Description of Title VII, Section 747 Programs

Objectives of Title VII, Section 747 Programs

A well-prepared, effective primary care workforce reduces healthcare costs and can play a significant role in the prevention of disease and the management of both acute and chronic conditions. Supply and distribution of primary care providers are critical to delivering care to underserved populations and communities, both rural and urban; when the ratio of providers to population is low, providers must be able to address a broad range of healthcare needs (Starfield, Simpson, 1993; Hart, 2001). Primary care providers can play a significant role in disease prevention. For example, the future burden of chronic diseases, such as obesity, can be reduced by adequately addressing nutrition and health maintenance during childhood (Krebs, Jacobson, 2003). In other industrialized nations, the primary care physician remains a prominent element of the healthcare delivery system (Starfield, 1992; Macinko, Starfield, et al., 2003), and these nations achieve better health outcomes with fewer resources (Macinko, Starfield, et al., 2003; Organisation for Economic Co-Operation and Development, 2003). There is also compelling evidence of international comparisons that demonstrate better health outcomes and decreased healthcare costs when primary care providers compose over 50 percent of a nation’s physicians (Starfield, 1992).

The Title VII, section 747 programs have been very effective in transforming the medical and dental education landscape with their increased emphasis on the education and training of the primary care workforce. The programs have helped to create a diverse, broadly competent primary care medicine and dentistry workforce. Over the past 40 years, Title VII, section 747 has helped to develop and expand education and training programs for primary care providers, promote diversity in the workforce, and ensure that curricula within the health professions respond to the changing demands and emerging health needs of the U.S. population, including addressing health outcome disparities in vulnerable groups. Title VII, section 747 programs are also designed to improve the Nation’s health by educating and training a quality primary care healthcare workforce, particularly for those patients who are medically and dentally underserved.

The Program funds primary care education, faculty development, and the creation of innovative primary care curricula and models of care. The Program has long emphasized education and training of primary care providers for underserved populations, thereby improving the health and quality of life in these populations with an emphasis on prevention and early intervention. The Program has also created a multidisciplinary focus, while supporting primary care leadership development. Title VII, section 747 programs have been unique in attempting to encourage primary care as a career choice among graduates of medical, dental, and physician assistant training institutions.

The current legislation of Title VII, section 747 sets forth a purpose that 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.

On the basis of review of authorizing legislation and broader goals of the Bureau of Health Professions (BHPr) and an examination of the past successes and capabilities of the programs, the Committee concludes that the primary purpose of Title VII, section 747 programs is:

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.

Further, the Committee believes that there are seven key objectives for these programs.

Key Objectives

1. Improve the quality of education and training of the Nation’s primary care workforce.
2. Improve the capacity for education and training of the Nation’s primary care workforce, with special emphasis on individuals from disadvantaged backgrounds and underrepresented minorities.
3. Improve primary care education and training curricula.
4. Improve primary care faculty development.
5. Identify, develop, and disseminate primary care education and training innovations along with best practices among programs, accrediting bodies, and other constituents.
6. Improve the preparation of faculty, residents, and students (or learners) to work with medically and dentally underserved populations and build linkages to communities.
7. Improve the diversity and number of primary care faculty and students (or learners), with special emphasis on individuals from disadvantaged backgrounds and underrepresented minorities.

In this report, the term “disadvantaged” is used to refer to those individuals who are either economically or educationally disadvantaged. The term is broadly inclusive of racial minorities, ethnic minorities, and poor whites (Anglos). Individuals from disadvantaged backgrounds do not fit geographic boundaries. They can exist in rural and frontier communities as well as in urban and suburban communities.

These seven objectives are important to both stakeholders and constituents of the Program. Stakeholders are entities who are not the direct beneficiaries of the Program’s activities, but have a vital interest either as indirect beneficiaries or policy makers. Key stakeholders of the programs include the public and taxpayers, the Congress, the White House, and the U.S. Department of Health and Human Services (DHHS). Constituents are direct beneficiaries of the programs’ activities. Key constituents include grantee institutions and learners at those institutions.

Some objectives are more important to stakeholders, whereas others are of greater concern to constituents. Some objectives are equally important to both. For example, Objective 2, Improve the capacity for education and training of the Nation’s primary care workforce, with special emphasis on individuals from disadvantaged backgrounds and underrepresented minorities, is more important to stakeholders than it is to constituents. Objective 3, Improve primary care education and training curricula, is of greater concern to constituents.

The key activities performed in order to achieve the objectives important to stakeholders and constituents are depicted in a strategic framework (Figure 3 on the next page).

Types of Education and Training Programs Supported by Title VII, Section 747 Programs

The current grant program authorized by the Public Health Service Act, Title VII, section 747 consists of a variety of structures and different funding purposes. BHPr’s 2005 funding announcement for the Program identified six different funding purposes. These are Residency Training in Primary Care, Pre-doctoral Training in Primary Care, Faculty Development in Primary Care, Academic Administrative Units, Physician Assistant Training, and General and Pediatric Dentistry. Title VII, section 747 programs are funded through the competitive grants and cooperative agreements awarded to organizations that train and educate healthcare professionals at more than 1,700 institutions. The individual program areas are detailed below:

• Residency Training in Primary Care. Plan, develop, and operate or participate in (including provision of financial assistance) approved residency programs in family medicine, general internal medicine, and general pediatrics.
• Pre-doctoral Training in Primary Care. Plan, develop, and operate or participate in (including provision of financial assistance) pre-doctoral programs in family medicine, general internal medicine, and general pediatrics.
• Faculty Development in Primary Care. Plan, develop, and operate (including provision of financial assistance) programs for the training of physicians who plan to teach in family medicine (including geriatrics), general internal medicine, and general pediatrics training programs.
• Academic Administrative Units. Meet the costs of projects to establish, maintain, or improve academic administrative units to provide clinical instruction in family medicine, general internal medicine, and general pediatrics.
• Physician Assistant Training. Meet the costs of projects to plan, develop, and operate or maintain approved programs, as defined in section 799B, for the training of physician assistants and for the training of individuals who will teach in programs to provide such training.
• General and Pediatric Dentistry. Meet the costs of planning, developing, or operating approved residency programs of general or pediatric dentistry, including providing financial assistance to the learners in these programs.

