Nurses can be key "REACH" accountable care organization partners to mitigate Medicare inequity.

We propose that Advanced Practice Registered Nurses (APRNs) can be key Accountable Care Organization (ACO) partners in mitigating Medicare inequity due to a shortage of primary care physicians. This shortage particularly impacts minority Medicare beneficiaries residing in urban and rural Health Professional Shortage Areas. In order to expand the primary care workforce to open the gateway to our health care system for these beneficiaries, we propose that APRNs provide primary care in a Medicare Neighborhood Clinic, as key partners of a modified "REACH" (Realizing Equity, Access, and Community Health) ACO model. We review the long history of ineffective efforts to alleviate the physician primary care shortage. After highlighting a report emphasizing the importance of nurses in achieving health equity, we describe the APRN role in a Medicare Neighborhood Clinic, and its potential for alleviating the primary care shortage. This clinic, as part of the modified "REACH" strategy, provides nurses with a key role in achieving Medicare equity. We contend that this strategy, as a means of APRNs providing value-based care to all Medicare beneficiaries while restraining the Medicare budget, contributes to transforming primary care for Medicare equity.

We propose that Advanced Practice Registered Nurses (APRNs) can transform primary care as key Accountable Care Organization (ACO) partners for Medicare equity. They can relieve a shortage of primary care physicians, which impacts minority Medicare beneficiaries residing in Health Professional Shortage Areas. APRNs would be instructed as certified specialty practitioners. An ACO is a health care organization that ties provider reimbursement to quality and to reductions in cost of care. In order to expand the primary care workforce to open the gateway to our health care system for all Medicare beneficiaries, we propose that APRNs provide primary care in a Medicare Neighborhood Clinic, as key partners of a modified "REACH" (Realizing Equity, Access, and Community Health) ACO model. We review the long history of ineffective efforts to alleviate the physician primary care shortage and describe the APRN role in the Medicare Neighborhood Clinic in alleviating this primary care shortage. This clinic, as part of a modified "REACH" ACO strategy, provides nurses with the opportunity to assume a key role in Medicare equity. We contend that this strategy, as a means of providing value-based care to all Medicare beneficiaries while restraining the Medicare budget, contributes to a primary care transition for Medicare equity.

Community Health Centers: a Key Partner to Achieve Medicaid Expansion.

Medicaid expansion is an important feature of the "Affordable Care Act" and also is proposed as a component of some incremental plans for universal healthcare coverage. We describe (1) obstacles encountered with Medicaid coverage, (2) their potential resolution by federally qualified community health centers (CHCs), (3) the current status and limitations of CHCs, and (4) a proposed mega CHC model which could help assure access to care under Medicaid coverage expansion. Proposed development of the mega CHC model involves a three-component system featuring (1) satellite neighborhood outreach clinics, with team care directed by primary care nurse practitioners, (2) a hub central CHC which would closely correspond to the logistics and administration of current CHCs, and (3) a teaching hospital facilitating subspecialty care for CHC patients, with high-quality and cost-effectiveness. We believe that this new model, designated as a mega CHC, will demonstrate that CHCs can achieve their potential as a key partner to insure care under Medicaid expansion.

Community Health Centers Could Provide Better Outsourced Primary Care for Veterans.

The "VA Mission Act of 2018" will expand the current "Choice Program" legislation of 2014, which has enabled outsourcing of VA care to private physicians. As the ranks of Veteran patients swell, Congress intended that the Mission Act will help relieve the VHA's significant access problems. We contend that this new legislation will have negative consequences for veterans by diverting support from our VA system of 1300 hospitals and clinics. We recommend modification of this legislation, promoting much greater utilization of Community Health Centers (CHCs) for veterans outsourced primary care. In support of this proposal, we describe (1) features of the "VA Mission Act" relevant to outsourcing, (2) the challenges of the present "Choice Program" and likely future obstacles with the new legislation, and (3) the advantages of expanding CHC VA outsourced primary care. This policy would focus more on providing specialized care for veterans in the VA system, while coordinating with CHCs for the necessary expanded outsourced, holistic primary care. We conclude that failure to develop an incremental, cost-effective alternative as described herein represents a potential threat to adequate future support of our VA hospital system, and thus outstanding care for our veterans.

A New Community Health Center/Academic Medicine Partnership for Medicaid Cost Control, Powered by the Mega Teaching Health Center.

