BILL ANALYSIS Ó
AB 2216
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Date of Hearing: April 12, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
AB 2216
(Bonta) - As Amended March 28, 2016
SUBJECT: Primary care residency programs: grant program.
SUMMARY: Establishes the Teaching Health Center (THC) Primary
Care Graduate Medical Education Fund for purposes of funding
primary care residency programs. Specifically, this bill:
1)Establishes the Teaching Health Center Primary Care Graduate
Medical Education Fund (Fund) in the State Treasury.
2)Requires the Director of the Office of Statewide Health
Planning and Development (OSHPD) to award planning and
development grants from the Fund to teaching health centers
for the purpose of establishing new accredited or expanded
primary care residency programs.
3)Provides that grants awarded must not be for more than three
years and that the maximum award to a teaching health center
must not be more than five hundred thousand dollars
($500,000).
4)Specifies that grants be used to cover the costs of
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establishing or expanding a primary care residency training
program, including costs associated with curriculum
development, recruitment, training, and retention of residents
and faculty, accreditation by the Accreditation Council for
Graduate Medical Education (ACGME), the American Dental
Association (ADA), or the American Osteopathic Association
(AOA), faculty salaries during the development phase, and
technical assistance.
5)Requires OSHPD, subject to an appropriation by the
Legislature, to award sustaining grants from the Fund to THCs
operating primary care residency programs accredited by the
ACGME, ADA, or AOA, and requires OSPHD to determine the amount
of grants awarded per resident by taking into account the
direct and indirect costs of graduate medical education.
EXISTING LAW:
1)Establishes OSHPD to, among other functions, collect data and
disseminate information about California's health care
infrastructure, promote equitable distribution of health care
outcomes, and publish information about health care outcomes.
2)Establishes the California Healthcare Workforce Policy
Commission (Commission) and requires the Commission to, among
other things, identify specific areas of the state where unmet
priority needs for primary care family physicians and
registered nurses exist; establish standards for family
practice training programs, family practice residency
programs, primary care physician assistants programs, and
programs that train primary care nurse practitioners; and,
review and make recommendations to OSHPD concerning the
funding of those programs that are submitted to the Health
Professions Development Program for participation in the state
medical contract program.
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3)Establishes the Health Professions Education Foundation (HPEF)
within OSHPD. Requires the HPEF to solicit and receive funds
from foundations and other private and public sources and to
provide financial assistance in the form of scholarships or
loans to students in the health professions who are from
underrepresented groups. Provides that HPEF governed by a
board consisting of 13 members appointed by the Governor,
Speaker of the Assembly, and Senate Rules Committee.
4)Establishes, under the HPEF, scholarship, loan, and loan
repayment programs for registered nurses, vocational nurses,
geriatric nurse practitioners, clinical nurse specialists, and
mental health professionals who agree to practice for
specified periods of time in underserved areas and in
designated practice settings.
5)Establishes, under HPEF, the Steven M. Thompson Physician
Corps Loan Repayment Program (STPCLRP), which provides for the
repayment of educational loans for licensed physicians and
surgeons who practice in medically underserved areas of the
state. Requires HPEF, in administering the STPCLRP, to use
and develop guidelines for applicants that give preference to
applicants who are best suited to meet the cultural and
linguistic needs of patients in medically underserved
populations, as specified, and who agree to practice in
geriatric care settings. Also allows HPEF to appoint a
selection committee to provide policy direction and guidance
to the STPCLRP. Requires funds for loan repayment under the
STPCLRP to have a funding match from a foundation or other
private source. Establishes a Medically Underserved Account
for Physicians within the Fund, the primary purpose of which
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is to provide funding for the STPCLRP.
6)Establishes within OSHPD the Health Professions Education Fund
to receive funds for scholarships and loans to students from
underrepresented groups who are enrolled in or accepted to
schools of medicine, dentistry, nursing, and other health
professions. Provides that moneys in the fund are
continuously appropriated.
7)Establishes the Song-Brown Health Care Workforce Training Act
of 1973 (Song-Brown Act), administered by OSHPD to provide
financial support to family practice residency programs, nurse
practitioner and physician assistant programs, and registered
nurse education programs to increase the number of students
and residents receiving education and training in family
practice and nursing. The Song-Brown Act also encourages
universities and primary care health professionals to provide
health care in medically underserved areas.
