[Senate Hearing 111-656]
[From the U.S. Government Publishing Office]
S. Hrg. 111-656
PRIMARY HEALTH CARE ACCESS REFORM:
COMMUNITY HEALTH CENTERS AND THE
NATIONAL HEALTH SERVICE CORPS
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
ON
EXAMINING PRIMARY HEALTH CARE ACCESS REFORM, FOCUSING ON COMMUNITY
HEALTH CENTERS AND THE NATIONAL HEALTH
SERVICE CORPS
__________
APRIL 30, 2009
__________
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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 JOHN McCAIN, Arizona
BERNARD SANDERS (I), Vermont ORRIN G. HATCH, Utah
SHERROD BROWN, Ohio LISA MURKOWSKI, Alaska
ROBERT P. CASEY, Jr., Pennsylvania TOM COBURN, M.D., Oklahoma
KAY R. HAGAN, North Carolina PAT ROBERTS, Kansas
JEFF MERKLEY, Oregon
J. Michael Myers, Staff Director and Chief Counsel
Frank Macchiarola, Republican Staff Director and Chief Counsel
(ii)
?
C O N T E N T S
__________
STATEMENTS
THURSDAY, APRIL 30, 2009
Page
Sanders, Hon. Bernard, a U.S. Senator from the State of Vermont,
opening statement.............................................. 1
Clyburn, Hon. James E., a U.S. Representative from the State of
South Carolina................................................. 2
Bascetta, Cynthia, Director of Health Care, Government
Accountability Office (GAO), Washington, DC.................... 4
Prepared statement........................................... 5
Hawkins, Daniel R., Jr., Senior Vice President, National
Association of Community Health Centers, Bethesda, MD.......... 12
Prepared statement........................................... 14
Hatch, Hon. Orrin G., a U.S. Senator from the State of Utah...... 18
Brown, Hon. Sherrod, a U.S. Senator from the State of Ohio....... 19
Merkley, Hon. Jeff, a U.S. Senator from the State of Oregon...... 19
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of
Pennsylvania................................................... 19
Mullan, Fitzhugh, M.D., Murdock Head Professor of Medicine and
Health Policy, Washington, DC.................................. 20
Prepared statement........................................... 21
Evans, Caswell A., Jr., D.D.S., M.P.H., Associate Dean for
Prevention & Public Health Services, University of Illinois at
Chicago College of Dentistry, Chicago, IL...................... 33
Prepared statement........................................... 34
Davis, Yvonne, Community Health Center Board Member, Florence, SC 43
Prepared statement........................................... 45
Matthew, John D., M.D., The Health Center, Plainfield, VT........ 47
Prepared statement........................................... 48
Nichols, Lisa, Executive Director, Midtown Community Center,
Ogden, UT...................................................... 54
Prepared statement........................................... 55
Harkin, Hon. Tom, a U.S. Senator from the State of Iowa.......... 70
(iii)
PRIMARY HEALTH CARE ACCESS REFORM: COMMUNITY HEALTH CENTERS AND THE
NATIONAL HEALTH SERVICE CORPS
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THURSDAY, APRIL 30, 2009
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 10:00 a.m. in
Room SD-430, Dirksen Senate Office Building, Hon. Bernie
Sanders presiding.
Present: Senators Sanders, Harkin, Merkley, Hatch, Brown,
and Casey.
Opening Statement of Senator Sanders
Senator Sanders. Good morning. I am Senator Bernie Sanders
of Vermont. I want to welcome and thank all of our guests for
being here. I especially want to thank Congressman Jim Clyburn
of South Carolina for joining us today. It's important that he
be here because he has been a leader in the House of
Representatives on the issues of primary health care and
community health care centers in particular.
As I think everybody in this room understands our country
faces extraordinary problems in terms of health care. They run
the gamut. But I think one area where there is widespread and
clear understanding, where we have a major problem, is in terms
of primary health care. Some of you may have seen a front page
article in the New York Times just a few days ago highlighting
that issue.
The reality is a pretty simple one. At the time when 46
million Americans have no health insurance, that is not the
total problem. Because even if tomorrow, by some magical
circumstance, we were to pass a national health care program
and provide an insurance card for every American, we would by
no means solve the health care crisis.
We have some 60 million Americans, many with insurance, who
can't find a medical home. They can't find a doctor. They can't
find a dentist. They can't find mental health counseling. They
can't gain access to low cost prescription drugs.
Clearly what all of us understand is that there is not
going to be real reform or the bringing of cost effectiveness
to our health care system unless we address that issue.
I expect that our witnesses will be focusing on that as
well and what primary health care is all about and what
community health care centers do to make quality health care
and dental care and mental health counseling accessible to
people of all incomes in their community.
I look forward to hearing what our witnesses have to offer
about this. And let me just briefly tell you how this hearing
will proceed. Members, I suspect, will be dropping in and out.
But we will hear from Congressman Clyburn in a moment. Other
members, if they come in, will say a few words. Then we will
just go to brief comments, a couple of minutes each, from
members of the panel.
What we have found in general is that it is a richer
process if we exchange and engage in discussion, rather than us
giving you lengthy speeches and you giving us lengthy speeches.
So we will have a dialogue. We will have a conversation,
informal, and everybody should feel free to pop up and comment
whenever they want.
Now in the midst of a lot of bad news in our country, let
me give you some very good news. This is the result of the work
done by a lot of people, including many of our panelist, people
in the House, people in the Senate. Congressman Clyburn played
a great role in this.
We have in the stimulus package, taken this country a
major, major, major, major step forward in terms of improving
primary health care. At a time when community health care
centers were receiving about $2.1 billion a year, we basically
doubled in that package--doubled--it went from $2.1 to $4
billion, the amount of money going to community health centers.
Many are aware that President Obama, a month or so ago,
announced 126 new centers in 1 day, that is extraordinary.
In addition to that we all understand that we are not going
to solve the primary health care crisis unless we have far more
primary health care physicians and dentists and other medical
personnel.
Within that same stimulus package we almost tripled the
amount of money for the National Health Service Corps, going
from $120 million to $300 million.
So the good news is I think in a very bipartisan manner,
people understand the crisis and we are beginning to address
it.
Having said that, let me introduce Congressman Clyburn for
some opening remarks and then we will just take it to the
panel.
Jim.
STATEMENT OF HON. JAMES E. CLYBURN,
U.S. REPRESENTATIVE FROM SOUTH CAROLINA
Representative Clyburn. Let me thank you very much, Senator
Sanders, for allowing me to be a part of this hearing today.
Thank you so much for your tremendous leadership on this issue
that is very, very important to this great country of ours.
I do have a statement and I heard you when you made your
opening statement. This PK, this preacher's kid will get on the
soap box every now and again, so to resist that temptation I am
going to ask that you allow me to put my statement into the
record, but let me take a couple of minutes to thank a few
people.
I want to thank Ms. Davis for being here. She comes from a
county in my congressional district, Marion County, I believe.
Ms. Latian Woodard, comes from the county that I was born in.
Thank you so much for being here. And I want to say this about
Ms. Davis' county. Marion County today, as we sit here, is
situated along what we call the I-95 corridor that many of you
have heard referred to in recent weeks as the corridor of
shame. Many of you may recall that President Obama, when he
spoke to the joint session a few weeks ago, had with him a
student from Dillon County, next door to Marion, talking about
the educational problems along that corridor. I think that all
of us know that a big part of the problem that we have with
delivering accessible, affordable, quality health care to all
of our citizens has to do with a lack of education on so many
fronts, not just what may be garnered from the classroom, but
the lack of education on many fronts.
If I might use a personal experience. My wife, about 6
years ago had 5-vessel bypass surgery. On the night that she
took ill, we knew from her history, we knew from the symptoms
what was happening. And when the emergency room medical staff
wanted to send her back home, my daughters said, ``No. We are
not taking her back home. We know that there is something else
wrong. It is not over.''
Simply because they were educated to what could happen and
would happen with her history, and a few days later, they found
three 100 percent blockages, one 90 and one 50. Now what would
have happened but for the education about her condition that my
daughter's had when they would not take her back home that
night? I can think, as I said to the President last week, I can
think of no better way for us to put prevention at the center
of this problem than through community health centers.
We have got to pass H.R. 1296, as I call on the House side,
Senators Sanders has a different number on the Senate side.
Whatever it is, they are companion bills. We need to go from
1,100 health centers that we have now to 4,800, which will give
us 100 percent coverage, we need to increase the funding up to
$9 billion per year over a 5-year period of this new budget
that we just approved yesterday, and we need to do it now.
It will create not just the prevention measures that we
need, but it would create or adjust the shortages of the
deliverance of health care. It would create new employment
opportunities for people who we know represent services where
we have tremendous shortages.
So I am pleased to be here today and to put this in the
record and to say to Senator Sanders how much I appreciate
working with him on the bill, and to our staffs, thank you all
so much for making us look intelligent on these issues, and
thanks to my constituents for being here to help drive this
issue home.
Thank you, Senator Sanders.
Senator Sanders. Thank you very much Congressman Clyburn.
I am just looking at--just as one further word. I concur
with everything that the Congressman said, that at the end of
the day when we make this $8.5 billion investment, do you know
what we are also doing? We are saving money. How's that? We are
keeping people well. We are keeping them out of emergency
rooms. We are keeping them out of hospitals. And what the
studies suggest is we are saving substantial sums of money.
This is a win-win-win situation and we are going to go forward
and pass this legislation.
