“Supporting Tomorrow’s Health Providers: Examining Workforce Programs Under the Public Health Service Act.”

Chairman Burgess, Ranking Member Green, and Distinguished Members of the Subcommittee:

Thank you for inviting me to speak to you about the THCGME or Teaching Health Center Graduate Medical Education Program.

I am a family physician who has practiced for 40 years in the South Bronx and the Lower East Side of Manhattan. I am President and Chief Executive Officer of the Institute for Family Health, a nonprofit network of 31 Federally Qualified Community Health Centers (FQHCs) and 3 family medicine residency programs.

I am pleased to provide some background on the substantial benefits for our nation generated by the THCGME program. I am also here today on behalf of my institution and as the President of the American Association of Teaching Health Centers to urge Congress to enact reauthorization legislation that funds this program sustainably for at least three years and provides for expansion into new communities. The essence of what our association stands for, working with a number of stakeholder organizations, is reflected in the legislation introduced by Congresswoman McMorris Rodgers, Congresswoman Niki Tsongas, Congressman Denham and many members of the Energy and Commerce Committee, H.R. 3394. Put most simply, the teaching health centers and the communities they serve need the program reauthorized before it lapses on September 30 at the level recommended in the HRSA-funded study published last year, which is $157,000 per resident, per year. That works out to a three-year authorization at $116.5 million per year so that centers will not terminate their training programs and can continue recruiting new residents. In addition, our coalition of stakeholders has made a strong case for additional funding to cover the cost of adding up to 10 new programs, with up to 60 residents in each class, meaning that during a two-year period, 120 new physicians would be training in teaching health centers to go along with the 732 existing residency slots.

In order to understand why this legislation is so critical, please permit me to share some background about our own teaching health center programs, our residents, and our patients.

The Institute for Family Health - Teaching Health Centers in New York

The Institute employs over 1200 people, including almost 200 primary care physicians and family medicine residents. Last year, we cared for over 102,000 patients who made 650,000 primary care, behavioral health care and oral health visits. The Institute serves high-need, medically underserved communities in the inner-city neighborhoods of the Bronx, Manhattan, and Brooklyn in New York City, as well as the upstate, rural communities of the Mid-Hudson Valley.

Nearly 80 percent of our patients are African American or Latino; 12 percent are uninsured; 45 percent receive Medicaid and 15 percent receive Medicare; 65 percent are below 200 percent of the federal poverty level; and 18 percent are estimated to require services in a language other than English. Our patients suffer disproportionately from an array of largely preventable health problems prevalent in low-income neighborhoods, including high rates of asthma, diabetes, hypertension, obesity, depression, mental illness, and substance abuse.

One of the communities we serve, in Ellenville, New York, is a poor rural community of 4,000 in the Catskill Mountains, once home to a thriving resort business, abandoned long ago. More recently, Ellenville has become the hub for health services for over 13,000 people in western Ulster County. Outside of our community health center, there are only three family doctors in the area, all of whom have very limited practices. The one primary care doctor who practiced full-scope family medicine retired a few years ago. There hasn't been a new primary care doctor that lived and worked in that community for over 40 years!

Five years ago, when the Teaching Health Center program was started, the Institute for Family Health applied for funding to expand its existing family medicine training program in Ulster County into two new rural communities, New Paltz and Ellenville. One of the first residents to be accepted into this program was Dr. Kristina Ursitti who grew up in Carmel, 60 miles southeast of Ellenville. After a 4th grade fieldtrip to the Catskills, she told her parents she was going to move there when she grew up. While in medical school she did a clinical rotation at Kingston Hospital, a small city in the area. When she found out that the Teaching Health Center program would provide an opportunity for her to do her training in Ellenville, she was sold.

Kristina entered residency training in Ellenville and fell in love with the community. Eager to woo a new doctor who wanted to settle in the area, community agencies got together and offered to pay the down payment for a house for while she was still in training! She now lives and cares for patients in this needy community, and serves as a faculty member in the program where she trained, teaching doctors who she hopes will join her in this growing community health center medical practice.

Dr. Ursitti is one of many doctors who are in training all across the country in our teaching health centers. The Teaching Health Center program has given these young doctors a chance to come home to work in community's close to where they grew up, or in similar communities elsewhere in the country. Their stories tell more than any statistics about the potential of this program to bring new doctors into needy areas.

The Primary Care Physician Shortage and Teaching Health Centers

When the program started, I was asked by my colleagues to lead the newly established American Association of Teaching Health Centers, an organization founded to support the new Teaching Health Center programs around the country with technical assistance, organize collaboration among grantees, and to engage in legislative advocacy. I am here today on behalf of that Association, to implore you to reauthorize the Teaching Health Center Graduate Medical Education program.

The U.S. faces a severe doctor shortage. In fact, by 2020 we will need more than 90,000 physicians to meet the growing demand for health care services across the country. According to the American Academy of Family Physicians, by 2025, the United States will require an additional 52,000 primary care physicians, and the shortage is being felt most deeply in health professional shortage areas (HPSAs) and medically underserved areas (MUAs). As many as 60 million people living in these areas experience disparities in health care access either because they are uninsured, or because they live in rural, urban, or suburban areas without enough primary care physicians. Additionally, we are reaching a critical time, when the number of medical school graduates will be greater than the number of residency slots. Without a residency, medical school graduates are unable to obtain a medical license.

