Fiscal Year 2011 Report to Congress on the Preventive Medicine and Public Health Training Grant Program

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1 Fiscal Year 2011 Report to Congress on the Preventive Medicine and Public Health Training Grant Program U.S. Department of Health and Human Services Health Resources and Services Administration

2 EXECUTIVE SUMMARY Section 768 of the Public Health Service (PHS) Act (42 U.S.C. 295c), as amended by section 10501(m)(1) of the Affordable Care Act, requires that the Secretary of Health and Human Services submit an annual report to the United States Congress on the Preventive Medicine and Public Health Training Grant Program. This second annual report provides a brief description of preventive medicine as a specialty and the history of the Preventive Medicine Residency (PMR) Program administered by the Health Resources and Services Administration (HRSA). This report includes a summary of the grant funding awarded through the program and the activities supported through those grants for fiscal year (FY) This report represents the budget period effective July 1, 2011, through June 30, Preventive medicine is one of 24 medical specialties recognized by the American Board of Medical Specialties. Preventive medicine physicians are trained in both clinical medicine and public health. Within the specialty, there are three disciplines: aerospace medicine, occupational medicine, and preventive medicine and public health. The Preventive Medicine and Public Health Training Grant Program enables the Secretary of Health and Human Services, acting through the Administrator of HRSA, in consultation with the Director of the Centers for Disease Control and Prevention, to award grants to or enter into contracts with eligible entities to provide training to graduate medical residents in preventive medicine specialties. The Affordable Care Act amended the PHS Act to expand the applicant eligibility beyond accredited schools of public health and medicine or osteopathic medicine to include accredited residency programs in public or private nonprofit hospitals; state, local, or tribal health departments; or a consortium of two or more eligible entities. The statute authorizes the Preventive Medicine and Public Health Training Grant Program to provide funding to: 1. plan, develop, operate or participate in an accredited residency or internship program in preventive medicine or public health; 2. defray the costs of practicum experiences, as required in such a program; and 3. establish, maintain or improve academic administrative units in preventive medicine and public health or programs that improve clinical teaching in preventive medicine and public health. HRSA began awarding grants to support PMR training over 3 decades ago. The program was authorized by section 2746 of the Omnibus Budget Reconciliation Act of 1981, Public Law In 2010, the Affordable Care Act amended the PHS Act and reauthorized the program as the Preventive Medicine and Public Health Training Grant Program. This second annual report builds on the first report for FY The report provides information on individual funding levels and summary activities conducted by nine grantees in year 2 of a 3-year project period whose grants were supported with $3,408,395 in FY 2011 general appropriations. The report also provides information on the eight PMR grantees funded in FY 2010 with $6.7 million from the American Recovery and Reinvestment Act (ARRA). The ARRA grantees, fully funded from July 1, 2010, through June 30, 2013, received a 3-year project and budget period. The PMR grant funds (whether supported by ARRA or through general appropriations) supported residents in their second and third years of training in preventive medicine. 2

3 Table of Contents BACKGROUND...4 Preventive Medicine as a Specialty...4 Legislative Funding History...6 HRSA PREVENTIVE MEDICINE PROGRAM...7 PMR Programs and Funding Levels...7 American Recovery and Reinvestment Act Grantees...9 Program Highlights...9 SUMMARY

