Future of Family Medicine Task Force Meeting at LSU

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					                 Louisiana Interagency Task Force on the
                        Future of Family Medicine

March 16, 2005

  Present: Ms. Lee Ann Albert, Mr. Miles Bruder, Dr. Arthur Fort, Dr.
  Michael Harper, Ms. Jeanne Haupt, Dr. John Haynes, The Honorable Roy
  “Hoppy” Hopkins, Dr. Kevin Ingram (3Y resident from Alexandria
  program), Mr. Carl Kelly, Mr. Tony Kick, Dr. Brian Krier, Dr. Michael
  Madden, Dr. Ed Martin, Ms. Kristy Nichols, Mr. Joe Parish (United Way
  of NW LA), The Honorable Michael Powell, Ms. Jo Rose, Dr. Greg Salard
  (Chief Resident of Vivian Residency program), Ms. Angela Sheffie
  (LPCA), Dr. Eli Sorkow, Dr. Rick Streiffer, Dr. Jeff Tanita (3Y
  resident from Alexandria program), Dr. Steven Taylor, Katrina Wims,
  FNP (Vice-president of LA FNP Assoc.), and Ms. Sharon Womack,


  Absent: Dr. Derek Anderson, Ms. Linda Beauvais, Ms. Laurinda
  Calongne, Mr. Clay Coco, Ms. Gerrelda Davis, The Honorable Sydnie Mae
  Durand, Ms. Pat Faxon, Dr. Norman Francis, The Honorable Nick
  Gautreaux, The Honorable Donald Hines, Ms. Linda Holyfield, The
  Honorable Willie Hunter, Mr. Brian Jakes, Jr., Ms. Ruth Landis, Dr.
  Kim LeBlanc, Ms. Rhonda Litt, Dr. Pamela McMahon, The Honorable Joe
  McPherson, Ms. Susan Moreland, Ms. Joni Nickens, Ms. Vera Olds, Mr.
  Joe Pierce, Ms. Lisa Plauche, The Honorable Cederic Richmond, T he
  Honorable John Schedler, Ms. Angela Sheffie, Ms. Forest Smith, Ms.
  Jeanne Solis, The Honorable Michael Strain, Ms. Sonora Thigpen, Ms.
  Linda Welch, Dr. Gary Wiltz, Mr. Michael Zeringue, and Ms. Karen Sue
  Zoeller,


  Dr. Martin called the meeting to order at 1:18 p.m.   The minutes from
  the January meeting were accepted as presented.

  Dr. Strieffer reviewed the issue of Title VII funding. He will
  forward articles on this important topic via e-mail for further
  review. This program has important initiatives for LA. Title VII has
  been in place for 30 years. It includes grant funding to increase
  Family Medicine Practice. AHECs are funding through Title VII money.
  Also, the FM Education Program is funded with Title VII money. The
  amount of money dedicated to Title VII is a minor amount of the
  federal health care budget and has demonstrable effectiveness,
  especially to get FP MDs to rural areas. Every year this fund is
  zeroed out. The problem is the Office of the Inspector General lumps
  together all Title VII programs, which results in the program being
  rated as ineffective. Title VII programs related to FP
  incentives/AHECs/rural recruitment are effective but need to be
  disaggregated from other ineffective programs funded with Title VII
  money. These programs should be judged on their own merit in order
  for funding to be reinstated, if not increased. CHC/FQHCs receiving


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an increase in funding will help since half of the positions in these
clinics are usually filled by FPs. As the federal budget is being
reviewed, we need to be aware of this issue in order to alert our
legislators to the importance of this money to LA. Two main points
need to be made:
     1) Title VII increases the number of FPs who practice in rural
        areas.
     2) More FQHCs without more FPs does not make sense.

AAFP has a one page synopsis of the economic impact of FPs in rural
areas. It states that the impact of 1 FP in rural areas is $1.2
million and $.9 million in urban areas.

