Impact of Title VII Funding on Community Health Center Staffing AcademyHealth 2007 Annual Research Meeting Diane R. Rittenhouse, MD, MPH Department of.

Impact of Title VII Funding on Community Health Center Staffing

Impact of Title VII Funding on Community Health Center Staffing

AcademyHealthAcademyHealth

2007 Annual Research Meeting 2007 Annual Research Meeting

Diane R. Rittenhouse, MD, MPHDiane R. Rittenhouse, MD, MPHDepartment of Family and Community MedicineDepartment of Family and Community Medicine

University of California, San FranciscoUniversity of California, San Francisco

CollaboratorsCollaborators

Kevin Grumbach, MD & Christine Nielsen, BAKevin Grumbach, MD & Christine Nielsen, BA• UCSF Department of Family & Community Medicine and Center for UCSF Department of Family & Community Medicine and Center for

California Health Workforce StudiesCalifornia Health Workforce Studies

George E. Fryer, Jr., PhD & Thomas Miyoshi, MSWGeorge E. Fryer, Jr., PhD & Thomas Miyoshi, MSW• New York University, Center for Child Health ResearchNew York University, Center for Child Health Research

Robert L. Phillips, Jr., MD, MSPHRobert L. Phillips, Jr., MD, MSPH• The Robert Graham Center for Policy Studies in Family Medicine and The Robert Graham Center for Policy Studies in Family Medicine and

Primary CarePrimary Care

David C. Goodman, MD, MSDavid C. Goodman, MD, MS• Dartmouth Medical School, Department of PediatricsDartmouth Medical School, Department of Pediatrics

Community Health CentersCommunity Health Centers

• Federally Qualified Health Centers (FQHCs) Federally Qualified Health Centers (FQHCs) are a critical component of the health care are a critical component of the health care safety net. (2004: 6,651 FTE physicians)safety net. (2004: 6,651 FTE physicians)

• President Bush’s Community Health Center President Bush’s Community Health Center Initiative = MAJOR EXPANSIONInitiative = MAJOR EXPANSION

• FQHCs are experiencing difficulty recruiting FQHCs are experiencing difficulty recruiting physicians (2004: 809 vacancies).physicians (2004: 809 vacancies).

Title VII Primary CareTraining Grants

Title VII Primary CareTraining Grants

• HRSA Title VII Section 747 Primary Care HRSA Title VII Section 747 Primary Care Training Grants to medical schools & primary Training Grants to medical schools & primary care residency programs are associated with:care residency programs are associated with:

• increased production of primary care increased production of primary care physiciansphysicians

• choice of practice in underserved areaschoice of practice in underserved areas

• Not known whether associated with work in Not known whether associated with work in Community Health Centers.Community Health Centers.

ObjectiveObjective

• To examine the association between physicians’ To examine the association between physicians’ exposure to HRSA Title VII Section 747 exposure to HRSA Title VII Section 747 Primary Care Training Grants during medical Primary Care Training Grants during medical school and residency, and subsequent work in a school and residency, and subsequent work in a community health centercommunity health center

Building the “Megafile”Building the “Megafile”

• 2004 AMA Masterfile containing updated 2004 AMA Masterfile containing updated information on all U.S. allopathic and most information on all U.S. allopathic and most osteopathic physicians (N = 936,178).osteopathic physicians (N = 936,178).

• Added Medicare UPIN numbers and Added Medicare UPIN numbers and additional residency training informationadditional residency training information

Title VII Training Program Grantee Database

Title VII Training Program Grantee Database

• HRSA’s Bureau of Health Professions HRSA’s Bureau of Health Professions

• 3 relevant grant categories: 3 relevant grant categories: • Pre-doctoral EducationPre-doctoral Education• Academic Administrative Unit (AAU)Academic Administrative Unit (AAU)• Residency TrainingResidency Training

• 3606 Pre-doctoral & AAU awards to 137 U.S. medical schools3606 Pre-doctoral & AAU awards to 137 U.S. medical schools• 6245 residency awards to 819 residency programs6245 residency awards to 819 residency programs

Physician “Exposure” to Title VII Funds

Physician “Exposure” to Title VII Funds

““Exposed during medical school” Exposed during medical school” • attended a medical school during at least one year attended a medical school during at least one year

that the school received Title VII funds that the school received Title VII funds • (Pre-doctoral grant, AAU grant, or both)(Pre-doctoral grant, AAU grant, or both)

““Exposed during residency” Exposed during residency” • attended a primary care residency program attended a primary care residency program

during at least one year that the program received during at least one year that the program received a Title VII residency granta Title VII residency grant

Identifying Physicians Working in CHCs

Identifying Physicians Working in CHCs

CMS Outpatient File CMS Outpatient File --all beneficiaries who had Medicare --all beneficiaries who had Medicare outpatient facility claims filed in 2001, 2002 & outpatient facility claims filed in 2001, 2002 & 2003 for primary care services2003 for primary care services• billing physician’s UPIN number billing physician’s UPIN number • whether the claim was for a visit to a FQHCwhether the claim was for a visit to a FQHC

• Claims data linked to Masterfile at level of Claims data linked to Masterfile at level of individual physician using UPIN numbersindividual physician using UPIN numbers

Data AnalysisData Analysis

• Compared proportions of “exposed” physicians and Compared proportions of “exposed” physicians and “not-exposed” physicians that worked in an CHC “not-exposed” physicians that worked in an CHC (2001-2003).(2001-2003).