OK. Enough from us. My preference would be that people keep
their remarks brief so we can engage in a dialogue. Let's begin
with Ms. Bascetta, who is the director of health care for the
Government Accountability Office, the GAO. Cynthia, thank you
very much for being with us.
STATEMENT OF CYNTHIA A. BASCETTA, DIRECTOR OF HEALTH CARE,
GOVERNMENT ACCOUNTABILITY OFFICE (GAO), WASHINGTON, DC
Ms. Bascetta. Thank you, Senator Sanders and Mr. Clyburn. I
am happy to be here today to discuss our work on community
health-centered programs, whose mission, as you know, is to
increase access to primary health care services for the
medically underserved. More than 6,000 health center sites
provide comprehensive primary health care services to about 17
million people through preventative, diagnostic, treatment and
emergency services, as well as referrals to specialty care.
Although our work and the work of others has shown problems in
the referral process.
Our work focused on the provision of these services for
people who reside in the federally designated medically
underserved areas, called MUAs.
People served by health centers are often Medicaid
beneficiaries and the uninsured. And because more people in
employer-based health insurance may need to rely on health
centers in times of growing unemployment, the Recovery Act
anticipates a growth in demand for health center services and
it includes a significant infusion of funds for HRSA to expand
the program.
My remarks today are based on our August 2008 report for
which we analyzed data from HRSA's uniform data system,
commonly called the UDS.
We compared the location of health care center sites with
the locations of MUAs. At the time of our review, the most
recent UDS data available was for 2006. We also examined how
new access point grants awarded in 2007 changed the
distribution of health centers across MUAs.
Because of the UDS lag time, we contacted agency officials
this week, who told us that the most recent round of awards did
not significantly change our findings, which I am about to
report to you today.
We found that almost half of MUAs nationwide, 47 percent,
lacked a health center site. We also reported wide variation
among the four census regions, and across States and the
percentage of MUAs that lacked sites. Specifically 62 percent
of MUAs in the Midwest lacked a health center site compared to
32 percent in the West.
The awarding of new access point grants in 2007 was
modestly successful in reducing the number of MUAs without a
site to 43 percent, however differences between the regions
persisted. The West continued to show the lowest percentage of
MUAs without health center sites, 31 percent, while 60 percent
of MUAs in the Midwest still did not have health center sites.
We have a map in our testimony that shows significant
variation among States within those census regions.
The 2007 awards had minimal impact on regional variation
largely because more than two-thirds of the nationwide decline
in MUAs lacking a health center site occurred in the South
census region. HRSA awarded grants to 40 percent of applicants
in the South compared to only 17 percent in the Midwest.
In our report we also recommended that HRSA collect data on
the services provided at each site. Currently they only have
readily available data at the grantee level, which limits their
ability to place new sites where they are most needed.
We continue to believe that this information is essential
for HRSA to use in assessing any potential gaps or overlaps in
services and that it will more effectively distribute Federal
resources to meet primary health care needs, especially in
light of the stimulus.
[The prepared statement of Ms. Bascetta follows:]
Prepared Statement of Cynthia A. Bascetta
SUMMARY
Why GAO Did This Study
Health centers funded through grants under the Health Center
Program--managed by the Health Resources and Services Administration
(HRSA) of the U.S. Department of Health and Human Services (HHS)--
provide comprehensive primary care services for the medically
underserved. The statement GAO is issuing today summarizes an August
2008 report, Health Resources and Services Administration: Many
Underserved Areas Lack a Health Center Site, and the Health Center
Program Needs More Oversight (GAO-08-723). In that report, GAO examined
to what extent medically underserved areas (MUA) lacked health center
sites in 2006 and 2007. To do this, GAO obtained and analyzed HRSA data
and grant applications and interviewed HRSA officials.
What GAO Recommends
In its report, GAO recommended, among other things, that HRSA
collect site-specific data on services provided at each health center
site. HHS commented that collecting these data would be helpful for
many purposes, but would create a burden on grantees and add expense to
the program. While GAO acknowledges that effort and cost are involved
in program management activities, this information is essential for
effective HRSA decisionmaking on placement of new health center sites
and for evaluating potential service area overlap in MUAs.
What GAO Found
In its August 2008 report, which is summarized in this
statement, GAO found the following:
Grant awards for new health center sites in 2007 reduced
the overall percentage of MUAs lacking a health center site from 47
percent in 2006 to 43 percent in 2007.
There was wide geographic variation in the percentage of
MUAs that lacked a health center site in both years. (See figure.)
Most of the 2007 nationwide decline in the number of MUAs
that lacked a health center site occurred in the South census region,
in large part because half of all awards made in 2007 for new health
center sites were granted to the South census region.
HRSA lacked readily available data on the services
provided at individual health center sites.
GAO concluded that from 2006 to 2007, HRSA's grant awards to open
new health center sites reduced the number of MUAs that lacked a site
by about 7 percent. However, in 2007, 43 percent of MUAs continued to
lack a health center site, and the grants for new sites awarded that
year had little impact on the wide variation among census regions and
States in the percentage of MUAs lacking a health center site. GAO
reported that HRSA's grants to open new health center sites increased
access to primary health care services for underserved populations in
needy areas, including MUAs. However, HRSA's ability to place new
health center sites in locations where they are most needed was limited
because HRSA does not collect and maintain readily available
information on the services provided at individual health center sites.
Because each health center site may not provide the full range of
comprehensive primary care services, having readily available
information on the services provided at each site is important for
HRSA's effective consideration of need when distributing Federal
resources for new health center sites.
______
Mr. Chairman and members of the committee, I am pleased to be here
today to discuss our work on the extent to which health centers in the
Federal Health Center Program are located in areas having a shortage of
health care services. Health centers provide comprehensive primary
health care services--preventive, diagnostic treatment, and emergency
services, as well as referrals to specialty care--to federally
designated medically underserved populations (MUP), or those
individuals residing in federally designated medically underserved
areas (MUA).\1\ The people served by health centers include Medicaid
beneficiaries, the uninsured, and others who may have difficulty
obtaining access to health care. To fulfill the Health Center Program's
mission of increasing access to primary health care services for the
medically underserved, the Health Resources and Services Administration
(HRSA)--the agency within the U.S. Department of Health and Human
Services (HHS) that administers the Health Center Program--provides
grants to health centers.\2\ A health center grantee may provide
services at one or more delivery sites--known as health center sites.
HRSA does not require all health center sites to provide the full range
of comprehensive primary care services; some health center sites may
provide only limited services, such as dental or mental health
services. In 2006, approximately 1,000 health center grantees operated
more than 6,000 health center sites that served more than 15 million
people. Additional people may need to rely on health centers for their
care during the current economic period.
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\1\ The Health Resources and Services Administration designates
MUAs based on a geographic area, such as a county, while MUPs are based
on a specific population that demonstrates economic, cultural, or
linguistic barriers to primary care services.
\2\ In 2006, Health Center Program grants made up about 20 percent
of all health center grantees' revenues. Other Federal benefits include
enhanced Medicaid and Medicare payment rates and reduced drug pricing.
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Beginning in fiscal year 2002, HRSA significantly expanded the
Health Center Program under a 5-year effort--the President's Health
Centers Initiative--to increase access to comprehensive primary care
services for underserved populations, including those in MUAs. Under
the initiative, HRSA set a goal of awarding 630 grants to open new
health center sites--such grants are known as new access point grants--
and 570 grants to expand services at existing health center sites by
the end of fiscal year 2006. New access point grants fund one or more
new health center sites operated by either new or existing health
center grantees. In July 2005, we reported challenges HRSA encountered
during this expansion of the Health Center Program.\3\ In particular,
we found that HRSA's process for awarding new access point grants might
not sufficiently target communities with the greatest need for
services, although we concluded that changes HRSA had made to its grant
award process could help the agency appropriately consider community
need when distributing Federal resources. We also reported that HRSA
lacked reliable information on the number and location of the sites
where health centers provide care, and we recommended, among other
things, that HRSA collect this information. In response to our
recommendation, HRSA took steps to improve its data collection efforts
in 2006 to more reliably account for the number and location of health
center sites funded under the Health Center Program.
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\3\ GAO, Health Centers: Competition for Grants and Efforts to
Measure Performance Have Increased, GAO-05-645 (Washington, DC: July
13, 2005).
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By the end of fiscal year 2007, HRSA had achieved its grant goals
under the original President's Health Centers Initiative and launched a
second nationwide effort, the High Poverty County Presidential
Initiative. In fiscal year 2007, HRSA held two new access point
competitions, one focused on opening new health center sites in up to
200 HRSA-selected counties lacked a health center site--part of the
High Poverty County Presidential Initiative--and one that was an open
competition.\4\
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\4\ This new access point competition is described as open because
applicants were not required to be located in certain geographic areas
in order to apply, but were required to demonstrate in the proposal
that the health center and its associated sites would serve, in whole
or in part, an MUA or MUP.
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My statement today is based largely on our August 2008 report
entitled Health Resources and Services Administration: Many Underserved
Areas Lack a Health Center Site, and the Health Center Program Needs
More Oversight.\5\ In the August 2008 report, we examined, among other
things, (1) for 2006, the extent to which MUAs lacked health center
sites and the services provided by individual sites in MUAs, and (2)
how new access point grants awarded in 2007 changed the extent to which
MU lacked health center sites.
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\5\ GAO, Health Resources and Services Administration: Many
Underserved Areas Lack a Health Center Site, and the Health Center
Program Needs More Oversight, GAO-08-723 (Washington, DC: Aug. 8,
2008).
