National groups look to increase HIV doctors

Increased federal support is top need

Medical schools, HIV organizations, foundations, and the federal government will need to work together to avert a crisis as the supply of HIV-trained physicians dwindles, experts say.

Fortunately, all three groups have begun efforts to solve the problem.

"This is a challenging time," says Andrea Weddle, executive director of the HIV Medicine Association (HIVMA) of Arlington, VA.

"There are opportunities to hopefully make some headway, but we have to be creative to make those happen," Weddle says.

The Association of American Medical Colleges (AAMC) of Washington, DC, has urged its members to increase the number of students by nearly a third to address the national physician shortage, says Len Marquez, director of government relations for the AAMC.

AAMC's data show that there will be an additional 7,000 medical school graduates every year over the next decade. But there might be no substantial increase in the number of residency training positions supported with federal funding, and this is the bigger issue, Marquez says.

"The problem is if you increase the number of graduates, but they don't have residency slots to match the increased numbers then you face a problem where you have more graduates than residency slots, and you end up losing physicians," Marquez says.

Any residency program can increase its number of residents being trained, but it has to be approved, he adds.

"There's a cap on the number of slots that have a portion of the costs reimbursed by Medicare," he says.

The U.S. Congress can lift the freeze on Medicare-supported residency positions, which has been in place since 1997. With a 15% increase in these positions, teaching hospitals could prepare an additional 4,000 physicians a year.

Networking, mentoring

There are other changes the federal government and others can make to increase our supply of HIV physicians. Even current HIV clinicians can attract new doctors to their field through networking and mentoring altruistic-minded health care practitioners before they enter medical school.

For example, the HIVMA and the American Academy of HIV Medicine jointly have recommended that the United States take these actions to address the HIV clinician shortage:

• Increase the National Health Service Corps loan forgiveness program to target HIV medical providers that work at Ryan White Part C-funded sites: The Health Resources and Services Administration (HRSA) under the U.S. Department of Health and Human Services (HHS) has been charged with creating a negotiated role-making committee to look at criteria used in the loan forgiveness program, Weddle says.

"The criteria now used to designate clinician shortages were developed in the 1970s and have not been updated," she says. "So HRSA looked at those criteria and made recommendations to update them."

HIVMA advocates for the criteria to include areas with high rates of HIV disparity and underservice, she adds.

"We'd like to increase opportunities for loan forgiveness in HIV clinics funded by Ryan White," Weddle explains.

One solution would be for the loan forgiveness program to include a mechanism for HIV clinics to qualify for the program if they are serving special populations, where the patients are low income and underserved, Weddle says.

The HRSA negotiated role-making committee is expected to come up with a proposal by October, she adds.

• Provide more federal support for clinical training opportunities in HIV medicine: HIVMA began the HIV Minority Clinical Fellowship Program four years ago. The small, but successful initiative targets fellowship grants to African American and Latino physicians who wish to pursue a year of HIV-dedicated training, Weddle explains.

"Physicians who are willing to serve underserved populations can use this as a pathway to enter HIV medicine, and we've trained 10 physicians as of June 30, 2011," she says. "The feedback we've gotten has all been positive, and all of the physicians are staying in the HIV field, most continuing to work with underserved populations, and most say it would not have been possible without this year of training."

This is a good model that should be expanded with federal support, Weddle says.

"Right now there's not a specific training pathway for physicians, nurse practitioners, or physician assistants who are interested in focusing on HIV medicine in their career," she says.

• Raise Medicaid payment rates for HIV providers: Currently, 40% of HIV patients depend on Medicaid for health coverage, and that percentage is expected to grow as health reform is implemented: "This is the solution that's more complicated and the one we're most concerned about," Weddle says. "The Affordable Care Act does increase payments for primary care physicians up to Medicare levels for some services, but it's narrowly defined."

The increase basically covers internists and family medicine and pediatricians who primarily provide primary care services, she adds.

"We're concerned HIV clinicians will be left out of this," Weddle says.

Ideally, states would have flexibility to create coordinated programs similar to the level of care under Ryan White for chronic and HIV care delivery, she says.

"We're hoping states will provide these for HIV beneficiaries," she adds. "We hope to document the value of investing in payment upfront in terms of cost effectiveness and patient outcomes."

Another model for addressing the HIV workforce shortage is one that combines physician organizations with private industry and foundation funds. For instance, the American College of Physicians (ACP) Foundation, with a Bristol-Myers Squibb Awards Grant, has an HIV workforce capacity building initiative that will address the U.S. medical provider shortage.

Called Positive Charge, the $2.93 million, three-year grant will support skills transfer programs that benefit HIV patients in areas of high unmet needs. For instance, there will be a mentoring program that pairs HIV experts with primary care clinicians in areas of high HIV prevalence.

"Increasingly, we have a young, minority, disenfranchised population that often has no health insurance, and Ryan White is maxed out," says Donna E. Sweet, MD, AAHIVS, MACP, a professor of internal medicine at the University of Kansas School of Medicine in Wichita, KS. Sweet is the chair of the American College of Physicians (ACP) Foundation initiative's national HIV workforce expansion steering committee.

There are federally-funded community health centers (CHC) that could care for this population. CHCs are receiving increased funding through the Affordable Care Act, but these primary care sites have clinicians who typically are untrained in HIV care, Sweet explains.

"My group is trying to mentor people at CHCs," she adds. "We're trying to expand the workforce."

The plan is to expand HIV care to CHCs and other primary care settings because HIV disease now is a chronic illness, so CHCs could be a medical home for many patients with HIV infection, Sweet says.

CHCs provide access to care for everyone, regardless of their ability to pay, she notes.

The HIV new infection rate continues at a steady pace, and those already infected with the virus are living longer, which means there are rising numbers of people in need of HIV care.

This trend will continue as predictions suggest that half of the people with HIV/AIDS by 2015 will be over the age of 50 and in need of colonoscopies, heart disease treatment, and other preventive measures for older populations, Sweet says.

The concept of medical homes for HIV patients is not new, as Ryan White pioneered the model of providing care for all of the medical needs HIV patients have, she notes.

What's new is the idea of building the medical home for HIV patients in hundreds of primary care settings where physicians are not infectious disease specialists, she adds.

Primary care physicians in private community practices also could be trained to handle HIV patients.

"Primary care is becoming the major model of care because we've been so successful at controlling direct replication of HIV," says Kathleen Squires, MD, professor of medicine, director of the division of infectious diseases, Jefferson Medical College, Thomas Jefferson University of Philadelphia, PA.