Teaching Health Centers
A pilot reform of the graduate medical education system
Introductions
 MS4 at Loyola Stritch School of Medicine in Chicago
 Inspired by Community Health Center (CHC) experience
in 3rd year
 When looking for CHC-connected Family Medicine
Residencies (FMRs), came across the term “Teaching
Health Center” (THC)
 Subsequently matched at one of the “Original 11”
 In addition, survey of THC applicants had recently been
completed, but not yet analyzed
Objectives
 Describe the complex history of THCs
 Present the survey results of 2012 applicants
 Utilize the expertise in the room
 Refine survey analysis
 Discuss possible THC action items
What is a THC?
 Old idea
 Connecting
CHCs and FMRs
 New legislation
 Section 5508 of
Patient
Protection and
Affordable Care
Act (2010)
 Why?
Origins of the CHC Movement
 Originated in apartheid
South Africa with John
Cassel and Sidney Kark
 Brought to the US by Jack
Geiger and Count Gibson
 First two U.S. CHCs in
Massachusetts and
Mississippi delta in the
1960s
CHC Principles
 Fusion of primary care and public health
 Community-based and community-driven
 “Epidemiological assessment of demographically
defined communities, prioritization, planned interventions
and evaluation”
 “Their commonsense holistic philosophy came from an
understanding that good health is impossible if you have
to choose between food, rent and medicine”
Brief Political History of CHCs
 Initial federal adoption as a result of Ted Kennedy visiting
the CHC in Boston
 Started under institutional partnerships, but these broke
down as local communities pressed for local control
 Community-based board regulations enacted over
presidential veto in 1975
 Block grant legislation under Reagan in 1981
 Reversed the legislation despite presidential veto in 1985
 Largest growth under the two Bush administrations
Why such legislative success?
 Strong community buy-in
 Powerful local leaders
 Provides concrete services
where they are needed
most
 “Only two groups of
people…”
CHCs Today
 Federal Funding of 2.6 billion annually
 2 billion more from the stimulus bill and another 11 billion in
PPACA
 1,131 Centers with 8,000 sites serving 18 million people
 70% below poverty line, another 20 % near poor
 63% Minorities and 40% uninsured
 Studies show despite more complex and sicker patients,
outcomes are better, hospital admissions lower and ER
visits less
Supporting Programs
 Federal Tort Claims Act (FTCA)
 340B Drug discount program
 Provides 20-50% in total savings
 FQHC Look-alikes
Graduate Medical Education
(GME)
The other side of the THC coin
Quick Summary of GME in the U.S.
 First connected to Medicare in 1965
 Has since become backbone of GME funding

Especially for centers who lack substantial NIH support
 Based upon direct and indirect costs estimates
 Indirect being tied to inpatient care provided to Medicare recipients
 Positions capped per the balanced budget act (BBA) in 1977
 Fiscal Year (FY) 2009 Fund distribution
 9.5 billion from Medicare
 3.2 billion from Medicaid
 800 million from Veteran’s Affairs (VA)
Common Critiques of GME
 Payments have limited
relationship to costs
 Minimal Accountability
 Financial incentives for inpatientbased and subspecialty
programs—since BBA:
 46 FM programs closed
 133 subspecialty
fellowships opened
 Unable to match specialty mix
and geographic distribution with
population needs
Who Loses?
Connecting GME back to CHCs
 Since 1996, a 52.6% decrease in US Med students going
into Family Medicine
 Currently, 31% of total MDs practice primary care
 And only 25% of grads are planning to do it
 National Association of Community Health Centers
(NACHC) projects an additional 15,000 providers will be
needed to cover their patients by 2015
 In perspective—for 2011:
 25,020 residents matched, with 2,555 in FM
CHC-FMR Partnerships:
A Possible Solution?
