[Senate Hearing 110-833]
[From the U.S. Government Publishing Office]
S. Hrg. 110-833
ADDRESSING HEALTHCARE WORKFORCE ISSUES FOR THE FUTURE
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
ON
EXAMINING THE WAYS TO ADDRESS HEALTHCARE WORKFORCE ISSUES FOR THE
FUTURE, FOCUSING ON PRIMARY CARE PROFESSIONALS
__________
FEBRUARY 12, 2008
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut MICHAEL B. ENZI, Wyoming,
TOM HARKIN, Iowa JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico RICHARD BURR, North Carolina
PATTY MURRAY, Washington JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island LISA MURKOWSKI, Alaska
HILLARY RODHAM CLINTON, New York ORRIN G. HATCH, Utah
BARACK OBAMA, Illinois PAT ROBERTS, Kansas
BERNARD SANDERS (I), Vermont WAYNE ALLARD, Colorado
SHERROD BROWN, Ohio TOM COBURN, M.D., Oklahoma
J. Michael Myers, Staff Director and Chief Counsel
Ilyse Schuman, Minority Staff Director
(ii)
C O N T E N T S
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STATEMENTS
TUESDAY, FEBRUARY 12, 2008
Page
Sanders, Hon. Bernard, a U.S. Senator from the State of Vermont,
opening statement.............................................. 1
Prepared statement........................................... 3
Kennedy, Hon. Edward M., Chairman, Committee on Health,
Education, Labor, and Pensions, opening statement.............. 6
Prepared statement........................................... 8
Murkowski, Hon. Lisa, a U.S. Senator from the State of Alaska,
statement...................................................... 9
Murray, Hon. Patty, a U.S. Senator from the State of Washington,
statement...................................................... 11
Prepared statement........................................... 12
Brown, Hon. Sherrod, a U.S. Senator from the State of Ohio,
statement...................................................... 13
Allard, Hon. Wayne, a U.S. Senator from the State of Colorado,
statement...................................................... 14
Steinwald, A. Bruce, Director, Healthcare, Government
Accountability Office, Washington, DC.......................... 15
Prepared statement........................................... 17
Grumbach, Kevin, M.D., Director, UCSF Center for California
Health Workforce Studies, Professor and Chair, UCSF Department
of Family and Community Medicine, San Francisco, CA............ 27
Prepared statement........................................... 27
Hooker, Roderick S., Ph.D., P.A., Director of Research,
Rheumatology Section, Medical Service Department of Veterans
Affairs, Dallas VA Medical Center, Dallas, TX.................. 35
Prepared statement........................................... 35
Salsberg, Edward S., M.P.A., Director, Center for Workforce
Studies, Association of American Medical Colleges, Washington,
DC............................................................. 38
Prepared statement........................................... 39
Swift, James Q., D.D.S., Board President, American Dental
Education Association, Professor, University of Minnesota
School of Dentistry, Minneapolis, MN........................... 46
Prepared statement........................................... 47
Auerbach, Bruce, M.D., President-Elect, Massachusetts Medical
Society, Vice President and Chief of Emergency Medicine, Sturdy
Memorial Hospital, Attleboro, MA............................... 60
Prepared statement........................................... 61
Landon, Beth, M.H.A., M.B.A., Director, Alaska Center for Rural
Health, University of Alaska, Anchorage, AK.................... 69
Prepared statement........................................... 69
Laurent, Jennifer, M.S., FNP-BC, President, Vermont Nurse
Practitioner Association, Family Nurse Practitioner, Cambridge,
VT............................................................. 76
Prepared statement........................................... 77
Maupin, John E., Jr., D.D.S., M.B.A., President, Morehouse School
of Medicine, Atlanta, GA....................................... 84
Prepared statement........................................... 85
Enzi, Hon. Michael B., a U.S. Senator from Wyoming, prepared
statement...................................................... 110
(iii)
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Senator Bingaman............................................. 113
Senator Clinton.............................................. 114
American College of Physicians............................... 115
Response of Bruce Steinwald to questions of:
Senator Kennedy.......................................... 117
Senator Bingaman......................................... 118
Senator Sanders.......................................... 119
Senator Mikulski......................................... 119
Senator Enzi............................................. 119
Senator Murkowski........................................ 120
Response of Kevin Grumbach, M.D. to questions of:
Senator Kennedy.......................................... 120
Senator Mikulski......................................... 121
Senator Bingaman......................................... 121
Senator Clinton.......................................... 123
Senator Sanders.......................................... 123
Senator Enzi............................................. 127
Senator Murkowski........................................ 127
Response of Roderick S. Hooker, Ph.D., P.A. to questions of:
Senator Mikulski......................................... 129
Senator Sanders.......................................... 129
Senator Enzi............................................. 130
Senator Murkowski........................................ 130
Response of Edward S. Salsberg, M.P.A. to questions of:
Senator Mikulski......................................... 131
Senator Bingaman......................................... 133
Senator Clinton.......................................... 134
Senator Sanders.......................................... 135
Senator Enzi............................................. 136
Senator Murkowski........................................ 137
Response of Beth Landon, M.H.A., M.B.A. to questions of:
Senator Mikulski......................................... 137
Senator Enzi............................................. 138
Senator Murkowski........................................ 138
Response of Jennifer S. Laurent, M.S., FNP-BC to questions
of:
Senator Sanders.......................................... 140
Senator Mikulski......................................... 141
Response of HRSA to questions of:
Senator Mikulski......................................... 141
Senator Bingaman......................................... 141
Senator Brown............................................ 142
Senator Enzi............................................. 142
Senator Murkowski........................................ 142
ADDRESSING HEALTHCARE WORKFORCE ISSUES FOR THE FUTURE
----------
TUESDAY, FEBRUARY 12, 2008
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 2:34 p.m. in Room
SD-106, Dirksen Senate Office Building, Hon. Bernard Sanders,
presiding.
Present: Senator Sanders, Kennedy, Murray, Brown,
Murkowski, and Allard.
Opening Statement of Senator Sanders
Senator Sanders. Thank you all very much for coming for
what is going to be a very important hearing. I want to very
much thank Chairman Kennedy and Ranking Member Enzi for helping
us put together this meeting on what I consider to be one of
the most important issues facing the United States in terms of
the healthcare crisis.
As everybody knows, what this hearing today will focus on
is the future supply of essential primary care providers--
physicians, nurse practitioners, physician assistants, and
dentists. While the scope of this hearing is limited to these
health professions, we are all aware that the problem goes
beyond those particular professions. Therefore, we have invited
additional health professions, groups, to submit written
statements that will be made part of the record of this
hearing.
[The information referred to can be found in additional
material.]
Senator Sanders. We have also received the testimony from
the Administration, whose witness is unable to attend, but
their testimony will also, of course, be part of the record.
[The information referred to can be found in additional
material.]
Senator Sanders. After the opening remarks from the
Senators, what we will hear is 2 minutes from each of the
panelists, and then we will be able to engage in an informal
discussion as to what the root causes of the problem are and
how we can resolve it.
Now my view--and few will disagree, regardless of their
political persuasion--our country faces a major healthcare
crisis. There are 47 million people who are uninsured. Even
more are underinsured. Costs of healthcare keep going up, and
we end up spending twice as much per person on healthcare as do
the people of any other Nation.
In addition, when we look at our healthcare crisis and all
that we spend, it is important to understand that many of the
important indices, like infant mortality or longevity, we fall
behind dozens and dozens of other countries.
When people look at this crisis, they sometimes think that
the only issue is universal healthcare. Well, I happen to be a
strong advocate of a national healthcare program. In my view,
if tomorrow, magically, we had healthcare for all of our
people, we would still continue to have a major healthcare
crisis in terms of accessibility of many people, from one end
of this country to another, to doctors and dentists.
We have got to focus and what today's hearing is about is
focusing on accessibility. Today, in America, over 56 million
Americans do not have adequate access to primary healthcare
services. My guess is that the number of people who lack access
to dental care is even higher.
Fewer and fewer U.S. medical and dental students are
choosing primary care as their area of specialty. One of the
issues that we have got to look at--it is not just the number
of doctors out there or the number of dentists--what kind of
practices do they have? Are they all specialists? Are there
rural areas like my State of Vermont, where we have a whole lot
of specialists in Burlington, but in the rural areas, you can't
find the number of physicians that you need.
When you are looking at dentists, we all know that dentists
want to make us smile better and clean up our teeth and make
them look all white and lovely. What about the people all over
this country, working people who don't have front teeth and
can't find a dentist to help them, or the kids who are
suffering today because they can't find dentists to fill their
cavities.
I can go on and on with anecdotes. I will just mention one.
Several years ago, I had a hearing on dental care in the State
capital, Montpelier, VT. A woman gets up who works in a school,
a low-income school. She said a kid in my school has teeth
rotting in his mouth. He is in pain. She got on the phone.
Called up everybody from the governor's office on down. She
could not find a dentist to take care of that child.
In the last few years in Vermont, we have had some success.
We have built a number of clinics. The problem that remains in
Vermont and all over this country is very severe.
Further, when we talk about this crisis, we have to ask
ourselves an important question. That is that while there has
been an increase in the overall number of primary care
physicians, it is troubling to me that the number of Americans
pursuing a career in primary care has declined. Why is that? We
hope that you will help us get some answers to that problem.
As a nation, as the wealthiest Nation in the history of the
world, for whatever reason, we are increasingly dependent on
international medical school graduates to meet our needs. Why?
Why can't the United States of America educate enough of our
own physicians?
Now, one of the problems about being dependent upon the
international community is that we are depleting their
healthcare talent, whether it is doctors or nurses in poor
countries, being trained in those countries, and now coming to
the United States of America. Is that fair to those countries?
Let me just conclude, before I introduce Senator Kennedy
and then Senator Murkowski, with a few thoughts as to where we
should be going. I would like others to be thinking about this.
We need to reauthorize title VII, our major health professions
training act, with improvement in funding levels for grants,
scholarships, and loan repayment that support needed
professional development and community-based initiatives.
We need to, in my view--and I know Senator Murkowski has
legislation to do just this--double the funding and size of the
National Health Service Corps. We need to, in my view, assure
accessible care in underserved communities by significantly
increasing the appropriations level each year for community
health centers, a program that Senator Kennedy started a number
of years ago, which has a huge impact all over this country in
providing primary healthcare to tens of millions of Americans.
Further, we need to reform the way the $8 billion that
Medicare spends in support of graduate medical education to
reward training models that address public health needs and
allow flexibility for training to occur outside of the
traditional limited number of sites of care.
Last, we need to correct the disparity in Medicare and
Medicaid reimbursement that favors specialty care over primary
care. Those are some of my thoughts. We will discuss those
ideas and many others in a few minutes. I will put my whole
statement in the record.
[The prepared statement of Senator Sanders follows:]
Prepared Statement of Senator Sanders
I would like to call this hearing to order. I wish to thank
Chairman Kennedy and Ranking Member Enzi for arranging a
hearing on this critical topic. Today's hearing will explore a
long neglected area of health care delivery. It will
concentrate on the future supply of essential primary care
providers: physicians, nurse practitioners, physician
assistants, and dentists. While the scope of this hearing is
limited to these health professions, I know full well that
shortage issues affect many other health professions as well.
Therefore, we have invited additional health professions groups
to submit written statements that will be made part of the
record of this hearing. We have also received testimony from
the Administration whose witness is unable to attend. We will
enter that testimony into the record as well. I thank and
welcome the witnesses who are here today.
I look forward to a fruitful exchange with them that will
highlight not just the problems, but that will also offer us
potential solutions to what I see as a crisis that will worsen
in the future if nothing is done.
The truth is that the American health care system is badly
deteriorating for more and more Americans. The crisis in health
care coverage is well-documented with over 47 million Americans
now uninsured, and untold millions of others with increasingly
inadequate coverage. It is unfathomable to me that, unlike
every other industrialized nation in the world, we do not
provide health care to all, as a right of citizenship.
In addition, while we spend more as a society on health
care per capita than any other nation, our outcomes in terms of
many health status measures rank below even many developing
countries. Over 30 nations have better infant mortality rates
and longer life expectancy than the United States.
Many assume wrongly that, by providing health care coverage
to all, we would solve the problem. While I am a strong
advocate that health care should be a right of citizenship for
all Americans, I also realize that this is just part of the
solution to achieving access to care for all. Let me be
perfectly clear, if universal health care coverage were
miraculously achieved tomorrow, it alone would not solve the
access problem.
Today, in America, over 56 million Americans do not have
adequate access to primary health care services, (CHART)
according to a study by the National Association of Community
Health Centers. In terms of oral health, the number of
Americans without access to dental care is even higher.
Even though many of these Americans have insurance
coverage, they live in communities with too few primary care
providers.
Fewer and fewer U.S. medical and dental students are
choosing primary care as their area of specialty. There are
simply not enough primary care providers now and the situation
will become far worse in the future unless something is done.
Clearly, we have a crisis when community health centers,
generally recognized for their ability to provide
comprehensive, cost-effective care, are unable to fill over 750
vacancies in their physician staffing.
To give a couple of examples of the difficulty that many
face in accessing care: the small town of Island Pond, in the
most isolated and rural part of northern Vermont, is fortunate
to have a federally qualified health center that offers dental
care to all regardless to ability to pay. It regularly receives
calls from Vermonters from all over the State seeking dental
care because either their towns do not have a dentist or
because the few dentists they have are overbooked and not
accepting patients.
Sadly, little has changed since the time the State Welfare
Office in Brattleboro, VT called to ask if the Island Pond
dental practice would see some of their clients if they bused
them there. Brattleboro is 165 miles away from Island Pond!
For those who would deny this is a crisis, consider this:
another community health center in Hardwick, VT got an urgent
call from Walter Reed Hospital. A wounded returning veteran
from Iraq was ready to be discharged to return home to Vermont,
but, because of his need for ongoing medical treatment, he
could not be discharged unless he had a local primary care
provider. There were none available where he lived, so even
though he was far from the Hardwick Health Center service area,
the health center agreed to take him as a patient so that he
could return home. Such situations should not exist in America
and Congress should do all it can to correct this appalling
situation.
While I understand that there has been an increase in the
overall number of primary care physicians, it is troubling to
me that the number of Americans pursuing a career in primary
care has declined. Therefore, the growth has been totally due
to the number of international medical students training in
America. We are increasingly dependent on international medical
school graduates to meet our needs. Currently, one in four new
physicians in the United States is an international medical
graduate. (CHART)
And, in America's underserved communities, international
medical graduates make up 3 out of 5 of all physicians, 60
percent! This is shameful. It is beyond my comprehension that
the richest Nation in the history of the world is not able to
graduate the kinds of health professionals we need. Instead, we
are dependent on medical students trained abroad, whose
education is often supported by their home countries.
We ought to be able to encourage and develop enough primary
care providers and not have to import doctors from countries
that have arguably greater needs and fewer resources to care
for their populations. It is morally wrong that we are
depleting the number of health care providers from the poorer
countries of the world. It is extremely important that we
understand why we are not educating the kinds of doctors and
dentists we need, and I look for this panel to provide us with
information to correct this.
We can debate forever whether the current supply of primary
care doctors and dentists is sufficient. But I have no doubt
that future demand will exceed supply. First year medical
school enrollment per 100,000 people has declined since 1980.
(CHART) At the same time, the number of elderly will double
over the next 20 years. (CHART) With over one-third of active
physicians over the age of 55 and likely to retire by 2020, we
are looking at a major crisis.
So, today's hearing and what we do as a result of it, is of
extreme and urgent importance. As I stated earlier, I am
looking for the panel to provide ideas for solving this
problem. This is quite timely since the HELP Committee will be
reauthorizing Title VII of the Public Health Service Act, which
supports the major health professions training programs funded
by the government. There is also action pending in the Senate
to reauthorize the National Health Service Corps.
I believe part of the solution lies in making medical,
dental, and nursing education affordable for all Americans, not
just for those with means. I applaud the efforts of Senators
Kennedy and Enzi in the recently passed Higher Education bill,
which will allow for loan forgiveness for those who work for 10
years in the public or non-profit sector. This represents a
good start, but I am committed to doing more. I look forward to
working with my colleagues to:
1. Reauthorize title VII, our major health professions
training act, with improvement in funding levels for grants,
scholarships, and loan repayment that support needed
professional development and community-based initiatives. This
vital program, funded at about $195 million, is targeted to be
eliminated in the President's 2009 budget. This must not
happen.
2. Double the funding and size of the National Health
Service Corps, as called for in a bill introduced by Senator
Murkowski that I am pleased to be an original co-sponsor of.
Funding for this program is currently $125 million and
incredibly has actually declined in the past several years. And
once again, the President would cut its funding in 2009 by $3
million.
3. Assure accessible care in underserved communities by
significantly increasing the appropriation level each year for
community health centers. This program, funded at just under $2
billion, has been judged by the Office of Management & Budget
to be one of the most efficient in using taxpayer dollars. If
adequately funded over the next several years, it could
increase the number of people in underserved areas who receive
comprehensive primary care services from 16 million to 30
million.
4. Reform the way the $8 billion that Medicare spends in
support of Graduate Medical Education to reward training models
that address public health needs and allow flexibility for
training to occur outside of the traditional, limited numbers
of sites of care.
5. Correct the disparity in Medicare and Medicaid
reimbursement that favors specialty care over primary care, and
rebase the Medicare FQHC reimbursement cap, as was promised
when the program began in 1991, but which has never occurred.
In the face of this compelling health professions shortage
crisis, I look forward to an exchange of your ideas as to how
to correct this worsening situation.
Senator Sanders. Now let me introduce the Chair of this
committee, who, as everyone knows, has been a leader in the
U.S. Congress in so many areas in fighting the fight for
healthcare for all Americans.
Senator Kennedy.
Opening Statement of Senator Kennedy
The Chairman. Thank you. Thank you very much, Senator
Sanders, for chairing this hearing. Thank you, Senator
Murkowski, for being so constructive and helpful to this
committee about the needs that we are facing in the health
profession in underserved areas, and in the challenges that
underserved areas have just generally. It is a pleasure as well
to be with Patty Murray, who has been so involved in health and
education issues as well.
Our Chairman Sanders has outlined, a central concern that
we are facing as a country and as a Nation. There is a great
debate that is taking place about this country trying to deal
with the core challenge that we are facing, and that is to
develop a comprehensive universal healthcare system.
Well, it starts right where we are today, with the type of
personnel that we are going to have. They are going to be able
to help develop such a system. If we don't have it right in
terms of the medical personnel, the allied health, the health
professions, family physicians, and all the attendant kind of
health assistants, we are just not going to get there.
As we find individuals that are criss-crossing the country
talking about healthcare and healthcare reform, this hearing is
of the most importance because your ideas, your suggestions are
absolutely indispensable not only for local communities, for
what is happening in rural areas, and for what is happening in
urban areas in the country, but also in terms of system reform,
your comments are enormously helpful. I hope you will give us
some of your guidance on this.
I can remember having a similar hearing on this about 35
years ago, I date myself. We had the strong representation of
the AAMC and wonderful panels, and I always remember what I was
told at that time. It still may be true, although, hopefully,
we are getting away from it. That was in terms of medical
schools, freshmen, by and large, when they enter medical
schools, they want to be primary care physicians, and then the
system begins to work against them.
The indebtedness, primarily the indebtedness, works so that
by the time they are graduating, they have a debt, what is
piled on in terms of their college debt now $20,000, depending
where you are, in what part of the country, and you add that to
the medical school debt, and you are up to, what, $110,000,
$120,000, perhaps even more. That drives their decisions in a
very important way and skews and changes these issues.
Last year here, in the Senate, we passed legislation to put
a limitation on what individuals have to repay each year and
put a limitation that no more than 15 percent of their income,
no matter how indebted they are, would be required, with the
hope that this might have some impact in terms of health
professions. It is not the answer. We are going to hear a lot
of different suggestions today. But at least we are going to
try to begin to answer. You have other ideas in terms of how
this is skewed. I hope you are going to help us.
I hope you are going to help us understand why we always
give short shrift to dental care and eye care. As someone who
has been interested in education, when we were developing the
SCHIP program, Senator Hatch and myself, trying to model it
after what had happened up in Massachusetts. It was
interesting. When we went to the floor of the U.S. Senate, we
couldn't mandate eye care or dental care.
Even though if children don't have dental care, as Senator
Sanders points out, they are going to get sick, and they are
going to be unable to go to school. If they can't see the
blackboard, they are not going to be able to learn. If they
can't hear the teacher, they are not going to learn. We give
short shrift to dental care and to eye care as well. We have to
understand we are talking about what do we really need in
personnel to have a healthy Nation, a healthy country, a
healthy population? That is what we are really interested in.
I won't review because you know the facts about what is
happening. What is happening in my State is we are trying to
deal with a newer kind of healthcare system and how that is
being skewed because of the lack of health personnel in the
right areas. We need well-trained, well-led personnel, but we
need them in the right areas professionally and in the right
areas geographically. This is a constant issue and a constant
question.
Quite frankly, I don't intend this to be a partisan
comment. But when you have an administration that sends a
budget up here that zeroes out title VII and slashes title
VIII, and then talks about trying to do something about
healthcare and the personnel, it just rings hollow.
This is going to take resources, and it is going to take
also understanding the changes, which are taking place in the
whole health delivery system. We need that kind of guidance
that this panel can give. Let me just give you the assurance
that we consider this to be an immensely important hearing
today, and we will certainly share with our colleagues on this
committee and with others as well.
I thank Senator Sanders so much. He has been relentless,
relentless. That is saying something when you say that about
Senator Sanders, that he is relentless in his commitment and
dedication on this issue. I thank again Senator Murkowski for
all of her constructive help in terms of rural areas and the
communities, and Patty Murray, who always adds a special
dimension on health issues and education.
I will put my whole statement in the record, and I thank
you very much.
[The prepared statement of Senator Kennedy follows:]
Prepared Statement of Senator Kennedy
I want to thank Senator Sanders for his dedication to this
topic and for working so hard on this hearing today. I also
want to thank Senators Enzi and Murkowski for their work on
this issue.
To create a healthy nation we must not only have health
care professionals that are excellently trained--we need health
care professionals that are excellently trained in the right
fields and practicing in the communities that need them the
most. Over the years, experts have predicted a physician
shortage, only to change those projections years later. We've
heard of shortages in one specialty or another, only to have
that prediction change as well. But one thing that has remained
constant is the need for a strong network of primary care
providers.
The health of our Nation depends on a strong primary care
system. And that system can not run without an adequate supply
of primary care physicians, nurse practitioners, physician
assistants and other providers. In implementing health reform
in Massachusetts one thing has become very clear--comprehensive
health reform can not take place without appropriate access to
primary care providers. Unfortunately, we are facing a crisis
in primary care. Family medicine residency positions have
dropped by 50 percent since 1997 and the growth in the supply
of primary care physicians for adult patients is now lagging
behind the rate of growth of adults. Community health centers
continue to report significant vacancies for primary care
providers.
We must take the steps needed to ensure a strong primary
care workforce. One of those steps is making sure that the
title VII health professions training programs are adequately
funded. Amazingly, President Bush dramatically cut these
programs in his budget. It is incomprehensible to me that
President Bush would cut funding for these important programs
in the face of primary care physician and other provider
shortages. He even eliminated the health professions diversity
programs that help to create a culturally competent diverse
workforce that will serve in communities that need care the
most.
This hearing will inform our committee as we move forward
on our work to reauthorize the title VII and title VIII
programs. I want to thank all of our witnesses that have joined
us today. They will provide us with a wealth of knowledge on
the current state of affairs with the primary care workforce,
including the challenges in rural and frontier areas and the
importance of diversity in the health professions. There are
also other primary care providers that we were not able to
accommodate at this hearing, but we have asked for their
official testimony to be included in the record so we can
receive their important input.
I also want to acknowledge that while this hearing focuses
on primary care providers, I am aware of the profound nursing
shortage in our country and I will be working with Senator
Mikulski and other members of the committee in the coming
months to address that issue as well.
We know that primary care helps to reduce healthcare cost
and results in a better quality of care of patients and I look
forward to hearing more about what we can do to support our
Nation's primary care providers.
Senator Sanders. Thank you very much, Senator Kennedy.
Senator Murkowski has, in fact, been a leader in the Senate
on rural healthcare. Senator Murkowski, thanks very much for
being with us.
Statement of Senator Murkowski
Senator Murkowski. Well, thank you. I want to thank all
that have assembled to join us here today on the panel and also
in the audience. I don't know if you all noticed, but there was
a group of about 20-some odd young people who came in, listened
for about 5 minutes, and then they left. I wish that they had
stayed because I need to recruit each and every one of them to
come to the State of Alaska or to rural Vermont.
We have a crisis in access to healthcare in this country in
our medically underserved areas, and I am very pleased, Mr.
Chairman, that you and Senator Enzi have kept your commitment
certainly to Senator Sanders and myself to hold this very
important hearing on healthcare workforce issues.
With the panel that we have today, we are going to hear as
they speak on the primary care shortages. That includes the
physicians. It includes the dentists, the nurse practitioners,
the physician assistants. We are going to hear from folks today
who have come from all across the country. I have a constituent
from Alaska that I am proud to welcome today.
We are going to hear their comments about how important it
is to reauthorize the funding for title VII and title VIII
programs not just for rural America, but also for the so many
economically disadvantaged urban areas. We know that while many
of these areas aren't rural, they are medically underserved.
They are equally affected by some of the very persistent
shortages that we have in the workforce out there.
As you have mentioned, Chairman Kennedy, the President has
zeroed out funding for all of the title VII programs in this
2009 budget and has said that they were ineffective. I
absolutely disagree. Title VII, title VIII programs have a long
and successful history. They go back to 1963 with the Health
Professions Education Assistance Act that we passed to address
the projections of the health professional shortages.
This legislation sought to establish education and training
programs for the primary healthcare workforce and has continued
to do so by providing grants to the students, to the health
professions, to the institutions, the community organizations,
to provide the education, the training in primary care
medicine, whether it is internal medicine, or general
pediatrics. As a result, we have a larger number of individuals
from rural and underserved communities, economically
disadvantaged backgrounds, and diverse groups that have been
entering that primary care profession.
We know that these programs have been successful. We have
seen reports out there, 70 to 80 percent of students are
returning to serve as healthcare professionals in their
communities. These are the kinds of statistics that we need to
keep seeing.
I am hoping that the testimony from those of you today
includes recommendations to help deal with the primary care
shortages that face nearly 62 million Americans living in rural
and medically underserved areas.
Senator Sanders, you have mentioned my legislation, some of
the things that we are promoting in the Physician Shortage
Elimination Act. I look forward to hearing from the panel
members on some of the issues such as the integrated rural
training track that will provide the graduate medical education
or the GME reimbursement for residency training that is
obtained in a non-hospital setting, as well as funding
community health centers to enable them to provide shared
residency training time with a teaching hospital.
The third issue--and, Senator Sanders, you mentioned this--
is that my legislation will double the funding to $300 million
annually for the National Health Service Corps. This is an
immensely successful program that places primary healthcare
workers in rural and medically underserved areas.
Unfortunately, due to the reductions in funding, we turn away
nearly 80 percent of program applicants every year from this--
80 percent.
In Alaska, we are undoubtedly suffering from the most
severe primary care vacancy rates, particularly in our rural
and our frontier areas. We have unfulfilled physician assistant
job openings at about 25 percent. Our family nurse practitioner
jobs openings are at about 36 percent.
Alaska, many of you think that it is this State with a
young population. We are young, but we also have the fastest-
growing elderly population in the country, behind Nevada. We
have got a very young, young population. In many of our
villages, the average age is 18. Then we have the second
fastest-growing elderly population in the country.
There is not a day--seriously, there is not a day that
doesn't go by when one of my offices around the State or back
here in Washington, DC, doesn't get a phone call from an
elderly constituent or from a son or a daughter who is calling,
some of them in tears, searching for someone to provide for a
level of care because the healthcare providers are not
accepting Medicare.
This is what reduced Medicare reimbursements to primary
care providers in rural America brings about. Zero access to
primary care healthcare services for the most vulnerable
population, and that is the disabled and the elderly.
I am going to end with a statistic that is really
compelling when we talk about rural health disparities. Sixty-
two million Americans, this is about 20 percent of the U.S.
population, live in designated medically underserved areas,
many of them rural. Yet only 9 percent of the Nation's
physicians practice there.
Clearly, this situation deserves the Congress's attention.
I look forward to hearing the comments and the suggestions from
all of you and I appreciate your work, collaboratively,
together and with the committee as well.
Thank you.
Senator Sanders. Thank you, Senator Murkowski.
Senator Patty Murray has long been a leader on healthcare
issues in the Senate.
Senator Murray.
Statement of Senator Murray
Senator Murray. Mr. Sanders, thank you so much for holding
this hearing. You and Senator Murkowski are just right on
target on bringing everybody together.
I will submit my opening statement to the record.
Just let me say this. I have been holding a series of
roundtables around my State to focus on the issue of healthcare
providers and the lack of access and how it is impacting the
cost of healthcare. Because, as more and more people are
getting older and needing healthcare, there is fewer and fewer
healthcare workers. Access is becoming harder. It is driving up
the cost, and it is an issue that all of us have to deal with.
I have heard of how our nursing shortage is becoming very
acute, yet even the University of Washington doesn't have
enough slots to fill because they don't have enough faculty to
teach nurses. Rural healthcare training and helping our rural
healthcare folks is a huge issue in my State. Primary care
physicians, lack of primary care physicians going into that
field is really very, very worrisome to all of us.
It is a very timely hearing. I am very concerned about the
President's budget. As has been stated, I am sorry that we
don't have a witness from the Department of Health and Human
Services. I understand they could not show up today so we could
talk about that.
Focusing all of us on providing the type of people who need
to go in all the career fields of healthcare will help us with
access and, in turn, help us with bringing down the cost of
healthcare, which I know is a goal of every single business,
every single community, every single government agency that we
have in this country today.
Thank you very much.
[The prepared statement of Senator Murray follows:]
Prepared Statement of Senator Murray
I want to thank Senator Sanders and Senator Kennedy for
organizing this hearing.
The shortage of doctors, nurses, and workers across the
health care field is one of the most serious workforce
challenges our country faces. And as the baby boomers retire,
the problem is only going to get worse.
Experienced health care professionals are set to retire in
large numbers in the near future--just as the baby boom
generation will begin to need more care. The problem is already
acute in some rural communities where it's increasingly
difficult to recruit and retain doctors and nurses.
Senator Sanders, I've been concerned about this issue for
many years, as I know you have. Like you, I believe we must
make building our health care workforce a national priority, so
I'm glad we're having this hearing today.
In the last year, I've held roundtables across my home
State of Washington so I could talk to health care
professionals and others experiencing this challenge firsthand,
and learn more about what we can do to address this problem.
I know that what we're seeing in Washington State is
similar to what is going on across the country. So I wanted to
share just a few things I've heard at those roundtables:
In the next 10 years, the need for new nurses will
spike dramatically as our experienced nurses retire.
At the same time, colleges--including the
University of Washington--say they don't have the capacity to
accept all the qualified nursing applicants, and they are
struggling to recruit and retain nursing faculty.
Several health care executives have told me that
the number of medical students interested in primary care is
dropping across the board, making it difficult to recruit
primary care doctors.
And there is a great need to find better ways to
get more skills training and education for workers. Health care
workers in rural areas say this is especially challenging--
either because there aren't enough opportunities--or because
they can't afford to leave work to get training or go back to
school.
Given how severe this problem is, I have to say I was
extremely disappointed to see that--instead of taking action
and planning for the future--the President proposed significant
cuts in this area in his fiscal year 2009 budget. He cut the
overall health professions budget by $252 million. That's an 80
percent cut to one of the few government programs that could
address this shortage.
Despite the fact that the Bureau of Labor Statistics
reports that between 2004 and 2014, registered nursing will
have the second greatest job growth of all U.S. professions,
the Administration slashed the budget for nurse training. For
example, the President zeroed out the $61 million Advanced
Education Nursing program and several others.
I know we were expecting a witness from the Department of
Health and Human Services to attend this hearing. I was sorry
to hear no one was able to make it today because I have several
questions for the Administration on this subject.
But I'm looking forward to hearing from our excellent panel
of witnesses about what they think we can do to address these
workforce challenges. Finding a way to train and recruit
workers to the health care field--and to keep them in those
jobs--must be a priority.
Thank you.
Senator Sanders. Thank you very much.
Senator Sherrod Brown has been a leader when he was in the
House and in the Senate on quality healthcare for all
Americans. Senator Brown, thank you.
Statement of Senator Brown
Senator Brown. Thank you, Senator Sanders, and thank you,
Senator Murkowski. Dr. Auerbach, nice to see you. There always
seems to be a lot of Massachusetts representation in the
witness panels here. I may be confused about that, but nice to
see you.
In the last year, during my first year in the Senate, I
have been part of about 80-plus roundtables in 55 Ohio
counties, made up of a cross-section of people in these
communities. In almost every single one of these 50-plus
counties, I have heard from a hospital administrator or a nurse
or a physical therapist or a public health official that we
have shortages in all kinds of healthcare services.
We all know that. In Cincinnati, at Cincinnati Children's,
it was made very clear to me we don't train enough pediatric
nurses in my State or in this country. In southeast Ohio, I
repeatedly heard we don't have enough dentists, and
particularly dentists that accept Medicaid, to take care of the
basic needs, the basic needs particularly for children. We know
how that affects those children long-term.
In Mansfield, OH, the town I grew up in, I met with some
community health workers, high school graduates that are being
trained. Some were GED and had gotten their high school diploma
that way. They are trained in doing outreach, and particularly
in two zip codes in Mansfield, a town of about 50,000. One zip
code was predominantly white, Appalachia. One was predominantly
black. This zip code had, in the past several years, a rate of
about 21 or 22 or 23 percent low-birth weight babies in these
two zip codes.
After these community health workers began to go into the
community whenever they knew of a pregnant woman and met with
them and get them to an OB/GYN, the percentage of low-birth
weight babies dropped--in the space of about 3 years, dropped
to under 5 percent, which is the national average. That is what
these professions can do, particularly community health workers
and physician assistants and nurses aides and all that Senator
Murkowski was talking about.
That is why title VII and title VIII are so important to
this country. That is why we are incredulous that President
Bush would choose to give a tax cut of literally $51 billion
for 2009 to people making over $1 million a year--$51 billion--
and then cut GME training and title VII and title VIII and
refuse to sign a children's health insurance bill. Clearly, our
priorities are wrong in this country, and we have to go to in a
very different direction on healthcare.
One last point on this, which perhaps, is also a moral
question: we see more and more America bringing people from
across the ocean to be nurses, to be other healthcare
professionals. To me, there is a bit of a moral question there.
I certainly don't judge the people that come across the ocean,
who want to be in our country and get a middle-class standard
of living and a decent lifestyle and take care of their kids. I
also think that we should be training our own physicians, our
own nurses, our own healthcare providers so that the training
that those countries do, wherever it is, especially nurses and
especially other kinds of healthcare workers like that, that
they can stay in their country and do the kind of work that
their people paid for to train them.
We have a lot of work to do. Cutting title VII and title
VIII is not the way to go. That is the importance of this
hearing. I thank Senator Murkowski and Senator Sanders.
Senator Sanders. Thank you, Senator Brown. Senator Wayne
Allard of Colorado has joined us. Thank you very much.
Senator Allard.
Statement of Senator Allard
Senator Allard. Thank you, Mr. Chairman.
I know that this hearing is on primary care in the health
profession, but I also want to speak from my experience as a
veterinarian. Veterinarians are on the front line. I once
diagnosed bubonic plague in cats who lived daily with the
family; I may have saved that family because I made that
diagnosis.
We have diseases such as toxoplasmosis and rabies and
encephalitis. As a veterinary health officer, I was out there
on the front line dealing with encephalitis outbreaks in the
community in which I practiced. I just ask that you not forget
about the veterinary profession. Veterinarians play a critical
role in public health.
We have had testimony before this committee from the Food
and Drug Administration, from the Department of Agriculture,
and various agencies which simply do not have enough
veterinarians on their staff to fulfill their missions.
Veterinarians are highly trained in laboratory and research
techniques, playing a key role in approval of drugs. For
instance, they play a key role in public health diseases with
the CDC.
I just ask that you keep these things in mind when we have
this discussion. I certainly think we need to recognize that
the veterinarians do play a key role in public health.
Thank you, Mr. Chairman.
Senator Sanders. Thank you very much. OK. Thank you very
much, Senator.
We are prepared to begin the discussion. The format will
begin with Bruce Steinwald, who is the Director of Healthcare
for the GAO, the Government Accountability Office. He will have
5 minutes. Then we will just go around, and people will have 2
minutes. Then we will just open it up for questions and
comments.
Mr. Steinwald, if you could begin, please?
STATEMENT OF A. BRUCE STEINWALD, DIRECTOR, HEALTH-
CARE, GOVERNMENT ACCOUNTABILITY OFFICE,
WASHINGTON, DC
Mr. Steinwald. Thank you, Senator Sanders and members of
the committee. Thank you for inviting me to participate in this
discussion.
In my prepared testimony, I have provided information on
three areas. First, the recent trends in the supply, training,
and demographics of primary care professionals. By that, I mean
physicians, physician assistants, nurse practitioners, and
dentists. I am sorry, not veterinarians, Senator Allard. Sorry.
Second, projections of the future supply of primary care
professionals. And third, how primary care services are
undervalued by our payment systems in the United States. I will
try to tie those points together as I go on.
Please direct your attention to the first exhibit behind
me, which, for the audience, is a variation on Table 1 on page
7 of the written statement. For all categories of primary care
professionals, over a recent period of roughly 10 years, the
average annual growth has been positive with some categories,
especially nurse practitioners and physician assistants,
growing faster than others.
Over a 10-year period, we do find an increase in primary
care professionals. We have found that the supply of primary
care physicians grew faster than the supply of specialists from
1995 to 2005. Looking to the future, we examined trends among
participants in primary care training programs in the United
States. In the interest of time, I will focus my remarks on
residency programs for physicians only.
From 1995 to 2006, the number of primary care residents
increased 6 percent. At the same time, the number of residents
in specialty training increased 8 percent. These increases
compare with population growth of about 15 percent over that
same period.
Underlying the data on physicians is a change in the
composition of residents. If you will turn your attention to my
second exhibit, which is based on Table 4 on page 10 of the
written statement, you will notice that looking at primary care
residents, there has been a decline in the proportion, as you
pointed out, Senator Sanders, in the proportion that are U.S.
medical school graduates and an increase in the proportion that
are either international medical graduates or doctors of
osteopathy.
This decline in U.S.-trained primary care residents is
often cited as a reason to be concerned about how our system
undervalues primary care services. When looking at the
demographic information and, in particular, minority
representation, we found little data specific to primary care.
What we did find is an increase, a modest increase in minority
representation among all of the professional groups, but only a
modest increase.
When identifying projections of future supply, we again
found little information specific to primary care
professionals. Most workforce projections focus on physician
supply, and we identified two projections that were specific to
primary care doctors--those of HRSA and of the American Academy
of Family Physicians. Both projections indicate that we may
face a shortage of primary care physicians by around the year
2020, depending on underlying assumptions.
Our third finding has to do with the valuation of primary
care services, which may be a factor in future supply. This
finding is mostly about physicians and draws on information
from the Medicare program. Our current system is predominantly
a fee-for-service system, and fees are generally sensitive to
the complexity of resources required to perform a service.
As an example of how the system undervalues primary care
services, please turn your attention to Exhibit 3. Now I would
like to say I have nothing against diagnostic colonoscopies. In
fact, according to my primary care doctor, I am due to have one
when I get around to scheduling it. I could have picked from
hundreds of other comparable diagnostic and other kinds of
services.
Anyway, you will note that in Boston, Medicare's fees for
two services of similar duration--a diagnostic colonoscopy and
a complex office visit--are vastly different. Because of the
way the services are valued, specialists are already way ahead
of the game. In this instance, the payment to a doctor for
roughly a half an hour's work varies by a factor of four.
Exacerbating the disparity between primary care doctors and
specialists are technological innovations and improvements that
enhance the ability of specialists over time to provide more
services and more complex services and, thereby, increase their
revenues. On the other hand, most primary care physicians,
whose principal services are office visits, have little ability
to improve efficiency and save time and provide more services.
There are limits to how much he or she can reduce the time
spent with patients without compromising quality of care.
Furthermore, this undervaluing of primary care services
appears to be counterproductive, given the vast literature
describing the relationship between primary care costs and
quality. In fact, we note several findings in our testimony on
the benefits of primary care medicine. When I say that primary
care services are undervalued, this doesn't mean that just
increasing the prices paid for primary care is the solution.
I will wrap up now. As you are aware, though, we face
unsustainable trends in the Medicare program and our health
system as a whole. Just as payment incentives are misaligned in
primary care, they are misaligned in specialty medicine as
well. The reforms that we need are not just a question of
raising fees for primary care services, but for recalibrating
fees and evaluating costs and benefits of different modes of
healthcare delivery as well as financing.
Mr. Chairman, this concludes my prepared remarks, and I
look forward to your questions and to hearing the views of the
other panelists.
[The prepared statement of Mr. Steinwald follows:]
Prepared Statement of A. Bruce Steinwald, Director of Health Care
Highlights
why gao did this study
Most of the funding for programs under title VII of the Public
Health Service Act goes toward primary care medicine and dentistry
training and increasing medical student diversity. Despite a
longstanding objective of title VII to increase the total supply of
primary care professionals, health care marketplace signals suggest an
undervaluing of primary care medicine, creating a concern about the
future supply of primary care professionals--physicians, physician
assistants, nurse practitioners, and dentists. This concern comes at a
time when there is growing recognition that greater use of primary care
services and less reliance on specialty services can lead to better
health outcomes at lower cost.
GAO was asked to focus on (1) recent supply trends for primary care
professionals, including information on training and demographic
characteristics; (2) projections of future supply for primary care
professionals, including the factors underlying these projections; and
(3) the influence of the health care system's financing mechanisms on
the valuation of primary care services.
GAO obtained data from the Health Resources and Services
Administration (HRSA) and organizations representing primary care
professionals. GAO also reviewed relevant literature and position
statements of these organizations.
what gao found
In recent years, the supply of primary care professionals
increased, with the supply of nonphysicians increasing faster than
physicians. The numbers of primary care professionals in training
programs also increased. Little information was available on trends
during this period regarding minorities in training or actively
practicing in primary care specialties. For the future, health
professions workforce projections made by government and industry
groups have focused on the likely supply of the physician workforce
overall, including all specialties. Few projections have focused on the
likely supply of primary care physician or other primary care
professionals.
Health professional workforce projections that are mostly silent on
the future supply of and demand for primary care services are
symptomatic of an ongoing decline in the Nation's financial support for
primary care medicine. Ample research in recent years concludes that
the Nation's over reliance on specialty care services at the expense of
primary care leads to a health care system that is less efficient. At
the same time, research shows that preventive care, care coordination
for the chronically ill, and continuity of care--all hallmarks of
primary care medicine--can achieve improved outcomes and cost savings.
Conventional payment systems tend to undervalue primary care services
relative to specialty services. Some physician organizations are
proposing payment system refinements that place a new emphasis on
primary care services.
Supply of Primary Care Professionals
----------------------------------------------------------------------------------------------------------------
No. of primary care No. of primary
professionals care
---------------------- professionals Average
per 100,000 annual
people percentage
Base year Recent ---------------- change per
year Base Recent capita
year year
----------------------------------------------------------------------------------------------------------------
Primary care physicians....................................... 208,187 264,086 80 90 1.17
Physician assistants.......................................... 12,819 23,325 5 8 3.89
Nurse practitioners........................................... 44,200 82,622 16 28 9.44
Dentists...................................................... 118,816 138,754 46 47 0.12
----------------------------------------------------------------------------------------------------------------
Sources: GAO analysis of data from HRSA's Area Resource File and organizations representing primary care
professionals.
Notes: Data on primary care physicians are from 1995 and 2005. Data on physician assistants are from 1995 and
2007. Data on nurse practitioners are from 1999 and 2005. Data on dentists are from 1995 and 2007. Data for
identical time periods were not available. The average annual percentage change is not sensitive to these time
period differences.
GAO discussed the contents of this statement with HRSA officials
and incorporated their comments as appropriate.
__________
Mr. Chairman and members of the committee, I am pleased to be here
today as you prepare to consider the reauthorization of health
professions education programs established under title VII of the
Public Health Service Act.\1\ Most of the funding for title VII
programs goes toward primary care medicine and dentistry training and
increasing medical student diversity.
---------------------------------------------------------------------------
\1\ 42 U.S.C. Sec. Sec. 292-295 p.
---------------------------------------------------------------------------
Despite a longstanding objective of title VII to increase the total
supply of primary care professionals, health care marketplace signals
suggest an undervaluing of primary care medicine, creating a concern
about the future supply of primary care professionals. As evidence,
health policy experts cite a growing income gap between primary care
physicians and specialists and a declining number of U.S. medical
students entering primary care specialties--internal medicine, family
medicine, general practice, and general pediatrics. Moreover, the
Federal agency responsible for implementing title VII programs, the
Health Resources and Services Administration (HRSA), notes that
physician ``extenders''--namely, physician assistants and nurse
practitioners--may also be choosing procedure-driven specialties, such
as surgery, cardiology, and oncology, in increasing numbers.\2\ \3\
---------------------------------------------------------------------------
\2\ Physician assistants are health care professionals who practice
medicine under physician supervision. Physician assistants may perform
physical examinations, diagnose and treat illnesses, order and
interpret tests, advise patients on preventive health care, assist in
surgery, and write prescriptions. Unlike physician assistants, nurse
practitioners are licensed nurses who work with physicians and have
independent practice authority in many States. This authority allows
them to perform physical examinations, diagnose and treat acute
illnesses and injuries, administer immunizations, manage chronic
problems such as high blood pressure and diabetes, and order laboratory
services and x-rays with minimal physician involvement.
\3\ For the purposes of this testimony, we considered primary care
physicians to be those practicing in family medicine, general practice,
general internal medicine, and general pediatrics. Some physician
groups, such as the American Medical Association (AMA), consider
physicians practicing in obstetrics/gynecology to also be primary care
physicians. In addition, we considered general dentists and pediatric
dentists to be primary care dentists. We defined primary care physician
assistants as those practicing in family practice, general practice,
general internal medicine, and general pediatrics. We defined primary
care nurse practitioners as those practicing in adult, family, and
pediatric medicine. Other types of health professionals, such as
registered nurses, can provide primary care services in a variety of
settings, but they were outside the scope of our review.
---------------------------------------------------------------------------
A paradox commonly cited about the U.S. health care system is that
the Nation spends more per capita than all other industrialized nations
but ranks consistently low in such quality and access measures as life
expectancy, infant mortality, preventable deaths, and percentage of
population with health insurance. Moreover, experts have concluded that
not all of this spending is warranted, and overutilization of services
can, in fact, lead to harm.\4\ These findings come at a time when there
is growing recognition that greater use of primary care services and
less reliance on specialty services can lead to better health outcomes
at lower cost.
---------------------------------------------------------------------------
\4\ For example, noted studies show that Medicare spending for
physician services varies widely by geographic areas and is unrelated
to beneficiary health status. Elliott S. Fisher and H. Gilbert Welch,
``Avoiding the Unintended Consequences of Growth in Medical Care: How
Might More Be Worse?'' Journal of the American Medical Association,
vol. 281, no. 5 (1999), 446-453; E.S. Fisher, et al., ``The
Implications of Regional Variations in Medicare Spending. Part 1: The
Content, Quality, and Accessibility of Care,'' Annals of Internal
Medicine, vol. 138, no. 4 (2003), 273-287; E.S. Fisher, et al., ``The
Implications of Regional Variations in Medicare Spending. Part 2:
Health Outcomes and Satisfaction with Care,'' Annals of Internal
Medicine, vol. 138, no. 4 (2003), 288-298; and Joseph P. Newhouse, Free
for All? Lessons from the RAND Health Insurance Experiment (Cambridge,
Mass.: Harvard University Press, 1993).
---------------------------------------------------------------------------
To examine the supply of primary care professionals in more detail,
you asked us to provide information related to the current and future
supply of these professionals. My remarks today will focus on: (1)
recent supply trends for primary care professionals, including
information on training and demographic characteristics; (2)
projections of future supply for primary care professionals, including
the factors underlying these projections; and (3) the influence of the
health care system's financing mechanisms on the valuation of primary
care services.
To discuss the recent supply trends for primary care
professionals--including information on training and demographic
characteristics--we obtained data from HRSA's Area Resource File; the
American Academy of Physician Assistants (AAPA); and the American
Academy of Nurse Practitioners (AANP). In addition, we reviewed
published data from AMA, the American Association of Colleges of
Nursing (AACN); and the American Dental Education Association
(ADEA).\5\ We also obtained published annual estimates from the U.S.
Census Bureau on the noninstitutionalized, civilian population.
---------------------------------------------------------------------------
\5\ We obtained the most recently available data on supply for each
professional group, the groups' training programs, and the groups'
demographic characteristics. We compared the most recent data to a
prior data point, in many cases 10 years earlier. For primary care
physicians, we obtained data on supply for 1995 and 2005 from the Area
Resource File and information on training and demographics from
published AMA data for 1995 and 2006. For physician assistants, we
obtained data on supply and demographic characteristics from AAPA for
1995 and 2007. For nurse practitioners, we obtained data on supply and
demographic characteristics from AANP for 1999, 2003, and 2005 and
information on training from published AACN data for 1994 and 2005. For
dentists, we obtained data on supply for 1995 and 2007 from the Area
Resource File and information on demographics from published ADEA data
for 2000 and 2005.
---------------------------------------------------------------------------
To obtain information about projections of future supply of primary
care professionals, we reviewed relevant literature and the position
statements of organizations representing primary care professionals,
including the American Academy of Family Physicians (AAFP) and the
American College of Physicians (ACP). We also interviewed officials
from HRSA, AAPA, AANP, the American Dental Association (ADA), and the
Association of American Medical Colleges (AAMC). In selecting workforce
supply projections for review, we focused on the projected estimates of
national supply for primary care professionals from the past decade.
To obtain information on the influence of the health care system's
financing mechanisms on the valuation of primary care services, we
reviewed relevant literature on Medicare's resource-based physician fee
schedule and the influence of primary care supply on costs and quality
of health care services.
We assessed the reliability of HRSA's Area Resource File data by
interviewing officials responsible for producing these data, reviewing
relevant documentation, and examining the data for obvious errors.\6\
We assessed the reliability of the data provided by the AAPA and the
AANP by discussing with association officials the validation procedures
they use to ensure timely, complete, and accurate data. We determined
the data used in this testimony to be sufficiently reliable for our
purposes. We discussed a draft of this testimony with HRSA officials.
They provided technical comments, which we incorporated as appropriate.
We conducted this work from December 2007 through February 2008, in
accordance with generally accepted government auditing standards.
---------------------------------------------------------------------------
\6\ Data from the AMA Masterfile and the American Osteopathic
Association (AOA) Masterfile--on which data on physicians in the Area
Resource File is based--are widely used in studies of physician supply
because they are a comprehensive list of U.S. physicians and their
characteristics.
---------------------------------------------------------------------------
In summary, in recent years, the supply of primary care
professionals increased, with the supply of nonphysicians increasing
faster than physicians. The numbers of primary care professionals in
training programs also increased. Little information was available on
trends during this period regarding minorities in training or actively
practicing in primary care specialties. For the future, health
professions workforce projections made by government and industry
groups have focused on the likely supply of the physician workforce
overall, including all specialties. Few projections have focused on the
likely supply of primary care physician or other primary care
professionals.
Health professional workforce projections that are mostly silent on
the future supply of and demand for primary care services are
symptomatic of an ongoing decline in the Nation's financial support for
primary care medicine. Ample research in recent years concludes that
the Nation's over reliance on specialty care services at the expense of
primary care leads to a health care system that is less efficient. At
the same time, research shows that preventive care, care coordination
for the chronically ill, and continuity of care--all hallmarks of
primary care medicine--can achieve improved outcomes and cost savings.
Conventional payment systems tend to undervalue primary care services
relative to specialty services. Some physician organizations are
developing payment system refinements that place a new emphasis on
primary care services.
background
Among other things, title VII programs support the education and
training of primary care providers, such as primary care physicians,
physician assistants, general dentists, pediatric dentists, and allied
health practitioners.\7\ HRSA includes in its definition of primary
care services, health services related to family medicine, internal
medicine, preventative medicine, osteopathic general practice, and
general pediatrics that are furnished by physicians or other types of
health professionals. Also, HRSA recognizes diagnostic services,
preventive services (including immunizations and preventive dental
care), and emergency medical services as primary care. Thus, in some
cases, nonprimary care practitioners provide primary care services to
populations that they serve.
---------------------------------------------------------------------------
\7\ Allied health professionals include, for example, audiologists,
dental hygienists, clinical laboratory technicians, occupational
therapists, physical therapists, medical imaging technologists, and
speech pathologists.
---------------------------------------------------------------------------
Title VII programs support a wide variety of activities related to
this broad topic. For example, they provide grants to institutions that
train health professionals; offer direct assistance to students in the
form of scholarships, loans, or repayment of educational loans; and
provide funding for health workforce analyses, such as estimates of
supply and demand.\8\ In recent years, title VII programs have focused
on three specific areas of need--improving the distribution of health
professionals in underserved areas such as rural and inner-city
communities, increasing representation of minorities and individuals
from disadvantaged backgrounds in health professions, and increasing
the number of primary care providers. For example, the Scholarships for
Disadvantaged Students Program awards grants to health professions
schools to provide scholarships to full-time, financially needy
students from disadvantaged backgrounds, many of whom are minorities.
---------------------------------------------------------------------------
\8\ For fiscal year 2007, funding for the title VII health
professions programs was about $183 million. This excluded funding for
student loans, which did not receive funds through the annual
appropriation process.
---------------------------------------------------------------------------
Primary Care Education and Training Programs
After completing medical school, medical students enter a multi-
year training program called residency, during which they complete
their formal education as a physician. Because medical students must
select their area of practice specialty as part of the process of being
matched into a residency program, the number of physician residents
participating in primary care residency programs is used as an
indication of the likely future supply of primary care physicians.
Physician residents receive most of their training in teaching
hospitals, which are hospitals that operate one or more graduate
medical education programs. Completion of a physician residency program
can take from 3 to 7 years after graduation from medical school,
depending on the specialty or subspecialty chosen by the physician.
Most primary care specialties require a 3-year residency program. In
some cases, primary care physicians may choose to pursue additional
residency training and become a subspecialist--such as a pediatrician
who specializes in cardiology. In this case, the physician would no
longer be considered a primary care physician, but rather, a
cardiologist.
According to the AAPA, most physician assistant programs require
applicants to have some college education. The average physician
assistant program takes about 26 months, with classroom education
followed by clinical rotations in internal medicine, family medicine,
surgery, pediatrics, obstetrics and gynecology, emergency medicine, and
geriatric medicine. Physician assistants practice in primary care
medicine, including family medicine, internal medicine, pediatrics, and
obstetrics and gynecology, as well in surgical specialties.
After completion of a bachelor's degree in nursing, a nurse may
become a nurse practitioner after completing a master's degree in
nursing. According to the AACN, full-time master's programs are
generally 18 to 24 months in duration and include both classroom and
clinical work. Nurse practitioner programs generally include areas of
specialization such as acute care, adult health, child health,
emergency care, geriatric care, neonatal health, occupational health,
and oncology.
Dentists typically complete 3 to 4 years of undergraduate
university education, followed by 4 years of professional education in
dental school. The 4 years of dental school are organized into 2 years
of basic science and pre-clinical instruction followed by 2 years of
clinical instruction. Unlike training programs for physicians, there is
no universal requirement for dental residency training. However, a
substantial proportion of dentists--about 65 percent of dental school
graduates--enroll in dental specialty or general dentistry residency
programs.
supply of primary care professionals increased; little data available
on minority representation
In recent years, the supply of primary care professionals
increased, with the supply of nonphysicians increasing faster than
physicians. The numbers of primary care professionals in training
programs also increased. Little information was available on trends
during this period regarding minorities in training or actively
practicing in primary care specialties.
