Training Maine’s Family Physicians: Vital Health Care Providers

One of the biggest challenges facing rural communities in Maine and throughout the nation is ensuring access to health care. In Maine, we are experiencing a significant shortage of physicians, particularly in the area of primary care. According to the Maine Recruitment Center, our state is facing its greatest shortage of physicians since the Center began in 1999, with 206 positions going unfilled. Ninety-two of these openings are for primary care physicians. That is why I have been so concerned about actions on the part of the Centers for Medicare and Medicaid Services (CMS), the agency that funds many of the nation’s medical training programs, which are compromising the training of resident physicians in our state, and particularly those in primary care specialties. With its many medically underserved areas, Maine depends on five medical residency programs as pipelines for recruiting physicians to locate and practice in our state. Not only are these programs critical to providing medical students with the quality education and diverse range of training and experience they need to become good doctors, but they also result in a pool of qualified doctors for our state, many of whom choose to practice in Maine’s rural communities. The evidence is clear that medical residents who train in Maine are much more likely to stay on to practice in our State. An important component of Maine’s residency programs is their use of community-based teaching sites. This is particularly true for primary care residencies. Community-based training is designed to expose residents to a variety of practice settings such as physician offices, nursing homes, and community health centers. These programs often rely upon volunteer physician faculty to provide educational opportunities in practice settings that are similar to those in which these physicians-in-training will ultimately practice. Such training is particularly important for residents contemplating practices in medically underserved rural areas. The federal government is required by law to provide dollars to help fund these training programs. Unfortunately, the regulations and guidance governing these programs that have been issued by CMS are complex, confusing, and in some cases even contradictory. In 2002, CMS began denying, oftentimes retroactively, payments for the time residents spent in community-based settings where physicians were freely volunteering their time to supervise resident training. Over the past four years, Maine’s programs have been asked to repay millions of dollars and have had the number of residents they can train reduced. Most recently, CMS has told two of Maine’s programs – one based at Southern Maine Medical Center in Biddeford and one at Maine General Medical Center in Waterville – that they may have to repay $5.4 million. Directors of both these programs have told me that they will be forced to close if CMS follows through with this action. If we lose these two teaching programs, we will lose approximately one-third of our graduate medical education population and our major pipelines for future primary care physicians. As a result, the residents of Maine – particularly those in rural communities – will face decreased access to health care. These hospitals and teaching programs have dedicated themselves to training primary care physicians and placing their graduates in Maine communities. They are not-for-profit institutions that provide health care to Maine’s most vulnerable populations. And they are doing their best to comply with a myriad of complex regulations in order to serve the people of Maine. I have been working with CMS officials over the past four years to resolve these issues. In 2003, I was able to include a provision in the Medicare Modernization Act calling for a one-year moratorium on these kinds of payment denials. More recently, during a hearing of the Aging Committee on which I serve, I secured a commitment from CMS Administrator Mark McClellan that he would suspend the repayments while the issue is being addressed. This is a positive step that will give us time to work for a longer-term solution. It is clear that CMS is not seeing the forest for the trees. There is a direct connection between these hospital teaching programs and access to care, particularly for rural Mainers. Maine already faces many challenges in ensuring that our citizens have access to health care. If these hospital teaching programs are forced to close, doctors in our state will be in even shorter supply and access to quality care will be seriously diminished. I am determined not to let that happen.