Today, we will be addressing the subject of financing of the U.S. preventive medicine residency programs and the unique nature of the preventive medicines training that makes it different from other specialties. In this session, we will describe the various federal funding mechanisms for preventive medicine residency programs. We will also differentiate between various mechanisms of funding for preventive medicine training, and we will understand how available federal funding opportunities could provide a basis for strategies to expand the reach of preventive medicine. Today, I have the honor to present our first speaker, Captain Paul Jung. Dr. Jung is the Director of Division of Medicine and Dentistry in the Bureau of Health Professions at the Health Resource and Service Administrations. He is also a fellow of the American College of Preventive Medicine. Dr. Jung, if you don't mind, please join us today. I think I'm on live. Ifeanyi, did you want to say something else? Yes. I'm going to introduce our co-presenter, Rear Admiral Boris Lushniak, who has been a dean of the School of Public Health at the University of Maryland since January 2017, after serving as the department chair of preventive medicine and professor of dermatology at the Uniformed Services University. He was the U.S. Deputy Southern General from 2010 to 2015, Acting Southern General from 2013 to 2014, and was responsible for the 50th anniversary of the Southern General Report on Smoking and Health and the Southern General Call for Action to Prevent Skin Cancer during the Ebola response in 2015. He commanded the U.S. Public Health Service in Moravia, Liberia. Captain Boris Lushniak, and you are welcome, and thank you for joining us today. Great. Good afternoon, everybody. My name is Paul Jung. I'll be presenting today on the topic of Financing Preventive Medicine, Graduate Medical Education, or How to Fund a Residency Program in Preventive Medicine. As they said in the introduction, I'm the director of the Division of Medicine and Dentistry in the Health Resources and Services Administration's Bureau of Health Workforce. My partner in crime is Dr. Boris Lushniak, the dean of the University of Maryland School of Public Health, and the content presented here was recently published in an article written by us in the May supplement of the Journal of Public Health Practice and Management. I want to thank ACPM for letting us present on this topic. It's a bit of an esoteric one, but I think it's important nonetheless as the future of our specialty depends on it. Today we're going to discuss what Graduate Medical Education, or GME, is, who pays for GME in general. We'll then discuss who pays specifically for preventive medicine residency programs and why they're different from other residency training programs. We will discuss other potential opportunities for funding preventive medicine GME, and then we'll open it up for your questions. In 1980, one of the old guards of our specialty, Dr. Douglas Scutchfield, indicated in a paper that quote, financing of preventive medicine is most often creative, unquote. What he meant by that is that back in 1980, most preventive medicine programs had to cobble together funding from various sources to finance their residency programs. That fact has not changed over the ensuing decades, but the sources and types of funding that are available now are different than they were back then. Most medical residency training is financed through various combinations of clinical revenue and Medicare graduate medical education funding. Medicare is the largest single funding source for medical residency programs in the US. However, preventive medicine programs don't typically generate clinical revenue, definitely not enough to sustain residency training. Preventive medicine training does not always occur in facilities that are eligible for Medicare GME reimbursement. The main point here is that what our specialty does combined with where we do it makes funding our residency programs difficult. Medicare GME, for example, is based on the location of the training, not the specialty itself as we'll go into later. That's one of the issues that I would like to emphasize during the course of this presentation. We'll cover each funding source in more detail. Medicare GME is a formula-based reimbursement program that pays the cost of resident training at Medicare-eligible facilities. It's important to note the key word here is reimbursement. The facility where training occurs first has to incur the costs before Medicare reimburses them. When Medicare does pay, it pays very well. Medicare made $11.1 billion in payments in 2015. That includes $3.7 billion in direct payments and $7.4 billion in indirect payments. Direct payments include the cost of resident salaries and expenses like supplies, textbooks, laundry. Indirect payments are intended to cover the costs of training such as faculty salaries, extra lab tests that inexperienced residents might order, et cetera. But this is not a dollar-for-dollar reimbursement. There are formulas involved. The formula for direct payments includes a computation of inpatient days. That means if there are no inpatients in the facility where you are trained, the formula is moot. Think about what that means for preventive medicine. The Medicare formula for indirect payments includes the ratio of number of residents to the number of beds. Again, think about this formula and the requirement to count the number of residents per bed and what that means for preventive medicine. I'm not sure how many beds there are at local health departments, but I think it's close to zero. There is a misconception that preventive medicine as a specialty somehow itself is categorically ineligible for Medicare reimbursement. That is incorrect. In fact, preventive medicine is specifically noted in Medicare regulations as an eligible primary care specialty. We don't need to go into whether preventive medicine is primary care or not, but the point I want to make is that the specialty is eligible for Medicare funding, but it's the setting of our training that limits our eligibility for GME for Medicare, not the specialty itself. The next time