In Recent Years, Supply of Primary Care Professionals Increased
In recent years, the number of primary care professionals
nationwide grew faster than the population, resulting in an increased
supply of primary care professionals on a per capita basis (expressed
per 100,000 people). Table 1 shows that over roughly the last decade,
per capita supply of primary care physicians--internists,
pediatricians, general practice physicians, and family practitioners--
rose an average of about 1 percent per year,\9\ while the per capita
supply of nonphysician primary care professionals--physician assistants
and nurse practitioners--rose faster, at an average of about 4 percent
and 9 percent per year, respectively. Nurse practitioners accounted for
most of the increase in nonphysician primary care professionals. The
per capita supply of primary care dentists--general dentists and
pediatric dentists--remained relatively unchanged.
---------------------------------------------------------------------------
\9\ Allopathic medicine is the most common form of medical
practice. Graduates of allopathic medical schools receive doctor of
medicine (M.D.,) degrees. Osteopathic medicine is a form of medical
practice similar to allopathic medicine that also incorporates manual
manipulation of the body as a therapy. Graduates of osteopathic medical
schools receive doctor of osteopathic (D.O.) medicine degrees. The
number of primary care physicians includes both M.D.'s and D.O.'s.
Table 1.--Supply of Primary Care Professionals
----------------------------------------------------------------------------------------------------------------
No. of primary care No. of primary
professionals care
---------------------- professionals Average
per 100,000 annual
people percentage
Base year Recent ---------------- change per
year Base Recent capita
year year
----------------------------------------------------------------------------------------------------------------
Primary care physicians \1\................................... 208,187 264,086 80 90 1.17
Physician assistants \2\...................................... 12,819 23,325 5 8 3.89
Nurse practitioners \3\....................................... 44,200 82,622 16 28 9.44
Dentists \4\.................................................. 118,816 138,754 46 47 0.12
----------------------------------------------------------------------------------------------------------------
Sources: GAO analysis of data from HRSA's Area Resource File, AAPA, AANP, and the U.S. Census Bureau.
Notes: Data on primary care professionals for identical time periods were not available. The average annual
percentage change is not sensitive to these time period differences.
\1\ Data on primary care physicians include numbers for both M.D.'s and DOs. Data for M.D.'s are from 1995 and
2005, and for D.O.'s are from 1995 and 2004.
\2\ Data on physician assistants are from 1995 and 2007. Data on the total number of physician assistants were
obtained from AAPA, then weighted by using the percentage of physicians assistants who practiced primary care
according to the 1995 AAPA membership survey and the 2007 AAPA physician assistant census survey.
\3\ Data on nurse practitioners are from 1999 and 2005. Data on the total number of nurse practitioners were
obtained from AANP, then weighted by using the percentage of nurse practitioners who practiced primary care
according to the AANP.
\4\ Data on dentists are from 1995 and 2007.
Growth in the per capita supply of primary care physicians outpaced
growth in the per capita supply of physician specialists by 7
percentage points in the 1995-2005 period. (See Table 2.)
Table 2.--Supply of Primary Care and Specialty Care Physicians, 1995 and 2005
----------------------------------------------------------------------------------------------------------------
No. of physicians No. of
---------------------- physicians per
100,000 Percentage
people change per
1995 2005 ---------------- capita
1995 2005
----------------------------------------------------------------------------------------------------------------
Primary care physicians....................................... 208,187 264,086 80 90 12
Specialty care physicians..................................... 468,843 553,451 181 189 5
All physicians................................................ 677,030 817,537 262 280 7
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of data from HRSA's Area Resource File.
Note: Numbers do not add to totals due to rounding.
By definition, aggregate supply figures do not show the
distribution of primary care professionals across geographic areas.
Compared with metropolitan areas, nonmetropolitan areas, which are more
rural and less populated, have substantially fewer primary care
physicians per 100,000 people. In 2005, there were 93 primary care
physicians per 100,000 people in metropolitan areas, compared with 55
primary care physicians per 100,000 people in nonmetropolitan
areas.\10\ Data were not available on the distribution of physician
assistants, nurse practitioners, or dentists providing primary care in
metropolitan and nonmetropolitan areas.\11\
---------------------------------------------------------------------------
\10\ Specialty care physicians are even more concentrated in
metropolitan areas. In 2005, there were 33 specialty care physicians
per 100,000 people in nonmetropolitan areas, compared with 200
specialty care physicians per 100,000 people in metropolitan areas. In
total, there were 87 physicians per 100,000 people in nonmetropolitan
areas and 293 physicians per 100,000 people in metropolitan areas in
2005.
\11\ One researcher, analyzing HRSA data, reported that in 2007
more than 30 million people were living in areas with too few dentists.
Shelly Gehshan, ``Foundations' Role in Improving Oral Health: Nothing
to Smile About,'' Health Affairs, vol. 27, no. 1 (2008).
---------------------------------------------------------------------------
Number of Primary Care Professionals in U.S. Training Programs
Increased from 1995 to 2006
For two groups of primary care professionals--physicians and nurse
practitioners--the number in primary care training has increased in
recent years. Over the same period, the number of primary care training
programs for physicians declined, while programs for nurse
practitioners increased. Comparable information for physician
assistants and dentists was not available.
From 1995 to 2006, the number of physician residents in primary
care training programs increased 6 percent, as shown in Table 3. Over
this same period, primary care residency programs declined, from 1,184
programs to 1,145 programs.
Table 3.--No. of Physicians in Residency Programs, in the United States,
1995 and 2006
------------------------------------------------------------------------
No. of resident
physicians Percentage
-------------------- change
1995 2006
------------------------------------------------------------------------
Primary care residents.................. 38,753 40,982 6
Specialty care residents................ 59,282 63,897 8
All physician residents................. 97,416 104,526 7
------------------------------------------------------------------------
Sources: AMA, ``Appendix II: Graduate Medical Education,'' Journal of
the American Medical Association (JAMA) vol. 276, no. 9 (September
1996) and ``Appendix II: Graduate Medical Education, 2006-2007,'' JAMA
vol. 298, no. 9 (September 2007).
Note: Primary care residencies include those for family medicine,
internal medicine, pediatrics, internal medicine/family practice, and
internal medicine/pediatrics.
The composition of primary care physician residents changed from
1995 to 2006. A decline in the number of allopathic U.S. medical school
graduates (known as USMD) selecting primary care residencies was more
than offset by increases in the numbers of international medical
graduates (IMG) and doctor of osteopathy (D.O.) graduates entering
primary care residencies.\12\ Specifically, from 1995 to 2006, USMD
graduates in primary care residencies dropped by 1,655 physicians,
while the number of IMGs and D.O.'s in primary care residencies rose by
2,540 and 1,415 physicians respectively. (See Table 4.)
---------------------------------------------------------------------------
\12\ Physicians who enter U.S. residency programs include graduates
of both U.S. medical schools and foreign medical schools. Physicians
from foreign medical schools--international medical graduates--can be
citizens of other countries or U.S. citizens who attended medical
school abroad.
Table 4.--Number of Physicians in Residency Programs, by USMDs, IMGs, and D.O.'s, 1995 and 2006
----------------------------------------------------------------------------------------------------------------
1995 2006
---------------------------------------------------------
USMDs IMGs D.O.'s USMDs IMGs D.O.'s
----------------------------------------------------------------------------------------------------------------
Primary care residents................................ 23,801 13,025 1,748 22,146 15,565 3,163
Specialty care residents.............................. 45,300 11,957 1,585 47,575 12,611 3,466
All physician residents............................... 69,101 24,982 3,333 69,721 28,176 6,629
---------------------------------------------------------
Total (USMDs + IMGs + D.O.'s)....................... 97,416 104,526
----------------------------------------------------------------------------------------------------------------
Sources: AMA, ``Appendix II: Graduate Medical Education,'' JAMA vol. 276, no. 9 (September 1996) and ``Appendix
II: Graduate Medical Education, 2006-2007,'' JAMA vol. 298, no. 9 (September 2007).
Note: Primary care residencies include those for family medicine, internal medicine, pediatrics, internal
medicine/family practice, and internal medicine/pediatrics.
From 1994 to 2005, the number of primary care training programs for
nurse practitioners and the number of graduates from these programs
grew substantially. During this period, the number of nurse
practitioner training programs increased 61 percent, from 213 to 342
programs. The number of primary care graduates from these programs
increased 157 percent from 1,944 to 5,000.
Little Information Available Regarding Minorities in Training or
Actively Practicing In Primary Care Specialties
Little information was available regarding participation of
minority health professionals in primary care training programs or with
active practices in primary care.\13\ Physicians were the only type of
primary care professional for whom we found information on minority
representation. We found information not specific to primary care for
physician assistants, nurse practitioners, and dentists identified as
minorities, which may be a reasonable substitute for information on
proportions of minorities in primary care.
---------------------------------------------------------------------------
\13\ HRSA's Health Careers Opportunity Program defines
underrepresented minorities as racial and ethnic groups that are
underrepresented in the health professions relative to their numbers in
the general population. According to HRSA, African-Americans,
Hispanics, American Indians, and Alaska Natives are underrepresented in
the health professions. During the period we examined, minority
representation increased among the general population. Specifically,
from 1995 to 2006, the proportion of African-Americans in the general
population increased from 12.0 percent to 12.3 percent; the proportion
of Hispanics increased from 10.3 percent to 14.8 percent; and the
proportion of American Indian/Alaska Natives increased from 0.7 percent
to 0.8 percent.
---------------------------------------------------------------------------
For physicians, we used the proportion of minority primary care
residents as a proxy measure for minorities in the active primary care
physician workforce. From 1995 to 2006, the proportion of primary care
residents who were African-American increased from 5.1 percent to 6.3
percent; the proportion of primary care residents who were Hispanic
increased from 5.8 percent to 7.6 percent. Data on American Indian/
Alaska Natives were not collected in 1995, so this group could not be
compared over time; in 2006, 0.2 percent of primary care residents were
identified as American Indian/Alaska Natives.
Minority representation among each of the other health professional
types--overall, not by specialty--increased slightly. AAPA data show
that from 1995 to 2007, minority representation among physician
assistants increased from 7.8 percent to 8.4 percent. AANP data show
that from 2003 to 2005, minority representation among nurse
practitioners increased from 8.8 percent to 10.0 percent. ADEA data
show that from 2000 to 2005, the proportion of African-Americans among
graduating dental students rose slightly from 4.2 percent to 4.4
percent, while the proportion of Hispanics among graduating dental
students increased from 4.9 percent to 5.9 percent. The proportion of
Native American/Alaska Native among graduating dental students grew
from 0.6 percent to 0.9 percent.
Other demographic characteristics of the primary care workforce
have also changed in recent years. In two of the professions that were
traditionally dominated by men in previous years--physicians and
dentists--the proportion of women has grown or is growing. Between 1995
and 2006, the proportion of primary care residents who were women rose
from 41 percent to 51 percent. Growth of women in dentistry is more
recent. In 2005, 19 percent of professionally active dentists were
women,\14\ compared with almost 45 percent of graduating dental school
students who were women.
---------------------------------------------------------------------------
\14\ American Dental Association, ``Survey and Economic Research on
Dentistry: Frequently Asked Questions'' (Chicago, Ill.: American Dental
Association), http://www.ada.org/ada/prod/survey/faq.asp (accessed Jan.
7, 2008).
---------------------------------------------------------------------------
uncertainties exist in projecting future supply of health care
professionals; few projections are specifically for primary care
Accurately projecting the future supply of primary care health
professionals is difficult, particularly over long time horizons, as
illustrated by substantial swings in physician workforce projections
during the past several decades. Few projections have focused on the
likely supply of primary care physician or nonphysician primary care
professionals.
History of Physician Workforce Supply Predictions Illustrates
Uncertainties in Forecasting
Over a 50-year period, government and industry groups' projections
of physician shortfalls gave way to projections of surpluses, and now
the pendulum has swung back to projections of shortfalls again. From
the 1950s through the early 1970s, concerns about physician shortages
prompted the Federal and State governments to implement measures
designed to increase physician supply. By the 1980s and through the
1990s, however, the Graduate Medical Education National Advisory
Committee (GMENAC), the Council on Graduate Medical Education (COGME),
and HRSA's Bureau of Health Professions were forecasting a national
surplus of physicians. In large part, the projections made in the 1980s
and 1990s were based on assumptions that managed care plans--with an
emphasis on preventive care and reliance on primary care gatekeepers
exercising tight control over access to specialists--would continue to
grow as the typical health care delivery model. In fact, managed care
did not become as dominant as predicted and, in recent years, certain
researchers, such as Cooper,\15\ have begun to forecast physician
shortages. COGME's most recent report, issued in January 2005, also
projects a likely shortage of physicians in the coming years and,\16\
in June of 2006, the AAMC called for an expansion of U.S. medical
schools and federally supported residency training positions.\17\ Other
researchers have concluded that there are enough practicing physicians
and physicians in the pipeline to meet current and future demand if
properly deployed.\18\
---------------------------------------------------------------------------
\15\ Richard A. Cooper, et al., ``Economic and Demographic Trends
Signal an Impending Physician Shortage,'' Health Affairs, vol. 21, no.
1 (2002).
\16\ COGME, ``Sixteenth Report: Physician Workforce Policy
Guidelines for the United States, 2000-2020'' (January 2005).
\17\ AAMC, ``AAMC Statement on the Physician Workforce'' (June
2006).
\18\David Goodman, et al., ``End-Of-Life Care At Academic Medical
Centers: Implications For Future Workforce Requirements,'' Health
Affairs, vol. 25 no. 2 (2006) and Jonathan P. Weiner, ``Prepaid Group
Practice Staffing And U.S. Physician Supply: Lessons For Workforce
Policy,'' Health Affairs, Web Exclusive (Feb. 4, 2004).
---------------------------------------------------------------------------
Few Projections Address Future Supply of Primary Care Professionals
Despite interest in the future of the health care workforce, few
projections directly address the supply of primary care professionals.
Recent physician workforce projections focus instead on the supply of
physicians from all specialties combined. Specifically, the projections
recently released by COGME point to likely shortages in total physician
supply but do not include projections specific to primary care
physicians.\19\ Similarly, ADA's and AAPA's projections of the future
supply of dentists and physician assistants do not address primary care
practitioners separately from providers of specialty care. AANP has not
developed projections of future supply of nurse practitioners.
---------------------------------------------------------------------------
\19\ COGME does not currently hold a position on the appropriate
ratio of primary care physicians to specialty physicians. This is in
contrast to the position COGME held from 1992 through 2004, which
recommended that half of all physicians should be primary care
physicians.
---------------------------------------------------------------------------
We identified two sources--an October 2006 report by HRSA and a
September 2006 report by AAFP--that offer projections of primary care
supply and demand, but both are limited to physicians.\20\ HRSA's
projections indicate that the supply of primary care physicians will be
sufficient to meet anticipated demand through about 2018, but may fall
short of the number needed in 2020. AAFP projected that the number of
family practitioners in 2020 could fall short of the number needed,
depending on growth in family medicine residency programs.
---------------------------------------------------------------------------
\20\ U.S. Department of Health and Human Services, HRSA, Bureau of
Health Professions, ``Physician Supply and Demand: Projections to
2020'' (October 2006) and AAFP, ``Family Physician Workforce Reform (as
approved by the 2006 Congress of Delegates) Recommendations of the
AAFP'' (September 2006).
---------------------------------------------------------------------------
HRSA based its workforce supply projections on the size and
demographics of the current physician workforce, expected number of new
entrants, and rate of attrition due to retirement, death, and
disability. Using these factors, HRSA calculated two estimates of
future workforce supply. One projected the expected number of primary
care physicians, while the other projected the expected supply of
primary care physicians expressed in full-time equivalent (FTE) units.
According to HRSA, the latter projection, because it adjusts for
physicians who work part-time, is more accurate.\21\ The agency
projected future need for primary care professionals based largely on
expected changes in U.S. demographics, trends in health insurance
coverage, and patterns of utilization. HRSA predicted that the supply
of primary care physicians will grow at about the same rate as demand
until about 2018, at which time demand will grow faster than supply.
Specifically, HRSA projected that by 2020, the nationwide supply of
primary care physicians expressed in FTEs will be 271,440, compared
with a need for 337,400 primary care physicians. HRSA notes that this
projection, based on a national model, masks the geographic variation
in physician supply. For example, the agency estimates that as many as
7,000 additional primary care physicians are currently needed in rural
and inner-city areas and does not expect that physician supply will
improve in these underserved areas.
---------------------------------------------------------------------------
\21\ The FTE projection takes into account an expected decrease in
the number of hours worked by physicians due to demographic workforce
changes, including a greater share of female physicians and older
physicians, some of whom are likely to work less than full-time.
---------------------------------------------------------------------------
In a separate projection, AAFP reviewed the number of family
practitioners in the United States. AAFP's projections of future supply
were based on the number of active family practice physicians in the
workforce and the number of completed family practice residencies in
both allopathic and osteopathic medical schools. AAFP's projections of
need relied on utilization rates adjusted for mortality and
socioeconomic factors. Specifically, AAFP estimated that 139,531 family
physicians would be needed by 2020, representing about 42 family
physicians per 100,000 people in the United States. To meet this
physician-to-population ratio, AAFP estimated that family practice
residency programs in the aggregate would need to expand by 822
residents per year.
Both reports noted the difficulties inherent in making predictions
about future physician workforce supply and demand. Essentially, they
noted that projections based on historical data may not necessarily be
predictive of future trends. They cite as examples the unforeseen
changes in medical technology innovation and the multiple factors
influencing physician specialty choice. Additionally, HRSA noted that
projection models of supply and demand incorporate any inefficiencies
that may be present in the current health care system.
move toward primary care medicine, a key to better quality and lower
costs, is impeded by health care system's current financing mechanisms
Health professional workforce projections that are mostly silent on
the future supply of and demand for primary care services are
symptomatic of an ongoing decline in the Nation's financial support for
primary care medicine. Ample research in recent years concludes that
the Nation's over reliance on specialty care services at the expense of
primary care leads to a health care system that is less efficient. At
the same time, research shows that preventive care, care coordination
for the chronically ill, and continuity of care--all hallmarks of
primary care medicine--can achieve better health outcomes and cost
savings. Despite these findings, the Nation's current financing
mechanisms result in an atomized and uncoordinated system of care that
rewards expensive procedure-based services while undervaluing primary
care services. However, some physician organizations--seeking to
reemphasize primary care services--are proposing a new model of
delivery.
Payment Systems That Undervalue Primary Care Appear To Be
Counterproductive
Fee-for-service, the predominant method of paying physicians in the
United States, encourages growth in specialty services. Under this
structure, in which physicians receive a fee for each service provided,
a financial incentive exists to provide as many services as possible,
with little accountability for quality or outcomes. Because of
technological innovation and improvements over time in performing
procedures, specialist physicians are able to increase the volume of
services they provide, thereby increasing revenue. In contrast, primary
care physicians, whose principal services are patient office visits,
are not similarly able to increase the volume of their services without
reducing the time spent with patients, thereby compromising quality.
The conventional pricing of physician services also disadvantages
primary care physicians. Most health care payers, including Medicare--
the Nation's largest payer--use a method for reimbursing physician
services that is resource-based, resulting in higher fees for
procedure-based services than for office-visit ``evaluation and
management'' services.\22\ To illustrate, in one metropolitan area,
Boston, Massachusetts, Medicare's fee for a 25- to 30-minute office
visit for an established patient with a complex medical condition is
$103.42 \23\; in contrast, Medicare's fee for a diagnostic
colonoscopy--a procedural service of similar duration--is $449.44.\24\
---------------------------------------------------------------------------
\22\ Evaluation and management (E/M) services refer to office
visits and consultations furnished by physicians. To bill for their
service, physicians select a common procedural terminology (CPT) code
that best represents the level of E/M service performed based on three
elements: patient history, examination, and medical decisionmaking. The
combination of these three elements can range from a very limited 10-
minute face-to-face encounter to a very detailed examination requiring
an hour of the physician's time.
\23\ The fee for this service in Boston, MA, is represented on the
fee schedule as CPT code 99214.
\24\ The fee for this service in Boston, MA, is represented on the
fee schedule as CPT code 45378.
---------------------------------------------------------------------------
Several findings on the benefits of primary care medicine raise
concerns about the prudence of a health care payment system that
undervalues primary care services. For example:
Patients of primary care physicians are more likely to
receive preventive services, to receive better management of chronic
illness than other patients, and to be satisfied with their care.\25\
---------------------------------------------------------------------------
\25\ A.B. Bindman, et al., ``Primary Care and Receipt of Preventive
Services,'' Journal of General Internal Medicine vol. 11, no. 5 (1996);
D.G. Safran, et al., ``Linking Primary Care Performance to Outcomes of
Care,'' Journal of Family Practice, vol. 47, no. 3 (1998); and A.C.
Beal, et al., ``Closing the Divide: How Medical Homes Promote Equity in
Health Care: Results From The Commonwealth Fund 2006 Health Care
Quality Survey'' (The Commonwealth Fund, June 2007).
---------------------------------------------------------------------------
Areas with more specialists, or higher specialist-to-
population ratios, have no advantages in meeting population health
needs and may have ill effects when specialist care is unnecessary.\26\
---------------------------------------------------------------------------
\26\ B. Starfield, et al., ``The Effects Of Specialist Supply On
Populations' Health: Assessing The Evidence,'' Health Affairs web
exclusive (2005).
---------------------------------------------------------------------------
States with more primary care physicians per capita have
better health outcomes--as measured by total and disease-specific
mortality rates and life expectancy--than States with fewer primary
care physicians (even after adjusting for other factors such as age and
income).\27\
---------------------------------------------------------------------------
\27\ B. Starfield, et al., ``Contribution of Primary Care to Health
Systems and Health,'' Milbank Quarterly, vol. 83, no. 3 (2005).
---------------------------------------------------------------------------
States with a higher generalist-to-population ratio have
lower per-beneficiary Medicare expenditures and higher scores on 24
common performance measures than States with fewer generalist
physicians and more specialists per capita.\28\
---------------------------------------------------------------------------
\28\ K. Baicker and A. Chandra, ``Medicare Spending, the Physician
Workforce, and Beneficiaries' Quality of Care,'' Health Affairs web
exclusive (2004).
---------------------------------------------------------------------------
The hospitalization rates for diagnoses that could be
addressed in ambulatory care settings are higher in geographic areas
where access to primary care physicians is more limited.\29\
---------------------------------------------------------------------------
\29\ M. Parchman, et al., ``Primary Care Physicians and Avoidable
Hospitalizations,'' Journal of Family Practice, vol. 39, no. 2 (1994).
---------------------------------------------------------------------------
Some Health Care Reform Proposals Seek to Re-emphasize Primary Care
Medicine
In recognition of primary care medicine's value with respect to
health care quality and efficiency, some physician organizations are
proposing a new model of health care delivery in which primary care
plays a central role. The model establishes a ``medical home'' for
patients--in which a single health professional serves as the
coordinator for all of a patient's needed services, including specialty
care--and refines payment systems to ensure that the work involved in
coordinating a patient's care is appropriately rewarded.
More specifically, the medical home model allows patients to select
a clinical setting--usually their primary care provider's practice--to
serve as the central coordinator of their care. The medical home is not
designed to serve as a ``gatekeeper'' function, in which patients are
required to get authorization for specialty care, but instead seeks to
ensure continuity of care and guide patients and their families through
the complex process of making decisions about optimal treatments and
providers. AAFP has proposed a medical home model designed to provide
patients with a basket of acute, chronic, and preventive medical care
services that are, among other things, accessible, comprehensive,
patient-centered, safe, and scientifically valid. It intends for the
medical home to rely on technologies, such as electronic medical
records, to help coordinate communication, diagnosis, and treatment.
Other organizations, including ACP, the American Academy of Pediatrics
(AAP), and AOA, have developed or endorsed similar models and have
jointly recommended principles to describe the characteristics of the
medical home.\30\
---------------------------------------------------------------------------
\30\ AAFP, AAP, ACP, AOA, ``Joint Principles of the Patient-
Centered Medical Home'' (March 2007).
---------------------------------------------------------------------------
Proposals for the medical home model include a key modification to
conventional physician payment systems--namely, that physicians receive
payment for the time spent coordinating care. These care coordination
payments could be added to existing fee schedule payments or they could
be included in a comprehensive, per-patient monthly fee. Some physician
groups have called for increases to the Medicare
resource-based fee schedule to account for time spent coordinating care
for patients with multiple chronic illnesses. Proponents of the medical
home note that it may be desirable to develop payment models that blend
fee-for-service payments with per-patient payments to ensure that the
system is appropriately reimbursing physicians for primary, specialty,
episodic, and acute care.
concluding observations
In our view, payment system reforms that address the undervaluing
of primary care should not be strictly about raising fees but rather
about recalibrating the value of all services, both specialty and
primary care. Resource-based payment systems like those of most payers
today do not factor in health outcomes or quality metrics; as a
consequence, payments for services and their value to the patient are
misaligned. Ideally, new payment models would be designed that consider
the relative costs and benefits of a health care service in comparison
with all others so that methods of paying for health services are
consistent with society's desired goals for health care system quality
and efficiency.
Mr. Chairman, this concludes my prepared statement. I will be happy
to answer any questions that you or members of the committee may have.
Senator Sanders. Thank you very much, Mr. Steinwald.
In no particular order, let us begin with Dr. Grumbach, who
is the Director of the University of California at San
Francisco Center for California Health Workforce Studies.
Thank you very much for being with us, Dr. Grumbach. Please
take 2 minutes.
STATEMENT OF KEVIN GRUMBACH, M.D., DIRECTOR, UCSF CENTER FOR
CALIFORNIA HEALTH WORKFORCE STUDIES, PROFESSOR AND CHAIR, UCSF
DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE, SAN FRANCISCO, CA
Dr. Grumbach. Thank you for inviting me, Senator Sanders,
members of the committee. I would like to honor the brevity of
the requests for these opening remarks. I want to just hit on a
couple of points.
One, the Senators have identified the key issues. There is
a crumbling infrastructure of primary care. It hits hardest in
the most underserved communities of our Nation. What I would
like to impress upon you is our research and research of
colleagues that make it clear that certain Federal programs are
quite effective in achieving their goals.
There is now a very solid research base to support with
good evidence the effectiveness of title VII training programs,
that institutions that get title VII funding are more likely to
have their graduates work in primary care, to serve in
underserved areas, to work at community health centers, to join
the National Health Service Corps, about 50 percent more likely
yield of physicians who will work at community health centers.
When asked the question, a simultaneous program of
expansion of community health centers without investment in the
pipeline that actually preferentially feeds physicians in the
health centers.
Second, there is a good evidence basis for the effects of
the National Service Corps that have lasting effect on
underserved communities, a very solid research base there.
The last thing I would like to emphasize is the distorted
incentives in the Medicare program and to pick up on Mr.
Steinwald's comment. One way Federal policies can influence
this is through proactive policies, such as title VII, title
VIII, National Service Corps, but the other key problem is
looking at the Medicare program, which has incentives in
everything from GME to physician payment policies that pull
people away from primary care. That without addressing the
incentives of the Medicare program, It will be impossible to
fully correct some of the deficits in primary care and people
working in underserved communities.
Thank you.
[The prepared statement of Dr. Grumbach follows:]
Prepared Statement of Kevin Grumbach, M.D.
Summary
1. Primary care is the essential foundation of a well-performing
health system.--Health systems built on a solid foundation of primary
care deliver more effective, efficient, and equitable care than systems
that fail to invest adequately in primary care.
2. The primary care infrastructure in the United States is
crumbling, and patient access to primary care is suffering throughout
the Nation.--From 1997 to 2005, the number of U.S. medical school
graduates entering careers in family medicine residencies dropped by 50
percent, as did the number of internal medicine residents planning
careers in primary care rather than specialty medicine. In a 2006
survey of 92 large- or medium-sized physician groups, 94 percent of the
respondents ranked internists or family physicians as the most
difficult to recruit. Federally funded community health centers
reported more than 750 vacant positions for primary care physicians in
2004. In 2007, 29 percent of Medicare beneficiaries reported a problem
finding a primary care physician, up from 24 percent in 2006.
3. The Federal Government can address the crisis in primary care
through:
a. Targeted health professions primary care training programs such
as title VII programs.--Research evidence demonstrates the
effectiveness of these programs, finding that institutions receiving
Title VII Section 747 Primary Care Training Grants are more likely to
produce graduates who enter primary care fields, work at Community
Health Centers, and participate in the National Health Service Corps.
b. Reform of Medicare Graduate Medical Education funding.--Medicare
GME funding policies tie funds to hospital-based settings emphasizing
specialty training and hospital service priorities, rather than the
public's workforce needs. Medicare GME funding needs to be reformed to
become more aligned with primary care workforce needs and less rigidly
tied to hospital-based training sites.
c. The National Health Services Corps.--Research has shown that
many NHSC participants remain in service to the underserved after
completing their service obligations, and that temporary placement of
NHSC physicians in rural underserved areas positively impacts the long-
term non-NHSC physician supply in those areas. In 2006, there were over
4,200 vacant positions in underserved areas for NHSC physicians, yet
only 1,200 funded NHSC positions to fill these slots.
d. Medicare physician payment reform.--Between 1995 and 2003, the
real take home income of primary care physicians decreased by 10.2
percent, and the gap in earnings between primary care and specialist
physicians widened considerably. From 1997 to 2006, Medicare
expenditures for specialty-oriented physician services (e.g., surgery,
imaging studies) increased 36 percent faster than expenditures for
primary care-oriented evaluation and management (E&M) services. In
2006, non-E&M services accounted for 86 percent in the overage in
Medicare physician expenditures above the overall SGR target. To
reverse the current disincentives for primary care practice, Medicare
payment reforms should include:
i. Splitting the SGR and creating separate SGR accounts for E&M
and non-E&M services,
ii. Adding a medical home care coordination payment, in addition
to fee-for-service payments,
iii. Subsidies for capital investment to modernize the medical
home through EMR installation and related IT, training and hiring of
primary care office staff for innovative chronic and preventive care
programs, and other infrastructure needs, and
iv. Greater performance-based payment incentives linked to
achieving progress on quality and access targets.
______
Senator Kennedy, Senator Enzi, and members of the Senate Committee
on Health, Education, Labor, and Pensions, thank you for inviting my
testimony today on this hearing on the health care workforce. My name
is Dr. Kevin Grumbach. I am a family physician and Professor and Chair
of the Department of Family and Community Medicine at the University of
California, San Francisco. I also am Director of the Center for
California Health Workforce Studies and Co-Director of the Center for
Excellence in Primary Care at UCSF. My testimony today will focus on
the crisis in the Nation's primary care physician workforce.
There are three main points I would like to emphasize:
1. Primary care is the essential foundation of a well-performing
health system.
2. The primary care infrastructure in the United States is
crumbling, and patient access to primary care is suffering throughout
the Nation.
3. The Federal Government can address the crisis in primary care
through:
a. Targeted health professions primary care training programs
such as title VII programs,
b. Reform of Medicare Graduate Medical Education funding,
c. The National Health Services Corps, and
d. Medicare physician payment reform.
Let me review the evidence in support of each of these points.
1. primary care is the essential foundation of a well-performing
health system
A primary care home serves as the patient's door into the health
care system and the patient's guide through the system. Patients and
families can choose a family physician, general internist, or
pediatrician to be their primary care physician. Working closely with
these physicians, nurse practitioners and physician assistants also
deliver primary care. When people say, ``I'm going to see my personal
physician,'' they are usually talking about their primary care
physician. Primary care has the job of preventing illness; treating
acute problems; caring for the millions of people with chronic
conditions such as high blood pressure, arthritis, and diabetes;
providing compassionate care at the end of life; and coordinating
specialty and other referral services.
Research evidence makes it clear that health systems built on a
solid foundation of primary care deliver more effective, efficient, and
equitable care than systems that fail to invest adequately in primary
care:
Costs.--Patients with a regular primary care physician
have lower overall costs than those without. Compared with specialty
medicine, primary care provides comparable quality of care at lower
cost for a variety of conditions such as diabetes, hypertension, and
low back pain. In comparisons of regions and States in the United
States, increased primary care physician to population ratios are
associated with reduced hospitalization rates and lower overall health
care costs.
Quality.--States with more primary care physicians per
capita--but not specialists--have better population health indicators
such as total mortality, heart disease and cancer mortality, and
neonatal mortality. Medicare patients in these States also receive
better quality of care, including more appropriate care for heart
attacks, diabetes, and pneumonia. Patients with a primary care home are
more likely to receive appropriate preventive services such as cancer
screening and flu shots.
Equity.--Racial disparities are reduced when patients
receive care from a well-functioning medical home.
2. the primary care infrastructure in the united states is crumbling,
and patient access to primary care is suffering throughout the nation
From 1997 to 2005, the number of U.S. medical school graduates
entering careers in family medicine residencies dropped by 50 percent.
A similarly large decrease has occurred in the number of internal
medicine residents planning careers in primary care rather than
specialty medicine.
An analysis performed by Dr. Jack Colwill and colleagues at the
University of Missouri indicates that the growth in the supply of
primary care physicians for adult patients is now lagging behind the
rate of growth in the adult population, with the gap projected to widen
dramatically over the next decade.
SOURCE: J Colwill, unpublished data, 2007.
NOTES: ``aging of pop'' based on visits per age group;
``Adjusted supply''--adjusted for age and gender.
Graduate decline''--extends the 2001-2004 rate of
decline of graduates through 2007.
The human resource crisis in primary care is apparent in the
difficulties faced by health organizations in recruiting primary care
physicians. In a 2006 survey of 92 large- or medium-sized physician
groups, 94 percent of the respondents ranked internists or family
physicians as the most difficult to recruit. Federally funded community
health centers reported more than 750 vacant positions for primary care
physicians in 2004.
These workforce trends are having a deleterious effect on patients.
Lack of access to primary care physicians is becoming an alarming
problem in communities throughout the Nation, not just in traditionally
underserved rural and inner city communities. In 2007, 29 percent of
Medicare beneficiaries reported a problem finding a primary care
physician, up from 24 percent in 2006. Soon after Massachusetts began
implementing its universal coverage plan, it confronted the glaring
deficiency of having an insufficient supply of primary care physicians
to provide medical homes to the patients newly insured by the State
health plan.
3. federal policies to address the primary care workforce crisis:
an evidence-based approach to effective policy
Research evidence supports the critical influence of Federal
policies on the State of the Nation's primary care workforce, and
points to effective interventions to address the current crisis.
a. Targeted Health Professions Primary Care Training Programs: Title
VII Programs
Title VII Section 747 Primary Care Training Grants are intended to
strengthen the primary care educational infrastructure at medical
schools and residency programs and to encourage physicians-in-training
to pursue careers working with underserved populations. Research shows
an association between title VII grants to medical schools and
increased production of primary care physicians and a greater
likelihood that graduates will practice in underserved areas. In
addition, a study of title VII grants to family medicine residency
programs in nine States found that graduates of title VII residencies
were more likely to practice in rural and low-income areas than their
counterparts trained at residencies that did not receive title VII
grants.
Recent research conducted by our own team at UCSF, led by Dr. Diane
Rittenhouse, has documented the importance of title VII grants for
strengthening the educational pipeline producing primary care
physicians who work at federally qualified community health centers and
join the National Health Service Corps. Physicians who graduated from
title VII-funded U.S. medical schools were 50 percent more likely to be
practicing at a CHC in 2001-03 than physicians who graduated from
medical schools that did not receive title VII funding. As the figure
below indicates, 3.0 percent of graduates of title VII-funded medical
schools were working at CHCs in 2001-03, compared with 1.9 percent of
graduates of schools not funded by title VII. Similar results were
found for title VII-funded residency programs. Of family physicians who
trained at title VII-funded residencies, 6.8 percent worked at CHCs in
2001-03, compared to 5.0 percent of family physicians who trained at
residencies not funded by title VII.
These same patterns were found for the association between title
VII funding and physician participation in the National Health Services
Corps. For example, family physicians who attended title VII residency
programs were 50 percent more likely to participate in the NHSC Loan
Repayment Program than family physicians who trained at residencies not
funded by title VII.
This recent research provides evidence that the title VII section
747 grant program supports the training of primary care physicians who
are more likely to staff CHCs and participate in the NCHS. These
findings have important implications for Federal policy decisions,
including the recent major reduction in title VII section 747 funding.
Reductions in title VII destabilize institutions that
disproportionately serve as the pipeline for producing primary care
physicians who participate in the NHSC and/or work at CHCs, undermining
the Federal effort to improve access for the underserved through CHC
expansion. Ongoing Federal investment in the medical education pipeline
to prepare and motivate physicians to participate in the NHSC and to
work in CHCs should be considered an integral component of efforts to
improve access to care for the underserved.
b. Reforming Medicare Graduate Medical Education Funding
Medicare GME funding policies tie funds to hospital-based settings
emphasizing specialty training and hospital service priorities, rather
than the public's workforce needs. Medicare GME funding needs to become
more aligned with primary care workforce needs and less rigidly tied to
hospital-based training sites. The minutes of the September 2008
meeting of the Council of Graduate Medical Education summarize draft
recommendations on GME funding that are consistent with the priorities
identified by many medical educators as fundamental to more rational
GME funding that corrects current disincentives for primary care
training. These include:
Broadening the definition of ``training venue'' beyond
traditional training sites,
Removing regulatory barriers limiting flexible GME
training programs and training venues, and
Making accountability for the public's health the driving
force for graduate medical education, including by:
developing mechanisms by which local, regional or
national groups can determine workforce needs, assign
accountability, allocate funding, and develop innovative models
of training which meet the needs of the community and of
trainees;
linking continued funding to meeting pre-determined
performance goals.
Deliberations about altering the current funding formulae for
Medicare GME allocations to reduce overall Medicare GME funding must
carefully consider the potential impact on vulnerable primary care
residency training programs. Funding formulae should not be revised
without considering the types of principles under discussion by the
Council of Graduate Medical Education to create a more accountable and
rational approach to GME funding.
c. National Health Services Corps
National Health Service Corps physicians comprise a substantial
proportion of physicians staffing CHCs. Research indicates that after
completing their NHSC obligation, a large proportion of NHSC
participants remain in service to the underserved. In addition,
temporary placement of NHSC physicians in rural underserved areas
positively impacts the long-term non-NHSC physician supply in those
areas. Unfortunately, the demand for NHSC physicians far exceeds the
supply. In 2006 there were over 4,200 vacant positions in underserved
areas for NHSC physicians, yet only 1,200 NHSC physicians available to
fill these slots.
The NHSC is an effective strategy to provide incentives to
physicians in training to enter primary care and provide service where
it is most needed.
d. Medicare Physician Payment Reform
One of the major disincentives for physicians in training to pursue
careers in primary care is the widening gap in earnings between primary
care physicians and physicians in subspecialty fields. The income of
primary care physicians, adjusted for inflation, decreased by 10.2
percent from 1995 to 2003. Median specialist income in 2004 was 180
percent of primary care income. Unadjusted for inflation, specialist
income grew almost 4 percent per year from 1995 to 2004, while primary
care income grew 2 percent per year. A specialist spending 30 minutes
performing a surgical procedure, a diagnostic test, or an imaging study
is often paid three times as much as a primary care physician
conducting a 30-minute visit with a patient who has diabetes, heart
failure, headache, or depression.
Although Medicare is only one payor among many in the U.S. health
system, Medicare has a dominant influence on physician payment policies
for all payors. Most private health plans base their payment policies
on Medicare's relative value unit system. Thus, Medicare physician
payment policy is physician workforce policy. Changes to Medicare
physician payment policies that reverse the financial disincentives for
primary care practice can play a powerful role in addressing the crisis
in the primary care workforce.
i. Splitting the Sustainable Growth Rate (SGR)
From 1997 to 2006, Medicare expenditures for specialty-oriented
physician services (e.g., surgery, imaging studies) increased 36
percent faster than expenditures for primary care-oriented evaluation
and management (E&M) services. In 2006, non-E&M services accounted for
86 percent in the overage in Medicare physician expenditures above the
overall SGR target.
Although there are valid reasons for Medicare to use some type of
SGR approach to control overall physician expenditures, the specific
manner in which the SGR has been implemented has had a
disproportionately adverse impact on Medicare payments to primary care
physicians. Because there is one conversion factor for all services,
primary care physicians are essentially penalized when large increases
in expenditures for specialized services drive down the conversion
factor that is applied to E&M and non-E&M services alike.
A simple policy that could mitigate much of this unintended effect
of the SGR that disproportionately penalizes primary care physicians
would be to use a split SGR system for E&M and non-E&M services, such
that the conversion factor for each category of service would rise or
fall based on expenditure trends within that category of service.
We have modeled the implications of a split SGR. In our modeling
scenario, we allowed total Medicare physician expenditures to increase
from 1997 to the actual observed 2006 level of $93.7 billion. However,
instead of allowing total expenditures to increase more rapidly in the
non-E&M service category than in the E&M category, as historically
occurred, we kept the 1997 2006 rate of expenditure increase (90
percent) equivalent within each of the E&M and non-E&M SGR pools. Under
this scenario, E&M spending in 2006 would have been $37.5 billion
rather than $34.4 billion, and fees for E&M services would have been 9
percent greater in 2006 than they actually were. Non-E&M spending in
2006 would have been $56.2 billion rather than the actual $59.3
billion. The conversion factors in 2006 under the high growth scenario
would have been 41.3 for E&M services and 35.9 for non-E&M services.
These compare with the actual 2006 conversion factor of 37.9 for both
E&M and non-E&M services. This modeling exercise indicates how
implementation of a split SGR could allow Medicare to provide more
incentives for primary care services without increasing overall
Medicare expenditures.
ii. Adding a Medical Home Care Coordination Payment, in
Addition to Fee-for-Service Payments
Providing comprehensive care to patients with chronic illnesses and
complex medical problems requires that physicians spend considerable
time coordinating services, communicating with patients and caregivers
by phone and e-mail, and devoting effort to similar types of activities
not reimbursed under the traditional ``piecemeal'' payment approach of
fee-for-service. The Patient Centered Primary Care Collaborative, a
coalition of large employers and primary care physician associations,
has called for payors to add a monthly care coordination payment ``for
the physician work that falls outside of a face-to-face visit and for
the heath information technologies needed to achieve better outcomes.
Bundling of services into a monthly fee removes volume-based incentives
and promotes efficiency. The prospective nature of the payment
recognizes the up-front costs to maintain the required level of care.
Care coordination payments should be risk-adjusted to ensure that there
are no inherent incentives to avoid the treatment of the more complex,
costly patients.''
An example of the cost-effectiveness of such a care coordination
payment is illustrated by the experiences of North Carolina's Medicaid
management program, known as Community Care of North Carolina. To
qualify for a monthly coordination payment of $5.50 per Medicaid
patient per month, primary care practices must agree to use evidence-
based guidelines for at least 3 conditions, track tests and referrals,
and measure and report on clinical and service performance. The program
spent $8.1 million between July 2002 and July 2003, but saved more than
$60 million over historic expenditures. In the second year of the
program $10.2 million were spent but $124 million was saved. In 2005
the savings grew to $231 million.
iii. Subsidies for Capital Investment to Modernize the
Medical Home Through EMR Installation and Related
IT, Training and Hiring of Primary Care Office
Staff for Innovative Chronic and Preventive Care
Programs, and Other Infrastructure Needs
Specialist physicians who spend a large amount of their work time
in hospitals benefit from the capital investments and staffing paid for
by hospitals. Hospitals pay for installation of hospital-based
electronic medical records, operating room equipment, and the nurses
and other personnel to staff operating rooms and intensive care units.
Primary care physicians are largely on their own when it comes to
finding resources for capital improvement and staffing support. The
work of primary care occurs mainly in the physician's office.
Investments in purchasing an EMR or hiring a health educator to assist
patients to learn how to manage their chronic illnesses come out of the
physician's own practice earnings. In an environment where real net
income for primary care physicians is falling, there is little margin
in practice revenues to pay for such practice improvements.
conclusion
Primary care is essential, and it is in crisis. Decisive action is
required by the Federal Government to avert the collapse of primary
care and its catastrophic consequences for the public. Many leaders in
the private sector, such as large employers, are already taking action
on issues such as physician payment reform to support new models of
primary care.
Research provides evidence of strategies that are of proven
effectiveness in strengthening the primary care workforce and providing
incentives for primary care practice. Some of these strategies, such as
implementing a split SGR for Medicare physician payment or reforming
Medicare GME payments, do not require new funds but rather a
reconsideration of how existing funds are allocated. Other strategies,
such as a reasonable level of funding for the Section 747 Title VII
Primary Care Training Grants Program, require small investments. For
example, restoring title VII section 747 funding to its 2003 level of
$92.4 million would represent an annual investment equivalent to 0.02
percent of the annual Medicare budget. Such investments in the future
of the Nation's primary care physician workforce are a cost-
effective investment in the Nation's health care infrastructure and in
the health of the public.
Thank you.
Senator Sanders. Thank you very much.
Dr. Roderick Hooker is the Director of Research,
Rheumatology Section, Medical Service Department of Veterans
Affairs at the Dallas VA Medical Center.
STATEMENT OF RODERICK S. HOOKER, Ph.D., P.A., DIRECTOR OF
RESEARCH, RHEUMATOLOGY SECTION, MEDICAL SERVICE DEPARTMENT OF
VETERANS AFFAIRS, DALLAS VA MEDICAL CENTER, DALLAS, TX
Mr. Hooker. Thank you, Senator Sanders and others on the
committee.
Senator Sanders. Is your mike on, sir?
Mr. Hooker. I, too, want to keep my remarks brief so we can
have a richer discussion around the table.
Approximately little over 35 years ago, an experiment was
begun in the United States at three different locations--at
Duke University, at University of Washington, and University of
Colorado. These were experiments in trying to deliver primary
care without the use of doctors for every visit. Physician
assistants was that experiment. It is now over 65,000 P.A.s
have graduated. Over 60,000 are in some sort of clinical role.
They are widely dispersed throughout Alaska and many other
States. Most States except Vermont have P.A. programs. It seems
to be working. It works very well for a number of reasons. They
are economically trainable. They get out into primary care at a
greater percentage than physician ratios, and they seem to
deliver very high numbers of primary care visits.
I believe that there are opportunities here to expand on
this, especially coupled with the other noble experiment that
began little over 35 years ago with family medicine. These two
professions have pretty much grown alongside each other with
the benefit of title VII. I believe that title VII can be
enhanced to try to expand this particular endowment of the
United States that is now being emulated in seven other
countries around the world, and many others are looking to the
experience here as well.
With that, I will conclude my opening remarks and pass on.
[The prepared statement of Mr. Hooker follows:]
Prepared Statement of Roderick S. Hooker, Ph.D., P.A.
Good morning. Thank you, Senators Kennedy, Enzi, and other members
of the committee for the opportunity to provide comments this morning
on the primary health care workforce. I will address the implications
for reauthorization Title VII Health Professions Programs under the
Public Health Service (PHS) Act.
My name is Roderick Hooker. My role in health care began many years
ago as a Hospital Corpsman in the U.S. Navy. I have been a physician
assistant for 30 years. In addition, I hold an MBA in Health Care
Management and Organization and a Ph.D. in Health Policy. I am a
physician assistant in the Department of Veterans Affairs Medical
Center in Dallas, TX. I am also an Associate Professor at the
University of North Texas, School of Public Health, and the University
of Texas Southwestern Medical School. My research career has focused on
the medical workforce and organizational efficiency in health care
delivery.
I am particularly interested in the critical role of physician
assistants (PAs) and nurse practitioners (NPs) and how they expand
access to primary health care. The research shows that absent a PA or
NP, some populations would have no access to health care.
Today, I'd like to briefly share my thoughts on the supply and
demand of PAs and NPs in the United States. There is a critical need to
reinvigorate the title VII program's investment to increase the supply,
diversity, and distribution of PAs in medically underserved
communities. (NP programs receive Federal funding support through title
VIII of the PHS Act.)
physician assistants
Physician assistants are licensed health professionals. They:
practice medicine as a team with their supervising physicians;
exercise autonomy in medical decisionmaking; and
provide a comprehensive range of diagnostic and therapeutic
services, including physical examinations, taking patient
histories, ordering and interpreting laboratory tests, diagnosing
and treating illnesses, suturing lacerations, assisting in surgery,
writing prescriptions, and providing patient education and
counseling.
PA educational preparation is based on the medical model. They
practice medicine as delegated by and with the supervision of a doctor.
Physicians may delegate to PAs those medical duties that are within the
physician's scope of practice and the PA's training and experience, as
allowed by law. A physician assistant provides health care services
that were traditionally only performed by a physician.
overview of physician assistant education
All physician assistant programs provide students with a primary
care education that prepares them to practice medicine with physician
supervision. PA programs are located at schools of medicine or health
sciences, universities, teaching hospitals, and the Armed Services. All
139 PA educational programs are accredited by the Accreditation Review
Commission on Education for the Physician Assistant and offer a
bachelor or master's degrees.
title vii support of pa education programs
The title VII support for PA educational programs is the only
Federal funding available, on a competitive application basis, to PA
programs.
Targeted Federal support for PA educational programs is authorized
through section 747 of the Public Health Service Act. The program was
reauthorized in the 105th Congress through the Health Professions
Education Partnerships Act of 1998, P.L. 105-392, which streamlined and
consolidated the Federal health professions education programs. Support
for PA education is now considered within the broader context of
training in primary care medicine and dentistry.
P.L. 105-392 reauthorized awards and grants to schools of medicine
and osteopathic medicine, as well as colleges and universities, to
plan, develop, and operate accredited programs for the education of
physician assistants with priority given to training individuals from
disadvantaged communities. The funds ensure that PA students have
continued access to an affordable education and encourage PAs, upon
graduation, to practice in underserved communities. These goals are
accomplished by funding PA education programs that have a demonstrated
track record of: (1) placing PA students in health professional
shortage areas; (2) exposing PA students to medically underserved
communities during the clinical rotation portion of their training; and
(3) recruiting and retaining students who are indigenous to communities
with unmet health care needs.
The title VII program works as intended.
A review of PA graduates from 1990-2006 demonstrates that
PAs who have graduated from PA educational programs supported by title
VII are 59 percent more likely to be from underrepresented minority
populations and 46 percent more likely to work in a rural health clinic
than graduates of programs that were not supported by title VII.
A study by the UCSF Center for California Health Workforce
Studies found a strong association between physician assistants exposed
to title VII during their PA educational preparation and those who ever
reported working in a federally qualified health center or other
community health center.
The PA programs' success in recruiting underrepresented minority
and disadvantaged students is linked to their ability to creatively use
title VII funds to enhance existing educational programs. For example,
a PA educational program in Iowa used title VII funds to target
disadvantaged students, providing mentoring opportunities for students,
increasing training in cultural competency, and identifying new family
medicine preceptors in underserved areas. PA programs in Texas use
title VII funds to create new clinical rotation sites in rural and
underserved areas, including new sites in border communities. They
establish non-clinical rural rotations to help students understand the
challenges faced by rural communities. One Texas program developed web-
based and distant learning technology and methodologies so students can
remain at clinical practice sites. A PA program in New York, where over
90 percent of the students are ethnic minorities, used title VII
funding to focus on primary care training for underserved urban
populations. They did this by linking with community health centers,
expanding the pool of qualified minority role models that engage in
clinical teaching, mentoring, and preceptorship for PA students.
Several other PA programs use title VII grants to leverage additional
resources to assist students with the added costs of housing and travel
that occur during relocation to rural areas for clinical training.
Without title VII funding, many special PA training initiatives
would be eliminated. Institutional budgets and student tuition fees are
not sufficient to meet the special, unmet needs of medically
underserved areas or disadvantaged students. The need is very real, and
title VII is critical in leveraging innovations in PA training.
The clinical training opportunities that are made available through
the section 747 program are substantial and documented. They result in
the delivery of essential health care services in medically underserved
communities that would otherwise not be available.
title vii and the distribution of health care professionals
The Health Resources and Services Administration (HRSA) estimate
the need for an additional 7,802 health professionals to remove the
Primary Care Health Professional Shortage Areas (HPSAs) designation
nationwide.
The title VII programs are the only Federal education programs that
are designed to address the supply and distribution imbalances in the
health professions. Since the establishment of Medicare, the costs of
physician residencies, nurses, and some allied health professions
training has been paid through Graduate Medical Education (GME)
funding. However, GME funding has never been available to support PA
education. More importantly, GME was not intended to generate a supply
of providers who are willing to work in the Nation's medically
underserved communities.
There is compelling evidence that race and ethnicity correlate with
persistent, and often increasing, health disparities. Further evidence
substantiates the need for increasing the diversity of health care
professionals. Title VII programs recruit providers from a variety of
backgrounds.
Changes in the health care marketplace reflect a growing reliance
on PAs as part of the health care team. The supply of physician
assistants is inadequate to meet the needs of society; demand for PAs
is expected to increase. Title VII continues to provide a crucial
pipeline of trained PAs to underserved areas. The U.S. Bureau of Labor
Statistics, US News and World Report, and Money magazine all speak to
the growth, demand, and value of the PA profession. Medically
underserved communities need additional assistance to attract health
care professionals who are in high demand in the private market.
need for increased title vii support for pa education programs
Despite the increased demand for PAs, funding has not increased for
title VII programs. More is needed to educate and place physician
assistants in underserved communities. Nor has title VII support for PA
education kept pace with increases in the cost of education. In fact,
title VII support has decreased sharply. A review of HRSA section 747
grants reveals that 42 PA educational programs received a total of
$7,011,443 million in fiscal year 2005, compared to $3,292,535 million
awarded to 27 grantees in fiscal year 2006, and just $2,616,129 awarded
to 15 grantees in fiscal year 2007.
recommendations for reauthorization
The Title VII Health Professions Programs needs to be reauthorized
by the 110th Congress. Little needs to be tweaked or substantially
changed during the reauthorization process. I do, however, believe that
title VII needs to be reinvigorated, valued, and recognized as
providing an important public good. Evidence now supports the notion
that title VII has lived up to the expectations of its early creators.
Support for the education of primary care providers is sorely
needed. There is a pressing need to recruit underrepresented minorities
and disadvantaged populations. Doing so provides quality health care in
medically underserved communities; a cornerstone.
Finally, an increased emphasis must be placed on support for PA
educational programs through the reauthorization process. The current
funding for primary care medicine and dentistry has been at the expense
of funding support for PA education. I believe that PA educational
programs must be eligible to participate in all title VII programs. In
particular:
Section 738 (a)(3) Loan Repayments and Fellowships Regarding
Faculty Positions;
Section 736(g)(1)(A) Programs of Excellence in Health
Professions Education for Under-represented Minorities; and
Sections 701-720 Health Education Assistance Loan (HEAL)
Program.
I appreciate the opportunity to provide comments during the
committee's roundtable discussion.
Thank you.
Senator Sanders. Thank you very much, Dr. Hooker.
Edward S. Salsberg, M.P.A., is Director, Center for
Workforce Studies, Association of American Medical Colleges in
Washington.
STATEMENT OF EDWARD S. SALSBERG, M.P.A., DIRECTOR, CENTER FOR
WORKFORCE STUDIES, ASSOCIATION OF AMERICAN MEDICAL COLLEGES,
WASHINGTON, DC
Mr. Salsberg. Thank you, Senator Sanders. The AAMC
appreciates the opportunity to talk to you today. I am going to
very briefly summarize some of the comments in my submitted
testimony.