Susan Moreland said AAMC (American Association of Medical Collages),
HPNEC (Health Professions and Nursing Education Coalition) and NAO
(National AHEC Organization) will be meeting this Friday with Senator
Landreau, who is on the Appropriations Committee, about Title VII.
Susan will send an e-mail to Rosemary on Senator Landrieu’s staff to
let her know her position if she has time before the Friday meeting.

Dr. Madden asked if Tulane gets any Title VII money. Dr. Strieffer
answered, yes. Tulane receives some money for students to go to
rural areas and Tulane’s clerkship is funded in part with Title VII
funds.

Dr. Martin reminded everyone that without Title VII funds the Task
Force would have even more of an uphill battle. This money is
directly related to increased numbers of MDs in rural and
impoverished areas. This money is always in jeopardy no matter who
is in power. We have to let everyone know our position, espe cially
LA federal legislators. It’s a very serious issue that has to be
fought to be re-instated every year.

Dr. Madden gave a brief overview of the Alexandria residency program,
which is an extension of the LSUHSC-Shreveport program. In 1997, Dr.
Dennis Arabia was the first program director. He put good MDs in
small towns in central LA. In 1998, Dr. Madden came to the program
from Raceland. He mentioned some MDs who are now practicing in
central LA (two in Marksville and one in Sicily Island—others also
went to other small towns in central LA). About a year ago, the
Alexandria Residency Program changed its mission to focus on placing
family physicians in central LA. Therefore, when they ranked
residents this year they put an emphasis on whether the resident
would be interested in a rural FP practice. They are fully matched
this year and got 3 out of their top 4 matches. There has been a
decline over recent years in FP nationally and in LA. We all know
there is a need to increase interest in FP in medical schools.
Nationwide, only 82% of FP openings were filled this year which is
105 fewer positions than last year. Last year only 79% of FP
openings were filled. Residents in the Alexandria program go to


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rural sites to increase exposure and interest in these types of
practices. They have also “rediscovered” the AHECs. They had a very
successful social event for their residents to meet physicians from
hospitals and practices in underserved areas interested in recruiting
them to central LA and building a relationship with them in order to
increase the likelihood of them staying in this area. (This was a
Med Job LA event). He also mentioned how successful the annual
Medical Job Fair has been for the residents in his program. There are
two residents who are going to small towns in the central LA area and
the Chief Resident from the Vivian program is in Shreveport. He
wanted these residents to tell about themselves, but Dr. Streiffer
asked if this can wait since the state legislators are not in
Shreveport yet and he believed it was very important for them to hear
these residents’ stories. It was decided to wait until the
legislators arrived to meet the residents.

Other items were discussed. For example, the association between the
residency programs and the AHECs are growing. Dr. Martin discussed
his experience as a NHSC clinician in Tarboro SC. The first AHEC was
located in SC. Eight physicians came the same year to that area of
the state; the AHEC flew the students in to expose them to a rural
practice. Dr. Martin wants to encourage the strengthening of ties
between the AHECs and all organizations that are involved in
increasing primary care access.

Dr. Streiffer asked Susan Moreland and Sharon Womack if they could
describe what is happening right now nationally with AHECs and
residency programs. He also asked for information about other states
that have their residency programs closely tied to their AHEC
programs. Specifically, he asked how they set this up and should we
be aiming for this model?

Dr. Sorkow said that AR runs their residency programs with the AHECs
sponsoring the programs. Lake Charles tried this model but could not
get it off the ground.

Sharon Womack stated that CLAHEC is working very closely with the
Alexandria residency program by trying to help with marketing and
start-up. They currently are working on recruitment in order to
increase the number at the medical student level and thus increase
the number of residents later on. They also want to link the
residents to the community they’re from so throughout their time in
school and residency they have a contact person who will be there to
encourage them, to send them letters, and see them when they are home
on breaks in order to increase the likelihood that the students will
return to these areas. They are trying to identify more students who
are interested in Family Medicine in order to increase the number of
FM residents in LA.
Susan Moreland said LA AHECs used AR as a model when starting the
AHECs. They used many of the same models in regards to acting as


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community liaison. The primary difference between the two programs
is responsibility. LA’s residency programs were already established
when LA AHECs were being started whereas AR and NC AHECs and Family
Medicine residency programs were formed at the same time. AHECs even
in the state of LA differ from one another. The main thing they have
in common is that they are all flexible enough to be able to bend to
work together on programs.