While patient care increasingly occurs in ambulatory settings, such as CHCs, medical education occurs mainly in inpatient hospital facilities. This produces a health care workforce whose skills and experiences are poorly matched to the primary care needs of the population. In order to address the changing healthcare system and address the disparities in the health care workforce, the THCGME is training medical residents in community-based settings, including low income, underserved rural and urban neighborhoods.

The traditional method of residency training, funded primarily by CMS under a Medicare formula, is mainly focused on hospital-based training and the profile of physicians trained no longer matches the nation's needs - too few enter primary care and even fewer choose to practice in rural or underserved locations. In contrast, the THC model uses community-based ambulatory health centers, such as nonprofit community health centers and community consortia, to train primary care residents who will practice 21st century care in underserved communities during their training and after they complete their residencies. During their residency training, THC residents practice in the approved primary care specialties of Family Medicine, General Internal Medicine, Obstetrics and Gynecology, Pediatrics, Psychiatry and General Dentistry.

According to the 21st Report of the Council on Graduate Medical Education (COGME), "the shortage in primary care providers, particularly those capable of caring for adults with chronic disease (Family Medicine and General Internal Medicine), overshadows the deficits in all other specialties. One way to address the physician workforce shortage is to train resident physicians in underserved settings, based on the precept that training providers in areas of need will produce the workforce with the necessary skills to serve in underserved areas. Evidence has shown that resident physicians who train in health center settings are nearly three times as likely to practice in underserved settings after graduation. They are also 3.4 times more likely to work in a health center, compared to residents who did not train in health centers. The difficulties in recruiting community-based primary care physicians is also well documented; only investment in the community health care workforce pipeline will help meet the workforce demands. By moving primary care training into the community, THCGME programs are on the leading edge of innovative educational programming dedicated to meeting future health care workforce needs.

Analysis of the THCGME programs continue to show promising results:

Reauthorization and the Benefits of H.R. 3394/S. 1754

With the looming primary care shortage on the horizon, investments in graduate medical education training will be critical to meet the needs of the evolving healthcare delivery system. The THCGME program is one of the most reliable training models for primary care physicians and has an overwhelming documented success, but has been critically underfunded and is at the brink of collapse. Without immediately strengthening and expanding, the program will unravel just as it is beginning to produce the urban and rural primary care workforce that is desperately needed.

Thankfully, Congresswoman Cathy McMorris-Rodgers, Senator Susan Collins, and other leading Members of the House and Senate have listened to our Association and our counterpart associations and have developed a legislative proposal that achieves many of our objectives in the reauthorization process. It is the bill we hope you will consider including in any legislative package or which we hope you will enact as a free-standing, bipartisan and bicameral bill.

Congresswoman McMorris Rodgers is very familiar with the THC program in Spokane and has been a champion for increasing our health workforce in medically underserved areas, especially in rural America. We are so grateful to her for introducing her bipartisan legislation to reauthorize the program sustainably for three years and to fund expansion to help satisfy the pent-up demand throughout the country for new teaching health centers. We appreciate that Congresswoman Tsongas and 62 other Members of Congress co-sponsored this legislation, including Congressman Jeff Denham, who not only cosponsored it, but also introduced his own innovative legislation that would appropriate even more funds for expansion.

Primary care saves lives and saves money and the Teaching Health Center Graduate Medical Education program helps solve our primary care crisis. However, it is two weeks away from extinction.

We need it reauthorized now, and at the level recommended in the HRSA-funded study published last year, of $157,000 per resident, per year. We need a three-year authorization at $116.5 million per year so that centers will not terminate their training programs and can continue recruiting new residents.

We are aware of fiscal pressures that Congress faces but it is important that this Committee fully recognizes the fiscal pressures that we face. When our Center extends an offer to a resident, we make a commitment to them for three years. A two-year federal funding commitment is insufficient to stabilize our programs. In addition, we have had grossly inadequate funding for the past two years - as low as $95,000 per resident. As a result, some centers, were forced to stop recruiting new residents. In my program at the Institute, the decrease in funding from the initial level of $150,000 per resident per year created a loss of $2 million and forced us to reduce our Harlem residency from 36 to 18 doctors. If Congress again were to provide flat funding of $60 million, that would work out to roughly $82,000 per resident, per year, which is around half the national median cost for such training and thus will lead to substantial dislocation, program closures, resident terminations, and a loss of hundreds of thousands of patient visits throughout the nation.

The McMorris Rodgers-Tsongas legislation funds $157,000 in training costs per resident for all 732 current medical residents and additional funds to establish up to 10 new programs, either entirely new centers or expansion of programs offered at existing centers, which would add another 120 residents to the program. It should be where Congress ends up at the end of the legislative process, not a mere aspirational starting point. Every dollar can be accounted for and will generate tangible benefits for your communities and those of other Members. Lives will be saved, economic growth generated, and we will make a dent in the medical care shortage that plagues too many parts of our country to this day.

In closing, I want to stress that the health of all Americans requires that the other programs that you will hear about today, are also funded, timely and adequately. The National Health Service Corps, provides doctors who serve in our Nation's Community Health Centers, Centers that provide care to 24 million Americans, while Title VII and VIII supports training in the critical disciplines of medicine, nursing, dentistry and others.

Thank you for giving me the time to testify this morning.

Read this original document at: http://docs.house.gov/meetings/IF/IF14/20170914/106404/HHRG-115-IF14-Wstate-CalmanN-20170914.pdf