Report Title:

Family Medicine Rural Training Initiative; Healthcare Workforce; Physician Training

 

Description:

Stabilizes the Family Medicine Residency Program and access to primary care services in Central and Northern Oahu for the next 2 years while further program transition is occurring.  Develops the Hawaii Island Family Medicine Rural Training Track, which expands the number of family physicians training in the state.  Appropriates funds.  Effective date 7/1/2007.

 


HOUSE OF REPRESENTATIVES

H.B. NO.

1119

TWENTY-FOURTH LEGISLATURE, 2007

 

STATE OF HAWAII

 

 

 

 

 

 

A BILL FOR AN ACT


 

 

RELATING TO rural primary healthcare and workforce development in the short-term.

 

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

 


     SECTION 1.  The legislature finds that, aside from Oahu, most of the state is federally designated as Medically Underserved Areas, Medically Underserved Populations, or Health Professions Shortage Areas.  Physicians are choosing to relocate out of rural areas and Hawaii.  There is an urgent need to provide high quality primary care services to already underserved populations with disparate health indicators.  Maternal and child health risk, cardiovascular risk, and socio-economic risk are greatest in rural Hawaii.  According to the department of health's 1999 statistics, the top ten highest risk areas are all located in rural communities.  The need for physicians in rural areas will only increase with the aging population and projected population growth on the neighbor islands.

     National studies have demonstrated that substantial residency training in rural areas increases placement and retention of physicians in rural practices.  Additionally, adults with a primary care physician, rather than a specialist as their personal physician, have been shown to have a thirty three per cent lower cost of care and were nineteen per cent less likely to die (after controlling for age, gender, income, insurance, smoking, and many other health conditions).

There are approximately three thousand five hundred licensed physicians in Hawaii, but some of these physicians are not actively practicing in Hawaii.  Forty-two per cent of these physicians are primary care physicians but most of these physicians are clustered around Honolulu.  Currently, there are one hundred and ten family physicians working on the neighbor islands and many of their practices are not accepting new patients because of very high demand or insurance considerations, or both.

Currently, the University of Hawaii John A. Burns school of medicine (UH JABSOM) Family Medicine Residency Program (FMRP) conducts the only civilian FMRP in the state.  This program’s mission is to provide well-trained primary care doctors to meet the needs of rural and underserved areas of Hawaii and over eighty per cent of its graduates meet this mission.  Family medicine is the only discipline that provides primary medical care to the entire life span – caring for children, adults, and the elderly – in the outpatient, inpatient, and long-term care settings.  The scope of services for a well-trained family physician also includes maternity care, women’s health, and mental health care in the outpatient settings.  Family medicine also emphasizes using a systems-based and interdisciplinary team approach to health care.  The UH JABSOM FMRP has an outstanding accreditation, a solid curriculum, a diverse faculty, and academically strong residents.  The precarious financial situation at Wahiawa General Hospital, the primary sponsoring hospital in the area has the potential to further disrupt clinical services in Central and Northern Oahu.  An interruption of the residency program on Oahu would end the development of a rural training track in Hilo and further deplete the primary care workforce, resulting in diminished health care access in the state.

The residency training curriculum for family medicine emphasizes continuity of care across the different health care settings during the three-year residency-training period.  Residents care for a panel of patients and their families and also provide education and outreach in local high schools and at community events.  The curriculum also emphasizes delivery of culturally appropriate, cost effective, community-based care.  Resident and faculty research projects examine health disparities and develop curricula or propose enhancements to existing systems to ultimately reduce those disparities.

The current base FMRP at UH JABSOM trains eighteen residents in a program that trains six residents per year for three years.  Wahiawa General Hospital supports the salaries of eighteen residents but receives Graduate Medical Education (GME) funding from the Centers for Medicare and Medicaid Services (CMS) for only fourteen residents.  The salary shortfall adds to the financial strain on Wahiawa General Hospital.  Of the three years of training, two months are presently spent in Hilo where residents rotate among private physician offices, emergency departments, and provide outreach and education to the community.  This CMS-funded demonstration project and resident rotation started in Hilo in January 2006.  In a "rural training track,” residents do the bulk of their tertiary and specialty training in their first year at the base program on Oahu, then physically relocate to the rural site for the remaining two years of training.  To realize a full rural residency track in Hilo, a full-time Hilo-based faculty is required to work in close conjunction with the Oahu based residency program to develop the Hawaii Island Family Medicine Rural Training Track.

