With primary care physicians so hard to come by, Billings Clinic has come up with an innovative solution.
It plans to grow its own.
The Clinic is developing an internal-medicine residency program that at full capacity could be producing as many as six new doctors a year.
The hope is that those new doctors will choose to practice in Montana where most counties have a shortage of primary care physicians and 10 counties have no physician at all.
The startup investment of "several million dollars" will be underwritten by Billings Clinic, Billings Clinic Foundation and grants.
Jim Duncan, president and CEO of the Billings Clinic Foundation, said the proposed program is “one of the most transformational initiatives” the Clinic has undertaken in nearly two decades.
Billings Clinic last fall applied for accreditation from the Chicago-based Accreditation Council for Graduate Medical Education and completed the site evaluation process in February. A decision is expected in early June.
“I feel very positive about that result but you never know until you actually get the letter,” said Dr. Roger Bush, the program's director.
If approved, the program would open to the first class of students in July 2014. The program will feature six positions each year in the three-year curriculum, a total of 18 slots when full.
It would be the first program of its kind in Montana, Wyoming and North Dakota. There is one program in South Dakota, two in Iowa and three in Minnesota.
The core faculty will be composed of about two dozen Billings Clinic physicians, drawn from the hospital’s 240 physicians, and nearly 100 nurse practitioners and physician assistants.
“It ups our game,” said Dr. Steven Gerstner, an internist who will serve as associate director of the program. “It will be a blast.”
In the next decade, the country will be short an estimated 50,000 primary-care physicians to meet the need. Compounding the shortage is health care reform under the Affordable Care Act, which is expected to flood the system with new patients in the coming years. More than 30 million Americans will be newly eligible for health care, according to Dr. Bill Iobst, vice president of academic affairs for the American Board of Internal Medicine.
Montana has been feeling the squeeze for several years. Hiring enough internists is so difficult, Billings Clinic and other hospitals are in perpetual recruitment mode.
Lack of access to primary care was identified as the most pressing health care need in a 2011 assessment that Billings Clinic, St. Vincent Healthcare and RiverStone Health conducted.
More than 20,000 Montanans live in counties without a primary-care physician, according to MHA – An Association of Montana Health Care Providers. Ten counties in the state have no physician at all. And, at least 52 of the state’s 56 counties are federally designated primary-care physician shortage areas.
“There are doctors out there but there are far too few,” Bush said. “People shouldn’t have to drive 400 miles to see a doctor. That’s what this is about, bringing care to people in their community.”
He said “homegrown” internal-medicine physicians will best fill the void, because no one will have to explain to them the context of a miner in Colstrip or a rancher in Malta.
“They’ll understand something about these people,” Bush said.
A residency typically is the final step in 11 years of post-secondary training. A high school graduate planning to become a physician needs four years of college for a bachelor’s degree, four years of medical school and then three more years as a resident under another doctor’s guidance.
The plan has been called “innovative,” “bold” and “a breakthrough” by some of the most respected national leaders in internal medicine.
“It is a big deal for Montana, said Dr. Steven Weinberger, executive vice president and CEO of the Philadelphia-based American College of Physicians. “I think it’s a real breakthrough.”
Dr. Richard Baron, president and CEO of the American Board of Internal Medicine, said launching an educational training program is an important step for Billings Clinic, which is renowned nationally, primarily for its clinical care.
“It’s a real innovation in the sense that training programs are traditionally housed in academic centers,” Baron said.
It is difficult to lure physicians to rural and frontier areas of the country unless they have trained in those areas, Weinberger said.
“People who have trained in places like Billings are much more likely to stay in that area or elsewhere in Montana," he said. “It’s a major accomplishment for Billings Clinic.”
There are currently 385 certified internal-medicine residency programs in the country. Only one program was accredited to start July 1, 2013. Six accredited programs began July 1, 2012, according to the Accreditation Council for Graduate Medical Education.
If approved, it would not be Billings Clinic’s first time teaching. The not-for-profit hospital has a history of educating students, including 30 years of involvement with the WWAMI program offered through the University of Washington School of Medicine. It also has spent 15 years working with residents in the Montana Family Medicine Residency.
Montana is among the most successful states for retaining physicians who complete a residency program in the sate, with a retention rate of 60 to 75 percent, according to the Association of American Medical Colleges. Montana is home to the Montana Family Residency Program at RiverStone Health in Billings and the Family Medicine Residency of Western Montana in Missoula. RiverStone Health also has a dental residency program.
Since its inception in 1996, more than 70 percent of the graduates of the Montana Family Medicine Residency have stayed in Montana, according to John Felton, president and CEO of RiverStone Health.
“It has great potential to really make adult health care more accessible and more available in a region of the country that has no internal-medicine residency programs,” said Dr. Nicholas Wolter, CEO of Billings Clinic. “It’s a very important development in the history of the Billings Clinic.”
Until now, even if Billings Clinic had wanted to start its own internal-medicine residency program it would not have been possible. Federal money that historically covers residency costs through Medicare was capped in the 1990s. Since then, no additional residency training positions have been funded.
The Clinic is only able to pursue its residency program now because of the Affordable Care Act. The unused residency slots in urban and over-doctored areas that were unable to attract students have been redistributed to underserved, rural areas such as Billings Clinic.
“San Francisco and Boston do not need more doctors,” Bush said.
The Clinic's internal-medicine program, which has been in the planning stages for about three years, is designed to complement – not compete with – the Montana Family Residency Program. Billings Clinic was one of the first supporters of that program and remains “very committed” to it, said Wolter.
Felton from RiverStone Health also supports creation of the Internal Medicine Residency Program. “Having another residency option in Billings, and ultimately more practicing primary-care doctors, will positively impact each of us as health care consumers.”
Still, there are reservations among some Billings Clinic staff about the ambitious residency program.
“Some folks are a little concerned,” Gerstner said. “They want to make sure it’s a quality product. There are some folks who want to be teachers and some don’t. Some think we’ve got a good thing going so why mess with it.”
Wolter said there are always mixed points of view whenever something new is tried.
“It’s a big change for us and there are risks,” Wolter said.