Impact of Title VII Funding on Community Health Center Staffing
AcademyHealth
2007 Annual Research Meeting
Diane R. Rittenhouse, MD, MPH
Department of Family and Community Medicine University of California, San Francisco
Collaborators
Kevin Grumbach, MD & Christine Nielsen, BA
• UCSF Department of Family & Community Medicine and Center for California Health Workforce Studies
George E. Fryer, Jr., PhD & Thomas Miyoshi, MSW
• New York University, Center for Child Health Research
Robert L. Phillips, Jr., MD, MSPH
• The Robert Graham Center for Policy Studies in Family Medicine and Primary Care
David C. Goodman, MD, MS
• Dartmouth Medical School, Department of Pediatrics
Community Health Centers
• Federally Qualified Health Centers (FQHCs) are a critical component of the health care safety net. (2004: 6,651 FTE physicians) • President Bush’s Community Health Center Initiative = MAJOR EXPANSION • FQHCs are experiencing difficulty recruiting physicians (2004: 809
Title VII Primary Care Training Grants
• HRSA Title VII Section 747 Primary Care Training Grants to medical schools & primary care residency programs are associated with:
• increased production of primary care physicians • choice of practice in underserved areas
• Not known whether associated with work
Objective
• To examine the association between physicians’ exposure to HRSA Title VII Section 747 Primary Care Training Grants during medical school and residency, and subsequent work in a community health center
Building the “Megafile”
•
2004 AMA Masterfile containing updated information on all U.S. allopathic and most osteopathic physicians (N = 936,178). Added Medicare UPIN numbers and additional residency training information
•
Title VII Training Program Grantee Database
• HRSA’s Bureau of Health Professions • 3 relevant grant categories: • Pre-doctoral Education • Academic Administrative Unit (AAU) • Residency Training
• 3606 Pre-doctoral & AAU awards to 137 U.S. medical schools • 6245 residency awards to 819 residency programs
Physician “Exposure” to Title VII Funds
“Exposed during medical school” • attended a medical school during at least one year that the school received Title VII funds • (Pre-doctoral grant, AAU grant, or both) “Exposed during residency” • attended a primary care residency program during at least one year that the program received a Title VII residency grant
Identifying Physicians Working in CHCs
CMS Outpatient File --all beneficiaries who had Medicare outpatient facility claims filed in 2001, 2002 & 2003 for primary care services
• billing physician’s UPIN number • whether the claim was for a visit to a FQHC
• Claims data linked to Masterfile at level of individual physician using UPIN numbers
Data Analysis
• Compared proportions of “exposed” physicians and “not-exposed” physicians that worked in an CHC (2001-2003).
• Looked separately at medical school and residency exposure. • Logistic regression to examine the independent contribution of Title VII exposure during medical school and residency on CHC staffing.
Exposure to Title VII Funding During Medical School
All Physicians Exposed Primary Care FPs/GPs
201,186 (49.8%) 210,826 n = 412,012
78,612 (56.9%) 59,585
36,326 (62.3%) 21,973
Notexposed Total
n = 138,197 n= 58,299
Exposure to Title VII Funding During Residency
Primary Care
Exposed 70,529 (40.6%) 103,127
Not-exposed Total
Family Physicians 25,098 (42.3%) 32,256 n = 59,354
n = 173,656
Effects of Medical School Title VII Exposure on CHC Staffing, 2001-3
Percent of Physicians Working in CHCs
8.0%
6.2%
6.0%
4.5%
4.0%
4.3% 3.0%
3.0% 1.9%
2.0%
0.0% Exposed Not Exposed Exposed Not Exposed Exposed Not Exposed
All Physicians
Prim ary Care Physicians Only
FP/GPs Only
Effect of Title VII Funding During Medical School on Staffing of CHCs, 2001-2003, by Grant Type (All Physicians)
5.0%
Percent Working in a CHC
4.0%
3.1%
3.0%
3.0% 2.7% 1.9%
2.0%
1.0%
0.0% Exposed - Both Exposed - AAU Only Exposed Predoc Only Not Exposed
Effect of Title VII During Medical School, by Grant Type, 2001-3, (FPs/GPs Only)
10.0%
Percent Working in a CHC
8.0% 6.4% 6.0% 6.5% 5.7% 4.3% 4.0%
2.0%
0.0% Exposed - Both Exposed - AAU Only Exposed Predoc Only Not Exposed
Effect of Title VII During Residency on CHC Staffing, 2001-2003
Percent Working in CHCs
8.0%
6.8%
6.0%
4.4%
4.0%
5.0% 3.5%
2.0%
0.0%
Exposed
Not exposed
Exposed
Not exposed
Primary Care Physicians
Family Physicians Only
Independent Effects of Title VII Grant Type on Physicians Work in CHC, 2001-3
Odds Ratio (95% Confidence Interval)
All Physicians
Pre-Doctoral Training Grant
Departmental AAU Grant
PCPs Only
FPs Only
1.025 (0.972-1.082)
1.114 (1.058-1.174)**
0.936 0.857 (0.869-1.008) (0.776-0.947)*
1.115 (1.038-1.197)* 1.077 (0.981-1.183)
Residency Training Grant
1.083 (1.038-1.129)**
1.232 (1.1621.307)**
1.407 (1.3001.522)**
Limitations
Cross-sectional study shows association, not causation Medicare claims data to identify CHC physicians Osteopathic physicians – 40% have no GME data in AMA Masterfile
Conservative Estimates of Title VII Effect
CHC work cross-sectional during 20013 only FQHCs only “Exposed to Title VII funds” definition Pediatricians not well-represented in Medicare claims files
Conclusions
Physician exposure to Title 7 Section 747 grants during medical school and/or primary care residency is associated with subsequent work in CHCs. Recent reductions in Title VII Section 747 program funding may exacerbate the difficulties CHCs are facing in trying to recruit primary care physicians. 2,210 fewer physicians – more than double the current vacancy rate for all physicians at CHCs.
Funding
Health Resources and Services Administration