The Primary Care Clinicians Work Group identified the following priorities for action planning. Work group members engaged in discussions and review of best practices related to leveraging Medicaid to support the viability of primary care clinicians in rural settings, provider loan repayment programs, and the need for provider trainings within rural communities.

• Expand healthcare provider training onsite in rural communities
• Increase funding for provider loan repayment programs
• Leverage Medicaid, including Medicaid Expansion, to support the viability of all primary care clinicians in rural settings

The Primary Care Clinicians Work Group's priority recommendations are included below.

Priority: Leverage Medicaid, including Medicaid Expansion, to support the viability of all primary care clinicians in rural settings

• Strategies and Action Plans
  • Making primary care economically viable for prospective providers also results in communities becoming more economically viable.  Consider the lack of success in primary care provider recruitment to be an economic issue and invest accordingly, similar to attracting new industry to North Carolina through economic incentives.
  • Improving primary care reimbursement and simplifying related administrative burdens will result in healthcare students making rational choices to enter all forms of primary care practice while in school and residency programs.
  • The states of Massachusetts and Rhode Island offer two examples of states and health insurers reaping rewards by investing differently in primary care and simplifying the process for administering primary care reimbursements.
  • Establish a Center on Workforce for Health to develop, coordinate and implement strategies to meet primary care workforce needs in targeted geographies of greatest need.

Priority: Increase funding for provider loan repayment programs

• Strategies and Action Plans
  • Explore the growing number of conditional acceptance programs for primary care clinicians that align with and incentivize providing primary care in rural and underserved communities.
  • Be intentional about recruiting primary care clinician students that match the demographic of the communities where they will serve.
  • Consider how to simplify, enhance and improve the current process for incentive and loan repayment programs currently administered in North Carolina that are based on HPSA (Health Professional Shortage Areas) scores.
  • In addition to loan repayment programs, support scholarship programs for primary care clinicians that are tied to service in rural and underserved communities.

Priority: Expand healthcare provider training onsite in rural communities

• Strategies and Action Plans
  • Develop a plan to financially support rural preceptors in rural and underserved communities as primary care clinicians are more likely to practice in those areas if they are trained there and have exposure to rural settings. More rural rotations are needed for all types of providers.
  • Consider creative uses of Medicaid and other funding sources to address health provider recruitment in rural communities (e.g., New Mexico uses Medicaid dollars to pay for more Graduate Medical Education (GME) slots in rural communities).
  • Align community development, provider training and provider recruitment programs in rural and underserved communities to increase primary care clinician retention. 

April 17, 2023, 3:00 to 4:00 pm, Work Group Meeting

Co-Leaders: Mark Snuggs and Randy Jordan; Absent: Anshita Chaturvedi

Attendees: Greg Griggs, Becca Hayes, Elizabeth Hudgins, Chris Shank, Kristen Spaduzzi, Hugh Tilson, Jr., Adam Zolotor

Discussion:

• Reviewed and discussed comments related to the prioritized policies, strategies, and action plans.
  • Policy: Leverage Medicaid, including Medicaid Expansion, to support the viability of all primary care clinicians in rural settings.
    • Strategies and Action Plans
      • Making primary care economically viable for prospective providers also results in communities becoming more economically viable.  Consider the lack of success in primary care provider recruitment to be an economic issue and invest accordingly, similar to attracting new industry to North Carolina through economic incentives.
      • Improving primary care reimbursement and simplifying related administrative burdens will result in healthcare students making rational choices to enter all forms of primary care practice while in school and residency programs.
      • The states of Massachusetts and Rhode Island offer two examples of states and health insurers reaping rewards by investing differently in primary care and simplifying the process for administering primary care reimbursements.
      • Establish a Center on Workforce for Health to develop, coordinate and implement strategies to meet primary care workforce needs in targeted geographies of greatest need.
  • Policy: Increase funding for provider loan repayment programs.
    • Strategies and Action Plans
      • Explore the growing number of conditional acceptance programs for primary care clinicians that align with and incentivize providing primary care in rural and underserved communities.
      • Be intentional about recruiting primary care clinician students that match the demographic of the communities where they will serve.
      • Consider how to simplify, enhance and improve the current process for incentive and loan repayment programs currently administered in North Carolina that are based on HPSA (Health Professional Shortage Areas) scores.
      • In addition to loan repayment programs, support scholarship programs for primary care clinicians that are tied to service in rural and underserved communities.
  • Policy: Expand healthcare provider training onsite in rural communities.
    • Strategies and Action Plans
      • Develop a plan to financially support rural preceptors in rural and underserved communities as primary care clinicians are more likely to practice in those areas if they are trained there and have exposure to rural settings. More rural rotations are needed for all types of providers.
      • Consider creative uses of Medicaid and other funding sources to address health provider recruitment in rural communities (e.g., New Mexico uses Medicaid dollars to pay for more Graduate Medical Education (GME) slots in rural communities).
      • Align community development, provider training and provider recruitment programs in rural and underserved communities to increase primary care clinician retention. 