     When the Family Medicine Rural Training Track is fully developed on the island of Hawaii, there will be eight residents living and working on the island that include rotations to other neighbor island sites.  The first graduates would enter practice in 2011.  The aim is to replicate a rural training track on Kauai once the Hawaii Island model is successfully implemented.  While in training, residents will have approximately six thousand patient encounters over their two years of training.  By partnering with community organizations, community health centers, and other health professions training programs to conduct residency training, the impact on the health of the neighbor island population is anticipated to be substantial. Residency training programs tend to provide care to those with limited or no access to health care.  Community medicine and community based participatory research will be a major focus of the curriculum so that residents can begin to collaborate with communities to address priority issues while they are in training.  With an interdisciplinary approach to caring for medically or socially complex families, or both, more cost effective and culturally appropriate care can be anticipated.  This expanded statewide model of family medicine rural training aims to double the number of family medicine graduates practicing in rural and underserved areas in the state in the next ten years.  Perhaps more importantly, it is anticipated that many of these physicians will be "homegrown" since an increasing number of JABSOM medical students are from the neighbor islands and many of them choose family medicine as a specialty.

     To attain a successful model of family medicine training to meet the health workforce needs of the state, the base program on Oahu must be stabilized.  If not, the present Hilo initiative, which is the springboard for the larger family medicine rural training initiative, will die.  In addition to supporting four "unfunded" resident positions, Wahiawa General Hospital also funds approximately two and nine-tenths full-time equivalent (2.9 FTE) faculty salaries to operate the residency program that consists of inpatient and outpatient care and teaching.  To maintain the present excellent level of training of residents and medical students, eight full-time equivalent (8 FTE) faculty members are required.  Should financial support from Wahiawa General Hospital cease, clinical services will drastically decrease, and education of future physicians will also be severely impacted.

     The purpose of this Act is to appropriate funds in the short-term to:

     (1)  Stabilize the FMRP on Oahu for the next two years while further program transition is occurring; and

     (2)  Provide short-term financial support to begin development of the Hawaii Island Family Medicine Rural Training Track that will expand the opportunities for family physician training in the state.

Additional legislation is being requested to support development of the larger family medicine rural training initiative which will be more sustainable in the long-term. It should be noted that states such as Texas and Washington presently fund portions of their family medicine residency programs through legislative line items to guarantee a sustainable primary care physician workforce.

     Funding of $150,000 for fiscal year 2008-2009 and $150,000 for fiscal year 2009-2010 is being requested directly for the Hawaii Residency Programs, Inc., for two resident positions per year for the next two years.

     Funding of $360,000 for fiscal year 2007-2008 and $360,000 for fiscal year 2008-2009 is being requested directly for the University Clinical, Educational and Research Associates, which is the faculty practice plan of UH JABSOM to secure two and nine-tenths full-time equivalent (2.9 FTE) faculty positions for two years.  Additionally, funding of $150,000 is requested for one full-time equivalent (1.0 FTE) faculty member, based in Hilo, to work with the Oahu-based faculty in developing a full family medicine rural training track.  In the second year, funding of $225,000 is requested in anticipation that one and one half full-time equivalent (1.5 FTE) facility members will be needed to support the increase in clinical volume and academic responsibilities.

     SECTION 2.  There is appropriated out of the general revenues of the State of Hawaii the sum of $660,000 or so much thereof as may be necessary for the fiscal year 2007-2008 and the sum of $735,000 or so much thereof as may be necessary for fiscal year 2008-2009 to stabilize the University of Hawaii John A. Burns school of medicine Department of Family Medicine and Community Health rural primary health care services on Oahu and expand workforce development to the island of Hawaii.

     The sum appropriated shall be expended by the department of health for the purposes of this Act.


     SECTION 3.  This Act shall take effect on July 1, 2007.

 

 

INTRODUCED BY:

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