TN is 7th worst in physician/pop ratio. FP most likely to meet state's needs, FP needs more support. Loan repayment helping but needs to be a constant (20 or so described in relation to numbers lost per year)
Describe pipeline, programs, and states efforts
TN Communities are made up of four components
Education
Economy
Health care
Leadership
Rural family physicians support 18 jobs and $380000 in local economy. TN communities lose jobs and businesses because of inadequate health care. Hospitals also close and can deplete communities of a major employer and over $3 million in local economy.
lose rural physicians due to condition of schools
Support for medical education and healthcare can be coordinated to benefit each. Institutions provide support (CHC), technical assistance, service (dungannon, mtn city), stabilize groups (of TN rural docs), facilitate state programs (recruitment fair, aafp stud-res, harmony)
Must work with all the above areas. All are interconnected. With major expenditures in education and economic development, health care must keep abreast or those monies are wasted. The following represents such an effort:
Impacting on
Education
better health, safety, academic performance, health careers promotion, community evaluation of all needs, esp education
Economy
jobs, local economy
Health care
services, hospital support
Leadership
physicians are leaders stimulation for community evaluation
Recruitment is key. Currently all of our TN FP programs struggle to match consistently. Some obstacles:
Shortages of students with FP interest
Resident environment not competitive with other states
Faculty shortages
Low pay
Not enough faculty
Program expansions
Little or no state funding of recruitment
Reimbursement problems -
Medicaid overrun - FP programs overrun with Medicaid or no pay patients. These patients do not provide adequate revenue to the programs who provide for them. Recruits need to see a balance between the numbers of patients and the practitioners to care for them.
Distribution of reimbursement
Subspecialty and emergency reimbursement detract from primary care systems. Fragmented, costly, redundant care is the result. Currently we lose FP and other primary care doctors to emergency rooms and costly urgent care centers.
Retention of practitioners can also be promoted by attracting those most likely to stay and supporting those who have underserved practices.
To attract students
$5000 - 5 booth spaces at AAFP Student-Resident Meeting in Kansas City each August, acts to increase the pool of applicants and improve retention of those more likely to stay in TN - Booths 1500, person from each 6 x 3 x 100=1800, materials 1000, coordination 700, Advertises residencies, rural programs, faculty vacancies
Department of Health
TN Primary Care
ETSU
Meharry
UT Knoxville
UT Memphis
$5000 - 2000 x $2 1000 coordination State mailings to selected students regarding state attractions, loan repayment, state's training programs
To address the resident environment problems
$1,540,000 Resident Salaries and Benefits - (120x12000) Boost FP resident salaries by $1000 a month. (667x150) Provide $2000 to FP residents for relocation expense. (NC) Provide a $5000 bonus to TN FP residents who sign with an underserved practice (apply for state loan repayment and community match halfway into 2nd yr). Underserved community must pay 10000 of salary and bonus costs when resident starts practice. Require two months of service by residents during their second and third years in an underserved area. To participate, communities must pay $2500 for state agency or institution to do a needs assessment.
To address faculty shortages
$800,000 - (100,000x8) - Support for one faculty member for each FP program, charged to advise residents, recruit students, coordinate recruitment, work with nearby Community Health Agencies and indigent practices, assist state recruitment fair, participate in student-resident recruitment booth
$40,000 - (5000x8) Support for recruitment of FP faculty
$80,000 - Recruitment Fair in late September in Nashville - for 2nd and 3rd yr residents from TN interested in underserved plus any 3rd yrs attracted by mailings or prior contacts (see above)
Consider rotating site between Memphis, Knoxville, Johnson City and Nashville
$500,000 - 5 extra slots a year for loan repayment 20000x5 25000x5 OB liability x first 4 yr 10000 per yr bonus
5 yrs 25 slots 50000 25000 25000
$240,000 - 8 x 30000 - Out of state rotations for FP residents supported -One extra resident slot to use for out of state residents to come for 6 - 8 wks, must have defined curriculum and proven preceptors, must go to underserved area and into a practice that is recruiting, can use for locums help, can be used in addition to hospital stipends received
Attracts residents (montana attracts over 15%)
Supports underserved areas
Supports physicians who need help
"Steals" other states tax dollars
$50,000 - Preceptorships for 40 - 50 additional students between yr 1 and 2 in underserved areas with good preceptors and curricula - ETSU and UT Memphis
Attracts those interested in underserved
Attracts out of state students to TN FP residencies Supports faculty
$50000 - Primary care research by students in first years - ETSU and UT Memphis
Gives alternative to biomedical, emphasizes clinical and general, not subspecialty and tertiary
Supports faculty
Supports practical, primary care research
Attracts federal and foundation dollars
$150,000 Two Centers for Rural Health and one for Urban Health - ETSU and UT Memphis poss Meharry
Track students, residents, practitioners
Coordinate programs
Arrange health career fairs
Advise high schools on health careers
$100,000 Center in Nashville
Documents efforts
Central coordination with state agencies
Central database of communities
Database of those recruited
Inappropriate reimbursement - Takes Medicaid reimbursement dollars away (fee scale adjustments) from tertiary, subspecialty, and ER care and puts it in a primary care pool of $500,000. Add to this an extra $1,000,000 in extra licensure fees from physicians not taking medicaid or taking in low numbers:
Revenue of 1,000,000 (adjust per physician to provide licensure fees from all physicians with little or no Medicaid (such as less than 25% patient visits Medicaid plus indigent) All physicians should share these burdens equally. Exemptions from extra cost - resident physicians and new physicians in underserved areas for first two years
Penalizes subspecialty, tertiary care
Encourages shared burden of indigent care/medicaid
Encourages family practice, pediatrics, general internal medicine.
