By Joel Teitelbaum

Background

Strengthening and modernizing the health care workforce was a major goal of the Affordable Care Act. The ACA contains dozens of provisions related to health care workforce issues, including strengthening primary care, national workforce policy development, increasing the supply of health care workers, education and training of the workforce, and other supports and improvements to the existing workforce. This Implementation Brief focuses on teaching health centers (THCs), a new type of health care entity created by the ACA.

The effort to expand and strengthen primary health care has underscored the shortage of primary health care providers, particularly in medically underserved communities. At community health centers — comprehensive primary health care clinics supported with federal funds under the Public Health Service Act — evidence of this shortage is particularly acute;^[1] evidence suggests that family physician vacancies have sky-rocketed at health centers, with over 40% of community health center vacancies open for 7 months or longer.^[2]

In an effort to reduce the workforce strain in underserved areas, the ACA promotes the creation and expansion of THCs. Under the ACA, a teaching health center is an entity that combines primary care service capacity with a primary care residency program. Numerous types of entities may qualify as THCs under the Act, assuming that they operate a primary care residency program: federally qualified health centers; community mental health centers; rural health clinics; health centers operated by the Indian Health service, an Indian tribe or tribal organization, or an urban Indian organization; and an entity receiving family planning funds under title X of the Public Health Service Act.^[3] Recent studies have demonstrated that graduates from THC residency programs are more likely to practice in underserved areas, helping to relieve the workforce shortage issues.^[4] However, the growth of THC’s to date has been marginal as a result of lack of financial resources and the administrative complexity of finding community-based primary health care providers that actually administer, rather than participate in, teaching programs.^[5]

Changes Made by the Health Reform Law (P.L. 111- 148, § 5508)

The ACA makes two amendments to the Public Health Service Act to encourage the creation and expansion of Teaching Health Centers:

• It authorizes the Secretary of the U.S. Department of Health and Human Services (HHS) to award grants to THCs “for the purpose of establishing new accredited or expanded primary care residency programs.”^[6] Primary care residency programs include training programs in family medicine, internal medicine, pediatrics, internal medicine-pediatrics, obstetrics and gynecology, psychiatry, general dentistry, pediatric dentistry, and geriatrics.^[7] Program funds can be used for costs associated with curriculum development, recruitment, training, and retention of residents and faculty, accreditations, faculty salaries, and technical assistance. As noted above, however, under the ACA a THC must “operate” a primary care residency program,^[8] a requirement that could severely limit the scope of the THC program. Indeed, HRSA’s Funding Opportunity Announcement for the program states that “…the eligible entity must be listed as the institutional sponsor by the relevant accrediting body, including the Accreditation Council for Graduate Medical Education (ACGME), American Osteopathic Association (AOA), or the American Dental Association (ADA). …The applicant MUST provide documentation that they are accredited, and must name their accrediting body and date of accreditation for verification purposes.”^[9]
• It creates a Graduate Medical Education (GME) payment program under which the Secretary may make payments for direct and indirect expenses to qualified teaching health centers for expansion and establishment of new approved residency training programs.^[10] The direct payments will be made based on the product of the number of full-time equivalent (FTE) residents and the HRSA-calculated THC per-resident amount.

Implementation

Agency

The HHS Health Resources and Services Administration (HRSA) is the fiscal and administrative agent for the Teaching Health Center programs.

Key Dates

None.

Process

The health reform law does not provide specific direction to HHS regarding the administrative process used to implement the law. The agency therefore has the discretion to use a range of tools to implement the statute, such as publishing regulations in the Federal Register with a public notice and comment period, or using other types of approaches such as posted policy instructions, funding availability announcements (where applicable), official letters to affected entities (such as letters to state Medicaid agencies), and posted rulings and notices. Agency websites can be checked regularly for updates.

Key Issues

Program qualifications: The most important issue is how many institutions will actually be able qualify as THCs, given the language in the ACA. Will the term “Teaching Health Center” be fleshed out or expanded through regulations? How will the requirement that a THC must “operate” a residency program — as opposed to participating in it — affect the new program’s ability to draw in a range of entities?

Uniformity of GME payments: Currently, GME payments made through Medicare range significantly among teaching hospitals, and the true costs associated with GME are unclear. Since HRSA is tasked in the ACA with “accurately calculating” the direct and indirect GME payments for THCs, might HRSA’s determinations be a first step towards making GME payments more uniform?

Reporting requirements: THCs will have reporting and evaluation requirements not required under the Medicare GME program; what types of additional data will be required of THCs, and what information will the data yield?

THC development grants and up-front residency costs: Because THC development grants have been authorized but not appropriated, will health centers find it difficult to cover the up-front costs of starting a new residency program?

Agency Action

On November 29, 2010, HRSA released the Funding Opportunity Announcement for the Teaching Health Center Graduate Medical Education Program. The grant information can be found here.

Authorized Funding Levels

For the Teaching Health Centers Development Grants: Congress authorized to be appropriated $25 million for fiscal year 2010, and $50 million for fiscal years 2011 and 2012, and such sums as necessary for the following years.

For the Teaching Health Center GME Payments: Congress appropriated such sums as necessary, up to $230 million, for the period of fiscal years 2011 through 2015.