Dr. Martin asked if there was a program in place to match residents
with community hospitals? If not, can the AFP help set one up?

Carl Kelly spoke up and described the Med Job Louisiana program. Med
Job LA is a collaborative effort between all the state’s AHECs, DHH
Bureau of Primary Care and Rural Health, and LA Rural Health Access
Program to provide free recruitment services for LA’s underserved
areas. He explained that 8 Family Medicine MDs have been placed in
rural areas this year so far and 7 were placed last year. They use
Practice Sites software which can match residents to openings based
on their interest and experience. The Med Job recruiters are trying
to reach out to FM Interest Groups to increase their support of this
program. Lee Ann Albert mentioned that they have been attending the
LAFPP quarterly meetings to increase contacts with this group. They
also went to a couple of local resident recruitment events with the
annual Medical Job Fair in order to encourage faculty, staff and
directors to build relationships.

Susan Moreland said the AHEC is trying to build relationships with
students from the high school level on in order to have to be able to
give them a better idea of what FM/rural practice physicians do.
Maybe the LAFP needs to be more involved in this process. Perhaps
there should be annual/bi-annual/tri-annual meetings with AHEC
directors and residency program directors to build relationships
between these people.

Dr. Strieffer asked if residency directors could tell him if there is
a rural rotation required in LSUHSC—Shreveport. Since 1992, rural
rotation is required in the second year either in the Homer or Vivian
sites. Prior to this requirement, 34% of their residents go to small
towns to practice. Over the last 12 years, 45% of their residents
have gone to small (under 20,000 population) towns. They feel this
shift is due to the required rural rotation.

Dr. Krier said LSU-Monroe does not have a rural rotation requirement.
The residents have been doing it, but are not required to do so.

Dr. Strieffer asked if they could require a rural rotation in all
residency programs. They could look at Colorado’s set-up. A rural
rotation is required in Colorado in order for residencie s to receive
funding.



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Katrina Wims said that NPs and PAs have to do a rural rotation as a
part of their programs. Everyone believed this is a very important
issue to include in any future legislation.

Dr. Martin wanted to give Dr. Steve Taylor and Dr. John Hayes a
chance to talk about the Vivian residency program. Dr. Hayes said
that program started 4 years ago and they are doing exceptionally
well on graduating residents who are primarily trained for going into
rural areas (in one stop shopping practice) OG/ER/ICU/procedures (300
scopes a year)/treadmills, etc.

Dr. Greg Salard, Chief Resident of the Vivian program, said he was
well prepared to stay in rural areas. He will stay in Vivian when he
graduates. He also said that residents of LSUHSC—Shreveport come to
Vivian to do their rural rotation. The Chief resident at LSU-S will
practice in Farmerville. Dr. Martin asked him what made him choose
the rural path. Dr. Salard said that the programs should advertise
more because he found out by chance about the Vivian Residency
Program from Dr. Harper. AHEC sent him there for a month to see the
program, and he decided Vivian was for him because the training was
so varied and so much better than anywhere else. Dr. Fort said this
program is very popular with LSU-S students; there are more
applicants than spots available.

Dr. Martin said if some of these graduates can train new residents
then it will impact the residents because they will see that you
don’t have to go into a specialty to have a financially success ful
practice. Even if these residents do not go into rural areas; this
rural requirement would benefit them because they would acquire
experience doing a wider variety of procedures which will increase
their earning potential when they set-up their own practices.