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In carrying out the work for our August 2008 report examining the
extent to which MUAs lacked health center sites and the services
provided by individual sites in 2006, we interviewed HRSA officials and
obtained health center site data from HRSA's uniform data system (UDS),
and then compared the location of health center sites with the location
of MUAs by census region and State.\6\ We limited our analysis to
health center sites operated by grantees that received community health
center funding--the type of funding that requires sites to provide
services to all residents of the service area regardless of their
ability to pay.\7\ In addition, because HRSA takes into account the
location of federally qualified health center look-alike sites--
facilities that operate like health center sites but do not receive
HRSA funding \8\--when deciding where to award new access point grants,
we obtained from HRSA the location of health center look-alike sites in
2006 and compared them with the location of MUAs. To examine how new
access point grants awarded in 2007 changed the extent to which MUAs
lacked health center sites nationwide, we obtained data from HRSA and
compared the location of proposed and funded new health center sites in
2007 with the location of MUAs in 2007.\9\ As with the 2006 analysis,
we limited our review to health center sites operated by grantees that
requested community health center funding, and we obtained from HRSA
the location of health center look-alike sites in 2007 and compared
them to the location of MUAs in 2007. We discussed our data sources
with knowledgeable agency officials and performed data reliability
checks, such as examining the data for missing values and obvious
errors, to test the internal consistency and reliability of the data.
After taking these steps, we determined that the data were sufficiently
reliable for our purposes. We conducted the performance audit for the
August 2008 report from 2007 through July 2008, in accordance with
generally accepted government auditing standards. Those standards
require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives. A detailed explanation of our
methodology is included in our August 2008 report.
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\6\ In our report, we considered the District of Columbia a State.
\7\ 42 U.S.C. 254b(a)(1). In contrast, HRSA grantees that operate
health center sites targeting migrant farmworkers, public housing
residents, and the homeless are not required to serve all residents of
their service areas. 42 U.S.C. 254b(a)(2). Because the UDS does not
allow separate identification of individual health center sites for
grantees that receive a combination of community health center funding
and health center funding to target migrant farmworkers, public housing
residents, or the homeless (27 percent of all grantees in 2006), we
could not distinguish sites supported exclusively by community health
center funding from sites supported exclusively by health center
funding for migrant farmworkers, public housing residents, or the
homeless. Therefore, we included all sites associated with health
center grantees that received, at a minimum, community health center
funding (90 percent of all grantees in 2006). As a result, some health
center sites included in our analysis are not sites exclusively
supported by community health center funding.
\8\ Some organizations choose not to apply for funding under the
Health Center Program; however, they seek to be recognized by HRSA as
federally qualified health center look-alikes, in large part, so that
they may become eligible to receive other Federal benefits, such as
enhanced Medicare and Medicaid payment rates and reduced drug pricing.
For our purposes, federally qualified health center look-alike sites
are referred to as health center look-alike sites.
\9\ Because the UDS had not been updated for 2007 at the time of
our review, we could not determine whether any health center sites that
were in operation in 2006 were no longer operating in 2007; therefore,
we assumed that all health center sites operating in 2006 were still
operating in 2007.
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In brief, we found that grant awards for new health center sites in
2007 reduced the overall percentage of MUAs lacking a health center
site from 47 percent in 2006 to 43 percent in 2007. In addition, we
found wide geographic variation in the percentage of MUAs that lacked a
health center site in both years. We reported that, for 2006, we could
not determine the types of services provided by individual health
center sites in MUAs because HRSA does not collect and maintain data on
the types of services provided at each site. Because HRSA lacks readily
available data on the types of services provided at individual sites,
the extent to which individuals in MUAs have access to the full range
of comprehensive primary care services is unknown. In reporting on
geographic variation, we found that, for 2007, the West and Midwest
census regions continued to show the lowest and highest percentages,
respectively, of MUAs that lacked health center sites. In addition,
three of the four census regions showed a 1 or 2 percentage point
decrease since 2006 in MUAs that lacked a health center site, while the
South census region showed a 5 percentage point decrease. The minimal
impact of the 2007 awards on geographic variation overall was due, in
large part, to the fact that the majority of the decline in MUAs that
lacked a health center site was concentrated in the South census
region, which received the largest proportion of the awards made in
2007. To help improve the agency's ability to measure access to
comprehensive primary care services in MUAs, we recommended that HRSA
collect and maintain readily available data on the types of services
provided at each health center site. In commenting on a draft of our
report, HHS raised concerns regarding this recommendation. HHS
acknowledged that site-specific information would be helpful for many
purposes, but said collecting this information would place a
significant burden on grantees and raise the program's administrative
expenses.
While we acknowledge that effort and cost are involved in program
management activities, we believe that having site-specific information
on services provided is essential to help HRSA better measure access to
comprehensive primary health care services in MUAs when considering the
placement of new health center sites and to facilitate the agency's
ability to evaluate service area overlap in MUAs.
almost half of muas lacked a health center site in 2006, and types of
services provided by each site could not be determined
In August 2008, we reported that almost half of MUAs nationwide--47
percent, or 1,600 of 3,421--lacked a health center site in 2006,\10\
and there was wide variation among the four census regions and across
States in the percentage of MUAs that lacked health center sites. (See
fig. 1) The Midwest census region had the most MUAs that lacked a
health center site (62 percent), while the West census region had the
fewest MUAs that lacked a health center site (32 percent). More than
three-quarters of the MUAs in 4 States--Nebraska (91 percent), Iowa (82
percent), Minnesota (77 percent), and Montana (77 percent)--lacked a
health center site. (See Appendix I for more detail on the percentage
of MUAs in each State and the U.S. territories that lacked a health
center site in 2006.) In 2006, among all MUAs, 32 percent contained
more than one health center site; among MUAs with at least one health
center site, 60 percent contained multiple health center sites, with
about half of those containing two or three sites. Almost half of all
MUAs in the West census region contained more than one health center
site, while less than one-quarter of MUAs in the Midwest contained more
than one site. The States with three-quarters or more of their MUAs
containing more than one health center site were Alaska. Connecticut,
the District of Columbia, Hawaii, New Hampshire, and Rhode Island. In
contrast, Nebraska, Iowa, and North Dakota were the States where less
than 10 percent of MUAs contained more than one site.
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\10\ When we included the 294 health center look-alike sites
operating in 2006, we found that the percentage of MUAs lacking either
a health center site or health center look-alike site in 2006 was 46
percent (or 1,564 MUAs).
We could not determine the types of primary care services provided
at individual health center sites because HRSA did not collect and
maintain readily available data on the types of services provided at
individual sites. While HRSA requests information from applicants in
their grant applications on the services each site provides, in order
for HRSA to access and analyze individual health center site
information on the services provided, HRSA would have to retrieve this
information from the grant applications manually. HRSA separately
collects data through the UDS from each grantee on the types of
services it provides across all of its health center sites, but HRSA
does not collect data on services provided at each site. Although each
grantee with community health center funding is required to provide the
full range of comprehensive primary care services, HRSA does not
require each grantee to provide all services at each health center site
it operates. HRSA officials told us that some sites provide limited
services--such as dental or mental health services. Because HRSA lacks
readily available data on the types of services provided at individual
sites, it cannot determine the extent to which individuals residing in
MUAs have access to the full range of comprehensive primary care
services provided by health center grantees. This lack of basic
information can limit HRSA's ability to assess the full range of
primary care services available in needy areas when considering the
placement of new access points and can also limit the agency's ability
to evaluate service area overlap in MUAs.
2007 AWARDS REDUCED THE NUMBER OF MUAS THAT LACKED A HEALTH CENTER
SITE, BUT WIDE GEOGRAPHIC VARIATION REMAINED
In August 2008, we reported that our analysis of new access point
grants awarded in 2007 showed that these awards reduced the number of
MUAs that lacked a health center site by about 7 percent. Specifically,
113 fewer MUAs in 2007--or 1,487 MUAs in all--lacked a health center
site when compared with the 1,600 MUAs that lacked a health center site
in 2006. (See Appendix I) As a result, 43 percent of MUAs nationwide
lacked a health center site in 2007.\11\ Despite the overall reduction
in the percentage of MUAs nationwide that lacked health center sites in
2007, regional variation remained. The West and Midwest census regions
continued to show the lowest and highest percentages of MUAs that
lacked health center sites, respectively. (See fig. 2) Three of the
four census regions showed a 1 or 2 percentage point decrease since
2006 in the percentage of MUAs that lacked a health center site, while
the South census region showed a 5 percentage point decrease.
---------------------------------------------------------------------------
\11\ When we included the 265 health center look-alike sites
operating in 2007, we found that 1,462 MUAs lacked a health center site
or health center look-alike site in 2007, which did not change the
overall percentage (43 percent) of MUAs in 2007 that lacked a health
center site.
We found that the minimal impact of the 2007 awards on regional
variation was due, in large part, to the fact that more than two-thirds
of the nationwide decline in the number of MUAs that lacked a health
center site--77 out of the 113 MUAs--occurred in the South census
region. In contrast, only 24 of the 113 MUAs were located in the
Midwest census region, even though the Midwest had nearly as many MUAs
that lacked a health center site in 2006 as the South census region.