January 23, 2023, 3:00 to 4:45 pm, Work Group Meeting

Co-Leads: Anshita Chaturvedi, Mark Snuggs, and Randy Jordan

Attendees: Adam Zolotor, Alice Salthouse, Ashley Rink, Becca Hayes, Chris Shank, Christopher Ray Vann, Elizabeth Hudgins, Gregg Griggs, Hugh Tilson, Kristen Spaduzzi, Patrick Brown , Savannah Junkins, Stephanie Nantz

Presenters: Kathy Dail

Discussion:

• Kathy Dail shared her deep appreciation to each work group member for their leadership within the NC SHIP Community Council. As the work group wraps up this year’s work, the work group is empowered to make decisions to pursue the prioritized policies, designate lead organizations, and identify others that should be a part of this work group. All work group members are welcome to continue to be involved.
• Reviewed and discussed the comments from subject matter experts received prior to the meeting about the approved priorities. Discussion highlights are included below each policy.
  • Policy: Expand Medicaid to support the viability of primary care clinicians in rural settings.
    • Lack of primary care provider recruitment being considered an economic issue. Primary care needs to be economically viable, which makes communities more economically viable.
    • From an education and training perspective, as providers are going through school, they make rational choices and if reimbursement is not fixed, cannot expect providers to go into primary care.
    • Massachusetts and Rhode Island are two examples economic drivers. There needs to be greater recruitment in rural areas where primary care is needed. Consider ways to invest differently in primary care and simplify the process and long-term planning.
  • Policy: Increase funding for provider loan repayment programs.
    • There are a growing number of conditional acceptance programs for students that might not always be admitted to medical school with alignment with rural and underserved communities.
    • Important to recruit people that look like the community they are serving; this is important for recruitment and sustainability.
    • North Carolina administers several incentive programs and loan repayment programs. Incentives are influenced for some programs based on HPSA (Health Professional Shortage Area) scores. Simplification of these processes and programs is needed.
  • Policy: Expand healthcare provider training onsite in rural communities.
    • Need to financially support rural preceptors. Clinicians are more likely to go to rural areas if are from there and have exposure to rural settings. Need rural rotations for all kinds of providers.
    • Recommendation for a strategic planning process for health provider recruitment in rural communities. Referred to the New Mexico example to use Medicaid dollars to pay for more GME (Graduate Medical Education) slots.
    • Alignment of community development and provider recruitment can make a bigger difference in providers staying in communities. 
• Reviewed next steps were to narrow comments and consider who all should be included in this work group and who could pick up this work and keep it moving forward.

November 16, 2022, 1:00 to 2:00 pm, Co-Lead Planning Meeting

Co-Leads: Randy Jordan, Anshita Chaturvedi, and Mark Snuggs

Discussions:

• Reached a consensus on which ongoing priorities to continue and which ones to move to developmental policy status. Revised wording of ongoing policies and clarified which policies required additional input from external sources to allow to moving forward with strategies and action plans for each ongoing priority.
• Approved Policy Priorities: (Further input on all policies will be solicited from NC AHEC.)
  1. Expand Medicaid to support the viability of primary care clinicians in rural settings. Making progress on this policy priority was considered preeminent in achieving a long-term solution to the primary care crisis. Primary care cannot be sustained, particularly in rural NC, under the current reimbursement rate structure.
  2. Increased funding for provider loan repayment programs. This policy was also considered a high priority and the topic of scholarships for providers is a related topic. Loan or scholarship programs should be available for physician assistants and nurse practitioners as they by far represent the fastest growing resource for primary care in rural communities.
  3. Expand healthcare provider training onsite in rural communities. The retention rate for preceptorships and other forms of experience-based training in rural communities are better than expected. Investing in this type of training of primary care physicians, physician assistants and nurse practitioners might be the best short-term solution to rural workforce issues. 
• Eliminated or Repositioned Policy Proposals:
  1. Solutions for healthcare workforce challenges. This topic was considered important, but needed more work by other groups who are currently focusing on the broad subject of healthcare workforce shortages.