Community health centers (CHCs), a principal source of primary care for over 24 million patients, provide high-quality affordable care for medically underserved and lower-income populations in urban and rural communities. The authors propose that CHCs can assume an important role in the quest for health care reform by serving substantially more Medicaid patients. Major expansion of CHCs, powered by mega teaching health centers (THCs) in partnership with regional academic medical centers (AMCs) or teaching hospitals, could increase Medicaid beneficiaries' access to cost-effective care. The authors propose that this CHC expansion could be instrumental in limiting the added cost of Medicaid expansion via the Affordable Care Act (ACA) or subsequent legislation. Nevertheless, expansion cannot succeed without developing this CHC-AMC partnership both (1) to fuel the currently deficient primary care provider workforce pipeline, which now greatly limits expansion of CHCs; and (2) to provide more CHC-affiliated community outreach sites to enhance access to care. The authors describe the current status of Medicaid and CHCs, plus the evolution and vulnerability of current THCs. They also explain multiple features of a mega THC demonstration project designed to test this new paradigm for Medicaid cost control. The authors contend that the demonstration's potential for success in controlling costs could provide help to preserve the viability of current and future expanded state Medicaid programs, despite a potential ultimate decrease in federal funding over time. Thus, the authors believe that the new AMC-CHC partnership paradigm they propose could potentially facilitate bipartisan support for repairing the ACA.

Ambulatory training for primary care general internists: innovation with the affordable care act in mind.

BACKGROUND: Although primary care general internists (PCGIs) are essential to the physician workforce and the success of the Affordable Care Act, they are becoming an endangered species. OBJECTIVE: We describe an expanded program to educate PCGIs to meet the needs of a reformed health care system and detail the competencies PCGIs will need for their roles in team-based care. INTERVENTION: We recommended 5 initiatives to stabilize and expand the PCGI workforce: (1) caring for a defined patient population, (2) leading and serving as members of multidisciplinary health care teams, (3) participating in a medical neighborhood, (4) improving capacity for serving complex patients in group practices and accountable care organizations, and (5) finding an academic role for PCGIs, including clinical, population health, and health services research. A revamped approach to PCGI education based in teaching health centers formed by community health center and academic medical center partnerships would facilitate these curricular innovations. ANTICIPATED OUTCOMES: New approaches to primary care education would include multispecialty group practices facilitated by electronic consultation and clinical decision-support systems provided by the academic medical center partner. Multiprofessional and multidisciplinary education would prepare PCGI trainees with relevant skills for 21st century practice. The centers would also serve as sites for state and federal Medicaid graduate medical education (GME) expansion funding, making this funding more accountable to national health workforce priorities. CONCLUSIONS: The proposed innovative approach to PCGI training would provide an innovative educational environment, enhance general internist recruitment, provide team-based care for underserved patients, and ensure accountability of GME funds.

States Can Transform Their Health Care Workforce.

The United States faces the simultaneous challenges of improving health care access and balancing the specialty and geographic distribution of physicians. A 2014 Institute of Medicine report recommended significant changes in Medicare graduate medical education (GME) funding, to incentivize innovation and increase accountability for meeting national physician workforce needs. Annually, nearly $4 billion of Medicaid funds support GME, with limited accountability for outcomes. Directing these funds toward states' greatest health care workforce needs could address health care access and physician maldistribution issues and make the funding for resident education more accountable. Under the proposed approach, states would use Medicaid funds, in conjunction with Medicare GME funds, to expand existing GME programs and establish new primary care and specialty programs that focus on their population's unmet health care needs.

Academic medicine: a key partner in strengthening the primary care infrastructure via teaching health centers.

In the United States, a worsening shortage of primary care physicians, along with structural deficiencies in their training, threaten the primary care system that is essential to ensuring access to high-quality, cost-effective health care. Community health centers (CHCs) are an underused resource that could facilitate rapid expansion of the primary care workforce and simultaneously prepare trainees for 21st-century practice. The Teaching Health Center Graduate Medical Education (THCGME) program, currently funded by the Affordable Care Act, uses CHCs as training sites for primary-care-focused graduate medical education (GME).The authors propose that the goals of the THCGME program could be amplified by fostering partnerships between CHCs and teaching hospitals (academic medical centers [AMCs]). AMCs would encourage their primary care residency programs to expand by establishing teaching health center (THC) tracks. Modifications to the current THCGME model, facilitated by formal CHC and academic medicine partnerships (CHAMPs), would address the primary care physician shortage, produce physicians prepared for 21st-century practice, expose trainees to interprofessional education in a multidisciplinary environment, and facilitate the rapid expansion of CHC capacity.To succeed, CHAMP THCs require a comprehensive consortium agreement designed to ensure equity between the community and academic partners; conforming with this agreement will provide the high-quality GME necessary to ensure residency accreditation. CHAMP THCs also require a federal mechanism to ensure stable, long-term funding. CHAMP THCs would develop in select CHCs that desire a partnership with AMCs and have capacity for providing a community-based setting for both GME and health services research.

Medical student exposure to and attitudes about pharmaceutical companies.