you're doing a preventive medicine residency rotation, think about the Medicare GME funding formula and ask yourself, how many inpatient beds are there in this facility? If the answer is none, that's why Medicare isn't funding your residency. But another way to think about this is if you are a preventive medicine residency program director and you've set up rotations for your residents at a hospital, maybe doing some quality improvement analyses or infection control reports. If that hospital is a Medicare eligible hospital, you should be bringing in Medicare GME payments for that hospital, and some of those funds should be funneled into your program. So, next slide. There we go. Medicaid GME. Medicaid also has a GME component to its funding, but since it's a joint federal state program, there are 50 different sets of rules and regulations. Each state's Medicaid program may make GME payments. In 2018, for example, 43 states and the District of Columbia made a total of $5.6 billion in Medicaid GME payments. The way these payments are made can copy the Medicare GME structure with direct and indirect payments, but states can also make lump sum payments using what's called Section 1115 waivers. This can get complicated, but the bottom line is that your state Medicaid program may be able to make GME payments for preventive medicine training, and this should be thoroughly investigated as a potential source for your residency program. Next up is the Veterans Health Administration. It's a huge source of GME funding, $1.8 billion in fiscal 2017. Payments are made to residency programs at a local rate based on the number of residents that rotate through the VA facility. There's no categorical restriction on specific specialties, but each VA facility determines which specialties they'll support. Similarly to the scenario that I painted with the Medicare GME program, the question should arise if a preventive medicine resident is rotating through a VA facility, they should be bringing payments back to the program. There is recent legislation that requires the VA to increase the number of residents rotating through its facilities, and also increasing the number of residents that they pay for. Preventive medicine is not explicitly prohibited in this expansion, so preventive medicine residency programs should be making friends with their local VA facilities. Next up is the Children's Hospital GME program. It's a specific funding program to pay for residency rotations at children's hospitals. Unlike Medicare and Medicaid GME, which is an open-ended entitlement, funding for Children's Hospital GME is limited by annual discretionary appropriations set by Congress. That was $323 million in 2019. Please note that this is not a program to pay for pediatrics residencies. In fact, only about 40% of Children's Hospital GME funding goes to general pediatrics residencies. About 30% goes to pediatric subspecialties, and 30% go to non-pediatrics residencies with residents that rotate through a children's hospital. For example, a general surgery resident who does a one-month rotation at a children's hospital, or a radiology resident who does a rotation, each would result in payments to their residency through this program. There is no prohibition against funding preventive medicine through the Children's Hospital GME program. Prejudices are hard to escape. When I made the case for preventive medicine rotations at children's hospitals, one program director said, why would a preventive medicine resident want to rotate through a children's hospital? Which, to me, was a stunning remark, if you think about it. Maybe folks are under the mistaken belief that a rotation must involve direct clinical care, and what that person meant was, why would a preventive medicine resident want to do a pediatrics rotation, which is a legitimate question. But if you think about preventive medicine-specific opportunities at children's hospitals, like a quality improvement project, or an outcomes research project, a children's hospital would be a great location for that kind of a rotation, and it would result in payments made to the preventive medicine program. That's exactly why I think it's important that everyone understand the different funding opportunities that are out there, and the intricacies involved in each one. All right, next up is the Teaching Health Center GME. It's another HRSA program, very similar in structure to the Children's Hospital GME program in terms of funding. In 2019, the total funding was set at $126.5 million. And THCs are ambulatory community-based residency training sites. I want to make clear at the outset here that although many specialties are eligible for the THC program, preventive medicine is specifically excluded from this program. But I bring it up because when this program was first conceived as part of the Affordable Care Act, it funded internal medicine, pediatrics, and family medicine. And then as it wound its way through the legislative process, they added OB-GYN, psychiatry, geriatrics, and general dentistry to this program. An expansion of congressional authority for preventive medicine is not out of the question, especially if the idea was to fund combined preventive medicine and a primary care specialty, for example, to focus on community health. Next is the Primary Care Training and Enhancement, or PCTE program. It's different from the previous programs that we described because it's designed to fund programs, not individual residents or FTEs on a rotation to a particular facility. Hence, PCTE is typically not considered a GME program in the sense that it doesn't reimburse for residency costs. It's a grant program. Programs are at approximately $50 million per year, and the authorizing statute limits funding to general internal medicine, general pediatrics, family medicine, and physician assistant programs. And similar to the Children's Hospital Program, one comment I received when promoting PCTE to preventive medicine was, if preventive medicine is excluded by statute from PCTE, why do we need to know about this? The statute also provides wide flexibility in the types of training for primary care physicians. Specifically, the statute