Tri-Committee Draft Proposal for Health Care Reform

The Tri-Committee draft legislation takes a significant step towards establishing a health care workforce which will sustain a high-quality, cost-effective, fully accessible health care system. Moves to establish an Advisory Committee on Health Workforce Evaluation and Assessment, re-invest in the National Health Service Corps and Title VII of the Public Health Service Act, redistribute unused Medicare GME positions to primary care programs and establish teaching health centers, and address payment and practice challenges to primary care through the medical home and accountable care organization pilot programs are all positive moves towards a sustainable health care workforce. However, to fully achieve workforce reform, the following are recommended: Promoting the Advisory Committee on Health Workforce Evaluation and Assessment to a National Commission on the Health Workforce, providing it with an authorization and clarifying its role in reporting to Congress, including addressing Medicare GME payments. Fully supporting the Teaching Health Centers program, converting it to at minimum a pilot program rather than a demonstration project and creating a Teaching Health Centers Development Grant within Title VII. Further increasing National Health Service Corps authorization for appropriations to maximize the program\u27s full potential to provide health care in the most underserved areas. Increasing primary care bonus payments and SGR target growth rate to ensure effective maintenance and incentives for primary care. Invest in a primary care extension program to provide technical assistance and training programs for strengthening primary care practice

Health Care Workforce Issues and Access to Care: Assessing the Present and Preparing for the Future

Summary of Testimony Fitzhugh Mullan, M.D. Before the House Energy and Commerce Subcommittee on Health, March 24, 2009 Improving access to health care in the United States will require modifications in the structure of the U.S. physician workforce, the foremost of which will be the construction of a strong primary care delivery base. There are over 800,000 practicing physicians today or 280 physicians per 100,000 people. This represents a greater physician density than Canada (210) and the United Kingdom (250) but a density less than France (340) and Germany (350). The distribution of physicians in the U.S. heavily favors urban areas. Metropolitan areas have 2-5 times as many physicians as non-metropolitan areas. Economically disadvantaged areas have significant physician access problems. Two-thirds of the U.S. physician workforce practice as specialists. The number of young physicians indicating an interest in primary care is declining. Approximately 100,000 nurse practitioners (NPs) and 70,000 physician assistants (PAs) are practicing in the United States today. This represents an important asset for service delivery. Today\u27s physician-to-population ratio is in the zone of adequacy and should be maintained with appropriate growth in the number of physicians trained to parallel growth in the population. Increased requirements for patient care due to the aging of the population or the inclusion of more Americans in a universal care plan should be met by more strategic distribution of physicians, both geographically and across the primary care – specialty spectrum, and the expanded use of physician assistants and nurse practitioners. The role of PAs and NPs should be in both the generalist and specialist sectors of the care delivery system. Medical schools – The current expansion of medical schools is welcome but Title VII legislation needs to be reinvigorated and up-funded to augment primary care training in medical schools. Graduate Medical Education – The current number of Medicare funded slots is sufficient to maintain workforce numbers. However, reforms need to be made in current legislation to prioritize and incentivize community-based and ambulatory training. Beyond that, serious consideration needs to be given to aligning Medicare GME with the workforce needs of the country. This would entail designing a new GME allocation system. Medical Practice – Primary care payment reform, support for new practice organizations such as primary care medical homes, and investment in health information technology are all important reforms that will help to promote a strong primary care practice base in the country. Data and leadership in the field of U.S. health workforce development is insufficient. A National Center for Health Workforce Studies and a National Health Workforce Commission would both be important assets at the federal level in managing health care workforce reform

Affirmative action, Cuban style

Twenty-five percent of the U.S. population is black, Hispanic, or Native American, whereas only 6.1 percent of the nation’s physicians come from these backgrounds. Students from these minority groups simply don’t get into medical school as often as their majority peers, which results in a scarcity of minority physicians. This inequity translates into suffering and death, as documented by the Institute of Medicine. Poorer health outcomes in minority populations have been linked to lack of access to care, lower rates of therapeutic procedures, and language barriers. Since physicians from minority groups practice disproportionately in minority communities, they are an important part of the solution to the health-disparities quandary

