DART Proposal from WWAMI

In response to Bob Bowman's request for three initiatives that could boost rural, I would like to suggest supporting his proposal and add two.

1. Bob suggested federalizing liability coverage. I would support that and at a minimum we should look to that support in primary care health professional shortage areas (HPSA). He explains the reasons well below.

I would suggest two more.

2. Payment -We should make every non-contiguous county (or use the rural classification that best describes these areas) a HPSA eligible for the

Medicare bonus and every clinic in those areas eligible to be rural health clinics and get added payments for Medicaid. Clearly, rural practices have a higher percentage of poor and elderly. Those clinics that do avail themselves of these programs are financially healthier. Payment does make a big difference in these fragile settings.

3. Pipeline - we need more students from rural communities in the pipeline and we need to give them experiences in those rural communities so they return. In the NW we are proposing and looking for funding for a proposal that demonstrates the benefit of increased activities of outreach into schools and colleges using techniques we have used successfully for minority recruitment combined with support for rural training of FP residents. I have attached the proposal if you are interested.

This type of program could be expanded nationally. See below for details.

Robert A. Crittenden MD, MPH

Associate Professor, University of Washington School of Medicine

Chief, Family Medicine Service, Harborview Medical Center

Director, Office of Education Policy, Office of the Dean

325 Ninth Avenue Box 359781

Seattle, WA 98104-2499

(206)731-6770

Fax: (206) 731-6778

Email: docbob@u.washington.edu

The shortage of health professionals including primary care physicians delivering health care services in rural areas results in substandard health care delivery in the rural parts of our nation. The shortage of health services providers and primary care physicians in rural America is a national problem. The shortage of physicians in rural communities does decrease the health status in those communities. This inequity can be decreased but it will take direct and decisive action.

Recruiting students from rural communities into the health professions is essential to train enough health professionals who are needed in rural America. The problem is that too few students from rural communities apply for health-sciences schools. Once they apply they have an equal chance of being accepted. An applicant pool enriched with students from rural communities is needed.

Rural communities are very underrepresented in the applicant pool. Identifying these rural students, encouraging them to complete the needed educational pre-requisites and encouraging them to apply for admission provides a needed addition of rural students in the applicant pool for health science and medical schools. To identify rural students and to help orient them to health and medical professional education, four programs are needed.

1. A high school oriented program that identifies promising high school students and encourages them to look at all health professions, introduces them to the options available, and promotes students attending state-focused programs introducing them to the health professions. (U-DOC program)
2. Focused outreach efforts in colleges that are identified as feeder programs for health science and medical schools in the region where rural students are more likely to attend.
3. A one-week ‘training camp’ for college students interested in serving rural communities modeled after a successful minority training program. The time at the program would be focused on introducing the students to the medical professions and to rural health care, providing information on pre-requisites, and assisting students with the application process.
4. Support and expand programs for medical students that encourage and support their continued interest in rural practice.

These programs will feed the pipeline for health professionals and physicians interested in practicing in rural communities. The identified students who are interested in working in rural communities need continuing support and skills to practice in rural communities that can be gained in rural focused training.

In addition, the national shortage of primary care physicians available in rural settings stems from a variety of economic and cultural factors. Current national policy and practice creates strong disincentives for those wishing to work in a rural setting. Institutions as well as the students themselves are disadvantaged if they choose to engage in physician training in a rural setting. There are national programs that do help, such as the National Health Service Corps and the Rural Health Clinic programs. These programs do help attract and retain already trained physicians to needy communities, but we need to identify and enroll qualified people interested in rural health care and train these students and residents to work in these underserved rural communities. Attracting students from rural communities who are interested in family practice is essential. And, training physicians in rural communities has been proven to keep medical students and residents focused and interested in working in rural communities.

There is strong evidence that physicians from rural communities are more likely to return to rural practice. There is also evidence that students who enter medical school desiring to do family practice are more likely to practice in rural health settings.

This proposal encourages more rural students to apply to all health profession schools. Those that enter medical school will get enhanced rural experiences and those entering the family medicine residencies will have increased opportunities to train in rural communities.

WWAMI, a 30 year long partnership among five of the nation's most rural states has, as its mission, the training and placement of physicians in rural settings. WWAMI, the partnership among Washington, Wyoming, Alaska, Montana and Idaho, is a program that has developed a formula for success in training physicians to work in the five-state region. This nationally recognized program within the University of Washington Medical School has empirical data as well as anecdotal experience in understanding the incentives for embracing rural practice. It is a program that has worked.

