title VII Section 747 Primary Care
Training Grants to medical schools & primary
care residency programs are associated with:
• increased production of primary care
physicians
• choice of practice in underserved areas
• Not known whether associated with work in
Community Health Centers.
Objective
• To examine the association between physicians’
exposure to HRSA Title VII Section 747
Primary Care Training Grants during medical
school and residency, and subsequent work in a
community health center
Building the “Megafile”
•
2004 AMA Masterfile containing updated
information on all U.S. allopathic and most
osteopathic physicians (N = 936,178).
•
Added Medicare UPIN numbers and
additional residency training information
Title VII Training Program
Grantee Database
• HRSA’s Bureau of Health Professions
• 3 relevant grant categories:
• Pre-doctoral Education
• Academic Administrative Unit (AAU)
• Residency Training
• 3606 Pre-doctoral & AAU awards to 137 U.S. medical schools
• 6245 residency awards to 819 residency programs
Physician “Exposure”
to Title VII Funds
“Exposed during medical school”
• attended a medical school during at least one year
that the school received Title VII funds
• (Pre-doctoral grant, AAU grant, or both)
“Exposed during residency”
• attended a primary care residency program
during at least one year that the program received
a Title VII residency grant
Identifying
Physicians Working in CHCs
CMS Outpatient File
--all beneficiaries who had Medicare
outpatient facility claims filed in 2001, 2002 &
2003 for primary care services
• billing physician’s UPIN number
• whether the claim was for a visit to a FQHC
• Claims data linked to Masterfile at level of
individual physician using UPIN numbers
Data Analysis
• Compared proportions of “exposed” physicians and
“not-exposed” physicians that worked in an CHC
(2001-2003).
• Looked separately at medical school and residency
exposure.
• Logistic regression to examine the independent
contribution of Title VII exposure during medical
school and residency on CHC staffing.
Exposure to Title VII Funding
During Medical School
All Physicians
Primary Care
FPs/GPs
Exposed
201,186
(49.8%)
78,612
(56.9%)
36,326
(62.3%)
Not-exposed
210,826
59,585
21,973
n = 412,012
n = 138,197
n= 58,299
Total
Exposure to Title VII Funding
During Residency
Primary Care
Exposed
Not-exposed
Total
70,529
(40.6%)
103,127
Family
Physicians
25,098
(42.3%)
32,256
n = 173,656
n = 59,354
Percent of Physicians Working in CHCs
Effects of Medical School Title VII
Exposure on CHC Staffing, 2001-3
8.0%
6.2%
6.0%
4.5%
4.0%
3.0%
4.3%
3.0%
1.9%
2.0%
0.0%
Exposed
Not Exposed
All Physicians
Exposed
Not Exposed
Prim ary Care Physicians
Only
Exposed
Not Exposed
FP/GPs Only
Effect of Title VII Funding During Medical School
on Staffing of CHCs, 2001-2003, by Grant Type
(All Physicians)
Percent Working in a CHC
5.0%
4.0%
3.1%
3.0%
2.7%
3.0%
1.9%
2.0%
1.0%
0.0%
Exposed - Both
Exposed - AAU
Only
Exposed Predoc Only
Not Exposed
Effect of Title VII During Medical School,
by Grant Type, 2001-3, (FPs/GPs Only)
Percent Working in a CHC
10.0%
8.0%
6.4%
6.5%
5.7%
6.0%
4.3%
4.0%
2.0%
0.0%
Exposed - Both
Exposed - AAU
Only
Exposed Predoc Only
Not Exposed
Percent Working in CHCs
Effect of Title VII During Residency on
CHC Staffing, 2001-2003
8.0%
6.8%
6.0%
5.0%
4.4%
3.5%
4.0%
2.0%
0.0%
Exposed
Not exposed
Primary Care Physicians
Exposed
Not exposed
Family Physicians Only
Independent Effects of Title VII Grant
Type on Physicians Work in CHC, 2001-3
Odds Ratio (95% Confidence Interval)
All Physicians
PCPs Only
FPs Only
1.025
(0.972-1.082)
0.936
(0.869-1.008)
0.857
(0.776-0.947)*
Departmental
AAU Grant
1.114
(1.058-1.174)**
1.115
(1.038-1.197)*
1.077
(0.981-1.183)
Residency
Training Grant
1.083
(1.038-1.129)**
1.232
1.407
(1.162-1.307)** (1.300-1.522)**
Pre-Doctoral
Training Grant
Limitations
Cross-sectional study shows association,
not causation
 Medicare claims data to identify CHC
physicians
 Osteopathic physicians – 40% have no
GME data in AMA Masterfile

Conservative Estimates
of Title VII Effect
CHC work cross-sectional during 2001-3
only
 FQHCs only
 “Exposed to Title VII funds” definition
 Pediatricians not well-represented in
Medicare claims files

Conclusions

Physician exposure to Title 7 Section 747 grants
during medical school and/or primary care
residency is associated with subsequent work in
CHCs.

Recent reductions in Title VII Section 747 program
funding may exacerbate the difficulties CHCs are
facing in trying to recruit primary care physicians.

2,210 fewer physicians – more than double the
current vacancy rate for all physicians at CHCs.
Funding
Health Resources and Services
Administration