4 BACKGROUND HRSA works to improve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs. The Preventive Medicine and Public Health Training Grant Program supports the training of these valuable providers. Under the PHS Act, Title VII, Section 768 (42 U.S.C. 295c), as amended by section 10501(m)(1) of the Affordable Care Act (P. L ), the Secretary of the Department of Health and Human Services (HHS) is required to submit an annual report to Congress regarding the HRSA Preventive Medicine Residency and Public Health Training Grant Program. This is the second annual report developed in response to this requirement. Preventive Medicine as a Specialty Preventive medicine is one of 24 medical specialties recognized by the American Board of Medical Specialties. 1 Preventive medicine physicians are trained in both clinical medicine and in public health areas such as biostatistics, epidemiology, environmental and occupational medicine, planning and evaluation of health services, management of health care organizations, research into causes of disease and injury in population groups, and the practice of prevention in clinical medicine. Within preventive medicine, there are three specialty areas that share common core knowledge, skills, and competencies, but emphasize different populations, environments, or practice settings. These areas are aerospace medicine (AM), occupational medicine (OM), and public health and general preventive medicine (PH/GPM). 2 The American Board of Preventive Medicine defines each specialty on its website. AM focuses on the clinical care, research, and operational support of the health, safety, and performance of crewmembers and passengers of air and space vehicles and support personnel who assist with the operation of such vehicles. OM focuses on the health of workers, including the ability to perform work; the physical, chemical, biological, and social environments of the workplace; and the health outcomes of environmental exposures. PH/GPM focuses on promoting health, preventing disease, and managing the health of communities and defined populations. The PH/GPM physicians combine populationbased public health skills with the knowledge of all three levels of disease prevention, primary, secondary, and tertiary prevention in clinical practice. Primary prevention aims to prevent the disease from occurring, such as urging people to protect themselves from the sun s ultraviolet rays to prevent skin cancer. Secondary prevention is used after the disease has occurred and often before the person notices any symptoms. The goal is to find and treat disease early, with hopes that the condition can be cured. Tertiary prevention addresses the needs of an individual who already has the symptoms of a disease often in order to prevent additional damage and pain, to slow down the progress of the disease, to prevent the disease from causing other complications, to give better care 1 American Board of Medical (ABMS) Specialties, About ABMS Member Boards website: accessed May 1, Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in Preventive Medicine accessed May 4,

5 to those with the disease, and to make people with the disease healthy again. This includes the development of better treatments. 3 PMR programs are accredited by the Accreditation Council for Graduate Medical Education (ACGME) and/or the American Osteopathic Association. As of July 2011, ACGME has modified training requirements to require 24 months duration including 4 months of direct patient care in the 2 years. ACGME requires that residents must have a minimum of 2 months of direct patient care experience during each year of the program. The training requirements consist of 2 years of competency-based education that includes both academic and practicum based training. The preventive medicine residency curriculum incorporates the attainment of a Master s of Public Health (MPH) or other appropriate postgraduate degree as described below. Accredited PMR programs require prior graduate medical education training, including at least 1 year of clinical training. Teaching hospitals may receive Medicare graduate medical education (GME) payments for residents in accredited preventive medicine programs, but Medicare places limitations on GME payments for resident activities in non-hospital (community) settings. The new requirements specify that preventive medicine physicians may complete either the MPH or an equivalent degree, such as a Master s of Science in Epidemiology, Preventive Medicine, Community Health, Tropical Medicine and Hygiene, Occupational Health, Environmental Science, Environmental Toxicology, Health Sciences, Health Administration or Business Administration. These equivalent degrees are in lieu of the previously required MPH degree. The residents must also complete didactic courses specific to their concentration. All residents must complete graduate level courses in epidemiology, biostatistics, health services management and administration, environmental health, and the behavioral aspects of health. Required content is specific to the concentration of the program. The public health and general preventive medicine residents should complete applied epidemiology (to include acute and chronic disease), advanced biostatistics, advanced health services management, clinical preventive services, and risk/hazard control and communication. The occupational medicine concentration residents should complete courses in toxicology, occupational epidemiology, industrial hygiene, safety and ergonomics, and risk/hazard control and communication. The aerospace medicine residents should complete courses in toxicology; global health and travel medicine; principles of aviation and space medicine; and accident investigation/risk management and mitigation. 4 The American Medical Association publication Physician Characteristics and Distribution in the U.S., 2012, provides data on physicians located in the United States and its territories. According to the 2010 survey data cited in this publication, less than one percent of all active physicians (3,612 male and 1,454 female) identified themselves as preventive medicine specialists. 5 According to the American College of Preventive Medicine, the national professional society for physicians committed to health promotion and disease prevention, preventive medicine physicians work in diverse settings to promote health and to modify or eliminate the risks of disease, injury, disability, and death. Career paths include managed care, public health, 3 Centers for Disease Control and Prevention Module 13: Levels of Disease Prevention accessed August 1, ACGME Program Requirements for Graduate Medical Education in Preventive Medicine, Effective July 1, Physician Characteristics and Distribution in the U.S., American Medical Association, Washington, D.C. 5