Dr. Kevin Ingram spoke next. He was going to Ferriday as a 3 rd Year
FM resident. He told about his history. He was born in Natchez, MS
but raised in Monterey, CA. His dad was a farmer, and his mom was a
nurse. He was in the Army for 18 years. He was stationed in Auckland,
the Netherlands, and Ireland. He applied to medical schools in the
states but could not get in. He went to American University in the
Caribbean. He wanted to come to Louisiana for his residency because
he wanted to have a rural experience. His wife is from Concordia
Parish. She has a lot of family in this area, therefore, strong ties
to the area. He contacted Riverland Hospital about getting a position
there after he finishes his residency.

Dr. Strieffer brought up the point that Dr. Ingram is the “classic”
example of an older student who doesn’t come from professional
parents who didn’t go to a huge school but knows where they want to
go and what they want to practice. Dr. Ingram’s inability to get into
an American medical school highlights the problem with our admission
system. Dr. Martin asked Dr. Ingram if he has significant debt. He


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has $218,000 worth of loans. This amount of debt could have tempted
him to go into a specialty if he wasn’t so sure of what he wanted to
do with his practice.

Dr. Fort broke in the meeting to introduce Representative Mike Powell
who joined the meeting. Dr. Martin took a moment to review what the
residents had said. Kristy Nichols asked Dr. Ingram what his exposure
was to rural areas before he decided where he wanted to go for
residency. He told the group that he sought the Alexandria program
specifically because he wanted to go to a rural area. She also asked
him if he knew about the Student Loan Repayment Program. He said he
did and was planning to call when he started his practice. Katrina
Wims mentioned that she also went the Army route and asked Dr. Ingram
about the GI bill that would have covered his expenses. There was a
reason that he was not able to use this option which he explained to
the group.

Dr. Jeff Tanita spoke next. He plans on setting up a practice in
Olla. He is a 3rd year Family Medicine resident. He was originally
from San Diego, CA. He went to medical school offshore and chose
Alexandria for residency. The things that were important to him in
choosing a residency program/specialty were financial issues,
character issues, variety in practice, and a feeling that he would be
fulfilling a need. He said he thinks many medical students have a
misconception about the amount of money to be made in rural FM. They
feel it would be a pay cut, but he points out that the opposite is
often true. He found most rural areas had better salaries and better
benefit packages than some urban practices. He pointed out that the
cost of living in rural areas makes a huge difference in the amount
of salary a physician receives. He learned about these differences at
Job Fair. The AHEC/Med Job staff assisted him to get on track to
apply for NHSC loan repayment. This incentive makes rural practices
more attractive. He discussed the character issues which are very
important in determining which students will choose F M. He’s from a
small town and has a family. He also wants to be around a certain
type of people—people who like living in a small town and who have
the same values as he has. Another factor which drives students’
decisions about going into FM is having the chance to do a wider
variety of procedures in their practices. This variety can be a draw
for certain residents. Dr. Morton has been in Olla for 30 years. Dr.
Morton had to take over the OBG care when the local OBG quit. This is
one example of how a FM doctor has to be flexible in meeting the
community’s needs. Dr. Tanita also believes that a student who has a
strong desire to contribute and make a difference in society is much
more likely to go into FM. He believes that the need is huge in rural
areas. If it is possible to make students more aware of the benefits
of rural practice, more medical students may decide to go into rural
Family Medicine practice.




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Dr. Martin stated he wishes he could get these residents to make
their statements to the legislature to show them examples of what’s
happening in medical schools now and highlight the problems facing F M
programs.

Dr. Strieffer mentioned Michael Zeringue who is a 4th year medical
student at Tulane with an M.P.H. degree and who will match tomorrow.
He would like to have him describe why he chose the FM track.