Primary Health Care Access Reform: Community Health Centers and the National Health Service Corps

This testimony by Fitzhugh Mullan, M.D., addresses the following issues: Improving access to health care in the United States will require modifications in the U.S. health care workforce, the foremost of which will be the construction of a strong primary care base. Two-thirds of the U.S. physician workforce practice as specialists and the number of young physicians entering primary care is declining. The distribution of health care providers in the U.S. heavily favors urban areas. Metropolitan areas have 2-5 times as many physicians as non-metropolitan areas and economically disadvantaged areas have significant health care access problems. Today\u27s physician-to-population ratio is in the zone of adequacy and should be maintained with growth in the number of physicians trained to parallel growth in the population. Increased requirements for patient care due to the aging of the population or the inclusion of more Americans in a universal care plan should be met by more strategic distribution of physicians, both geographically and across the primary care – specialty spectrum, and the expanded use of physician assistants and nurse practitioners. Strategies: Medical schools – Medical schools are currently expanding, and Title VII legislation needs to be reinvigorated and up-funded to augment primary care training. Graduate Medical Education – The current number of Medicare funded slots is sufficient to maintain workforce numbers. However, reforms need to be made in current legislation to prioritize and incentivize community-based and primary care training. Serious consideration also needs to be given to aligning Medicare GME with the workforce needs of the country. This would entail designing a new GME allocation system. Medical Practice – Primary care payment reform, support for new practice organizations such as primary care medical homes, and investment in health information technology are all important reforms that will promote a strong primary care practice base in the country. National Health Service Corps – The NHSC is a proven program that delivers primary care clinicians to needy communities in return for student debt reduction. It is a brilliant and successful strategy that has always been under funded. It is time to radically increase its budget toward the end of fully staffing Community Health Centers and addressing the oncoming needs for clinical service in the U.S. Teaching Health Centers – Establishing stable funding for both undergraduate and graduate medical education in health centers will promote a workforce prepared with skills needed for practice and improve recruitment and retention for health centers, which are critical providers of health care to underserved communities. Data and leadership in the field of U.S. health workforce development is insufficient. A National Health Workforce Commission would be an important asset at the federal level in managing health care workforce reform

Workforce Issues in Health Care Reform: Assessing the Present and Preparing for the Future

Summary of Testimony Fitzhugh Mullan, M.D. Before the Senate Finance Committee March 12, 2009 Health Care Reform will require modifications in the structure of the U.S. physician workforce the foremost of which is the construction of a strong primary care delivery base. There are over 800,000 practicing physicians today or 280 physicians per 100,000 people. This represents a greater physician density than Canada (210) and the United Kingdom (250) but a density less than France (340) and Germany (350). The distribution of physicians in the U.S. heavily favors urban areas. Metropolitan areas have 2-5 times as many physicians as non-metropolitan areas. Economically disadvantaged areas have significant physician access problems. Two-thirds of the U.S. physician workforce practice as specialists. The number of young physicians indicating an interest in primary care is declining. Approximately 100,000 nurse practitioners (NPs) and 70,000 physician assistants (PAs) are practicing in the United States today. This represents an important asset for service delivery. Today\u27s physician-to-population ratio is in the zone of adequacy and should be maintained with appropriate growth in the number of physicians trained to parallel growth in the population. Increased requirements for patient care due to the aging of the population or the inclusion of more Americans in a universal care plan should be met by more strategic distribution of physicians, both geographically and across the primary care – specialty spectrum, and the expanded use of physician assistants and nurse practitioners in both the generalist and specialist sectors of the care delivery system. Medical schools – The current expansion of medical schools is welcome but Title VII legislation needs to be reinvigorated and up-funded to augment primary care training in medical schools. Graduate Medical Education – The current number of Medicare funded slots is sufficient to maintain workforce numbers. However, reforms need to be made in current legislation to prioritize and incentivize community-based and ambulatory training. Beyond that, serious consideration needs to be given to aligning Medicare GME with the workforce needs of the country. This would entail designing a new GME allocation system. Medical Practice – Primary care payment reform, support for new practice organizations such as primary care medical homes, and investment in health information technology are all important reforms that will help to promote a strong primary care practice base in the country. Data and leadership in the field of U.S. health workforce development is insufficient. A National Center for Health Workforce Studies and a National Health Workforce Commission would both be important assets at the federal level in managing health care workforce reform