includes, quote, competencies recommended by the Federal Advisory Committee on Training in Primary Care Medicine and Dentistry, the ACTPCMD for short. One of the recommendations that this advisory committee made in a report several years ago is that training for primary care physicians in public health, for primary care physicians should include training in public health and population health. And that's why HRSA recently made a new PCTE funding opportunity available to train primary care physicians in the specialty of preventive medicine, essentially as a second residency. This was called the PCTE Community Prevention and Maternal Health Program, and it's a great example of how preventive medicine can be an add-on specialty that brings funding with it. So if you ever had a preventive medicine resident in your program who already completed a primary care residency first before coming to preventive medicine, then your program would be eligible for the PCTE funding opportunity. The Preventive Medicine Residency Funding Program on the slide here is probably the one program that you're all most familiar with. It's the only federal program devoted specifically to preventive medicine, and it spends about $7 million per year, and it funds 17 residency programs. Like PCTE, it funds programs, not residents or FTEs, and so it's also not a GME program per se. It's a grant program. And that leads to a unique situation in which different programs train different numbers of residents but receive similar levels of funding. I agree with everyone that $7 million is not enough to fund every accredited program, but this is still the only game in town for our specialty. Next up is the Federal Office of Rural Health Policy, or FORHP. They have a Rural Residency Development Program, and that funds the development of new residency programs in rural areas. This program is not a maintenance program as it only provides startup funds for three years to achieve accreditation, and it's not meant for ongoing financial support. But with a little persuasion, they included Public Health and General Preventive Medicine in their fiscal year 2020 application program, but there were no applicants. So think about that. If you were the funding decision maker at the Federal Office of Rural Health Policy and you stuck your neck out for preventive medicine in this program but no residencies applied for funding, what would you do in terms of continued funding for preventive medicine? What would you say if constituents complained that there's not enough funding for this residency? There is no question that there is a need for preventive medicine in rural areas, and that's what they were trying to address with the FORHP program. Hopefully they'll continue to include Public Health and General Preventive Medicine in their funding opportunities. Next up is NIOSH. I can get the clicker to work here. The National Institute for Occupational Safety and Health, I apologize for the typo at the title there, this is a part of the Centers for Disease Control and Prevention. They fund the Education and Research Centers, or ERCs, and separately they fund training project grants, TPGs. Funding amounts were $28.4 million for ERCs in 2018 and $4.5 million for TPGs. Both of these provide funding for occupational medicine residency programs. In 2018, both programs combined funded a total of 144 residents across the country. That's about 65% of all occupational medicine residents in the United States. But these programs not only fund occupational medicine, they also support a wide variety of disciplines like industrial hygiene, occupational health nursing, and allied health, but occupational medicine residencies grab a share of that pie. Public Health and General Preventive Med as well as Aerospace Med are ineligible for these NIOSH programs, but this is a huge source of funding for OCMED. One of the questions that has come up is whether HRSA should continue to allow OCMED to come in for the Preventive Medicine Residency Program if NIOSH also provides funding specifically for occupational medicine. Next up is the Department of Defense. They also fund a few Preventive Medicine Residency Programs, both directly and indirectly. Some training is funded intramurally through DOD residency programs like the Walter Reed Capital Area PrevMed Residency Program. Other funding pays to have military physicians trained extramurally in civilian programs. DOD spent a total of $16.5 million in all of its GME in 2012. Some of this funding obviously included Preventive Medicine. Those of you with residency programs looking for residents that arrive with their own funding, DOD is the place to look for that. And finally, this summary table lists all the funding programs, their annual amounts, their mechanism of funding, and the unit that is funded. I think the most important columns in this table are the mechanism of funding and the unit of funding. That appears to be the area where most people don't understand how this funding works. This table in its entirety is included in our publication in JPH MP, and we can refer back to this table during Q&A as needed. So in conclusion, the purpose of this presentation was to review federal funding opportunities for the specialty of preventive medicine. I believe it's important, it's most important to understand the funding mechanism and the unit of funding for each program and to understand eligibility. Right now, congressional appropriations in the HRSA preventive medicine funding program only fund 17 out of the 75 accredited residency programs or 11% of all accredited preventive medicine training slots. That's not enough, but it also means that 58 residency programs are getting by without HRSA preventive medicine funding. No single GME program, especially a federal GME program is a panacea, but on the other hand preventive medicine is the only specialty with a directed congressional appropriation. Preventive medicine residencies should be resourceful in exploring the full range of available funding. More importantly, this information could be utilized by various preventive medicine organizations in their effort to strengthen the specialty. And this final slide