Caring for the underserved: the National Health Service Corps

Forty years ago, Eric Redman's classic book The Dance of Legislation provided a compelling "insider's account" of how the U.S. Senate worked by following the winding path of Public Law 91-623 (The Emergency Health Personnel Act of 1970), which created the National Health Service Corps (NHSC). Envisioned by Seattle pediatrician Abraham Bergman, MD as a way to recruit idealistic young physicians to "doctor deficient" communities throughout the U.S., the NHSC and its authorizing legislation successfully navigated a perilous policymaking process, an unsupportive Administration, and the threat of a pocket veto to become law in the final days of the 91st Congress. Later legislation added scholarship and loan repayment programs to the NHSC, and recent funding increases provided by the American Recovery and Reinvestment Act and the Affordable Care Act have tripled the size of the corps from 3600 to nearly 10,000.

In this month's Georgetown University Health Policy Seminar, we critically evaluated the accomplishments and limitations of the NHSC in improving access to care for the medically underserved. A literature review by Dr. Robert Politzer and colleagues in 2000 found mixed results: although the NHSC relieved health professional shortages in many communities over the years, physicians often did not stay in these communities beyond their 2-year service commitments, and the neediest areas were actually less likely to be successful in recruiting clinicians. The absence of a service analogous to the National Resident Matching Program meant that the NHSC placement process favored well-organized communities with more resources, rather than matching greater numbers of clinicians to areas with greater needs. At around the same time, a commentary by Dr. Fitzhugh Mullan advocated for a more expansive role for the NHSC in the 21st century, including options to practice community-oriented primary care, in urban hospitals, in public health, and in prison and international health settings.

Currently, the collective impacts of the individual and employer mandates and guaranteed insurance issue provisions of the Affordable Care Act on underserved communities remain uncertain. Will the implementation of the ACA make the NHSC less necessary, or will projected gaps in coverage among immigrants and Medicaid-ineligible adults continue to leave many areas with health professional shortages? Physicians of all ethnic and cultural backgrounds tend to migrate to affluent areas, and retirements of small-town family doctors may end up relegating some communities to welcoming a new crop of primary care clinicians every few years. Are there alternative health policies that could attract primary care and subspecialist physicians to areas where they are most needed?

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The above post first appeared on The Health Policy Exchange.

$10 billion per year to train the wrong physicians

Earlier this year, the physicians at my academic family medicine practice met with two senior officials from our parent health care organization to be oriented to its new initiatives and projects. Their presentation documented the organization's ongoing investments of many millions of dollars into renovating subspecialty care suites and purchasing new radiology equipment that was likely to be highly profitable, but provide dubious benefits to patients. Two of my colleagues asked why, given the expected influx of millions of newly insured patients into primary care starting in 2014, and an estimated shortfall of more than 50,000 primary care physicians by 2025, the organization had not identified expansion of primary care training as a financial priority. Where exactly did they expect to find family physicians to staff all of the new community offices they planned to open? An awkward silence ensued, followed by some polite hemming and hawing about how this was a complicated issue, and that supporting generalist training would likely require additional funding that was perhaps beyond the organization's limited resources.

Additional funding required? How about $9.5 billion? That's the approximate amount that that Medicare spends each year, with no strings attached, to subsidize the cost of training physicians in U.S. residency programs. Noting that the federal government doles out these dollars without requiring any particular outcomes from the institutions that benefit from them, some have called for Medicare to hold institutions more accountable for meeting America's physician workforce needs. If we have a surplus of radiologists and a shortage of general surgeons, why not tie funding to training more of the latter and fewer of the former? Given the decentralized nature of the U.S. health system, though, that has been easier said than done. In particular, it is challenging to follow the money trail and determine which institutions end up producing which types of doctors.

A new study in Academic Medicine by health services researchers at The George Washington University and the Robert Graham Center fills this information gap. Painstakingly assembling and cross-checking data from several sources on actively practicing physicians who completed their residency training from 2006 to 2008, they were able to identify residency-sponsoring institutions that were top producers of primary care physicians, that produced lower proportions relative to all physicians, and that produced none at all. Notably, they conclusively disproved "The Dean's Lie" that counts all internal medicine residents as going into primary care (when only 1 in 5 actually plan to do so), demonstrating that at some institutions fewer than 1 in 10 internists become primary care physicians. They also identified a large funding discrepancy between the top and bottom primary care producers.

The top 20 primary care producing sites graduated 1,658 primary care graduates out of a total of 4,044 graduates (41.0%) and received $292.1 million in total Medicare GME payments. The bottom 20 graduated 684 primary care graduates out of a total of 10,937 graduates (6.3%) and received $842.4 million.

In short, where physician production is concerned, you get what you pay for. In this case, Medicare pays a disproportionate amount of its nearly $10 billion per year in subsidies to institutions that produce mostly subspecialists, even in specialties where supplies are plentiful, at the expense of training sorely needed family physicians and other generalists whose presence has been shown time and again to deliver better health outcomes.

That's the big picture. Since all politics is local, policymakers who want to know what types of physicians their teaching hospital or health system is training can use the Graham Center's free GME Outcomes Mapper tool to find out. And if enough of them do so, maybe we can all have a serious national conversation about moving beyond guaranteed health insurance coverage to ensuring that the care (and the workforce) that coverage is paying for will actually help us to live longer or better.

Rosiglitazone for diabetes: helpful, harmful, or neither?

Recently, an advisory panel convened by the U.S. Food and Drug Administration (FDA) voted to relax safety restrictions on the diabetes drug rosiglitazone (Avandia) that were put in place in response to previous evidence that rosiglitazone may increase the risk of heart attacks and cardiovascular deaths. American Family Physician first highlighted these safety concerns in its March 15, 2008 Tips From Other Journals, which Dr. Kenneth Moon concluded:

There is substantial circumstantial evidence that rosiglitazone is associated with higher risks of heart failure and myocardial infarction. Despite the awkwardness of persuading a patient to use a drug that may provide similar benefits but pose greater risks than other proven agents, the legitimate concerns raised by these studies make this a serious issue. Until there is conclusive evidence about the safety of rosiglitazone, many physicians and their patients may be more comfortable using alternative treatments.

Subsequent AFP articles on management of blood glucose in type 2 diabetes and rosiglitazone vs. pioglitazone reinforced cautionary messages about rosiglitazone. However, the results of a large randomized trial published in 2009 found similar risks for cardiovascular hospitalizations and death in patients using rosiglitazone compared to patients taking other oral diabetes drugs. This trial, which was sponsored by rosiglitazone's manufacturer GlaxoSmithKline, was criticized for methodological problems, but an independent re-analysis of the trial's data persuaded the FDA advisory panel that the drug's safety risks had been exaggerated in previous studies.

If the FDA acts on the advisory panel's recommendations and makes rosiglitazone more widely available, should family physicians prescribe it? It is worth noting that the panel considered only the drug's safety, not its effectiveness. A previous AFP Journal Club reminded readers that the disease-oriented outcome of improved glycemic control does not necessarily lead to patients living longer or better. Rosiglitazone causes more weight gain and congestive heart failure than metformin, and is more expensive than metformin and sulfonylureas. For those reasons, it should be a second- or third-line drug choice for patients with type 2 diabetes.

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This post was first published on the AFP Community Blog.