While the number of MUAs that lacked a health center site declined by
12 percent in the South census region, the other census regions
experienced declines of about 4 percent. The South census region
experienced the greatest decline in the number of MUAs lacking a health
center site in 2007 in large part because it was awarded more new
access point grants that year than any other region. Specifically, half
of all new access point awards made in 2007--from the two separate new
access point competitions--went to applicants from the South census
region. For example, when we examined the High Poverty County new
access point competition, in which 200 counties were targeted by HRSA
for new health center sites, we found that 69 percent of those awards
were granted to applicants from the South census region. The greater
number of awards made to the South census region may be explained by
the fact that nearly two-thirds of the 200 counties targeted were
located in the South census region. When we examined the open new
access point competition, which did not target specific areas, we found
that the South census region also received a greater number of awards
than any other region under that competition. Specifically, the South
census region was granted nearly 40 percent of awards; in contrast, the
Midwest received only 17 percent of awards.
CONCLUDING OBSERVATIONS
In our August 2008 report, we noted that awarding new access point
grants is central to HRSA's ongoing efforts to increase access to
primary health care services in MUAs. From 2006 to 2007, HRSA's new
access point awards achieved modest success in reducing the percentage
of MUA's that lacked a health center site nationwide. However, in 2007,
43 percent of MUAs continued to lack a health center site, and the new
access point awards made in 2007 had little impact on the wide
variation among census regions and States in the percentage of MUAs
lacking a health center site. The relatively small effect of the 2007
awards on geographic variation may be explained, in part, because the
South census region received a greater number of awards than other
regions, even though the South was not the region with the highest
percentage of MUAs lacking a health center site in 2006.
We reported that HRSA awards new access point grants to open new
health center sites, which increase access to primary health care
services for underserved populations in needy areas, including MUAs.
However, HRSA's ability to target these awards and place new health
center sites in locations where they are most needed is limited because
HRSA does not collect and maintain readily available information on the
services provided at individual health center sites. Having readily
available information on the services provided at each site is
important for HRSA's effective consideration of need when distributing
Federal resources for new health center sites, because each health
center site may not provide the full range of comprehensive primary
care services. This information could also help HRSA assess any
potential overlap of services provided by health center sites in MUAs.
Mr. Chairman, this concludes my prepared statement. I would be
happy to answer any questions that you or members of the committee may
have.
______
Appendix I
Number and Percentage of Medically Underserved Areas (MUA) Lacking a Health Center Site, 2006 and 2007
----------------------------------------------------------------------------------------------------------------
Total no. of No. of MUAs Percentage of
MUAs lacking a health MUAs lacking a
------------------ center site health center
------------------ site
2006 2007 -----------------
2006 2007 2006 2007
----------------------------------------------------------------------------------------------------------------
Midwest census region..................................... 1,027 1,029 641 617 62 60
Illinois................................................ 146 143 71 63 49 44
Indiana................................................. 61 61 35 34 57 56
Iowa.................................................... 73 73 60 56 82 77
Kansas.................................................. 66 71 49 52 74 73
Michigan................................................ 89 89 44 43 49 48
Minnesota............................................... 96 97 74 75 77 77
Missouri................................................ 116 116 62 58 53 50
Nebraska................................................ 82 82 75 73 91 89
North Dakota............................................ 55 55 40 39 73 71
Ohio.................................................... 111 110 48 42 43 38
South Dakota............................................ 65 65 40 40 62 62
Wisconsin............................................... 67 67 43 42 64 63
Northeast census region................................... 395 400 153 147 39 37
Connecticut............................................. 17 17 1 1 6 6
Maine................................................... 30 32 10 11 33 34
Massachusetts........................................... 40 40 10 9 25 23
New Hampshire........................................... 5 5 1 1 20 20
New Jersey.............................................. 28 28 1 1 4 4
New York................................................ 115 116 56 53 49 46
Pennsylvania............................................ 137 139 63 61 46 44
Rhode Island............................................ 7 7 0 0 0 0
Vermont................................................. 16 16 11 10 69 63
South census region....................................... 1,435 1,441 651 574 45 40
Alabama................................................. 96 96 24 19 25 20
Arkansas................................................ 92 93 38 33 41 35
Delaware................................................ 4 4 0 0 0 0
District of Columbia.................................... 9 8 1 1 11 13
Florida................................................. 35 35 17 15 49 43
Georgia................................................. 147 149 88 78 60 52
Kentucky................................................ 78 78 51 45 65 58
Louisiana............................................... 73 73 39 33 53 45
Maryland................................................ 38 38 11 10 29 26
Mississippi............................................. 91 91 18 17 20 19
North Carolina.......................................... 107 108 59 55 55 51
Oklahoma................................................ 65 66 34 30 52 45
South Carolina.......................................... 68 69 17 15 25 22
Tennessee............................................... 101 101 38 35 38 35
Texas................................................... 282 283 167 145 59 51
Virginia................................................ 92 93 38 34 41 37
West Virginia........................................... 57 56 11 9 19 16
West census region........................................ 485 487 155 149 32 31
Alaska.................................................. 17 17 0 0 0 0
Arizona................................................. 33 33 13 13 39 39
California.............................................. 165 167 33 31 20 19
Colorado................................................ 42 42 9 9 21 21
Hawaii.................................................. 4 4 0 0 0 0
Idaho................................................... 35 35 15 14 43 40
Montana................................................. 44 44 34 33 77 75
Nevada.................................................. 8 8 4 4 50 50
New Mexico.............................................. 36 36 5 4 14 11
Oregon.................................................. 42 42 17 16 40 38
Utah.................................................... 17 17 7 7 41 41
Washington.............................................. 31 31 12 12 39 39
Wyoming................................................. 11 11 6 6 55 55
U.S. territories.......................................... 79 79 0 0 0 0
American Samoa.......................................... 4 4 0 0 0 0
Guam.................................................... 0 0 n/a n/a n/a n/a
Northern Mariana Islands................................ 0 0 n/a n/a n/a n/a
Puerto Rico............................................. 72 72 0 0 0 0
U.S. Virgin Islands..................................... 3 3 0 0 0 0
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of Health Resources and Services Administration and U.S. Census Bureau data.
Senator Sanders. Thank you very much. Dan Hawkins is the
Senior Vice President with the National Association of
Community Health Centers in Bethesda.
Dan, thank you for being here.
STATEMENT OF DANIEL R. HAWKINS, Jr., SENIOR VICE PRESIDENT,
NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS, BETHESDA, MD
Mr. Hawkins. Thank you, Mr. Chairman. Good morning,
Majority Whip, Senator, members of the committee, thank you for
the opportunity to speak with you today about the important
role of community health centers and health reform.
Senator Sanders. And if you could pull that mike a little
closer, please?
Mr. Hawkins. Sure. Well, it's an honor to share this panel
with many distinguished colleagues, many of whom are on the
front lines today delivering quality health care to thousands
of Americans, as part of the health center family that provides
care to more than 18 million Americans across the country
today.
Mr. Chairman, I have personally seen the power of some
health centers to lift the health and the lives of communities
and people all across the country, both as a VISTA volunteer
and as director of one of the earliest, vibrant community
health care centers back in the 1970's.
The beauty is that this patient-directed model thrives
today in more than 7,000 communities across America, and I am
honored to share its success story.
What is the secret of the successful health centers? I
think there are several key points. No. 1, as was pointed out
by my colleague a moment ago, every single health center in
every single one of those 7,000 sites is located in a
designated underserved area where there are shortages of
providers and barriers to access to care that cause millions,
to have to forego care, delay care, get sicker and not be able
to receive care when it's timely and appropriate.
No. 2, they occupy the most opportune place in the entire
health care system, at the entry point, where good quality,
preventative and primary health care can not only improve and
maintain health, it can reduce the need for later care for
illnesses that might otherwise not have been treated, and save
the system billions.
Last year we reported together with the Robert Graham
Center of the American Academy of Family Physicians that health
centers saved the entire health care system $18 billion a year.
That is more than twice the total amount of money that they
spent.
Senator Sanders. Say that again.
[Laughter.]
Mr. Hawkins. I've got even better news for you. Last year,
health centers saved the health care system more than $2 for
every dollar they spent. If you look at $2 billion in grant
funding, they saved $18 billion. That's $9 billion for every
dollar that this committee and Congress has invested in them,
and more than $2 for every other dollar that they secured from
other sources.
That colleague, from the American Academy of Family
Physicians, last week noted to another colleague that if every
person in America received the care that the health care
centers provide, Senator, are you ready for this, more than
$500 billion a year could be saved in health care spending
today.
Senator Sanders. That is such an important statistic.
Everybody is wrestling with skyrocketing health care costs.
Everybody is wrestling with that. We are going to ask you to
repeat that fact one more time.
Mr. Hawkins. I will and I know Senator Hatch has been a
long time champion and believer of health centers, and has
visited health centers in Ogden and throughout his State of
Utah, will enjoy this as well. If every person in America
received the care that is provided by health centers, more than
$500 billion a year could be saved in health care spending
today. Today!
There was an article published just earlier this week that
said that health center patients receive less specialty care
than patients seen by other providers. The interesting thing--
there was a worry that health centers are stinting on care, in
fact, though, even the authors of that study said we don't know
whether it's because health center patients have less care than
they need or the patients of other providers get much more care
than they need.
We think the answer is probably a combination of those two.
At any rate, I just want to close by saying that health care
centers are eager to be full partners and full participants in
health care reform and know that their role will truly be
integral because they are the one place in America that can
turn the promise of coverage into the reality of high quality,
cost-effective care.
[The prepared statement of Mr. Hawkins follows:]
Prepared Statement of Daniel R. Hawkins, Jr.
SUMMARY
Community Health Centers are a 40-plus year unprecedented success
story. Health center patients have better health outcomes than patients
in other settings, and they receive this care at a lower cost.
Health centers improve the health and quality of life of
their patients through vigorous clinical improvement efforts such as
the Health Disparities Collaboratives. These efforts result in
documentable improved outcomes.
