Funding instability plagues program that brings docs to underserved areas

For Diana Perez, a medical resident at the Family Health Center of Harlem, the handwritten thank-you note she received from a patient is all the evidence she needs that she has chosen the right training path.

Perez helped the patient, a homeless, West African immigrant who has HIV and other chronic conditions, get the medications and care he needed. She also did the paperwork that documented his medical needs for the nonprofit that helped him apply for asylum and secure housing.

"I really like whole-person care," said Perez, 31, who has been based at this New York City health center for most of the past three years. "I wanted to learn and train, dealing with the everyday things I will be seeing as a primary care physician and really immersing myself in the community," she said.

Few primary care residents get such extensive community-based outpatient training. The vast majority spend most of their residencies in hospitals. But Perez, who is being trained through the Teaching Health Center Graduate Medical Education program, is among those treating patients in federally qualified health centers and community clinics in medically underserved rural and urban areas around the country. After graduating, these residents are more likely than hospital-trained graduates to stay on and practice locally where they are often desperately needed, research has found.

Amid the long-term shift from inpatient to outpatient medical care, training primary care doctors in outpatient clinics rather than hospitals is a no-brainer, according to Robert Schiller, chief academic officer at the Institute for Family Health, which runs the Harlem THC program and operates dozens of other health center sites in New York. "Care is moving out into the community," he said, and the THC program is "creating a community-based training environment, and the community is the classroom."

Yet because the program, established under the 2010 Affordable Care Act, relies on congressional appropriations for funding, it routinely faces financial uncertainty. Despite bipartisan support, it will run out of funds at the end of December unless lawmakers vote to replenish its coffers — no easy task in the current divided Congress in which gaining passage for any type of legislation has proved difficult. Faced with the prospect of not being able to cover three years of residency training, several of the 82 THC programs nationwide recently put their residency training programs on hold or are phasing them out.

That's what the DePaul Family and Social Medicine Residency Program in New Orleans East, an area that has been slow to recover after Hurricane Katrina in 2005, has done. With a startup grant from the federal Health Resources and Services Administration, the community health center hired staff for the residency program and became accredited last fall. They interviewed more than 50 medical students for residency slots and hoped to enroll their first class of four first-year residents in July. But with funding uncertain, they put the new program on hold this spring, a few weeks before "Match Day," when residency programs and students are paired.

"It was incredibly disappointing for many reasons," said Coleman Pratt, the residency program's director, who was hired two years ago to launch the initiative.

Until we know we've got funding, we're "treading water," Pratt said.

"In order to have eligible applications in-hand should Congress appropriate new multi-year funds, HRSA will issue a Notice of Funding Opportunity in late summer for both new and expanded programs to apply to be funded in FY 2025, subject to the availability of appropriations," said Martin Kramer, an HRSA spokesperson, in an email.

For now, the Teaching Health Center program has $215 million to spend through 2024.

By contrast, the Centers for Medicare & Medicaid Services paid hospitals $18 billion to provide residency training for doctors in primary care and other specialties. Unlike THC funding, which must be appropriated by Congress, Medicare graduate medical education funding is guaranteed as a federal entitlement program.

Trying to keep THC's three-year residency programs afloat when congressional funding comes through in fits and starts weighs heavily on the facilities trying to participate. These pressures are now coming to a head.

"Precariousness of funding is a theme," said Schiller, noting that the Institute for Family Health put its own plans for a new THC in Brooklyn on hold this year.

The misalignment between the health care needs of the American population and the hospital-based medical training most doctors receive is a long-recognized problem. A 2014 report by the National Academies Press noted that "although the GME system has been producing more physicians, it has not produced an increasing proportion of physicians who choose to practice primary care, to provide care to underserved populations, or to locate in rural or other underserved areas."

The Teaching Health Center program has demonstrated success in these areas, with program graduates more likely to practice in medically underserved areas after graduation. According to a study that analyzed the practice patterns of family medicine graduates from traditional GME training programs vs. those who participated in the THC program, nearly twice as many THC graduates were practicing in underserved areas three years after graduating, 35.2% vs. 18.6%. In addition, THC graduates were significantly more likely to practice in rural areas, 17.9% vs. 11.8%. They were also more likely to provide substance use treatment, behavioral health care, and outpatient gynecological care than graduates from regular GME programs.

But the lack of reliable, long-term funding is a hurdle to the THC training model's potential, proponents say. For 2024, the Biden administration had proposed three years of mandatory funding, totaling $841 million, to support more than 2,000 residents.

"HRSA is eager to fund new programs and more residents, which is why the President's Budget has proposed multi-year increased funding for the Teaching Health Center program," Kramer said in an email.

The American Hospital Association supports expanding the THC program "to help address general workforce challenges," said spokesperson Sharon Cohen in an email.

The program appeals to residents interested in pursuing primary and community care in underserved areas.

"There's definitely a selection bias in who chooses these [THC] programs," said Candice Chen, an associate professor of health policy and management at George Washington University.

Hospital primary care programs, for instance, typically fail to fill their primary care residency slots on Match Day. But in the THC program, "every single year, all of the slots match," said Cristine Serrano, executive director of the American Association of Teaching Health Centers. On Match Day in March, more than 19,000 primary care positions were available; roughly 300 of those were THC positions.

Amanda Fernandez, 30, always wanted to work with medically underserved patients. She did her family medicine residency training at a THC in Hendersonville, North Carolina. She liked it so much that, after graduating last year, the Miami native took a job in Sylva, about 60 miles away.

Her mostly rural patients are accustomed to feeling like a way station for physicians, who often decamp to bigger metro areas after a few years. But she and her husband, a physician who works at the nearby Cherokee Indian Hospital, bought a house and plan to stay.

"That's why I loved the THC model," Fernandez said. "You end up practicing in a community similar to the one that you trained in."