 Not a new idea at all (original CHCs had visiting
residents)
 But, has been formalized and institutionalized with mixed
results
 Natural partnership
 Common commitments, increased sustainability, strong
educational environment, and improved patient outcomes
 But, significant challenges
 Contrasting missions, chronic underfunding of both parties,
and asynchronous governing bodies with vastly different
oversight regulations
Section 5508 of the PPACA
The first “Teaching Health Centers”
Section 5508 at a Glance
 230 million for FY 2011-2015
 For primary care GME programs based out of a health center
 Not required to be a FQHC or look-alike
 First awards given in January 2011 to 11 of the 24 programs that
applied
 In 2012, 11 more recipients selected giving total of 22 THCs
 Will not reach $230 million cap without significant further expansion
 Central impact: GME funds given directly to outpatient site and
with significantly increased accountability measures
The “Original 11”
 9 FM, one IM, one Dentistry
 6 of 11 directors run CHC
and FMR
 5 include rural training
 All 11 use EMR and are
either FQHC or FQHC-look
alikes
Survey Results
2012 Interviewees of THCs
Methods
 Population studied:
 All applicants that received interviews a THC for 2012
 549 surveys sent, with 282 responses
 51% response rate
 Some items written to mirror other common survey results
 Graduation Questionnaire (GQ)
 ERAS and NMRP data
Birth by State
Foreign
CA
NY
TX
WA
MA
PA
IL
MN
NJ
CO
OH
90
34
19
13
12
10
8
7
7
7
6
6
High School by State
Foreign
CA
NY
TX
WA
MA
PA
FL
IL
OH
MI
NJ
58
53
17
13
13
12
8
7
7
7
6
6
Race/Ethnicity
100%
12.00%
90%
White
80%
Axis Title
70%
Latino**
60%
10.00%
8.00%
Other
50%
40%
Pacific Islander
6.00%
Black
Latino**
30%
Black
20%
4.00%
Asian*
10%
2.00%
0%
Total
MS4s
(MD)
FM
Only
(MD)
Axis Title
THC
Only
(MD)
Native
American
0.00%
Total MS4s FM Only
(MD)
(MD)
THC Only
(MD)
U.S. Grads vs. FMGs
FMGs
71.39%
49.08%
47.94%
37.96%
29.63%
Total MS4s
(Applied)
Total MS4s
(Matched)
FM Only (Applied) FM Only (Matched)
THC Only
(Interviewed)
Public vs. Private Med School
Total MS4s
THC Only (MD)
Public
41%
Private
59%
Private
31%
Public
69%
Other Demographics
 Average age: 29.8 years
 High School: 74% public, 26% private
 Marital Status: 52% single, 43% married, 3.5% domestic
partnership
Residency Selection Criteria
Residency Selection Criteria
Faculty
57.35%
Underserved setting or rotations
48.75%
Innovative Curriculum
48.75%
Proximity to Family
39.43%
Opportunities for significant other/spouse
27.60%
Teaching Health Center designation
25.81%
Rural setting or rotations
Income and benefits
Research opportunities
Proximity to social and cultural event
16.49%
12.19%
11.11%
10.04%
Residency Selection Criteria
MS4s vs. FM vs. THCs
70.00%
60.00%
Axis Title
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Faculty
Salary
Social/Recreation
Research
Total MS4s
42.00%
40.00%
26.00%
11.00%
FM Only
49.00%
41.00%
23.00%
2.00%
THC Only
57.35%
12.19%
10.04%
11.11%
Residency Selection cont.
 Other specialties considered:
 23% IM
 15% Peds
 8% OB/GYN
 Average total THC programs applied to:
 1.4
 Only 69.5% of interviewees had ever heard of THCs
before interviewing
Future Practice Plans
Underserved Area?
120.00%
100.00%
80.00%
No
60.00%
Undecided
Yes
40.00%
20.00%
0.00%
Total MS4s
THC Only (MD)
Future Practice cont.