October 17, 2022, 3:00 to 4:45 pm, Work Group Meeting

Co-Leads: Anshita Chaturvedi, Randy Jordan, and Mark Snuggs

Attendees: Alice Salthouse, Chris Shank, Christopher Ray Vann, Elizabeth Hudgins, Gregg Griggs, Hugh Tilson, Kristen Spaduzzi, Savannah Junkins

Presenter: Adam Zolotor

Discussion:

• Received the following presentation:
  • Adam Zolotor, M.D., provided an overview of Healthy North Carolina 2030 process and current efforts to expand primary care clinician services.
• Reviewed approved policy priorities and related strategies and action plans. Discussed questions and clarifications needed to move forward.
  • Expand Medicaid to support viability of primary care clinicians. Making progress on this policy priority was considered preeminent in achieving a long-term solution on the primary care crisis. Primary care cannot be sustained, particularly in rural NC under the current rate structure.
  • Increased funding for provider loan repayment programs. This policy was also considered a high priority, although retention rates in rural settings are relatively low from loan repayment programs. There was discussion about the value of scholarships for primary care providers as opposed to loans. Scholarship recipients who failed to serve in rural settings, could have their scholarships revert to loans. Also, loan or scholarship programs should be available for physician assistants and nurse practitioners as they by far represent the fastest growing resource for primary care in rural communities.
  • Solutions for healthcare workforce challenges. There was a suggestion that this issue should be referred to a group that was already conducting strategic planning on workforce training. Additional discussions are needed to determine whether this policy priority should be retained.
  • Expand medical school training on practice in rural communities. Adam Zolotor from NC AHEC presented data that suggested the retention rate for preceptorships and other forms of experience-based training in rural communities were better than expected. A variety of such programs were identified, and it was suggested that investing in this type of training of primary care physicians, physician assistants and nurse practitioners might be the best short-term solution to rural workforce issues. HOSA and middle and high school programs offering students exposure to healthcare were also considered good longer-term solutions to increasing the rural healthcare workforce. There seemed to be consensus that this policy priority would be a worthy third priority if the list extended to 3 priorities.

August 15, 2022, 3:00 to 5:00 pm, Work Group Meeting

Co-Leads: Anshita Chaturvedi, Randy Jordan, and Mark Snuggs

Work Group Members & Others Present: Alice Pollard, Alice Salthouse, Brian Toomey, Charlene Green, Chris Shank, Christopher Ray Vann, Don Holloman, Elizabeth Hudgins, Gregg Griggs, Karen Gliarmis, Kathy Dail, Katye Griffin, Kristen Spaduzzi, Savannah Junkins, and Shaunna Herrman

Discussion:

• Received presentation from Karen Gliarmis (Substitution for Stephanie Nantz). 
• Reviewed 14 proposed policies and advanced 4 of 14 policies for strategic planning; 8 policies were deferred/not selected as priorities and 2 policies were removed. Refer to proposed policies tagged Primary Care Clinicians below. 
  • Advanced:
    • Expand Medicaid to support financial viability of primary care providers serving low-income patients (8 votes)
    • Support increased funding for provider loan repayment programs that incentivize primary care providers to practice in medically underserved areas (4 votes)
    • Develop long-term solutions to healthcare workforce challenges with a particular emphasis on increasing the number of North Carolina health care providers from historically marginalized populations (3 votes)
    • Expand medical school training and learning experiences focused on the skills necessary to practice successfully in rural areas (1 vote)
  • Deferred: (All of the following received 0 votes)
    • Assess recruitment strategies used by colleges and universities that focus on rural needs
    • Ensure highspeed Internet access to support access to telehealth, electronic health records and controlled substance reporting system sites 
    • Grow NCCARE360 by adding more health systems, payers, providers 
    • Increase patient access and provide for adequate compensation for consultations with specialists 
    • Increase requirement for number of rural health clinical rotations for physician assistants (PAs) and Advanced Practice Nurses (APNs) 
    • Increase telehealth primary care initiatives in rural areas 
    • Increase the number of residency positions in rural areas 
    • Support pipeline programs in rural areas to encourage high school and college students to pursue careers in medicine and primary care 
  • Removed: (All of the following received 0 votes)
    • Invest in rural economies
    • Review and optimize middle and high school career and tutoring programs to augment math and science skills