Health centers achieve these outcomes at a lower cost. For
example, in one study in South Carolina diabetic patients enrolled in
the State employees' health plan treated in non-CHC settings were four
times more costly than those in the same plan who were treated in a
community health center.
Indeed, literally dozens of studies done over the past 25
years have concluded that health center patients are significantly less
likely to use emergency rooms or to be hospitalized for avoidable
conditions, resulting in large cost savings. A recent national study
done in collaboration with the Robert Graham Center found that people
who use health centers as their usual source of care have 41 percent
lower health care expenditures than people who get their care
elsewhere. As a result, health centers saved the health care system $18
billion last year alone.
Community Health Centers are critical to ensuring access to care.
As Congress turns its attention to universal health
reform, health centers are eager to be full and active participants in
a new and improved health care system.
Community health centers will be integral to ensuring that
increased health coverage translates into universal health care access
for all Americans.
``Access'' means a physical place to go to receive high
quality health care services. But beyond that, to be truly accessible,
care should be culturally competent, affordable, and nearby.
Health centers have identified several key principles for health
reform that we believe will help to guarantee universal access.
First, health reform should strive to achieve universal
coverage that is both available and affordable to everyone; second,
coverage must be comprehensive, including medical, dental, and mental
health services, with an emphasis on prevention and primary care;
finally, reform must strive to guarantee that everyone has access to a
medical or health care home where they can receive high quality, cost-
effective care for their health needs.
Expanding community health centers is a key to making
these principles a reality, especially for our most vulnerable
populations, most of whom live in medically underserved areas. The
Health Care Safety Net which became law last year, thanks to the
bipartisan work of this committee, would significantly expand health
centers program over the next 5 years.
S. 486, the Access for All America Act introduced by
Senator Sanders would even more rapidly expand the program and NACHC
supports that legislation.
In order to make health care reform a true success, we must ensure
that access to care is front and center. Community health centers' 40-
plus year track record of success demonstrates that we are well-
equipped to play a pivotal role in providing this health care access
and doing so in a way that will ultimately save the health care system
money. We look forward to that opportunity.
______
Mr. Chairman and members of the committee, my name is Dan Hawkins
and I am Senior Vice President for Policy and Programs for the National
Association of Community Health Centers. On behalf of America's Health
Centers and the more than 18 million patients they serve, I want to
express my gratitude for the opportunity to speak to you today about
the importance of the Community Health Centers program to ensuring that
all Americans have access to high quality, affordable health care.
NACHC and health centers appreciate the unwavering support of this
committee over many years, dating back to the original authorizing
legislation introduced by Chairman Kennedy and approved by this
committee in 1975. The ongoing, bipartisan support from this committee,
including through last year's historic reauthorization law, has allowed
health centers to carry out their important mission, and we look
forward to continuing to work with you both in health reform and in the
years to come.
Mr. Chairman, I have personally seen the power of health centers to
lift the health and the lives of individuals and families in our most
underserved communities. As a VISTA volunteer assigned to south Texas
in the 1960s, the residents of our town asked me to work on improving
access to health care and clean water in our community. We decided to
apply for funds through a relatively new, innovative program--the
Migrant Health program. I stayed on and served as executive director of
the health center from 1971 to 1977. That health center is still in
operation today, and has expanded to serve over 40,000 patients
annually. The community empowerment and patient-directed care model
thrives today in every health center in America, and I am honored to be
here to share this success story and how health centers' 40-plus-year
track record makes them uniquely positioned to be important
participants in a reformed health care system.
HISTORY AND OVERVIEW OF THE HEALTH CENTERS PROGRAM
Conceived in 1965 as a bold new experiment in the delivery of
preventive and primary health care services to our Nation's most
vulnerable populations, health centers are an enduring model of primary
care delivery for the country. The Health Centers program began in
rural Mississippi and inner-city Boston in the mid-1960s to serve
rural, migrant, and urban individuals who had little access to health
care and no voice in the delivery of health services to their
communities. In the 1980s and 1990s, the Health Care for the Homeless
and Public Housing health centers were created. In 1996, the Community,
Migrant, Public Housing and Health Care for the Homeless programs were
consolidated into a single statutory authority within Section 330 of
the Public Health Service Act.
Congress established the program as a unique public-private
partnership, and has continued to provide direct funding to community
organizations for the development and operation of health systems that
address pressing local health needs and meet national performance
standards. This Federal commitment has had a lasting and profound
effect on health centers and the communities and patients they serve in
every corner of the country. Now, as in 1965, health centers are
designed to empower communities to create locally tailored solutions
that improve access to care and the health of the patients they serve.
Federal law requires that every health center be governed by a
community board with a patient majority, which means care is truly
patient-centered and patient-driven. Health centers are required to be
located in a federally designated Medically Underserved Area (MUA), and
must provide a package of comprehensive primary care services to anyone
who comes in the door, regardless of ability to pay. In last year's
reauthorization, this committee strongly endorsed the preservation of
these core requirements.
Because of these characteristics, the insurance status of health
center patients differs dramatically from other primary care providers.
As a result, the role of public dollars is substantial. Federal grant
dollars, which make up roughly 22 percent of health centers' operating
revenues on average, go toward covering the costs of serving uninsured
patients and delivering care effectively to our medically underserved
patients. Just over 40 percent of health centers' revenues are from
reimbursement through Federal insurance programs, principally Medicare
and Medicaid. The balance of revenues come from State and community
partnerships, privately insured individuals, and low-income uninsured
patient's sliding-fee payments.
Health centers have also been pioneers in improving health care
quality, particularly in the area of chronic disease management. The
majority of health centers now participate in the Health Resources and
Services Administration's (HRSA) Health Disparities Collaboratives. The
Collaboratives are delivery system improvement initiatives specifically
designed for health centers, focused on improving the performance of
clinical staff and strengthened care-giving through the development of
extensive patient registries that improve clinicians' ability to
monitor the health of patients both individually and as a group, and on
effectively educating patients on the self-management of their
conditions such as cancer, diabetes, asthma, and cardiovascular
disease. Health centers participating in the Collaboratives almost
unanimously report that health outcomes for their patients have
dramatically improved. Published studies have documented these
outcomes, including one study on the Diabetes Collaboratives where
evidence showed that over a lifetime, the incidence of blindness,
kidney failure, and coronary artery disease was reduced.
Health centers not only improve health and save lives, they also
cost significantly less money, saving the health system overall. In
Yvonne Davis' home State of South Carolina, a study showed that
diabetic patients enrolled in the State employees' health plan treated
in non-CHC settings were 4 times more costly than those in the same
plan who were treated in a community health center. The health center
patients also had lower rates of ER use and hospitalization.\1\ In
fact, literally dozens of studies done over the past 25 years, right up
to this past year, have concluded that health center patients are
significantly less likely to use hospital emergency rooms or to be
hospitalized for ambulatory care-sensitive (that is, avoidable)
conditions, and are therefore less expensive to treat than patients
treated elsewhere.\2\ A recent national study done in collaboration
with the Robert Graham Center found that people who use health centers
as their usual source of care have 41 percent lower total health care
expenditures than people who get most of their care elsewhere.\3\ As a
result, health centers saved the health care system $18 billion last
year alone.
---------------------------------------------------------------------------
\1\ Proser M. ``Deserving the Spotlight: Health Centers Provide
High-Quality and Cost-Effective Care.'' October-December 2005 Journal
of Ambulatory Care Management 28(4):321-330.
\2\ Rust G., et al. ``Presence of a Community Health Center and
Uninsured Emergency Department Visit Rates in Rural Counties.'' Journal
of Rural Health, Winter 2009 25(1):8-16; Dobson D., et al. ``The
Economic and Clinical Impact of Community Health Centers in Washington
State: Analyses of the Contributions to Public Health and Economic
Implications and Benefits for the State and Counties.'' Dec 2008
Community Health Network of Washington and Washington Association of
Community and Migrant Health Centers; McRae T. and Stampfly R. ``An
Evaluation of the Cost Effectiveness of Federally Qualified Health
Centers (FQHCs) Operating in Michigan.'' October 2006 Institute for
Health Care Studies at Michigan State University. www.mpca.net. Falik
M., Needleman J., Herbert R., et al. ``Comparative Effectiveness of
Health Centers as Regular Source of Care.'' January-March 2006 Journal
of Ambulatory Care Management 29(1):24-35; Proser M. ``Deserving the
Spotlight: Health Centers Provide High-Quality and Cost-Effective
Care.'' October-December 2005 Journal of Ambulatory Care Management
28(4):321-330; Politzer R.M., et al. ``The Future Role of Health
Centers in Improving National Health.'' 2003 Journal of Public Health
Policy 24(3/4):296-306; see also, e.g., Politzer R.M., et al.
``Inequality in America: The Contribution of Health Centers in Reducing
and Eliminating Disparities in Access to Care.'' 2001 Medical Care
Research and Review 58(2):234-248; Falik M., et al. ``Ambulatory Care
Sensitive Hospitalizations and Emergency Visits: Experiences of
Medicaid Patients Using Federally Qualified Health Centers.'' 2001
Medical Care 39(6):551-56; Starfield, Barbara, et al., ``Costs vs.