Title VII, Section 747’s Influence on the Workforce

Title VII, section 747 programs form the centerpiece of HRSA’s efforts to prepare the primary care health workforce. HRSA programs tend to work -synergistically and complement each other. For example, Title VII, section 747 programs train high-quality primary care providers, many of whom go on to join the National Health Service Corps (NHSC) and/or work in federally funded community, migrant, and rural health centers. The expansion of community health centers and the NHSC are Presidential initiatives. The NHSC is a postgraduate program that presently focuses on loan repayment (80 percent), with a small scholarship component (20 percent) for students who commit to serving in an underserved area upon completion of their education. Title VII, section 747 education and training programs support HRSA’s overall workforce goals through their complementary relationship with these programs. In addition to directly preparing practitioners of related programs, the presence of Title VII, section 747 programs can indirectly increase overall sensitivity of students to issues related to primary care and underserved populations. For example, many students who go on to do specialty training and set up a practice in a medical or dental specialty routinely provide care to underserved patients. For such specialty providers, service to underserved populations can form a sizeable portion of their practices.

Title VII, Section 747 and Related Federal Programs

In addition, there are several other related training programs funded by HRSA that, along with Title VII, section 747 programs, influence learners in different stages of their training and education. Potential opportunities to pursue a career in primary care exist along a continuum, or a “pipeline,” of education and training. Title VII, section 747 programs are opportunities at the latter end of this pipeline that expose learners to primary care education and training experiences that may influence their career choices. Examples of related programs in the education and training pipeline include:

• Health Careers Opportunity Program (HCOP). Grants that increase the number of individuals from disadvantaged backgrounds in the health and allied health professions.
• Rural Interdisciplinary Training. Grants that support innovative training that prepares healthcare providers for practice in rural communities. This program is focused on rural areas.
• Area Health Education Centers (AHECs). Academic–community partnerships that train healthcare providers in sites and programs that are responsive to State and local needs.
• NHSC Scholarship Program. A program that provides service-obligated scholarships for students of various healthcare disciplines. In return for the scholarships provided, students are obligated to serve in a Health Professional Shortage Area (HPSA).

Figure 4 on the following page depicts the contribution of these programs in the healthcare provider education and training pipeline and some of the marketplace forces that influence the number of providers.

Title VII, Section 747 and Other Influences on the Workforce

Programs authorized under Title VII, section 747 are designed to improve health professions education and training and thereby prepare more primary care graduates to respond to the Nation’s well-established healthcare needs. The programs are designed to bring about direct benefits in education and training outcomes. Addressing BHPr’s overall workforce goals, however, requires consideration of a complex set of market and social forces that, along with individual preferences, may serve as more powerful influences on individuals considering a career in primary care. Furthermore, individuals who are underrepresented minorities are affected by these same forces and individual preferences in determining their career choices. The Title VII, section 747 programs contribute to BHPr’s overall workforce goals through the combined effect of Title VII, section 747 and related BHPr programs such as those discussed above. Among these market and social forces are:

• Lifestyle preferences. Lifestyle preferences persist that encourage providers to seek practice locations in affluent suburban and urban areas (Rabinowitz, Diamond, et al., 1999). In addition, perception of a controllable lifestyle, characterized by control over personal time and freedom from practice requirements allowing leisure, family, and avocational pursuits, is a significant factor in specialty choices of graduating U.S. medical students (Dorsey, Jarjoura, et al., 2003). Encouraging providers to settle and practice in rural or underserved areas continues to be a challenge for health workforce planners.
• Insufficient rural residencies. Despite strong evidence that residency graduates are likely to practice near their training sites, and that rural residency programs graduate higher rates of rural physicians, there is a paucity of primary care residency programs that are actually located in rural areas. Similarly, there is a decreasing number of urban and suburban residency programs that prepare physicians for service in rural and underserved areas through rural training tracks or rural clinical rotations (Schneeweiss, Rosenblatt, et al., 2003).
• Market emphasis on specialty care. Powerful market mechanisms have created disincentives for students to choose careers in primary care and practices in rural or underserved communities. It has become increasingly difficult for a career in primary care to be economically attractive, or in some instances, even viable compared with most other specialties (Larson, Roberts, et al., 2005). Current reimbursement mechanisms for healthcare continue to encourage lucrative careers in specialized practice, rather than in primary care. Primary care practice involves more telephone and e-mail communication with patients and more time spent on management and coordination of care. Payors have been reluctant to cover these services (Ginsberg, 2003).
• Small numbers of ethnic minority students. There continues to be an underrepresentation of certain racial and ethnic minorities in medical, dental, and physician assistant education and training programs. Despite recent rulings supporting some forms of affirmative action, many educational institutions are hesitant to use racial diversity as an explicit factor in selecting students. Certain ethnic and racial minorities are more likely to practice in inner cities. Increased representation in these educational institutions and programs would help to address shortages of health professionals in inner cities.