Modesto Bee Article

By Ken Carlson, Modesto Bee Staff Writer
last updated: March 22, 2009


Modesto Bee - Resident Todd Bouchier, goes over paperwork with attending physician, Juan-Lopez Solorza. Stanislaus Family Medicine Residency program has lost its federal funding and its future is in doubt. March 18, 2009. (Debbie Noda/The Modesto Bee)


Resident Abilene Enriquez prepares to examine Cadie Winkle, 6 months, her mom's Kristin Winkle arms. (Debbie Noda / The Modesto Bee)


Stanislaus Family Medicine Residency program has lost its federal funding and its future is in doubt. (Debbie Noda / The Modesto Bee)

Multimillion dollar deficits and budget cuts in recent years haven't stopped the Stanislaus County health system from providing care for more than 70,000 low-income residents.

Now, another threat is striking at its foundation.

The Stanislaus Family Medicine Residency Program, a source of pride for the medical community and an integral part of the county health system, recently lost its federal funding because of policies tied to the Balanced Budget Act of 1997.

At a time when President Barack Obama wants to expand health access for millions of Americans, the Centers for Medicare and Medicaid Services, also known as CMS, has eliminated funding used to train physicians in a region with high numbers of unemployed and uninsured.

The agency also ordered Doctors Medical Center and the county, which share the cost of the program, to return $19.1 million in reimbursements that funded the program from 2001 to 2008.

The issue could disrupt health care in a county where 16 percent of the population is uninsured and 22 percent rely on the state Medi-Cal system.

The program's 27 residents care for uninsured hospital patients and handle 35,000 patient visits per year in the county health clinics. In addition, the 30 primary care doctors in the six county clinics serve as faculty for the program.

So, what happens to the program has broad implications.

"We've got to get this fixed," said Mary Ann Lee, managing director of the county Health Services Agency. "It is the single most important source of physicians for this community, at a time when the valley already is short on physicians."

Since 1975, 223 doctors trained in family medicine have graduated from the program; 70 of them practice in Stanislaus County and 16 work in the county health clinics.

The three-year program, graduating nine doctors per year, is affiliated with University of California at Davis and is in good standing with the Accreditation Council for Graduate Medical Education.

Stanislaus Medical Center served as the teaching site for the family practice residents from 1975 until the county hospital closed in 1997, then the program was transferred to Doctors, which guarantees beds to patients in the county indigent health program.

According to CMS, the program no longer qualified for graduate medical education funding after the move to Doctors, even though an administrative contractor approved the reimbursements for several years.

Feds: Following spirit of law

Marc Hartstein, deputy director of the hospital and ambulatory policy group for CMS, said the Balanced Budget Act placed caps on the number of residents that hospitals could count for reimbursements and placed limits on new programs. There were no provisions for moving the training slots from the defunct county hospital to Doctors, he explained.

The mistake in approving the funding was discovered when Doctors submitted a Medicare cost report to the agency three or four years ago, he said. The agency has been discussing the issue with local officials for about 18 months.

The agency is aware of the health care needs of the county, Hartstein said, but has to apply the rules within the spirit of the 1997 act.

"Even though it was a difficult decision for us, we have an obligation," he said. "We are sympathetic to the situation out there and would like to see the training continue."

The program sponsors can apply for reimbursements by creating a new program. But the agency says it has to be new to comply with the law. So the program would have to close for a year and reopen with a new curriculum, a new director, a new faculty and new residents.

County officials said dismantling the program would cause an upheaval in patient care for more than 70,000 county residents. Besides scrapping a well-regarded program, the staffing shortages in the hospital and clinics would be acute.

Presumably, the county would have to dismiss the current faculty and recruit new physicians to teach the residents. The county would lose dedicated physicians who divide their time between seeing clinic patients and teaching residents. Clinic patients would lose their regular doctors.

"To dismantle a program is quite a traumatic experience," said Dr. Peter Broderick, residency program director. "There is no other residency that was ever given that requirement. I have some excellent faculty here and there is no reason why they shouldn't continue as teachers in the residency."

County officials would like a second opinion from the Obama administration or top brass of the Department of Health and Human Services or CMS. But the presidential appointments to key positions are pending.

Rep. Dennis Cardoza, D-Merced, said through a spokesman that he would continue fighting for a solution.

"He is more frustrated with this agency than any other he has dealt with in his political career," said Mike Jensen, spokesman for the congressman.

Doctors Medical Center has challenged the CMS action to terminate and recoup the funding by filing an appeal with the Medicare Provider Reimbursement Review Board. The process could take years.

In the meantime, the hospital has committed to covering half of the cost of continuing the program for at least two years.

On Tuesday, county staff will ask the Board of Supervisors to approve as much as $11 million for the county share of the repayment to CMS and to fund the other half of the program's $4.4 million annual budget for two years.

The county is contractually obligated to share the costs with Doctors and also needs to support the current residents so they complete the training, said Supervisor Bill O'Brien. The $11 million would come from an extended tobacco tax loan to the Health Services Agency.

"The county has done nothing wrong," he said. "The federal government looked at the program back in 1997 and they determined the level they were going to fund it. Ten years later, they pulled the rug out from under our feet."

Initial talks have taken place to form a consortium to reconstruct the program; it's hoped more lenient terms can be negotiated with the federal government. Memorial Medical Center, Doctors and Kaiser Modesto Medical Center could serve as training sites. The new faculty could include osteopathic doctors and community-based physicians.

Doctors already sparse here

Other folks have been watching the county's dispute with CMS, including Dr. Jeffrey Luther, president of the California Academy of Family Physicians. He said federal funding for physician training has been tenuous for 15 years.

"The new administration has voiced support for it and his budget calls for investment in medical education," Luther said. "We already have an inadequate supply of primary care physicians to meet the needs of the population, especially in areas like Stanislaus County. We need to be pouring more resources into training physicians. It's not a time to be cutting them loose."

The decision also stunned Scenic Faculty Medical Group, which contracts with the county to staff the clinics and teach the residents.

Dr. Glen Villanueva said physicians would consider other opportunities if the residency program ceased to exist.

"I came here to teach and take care of the underserved," he said. "There is a disconnect between the needs of the community and what CMS has done. It is very difficult to understand why they came to this conclusion."

Bee staff writer Ken Carlson can be reached at kcarlson@modbee.com or 578-2321.