Quality in Different Types of Primary Care Settings,'' Journal of the
American Medical Association 272,24 (December 28, 1994): 1903-1908;
Stuart, Mary E., et al., ``Improving Medicaid Pediatric Care,'' Journal
of Public Health Management Practice 1(2) (Spring, 1995): 31-38;
Utilization and Costs to Medicaid of AFDC Recipients in New York Served
and Not Served by Community Health Centers, Center for Health Policy
Studies (1994); Stuart, Mary E., and Steinwachs, Donald M., (Johns
Hopkins Univ. School of Public Health and Hygiene), ``Patient-Mix
Differences Among Ambulatory Providers and Their Effects on Utilization
and Payments for Maryland Medicaid Users,'' Medical Care 34,12
(December 1993): 1119-1137; Health Services Utilization and Costs to
Medicaid of AFDC Recipients in California Served and Not Served by
Community Health Centers, Center for Health Policy Studies/SysteMetrics
(1993).
\3\ NACHC and the Robert Graham Center. Access Granted: The Primary
Care Payoff. August 2007. www.nachc.com/access-reports.cfm.
---------------------------------------------------------------------------
HEALTH CENTERS' ROLE IN ENSURING ACCESS TO CARE
As Congress turns its attention to shaping universal health reform
legislation, health centers are eager to be full and active
participants in a new and improved health care system. We look forward
to sharing our decades of experience caring for millions of Americans
in a high quality, cost-effective way. Above all, we know that
community health centers will be integral to ensuring that the
increased health coverage we all support translates into universal
health care access for all Americans.
What do we mean by ``access''? Well, first, access means a physical
place to go to receive high quality health care services. However, to
be truly accessible, that care should be culturally competent,
affordable, nearby, and without barriers to care. We believe that
access must be front and center in health reform discussions in order
to maximize the value of our investments in expanded coverage.
Health centers have identified several key principles for health
reform that we believe will help to guarantee universal access. First,
health reform should strive to achieve universal coverage that is both
available and affordable to everyone, especially low-income individuals
and families. Second, coverage must be comprehensive, including
medical, dental, and mental health services, and it should emphasize
prevention and primary care. Finally, reform must also strive to
guarantee that everyone has access to a medical or health care home
where they can receive high quality, cost-effective care for their
health needs. Expanding health centers is a key step toward making
these principles a reality, especially for our most vulnerable
populations, most of whom live in medically underserved areas.
For this reason, we believe that health centers will have an
increased and even more important role in a post-health reform
environment. Indeed, the Massachusetts experience has born this out: as
the percentage of insured residents in the State increased, the number
of health center patients increased as well. Yet, at the same time,
health centers in that State have also increased the percentage of the
State's remaining uninsured who they serve.
PROPOSALS FOR EXPANDING THE HEALTH CENTERS PROGRAM
Thanks in large part to the work of this committee, last year
Congress reauthorized the Community Health Centers Program, passing the
Health Care Safety Net Act of 2008. This legislation preserved all of
the essential elements of the Health Centers program and reaffirmed
Congress' support for our successful model. The Health Care Safety Net
Act also included significantly increased authorizations of
appropriations. If the authorization levels approved in the
reauthorization are appropriated, health centers will be on target to
meet our goal, contained in our Access for All America plan, of serving
30 million patients by 2015.
However, community health centers know better than anyone that the
need right now is greater still. Indeed, a report recently released by
our Association, entitled ``Primary Care Access, An Essential Building
Block of Health Reform'' found that there are currently 60 million
medically disenfranchised Americans--people who lack access to a
regular source of medical care.
Given Congress' intention to dramatically improve and reform our
health care system, and the essential role that health centers will
play in providing many of the newly insured with access to care, some
have proposed to grow the health centers program more rapidly. S. 486--
the Access for All America Act introduced by Senator Bernie Sanders and
co-sponsored by five members of this committee is one such proposal.
NACHC has endorsed this legislation and the strong message that it
sends: that growing the Health Centers grant program in conjunction
with health reform is the most effective way to guarantee that access
grows along with coverage.
What will happen if we increase coverage and do not address access?
One of my health center colleagues came up with this illustration.
Giving everyone an insurance card without increasing access would be
like giving everyone in town a free bus pass but not adding any new
buses. That's a lot of people standing on the side of the road. When it
comes to people's health, the issue is far more serious and the costs
are much higher, both in moral and fiscal terms. We must ensure that
health care access is a part of health reform.
THE ROLE OF THE NATIONAL HEALTH SERVICE CORPS
When defining access, I mentioned having a health care home where
people can go to receive high quality health care services. However,
patients can't receive these health care services without a health
professional to provide them. The National Health Service Corps (NHSC),
also administered by HRSA, plays an essential role in ensuring that
health centers have the health care providers they need to care for
their patients.
Back in South Texas as a health center director, our community
benefited from the services of one of the first NHSC participants, who
was placed there in 1972. I can't express what it meant to our center
and our patients to have the services of that additional physician.
Today, health centers across the country know what an invaluable tool
the NHSC is to recruiting and retaining a primary care workforce in
underserved areas. Without it, the impact of the nationwide problem of
a diminishing primary care workforce and the maldistribution of
providers would be devastating to health centers. The Corps is a vital
tool as health centers work to maintain the workforce they need to keep
their patients healthy.
Indeed, between the years 2000 and 2007, health centers
successfully increased their physician staff by 72 percent, their Nurse
Practitioner/Physician Assistant staff by 80 percent, and their dentist
staff by 116 percent, well ahead of their overall 68 percent growth in
patients during that period. This was accomplished with support,
assistance, and encouragement from HRSA, NACHC, and the State and
Regional Primary Care Associations. However, to reach their goal of
serving 30 million patients, health centers will need an additional
16,000 primary care providers; to reach 60 million people, they will
need over 50,000 more primary care providers. Addressing these deficits
will involve more than a continuation of current workforce policy.
As we look toward comprehensive health reform and continued growth
of the Health Centers program, expansion of the Corps is critical to
ensuring we have a primary care workforce capable of meeting the needs
of the 21st century. This committee recognized that health centers and
the NHSC go hand in hand when they included a reauthorization and
significant expansion of the Corps in the Health Care Safety Net Act.
The American Recovery and Reinvestment Act also included a landmark
amount of funding for the Corps: $300 million, essentially doubling the
program over the next 2 years. We must sustain this investment and grow
it further in the years to come. S. 486 would accomplish that goal,
growing the program from its current 4,000 clinical field strength to
over 21,000 clinicians by 2015.
CONCLUSION
In conclusion, in order to make health care reform a true success,
we must ensure that access to care is front and center. Providing every
American with access to comprehensive, affordable care is key to
achieving a healthier nation. Community health centers' 40-plus-year
track record of success demonstrates that we are well equipped to play
a pivotal role in providing this health care access and doing so in a
way that will ultimately save the health care system money. As you
consider the myriad challenges facing our health care system, America's
health centers offer a real, proven solution to many of these complex
questions. We thank this committee for your years of stalwart,
bipartisan support and we look forward to continuing to work with you
as partners in improving the health of all Americans.
Senator Sanders. Thank you very much, Mr. Hawkins. We are
pleased to be joined by Senator Merkley, Senator Hatch and
Senator Brown, all long time champions of primary health care
and community health centers.
Senator Hatch. Mr. Chairman.
Senator Sanders. Yes.
Senator Hatch. I have to go to another hearing. Could I
just make a remark?
Senator Sanders. You sure can. Please.
Statement of Senator Hatch
Senator Hatch. Very briefly. I am very grateful to all of
you for showing up and, as you know, I'm a long supporter of
this. We just had major meetings in the Finance Committee about
the fact that we don't have enough primary care physicians in
this country, and yet we have some of the greatest primary care
in the world through community health centers.
So I just want to personally congratulate all of you and I
would like to take this opportunity to welcome Ms. Lisa
Nichols, the executive director of the Midtown Committee Center
in Ogden, UT. We are grateful that you would take the time to
come here and participate with us. I want to thank you for
being here.
Midtown Community Health Center has done an excellent job
providing health care services to residents throughout the
Ogden community, which is one of our fastest growing
communities in Utah. I am very proud of you. We are proud of
all of you. I intend to do whatever I can to help keep
community health centers strong and expand them. They have to
be an effective part of total health care reform, in my
opinion, and I'm just very proud of all of you who work so hard
and do so much for so many people in the community health
centers. I want to thank you, Mr. Chairman, for allowing me to
interrupt, and for having may buddy here, Congressman Clyburn
from South Carolina, and actually there are some other buddies
here, too.
[Laughter.]
Senator Sanders. Thank you for your support for community
health centers and we look forward to working with you to
significantly expand them.
Senator Brown wanted to say a word and then we will go to
Senator Merkley and then we will go back to the panel.
Statement of Senator Brown
Senator Brown. Mr. Chairman, thank you very much. I am
thrilled to see Congressman Clyburn here, who I saw up close
for many years in the House do such outstanding work on primary
care and especially on community health centers. Thank you
panel for all that you do for community health service centers
and for primary care. There is no better story of health care
in my State than what community health care centers do.
A special mention of Dr. Evans, and what dental--we are
pushing in my State, and I know around the country,
particularly on primary dental care for children and what a
difference it makes in their lives, in terms of their health,
in terms of their appearance when they go out job seeking, and
just in terms of their going through school; all the kinds of
things that good dental care at a young age could mean for our
Nation's children. I want to thank you again for all that you
do and you make such a difference.
Mr. Chairman. Thank you, Senator.
Senator Merkley.
Statement of Senator Merkley
Senator Merkley. Thank you very much, Mr. Chair. I
certainly want to say that my State legislative experience
there is wide bipartisan support for community health centers
in underserved areas, be they urban, be they rural; hugely
popular recognition that this is a doorway into the health care
system, both providing significant care but also providing a
doorway to the other care.