Chancellor McDonald, the Dean of LSUHSC-Shreveport, broke in to say
that State Representative Roy Hopkins, who is on the Rural Caucas and
Appropriations, and State Representative Mike Powell, who represents
Shreveport and Bossier and is on the Rural Caucas, are both in
attendance at the Shreveport site. Dr. Martin updated them on what
the residents have shared and where we are as a Task Force. He gave a
brief history of how the LAFP recognized the need to increase the
number of FM physicians in rural areas of the state and decided to
craft the legislation that created this Task Force. This is the
fourth meeting of the Task Force. We have accomplished a lot in the
time since it was formed. We have reviewed a lot of research that
affirms and documents that FM is the specialty to foster if you want
to increase the number of physicians in rural areas. The hope is to
gather as many groups together as possible to attack th e problem of
lack of access to primary care. AL, WS, AR, and CO are states that
had similar problems and have developed successful programs that we
might consider emulating. He mentioned a tendency of medical students
to gravitate toward specialties because the perception is that there
is more money to be made in other specialties. Part of the challenge
of the Task Force is to make FM more attractive and increase
student’s interest in this specialty.

Miles Bruder asked why we don’t just open more rural residency
programs if they are so effective in producing FM doctors who will
practice in rural areas. He also asked about the current
reimbursement structure for residency programs and what would stop us
from just opening more programs. Shreveport’s program was started in
1995 and was designed for a rural track in Homer. The students were
to spend the first year at LSU then the 2nd and 3 rd years in Homer.
Several years later a program was opened in Vivian. Willis-Knighton
is paying for the 2nd & 3rd years in Vivian.

The current residency programs need to expand because of the numbers
needed for the accreditation process. It’s a lot of work —just like
starting a brand new residency with a small number of graduates.
Finding good sites for the residents to practice and increased
medical malpractice are two problems for these programs.

Kristy Nichols asked if there is an issue with current residency
programs that prevents them from getting increased reimbursement. In
Shreveport they looked at rural CO to see how they were running their


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programs. Medicaid probably won’t recognize them as a medical
education site. The bigger hospitals have a cap placed on the number
of house officers they can have since 1997. If new residents start,
others will not be reimbursed. Dr. Haynes says that it is
complicated, but with Willie-Knighten they only get partial
reimbursement.

At the Alexandria site, Dr. Madden explains that Rapides Regional
Medical Center funds 18 positions. They are like grantors; the money
is paid through the medical school and money comes back through
salaries. Approximately $1.2 million is generated by FP centers. It’s
a tenuous situation (originally 2 hospitals were contributing to the
program then Christus St. Francis Cabrini dropped out. Rapides RMC
is doing the best they can with funding. Every year they have to show
that this is money well spent). It would be very good if the state
could help the hospitals cover some of these costs.

Dr. Martin says that the Medicare system probably is the primary
source of funding. There is a certain amount of money per primary
care resident; it varies from $50,000 to $100,000. In most cases,
these amounts are woefully inadequate to cover these FP residency
programs.

Dr. Strieffer wanted to address the question of why we are not trying
to open more residency programs. The main reason is that it is very
hard to do. The real answer is that the current programs need to be
re-tooled to meet both urban and rural needs. He said that the state
has gotten out of funding FP residents. There are no FP residents at
MCLNO. Earl K. Long, which was the oldest FP residency program in the
state, closed a couple of years ago. There are no FP residents at
Huey P Long MC. Dr. Strieffer believes that this argues for the state
to fund FP residency programs since they are currently underinvested.

Dr. Martin brought up the fact that LA currently spends the most per
capita for each Medicare recipient (about $8,000) with the lowest
quality of care. NH spends the least per capita (about $4,000) with
the highest quality of health care. LA has the lowest number of FPs
practicing, and NH has one of the highest.

Having more FPs is a way to increase the quality of H C in our state.
Dr. Martin asked what we would like to see passed this legislative
session. We know that redistribution of funds is probably the most
that can be hoped for, but change will take time. Things are moving
towards change now more than they have in a long time. He mentioned
that Senator Durand suggested forming a Commission on Family
Medicine. Alabama has had one for years which is legislatively
mandated. It has been very successful in pushing FM forward in that
state. Representative Strain also suggested a Commission to be
started as a sub-group of the Health Works Commission.



