Discussion Leader: Kevin Murray, MD, University of Washington/Tacoma General Hospital Family Medicine Residency Program
The concept of an “Educational Health Center” has evolved over several years as a result of collaborative process between the University of Washington School of medicine’s Department of Family Medicine (Department), Community clinics as represented by the Northwest Regional Primary Care Association (NWRPCA) with connection to the National Association of Community Health Centers (NACHC), and the University of Washington Affiliated Network of Family Medicine Residencies (Network).
In short, the concept is to combine the efforts and purposes of residency training and health center service in a more intentional model to serve the interests of both entities while expanding the network of service to the uninsured and the underinsured.
While these affiliations already exist in many forms between Health Centers (HC) and Family Medicine residencies across the country, the current regulatory and accreditation standards pose significant barriers to an efficient and economically sustainable co-location. That it is accomplished in scores of programs and clinics is a testament to the effort and shared vision the leaders of those residencies and health centers maintain. In other words, it is hard to do and it is heavily dependent on the existing leadership on site.
The current idea is not entirely new. However it started as a “new” idea in a Network strategic planning session. Many of our programs and many FM programs across the country were facing economic challenges to their survival. Approximately 10% of FM residencies had closed in the preceding 7 years, most for economic reasons. We knew that most of the physicians hired by HCs were FPs and we all considered graduates working in HC practices as a success.
We also knew they had many unfilled FP openings and yet were slated to be expanded by Federal plans as the government’s official way to provide care for the poor. We also felt that there was a strong overlap in the type of patients seen in residencies by social, insurance, illness, and economic characteristics. We knew the reimbursement for Medicare patients far exceeded our own in the federally Qualified Health centers and felt this adjustment could be a major help in stabilizing the economics of residencies. We felt residencies had a lot to offer Health Centers in terms of training potential employed physicians, increasing the workforce in the “safety net” for our communities, and possibly stabilizing existing physician workforce in the HCs themselves. This latter point of view came from our own experience of residencies either in HCs or with satellites in HCs.
We learned a lot! With support from the UW, faculty members performed qualitative research on the cultures of FMRs and HCs. Structured focus groups run by Dr. Carl Morris explored administrative, economic, service, educational, personnel, regulatory, governance, and cultural issues in these groups. This work has been published. In short, it revealed the same categories that had made us feel there was a good fit were the areas of barriers to collaboration. It confirmed that there was a very similar view as to the potential benefits and alignment of values related to service and education.
However, the basic regulatory and accreditation rules posed conflicting measures of successful performance that were critical to each group’s fundamental purpose. That is, direct clinical service to a defined volume of patients as versus successful provision of educational experiences that included service to patients but required significant elements other than patient service. There were many apprehensions each group had about the other in terms of erosion of their core commitments and purpose if collaboration occurred. These areas were explored and defined.
Dr. Morris, Dr. Frederick Chen, and others also reviewed our network’s history in future practice of our grads. They found that residents trained in a HC environment were significantly more likely to work in a HC after training as well as much more likely to work in a health professions shortage area after graduation. These trends have since been confirmed by other residency networks with similar differences of training sites within them.
Finally, a varied group of residency directors, faculty, health center administrators, and others developed a concept each group could support. It was felt that this type of entity could help supply an increased number of FPs for HC practice in the future, stabilize FMR finances, and simultaneously increase the role residencies play in “safety net” care in our communities. It was appreciated that not all HCs and not all residencies could or would wish to transform into this new entity. It was also appreciated that many legislative and regulatory changes were necessary to implement the Educational Health Center as we envisioned and defined. A copy of this is appended in what we often call our “one pager”.
Recently, a close version of this was proposed in Senate health reform legislative language as the “Teaching Health Center”. At the time of this writing, it has disappeared from the bill’s language but another bill creating funding for Medicare Pilots may allow it to be tried. As you will note, key to this new model clinic working will be allowing GME funding to flow to it for the educational expenses. Currently the GME funds flowing to residency training sites, or not, is totally dependent on voluntary agreements between the programs and their hospital sponsors. To stabilize these new programs, a stable funds flow for the educational enterprise will be critical.