TARGET 2020 The Future of Georgia's Primary Care Medical Workforce 2011 2020 - There is URGENCY to act; - Augusta ...

 
TARGET 2020 The Future of Georgia's Primary Care Medical Workforce 2011 2020 - There is URGENCY to act; - Augusta ...
TARGET 2020

  The Future of Georgia’s
   Primary Care Medical
        Workforce
          2011 – 2020
Recommendations from the October 2011
 Statewide AHEC Network Primary Care
               Summit

 There is URGENCY to act;
       The Time is NOW
TARGET 2020
Raise the primary care physician to population ratio from 2011 level of
82/100,000 to 100/100,000, by 2020
                          MEDICAL EDUCATION PIPELINE
PHASE 1                PHASE 2         PHASE 3                        PHASE 4
K-12 Education         Undergraduate / Medical School                 GME / Residency
                       College                                        Training
Years K-12             Years 13-16     Years 17-20                    Years 23-28

                             ROAD MAP TO ACHIEVE GOAL

2012:
Provide funding to create 400 new primary care Graduate Medical Education (GME) slots in
Georgia; establish a joint Senate-House Graduate Medical Education Study Commission to set
targets for primary care GME expansion in Georgia; (Phase 4)

Create GME “bridge fund” to support new Primary Care GME expansion programs; (Phase 4)

Create incentives for Georgia Medical School Graduates to select Georgia Primary Care
Residency Programs for training; (Phases 3-4)

Create incentives for community based faculty to provide clinical training for core medical
student clerkships, to accommodate medical school class expansions; (Phase 3)

Increase housing resources available to support community based training of medical students
completing 3rd and 4th year medical school core clerkships and rural/primary care electives;
(Phase 3)

Initiate mandatory Pre-Med advisor training for all USG institutions, and available to all private
education institutions; (Phase 2)
Create uniform messaging and marketing for Primary Care in Georgia; (all Phases)

Establish a joint legislative committee to develop and recommend incentives for primary care
practice, for rural practice, and to address payment obstacles for primary care; (Phases 3, 4
and post pipeline practice).

2013-2015:
Expand primary care GME slots each year, based on recommendations of Joint House-Senate
GME Study Commission; (Phase 4)

Increase primary care loan forgiveness programs to be competitive with National Health
Service Corps and with contiguous states to a minimum of $30,000 per year with a service
commitment; (Phase 4 and beyond)

Implement $25,000 per year salary supplements for Georgia medical school graduates
selecting primary care residency programs in Georgia; (Phase 4)

Implement holistic admissions protocols at 3 Georgia medical schools; (Phase 3)

Create primary care and/or rural admissions tracks / programs at 3 Georgia medical schools;
(Phase 3)

Expand and deliver secondary education advisors training in health career opportunities;
(Phase 1)

Implement regional Pathways to Medicine Programs across the state; (Phases 2-3).

2015-2020:
Continue to expand primary care GME slots each year based on Joint Committee
recommendations; (Phase 4)

Develop incentives for primary care GME residency graduates to remain in Georgia to
practice; (Phase 4).
SUMMARY OF THE 2011 STATEWIDE AHEC NETWORK

                        PRIMARY CARE PHYSICIAN SUMMIT
WHY HOST A PRIMARY CARE SUMMIT? According to the American College of Physicians,
“the nation is facing a severe shortage of primary care physicians for adults…44,000-46,000
by 2025” (ACP position paper, 9/2/11). The Macy Foundation in 2010 found “the shortage will
be in excel of 100,000 physicians by 2025…recommend an immediate increase of 3,000 entry
level positions in targeted residencies.” The Council of Graduate Medical Education (COGME)
in its 20th Report, published in 2010, recommended policies to increase the total of primary
care residencies from 32% to 40%. In Senate testimony, the General Accounting Office in
February 2008         reported the Health Resource and Service Administration (HRSA)
“estimated a need for 65,960 NEW primary care physicians to meet the need for 2020”. The
American Association of Medical Colleges in December of 2008 estimated “a shortage of
45,800 primary care physicians by 2020.” Overall, the national primary care physician to
population ratio is 100 primary care doctors / 100,000 population. In Georgia, Georgia had 82
primary care doctors / 100,000 population. According to Access Transformed- Building a
Primary Care Workforce for the 21st Century, 2010, Georgia will need 676 new primary care
physicians to meet the needs of the state’s Community Health Centers. For 2010-2011,
according to the Georgia Board of Physicians Workforce, the state produced 96 primary care
Georgia medical school graduates. Of these, only 47 chose to complete their training in a
Georgia residency program. The data is endless – we are facing an acute and critical
shortage of primary care physicians in Georgia. The current medical education pipeline in the
state has significant disconnects, and our capacity to provide the final level of training
(residency training) is severely limited by the lack of appropriate numbers of training slots.
These factors converge to create a looming crisis in the state, and one that will take many
partners and many systemic changes to address.