6 occupational medicine, aerospace medicine, clinical medicine, informatics, policy development, academic medicine, international medicine, educational institutions, organized medical care programs in industry, voluntary health agencies, professional health organizations, and research at all levels of government. 6 Legislative Funding History The PMR Program was initially authorized under section 793 of the PHS Act, as amended by the Omnibus Reconciliation Act of 1981 (P. L ), enacted August 13, Section 793 of the PHS Act regarding Training in Preventive Medicine provided authority to the HHS Secretary to make grants to and enter into contracts with schools of medicine, osteopathic medicine, and public health to meet the costs to plan and develop new residency training programs. The statute also provided the authority to maintain or improve existing training programs in preventive medicine and to provide financial assistance to residents enrolled in such programs. The Health Professions Education Partnership Act of 1998 (P. L ) authorized the Secretary of HHS to make grants to and enter into contracts with schools of medicine, osteopathic medicine, public health, and dentistry to meet the costs of planning and developing new residency training programs in Preventive Medicine and Dental Public Health. The Act also authorized the Secretary to maintain or improve existing residency training programs in preventive medicine and dental public health and to provide financial assistance to residency trainees enrolled in such programs. Funding opportunities for PMR programs and dental public health residency programs were offered under separate funding opportunities. Section 10501(m)(1) of the Affordable Care Act enacted March 23, 2010, amended section 768 of the PHS Act and authorized the Secretary, acting through the HRSA Administrator and in consultation with the Director of the Centers for Disease Control and Prevention, to award grants or contracts to eligible entities to provide training to graduate medical residents in preventive medicine specialties. Additionally, the section renamed the program the Preventive Medicine and Public Health Training Grant Program. The Affordable Care Act also expanded the types of entities eligible to apply for the program by including accredited public or private nonprofit hospitals; state, local or tribal health departments; or a consortium of two or more of the eligible entities. Prior to the Affordable Care Act, the eligible applicants for the PMR grant program were only accredited schools of allopathic medicine, osteopathic medicine, and public health. The Affordable Care Act also expanded the scope of how funds may be used. Under the Affordable Care Act, funds may be used to (1) plan, develop, operate, or participate in an accredited residency or internship program in preventive medicine or public health; (2) defray the costs of practicum experiences, as required in such a program; and (3) establish, maintain, or improve academic administrative units or programs that improve clinical teaching in preventive medicine and public health. Funds may also be used to support the cost of curricula development at departments, divisions, or other appropriate units in preventive medicine and public health. 6 American College of Preventative Medicine Resources For Medical Students and Prospective Residents accessed May 10,

7 HRSA PREVENTIVE MEDICINE PROGRAM PMR Programs and Funding Levels The HRSA-sponsored PMR grant program provides support for the second or third year (postgraduate years 2 and 3) of training. Residents are eligible to receive support in the form of stipends (living allowance), tuition, and fees. Programs may also provide travel support for those residents who make presentations on their research projects or poster presentations at national meetings. Grantees are awarded multi-year project periods (for FY 2011, the grantees were in the second year of a 3-year project period), but have annual budget periods for each year of the project period. The initial grant awards which define the project period are made through a competitive process. Annual awards for subsequent budget periods are made through a noncompetitive process until the project period has ended. Funding for each annual budget period depends on the appropriated funding level for that year and satisfactory grantee performance. During the new competing cycle in FY 2010, $2.8 million was awarded to support nine PMR programs. These nine grantees consisted of seven PH/GPM and two OM programs (see Table 1). Two of the funded grantees, the University of New Mexico and the University of Medicine and Dentistry of New Jersey-New Jersey School of Medicine, were newly accredited PMR programs. These two residency programs began implementing training plans with their first cohort of residents on July 1, The first class graduated on June 30, Table 1 below highlights total FY 2010 and 2011 funding levels supported through regular appropriations. FY 2011 award amounts were consistent with the budget requests submitted in the regular application. These requests were reviewed by HRSA before final award amounts were determined. Table 1: FY 2010 Competing and 2011 Noncompeting Award Levels (Regular appropriations) FY 2010 Competing Nine Grantees FY2010 Average Award FY 2011 Non Competing Nine Grantees FY 2011 Average Award $2,831,147 $314,571 $3,408,395 $378,711 Table 2 below identifies the individual grantees, award amounts for each grantee in FY 2010 and FY 2011, and the specialty discipline supported by each grantee. Table 2: FY 2010 and FY 2011 Regular Appropriations Award Amounts Per Preventive Medicine Residency and Public Health Training Grant State Grantee Discipline Award (FY 2010) Award (FY 2011) California University of California, San Francisco OM $118,589 $190,000 Colorado University of Colorado Health Sciences Center, Denver GPM/PH $204,704 $264,426 7