The AAMC is particularly concerned these days with the
likely shortage, major shortage of physicians in the coming
years. This shortage is really going to be driven by the
increasing U.S. population, the aging of the U.S. population
and, in fact, many of the advances in medicine that are keeping
people alive longer and using services, along with an aging
physician workforce and a younger generation of physicians that
aren't working the same long hours that physicians did in the
past.
We have recommended a 30 percent increase in medical school
enrollment, and we are seeing some progress. The reality is
that that increase is really not going to be enough to meet all
of the needs of Americans. We really have to look at how we
redesign the healthcare system, how we use other health
professionals, how we use our physicians more efficiently and
effectively.
We are already concerned about the problems of
distribution, and the reality is if we face major shortages of
physicians and other health professionals, unfortunately, it is
likely to be the rural and poorer communities, the inner city
areas that are going to really feel those shortages most
severely.
We think it is absolutely essential, in addition to
increasing the supply of physicians, that we support programs
that are going to address the maldistribution problem. There
are some programs that we know work. The National Health
Service Corps has an excellent track record, and we know that
there are more applicants than there are awards. We support
very strongly an increase in the funding for the National
Health Service Corps.
We know that title VII has been a complex and comprehensive
program with a lot of parts, and those parts are designed to
address a number of these problems of access, distribution,
supply, and diversity. We think those programs are clearly
essential to a comprehensive strategy.
Clearly, title VII alone isn't going to solve this problem,
but we can't see how you can solve the problem without those
pieces that are supported by title VII. That doesn't mean that
there isn't room for improvement of title VII, and AAMC would
be happy to work with the committee in exploring how we might
strengthen and improve the program.
[The prepared statement of Mr. Salsberg follows:]
Prepared Statement of Edward Salsberg, M.P.A.
Summary
The Nation is likely to face a major shortage of
physicians in the future due to a growing and aging population;
advances in medicine leading to longer life; an aging physician
workforce; and shorter work hours for younger physicians in practice.
Between 1980 and 2005, the U.S. population grew by more
than 70 million people (31 percent) while medical school enrollment was
essentially flat.
Shortages are likely to be greatest in poor and rural
communities and other communities that historically have had a
difficult time recruiting and retaining physicians.
It takes at least a decade to increase the supply of
American educated physicians; therefore action is needed now to assure
access and to prevent a crisis in the future.
AAMC recommends a 30 percent increase in medical school
enrollment by 2015 and funding for additional graduate medical
education (GME) positions.
While this is a necessary step it will not be
sufficient to assure access in the future; systems redesign,
improvements in productivity, greater use of non-
physician clinicians and more effective use of physicians is
also essential.
Increasing the physician supply alone will also not
address the problems of geographic and specialty mal-distribution. More
than 30 million Americans live in areas designated as having shortages.
The AAMC recommends a doubling of annual NHSC awards and increased--not
decreased--support for title VII.
The financing of graduate medical education has a major
impact on the physician workforce.
Existing funding is threatened in the President's
budget request and by the proposed rule prohibiting Federal
Medicaid payments for GME. The AAMC supports legislation (S.
2460) to extend the current moratorium prohibiting action on
the proposed rule.
Current GME regulations (Medicare) penalize
outpatient/primary care training.
aamc recommendations for title vii reauthorization
The AAMC strongly recommends continuation of programs
authorized under Title VII of the Public Health Service Act with
modifications. This program has numerous components designed to improve
access, distribution, effectiveness and equity.
Retain diversity programs as currently structured at a
higher authorization level, and create a new program to support
demonstration projects designed to increase the number of
underrepresented minority faculty. Increasing the diversity of the
health workforce should be a national priority. Title VII programs are
critical to this effort.
Improve data collection and program evaluation by
increasing the authorization for regional workforce analysis centers
and authorizing a new national workforce database to track the supply
and location of health professionals.
Improve the alignment between title VII grants and service
in underserved areas by restructuring the primary care programs to
preferentially award grants to applicants entering a formal
relationship with providers in underserved areas.
Create a new program to award grants for schools or
departments to administer demonstration projects to improve the quality
and efficiency of primary care.
Address inefficiencies in the title VII loan programs.
______
My name is Edward Salsberg, and I am the Director of the Center for
Workforce Studies at the Association of American Medical Colleges
(AAMC). Thank you for the opportunity to speak to you today regarding
the physician workforce and the response of America's medical schools
and teaching hospitals to a growing concern about potential future
physician shortages.
The AAMC is a nonprofit association representing all 126 accredited
U.S. allopathic medical schools; nearly 400 major teaching hospitals
and health systems, including Department of Veterans Affairs medical
centers; and 94 academic and scientific societies. Through these
institutions and organizations, the AAMC represents 109,000 faculty
members, 67,000 medical students, and 104,000 resident physicians.
Our mission is to improve the health of the public by enhancing the
effectiveness of academic medicine. Together with our members we pursue
this mission through the education of the physician and medical
scientist workforce, the discovery of new medical knowledge, the
development of innovative technologies for prevention, diagnosis and
treatment of disease, and the delivery of health care services in
academic settings.
The AAMC is committed to promoting an adequate supply of well-
educated physicians sufficient in number and competencies to assure
access to high quality medical care in the future. To this end, the
AAMC established its Center for Workforce Studies in 2004 to enhance
and make publicly available comprehensive data and analyses regarding
the supply of and demand for physicians. The Center is committed to
providing the medical education community (medical schools, medical
students, residency programs and teaching hospitals), the public, and
policymakers with superior information on current and likely future
physician workforce needs. The Center does this through original
research, analysis of existing data, collaboration with other
associations representing physicians and through an annual conference
on physician workforce research. In recent months, the Center has
updated a number of documents including our ``2007 State Physician
Workforce Databook'' and a listing of ``Recent Reports and Studies of
Physician Shortages in the United States.'' These reports accompany
this statement and are available along with additional information on
the Center on our Web site, http://www.aamc.org/workforce.
In my comments today, I want to provide you with some basic
background on the physician workforce, why we are concerned about the
likelihood of a future physician shortage, what the AAMC is
recommending in terms of physician workforce policies, and finally, how
the Nation's medical schools and teaching hospitals are responding. I
also want to specifically address the importance of the title VII
program in addressing physician workforce needs of the Nation.
background on the supply of physicians
The vast majority of licensed physicians in the United States are
educated in allopathic medical schools--those that confer an M.D.
degree--and residency training programs in the Nation's teaching
hospitals accredited by the Accreditation Council for Graduate Medical
Education (ACGME). Allopathic medical schools and their affiliated
teaching hospitals also are a critical source of research, new medical
knowledge, and clinical care, and are a vital part of the Nation's
medical safety net.
Physicians in the United States can practice medicine only
after completion of a medical degree (``undergraduate medical
education'' or UME), and several years of post-graduate training in an
accredited residency program (``graduate medical education'' or GME).
Each year approximately 16,000 physicians graduate from
U.S. medical schools with an M.D. degree; these graduates fill roughly
two-thirds of first-year residency positions in training programs--such
as internal medicine, general surgery, pediatrics, and others--that are
accredited by the Accreditation Council for Graduate Medical Education
(ACGME).
In 2006-07, nearly 6,800 graduates of foreign medical
schools, generally referred to as international medical school
graduates or IMGs, entered residency training, representing about 27
percent of the new residents that year; of those, about 1 in 4 were
U.S. citizens who attended schools outside of the United States.
Graduates of osteopathic medical schools (D.O.'s)
represent about 11 percent of all physicians entering graduate training
each year. More than half of D.O.'s enter ACGME accredited residency
programs.
Physicians in the United States are licensed by individual
States, all of whom require an M.D. or D.O. degree, as well as some
level of accredited graduate training (GME).
In 2006, there were almost 870,000 physicians active in
medicine in the United States, of which 56,000 were osteopaths. This
figure includes just under 105,000 physicians in residency training.
About 25 percent of active physicians in the United States are
graduates of non-U.S. medical schools.
why a physician shortage is likely
The expected future shortage of physicians is driven by likely
changes in both the supply and the demand for physicians. On the demand
side, key factors include: (1) the growing U.S. population (more than
25 million each decade). In fact, between 1980 and 2005, the U.S.
population grew by more than 70 million people (31 percent) while
medical school enrollment remained essentially flat; (2) the rapid
increase in the number of people over the age of 65 (who use twice as
many physician services per capita each year than those under 65); (3)
advances in medicine that prolong life and improve the quality of life
for millions of Americans; and (4) the rising expectations of Americans
along with increasing wealth that will motivate and enable them to use
more services. On the supply side, key factors include: (1) the aging
of the physician workforce (36 percent of active physicians are over 55
and most will retire by 2020); and (2) a new generation of physicians,
who value lifestyle and do not appear willing to work the long hours
that prior generations of physicians have worked. At current levels of
training, the physician-to-population ratio will peak before 2020 and
then fall, just as the baby boomers begin to reach 75 years of age.
Since 2002, there have been at least 35 studies showing current or
future physician workforce needs of a State or specialty.\1\ An October
2006 report by the Health Resources and Services Administration (HRSA)
predicts that the demand for physicians will exceed the supply by
2020.\2\ The underserved and elderly populations are most likely to be
affected. These shortages are likely to exacerbate the existing lack of
access for the 20 percent of Americans that live in government-
designated Health Professional Shortage Areas (HPSA).\3\ Many rural and
urban communities, economically disadvantaged and underrepresented
minority populations are likely to remain medically underserved for the
foreseeable future, and certainly will be more underserved if a
national shortage emerges.
---------------------------------------------------------------------------
\1\ http://www.aamc.org/workforce/recentworkforcestudies2007.pdf.
\2\ HRSA Bureau of Health Professions. Physician Supply and Demand:
Projections to 2020. October 2006. http://bhpr.hrsa.gov/
healthworkforce/reports/physiciansupplydemand/default.htm. Accessed:
February 5, 2008.
\3\ http://bhpr.hrsa.gov/shortage/.
---------------------------------------------------------------------------
the supply of physicians
For the last 50 years, the physician-to-population ratio has been
growing steadily. This reflects a doubling in medical school enrollment
in the 1960s and 1970s. However, with the report of the Graduate
Medical Education National Advisory Commission (GMENAC) in the late
1970s predicting a large surplus of physicians, medical school
enrollment stabilized. In fact, the number of graduates from U.S.
medical schools has been virtually flat since 1980. As a result, a very
large number of active physicians now are nearing retirement age. In
2005, a little more than 12,000 active physicians reached age 63; by
2017, this number will grow to more than 24,000.
The near-zero growth in U.S.-M.D. graduates has translated to a
decrease in the number of medical school slots per population in
America. In fact, between 1980 and 2005, the U.S. population grew by
more than 70 million (31 percent) \4\ while there was no growth in
allopathic enrollment; this has led to a significant and steady decline
in enrollment per 100,000 population. In addition to the large number
of physicians approaching retirement age, there are growing reports
that the newest generation of physicians do not want to work the long
hours of physicians in the past. Gender also plays a role. While only
10 percent of practicing physicians were female in 1980, they are now
about 50 percent of the medical students. While this trend is
encouraging from a societal perspective, it has implications for the
physician workforce because women tend to work fewer hours than their
male counterparts do. Moreover, there are growing reports that many of
today's young physicians, male and female, are choosing to work fewer
hours than their older counterparts regardless of their gender. As a
result, the future physician workforce may effectively be 10 percent
lower than their aggregate numbers may suggest.
---------------------------------------------------------------------------
\4\ U.S. Census Bureau.
---------------------------------------------------------------------------
In order to be able to forecast future supply of physicians more
accurately, the AAMC, in collaboration with physician specialty
societies and the American Medical Association (AMA) undertook two
major surveys: one of more than 9,000 physicians over 50, the other of
4,100 physicians under 50. The ``Over 50 Survey'' was designed to
understand factors influencing retirement patterns and plans; the
``Under 50 Survey'' was designed to assess whether in fact younger
physicians are working fewer hours than physicians in the past. The
surveys confirmed the likelihood of future physician shortages.
aamc workforce policy recommendations
While there are already shortages in many communities and for some
specialties today, the potential major nationwide shortages loom in the
future. However, we need to be concerned today as it takes at least a
decade to impact the supply of U.S.-educated physicians due to the time
to develop additional capacity and the length of education and
training. An appropriate supply of well-educated and trained physicians
is an essential element to assure access to quality health care
services for all Americans. The recommendations of the 2006 AAMC
Position Statement on the Physician Workforce are intended to better
assure an appropriate supply of physicians while increasing medical
education opportunities for Americans. The AAMC recommendations
include:
Enrollment in LCME-accredited medical schools should be
increased by 30 percent from the 2002 level by 2015. This expansion
should be accomplished by increased enrollment in existing schools as
well as by establishing new medical schools.--The United States medical
education community has spent decades developing standards and methods
to help assure that schools meet appropriate minimum standards and that
physicians that graduate from these schools have the skills and
knowledge necessary to provide high quality care. The nation is better
served when a greater, not lesser, proportion of future physicians are
held to these standards. Moreover,
There are large numbers of Americans who aspire to
attend U.S. medical schools but have been unable to gain
admission due in part to limited capacity. Many are so
committed that they are willing to pay high tuitions at schools
with varying standards and leave the United States for several
years to reach their goal. We estimate that more than 3,000
U.S. citizens enter medical school outside of the United States
each year;
There is growing international concern that English-
speaking countries may be draining valuable human resources
from less-developed countries. Increasing U.S. medical school
graduates will reduce the ``pull'' of physicians from less
developed countries without creating barriers for individual
migration.
Achieving the desired growth in medical school graduates will
require an increase in enrollment at most existing schools as well as
the creation of new medical schools. Increases in enrollment are
particularly appropriate in areas of the country where the population
has grown rapidly over the past 25 years and areas where the population
is projected to grow rapidly in future years. In addition, States with
low medical school enrollment per capita, with numerous underserved
areas and States with large and growing elderly populations may also be
appropriate areas for medical school enrollment growth.
The AAMC is making every effort to inform the medical education
community about the growing likelihood of a physician shortage but does
not control the number of medical student enrollments or training
positions available. The AAMC's recommendation to increase enrollment
has not gone unnoticed. The 2007 entering class to U.S. medical schools
is the largest in the Nation's history. The number of first-year
enrollees totals almost 17,800 students, a 2.3 percent increase over
2006. More than 42,300 individuals applied to enter medical school in
2007, an increase of 8.2 percent over 2006. Nearly 32,000 were first-
time applicants, the highest number on AAMC record. According to a 2007
survey of medical school deans, 100 of the Nation's 126 medical schools
already have increased their enrollment or plan to increase their
enrollment by five or more students within the next 5 years, when
compared to their baseline 2002-2003 enrollment. Data from this survey
projects that first-year enrollment will grow to 19,909 in 2012 from
16,488 in 2002, an increase of nearly 21 percent. It appears that our
member institutions will reach the 30 percent increase in enrollment
goal from both existing and new schools by 2017.
The aggregate number of graduate medical education (GME)
positions should be expanded to accommodate the additional graduates
from accredited medical schools.--U.S. medical schools face many
challenges in increasing the number of medical school graduates. A
primary goal of this expansion is to increase the supply of physicians
available to assure access to services in the future. Since all
physicians must complete accredited graduate training to become
licensed in the United States, the number of GME positions is a
critical choke point to increase the supply of physicians available to
care for Americans.
We strongly urge Congress to preserve Medicare support for GME. The
AAMC also recommends that Congress eliminate the current limit on the
number of Medicare-funded residency positions. This will allow GME
programs to expand in response to increased medical school enrollment
and other physician workforce dynamics. The AAMC welcomes the
opportunity to work with the committee to educate the public and
policymakers about the importance of stabilizing and expanding GME
support in the context of an impending physician shortage.
The AAMC believes the Resident Physician Shortage Reduction Act of
2007 (S. 588) is a useful beginning in meeting the Nation's needs for
future physician services. We express support for this important first
step in what we hope will be a systematic and rapid process to
eliminate the Medicare resident cap. However, we do wish to be clear
that financing this legislation from other cuts in Medicare in which we
have any interest will be self-defeating and unacceptable.
On a related matter, the President's fiscal year 2009 budget
proposes, over 5 years, to cut indirect medical education (IME)
payments to teaching hospitals by a total of $21.75 billion. The
Administration would accomplish this by reducing the add-on payment
from 5.5 percent to 2.2 percent over 3 years, as well as eliminating
IME payments to hospitals treating Medicare Advantage beneficiaries. We
ask Congress to reject these proposals, which are shortsighted in light
of the looming physician shortage.
Additionally, the AAMC strongly urges Congress to preserve Medicaid
support for GME. As you know, CMS has issued a proposed rule that would
reverse a long-standing policy of providing Federal matching funds for
State Medicaid GME payments. The AAMC asks you to delay further action
on this proposed rule by immediately taking up and passing S. 2460,
which extends by 1 year a current moratorium prohibiting CMS from
moving forward with these Medicaid GME cuts.
The AAMC also asks Congress to take up legislation to remove
regulatory barriers that penalize GME programs that train residents in
outpatient settings such as community-based primary care offices. We
also encourage Congress to continue funding programs that offer higher
reimbursement levels for physicians who practice in underserved areas.
The AAMC should continue to advocate for and promote
efforts to increase enrollment and graduation of racial and ethnic
minorities from medical school; and promote the education and training
of leaders in medical education and health care from racial and ethnic
minorities. Studies repeatedly have shown that medical students from
racial and ethnic minority groups are more likely to practice in
underserved communities and to care for a disproportionate number of
disadvantaged patients. This information, coupled with other compelling
arguments, underlies the AAMC's strong advocacy for greater diversity
in medical education. The implementation of lawful, race- and
ethnicity-conscious decisionmaking in medical school admissions and in
faculty recruitment and retention is essential to meet society's need
for a physician workforce capable of caring optimally for our
increasingly diverse population.
In the fall of 2006, the AAMC launched the AspiringDocs.org
campaign, which seeks to encourage well prepared African-American,
Hispanic/Latino, and Native American college students from all
undergraduate majors to pursue medicine as a career. U.S. medical
schools and teaching hospitals have a decades-long commitment to
building diversity in medicine. To complement efforts to increase the
pipeline of prospective students, the AspiringDocs.org campaign takes a
new approach--career marketing--to reach an untapped segment of
potential minority student applicants in America's colleges and
universities that was revealed by an innovative AAMC analysis.
The J-1 visa is the most appropriate visa for non-U.S.
citizen graduates of foreign medical schools entering graduate medical
education programs in the United States and should be encouraged.--The
primary purpose of graduate medical education is education. The J-1
program's purpose is educational and its administration by the
Educational Commission for Foreign Medical Graduates (ECFMG) assures
that J-1 residents and fellows possess valid educational credentials,
have successfully passed Steps 1 and 2 of the United States Medical
Licensing Examination (USMLE), and that their country of origin needs
the knowledge and skills that they will obtain through their education
in the United States. No other immigration program or visa category is
as consistent with the aims of U.S. graduate medical education or
offers an equal assurance of the quality of entrants.
The H-1 visa (an employment visa) is not appropriate for physicians
coming to the United States for education and training purposes. At the
national level, consideration should be given to clarifying and
expanding the types of visas available for physicians seeking GME in
the United States.
The National Health Service Corps (NHSC) has played an
important role in expanding access for underserved populations, and
continued expansion of this program is strongly recommended.--The NHSC
is a program sponsored by the Department of Health and Human Services
(HHS) that helps place physicians and other health care providers in
communities where they are most needed, both through scholarships and
through loan repayment. The NHSC has a proven track record of serving
the underserved in both rural and urban settings; 60 percent of its
clinicians are located in rural areas, while the remainder serve urban
populations in settings such as Community Health Centers (CHC), health
departments, and other critical access facilities. A recent report in
the Journal of the American Medical Association by Rosenblatt and
colleagues demonstrates the reliance of CHCs on NHSC scholars and loan
repayment recipients and the inability of these safety net sites to
recruit an adequate number of physicians.\5\
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\5\ Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of
medical personnel at community health centers: implications for planned
expansion. JAMA. 2006; 295(9):1042-9.
---------------------------------------------------------------------------
Since its creation, the NHSC consistently has received
significantly more applications for positions than it is able to
support with the funding provided by Congress. Funding for the NHSC has
decreased by $47 million (27 percent) since fiscal year 2003, when its
budget was $171 million. Limited funding has reduced new NHSC awards
from 1,570 in fiscal year 2003 to an estimated 947 in fiscal year 2008,
a nearly 40 percent decrease.
The growing debt of graduating medical students is likely to
increase the interest and willingness of U.S. medical school graduates
to apply for NHSC funding and awards. The scholarship program funds
tuition and other fees for over 150 medical students annually.
Moreover, almost 80 percent of the NHSC budget funds loan repayments
(numbering about 1,200 annually) for physicians that agree to serve
underserved communities after the completion of residency training. The
AAMC has recommended increasing annual NHSC awards by 1,500 to allow
more graduates to practice in underserved areas. A NHSC appropriation
of at least $400 million is necessary to sustain current NHSC levels
and the AAMC-recommended increase.
aamc recommendations for title vii reauthorization
While we are encouraged by the response of the medical education
community to our call for an increase in medical school enrollment, the
AAMC and our constituents recognize that increasing the supply of
physicians will not in and of itself address the problems of
geographical and specialty mal-distribution. Having an adequate
national supply of physicians is necessary but not sufficient to assure
access to health care services for all Americans. The AAMC believes
that Title VII of the Public Health Service Act is an essential part of
the elements needed to assure access.
Federal funding for the title VII health professions training
programs administered by the Health Resources and Services
Administration (HRSA) has been instrumental in increasing the supply of
the primary care workforce and in addressing the needs of the
underserved. Title VII programs support the training and education of
health care providers through loans, loan guarantees, and scholarships
to students, and grants and contracts to academic institutions and non-
profit organizations.
The statutory authority for these programs provided by the Health
Professions Education Partnerships Act of 1998 [P.L. 105-392] expired
in September 2002. Each year, the community, in its efforts to preserve
funding for these programs, faces opposition from the Office of
Management and Budget, and in fiscal year 2006, the programs sustained
a 51.5 percent cut in Federal funding. The President's budget request
for fiscal year 2009 recommends eliminating all funding for the title
VII programs.
Recognizing that a new approach to the title VII programs is needed
to strengthen them and improve their prospects for long-term survival,
the AAMC in September 2004 appointed a committee to review the missions
and effectiveness of the programs and propose recommendations as
Congress considers reauthorization. The AAMC Committee agreed that the
programs' shared goals should continue to be enhancing primary care,
bringing care to underserved areas, and improving the diversity of the
health care workforce. The committee also agreed that the
reauthorization of the title VII programs should improve accountability
of the programs by creating outcomes measures and enhancing the
collection and analysis of data to monitor the programs' impact.
The committee set forth a series of recommendations to align
current funding streams with these goals and enhance the future
viability of the programs. A copy of the AAMC Committee's final report
accompanies this statement.
Diversity (Sections 736-739).--The AAMC recommends the
programs under Sections 736-739 of the Public Health Service Act be
retained in their current structure, which includes the following
programs: Centers of Excellence, Health Careers Opportunity Program,
Faculty Loan Repayment Program, and the Scholarships for Disadvantaged
Students. They should be funded at $155 million. Additionally, the AAMC
notes the need for increased emphasis on the development of
underrepresented minority faculty, as these mentors create an
environment that allows minority health professions students to succeed
and graduate to provide care in their communities. The AAMC recommends
the creation of a new program to support demonstration projects
designed to increase the number of underrepresented minority faculty.
The program should receive $5 million of the $155 million recommended
for sections 736-739.
Health Workforce Information and Analysis (Section 761).--
Despite the emphasis of title VII programs on bringing care to
underserved areas, there continues to be a dearth of information on
their impact on workforce distribution. Additional funding is needed to
establish and maintain a system for linking physician practice location
and their medical education and graduate training experiences. A
national workforce-tracking database is needed to identify where title
VII-trained professionals are practicing and to produce benchmark data
to be used in evaluating the programs and determining preferences for
the granting process.
The Regional Centers for Health Workforce Studies supported by HRSA
have led the way in conducting health workforce studies and collecting
data to inform State and national programs regarding State and regional
health workforce needs. In addition, the Regional Centers have been
able to leverage Federal funding to obtain additional State and private
support. Yet, this component of title VII has remained unfunded since
fiscal year 2006. The AAMC supports the continuation and expansion of
these Centers, by reauthorizing section 761 at $2 million for the six
regional centers and authorizing $3 million for a new national
workforce database to track the location of health professionals
educated and trained in programs receiving title VII support.
Primary Care (Section 747).--Primary care is an effective
and necessary investment that benefits the health of all people. Title
VII funding is key to producing primary care providers and improving
their education. The section 747 programs are guided by two agendas:
caring for the underserved and preserving and promoting primary care.
The AAMC recommends a new structure, in which grants are
preferentially awarded to applicants who enter into a formal
relationship and submit a joint application with a Federally Qualified
Health Center (FQHC), an FQHC Look-Alike, Area Health Education Center
(AHEC), or a clinic located in a HPSA or MUA or a clinical practice
setting in which at least 40 percent of its patients are either
uninsured or supported by Medicaid. The AAMC recommends the
continuation of the funding priorities and preferences included in the
current statute.
Additionally, the AAMC proposes the creation of a new program under
section 747 in which grants will be awarded to schools or departments
to administer demonstration projects centered on improving the quality
of primary care in selected emphasis areas. A funding level of $198
million is recommended for section 747, with the distribution among the
disciplines and between undergraduate and graduate programs to remain
the same.
Address Inefficiencies in title VII loan programs.--The
title VII student loan programs offer long-term, low interest loans for
economically disadvantaged and underrepresented minority students in
the health professions. The average medical student participating in
the title VII student loan programs will save over $50,000 when
compared to current Stafford loans. Unfortunately, many medical
students will not accept a Primary Care Loan (PCL) due to the extended
service requirement and harsh default penalties. Students' avoidance of
the PCL program has resulted in a large portion of available funds
going unawarded each year, undermining the original intent of the
program, and thereby subjecting the program to annual Federal
rescissions.
In addition to reducing these harsh default penalties, the AAMC
recommends that the eligibility requirements for all HHS title VII and
title VIII health professions loan programs be amended to allow for the
waiver of parental financial information in extraordinary
circumstances.
Currently, the HHS Student Financial Aid Guidelines (section
101.3.142) indicate that ``institutions still must take parents'
information'' into account to determine students' eligibility PCL,
HPSL, LDS, and Nursing Student Loan (NSL) programs. In other Federal
financial aid programs--for instance, under the auspices of the
Department of Education--financial aid officers have the ability to
adjust this parental financial information requirement to reflect an
individual's specific situation; however, HHS regulations state that
the requirement to include parental data ``cannot be waived.''
There are compelling instances in which it would be appropriate for
financial aid officers to use professional judgment to waive parental
data for one or both parents, such as when a parent is incarcerated or
incapacitated during long-term hospital care, or when a parent's
whereabouts are unknown. Permitting financial aid officers to use their
professional judgment to waive this requirement in appropriate cases
would afford them greater flexibility in ensuring that scarce resources
are best targeted to those students who are truly in need. Furthermore,
the AAMC believes this is a more appropriate interpretation of the
Federal regulations that require the consideration of the ``expected
contribution from parents.'' (42 CFR Part 57.206).
Report language accompanying the FY 2007 Senate Labor-HHS-Education
Appropriations bill (S. 3708, S. Rept. 109-287) encouraged ``HRSA to
omit the consideration of parental income from the fiscal year 2007
competitions as well as from future guidance and methodology'' for
administering the title VII student loan programs. As you are aware,
discrepancies in availability of parental financial information have
disqualified already disadvantaged students from obtaining these
affordable loans. The AAMC has been working with HRSA to ensure that
students' fiduciary abilities are more appropriately represented in the
student aid process by granting financial aid administrators greater
professional discretion. The AAMC believes congressional direction
through title VII reauthorization will help ensure that title VII funds
are more appropriately allocated in the future.
The issues surrounding the physician workforce and potential
shortages are complex. The AAMC and our member institutions are
committed to assuring an adequate supply of well-educated physicians to
ensure that the future needs of Americans are met.
Senator Sanders. Thank you very much, Mr. Salsberg.
James Q. Swift, D.D.S., is Board President of the American
Dental Education Association, and he is a professor at the
University of Minnesota School of Dentistry. Dr. Swift, thanks
very much for being with us.
STATEMENT OF JAMES Q. SWIFT, D.D.S., BOARD PRESIDENT, AMERICAN
DENTAL EDUCATION ASSOCIATION, PROFESSOR, UNIVERSITY OF
MINNESOTA SCHOOL OF DENTISTRY, MINNEAPOLIS, MN
Mr. Swift. Thank you, Senator Sanders. Thank you to the
committee for allowing me to be here. I represent the American
Dental Education Association, which represents 15,000 dental
educators, dental students, residents, and educators and
students in allied dental health programs.
I would like to focus on three specific areas of my
testimony. The one relates to our diversity mission. In the
dental education environment, there is a significant shortage
of underrepresented minorities in education programs for the
dental profession. We do think that this needs to be addressed
because the future of the profession is dependent and critical
upon achieving optimum oral health for racial and ethnic
minority groups, which experience a higher level of oral health
problems and have limited access to dental care. We must
address that specific issue.
In addition, there is a significant access to dental care
problems, as illustrated by Senator Sanders and Senator Kennedy
earlier on. We need to get beyond the semantics of the concept
of dentist shortages or maldistributions. There is a
significant problem out there with access to oral health care,
as illustrated by the cases that you had mentioned.
There are millions of Americans, especially children, that
don't have access to oral health care, and there are several
solutions that have been proposed and several solutions that
can be influenced or impacted by this committee. I look forward
to working with you to determine that.
Last, there is a significant problem in the dental
education environment with dental faculty. This was also
referenced earlier in the testimony. It is difficult to entice
dentists after they graduate from dental school with a debt
somewhere between $175,000 on the average, depending on whether
you attend a private dental school or a publicly funded dental
school, in addition to the predoctoral costs prior to getting
to that point, makes it financially unable for these
individuals to be able to go out into some of these underserved
areas and work for lower income, when they have that type of
debt to face.
I look forward to giving further testimony and comments on
how we can perhaps achieve some solutions to these problems.
Thank you for letting me be here.
[The prepared statement of Mr. Swift follows:]
Prepared Statement of the American Dental Education Association (ADEA),
Presented by James Q. Swift, D.D.S.
summary
The testimony of the American Dental Education Association (ADEA)
is presented by Dr. James Q. Swift, ADEA President and Professor and
Director of the Division of Maxillofacial Surgery at the University of
Minnesota School of Dentistry. The testimony speaks to the primary
challenges faced by academic dentistry, the dental profession, and
Congress.
Chief among the challenges that we face together is the need to
increase diversity among professionally active dentists and allied
dental professionals, which are at the present time predominately White
non-Hispanic. The low number of African American, Hispanic, and Native
American students in dental schools remains disproportionate to their
numbers in the U.S. population.
Although the U.S. population is mostly homogenous, there is growing
diversity for which we are unprepared. Increasing diversity in the
dental profession is vital to the future of the profession and it is
central to achieving optimal oral health for racial and ethnic minority
groups, which experience a higher level of oral health problems and
have limited access to dental care.
Furthermore we need to move past the semantics of dentist
``shortage'' or dentist ``maldistribution.'' There can be no doubt that
there is a significant access problem for millions of Americans. We
must acknowledge that the current dental workforce is unable to meet
present day demand and need for dental care. Millions of Americans
experience dental pain daily and cannot afford to buy dental insurance
or pay for dental care out-of-pocket. The dental safety-net as well as
charity dental care provided by dentists cannot solve the problem.
Interest in the dental profession remains high and competition to
enter dental school is robust. Several new dental schools are scheduled
to open across the country to meet individual State workforce and
access needs. This will exacerbate the current shortage of dental
faculty to educate and train the future dental workforce. We face a
crisis if resources are not dedicated to help recruit and retain
faculty for the Nation's dental schools.
ADEA suggests several straightforward steps that Congress can take
to immediately address the challenges we face. The answers lie in
prioritizing resources both in terms of manpower and funding to tackle
these challenges. Some are fairly simple and pragmatic while others,
admittedly, will require coordination among multiple interested parties
and compromise. ADEA stands ready to work with Congress and our
colleagues in the dental community to ameliorate the access to dental
care problems the Nation faces and to meet the needs for the future
dental workforce.
introduction
The American Dental Education Association (ADEA) \1\ welcomes the
committee's examination of issues related to the dental workforce and
diversity of the profession. I am Dr. James Q. Swift, Professor and
Director of the Division of Maxillofacial Surgery at the University of
Minnesota School of Dentistry. I appear before you this morning as the
President of ADEA and am honored to share my views with you.
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\1\ The American Dental Education Association (ADEA) represents all
57 U.S. dental schools, 714 dental residency training programs, 285
dental hygiene programs, 271 dental assisting programs, and 21 dental
laboratory technology programs, as well as the faculty, dental
residents and dental allied dental students at these institutions as
well as 10 Canadian dental schools. It is at academic dental
institutions that future practitioners and researchers gain their
knowledge, the majority of dental research is conducted, and
significant dental care is provided. Our member institutions serve as
dental homes to thousands of patients, many of whom are underserved
low-income patients covered by Medicaid and the State Children's Health
Insurance Program.
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Profound disparities in the oral health of the Nation's population
have resulted in a ``silent epidemic'' of dental and oral diseases
affecting the most vulnerable among us. These disparities, in
combination with the current shortage of dental school faculty, the
scarcity of underrepresented minority dentists, and the need for
targeted incentives to draw dentists to practice in rural and
underserved communities, make this committee's examination timely and
necessary.
The challenge to Congress and the dental community is not only how
to expand the capacity of the dental workforce, but also how to improve
access to oral health care. According to Delta Dental Plans Association
and the National Association of Dental Plans, 134 million Americans do
not have dental insurance. The lack of insurance is a significant
barrier to receiving needed preventive and restorative care. Having
insurance, however, does not guarantee quick access to dental care;
even insured Americans can wait weeks for appointments with their
general dentists and/or specialists.
Despite concerted efforts by Congress and the dental community to
address access to dental care, there has been little genuine progress
made since the untimely death of 12-year-old Deamonte Driver, 1 year
ago. Deamonte was a young Maryland boy who died from infection caused
by an abscessed tooth that spread to his brain. All of us know this
tragedy could have been avoided if his Medicaid coverage had not lapsed
and if he had had better access to dental care. I do congratulate
Congress for having approved a guaranteed dental benefit in the bill to
reauthorize the State Children's Health Insurance Program (SCHIP), even
though the bill was twice vetoed. ADEA and the entire oral health
community pledge to work for passage of this important bill in the next
Congress.
the dental and oral disease burden in the united states
It has been 7 years since the first-ever U.S. Surgeon General's
report \2\ was published which comprehensively examined the status of
the Nation's oral health (Table 1 provides a summary of the report's
major findings). The report identified oral health as integral to
general health stating that ``Oral health is a critical component of
health and must be included in the provision of health care and the
design of community programs.'' It also declared that ``oral health is
essential to the general health and well-being of all Americans.''
Unfortunately, millions are left wanting and needing dental care. There
are ``profound and consequential oral health disparities within the
population,'' the Surgeon General concluded, particularly among its
diverse segments ``including racial and ethnic minorities, rural
populations, individuals with disabilities, the homeless, immigrants,
migrant workers, the very young, and the frail elderly.''
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\2\ U.S. Department of Health and Human Services. Oral Health in
America: a Report of the Surgeon General. Rockville, MD: U.S.
Department of Health and Human Services, National Institute of Dental
and Craniofacial Research, National Institutes of Health, 2000.
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Over the past 55 years, discoveries stemming from dental research
have reduced the burden of dental caries (tooth decay) for many
Americans. However, the Surgeon General's report declared dental
carries to be America's most prevalent infectious disease, five times
more common than asthma and seven times more common than hay fever in
school children. The burden of the disease, in terms of both extent and
severity, has shifted dramatically to a subset of our population. About
a quarter of the population now accounts for about 80 percent of the
disease burden. Dental caries remains a significant problem for
vulnerable populations of children and people who are economically
disadvantaged, elderly, chronically ill, or institutionalized. This
high-risk group includes nearly 20 million low-income children (nearly
all are eligible for Medicaid or SCHIP). Early childhood caries is
found in children less than 5 years of age. It is estimated that 2
percent of infants 12-23 months of age have at least one tooth with
questionable decay whereas 19 percent of children 2-5 years of age have
early childhood caries in the United States.\3\ It should be noted that
the American Academy of Pediatric Dentistry recommends that all
children visit a dentist in their first year of life and every 6 months
thereafter, or as indicated by the individual child's risk status or
susceptibility to disease. ADEA concurs with this recommendation.
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\3\ Savage MF, Lee JY, Kotch JB. Early Preventive Dental Visits:
Effects on Subsequent Utilization and Costs. Pediatrics 2004;(114)4.
Table 1.--Major Findings of the U.S. Surgeon General's Report
------------------------------------------------------------------------
-------------------------------------------------------------------------
Oral diseases and disorders in and of themselves affect health
and well-being throughout life.
Safe and effective measures exist to prevent the most common
dental diseases--dental caries and periodontal diseases.
There are profound and consequential oral health disparities
within the U.S. population.
More information is needed to improve America's oral health and
eliminate health disparities.
The mouth reflects general health and well-being.
Oral diseases and conditions are associated with other health
problems.
Scientific research is key to further reduction in the burden
of diseases and disorders that affect the face, mouth and teeth.
Each year, millions of productive hours are lost due to dental
diseases. Children miss 51 million hours of school due to treatment
problems. Workers lose 164 million work hours because of dental
disease.
Lifestyle behaviors that affect general health such as tobacco
use, excessive alcohol use, and poor dietary choices affect oral and
craniofacial health as well.
the u.s. population and the dental workforce
The U.S. Bureau of Labor Statistics (BLS), which placed the number
of practicing dentists at 161,000 in 2006,\4\ projects a 9 percent
growth in the number of dentists through 2016. This rate would bring
the total number of practicing dentists to 176,000.
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\4\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/
content/ocos072.stm, accessed February 5, 2008.
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About 80 percent of dentists are solo practitioners in primary care
general dentistry while the remaining dentists practice one of nine
recognized specialty areas: (1) endodontics; (2) oral and maxillofacial
surgery; (3) oral pathology; (4) oral and maxillofacial radiology; (5)
orthodontics; (6) pediatric dentistry; (7) periodontics; (8)
prosthodontics; and (9) public health dentistry.
Table 2.--Approximate Number of Dentists in the United States in 2006
------------------------------------------------------------------------
------------------------------------------------------------------------
General Dentists........................................... 136,000
Specialists: 34,878
Orthodontists............................................ 9,400
Oral and Maxillofacial Surgeons.......................... 7,700
Pedodontists............................................. 4,978
Prosthodontists.......................................... 3,300
Periodontists............................................ 5,100
Endodontists............................................. 4,400
Other dentists and specialists........................... 5,756
The vast majority of the 176,634 professionally active dentists in
the United States are White non-Hispanic. At the present time the U.S.
population is 303,375,763. \5\ At the time of the last census, when
there were 22 million fewer people, the largest segment of the U.S.
population was White (75 percent) but an increasing percentage was
minority with 35.3 million (13 percent) Latino, and 34.6 million (12
percent) Black or African-Americans (see Table 3).
---------------------------------------------------------------------------
\5\ U.S. Bureau of the Census, http://www.census.gov/population/
www/popclockus.html, February 5, 2008.
Table 3.--U.S. Population by Race and Hispanic Origin for the United
States: 2000 \6\
------------------------------------------------------------------------
Percent of
Race and Hispanic or Latino Number Number total
population
------------------------------------------------------------------------
Race:
One race.................................. 274,595,678 97.6
White..................................... 211,460,626 75.1
Black or African-American................. 34,658,190 12.3
American Indian and Alaska Native......... 2,475,956 0.9
Asian..................................... 10,242,998 3.6
Native Hawaiian and Other Pacific Islander 398,835 0.1
Some other race........................... 15,359,073 5.5
Two or more races......................... 6,826,228 2.4
---------------------------
Total population........................ 281,421,906 100.0
---------------------------
Hispanic or Latino:
Hispanic or Latino........................ 35,305,818 12.5
Not Hispanic or Latino.................... 246,116,088 87.5
---------------------------
Total population........................ 281,421,906 100.0
------------------------------------------------------------------------
\6\ Source: U.S. Census Bureau, Census 2000 Redistricting (PL 94-171)
Summary File, Tables PL1 and PL2, http://www.census.gov/prod/2001pubs/
c2kbr01-1.pdf, February 5, 2008.
dental hygiene, dental assisting, dental laboratory technology
The allied dental workforce, comprised of dental hygienists, dental
assistants and dental laboratory technologists, is central to meeting
increasing needs and demands for dental care. About 167,000 \7\ dental
hygienists, 280,000 \8\ dental assistants and 53,000 \9\ dental
laboratory technologists were in the U.S. workforce in 2006. Both
dental hygiene and dental assisting are among the fastest growing
occupations in the country with expected growth of 30 percent and 29
percent respectively through 2016 bringing the total numbers of dental
hygienists to about 217,000 and dental assistants to 361,000. Only
about 2,000 dental laboratory technologists will be added to the
workforce by 2016. The ability to increase the number is limited. At
the present time there are only 21 accredited training programs.
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\7\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/pdf/
ocos097.pdf, accessed February 5, 2008.
\8\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/
ocos163.htm, accessed February 5, 2008.
\9\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/
ocos238.htm, accessed February 5, 2008.
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Dental hygienists are licensed professionals who perform a variety
of clinical tasks while dental assistants work alongside dentists
during dental procedures and provide assistance. However, both dental
hygienists and assistants perform substantial routine preventive and
certain other radiographic and treatment services in compliance with
State practice acts. Dental laboratory technicians fill prescriptions
from dentists for crowns, bridges, dentures, and other dental
prosthetics and may specialize in one of five areas: orthodontic
appliances, crowns and bridges, complete dentures, partial dentures, or
ceramics.
dentist shortage or maldistribution
Some say we have a dental shortage. Others say we have a
maldistribution of dentists to meet the Nation's oral health needs. No
matter how one defines it, there can be no doubt that there is a
significant access problem for millions of Americans. We must
acknowledge that the current dental workforce is unable to meet present
day demand and need for dental care.
If every man, woman and child were to have a dental home and were
covered by dental insurance, then the Nation would clearly have an
insufficient number of dentists to care for the population. We are not
close to being at this point but we aspire to get there as quickly as
possible so everyone who needs and wants dental care is able to achieve
optimal oral health. The need and demand for dental services continues
to increase; in large measure this is due to the population explosion.
Also, Baby Boomers as well as the geriatric population, are retaining
more teeth and there is a growing focus on increasing access and
preventative dental care.
Each year academic dental institutions (ADIs), including dental
schools, allied dental programs and postdoctoral/advanced dental
education programs), graduate thousands of new practitioners to join
the dental workforce. About 4,500 predoctoral dental students graduate
annually. About half of these new graduates immediately sit for a State
licensure exam before beginning private practice as general dentists,
or they join the military, the U.S. Public Health Service, or they
advance their education in a dental specialty. Approximately 2,800
graduates along with hundreds of practicing dentists apply to residency
training programs. Nearly 23,000 allied dental health professionals
graduate from ADIs each year and join the dental workforce.
Approximately 14,000 dental hygiene students, 8,000 dental assistants,
and 800 dental laboratory technologists graduate annually.
According to the U.S. Surgeon General, the ratio of dentists to the
total population has been steadily declining for the past 20 years, and
at that rate, by 2021, there will not be enough active dentists to care
for the population. The number of Dental Health Professions Shortage
Areas (D-HPSAs) designated by the U.S. Health Resources and Services
Administration (HRSA) has grown from 792 in 1993 to 3,527 in 2006. In
1993, HRSA estimated 1,400 dentists were needed in these areas; by
2006, the number grew to 9,164. Nearly 47 million people live in D-
HPSAs across the country. Although it is unknown how many of these
areas can financially support a dentist or attract a dentist by virtue
of their infrastructure or location, it is clear that more dentists are
needed in these areas.
Modified and updated criteria for Dental HPSAs designation has been
in ``clearance'' at the U.S. Department of Health and Human Services
for more than 2 years. At the present time the HPSA criteria require
three basic determinations for a geographic area request: (1) the
geographic area involved must be rational for the delivery of health
services, (2) a specified population-to-practitioner ratio representing
shortage must be exceeded within the area, and (3) resources in
contiguous areas must be shown to be over-utilized, excessively
distant, or otherwise inaccessible. HPSA designation is used by a
variety of purposes by Federal programs. \10\
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\10\ Several Federal programs utilize the Federal HPSA designation
in the administration of their programs including the National Health
Service Corps and the U.S. PHS Grant Programs administered by HRSA-BHPr
gives funding preference to title VII and VIII training programs in
HPSAs.
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need/demand for dental care
Need for oral care is based on whether an individual requires
clinical care or attention to maintain full functionality of the oral
and craniofacial complex. The disproportionate burden of oral diseases
and disorders indicates that specific population groups are in greater
need of oral health care. Demand is generally understood as the amount
of a product or service that users can and would buy at varying prices.
Americans spent roughly $91.5 billion on dental procedures in 2006,
the vast majority of this amount was paid out of pocket ($40.6 billion)
or through private insurance ($45.3 billion) while $5.5 billion was
paid through public programs, Medicare ($0.1 billion) and Medicaid/
State Children's Health Insurance Program ($5.3 billion). \11\ Mostly
this was spent on fillings, crowns, implants, and high-end restorative
procedures. The extent of oral health care disparities clearly
indicates that many of those in need of oral health care do not demand
oral health care.
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\11\ Catlin, Aaron, Cowan, Cathy et al., Health Spending in 2006,
Health Affairs, 2008, 27 (1): page 14-29.
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Unfortunately millions of Americans experience dental pain daily
and cannot afford to buy dental insurance or pay for dental care out-
of-pocket. Since few oral health problems in their early stages are
life-threatening, people often delay treatment for long periods of
time. Often, when they do seek care, it is hospital emergency rooms or
others in the dental safety-net system--ADIs, community health centers,
school-based clinics, and municipal clinics. This system of care is
inadequate to effectively deal with the magnitude of the problem.
Additionally, charity dental care provided by dentists cannot solve
the problem. Each year, ADIs eagerly join with dentists in the
community and others to participate in Give Kids a Smile Day, a
national initiative by the American Dental Association to focus
attention on the epidemic of untreated oral disease among disadvantaged
children. The 5th annual Give Kids A Smile Day held on February 1, 2007
provided care to 751,000 children at more than 2,000 locations across
the country. Approximately $72 million in dentistry was provided at no
charge to patients. Taking part were 14,315 volunteer dentists and
38,000 others including dental school faculty and students. While this
event is noteworthy for all care it provides, it is not a cure for the
problem. State dental societies regularly organize Missions of Mercy in
which thousands of people receive free care in temporary dental
``hospitals'' and about 74 percent of dentists routinely provide free
or discounted care to people who otherwise could not afford it. Charity
has exceeded $1.5 billion annually. \12\
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\12\ American Dental Association, ``Insuring Bright Futures:
Improving Access to Dental Care and Providing a Healthy State for
Children'' statement to Energy and Commerce Committee hearing March 27,
2007.
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While dental care demands are higher than many other health care
demands, many people in the United States do not receive basic
preventive dental services and treatment. Most oral diseases are
preventable if detected and treated promptly. Preventative care is
essential to contain costs associated with oral health care treatment
and delivery. Children who have early preventive dental care are more
likely to continue using preventive services. Those who wait to visit a
dentist are more likely to visit for a costly oral health problem or
emergency.
access to care and academic dental institutions
U.S. academic dental institutions are the fundamental underpinning
of the Nation's oral health. As educational institutions, dental
schools, allied dental education, and advanced dental education
programs are the source of a qualified workforce, influencing both the
number and type of oral health providers. U.S. academic dental
institutions play an essential role in conducting research and
educating and training the future oral health workforce. All U.S.
dental schools operate dental clinics and most have affiliated
satellite clinics where preventative and comprehensive oral health care
is provided as part of the educational mission. All dental residency
training programs provide care to patients through dental school
clinics or hospital-based clinics. Additionally, all dental hygiene
programs operate on-campus dental clinics where classic preventive oral
health care (cleaning, radiographs, fluoride, sealants, nutritional and
oral health instruction) can be provided 4-5 days per week under the
supervision of a dentist. All care provided is supervised by licensed
dentists as is required by State practice acts. All dental hygiene
programs have established relationships with practicing dentists in the
community for referral of patients.
As safety net providers, ADIs are the dental home to a broad array
of vulnerable and underserved low-income patient populations including
racially and ethnically diverse patients, elderly and homebound
individuals; migrants; mentally, medically or physically disabled
individuals; institutionalized individuals; HIV/AIDS patients; Medicaid
and State Children's Health Insurance Program (SCHIP) children and
uninsured individuals. These dental clinics serve as a key referral
resource for specialty dental services not generally accessible to
Medicaid, SCHIP, and other low-income uninsured patients. ADIs provide
care at reduced fees and millions of dollars of uncompensated care is
provided each year.
no professors--no profession: strains on academic dentistry
The math is simple on this equation. There is an increasing need
and demand for dental care. There is a current shortage of dental
faculty to educate and train the future dental workforce. Several new
dental schools are scheduled to open across the country to meet
individual State workforce and access needs. We face a crisis if
resources are not dedicated to help recruit and retain faculty for the
Nation's dental schools.
The number of vacant budgeted faculty positions at U.S. dental
schools increased throughout the 1990s, with a peak of 358 positions in
2000. Following this peak, the number of vacancies declined, falling to
275 in 2004-2005. Since that time, there has been a rapid increase in
the number of estimated vacancies, reaching 417 in 2005-2006, falling
slightly to 406 in 2006-2007. Competition for this scarce resource of
faculty will be exacerbated by the opening of new academic dental
institutions across the country.
At the present time there are 57 U.S. dental schools in 34 States,
the District of Columbia and Puerto Rico. There are 714 dental
residency training programs located in 44 States, the District of
Columbia and Puerto Rico. There are 285 dental hygiene programs in all
50 States and the District of Columbia, 271 dental assisting programs
located in 47 States and Puerto Rico and 21 accredited dental
laboratory technology programs located in 21 States.
Growing demand for dental care in certain areas of the country has
precipitated the opening of seven new dental schools. In 2003 the
Arizona School of Health Sciences, the University of Nevada Las Vegas
in 2002, and the Nova Southeastern University in Florida in 1997.
Midwestern University in Glendale, AZ will open a dental school in
August 2008 with an enrollment of 100 students per class. The dental
school is part of Midwestern's expansion plan to address the State of
Arizona's health care workforce shortages. Western University of Health
Sciences in Pomona, CA plans to open a dental school in 2009. The
University is in the preliminary phase of the accreditation process.
The North Carolina State legislature plans to open a dental school at
East Carolina University in Greenville, NC to focus on rural dentistry.
The school plans to operate 10 student dental clinics in underserved
communities throughout the State enrolling 50 students per class. Very
recently New Mexico Governor Bill Richardson included funding in his
fiscal year 2009 budget for construction of a facility at the
University of New Mexico for a dental residency program and to begin
planning for a new dental school.
academic dental institutions and research
Oral health is an important, vital part of health throughout life,
and through dental research and education, we can enhance the quality
and scope of oral health. Despite tremendous improvements in the
Nation's oral health over the past decades, the benefits have not been
equally shared by millions of low-income and underserved Americans.
Dental research, the underpinning of the profession of dentistry, is
needed to identify the factors that determine disparities in oral
health and disease. Translational and clinical research is underway to
analyze the prevalence, etiology, and impact of oral conditions on
disadvantaged and underserved populations and on the systemic health of
these populations. In addition, community- and practice-based
disparities research, funded by the National Institute of Dental and
Craniofacial Research (NIDCR) and the Centers for Disease Control and
Prevention's Oral Health Programs, can help to identify and reduce
risks, enhance oral health-promoting behaviors, and help integrate
research findings directly into oral health care practice.
applications, diversity and the dental pipeline
Interest in the dental profession remains high and competition for
first-year positions is robust. The application cycle for 2008 is still
in process, but it appears that applicant to enrollee ratio is about
3:1. The number of applicants increased from 4,644 in 1960 to 15,734 in
1975, a dramatic increase of 239 percent. A precipitous decline
followed that peak, falling to 4,996 in 1989. Applicants increased 97
percent between 1989 and 1997, to 9,829; falling again over the last 2
years to 9,010. First-year enrollments varied less during these time
periods, increasing 76 percent between 1960 and 1978, from 3,573 to
6,301. First-year enrollments declined then through 1989 to 3,979.
Since 1989, first-year enrollment has increased nearly 20 percent.
The number of African-American, Hispanic, and Native American
students in dental schools remains disproportionate to their numbers in
the U.S. population. In 2006, underrepresented minority (URM) students
comprised 12.4 percent of the applicants and 11.6 percent of first-year
enrollees. Asian/Pacific Islanders and whites comprised 69.7 percent of
applicants and 71.1 percent of first-year enrollees. The proportion of
URM applying and enrolling in U.S. dental schools is far less than the
proportion of URM in the communities served by the dental school. For
example, during the 2003-2004 academic year, 7 percent of dental
students enrolled at the University of California Los Angeles and the
University of Southern California were Hispanic, while 46.5 percent of
the Los Angeles population were Hispanic. Also in 2003-2004, total
African-American enrollment at all U.S. dental schools was 5.41
percent, while 12.8 percent of the U.S. population were black. The
proportion of URM dentists also remains significantly lower than the
proportion of URM in the U.S. population. Currently, about 6.8 percent
of professionally active dentists are URM, while 27.9 percent of the
U.S. population are URM.
Increasing diversity in the dental profession is vital to the
future of the profession and it is central to achieving optimal oral
health for racial and ethnic minority groups, which experience a higher
level of oral health problems and have limited access to dental care.
Recognizing that enrollment of underrepresented minorities (URM) had
remained largely stagnant, ADEA has become actively engaged in
supporting programs that bolster underrepresented minority recruitment
and retention into dentistry and partnered with foundations and others
to make headway:
The ``Pipeline, Profession, and Practice: Community-Based
Dental Education'' program sponsored by the Robert Wood Johnson
Foundation (RWJF). This program has also been supported by the
California Endowment and the W.K. Kellogg Foundation. The 5-year
initiative launched in 2003 was to help increase access to oral health
care. This program provided institutions with grants to link their
schools to communities in need of dental care and to boost their URM
and low-income (LI) student enrollment numbers. Dental Pipeline I
successfully concluded with 15 dental schools participating. Dental
students and residents in the program provided care to thousands of
low-income patients through partnerships with 237 community-based
clinics. The success of the first Pipeline has spurred the RWJF and the
California Endowment to continue the program with Pipeline II, adding a
mentoring portion to the curriculum. Awards will soon be announced.
The ``Summer Medical and Dental Education Program
(SMDEP)'' is a collaborative program administered by ADEA and the
Association of American Medical Colleges and funded by the Robert Wood
Johnson Foundation-RWJF. The program will run from summer 2006 through
summer 2009 and offer academic enrichment for disadvantaged
undergraduate freshmen/sophomores. The curriculum includes classes in
organic chemistry, physics, biology and pre-calculus/calculus. Students
gain learning and communication skills; get exposure to medicine and
dentistry issues and get clinical exposure. Finally, students have a
financial planning workshop to learn about financial strategies and
issues. Nearly 1,900 students have participated (333 dental and 1,564
medical). Seventy-one percent of the participants have been women, 48
percent have been Black or African-American, 21 percent have been
Hispanic or Latino, and two percent have been American Indian.
ADEA has received a grant from the Josiah Macy, Jr.