FISCAL EFFECT: This bill has not been analyzed by a fiscal
committee.
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author THCs are a
proven model for addressing the primary care provider shortage
that six of nine California regions face. The author notes
that 40% of THC graduates entering into primary care practice
in nonprofit, community health centers in underserved
communities as opposed to just 4% of traditional medical
residents. The author concludes that this bill will help
ensure California has a sufficient supply of health workforce
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professionals to serve the needs of our diverse state.
2)BACKGROUND.
a) Primary Care in California. California is home to the
largest number of primary care physicians and nurse
practitioners in the country. However, the state ranks
23rd in the number of primary care physicians per resident.
An August 2014 report by the California HealthCare
Foundation states that California has only 35 to 49 primary
care physicians per 100,000 Medi-Cal enrollees. Federal
guidelines call for the state to have 60 to 80 doctors per
100,000 patients. The supply of primary care physicians
also varies substantially across California's counties.
The number of primary care physicians actively practicing
in California counties is, in too many cases, at the bottom
range of, or below, the state's need. According to 2011
Health Resources and Services Administration (HRSA) data,
29 of California's 58 counties fall at the lower end, or
below, the needed supply range for primary care physicians.
In other words, half of Californians live in a community
where they do not have adequate access to the health care
services they need.
b) The Teaching Health Center Graduate Medical Education
(THCGME) program. THCGME, funded since 2011 and set to
expire in 2015, has increased the numbers of primary care
physicians and dentists training to care for underserved
populations nationwide. Without continued federal funding,
most of these THCs report that they would be unlikely to
continue current residency recruitment and enrollment,
threatening the initial program investments and even the
viability of the program itself.
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According to a 2015 Robert Graham Center report, "Teaching
Health Center GME Funding Instability Threatens Program
Viability," residents who train in underserved settings are
more likely to continue to practice in similar
environments. The THCGME program supports new and expanded
community-based primary care training programs.
Organizations that can qualify to be THCs include federally
qualified health centers, rural health clinics, and tribal
clinics-all organizations that care for the underserved.
Unlike most other GME payments, funds flow directly to the
community-based, ambulatory patient care centers where
residents train, instead of teaching hospitals. The
investment of $230 million over five years (2011 to 2015)
represents 0.3% of the annual $15 billion federal GME
funding that supports more than 120,000 residents in
training each year nationwide. THCGME will expire in 2015
if there is no congressional action to extend it.
Since their creation under the Patient Protection and
Affordable Care Act (ACA) six THCs have opened in
California, however they are in danger of closing due to
the uncertain funding. They are located in Modesto,
Fresno, San Bernardino, Redding, Bakersfield, and San
Diego.
Nationally, the majority of THCGME supported programs are
just beginning to have their first graduating classes. The
first grants did not start in California until fiscal year
2011 for Academic Year 2011-2012. Primary care residencies
are three years long.
According to a California Primary Care Association (CPCA)
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January 2015 report, "Horizon 2030," preliminary results
from the national study demonstrate positive and promising
results for THCGME. Most notably:
i) Almost all (91%) of THC graduates remain in primary
care practice, compared to less than one-quarter (23%) of
traditional GME graduates;
ii) About three times as many THC graduates (76%) choose
to practice in underserved communities, compared to 26%
of traditional graduates;
iii) Almost four times (21%) as many THC graduates enter
practice in rural areas, versus 5% of traditional
graduates;
iv) Forty percent (40%) of THC graduates go on to
practice at Community Clinic Health Centers, compared to
2% of traditional graduates; and,
v) Most (66%) of the initial THC graduates continue to
practice in the states where they were residents.
3)SUPPORT. CPCA is the sponsor of this bill and states that
this bill will help address California's primary care provider
shortage by establishing the Fund, providing planning and
development grants to THCs for the purpose of establishing new
accredited or expanded primary care residency programs, and
make available sustaining grants to ensure the continued
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operation of accredited THCs. CPCA estimates that 8,243
additional primary care physicians will be needed in
California by 2030, and notes that with dwindling federal
support for current THC sites and no federal investment to
develop new sites, California must prioritize and demonstrate
its commitment to providing access to primary care through a
greater investment in the THC model.