Rural vs. Urban
70.00%
60.00%
50.00%
40.00%
Rural
Urban
30.00%
Other
20.00%
10.00%
0.00%
Total MS4s
THC Only (MD)
Future Practice Setting
Undecided or No Preference
20.83%
Rural/Unincorporated Area
Small Town(Population Less Than 2,500)
Town (Population 2,500 to 10,000—Other Than Suburb)
15.42%
8.33%
15.83%
Small City (Population 10,000 to 50,000—Other Than Suburb)
Suburb of a Moderate Size City
27.08%
17.92%
City of Moderate Size (Population 50,000 to 500,000)
Suburb of a Large City
Large city (population 500,000 or more)
31.25%
17.92%
27.50%
Determining Future Practice
80.00%
70.00%
60.00%
Percent
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
ALL
FM Only
THC Only
Birth
33.20%
40.89%
65.00%
Med School
37.99%
45.64%
63.00%
Residency
50.41%
60.98%
69.00%
Future Practice Criteria
Full-scope Family or Internal Medicine
53.60%
Underserved population
46.40%
Geographic location
42.09%
Proximity to family
33.45%
Opportunities for significant other/spouse
24.46%
Income and benefits
22.30%
Academic opportunities
21.94%
Federally Qualified Health Center (or look-alike)
National Health Service Loan Repayment site
Other Student Loan Repayment options
18.71%
15.11%
11.51%
Results Summary
 Possible challenge with diversity?
 Significant interest in underserved and rural medicine
 Looking for strong faculty and research opportunities
 Significantly less interested in salary and social opportunities
 Limited knowledge of THCs
Next Steps…
 THCs have incredible potential
 Possible impetus for GME restructuring
 Institutionalized pipeline for CHC providers
 What can THC residents do?
Suggested Action Items
 Education
 Re-distribute slides and reference list
 Shared webinar of UDS mapper
 Advocacy
 Shared 2-pager
 arrange site visits
 Research
 Select 2-3 best practices and scale up?
 Communication
 Blog
 Exchange rotations?
 Future?
 THC Faculty Development Fellowship
Thank you Robert Graham Center!
References
Blewett LA, Smith MA, Caldis TG. Measuring the Direct Costs of Graduate Medical Education Training in Minnesota. Acad Med. 2001; 65: 446452.
Covey AS, Friedlaender GE. Financing Graduate Medical Education: Sorting out the confusion. Journal of Bone and Joint Surgery. 2003; 85:
1594-1604.
Fryer GE, Green LA, Dovey S, Phillips RL. Direct Graduate Medical Education Payments to Teaching Hospitals by Medicare: Unexplained
Variation and Public Policy Contradictions. Acad Med. 2001; 76: 439-445.
Geiger HJ. Community-Oriented Primary Care: A Path to Community Development. Amer J of Pub Health. 2002; 92: 1713-1716.
Jones TF. The Cost of Outpatient Training of Residents in a Community Health Center. Fam Med. 1997;29:347-52.
Jones TF, Culpepper L, Shea C. Analysis of the Cost of Training Residents in a Community Health Center. Acad Med. 1995; 70: 523-531.
Lefkowitz B. The Health Center Story: Forty Years of Commitment. J Ambulatory Care Manage. 2005; 28: 295-303.
Morris CG, Chen FM. Training Residents in Community Health Centers: Facilitators and Barriers. Ann Fam Med. 2009;7.
Morris CG, Johnson B, Kim S, Chen F. Training Family Physicians in Community Health Centers: A Health Workforce Solution. Fam Med.
2008;40:271-6.
Mullan F, Epstein L. Community-Oriented Primary Care: New Relevance in a Changing World. Amer J of Pub Health. 2002; 92: 1748-1755.
National Association of Community Health Centers, Robert Graham Center, The George Washington University School of Public Health and
Health Services. Access Transformed: Building a Primary Care Workforce for the 21 st Century. Bethesda, MD; 2008.
Patient Protection and Affordable Care Act, P.L. 111-148, 111th Congress, 2nd Session (2010).
Phillips RL, Turner BJ. The Next Phase of Title VII Funding for Training Primary Care Physicians for America’s Health Care Needs. Ann Fam Med.
2012; 10: 163-168