is our plug for our article in the Journal of Public Health Medicine Management and Practice. It's available free to anyone right now, so go and grab it before it goes behind the pay wall, and I will turn it over to Dr. Lushniak for any comments before we start the Q&A session. Thank you, everybody. Great. Thank you, Dr. Jung. I think I'm on right now with the whole group. We'll be starting the questions and answers right now. Thank you to our resident moderators here today. It's always great seeing the residents involved in all this. And, you know, part of what we've been doing, and if you do, you know, look at the publications that under Dr. Jung's leadership that I've been blessed to be part of, over the last several years it really emphasizes several things, right? Amongst these things are really the survival of preventive medicine and its future. To a large extent, we've looked at various aspects of this, which includes everything from the training aspects to the, you know, the licensure aspects to what we really do within our various settings. And I have to admit, right, as a person who came in to PrevMed through the occupational medicine route, part of our beauty is the variety that exists out there, right? You know, under the American Board of Preventive Medicine, obviously you all know it's aerospace medicine, general PrevMed, occupational. So we are kind of a potpourri of things. We're also a potpourri of things when it comes to our backgrounds coming in. Some look at PrevMed as being their primary source of postgraduate medical education. Others view it as additional on top of something else. Some of you view it as transitional, i.e. went a certain pathway, it didn't satisfy an individual and they came into PrevMed. And then at the end of all this is the utilization of PrevMed docs in all their different sizes, shapes, and flavors for the good of public health, right? Whether it's aerospace public health, whether it's occupational health, whether it's general preventive medicine. That being said, amongst this survival issue, as Dr. Jung has already reiterated, is the sense is the financial survival, right? You all know, those of you who have been through PrevMed, that's already unique, right? As I mentioned, unique in terms of the personnel, unique in terms of the backgrounds of individuals coming in, unique of what people do with this residency training, where they end up. Unique in the matching program in general, but also unique as we're emphasizing here today in terms of the funding of this program. And again, without requisite patterns of funding, this becomes a very difficult process. Now there is that unique feature of having an aspect of this of federal funding, but beyond that, it really then becomes, you know, and part of what we'd like this to be in the questions and answers is come up with your ideas. Come up not only with your questions, but your ideas of saying, what is the pattern that we need to be looking at? Also unique, obviously, to the general preventive medicine residency programs and all three of the residency programs associated with PrevMed is what? Is the scholastic nature of things, right? It is the granting of a master's in public health degree. I, as a dean of a school of public health, am now involved heavily in the idea of education. And here we really do a formal aspect of education embedded into a preventive medicine residency. Now, one of the patterns that have been seen, as we've seen, you know, in terms of what's happening in the market right now is other residencies are beginning to sort of put on other aspects of training. You know, other specialties are looking at MPHs as part of potentially the pathway. And so therefore, where we were at one time unique, we may now become more similar to other specialty arenas. But in essence, this now is an opportunity for us, not only to answer the questions for the next half hour or so, is for us to share ideas. And once again, the mission is viability of the future of preventive medicine. So thank you, Dr. Jung, and thank you to our moderators. And let's begin a vibrant discussion on this. Thanks. Thank you, Dr. Paul and Dr. Bari. Thank you guys for your presentation and all your work you've been doing on behalf of PrevMed. As of now, we have 49 people online, no question yet. So I will start the discussion before somebody joins in. So Dr. Paul, you talked about the FORHP Rural Residency Program, you know, and what he applied for funds in the 2020 year. Do we know if our programs know about availability of these funds or not? I'm surprised. I know my program is bleeding for funds, so I'm surprised nobody applied for, so I don't know if we know about it or not. Yeah, that's an excellent question. That comes up with all new HRSA programs. But there's a, the dynamic that we have to deal with is the inability, well, we have to provide information at the same time to everybody. And so there's no way for us to give any advance notice to anyone about a new funding program that's going to happen. We have to make it public and accessible to everyone at the same time. In addition to that, we have to make sure that there's enough lead time for folks that are interested to have enough time to get their grant application together and to submit it. And I know very well that it's difficult to complete a grant application for HRSA programs, any HRSA program, even the National Health Service Corps. It is not easy. There's a lot involved. One of the criticisms that we hear is that the same institutions tend to get all of the funding from various federal programs. And I think one of the reasons is because they have an entire office, the successful programs tend to have an office dedicated to writing grant proposals, whether it's for federal grants or other grants. And they know how to write the grant applications in the correct way to get all the important information out there. So the advice that I would give to folks is to not only keep an eye on what's out there for preventive medicine, but to have a grant proposal essentially ready to go. If you look at a lot of the HRSA programs, most of the application is boilerplate. It's the same information that