Foundation to increase the diversity of the dental workforce in the
United States. ADEA is serving as the host organization and
coordinating committee of the program entitled Moving Forward: Bridging
the Gap. The grant funds the planning process to implement a flexible
7-year dental curriculum, modeled after one currently used in medicine,
to prepare a new cadre of underrepresented minority and low-income
(URM/LI) students for the practice of dentistry. The program aims to
move toward the implementation of a 7-year curriculum that will
significantly increase the number of URM students that receive a dental
education and then enter the workforce as dental school graduates.
recommendations to address dental workforce challenges
There are several straightforward steps that Congress can take to
immediately address the challenges we face. The answer lies in
prioritizing resources both in terms of manpower and funding to tackle
these challenges. Some are fairly simple and pragmatic while others,
admittedly, will require coordination among multiple interested parties
and compromise. ADEA stands ready to work with Congress and our
colleagues in the dental community to ameliorate the access to dental
care problems the Nation faces and to meet the needs for the future
dental workforce. Specifically, we recommend:
1. Strengthen and Improve Medicaid
Early intervention is the key to assuring that children have good
oral health. While children enrolled in Medicaid have a Federal
guarantee for access to dental services through the Early Periodic
Screening Diagnosis and Treatment program (EPSDT),\13\ accessing
services is often difficult due to low reimbursement rates and the
number of participating dentists. Other barriers include a lack of
community-based oral health projects and public outreach. Unfortunately
millions of children covered by Medicaid are not getting regular dental
care. Many dentists decline Medicaid patients because of low
reimbursement levels and complain about Medicaid paperwork. We urge
Congress to work with States to increase reimbursement rates and to
simplify and streamline the application, enrollment and recertification
process for Medicaid, and lessen the administrative burden associated
with this program. These actions would significantly increase access to
care for children insured by Medicaid.
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\13\ Medicaid statutes, P.L. 101-239, Section 6403, require that
dental services for children shall at a minimum, include relief of pain
and infection, restoration of teeth, and maintenance of dental health.
Medicaid guarantees medically necessary services, including preventive
dental care, under its EPSDT provision.
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Children covered by Medicaid have access to excellent care.
Medicaid regulations \14\ define dental as diagnostic, preventive, or
corrective procedures provided by or under the supervision of a dentist
in the practice of his or her profession, including treatment of: (1)
the teeth and associated structures of the oral cavity and (2) disease,
injury or impairment that may affect the oral or general health of the
recipient.
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\14\ 42 CFR 440.100.
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2. Include Dental Guarantee in SCHIP
Congress can improve the Nation's oral health and increase access
to dental care for vulnerable children covered by the State Children's
Health Insurance Program (SCHIP) by: (1) Establishing a Federal
guarantee for dental coverage in SCHIP; (2) Developing a dental wrap-
around benefit in SCHIP; (3) Facilitating ongoing outreach efforts to
enroll all eligible children in SCHIP and Medicaid; and (4) Ensuring
reliable data reporting on dental care in SCHIP and Medicaid. These
objectives are supported by ADEA and the entire dental community and
were strongly advocated during the recent congressional action on the
Children's Health and Medicare Protection Act (H.R. 3162--CHAMP Act).
Presently dental coverage is an optional benefit in SCHIP. Dental
care sits atop the list of parent-reported unmet needs. For children
with special needs dental care is the most prevalent unmet health care
need surpassing mental health, home health, and all other services.
Dental coverage is often the first benefit cut when States seek
budgetary savings. SCHIP lacks a stable and consistent dental benefit
that would provide a comprehensive approach to children's health while
reducing costly treatments caused from advanced dental disease.
Congress can help stabilize access to oral health care services by
improving funding for the SCHIP program.
3. Establish Dental Homes for Everyone
Ideally everyone should have a continuous and accessible source of
oral health care--a dental home--established early in childhood and
maintained throughout one's life. Having an established dental home
makes oral health care accessible, continuous, comprehensive,
coordinated, compassionate, and culturally effective. The dental home
should be able to provide the following: (1) An accurate risk
assessment for oral diseases and conditions; (2) An individualized
preventive dental health program based on risk assessment; (3)
Anticipatory guidance about growth and development issues; (4) A plan
for emergency dental trauma; (5) Information about proper care of
patients', infants' or children's teeth and soft tissues; (6)
Information about proper nutrition and dietary practices; (7)
Comprehensive dental care in accordance with accepted guidelines and
periodicity schedules for general and pediatric dental health; and (8)
Referrals to other dental specialists when care cannot be provided
directly within the dental home.
4. Reauthorize and Fund the Dental Health Improvement Act
The Dental Health Improvement Act (DHIA), championed by Senators
Susan Collins and Russ Feingold, is up for reauthorization. The program
assists States in developing innovative dental workforce programs. The
first grants were awarded to States last Fall 2006 and are being used
to increase hours of operation at clinics caring for underserved
populations, to recruit and retain dentists to work in these clinics,
for prevention programs including water fluoridation, dental sealants,
nutritional counseling, and augmenting the State dental offices to
coordinate oral health and access issues. Eighteen States were among
the inaugural cohort awarded.
5. Establish a Dental Disproportionate Share (DDS) Program
The capacity of ADI clinics to meet the needs of publicly insured
and uninsured patients is compromised by inadequate payments from
Medicaid and other Federal and State programs which threaten their
financial viability as critical dental safety net providers. ADEA urges
Congress to establish a Medicaid allotment for each State and territory
that would be distributed in quarterly payments to qualified dental
clinics operated directly by ADIs or those with an affiliation
agreement with an ADI. Federal payments made to qualified clinics
should require State matching funds. Qualified dental clinics would be
required to have a pediatric Medicaid, SCHIP, and uninsured dental
patient load equal to or more than a specified threshold compared to
the total of their pediatric patients. Payments from the allotment
would be based on a specified percentage of Medicaid payments for
children's dental services in the previous quarter. ADEA is eager to
explore this proposal with the committee.
6. Pass Deamonte's Law, H.R. 2371
This legislation would authorize $10 million for two pilot programs
that would greatly assist academic dental institutions and community
health centers to address access issues. The bill calls for $5 million
for grants to accredited dental education programs to support training
that enhances and strengthens skills of dental students, dental
residents and dental hygiene students in the provision of oral health
care to children. Funding could be used to support continuing education
for practicing dentists and dental hygienists in pediatric dentistry.
Additionally, the bill would authorize $5 million for grants to
federally qualified community health centers (CHC) to increase access
to oral health care for patients seeking treatment. Funding could be
used to hire dentists, purchase of dental equipment and construction of
dental facilities. Also, funding could be used to support contractual
relationships between CHCs and surrounding private practice dentists.
7. Pass the Essential Oral Health Act, H.R. 2472
The legislation aims to improve the delivery of dental services
through a variety of measures. It would provide each State an option to
accept an increase in its Federal Medical Assistance Percentage rate
for its dental Medicaid and SCHIP programs provided certain access to
care provisions are met. States that increase the percentage of plan
users and participating dentists will continue to receive the enhanced
match. It would authorize grants to pilot the Community Dental Health
Coordinator (CDHC) position which will work in underserved communities,
in collaboration with health and community organizations and schools to
provide community-focused oral health promotion. The CDHC will also
connect residents with limited dental care access to dentists. The bill
would authorize grants for volunteer dental programs by community-based
organizations, State dental associations, dental schools, and hospitals
with postdoctoral dental education programs to provide free dental care
to underserved populations. Finally, the legislation would encourage
dentists to provide additional donated dental services by providing a
$5,000 tax credit for free and discounted services provided.
8. Pass the Special Care Dentistry Act
This legislation introduced in previous Congresses aims to provide
dental care to the most vulnerable citizens, poor children, aged, blind
and disabled. This includes developmentally disabled and mentally
retarded, disabled, the aged frail elderly and medically compromised
elderly as well as medically compromised patients. Across the country
there are approximately 31 million such patients. The bill would permit
flexibility for States allowing them to either make provision for
special care dentistry coverage through a State's existing EPSDT
program or by creating a separate program for Aged, Blind or Disabled
Adults.
9. Restore Dental Graduate Medical Education for Programs in Non-
Hospital
Settings
Congress should bolster support for dental residency training in
both hospitals and non-hospital sites through Medicare Graduate Medical
Education (GME). While all medical residency training positions are
supported by Medicare GME only some dental residencies are. No dentist
may practice a specialty without having first successfully completed
residency training. The current number of positions and funding is
woefully insufficient for all dental graduates to participate in a year
of service and learning in an accredited program. ADEA encourages
dental graduates to pursue postdoctoral dental education in either
general dentistry, advanced dental education program or a dental
specialty. To accommodate advanced education in general dentistry and
specialties additional supported training positions are needed. Meeting
this challenge would help to strengthen the dental workforce and would
help provide access to care.
10. Make Dentistry Eligible for Title VII Administrative Academic
Units, Predoctoral Training, Faculty Development
At the present time academic dental institutions are ineligible to
compete for three important programs within the title VII primary care
medicine and dentistry cluster; namely the Academic Administrative
Units in Primary Care (AAU), Faculty Development in Primary Care (FD),
and Predoctoral Training (PDTP) Programs. Congress should broaden
eligibility to include dentistry and increase funding to accommodate
this eligibility. In its November 2001 report to Congress, the HRSA
Advisory Committee on Training in Primary Care Medicine and Dentistry
(ACTPCMD) also recommended this modification.
Academic Administrative Units in Primary Care grants
establish and improve primary care units so that they are equal to
other departments or divisions in the medical school. Resources may be
used to enhance the ability of the primary care unit to significantly
expand their primary care mission in teaching, research and faculty
development. ADEA suggests general and pediatric dentistry and dental
public health units be added within the dental school.
Faculty Development in Primary Care grants help to plan,
develop, and operate programs, and pay stipends, for training of
physicians who plan to teach in family medicine, general internal
medicine and general pediatrics training programs. Four grant types:
Type I Primary Care Clinician Researchers; Type II Primary Care Master
Educators; Type III Primary Care Community Faculty Leaders; and Type IV
Community Preceptors. ADEA suggests training for dentists who plan to
teach in general and pediatric dentistry and public health dentistry be
added.
The Predoctoral Training grants help to plan, develop, and
operate or participate in predoctoral programs in family medicine,
general internal medicine and general pediatrics. ADEA suggests that
both general and pediatric dentistry and public health dentistry be
added.
11. Maintain Support for Title VII General and Pediatric Dentistry
Support for title VII programs is essential to expanding existing
or establishing new general dentistry and pediatric dentistry residency
programs. Title VII general and pediatric dental residency training
programs have shown to be effective in increasing access to care and
enhancing dentists' expertise and clinical experiences to deliver a
wide range of oral health services to a broad patient pool, including
geriatric, pediatric, medically compromised patients, and special needs
patients. Title VII support increases access to care for Medicaid and
SCHIP populations. The value of these programs is underscored by
reports of the Advisory Committee on Training in Primary Care Medicine
and Dentistry and the Institute of Medicine. Without adequate funding
for general dentistry and pediatric dentistry training programs it is
anticipated that access to dental care for underserved populations will
worsen.
General Dentistry and Pediatric Dentistry Residency Training
programs are essential to building and the primary care dental
workforce are effective in increasing access to care for vulnerable
populations including patients with developmental disabilities,
children and geriatric patients. These programs are safety net
providers of oral health care and generally include outpatient and
inpatient care and afford residents with an excellent opportunity to
learn and practice all phases of dentistry including trauma and
emergency care, comprehensive ambulatory dental care for adults and
children under the direction of experienced and accomplished
practitioners.
12. Restore Funding for Title VII Diversity Programs
The only Federal programs whose goal it is to strengthen and
diversify the health professions are the Title VII Centers of
Excellence (COE) and Health Careers Opportunity Program (HCOP). These
programs work in diverse communities to achieve this national goal.
After several years of cuts to these programs saw small increases;
however, they remain woefully underfunded. Congress should restore
their funding to fiscal year 2005 levels.
Table 4.--COE and HCOP Funding by Fiscal Year (FY)
[In millions of dollars]
------------------------------------------------------------------------
FY 2005 FY 2006 FY 2007 FY 2008
------------------------------------------------------------------------
COE................................. $35 $12 $11.88 $12.77
HCOP................................ 33 4 3.9 9.8
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These programs assist institutions in developing a more diverse
applicant pool, establishing and strengthening the academic performance
of under-represented minority students enrolled in health professions
schools, improving institutional academic, research and library
capacity, and enhancing pipeline efforts to undergraduate and pre-
college students. Also, HCOP makes grants to community-based health and
educational entities to support student pipeline and other academic
activities.
13. Limit Graduating Student Loan Debt Is Key to Access and Career
Choice
Students are graduating from dental school with increasing amounts
of educational debt. In 2007 the average for all graduates with debt
averaged $172,627, those graduating from a public school averaged
$148,777 while those graduating from private/State-related schools
averaged $206,956. This level of debt places a great deal of pressure
on new dentists. Many new graduates who wish to further their education
in a specialty or general dentistry forgo the option. New dentists who
might otherwise choose a career in the U.S. Public Health Service or
Armed Forces shun the option. By virtue of the staggering debt new
dentists have upon graduating, many seek practice opportunities in
relatively affluent areas where they are likely to earn higher
salaries. This cycle has repeated itself year after year leaving
underserved areas chronically understaffed. Congress can alleviate the
debt burden new dentists face upon graduating by doing the following:
1. Restore nearly $50 million taken through rescissions from the
title VII and VIII revolving health professions student loan programs
\15\. These low-interest loan programs designed and authorized by
Congress to address shortages in the health professions workforce help
limit borrowing from higher cost private loan programs. No Federal
funds are required to maintain these programs and they receive no
annual appropriation, thereby posing no burden on taxpayers. They are
funded with the interest from student/graduate repayment, creating a
self-sustaining revolving fund designed by Congress to address
shortages in the health professions workforce.
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\15\ As part of the Labor-HHS-Education Appropriations for FY 2005
and FY 2006, Congress rescinded the ``unobligated balances'' from the
title VII and VIII student loan programs. Consequently, HRSA returned
$21 million to the U.S. treasury in 2005 and $26.5 million in 2006.
HRSA administers the loan programs authorized under Titles VII and VIII
of the Public Health Service Act: (1) the Health Professions Student
Loan (HPSL) program awards funds to accredited schools of dentistry,
optometry, pharmacy, podiatric medicine, and veterinary medicine; (2)
The Loans for Disadvantaged Students (LDS) program awards funds to HPSL
and Primary Care Loan eligible students who are from a disadvantaged
background as defined by HHS; (3) The Primary Care Loan (PCL) program
awards funds to accredited schools of allopathic and osteopathic
medicine for medical students who agree to enter and complete residency
training in primary care within 4 years after graduation and practice
in primary care for the life of the loan; and (4) The Nursing Student
Loan (NSL) program awards funds to accredited schools of nursing under
title VIII.
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2. Increase the aggregate unsubsidized Stafford Loan limits \16\
that dental and medical students use. The current annual cap is $38,500
while the aggregate is limited to $189,125. The cap forces dental and
medical students into less favorable loan options such as the GradPLUS
or private student loans. This needlessly drives up graduating debt.
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\16\ The aggregate combined Stafford Loan limit for health
professions should be adjusted to reflect the annual unsubsidized
Stafford Loan limits. The aggregate combined Stafford Loan limit for
health professions students has remained stagnant for over a decade,
does not account for increases in annual unsubsidized Stafford Loan
limits or reflect programs of different duration, and is not defined in
regulation. The ``Deficit Reduction Act of 2005'' (DRA) increased the
annual unsubsidized Stafford Loan limit for graduate/professional
students from $10,000 to $12,000 (effective July 1, 2007). This
increased the annual combined Stafford Loan limit from $18,500 to
$20,500. Certain health professions students in 9-month and 12-month
programs are eligible for an additional $20,000 and $26,667 in
unsubsidized Stafford Loans per year, respectively. The current
aggregate combined Stafford Loan limit for health professions is
$189,125. The justification for this figure is defined in the Federal
Student Aid handbook as: This increased aggregate loan limit would
permit a student to receive the current maximum Stafford annual loan
limits for 4 years of undergraduate study ($6,625 + $7,500 + $10,500 +
$10,500) and 4 years of graduate/professional study ($18,500 x 4), plus
the maximum increased unsubsidized loan limit for an academic year
covering 9 months for 4 years of graduate/professional study ($20,000 x
4). However, this current aggregate limit does not reflect the
increased annual unsubsidized loan limits mandated by the DRA nor does
it recognize the annual increases allowed for health professions
students in 12-month programs.
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3. Congress should immediately and permanently restore the Economic
Hardship Deferment option that was eliminated when Congress passed the
College Cost Reduction and Access Act.\17\
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\17\ On September 27, 2007, President Bush signed the ``College
Cost Reduction and Access Act'' (CCRAA, H.R. 2669, H. Rpt. 110-317).
The measure included a change to the definition of economic hardship
deferment, which has the potential to eliminate the pathway that most
hospital-based dental residents as well as most medical residents use
to qualify for the program. CCRAA changed the definition of economic
hardship deferment. The new definition does not include the debt-to-
income pathway, which is the most common means by which hospital-based
dental residents and most medical residents obtained eligibility. Under
the new definition, a borrower's income cannot exceed the greater of
either the minimum wage rate or 150 percent of the poverty line
applicable to the borrower's family size. For an independent single
student the maximum qualifying monthly income will be $1,276.
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14. Increase Access for Native American and Alaska Native Populations
Congress should increase the award size for the Indian Health
Service (IHS) loan repayment program and make both the loan repayment
and the IHS scholarship programs tax free. By taking this action
Congress would help to boost the number of dentists and other health
care providers in Indian country. Eliminating taxation of IHS
scholarship and loan repayment programs would be equivalent to
increasing the programs' appropriations substantially without costing
any additional money. Equalizing the programs will enhance the IHS
competitiveness for health care providers seeking loan repayment in
exchange for service in eligible sites. The current playing field
between IHS and the National Health Service Corps and Department of
Defense scholarship and loan repayment programs \18\ are not
competitive. Also, unlike other Federal scholarship and loan repayment
programs, IHS scholarship stipends are subject to income and FICA
taxation so the IHS pays up to 20 percent of Federal taxes directly to
the Internal Revenue Service (IRS). As a result in fiscal year 2006 IHS
withheld 27.65 percent of each scholarship recipient's stipend to pay
taxes. An additional 7.65 percent of the IHS contribution to the FICA
tax also comes from the scholarship program funds. IHS had to use $2.3
million (17.5 percent) of its fiscal year 2006 appropriation to pay
taxes rather than award scholarships to deserving NA/IA health
professions students.
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\18\ P.L. 107-16, Section 413, the Economic Growth and Tax Relief
Reconciliation Act of 2001, which provides for the scholarship
programs, and P.L. 108-357, Section 320, the American Jobs Creation Act
of 2004, provides for the loan repayment programs.
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15. Prioritize Dental Access in Rural Health Clinics
Delivery of health care in rural America is changing rapidly;
however, one thing remains constant: rural communities across America
rely on rural health clinics to provide care to everyone including
those who are uninsured or underinsured. Full-service community
hospitals in rural areas are safety net providers providing basic
health services but often oral health care is unavailable. To improve
the oral health status of rural America, Congress should incentive
rural health clinics to add preventive and restorative dental services
to the list of core services they provide on-site or under arrangement.
16. Increase Funding for Dental and Craniofacial Research and
Disparities Research
Funding for dental research must be both reliable and increased.
Oral health researchers funded by the National Institute of Dental and
Craniofacial Research (NIDCR) have built a base of scientific and
clinical knowledge that has been used to improve oral health. NIDCR is
the only Institute within the NIH that is committed to oral health
research and training. Institute-sponsored research continues to link
oral infection to such systemic diseases as diabetes, cardiovascular
disease (heart attack and stroke) and adverse pregnancy outcomes (pre-
term birth and low-birth weight). Dental research is advancing
investigations in bone formation and craniofacial development,
treatment of facial pain, salivary gland disorders. The Institute
remains the primary public agency that supports dental behavioral,
biomedical, clinical, and translational research. Research is needed to
identify the factors that determine disparities in oral health and
disease. These factors may include proteomic, genetic, environmental,
social, and behavioral aspects and how they influence oral health
singly or in combination. Translational and clinical research is
underway to analyze the prevalence, etiology, and impact of oral
conditions on disadvantaged and underserved populations and on the
systemic health of these populations. In addition, community- and
practice-based disparities research, funded by the NIDCR and the
Centers for Disease Control and Prevention's Oral Health Programs, can
help to identify and reduce risks, enhance oral health-promoting
behaviors, and help integrate research findings directly into oral
health care practice.
17. Bolster Prevention to Eradicate Dental Caries
Congress could make great strides in reducing dental caries if they
focused on preventive strategies that can save millions of dollars. The
cost of providing restorative treatment is much higher than providing
preventive services. Among the most immediate and effective strategies
would be to establish a national water fluoridation standard. This is
the best and safest public health measure to prevent dental disease.
The CDC reports that approximately one-third of Americans lack access
to a community fluoridated water supply. Other strategies to reduce
dental caries include: (1) applying pit and fissure sealants (plastic
coating that are applied to the grooves and fissures of primary and
permanent teeth) to patients at high-risk for dental caries. Only 18.5
percent of children have at least one sealed tooth. A nationally based
dental sealant program in the public schools is an ideal way to deliver
cost-effective services to children; (2) increasing dietary and hygiene
counseling for patients at high-risk for dental caries; and (3)
professionally applying topical fluoride 1-2 times annually for
patients at high-risk for dental caries.
The Centers for Disease Control and Prevention (CDC) found that
delivering sealants to all children attending low-income schools was
the most cost-effective strategy in significantly reducing as child's
risk of having untreated dental disease. Combining oral health
promotion and education with prevention strategies will improve the
oral health of children who are at a higher risk for dental disease.
Almost as importantly, these programs save money. Delta Dental, a
private dental insurer estimates that preventive care, early detection,
and treatment of oral health conditions save $4 billion annually in the
United States. According to the Children's Dental Health Project,
dental costs for children who receive preventative dental care early in
life are 40 percent lower than costs for children whose oral health is
neglected. The American Dental Hygienists Association estimates that
for every $1 spent on prevention in oral health care, $8 to $50 are
saved on restorative and emergency dental procedures.
18. Adequately Fund the Centers for Disease Control and Prevention
(CDC) Division of Oral Health
Congress should continue to support this important program. The
Centers for Disease Control and Prevention Oral Health Program expands
the coverage of effective prevention programs by building basic
capacity of State oral health programs to accurately assess the needs
in their State, organize and evaluate prevention programs, develop
coalitions, address oral health in State health plans, and effect
allocation of resources to the programs. CDC's funding and technical
assistance to States is essential to help oral health programs build
capacity.
conclusion
In conclusion, I thank the committee for considering ADEA's
recommendations with regard to addressing access to dental care and
dental workforce issues. A sustained Federal commitment is needed to
meet the challenges oral disease poses to our Nation's citizens
including children, the vulnerable and disadvantaged. Congress must
address the growing needs in educating and training the oral health
care and health professions workforce to meet the growing and diverse
needs of the future. ADEA stands ready to partner with you to develop
and implement a national oral health plan that guarantees access to
dental care for everyone, eliminates oral health disparities, bolsters
the Nation's oral health infrastructure, eliminates academic and dental
workforce shortages, and ensures continued dental health research. I am
happy to answer any questions you may have.
Senator Sanders. Dr. Swift, thank you very much.
Bruce Auerbach, M.D., is President-Elect, Massachusetts
Medical Society, Vice President and Chief of Emergency Medicine
at Sturdy Memorial Hospital in Attleboro, MA. Dr. Auerbach,
thanks very much.
STATEMENT OF BRUCE AUERBACH, M.D., PRESIDENT-ELECT,
MASSACHUSETTS MEDICAL SOCIETY, VICE PRESIDENT AND CHIEF OF
EMERGENCY MEDICINE, STURDY MEMORIAL HOSPITAL, ATTLEBORO, MA
Dr. Auerbach. Thank you, Senator Sanders and members of the
committee, for allowing us to be here and participate in this
very important hearing.
We are all in agreement today that unless we take the
necessary steps to increase the number of physicians,
particularly those going into primary care, our goal to
increase access to quality healthcare and reduce costs will
fail.
As Senator Sanders mentioned earlier, even if we
instantaneously snapped our fingers and had universal
healthcare tomorrow, that would not solve the access problem.
The experiment that we are doing in Massachusetts proves that.
We are adding hundreds of thousands of residents that were
previously uninsured into the system. It has really not done
anything except worsen the primary care shortage or the
perception of the primary care shortage.
The Massachusetts Medical Society has chronicled for
several years the deterioration in the workforce in
Massachusetts. During the last 2 years, we experienced for the
first time critical shortages to severe shortages in primary
care. Primary care physicians have a unique role in managing
and coordinating care. When you consider that all of the
national studies have shown that the healthcare systems that
provide the best and lowest cost care to those with the most,
are those with the most robust primary care systems, the
imperative is clear.
I would like to make three main points that, hopefully, we
will discuss more fully. National and State data confirm that
we are in or at least on the verge of a primary care crisis.
The critical role of these physicians in providing cost-
effective quality care is without dispute. The key focus of
much of our work in Massachusetts, as we implement our new
State law, is to correct this issue.
Second, the title VII program is one of the only federally
funded programs designed specifically to increase the number of
primary care providers, particularly in underserved areas. Our
experience in Massachusetts, confirmed by national data, shows
that these dollars have been very effective in training
physicians who continue to practice in community health centers
and underserved areas. It is essential that title VII be
reauthorized and well funded.
There are several steps the Federal Government could take
to address these issues and two I would like to highlight.
First, a more accurate count of full-time practicing
physicians. Current databases rely on the number of medical
licenses and misrepresent the number of physicians taking care
of patients full time. Second, we need to have a focus on
medical student debt relief and other financial incentives for
physicians--or students who pursue primary care.
I thank you very much and I'm looking forward to working
with you on this issue.
[The prepared statement of Dr. Auerbach follows:]
Prepared Statement of Bruce Auerbach, M.D.
Good Morning. I am Dr. Bruce Auerbach, President-Elect of the
Massachusetts Medical Society and Vice President and Chief of Emergency
and Ambulatory Services at Sturdy Memorial Hospital in Attleboro, MA.
It is my distinct pleasure to represent the Massachusetts Medical
Society at today's hearing on the ``Health Care Workforce Shortages for
the Future'' and reauthorization of Title VII of the Public Health
Services Act. The Massachusetts Medical Society represents over 19,000
physicians, students and residents and is dedicated to improving the
health and welfare of the residents of the Commonwealth.
At the outset I want to emphasize the fundamental importance of the
title VII program and why we at the Massachusetts Medical Society
believe these programs are imperative to achieve our overall goal of
universal access to quality health care for all Americans. The title
VII program is one of only two federally funded programs specifically
designed to increase the number of primary care physicians and
providers, particularly in underserved areas. The importance of the
primary care physician in the medical home is without dispute. There is
strong evidence to demonstrate the effectiveness of physicians who
provide first contact, comprehensive, longitudinal care, and
coordination of care. Countries with strong primary care systems have
lower health care costs than those with weaker primary care systems. In
this Nation we know that States with more primary care resources tend
to mirror these lower costs and have better health care outcomes.
And yet at a time when health care reform is a priority on national
and State agendas, and efforts to increase access to care are
intensifying, we face burgeoning shortages of physicians, including
primary care physicians. The American College of Physicians recently
warned that ``primary care, the backbone of the Nation's health care
system, is at grave risk of collapse.'' (Bodenheimer, ``Primary Care--
Will It Survive? NEJM August 31, 2006) (Appendix I) It is a fundamental
truth--which we are learning the hard way in Massachusetts--
comprehensive health care reform cannot work without appropriate access
to primary care physicians and providers. In this context it is clear
that the need for title VII funds is perhaps even greater than when the
program was originally conceived. When you consider that all the
national studies have shown that the health care systems providing the
best and lowest cost care to their populations are those with the most
robust primary care systems, the imperative is clear.
My testimony today will focus on three areas: (1) outlining the
primary care crisis in Massachusetts and our efforts to address this
problem; (2) review the successes and history of title VII programs and
the impact on primary care, including community health centers; and (3)
share our recommendations for title VII and related programs.
i. primary care crisis--massachusetts perspective
For nearly a decade the Massachusetts Medical Society has
systematically studied and documented changes in our physician
workforce and medical practice environment. The need for this data was
clear. While our physicians and patients reported increasing stresses
to the system, others maintained that the Commonwealth suffered from an
oversupply of physicians. To this end the Massachusetts Medical
Society, in consultation with outside consultants, initiated two annual
studies that profile changes in the medical practice environment and
physician workforce.
The first of these two studies, the Physician Practice Environment
Index report (Appendix II) was first published in 1997 and is a
statistical indicator of nine selected factors that impact the delivery
of patient care in Massachusetts and the United States. The indicators
are as follows:
1. Applications to medical schools,
2. Percent of physicians over 55 years of age,
3. Median physician income levels,
4. Ratio of median housing prices to median physician income,
5. Mean number of hours spent on patient care activities,
6. Physician cost of doing business,
7. Number of visits per emergency department,
8. Change in average malpractice rates, and
9. Number of advertisements for physician employment in the New
England Journal of Medicine.
This year's report published in April 2007 shows a decline in the
Massachusetts medical practice environment for the 13th consecutive
year. Further, the rate of deterioration in Massachusetts was 26
percent faster than in the United States as a whole over the 14-year
period from 1992-2006. This lengthy deterioration is one principle
cause of accelerating physician shortages and reflects the growing
imbalance between high costs of medical practice relative to a low rate
of reimbursement in a State dominated by managed care. This economic
imbalance is particularly harmful to primary care practices where
revenues are historically proportionally much lower than costs.
The second report, The Massachusetts Medical Society Physician
Workforce Study (Appendix III) was developed with the input of
prominent labor economists and chronicles changes in physicians supply.
In addition to ongoing shortages in several specialties, the 2007
Workforce Report shows severe to critical shortages in primary care for
the second year in a row. The impact of shortages in primary care
physicians is of great concern given the unique role primary care
physicians serve in managing individual patient care.
Among its findings, the study found that in 2006, 53 percent of
patients were able to see primary care physicians within a week of
contacting the physicians. In 2007, however, that rate dropped to 42
percent. Moreover, 17 percent of survey respondents with a serious, but
not life threatening medical problem say the wait for a doctors
appointment was a problem in 2007, an increase of 7 percent from 2006.
Hospitals and physician practices report increasing delays in their
ability to recruit or retain primary care providers. In my own
community, where I am on the Board of the large multispecialty group
practice, the time to recruit primary care physicians has doubled and
tripled in the last 5 years. The impact of the shortages on patients
and physicians ability to provide quality care is multifold. In
addition to significantly longer waiting times, physicians are forced
to see many more patients in less time.
The Massachusetts Medical Society workforce study concluded ``The
task before those concerned about workforce issues is to educate
policymakers about how changes in the physician workforce will affect
cost, access and quality and impress upon them that serious efforts to
promote quality of care and reduce costs will not be effective unless
qualified physicians are there to provide care.'' Taking heed of this
statement is more important than ever as Massachusetts implements
universal health care and attempts to provide affordable insurance to
hundreds of thousands of previously uninsured residents.
These numbers are reflected nationally. The 2006 American Academy
of Family Physicians Workforce study reports that in 2005 there were
31.2 family physicians per 100,000 people in the United States. The
study found that meeting the Nation's anticipated need for primary care
in 2020 will require a workforce of 139,531 family physicians, or a
ratio of 41.6 family physicians per 100,000 people. To achieve the 2020
target, the AAFP concluded that 3,725 family physicians will need to be
produced annually by ACGME-accredited family medicine residencies and
714 annually by AOA-accredited family medicine residencies. As such,
the typical ACGME-accredited family medicine residency would need to
expand from an average of 21.7 residents to 24 residents.
Portending worse shortages for the future, the AAMC reported the
number of family medicine residency positions available in the 2007
Match (2,603) continued to decline this year--100 fewer positions
available than in 2006, and more than 500 fewer than were available in
the 2000 Match. As the following charts dramatically illustrate, the
escalating trend with resident's choices over the past 8 years has been
away from primary care.
It is important to underscore that the impact of shortages in
primary care physicians is exacerbated in terms of their impact on
community health centers. Like most health care providers,
Massachusetts' community health centers are facing staffing shortages
of primary care physicians and non-clinical staff. The Massachusetts
League of Community Health Centers estimates that a total of 100
physicians will be required in the current year to meet the needs of
existing patients as well as newly insured patients seeking care at
community health centers under health care reform. That number is
expected to be the same in each of the next 2 years. At the national
level a 2006 JAMA Article, Shortages of Medical Personnel at Community
Health Centers, concluded that while primary care physicians
constituted 89 percent of physicians working in Community Health
Centers, there were 428 vacant funded full-time equivalent for family
physicians and 376 vacant FTEs for registered nurses. There were
vacancies for 13.3 percent of family physicians positions, 20.8 percent
of obstetrician's gynecologist's positions and 22.6 percent for
psychiatrists. Of particular note, the study concluded that physician
recruitment in CHS was heavily dependent on National Health Service
Corps scholarships, loan repayment programs and international medical
gradates with J-1 visa waivers.
While a number of factors contribute to the primary care shortages,
most agree that rising medical student debt is particularly formidable
to those interested in practicing primary care. The AAMC reports that
in 2006 medical school graduates owed on average about $130,000, with
estimates for Massachusetts medical schools estimated to be about 10
percent higher. This figure is expected to increase as both private and
public institutions face increasing costs in all areas, and
accordingly, must raise tuitions. Median tuition and fees for the
school year ending in 2004 increased 5.7 percent at private schools
over the previous year, and 17.7 percent at public institutions. The
burden of medical school debt, coupled with undergraduate debt,
compounded by interest rates is a significant detriment to primary care
where predicted revenues are 30 percent lower than the mean.
The Massachusetts Medical Society is working on a number of
initiatives to address the primary care shortage and to better
understand factors influencing medical student's decision as to career
choice. The previously referenced NEJM article also noted that it is
generally believed that lifestyle concerns also play a role, as primary
care physicians often experience heavy loads of after hours call with
little or no reimbursement. Furthermore it notes that primary care
physicians typically receive less reimbursement both in terms of
resources and prestige when compared to specialists. On the global
level, it is clear that reimbursement reform for primary care
physicians will be necessary to allow for financial stability for these
practices. In addition to increasing reimbursement, payment methodology
should reflect the nature and value of primary care practices which are
based on cognitive skills, longitudinal management and prevention.
At the State level, the Massachusetts Medical Society is currently
surveying medical students to determine the factors which most
influence their decision in choosing a specialty or primary care. The
Massachusetts Medical Society is also working closely with the State
Commission on Workforce, Secretary of Heath and Human Services Bigby,
and Mayor of the City of Boston Thomas Menino on various task forces
and commission to develop recommendations to address the primary care
problems. The Massachusetts Medical Society supports legislation that
was recently reported out of committee (House Bill 4514) which will
provide loan forgiveness for physicians choosing to practice primary
care. The Medical Society has proposed amendments which are referenced
in my attached testimony (Appendix III). Internally the Medical Society
has convened several internal workgroups to focus on physician's
shortages, primary care shortages and medical student debt relief.
ii. title vii: health professions education assistance act
Since 1978, the Bureau of Health Professions, via section 747 of
title VII, has been a critical source of support for medical education
in primary care. In fact, given the absence of a Center for Primary
Care at the NIH, relatively small and static funding at AHRQ, and
ongoing decreases in Medicare GME reimbursement, Title VII is one of
the only outside sources of funding to stimulate medical education,
residency education, faculty development, and academic development in
Primary Care. Title VII funds are often currently linked to training
physicians to work in underserved communities. Several programs in
Massachusetts are recognized as leaders in the training of medical
students and residents within federally funded Community Health
Centers--an important goal of title VII programs. These include: (1)
the Family Medicine Residency at Boston University Medical Center which
utilizes Community Health Centers to train residents, (2) University of
Massachusetts Medical School in Worcester which enjoys a national
reputation for its development of education/service models within
federally funded CHC's; and (3) the Greater Lawrence Family Health
Center which is the only Community Health Center in the country that
serves as the primary sponsor of a Family Medicine Residency Program.
Community Health Centers play a vital role in ensuring access to
health care and are a priority for health care reform initiatives.
There are 52 non-profit community health centers in Massachusetts which
serve one out of nine (700,000) State residents. In 2006, these health
centers provided more than 3 million outpatient visits. Massachusetts
health centers care for patients of all ages and racial and ethnic
backgrounds, and represent a major source of care for medically
underserved women and children. Health center patients are
disproportionately low-income, publicly insured or uninsured, and are
at higher risk for contracting chronic and complex diseases. There are
dozens of national studies which document the cost effectiveness and
quality of care provided by community health centers.
While the Federal Government has made significant investments in
the growth of Community Health Centers, as noted previously, it has not
made a companion investment in the training of physicians who work in
these health centers (Rosenblatt et al., Shortages of Medical Personnel
at Community Health Centers). There are significant data to show that
title VII funding has a direct impact on Community Health Center
staffing. As the following chart details, medical schools and primary
care residency programs funded by title VII, section 747
disproportionately serve as the medical education pipeline that
produces physicians who go on to work in CHCs and participate in NHSC.
This finding is particularly true among family physicians.
The authors of this study concluded that exposure to Title VII,
Section 747, funds during medical school is strongly associated with
subsequent work in community health centers. Almost 4,000 family
physicians and general practitioners were exposed to title VII funding
during medical school and subsequently chose to work in a CHC. If these
physicians had not been exposed to title VII funds the authors
anticipate over 750 fewer family physicians would have been working in
a CHC in 2003. A recent JAMA article (March 1, 2006) shows currently
600 vacancies for family physicians in CHCs. Without title VII dollars
we would expect there to be twice as many vacancies. These are
conservative estimates: data are from Medicare so pediatrics is
underrepresented.
The same finding applied to the impact of title VII funds during
medical school on participation in the National Health Service Corps.
This association is true for all physicians, but it is even stronger
among primary care physicians, family physicians and general
practitioners. As the following chart details, almost 2,500 family
physicians were exposed to title VII funding during medical school and
subsequently participated in the National Health Service Corps. Without
title VII funding, it is expected that only 350 physicians have served
in the NHSC.
massachusetts models
As noted previously, several primary care training programs in
Massachusetts receive title VII funds. The successes of the
Massachusetts programs in training family physicians who demonstrate a
long-term commitment to practicing in a community health setting are
significant and dramatic. The impact of these programs coupled with the
national data should dispel any debate as to the efficacy and import of
title VII funds.
University of Massachusetts Medical School (Worcester)
Learning contract: Since graduating its first class in 1974, the
University of Massachusetts Medical School has maintained a Learning
Contract that provides for partial tuition waivers for medical students
who agree to: (1) return to Massachusetts to practice a Primary Care
specialty, or (2) return to Massachusetts to practice a specialty with
a focus on providing care for vulnerable populations. Failure to do so
triggers a payback.
Training in underserved communities produces physicians who
practice in underserved communities: In 1976, Umass established the
State's first Family Medicine training program, which graduated 454
Family Physicians through 2005, training in four tracks--a Community
Health Center (Family Health Center of Worcester), a rural health
center (Barre Family Health), an urban site (Hahnemann Family Health
Center), and a small urban area (Fitchburg Family Practice). The
results from the program are impressive.
50 percent of graduates have remained to practice in
Massachusetts; 65 percent practice in New England;
44 percent of graduates from the CHC track went on to
practice in a Health Professions Shortage Area (HPSA); and
Graduates from the rural training site are more likely to
practice in a rural area.
Recent approach.--Establishment of an Office for Primary Care: In
2007, UMass Medical School and UMass Memorial Health Care established
an Office for Primary Care. This office is charged with ensuring that
the hospital system and the medical school will maintain a robust
primary care network. Strategies include:
Program development to stimulate student interest in
primary care careers;
Working with payers to Develop new models for primary care
practice that enhance quality while improving both patient and
physician satisfaction;
Developing a longitudinal curriculum devoted to quality
improvement in patient safety (funded through title VII). This first-
of-a-kind project will impact curricula across all 4 years of the
medical school, the residency programs at the three primary care
disciplines, and will provide training programs for primary care
attendings, physicians, and faculty who interact with students and
residents on a regular basis.
Greater Lawrence Family Health Center
Using title VII funds, the Greater Lawrence Community Health Center
teamed up with Lawrence General Hospital to sponsor the first community
health center residency program in the country. At the time Lawrence
was considered one of the most underserved communities in the State
with a severe shortage of primary care physicians. At that time the
Community Health Center took care of about 10,000 to 12,000 patients
out of community of 75,000. Using title VII primary care funds, the
Community Health Center partnered with Lawrence General Hospital for a
unique residency program. As a result of their partnership the
Community Heath Center sees about 45,000 patients and is no longer
considered an acutely underserved area. The infant mortality rate in
Lawrence, once in the high teens, has now been dramatically reduced to
single digits, even though the risk factors for infant mortality
continue. In terms of workforce issues, about half of the physicians
from the program have continued to work at the Community Health Center,
while the other half have continued their work for the underserved in
other areas. The success of the program and the collaboration between
the Hospital and Community Health Center was cited by then-Secretary of
HHS Donna Shalala as a national model.
Family Medicine Residency at Boston University Medical Center
The Family Medicine Residency at Boston University Medical was
established in 1997 with funding from title VII grants which have been
critical to its success. By establishing and maintaining a strong link
between the residency programs, hospital and community health canter,
this program has significantly increased the number of family
physicians who practice in the community health centers, while
improving coordination and access to care between the hospital and
centers. The BU program currently provides inpatient services for 12 of
the 15 Health Net community centers with each attending providing care
to about 40 to 50 patients at any one time. Their physicians provide
inpatient services for about half of the ob-gyn and nursery where
overall deliveries have increased from about 1,600 to 28,000, mostly
from community health center patients. In one center, these physicians
also serve as hospitalists throughout the year, thus allowing the
physicians to continue to care for their patients during their
hospitalization. Although the acuity of these patients' illness is
generally more severe, the length of stay for their patients is about a
3.4 day shorter. The advantage of this approach is significant--two
thirds of the graduates who have trained in this program either
practice in a community health center in Massachusetts or elsewhere. By
linking the community health centers with the hospital, the program has
arguably improved the quality of care provided while increasing the
physician's satisfaction that care for their patients throughout the
continuum. From a policy perspective it is significant, that these
programs graduate family physicians that stay committed to primary care
and choose to practice in needed areas.
iii. recommendations
As noted previously there are a number of barriers to increasing
the number of primary care physicians. These recommendations focus on
efforts specific to title VII and boarder policy areas.
1. Reauthorize Title VII With Significant Increases
Absent reauthorization in the past several years, title VII
programs have experienced a decrease in funding. For example, in fiscal
year 2005 Massachusetts received $3,558,576 in Section 747 Primary Care
Grants. In fiscal year 2006, funding was reduced by $1,992,863 for a
total of $1,565,713. Given data to show the positive impact of these
programs, and the growing shortage of primary care providers, we
recommend that Congress reauthorize the title VII programs with
increases commensurate with the projected needs.
2. Improved Methodology To Determine Number and Location of Practicing
Physicians
Surprisingly one of our biggest challenges continues to be the
creation of a national data base that records the number of practicing
physicians in each State and location of their practice. It is our
understanding that current Federal data bases which are used for these
designations count the number of physicians with medical licenses.
These figures do not accurately reflect those physicians who actively
practice medicine on a full-time basis and the true number of hours
devoted to patient care. Thus, in areas such as Massachusetts with a
significant number of academicians and researchers, the data base is
grossly misleading. An additional flaw is that the information may
reflect a physicians' homes address, as opposed to where he/she
practices medicine, further compounding the problem of accurately
defining underserved areas. Reliable data bases will require better
coordination with State and county medical societies to ensure accuracy
and timeliness of the information.
While Medicare has created a number of shortage designations we
believe eligible counties are not being recognized given the faulty
data base. When the Medicare Modernization Act created new categories
for physicians' shortages, compared to the number of Medicare
beneficiaries, we were stunned that several counties in Massachusetts
did not qualify. One area was on the Cape, where the percentage of
Medicare beneficiaries to physicians is very high and waiting times to
see a physician were becoming legendary. In our experience, the
national data base was seriously outdated and based on the licensed, as
opposed to practicing physicians, in the area. It was only after
several attempts and a great deal of grassroots work by the
Massachusetts Department of Public Health and the local hospital--
literally calling physicians to determine how many hours they practiced
and where their office was located--did the region qualify for national
shortage dollars. Our experience suggested this problem was not unique.
3. New Approach To Defining Shortage Areas
Given the growing shortages of primary care physicians across the
board, we would encourage a creative look at the definitions of
shortage areas. Historic definitions have not kept pace with the
increasing shortages in primary care physicians nationally. This being
said, it is not our intent to disrupt or divert funding from those
areas and programs which are historically considered health
professional shortages. These localities must continue to receive
additional funds to address acute problems. However, we do believe
Congress should develop additional funding programs to help those areas
which are also experiencing significant problems but have not qualified
under historic definitions. While the concept of new dollars may seem
irresponsible against soaring budget deficits, we would encourage you
to consider the cost savings that will accrue from primary care.
4. Medical Student Debt Relief And Other Financial Incentives For
Medical Students Who Pursue Primary Care
Given the significant burden of medical school debt, we recommend
funding a demonstration project for a new type of grant program to
forgive federally funded medical student loans. Eligible physicians who
commit to practicing primary care in the demonstration grant States
would have a portion of their Federal loan forgiven. In order to
encourage primary care physicians to practice in community health
centers, consider forgiving a greater percentage or all of the debt for
those who commit to practicing in a community health center.
The model differs from the current National Health Service Corps
program in several respects. The demonstration project program would
allocate funds to post-
medical school pre-residency physicians who have chosen to practice
primary care in the demonstration grant State for a determined period
of time. The NHSC focuses on medical students who, at times, have
changed their preference for primary care during medical school.
According to testimony presented at the State by the University of
Massachusetts, ``national data have consistently indicated that most
physicians will establish their practice within 50 miles of where they
complete their residency regardless of where they attended medical
school. Furthermore, residents are nearer to the completion of their
training, and so investments in individual residents will yield
measurable results, in terms of the numbers of practicing primary care
physicians much sooner than investments in incoming first year medical
schools.'' In addition, this program would not be tied to current
definitions of underserved areas. As noted previously, the current
Federal definitions of shortage designation are extremely narrow thus
preventing otherwise qualified counties from participating. The Medical
Society is pursing a similar strategy at the State level suggesting
that a Federal-State partnership for the grants might be advisable.
5. Overall Payment Reform
There is no question that ultimately Congress will need to address
comprehensive payment reform for all physicians and health care
providers. While not under the jurisdiction of this hearing, it is
important to underscore that we believe the above recommendations will
address temporarily acute problem areas in primary care. At a minimum,
reform for primary care physicians should focus on increased value for
cognitive and preventive services, comprehensive longitudinal
management of patients and proposals to incent quality and the medical
home. While it would be impossible here to detail all the provisions
necessary for such a systemic change, one thing is clear--without a
sound financial model that incents quality care and a robust physician
workforce, our efforts to improve access to health care and to reduce
costs, will fail.
On behalf of the Massachusetts Medical Society, I want to thank you
for holding this hearing on an extremely important issue. We look
forward to working closely with you on this and other health care
issues facing our Nation.
Senator Sanders. Thank you very much, Dr. Auerbach.
Beth Landon is an M.H.A., M.B.A., Director of the Alaska
Center for Rural Health, University of Alaska in Anchorage.
Thank you very much for being with us.
STATEMENT OF BETH LANDON, M.H.A., M.B.A., DIRECTOR, ALASKA
CENTER FOR RURAL HEALTH, UNIVERSITY OF ALASKA, ANCHORAGE, AK
Ms. Landon. Thank you, Senator Sanders.
Rural America faces a growing crisis. In Alaska, since this
committee's field hearing, we have learned that at least 15
percent of our primary care positions are vacant, often for up
to 3 years. Projections indicate this will only get worse.
On behalf of the Alaska Center for Rural Health, the
National Rural Health Association, national AHEC organization,
and others, I ask Congress to work with us in developing our
future health workforce. Addressing the projected health
workforce shortages requires a multifaceted approach through
sustained and collaborative efforts. It is good for the
economy. It is good for the community.
It starts with recruitment of young people into the health
professions, beginning as young as elementary school. It
continues through clinical education and then programs to
retain our health professionals. What I have just described for
you is what area health education centers do every day and do
well.
In Alaska, I have seen how our very new, 2-year-old program
is already successful. Youth are choosing careers in
healthcare, and clinical students are selecting employment in
our frontier communities.
Senator Sanders, Senator Murkowski, other distinguished
members of this committee, I thank you for your continued
commitment to the health workforce needs of rural America and
efforts to address this crisis.
[The prepared statement of Ms. Landon follows:]
Prepared Statement of Beth Landon, M.H.A., M.B.A.
summary
Rural America faces a looming health professions workforce crisis.
Already in my State of Alaska, rural primary care positions have
vacancy rates of almost 15 percent. Surveys show that many of these
vacancies last up to 3 years. The crisis is only going to get worse as
the baby boomer generation gets older and a large percentage of current
health professionals begin to retire. Rural America cannot wait; we
must begin to train the future health care workforce today.
We know how this can be accomplished. Studies show that students
from rural areas and/or those who were exposed to rural practice while
in school are more likely to pick sub-specialties in communities that
are in the most need. Programs such as Area Health Education Centers
and other programs within the title VII and VIII lines are essential in
providing rural students the skills they need to go to medical school.
Other programs such as the National Health Service Corps have been and
should continue to be used to help pay for the education of these
students that are considering practicing in underserved communities.
Finally, graduate medical education should be reoriented so that more
students are exposed to rural training and residency programs.
We can and must meet the needs of rural America by providing a
health workforce of tomorrow that is stronger, more diverse and better
geographically dispersed. We need Congress to act to remove some of the
many barriers to the realization of this goal.
______
On behalf of the National Rural Health Association (NRHA) and as
the director of the Alaska Center for Rural Health, Alaska's Area
Health Education Center (AHEC) in Anchorage, AK, thank you for this
opportunity to testify before the committee on the looming health
workforce crisis unfolding in rural America. The NRHA is a national,
non-profit membership organization whose mission is to improve the
health of rural Americans. The NRHA provides leadership on rural health
issues through advocacy, communications, education and research.
Although my comments will specifically address the looming
shortages in my home State of Alaska, interactions with my colleagues
across the country and the data included in my testimony make clear
that similar trends are occurring throughout our Nation. In short,
while over 62 million Americans call rural home (slightly over 20
percent of the Nation's population), less than 10 percent of the
Nation's physicians practice there. Other health professions have
similar, if not higher disparities. Studies show that rural areas
consistently had the largest gap between predicted need for nurses and
numbers employed. This will grow worse, the Bureau of Labor Statistics
estimates, within 15 years there will be over a million nurse openings,
most will be in rural areas. Frontier States, those with the most rural
of populations like my own, are in even worse shape. Taken together,
rural Americans cannot continue to expect access to health care without
a concerted effort of all stake holders to address workforce shortages.
As will be clear throughout my testimony, the Federal Government is
not the only stakeholder addressing this situation. However, the
Federal Government is a very important one. Without the efforts of a
number of government agencies and programs, States like my own cannot
expect to continue to provide basic levels of health care for our
citizens, leaving our economic future to the hopes of miracle cures or
a post-illness society. Our concern is primarily that without a large
Federal investment in our future, we cannot assume that our children
will have access to health care in rural America.
introduction--the health workforce crisis
This committee is well acquainted with the health workforce crisis
and the unique challenges of rural Alaska due to the field hearing that
you held in Alaska in 2007. I would like to thank Chairman Kennedy,
Ranking Member Enzi and Senator Murkowski for this commitment to our
State and to the workforce challenges throughout the Nation. As was
made clear during that hearing, the health workforce crisis faced by
Alaska and the rest of rural America is growing and acute. Twenty
percent of the U.S. population lives in rural America, yet only 9
percent of the Nation's physicians are practicing in these areas. This
is not a new problem, shortage of physicians, in rural areas of the
country, represents one of the most intractable health policy problems
in the past century. As a result of these deficiencies, rural patients
are often denied both access to care and high quality care. All told,
over 50 million Americans, many of them rural, live in areas that have
a shortage of physicians to meet their basic needs.
This will only get worse. Experts predict that by 2030, when over a
fifth of our Nation's population is over 65 years of age and needing
increasing levels of care, the Nation will have shortages of at least
100,000 physicians and perhaps as many as 200,000. With demands for
health care increasing rapidly, our Nation is producing the same number
of medical school graduates as we did 25 years ago. Yet, we are slated
to see a huge number of retirements in the coming years. A third of the
Nation's active physicians are older than 55 and likely to begin
retiring in the next few years. In fact, by 2020, physicians are
expected to hang up their stethoscopes at a rate nearly 2\1/2\ times
the retirement rate of today.
It is no wonder then that States like my own are beginning to show
major cracks. Last year, my center, the Alaska Center for Rural
Health--Alaska's AHEC, conducted a statewide survey of workforce
vacancies across the State. We found that in all types of health
providing agencies--hospitals, private and non-profit clinics, dental
offices, physician offices, imaging centers, mental health centers,
school districts and across 119 different health occupations, that 1
out of 10 positions were unfilled. For key primary care occupations,
vacancy rates were much higher. Over 15 percent for family physicians,
20 percent for general internists, nearly 25 percent for pharmacists
and around 19 percent for family nurse practitioners (FNPs) and
physician assistants (PAs). All of these numbers were higher in rural
and frontier areas--PAs over one-quarter of positions and for FNPs over
36 percent. Looking at our tribal health organizations, which serve an
extremely vulnerable and primarily remote population, the average
vacancy rate climbed to 16.5 percent, with notable spikes of 42 percent
for pharmacists and over 50 percent for dentists. Further, the survey
revealed that it was not uncommon for a position to go unfilled for 3
or more years.
Similar to national trends, the ``Last Frontier'' State will face
growing challenges in the years to come. While it may seem odd for such
a frontier State to complain about a growing population, ours will
cause major challenges in the years to come. Alaska has the second
fastest increasing elderly population in the Nation behind only Nevada.
Each of these seniors will place increasing demands on the Alaska
health care system, especially the rural underserved system. This is
worrisome because the study found that one of the top reasons for
vacancies was population growth and an increased need/burden for health
services were the reasons for causing strain for the few practicing
physicians Alaska has.
In rural Alaska this is of particular concern as there is not an
option of simply driving elsewhere in the State for these services.
Despite an area larger than the combined sizes of California, Texas and
Montana, Alaska has fewer miles of road than any other State. This
means that even in the best weather conditions, over 150,000 people in
230 communities, including our State capital of Juneau, can only access
services outside their area by air or water transportation. A health
care workforce that is able to provide all aspects of basic care is
necessary in these communities that cannot reach urban areas in a
timely or cost-effective manner. Unfortunately, this is not currently
the case as rural Alaska has the worst physician to population ration
in the Nation. But even in the rest of the Nation, rural citizens
deserve the ability to access care in their own communities. And Alaska
is not unique in the challenges of weather and distance that would make
such travel impractical and dangerous.
Our partners in the Washington, Wyoming, Alaska, Montana and Idaho
(WWAMI) region are also facing major challenges. Since we share a
medical school, this means that we are all in it together to generate
enough health care providers. But none of us are. For instance, the
State of Washington with the largest population in the region has
entire counties with not a single physician. Ferry County, population
of over 7,300 people, has a single doctor. This leaves the State's
population without access to even basic care. Statewide, Washington
lags behind even my own State of Alaska in the percentage of
pediatricians, family practitioners, obstetric providers and surgeons
to the population. Similarly the State is experiencing nurse vacancies
of up to 10 percent of all positions. The workforce crisis is
throughout the northwest and we must work together to deal with it.
meeting the challenge--growing our own workforce
Despite the gathering crisis, we know how we can get ourselves out
of this hole--we must train our own workforce in rural and frontier
America. One reason that we must train our own professionals is the
value they provide to our rural communities. Health care is a vital
segment of the rural economy, usually the second largest employer in
the community. Quality health care in rural America not only provides
for the health of the community, but creates jobs, infuses capital into
the local economy, attracts businesses and encourages families and
seniors to maintain residency within the community. The health folks
call this ``ensuring access to culturally competent care'' and the
business folks call it ``economic development.''
