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, The 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 January meeting were accepted as presented. The minutes from
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, especially 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 residencies 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 successful 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 3rd 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 FM. 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 FM 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 the 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 3rd 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 HC 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 data 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 they 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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