they ask for in every grant program. So the key is finding what is different in this program versus that program and writing the application to match that. But the bottom line is I think for that rural health program in particular, I think the unique problem that we ran into is that nobody ever expected anything for preventive medicine other than the standard HRSA preventive medicine funding program. And so when it came out, I think it took everyone by surprise when we were finally allowed to tell people about it. And it just didn't provide enough time for people to get their applications together. So we'll see what happens if they continue to put preventive medicine into that program. We'll see if there are other programs that apply. Again, we know that preventive medicine in rural areas is a huge issue, and we need more rural preventive medicine programs. There was an excellent article written by the folks at West Virginia University about the need for rural preventive medicine programs in the supplement in JPHMP. And so hopefully people will heed that call and look out for the next iteration of this program and submit their applications. I'm going to sort of expand as we wait for questions from others. This becomes a discussion amongst, in essence, the four of us with others listening. So again, get involved if you have an opinion, if you have anything to share or any question. That being said, even amongst just the three of you out there, the two resident moderators and Dr. Jung, is do you view this time period as being an opportunity? We all state that in the midst of the pandemic, what I call in fact are the syndemics of multiple components that have stressed the public health system, is public health at a stage right now that basically can turn to the federal programs and say, look at what's being achieved. Have we documented this well enough? And to say that, you know, for the future, as we look at the aspect of preparedness for the next pandemic, does that give us any credence or any ammunition, if you will, for further funding and expansion of funding? I think I have to comment. My perception of this is, I'm doing an MPH program. So I think what happens in the MPH program that we do is transforming our individual patient care to a population care. So the problem is explaining to an individual what a PrevMed person does. So like in this case of the pandemic, during the period of the pandemic, I was opportune to be a member of the Prisma Health Vaccine Task Force. I was part of the team that developed how we established our vaccine site. But in that process, I learned a lot about what goes into developing a vaccine site, what decisions people take and how we were able to get the vaccines to people. We have at least like four big mass vaccine sites in South Carolina that was done by Prisma Health and the mobile clinics that we use for our rural areas, giving the J&J vaccine. But in all that, I'm the only PrevMed person, because Ahmad was in public health, the Department of Health. But I kept on the question that always comes in, because you see folks from quality control, folks from internal medicine, family medicine. The question comes in, what do PrevMeds do? And like every time I answer the question, I tell them, this is my, this is my thought. This is our playing field. We should take the lead in this, but we don't have enough faculty to go in there and imagine a resident talking to the VPs of different sects, of different departments, and we don't have enough faculty going in there to go in and say, oh, this is our spot. This is what we do. We can help do this, do this, do this. And you know, like we're talking about vaccine hesitance. We are all busy and none of us is out front here, going in to go and talk to the health department, talk to the communities about having these vaccines. So I think the problem is, is how we present ourself and how we are perceived. So it all is all encompassing. I want to take the opportunity actually to go through some of the questions that our attendees has been asking. This question is actually for both our presenters. This one has been the most upvoted, and actually I'm one of the ones that upvoted it too. So the question says, any chance the Master of Public Health degree could get funded by the CMS, the VA, or Medicaid, or GME, et cetera, as it is required for certification? So I would say that that's a tough sell. And only because the residency GME funding programs like Medicare and the VA, they pay a certain rate for the activities that the resident does in the facilities, meaning they don't pay for a degree. They don't pay for a credit hour or a course. They pay X amount of dollars based on a formula for work done at the facility by the resident. So to change that into a program where a degree is funded would take a lot of effort and a lot of explanation, and it would result, I think, in a lot of other residency programs saying, well, if you're going to do that, then why don't you try this or that? It might be too difficult to do. Now, incorporating... So my solution, if I were running a residency program, would be to incorporate the cost of the degree into the full cost of the residency. And so instead of saying that the resident's salary during PGY MPH is $40,000 or whatever extravagant amount the residents make nowadays, include the cost of the MPH into that and make the cost of the resident include the cost of the MPH. And maybe you could spread it out over the two or three years of your residency program. There's different ways to do it. But this is an issue that we've discussed before. Simply sliding an MPH into the residency program and having that as a separate item, a separate cost, a separate thing, makes our residency, our specialty, my opinion, a little more difficult to say that we have something unique. Instead, we're just a residency that gives you an MPH, which I think does more harm than good. Again, my opinion on things. I'm in agreement with that approach. I mean, you know, in essence, as already sort of stipulated in the slides and the presentation by Dr. Jung, is that we're unlike any other specialty arena where, in essence, the patient care component