Encourages those who are most providing the care
A Robin Hood program
Also savings due to delayed reimbursement
Able to match with feds for another $2,000,000
Total indigent pool of $1,500,000 used to compensate physicians with an overwhelming indigent burden - compensation in the form of end of year bonuses for primary care physicians (not ERs) with large Medicaid and indigent practices.
Eligibility - Physicians - must make less than $100,000 (verified by income tax copy) Centers - not for profit, community board advisory Either - Providers must take call at night, take all patients. Must reduce charges for indigent. Must provide services to all comers. Physicians may direct the centers but must have medical practice income of less than $100,000 (verified by income tax copy) or else the physician must be a volunteer. Paid reimbursement from state pool based on per visit basis. Expect $1 - 5 a visit bonus. Benefits those with large Medicaid and indigent Reimburses based on meeting needs of underserved
Benefits state agencies, residency programs, CHCs, community-oriented and mission-oriented practices
Expect - hospitals can support or establish PC centers to care for medicaid and indigent to qualify for bonuses
ERs can charge $3 for each medicaid patient visit, payable at the ER upon registration
Physicians may charge $1 per visit to medicaid patients
Retention of practitioners
more academic contacts
more service help
more recruitment and peers
better indigent burden sharing
more hope for help in future
Reforms pertaining to specialists
Sales taxes
Licensure fees
Must have referral documents from pc doc to attach to billing
Reforms pertaining to Emergency Rooms and for profit look alikes - those billing above routine office day charges
Too much reimbursement for ER Docs
Loss of FP and other PC docs to ER, urgent care
Episodic care is higher priced, more costly
Registration fee on a per visit basis per year (2 million)
May charge $3 per medicaid visit if ER, $10 if clinic
ACLS personnel
Must accept medicaid
Basic lab services
Registrations - paid quarterly - half of funds to primary care pool, half to go to fund demonstrations of interventions to decrease ER visits, by establishing primary care systems
New state revenue from health care
$3,000,000 Sales tax applied
except those doing indigent care
$2,000,000 ER registration fee
$1,000,000 Licensure fee increases
except those serving indigent
12,000,000 Federal match dollars
18 million new dollars for Medicaid
Hospital effects
Gains - $2 per Medicaid ER visit
Losses - decreased visits, registration fees
decreased admissions
ER physician effects
Less income
PC physician effects
more income
more continuity
more appropriate visits
no sales tax
increased paperwork for referrals
Specialists effect
decreased income
lower reimbursement
less referrals
paperwork hassle
less pc done
more appropriate referrals
Overall Financial Picture
Incentives for decreased costs
Less specialists in state
Less Medicaid visits due to up front charges
More primary care providers
More systems of care, better continuity, less
extra lab, x-rays
Increased hassle for pc docs to get specialists
(forms to fill out) - doing what supposed to do according to best medical practice, getting paid more to do this
Medicaid patients not able to self-refer to PC
Benefits to state
Better information about referrals
Implementation
try to enlist TAFP, TPCA, legislators, health depts, citizens groups
Passage
1 year warning period, better be doing indigent, taking Medicaid
3 month warning - not likely to be eligible for bonus as not enough medicaid, send documentation of medicaid, volunteer care, indigent care
1st month - notification of participation or rejection for bonus, may reapply in 6 months
research on ETSU dept FM research students outcome, choice of pc,fp,research