Health professionals who live, train and work in rural areas feel
appreciated by the communities in which they serve and know that they
are making a difference in people's lives. The difficulty is in getting
health professionals to give rural areas a try. Studies have
consistently shown that providers who are most willing to practice in
rural and underserved areas come from those same areas. In addition,
evidence shows that rural residency rotations, brief perceptorships in
rural areas, and graduation from residency programs that emphasize
rural, underserved health care have the most promise in preparing
physicians for rural practice and in lengthening the time that they
serve in rural communities.
We acknowledge that as rural communities we have a role in this. In
Alaska, we have reviewed the literature and found that in addition to
training our own health professions, we must commit ourselves to making
our communities more attractive to other health professionals. This
simply has to do with numbers. Our State recently expanded from 10 to
20 medical slots a year at a jointly sponsored WWAMI Medical School and
another 12 residency spots; compared to the nearly 100 physicians we
would need to train annually just to keep pace with our current
insufficient supply of health professionals. Some key recruitment
strategies we employ include considering the needs of the entire
family, being willing as a community to open up and accept health
professionals that have ``outsider'' status and finding creative ways
to provide clinical, professional and financial support. Once the right
person is found, there needs to be continual work to retain that person
through community inclusion and support. Otherwise, the high costs of
recruitment and training will be spent again with turnover.
Finally, nationwide, there is a body of evidence that family
practice and osteopathic physicians, which constitute a majority of
rural primary care physicians, are more likely to distribute themselves
in proportion to the population compared to specialists as long as
payment methodology is fair for rural and underserved areas.
Unfortunately, payment methodology is not fair and medical school
students are growing more unlikely to choose general practice compared
with subspecialties. While there are a variety of theories for these
choices, including following the higher pay, less emphasis on primary
care during school, and lack of perceived prestige, it is unclear to
what extent each of these play in the individual choices of medical
students. What is needed is for Congress to place a priority in public
policy to encourage medical students to make the choice to serve their
communities and country by serving rural and underserved areas.
public policy priority one: title vii and viii reauthorization and
expansion
As stated, the workforce shortages faced by my State and the Nation
are the direct result of the individual choices made by medical
students. However, policymakers and educators cannot simply walk away
and say that it is an individual's choice. Too many factors play a
major role in whether a rural student even has the option to serve
their community as a health professional. By the time a student enters
medical school, they must have years of math and science training. Many
rural schools are economically disadvantaged when it comes recruiting
these teachers making it difficult for even an eager student to take
the classes required for admission to advance programs. Further, many
students that may want to become health professionals do not have the
mentorship of people from their community to explain the necessity of
math and science. Rural communities therefore at an early age often
have a large gap between the desire to serve their community and the
ability to do so.
At the Federal level, a group of 40 programs have been developed to
help fill this niche. They are known collectively as the Title VII and
Title VIII Health Professions and Nursing Education Training Programs.
These programs each focus on different facets of the challenge of
training health professionals who will serve rural and underserved
communities, and minority populations. Like many collective groups of
programs, there are some issues of overlap and missing links, but as a
whole, the title VII and VIII programs provide support to students,
programs, departments and institutions to improve racial and ethnic
diversity, accessibility especially to rural areas and the quality of
the health care workforce.
While each of the 40 programs deserve your full attention, I would
like to focus my remarks on the Area Health Education Centers (AHECs)
that I know best. AHECs are the workforce development, training and
education machine for the Nation's health care safety-net programs. In
my own experience, I have seen firsthand how our new program, just over
2 years old, is already making a difference in Alaska. We are
successfully encouraging youth to pursue careers in health care, and
health professions students who participate in our frontier clinical
rotations are selecting employment in those communities. Nationwide,
AHECs develop and support the community-based training of health
professions students, particularly in rural and underserved areas. They
recruit a diverse and broad range of students into health careers, and
provide continuing education, and other learning resources that improve
the quality of community-based healthcare for underserved populations
and areas.
The Area Health Education Center program is effective and provides
vital services and national infrastructure. Nationwide, in 2006, AHECs
introduced over 308,000 students to health career opportunities, and
over 41,000 mostly minority and disadvantaged high school students
received more than 20 hours each of health career programs and academic
enhancement. AHECs support health professional training in over 19,000
community-based practice settings, and over 111,000 health professional
students received training at these sites. Further, over 368,000 health
professionals received continuing education through AHECs.
Together with the other title VII and VIII programs, AHECs have
proven their effectiveness. Congress, together with this
Administration, has shown a commitment to the Community Health Center
program to provide safety-net care. This has been a noble approach
which the NRHA supports to provide resources to provide care for our
Nation's most vulnerable populations. But while these resources have
facilitated an expansion in CHC facilities, there is a huge shortage of
professionals to actually work in them. In fact, it has been shown that
CHCs have over 400 physician shortages today for the current health
center, not to mention further expansion or retirements in the years to
come. In the past, these professionals would have been trained in title
VII and VIII programs. Today, over 60 percent of CHC physicians were
exposed to title VII funding during their time in medical school.
Likewise, over 57 percent of National Health Service Corp physicians
(detailed in the next section of this testimony) were exposed to this
funding during school. Where will our Nation's safety net physicians
come from if Congress continues recent trends of underfunding and
defunding title VII and VIII programs?
One more word is needed on the effectiveness of the title VII and
VIII programs. The Bush administration, using their Program Assessment
Rating Tool (PART), has labeled these collective programs as
ineffective. This is both deceptive and unfair. While each of the 40
individual programs has their own program goals and objectives, they
were lumped together for a single evaluation. Programs like AHECs were
not considered on their own merits. In fact, the PART assessment even
singled out AHECs as a program that may be working if they had their
own assessment. Second, the long-term measures that the programs were
asked to meet were blatantly unfair. The PART measure selected was the
``proportion of persons who have a specific source of reliable,
continuing healthcare.'' This measure is impacted by a myriad of
factors including insurance coverage, income, geographic location and a
host of other factors. Surely, Congress does not expect training
programs to be able to cover all of these separate policy
considerations. Compare this, as the Administration did, with the
National Health Service Corp measures that evaluate the number of
patients served by NHSC physicians and the placement and retention into
underserved areas. These are factors that the NHSC has control over.
Title VII and VIII programs also deserve to have measures relevant to
the program goals, so that our proven effectiveness is demonstrated to
the Administration and Congress.
Recommendations: Reauthorize and expand Title VII and VIII Training
Programs including Area Health Education Centers that have been proven
to be highly effective in training health professionals who will
practice in rural and underserved areas. This reauthorization should be
for at least 5 years. Further, these programs have been underfunded and
cut since at least fiscal year 2005. Congress must appropriate adequate
funding levels for these programs to continue success in training the
future rural health workforce. Finally, the PART assessment of these
programs should look at each program individually in a way that will
actually measure the mission and goals of the individual program.
public policy priority two: reauthorization of the nhsc
For more than 35 years, the National Health Service Corps (NHSC)
has been recruiting health professionals to serve in communities where
needs are greatest. We thank this committee in acknowledging this
important program this past fall and urge that the reauthorization is
quickly taken up by the full Senate. The communities served by the
program include both rural areas, where the nearest clinic may be miles
away, and in inner-city neighborhoods, where economic and cultural
barriers prevent people from seeking and receiving the health care they
deserve. To qualify for a NHSC physician or other health professional,
the community must be located in a primary care health professional
shortage area (HPSA). Currently, 4,000 NHSC clinicians provide care to
nearly 6 million people nationwide. Tragically, this leaves some 50
million Americans residing in a primary care HPSA without access to the
care they need. While the NHSC has been essential in making sure that
some of these communities are and will continue to be served in the
years to come, more help is needed.
The program was originally created as a scholarship program for
those in medical school. For a year of scholarship support, a NHSC
scholar agreed to dedicate a year working in an underserved area. The
experience with this has been that many of the scholars go on to serve
underserved communities their entire careers. More recently, more
emphasis has been placed in a loan repayment program. This has been
effective in introducing medical school graduates to underserved
communities and allowed more participation at a lower cost to the
Federal Government. However, our experience with the two programs shows
us that the scholarship program is more likely to generate longer terms
of service due to an upfront commitment than the loan repayment
programs.
But no matter which portion of the program a student takes
advantage of, rural communities need this program to be reauthorized,
expanded and slightly modified. Currently, over 80 percent of NHSC
applicants are turned down in a given year. The current appropriations
of approximately $130 million is not enough. Senator Murkowski
introduced a bill last year that would have expanded authorization to
$400 million annually. The NRHA strongly endorses these efforts.
In terms of modifications, the rural experience with primary health
care shows that not all primary care disciplines are included in the
NHSC program. For instance, pharmacists and optometrists are often
front line workers on primary care issues in our communities. In
Alaska, pharmacy services are often mentioned in our survey as one of
the most difficult provider types to recruit with a quarter of all
positions vacant. The list of primary care providers should be
expanded. Second, the most rural of communities, frontier, are often at
a disadvantage in acquiring and keeping a HPSA score that would allow
them to recruit NHSC providers. This has to do with the population size
being served factored into the equation. Due to the lack of population
in rural and frontier communities, our scores often lag behind urban
areas. Further, in communities that are able to acquire a single NHSC
provider, they often lose their HPSA designation since the number of
providers now exceeds the number that would make sense in an urban
area. This means many frontier communities can only have one provider
to be a HPSA, leaving that person with no coverage if they take a week
off. This can be disastrous if that provider leaves the community as
they are unable to immediately recruit a provider that will receive
loan assistance. Frontier communities must have automatic HPSAs that
protect them from these formulaic mistakes.
In addition, when the Senate considers reauthorization of the NHSC
and other programs like Community Health Centers, the 330A Outreach and
Network grant programs should be included. These grant programs have a
track record of improving quality and access to care in rural
communities by allowing communities to tackle unique health challenges
in their own community. These grants have been used for a variety of
health challenges, including health information technology networks,
diabetes prevention, school-based health care and workforce challenges.
Despite the variety of uses for the program, a quarter of the grants
are used annually on workforce projects. This is clearly relevant to
the work of this committee. These programs should be reauthorized as
they have been very effective as 85 percent of the recipients continue
the project after grant funding has run out.
Recommendations: The NHSC is an essential program in providing
health professionals to underserved communities. It needs to be
expanded, fully funded and slightly modified to allow a more
appropriate list of primary care providers and communities that are in
most need of the program to participate despite flaws in formula. In
addition, 330A Grant Programs (Outreach and Network Grants) should be
reauthorized.
other priorities: rural graduate medical education
This next two topics may be outside the scope of both this hearing
and this committee's jurisdiction, so I will be brief, but no workforce
discussion is complete without at least mentioning the problems with
our graduate medical education and reimbursement structures in this
country. First, medical education in the United States has become
specialized, centralized and urban, embracing uniform standards of
patient care, education and research. While this has led to a higher
quality of care than in the old apprentice style system, it has led to
a sharp decrease in the availability of health care in some parts of
the country. As has been outlined previously, rural students are more
likely to practice in rural communities. In fact, studies show that
over half of medical students will practice within 100 miles of their
medical school, and usually in a similar practice environment to where
they trained. Public policy necessitates that medical schools do
training in rural communities and recruit from across their States to
make sure they have a diverse workforce that serves all communities.
However, urban medical schools often favor continuing high quality
research and cutting edge procedures at the expense of training a
workforce for their State that will practice throughout their State.
Alaska is largely impacted by this trend. We have no medical school
in the State. We have recently increased to 20 slots annually through a
joint project with WWAMI Medical School that enables Alaskans to study
three out of the four medical school years in Alaska. In addition, we
have 12 residency slots a year in the Anchorage area. Thankfully this
has been extraordinarily successful as 75 percent of the graduates of
the Alaska Family Residency Program have remained in Alaska, with the
vast majority working in underserved communities or with underserved
populations. Unfortunately, the program is too small to meet the
growing needs of rural Alaska. And our State is not alone.
Policies must change to encourage medical schools to train more
health professionals who will practice in rural communities. At the
Federal level, you have two levers that you can easily pull to help
make this change a reality. First, Congress has already placed in
statute a waiver to Graduate Medical Education (GME) payment caps to
those programs that included integrated rural training tracks (IRTT).
Unfortunately, since Congress never defined IRTT, CMS has not
implemented this waiver. Congress needs to go back and define what they
meant by IRTT so students that are exposed to rural practice and are
trained in primary care, obstetrics, pediatrics, emergency medicine and
community health are not held to the same cap as Congress implemented
for specialty training. Second, Congress should take advantage of the
relatively small number of medical schools in this country that operate
rural residencies to streamline reporting and payment so that rural
residencies get the money directly from Medicare. This would increase
efficiency and accountability and make it more likely that rural sites
could and would participate in residency training programs.
To compound the difficulty in training a rural health workforce,
the cost of going to medical school continues to rise. Even in public
medical schools, the cost has risen 900 percent in the last 25 years.
Rural students and those that will go into rural medicine cannot afford
these levels of debt as they will get paid less than sub-specialists
and those that choose to practice in urban settings. Congress should
continue to examine ways to reduce this debt burden either through the
previously mentioned NHSC program, more GME payments to reduce tuition
or other tax incentives. These should be predicated on a commitment to
practicing in rural, underserved areas.
Recommendations: Graduate medical education in this country has
become specialized, centralized and urban. Congress should work to make
sure that medical education continues to train rural practitioners by
defining IRTT and encouraging more rural residency programs. Finally,
the debt level of medical school graduates is out of control and needs
to be reigned in for students that choose to practice in underserved
areas.
other priorities: fair reimbursement structure
Finally, without fair payment for rural health professionals, many
will choose to either reduce or eliminate the number of Medicare
patients they see, relocate their practices to areas of the country
where they are paid better, retire earlier than they intended, or a
combination of all three. These inequalities must be addressed.
While payment structures are complicated and diverse, there is one
element of the Sustainable Growth Rate for physicians that further
complicates the ability to recruit and retain rural physicians--the
Work Geographic Practice Cost Index. There are a number of indices that
factor in different costs of operating a practice in different areas
including the extra costs of rent in urban areas. But the index that
adjusts for work costs is both imprecise and unfair. Physicians have
the choice of practicing all across this Nation. Pay must be comparable
in a rural community for them to even consider these facilities. It is
the same work. It should be paid the same. It is unfair and bad public
policy to pay better served communities more. Due to these unfair
payment structures, in Alaska, Medicare payments only reflect about 40
percent of serving a Medicare patient. This is both not sustainable,
nor is it fair for our rural communities.
We would have a better understanding of how these decisions have
impacted rural America if the Medicare Payment Advisory Commission
(MedPAC) had proportional rural representation. Current law states that
the Commission must be ``balanced'' between urban and rural
commissioners, yet only 2 of the 17 commissioners have rural
credentials. With one rural commissioner departing this spring, we face
having only one rural commissioner on MedPAC when 27 percent of the
Medicare population resides in rural America.
In addition to Medicare, rural communities disproportionately rely
on the Medicaid and State Children's Health Insurance Programs. While
the stereotype of those covered by these public programs may be the
urban poor, 32 percent of rural kids were on one of these public
programs, compared with only 26 percent of those in urban America. Any
Federal changes to Medicaid and SCHIP need to take this into
consideration, so that rural providers continue to accept these payment
rates to take care of our most vulnerable kids.
Recommendations: Enact legislation that fixes the Medicare
physician payment system so that it realistically reflects physician
practice costs and does not unfairly pay less to those providers that
serve these communities that need their help the most. Second, ensure
proportional representation on MedPAC. Finally, protect payments to
Medicaid and SCHIP that cover rural children.
conclusion
Over the next 20 years, this Nation's health professions workforce
shortage will reach the crisis proportions being experienced today in
rural, frontier, and other underserved areas. My State of Alaska is
already in the midst of it. We know from experience that this will
force us to try new things--we have already heavily invested in health
information technology both as a means of training our health
professionals and to monitor patients from a distance. But this will
not solve all of our problems.
We must have culturally competent health professionals in our
communities. We must have more providers in our CHCs so that the most
vulnerable population is served. We want to make sure that our
grandparents are able to receive the care they deserve in the community
that they have spent their lives. We also want to make sure that our
children are able to receive the checkups early in life that they need
to be productive citizens. But this will not happen if we do not begin
training the future rural health workforce today.
In rural and frontier States all across this Nation, including my
own of Alaska, we are willing and able to begin to make the changes
necessary to train and recruit this workforce. But a number of barriers
are in our way. Congress must act appropriately and eliminate the
barriers at a Federal level, and invest in our future. Without these
efforts and funding for title VII and VIII programs, the National
Health Services Corp, graduate medical education and a fair
reimbursement structure, we will not be able to train the professionals
we know we need. We look forward to working with you to make sure that
the predicted crisis does not come to pass.
sources
Alaska Center for Rural Health, ``2007 Alaska Health Workforce Vacancy
Study Research Summary,'' August 2007.
Frederick M. Chen, M.D., MPH, Meredith A. Fordyce, PhC, and L. Gary
Hart, Ph.D., ``WWAMI Physician Workforce 2005,'' Working Paper #98,
WWAMI Center for Health Workforce Studies, May 2005.
Health Professions and Nursing Education Coalition, ``Health
Professions Programs: Over 1,000,000 Trained and Counting,'' 2007.
Health Resources and Services Administration, ``Nursing Education in
Five States,'' 2005.
Joshua Freeman, M.D. and Jerry Kruse, M.D., MSPH, ``Title VII: Our
Loss, Their Pain,'' Annals of Family Medicine, 2006.
National AHEC Organization, ``Response to the OMB Performance and
Management Assessment of the Health Professions Program,'' April
2003.
National Rural Health Association, Issue Paper, ``Recruitment and
Retention of a Quality Health Workforce in Rural Areas,'' March
2005.
National Rural Health Association, Policy Brief, ``Health Professions:
Title VII of the Public Health Service Act Reauthorization,''
January 2004.
United States Senate, Health, Education, Labor and Pensions Committee
Field Hearing, February 20, 2007 in Alaska.
Senator Sanders. Thank you very much.
Jennifer Laurent is an M.S., FNP-BC, President of the
Vermont Nurse Practitioner Association. She is a family nurse
practitioner in Cambridge, VT. Thanks for being with us.
Turn the mike on and hold it close to your mouth.
STATEMENT OF JENNIFER LAURENT, M.S., FNP-BC, PRESIDENT, VERMONT
NURSE PRACTITIONER ASSOCIATION, FAMILY NURSE PRACTITIONER,
CAMBRIDGE, VT
Ms. Laurent. Closer, there we go. Thank you, Senator
Sanders, committee members, for asking me, inviting me to be
here.
As Senator Sanders said, I am a nurse practitioner, and I
consider myself on the front lines of primary care, where I
work seeing patients. I would like to acknowledge the
importance that nurse practitioners play in answering a lot of
the primary care shortage. Sixty-three percent of nurse
practitioners are in a primary care setting, and there is room
for many more nurse practitioners to be added to the primary
care workforce, except for barriers such as title VIII cuts
that are anticipated.
My recommendation is that it is vital that we have that
title VIII funding and increase that funding. There are three
reasons for that. One is, we all know that there is a nursing
shortage. As there is a nursing shortage, there is going to be
a nurse practitioner shortage, which means that we are going to
really have a crunch in many ways. We are not going to have
access to primary care, and there is also not going to be
enough nurses out there.
The title VIII funding, especially in Vermont, is vital to
answering the primary care crisis. From my standpoint, we are
in a crisis. There are several people who call my practice on a
regular basis, almost daily, that are turned away because they
are two counties away from us, and they can't get primary care
in their counties. They are looking for primary care in my
county. We are a very small, rural practice, and that is pretty
consistent with most of Vermont, except for Burlington.
That would be one recommendation that I would have. The
other one is, and it is actually not in my testimony, but it is
a bill that I came across. It is Senate bill 2112, looking at
nurse-run managed health centers and funding to add to current
nurse managed health centers to allow them to continue to serve
the underserved. These people are serving the majority of
people who don't have insurance and are self-pay.
Those are two recommendations that I have. In closing, I
would just like to say that there are actually nurse
practitioners out there who would like to be primary care
providers, but cannot find a job even given the primary care
shortage.
Thank you.
[The prepared statement of Ms. Laurent follows:]
Prepared Statement of Jennifer S. Laurent, M.S., FNP-BC
Summary
Thank you for inviting me to participate in this hearing on
healthcare workforce issues, its impact on access to primary care
services for the United States, and the role of the nurse practitioner
in meeting this need.
Nurse practitioners are primary care and specialty clinicians who
practice in ambulatory, acute and long-term care settings. According to
their practice specialty they provide nursing and medical services to
individuals, families and groups. In addition to diagnosis and
management of acute episodic and chronic illness, NPs emphasize health
promotion and disease prevention. Services include but are not limited
to ordering and interpreting diagnostic tests, prescribing therapeutic
medications and non-medication therapies. Teaching and counseling are a
major part of nurse practitioner care.
Nurse practitioners currently practice autonomously and
collaboratively with other health care professionals, under their own
license and with their own provider number. They serve as healthcare
researchers, interdisciplinary consultants and patient advocates.
Research indicates that when nurse practitioners (NPs) practice
within their areas of expertise, there are no important differences
between NPs and primary care physicians regarding quality of care,
number of visits per patient, use of the emergency room, and
prescribing practices. Furthermore it is well-documented in the
literature through randomized clinical trials and meta-analyses that
there is no major difference in patient outcomes and some research
indicates higher patient satisfaction with NP over physician (M.D.)
care.
Outcome studies consistently demonstrate increased satisfaction,
comparable outcomes to physician-provided care, and both direct and
indirect cost savings. National databases demonstrate patient safety
with NP directed and managed care in all States including those
currently practicing autonomously.
In my home State of Vermont, available and accessible primary care
services are inadequate. Eight of Vermont's 14 counties fall below
Federal standards for the ratio of primary care physicians to area
residents. Nineteen percent of family physicians and 27 percent of
internists are not accepting new patients. In Washington County this
percentage rises to 54 percent. As fewer medical students seek primary
care residencies and the population of the elderly grows
disproportionately, accessible healthcare services will decline.
Vermont NPs are a stable workforce, providing care for a primarily
rural population.
The obvious need for accessible quality healthcare, healthcare cost
control, and provisions for health promotion presents an optimal
opportunity for nurse practitioners meet the critical demand. The
following recommendations are made:
1. Reauthorization and increased funding of title VIII to encourage
an increase in the number of faculty that will be required to support
the demand for nurse practitioners in primary care. This is the only
Federal funding source for these programs since they have no access to
graduate medical (GME) funds.
2. Support S. 1795 to improve access to workers' compensation
programs for injured Federal employees by adding nurse practitioners to
the list of providers authorized to provide services under this
statute.
3. Federal support at State levels to increase access and
reimbursement to nurse practitioner services for all individuals.
I welcome the opportunity to provide further information should you
have questions. Please do not hesitate to contact me if the need
arises.
(Jennifer S. Laurent, M.S., FNP-C, 281 Shelburne Street,
Burlington, Vermont 05401, [email protected] (802) 644-5114.)
______
Thank you for inviting me to participate in this hearing on
healthcare workforce issues, its impact on access to primary care
services for the United States, and the role of nurse practitioner in
meeting this need.
Nurse practitioners are playing a critical role in meeting the
workforce needs of the Nation's primary care healthcare providers. My
comments are organized into the following areas:
1. The Professional Role of Nurse Practitioners
2. Quality of Nurse Practitioner Care
3. Nurse Practitioner Care and Patient Safety
4. Nurse Practitioner Cost Effectiveness
5. Barriers to Accessing Primary Care Services: An Example from the
Rural State of Vermont
6. Recommendations
professional role
Nurse practitioners are primary care and specialty clinicians who
practice in ambulatory, acute and long-term care settings. According to
their practice specialty they provide nursing and medical services to
individuals, families and groups. In addition to diagnosis and
management of acute episodic and chronic illness, NPs emphasize health
promotion and disease prevention. Services include but are not limited
to ordering and interpreting diagnostic tests, prescribing therapeutic
medications and non-medication therapies. Teaching and counseling are a
major part of nurse practitioner care.
Nurse practitioners currently practice autonomously and
collaboratively with other health care professionals, under their own
license and with their own provider number. They serve as healthcare
researchers, interdisciplinary consultants and patient advocates.
quality of nurse practitioner care
Research indicates that when nurse practitioners (NPs) practice
within their areas of expertise, there are no important differences
between NPs and primary care physicians regarding quality of care,
number of visits per patient, use of the emergency room, and
prescribing practices. \1\ Furthermore it is well documented in the
literature through randomized clinical trials and meta-analyses that
there is no major difference in patient outcomes and some research
indicates higher patient satisfaction with NP over physician (M.D.)
care. This is true in European studies as well.
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\1\ Phillips, R.L., Jr., Harper, D.C., Wakefield, M., Green, L.A.,
& Fryer, G.E., Jr. (2002). Can Nurse Practitioners And Physicians Beat
Parochialism Into Plowshares? Health Aff, 21(5), 133-142.
Studies show that NPs rate high in consumer
satisfaction.\2\ \3\ \4\
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\2\ Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic
review of whether nurse practitioners working in primary care can
provide equivalent care to doctors. BMJ, 324(6), 819-823.
\3\ Kinnersley, P., Anderson, E., Parry, K., Clement, J., Archard,
L., Turton, P., et al. (2000). Randomised controlled trial of nurse
practitioner versus general practitioner care for patients requesting
``same day'' consultations in primary care. BMJ, 320(7241), 1043-1048.
\4\ Hooker, R.S., & McCaig, L.F. (2001). Use of physician
assistants and nurse practitioners in primary care, 1995-1999. Health
Aff, 20(4), 231-238.
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The congressional OTA reviewed studies comparing NPs and
M.D.'s: NPs appear to have more effective communication, counseling,
and interviewing skills than M.D.'s.\5\
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\5\ Congressional Budget Office (1979). Physician extenders: Their
current and future role in medical care delivery. Washington, DC: U.S.
Government Printing Office.
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NPs score higher in areas such as depth of discussion
regarding preventive health and wellness and child health care; amount
of advice, therapeutic listening and support offered; completeness of
history and follow-up on history findings; completeness of physical
exam and interviewing skills; and patient knowledge and comprehension
regarding the plan of care given to them by the NP.\6\
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\6\ Prescott, P.A. & Driscoll, L. (1980). Evaluating nurse
practitioner performance. Nurse Practitioner, 1 (1), 28-32.
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80 percent to 90 percent of adult primary care and up to
90 percent of pediatric primary care can be provided by NPs. Large
randomized studies show that these services were provided as safely and
effectively as when provided by M.D.'s.\7\
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\7\ Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai,
W.Y., Cleary, P.D., Friedewald, W.T., Siu, A.L., & Shelanski, M.L.
(2000). Primary care outcomes in patients treated by nurse
practitioners or physicians: A randomized trial. JAMA, 283 (1), 59-68.
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In regards to measurement of diagnosis, treatment, and
patient outcomes, several studies show that the quality of care
provided by NPs is equal to that of physicians.\8\ \9\ \10\ \11\
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\8\ Roblin, D.W., Becker, R., Adams, E.K., Howard, D.H., & Roberts,
M.H. (2004). Patient satisfaction with primary care: Does type of
practitioner matter? Medical Care, 42 (6).
\9\ Horrocks, S., Anderson, E., Salisbury, C. (2002). Systematic
review of whether nurse practitioners working in primary care can
provide equivalent care to doctors. BMJ, 324, 819-823.
\10\ Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol,
R., & Sibbald, B. (2006). Substitution of doctors by nurses in primary
care. Cochrane Database of Systematic Reviews. 2006, Issue 1.
\11\ Lenz, E.R., Mundinger, M.O., Kane, R.L., Hopkins, S.C., & Lin,
S.X. (2004). Primary care outcomes in patients treated by practitioners
or physicians: Two-year follow-up. Medical Care Research and Review 61
(3), 332-351.
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NPs tend to provide a more relaxed atmosphere where
patients feel more comfortable to ask questions that they regard as too
trivial for physicians.\12\
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\12\ Robyn, D. & Hadley, J. (1980). National health insurance and
the new health occupations: Nurse practitioners and physicians. J
Health Polit Policy Law.
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A large randomized study found that NPs made appropriate
referrals when further intervention was necessary.\13\
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\13\ Spitzer, W.O., Sackett, D.L., Sibley, J.C., Roberts, R.S.,
Gent, M., Kergin, D.J., et al. (1990). 1965-1990: 25th anniversary of
nurse practitioners: The Burlington randomized trial of the nurse
practitioner Journal of the American Academy of Nurse Practitioners,
2(3), 93-99.
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nurse practitioner care and patient safety
Outcome studies consistently demonstrate increased satisfaction,
comparable outcomes to physician provided care, and both direct and
indirect cost savings. National databases demonstrate patient safety
with NP directed and managed care in all States including those
currently practicing autonomously.
The National Practitioner Data Bank (NPDB) and the
Healthcare Integrity and Protection Data Bank (HIPDB), were established
to protect the public from and increase awareness of potentially
harmful healthcare providers. the NPDB assists in preventing
incompetent practitioners from moving State to State without disclosure
or discovery of previous damaging or incompetent performance. This data
provides total accumulated reports of malpractice and adverse actions
of healthcare providers in the United States.\14\ Reports accessed from
the NPDB, August 1996 through September 2005, demonstrate the safety of
NP-provided care independent of autonomous practice level. Filings for
physicians are far higher than 8:1, the average ratio of physicians to
NPs in the United States.\15\ \16\ Autonomous practice States
demonstrate very low rates of NPDB filings nationally compared to other
States with practice agreements.
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\14\ National Practitioner Data Bank (2004). NPDB 2004 annual
report. Retrieved March 16, 2006, from http://www.npdbhipdb.com/pubs/
stats/2004_NPDB_Annual_Report.pdf.
\15\ National Practitioner Data Bank (2006). Healthcare integrity
and protection data bank. Retrieved April 15, 2006, from http://
www.npdbhipdb.com/hipdb.html.
\16\ Pearson, L. (2006). The Pearson report. The American Journal
for Nurse Practitioners 10(1), 1-163.
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The HIPDB reports total number(s) of accumulated adverse
action reports, civil judgments, and criminal conviction reports for
NPs, physicians, and Doctors of Osteopathic Medicine in the United
States. This includes licensure actions and any other adverse actions,
findings, or adjudicated actions.\17\ Reported filings of NP misconduct
are extremely low and consistent with the NPDB reports for all States.
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\17\ National Practitioner Data Bank (2006). Healthcare integrity
and protection data bank. Retrieved April 15, 2006, from http://
www.npdbhipdb.com/hipdb.html.
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In 1990, the Canadian Burlington Randomized Trial
demonstrated NPs safely and effectively manage 67 percent of their
patient visits without physician consultation, the remaining 33 percent
of patients were referred appropriately to other providers for
care.\18\
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\18\ Spitzer, W.O., Sackett, D.L., Sibley, J.C., Roberts, R.S.,
Gent, M., Kergin, D.J., et al. (1990). 1965-1990: 25th anniversary of
nurse practitioners: The Burlington randomized trial of the nurse
practitioner. Journal of the American Academy of Nurse Practitioners,
2(3), 93-99.
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nurse practitioner cost effectiveness
NPs are a proven response to the evolving trend towards wellness
and preventative health care driven by consumer demand. For over four
decades, NPs have been proven to be cost-effective providers of high-
quality care.
Over 25 years ago, the Office of Technology Assessment \19\
conducted an extensive case analysis of NP practice and reported that
NPs provided equivalent or improved medical care at a lower total cost
than physicians. The authors determined that NPs could manage up to 80
percent of adult primary care and 90 percent of pediatric primary care
needs at that time. NPs in a physician-practice were found to have the
potential to decrease the cost per patient visit by as much as one-
third, particularly when seeing patients in an independent, rather than
complementary manner. Since that time, continued reports have supported
ongoing cost-effectiveness of NP practice. When OTA later re-examined
the role of NP practice, the positive analysis was confirmed.\20\
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\19\ Office of Technology Assessment (1981). The Cost and
Effectiveness of Nurse Practitioners. Washington, DC: U.S. Government
Printing Office.
\20\ Office of Technology Assessment (1986). Nurse Practitioners,
Physician Assistants, and Certified Nurse Midwives: A policy analysis.
Washington, D.C.: U.S. Government Printing Office.
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In 1981, the OTA reported that the hourly cost of an NP
was one-third to one-half the cost of a physician. The median total
compensation for primary care physicians in 2004 ranged from $130,000
to $208,700, depending on type and size of practice.\21\ The median
2004 salary for NPs across all specialties who practiced full-time was
$71,000, with a mean of $73,630.\22\ NP preparation currently costs 20-
25 percent that of physician preparation.\23\ When productivity
measures, salaries, and costs of education are considered, NPs are
cost-effective providers of health services.
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\21\ Lowes, R. (2005). Exclusive survey: The earnings freeze--now
it's everybody's problem. Medical Economics, Sept 16, 2005.
\22\ AANP (2004). 2004 national NP sample survey, Part III: NP
income and benefits. JAANP, 18 (1), 2-5.
\23\ AACN (2000). Nurse Practitioners: The growing solution in
health care delivery. Accessed online at: http://www.aacn.nche.edu/
Media/FactSheets/npfact.htm.
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A recent study of 26 capitated primary care practices with
approximately two million visits by 206 providers determined that the
practitioner labor costs per visit and total labor costs per visit were
lower in practices where NPs and physician assistants (PA) were used to
a greater extent.\24\
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\24\ Roblin, D.W., Howard, D.H., Becker, E.R., Adams, E., &
Roberts, M.H. (2004). Use of midlevel practitioners to achieve labor
cost savings in the primary care practice of an MCO. Health Services
Research, 39 (3), 607-26.
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A cost analysis comparing the cost of providing services
at an NP managed center for homeless clients with other community
alternatives showed earlier and less costly interventions by the NP-
managed center.\25\ NPs delivering care in Tennessee's State-managed
MCO, TennCare, delivered health care at 23 percent below the average
cost of other primary care providers with a 21 percent reduction in
hospital inpatient rates and 24 percent lower lab utilization rates
compared to physicians.\26\ Jenkins & Torrisi performed a 1-year study
comparing a family practice physician-managed practice with an NP-
managed practice within the same managed care organization.\27\ The NP
managed practice had 43 percent of the total emergency department
visits, 38 percent of the inpatient days, and a total annualized per
member monthly cost that was 50 percent that of the physician practice.
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\25\ Hunter, J., Ventura, M., & Kearns, P. (1999). Cost analysis of
a nursing center for the homeless. Nursing Economics, 17 (1), 20-8.
\26\ Spitzer, R. (1997). The Vanderbilt experience. Nursing
Management, 28 (3), 38-40.
\27\ Jenkins, M. & Torrisi, D. (1995). NPs, community nursing
centers and contracting for managed care. Journal of the American
Academy of Nurse Practitioners, 7 (3), 119-23.
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A study conducted in a large HMO setting found that adding an NP to
the practice could virtually double the typical panel of patients seen
by a physician. The projected increase in revenue was $1.28 per member
per month, or approximately $1.65 million per 100,000 enrollees per
year. \28\
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\28\ Burl, J., Bonner, A., Rao, M. (1994). Demonstration of the
cost-effectiveness of a nurse practitioner/physician team in primary
care teams. HMO Practice, 8 (4), 156-7.
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Chenowith et al. analyzed the health care costs associated
with an innovative on-site NP practice for over 4,000 employees and
their dependents.\29\ Compared with claims from earlier years, the NP
care resulted in significant savings of $.8 to $1.5 million, with a
benefit-to-cost ratio of up to 15 to 1. Paez and Allen compared NP and
physician management of hypercholesterolemia following
revascularization. Patients in the NP-managed group were more likely to
achieve their goals and comply with prescribed regimen, with decreased
drug costs.\30\
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\29\ Chenowith, D., Martin, N., Pankowski, J., & Raymond, L.W.
(2005). A benefit-cost analysis of a worksite nurse practitioner
program: First impressions. Journal of Occupational and Environmental
Medicine, 47 (11), 1110-6.
\30\ Paez, K. & Allen, J. (2006). Cost-effectiveness of nurse
practitioner management of hypercholesterolemia following coronary
revascularization, Journal of the American Academy of Nurse
Practitioners, 18 (9), 436-444.
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When comparing the cost of physician-only teams with the cost of a
physician-NP team in a long-term care facility, the physician-NP team's
cost were 42 percent lower for the intermediate and skilled care
residents and 26 percent lower for those with long-term stays. The
physician-NP teams also had significantly lower rates of emergency
department transfers, shorter hospital lengths of stays, and fewer
specialty visits.\31\
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\31\ Hummel, J., Pirzada, S. (1994). Estimating the cost of using
non-physician providers in an HMO: Where would the savings begin? HMO
Practice, 8 (4), 162-4.
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A collaborative NP/physician team was associated with decreased
length of stay and costs and higher hospital profit, with similar
readmission and mortality rates.\32\ \33\ Larkin cites a number of
studies supporting decreased costs, complication rates, and lengths of
stay associated with NP-managed care.\34\ For instance, he cites
University of Virginia Health System's 1999 introduction of an NP model
in the area of neuroscience, resulting in over $2.4 million savings the
first year and a return on investment of 1,600 percent. The NP model
has been expanded in this system, with similar savings and improved
outcomes documented. Another example cited includes an NP model
introduced at Loyola University Health System's cardiovascular area,
with a decrease in mortality from 3.7 percent to 0.6 percent and over 9
percent decreased cost per case (from $27,037 to $24,511).
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\32\ Cowan, M.J., Shapiro, M., Hays, R.D., Afifi, A., Vazirani, S.,
Ward, C.R., et al. (2006). The effect of a multidisciplinary
hospitalist/physician and advanced practice nurse collaboration on
hospital costs. The Journal of Nursing Administration, 36 (2), 79-85.
\33\ Ettner, S.L., Kotlerman, J., Abdemonem, A., Vazirani, S.,
Hays, R.D., Shapiro, M., et al. (2006). An alternative approach to
reducing the costs of patient care? A controlled trial of the multi-
disciplinary doctor-nurse practitioner (MDNP) model. Medical Decision
Making, 26, 9-17.
\34\ Larkin, H. (2003). The case for nurse practitioners. Hospitals
and Health Networks. Aug. 2003, 54-59.
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Direct-cost savings estimated by the Department of Health and Human
Services of an office visit with an NP was 10-40 percent less than
comparable services provided by physicians.\35\ According to the
American College of Nurse Practitioners, nurse practitioners cost 40
cent less per U.S. dollar than physicians and provide value-added
effects. Advanced practice nurses are particularly cost-effective with
their expertise in counseling, education and case management in
administering preventive care.\36\ Some estimates suggest that up to
8.75-billion U.S. dollars could be saved in long-term costs by fully
utilizing nurse practitioners.\37\
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\35\ Fitzgerald, M., Jones, E., Lazar, B., McHugh, M., & Wang, C.
(1995). The Mid-level Provider: Colleague or Competitor? Patient Care,
23-37.
\36\ Appleby, C. (1995). Boxed in? Hospitals and Health Networks,
28-34.
\37\ Canadian Nurses Association. (2002). Cost effectiveness of the
nurse practitioner role: Fact sheet. Retrieved April 15, 2006, from
http://72.14.203.104/search?q=cache:Ubt5MfCIeV0J:
www.cna-nurses.ca/CNA/documents/pdf/publications/
FS10_Cost_effectiveness_Nurse_
Practitioner.
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barriers to accessing primary care services: an example from the rural
state of vermont
Available and accessible primary care services in Vermont are
inadequate. Eight of Vermont's 14 counties fall below Federal standards
for the ratio of primary care physicians to area residents. Nineteen
percent of family physicians and 27 percent of internists are not
accepting new patients. In Washington County this percentage rises to
54 percent. As fewer medical students seek primary care residencies and
the population of the elderly grows disproportionately, accessible
healthcare services will decline.\38\ Vermont NPs are a stable
workforce, providing care for a primarily rural population. Removing
the restrictive language linking NP workforce to physician involvement
will provide the citizens of Vermont access to necessary, high quality
healthcare. Increased access to preventative services will greatly
reduce morbidity and mortality of Vermont's highest ranking health
problems: diabetes-related death, colorectal cancer, obesity, and
hypertension.\39\
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\38\ Dritschilo, G & Palmer, R. (2006). Patients struggling to find
local physicians. Retrieved on April 2, 2006 from http://
www.rutlandherald.com/apps/pbcs.dll/article?AID=/20060305/NEWS/
603050377/1024.
\39\ Pearson, L. (2006). The Pearson report. The American Journal
for Nurse Practitioners, 10(1), 1-163.
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In 2002 there were 451 practicing NPs in the State of Vermont. Of
that number 63 percent were in a primary care setting. Sixty-five
percent of NP workforce has been in practice for 5 or more years and 93
percent possess prescriptive authority. Seventy-three percent of NPs
hold a masters degree or higher. Most NPs work in a physician/NP group
setting (34 percent), a hospital-based setting (33 percent), or a
community health center (17 percent).\40\ Pearson reports Vermont NPs
are among the lowest in the Nation for reported misconduct, reflecting
their safety in providing healthcare. \41\ Vermont advanced practice
nurses may apply for hospital privileges and are recognized as primary
care providers for Vermont Medicaid.
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\40\ Vermont Department of Health (2004). Advanced practice
registered nurses: 2002 statistical report and survey. In Vermont
Department of Health (Ed.): State of Vermont.
\41\ Ibid.
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The current language of the Administrative Rules obligates a
professionally educated, trained, and nationally board certified NP to
sign a practice agreement with a physician prior to being endorsed by
the Board of Nursing as a nurse practitioner in the State of
Vermont.\42\ This has created barriers to practice, which could be
interpreted as barriers to accessing care for the people of Vermont.
Examples of this include:
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\42\ Vermont State Board of Nursing (2004). Board of nursing
administrative rules (March 4 ed., pp. 55 0957): State of Vermont.
NPs are having difficulty locating physicians willing to
enter into and maintain collaborative agreements. NPs who wish to
practice in areas such as Franklin County, a rural federally designated
underserved area, and are unable to open their own practice due to
inability to find a physician to sign a practice agreement;
Certified nurse mid-wives (CMNs) and NPs who must pay up
to $8,000.00 annually to a physician for a written practice agreement
which makes practicing economically unfeasible for the NP;
Perpetuates confusion for insurers who continue to resist
recognizing NPs as primary care providers, therefore refusing to
reimburse for delivered services;
Physicians are fearful that they will be held liable if
they sign an agreement with an NP.
Physicians can at anytime sever an agreement.
NPs cannot abandon patients when a collaborative agreement
is severed, yet cannot legally under the current statute continue to
provide care to patients.
NPs will continue to be seen as ``extenders'' of the
medical model and remain virtually invisible at the policy reform
table;
NPs who are comfortable in their current practice
arrangements are not aware of the implications that this outdated
language has on provision and reimbursement of health services and the
vulnerability of NP reliance on M.D.'s choice to support or not support
NP practice.\43\ It is important to recognize ultimately that the
language change does not affect scope of practice, including the
ability to collaborate.
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\43\ Edmunds, M. (2000). NPs face systematic opposition from
physicians. The Nurse Practitioner, 25(12), 65 0968.
``Given that no health care professional practices independently
any longer, statutory language, professional organization policies, and
even separate ethical principles may be outdated for both professions
[NPs and M.D.'s] .'' \44\ As a better understanding evolves as to how
to reconfigure the health care system to address the changing needs of
our society, legislated barriers to collaboration should be removed and
replaced by cooperative model practice acts.\45\
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\44\ Phillips, R.L., Jr., Harper, D.C., Wakefield, M., Green, L.A.,
& Fryer, G.E., Jr. (2002). Can nurse practitioners and physicians beat
parochialism into plowshares? Health Aff, 21(5), 133-142, p. 139.
\45\ Ibid.
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recommendations
While the healthcare system appears in dire straits, the
identification of problems as central and urgent as the frail U.S.
healthcare system is not enough to warrant a place on the healthcare
policy agenda. Problems which drive policy formation depend on ``public
salience and the degree of group conflict surrounding it '' \46\ and
the feasibility of such solutions. Potential solutions to identifiable
problems must be available. The Clinton Health Security Act of 1993
proposed to reform healthcare through cost control and provision of
universal healthcare. This proposal was never enacted.\47\ Other
possible solutions may be targeted towards increasing the population of
primary care physicians through incentives. This does not address
either healthcare cost control or the current need for services.
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\46\ Longest, B. (2002). Health Policymaking in the United States
(3rd ed.). Chicago: Health Administration Press, p. 131.
\47\ Ibid.
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Since the birth of the NP, a wealth of literature exits in support
of NP-provided care. A recent study concluded NPs could safely provide
75 percent of primary care, 90 percent of pediatric primary care, 65
percent of routine anesthesia care, 85 percent of rural anesthesia
care, and 98 percent of routine obstetrical care if the appropriate
workforce was available.\48\
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\48\ Brooten, D., Youngblut, J., Kutcher, J., & Bobo, C. (2004).
Quality and the nursing workforce: APNs, patient outcomes and
healthcare costs. Nursing Outlook, 52, 45 0952.
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The obvious need for accessible quality healthcare, healthcare cost
control, and provisions for health promotion presents an optimal
opportunity for nurse practitioners to meet the critical demand. The
following recommendations are made:
Reauthorization and Increased Funding of Title VIII
In the presence of spiraling medical care costs and the shortage of
professional nurses and primary care providers, the need to prepare
quality, cost effective clinicians such as nurse practitioners
continues to be acute. The need for primary care providers to serve
vulnerable populations, increase the public health infrastructure and
serve as first responders in the presence of national disasters has
been clearly articulated by both Congress and the Administration. Nurse
practitioners are primary care providers who can meet all of these
national needs.
Nurse practitioners have been demonstrated to provide high quality,
cost-effective care in whatever environment they practice. It is
important that the proper preparation of enough of these providers is
maintained to meet health care needs identified in these current
national priorities. This cannot be accomplished if educational
programs are unable to be funded at higher levels. Only a limited
number of programs are able to be funded each year at the current
funding levels. Increases are needed for nurse practitioner educational
programs and traineeships to work toward this need. This is the only
Federal funding source for these programs since they have no access to
graduate medical (GME) funds.
Nurse practitioners want to help meet the growing health needs of
the Nation, but they will need assistance to do it. This means that
nurse practitioner educational programs and scholarship funding needed
to be maintained and increased in the Federal budget. Reauthorizing and
increasing funding for title VIII will improve the workforce of primary
care nurse practitioners by providing and educating the faculty that
will be needed to accomplish this goal.
Support S. 1795 To Improve Access To Workers Compensation Programs for
Injured Federal Employees by Adding Nurse Practitioners to the
List of Providers Authorized to Provide Services Under This
Statute
While nurse practitioners have been recognized and reimbursable
providers in the Federal Employees Health Insurance Program for nearly
20 years, they have not been identified as authorized providers in the
Federal Employee Workers Compensations Program.
Nurse practitioners diagnose and treat injuries and illnesses
currently covered by the Federal Employees Workers Compensation
Program. Because nurse practitioners are not listed as covered
providers, patients must seek care from other providers, often in more
costly practice sites such as emergency rooms, adding cost and lapsed
time prior to appropriate and necessary treatment. Nurse practitioners
have long been demonstrated to provide safe and responsible care to the
patients they serve. They have expert knowledge and skills that allow
them to provide high quality care to patients needing care under the
provisions of this statute. Yet they are not among the list of
providers (often with more limited scopes of practice) authorized under
this legislation. Nurse practitioners have been recognized as a cost-
effective source of high quality care that should be authorized to
provide care under the provisions of this statute.
Currently nurse practitioners provide reimbursable services to
Federal employees under the Federal employees health plan. Likewise in
approximately half of all States, nurse practitioners are authorized to
sign for and provide workers compensation services. This bill will
provide consistency with both Federal health care insurance laws and
State workers compensation laws.
Federal Support at State Levels to Increase Access and Reimbursement to
Nurse Practitioner Services for all Individuals
Nurse practitioners face similar barriers to those of physician
primary care providers such as increasing administrative demands,
sicker patients, growing patient panels, and decreasing reimbursement.
Exacerbating the growing burden of providing primary care for NPs is
the restrictive practice guidelines set forth decades ago limiting
patient access to available high quality primary care providers.
Nursing has been and remains a distinct, self-regulating profession
like law and medicine. As a profession, nursing has the authority and
responsibility to define its standards of practice. NPs are not
``junior physicians'' or ``underlings'' of the physician. NPs will
increase access to cost-effective, high quality primary healthcare by
removing workforce dependency on physician collaboration, practice
agreements, and/or physician oversite.
Given that only one out of four medical school graduates select
residencies in the primary care specialties,\49\ NPs present an
available, stable, and high quality workforce to address the health
care needs of the Nation.
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\49\ Dritschilo, G. & Palmer, R. (2006). Patients struggling to
find local physicians. Retrieved on April 2, 2006 fromhttp://www.
rutlandherald.com/apps/pbcs.dll/article?AID=/20060305/NEWS/603050377/
1024.
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summary
I would like to thank Senators Sanders, Kennedy, Enzi, and their
staff for this opportunity to discuss how nurse practitioners are vital
in solving the primary care shortage in the United States. Nurse
practitioners provide different healthcare services and products than
that of physicians. NPs place emphasis on health promotion, disease
prevention, self-management of chronic disease, education, and health
for the individual, family, and/or community. We are skilled at
improving the knowledge base and the level of physical functioning of
individuals, families, and their communities. We provide comfort and
assist in adapting to loss or change. Nurse practitioner care is
holistic. The ``value-added'' NP effects result in indirect cost
savings, increased satisfaction, and improved outcomes for our patients
and society. With your support and assistance, nurse practitioners will
go a long way in addressing the primary care shortage for the Nation.
Note: For more information please contact author.\50\
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\50\ Jennifer S. Laurent, MS, FNP 09C, 281 Shelburne Street,
Burlington, Vermont 05401, phone 802.644.5114, e-mail:
[email protected].
Senator Sanders. Thank you very much.
Dr. John Maupin, D.D.S, M.B.A., is the President of the
Morehouse School of Medicine in Atlanta. Dr. Maupin, thanks
very much for being with us.
STATEMENT OF JOHN E. MAUPIN, JR., D.D.S, M.B.A., PRESIDENT,
MOREHOUSE SCHOOL OF MEDICINE, ATLANTA, GA
Mr. Maupin. Thank you for allowing me to be here today.
First, I represent one of four historically black medical
schools, also the Association of Minority Health Professions
Schools, which represents 12 historically black institutions
that train physicians, dentists, veterinarians, pharmacists,
and nurses.
Collectively, we have trained over 50 percent of all
African-Americans or black health professionals in this
country. Much of our success has come from the support of the
title VII programs and particularly the diversity programs. Our
success has always been demonstrated by our graduates. Over 70
percent practice in underserved communities. They work in
federally qualified community health centers, public health
departments. They work in their own private practices in areas
where there are predominantly uninsured and underinsured
individuals.
This is the front line of the safety net group that
continues to serve this country in many ways. It is because of
those programs that the institutions have been successful, and
much of that has to do with their mission.
When your mission is about training primary care, when your
mission is serving a disproportionate share of uninsured, when
your mission is not on research focus, and when you have
patients who will not become your wealthy donors, then you are
forced, in many ways, to depend on these programs to survive in
today's environments that are capital intense and very
competitive.
The diversity programs in particular, and title VII in
general, have allowed us to connect with AHECs, to work with
federally qualified community health centers, to provide
training experience. This success rate is not by accident. It
is by design.
I am one of those. I came to Meharry Medical College in
1968. I was exposed to a federally qualified community health
center in Los Angeles, Watts Community Health Center. I was
there. In 1970, I was allowed to go to Baltimore and train in
an externship in the hospital. Across the street was a
federally qualified community health center. That community
health center led me to believe that should be my career.
We talked about it back in Nashville in my training. We
were exposed to it, both my medical colleagues, my dental
colleagues, and others. It is where you train and how you train
that determines where you go to serve. These institutions can
carry that mission out and make a great contribution, but right
now, quite frankly, they are faced with a daunting future.
When you cut back on Medicaid, when you reduce GME, when
you want to talk about eliminating DSH funding, and all of
those things that support any institution, and then you zero
out title VII, you are asking for them to close and not
participate at all in the future.
Thank you, sir.
[The prepared statement of Dr. Maupin follows:]
Prepared Statement of John E. Maupin, Jr., D.D.S., M.B.A.
Mr. Chairman and members of the committee, thank you for the
opportunity to discuss the critical importance of diversity in the
health professions, and specifically the health professions training
programs at the Health Resources and Services Administration (HRSA).
I am Dr. John E. Maupin, President of the Morehouse School of
Medicine (MSM) in Atlanta, GA, MSM is one of only four historically
Black medical schools in the country, and one of twelve (12)
Historically Black health professions institutions that compromise the
Association of Minority Health Professions Schools (AMHPS).
Historically, the small number of schools have collectively trained 50
percent of the African-American physicians and dentists in this
country. Sixty percent of African-American pharmacists, and 75 percent
of African-American veterinarians. Many have called our institutions a
national resource, and they are correct. These schools go a long way in
making the healthcare workforce look like America. I want you to know
that it is not lost on me that I am making this statement to your
committee in February, Black History Month. I think this is as
appropriate a time as any to have a discussion about health disparities
in America, and hopefully we can agree on a legislative solution. Mr.
Chairman, I understand that the historically Black institutions are not
the only ones who are combating health disparities. I have provided the
committee with a list of all institutions which were able to compete
well for the key programs which support the training of minority health
professionals, when those programs were funded more robustly.
In 1997, then as President of Meharry Medical College (MMC) in
Nashville, TN, I testified before this committee, and discussed the
challenges of health disparities in America. There have been some
improvements, thanks to the work this committee did to reauthorize,
restructure, and empower certain programs that created and strengthened
a pipeline of minority health professionals. Those health professionals
have dedicated themselves to serving in the areas where they are most
needed--rural and urban medically and underserved communities. The
diversity cluster of the title VII health professions training
programs: Minority Centers of Excellence (COE), Health Careers
Opportunity Program (HCOP), Scholarships for Disadvantaged Students
(SDS), and Faculty Loan Repayment Program are the programs that made
the training of a diverse healthcare workforce possible, and they are
the lifeblood of institutions like Morehouse School of Medicine,
Meharry, and our sister institutions at AMHPS. Unfortunately, the
funding for these programs was dramatically cut in fiscal year 2006,
and the programs have struggled to regain that funding. Shortly, I will
explain the unique mission of our small set of institutions, the reason
why the aforementioned programs are so important, and what this
committee can do to make sure we continue to produce quality primary
care health professionals.
the health status of minorities
Mr. Chairman, in 2005 the Centers for Disease Control and
Prevention (CDC) still claimed that ``non-Hispanic blacks bear a
disproportionate burden of disease, injury, death, and disability.'' It
is still fair to say that African-Americans and other minorities suffer
a disproportionately low health status when compared to their non-
minority counterparts in our country. In a 1985 landmark study
conducted by the U.S. Department of Health and Human Services, The HHS
Secretary's Task Force Report on Black and Minority Health, confirmed
this national problem. Allow me to share updates on some of the
highlights from that report:
African-American infants are nearly 2\1/2\ times more
likely to die before their first birthday than white infants.