of almost every single other residency program really does the major sort of source of payment, if you will, right? Because you are out there taking care of patients, there is this potential influx. For us, the question is, who is the patient, right, in the midst of the preventive medicine residency, right? We like to say, well, the patient is the population. Well, if the patient is the population, then it's hard to do a per capita, a per head approach in saying, well, here's the number of patients treated by us or evaluated by us and to tap it into some payment mechanism. At the same time, as mentioned earlier, with the uniqueness of us mandating as part of the board certification process to have an academic degree, there's only two ways of dealing with this, one of which is, which I think would not be the right approach, is you require an MPH prior to a preventive medicine residency, right? So do it on your own. I don't care how you do it. And then I'll train you appropriately. And so therefore, we've decreased the cost of that. But at the same time, already, what are small numbers of people who ultimately come into PrEP Med will become even smaller, right? Because right now, you got to kind of say that part of our draw is, and Paul's right in this, you know, it's not that we do a PrEP Med residency and add in an MPH. That's part of the training. That's part of the didactics. Now, putting my dean's hat on, right, where I realize how much it costs to educate my master's level students, don't expect academia to give you a break on this necessarily, right? Because academia isn't doing very well, right, in terms of paying the bills. So somebody's going to have to come up with a formula here. And one way is, in essence, maybe looking at it as saying, well, here's the salary for a PrEP Med resident. And over the years of that residency, you bundle in the aspects of the tuition and, you know, and work out from those numbers, right? I mean, you know, this is, again, makes us unique. That's why we're special. But because we're special, we don't align ourselves well with the other clinically directed residency programs. Okay. Thank you so much. I appreciate it. I mean, we do have several questions I'll try to use, like, the most upvoted ones and the ones that are most going to be beneficial for our attendees. There is a question that's actually been through the chat, and it's been incorporated into the question one. And I'm just going to quote whatever in the question that says, Paul, excellent rundown of existing GME funding opportunities for, by Medicare, Medicaid, VA, and children hospital sources. Has a checklist or a formula for each of these be made for PMR directors to advocate for getting these services funded under these for existing or future residents? That's an excellent question. Well, first I would direct everyone to our article in JPH MP, and you could use that table as a checklist to see if your residency program has explored all of the various opportunities. But I think what the question is asking is within each one of these, for example, Medicare GME, what are the steps that a residency program should take or might take to try to access that source of funding? And I don't believe there's been any type of checklist like that for preventive medicine residency programs, and maybe that's something that would be valuable. And whether the program directors want to get together and do something like that, or maybe it's time to write another paper, I think that would be beneficial. But the bottom line is, since preventive medicine is different, and since we have a lot of explaining to do about who we are and what we do, a lot of the interactions between residency programs and the facilities that might fund them are made by personal connections. And so, for example, the VA is probably the best example. There are some residency programs that regularly send their residents through a VA for rotations. They have a good established relationship. The projects that the residents work on, it's not just patient care. They work on preventive medicine projects, and there's funding that comes from the VA to the residency program. That all started with a relationship where the folks at the VA, in the education part of the VA, understood what preventive medicine was, and vice versa. And they sat down and decided, these are the things that our residents could do that would be beneficial to both us and the VA. And that relationship started and kept going, and then funding came along. So that's how I think preventive medicine residency programs should explore this. There's no reason that they can't find VAs, Medicare-eligible hospitals, Medicaid-eligible hospitals, children's hospitals, and sit down and say, look, this is our situation. We have a residency program. This is what our residents can do for you. And I think that's the key. It's not just, we need a place where our residents can see patients and crank things out in your clinic. To me, that would not be the best use of preventive medicine residents in their second and third year. And so, for the residency program to approach a facility and say, let's talk about what our residents can do for you, and then let's talk about the potential funding that might come along with it. I think that's the key to establishing these relationships. And the other thing to remember is that what works for one program on the East Coast, for example, is not going to work in the Midwest and is not going to work in California. Facilities are different. Attitudes are different. What facilities need are different, depending on where you are. So it's really up to the program to understand their local environment and to reach out to the folks that they can establish relationships with there. Okay. There are a lot of questions that says, I'll read it out how the question is asked. Thank you, Dr. Jung and Dr. Lisniak. As health systems navigate population health, how can we market ourselves and the population health specialists to these systems, with one goal being funding our GME program? Any of you can take it. Let me begin first and I'll hand it over to Dr. Jung. So I currently sit on the American College