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Kristy Nichols stated that Med Job LA is funded by DHH and operated
out of the AHECs. They recruited 31 primary care providers, 15 of
which were FM MDs.

Dr. McDonald mentioned the Graduate Medical Education Fund. The state
puts money into the Graduate Medical Education Fund through DSH
(disproportionate share money). Residency programs have to be in
areas where there will be opportunities for clinical support. Dr.
Martin thanked Dr. McDonald for participating in this meeting.

Dr. Strieffer mentioned that the training of rural FPs does not have
to be in rural areas. There are barrier,s but mainly there has to be
will.

Representative Hopkins lives in a rural area. He said that one of
the biggest problems in the state is that legislators are not aware
of these problems. He said there are 65 members in the Rural Caucas
out of the 105 members of the legislature. He thinks it’s wise to
form a Commission. The next 3 years are the ideal time to push things
through because major rural legislators are now serving on the
Appropriations and other important committees. A Commission is a very
good idea to help bring agenda forward. Looking at other successful
Commissions might be the best way to go. Dr. Martin asked if the Task
Force should form under the Health Works Commission. Representative
Hopkins said he didn’t know. However, we should determine if there
is a way to quickly form a Commission and make the legislative body
aware of these problems.

Dr. Strieffer said he thinks that the data are misinterpreted since
IMs who often subspecialize are included in primary care. He wants to
be able to make sure that we can generate reports with adequate d ata
that truly represents the FM situation.

Tony Kitch (graduate student at Tulane.) asked if the most successful
Commissions are focused solely on workforce issues, or, are they
broader in scope? Dr. Martin said that they are usually broader and
that we are also interested in loading the pipeline in order to
address future problems. Kitch says that the Task Force needs to look
at where its focus should be since there are recruitment and
retention issues as well as demand issues. The Task Force should
think about where the focus should be in regards to deciding about
forming under the Health Works banner. Dr. Madden mentioned that
retention is a major issue, not just recruitment. We need to support
the network in order to retain these physicians.

Dr. Martin believes we should take Senator Durand’s advice to form
under the Health Works Commission. The broader network (there will be
more significant results if we work together with other Commissions
instead of everyone doing their own thing). He asked the
Representatives if they think we could put forth a fiscal bill this


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session or is that too naïve; would that have to be brought forth in
this session?

Dr. Krier says that there are no rural MDs involved and th ey need to
be involved in this Commission. The members of the Commission need
to be on-site for maybe half a day to talk to the legislators which
could be a hardship for some rural practitioners since they often do
not have people to back them up in their practices.

Dr. Martin asked for 2 things to target this session:
  1) forming the Commission
  2) funding the scholarships that were appropriated last session

Representatives Powell and Hopkins told the task force that it might
be difficult to address a lot of issues this session since it is a
short fiscal session. The Task Force might just focus on forming the
Commission and funding the scholarships. Representative Powell stated
that any legislation attempt needs to be very focused and defined
because the session will be short. Dr. Stieffer asked if they could
think of ways to give incentives to leadership in rural practices in
order to increase options for these FP residents.

Representative Hopkins agrees with Rep. Powell. It’s difficult to put
legislation through this year. The scholarship issue needs to be
addressed. The legislature thought it was taken care of last year,
but there was a mix up with the staff who did not put the money in
the appropriate account. The money went into another fund. They are
also looking at a rural tax break, especially for new MDs in rural
areas.

Dr. Fort asked if there is a way to come up with funds to support new
positions. Representative Hopkins said that projections for coming
years are going to be worse. He suggested contacting federal
legislators to let them know about funding cuts. Dr. Martin agrees
with talking to others to let them know what’s happening to funding.
Rep. Hopkins again advises going slowly, one step at a time because
of the short session. He stressed that we should focus on very
specific issues.

Dr. Martin said that the Executive Committee will be meeting to try
and craft a rough draft of a bill to put through since the next
meeting of the full Task Force will be after the session is over.

The meeting closed at 3:56 p.m.




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