8 State Grantee Discipline Award (FY 2010) Award (FY 2011) Georgia Morehouse School of Medicine GPM/PH $520,478 $542,457 Michigan University of Michigan, Ann Arbor GPM/PH $655,981 $782,889 New Jersey University of Medicine and Dentistry of New Jersey New Jersey Medical School (UMDNJ-NJMS) GPM/PH $172,878 $325,976 New Mexico University of New Mexico Health Sciences Center GPM/PH $298,533 $343,643 New York State University of New York SUNY at Stony Brook GPM/PH $293,214 $296,702 Oregon Oregon Health and Science University (OHSU) GPM/PH $261,443 $321,347 Utah University of Utah OM $305,327 $340,955 Total $2,831,147 $3,408,395 Table 3 provides information about the number of residents supported by each PMR grantee, including the number supported through the HRSA grant, and the total number of residents enrolled in preventive medicine at the grantee institutions. In 2011, HRSA supported slightly more than half of the residents enrolled in preventive medicine programs at the nine grantee institutions. Specifically, HRSA grants provided financial support for 27 of the 50 preventive medicine residents enrolled by HRSA grantees. This funding supports the second and third years (postgraduate years 2 and 3) of training in preventive medicine, which consists of an academic year and a practicum year. Table 3: FY 2011 Number of Residents Receiving Support by Grantee State Grantee Residents Supported by HRSA PMR Grant Total Number of Residents in Training California University of California, San Francisco 2* 4* Colorado University of Colorado Health 6* 7* Sciences Center, Denver Georgia Morehouse School of Medicine 6* 8* Michigan University of Michigan, Ann Arbor 4* 7* New UMDNJ NJMS 7 2* 2* Jersey New University of New Mexico Health 2* 2* Mexico Sciences Center 8 New York SUNY at Stony Brook 2* 8* 7 UMDNJ-NJMS the first resident cohort started July 1, The first graduating class is expected in June University of New Mexico the first resident cohort started July 1, The first graduating class is expected in June

9 State Grantee Residents Supported by HRSA PMR Grant Total Number of Residents in Training Oregon Oregon Health Sciences University 0** 4* (OHSU) Utah University of Utah 3* 8* Total *Information reported by the PMR grantees. ** OHSU received its award after the performance reporting period. American Recovery and Reinvestment Act (ARRA) Grantees In addition to the grantees supported through regular FY 2011 appropriations, eight PMR programs continued to operate with $6.7 million in funds awarded previously in FY 2010 through the ARRA. The ARRA grantees, fully funded from July 1, 2010, through June 13, 2013, received a 3-year project and budget period. The ARRA funded grantees include the following: University of California, Davis; University of California, San Diego; Griffin Hospital Inc.; Emory University; Tulane University; Johns Hopkins University; University of Rochester; and University of Pennsylvania. At the end of the academic year, the eight ARRA grantees reported 28 enrolled residents, 11 of which were supported through HRSA funds. For the academic year, these grantees retained 25 residents from the first year of training and enrolled 23 new residents for a total of 48 residents. Of the 48 residents trained in the academic years, 26 of them received HRSA support. HRSA provides funding to 23 percent, or 17 of the 73, ACGME accredited preventive medicine residency programs with nine receiving funds from regular appropriations and eight receiving ARRA funds. The HRSA PMR grants are a significant mechanism for improving diversity within the health professions. In 2011, over a third (35 percent) of the graduates from these grantee programs were underrepresented minorities. Program Highlights The HRSA-funded residency programs may support residents directly through stipends for reasonable living expenses, tuition, and fees. A portion of the funds may support faculty who are directing the program, developing curricula, and teaching. The residency programs are addressing emerging topics in public health, preventive medicine, and population health care needs of diverse populations. Grantees annually report their progress in meeting objectives and data on resident and project characteristics in the performance measures reports. They also provided presentations to their grantee peers through webinars. These self-reported highlights from the 17 preventive medicine residency programs include the following: University of California, San Francisco is expanding occupational and environmental medicine (OEM) training opportunities. This program is also developing partnerships with community-based clinics to arrange site-visits, clinical lectures, health screenings, and clinical consultations for patients with OEM issues. 9