of Preventive Medicine on the Board of Regents. And that's always been sort of a big tabulation and a big part of the mission of the Board of Regents and by the leadership of the American College. That being, how do we sell ourselves, right? Right now, we're spending a lot of time and effort and aspects of, first of all, as we had mentioned, is defining what preventive medicine is, right? Trying to be succinct in that. And the current sort of initiative that's been unfolding is termed the power of prevention initiative, right? The power of prevention, in that sense, aligns many things, right? And part of it is the realization, like all of us in PrevMed knows, is that we spend an inordinate chunk of money, $3.6 trillion a year, on what we call healthcare. But in essence, it is pretty much sick care that we spend money on. We define health by the World Health Organization definition of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. That being said, you know, when you look at how much prevention is being funded, and this is prevention and public health, you're talking anywhere between 2 to 3 percent of those $3.6 trillion actually goes into those mechanisms. And now is the time, more so than ever, as we're talking in the midst of this pandemic, of what the problem was, where the breakdown is. So vaccines and vaccine hesitancy is a preventive medicine issue, isn't it, right? So much of what we're talking about from a preparedness aspect for the next pandemic is a prevention medicine aspect to this, and is part of the mission. So part of it is, how do we label and bundle the idea that prevention works, and that prevention needs to be funded in order to make our society a healthier society? You know, others have coined a term. The problem is we're not out there always celebrating the successes of prevention, all right? There's a saying that says, you know, when prevention works, and it has a double entendre. I love this saying because it says, when the prevention works, nothing happens, right? And in reality, that means, well, we exceeded our goal, right? If we prevented a lung cancer because of the prevention strategies associated with tobacco use, nothing happened to that individual. The problem, of course, is they use that double entendre and say, when prevention works, nothing happens, is we don't celebrate it, right? We don't go out there and shoot off fireworks and release doves and say, look at what we did, right? We saved a life, we saved a family's well-being, we saved a community, we saved a nation from this. And I think that's where we need to be going on this, is we got to figure out a way where people not only begin to understand what we do, but understand the benefit of what prevention is all about. Paul? Yeah, I agree 100%. But I would say that a lot of health systems, large health systems included, even Medicare, are gradually moving to this idea of health, population health specifically. And they're trying their best to tie reimbursement to the health of the population being served. And I think that's our opportunity, to be able to say that we are the specialists who can straddle the world of the two worlds of direct patient care, one-on-one patient care and population health, to be able to communicate and explain each world to each other. I think that's where the money is, literally and figuratively, for our specialty. Doctors are trained in direct patient care. They are good at taking care of patients, the patient in front of them in the clinic, that's their job. And what amazes me is that there's just this expectation that physicians should therefore understand population health and how to take care of populations. And unfortunately, that usually turns into, well, if we do a better job in the clinic and treat more people, then we'll have a healthier population. But they've done the studies, only about 20% of health is a direct result of clinical care. The rest is from the environment, the way we live. And that is where we can make the difference in terms of explaining ourselves and explaining specific population level health, population science, to those who are interested in that, interested in the outcomes and willing to pay for it. Thank you so much, Dr. Lushniak and Dr. Jung, for this beautiful explanation. Dr. Jung, I believe you touched into this next question a little bit, but I believe this question is important, especially for new people who decide to join preventive medicine in the future. The question states, do you have to participate in direct patient care in order to access the GME funding for the program? I think the question is geared towards the Medicare and specifically the Medicare GME program, maybe Medicaid too. That is an excellent question, and I think the answer is no. I say I think because I haven't been able to get anyone from CMS to answer this question, and maybe that's why it might be yes or it might be no. Think about your standard clinical residency program, internal medicine, surgery, and so on. Not every month spent by those residents is in direct patient care. Occasionally there's a month doing research. Occasionally there's a month for vacation. There's a month doing literature review, for example. If that happens, the question is, during that month, is that resident counted towards the GME payments? I would say that yes, they are, and I don't think there's a distinction made as to whether that resident is seeing patients that month or not seeing patients that month. I think the way the spreadsheets are sent back and forth, they simply count the number of residents on duty and the number of beds, the number of Medicare patients seen that month and so on and so forth. I believe that a resident in the facility who might be doing a chart review to assess the outcomes of a particular treatment plan would still count in the resident count for that month, and that's for Medicare specifically. My understanding at the VA is that that is absolutely the case. If there was a resident doing quality improvement, for example, that they do count and they are eligible for funding. It actually is simply the number of residents, not whether the residents are directly seeing patients