In October of 2011, the Statewide AHEC Network invited key stakeholders across Georgia to
come together to craft a Primary Care Physician Plan for the state. The Statewide AHEC
deliberately chose to limit the focus of the Summit to the production of primary care physicians
in the state, while acknowledging the key roles to be played by other health care providers
(e.g. nurse practitioners, physician assistants, etc.) The Plan was envisioned to address
issues and challenges across all four phases of the Medical Education Pipeline and to provide
a comprehensive set of recommendations for each phase. It is clearly understood that
intervention in one area is not sufficient to meet Georgia’s short and long term needs.
For example, the recent investments in medical school expansions have certainly increased
the number of medical students training in Georgia, but we have not addressed the resource
needs to support community based training in the third and fourth year, and we have not
expanded our GME slots to provide an in-state opportunity to complete medical training. Thus
we have created an imbalance that, if not corrected, may lead Georgia to become the nation’s
largest exporter of medical students into residency training programs. A balanced and multi-
faceted approach is required if we are to meet the goal of providing Georgia with the
appropriate primary care physician workforce for 2020 and beyond.

                         MEDICAL EDUCATION PIPELINE
PHASE 1               PHASE 2         PHASE 3                     PHASE 4
K-12 Education        Undergraduate / Medical School              GME / Residency
                      College                                     Training
Years K-12            Years 13-16     Years 17-20                 Years 23-28

Summit attendees were divided into workgroups to discuss specific questions relative to each
Phase in the medical education pipeline. (Pre-summit materials had been circulated, and short
presentations provided to create a framework for these facilitated workgroup discussions;
presentations are available at www.georgiahealth.edu/ahec).         The following Summit
Recommendations and Phase Summaries of the workgroup deliberations are provided as
background to support the Target 2020 recommendations.

      SUMMIT FUNDING ISSUES AND ACTIONS: RECOMMENDATIONS
                              MEDICAL EDUCATION PIPELINE
PHASE 1               PHASE 2              PHASE 3                PHASE 4
K-12 Education        Undergraduate /      Medical School         GME / Residency
                      College                                     Training
Years K-12            Years 13-16          Years 17-20            Years 23-28

PHASE 1
1. Design, develop, and launch a statewide coordinated primary care messaging campaign to
   create a more responsive audience for primary care medicine recruitment and training.
2. Provide funds to develop training and resources for middle and high school guidance
   counselors for guiding students into primary care medical careers.
3. Increase funding to regional AHEC centers to deliver messaging to school systems through
   health career recruiters, classroom tools / aids, etc.
4. Provide funds for innovative programming offered by medical schools in partnership with
   local schools, boards of education, or districts.

PHASE 2
1. Fund the Statewide AHEC Network to develop and deploy a standardized pre-medical
   student advisor training to be offered regionally and on-line.
2. Expand the Pathways to Medicine program from southwest Georgia to four other (largely
   rural) AHEC regions.
3. Fund the Board of Regents to develop and open three regional Primary Care Post-
   Baccalaureate programs in the University System.
4. Create an innovation fund to develop new web based resources and tools for advisement
   and guidance (available to both students and college advisors).

PHASE 3
1.  Provide start-up funds / technical assistance resources for any Georgia medical school
      willing to implement Holistic Admissions processes.
2.    Provide start-up funds / technical assistance resources for any Georgia medical school
      willing to implement a primary care and/or rural admissions and training track.
3.    Provide innovation funds to any Georgia medical school willing to implement an
      accelerated primary care track.
4.    Create incentives tied to state appropriations for high percentage of graduates selecting
      primary care specialties.
5.    Expand primary care loan forgiveness resources to allow more students to be offered
      these resources.
6.    Create capacity to award provisional loan forgiveness based on completion of primary
      care specialty selection for residency training.
                                                           rd      th
7.    Increase funding to support housing needs of 3 and 4 year medical students on
      rotations in community based training sites.
8.    Increase funding for travel stipends for 3rd and 4th year medical students completing
      rotations remote from their campus.
9.    Provide tax credits for primary care community based faculty precepting 3 rd and 4th year
      Georgia medical students.

PHASE 4
1.    Educate policy leaders about the impact of failure to act.
2.    Request the Governor and General Assembly to appoint a Joint Legislative Committee
      on the GME crisis in Georgia.
3.    Adopt a Primary Care Physician Plan for Georgia with a timeline of
      implementation and clear outcome goals articulated.
4.    Provide funding for 400 new residency slots in Georgia.
5.    Explore legislation encouraging insurance companies to provide some level of support
      for GME start up and expansions.
6.    Create a revolving fund to support new GME Program Start-Up and to support pairing
      of hospitals / programs to expand or establish primary care residency slots.
7.    Create tax incentives for hospitals to partner and collaborate to provide local funds to
      support GME expansion or creation of new programs.
8.    Address the existing and worsening deficit of GME faculty to support expanded
      residency slots by providing funding for accelerated learning and for recruitment.
9.    Increase primary care loan forgiveness programs to a minimum of $30,000 per year
      with a service commitment, be competitive with National Health Service Corps and with
      contiguous states.
10.   Implement $25,000 per year salary supplements for Georgia medical school graduates
      selecting primary care residency programs in Georgia.
11.   Launch a high tech marketing campaign promoting Georgia Primary Care residency
      training opportunities, targeting Georgia medical school graduates and Georgia
      graduates from out of state / off shore medical schools.
12.   Provide cash stipends for residents completing rural residency training tracks.