The WWAMI program and supporting research also demonstrate that the rural training experience is an effective and large factor in the decision for physicians to practice in a rural setting. In fact, 45% of family practice residents who spend two months in a rural setting and 75% of residents who train for twenty-four months or more in a rural setting practice in a rural community. Given the crippling shortage of physicians in rural America and the proven importance of the rural training experience, it is alarming that many institutions are cutting out or contemplating ending their rural training experiences. For example, Southwest Family Medicine has stopped sending residents into rural communities for two-month rotations. Spokane, the originator of the rural training track (placing residents for the final two years of their training in rural communities) is unable to find full funding for its rural sites. Boise Family Medicine is struggling to support its rural training experiences including its rural training track. Montana Family Practice Residency is hoping to expand to more rural communities if funds are available. Now the rural hospital in Glasgow, Montana must pay for this training out of operating funds. These programs are valuable, but given the current financing are unable to operate without modest direct subsidies.

At this time, the WWAMI family medicine residencies are undertaking ground breaking educational programs to meet the needs of the people in this region. One example is the oral health program where residents are being trained to screen for oral disease in infants to discern who needs immediate referral and those who are at high risk and can have reduced risk of caries by varnish application in the family physicians office. Dental care is often lacking in these communities and a preventive approach such as this has the ability to decrease the burden of dental disease faced by these children. Ensuring the delivery of needed services including this innovative care in rural communities is the purpose of this proposal.

Rural training programs are more expensive because:

1. For students there are a number of added expenses. A) Identifying potential students from rural communities and orienting them to medical education is a task that will require new efforts and a modest investment. The WWAMI region has the infrastructure to accomplish the needed outreach. B) The rural training experiences of medical students are needed and effective programs but there are expenses for which there are no sources of support. The programs need administrative support to arrange and support the students. Medical students need support to spend part of their education introducing them to rural practice. These rural experiences are mainly accomplished during the summer when students have competing offers to do federally funded bench research with compensation. A small and comparable stipend enables more students to afford to spend time in rural communities. Students are already looking at a huge debt load and adding on to that debt to finance an experience in training in a rural community is a real barrier.
2. For residents, there are other barriers. The rural experience removes residents from the home program which results in the program losing the residents' practice income and much of the Medicare Graduate Medical Education funds (Indirect Medical Education funds -IME) it would otherwise receive. Even when a rural hospital is able to receive the IME funding, the amounts available are less than urban programs.
3. All of these programs must go through an enormous amount of pre-planning, writing of accreditation documents, facilitating site visits by the Accreditation Council for Graduate Medical Education (ACGME), recruitment for these positions, and maintenance of the minimum number of residents required by the ACGME.
4. The programs all have added costs such as travel costs for students, residents and faculty as they work in and with the rural site.

Outreach into rural communities to identify promising students is beyond the capacity of most schools. Waiting for rural students to apply does not work and results in a lower rural representation in the applicant pool. External support is needed to do this outreach. The need for rural health care providers is a national problem that requires a national solution.

Some of the disincentives for institutions to provide programs enabling rural practice experience are federally generated (e.g. loss of IME). The need for a well established national medical network is critical. Every American should be able to receive quality health care, and with its population older than the rest of the country, rural America should be able to have the benefits of good and available primary and preventive care. The cost to the country of untreated disease is greater than providing regular care. This is most evident and critical in rural communities.

In sum, those students and young physicians who would like to work in rural communities should be encouraged and provided incentives to help with this national effort. The institutions that are willing to go through the arduous and expensive effort to identify students, interest them in the health professions, recruit them, train them, and establish rural training sites ought to be assisted, not penalized, by the government. The cost efficient, market-driven institutional response is to abandon the programs. Supporting the outreach to recruit more rural students and the training of physicians in rural settings is an appropriate federal endeavor.

The incentives need to be changed both for individuals and for institutions. Students interested in rural health care and medical practice need to be encouraged. More rural students need to be in the applicant pools of health science and medical schools. There need to be rural experiences available in medical school and in residency. We propose using the WWAMI program as the framework for a pilot to develop and test programs in recruiting and placing students in rural communities.

The WWAMI program has an excellent track record in designing programs that work. The WWAMI platform, which covers 27% of the landmass of the U.S. with only 3.3% of the population of the U.S., can be a laboratory. It has a regionally focused medical school with a mission to train physicians for the communities within these five states. Medical education is accomplished throughout the five-state region. There are 16 civilian Family Medicine residency programs spread throughout five states. It is organized into a very functional educational consortium that includes pre-medical student, medical student, residency training, and practice support activities. The student programs include potential experiences in rural communities between the first and second years of medical school. There is a potential to do six months of clinical training in rural communities in the third year. There are multiple other training opportunities that can direct and support students in experiences in rural medicine. Recently, about half of each class is involved in some rural experience.

The residency programs are in every state in the region. Some have rural training opportunities and these programs have been extremely successful. There are two types of experiences. Many of the network residencies in all of the five states have two to four month experiences in rural communities. A few others have in-depth two-year rural experiences called Rural Training Tracks (RTT). An example is the Family Medicine Spokane Rural Training Track based in the Spokane, Colville, and Goldendale, Washington. There have been twenty graduates from this rural based family practice residency program, sixteen of whom now practice in rural communities in Washington and Alaska. Similar programs are in Idaho and Montana. All of these rural experiences are facing financial disincentives mentioned above.

