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Primary care and graduate medical education funding: a new model?

November 2, 2012

A new study in the journal Academic Medicine provides one of the first looks at a program created by the Affordable Care Act in 2010 to train more primary care doctors. It’s a pretty different model than the traditional one, where the government, through Medicare, makes payments to teaching hospitals to help fund graduate medical education (like a residency program for doctors-in-training).

The program is called “Teaching Health Centers.” It provides payments to so-called “ambulatory care centers,” or places like community health centers and outpatient care settings, to help train residents in the field of primary care. (It’s not a new idea. See this 1989 IOM report on the benefits. But I believe this is Medicare’s first foray into funding this way. Please correct me if I’m wrong.)

A refresher for you: a primary care doctor is one who is a patient’s first point of contact, either when she feels sick or for a regular check up. They can diagnose a wide range of conditions, make referrals, and coordinate with specialists. There’s lots of research out there right now (like this one from the Journal of the American Medical Association that looked at health outcomes for Medicare recipients) that shows more – and better – primary care results in better health outcomes for people and communities.

In some academic-y language, here’s the conclusion of the researchers from George Washington University and the University of Washington who looked at Teaching Health Centers:

This initial look at the 11 inaugural teaching health centers (THCs) shows that they are training primary care residents in relevant delivery models (e.g., interprofessional teams, patient-centered medical homes), developing educational initiatives that address primary care practice in underserved areas, and transforming organizational and funding structures to support community-based training. The THCs plan to evaluate and report resident performance, patient quality of care, and graduate outcomes. The work of the first THCs has implications for primary care training, the GME system, and future policies and legislation aimed at strengthening the health care workforce.

What that means is this: maybe we don’t have to do things the way we’ve always done them. Maybe the way we pay for graduate medical education – from the time a student graduates from medical school to the time they go into professional practice – could address not only the important work of teaching hospitals, which often have a breadth of specialties, expensive but vital equipment, and a spectrum of the sickest patients, but also the ways in which health care is changing. Lots more health care is taking place in outpatient settings. And community health centers are becoming an ever more important lifeline for people who can’t afford care elsewhere. There’s broad agreement that those community health centers will see another increase in patients when the major components of the Affordable Care Act take effect and enable many more people to get insurance. So, it makes a lot of sense to train residents to deliver care in those settings.

Rhode Island’s biggest teaching hospital

The other “delivery models” this study mentions, including patient-centered medical homes, also seem to be a sign of what’s to come. Insurers and health care systems are being encouraged to move to these kinds of models, where a multi-disciplinary team of providers can care for a patient and, hopefully, avoid unnecessary care. Just check out some of the projects Rhode Island’s health insurance commissioner’s office working on.

So, what do you think? Are Teaching Health Centers a step in the right direction for training new doctors – or not?

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