We need a lot more doorways and we need a lot more primary
care, and I look forward to hearing and learning additional
details, and thank all of you for coming to testify.
Senator Sanders. Thank you.
Senator Casey.
Statement of Senator Casey
Senator Casey. Mr. Chairman, thank you very much. I am
going to be looking forward to engaging in this discussion. We
had an opportunity over the last couple of months to make
positive steps forward on health care, in particular with
regard to children. We finally got that done, but believe it or
not, there's a lot more to do with regard to children. There
are still millions who are not covered despite the great work
that everyone has done. Senator Sanders has been a real
champion of this issue of community health centers and I know
the impact that they have had on our State of Pennsylvania, a
substantial impact, I am proud to be a co-sponsor of the bill
and we are grateful for Senator Sander's leadership and look
forward to the discussion.
Thank you.
Senator Sanders. Thanks very much.
OK. Let's go now to Dr. Fitzhugh Mullan, who is the Murdock
Head Professor of Medicine and Health Policy. We appreciate
very much your being here. Thank you, Dr. Mullan.
STATEMENT OF FITZHUGH MULLAN, M.D., MURDOCK HEAD PROFESSOR OF
MEDICINE AND HEALTH POLICY, WASHINGTON, DC
Dr. Mullan. Thank you, Senator Sanders, Congressman
Clyburn, collaborative colleagues. I am pleased to be able to
speak with you today about a sister program that is almost as
old as the health center program, the last day of 1970 signed
into law by President Nixon, the National Health Service Corps.
The Corps has grown from that point, but not as one might like
to see it grow and not as the growth is envisioned in Senate
bill 486 and House bill 1276. So I am delighted to be able to
envision with the committee how that might be.
Just stepping back for a moment, I started my career in
medicine as a National Health Service Corps physician in New
Mexico following residency. First generation, first year out of
the chute, I was privileged to come back and for some years
thereafter, run the National Health Service Corps. It was the
early years of the scholarship program. We were very excited.
We went from 500 to upwards of 2,000 people in the field, this
being the late 1970's. And I will argue that it was then a
fabulous demonstration program. Its biggest problem is that 30
years later, it's still a demonstration program. We need to
move beyond that.
A quick word about how to envision or frame the issue. I
took the liberty of putting up a graphic here in back. I am
sorry it's--I couldn't figure out where to put it in the room
so that everybody could see--but in terms of primary care work
force reform, I would suggest three elements to the life cycle
of a health worker, a physician in this case: medical school,
graduate education, and practice.
The latter, of course is the longest. But the other two are
formative--the pipeline. And there are a number of instruments
that are in play and others could be put in play to influence
that.
Importantly, we need influence in all three. If you fix the
pipeline and don't fix practice, or you do something good about
practice and upscaling reimbursement, but you don't do anything
about the pipeline, you are going to have far less than a
satisfactory outcome. So all of this is a framing concept.
A quick word about where we are about the physician work
force in general. While we have 280 physicians per 100,000, it
puts us about in the middle of the pack for developed nations.
Europe has a few more, Canada and the UK have a few less.
I think we are in a zone of sufficiency. And folks who are
yelling about we need more physicians, we need more nurse
practitioners and more physicians assistants to make more use
and better use of what we have in the way of a very excellent
physician work force, but I think roughly we are in a pretty
good zone in terms of what we are producing.
We do have enormous distribution problems. And that's where
health centers, aided by the National Health Service Corps have
shown the way thus far, but it's no where near the way that it
might be shown in the future.
Let me talk just briefly about the Corps and where it sits,
emphasizing I am not a representative of the program, but I've
been a fan of it and a participant in it over the years, and I
did a little homework coming in.
The essence of the physician distribution problem, is
shortage areas, which are some combination of local economics
and local geography that are not sufficiently incentivized to
get physicians to go there.
This is a problem throughout the world. Every country has
it. There is a gradient, docs like well-to-do communities, and
they like urban areas. So how do we get them to go where they
don't want to go? That's what democratic incentive programs are
about and that's what the Corps is.
In closing, let me just say quickly that one could envision
under this bill what I've called in the past the muscular
Samaritan. The Corps is a samaritan--but there are many ways it
could be developed and more fully impact the country's health
centers, build them out as we build health centers. There is
prison health. There is urban health. There is public health.
There are many ways this instrument could benefit the country.
And finally the Corps, itself, needs some modest changes.
It's a great formula. Education for service for things like
better flexibility in terms of where people serve, teaching
health centers where there is much more education that goes on
in health centers, for recruitment purposes, many things could
be done. The bills proposed would allow that to happen, a real
revolution in health workforce of the country.
[The prepared statement of Dr. Mullan follows:]
Prepared Statement of Fitzhugh Mullan, M.D.
SUMMARY
Improving access to health care in the United States will
require modifications in the U.S. health care workforce, the foremost
of which will be the construction of a strong primary care base.
Two-thirds of the U.S. physician workforce practice as
specialists and the number of young physicians entering primary care is
declining.
The distribution of health care providers in the United
States heavily favors urban areas. Metropolitan areas have 2-5 times as
many physicians as non-metropolitan areas and economically
disadvantaged areas have significant health care access problems.
Today's physician-to-population ratio is in the zone of
adequacy and should be maintained with growth in the number of
physicians trained to parallel growth in the population. Increased
requirements for patient care due to the aging of the population or the
inclusion of more Americans in a universal care plan should be met by
more strategic distribution of physicians, both geographically and
across the primary care--specialty spectrum, and the expanded use of
physician assistants and nurse practitioners.
STRATEGIES
Medical Schools.--Medical schools are currently expanding,
and title VII legislation needs to be re-invigorated and up-funded to
augment primary care training.
Graduate Medical Education.--The current number of
Medicare funded slots is sufficient to maintain workforce numbers.
However, reforms need to be made in current legislation to prioritize
and incentivize community-based and primary care training. Serious
consideration also needs to be given to aligning Medicare GME with the
workforce needs of the country. This would entail designing a new GME
allocation system.
Medical Practice.--Primary care payment reform, support
for new practice organizations such as primary care medical homes, and
investment in health information technology are all important reforms
that will promote a strong primary care practice base in the country.
National Health Service Corps.--The NHSC is a proven
program that delivers primary care clinicians to needy communities in
return for student debt reduction. It is a brilliant and successful
strategy that has always been under-funded. It is time to radically
increase its budget toward the end of fully staffing Community Health
Centers and addressing the oncoming needs for clinical service in the
United States.
Teaching Health Centers.--Establishing stable funding for
both undergraduate and graduate medical education in health centers
will promote a workforce prepared with skills needed for practice and
improve recruitment and retention for health centers, which are
critical providers of health care to underserved communities.
Data and leadership in the field of U.S. health workforce
development is insufficient. A National Health Workforce Commission
would be an important asset at the Federal level in managing health
care workforce reform.
______
INTRODUCTION
Thank you, Mr. Chairman, for this opportunity to testify today.
During the 40 years since I graduated from medical school, I have
practiced medicine as a member of the National Health Service Corps in
New Mexico; I have directed workforce programs including the National
Health Service Corps; and I have been a student of and commentator on
U.S. workforce policy in my current role as a Professor of Health
Policy at The George Washington University.
Therefore, it is with experience as a practitioner, administrator,
and scholar that I come before you this morning.
Current health care access and the expansion of access to all
Americans are necessarily reliant on both the number and make-up of the
workforce available to provide care. In my remarks, I will briefly
review the history, demographics, trends, and problems associated with
the U.S. health professions workforce. I will focus on the physician
workforce, which is large, at the center of the delivery system, and
closely associated with the costs of the health care system. I will
also talk about nurse practitioners and physician assistants who make
major contributions to clinical care delivery in the country. I will
discuss the current and potential future role of the National Health
Service Corps. Much of my commentary will reference the challenge of
providing a strong and efficient base to the U.S. health care system--
the sector of practice termed primary care. I will propose a number of
areas in which legislative action would, in my judgment, support and
augment the training and practice of primary care providers, thereby
improving the availability, efficiency and effectiveness of the overall
health delivery system.
HEALTH CARE ACCESS AND THE HEALTH CARE WORKFORCE
Increasing health care access in the United States is necessarily
dependant upon the current and future status of the health care
workforce--in absolute numbers, specialty make-up, and geographic
distribution. Health care reform in Massachusetts provides one
instructive example of achieving health care reform without
concurrently addressing the health care workforce. In 2006,
Massachusetts enacted universal health care measures, increasing the
number of insured by 340,000. However, within 2 years, reports of
access problems due to an insufficiency of primary care providers
emerged, causing the State legislature to scramble to enact primary
care legislation.
In addition to the Massachusetts example, many organizations are
indicating increasing concern over the primary care workforce. The
National Association of Community Health Centers (NACHC) reports health
centers currently have a shortage of over 1,800 primary care providers.
Further, if health centers are to increase their services and access,
they will need an additional 15,585 primary care providers to reach 30
million patients by 2015 or an additional 51,299 primary care providers
to reach 69 million patients.\1\
Both the Massachusetts experience and the NACHC report remind us
coverage does not equal access. In order to increase access, we must
build a high quality, cost-effective, well distributed workforce.
THE DEMOGRAPHICS OF THE WORKFORCE
Today, there are over 800,000 practicing physicians in the United
States. This number represents a steady increase over the last 50 years
in both the number of physicians and the physician-to-population ratio
(see Figure 1). The current density of physicians is 272 per 100,000.