                        SUMMIT WORKGROUP SUMMARIES
                              MEDICAL EDUCATION PIPELINE
PHASE 1               PHASE 2              PHASE 3                  PHASE 4
K-12 Education        Undergraduate /      Medical School           GME / Residency
                      College                                       Training
Years K-12            Years 13-16          Years 17-20              Years 23-28

PHASE 1: SECONDARY EDUCATION (K-12)
CHALLENGE: To graduate Georgia high school students who are academically
prepared and appropriately advised to pursue primary care medical careers.

SUMMARY OF DELIBERATIONS
Are Georgia students adequately prepared to succeed in college and beyond? This key
question drives much of the discussion about the first critical component of the medical
education pipeline. How can we better prepare Georgia students for college? Appropriate K-
12 education and preparation is essential to insure student success in higher level careers,
such as those in medicine.

Parents have tremendous influence during the first phase of the medical education pipeline.
How do we educate the families/parents about available resources that could support their
children financially through medical school? Parents can discourage their children from
pursuing a primary care career based on incorrect knowledge about funding and supports
available to assist their child.

Georgia students have a prodigious gift in the HOPE scholarship that can make undergraduate
education more affordable or even free. The AHECs and other organizations have done
significant work in educating small populations that they can afford medical school through
various loan repayment and scholarship programs. The need is to take this information to
larger populations through multi-media assets, classroom tools, and consistent messaging.
We have to develop a very concrete strategy that connects these programs and organizations
to better educate students and parents.

The need for better academic and career advisement continues to emerge as a strong theme,
especially with the wide array of choices available for student consideration. The need to
excite students about pursuit of a primary care career is even more complex and urgent. The
advisement piece needs to be strengthened at all levels within the K-12 years. Programs that
focus on early identification of students early in the K-12 years (much like the AHEC Pathway
Program for College students) have proven successful in Chicago and other sites, proving their
application in Georgia has great potential.

Consistent messaging is an ongoing challenge. A strategy defining how we market existing
primary care programs and information must be developed and deployed. The K-12 educators
with contact to the students on the front line need to be targets of these marketing efforts, so
they can identify, guide, connect, and mentor students along the correct career trajectory from
an early age.

We need to engage local business organizations and communities in creating a primary care
workforce pipeline for their regions. This type of support would reflect the significant economic
impact created by recruitment of a primary care physician. Additionally, linking the presence of
a developed and well-staffed health care system to medical recruitment in communities
conveys a strong message.

We need this strong “mission mentality”. There are considerable outside (community) funds
invested in high school sports, but not comparable funding provided to enhance academics.
Students need emotional, family, and community support to succeed in medical school and
training for a primary care career.

PHASE 1: PRIORITY ISSUES
   1. EARLY INTERVENTION / IDENTIFICATION OF STUDENTS
      A. Increase the professional development opportunities available to all levels of Math
         and Science teachers to improve student outcomes in their classes.
      B. Enhance academic advisement at middle and high school levels through increased
         training opportunities, development of tools and resources to support counselors,
         and development of advanced training opportunities for health careers; focus on
         identification of potential medical students in middle school.
      C. Develop resources to improve test taking skills such as rigorous online training for
         key standardized tests (ACT, SAT, Compass, etc.).
      D. Increase number of magnet schools devoted to health care sciences.

   2. MARKETING OF CAREERS
      A. Create High School Pathways to Medicine programs to support students who
         indicate potential to successfully complete primary care medical training.
      B. Create a Georgia Youth Health Service Corps initiative dedicating to exposing high
         school students to primary care medicine in the field.
      C. Connect with Georgia Health Occupation Students of America (HOSA) to increase
         involvement and exposure to Primary Care careers.

   3. UNIFORM PRIMARY CARE CAREER MARKETING MESSAGE
      A. Connect students with collaborative community partners to show them future
         opportunities.
B. Provide comprehensive communications with parents and students stressing the
        importance of maths and sciences, and of following the correct primary care
        pathways through high school to increase their potential odds of acceptance into
        medical school.
     C. Develop consistent messaging strategies to be utilized by the AHECs and other
        community / organizational / academic partners, with support from medical schools.

PHASE 1: PROPOSED STRATEGIES
  1. Utilize AHECs to promote existing primary care programs to K-12 students in Georgia.
  2. Improve quality of K-12 career advisement through advanced training and tools /
     resource development.
  3. Begin concentrated education of students about primary care career options, by
     entrance to middle school.
  4. Support development and implementation of “Mini-Med School”, “Saturday Medical
     School”, or similar pipeline programs whose goal is exposure of students to primary
     care careers prior to college matriculation.
  5. Utilize medical students as college coaches in middle and high schools in communities
     where they rotate for clerkships and / or electives.
  6. Improve the “Marketing” of primary care medicine as a viable career choice.
MEDICAL EDUCATION PIPELINE
PHASE 1               PHASE 2           PHASE 3                    PHASE 4
K-12 Education        Undergraduate /   Medical School             GME / Residency
                      College                                      Training
Years K-12            Years 13-16       Years 17-20                Years 23-28

PHASE 2: UNDERGRADUATE / COLLEGE YEARS
CHALLENGE: To appropriately prepare for and direct college students towards primary
care careers, specifically but not exclusively, primary care medicine.

