Acknowledgment of Public Comment

The Advisory Committee on Training in Primary Care Medicine and Dentistry appreciates the comments provided on the draft report during the public comment period. Many thoughtful comments were received, and these were considered carefully in preparing the final report. The organizations providing comments included:

• Academic Family Medicine Advocacy Alliance
• American Academy of Pediatric Dentistry
• American Academy of Pediatrics
• American Dental Association
• American Dental Education Association
• American Osteopathic Association
• Association of Academic Health Centers
• Association of Pediatric Program Directors
• National Alliance for Hispanic Health
• Society of General Internal Medicine
• Society of Primary Care Policy Fellows

This acknowledgment is not to imply that these organizations endorse the content of this report.

Abstract

A well-prepared, effective primary care workforce reduces healthcare costs and plays a significant role in the prevention of disease and the management of both acute and chronic conditions. Over the past 40 years, the Title VII, section 747 programs have transformed the medical and dental landscape with their increased emphasis on the education and training of the primary care workforce. These programs have developed and expanded education and training programs for primary care providers and promoted diversity in the workforce. In addition, the programs have ensured that health professions curricula respond to the changing demands and emerging health needs of the U.S. population, including addressing the disparities in health outcomes of vulnerable groups.

The legislative intent for Title VII, section 747 has evolved over the years in response to the changing healthcare workforce needs and demands. The initial legislative purpose of Title VII, section 747 programs, created in 1963, was to increase the general supply of physicians. In successive reauthorizations, the focus of the Program shifted to education and training of primary care providers, later to addressing geographic distribution problems of healthcare providers and, more recently, to education and training of primary care providers to serve medically and dentally underserved populations and high-risk groups.

Title VII, section 747 programs form the centerpiece of the Health Resources and Services Administration’s (HRSA’s) efforts to prepare the primary care health workforce. HRSA programs tend to work synergistically and complement one another. For example, Title VII, section 747 programs educate and train high-quality primary care providers, many of whom go on to join the National Health Service Corps (NHSC) and/or work in community, migrant, and rural health centers. In this way, Title VII, section 747 programs support the overall workforce goals of HRSA’s Bureau of Health Professions (BHPr).

The evaluation of Title VII, section 747 programs has been challenging for two major reasons. First, the ability to define meaningful longitudinal outcome measures for the programs has been complicated by the changing nature of the legislation. Second, the myriad related programs funded by Title VII, section 747 and Title VIII (which supports nursing grant programs) under HRSA has created some blurring of program goals, making it difficult to ascertain the discrete contributions of individual programs to specific outcomes.

Evaluations that have examined specific educational and clinical outcomes of Title VII, section 747 programs have found beneficial impact. Studies have shown that Title VII, section 747 helped develop high-quality primary care education and training programs, established and maintained family medicine departments, and through the training of a primary care workforce, helped decrease the number of Health Professional Shortage Areas (HPSAs). However, the assessment done of these programs by the Office of Management and Budget (OMB) was more critical in substance and tone. In aggregating 40 separate health professions programs, including the lumping together of Title VII, section 747 and Title VIII programs in its assessment process, OMB was not able to isolate the specific effectiveness of Title VII, section 747 programs. Although Title VII, section 747 programs work synergistically with other programs in HRSA’s portfolio, they are specifically designed to bring about significantly different outcomes from those of other programs. Collectively, the programs contribute to HRSA’s overall goals.

The focus of this report is to clarify the purpose and objectives of the Title VII, section 747 Program and to put forward recommendations regarding outcome measures for evaluating Program impact based on the Program’s purpose and objectives. Based on the legislation, this purpose includes provision of funding for approved training of students, interns, and residents in family medicine, general internal medicine, and general pediatrics; training of physician assistants; training of residents in general dentistry and pediatric dentistry; and training of individuals who plan to teach in family medicine, internal medicine, pediatrics, and physician assistant training programs.

Conclusion

Evaluations of Title VII, section 747 programs in the past have not always been based on well-defined outcome measures that are directly related to the Program’s purpose and objectives. Adoption of a consistent set of outcome measures, based on Program purpose and objectives, will facilitate more meaningful assessments of the Program’s impact and foster continuous program improvement.

Recommendations

Consistent with the stated purpose:

To educate and train physicians, pediatric and general dentists, and physician assistants to enhance the quality, capacity, and diversity of the Nation’s primary care workforce, giving special consideration to the healthcare needs of underserved populations and other high-risk groups.

The Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD) recommends that:

1. The outcome measures utilized to evaluate Title VII, section 747 programs should reflect the Program’s statutory focus on health professional education and training.
2. The proposed logic model and near- and longer-term outcome measures should guide the evaluation of Title VII, section 747 programs.
3. Outcome measures should be identified that evaluate the synergistic role of Title VII, section 747 programs with other Bureau of Health Professions (BHPr) programs, especially the National Health Service Corps (NHSC), as well as the Health Careers Opportunity Program (HCOP), Area Health Education Centers (AHECs), and Rural Interdisciplinary Training.
4. BHPr should develop procedures for data collection, analysis, and reporting of Program outcome measures.
5. Additional financial resources should be made available to BHPr to implement effective evaluation processes for the programs in Title VII, section 747.