African-Americans are twice as likely to die from a stroke
as Caucasians. The rate of first strokes in African-Americans is almost
double that of Caucasians.
African-Americans who died from HIV-AIDS had approximately
11 times as many age-adjusted years of potential life lost before age
75 years per 100,000 population as non-Hispanic whites. African-
Americans also had substantially more years of potential life lost than
non-Hispanic whites for homicide (nine times as many), stroke (three
times as many), prenatal diseases (three times as many) and diabetes
(three times as many).
Cancer is the second leading cause of death for African-
Americans.
Only 56 percent of African-Americans have private health
insurance coverage. Medicaid covers an additional 21 percent, but
almost one quarter (23 percent) are uninsured. The uninsured rate for
African-Americans is more than 1\1/2\ times the rate for white
Americans.
Of African-American families, 24.7 percent lived below the
poverty level, including 46 percent of African-American children.
Mr. Chairman, if improving upon these health disparities is a
national priority, the need for an aggressive Federal commitment to
address these problems still very much exists.
the need for strengthening and funding federal health professions
training programs
The national priority to improve the health status of minorities,
by doing so all Americans, rests in large part on our ability to train
competent and dedicated individuals to serve our Nation's underserved
and disadvantaged areas. Currently, Mr. Chairman, eventhough African-
Americans represent about 13 percent of the U.S. population, only 2-3
percent of all physicians, dentists, pharmacists, veterinarians, and
allied health professional are African-Americans. There is also a wide
body of research demonstrating that language, communication patterns,
socioeconomics barriers, and diverse health/disease belief systems play
a major role in eliciting history, establishing diagnoses, obtaining
the help and cooperation of family and friends, and influencing the
patients' compliance with a recommended course of treatment. There are
also ethnic and racial differences in response to drugs and how
diseases manifest themselves. Therefore, Federal health professions
training programs support targeted to institutions that significantly
influence the number of under represented minorities practicing in
these areas is critical not only to addressing issues of access to care
but to the quality of healthcare provided as well.
Every credible study ever conducted demonstrates that an individual
who comes from a disadvantaged background or underserved area is much
more likely to serve in underserved areas as a health professional.
Increasing the numbers of health professionals that serve in an
underserved areas can and does improve health status. Many of the
health professions training and institutional support programs being
reviewed today have, and continue to have a dramatically positive
impact on the ability of our schools to train the health professions
workforce that will serve in underserved areas and improve the health
status of disadvantaged and minority populations. Those programs have a
positive impact when they are well-funded.
the role of historically minority institutions in training african-
american health professionals
Collectively, the goal of historically minority institutions has
been to train African-Americans to serve in medically underserved
areas. As demonstrated by the figures outlined in the opening part of
my statement, this small contingent of schools has been hugely
successful in accomplishing this mission. Yet, in spite of our proven
success in training minority health professionals, our institutions
endure a financial struggle that is inherent in our mission to train
disadvantaged individuals to serve in underserved areas. That is why we
say that MSM, like Meharry and our other sister institutions, is a
private institution with a public mission.
The financial plight of the majority of our students has affected
our schools in numerous ways such that we are not able to depend on
more traditional means of support such as annual gifts and generous
endowment contributions. Additionally, the patient populations served
by the AMHPS institutions have historically been poor, uninsured and
under-insured, therefore our institutions have not generated revenue
from the process of much more lucrative patient care at the 40-50
percent level achieved by majority schools. In other words, as a
colleague of mine says, our schools have grateful patients, but not
wealthy, grateful patients.
With regard to student financial assistance, there is a desperate
need for this committee to understand that scholarship support is the
only way to a health professions education for severely disadvantaged
students. Student aid officers tell us time and time again that poor
students will not agree to incur debt for tuition cost that is about
twice the level of their family's annual household income. The effect
of wiping out scholarship support is to ensure that poor people do not
become health professionals. Further, that almost guarantees that the
poor will not be well.
The very nature of our mission directs us to admit students that do
not come from affluent backgrounds. In fact, at MSM, 72 percent of
entering MSM are classified as disadvantaged. Because of the lack of a
sizable financial base at most historically minority institutions, we
are unable to provide scholarship assistance to our students at the
same level of other institutions. For example, at MSM:
Only 25 percent of the scholarships awarded annually are
from endowment funds.
The remaining 75 percent are non-endowed scholarships and
are funded by sources that are cyclical in nature so that the numbers
and amounts of scholarships fluctuate annually and are therefore less
stable sources of funding.
The average annual scholarship award is $9,480, which
comprises only one-third of the College's tuition and fees for medical
students. More significantly, this average award represents only one-
fourth of the total cost of a medical education at MSM.
Because MSM's scholarships only cover 25 percent of the
educational costs, the students must secure the remaining 75 percent of
the funding from loans. When they graduate, the students have often
amassed debt which exceeds the national averages for students entering
similar professions.
Therefore, targeted Federal scholarship support is crucial to the
fulfillment of our missions. Scholarship support is the most important
way to assist the health professions education of severely
disadvantaged students. The program that accomplishes this is the
Scholarships for Disadvantaged Students (SDS).
Health professions training grants, targeted towards our
institutions and authorized by this committee, have helped our schools
level the playing field by a small measure. They have also allowed us
to continue to address the critical disparity needs. Make no mistake,
without such programs as the Minority Centers of Excellence (COE), MSM
would be a much different place. Health professions training programs
represent life blood for our institutions.
However, that life blood, like the pipeline of health
professionals, has been choked off. In fiscal year 2006, the Congress
passed a Labor-Health and Human Services (HHS)-Education Appropriations
bill that severely cut the funding stream for the programs that fund
our institutions' core activities. The programs cut were COE (funded in
fiscal year 2005 at $33.6 million, funded in fiscal year 2008 at
$12.773 million), HCOP (funded in fiscal year 2005 at $35.647 million,
funded in fiscal year 2008 at $9.825 million), Faculty Loan Repayment
Program (funded in fiscal year 2005 at $1.302 million, funded in fiscal
year 2008 at $1.266 million), and Scholarships for Disadvantaged
Students (funded in fiscal year 2005 at $47.128 million, funded in
fiscal year 2008 at $45.842 million). I appreciate the fact that the
HELP Committee is an authorizer, but the negative impact of this low
level of funding for these programs cannot be understated. In terms of
the COE program, the funding level is so low that MSM cannot compete
for a grant. MSM is adversely affected by our inability to compete for
COE and the low level of HCOP funding which inhibits our outreach
efforts towards students in primary education, especially the poor, to
show them which math and science courses to take to begin the road to
the health professions. Secondly, MSM boasts the No. 1 rated program in
the Nation for producing minority medical school faculty. That program,
previously funded by our COE grant, is in serious jeopardy of closing.
Like MSM, that program is a national and State treasure. It is fair to
say that if these programs continue to be funded at these low levels,
many of the minority health professions institutions may not exist in
their current form, furthering the disparity of minority health
professionals. These are the kinds of ramifications that occur when the
core funding stream for our programs and institutions are drastically
reduced.
This has occurred at a particularly sensitive time for the minority
health training community. Our institutions face the threat of loss of
Graduate Medical Education (GME) funding, financing our residency
programs, withdrawn unless the moratorium on the CMS rule is extended.
No matter the vehicle this committee chooses to reauthorize the
diversity cluster of the title VII health professions training
programs--either as a portion of Senator Kennedy's Minority Health
Improvement and Health Disparities Elimination Act (S. 1576) or a title
VII reauthorization bill--our institutions are in favor of adding an
evaluation component to each program. Some criticize these programs for
not having enough evidence of effectiveness. Mr. Chairman, our students
disproportionately dedicate themselves to practicing in the medically
underserved areas. That is a direct result of the programs I mentioned
above. Morehouse School of Medicine and its sister HBCU health
professions schools, only 12 in all, have historically trained about
half of the black health professionals in the country. I don't know how
much more evidence anyone needs to appreciate the impact of these
institutions and the importance of these Federal programs in responding
to their needs.
recommendations for the reauthorization of the health professions
training programs
Mr. Chairman, we urge that the committee move quickly to
reauthorize the Centers of Excellence, Health Careers Opportunities
Program, Scholarships for Disadvantaged Students, and Minority Faculty
Loan Repayment Program to respond to the unwarranted criticism that it
is difficult to link the effectiveness of these programs. Please do
incorporate a strong evaluation and data collection component into the
reauthorization.
We also encourage each member of this committee to advocate for the
full restoration of funding for COE, HCOP, Faculty Loan Repayment, and
Scholarships for Disadvantaged Students in the fiscal year 2009 L-HHS
Appropriations bill. The full funding of these programs gives
institutions like MSM the opportunity to compete and invest in the
education of the Nation's future health professionals that will
actively combat racial and ethnic health disparities in the United
States.
Mr. Chairman, I hope these suggestions are helpful to the
committee. Thank you for the opportunity to present views of the
Association of Minority Health Professions Schools and Morehouse School
of Medicine.
Senator Sanders. Thank you very much.
Why don't we begin? Let me start off with a question, and
then we will go to the other Senators. Everybody jump in, and
Senators jump in, and we will go where we will go and keep this
moving.
Let me start off with what is a fairly dumb-bunny question,
I must confess. This is the richest country in the history of
the world, and people all over the world would find it hard to
understand why, in this Nation, we are not educating and
sending forth the number of primary care medical professionals
that we should. The result being that tens of millions of
people lack access to primary healthcare.
This is the simple question. Why is this? Very briefly, how
do we resolve that crisis? Who wants to begin, okay, Dr.
Grumbach?
Dr. Grumbach. You know, there is a saying that every system
is perfectly designed to achieve the outcomes it is achieving.
We have a perfect system to provide all the incentives for
physicians, for nurses, for others to practice in highly
specialized, highly centralized areas. Again, Mr. Steinwald
showed you can make four times more per hour doing procedural
work than you can working in a primary care area, and that is
not lost on people going into the field.
Unless you look at the incentives, drawing people into
where they are not as needed as they might otherwise be, you'll
never tackle the problem. It is not a lack of money, as you
point out. It is ultimately not even a lack, truly, that we
have a shortage overall of personnel. It is just all the
incentives are to not have somebody practice in a community
health center in rural Alaska. It is to do specialized medicine
in Beverly Hills, in downtown San Francisco.
Unless you address that, you will just keep seeing the same
patterns.
Mr. Steinwald. Let me add to that, if I may, Senator? It is
absolutely true that the incentives are paramount, and we have
this paradox of plenty existing side by side with shortage. The
incentives are our payment systems--not just Medicare, but most
private insurances--to do more and do more complex procedures.
That, in turn, generates revenue.
As has been pointed out, medical students are not blind to
that. Those that have substantial debt can see the difference
in earning potential between primary care and specialty care.
The paradox is extended when you consider that the systems that
do exist in this country that emphasize primary care tend to
get better outcomes at lower cost. That includes not only
closed systems like our staff model HMOs, it also includes
certain areas of the country where there are fewer specialists,
more primary care doctors tend to deliver quality services at a
lower cost.
Senator Sanders. Other thoughts?
Dr. Maupin.
Mr. Maupin. I would say that not only the payment system to
the individual physician or provider, whether it be a dentist
or other, but also the reimbursement or the payment system for
graduate medical education, which comes through Medicare and
sometimes Medicaid.
When you look at a hospital with a high number of
subspecialty services and a high number of Medicare patients,
you will find that they are reimbursed at a higher rate than
you will find a public hospital trying to serve the
underserved. There is just no way that they can survive in
today's environment under the current payment system and
reimbursement system.
Senator Sanders. Dr. Auerbach.
Dr. Auerbach. Yes, in addition to these issues, which have
been brought up repeatedly by people, the issue of medical
student debt, is a very significant factor. In most of the rest
of the world, students that graduate from medical school
graduate with virtually no debt.
I actually was in medical school in France for a couple of
years, and it cost me $100 a year as a non-national to go to
medical school, let alone, it was $20 a year for the French
medical students. It is a huge difference between getting your
schooling for free, essentially, and getting your schooling for
$40,000, $50,000 a year, which, as Senator Kennedy indicated,
students are graduating with $140,000 to $160,000 worth of
debt.
At the Mass Medical Society, we have actually been going to
the medical schools and interviewing the medical students
around the issue of primary care. When we asked them the
question how many of you are going to be choosing your
specialty because of the amount of debt you are leaving medical
school with, more than 50 percent of the hands go up. It is a
very clear equation when you think about the relative
difference in reimbursement.
Senator Sanders. Dr. Swift.
Mr. Swift. In the dental environment, there actually is a
preponderance of primary care people educated through the
educational system. Of the dental school graduates, 80 percent
go into general dental practice, and a few more go into
pediatric dental practice, which is a primary care type of
situation.
The challenge, however, is the disregard for oral health or
dental health as a component of overall general health. It has
existed for decades. As a result, it is difficult for anyone to
get reimbursement for any type of dental treatment procedure,
whether it be the Medicaid program.
We attempted to get a dental benefit, dental guarantee in
the SCHIP, and as you all know, SCHIP didn't go. We were
hopeful that that would be something that would be passed. That
was the first time, that we are aware of, that dentistry was
carved out as a specific area in any bill that addressed the
issues related to oral healthcare.
It is a relative problem that is related to reimbursement
rates, access to care, and the identity that oral health and
the oral systemic connection is an important feature of overall
general health.
Senator Sanders. Mr. Salsberg.
Mr. Salsberg. One of the problems, we think, is again we
are not producing enough U.S.-medical school graduates. We
graduate about 16,000 physicians each year, but we have 25,000
first-year residency positions. And then comes into play the
system's incentives, which say they can get higher rewards and
benefits going into other specialties.
Increasing the number of U.S.-medical school graduates
would be one step. Obviously, having the system rewards and
incentives in the right place is also critical. And then having
a delivery system that is well designed, that is interesting
and challenging for the primary care physician is critical. We
think we need to do more in terms of interdisciplinary care and
treatment and education. A physician should learn through the
education process that they work with nurse practitioners,
P.A.'s, and others, and we deliver care in a team setting.
Senator Sanders. OK. Yes, Doctor?
Mr. Maupin. I want to take this opportunity to highlight
something, an experience I had. I served in Desert Shield and
Desert Storm, and one of my assignments during Desert Shield,
as a dentist, was to prepare the National Guard for their
service. The No. 1 issue of calling them noncombat ready was
their oral health status, their oral health status. It is so
widespread that the access to care for people who work in jobs
and don't have insurance and the ability to find practitioners
willing to serve in Medicaid, high Medicaid areas and uninsured
areas is so great that it is not only a shame for the country,
but it is a challenge for our military issues and strengths
across this country.
Senator Sanders. Ms. Laurent.
Ms. Laurent. I just wanted to acknowledge the under
utilization of nurse practitioners as primary care providers in
the Nation. I am happy to say in the State of Vermont, nurse
practitioners are recognized as primary care providers by
Medicaid. But, that is not really true for the Nation as a
whole.
Nurse practitioners are educated with pretty much the sole
purpose of health promotion, disease prevention, in a cost-
effective, high-quality role. The barriers that presents to the
Nation by not reimbursing these primary care providers by
Medicaid really is a significant barrier to access and quality
of care.
As we all are now learning, health promotion is really
where it needs to be. It doesn't need to be in treating people
after they have had their third or fourth MI or heart attack.
It needs to be, you know, diet and exercise and counseling, and
really, that is where nurses and nurse practitioners excel.
Utilizing those providers to their maximum extent really
has far-reaching consequences in the Nation, as we all get
older and the healthcare crisis continues.
Thank you.
Senator Sanders. Let me move on now to Senator----
Senator Allard. Mr. Chairman?
Senator Sanders. Yes? Sure.
Senator Allard. While we are on this subject, I would like
to ask a question if I might. Scientific programs are generally
finding it more difficult to recruit good quality students. Are
we seeing that in medicine, where we have maybe not as much
interest in going to the healthcare sciences as you maybe had
20, 30 years ago? Anybody want to respond to that?
Senator Sanders. Mr. Salsberg.
Mr. Salsberg. The AAMC tracks this for medical schools, and
we work closely with the osteopathic community. Actually, the
last 5 years, applications to medical schools has been up. It
was down from the mid-1990s to about 5 years ago, but it has
been up over the last several years. We believe we are getting
very well-qualified students applying for medical school and
osteopathic schools.
Senator Allard. It is about two applicants for every one
slot, right?
Mr. Salsberg. Yes.
Mr. Hooker. It is now more difficult to get into P.A.
school than it is to medical school. Our challenge is reaching
out to underrepresented minorities and other disadvantaged
populations because our experience in some States, especially
in Alaska, where we can bring those people from the community,
train them as P.A.'s, they tend to go back to those communities
and stay in those communities.
The big challenge for us is not the quality of the
applicants, which is as good as it gets. These applicants can
go into medical school, law school, any school that they want.
It is trying to get the people that the communities really
need, the rural underserved areas, and getting people like that
to get into P.A. school.
Senator Sanders. Ms. Landon.
Ms. Landon. To echo Dr. Hooker, it is the title VII
programs that are exposing youth, especially youth of minority
and disadvantaged backgrounds, to the health professions. The
area health education centers, the AHEC and the HCOPs, really
take the lead in that. They are really the Federal programs in
the country that are exposing these youth to health career
opportunities.
Not just exposure, but structured programming. Last year,
the area health education centers supported, over 300,000
youth, exposed them to health careers, and 41,000 of those
youth had 20 hours or more of structured programming to expose
them and get them interested in health careers.
It doesn't stop there. They have got to be academically
prepared. They need ongoing mentoring support to get in, to
matriculate into and continue through.
Senator Sanders. Dr. Swift.
Mr. Swift. With the dental school environment, it is
approximately three to one for application for a position at
the time, which is a high for us compared to what it was about
a decade ago. The challenge, however, is the underrepresented
minority. That is the issue.
We have about 6 percent or 7 percent of the dental
workforce a underrepresented minorities. We have been able to
get that up to about 12 percent first-year enrollment now in
dental schools, underrepresented minorities, through a couple
of programs that the American Dental Education Association has
supported.
One is called Pipeline Profession and Practice. It is
sponsored by the Robert Wood Johnson Foundation, W.K. Kellogg,
and the California Endowment. It is a 5-year initiative that
was started in 2003, limited to 15 dental schools across the
country. What they did was establish--or increase the numbers
of underrepresented minorities and low-income students within
the environment. As a result of that, they provided care to
over 237 community-based clinics. This program was so popular
and efficacious that the California Endowment agreed to fund it
again for this next phase.
In addition, we have the Summer Dental Education Program, a
collaborative effort with the AAMC, and this has been running
for approximately 3 years. It is an academic enrichment program
for disadvantaged undergrad freshmen and sophomores, where they
get classes in courses like organic chemistry and calculus,
physics, biology, and then they have improvement of their
communication skills and exposure to the health professions.
We, at the current time, have run this program through for
1,900 students. Sixteen hundred that are anticipating going
into medical school, 300 into dental school. Seventy-one
percent of this group are females. Forty-eight percent are
black or African American. Twenty-one Hispanic or Latino, and 2
percent American Indian. There will be some success with that.
Senator Sanders. Senator Murray, did you want to jump in
and ask a question?
Senator Murray. I am curious, we talked a lot about primary
care physicians and nurses that we all know there is a shortage
on. When I did the roundtables in Washington State, I heard a
lot about the support professions--lab technicians, dental
hygienists, people that are almost sort of behind the scenes.
Very real shortage, particularly in rural areas. Could anybody
comment on that?
Mr. Hooker. As I go around visiting rural areas, this is
really a critical area, regardless of what State that you go
in. All of the allied health disciplines are suffering to some
extent. I don't know to what extent, but they all are.
Senator Sanders. Mr. Salsberg.
Mr. Salsberg. Yes, what we are seeing has really been a
significant increase over the past two decades in the demand
for health services, a lot of it driven by the aging of the
population and the shortages we are beginning to feel across a
whole wide range of professions.
Perhaps in ways medicine and dentistry have an advantage.
We certainly have no shortage of applicants. We have to look at
expanding our educational capacity. There is a lot of interest
in a whole wide range of professions, and there have been some
good programs developed to try and build pipelines for
individuals into a wide range of programs.
One of the benefits of title VII is that it has tended to
look across professions and not be focused on just any one
profession.
Senator Sanders. Ms. Landon.
Ms. Landon. Senator Murray, in Alaska, last year we looked
at vacancy rates for 119 health occupations. It definitely
delved quite far into the allied health professions. Overall,
the vacancy rate across those 119 occupations across the State
was a little over 10 percent.
I have the data on the specific allied health occupations,
any one you would like to know about. Anecdotally, I recall
that for the therapy programs--PT, OT, speech path--the vacancy
rates were between 25 and 30 percent. If that isn't staggering
enough, those vacancies can endure 3 years, if you can imagine
that?
Senator Sanders. Yes, Dr. Maupin.
Mr. Maupin. While our poor applicant pool has gone up
slightly, I want to reiterate the issue of the minority
applicant, qualified applicant. What I am concerned about most
is the recent reductions in title VII support for many of our
outreach programs. We are beginning to see where that is taking
its toll on our ability to go out and reach out, participate in
summer programs, reach out to counseling in the undergraduate
programs.
We are going to continue to be very challenged. We have had
to cut, lay off people in certain areas, which means that we
really won't be able to continue the kind of success we have
had in the past with the outreach for minority students in the
health professions. That is across all of our schools.
The other point I would make is that if we had an increase
in the number of applicants, we brought all this together, and
there is a challenge for us to add, expand our class size so we
can increase the numbers of people and to address the looming
shortages. One of the concerns is the residency training
programs won't be available.
I may be able to increase the class size, but I won't have
a place for them to train in the residency training programs.
That is extremely concerning, and especially the support for
the primary care programs that need expansion and need special
attention.
Senator Sanders. Let me turn to Senator Murkowski now.
Senator Murray. Could we have Dr. Swift answer that? I want
to hear from the dental side.
Senator Sanders. Sure.
Mr. Swift. Yes, there are a couple of novel programs that
have been proposed by the American Dental Hygiene Association,
a workforce model in that particular situation or environment,
and also by the American Dental Association. They are, at the
current time, in the process of funding trials, pilot projects
to determine how those particular--what the roles of those
individuals will be and how they might integrate into the
community.
Senator Sanders. Senator Murkowski.
Senator Murkowski. Thank you. Dr. Hooker, you have
mentioned the role that P.A.s, certainly the role that they
play in the State. Ms. Laurent, certainly in the State of
Vermont the role of the nurse practitioner there. Mr.
Steinwald, this actually came from your report about the
statistics on the per capita supply of primary care physicians
rising at about an average of 1 percent a year, but while for
the P.A.s they are rising at about 4 percent, nurse
practitioners at about 9 percent.
The question to you all is do you see that investing in the
P.A. programs, the N.P. programs is a more rewarding benefit,
if you will, than investing in recruiting the physicians? In
Alaska and Idaho, Montana, Wyoming, we don't have medical
schools, but we do have the mid-level programs. Is this where
we should be focusing more of our attention?
If we can speak to it from the medical school perspective,
too, is it more effective to expand the residency slots, or do
we build more medical schools? I am going in two different
directions there, but I know everyone is going to be raising
their hands, and I won't be able to interject here. Dr. Hooker,
why don't we start with you?
Mr. Hooker. Well, first of all, let me just also touch on
the experiments that are underway. Alaska is a very good
example of where they have introduced dental therapists, and
this is a very exciting thing for Alaska to have this sort of
experiment and seeing if some other service other than a
dentist can deliver some aspect of healthcare service.
The idea of introducing nurse practitioners and P.A.s into
the American landscape was a good one, and we don't really know
how far we can extend that. It is still new territory. We do
know, after 40 years of examination, that when there is team-
based approach to care, when the doctor and the P.A., the
doctor and M.P.E., or all three of them, and in group model
HMOs, like Group Health Cooperative of Puget Sound or Kaiser
Permanente, where you have modules working together, you find
that the healthcare of those populations really improve
substantially.
There are opportunities to enhance that team approach. I
don't know what the right formula is. It is one of the
questions that Professor Grumbach and Mr. Salsberg and I get
asked all the time. What is the right ratio of doctor to P.A.
to M.P.E. to population?
Well, it is one of those ``it depends,'' and it depends on
many, many things; and how rural or healthy the population is.
Elderly people tend to be in higher concentrations in rural
areas. There is ample room--ample, ample room to embark on
many, many experiments in this area and that we should open our
opportunities to try to look at them.
Senator Murkowski. Dr. Grumbach.
Dr. Grumbach. I would echo a lot of what Dr. Hooker said.
It is all about team care. I wouldn't see it as an either/or
question. It is time we can say, well, if the docs are bailing
out of primary care, if we could just get some more nurse
practitioners, physician assistants, they all need each other,
and you need a whole team working in concert.
What we are also seeing is the same incentives are drawing
nurse practitioners and physician assistants away from primary
care. I don't know if Dr. Hooker wants to comment, but the data
I have seen show a plummeting number of P.A.s that are working
in the primary care sector because they can get, again, much
more attractive jobs doing orthopedic physician assistant work
in hospitals.
You all really have to look at the whole picture of primary
care and think of how do we assemble a cadre of workers that
are physician assistants, nurse practitioners, allied health
workers, physicians to really address this problem. There is
not going to be an easy fix of, well, if one group is dropping
out, we can just rely on another group because it is the same
endemic problems they are facing.
In terms of residency and medical schools, what we have
right now is about 25 percent more first-year residency
positions than the number of U.S. medical school graduates
every year, and that is what is being filled largely by
international medical school graduates. Many of us who aren't--
I'm not sure we necessarily need an overall output increase in
physicians in the United States. We could certainly close the
gap by training more of our own.
That gets into some of these issues around domestic
production, particularly if we focused on underrepresented
groups in medicine. Really, if we coupled that with an
expansion of medical school size, that would close the gap and
lessen our reliance on foreign-trained physicians to come in.
What many of us have emphasized, ultimately, it is about
distribution, not just about total numbers. It is not just
about how many residency positions, but it is in what fields.
Because you could train a whole lot more physicians, and they
would all practice in the same areas that are being
overserviced, high cost, poor outcomes, and isn't going to
address the fundamental problem.
Many of us think it is not so much counting the numbers as
how do we align the incentives, how do we restructure primary
care and really build that infrastructure so critical to our
Nation's health?
Senator Murkowski. Mr. Salsberg.
Mr. Salsberg. I would agree that it is not an either/or.
Nurse practitioners and physician assistants and other health
professionals have a major role to play. If you are a State
that does not have a medical school, then adding educational
capacity for an N.P. or P.A. program can be a good viable
strategy.
We actually know we have an excellent program at the
University of Washington, the WAMI program, which links the
medical school there, the academic medical center there with
several States, and that is an excellent model to look at the
branch campuses of medical schools that can be located in a
more rural or less populated area.
I agree with what Dr. Grumbach said about graduate medical
education. You do want to look at undergraduate and graduate
medical education together. Adding more residency slots without
adding more medical school capacity will probably be an
incentive to recruit more international medical school
graduates.
We are increasing U.S. medical school capacity. We should
be clear that we called for a 30 percent increase. The
osteopathic community is also increasing. We do forecast at
this point that medical school graduates will be up 20 percent
by 2012. We will have them. We will need more residency
training positions.
The ability to train physicians in ambulatory settings and
settings outside of the major academic medical centers are an
important part of the strategy. It may be that for a State like
Alaska or Vermont, getting more training programs in primary
care in those underserved communities may be one way of
introducing primary care physicians to those communities.
Senator Murkowski. Mr. Swift, in Alaska, we have instituted
the dental health therapist program. It has been successful,
and it is an effort to get to that mid level. Is the American
Dentistry Association considering mid-level practitioners, if
you will, within that area to help address some of the concerns
that we have heard here today?
Mr. Swift. Yes, thank you for the question. The American
Dental Education Association does not have a pilot or program
for a mid-level provider. The American Dental Association does.
Actually, two different types of providers. The American Dental
Hygiene Association has one. Then the third model that has been
discussed is the one that does exist in Alaska with the dental
health aide therapist.
The concern is that can the dental health aide therapist
provide services to the degree that they need to in their
environment? That is the question that remains. As you know,
there were a lot of concerns and issues related to that. We
think that there are ways to integrate mid-level providers
within an environment, provided the training programs are
exceptionally good and provided that they are essentially
embraced in the team concept as well. That has already been
mentioned.
Also, potentially, unlike medicine, in the dental
environment we actually have more applicants than we have
positions in primary care or residency training programs, both
the advanced education and general dentistry program and the
general practice residency program. We could utilize the
additional funding that originally provided some with the
Dental Health Improvement Act, championed by Senator Collins
and Feingold. Also, other title VII programs would be a benefit
as well.
Senator Murkowski. Dr. Auerbach.
Dr. Auerbach. Yes, again, to support the issues that have
been raised about the team concept, where certainly the primary
care, all the primary care specialties are pursuing the concept
of the medical home, which is basically a team concept and is a
physician working in concert with their physician assistants,
nurse practitioners, and other allied health professionals is
certainly something that we need to consider.
Again, these are all people, each individual and each
entity has an appropriate place in the healthcare delivery
system, but working together is the way that we are going to
achieve the most gain for our population.
Certainly increasing the residency slots is not going to
resolve the issue if we don't change the incentives for
reimbursement around our system because as was included in our
testimony from an article that was in the New England Journal
of Medicine relatively recently, in 1998, more than 50 percent
of the third-year internal medicine residents were choosing
careers as specialists. In 2005, that number was about 18
percent.
Increasing the number of residency slots is not necessarily
going to change the number of people that are actually going
into practice primary care. In terms of utilizing services and
resources, and particularly taking advantage of title VII
resources in underserved areas, one of the examples that we
have in Massachusetts is a community health center in the city
of Lawrence, which is a heavily underserved area. In using
title VII resources, they have really developed a robust
program to the point where they are now the primary sponsor for
a family medicine residency program.
That has really been a great boon to that community. We
have seen a tremendous improvement in healthcare outcomes and
drop in low birth weight infants and infant mortality and the
like. It really has been a model program that has been done
under the auspices of the title VII program.
Senator Murkowski. Can I ask, those doctors who train in
the community health centers, do they end up staying in those
more rural communities?
Dr. Auerbach. To a large degree. I can't remember exactly,
but it is somewhere in the neighborhood of 80 percent of the
physicians that have come up through the ranks, particularly
through title VII programming. At least that has been the
experience in Massachusetts with the three programs that we
have at UMASS, BU medical school, and in Lawrence. About 80
percent of them are staying in community health center practice
or practice in underserved areas, even if they leave the
primary area where they trained.
Senator Murkowski. So, providing residency training or
hands-on job experience in those rural communities will help to
get more?
Dr. Auerbach. That is absolutely correct.
Mr. Maupin. That was more of what I was trying to focus on.
We really are having trouble with the residencies in special
areas, not just open up all residencies.
The other, I would say what is interesting here is the
title VII, title VIII programs recognize the need to support
and balance everything. The trouble has come from the
appropriations side, not the authorization. The appropriation
and zero funding then puts one against the other for who can
have the most pressure to make something happen now.
We need to reauthorize and then focus heavily on making
sure that the right level of appropriation is there because
these programs work. They work to give balance, recognition of
team, all the unique issues are put together through these
programs, and they just have not been funded appropriately. We
need to make sure they are reauthorized. The lack of
reauthorization gives people strength to say, ``well, why
should we fund them?''
Senator Sanders. I would like to throw out a question that
comes from a slightly different direction. Many of us,
including myself, have mentioned the fact that we are filling
the gap in terms of the lack of primary care healthcare
practitioners--doctors, nurses, and others--by bringing in
people from other countries. Many of the people are coming from
countries that are quite poor.
Do any of you have information as to what is the impact on
those countries if we are bringing thousands of nurses in from
the Philippines or physicians from India or other countries?
Now it seems to me that if you are a poor country and you
are educating a medical practitioner--doctor or nurse or
whatever--you are spending a lot of limited resources, you are
probably not terribly enthusiastic that after education that
person is leaving for the United States, and it is probably
having a negative impact on the healthcare in that person's
native country.
Do we have any information about the impact on those
countries drawing primary healthcare professionals into this
country?
Dr. Hooker.
Mr. Hooker. We should be careful which continent we are
talking about. If we are talking about Sub-Saharan Africa, It
is a profound effect, and some of our colleagues are now doing
a very good job of documenting the effect of that.
If we are talking about places like India that have schools
purposely training doctors for export, or Philippines that are
training nurses for export, or places like Taiwan that have
surplus of nurses, then I don't think it is an issue. The
English-speaking countries primarily have been the ones that
have imported the most number of doctors from many of these
areas, and we use the term ``brain drain,'' of course, to
describe this phenomenon.
Many of us wonder why we can't train our own? That is
really the heart of the question.
Senator Sanders. Other comments on that?
Dr. Auerbach. Just to support what Dr. Hooker said, I know
a number of years ago, my hospital was in a severe nursing
shortage and got involved with an organization that was
basically recruiting Filipino nurses that were coming out of
schools that were specifically training nurses for export. It
really was an export industry for the country.
Because the nurses, when they came over here, sent so much
money back home that it was actually beneficial to the
government. In an area like that, it was not necessarily
strapping them from their resources. As was mentioned, there
are other parts of the country, where we are basically stealing
their resources that they have spent their money training them.
Senator Sanders. Other thoughts on that? Yes?
Mr. Salsberg. Well, I will just note, unfortunately, that
the number of international medical school graduates has been
increasing over the past decade. It is up about 25 percent per
year. It demonstrates the need that we need to continue to
encourage an increase of U.S. medical school production.
I share the comments, in some countries it clearly is more
likely to be having a major impact. The numbers, for instance,
from Sub-Saharan Africa are not necessarily significant
compared to the 25,000 new physicians we have each year. We
bring in 300 to 400 from Africa. For those countries, they are
very significant.
And so, there is growing concern. We are really just
beginning to try and track that migration a little better. Some
really good work done by Dr. Fitzhugh Mullen that has tracked
the migration patterns, and the numbers are significant.
By the way, I should note a different perspective on this.
The largest single source country is India, which we bring in
about 1,500 physicians each year from India. While some of
those may be coming from schools that are targeted for export,
many are coming from across the spectrum of schools in India.
As India develops economically over the next 10 or 20
years, I begin to get concerned can we even count on the steady
flow, as we know that India has about one-third as many
physicians per population as we have. We know that there will
be needs there, and as the country becomes wealthier, I am sure
there will be more opportunities.
Again, that speaks for us doing more to educate our own
supply. Especially when we know medicine is such a valuable
career for young people and that many young people want to
become physicians, it seems like we should be offering them
that opportunity.
Senator Sanders. Ms. Landon.
Ms. Landon. I would like to speak to another part of the
country that is losing its workers, and that is rural America.
Our youth go off to the big city for college. They get their
health professions training in an urban facility. They get
their clinical rotations training at a teaching hospital across
the street, and rural America, frontier America loses those
minds.
By using the title VII programs, such as AHEC and HCOP, and
supporting those youth to go into health careers and supporting
clinical rotations, opportunities in those rural and other
underserved areas, we are able to bridge the gap and keep the
rural youth in those communities, getting them to go back to
those communities.
Senator Sanders. Yes, Dr. Grumbach.
Dr. Grumbach. I just want to pick up on Ms. Landon's
comments because the parallels are profound if we are thinking
about our own domestic problems. Because it is a search for
policy solutions. When you look at the international migration
issue, it is fundamentally about the infrastructure of
healthcare in those countries and the lack of infrastructure to
retain their own health professionals.
It is very challenging to try to regulate movement when the
incentives are so strong to move out of the country and come
here. That is the same thing in rural America. It is the same
thing in primary care. That is what I would like to emphasize.
It is about the infrastructure. It is the infrastructure when
you are talking about international migration and what our
Nation will do to help support the infrastructure of developing
nations to build a healthcare system that will retain their own
workers.
It is about primary care. How do we invest in the primary
care infrastructure so our graduates, no matter how many
programs we have, don't flee away from that, but really serve
where the need is greatest in the types of positions where the
need is greatest? The same in how do we build the rural
healthcare infrastructure to attract and retain the best of our
health professionals?
It is a multidimensional question, which is, we need title
VII. We need title VIII. We need these programs, but we need
them to think much more comprehensively about how do we do what
you alluded to, Senator Sanders. How do we change the whole
thrust of our healthcare system so that it is not driven so
much by where the opportunity is around technological
imperatives, where the financial system provides so many
incentives? It seems so contrary to an efficient, cost-
effective health system that produces good health for all
Americans.
That is going to take some serious deliberation about what
are the incentives? How do we invest in electronic medical
records that we can put into rural communities, that we can put
into primary care offices? How do we look at medical education?
Maybe my caution is it, unfortunately, won't be just one
program and one appropriation. It will be a fundamental
rethinking of what is really the priority for reform of this
healthcare system and----
Senator Sanders. I fear not only serious deliberations, but
heavy-duty political struggle on this issue as well.
Dr. Hooker.
Mr. Hooker. I have heard a phenomenon that is being
predicted. Of course, any prediction is as good as the people
giving it. There are now Canadians who are recruiting and
successfully recruiting family practice doctors to go to Canada
for various reasons--lifestyle, salary, low bureaucracy, and
40-hour week. They can work as doctors. They don't have to
worry about the insurance infrastructure.
Some people are saying that Generation Y may be part of
this, that there will be more and more healthcare workers that
now want to bring their careers to the global stage to be able
to offer them to other countries instead of dealing with the
bureaucracy of the United States because of all the
administrative requirements.
Senator Sanders. You are raising a whole other issue which
I don't know that we have the time to get into and that is, in
certain respects, not only the issue of financial incentives
and the infrastructure, but the fact that physicians and nurses
and people within the healthcare profession are pulling out
their hair, sick and tired of filling out forms and dealing
with bureaucracy.
They went to graduate school or whatever to practice
medicine, to help people, not to be arguing with insurance
adjusters. That is another issue, I guess.
Senator Murkowski.
Senator Murkowski. Well, Senator Sanders, one of these
days, I need to sit down with you. We have got a program in
Alaska through the South Central Foundation that has taken a
lot of these concepts that we are talking about, the delivery,
how do you return a quality of life to the practitioner? How do
you integrate the nurse practitioner, the P.A., the primary
care guy, the guy that is dealing with the insurance? Allowing
for a system that reduces costs as well as provide for real
meaningful access to the patient.
It is an innovative model. Oregon has taken it up, I think
it is called Care Oregon. They talked about it as a paradigm
shift, if you will. If what we are going to be able to provide
in this country is a level of healthcare that we all want for
ourselves and for our family, and we want to encourage people
to go into the profession for the right reasons, we are going
to have to change how we are doing business.
It is kind of interesting listening to all of you around
the table. In terms of those in Government programs that have
proven effective, universally everyone is saying title VII is
essential. Title VIII is essential. The graduate medical
education, the ways that we can help move people in the right
direction. The challenge for us then is how you get them to
stay in these areas where that demand is so great?
Aside from these programs that we have talked about here
today, does anybody have any really great new ideas, any
wonderful brainstorm that you want to present here today that
can help us? Mr. Steinwald, you haven't talked much beyond your
initial comments about how we value the care that is provided.
What else do we need to be doing?
Mr. Steinwald. Since you addressed me, Senator, I will try
to respond. I am an economist by training, and so you don't
want me to provide any suggestions of a clinical nature.
[Laughter.]
Senator Murkowski. OK. That is fair.
Mr. Steinwald. I do spend most of my time looking at the
numbers and about the financial incentives that underlie them.
The technological imperative that someone, maybe it was Dr.
Grumbach, mentioned earlier, is a fact of life in our
healthcare system in the United States. It disadvantages
primary care because of the way it promotes specialization and
volume and complexity of care.
We waste an awful lot of money in this country on
unnecessary tests. We see huge variability across the country,
State by State or region by region, in how much we spend per
capita with no evidence that the areas that are spending the
most are, in any way, benefiting from it.
To me, that says that we have got enough money in our
system. We would like to hold the rate of growth at a slower
pace. We are increasing our healthcare spending per capita at
GDP plus 2.5 percent, and we cannot sustain it.
There are a lot of advantages to primary care and to
accomplishing a lot of the objectives that go with that,
services in underserved areas, by the paradigm shift that has
been mentioned here before. That takes away some of the rewards
for increasing volume and complexity of services and rechannels
those dollars to a more, to me, rational way of providing
healthcare that is team based, that emphasizes primary care.
You know, it has been pointed out that we have an aging
society. The baby boomers are aging into entitlement for
Medicare. There will be many, many more people with multiple
chronic illnesses. That is where a lot of the money is spent,
and that is where the benefits of a team approach to medicine
can be realized.
A lot can be accomplished just by rechanneling the money
that we spend in the direction that we believe it is most
needed.
Senator Murkowski. Who else?
Dr. Auerbach.
Dr. Auerbach. Yes, we have been talking about this all
afternoon, that the realignment of incentives is very clearly
an extremely important issue. The whole concept of team-
building, we probably need to understand more from the people
that are currently practicing in those environments what they
like about it and find a way to duplicate that.
The other thing that is important is that we need to take
advantage of other technologies. We have talked about
technologies that are helping to drive up the cost of
healthcare with high-tech imaging studies and so on and so
forth. There are other technologies that can bring a greater
depth of practice and more enjoyment in being in a rural
practice, like telemedicine.
Where you can have someone that doesn't have to feel--a lot
of the reason that when we talk to students and when we talk to
residents about going into underserved areas and going and
practicing in rural areas, most of them don't like the
isolation. They don't like the isolation from their colleagues.
Physicians tend to--like the rest of us are quite
gregarious, and we like to be able to communicate. We like to
be able to share with colleagues. Things that we can do to
encourage the use of those kinds of technologies so that a
physician practicing out in a rural setting still can feel like
they are part of the academic center or the other training
center where they developed their skill set, could be very
helpful in getting people to go and stay in those areas.
Senator Murkowski. Ms. Landon.
Ms. Landon. I appreciated your suggestion for new ideas,
thinking about it, it is a privilege to live in Alaska, where
people are so open to innovation and always willing to try a
new idea. In the context of this discussion, what we should
talk about is increasing funding for title VII programs.
Looking at the GAO report from February 2006, title VII
funding increased only 27 percent between 1999 and 2005, and
AHEC was essentially flat-funded during that period. Increasing
the funding is critical to meeting the need because these
programs are effective.
Think about the community health center line item. That has
been increasing. The number of sites are increasing. The JAMA
report, Journal of the American Medical Association, from a
little over a year ago documented the shortage of primary care
providers in the community health centers. AHECs are the ones
that are feeding the clinical rotations opportunities from the
academic facilities to those centers.
We need to be strengthening the title VII programs to
support that linkage. That is even before we talk about the
aging of America.
Thank you.
Senator Murkowski. Ms. Laurent.
Ms. Laurent. I would have to echo the comments of Ms.
Landon and really emphasize the importance of increasing
spending where--in title VIII, where it matters in the health
promotion area. As with the other panelists, I am in agreement
that the reimbursement is misaligned, and we need to really
kind of take a step back and think about how we can actually
prevent things from happening.
With title VIII funding and increasing funding, we have no
shortage of nursing applicants. We are turning away 33 percent
of people who are applying for undergraduate nursing. We are
turning away more for people who are trying to become nurse
practitioners. We have no faculty to train these people. We
have the access, but we do not have the faculty.
It is a trickle-down effect. If you don't have people
focusing on health promotion, we can do everything in the
world, but it is going to cost more and more money. If we can
kind of look back to where the cost-saving is, it is all about
preventing these things from happening and taking advantage of
the collaborative practice between physicians, nurse
practitioners, and nurses in primary care. It really is
realigning and focusing our needs on training healthcare
providers that are in primary care.
And title VIII is vital. I work at UVM as well, University
of Vermont, and every semester the question is where are we
going to find the faculty to teach these people? It is a
scramble every semester.
Senator Sanders. Let me just jump in and respond to that by
saying that in the higher education bill, which is meandering
its way around here, there is a provision that some of us
worked on, which would provide $3,000 per pupil to nursing
schools as they increase their student numbers. We think that
is----
Ms. Laurent. To encourage more faculty?
Senator Sanders. Exactly. So the schools can hire more
faculty because one of the problems is that faculty in nursing
schools are now running to hospitals, where they can make a
heck of a lot more money than they can as faculty in a nursing
school.
Dr. Grumbach.
Dr. Grumbach. I really appreciate your challenge, Senator
Murkowski, and I would echo everybody who said, I mean,
attention to title VII and title VIII. Let me go ahead and push
it to the next level because what there needs to be is more
Federal attention to demonstration projects about the ideal
medical home.
To put out those models that then can inspire everybody
else and show how it can be done, which is to think much more
creatively, and you are talking about the types of models in
Alaska and other areas. It is about aims. It is about bringing
in community health workers to teach self-management, being
able to think about how to staff a primary care team. It is
about how to then implement electronic technology, both for
telemedicine, but also for patients. So patients can get access
to their own test results or their medical records. So they can
e-mail with their clinician and communicate like that.
There are some demonstration projects under Medicare and
Medicaid in sort of the modernized medical home, and I would
really look at those because that is what we need. We need to
say the Federal Government is helping to point the way toward
what a modernized future patient-responsive primary care
medical home will look like. And really come up with those
experimental models that will then get away from some of the
traditional reimbursement formulas.
There is talk about then you needing a care coordination
fee, an additional fee-for-service. It is not always about just
a lot more money. It is about reusing some of the money you
have and getting out of some of the regulatory things that
handicap the ability to work creatively.
For example, right now, you can't bill--if you are a health
worker or a patient educator in the practice who sees a
patient, but a nurse practitioner or a physician or a dentist
doesn't--you can't bill Medicare, you can't bill Medicaid. It
is getting out of that to the idea it is really the team having
responsibility for care.
Maybe it is better that they see the health worker that can
work with them to take care of their diabetes. If you do an
electronic visit by e-mail or by phone, that is not
reimbursable.
It is re-altering, maybe not changing the overall pool all
the time, but how to allow more flexibility and really to work
with the American College of Physicians, the American Academy
of Family Physicians, the American Academy of Pediatrics, Nurse
Practitioner Associations, the Osteopaths, all have put forward
this idea that we are ready to leap forward into much more
sophisticated models of the medical home that will really meet
patients' need.
We just need a sense that the Government is there, seeing
that they would like to look at these test models to point the
way toward the future. And then that will excite people,
whether it is nurses, physicians, to say, ``boy, I see how this
could be a satisfying career, that you could really do what you
want to do as a health professional.'' There are models out
there that really could be a fulfilling practice and allow us
to do what we want to do. It would change the whole dynamic and
some of the disincentives that are out there.
Senator Murkowski. Mr. Salsberg.
Mr. Salsberg. Yes, and I want to echo that Dr. Grumbach's
ideas are really excellent. I would add not only
demonstrations, but valuation and dissemination because there
are some really good models--we mentioned the WAMI model--to
understand how that works and what pieces could be replicated
most easily.
It is in terms of new ideas, it is not really a new idea,
but we are looking at how the academic medical centers can play
a greater role in addressing distribution problems in
underserved urban and rural areas, whether it is telemedicine,
whether it is distance clinics, whether it is medical student
rotations or residency training sites, that our major medical
centers can play a role in helping address the distribution
problem.
There are also some strategies--again, I fully appreciate
the idea of what new ideas are out there. It is a little
frustrating sometimes when we know we have some good ideas
about what works. You get something like the National Health
Service Corps and many of the programs under the title VII, and
particularly the diversity programs, we know that if you
support the corps, you can get physicians and other
practitioners in underserved areas.
We know that if we increase diversity, we will get
physicians and practitioners going into underserved areas. We
know some things that work, and we need to do more to support
that, combine that with the valuation of new ideas and
assessment of what is out there so that we can disseminate to
the rest of the community the strategies that work.
Mr. Swift. We shouldn't forget the concept of the dental
home as well. And not dissociated from the medical home, by any
means, but there have been some successes along those lines in
academic and dental institutions establishing clinics in
outreach areas.
At my own institution, the University of Minnesota, we have
seven current outreach sites. Eighty percent of the patients
are public program patients or uninsureds that we manage in
that environment, with the cooperation of the community
practitioners in those areas that are wanting to have that type
of opportunity or experience. So that does work.
In addition, another story about one of our dental schools,
member institutions. The Arizona School of Dentistry and Oral
Health is a relatively new dental school. In fact their first
class, graduating this spring, was built on that model of doing
outreach clinics as the clinical component of their training.
A large number of them, a majority of the class, has made a
commitment to spend time managing patients in underserved areas
and providing dental services for patients based upon that
model through their educational training process. There are
some things out there, obviously, the academic dental
institutions can't meet the needs of all the dental patients
that are underserved in the country. It is a way to go.
Senator Murkowski. Dr. Hooker.
Mr. Hooker. Title VII, in many aspects, has been met with
success. The creators must surely be looking at many aspects of
title VII with pride and said we have achieved what we set out
to achieve. We now know that many of the experiments and
demonstration projects have turned out to be successful. They
need more funding.
One of the areas that I echo other people at this table,
though, is that there has been a great lack of documentation.
There has not been enough assessment. We don't exactly know how
effective these programs are. We just know. Some of it is
anecdotal that we have mentioned today from our own experience.
Some of it has reached the public domain. Clearly, more needs
to be done to be able to document just how successful it is.
Senator Sanders. Let me jump in and ask another question. I
know what the answer will be, but I want to ask it anyhow.
Senator Murkowski and I are working on legislation to double
the amount of money for the National Health Service Corps. Is
that a good idea? What has been your experience with the
National Health Service Corps?
Dr. Hooker.
Mr. Hooker. I just read a dissertation on this, and the
loan repayment seems to be highly successful. It does what it
supposedly intends to do. The scholarship program takes a much
longer time to repay. It is a yes/no. It is a binary answer
that the loan repayment is highly motivating for people to go
into those underserved areas and work off their loan.
Senator Sanders. Dr. Auerbach.
Dr. Auerbach. Yes, the National Health Service Corps is a
wonderful program. I will go back to a comment that I made in
my opening remarks, which is that we need to be sure that we
have accurate data about the physicians that are actually in
practice. In areas and States and in parts of the country where
there are large academic centers, you have huge numbers of
physicians that are still calculated based on their presence of
a medical license that are involved in research and other
activities and are not actually delivering patient care,
potentially making it look like that area is overserved, rather
than underserved with physicians.
That is a critical issue if we are going to be doing
anything to increase funding to National Health Service Corps.
Senator Sanders. Your concern is that the numbers may not
be correct in terms of how we define an underserved area?
Dr. Auerbach. That is correct.
Senator Sanders. Ms. Landon.
Ms. Landon. Several things to comment on. I agree that the
National Health Service Corps is an extremely effective
program. AHECs work arm-in-arm with them, works closely as part
of the safety net with the community health centers.
There is a problem with the designation of underserved
areas. Frontier areas are underrepresented because of the
population to provider ratio requirement, which we can't meet.
If we even came close to meeting it, the burnout from call
coverage for 24-7, well, it is just killing the providers.
I did want to add also it is interesting that the State
loan repayment program is perceived to be so effective. That is
great. Alaska and Vermont do not participate in the State loan
repayment program at this time. If you increase the funding, we
will be more competitive to do so.
Senator Sanders. Yes, Dr. Maupin?
Mr. Maupin. The National Service Corps program works. I
would only comment that all of these programs work when they
are in good partnership with each other. I was a community
health center director, and I recruited a number of National
Health Service Corps folks. The people that stayed after their
commitment were the people that came out of many of the
community-based medical schools across this country.
And so, there is this cycle. We have a group of schools
that have done a great job. They are extraordinarily dependent
upon many of these programs. I would say, to the question of
can we do something different, they usually are dependent upon
filling the gaps because there is an economic imbalance in
their mission with a host of issues, whether it is research,
the level of patient care, the extraordinary number of
uninsured and Medicaid patients, lack of subspecialty, more
generalist training, not part of a major medical center.
All of these community-based medical schools are challenged
economically, and they end up surviving by the many different
kinds of programs that they are dependent upon. Each of these
individual programs kind of get picked off or flat funded.
Probably the next idea is to say we ought to figure out how
to fully fund a community-based medical school, which is also
one of the key components that partners with AHEC. They partner
with National Health Service Corps. They partner with federally
qualified community health centers. The Centers of Excellence
program is one of the funded programs that if they are a
participant in that program, they get endowment funding for
research so they can participate in community-based
participatory research with community health centers.
There are so many things that are connected around their
mission focus that we haven't--and they are the ones that seem
to be always left out and having to go to all these desperate
programs to fill the gaps.
Senator Sanders. Let me pick up on your comment and ask
this. Medicare spends about $8 billion in graduate medical
education.
Mr. Maupin. Mm-hmm.
Senator Sanders. Do we make enough demands of those medical
schools that, in fact, are going to be graduating physicians
who are going to serve in underserved areas? No?
Mr. Maupin. Well, I would say no, but at the same time, I
would say that that is a difficult way to go about it. In other
words, to make a demand, I have a school that spends more--a
lot of our resident time is spent in community health centers
in the community, and we are connected to a public institution.
That institution, the Grady Hospital, is not receiving the
same level of Medicare funding. There are others that will.
Their focus is in subspecialty care. Their focus is different.
It is the incentives from the manner in which it is paid. We
have talked about it is how you align the incentives in any of
these programs. I wouldn't say you have this amount of money.
It really is how do you redistribute the incentives so that
they go to the right places?
If I want to start a program in a rural community and want
to be connected to a rural hospital and a rural community
health center, how do they participate in a training program?
How are they funded when they don't get the same level of
funding, yet they have the same needs for housing for
residents, for students, for all of the things, the
complexities that go with it?
Again, I wouldn't put something against and demand on
someone, I would look at are we missing out on how we fund
residency programs and other training opportunities in the
first place? The new model of medical education funding needs
to be looked at. We are so connected in so many different
unusual ways to get funding some place that it is easy for them
to get distorted when one starts to talk about it.
I remember a conversation that said, that one government
official, and I won't name where, but said, ``You have other
ways to get money. You don't need this money.'' Well, they
really didn't understand the complexity of all the funding
mechanisms that are tied up in so many odd ways that when we
decouple them a little bit and then really place them in the
right purity, if you will, and with the right incentives, I
think we have it.
I would be a little hesitant to say punish someone for not
doing something when they said, ``Look, we are here to do this
in the first place.'' It really wasn't their fault that the
funding came there. I don't blame my colleagues at Emory
because there is more money in graduate medical education for
Crawford Long Hospital, even though they also participate at
Grady Hospital, and it is funded less per resident because of
the severity and also the mix of Medicare patients.
Senator Sanders. Senator Murkowski.
Senator Murkowski. This is more a rhetorical question.
Great agreement around the table here today in terms of some of
the things that we can do, continue to do, and some new
approaches about how we have been doing business.
In the State of Alaska, we talk about the urban/rural split
in my State. I would imagine that in many rural States in this
country, you have those same tensions over funding. You have
got the population centers that get it all. They get the
research. Everything goes to them, and the rural areas remain
underserved.
In looking at the President's budget and what he is
proposing with the programs that we have been discussing here
today, we all seem to understand the situation that we are
facing in rural America and our medically underserved areas. Do
the rest of them just not get it, or what is happening?
I don't mean to be flip with that, but I look at this as an
impending crisis. In some parts of the country, we can say is
in crisis. What is causing this giant divide here? Is it
nothing more than an urban/rural split that we are seeing
around the country? Mr. Grumbach, you are shaking your head no?
Dr. Grumbach. No.
Senator Murkowski. Do they not get it? Or do they not
believe that it is as acute as you and I believe it is?
Dr. Grumbach. Yes, the crisis is just becoming adequately
apparent. It is easy to marginalize it when it is a rural
community or it is a minority inner city. Until it hits middle-
class America, it doesn't become a problem that galvanizes
political attention.