SUMMARY OF DELIBERATIONS
There is no standard curriculum for faculty pre-med student advisors at our colleges and
universities. Mandatory standard curriculum should be developed and delivered to all USG
pre-med advisors; the curriculum and training should be made available to private college and
university pre-med advisors at a reasonable cost. Many students who are in the pre-med track
do not possess the necessary scores or GPA to matriculate into a medical school. These
students should be redirected into other primary care careers rather than left to flounder and
seek other employment sectors for pursuit. Increased support in the first two years when
students are deciding on their majors should be provided, including tutoring in the sciences
and mathematics as needed (organic chemistry, etc.).

Many potential primary care medical students would benefit from a one year Post-
Baccalaureate program to further hone and refine their scientific and mathematical skills prior
to medical school matriculation. This one year Post-Baccalaureate Program should be offered
as a Masters level program to qualify with new federal financial aid policies. These programs,
specifically designed to academically bolster selected students, should result in increased
student performance upon admission into medical school.

Need exists for programs available to college students to immerse them in in primary care
medicine through mentoring, research, and “exploration”. Rural students could particularly
benefit from these programs, as evidenced by the success of the Pathways to Medical School
offered through the SOWEGA AHEC. Currently Pathways has a success rate of ___% of
graduates matriculating into a Georgia medical school. Students are exposed to a rigorous
curriculum featuring in-depth research projects, mentoring, shadowing, and exposure to the
wide domain of practice environments for primary care providers.

Professional organizations and medical school faculty could unite to support Programs / Clubs
at the college level, such as future Doctors of America, Campus Community for Health, etc., to
provide early exposure to primary care, rural health care, and to education, training, and
practice opportunities in Georgia.

PHASE 2: PRIORITY ISSUES
      A.     Strengthening and standardizing college pre-medical advisory skills and access
             to appropriate resources for guidance; provide broader advisement within the
             array of health careers rather than simply medicine.
      B.     Provide Primary Care Post-Baccalaureate Masters level programs to better
             prepare rural and/ or provisionally accepted students into the medical school
             education track.
      C.     Provide intensive mentoring, shadowing, and medical research programs for pre-
             medical students to validate their career choices and prepare for the rigors of
             medical school.

PHASE 2: PROPOSED STRATEGIES
       A. Develop and deploy a mandatory standardized curriculum and training for college
          pre-medical advisors in the University System; make curriculum and training
          available to private college and university advisors for a reasonable fee.
       B. Create provisional medical school admissions opportunities for rural students while
          in their 2nd or 3rd year of baccalaureate education as a strategy to retain students in
          the Georgia medical education pipeline.
       C. Expand the Pathways to Medicine program from Southwest Georgia to four other
          AHEC regions who serve largely rural populations.
       D. Create three regional Primary Care Post-Baccalaureate programs, with financial aid
          available, to strengthen rural, minority, or provisionally accepted student
          performance.
       E. Support the development of web-hosted guidance and advisement resources
          available for students and college advisors.
       F. Encourage professional organizations, medical schools, local medical societies to
          sponsor Primary Care oriented clubs / programs on college and university
          campuses statewide.
MEDICAL EDUCATION PIPELINE
PHASE 1               PHASE 2            PHASE 3                  PHASE 4
K-12 Education        Undergraduate /    Medical School           GME / Residency
                      College                                     Training
Years K-12            Years 13-16        Years 17-20              Years 23-28

PHASE 3: MEDICAL SCHOOL
CHALLENGE: Admitting students predisposed to primary care practice and/ or rural
medicine; supporting community based clinical training needs of the five medical
schools; developing rural / primary care training tracks.

SUMMARY OF DELIBERATIONS
The image of medical schools as elite meccas for high scoring students should be modified.
Admissions based heavily on high MCAT scores and GPAs can exclude students who can
succeed in medical school and who may have a predisposition to practice in primary care
and/or in underserved communities. Recruiting should be broadened to encompass a more
Holistic Admissions process that includes value for emotional intelligence, demographic
origins, and solid academic performance. The AAMC has begun work in defining Holistic
Admissions processes. Several medical schools have already moved to “blind admissions”
wherein students who meet the basic qualifications (MCAT scores and GPA) proceed through
Admissions interviews without their test scores and GPAs being available to interviewers.
Research has shown that a student does not to have a 4.0 GPA or the highest MCAT score to
successfully complete medical school and pass national boards. Changes in the admissions
process would not necessitate lowering the academic standards for admission, but could
broaden the pool of students being admitted.