These excellent programs, if operated under a new set of incentives and in partnership with the federal government, could be strengthened, expanded, and modified to provide a model to others who could train physicians for rural practice.

The Demonstration: Assistance in Rural Training (DART) program would be established as a pilot within the WWAMI program. The program would be monitored within the Office of Rural Health Policy (ORHP) in HHS. ORHP would have oversight and develop in a collaborative fashion improved and strengthened programs for rural training within the WWAMI region. All of the programs would be developed with the full cooperation of the regionally based partner institutions that are integral to the WWAMI concept. The focus of this three-year demonstration project would be:

1. Identification and outreach to high school students in rural communities to increase the interest in rural health care for qualified students.
2. Develop partnerships with colleges where rural students attend focusing on identifying and supporting rural students interested in rural health care.
3. Put on a one-week residential program yearly to assist identified rural focused college students in orienting and applying to medical school.
4. Develop and strengthen programs at the medical student and residency level that would increase and improve the rural training experiences of trainees.
5. Strengthen and expand student programs such as the Rural Underserved Opportunities Program (RUOP) to increase the number of first year medical students in rural communities and the WRITE program that currently places fifteen students for their third year in medical school in rural communities.
6. Strengthen and expand family medicine residency programs serving rural communities by supporting rural training opportunities. Residents would be encouraged to spend at least two months in rural communities and support would be available for rural training tracks that place and support residents in rural communities for two years of their training. Those residents placed in rural communities would be involved in recruiting local high school students into all of the health professions (a pilot of this element has been successfully completed in Alaska).
7. Evaluate the benefits of these interventions. An evaluation process would be completed by the HRSA sponsored WWAMI Workforce Center.

1. Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP, Critical factors for designing programs to increase the supply and retention of rural primary care physicians, JAMA 2001; 286: 1041-1048
2. Franks P, Fiscella K, Primary care physicians and specialists as personal physicians: health care expenditures and mortality experience. J Fam Pract 1998; 47:105-109
3. Damos, JR, C Christman, CL Gjerde, et al, A Case for Development of Family Practice Rural Training Tracks, JABFP, Sept-Oct. 1998, v. 11, no. 5:399-405
4. Rosenthal, TC, MH McGuigan, J Osborne, et al, One-Two Residency Tracks in Family Medicine: Are They Getting The Job Done?, Fam Med 1998;30:90-3
5. Damos et al above
6. The Rural Underserved Opportunities Program places approximately 90 medical students yearly in rural communities throughout the WWAMI region between their first and second year. The students work with a local physician and complete a community service project. The WWAMI Rural ITE (WRITE) is an innovative program that places third year students in rural communities for six months of their initial clinical training and appears to be an effective approach to encouraging physicians in rural communities.
7. Ramsey, PG, JB Coombs, DD Hunt, et al, From Concept to Culture: The WWAMI Program at the University of Washington School of Medicine, Academic Affairs, Vol.76, No. 8, Aug 2001
8. Maudlin et al, Changes and Challenges in Rural Graduate Medical Education: The Family Medicine Spokane Rural Training Track Experience in Colville WA, The J Rural Health, 2000;16:232-237

COST ESTIMATES:

Administrative support (student selection, orientation, coordination) $0.1m

U-DOC (High School outreach) $0.4m

Outreach to pipeline colleges $0.1m

Rural Mentoring Program (RMP) (one week residential program for

Total $0.8m

RTT months (eleven residents for 132 months)** $1.06m

Total $2.66m

@50% Growth over three years $3.99m

WWAMI Workforce Center $0.5m

FY 2003 $2.6m (resident)+ $0.8m (student)

FY 2004 $3.3m + $0.8m

FY 2005 $4m + $0.8m

* Costs for residents leaving their programs for a two to four month period are estimated as an average of funds forgone by placing a resident in a rural community each month (Medicare IME losses [$6K] +Lost Clinical Revenue [$2K]). Costs for residents engaged in RTT experiences are calculated based on the non-reimbursed costs of these programs (teaching costs, travel, administrative support, etc.). Total costs of the programs less Medicare GME payments to host hospitals. These estimates ($8K /resident/month) represent the incremental costs of establishing and supporting a rural training experience per month for both rural training tracks and resident rotations in rural communities.

**Rural Training Track

***This is an estimate for the WWAMI region. A fully nationalized program would cost approximately $10m for the medical school phase and $16.2 for the residency program initially increasing to $24.5m assuming a 50% increase in capacity over three years. Therefore the total cost would be $34m/year in 2001 dollars fully phased in nationally. (Assumptions - 20 medical schools develop student programs. For the residency phase - initially 59 residency programs have rural training representing 350 residents and that there are approximately 22 rural training tracks representing 80 residents in RTTs. )