Mr. Co-Chairs and members of the committee, I am Mark Richardson, Dean of the School of Medicine at the Oregon Health & Science University. I am President of the OHSU Faculty Practice Plan, which includes about 900 faculty physicians employed by OHSU. Thank you for the opportunity to testify. It is my pleasure and privilege to be here today.
Across the nation and in Oregon, many organizations and individuals are actively engaged in seeking to reform the health care system. As currently configured it does not meet the needs of many people and is increasingly expensive. Transforming this dysfunctional system into one that consistently delivers affordable, high quality and accessible health care is both an enormous challenge and a tremendous opportunity.
Reengineering our health care system is a long-term endeavor that will, ultimately, involve and engage every member at every level of our society. It will take many incremental steps over many years. In 2008, OHSU adopted a set of Eight Principles for Health Care Reform, which help guide OHSU’s engagement in this transformation. Our third principle states:
OHSU believes that a geographically well-distributed health care workforce, accurately mirroring in capacity and diversity the population it serves, is critical to ensuring long-term quality and access in Oregon.
Today, my testimony focuses on initiatives brought forward by the Oregon Academy of Family Physicians (OAFP) related to primary care workforce development. OHSU applauds and supports the initiatives presented by the OAFP that are focused on reducing student debt, increasing the number of Graduate Medical Education (GME) positions in Oregon and helping to transform primary care.
Oregon, like most states, faces a shortage of health care professionals. The reasons for this shortage are deeply intertwined with other challenges we face in how we deliver and reimburse health care, as well as how we fund our educational system. Over the long-term, together, we must address fundamental aspects of health care education so that curriculum and training encourage inter-professional partnership and team-based health care delivery. OHSU is hard at work making this education transformation a reality.
Speaking about physicians specifically, Oregon’s workforce challenges relate to both mal-distribution - by region, age and specialty - and absolute numerical shortages. Most of us have heard the stories from our friends and from patients in rural Oregon or other medically underserved areas about the challenges of accessing health care.
As Oregon’s only academic health center, OHSU has been educating physicians for Oregon since 1887. OHSU’s role in educating the highest caliber of health care professionals and leaders for Oregon is essential and long-standing.
• One-third of all licensed physicians in Oregon completed all or part of their training at OHSU – OHSU physicians currently practice in nearly every county in Oregon.
• OHSU is ranked #3 in the nation for excellence in primary care education, #2 for Family Medicine and #4 for Rural Medicine by US News & World Report. These national standings help to attract high quality students who are inspired to pursue primary care medicine;
• OHSU ranks #11 of all U.S. medical schools at meeting our social mission to educate the physicians most needed by society, as evaluated by a peer-reviewed study published in The Annals of Internal Medicine in 2010;
• OHSU’s Graduate Medical Education (GME) program is Oregon’s oldest and largest, by far, with over 780 training spots in 71 programs (accredited for both MD and DO trainees); this includes 190 positions in primary care (pediatrics, internal medicine and family medicine);
• OHSU’s GME program ranks 10th in the nation for in-state retention of residents and more than half of the new physicians completing their residencies at OHSU – which includes out-of-state physicians drawn here by the quality of our training programs – remain in Oregon to practice.
We are proud of our long history of contributing to Oregon’s workforce, including primary care. And while I have focused on physicians here, OHSU also educates nurses, physician assistants, dentists, midwives, nutritionists and many other types of health care professionals.
As noted, there are many challenges facing our health care system but there are three areas where we can make an immediate difference in reversing workforce shortages and enhancing primary care delivery: 1) Reduce student debt; 2) Support Graduate Medical Education; 3) Support transformative research in primary care and its dissemination throughout Oregon. I will provide brief background on each of these below along with perspective on the OAFP legislation.
1. Reduce student debt: We will make little progress in our goal of creating a robust and well-distributed workforce without reducing student debt load. This debt often forces students to choose higher paying specialties in urban areas.
Far too often, I hear MD students say: “I want to be in primary care or to practice in rural areas but the reality is I don’t know if I can afford it.” Helping students who may be inclined to select primary care to reduce their debt load through tailored loan repayment programs will allow them to follow their passion for medicine when choosing a practice, rather than letting debt load steer their decision.
The average debt of a student graduating from the MD program at OHSU is an astonishing $170,000; nationwide it is about $150,000 for public medical schools and $180,000 for private medical schools, according to data from the Association of American Medical Colleges.
Unfortunately, in-state tuition for medical education at OHSU is currently among the highest nationwide for public medical schools. As state support to OHSU has declined over the past decade, our MD tuition has increased in parallel and by necessity.