Implementing dedicated primary care and /or rural admissions tracks in medical schools has
been proven to yield a high number of successful graduates. Medical Schools in Minnesota,
Arizona, and Pennsylvania are but a few examples where these tracks are in place and
resulting in increased graduates in primary care and rural medicine. These programs focus on
recruiting students from rural and underserved areas in order to return physicians to those
areas, as well as identifying students early in the pipeline who have an expressed interest in
primary care.

Mentoring during the medical school experience is critical. Anecdotal stories indicate
preceptors of medical students are teaching students differently, based on their specialty
orientation. Many talented students are advised to choose a sub-specialty over primary care,
with inferences made that the best and brightest pursue specialties rather than primary care.
Much of what influences a student doctor to choose primary care physician has to do with the
environment of the medical school. Incentives should be implemented at the highest levels of
medical education to encourage faculty to support primary care choices and to be rewarded for
such choices. Tying state support to production of needed primary care providers may be an
avenue to explore.
With the recent investment in medical school class size expansion, a host of new problems
has been created. Specifically, the need to provide clerkship and elective rotations at the
community level have increased dramatically, but resources to support (through housing, travel
stipends, and community based faculty identification and development) these mandatory
clerkships and electives has been decreased. We need to increase support available to
support these critical years of medical education which occur in communities across the state.

Additionally, the need to find and develop more community based clinical faculty and teaching
sites is hampered by the demands already on these practices. To take a student into a
practice for training reduces the efficiency of the practitioner, and is done with no
remuneration. Out of state medical schools, along with off shore medical schools, have
targeted Georgia as a state to place their 3rd and 4th year medical students, and they provide
financial payments to sites to take these students. The need to provide some sort of tangible
benefit to community based faculty taking Georgia medical students is paramount and must be
addressed if the Georgia medical school students are to have access to the community based
training they require. Additionally, regulatory issues can create barriers for community based
faculty to take their students into local hospitals and nursing homes – significantly impacting
the quality potential of the community based teaching site.

Efforts need to be undertaken to identify and support more contemporary training sites for
primary care rotations. Students in this generation are immersed in technology and need to
see firsthand the applications and use of technology in primary care training sites.

Finally, the cost of medical education and the need to repay loans is a barrier to selecting a
primary care discipline for practice. Payment reform is needed to recognize and appropriately
reward primary care medical services, and to lessen the salary gap between primary care and
specialty medicine.

PHASE 3: PRIORITY ISSUES

A.    Admissions processes and procedures
B.    Change culture of Medical Schools
C.    Medical School Debt and impact on specialty choice
D.    Support for 3rd and 4th year medical student rotations
E.    Support for community based faculty who provide free training to 3 rd and 4th year
      medical students

PHASE 3: STRATEGIES
A.    Admissions processes and procedures
      1.   Identifying admissions criteria that will meet the needs of the state
a.     Develop Rural Admissions Track
           b.     Develop Primary Care Admissions Track
           c.     Increase Diversity

     2.    Develop accelerated programs to move students through the medical school
           portion of the pipeline more quickly, e.g. allowing primary care medical students
           to forgo the 4th year and enter directly into residency programs.
     3.    Provide training and resources for medical schools willing to move to Holistic
           Admissions processes
     4.    Add more community representation on medical school admissions committees

B.   Change culture of medical schools to embrace primary care choices
     1.   Create incentives tied to state appropriations for percentage of graduates
          selecting primary care specialties
     2.   Create web-based training to teach medical school faculty on how to mentor
          medical students towards primary care

B.   Medical School Debt and impact on specialty choice
     1.    Expand primary care loan forgiveness resources to allow more students to be
           supported
     2.    Create capacity to award provisional loan forgiveness based on completion of
           primary care specialty selection for residency training

C.   Support for 3rd and 4th year medical student rotations
     1.   Increase support for housing needs of students on rotation
     2.   Increase support for travel stipends to students completing rotations remote from
          their campus.

D.   Support for community based faculty who provide free training to 3 rd and 4th year
     medical students
     1.    Provide Faculty Development and training
     2.    Provide tax credits for primary care community based faculty precepting 3 rd and
           4th year Georgia medical students
     3.    Establish more contemporary primary care training sites across the state to
           showcase technology in practice.
MEDICAL EDUCATION PIPELINE
PHASE 1               PHASE 2            PHASE 3                   PHASE 4
K-12 Education        Undergraduate /    Medical School            GME / Residency
                      College                                      Training
Years K-12            Years 13-16        Years 17-20               Years 23-28

PHASE 4: GME/ RESIDENCY TRAINING

SUMMARY OF DELIBERATIONS
The complexities of the medical education pipeline are most apparent when the final phase of
the medical education pipeline is examined. Many individuals (policy makers, community
leaders) do not understand the graduate medical education piece, or its importance for
meeting workforce needs. The lack of general awareness of this pipeline component must be
overcome and education must replace misinformation. Residents are licensed physicians who
provide services to individuals while in training, and comprise a significant workforce when
viewed in toto.