10 University of Colorado Health Sciences Center, Denver increased the number of minority and disadvantaged residents in the program through outreach. Morehouse School of Medicine developed a health informatics series to train its preventive medicine residents on the principles and methods of medical informatics, emphasizing the impact on health care delivery. University of Michigan-Ann Arbor developed a partnership with a HRSA-funded public health training center (PHTC) to provide training opportunities for preventive medicine residents. Training included face-to-face grand rounds and online topics that are not typically taught during medical school or the residency program. This teaching met requirements of the American College of Graduate Medical Education (ACGME) for experience in teaching. University of Medicine and Dentistry-New Jersey Medical School Urban Preventive Medicine/Public Health Residency Program formed a partnership with a New Jersey PHTC to provide preventive medicine residents with the opportunity to teach, supervise, and mentor medical students, meeting requirements established by ACGME. University of New Mexico Health Sciences Center preventive medicine residents received training with the First Nations Community HealthSource, a Federally Qualified Health Center and the only Title V Urban Indian Health Program in New Mexico. Residents provided patient care and education in diabetes and obesity prevention, smoking cessation, and women's health services. These activities help meet the HRSA priority of integrating public health and primary care and caring for vulnerable populations. State University of New York, Stony Brook developed a new course in vaccinology to provide a solid foundation in immunization for primary prevention; knowledge about the impact of vaccines on the public health; and the development, composition, testing, and use of vaccines. Oregon Health and Science University held a policy symposium with co-sponsorship from its Center for Evidence-Based Policy. The program convened a variety of local and regional health professionals, members of the community, and local policy organizations to discuss early childhood health policy and other issues. University of Utah emphasized interdisciplinary collaboration in developing new training rotations and educational experiences in clinical prevention, workplace health promotion, and occupational health program development and management. Emory University established rotations and practical learning experiences with an advisory committee for its maternal, child, and family health track. The committee consisted of leaders in population health; community-based health care; and clinical maternal, child, and family health. Griffin Hospital Health Services implemented new rotations for preventive medicine 10

11 residents at the Yale Addiction Medical Clinic, University of Connecticut (for comparative effectiveness research), and the Harvard Institute of Lifestyle Medicine. Johns Hopkins University had more than 50 percent of its residents work directly with vulnerable populations. Residents directed community intervention projects related to health behavior change, health coaching, and other activities to improve health choices and behavior. Tulane University established partnerships with the Louisiana Office of Public Health. Residents received the majority of their practicum educational experience, and professional mentoring in infectious diseases, epidemiology, environmental health, vaccine preventable diseases, maternal and child health, family planning, genetic screening, chronic disease surveillance and control, and public health administration. University of California, Davis School of Medicine established a memorandum of understanding with the California Department of Public Health Preventive Medicine Residency Program to increase collaboration between the two institutions in the areas of teaching, research, and public health practice. San Diego State University and University of California, San Diego operated a refugee health clinical screening program in partnership with the local public health department. Residents received trainings in specific competencies, communication, cultural diversity, teamwork, systems practice in the complex refugee health and social services systems, quality improvement, public speaking, and population-based assessment of health care needs. University of Pennsylvania program focused on occupational medicine directed primarily at experienced physicians making a mid-career change to full-time practice in the field. The program implemented subject-area rotations, intensive didactic training in specific competencies, and clinical training rotations. University of Rochester School of Medicine and Dentistry strengthened their residency program through enhancing their ongoing systematic evaluation of its programs. Variables assessed included the educational quality of existing and newly developed training sites; demonstrated commitment to preventive medicine practice in underserved areas among applicants and residents; and quantity and quality of training in direct patient care settings. SUMMARY Preventive medicine physicians provide leadership in public health and enhance the quality of preventive medicine services. Preventive medicine is tasked with addressing population health needs and coordinating population training with specialties that can strengthen the clinical aspect of preventive medicine and primary care. Specific challenges to the development of preventive medicine as a specialty are the ability to attract more residents who will serve as public health leaders and the ability to maintain ample funding for programs to train, supervise, and evaluate their residents. 11

12 In 2011, the HRSA PMR Program supported, through regular appropriations and ARRA funding, almost a quarter (23 percent) of the ACGME-accredited preventive medicine residency programs in the country. In addition, the programs have trained many of their residents in medically underserved areas, and a significant portion of the residents are underrepresented minorities. As a result, these programs increased the opportunities for their residents to become more culturally competent. These programs have also enhanced access to preventive care by vulnerable and underserved populations. The health problems of today, such as emerging infectious diseases and non-communicable chronic diseases, present tremendous challenges and require extraordinary solutions involving prevention, public health, and ongoing and increased leadership from preventive medicine physicians. HRSA is committed to strengthening preventive medicine training through innovative programs and increasing access to health care by developing a diverse, culturally competent health workforce. 12

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