Student debt load is an issue everywhere but if we can develop strong programs in Oregon to help reduce debt it will be a significant incentive for MD graduates to practice in Oregon. We need a comprehensive solution that includes scholarships, loan repayment and higher state support for OHSU MD students who commit to practicing in Oregon.
The loan repayment and loan forgiveness programs proposed by OAFP meet an important part of this integrated approach to reducing debt. OHSU strongly endorses and supports HB 2400 and HB 2397 which are designed specifically to reduce debt for health care professionals, including physicians, committed to primary care in rural settings.
2. Support for Graduate Medical Education (GME). Upon completion of medical school, all new graduates pursue a “residency” in Graduate Medical Education (GME) in a specialty of his or her choice in one of thousands of GME training slots in teaching hospitals and clinics throughout the country. The process by which graduates are assigned to teaching hospitals for this training purpose is overseen at the national level. We have far more demand than availability for the limited slots in Oregon.
Studies show a strong correlation between where a new physician completes GME training and where s/he ends up practicing. Expanding GME capacity in Oregon to areas where physicians are most needed could have an immediate and ongoing impact on workforce shortages. OHSU is ranked tenth in the nation for physician retention, with 52 percent staying in Oregon to practice after their GME training.
OHSU currently has two small offsite training programs – a Family Medicine program in Klamath Falls, and a Surgery rotation in Grants Pass – that serve as models for new programs. OHSU is eager to build on these strengths to expand GME capacity – and hence the physician workforce – in Oregon.
Each year, 66 new slots for primary care (a three-year training program) open up at OHSU. Last year, these training slots – internal medicine, family medicine and pediatrics – drew the most applicants overall. OHSU received more than 3,900 applications for these 66 primary care GME slots from graduating medical students across the country. These figures clearly show that the demand to train in Oregon is high and that increasing the supply of training slots is justified.
OHSU is supportive of all collaborative and coordinated efforts to increase GME positions in Oregon, and looks forward to working with the Oregon Legislature, OAFP and community hospitals to develop a community-based program, whether through the OAFP Family Medicine Residency Network, the Oregon GME Consortium, a combination of both, or another program.
OHSU supports a community-based GME network or consortium that is:
• Able to earn national recognition to attract top-tier graduates;
• Responsive to community needs – as identified by those communities;
• Coordinated across communities and health systems;
• Structured to minimize duplication and maximize federal funding;
• Accredited for graduates of MD and DO degrees;
• Financially self-sustaining.
The federal government in 1997 froze the number of GME positions it would support for hospitals participating at that time. This number is known as the federal “cap” on residents/trainees, and OHSU is currently well above its cap. However, hospitals that do not have an existing GME training program are eligible to receive federal funding for establishing new programs.
Because of the federal dollars available for physician training in GME – once the program is up and running – and the likelihood of the willingness of Oregon’s health systems to contribute to training costs, new GME positions have the potential to, over time, no longer require state funding.
The OAFP proposes a Family Medicine Residency Network (HB 2401) that would increase GME training positions throughout the state in the family medicine specialty. This proposal is similar in intent to the collaborative Oregon GME Consortium for which OHSU has independently requested funding through a Policy Option Package. Both proposals have as their goal increasing the number of GME positions in Oregon.
3. Support for transformative research and training in primary care and its dissemination throughout Oregon. An essential element of redesigning our health care system is to demonstrate the effectiveness – in terms of both quality and cost – of new delivery models. The primary care medical home model, along with other innovative ideas, is likely to be a nucleus of fundamental changes in our primary care delivery system. Together, OHSU and OAFP can help to accelerate this transformation by establishing a center dedicated to furthering this primary care research and leveraging existing physician networks, such as the locum tenens program, to more broadly disseminate this knowledge.
In developing the primary care transformation research and training center and other initiatives outlined in HB 2391, OHSU is also committed to aligning and collaborating with public and private partners. Specifically, the Oregon Health Authority's Action Plan for Health outlines implementation steps for patient centered primary care homes. We want to complement and enhance OHA efforts currently underway to maximize resources and reduce provider burden in reshaping the primary care delivery system. With partnerships like with OHA and OAFP, we can work together to improve lifelong health; increase the quality, affordability and availability of care; and lower or contain the cost of health care for all Oregonians
In summary, OHSU applauds and supports OAFP initiatives to reduce the indebtedness of students in the health care professions, to increase GME positions, and to transform primary care delivery. However, we recognize that in today’s challenging economic climate, difficult decisions are required and not all programs and requests, however worthy, will be funded. In this context, it is ever more important to collaborate and find ways that we can leverage each other’s strengths and creativity. OHSU looks forward to the opportunity to be involved in this ongoing process.
Thank you for your time and I’m happy to answer any further questions.