Many medical students choose to leave the state for their residency training once medical
school is complete. Data indicate many factors influence this choice, including but not limited
to: desire to have exposure to another health care system different than where they completed
medical school; exposure to other geographic locales, family / spouse issues, resident salary,
perceived quality of in state residency programs, advice received from medical school faculty
or other medical mentors, etc. As a result, Georgia residency training programs are retaining
less than 30% of our Georgia medical school graduates. This disconnect has significant impact
on the likelihood of these Georgia graduates returning to our state to practice after residency
training.

Published research on students who go to college, medical school and GME training in the
same state indicate that these students will stay where they received their education rather
than leave Georgia to practice. Understanding the factors that break this cycle are important
and, if understood and addressed, could yield a significant increase in the number of providers
remaining to practice in the state.

The recent medical school class size expansions were not accompanied by a simultaneous
increase in available residency “slots” in Georgia. This has created a funnel that will only
worsen. We are producing more medical school graduates than we have capacity to provide
residency training for, thus making us an exporter of medical students to other states for
residency training.
Creating more residency training slots is the priority issue in the medical education pipeline.
The Board of Regents has stated that 400 new slots are needed immediately to begin to
address the “funnel”. Existing residency programs, particularly primary care, need to be
expanded, and new residency programs established in order to meet this high goal. Models
such as the Southwest Georgia GME Consortium are excellent examples of how to jump start
GME initiatives in regions across the state. Similar efforts are underway in Northeast Georgia
with St. Mary’s and Athens Regional Hospitals in Athens.
The fact that we do not currently fill our existing residency slots with Georgia medical school
graduates provides another immediate starting point to increase our in state physician supply.
While the slots are predominantly filled in existing programs, only a small percentage fills by
Georgia graduates. Incentivizing selection of Georgia residency programs in primary care
could help strengthen our pipeline and retain these graduates as providers for the state in the
future.

The provision of residency training in rural areas is also needed to increase the odds of
residents practicing in rural communities after graduation. Minnesota has one model of this
rural residency training that should be explored in Georgia.

Resident salaries provide another avenue to increase retention of Georgia graduates.
Providing signing bonuses, salary supplements, enhanced loan forgiveness are all strategies
that may be utilized to increase the number of primary care residents choosing to train in
Georgia.

Federal support for residency training continues to decline and is generally unstable. This will
require creative new funding partnerships to be developed if we are to meet Georgia’s needs.
Insurance companies are a logical potential funding partner, but creating an environment that
supports community, business, philanthropic, and foundations, etc. to come together will be a
critical task. Hospitals cannot depend on state and federal support to meet all of the financing
needs, and thus other alternatives must be identified and built.

An existing state agency should be identified and resources expanded to serve as a
clearinghouse for residents / communities to connect for placement. This would allow active
facilitation of collaborations with generalized oversight and reporting lines.

PHASE 4: PRIORITY ISSUES
   1. URGENCY

   A. Educating policy leaders about the impact of failure to act.
   B. Publishing inventories of what GME programs we have, how we fill, where graduates
      practice.
   C. Executive and legislative branches need to engage actively in resolving this issue.
   D. Clarification of uniform steps to start and maintain a residency program, including cost
      projections.
   E. Articulate economic impact of residency programs and residents on local economies.
   F. Articulate community level economic impact of successfully retaining a primary care
      physician resident after graduation.
2. FINANCIAL

     A. Insurance Companies should be leveraged to provide some level of support for GME.
     B. New Program Start-Up funds to support pairing of hospitals / programs to expand or
        establish primary care residency slots; Create an “Innovation Center around GME”.
     C. Create incentives for hospitals to partner and collaborate to provide local funds to
        support GME expansion or creation of new programs.
     D. Address the existing and worsening deficit of GME faculty to support expanded
        residency slots.

     3. RESIDENT RECRUITMENT

     A. Salary Supplements for primary care residents.
     B. Loan forgiveness beginning PGY1 for primary care residents.
     C. Marketing Georgia Primary Care Residency programs more effectively, focusing on
        quality of education and incentives.
     D. Define incentives for choosing rural residency training tracks.

PHASE 4: STRATEGIES
1.      URGENCY

A.      Educating policy leaders about the impact of failure to act.
B.      Georgia Trend and Atlanta Business Chronicle exposure – Write up the results from this
        summit and issues about GME to educate larger audiences about the crisis in primary
        care medicine.
C.      Create constant flow of educational information to legislators
D.      Request the Governor and General Assembly to appoint a Joint Legislative
        Commitment on the GME crisis in Georgia.
E.      Publish and promote examples of communities that have already expanded GME
        programs.
F.      Publishing inventories of what GME programs we have, how and with whom we fill,
        where graduates practice.
G.      Create clarified uniform steps to start and maintain a residency program, including cost
        projections to assist local hospitals considering start-up of residency programs.
H.      Articulate economic impact of residency programs and residents on local economies.
I.       Articulate community level economic impact of successfully retaining a primary care
        physician resident after graduation.
J.      Adopt a Primary Care Physician Plan for Georgia with a timeline of
        implementation and clear outcome goals articulated.