• Looked separately at medical school and residency Looked separately at medical school and residency exposure. exposure.

• Logistic regression to examine the independent Logistic regression to examine the independent contribution of Title VII exposure during medical contribution of Title VII exposure during medical school and residency on CHC staffing.school and residency on CHC staffing.

Exposure to Title VII Funding During Medical School

Exposure to Title VII Funding During Medical School

All PhysiciansAll Physicians Primary CarePrimary Care FPs/GPsFPs/GPs

Exposed Exposed 201,186 201,186

(49.8%)(49.8%)

78,612 78,612

(56.9%)(56.9%)

36,326 36,326 (62.3%)(62.3%)

Not-exposedNot-exposed 210,826 210,826 59,585 59,585 21,97321,973

TotalTotal n = 412,012 n = 412,012 n = 138,197n = 138,197 n= 58,299n= 58,299

Exposure to Title VII Funding During Residency

Exposure to Title VII Funding During Residency

Primary CarePrimary Care Family Family PhysiciansPhysicians

Exposed Exposed 70,52970,529

(40.6%)(40.6%)

25,09825,098

(42.3%)(42.3%)

Not-exposedNot-exposed 103,127103,127 32,25632,256

TotalTotal n = 173,656n = 173,656 n = 59,354n = 59,354

Effects of Medical School Title VII Exposure on CHC Staffing, 2001-3Effects of Medical School Title VII Exposure on CHC Staffing, 2001-3

3.0%

1.9%

4.5%

3.0%

6.2%

4.3%

0.0%

2.0%

4.0%

6.0%

8.0%

Exposed Not Exposed Exposed Not Exposed Exposed Not Exposed

All Physicians Primary Care PhysiciansOnly

FP/GPs Only

Pe

rce

nt

of

Ph

ys

icia

ns

Wo

rkin

g i

n C

HC

s

Effect of Title VII Funding During Medical School on Staffing of CHCs, 2001-2003, by Grant Type

(All Physicians)

Effect of Title VII Funding During Medical School on Staffing of CHCs, 2001-2003, by Grant Type

(All Physicians)

3.1% 3.0%2.7%

1.9%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

Exposed - Both Exposed - AAUOnly

Exposed -Predoc Only

Not Exposed

Perc

en

t W

ork

ing

in

a C

HC

Effect of Title VII During Medical School, by Grant Type, 2001-3, (FPs/GPs Only)

Effect of Title VII During Medical School, by Grant Type, 2001-3, (FPs/GPs Only)

6.4% 6.5%

5.7%

4.3%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

Exposed - Both Exposed - AAUOnly

Exposed -Predoc Only

Not Exposed

Perc

en

t W

ork

ing

in

a C

HC

Effect of Title VII During Residency on CHC Staffing, 2001-2003

Effect of Title VII During Residency on CHC Staffing, 2001-2003

4.4%

3.5%

6.8%

5.0%

0.0%

2.0%

4.0%

6.0%

8.0%

Exposed Not exposed Exposed Not exposed

Primary Care Physicians Family Physicians Only

Per

cen

t W

ork

ing

in

CH

Cs

Independent Effects of Title VII Grant Type on Physicians Work in CHC, 2001-3Independent Effects of Title VII Grant

Type on Physicians Work in CHC, 2001-3

  Odds Ratio (95% Confidence Interval)

  All Physicians PCPs Only FPs Only

Pre-Doctoral Training Grant

1.025(0.972-1.082)

0.936(0.869-1.008)

0.857(0.776-0.947)*

Departmental AAU Grant

1.114(1.058-1.174)**

1.115 (1.038-1.197)*

1.077 (0.981-1.183)

Residency Training Grant

1.083(1.038-1.129)**

1.232(1.162-1.307)**

1.407(1.300-1.522)**

LimitationsLimitations

Cross-sectional study shows association, Cross-sectional study shows association, not causationnot causation

Medicare claims data to identify CHC Medicare claims data to identify CHC physicians physicians

Osteopathic physicians – 40% have no Osteopathic physicians – 40% have no GME data in AMA MasterfileGME data in AMA Masterfile

Conservative Estimates of Title VII Effect

Conservative Estimates of Title VII Effect

CHC work cross-sectional during 2001-3 CHC work cross-sectional during 2001-3 onlyonly

FQHCs onlyFQHCs only ““Exposed to Title VII funds” definitionExposed to Title VII funds” definition Pediatricians not well-represented in Pediatricians not well-represented in

Medicare claims filesMedicare claims files

ConclusionsConclusions

Physician exposure to Title 7 Section 747 grants Physician exposure to Title 7 Section 747 grants during medical school and/or primary care during medical school and/or primary care residency is associated with subsequent work in residency is associated with subsequent work in CHCs.CHCs.

Recent reductions in Title VII Section 747 program Recent reductions in Title VII Section 747 program funding may exacerbate the difficulties CHCs are funding may exacerbate the difficulties CHCs are facing in trying to recruit primary care physicians.facing in trying to recruit primary care physicians.

2,210 fewer physicians – more than double the 2,210 fewer physicians – more than double the current vacancy rate for all physicians at CHCs.current vacancy rate for all physicians at CHCs.

FundingFunding

Health Resources and Services Health Resources and Services AdministrationAdministration