The Patient Protection and Affordable Care Act of 2010 (ACA) established the Teaching Health Center Graduate Medical Education (THCGME) program to expand training in community-based primary care settings, particularly in rural and underserved areas. To achieve this goal, the Health Resources & Services Administration (HRSA)-administered THCGME program supports residency training in family medicine, internal medicine, pediatrics, internal medicine-pediatrics, obstetrics and gynecology, psychiatry, general dentistry, pediatric dentistry and geriatrics.
Instead of following Medicare GME funding rules, the THCGME program is structured to promote training in community-based settings by directing funds only to providers that qualify as "teaching health centers" (THCs). A THC is defined as a "community based, ambulatory patient care center" that "operates a primary care residency program. " Largely, THCs are located in federally qualified health centers (FQHCs), rural health clinics (RHCs), and health centers operated by the Indian Health Service (IHS). Over half of THCGME program training sites are in "medically underserved communities. " The ACA also requires that a THC's community-based training site be the accredited sponsor of record for the residency program, or a central partner in sponsoring a GME consortium.
Originally, the ACA funded the THCGME program at $230 million over five years (2011–2015). The Medicare and CHIP Reauthorization Act (MACRA, P.L. 114-10 ) provided $60 million per year to extend the THCGME program through FYs 2016 and 2017 (this amount was reduced to $55.9 million by the sequester). From the outset, THCGME funding has been tied to specific health care workforce goals. THCs are held accountable for these goals through annual reporting requirements, including requirements to report on the types of primary care training programs offered, the number of approved residency positions, and the number of residents who complete training and continue to practice in an underserved area.
Threatened with the September 30, 2017, expiration of the THCGME program, Congress appropriated $15,000,000 in funding to carry the program through the first quarter of FY2018 as part of a larger bill extending funding for the Federal Aviation Administration (P.L. 115-63 (9/29/17) ). The House bill to extend funding for the Children's Health Insurance Program (CHIP) program (H.R. 3922) includes language to appropriate $126,500,000 in funding for the THCGME program for each of FYs 2018 and 2019. Priority for THGME payments would be given to qualified THCs that serve health professional shortage areas and medically underserved communities, or that are located in a rural area. The Senate companion bill (S. 1827) does not include funding to extend the THCGME program beyond the first quarter of FY 2018. Therefore, whether this extension of funding will occur remains to be determined.
Through the THCGME program, over 700 residents have trained in nearly 60 THCs located in 27 states and the District of Columbia. Many policy questions raised during this most recent reauthorization cycle remain to be addressed. Because residency programs last several years, the most pressing issue is to ensure that funding will be available for residents who will not complete their training before the 2018 sunset. Additionally, with increased focus on GME funding sustainability, transparency and accountability, there have been calls to expand and extend the program for a longer period to maximize its effectiveness in bolstering primary care training and access to care.
Supporters of the program maintain that the THCGME program is playing a critical role in addressing geographic and specialty shortages in the healthcare workforce. Additionally, the THCGME program could serve as a model for GME payment methodologies that could incentivize training in the specialties and skills that are increasingly in demand in an evolving health care landscape.
Other health care stakeholders support the THC program and its goals and objectives, but emphasize that expansion should not come at a cost to current Medicare GME payments. Traditional Medicare GME payments, they argue, play a critical role in supporting stakeholders that will continue to bear significant costs associated with training tomorrow's physician workforce and providing acute care to vulnerable populations.