We see that. We see in 2006, 24 percent of Medicare
beneficiaries said they had a problem finding a primary care
physician. Last year, it was up to 29 percent. That is what is
probably--that wave--the canary in the mine is rural Alaska.
Senator Murkowski. Tell me.
Dr. Grumbach. It is Compton, L.A. It is Grady Memorial
Hospital. That is just the warning signs of a problem that is
starting to affect, middle America, and that is going to compel
some attention. I can only wonder along with you why this
crisis, as now unfolding in middle America, is not captivating
some of our political leadership to really understand that
action needs to be taken?
Senator Murkowski. It is starting to come.
Senator Sanders. They get it perfectly well. They get what
they want to get, and this is a political issue. It is an issue
of ideology, in my view. You have a President who, among other
things, doesn't believe in government and would prefer to give
tax breaks to billionaires than adequately fund programs that
have been demonstrably successful year after year.
Senator Murkowski and I are trying to double, as I
mentioned a moment ago, the National Health Service Corps. This
is all of $125 million a year increase, $125 million a year
increase. Compare that to the tax breaks that are going to
billionaires. Do they get it? I think they get it just fine. It
just is a philosophical divide in this country.
Mr. Steinwald.
Mr. Steinwald. Yes, I would like to actually answer your
earlier question. The $8 billion, it is not as big as the tax
break that you just mentioned, but it is certainly a nice big
number. I don't think there is sufficient accountability.
You are not going to achieve greater access in rural
communities with that $8 billion and you are not going to
achieve greater access on primary care services. There is very
little accountability for how those dollars are spent.
The incentives that we talk about in a fee-for-service
system drive right on down to, the medical education system,
and I will let Ed comment on that as well. Because you have
faculty practice plans, you have deans of medical schools
trying to fund clinical areas. The fees from services go in the
direction of funding those programs, in addition to providing
positions for doctors in training, who are selecting among
primary care versus specialty services and then seeing a
difference in remuneration as a result.
The whole system plays in one direction against what we
believe is our policy objectives toward primary care in
underserved areas. The accountability for that $8 billion just
isn't there.
Senator Sanders. Dr. Auerbach.
Dr. Auerbach. Yes, I don't know this for sure in terms of
whether they get it or not, as you proposed, Senator Murkowski.
It would be important to recognize that there is an industrial
medical complex that puts a very significant spin on this as
well. The specialists and subspecialists work with a huge
industrial medical complex that generates a very significant
amount of money in this country.
Not paying so much--primary care physicians don't really
participate in that very much not only from a reimbursement
perspective, but also from encouraging the continuation of that
complex. Whereas, specialists and subspecialists are heavily
invested in--not personally invested, but heavily invested in
making that industrial medical complex grow. That certainly
could be another factor in people not being willing to pay much
attention to the primary care crisis.
I know we have been talking title VII, a critical issue. I
would like to go back to another issue that I raised earlier
and was mentioned in your opening statements, Senators, which
does have the potential also to help with propagating primary
care in rural America, which is the issue of medical student
debt.
We are working both on the State level as well as working
with some of our Federal partners around some potential
demonstration projects for Federal loan and Federal debt
forgiveness above and beyond that in the National Health
Service Corps for not students, but residents that are agreeing
to go into primary care and working in areas where the need is
the greatest.
Senator Sanders. Dr. Auerbach, I am sure that you are all
aware that just recently one of the better pieces of
legislation passed last year was the Higher Ed----
Dr. Auerbach. Yes.
Senator Sanders [continuing]. Reconciliation act, which
will provide not only for people in the healthcare
professionals, but for all people who work for Government or in
public service. After 10 years, their debts will be forgiven.
Dr. Auerbach. Yes.
Senator Sanders. You see that as a step forward, I guess?
Dr. Auerbach. Absolutely. Because--and again, if we get
people to go and practice in those areas and they remain for
that time period, when their debt is repaid, even though they
still may have the opportunity to earn more in another area,
they are probably not going to leave because they are going to
be hooked into the community.
Senator Sanders. Yes?
Mr. Maupin. One, I want to echo support for that comment
and to talk really that we do need to look at debt forgiveness
and the issues around the students and the residents that
decide to stay in these communities. I wanted to, before we get
off--I don't want to miss one item.
As we look through all of what we do, I am also aware that
there are some critical specialties that we are having real
problems with in various States. You talk about healthcare is
always local. Looking at the State of Georgia, for example, the
lack of general surgeons is becoming extremely critical. We are
going to have to look at how all of these programs that we may
want to support don't also hurt something that may, in fact, be
a critical specialty that is needed in key areas. We don't want
to forget that issue.
Senator Murkowski. Ms. Landon, did you want to comment on
that? Because I know that in Alaska, there is a concern about
how we are able to provide for that surgical care.
Ms. Landon. Yes, and in fact, Fairbanks Memorial Hospital
just last month submitted an application to the University of
Washington to have seats for residency for general surgeons.
They will have 10 rotating up each year on rotation to start to
meet that need.
Senator Sanders. OK, Senator Murkowski.
Senator Murkowski. I just wanted to make sure that Senator
Enzi's statement was going to be entered into the record.
[The prepared statement of Senator Enzi follows:]
Prepared Statement of Senator Enzi
Thank you for holding this hearing and for providing an
important forum for the committee to work from to identify and
address the healthcare workforce issues that confront us.
Today's hearing will give us all an opportunity to highlight
not only those issues that are unique to our States but also
those that affect our Nation's healthcare system as a whole.
In my home State of Wyoming, one of our biggest challenges
is providing timely access to healthcare providers. That kind
of access has been hampered because Wyoming is currently facing
a shortage of health care professionals--and I am not referring
only to specialists. Clearly, that is a problem that needs to
be addressed on more than one level.
To begin with, to have access to more health care
professionals, we need more than a new, more effective grant
program to increase their numbers. We need real reform of our
medical system as a whole. I have introduced a Ten Step bill
that will, when it is adopted, greatly reduce the health
professional crisis we are already seeing in States like
Wyoming, Vermont, Alaska and Massachusetts.
We will be focusing on the training of health
professionals, today, but I want to make it clear that work-
force issues also include affordable medical insurance for
patients, health information technology, better telehealth
capabilities, and a liability environment for health care
providers. Together, these foundations will help to make people
feel more satisfied with their career choice, more fulfilled by
the work they do, and ultimately attracted to not only begin,
but pursue the call of medicine for many, many years.
That is necessary because Wyoming has a long list of health
care needs. We do not have enough primary care physicians,
dentists, physician assistants and nurse practitioners. That is
in addition to our shortage of subspecialists.
Title VII of the Public Health Service Act is an important
component of training our Nation's health care providers. Loan
repayment, underrepresented minority programs, faculty
training, and various other education programs are important
programs that need to be continued. At the same time, we must
coordinate the goals of the programs with the outcomes that we
measure. We need to improve these programs and our health care
delivery system. A few small tweaks are likely not sufficient.
That would be like adding a new heel to an old shoe that we
would be better off replacing with a new pair.
I appreciate the efforts of Senator Kennedy, Senator
Sanders and Senator Murkowski for beginning this conversation.
I look forward to examining many aspects of our health work
force training including how we plan and pay for our pre and
post graduate training. Before that, we need to encourage more
individuals to consider a career in health care and serving in
areas that are currently underrepresented. It seems to me it is
also important that we may need to broaden training sites to
include more ambulatory care sites in rural areas.
Recent experience in Wyoming shows that with concentrated
effort almost 2/3 of the family practice physicians who train
in Wyoming will stay in Wyoming.
I am interested in our witnesses' thoughts on establishing
a National Health Work Force Commission so that we can start
addressing the shortages identified today in a comprehensive
and coordinated way.
Senator Murkowski. He wasn't able to attend. Apparently, he
has--I don't know whether there are several questions for you,
Ms. Landon, but he did want to ask that we keep the record open
for 5 days.
Senator Sanders. Well, we are going to do it for 10 days.
Senator Murkowski. All right. That is right, get more
questions in here. I want to thank you for your leadership, for
the discussion that we have had here today. There is good
consensus in terms of those areas where we need to be doing
more. We need to make sure that the funding is there. We need
to make sure that the accountability is there. We need to make
sure that we are counting things right.
I look forward to working with you, certainly, Senator
Sanders, in making sure that we push on increasing funding for
the National Health Service Corps. We have got to do that. The
GME money for the training programs, the funding for the
community health centers, so that we can get the residency
training in there for this minimum period. We get people hooked
into these areas where they will stay.
Good suggestions, good input. I appreciate all that you are
doing throughout the country, and we will keep working on it. I
would just thank you all.
Senator Sanders. Well, let me just conclude by thanking
you, Senator Murkowski, and all of you. I want to thank you for
the work that you are doing back in your respective areas. This
is an issue of significance to tens of millions of Americans.
Your comments have been extraordinarily illuminating. We look
forward to working with you, and thank you very much for being
here today.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Senator Bingaman
Let me thank the Chairman for holding this important
hearing on health professions supply. This deserves our serious
attention.
In New Mexico, 30 of our 33 counties are federally
designated as health professions shortage areas or medically
underserved areas.
With a low per-capita income, and a high uninsured
population, having a health provider in our towns can mean the
difference between getting care while problems are manageable,
or waiting until problems became so serious that they require
hospitalization or worse.
In New Mexico, we have worked on creative interdisciplinary
models of health delivery, such as the Health Commons models
that provide an enhanced primary care home, including medical,
behavioral, and oral health, to our most needy populations.
We train our health professionals in these venues, and they
end up working in them at two to three times the rate of other
trainees when they graduate. These programs work. Title VII
funding supported their success. New Mexicans depend on these
programs for health care.
These programs are under severe threat. The President
proposed eliminating title VII funding, severely cutting title
VIII funding, and unilaterally changing Medicaid rules through
CMS that will devastate training programs and will unravel our
tenuous safety net in New Mexico, and across our Nation.
We have witnessed the unprecedented growth of our uninsured
under this Administration with 48 million Americans who are
medically uninsured and over 100 million who lack oral health
coverage.
This would be exactly the wrong time to cut funding, as the
President has proposed. While I support the President's call to
expand community health center funding, it is cynical, it is
illogical, to cut the funding of the title VII programs that
assure staffing of those centers.
While 21 percent of the U.S. population live in rural
areas, only 10 percent of our physicians work in rural areas.
Our population will grow by 25 million per decade, and
those over age 65 will double by year 2030. Those over age 65
have twice the number of doctor visits as younger individuals.
Our Nation faces physician shortages which will grow to
over 200,000 by 2020, while nursing shortages may exceed 1
million. Currently, few dentists accept Medicaid and access is
impossible for our uninsured.
Let us focus our legislative attention on our pipeline of
health professionals and the distribution of these graduates
into the areas they are most needed.
Let us support new interdisciplinary models of service and
learning, with a balance of urban and community-based
experience--addressing our Nation's most pressing health needs,
while admitting health professions students more reflective of
our Nation's diversity.
It is time for us to pass measures, using funding
mechanisms like GME and IME through Medicare and Medicaid, to
assure training of health professions to address our current
and future health workforce and access needs. CMS should not be
cutting funding of these programs through rule changes that
will blow up our pipeline supply when shortages are severe, and
getting worse.
Americans deserve, and should expect, better health
professions outcomes and return on our Federal investment. We
should expand funding to programs that produce the types of
health professionals most needed, and that succeed in placing
them in the cities and towns where we most need them.
It is time for Congress to address these shortages, to
support the hard-working health professionals both in our
cities and in our small towns, and to fund programs that
clearly and conclusively work, including title VII and title
VIII physician, nurse and dental training, scholarship,
diversity, and loan repayment programs.
Prepared Statement of Senator Clinton
I look forward to working with my colleagues on the HELP
Committee to reauthorize the title VII health professions
program. These programs have a great impact on New York, both
as a State with multiple health professions schools, and as a
State that has underserved communities who benefit from these
programs. Our State has 15 medical schools with over 15,000
residents in training and 11 accredited nursing schools. Our
rural and urban communities have critical needs for primary
care physicians, dentists, nurses and other health
professionals. Over 50 of New York's 62 counties have Medically
Underserved Areas (MUA's) and many of those counties have
multiple MUA designations, in both urban and rural areas. In
some of our rural regions, there has been a significant decline
in the number of health professionals filling demand, and at
this point, we do not have enough primary care providers to
meet the growing needs.
In addition to ensuring adequate workforce for both rural
and urban underserved areas, I believe that the title VII
programs are an important tool in addressing the growing
diversity of the U.S. population, which is not yet reflected in
our health workforce. New York State has a minority population
of 36 percent, yet enrollment in our medical schools by
minority students lags far behind at 10 percent. This under-
representation is associated with poor health outcomes in
minority communities, and I think that by improving the number
of underrepresented minorities in the health professions, we
can reduce health disparities. Title VII Health Professions
Programs address these issues by providing educational
pipelines that target minority students at all levels of
education, helping them to gain interest in and pursue careers
in health care.
The President's proposed budget for New York health
professions' programs this year is $13 million, compared to $29
million only 5 years ago. Yet the shortage of primary care
providers only continues to grow. If we are to meet the needs
of underserved communities in New York and the Nation, we must
increase our support for the title VII programs that are an
essential component in improving access to care for all
Americans.
I believe that the title VII programs should be re-
authorized to a level that will make them effective in
providing a pipeline to encourage a diverse range of
participants to enter the health professions, retain a
commitment, through years of training, and to serve in the
urban and rural communities where they are most needed.
We need to assure that training programs are aligned with
healthcare needs. These programs should be amended to improve
data collection in order to track health professionals,
identify shortage areas, and evaluate specific outcomes.
We need to address the primary care shortage by improving
linkages between health professions schools to medically
underserved areas.
Prepared Statement of the American College of Physicians
The American College of Physicians (ACP) is the largest medical
specialty society in the United States, representing 125,000 doctors of
internal medicine, residents and medical students. ACP commends
Chairman Edward Kennedy for addressing the challenges in the training
and supply of the healthcare workforce. The College is extremely
concerned about the looming crisis in the supply of primary care
physicians, particularly the pending undersupply of general internists
and the potential impact on the health care of the United States
population.
There has been a steady decline of medical students and residents
pursuing careers in primary care specialties and many areas of the
country are already facing shortages. The College is very concerned
that if current trends continue, there will not be an adequate supply
of well-trained primary care physicians to treat an aging population--
especially those 65 and older--many of whom will have multiple chronic
illnesses. Numerous studies show that the availability of primary care
is positively associated with lower rates of preventable mortality
(preventable deaths per 100,000 people) and fewer preventable hospital
admissions for chronic diseases like diabetes, lower overall
utilization of health care resources, and lower overall per capita
health care expenditures.
ACP is particularly concerned about the adequacy of the supply of
general internists who provide care in outpatient settings. Many
general internists are choosing to leave internal medicine, while
others near retirement, are choosing to retire earlier than planned.
Approximately 21 percent of physicians who were board certified in the
early 1990s have left general internal medicine, compared to a 5
percent departure rate for internal medicine subspecialists.\1\
Simultaneously, there has been a precipitous decline in the number of
medical students and residents choosing to pursue careers in office-
based general internal medicine.\2\ If this trend continues, a shortage
of primary care physicians will likely develop more rapidly than many
now anticipate.
---------------------------------------------------------------------------
\1\ Lipner RS, Bylsma WH, Arnold GK, Fortna GS, Tooker J, Cassel
CK. Who is maintaining certification in internal medicine--and why? A
national survey 10 years after initial certification. Ann Intern Med.
2005;144:29-36.
\2\ Popkave, CG. Research Associate, Office of Research, Planning,
and Evaluation, American College of Physicians. Personal communication.
February 2006. ITE Exam Survey Data.
---------------------------------------------------------------------------
The College is in agreement with the GAO's findings submitted to
the committee that primary care medicine is essential to better quality
and lower costs. The College also agrees that the health care system's
current financing mechanisms undervalue primary care services. However,
the College believes that the GAO understates the developing shortage
of primary care and feels that clarification is necessary on two
issues:
1. the number of primary care physicians per 100,000 people
The GAO study states that the number of primary care physicians has
increased from 80 primary care physicians per 100,000 people in 1995 to
90 primary care physicians per 100,000 people in 2005. However, the
Health Resources and Services Administration in its October 2006
report, Physician Supply and Demand: Projections to 2020, projects that
the estimated requirements in 2005 were 95 primary care physicians per
100,000 people. In the same report HRSA estimates that the baseline
primary care physician requirements per 100,000 people will increase to
100 by 2020.\3\
---------------------------------------------------------------------------
\3\ Health Resources and Services Administration. Physician Supply
and Demand: Projections to 2020. October 2006.
---------------------------------------------------------------------------
2. the number of residents training in primary care specialties
The GAO Study states that there were 40,982 residents in primary
care graduate medical training programs in 2006, based on data from the
National GME Census that appears annually in the Journal of the
American Medical Association. We believe that this number is misleading
as this number represents all primary care residents on duty without
regard to where they are in the training process. For example, while
22,099 of the 40,982 primary care residents reported were internal
medicine residents, it is important to consider that 3 years of an
internal medicine residency is a pre-requisite for subspecialty
training in cardiology, endocrinology, gastroenterology, hematology,
infectious disease, nephrology, oncology, pulmonary disease,
rheumatology and sports medicine.\4\ Many residents going on to careers
in other specialties also first complete preliminary programs in
internal medicine. It cannot be assumed that all 22,099 of those
residents will go on to practice primary care. In fact, data from
surveys of third-year internal medicine residents (chart below)
suggests otherwise. In 2006, only 24 percent of third-year internal
medicine residents surveyed stated that they intended to pursue careers
in general internal medicine, down from 54 percent in 1998. The
remainder indicated that they planned on pursuing careers in an
internal medicine subspecialty or hospital medicine.
---------------------------------------------------------------------------
\4\ Brotherton S. and Etzel S. Graduate Medical Education 2006-
2007. JAMA, 2005; 289 (9) 1081-1096.
Trends in Career Plans of Third-Year Residents Enrolled in U.S. Categorical and Primary Care Internal Medicine Training Programs, 1998-2006
--------------------------------------------------------------------------------------------------------------------------------------------------------
Career plan (in percent)
-------------------------------------------------------------------------------------------------
Year No. of General
respondents internal Hospitalist Subspecialty Other Undecided Missing
medicine
--------------------------------------------------------------------------------------------------------------------------------------------------------
1998.................................. 4008 54 N/A..................... 42 3 N/A..................... 1
1999.................................. 4338 49 N/A..................... 47 2 N/A..................... 2
2000.................................. 4562 44 N/A..................... 51 4 N/A..................... 2
2001.................................. 4565 40 N/A..................... 54 4 N/A..................... 2
2002.................................. 3495 28 4....................... 56 2 6....................... 4
2003.................................. 4732 27 7....................... 57 2 6....................... 1
2004.................................. 4974 24 8....................... 56 4 8....................... 0
2005.................................. 4926 20 12...................... 58 1 7....................... 1
2006.................................. 4817 24 8....................... 63 1 4....................... 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: Internal Medicine In-Training Examination Survey
With this in consideration and assuming that many of the 7,964
pediatric residents that were included in the 40,982 figure will also
likely subspecialize, it is evident that the number of residents who
choose to practice office-based primary care upon completion of
training is actually far less than what the GAO study indicates.
The GAO study found that preventive care, coordinated care for the
chronically ill, and continuity of care can achieve better health
outcomes and cost savings. These are the fundamental characteristics of
the care that general internists provide. The study also found that
States with more primary care physicians per capita have better health
outcomes than States with fewer primary care physicians and that States
with a higher generalist-to-population ratio have lower per-beneficiary
Medicare expenditures. The GAO study confirms that the Nation's
uncoordinated system of care, which has an over reliance on specialty
care services, has led to a less efficient health care system that
undervalues primary care services and rewards expensive procedure-based
services. The College strongly agrees with the GAO's findings and is a
strong proponent of the medical home model the GAO cited in its study.
recommendations
As the education and training of new physicians takes at least 10
years, immediate action is needed to assure access to care and to
prevent a crisis in the future. The College feels strongly that special
emphasis should be placed on increasing the supply of primary care
physicians including general internists through modifications in
Medicare GME funding, expansion of the National Health Service Corps,
increased funding for primary care training and faculty development
programs under title VII and expansion of program for student loan debt
relief. According to the Association of American Medical Colleges, the
average medical student debt in 2007 was $139,517. Those students with
debt that exceed $150,000 are the least likely to select a primary care
residency.\5\ Medical school scholarships and loan repayment programs
in exchange for service in underserved areas for those pursuing careers
in primary care are essential for those that are interested in careers
in these critical but less remunerative specialties.
---------------------------------------------------------------------------
\5\ Rosenblatt RA and Andrilla CHA. The Impact of U.S. Medical
Students' Debt on Their Choice of Primary Care Careers: An Analysis of
Data from the 2002 Medical School Graduation Questionnaire. Academic
Medicine (2005) 80: 815-819.
---------------------------------------------------------------------------
The College also urges improving the payment and practice
environment of existing primary care physicians and advocates reforming
Medicare payment policies so that physicians engaging in primary care
can receive reimbursement that is commensurate with the value of their
contributions. The College was encouraged by the GAO's findings that
payments for services and their value to the patient are misaligned and
that payment system reforms are necessary. Reducing existing income
disparities would make the field more attractive and increase the
number of physicians entering and continuing practice in primary care
specialties.
Additionally, the College strongly advocates adopting a patient-
centered primary care model of health care delivery. Patient-centered
primary care will facilitate the ability of physicians, working in
partnership with their patients, to implement a systems-based approach
to delivering patient-centered services that have been shown to result
in better quality, lower costs, and higher patient satisfaction. It
will also avert an impending collapse of primary care medicine by
restructuring payment policies to support the value of care provided by
a primary care physician. Moreover, patient-centered primary care will
extend the benefits of a patient-centered health care system to all
Americans by taking immediate steps toward making affordable coverage
available to the uninsured and by giving them direct access to
coordinated care through a medical home.
conclusion
The American College of Physicians appreciates the opportunity to
provide the Committee on Health, Education, Labor, and Pensions with
this summary of our views on the primary care workforce crisis. Without
general internal medicine, the health care system will become
increasingly fragmented, over-specialized, and inefficient--leading to
poorer quality care at higher costs. Unless steps are taken now, there
will not be enough general internists to take care of an aging
population with growing incidences of chronic diseases. An insufficient
supply of primary care physicians will also contribute to higher health
care costs and poorer outcomes, especially for patients with multiple
chronic diseases. Additional information on ACP's analysis and
proposals can be found on our Web site: Creating a New National
Workforce for Internal Medicine http://www.acponline.org/advocacy/
where_we_stand/policy/im_workforce.pdf; Medical Homes and Patient-
Centered Care http://www.acponline.org/advocacy/where_we_stand/
medical_home/.
Response to Questions of Senators Kennedy, Bingaman, Sanders, Mikulski,
Enzi, and Murkowski by Bruce A. Steinwald
questions of senator kennedy
Question 1. In your testimony, you indicate that over the last 50
years, government and industry groups predicted a shortage of
physicians, then a surplus, and now they are predicting a shortage
again. With this knowledge, what steps should we take now to address
this situation, and prevent shortages from reaching severe levels?
Answer 1. As we noted in our testimony, research in recent years
has concluded that the Nation's over reliance on specialty care
services at the expense of primary care leads to a health care system
that is less efficient. We also note that the predominant form of
payment to physicians--fee-for-service--and the conventional resource-
based pricing of services undervalues primary care. Ideally, payment
system reforms that address this undervaluing of primary care services
should not strictly be about raising fees but rather about
recalibrating the value of all services, both specialty and primary
care. It is unclear, however, whether there is currently a shortage of
primary care physicians.
Question 2. Your testimony indicates that the total supply of
primary care professionals is going up, but that the supply of
nonphysicians is increasing faster than the supply of physicians. To
ensure adequate numbers of primary care providers, we will need to
continue encouraging both physicians and non-physician providers to
enter primary care specialties. What steps should we be taking now to
encourage each of these groups to enter primary care specialties?
Answer 2. As we noted in our testimony, the health care system's
financing mechanisms result in an uncoordinated system of care that
rewards specialty services and undervalues primary care services. For
example, primary care physicians, whose principal services are patient
office visits, are not able to increase the volume of their services
without reducing the time spent with patients, thereby compromising
quality. Moreover, the resource-based pricing system used by most
health care payers, including Medicare, results in higher fees for
procedure-based services performed by specialty physicians than for
``evaluation and management'' services.
Some physician organizations are proposing a new health care
delivery model that establishes a primary care provider as the central
coordinator of a patient's medical care. This ``medical home'' model
allows patients to select a clinical setting--such as their primary
care physician's practice--to act as the coordinator of their medical
needs, including specialty care. These ``medical home'' proposals call
for the primary care provider to be appropriately compensated for
performing coordination duties.
Question 3. Your testimony indicates that the conventional pricing
of physician services undervalues primary care and appears to be
counterproductive. Could you describe the system-wide financial benefit
of investing in primary care?
Answer 3. The benefits of primary care services that we noted in
our testimony include:
Patients of primary care physicians are more likely to
receive preventive services, to receive better management of chronic
illness than other patients, and to be satisfied with their care.
Areas with more specialists, or higher specialist-to-
population ratios, have no advantages in meeting population health
needs and may have ill effects when specialist care is unnecessary.
States with more primary care physicians per capita have
better health outcomes--as measured by total and disease-specific
mortality rates and life expectancy--than States with fewer primary
care physicians (even after adjusting for other factors, such as age
and income).
States with a higher generalist-to-population ratio have
lower per-beneficiary Medicare expenditures and higher scores on 24
common performance measures than States with fewer generalist
physicians and more specialists per capita.
questions of senator bingaman
Question 1. In reviewing the testimony you submitted in regard to
Primary Care Professionals, and their valuation of services, you
reported that fee for service payment provide no incentive for quality
or outcomes, and also disadvantage primary care physicians. You also
cite data that communities with higher generalist physician to
population ratios have better outcomes. The number applying to family
medicine and general internal medicine residencies has decreased when
we need them most.
Can you tell the committee about how you might create payment
mechanisms to coordinate care in a primary care home?
Answer 1. Some physician organizations are proposing the
establishment of a medical home model for patients in which a single
health professional coordinates all the services a patient needs,
including specialty care. The medical home model would also include a
refinement to current payment systems to ensure that the work involved
in coordinating a patient's care is appropriately compensated.
More specifically, the proposed medical home model allows patients
to select a single primary care provider to serve as the central
coordinator of their care. The medical home model seeks to ensure
continuity of care and guide patients and their families through the
complex process of making decisions about their treatments and
providers. The proposal includes a key modification to conventional
physician payment systems so that physicians receive payment for the
time spent coordinating care. These care coordination payments could be
added to existing fee schedule payments or included in a comprehensive,
per-patient monthly fee.
Question 2. Has MedPAC or the GAO made recommendations to institute
payment to assure an adequate primary care workforce?
Answer 2. During its March 2008 public meetings, MedPAC discussed
potential payment adjustments for primary care physicians under the
current Medicare payment system. Based on this discussion, MedPAC may
be making recommendations to the Congress on payment for primary care
services in its June 2008 report.
The GAO, however, has not made recommendations about refining
payment systems to ensure the adequacy of the primary care workforce.
questions of senator sanders
Question 1. In your testimony, you point out that the total number
of primary health care professionals has been increasing--yet the
number of U.S.-trained medical graduates has decreased while the number
of international medical graduates has increased. So in essence, the
United States is not really increasing the number of primary care
health professionals. Therefore, don't we have a shortage? What would
it take for the United States to eliminate its reliance on
international medical graduates?
Answer 1. Our testimony notes that in recent years, the supply of
primary care physicians grew faster than the population, resulting in
an increased supply of primary care professionals on a per capita
basis. Between 1995 and 2006, the composition of primary care physician
residents did change. A decline in the number of allopathic U.S.
medical school graduates (USMDs) selecting primary care residencies was
offset by increases in the numbers of international medical graduates
(IMGs) and doctor of osteopathy (DO) graduates entering primary care
residencies.
We did not evaluate the relative contributions of USMDs, IMGs, and
DOs to the provision of primary care services in the United States.
Question 2. In your investigation, you note that few projections
directly address the supply of primary care professionals and instead
focus on the supply of all physicians combined. In my mind, if you
don't measure it, it's an invisible problem. Who should be responsible
for collecting this data?
Answer 2. The Health Resources and Services Administration (HRSA)
collects and disseminates a significant amount of data on the health
care professions. In our testimony, we relied on these data, as well as
data from nongovernmental organizations that represent the health care
professions.
Question 3. In your testimony, you highlighted the concept of a
``medical home'' as a means of reforming health care to reemphasize
primary care. Would you provide specific suggestions for changes that
Congress would need to enact to advance this medical home model?
Answer 3. We do not have specific recommendations for the Congress
to enact the medical home model. Other organizations, including MedPAC,
are addressing the issue and may make recommendations to the Congress.
During its March 2008 public meetings, MedPAC discussed a potential
recommendation for the Congress to launch a medical home pilot project
in Medicare. Under this draft recommendation, the medical homes would
be required to meet ``stringent criteria,'' such as providing primary
care; using health information technology; conducting case management
services to coordinate services; maintaining 24-hour patient
communication and access; keeping up-to-date records of advance
directives by patients about their wishes if they become medically
incapacitated; and being accredited or certified by an external
accrediting body. The draft recommendation also states that physicians
who provide medical home services should receive a modest per-
beneficiary payment.
Some physician organizations have advocated for increases to the
Medicare resource-based fee schedule to account for time spent
coordinating care for patients with multiple chronic illnesses.
Supporters of the medical home model contend that it may be desirable
to develop payment models that blend fee-for-service payments with per-
patient payments to ensure that the system is appropriately reimbursing
physicians for primary, specialty, episodic, and acute care.
question of senator mikulski
Question. With the aging baby boomer generation and the shortage of
geriatricians, what can be done to increase the number of
geriatricians?
Answer. In our study, physicians in general practice, family
medicine and general internal medicine were regarded as providers of
primary care services. While we did not specifically examine
geriatricians, we would expect that all providers of primary care
services would benefit from a re-evaluation of such services in
Medicare's payment system.
questions of senator enzi
Question 1. Recognizing that most resident physicians practice
within a limited distance of their training site, and that the majority
of current residency training programs exist in or near the major
metropolitan cities on the East Coast, West Coast and Great Lakes
areas, what should be done to equalize the distribution of residency
training sites in the United States?
Answer 1. We did not evaluate the distribution of residency
training sites in the United States, or what effect the location of
residency training sites have on where physicians choose to practice.
Question 2. As the number of primary care doctors in proportion to
the population has actually risen, will you discuss the cause of the
perceived shortage of these physicians?
Answer 2. We are not aware of any information that demonstrates a
current shortage of primary care physicians.
HRSA issued a report projecting that the current supply of primary
care physicians will be sufficient to meet anticipated need through
about 2018, but it may fall short of the amount needed in 2020. HRSA
based its physician supply projections on the size and demographics of
the current physician workforce, expected number of new entrants, and
rate of attrition due to retirement, death, and disability.
The American Academy of Family Physicians (AAFP) also issued a
report projecting the number of family practitioners in 2020 could fall
short of the number needed, depending on growth in family medicine
residency programs.
questions of senator murkowski
Question 1. I have heard concerns that HRSA's Healthcare work
shortages designation in frontier areas are not accurately reflected by
the area's HPSA scores. Do you think that HPSA scores accurately
reflect shortage needs in frontier areas? Can you suggest ways to
modify HPSA score formula or additional consideration that might be
used to better measure shortages of health professionals in frontier
areas?
Answer 1. The Department of Health and Human Services (HHS)
published a notice of proposed rulemaking regarding the designation of
medically undeserved populations (MUPs) and health professional
shortage areas (HPSAs) on February 29, 2008 (Federal Register, Vol. 73,
No. 41, pp. 11232-11281). The proposed rule would revise and
consolidate the criteria and processes for designating MUPs and HPSAs,
designations that are used in a wide variety of Federal Government
programs. The Federal Register notice discussed the impact of the
proposed rule on (1) the distribution of designations by Metropolitan/
Non-Metropolitan and Frontier Status, and (2) the distribution of
population of underserved area and underserved populations by
Metropolitan/Non-Metropolitan and Frontier Status (see p. 11258).
We have not evaluated HHS's proposed changes to the HPSAs and MUPs,
or how these changes would affect the measurement of shortages of
health professionals in frontier areas.
Question 2. In discussing health care provider shortages in
Wyoming, I have heard of health care providers who are always on call
as they are the only health care provider in an area and I am concerned
about this added stress. What is the best way to account for the strain
of professional isolation on providers that geographic isolation causes
in frontier areas?
Answer 2. We have not evaluated the effects of professional
isolation on health care providers in frontier areas.
Response to Questions of Senators Kennedy, Mikulski, Bingaman, Clinton,
Sanders, Enzi, and Murkowski by Kevin Grumbach, M.D.
questions of senator kennedy
Question 1. Dr. Grumbach, in your testimony you say that we should
take an evidence-based approach to developing effective Federal
policies in health care. How would you suggest we target title VII
funding to strengthen our primary care infrastructure?
Answer 1. The primary care workforce goals for title VII funding
should guide the targeting of title VII funds. In my view,
reauthorization of title VII should make explicit the following two
goals for the primary care components of this program: (1) preparing
primary care physicians and physician assistants to transform the 21st
Century primary care medical home into a modernized, high-quality,
patient-centered practice model for all Americans, and (2) an
additional special focus on preparing primary care physicians and
physician assistants to care for underserved populations in the United
States. The guidelines for targeting of title VII funds that logically
follow from these goals are: (1) prioritize funding for training
programs that demonstrate that they are preparing students and
residents to lead innovative models of primary care (e.g., are
providing training in applications of the Chronic Care Model, open
access scheduling methods, use of electronic medical records, group
medical visits, innovative team-based care models, etc.), and (2)
prioritize funding for training programs that demonstrate that they are
teaching skills in the care of underserved populations (e.g., working
with interpreters, culture competence, integrating oral health care
into primary medical care), recruiting individuals from underserved
backgrounds (underrepresented minority, socioeconomically
disadvantaged, and rural backgrounds), and having significant numbers
of their graduates practicing in underserved communities and caring for
vulnerable populations.
Question 2. Dr. Grumbach, in your testimony you make the case that
primary care is the foundation of a well-performing health system.
Could you please tell us what the literature shows about the use of
primary care in terms of quality, cost, and equity outcomes?
Answer 2. Research evidence makes it clear that health systems
built on a solid foundation of primary care deliver more effective,
efficient, and equitable care than systems that fail to invest
adequately in primary care:
Costs: Patients with a regular primary care physician have
lower overall costs than those without. \1\ \2\ \3\ Compared with
specialty medicine, primary care provides comparable quality of care at
lower cost for a variety of conditions such as diabetes, hypertension,
and pneumonia. \4\ \5\ In comparisons of regions and States in the
United States, increased primary care physician to population ratios
are associated with reduced hospitalization rates and lower overall
health care costs. \6\ \7\
Quality: Counties and States with more primary care
physicians per capita--but not specialists--have better population
health indicators such as total mortality, heart disease and cancer
mortality, and neonatal mortality. \8\ \9\ \10\ Medicare patients in
these regions also receive better quality of care, including more
appropriate care for heart attacks, diabetes, and pneumonia.\7\
Patients with a primary care home are more likely to receive
appropriate preventive services such as cancer screening and flu shots.
\11\ \12\
Equity: Racial disparities are reduced when patients
receive care from a well- functioning medical home. The Commonwealth
Fund 2006 Health Care Quality Survey found that when adults have a
health care setting that provides timely, well- organized care and
enhanced access to the range of health providers, racial and ethnic
disparities in access and quality are reduced or eliminated. With a
medical home, minority patients are just as likely as whites to have
care when needed, receive preventive screening, and have chronic
conditions managed appropriately. \13\
question of senator mikulski
Question. With the aging baby boomer generation and the shortage of
geriatricians, what can be done to increase the number of
geriatricians?
Answer. The forces discouraging physicians from entering the field
of geriatrics are the same forces discouraging physicians from entering
primary care fields in general:
inadequate promotion of geriatrics in institutions of
medical education,
inadequate reimbursement for the practice of geriatrics,
which almost exclusively involves under-valued evaluation and
management (E&M) services, and
inadequate reforms in practice models to create and reward
more team-based, innovative models of care for patients with chronic
illness.
Addressing any one of these problems in isolation is unlikely to
solve the problem of the geriatrician workforce. For example, funding
for title VII programs in geriatric training is a necessary, but
insufficient, policy response. Such support must be coupled by reforms
of Medicare physician payment to provide more incentive for physicians
to practice geriatrics, such as by increasing fees for E&M services. In
addition, Medicare should develop more creative approaches to
supporting team-based primary care such as by adding a monthly care-
coordination payment and directly subsidizing hiring of case managers,
health ``coaches'' to assist patients in self-management of chronic
illness, and related staff for the comprehensive primary care team.
Such a payment scheme has been proposed by Gorol, et al. (Fundamental
reform of payment for adult primary care: comprehensive payment for
comprehensive care. J Gen Intern Med. 2007;22(3):410-5).
questions of senator bingaman
Question 1. Dr. Grumbach, thank you for your testimony, and for
taking your valuable time to share your expert knowledge with the
committee.
In reviewing and hearing your testimony, I note that you have data
that demonstrate that title VII funding is correlated with getting
doctors to practice in areas where they are most needed. Can you
discuss the data demonstrating title VII effectiveness?
Answer 1. Our own study that I cited, led by Dr. Diane Rittenhouse
and funded by the Bureau of Health Professions (HRSA), demonstrated
that Title VII Section 747 Primary Care Training grants are
significantly associated with physicians and physician assistants being
more likely to work at federally funded Community Health Centers (CHCs)
and join the National Health Service Corps. Ours was the most
comprehensive study of title VII outcomes performed to date, utilizing
comprehensive historical grant files from HRSA, a complete historical
record of all NHSC participants, a national data base on all currently
active U.S. physicians, and Medicare claims files.
The key findings for CHCs are displayed in the following table:
Number (%) of Physicians Exposed to Title VII Grants During Training That Worked in CHC (2001-2003)
----------------------------------------------------------------------------------------------------------------
All [In [In FP/GPs [In
specialties percent] PCPs only percent] only (6) percent]
----------------------------------------------------------------------------------------------------------------
Medical School Exposure (3):
Exposed During Medical School............. 5,934 3.0% 3,515 4.5% 2,258 6.2%
AAU grant............................... 847 3.0 506 4.8 301 6.5
Pre-doctoral grant...................... 1,624 2.7 914 4.1 574 5.7
Both grants............................. 3,465 3.1 2,095 4.6 1,383 6.4
Not-exposed During Medical School......... 4,007 1.9 1,814 3.0 950 4.3
Residency Exposure (5,6):
Exposed During Residency.................. N/A N/A 3,130 4.4 1,698 6.8
Not-exposed During Residency.............. N/A N/A 3,629 3.5 1,710 5.0
----------------------------------------------------------------------------------------------------------------
All are significant at p<0.001 for comparisons between exposed and non-exposed physicians, using chi square
tests.
(1) Includes all U.S. physicians who completed residency in 1977 or later.
(2) International and Canadian medical school graduates were excluded because they are not eligible for the
NHSC.
(3) International and Canadian medical school graduates were excluded because they could not be exposed to title
VII during medical school.
(4) Includes all U.S. physicians who completed residency in 1987 or later.
(5) Osteopathic physicians were excluded from residency analyses due to insufficient osteopathic residency data
in the AMA Masterfile.
(6) General practitioners were excluded from residency analyses because they generally do not undergo full
residency training.
Primary care = family medicine, general practice, general internal medicine, and general pediatrics.
Data source: 2004 AMA Physician Masterfile & Health Resources and Services Administration Title VII Training
Program Grantee Database; CMS Outpatient Claims File, 2001, 2002, 2003; & HRSA Bureau of the Health
Professions NHSC Participant Database.
Prior published research has demonstrated an association between
title VII grants to medical schools and increased production of primary
care physicians (PCPs) \14\ \15\ \16\ \17\ and a greater likelihood
that graduates will practice in underserved areas.\17\ \18\ The only
published study to examine title VII grants to residency programs was
limited to family physicians (FPs) in 9 States, and found that FPs who
were exposed to title VII grants during residency training were more
likely to practice in rural and low-income areas than other FPs.\18\
I have also performed research on title VII programs focused on
health professions diversity. I led a study, funded by the Bureau of
Health Professions (HRSA) and completed in 2002, that reviewed all the
research evidence on the effectiveness of educational pipeline
interventions designed to increase the number of underrepresented
minorities entering health and health science careers. This critical
review concluded that while there had been a relative paucity of high
quality, rigorous evaluations of pipeline programs conducted to date,
those studies which had been conducted did consistently demonstrate a
significant, positive effect of these interventions.
Question 2. Can you tell the committee when you submitted these
data or reports to HRSA, and how long it was before that data was
released to the public?
Answer 2. Our final report on our Title VII--Community Health
Center--NHSC study was submitted to HRSA in April, 2006. To our
knowledge, HRSA has not to date taken any action on this report. We
have not received any formal comments from HRSA about our report, and
the report has never been published by HRSA or released to the public.
My report to HRSA on diversity pipeline programs was reviewed by
staff in the Bureau of Health Professions in 2002, and we revised the
report in response to this review. HRSA accepted our revised report and
planned to publish the report as a government document, but a final
review by the Office of the Secretary of Health and Human Services
deemed the report inappropriate for publication and the report was
never released by the Federal Government. A revised version of the
report was published in 2003 under the sponsorship of a private
foundation, The California Endowment.
question of senator clinton
Question. In your testimony, you noted that the Title VII Primary
Care Training Grants are ``more likely to produce graduates who enter
primary care fields, work at Community Health Centers, and participate
in National Health Service Corps.'' Given that the National Health
Service Corps is having trouble filling all available positions, and
that we are seeing fewer and fewer medical school graduates entering
primary care, it is imperative that we work to support efforts to
increase the supply of primary care professionals.
Title VII programs have contributed to training thousands of New
York students. Multiple experts and the research literature stress the
importance of the programs, yet the Administration has criticized the
effectiveness of these programs.
The basis for such criticism is the use of the Program Assessment
Rating Tool (PART), which does not accurately reflect the multiple
goals of title VII programs.
Given the success of these programs in increasing the number of
primary care physicians, what outcome measures would you recommend as
appropriate in evaluating the true impact of these valuable training
programs?
Answer. In my response above to the first question from Senator
Kennedy, I alluded to goals and performance targets for title VII
programs. More specifically, in terms of outcomes measures, I believe
that many of the outcomes measures being collected by the Bureau of
Health Professions as part of its Comprehensive Performance Monitoring
System are very appropriate for evaluation of these programs. Among the
valuable outcomes measures currently collected by BHPr are:
The number of graduates of funded institutions entering
careers in primary care fields,
The number of students and residents from underrepresented
minority and socioeconomically disadvantaged backgrounds enrolling and
graduating from funded programs, and
The number of program graduates entering practice in
underserved communities and settings.
In a report our research team recently submitted to BHPr for a
contract examining approaches to evaluating BHPr programs (K Grumbach,
et al., Pipeline Programs to Improve Racial and Ethnic Diversity in the
Health Professions: An Inventory of Federal Programs, Assessment of
Evaluation Approaches, and Critical Review of the Research Literature;
submitted November 2008), we pointed out the need to invest resources
to create more capacity in BHPr to perform more centralized and
systematic evaluation of its programs, such as by enhancing BHPr
capacity for matching program enrollee and graduate data bases with
centralized data bases such as the AAMC files on national matriculation
data for U.S. medical schools. In addition, when interpreting outcomes
measures, it is important to not only examine outcomes in reference to
some desired benchmark or target for performance, but to also give
credit to programs and institutions that demonstrate improvement over
time towards meeting such benchmarks, even if they still fall short of
the actual benchmark.
questions of senator sanders
Question 1. Over the years, projections regarding future physician
supply and adequacy have proven to be less than accurate. I have a
couple of basic questions about what goes into computing the need for
physicians. What is the presumed optimal population to physician ratio
on which projections are based? What factors are involved in
determining an appropriate population to physician ratio? Have we got
it right?
Answer 1. Senator Sander's question cuts to the heart of how policy
analysts define the adequacy of physician supply. First, I would
respectfully suggest that the assertion ``projections regarding future
physician supply and adequacy have proven to be less than accurate'' is
only half true. Past projections of physician supply have actually been
pretty much on target. For example, the forecast of physician supply
for 2000 made by the national Graduate Medical Education Advisory
Commission in the 1980s turned out to be very close to the actual
number in 2000. The problem, therefore, in determining the adequacy of
physician supply has not so much been due to inaccuracies in
forecasting supply, but rather to disagreement about how many
physicians the Nation actually requires.
One approach to determining the adequacy of physician supply
defines adequacy on the basis of ``demand'' for medical care. Adherents
of this view point to the growing number of patient visits per capita
and growth in the overall economy as signals that demand for physician
services will significantly increase in coming years, and thus the
Nation will need more physicians per capita. Critics of this demand-
based approach argue that health care does not operate as a true free
market and that physicians are able to create demand for their own
services, even if these services do not necessarily benefit the health
of the public. These critics of demand-based planning argue that
requirements should be based on assessments of population ``need'' for
physicians, and include considerations of quality, affordability, and
prioritization of health care services. My own perspective tends to be
one of a needs-based approach to assessing physician requirements.
When examining the question of whether more physicians are actually
needed or the optimal supply of physicians, the research evidence shows
a weak link between patient outcomes and physicians per capita, with
the exception of studies of primary care physician supply. Health care
regions are remarkably adaptable to 2- and 3-fold differences in
overall physician supply across similar populations, achieving
comparable outcomes despite large variation in supply.\19\ The 10
percent ``shortfall '' in physicians per capita in 2020 predicted by
the Council on Graduate Medical Education's demand-based models \20\ is
dwarfed by the current 200 percent difference in the supply of
physicians across Dartmouth Atlas of Health Care Hospital Referral
Regions, adjusted for differences in population age and sex.\21\
Differences in patient needs do not explain variation in physician
supply across locales. For example, the age-sex adjusted regional
supply of cardiologists is unrelated to the incidence of acute
myocardial infarction among Medicare beneficiaries.\22\ Studies
examining outcomes associated with higher supply demonstrate that while
a very low supply of physicians is associated with higher mortality,
once supply is even modestly greater, patients derive little further
survival benefit.\23\ \24\ \25\ \26\
However, as noted above in response to Senator Kennedy's second
question, research indicates that health systems with primary care as
the foundation of care provide the best outcomes at the lowest costs.
In these primary care-oriented systems and regions, Medicare
beneficiaries have fewer specialists involved in an episode of care and
more visits with primary care physicians, spend fewer hospital days in
intensive care, and have lower health care costs. Such high performing
health care systems include prepaid group practices, integrated
delivery systems in fee-for-service payer environments, and other
models organized around primary care.\27\
In conclusion, to answer the question ``have we got it right?,''
the answer is definitely, ``No!'' We spend too much time preoccupied
with counting the numbers of physicians on the head of a pin and
conjecturing about the future demand for physicians, and not nearly
enough time examining whether we are effectively deploying the existing
physician workforce that we have in the United States. It is reasonable
to set some floor for the minimum adequacy of physician supply. For
example, current Federal policies consider a population-to-primary care
clinician ratio of 3500-to-1 or greater to be one of the criteria for
defining Health Professions Shortage Areas, which is a defensible
policy. But research on the physician workforce makes it abundantly
clear that there is wide variation in specialist physician supply
across regions above such as minimum level of supply, with no evidence
that regions with the highest supply have better health outcomes than
those with more moderate levels--and may in fact have worse outcomes.
What we do know is that having more of these physicians in primary care
fields is associated with less costly and better quality care, and that
incentives are needed to ensure that physicians are delivering the care
that is most needed and delivering it with high quality and safety. As
a health economist once commented about physician supply, ``Let's make
sure we are stirring up the sugar already in our cup of tea before
adding another spoonful.'' Determining the optimal number of physicians
has a lot to do with how well we stir up the ``sugar already in the
cup:'' our existing supply.
Question 2. You noted that the National Health Service Corps is an
effective strategy for increasing the number of primary care
physicians. I strongly agree. What specific recommendations would you
make to improve and expand the National Health Service Corps?
Answer 2. I recommend:
Doubling the number of loan-repayment positions,
Allowing more flexibility in determining prioritization
for NHSC placement sites,
Creating a leadership training program as part of the NHSC
to assist NHSC clinicians to become change agents in their practice
settings, for example by becoming leaders of Bureau of Primary Health
Care chronic care improvement collaboratives.
Question 3. In your expert opinion, do we need more U.S. medical
students and/or schools or do we only need to get more U.S.-medical
school graduates to fill the increasing number of primary care
residency slots that are not filled by U.S. graduates?
Does it concern you that the increase in those pursuing primary
care residencies is the result of international medical graduates? What
are the implications of this?
Answer 3. I support increasing the number of students graduating
from U.S. medical schools, but I do not advocate a similar major
expansion of graduate medical education (residency) slots in the United
States. What I recommend would result in more opportunity for qualified
U.S. students to become physicians, and less reliance on foreign-
educated physicians to fill U.S. residency training slots. Because the
United States has about 25 percent more first-year residency positions
than the number of annual U.S.-medical school graduates, there would be
room to accommodate more U.S. graduates in the existing residency
training slots. Over time, the increase in the number of U.S.-medical
school graduates would reverse the trend of many primary care residency
positions being filled by international medical school graduates,
mitigating the ``brain drain'' of physicians from developing nations.
Question 4. To prevent under- or over-supply of primary care
physicians in the future, what should we be monitoring and what
adjustments should be made to avoid subsequent crises in access?
Answer 4. We should continue to monitor the overall supply of
physicians in the United States. My own view is that we currently have
a reasonable overall supply of physicians per capita, and should avoid
either a large increase or decrease in this supply in the coming
decades. We should also continue to assess the specialty distribution
of the physician workforce, and implement policies to reverse what
appears to be an impending substantial decrease in the proportion of
physicians in primary care fields which has ominous implications for
access to primary care and the overall functioning of the entire health
system. We should also monitor the geographic distribution of
physicians, and emphasize policies to promote more equitable
distribution of physician supply for underserved rural and urban
communities.
We should also monitor data on patient reports of their access to
care, such as the information obtained from the regular Medicare
Beneficiary Surveys conducted by CMS. Recent data from this survey
indicate that Medicare beneficiaries are reporting more difficulty
accessing primary care physicians. In 2007, 29 percent of Medicare
beneficiaries reported a problem finding a primary care physician, up
from 24 percent in 2006. However, one caveat needs to be mentioned
about interpretations of patient reports on access to care. Regional
physician supply is only one factor among many that influence patients'
access to care. Among the strongest influences are whether the patient
has insurance, and whether physicians accept the patient's insurance.
If low payment rates leads some physicians to no longer accept Medicare
beneficiaries into their practice, Medicare beneficiaries may report
problems in access to care even when there is adequate physician
supply. In the case of access to primary care physicians, Medicare
beneficiary reports of deteriorating access to care appears to be
correlated with the falling off of the supply of primary care
physicians for adults, particularly the decrease in new physicians
entering general adult internal medicine, and less a matter of fewer
primary care physicians accepting Medicare beneficiaries because of
payment issues. An example of the payment issue is the findings of a
recent study of patients' access to dermatologists. The study found
that it was much easier for a patient requesting cosmetic treatment to
get an appointment with a dermatologist than a patient requesting
evaluation of a skin lesion that was suspicious for skin cancer. This
study revealed how the existing supply of physicians in a particular
specialty may not be deployed in a way that prioritizes access to care
for the most pressing health concerns of the population.
Question 5. In your testimony, you call for reform of how the
Medicare Graduate Medical Education funding is directed. Are you able
to provide specific language for the committee's consideration that
would accomplish what you propose?
Answer 5. The recommendations for reform of Medicare GME policies
that have been drafted by the Council of Graduate Medical Education and
will appear in the Council's 19th Report to be released in early April
2008, provide an excellent template for legislative language in this
regard. The draft recommendations published in the minutes of the
Council's September 18-19, 2007 meeting (http://www.cogme
.gov/minutes09_07.htm), are as follow:
Recommendation 1: Align GME with future healthcare needs.
a. Increase funded GME positions by a minimum of 15 percent,
directing support to innovative training models which address community
needs and which reflect emerging, evolving, and contemporary models of
healthcare delivery.
Recommendation 2: Broaden the definition of ``training venue''
(beyond traditional training sites).
a. Decentralize training sites.
b. Create flexibility within the system of GME which allows for new
training venues while enhancing the quality of training for residents.
Recommendation 3: Remove regulatory barriers limiting flexible GME
training programs and training venues.
a. Revise current Centers for Medicare & Medicaid Services (CMS)
rules that restrict the application of Medicare GME funds to limited
sites of care.
b. Use CMS's demonstration authority to fund innovative GME
projects with the goal of preparing the next generation of physicians
to achieve identified quality and patient safety outcomes by promoting
training venues that follow the Institute of Medicine's (IOM) model of
care delivery.
c. Assess and rewrite statutes and regulations that constrain
flexible GME policies to respond to emergency situations and situations
involving institutional and program closure.
Recommendation 4: Make accountability for the public's health the
driving force for graduate medical education (GME).
a. Develop mechanisms by which local, regional or national groups
can determine workforce needs, assign accountability, allocate funding,
and develop innovative models of training which meet the needs of the
community and of trainees.
b. Link continued funding to meeting pre-determined performance
goals.
c. Alter title VII in order to revitalize support for graduate
medical education.
Question 6. Similarly, you echo much of what Mr. Steinwald of the
GAO advocated in terms of a ``medical home'' model that would
reemphasize primary care in terms of Medicare payment reform. Are you
able to provide the committee with specific language that would
accomplish this?
Answer 6. Two key payment reforms for Medicare to which I alluded
in my testimony are (1) splitting the Sustainable Growth Rate (SGR),
and (2) adding a medical home care coordination payment, in addition to
fee-for-service payments for patient visits. The first proposal would
begin to address what Mr. Steinwald refers to as the ``undervaluing''
of traditional fee-for-service Medicare payments to primary care
physicians.
The legislative language for a splitting of the SGR would need to
include the following elements:
Separating Evaluation and Management (E&M) payments codes
and non-E&M codes into separate ``buckets,''
Assigning SGR targets to each bucket,
Calculating conversion factors for physician fees for each
bucket based on the actual pattern of Medicare expenditures in each
bucket relative to the SGR target for the bucket of services.
This policy could be implemented in a manner that would be cost-
neutral for overall Medicare payments to physicians, while creating a
more equitable distribution of payments between primary care and non-
primary care services. More details about such a policy and its
implications for revaluing or primary care payments may be found in our
analysis at http://www.ucsf.edu/cepc/_pdf/The%20Split%20SGR
%20Proposal.pdf.
The medical home care coordination payment would provide a
mechanism for compensating primary care physicians for the work that
they perform in comprehensively caring for patients beyond the time
spent in face-to-face visits. This type of care coordination payment is
particularly important for primary care physicians caring for patients
such as Medicare beneficiaries who have chronic illnesses requiring
considerable physician time to coordinate referral and ancillary
services, provide patient education on self-management, monitor
patients' status at home, and perform similar tasks. The Web site of
the Patient Centered Primary Care Collaborative, led by large
employers, primary care professional organizations, and other members,
provides more details about care coordination payments at http://
www.pcpcc.net/content/physician-payment-reform. The Centers for
Medicare and Medicaid Services is considering this type of payment
reform, in response to Section 204 of the Tax Relief and Health Care
Act of 2006 which mandates that CMS establish a medical home
demonstration to provide ``targeted, accessible, continuous, and
coordinated family-centered care to high-need populations.'' Options
being considered by CMS include a tiered coordination payment indexed
to the level of illness of each patient, with monthly payments of $10,
$20-25, and $54 for Tier I, II, and III patients, respectively. To
receive these payments, physicians would have to document that their
practice meets essential features of a well-functioning medical home,
such as being able to produce registries of patients in the practice
with chronic illnesses, generate reminders for services needed, provide
coaching in patient self-management, assure accessibility when care is
needed, etc.