or not. If anybody has any official in writing information to the contrary, I would love to see it. That would just be more ammunition for the specialty to be able to say, this is unfair. If you want population health, you're not going to get it just by having everyone see more patients. It can go either way, depending on how we get the information on that. There is a lot of questions coming, and our time is going on so fast. I'm going to ask this question because it's the highest voted question for now for both of you. It says, can we provide feedback to CMS to make an exception to the formula for PREV-MED residents? Now seems to be the time when they may be most willing to hear us out, given the last year. Is there a mechanism for this? Well, we can always propose things, but there are several assumptions in that proposal. I like where it's headed, but number one, do we need Medicare to be the source of funding for preventive medicine? I wouldn't turn it down if that were the case, but is that really the best place to get it? Could there be another way to fund preventive medicine residency programs is the bigger question that I think we need to address, that the specialty, the college needs to address. Do we need to try to scramble and try to get the same funding source that everyone else has knowing that we're different and that every time we do this, we're going to have to explain ourselves over and over again. There's got to be a different way, a better way. I would like to think that preventive medicine could stand on its own for another source of funding somewhere, but without that, absolutely. There's no reason we can't propose this to CMS. It would be difficult, again, my opinion, it would be difficult to get CMS to say preventive medicine as a specialty will get this amount of money or will be treated this way simply because no other specialty does it that way. We would have to make the case, remember the mission of Medicare is the insurance of healthcare for senior citizens. We'd have to make a case as to why our specialty fits into that mission so much so that we need an exception that all the other specialties don't. It's going to be a real tough lift, right? I mean, again, we're different and we're trying to be the same as everybody else to some extent in that and it may not be the right formula to put our efforts into, but I think it's a good thought. I think that certainly needs to be part of the menu, if you will, of potential resolutions to this. Dr. Lusniak, I have a question for you. Since you said the preventive medicine residency programs are small, we don't have a large office like grant writing and we have higher people that write grants only in the board that does this for all the medical and preventive medicine residents. Is that possible? Yeah, actually the American College recently brought in a person to, you know, I mean, there's always been that struggle in terms of getting the grant writing components from a national level on board. I think we're sort of building out that expertise and that ability for us to do that. You know, to a large extent, you know, there is always this struggle. You know, as you know, the grant monies are always, one, difficult to come by, two, a lot of competition and the question ends up being, you know, who are we potentially partnering with in terms of this? I think that's part of the approach. And part of it is, yes, I think to get better. And I think we slowly are getting better at that aspect. Great question. One thing to keep in mind, one of the problems with the grant program is that it's a competitive program and there's a limited amount of funds. And when somebody wins and gets funding, that means somebody loses and doesn't get funding. Unless we have enough money to fund every program, cover every accredited resident, somebody's going to lose out. And so if the idea is that there would be a single source of grant writing assistance, that may not result in everything that you want because if all the grant applications start to look the same, then who knows how the decisions are going to be made in terms of who gets funded and who doesn't. Right. And the other aspect is, you know, and now being sort of in the academic world is don't forget grants are, you know, a lot of work put into them. Your happiest moment in the grant is the day you get it because guess what? At that point, a time clock starts and that means either reapplication or loss, right? So your big win is the day you're told of the grant. After that, you know, you're actually quite vulnerable to sort of grants, you know, when the time runs out. I mean, it's great. It's guaranteed, you know, support for a given time, but it's not guaranteed support forever. I think we're almost out of time, but we do have hopefully a minute or two just to answer this one last question since we're in the topic about funding. So the question says, are there potential opportunities to leverage funds to support preventive medicine residency slots as part of patient safety or quality funding? Sure. The answer is yes, absolutely. Those are two excellent examples of what a preventive medicine person can bring to a health system. And if there are grants to do that, then it's up to the residency program to make the case as to why the residency program should obtain some of those funds to perpetuate the training of the folks that will wind up doing the future work in prevention and safety. That's all it takes. It's just a matter of getting people to understand the vast, the wide array of things that we can say we're eligible of doing and bringing in some funding for that. Okay, I guess we're out of time. We thank our presenters for coming to give us these wonderful presentations, and we thank our listeners, our online audience. Thank you for your time, and we'll have a wonderful Preventive Medicine 2021 year. Thank you guys. Thanks, everybody. See y'all. Thank you.

funding mechanisms

preventive medicine residency programs

clinical revenue

Medicare GME

Medicaid GME

Veterans Health Administration

Children's Hospital GME program

Teaching Health Center GME program

Primary Care Training and Enhancement program

MPH degree