Non-physician clinicians in 47 sub-Saharan African countries

Many countries have health-care providers who are not trained as physicians but who take on many of the diagnostic and clinical functions of medical doctors. We identified non-physician clinicians (NPCs) in 25 of 47 countries in sub-Saharan Africa, although their roles varied widely between countries. In nine countries, numbers of NPCs equalled or exceeded numbers of physicians. In general NPCs were trained with less cost than were physicians, and for only 3–4 years after secondary school. All NPCs did basic diagnosis and medical treatment, but some were trained in specialty activities such as caesarean section, ophthalmology, and anaesthesia. Many NPCs were recruited from rural and poor areas, and worked in these same regions. Low training costs, reduced training duration, and success in rural placements suggest that NPCs could have substantial roles in the scale-up of health workforces in sub-Saharan African countries, including for the planned expansion of HIV/AIDS prevention and treatment programmes

The social mission of medical education: Ranking the schools

The study proposes a new method of ranking medical schools through the creation of a social mission score, reflecting that many believe that medical schools should be accountable to society and have a social mission to train physicians to care for the population as a whole, taking into account such issues as whether schools produce physicians who practice primary care, work in underserved areas, and represent the diversity of the population

A survey of Sub-Saharan African medical schools

<p>Abstract</p> <p>Background</p> <p>Sub-Saharan Africa suffers a disproportionate share of the world's burden of disease while having some of the world's greatest health care workforce shortages. Doctors are an important component of any high functioning health care system. However, efforts to strengthen the doctor workforce in the region have been limited by a small number of medical schools with limited enrolments, international migration of graduates, poor geographic distribution of doctors, and insufficient data on medical schools. The goal of the Sub-Saharan African Medical Schools Study (SAMSS) is to increase the level of understanding and expand the baseline data on medical schools in the region.</p> <p>Methods</p> <p>The SAMSS survey is a descriptive survey study of Sub-Saharan African medical schools. The survey instrument included quantitative and qualitative questions focused on institutional characteristics, student profiles, curricula, post-graduate medical education, teaching staff, resources, barriers to capacity expansion, educational innovations, and external relationships with government and non-governmental organizations. Surveys were sent via e-mail to medical school deans or officials designated by the dean. Analysis is both descriptive and multivariable.</p> <p>Results</p> <p>Surveys were distributed to 146 medical schools in 40 of 48 Sub-Saharan African countries. One hundred and five responses were received (72% response rate). An additional 23 schools were identified after the close of the survey period. Fifty-eight respondents have been founded since 1990, including 22 private schools. Enrolments for medical schools range from 2 to 1800 and graduates range from 4 to 384. Seventy-three percent of respondents (n = 64) increased first year enrolments in the past five years. On average, 26% of respondents' graduates were reported to migrate out of the country within five years of graduation (n = 68). The most significant reported barriers to increasing the number of graduates, and improving quality, related to infrastructure and faculty limitations, respectively. Significant correlations were seen between schools implementing increased faculty salaries and bonuses, and lower percentage loss of faculty over the previous five years (<it>P </it>= 0.018); strengthened institutional research tools (<it>P </it>= 0.00015) and funded faculty research time (<it>P </it>= 0.045) and greater faculty involvement in research; and country compulsory service requirements (<it>P </it>= 0.039), a moderate number (1-5) of post-graduate medical education programs (<it>P </it>= 0.016) and francophone schools (<it>P </it>= 0.016) and greater rural general practice after graduation.</p> <p>Conclusions</p> <p>The results of the SAMSS survey increases the level of data and understanding of medical schools in Sub-Saharan Africa. This data serves as a baseline for future research, policies and investment in the health care workforce in the region which will be necessary for improving health.</p