2.      FINANCIAL

A.      Provide funding for 400 new primary care residency slots in Georgia.
B.    Explore legislation encouraging insurance companies to provide some level of support
      for GME start up and expansions.
C.    Create revolving fund to support New GME Program Start-Up and to support pairing of
      hospitals / programs to expand or establish primary care residency slots.
D.    Create a “GME Innovation Center” as a clearinghouse for successful models and for
      provision of technical assistance.
E.    Create incentives for hospitals to partner and collaborate to provide local funds to
      support GME expansion or creation of new programs.
F.    Address the existing and worsening deficit of GME faculty to support expanded
      residency slots by providing funding for accelerated learning and for recruitment.

3.    RESIDENT RECRUITMENT

A.    Increase primary care loan forgiveness programs to $30,000 per year with a service
      commitment to be competitive with National Health Service Corps and with contiguous
      states. (Phase 4 and beyond)
B.    Implement $25,000 per year salary supplements for Georgia medical school graduates
      selecting primary care residency programs in Georgia. (Phase 4)
C.    Launch a high tech marketing campaign promoting Georgia Primary Care residency
      training opportunities, targeting Georgia medical school graduates and Georgia
      graduates from out of state / off shore medical schools. (Phase 4)
D.    Provide cash stipends for residents completing rural residency training tracks. (Phase 4)

PRACTICE ENVIRONMENT
In the course of deliberations several issues were identified relating to what happens after the
education pipeline is complete. The current practice environment has many challenges that
must be addressed to allow the strategies implemented in the medical education pipeline to be
successful. Without addressing these challenges, we will NOT realize the full potential of our
pipeline initiatives AND we will not meet Georgia’s primary care practice needs for the future.

Significant salary differences exist between primary care specialties and other specialties in
medicine. Payment reform, particularly for primary care providers, must be addressed. If
primary care physicians continue to receive significantly lower reimbursement for comparable
procedures, and if their cognitive services continue to be undervalued, it is unlikely that a
higher proportion of students will choose careers in primary care disciplines. We recommend
that a legislative task force address this issue and be directed to offer recommendations for the
2013 legislative session.

Tort Reform is another challenge that has been successfully addressed in other states,
specifically in Texas. Georgia needs to grapple with this issue and create realistic tort reform
initiatives to address barriers to primary care practice. This too could be addressed via a
legislative task force with recommendations for the 2013 legislative session.
Finally, incentives to practice in rural and underserved sites need to be continued and
enhanced. For example, extending the Rural physician tax credit to 5 years and expanding the
practice sites to include community health centers would provide further incentives for our
medical education pipeline graduates to practice in our underserved communities.

                           2011 Primary Care Summit Attendees List
          Name                           Title                        Organization
Andresen, Susan, MD
Barnes, Julie, MD            Chief Medical Officer          Redmond Regional Medical Center

Bina, William F., MD         Dean                           Mercer University School of
                                                            Medicine
Blumenthal, Daniel, MD       Chairman/ Professor            Moreshouse School of Medicine
Brown, Detra                 Director Recruitment and       Statewide AHEC Program Office
                             Evaluation
Bucholtz, John, DO           Director of Medical            The Medical Center Columbus
                             Education                      Family Practice Residency Program

Byrd-Verizzani, Daphne       Center Director                SPCC-Atlanta AHEC
Caldwell, Collette           Statistical Research           Georgia Board for Physicians
                             Analyst                        Workforce and State Medical
                                                            Education Board
Carter, Ashley               Preceptor Coordinator          Foothills AHEC
Caseman, Matt                Executive Director             Georgia Rural Health Association
Chastain, George, MD         Interim Assistant Dean SW      Georgia Health Sciences University
                             Clinical Campus
Cibirka, Roman, DDS, MS      VP & Associate Provost         Georgia Health Sciences University

Coggins, Margie              Senior Budget and Policy       House Budget Office
                             Analyst
Collins, Sonya               Notes Editor for Clinicians,   Primary Care Progress
                             Educators & Advocates
Craver, William, DO          Dean and Chief Academic        PCOM
                             Officer
Daniels, Mary                Executive Director             Georgia Chapter of the American
                                                            College of Physicians
Denson, Bobby                Preceptor Coordinator          SPCC-Atlanta AHEC
Dent, M. Marie, PhD, EdS     Assistant Dean                 Mercer School of Medicine,
                                                            Savannah Campus
Don Diego, Frank R., MD      Director                       Floyd Family Practice Residency
                                                            Program/ Floyd Medical Center
Dorage, Steve                Region Officer                 HRSA Regional Office (Georgia)
English, Kathy            Center Director             Three Rivers AHEC
Fincher, Jacqueline, MD   Georgia Chapter Governor    Georgia Chapter of the American
                                                      College of Physicians
Fleischmann, John, EdD,   Campus Executive Officer    PCOM
MBA, MPA
Frederick, George, MD      Family Medicine Residency Phoebe Putney Memorial Hospital
                           Program Dir.
Fulton-Brown, Fay          Executive Director        Georgia Academy of Family
                                                     Physicians
Gologan, Trena             Admissions                PCOM
                           Coordinator/Recruiter
Gregory, Paula, DO         Coordinator of Clinical   PCOM
                           Education
Hakman, Jeneva             Academic Director         Athens Regional Health System
Harrison, Sheila, PT, MLIS Center Director           Foothills AHEC
Hobbs, Joseph, MD          Chair, Family Medicine    Georgia Health Sciences University