PURPOSE: Medical students are at-risk to the influence of pharmaceutical company (Pharma) marketing. As interactions with the industry come under increasing scrutiny and regulation, previous studies on student-Pharma relations no longer may be accurate. This study assessed students' attitudes toward and interactions with Pharmas at the University of Wisconsin School of Medicine and Public Health (UWSMPH). METHOD: A modified questionnaire based on a previously administered national survey was completed by students in April and May 2009. The survey was analyzed to disclose the frequency of student-Pharma interactions, where interactions took place, and differences between preclinical and clinical students. RESULTS: The overall response rate was 53.6% (348/649). Most student-Pharma interactions took place at locations remote from the main campus, with free lunches (70.2%), snacks (66.9%), and small, non-educational items (55.8%) representing the most common gifts. Many clinical students had discussed medical personnel-Pharma interactions with a physician or friend. Of those surveyed, 78% felt they had received limited instruction from the school on how to interact with Pharma representatives. Preclinical students expressed greater uncertainty about using Pharmas as educational resources and were more reluctant to accept Pharma gifts than clinical students. DISCUSSION: Student attitudes toward interactions with Pharmas reveal the need for further education and guidance-particularly on the risks of using Pharmas as educational resources. Pharma exposures remote from the main campus account for a high proportion of all interactions, which further highlights the need to educate students on conflicts of interest during their preclinical training.

Teaching primary care in community health centers: addressing the workforce crisis for the underserved.

Universal coverage and multiple initiatives to improve health care delivery are crucial components of health care reform. However, the missing link has been a plan to rapidly address the primary care workforce crisis for the underserved. The authors propose a link between primary care graduate medical education and care for the underserved in community health centers, where expansion will be necessary for the anticipated increase in Medicaid and insured patients. This can be achieved by establishing primary care teaching health centers in expanded community health centers, which have established a patient-centered medical home practice environment. Residents would receive their final year of training in these centers, and then have the incentive of National Health Service Corps debt repayment if they subsequently practice in an underserved area. Primary care residents being trained in this setting would immediately increase the clinical capacity of community health centers and ultimately expand the primary care physician workforce. This proposal addresses the primary care physician workforce crisis and the associated key problems of limited access for the underserved and suboptimal primary care graduate medical education.

Wisconsin physician opinions on health care reform.

OBJECTIVE: To determine Wisconsin physicians' opinions regarding health care reform. METHODS: The University of Wisconsin Survey Research Center performed a 46-question mail survey of 2500 randomly selected physicians from the Wisconsin Medical Society master list of practicing physicians. Respondents rated opinions on a 5-point Likert scale. Demographics of respondents (sex practice type, geographic location, age) were compared to non-responders and the overall Wisconsin physician population. Data analysis quantified opinions regarding the health care system in Wisconsin and nationally, elements of health care reform proposals, and the role of public policy and government in health care. The analysis emphasized a comparison of primary care versus specialist physician responses. RESULTS: The survey yielded a 38% response rate. Respondent demographics were representative of Wisconsin physicians and very similar to nonresponders. Respondents revealed support for several topics, regardless of the respondent's practice type. Respondents also were in agreement on which elements of reform were most frequently favored and most frequently opposed. Nevertheless, there were many areas where primary care physicians strongly differed from specialists, such as favoring legislation for national health insurance (65.6% primary care versus 46.2% specialist). CONCLUSIONS: Wisconsin physicians responding to this survey expressed dissatisfaction with the health care system in which they currently practice and noted a clear desire for system reform. While most respondents agree on a few key priorities, primary care physicians significantly differ in their preferred strategies for reform and, in particular, the role of government in a reformed system. These results indicate a need for more dialogue and education among physicians in order to achieve a consensus that might help promote reform.

Short report: factors that affect specialty choice and career plans of Wisconsin's medical students.

OBJECTIVE: To identify factors that influence specialty choice among Wisconsin medical students and provide insight into approaches to encourage more students to pursue careers in primary care. METHODS: The importance of several factors in medical student career choice was surveyed using a Web survey convenience sample of all Wisconsin medical students. Students intending to pursue a career in primary care and in other specialties were compared. RESULTS: Respondents, regardless of specialty choice or gender, identified a similar group of factors as highly influential, and similar group of factors as non-influential in their decision-making. However, significantly more primary care students than other specialty students considered interest in underserved populations, relationships with patients, scope of practice, and role models important in their career choice. Significantly more primary care students than other specialty students responded that salary and competitiveness were "not at all" important. A greater number of other specialty students than primary care students stated that interest in scope of practice, role models, and training years were "not at all" important. Debt-related factors were reported as "not at all" important by nearly one-third of respondents. CONCLUSIONS: Although primary care and other specialty students report making their career plans based on the impact of similar factors, significant differences between primary care and other specialty students were reported in key areas. These results validate many previously reported factors, and indicate that salary and years of training may have been overemphasized in understanding student career choice. The results of this survey may be useful for Wisconsin medical schools in order to sustain, support, and foster student interest in primary care.