The County Health Executives Association of California and the
California School Employees Association support this bill,
noting that, since the passage of the ACA, the workforce of
primary care physicians in California has not kept pace,
especially with increasing enrollment in Medi-Cal, and this
bill will assist in meeting the need for physicians to serve
the growing number of newly insured and Medi-Cal patients.
The Association of California Healthcare Districts (ACHD)
states, healthcare districts located in rural and remote areas
of the state have a difficult time recruiting health
professionals to their areas. ACHD notes that THCs are on the
leading edge of innovation educational programming dedicated
to ensuring a relevant and sufficient supply of health
workforce professionals, however due to limited and uncertain
federal funding the six programs in California are in jeopardy
of closing. ACHD concludes that this bill will support the
expansion of primary care residency programs in California.
4)OPPOSITION. The California Right to Life Committee, Inc.
opposes this bill stating that because the definition of a
California Primary Care Residency Program includes obstetrics
and gynecology, they are assuming that Title X and family
planning education will be included in the medical education
for the residency program.
5)RELATED LEGISLATION.
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a) AB 2048 (Gray) requires OSHPD, in its administration of
the National Health Service Corps State Loan Repayment
Program (SLRP), to include all federally qualified health
centers (FQHCs) located in California on the program's
certified eligible site list. AB 2048 is currently pending
in the Assembly Appropriations Committee.
b) SB 22 (Roth) appropriate $300 million from the General
Fund to the director of OSHPD for the purpose of funding
new and existing GME physician residency positions, and
supporting training faculty. SB 22 is currently pending in
the Assembly Rules Committee.
6)PREVIOUS LEGISLATION.
a) SB 1416 (Rubio) of 2012 would have created the Graduate
Medical Education Trust Fund for the purpose of funding
grants to graduate medical education residency programs in
California, and would have required OSHPD to develop
criteria for distribution of available moneys. SB 1416 was
held in the Assembly Appropriations Committee
b) AB 589 (Perea), Chapter 339, Statutes of 2012,
establishes the Steven M. Thompson Medical School
Scholarship Program and would provide that the program is
open to persons who agree in writing, prior to entering an
accredited medical or osteopathic school, to serve in an
eligible practice setting, as defined, for at least three
years.
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c) SB 635 (EHernandez) of 2011 would have required funds
deposited in the Managed Care Administrative Fines and
Penalties Fund in excess of $1 million be transferred each
year to OSHPD for the purposes of the Song-Brown Program.
SB 635 was held in the Assembly Appropriations Committee.
d) TECHNICAL AMENDMENT. As currently drafted this bill
requires OSHPD to award sustaining grants from the Fund to
THCs operating primary care residency programs accredited
by the ACGME, ADA, or AOA, and requires OSPHD to determine
the amount of grants awarded per resident by taking into
account the direct and indirect costs of graduate medical
education, but does not define what a "sustaining grant"
is. This bill should be amended as follows:
On page 3, between lines 31 and 32 insert: (c) For
purposes of this section, "sustaining grant" means a grant
awarded to ensure the continued operation of an accredited
teaching health center, whether that accreditation is first
awarded pursuant to the process created by this article or
the accreditation is awarded prior to enactment of this
article.
REGISTERED SUPPORT / OPPOSITION:
Support
California Primary Care Association (sponsor)
Alameda Health Consortium
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AltaMed Health Services Corporation
Ampla Health
Association of California Healthcare Districts
Community Clinic Association of Los Angeles County
California School Employees Association
Clinica Sierra Vista
Community Clinic Consortium
Community Health Center Network
County Health Executives Association of California
Family Health Centers of San Diego
Health Alliance of Northern California
Health and Life Organization, Inc.
Kheir Center
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Marin Community Clinics
Mountain Valleys Health Centers
North Coast Clinics Network
North County Health Services
North East Medical Services
Omni Family Health
Open Door Community Health Centers
Ravenswood Family Health Center
Redwood Community Health Coalition
San Ysidro Health Center
St. John's Well Child & Family Center
Tiburcio Vasquez Health Center, Inc.
Valley Community Healthcare
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Western Sierra Medical Clinic
White Memorial Community Health Center
Opposition
California Right to Life Committee, Inc.
Analysis Prepared by:Lara Flynn / HEALTH / (916) 319-2097