North Carolina's Medicaid management program, known as Community
Care of North Carolina, successfully implemented a care coordination
payment for primary care. For a payment of $5.50 per Medicaid patient
per month, primary care practices in this Medicaid network use
evidence-based guidelines, track tests and referrals, and measure and
report on clinical and service performance. The program spent $8.1
million between July 2002 and July 2003, but it saved more than $60
million over historic expenditures. In the second year of the program
$10.2 million were spent but $124 million was saved. In 2005 the
savings grew to $231 million.
questions of senator enzi
Question 1. Recognizing that most resident physicians practice
within a limited distance of their training site, and that the majority
of current residency training programs exist in or near the major
metropolitan cities on the East Coast, West Coast and Great Lakes
areas, what should be done to equalize the distribution of residency
training sites in the United States?
Answer 1. Several models of decentralized residency training have
been successfully implemented in the United States, featuring rural-
based training sites linked to an academic hub at an urban medical
school. Examples include the rural family medicine residency tracks
affiliated with the University of Washington, University of Minnesota,
and University of New Mexico. Rural health centers and Critical Access
Rural Hospitals often serve as the training sites for these programs.
Other family medicine residency programs have developed partnerships
with federally funded community health centers to provide community-
based residency training as an alternative to centralizing all training
at large urban teaching hospitals. One of the most important actions
that the Federal Government could take to support these types of
decentralized residency training models would be to reform Medicare GME
payment policies so that these payments are not so tightly linked to
teaching hospitals and could be deployed to support training at rural
and urban health centers. (See my response to question three from
Senator Sanders for more information about suggested reforms of
Medicare GME.)
Question 2. The committee recognizes that there are many factors
that contribute to the waning interest in primary care, including
student debt, long hours, the physician fee schedule, a perceived lack
of prestige, and lack of exposure to primary care mentors. Of these
factors and others that may be present, can you rank these factors as
to the ones that have the greatest impact and that we should focus the
most resources on addressing?
Answer 2. Factors may be classified as ``pull factors'' and ``push
factors.'' Pull factors are those aspects of the practice environment
that either attract or deter medical students and physicians in
training from pursuing careers in primary care; these include earning
potential, lifestyle considerations, job opportunities, and the quality
of the practice environment. Push factors are factors in medical
education, such as prestige, role models, indebtedness, and the
training environment, that encourage or discourage individuals from
pursuing careers in primary care. Evidence suggests that pull factors
are most influential. It is therefore vital that Federal policies
address one of the most critical pull factors--the widening gap in
earnings between primary care and non-primary care physicians. Public
and private payers should also invest in improvements in the primary
care practice environment, such as by investing in installation and
maintenance of electronic medical records in primary care practices,
supporting the hiring of key support personnel for the primary care
team, and providing technical assistance for implementing innovative
practice models. At the same time, research I cited in my responses to
Senator Bingaman indicates that push factors also play a role and need
to be addressed. Title VII is one key mechanism for addressing push
factors. NHSC loan repayment programs that help to mitigate medical
student indebtedness are another important strategy.
questions of senator murkowski
Question 1. I have heard concerns that HRSA's Healthcare work
shortages designation in frontier areas are not accurately reflected by
the area's HPSA scores. Do you think that HPSA scores accurately
reflect shortage needs in frontier areas? Can you suggest ways to
modify HPSA score formula or additional consideration that might be
used to better measure shortages of health professionals in frontier
areas?
Answer 1. HRSA is currently in the process of modifying its
approach to designating Health Professions Shortage Areas. The proposed
new rules, published in the February 29, 2008 Federal Register, were
developed through a lengthy analytic process conducted by experts at
the Cecil G. Sheps Center of the University of North Carolina under
contract to HRSA, with input from many stakeholders in the designation
process. These proposed new rules should be carefully reviewed to
assess whether they will adequately reflect shortage needs in frontier
areas.
Question 2. In discussing health care provider shortages in
Wyoming, I have heard of health care providers who are always on call
as they are the only health care provider in an area and I am concerned
about this added stress. What is the best way to account for the strain
of professional isolation on providers that geographic isolation causes
in frontier areas?
Answer 2. There are several ways to support providers who work in
relative isolation in frontier communities. One way is to assist State
rural health associations to coordinate locum tenens relief programs
for rural providers, providing coverage for providers when they take
much needed time off for vacations and professional development.
Another way is to build virtual group practices through telemedicine.
Telemedicine offers several ways to support frontier providers, such as
by allowing specialists based at hub facilities to provide real-time,
remote consultations for patients being seen in the frontier provider's
office. Telemedicine can also provide a means to provide frontier
providers access to continuing medical education programs hosted at
urban sites through teleconferencing hook ups. The Federal
Communications Commission is currently sponsoring a telemedicine
initiative.
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Response to Questions of Senators Mikulski, Sanders, Enzi, and
Murkowski
by Roderick S. Hooker, Ph.D., P.A.
question of senator mikulski
Question 1. With the aging baby boomer generation and the shortage
of geriatricians, what can be done to increase the number of
geriatricians?
Answer 1. The role of the geriatrician in American healthcare is
vital, producing a number of benefits. However, it is difficult for
geriatricians to thrive in the current reimbursement structure. An
ideal ratio of geriatricians could be determined, followed by a planned
effort to produce this ratio.
When geriatricians team with physician assistants (PAs) and nurse
practitioners (NPs), there is a significant effect in lowering
hospitalization rates, lowering re-
admission rates, and improving satisfaction of patients and caregivers.
A team of two geriatricians and five PAs/NP can be remarkably effective
in cost containment and health outcomes. Vertically integrated prepaid
health plans and the Veterans Health Administration are the proving
grounds for the best use of geriatricians. The utility of geriatricians
continues to be revealed by demonstration projects such as the Social
HMO where the elderly are served in their homes instead of
institutions.
questions of senator sanders
Question 1. You made a compelling case for the role that Physician
Assistants and Nurse Practitioners can play in improving access and
overcoming shortages in the future supply of primary care
professionals. Can you give me some idea about a substitution effect?
For example, if we trained ``x number'' more PAs & NPs, we would need
``y fewer'' primary care physicians?
Answer 1. The ideal ratio of doctor to population is not yet known,
outside of certain large health maintenance organizations and the
military. A study performed 25 years ago determined that a PA can
offset 85 percent of a primary care physician's workload. This type of
study has not been repeated. What shapes this task transfer effect is
multifactorial: an aging population, advancing technology, and the
sustainability of chronic disease. Diabetes and rheumatoid arthritis
are examples of diseases that benefit from tighter control, resulting
in more office visits and laboratory monitoring (work that can be done
by a PA/NP). Also, the workweek of a doctor is shrinking, for various
reasons but sometimes due to employing PAs/NPs to ease their workload.
Up to 90 percent of a family medicine doctor's tasks can be delegated
to a PA or NP without compromising patient safety, and achieving
comparable outcomes of care and satisfaction.
Question 2. Are there any impediments or practice restrictions that
limit the use of PAs and NPs? If so, what are they and how could they
be overcome?
Answer 2. Forty years ago, an experiment was conducted by
introducing PAs and NPs into American society. The experiment was
successful in employing a team approach, thus expanding access to care.
Practice restrictions and impediments are lessening as research results
report the safety and capability are published. Many States have
adopted beneficial legislation for PAs. Progress for NP independent
practice has been slower. A national policy analysis on the utility of
PAs and NPs would give States better guidance.
question of senator enzi
Question. Recognizing that most resident physicians practice within
a limited distance of their training site, and that the majority of
current residency training programs exist in or near the major
metropolitan cities on the East Coast, West Coast and Great Lakes
areas, what should be done to equalize the distribution of residency
training sites in the United States?
Answer. The WWAMI (Washington, Wyoming, Alaska, Montana and Idaho)
program for Family Medicine residencies is a regional attempt to better
disperse residents. The WWAMI site in Casper, WY, is a model aimed at
sharing faculty development and family practice experience in less-
centralized areas. Residency sites in non-metropolitan areas may be
possible if leveraged with economic incentives. Creating areas of
medical training excellence in family medicine, general pediatrics, and
surgery in non-urban locations is possible through The National Area
Health Education Center Organization. This organization supports and
advances the Area Health Education Center (AHEC) network whose focus is
improving the health of individuals and communities by transforming
healthcare through education. Absent residency sites, PAs and NPs have
found these to be prime locations for clinical training.
questions of senator murkowski
Question 1. I have heard concerns that HRSA's Healthcare work
shortages designation in frontier areas are not accurately reflected by
the area's HPSA scores. Do you think that HPSA scores accurately
reflect shortage needs in frontier areas? Can you suggest ways to
modify HPSA score formula or additional consideration that might be
used to better measure shortages of health professionals in frontier
areas?
Answer 1. Health Professional Shortage Area (HPSA) scores do not
always reflect the geographical barriers (or enhancements) to primary
care. A gorge or mountain in Oregon may separate a population from a
clinic by time and/or distance 5 times longer than the air miles yet
the HPSA score may be low. Conversely being close to an Interstate in
east Texas may make healthcare access only 30 minutes away although the
distance is far and the HPSA score high. The Rural-Urban Commuting Area
Codes (RUCAs) is a new classification scheme that utilizes the standard
Bureau of Census Urbanized Area. Its value is it uses population
cluster definitions in combination with travel information to
characterize all of the Nation's Census tracts regarding their rural
and urban status and relationships. Matching HPSA with RUCAs offers a
refinement for understanding health professional shortages areas and
medically underserved areas.
Question 2. In discussing health care provider shortages in
Wyoming, I have heard of health care providers who are always on call
as they are the only health care provider in an area and I am concerned
about this added stress. What is the best way to account for the strain
of professional isolation on providers that geographic isolation causes
in frontier areas?
Answer 2. Role fatigue is one of the pitfalls for many healthcare
providers. Burnout occurs when the physician is ``on call'' all the
time. Rural doctors in the Far West may be at risk more than others due
to their scarcity and isolation. Coupling PAs and/or NPs with remote
and isolated physicians may relieve this role stress by providing
collegiality, respite and sharing the work burden. Medical
anthropological research is needed to better understand how scattered
populations in medical catchments and their providers view each other
in these circumstances.
Summary: Medical workforce research in the United States is only
now emerging from a descriptive phase and poised to undertake large
social experiments to improve care. Unfortunately innovative ideas and
creative research in this area have not always been well funded. While
the heterogeneity of the U.S. population present challenges for
healthcare, successful models are emerging. Sharing and learning what
works best under certain circumstances is critical. Finding the right
balance between optimal care and cost (and sustaining the balance) is
achievable. Flawed predictions were responsible for some of the
shortages today. Fortunately improved methods of calculating labor
supply and demands are now more reliable. Perhaps a central repository
of knowledge and a national health workforce action plan could
accomplish an improved understanding where emphasis is needed over
different time periods.
Response to Questions of Senators Mikulski, Bingaman, Clinton, Sanders,
Enzi, and Murkowski by Edward S. Salsberg, M.P.A.
questions of senator mikulski
Question 1. How can dental and medical schools be made more
affordable for the middle class?
Answer 1. The AAMC and its members share your concern with the
rising medical education debt. While we believe medicine is still an
excellent career choice for Americans, we too worry that some well-
qualified candidates may be discouraged from entering medicine and that
some physicians may be less likely to go into practice in an
underserved community. While we know of no easy solutions, the AAMC
recommends three steps that can begin to help:
Reinstate the 20/220 pathway of the Economic Hardship
Deferment in the ongoing Higher Education Act reauthorization;
Clarify that residency training qualifies as public
service under the new loan forgiveness program established by P.L. 110-
84 and that this is tax-exempt income; and
Significantly increase the number of awards given by the
National Health Service Corps.
The AAMC and its member institutions have for many years pursued a
common commitment to increase diversity among students attending U.S.
medical schools, based on a belief that including students from
different backgrounds, experiences, and identities enhances the
education of all medical students. While efforts have focused on
achieving racial and ethnic diversity, there also is a concern that
significant barriers confront students from all lower-income families.
Over the last three decades, the distribution of medical students by
family income has been remarkably consistent. The data suggests that
approximately 70 percent of medical students have come from the highest
two quintiles of family incomes (at least $57,660 in 2005).
In 2007, new medical school graduates reported an average
indebtedness of $140,000 and 87.6 percent graduated with some debt.
Under a typical 10-year repayment schedule at the current fixed 6.8
percent interest rate, the average medical resident can expect to have
a monthly loan payment greater than $2,000. With an average first-year
resident stipend of just over $3,700 a month, these sizeable loan
payments pose a substantial burden on young physicians while they
complete their medical training.
The Economic Hardship Deferment allows medical residents to
postpone repayment of their Federal student loans without penalty if
they meet the debt-to-income ratio requirement. Medical residents
qualify under this pathway (the ``20/220 pathway'') if: (1) they have
monthly loan repayments greater than 20 percent of their monthly
income; and (2) their monthly income minus their monthly loan payment
is less than 220 percent of a Federal poverty designation.
The recently enacted ``College Cost Reduction and Access Act''
(P.L. 110-84) eliminates this pathway requiring medical residents to
enter forbearance or a new income-based repayment program.
Unfortunately, the new income-based repayment program does not offer
medical residents the option to postpone loan repayment during their
initial years of residency. Rather, medical residents wishing to
postpone repayment will be forced to enter forbearance, during which
interest accrues on their entire Federal loan portfolio. On March 12,
2008, the AAMC and the American Medical Association urged the education
committees to re-instate the 20/220 pathway in the ongoing Higher
Education Act reauthorization.
P.L. 110-84 also creates a new public service loan forgiveness
program. While it is unclear which physicians will qualify, we are
pleased the program includes 501(c)(3) tax exempt organizations. It is
our understanding that medical residency training in teaching hospitals
will qualify as public service. We also urge Congress to clarify that
public service loan forgiveness should be tax-exempt income similar to
awards from the National Health Service Corps (NHSC).
The NHSC has the potential to both help the economically
disadvantaged and middle class medical students with the cost of
medical school and it is a very effective strategy to address the needs
of our most under-served communities through the service requirements.
The NHSC provides scholarship and loan repayment awards in exchange for
service in qualifying health professions shortage areas (HPSAs).
Considering the average medical education indebtedness, the majority of
physicians are able to forgive their entire educational debt after 5
years of service. Since its creation, the NHSC consistently has
received significantly more applications for positions than it is able
to support with the funding provided by Congress (approximately 10
applicants for every award). However, limited funding has reduced new
NHSC awards from 1,570 in fiscal year 2003 to an estimated 947 in
fiscal year 2008, a nearly 40 percent decrease. Funding for the NHSC
has decreased by $47 million since fiscal year 2003, over 27 percent of
its then $171 million
budget. In its June 2006 Statement on the Physician Workforce, the AAMC
recommended increasing annual NHSC awards to physicians by 1,500 to
allow more graduates to practice in underserved areas.
Question 2. With the aging baby boomer generation and the shortage
of geriatricians, what can be done to increase the number of
geriatricians?
Answer 2. Increasing the number of geriatricians requires a multi-
faceted approach, including changes to the delivery, financing, and
education systems. Raising the visibility of geriatrics among medical
students can be challenging given the current shortage of academic
geriatric faculty, who serve as important role models for medical
students. Further, emphasis on interdisciplinary learning as the health
system shifts to team-based systems of care is critical, particularly
in geriatrics. Interdisciplinary teams, in which health professionals
from multiple disciplines apply their special skills, knowledge and
values to achieve common goals, can enhance innovation, improve the
quality of patient care, and strengthen academic-clinical ties and
partnerships among institutions and settings.
Funding for the geriatrics programs under Title VII of the Public
Health Service Act has been instrumental in confronting these
challenges. The multidisciplinary geriatric education centers (GECs),
geriatric training programs (GTPs), and Geriatric Academic Career
Awards (GACAs) are effective in providing opportunities for health care
personnel to develop skills for providing better, more cost-effective
care for older Americans. Affiliated with educational institutions,
hospitals, nursing homes, community-based centers for the aged, and
veterans' hospitals, GECs include short-term faculty training,
curriculum, and other educational resource development, and technical
assistance and outreach. GTPs provide fellowships for medical and
dental faculty and provide for curriculum development, faculty
recruitment, and the first 3 months of fellowship training. GACAs
support career development of geriatricians in junior faculty positions
who are committed to academic careers teaching clinical geriatrics. In
fiscal year 2008, funding for the title VII geriatrics training
programs was $31 million, compared to $31.6 million in fiscal year
2005. The President's fiscal year 2009 budget request eliminates
funding for these programs. Increased support is necessary to allow the
programs to continue to prepare the health care workforce to care for
an aging population.
The AAMC has been encouraging changes in the education of
physicians to better prepare them to care for the elderly. Among other
initiatives, from 1999-2004, the AAMC coordinated and managed a grants
program for the John A. Hartford Foundation to enhance medical
education in gerontology and geriatrics. Through the program, 40 U.S.
medical schools received grants to develop and implement innovative
curricula that re-inforce the relevance and importance of geriatrics
throughout the 4 years of undergraduate medical education. The results
of the development, implementation, and evaluation of the curricula
were disseminated widely to all medical schools.
In July 2007, the AAMC hosted a consensus conference to develop
competencies in geriatrics education. The ultimate purpose of the
conference was to develop a consensus about the evidence that supports
the need for geriatrics education and establish standards for assessing
those outcomes. The competencies were defined and are available, and a
report of the consensus conference is in development. The AAMC and its
members continue to work to ensure that newly trained physicians are
well-schooled in providing high quality care for our senior population.
question of senator bingaman
Question. Mr. Salsberg--thank you for your testimony. In reviewing
your written testimony and hearing your brief comments, you mention the
importance of retaining diversity programs in title VII. The number of
rural applicants to medical school has remained the same, but the
number accepted has decreased 40 percent. In addition, the percentage
of underrepresented minority medical school graduates has remained
relatively stable at 13 percent, while the percentage of our
underrepresented minority population in the United States has grown to
25 percent. Data suggest that underrepresented minorities and rural
applicants are more likely to practice in rural and medically
underserved areas.
Does the AAMC have recommendations as to what we can do to increase
the percentage of underrepresented minority that graduate and rural
applicants that are accepted to our medical schools?
Answer. While the AAMC and its members have undertaken a number of
actions to address these issues, some of which are described below, we
think the Federal Government has an essential role to play as well.
Congress is at a critical juncture in terms of both rural residents and
underrepresented minorities entering medicine and other health
professions. As you know, the President has proposed eliminating all
funding for the extremely valuable programs under title VII that were
designed to address these issues. Assuring continued and adequate
funding for such programs as Area Health Education Centers (AHECs), the
Health Careers Opportunity Programs (HCOP) and Centers of Excellence
(COE) should be a priority.
The AAMC and its members have a decades-long commitment to building
diversity in medicine because diversity--both geographic and racial/
ethnic--in medical education improves the medical education environment
for all, and a more diverse physician workforce improves the Nation's
health care. Academic medical centers across the country employ a
spectrum of practices to build diversity in medicine, including
outreach and career awareness activities, mentoring, and summer
academic enrichment and research opportunities.
The AAMC compiles data annually on the demographics of applicants
and accepted students. The table below lists between 1992 and 2007 the
percentage of accepted students who provided a rural county of
residence when completing the American Medical College Application
Service (AMCAS). In 1992, 49 percent of rural applicants were accepted
to medical school, compared to 46 percent of rural applicants in 2007.
This ratio has remained relatively stable over the last 16 years,
fluctuating between 41 and 50 percent. These trends mirror those in the
total applicant pool; 47 percent of all applicants were accepted in
1992, compared to 45 percent in 2007, with acceptance percentages
varying between 37 and 50 percent.
----------------------------------------------------------------------------------------------------------------
Rural Total
Accepted/ Accepted/
AMCAS Year Rural Rural Applied Total Total Applied
Applicants Accepted [in Applicants Accepted [in
percent] percent]
----------------------------------------------------------------------------------------------------------------
1992.................................... 2,897 1,433 49% 37,402 17,465 47%
1993.................................... 3,324 1,445 43 42,806 17,361 41
1994.................................... 3,608 1,508 42 45,360 17,318 38
1995.................................... 2,842 1,201 42 46,586 17,356 37
1996.................................... 2,827 1,161 41 46,965 17,385 37
1997.................................... 2,666 1,112 42 43,016 17,312 40
1998.................................... 2,670 1,192 45 40,996 17,373 42
1999.................................... 2,543 1,151 45 38,443 17,421 45
2000.................................... 2,479 1,213 49 37,088 17,535 47
2001.................................... 2,417 1,182 49 34,860 17,454 50
2002 *.................................. 329 * 166 * 50 * 33,625 17,593 52
2003.................................... 2,184 1,094 50 34,791 17,542 50
2004.................................... 2,260 1,139 50 35,735 17,662 49
2005.................................... 2,277 1,121 49 37,373 17,987 48
2006.................................... 2,213 1,090 49 39,108 18,418 47
2007.................................... 2,369 1,097 46 42,315 18,858 45
----------------------------------------------------------------------------------------------------------------
* Incomplete data for rural applicants and acceptances in 2002.
As of 2006, 28.8 percent of the U.S. population was black/African-
American, Hispanic/Latino, or Native American, yet these groups
accounted for 14.6 percent of medical school graduates. The 2007
medical school applicant pool included more individuals from racial and
ethnic minorities than the previous year. The number of black male
applicants and Hispanic male applicants both increased by 9.2 percent
(higher than the growth rate of the total applicant pool, 8.2 percent).
The number of black males who ultimately were accepted and enrolled in
medical school increased by 5.3 percent, a rate nearly double that of
the first-year entrant increase overall. Hispanic male first-year
enrollees remained at the same level as 2006.
Outreach projects directed by the AAMC include a Minority Student
Medical Career Awareness Workshop and Recruitment Fair, which attracts
nearly 1,000 students annually, and AspiringDocs.org, a comprehensive
marketing campaign to increase diversity in medicine. Launched in the
fall of 2006, the AspiringDocs.org campaign takes a new approach--
career marketing--to encourage well-prepared
African-American, Hispanic/Latino, and Native American college students
from all undergraduate majors to pursue medicine as a career. The
interactive Web site featuring information, support, and encouragement
has logged 124,069 unique user visits and more than 3,373 registered
undergraduate and college graduate visitors since 2006.
Another reliable way to impact the applicant pool is to fortify the
pipeline that leads to a health professions education. Pipeline
programs, including those supported by title VII, play an important
role in promoting a health professions education at an early age and
helping to strengthen the math, science, and learning skills of
aspiring health professionals. The Title VII Area Health Education
Centers (AHECs), for example, offer an array of outreach activities for
students in rural and other undeserved areas. Federal funding for the
AHEC program, however, has slowly deteriorated over the last 9 years,
dropping from $33.4 million in fiscal year 2001 to $28.2 million in
fiscal year 2008.
Similarly, the Title VII Health Careers Opportunity Programs (HCOP)
and Centers of Excellence (COE) support the recruitment, retention, and
advancement of underrepresented minorities and disadvantaged students
in the health professions, through mentorship, academic and financial
support, and other activities. Since fiscal year 2006, the programs
have struggled to recover from virtual elimination of Federal funding
in fiscal year 2006. Despite a slight increase in fiscal year 2008,
funding for these programs remains well below fiscal year 2005 levels.
The AAMC strongly supports restoration of funding to fiscal year 2005
levels. The AAMC also recommends the creation of a new program under
title VII to support demonstration projects designed to increase the
number of underrepresented minority faculty. Underrepresented minority
faculty help create an environment that can minimize attrition rates
among minority health professions students through mentorship.
Loans, loan guarantees, and scholarships provided through the title
VII and other programs can play an instrumental role in diversifying
the health workforce as well. As mentioned previously, the NHSC has
demonstrated tremendous success in providing scholarships and loan
repayment for physicians that agree to serve rural and urban
underserved communities after completing residency training.
From 1996-2005, the AAMC directed the Health Professions
Partnership Initiative (HPPI). Funded by the Robert Wood Johnson and
W.K. Kellogg Foundations, HPPI supported collaboration between medical
and health professions schools, undergraduate institutions, and K-12
public school systems to improve curricula, provide learning
opportunities, and enhance academic performance among participating
students. The AAMC also has had 20 years of experience with what is now
the Summer Medical and Dental Education Program (SMDEP). SMDEP is a 12-
site summer academic enrichment program for underrepresented minority
and disadvantaged undergraduate students funded by the Robert Wood
Johnson Foundation and co-
directed by the AAMC and the American Dental Education Association.
From 1989 to 2005, 16,575 students participated in SMDEP. Of those
participants 60.9 percent (8,903) applied to medical school, and 64.3
percent of those who applied (5,723) were accepted.
Additionally, the AAMC is developing a comprehensive Holistic
Review Project to develop, distribute, and promote information and
tools to be used by medical schools in their efforts to create and
sustain institutional diversity--a specific focus on application and
admission processes linked to medical schools' missions and goals.
question of senator clinton
Question. In your testimony, you note the importance of Title VII
Primary Care Training Programs, specifically their role in
strengthening diversity of the workforce and improving professional
placements into under-resourced urban and rural communities.
You recommend reauthorization at levels greater than previously
funded. How do you recommend the funds be applied in order to maximize
outcomes?
Answer. Studies show that health centers and other clinics that
provide care to the underserved need more primary care physicians, as
well as physician assistants, and dentists. Primary care education
programs would benefit by providing their trainees access to sites in
underserved areas. The new structure proposed by the AAMC for the Title
VII Primary Care Training Programs would award grants preferentially to
applicants entering a formal relationship with one of these sites of
care (Output program) and would create a new program for demonstration
projects centered on improving the quality of primary care in selected
emphasis areas (New Competencies program). The AAMC recommends a
funding level of $198 million for the Primary Care Training Programs,
with the distribution among the disciplines and between undergraduate
and graduate programs to remain the same.\1\ A total of 80 percent of
this funding is directed to the Output program ($158.4 million) and 20
percent to the New Competencies program ($39.6 million).
---------------------------------------------------------------------------
\1\ Level recommended by the HRSA Advisory Committee on Training in
Primary Care Medicine and Dentistry.
---------------------------------------------------------------------------
Within the Output program, the AAMC reaffirms the funding
priorities and preferences outlined in existing statute and recommends
reserving a certain percentage of funding (e.g., 50 to 70 percent) for
already successful programs. The statute states: funding priority will
be given to applicants that have a significant improvement in the
percentage of providers entering primary care; preference will be given
to applicants that have a high rate for placing graduates in practice
settings having the focus of serving residents of medically underserved
communities or during the preceding 2 years have achieved a significant
increase in the rate of placing graduates in such setting.\2\ To
encourage new applicants, the AAMC further recommends a certain amount
of funding be reserved (e.g., 30 to 50 percent) for applicants that
outline a plan with strong potential to improve the number of their
students entering primary care and working in underserved areas.
---------------------------------------------------------------------------
\2\ Public Health Service Act, Sections 747(c) and 791(a).
---------------------------------------------------------------------------
questions of senator sanders
Question 1. Your Association is recommending a 30 percent increase
in medical school enrollment by 2015. Does this assume that we will
continue to rely on international medical graduates to be \1/4\ of our
physician workforce? If so, what would the U.S. enrollment increase
need to be to supplant our exploitation of poor countries?
Answer 1. The primary goal of the AAMC recommendation for a 30
percent increase in medical school enrollment is to promote an adequate
supply of well-educated physicians to meet the growing needs for care
in the United States. Based on the best available data, the Association
concluded that demand is likely to be rising more rapidly than supply
and steps are needed now to increase the total number of physicians
that will be available in the coming decades to serve a growing and
aging America.
Currently, more than 6,500 international medical graduates (IMGs)
enter the U.S. training system each year and nearly all stay to
practice in the United States. About a quarter of these physicians are
U.S. citizens who have gone abroad for medical education.
The recommended increase in enrollment assumes a continued flow of
international medical graduates into the United States. The recommended
30 percent increase in enrollment is equal to about 5,000 additional
graduates per year phased in between 2005 and 2015. This will not be
sufficient to meet all of the medical care needs of the Nation. We will
continue to need IMGs; the exact number is dependent on a number of
factors, including our success in improving the performance of the
delivery system. The Nation must also improve the efficiency and
effectiveness of our health care delivery system to make better use of
our physician supply. This includes increasing the supply of nurse
practitioners and physician assistants.
In the absence of major delivery system improvements, any
significant decrease in the number of international medical school
graduates would require significant additional increases in U.S.
medical school enrollment to ensure an adequate supply of physicians.
The AAMC is very concerned with the global need for physician
services and the potential impact of physicians migrating to the United
States from less developed countries. We believe America can and should
be a good global citizen and leader. To that end, the AAMC supports
efforts to improve medical education and health care throughout the
world. Increasing the number of U.S.-medical school graduates will
directly reduce the ``pull'' of physicians from less developed
countries without creating barriers for individual migration.
But there is more that needs to be done. The AAMC and its members
have valuable knowledge, skills and resources that would be of great
help to the medical community in less developed countries. Many AAMC
members already have begun to work with institutions and organizations
outside of the United States, demonstrating the commitment of the U.S.-
medical education community to improve health worldwide. These
initiatives include a wide range of programs and can involve medical
schools, teaching hospitals, medical students and physicians in
training.
As part of these efforts, the AAMC has joined with the Foundation
for Advancement of International Medical Education and Research
(FAIMER) and the Global Health Education Consortium (GHEC), to collect
information about international activities at U.S. medical schools.
More information on these programs is available at http://
www.faimer.org/resources/opportunities/index.html.
Question 2. If we don't significantly increase U.S. enrollment,
won't we be even more dependent on international medical graduates?
Answer 2. Yes, given expected shortages of physicians in the United
States, in the absence of a significant increase in medical school
enrollment, the expected increase in need and demand is very likely to
lead to an increasing demand for international medical graduates. We
worry that if we fail to increase the number of U.S. medical school
graduates and GME positions over the coming years, shortages will lead
to pressure to recruit even more physicians from abroad.
questions of senator enzi
Question 1. Recognizing that most resident physicians practice
within a limited distance of their training site, and that the majority
of current residency training programs exist in or near the major
metropolitan cities on the East Coast, West Coast and Great Lakes
areas, what should be done to equalize the distribution of residency
training sites in the United States? (AG)
Answer 1. The AAMC has called for an expansion of medical education
and training in the United States, and medical schools are responding.
However, the current restriction on Federal support of graduate medical
education (GME) through the Medicare program instituted through the
Balanced Budget Act of 1997 (P.L. 105-33) has severely limited the
ability of residency programs to respond to the impending shortage of
physicians. These shortages will be worse for those areas that are
already underserved and efforts must also be made to improve the
distribution of physicians nationwide.
The ``Resident Physician Shortage Reduction Act of 2007,'' (S. 588)
is a positive first step towards addressing the national shortage of
physicians in training. The bill will allow those States whose training
ratios fall below the national median level to begin the effort of
increasing the number of GME slots. This would be particularly helpful
to those areas of the country whose populations have grown most rapidly
and those that are already faced with an inadequate infrastructure for
training future physicians. While it is only a first step toward the
important elimination of the Medicare cap, it is a step in the right
direction.
Question 2. Mr. Salsberg: As the number of primary care doctors in
proportion to the population has actually risen, will you discuss the
cause of the perceived shortage of these physicians?
Answer 2. While the aggregate number of primary care physicians has
been increasing over the past several decades, there are growing
concerns with current and projected shortages of primary care
physicians. There are several reasons for this.
The need and demand for primary care services is rising.
This reflects a variety of factors including the growing number of
elderly and chronically ill who need far more primary care services
than others. For example, according to the National Ambulatory Medical
Care Survey, those over 65 make twice as many physician visits per
person per year as those under 65. As America ages and the number of
chronically ill increases we can expect total visits to physicians--
including primary care physicians--to continue to increase.
While the number of primary care physicians is still
growing, the U.S. population is growing more rapidly and may outpace
the growth in the supply of primary care physicians.
The length of an average visit also appears to be
increasing. This in part reflects the fact that visits by the elderly
take longer and their share of visits is increasing. Advances in
medicine and a wider array of diagnostic tests and interventions may
also be contributing to longer visits.
The physician workforce is aging; more than a third of
active physicians are now over the age of 55. This is important because
physicians in general tend to start to cut back on their work hours
slowly but steadily beginning in their early 50s.
In the past, younger physicians could be counted on to
pick up some of the extra demand; but the youngest generation of
physicians appears to be less willing to work the long hours worked by
earlier generations of physicians.
As need and opportunities in sub-specialties rise, an
increasing number of internal medicine and pediatric trainees are going
on to sub-specialize. While this helps meet the need for specialists,
it contributes to the shortage in primary care. An increasing number of
internists are also becoming hospitalists, working full time in the
hospital. While this may improve the quality of hospital care and
assist the community primary care physician, it also reduces the number
of physicians available to practice primary care in the community.
The demand and need for primary care physicians is expected to
continue to rise in the future for all of the reasons mentioned above.
This along with the decreasing number of physicians now going into
primary care, particularly among U.S.-medical school graduates, has
contributed to the growing concerns.
questions of senator murkowski
Question 1. I have heard concerns that HRSA's Healthcare work
shortages designation in frontier areas are not accurately reflected by
the area's HPSA scores. Do you think that HPSA scores accurately
reflect shortage needs in frontier areas? Can you suggest ways to
modify HPSA score formula or additional consideration that might be
used to better measure shortages of health professionals in frontier
areas?
Answer 1. A proposed new methodology for the designation of
Medically Underserved Areas (MUAs) and HPSAs (42 CFR parts 5 and 51c)
was published as proposed rules in the Federal Register on February 29,
2008. The Department of Health and Human Services is accepting comments
on the proposed new rules until April 29.
While we have not done an in-depth analysis of the proposed new
methodology, it was designed to respond to some of the concerns
expressed by rural communities. The proposed regulations were developed
in part by a research team at the University of North Carolina Cecil
Sheps Center. It appears that the new criteria will be more sensitive
to the needs of rural communities.
Question 2. In discussing health care provider shortages in
Wyoming, I have heard of health care providers who are always on call
as they are the only health care provider in an area and I am concerned
about this added stress. What is the best way to account for the strain
of professional isolation on providers that geographic isolation causes
in frontier areas?
Answer 2. Information technology and remote diagnosis and treatment
guidance will be vital to maximizing the effect of current health care
providers. In particular, strengthening linkages between providers in
remote areas with academic medical centers (teaching hospitals and
physicians) will better enable health professionals to utilize every
available expert that will benefit underserved populations. Recreating
these centers may not be feasible in every community; however, every
effort should be made to improve access to cutting edge health care by
patients and providers alike.
Thank you again for the opportunity to testify. The AAMC and its
member institutions look forward to working with Congress on this
important topic.
Response to Questions of Senators Mikulski, Enzi, and Murkowski
by Beth Landon, M.H.A., M.B.A.
question of senator mikulski
Question. With the aging baby boomer generation and the shortage of
geriatricians, what can be done to increase the number of
geriatricians?
Answer. Senator, as you are aware the aging of ``baby boomers''--
compounded with longer life expectancies and expectations for quality
of life--increasingly affect the delivery of health and social services
in our country. The need for health care professionals with training in
geriatrics will continue to grow in parallel. While there is ample
recognition of this phenomenon, funding is scarce to support training
in this arena. One noteworthy resource is the Geriatric Education
Center Program (GEC). Within Title VII of the Public Health Service
Act, GEC is legislatively required to develop the health professions
workforce providing geriatric services. They achieve this purpose with
programming in four areas:
i. Continuing education and continuing medical education
opportunities;
ii. Development and dissemination of curricula for the treatment of
health problems of elderly individuals;
iii. Instruction in geriatrics through a faculty-training program;
and
iv. Student clinical training in geriatrics, including geriatric
residencies, and traineeships.
As Congress continues its deliberations for reauthorization of
title VII programs, reauthorization of the GEC program, combined with
increased funding, is critical to our Nation's capacity to provide
competent geriatric health care.
question of senator enzi
Question. Recognizing that most resident physicians practice within
a limited distance of their training site, and that the majority of
current residency training programs exist in or near the major
metropolitan cities on the East Coast, West Coast and Great Lakes
areas, what should be done to equalize the distribution of residency
training sites in the United States?
Answer. Senator, your question highlights one of the great needs
for rural health in this country--rural training tracks for medical
residents. Rural training tracks, especially family medicine training
tracks, must be both developed and expanded. Family physicians
constitute nearly 90 percent of all primary care rural physicians and
are the only source of medical care in many remote rural communities.
Training programs designed for rural training have a proven track
record--76 percent of graduates of such programs are in rural
communities, while 61 percent were in federally designated HPSAs.
Despite this track record, only 29 of the 474 family medicine residency
programs in this country have an accredited rural training track and
only 143 programs offer a fellowship in rural medicine. Barriers exist
in rural physician residency programs and much of the need in rural
America for primary care is left unmet.
One of these barriers is a direct reflection of the caps under
Medicare Graduate Medical Education (GME) payments. To address rural
shortages, Congress created in statute a waiver to GME payment caps to
those programs that include integrated rural training tracks (IRTT).
Despite statutory authority, CMS has never approved an application for
this new training tract, claiming that Congress did not adequately
define IRTT. Therefore, Congress should clearly define this new IRTT,
thereby, exposing many more students to rural practice and receive
critical training in primary care, obstetrics, pediatrics, emergency
medicine and community health. This could have a large impact on the
future of rural training by encouraging a number of medical schools to
create these programs.
Compounding the difficulty in training a rural health workforce in
rural America is that the cost of going to medical school continues to
rise. Even in public medical schools, the cost has risen 900 percent in
the last 25 years. Rural students and those that will go into rural
medicine cannot afford these levels of debt as they will get paid less
than urban sub-specialists. Congress should continue to examine ways to
reduce this debt burden for those committed to practicing in rural,
underserved areas.
A final way of addressing the barriers around training physicians
and other health professionals in programs outside of the major
metropolitan cities in this Nation is through title VII and VIII
programs, such as Area Health Education Centers (AHECs). AHECs are
authorized to assist health professional schools to improve the
distribution, supply, quality, utilization and efficiency of health
personnel in scarcity areas through the efficient use of regional
educational resources. One way this is done is through AHEC Centers
that have clinical rotations.
questions of senator murkowski
Question 1. I have heard concerns that HRSA's Healthcare work
shortages designation in frontier areas are not accurately reflected by
the area's HPSA scores. Do you think that HPSA scores accurately
reflect shortage needs in frontier areas? Can you suggest ways to
modify HPSA score formula or additional consideration that might be
used to better measure shortages of health professionals in frontier
areas?
Answer 1. Senator, you are correct--the current HPSA scoring and
designation process do not accurately reflect shortages in frontier
areas, primarily due to processes based on urban, not rural,
communities. In fact, many of the most geographically-isolated
populations, who reside in frontier locations, often are not
categorized as a HPSA. These frontier regions are often ineligible for
a geographic designation because they exceed the required population to
provider ratio of 3,500:1. Receiving designation as a HPSA is critical
for all frontier areas because it would allow them to participate in
the NHSC program and other critical Federal programs.
A ``frontier designation'' can and should be added to the Health
Resource and Services Administration's list of HPSA designations. The
NRHA has developed designation criteria for a frontier HPSA using the
extensive input from health care leaders in seven frontier States. The
criteria currently in place, as well as anticipated proposed methods,
does not provide meaningful results in areas with sparse or
geographically isolated populations.
This new designation would establish ``Frontier'' as a geographic
area with fewer than seven people per square mile across a service
area, within which the time and/or distance to primary care is
excessive for the residents. Such areas should qualify as frontier
HPSAs whose populations are experiencing excessive time or distance to
primary care, oral health and mental health care.
It is important to note, that nearly all areas defined by this
definition as frontier are without public transportation. Many
experience dramatic seasonal fluctuations in population either for
employment or recreation, and many have seasonal weather barriers to
travel. For instance, the community of Unalaska, 800 air miles from the
nearest hospital, is served by a single community health center with
three and a half physicians and two mid-level providers. The population
fluctuates between 5,500 and 10,000 with the dangerous fishing seasons.
With this staffing, they are ineligible for consistent HPSA status,
compromising their ability to recruit and retain providers.
In addition to correcting HPSA inequities, other solutions exist to
strengthen the health care safety net in rural areas. As you know,
research consistently indicates that providers are more likely to work
in rural or frontier areas if they are from those areas or have spent
time in those areas. Title VII programs such as Area Health Education
Centers (AHEC) and Health Careers Opportunities Program (HCOP) are
specifically designed to support career exposure activities with youth
in the remote areas, improving their likelihood of matriculation into
those fields. AHECs prepare and socialize students to work in shortage
areas, and serve as a feeder program for the NHSC. Moreover, AHEC
supports health professions students to conduct part of their clinical
training in the remote areas.
For instance, as you know Senator Murkowski, one of the three AHEC
Centers in your State is located in Bethel, 500 air miles from
Anchorage in a region the size of Oregon with 25,000 residents living
in villages unconnected by roads. Securing health professionals in this
environment is extremely difficult. We know, from a study my office
conducted in 2006, that rural health organizations spend an average of
$106K to recruit a pharmacist and takes over 2.5 years (32.6 months) to
fill that vacancy. Last year, the Bethel AHEC Center coordinated and
funded 37 clinical rotations last year in medicine, dentistry,
pharmacy, and nearly 35 in other occupations. These are providers
recruited from programs in the Lower 48, since there is not an Alaskan
medical school. As a direct result of their clinical experiences in the
Bethel region, two of those pharmacy students have signed employment
contracts and one has already started. It is too early in training for
the medical or dental students to know if they will choose to return to
practice but we plan to get them out to Bethel for another clinical
rotation further along in their training. As we look at Alaska's
workforce shortages, and our Nation's, AHECs are a great investment in
providing residency training in rural and frontier communities.
Unfortunately, despite the importance of AHECs and other Title VII
Health Professions Programs to rural health care, Federal funding has
consistently decreased. The President's fiscal year 2009 budget request
eliminates funding for AHEC and other title VII programs. These
programs need to be adequately funded with appropriate inflationary
adjustments.
Question 2. In discussing health care provider shortages in
Wyoming, I have heard of health care providers who are always on call
as they are the only health care provider in an area and I am concerned
about this added stress. What is the best way to account for the strain
of professional isolation on providers that geographic isolation causes
in frontier areas?
Answer 2. Senator, AHEC is designed to decrease professional
isolation of practicing providers through programs that enhance
education, continuing education and new support programs. Studies have
shown that practitioners who serve as preceptors for health professions
students are more satisfied in their professional roles. They have
additional contacts with academic institutions through working with
students. AHECs design and deliver continuing education programs for
these providers. AHECs also provide support to these providers through
information dissemination on practice management, electronic health
records, and current best practices in clinical topics. AHECs work with
providers, facilities and local communities to strengthen recruitment
and retention of providers, as well as facilitating community planning
for the local health care system.
Mr. Chairman and other distinguished members of the committee,
thank you for this opportunity to respond to your questions on the
needs of a rural workforce. If you are in need of further follow-up or
clarification, please feel free to contact myself or Maggie Elehwany,
NRHA Vice President of Government Affairs and Policy (202-639-0550 or
[email protected]).
Response to Questions of Senators Sanders and Mikulski
by Jennifer S. Laurent, M.S., FNP-BC
question of senator sanders
Question. What restrictions exist nationwide that impede nurse
practitioner practice? Are they State specific or do they lend
themselves to action by Congress. What specifically would you recommend
Congress to do?
Answer. Rules and regulations for nurse practitioners (NPs)
practice vary State to State. Currently in 11 States NPs practice
independently (i.e. no physician involvement) they are ME, NH, AK, OR,
AZ, ID, MT, WY, NM, WA and the District of Columbia. Of the remaining
States restrictions vary from physician onsite oversite to written
practice agreements. The Pearson Report \1\ provides a detailed
overview of each State and their rules and regulations.
---------------------------------------------------------------------------
\1\ Pearson, L. (2008). Retrieved on March 17, 2008 at http://
www.webnp.net/downloads/pearson_report08/ajnp_pearson08.pdf.
---------------------------------------------------------------------------
Recognition of the value of NP high quality, cost-effective care by
Congress sends a strong signal to the States. Supporting bill S. 59:
Medicaid Advanced Practice Nurses and Physician Assistants Access Act
of 2007 which ``specifies as primary care case managers any nurse
practitioner, certified nurse-midwife, or physician assistant that
provides primary care case management services under a primary care
case management contract'' and ``revises the coverage of certain nurse
practitioner services under the Medicaid fee-for-service program to
remove the specification of certified pediatric nurse practitioner and
certified family nurse practitioner in order to extend such coverage to
services furnished by a nurse practitioner or clinical nurse
specialist.'' \2\
---------------------------------------------------------------------------
\2\ Library of Congress: Thomas. Retrieved on March 17, 2008 at
http://thomas.loc.gov/cgi-bin/bdquery/z?d110:SN00059:@@@L&summ2=m&.
---------------------------------------------------------------------------
The language in the Balanced Budget Act of 1997 is misleading and
created new barriers for NPs. State-driven Medicaid programs have
instituted Primary Care Case Management (PCCM) Programs. In many States
NPs have been excluded from these program provider panels resulting in
patients being denied access to NP services, primary care services, and
dual eligible Medicare/Medicaid patients from obtaining vital
prescriptions written by their NP. NPs are well recognized valuable
health care providers in Medicaid Managed Care and SCHIP programs in
the Nation and specifically in undeserved urban and rural communities.
Authorization of S. 59 will ensure continued access to high quality,
cost-effective primary care services for all individuals.\3\
---------------------------------------------------------------------------
\3\ AANP (2008). Medicaid managed care and SCHIP fact sheet
[electronic version]. Retrieved on March 14, 2008 at http://
www.aanp.org/NR/rdonlyres/ex312ckjf35s3pe5dlgqryyaxlxwmm
jedk2yhxzryd67tkv2ftfmarnxkgzkayhabrk6sgafg6ceowsj7h6gjmgrvzc/
Fact+Sheet+Medicaid+Man-
aged+Care+1-08.pdf.
---------------------------------------------------------------------------
Support S. 1678: Home Health Planning Improvement Act of 2007.
Currently, NPs are unable to order home health services for their
patients thereby requiring a M.D. provider to initiate care for an
unfamiliar patient potentially resulting in delay of necessary
services. This bill provides increased access to NPs health services
for Medicare beneficiaries which will expedite referrals for home care
services to those who need them and, in turn, decrease undue burdensome
paperwork for all parties.
Support S. 54: Nursing School Clinics Act. This bill would allow
Medicaid payment for services to NP faculty and students who provide
direct patient care in clinics within academic institutions as is
currently the model for medical residents.
Full recognition of NPs as PCP on a national level will serve as a
role model on State and local levels. Other recommendations include the
following:
Appointing NPs to national healthcare workgroups;
Avoiding ``physician'' only language;
Encouraging local legislators to follow Congresses lead.
These straight forward approaches prevent barriers to NP care and
enhance utilization of NPs as vital healthcare resources.
question of senator mikulski
Question. With the aging baby boomer generation and the shortage of
geriatricians, what can be done to increase the number of
geriatricians?
Answer. Nurse practitioners may specialize and receive board
certification in gerontology. Gerontological nurse practitioners (GNP)
are educated to diagnose and manage acute and chronic diseases using a
holistic approach to meet the complex medical, psychosocial, and
functional needs of older persons.
Unlike medical residency programs, NP programs are turning away
qualified NP applicants for several reasons.
Lack of faculty necessary to educate students;
Lack of funding for such programs;
Lack of scholarship funding.
Reauthorization and increased title VIII funding will improve the
workforce of geriatric nurse practitioners by providing and educating
the faculty that will be needed to accomplish the increased demand of
the baby boomer generation.
Thank you for the opportunity to provide further information. Nurse
practitioners are a valuable, untapped resource who are primed to
answer the primary care needs of the people by providing holistic, high
quality, health care. Should you require further information please do
not hesitate to contact me.\4\
---------------------------------------------------------------------------
\4\ [email protected] or [email protected].
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Response to Questions of Senators Mikulski, Bingaman, Brown, Enzi,
and Murkowski by HRSA
question of senator mikulski
Question. With the aging baby boomer generation and the shortage of
geriatricians, what can be done to increase the number of
geriatricians?
Answer. HRSA supports programs that provide direct primary care to
individuals for all life cycles, including the geriatric cycle. For
example, the 2009 HRSA budget supports funding for direct care services
through the National Health Service Corps (NHSC), the Nursing Education
Loan Repayment and the Nursing Scholarship programs.
In order to improve the distribution of health professionals and
improve the health of the underserved, the budget focuses on activities
that fund placement of more doctors, nurses and other health care
professionals in the regions of the country that face shortages.
The NHSC is building on its success in increasing health care
access for elderly and non-elderly residents of Health Professional
Shortage Areas, removing barriers to care, and improving the quality of
care to these underserved populations. The Nursing Education Loan
Repayment Program is providing nurses who can immediately begin
practicing in a health care facility with a critical shortage of
nurses. The Nurse Scholarship Program is reducing the financial barrier
to nursing education for professional nursing students, and thereby
increasing the pipeline supply of nurses who will care for elderly and
non-elderly patients. In addition to these programs, the fiscal year
2009 request includes funding for the Comprehensive Geriatric Nursing
program which will provide advanced practice nurses, registered nurses
and certified nursing assistants with specialized education and
training to care for the unique needs of the elderly.
questions of senator bingaman
Dr. Duke, we were disappointed that HRSA did not attend our hearing
on the health professions workforce. I and other committee members,
including Senators Kennedy, Harkin, Clinton, Obama, Murray, Reed,
Brown, Dodd, and Mikulski were disappointed that we were not provided
the 18th and 19th Council on Graduate Medical Education Reports in
advance of our hearing.
It is our understanding that the final versions of these reports
were submitted to HRSA in September 2007, and have yet to be forwarded
on to Secretary Leavitt. Despite multiple phone calls, e-mails, and the
formal request--those reports have yet to be released. One of our
expert witnesses had data demonstrating title VII effectiveness that
was delayed for many months. These data and reports are essential to
informing health professions workforce data and legislation to address
shortages especially in our rural and medically underserved areas.
Question 1. Why does it take so many months for HRSA to forward the
reports to the Secretary?
Answer 1. HRSA provides this timeline for the COGME reports in
question. On the last day of September, the 18th and 19th COGME reports
were submitted as documents for printing. The printed reports were
received the last week of December. During that period HRSA initiated
reviewing the reports, preparing comments and transmittal documents for
the HRSA Administrator to the Secretary. When HRSA completed its
review, the Administrator formally transmitted the reports to the
Office of the Secretary where pertinent components of this Office are
allocated 30 days to review the reports and HRSA's comments. Formal
release of these reports is expected in the near future.
Question 2. The Administration has eliminated funding for title VII
programs in the 2009 budget. Have HRSA staff been asked to delay
release of data, reports or recommendations that support expansion or
continuation of title VII programs?
Answer 2. The COGME, as is customary with similar advisory
committees, extends to the Department, i.e. the Secretary, the time
necessary to review reports before they are sent to the congressional
committees.
HRSA staff were not asked to delay these data releases or reports.
questions of senator brown
Question 1. I am aware the HRSA issued a report in May 2006 titled:
The Critical Care Workforce: A study of the Demand for and Supply of
Critical Care Physicians. The report concluded that there was a current
shortage of critical care physicians and that the shortage is projected
to worsen through 2020. The imbalance between supply and demand is
caused largely by the growth in the aging population and its predicted
increase use of critical care services. Do you agree with the findings
of the HRSA report and if so, what policy steps should Congress be
considering to address this physician shortage?
Answer 1. (See answer 2.)
Question 2. In your 2006 report on Physician Specialties, one of
the featured trends was specialty shortages, with vascular surgery
being the specialty with the least number of active physicians--2,452
or one for every 121,600 Americans. The majority of their patients are
Medicare beneficiaries and this population will be greatly increasing
when the Baby Boomer generation starts turning 65. What are your
recommendations for increasing the number of vascular surgeons and
other physician specialties that predominantly treat diseases of the
aged?
Answers 1 and 2. Numerous studies, including HRSA's May 2006 study,
have projected shortages for the physician primary care and
subspecialty workforces. Generally speaking, HRSA's statutory grant-
making authorities do not include programs that target the subspecialty
workforce. Funding through the Department of Education as well as
partnerships with private and corporate entities is available to
support health professions and meet anticipated needs.
question of senator enzi
Question. Recognizing that most resident physicians practice within
a limited distance of their training site, and that the majority of
current residency training programs exist in or near the major
metropolitan cities on the East Coast, West Coast and Great Lakes
areas, what should be done to equalize the distribution of residency
training sites in the United States?
Answer. The National Health Service Corps (NHSC) does not address
the distribution of residency training sites, but it does have an
impact on where physicians ultimately practice. It has been very
successful in placing and retaining clinicians in underserved areas
throughout the country. The NHSC's retention rate, the rate at which
clinicians remain in an underserved area at the conclusion of their
service commitment, measured at 1 year after service completion is
approximately 75 percent. The State Loan Repayment program, a matching
grant program for States, also helps to draw clinicians to underserved
areas in the United States by providing loan repayment to clinicians to
work in one of the 33 participating States.
questions of senator murkowski
Question 1. I have heard concerns that HRSA's Healthcare work
shortages designation in frontier areas are not accurately reflected by
the area's HPSA scores. Do you think that HPSA scores accurately
reflect shortage needs in frontier areas? Can you suggest ways to
modify HPSA score formula or additional consideration that might be
used to better measure shortages of health professionals in frontier
areas?
Answer 1. In the current HPSA methodology, HRSA works to take into
account the shortage needs in frontier and rural areas. One of the HPSA
scoring factors is time and distance traveled which is significant in
frontier and rural areas. Using this factor helps to portray a picture
of actual access to care in these areas.
On February 29, HRSA issued a Notice of Proposed Rulemaking (NPRM)
to revise the designation methodology for HPSAs and for Medically
Underserved Populations (MUP). The goal of the NPRM is to improve both
the methodology and the process for obtaining HPSA and MUP
designations. Under the NPRM, HRSA includes a population density factor
which is intended to reflect the shortage needs in frontier and rural
areas. HRSA realizes that frontier and rural areas face special issues
in accessing care, and we have sought to address those issues under the
current HPSA methodology and in our proposed methodology.
Question 2. In discussing health care provider shortages in
Wyoming, I have heard of health care providers who are always on call
as they are the only health care provider in an area and I am concerned
about this added stress. What is the best way to account for the strain
of professional isolation on providers that geographic isolation causes
in frontier areas?
Answer 2. The Department of Health and Human Services has sought to
recognize the strain of professional isolation for health professionals
practicing in frontier and rural areas. For example, Medicare Incentive
Payments provide an additional 10 percent in reimbursement than
otherwise permitted to physicians practicing in HPSA-designated areas.
In addition, telehealth programs can help to ameliorate
professional isolation by supporting professional quality of life in a
variety of areas. This includes supporting continuing education and
facilitating technology-mediated peer relationships. HRSA's 2009 budget
request includes $6.8 million for a range of telehealth activities,
including training for health care providers.
Last, higher education institutions can help prepare health-
professions students to practice in a variety of settings, including
rural and frontier areas. Faculty with experience in such settings
could be sought, and students with a rural background should be invited
to share their insights. Also mentoring arrangements in the form of
short-term student internships and more extensive training
opportunities in rural areas could foster networking that can continue
post-graduation.
[Whereupon, at 4:41 p.m. the hearing was adjourned.]