Hotz, James, MD           Board Member                SOWEGA AHEC
Jackson, Leslie           Assistant Director of       Mercer University SOM
                          Communications and
                          Recruitment
Keshinro, Carolyn L.      HRSA/NHSC Georgia           Bureau of Clinician Recruitment
                          Regional Recruitment        and Services
                          Representative
Kornegay, Denise          Executive Director          Statewide AHEC Program Office
Kundu, Bela               Preceptor Coordinator       Magnolia Coastlands AHEC
Lang, Sarah               Board Member                Three Rivers AHEC
Lockwood, Angie           Senior Project Director     Tripp-Umbach Consulting
Madaio, Michael, MD       Chair, Department of        Georgia Health Sciences University
                          Medicine
Malan, T.Phil., MD        Dean                        Mercer School of Medicine,
                                                      Savannah Campus
Mariani, Lisa             Region Officer              HRSA Regional Office (Georgia)
Martin, Kathryn, PhD      Assistant Dean for SE       Georgia Health Sciences University
                          Clinical Campus & Interim
                          Dean of Admissions
McCrory, Aldous           Board Member                SPCC-Atlanta AHEC
Middendorf, Bruce         Chief Medical Officer       St. Mary's Health System
Miller, Andy              Chief Executive Officer     Georgia Health News
Miracle, Steven, MBA      Board Chair                 Blue Ridge AHEC
Moreno, Raymond, MD       Vice President Medical      Tift Regional Medical Center
                          Affairs
Mundy, Erin                Director Community Based    Statewide AHEC Program Office
                           Training Programs
Newell, Paul, MD           Former District Health      GA District 8-2/ Southwest Cancer
                           Director/ Retired Board     Coalition
                           Member
Norman, Sharon             Center Director             Blue Ridge AHEC
Nuss, Shelley, MD          Campus Associate Dean       GHSU/UGA Medical Partnership
                           for GME
Owens, Charles             Executive Director          Office of Rural Health
Pallay, Robert, MD         Program Director, Family    Mercer University School of
                           Medicine                    Medicine Savannah Campus
                           Family Medicine Residency   Savannah FMRP Memorial Medical
                           Program Dir.                Center
Palmisano, Donald J., Jr   Executive Director          Medical Association of Georgia
Park, Margaret             Board Member                Three Rivers AHEC
Patten, Doug, MD           Chief Medical Officer and   Phoebe Putney Memorial Hospital
                           SVP
Pung, Mary Kate            Center Director             Magnolia Coastlands AHEC
Reeves, Leonard, MD        Board Chair                 Georgia Academy of Family
                                                       Physicians (GAFP)

                           Assistant Dean for NW       Georgia Health Sciences University
                           Campus                      (GHSU)
Reynolds, Pam              Center Director             SOWEGA AHEC
Risby, Emile               Medical Director            GA Department of Behavioral
                                                       Health/ Developmental Disabilities
Robinson, Ben              Executive Director          Center for Health Workforce
                                                       Planning and Analysis
Schuster, Barbara, MD      Campus Dean                 GHSU/UGA Medical Partnership
Shepherd, Tom              Sr. VP/ Planning &          Gwinnett Health System
                           Development
Shiver, Jan                Preceptor Coordinator       SOWEGA AHEC
Shurling, Christy          Community Educator          East Georgia Health Cooperative,
                                                       Inc.
Skelton, W. Douglas, MD    Board Member                Magnolia Coastlands AHEC
Smith, Pamela              Administration Manager      Georgia Board for Physicians
                                                       Workforce
Spires, Shelley            Deputy Director             Albany Area Primary Health Care
Strothers, Harry, MD       President                   Georgia Academy of Family
                                                       Physicians
Thompson, Melody,          VP, Physicians Practices    Southeast Georgia Health System
FACHE, CMPE
Tucker, Cherri         Executive Director       Georgia Board for Physicians
                                                Workforce
Umbach, Paul           Partner                  Tripp-Umbach Consulting
Vericella, Sharn       Preceptor Coordinator    Blue Ridge AHEC
Walker, Teresa         Program Manager          Statewide AHEC Program Office
Waters, Karen                                   Georgia Hospital Association
Wernick, Joel          President/CEO            Phoebe Putney Hospital
Wilkerson, Jan         Quality Manager          Georgia Association of Primary
                                                Care
Williams, Cassandra    Board Chair              Three Rivers AHEC
Williams, Joanne, MD   Assistant Professor,     Emory University
                       Department of Family
                       Medicine
Willocks, Stacey       Sr. Research Associate   GA Health Policy Center @ Georgia
                                                State University
Young, Suzanne, CNP    Georgia Rural Health     Georgia Mountains Health
                       Experience Director
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