However, the distribution of physicians in the United States trends
heavily towards urban and well-to-do areas. Less than 10 percent of
physicians practice in rural areas while 20 percent of the country's
population resides in these areas. Metropolitan areas have a primary
care physician-
to-population ratio of 93 doctors per 100,000 people compared to 55
primary care doctors per 100,000 people in non-metropolitan areas.
Specialists are even more concentrated, with greater than three times
the density of specialists in metropolitan areas versus non-
metropolitan areas.
American Medicine is highly specialized. Currently, there are 142
Accreditation Council on Graduate Medical Education (ACGME) recognized
specialties and combined subspecialties as well as multiple additional
unrecognized subspecialties. Physicians reporting that they practice
primarily as specialists comprise 63 percent of practitioners whereas
those working in the primary care specialties (family medicine, general
internal medicine and general pediatrics) comprise only 37 percent of
doctors in practice. This figure is markedly different than it was 50
years ago when 50 percent of America's physicians were generalists. In
Canada today, by contrast, 51 percent of physicians are currently
family physicians and GPs.
The situation in primary care, however, is more problematic than
the numbers might suggest. Hard work, low pay, and ``lifestyle''
expectations of medical graduates today have resulted in dramatic
reductions in interest in primary care in U.S. medical graduates (see
Figures 2 and 3). Between the mid-1990s and today, the number of
training positions in family medicine has declined 20 percent and the
percentage of the family medicine residency positions being selected by
U.S. graduates has fallen from 72 percent to 44 percent. The majority
of family medicine positions are now filled by international medical
graduates.
A recent questionnaire of senior medical students considering
careers in internal medicine showed that only 2 percent of them wanted
to be general internists.\2\ These trends have implications for the
future--a future that will require more primary care services for our
aging population. A recent study projects that we will be short
approximately 40,000 primary care doctors in 15 years \3\--and that
doesn't take into account the millions of Americans who will seek
primary care when universal coverage is implemented.
PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS
The United States is a global pioneer in the creation of new
categories of health professionals who contribute to the delivery of
clinical services. Separate pilot programs in the 1960s introduced the
world to the idea of the nurse practitioner (NP) and the physician
assistant (PA). Since those early programs, both professions have grown
enormously in size, stature and public acceptance. Approximately
125,000 nurse practitioners have been trained in the United States, the
majority of whom are engaged in clinical practice. There are almost
70,000 certified physician assistants in the United States and more
than 100 training programs.
Both of these professions are associated with primary care and
practice in rural and underserved areas. About 25 percent of all nurse
practitioners are located in non-metropolitan areas and an estimated 85
percent of them practice primary care. Physician assistants are active
across the spectrum of medical specialties with more than one-third of
them working in primary care practices and approximately one-fifth of
them working in rural areas.
THE CAREER LIFECYCLE OF A PHYSICIAN
Before considering questions of the sufficiency of the workforce or
policy options to modify its direction, I would like to suggest a
framework for considering physician careers. I call this the career
lifecycle of a physician. It has three phases--one of which is
educational, one of which is transitional and the final one of which is
vocational (see Figure 4). The phases are medical school, graduate
medical education, and practice. The first two might be considered
``pipeline phases'' since they determine the quantity and nature of
physicians prepared for practice. The final phase is the ``payout''
phase when the physicians are actually providing health care to the
Nation.
This framework allows us to consider capacity, cost and performance
in three separate but interlinked longitudinal phases of the career
path of physicians.
One further clarification is necessary to understand the dynamics
of the physician lifecycle. The governing sector in the lifecycle is
graduate medical education (GME). Contrary to popular belief, it is not
medical schools that determine the ultimate size and specialty
composition of the physician workforce of the country. Rather it is
residency programs, taken as a whole, that serve as the final pathway
into practice and largely govern the numbers and specialty distribution
of the physicians in practice. In order to practice medicine in the
United States, one needs a license from a State. All States require 1
to 3 years of residency in order to obtain a license. It is also
important to recognize that a significant proportion of practicing
physicians did not attend U.S. (allopathic) medical schools. Of the
current first year residents, for instance, 64 percent graduated from
U.S. allopathic (M.D.) medical schools, 7 percent from U.S. osteopathic
(D.O.) medical schools, and 29 percent from medical schools abroad
(International Medical Graduates or IMGs).\4\ Almost all of these
physicians will complete residency and enter practice in the United
States. Thus, it is the size and specialty offerings of the aggregated
residency programs of the country that really determine the future of
the U.S. physician workforce.
SUFFICIENCY
As we examine the Nation's health care system and as we consider
options to increase coverage, fairness, quality, and affordability, we
must wrestle with the question of how many physicians we need. This is
a central question, not only because it involves the physician
production process but also because it has important implications for
training requirements for other health professionals (i.e., nurse
practitioners and physician assistants). It also has ramifications for
prospective spending in a number of areas including hospital beds,
diagnostic testing, medication usage and locations of practice.
Many policy scholars and analysts have written on this topic with
strikingly different conclusions. Some have suggested that we are
training too many physicians while others issue predictions that we are
entering into a period of dramatic physician shortage. These
projections are largely dependent on the assumptions made about the
health care system of the future. If one assumes that the health care
system will be highly coordinated with the well-organized use of
physician services, such as is the case in prepaid managed care plans
like Kaiser Permanente, the case can be made that we might well have a
surplus of physicians. If one assumes the continuation of a minimally
organized, specialty dominated, predominantly fee-for-service system
that is an extrapolation of today's circumstances, one can make the
case for a perpetually escalating need for physicians. Both cases have
been argued eloquently.
My view is that the density of physicians (the physician-to-
population ratio) that we have at the moment is reasonable and the role
of public policy (financing and regulation at the Federal and State
levels) should be to maintain a physician workforce of approximately
the current size. This strategy should take into account projected
growth in the size of the U.S. population (which is projected at 1
percent per year) so that the absolute number of physicians would grow
in a modest but consistent fashion.
This strategy would be challenged by critics who would raise
objections in the following areas:
1. The American population is aging, and by all measures, older
citizens require more health care;
2. Physician practice patterns have changed and physicians don't
work as many hours as they used to;
3. Technology is advancing and we will need more specialists to
deliver the fruits of new technologies to the population:
4. Don't bet on better organization of the health care system.
These observations are all valid. A response to these concerns
could certainly be placement of greatly increased numbers of physicians
into practice--whether from U.S. medical schools or from physicians
trained abroad at the expense of other nations. However, all evidence
indicates this would be a very costly response since physicians are
expensive to train and to compensate in practice. Additionally,
excellent evidence shows an association of more physicians and,
especially, more specialist physicians with higher health care costs.
This is the case because more physicians and, particularly, more
specialty physicians are associated with higher hospital utilization
and increasingly costly patterns of practice. Importantly, this
evidence also shows no benefit in care from this higher intensity of
physician practice.
Reforming physician workforce policies in a way that promotes
quality and constrains costs requires a different strategy. The
essential elements of that strategy are three:
1. The revitalization of a primary care workforce that will be able
to staff an organized system of national primary care delivery that
needs to be created by reforms in the delivery system. Whether services
are delivered in primary care medical homes, accountable care
organizations (ACOs), prepaid group practices, or community health
centers, the size and skills of the primary care workforce need to be
robust.
2. The physician education pipeline needs to produce enhanced
numbers of primary care physicians prepared to work in hard pressed
inner city and economically challenged communities, cities and rural
areas as well as in economically comfortable urban and suburban
settings.
3. To the degree that the clinical care workforce as a whole needs
more providers to address the changing needs of the population, a
strong strategy of support for nurse practitioners and physician
assistants should be adopted. The increased use of PAs and NPs should
not be limited to the primary care sector. Both professions have
demonstrated excellent functionality as team members in all aspects of
medical practice from the pediatric office to the operating room. Nurse
practitioners and physician assistants are trained more quickly, at
less expense than physicians, cost less in practice, and are not, on
their own, drivers of ancillary clinical tests and services. Moreover,
they represent a highly flexible workforce--an important asset
generally lacking in the physician workforce. In contrast, physicians
(especially specialty physicians), invest enormous amounts of time,
money and deferred income in establishing their capabilities and
credentials. Training, retraining, and/or redirecting them is not
easily done. Physician assistants and nurse practitioners are,
comparatively speaking, ``stem cells'' and more able as individuals and
as professions to focus on areas of emerging or urgent need. NPs and
PAs provide a well-proven quality, clinical workforce that can
interdigitate with all aspects of physician practice and whose pipeline
can be turned up or down as needed to assist in addressing emerging or
changing clinical needs.
No discussion of the physician workforce would be complete without
reference to international medical graduates (IMGs) who constitute
approximately 25 percent of physicians in practice and 29 percent of
physicians in residency training. No American policy body--certainly
not the U.S. Congress--has ever advocated that we ``offshore'' one
quarter of our medical training or design a system in which our medical
schools are only capable of training three-quarters of the physicians
we need. Yet that is what we have done.
We can be proud that the appeal of our way of life and the prowess
of our medical institutions that have made the United States a magnet
for physicians from around the world for the last 50 years. Most have
arrived under educational visas and, in overwhelming numbers, have
remained in the United States following residency training. This has
been an enormous gift to the United States. In steadily escalating
numbers, these hard working, smart, and ambitious men and women from
all over the world have staffed our health system. They have also
allowed us to be casual in our medical education policy. There is no
need for planning or precision nor, even, adequate funding for medical
schools since large numbers of foreign graduates are always available
to fill in the gaps in residency programs and in specialties that are
out of favor with American graduates. Sixty percent of international
medical graduates come from poor countries--largely the Indian
subcontinent, Africa and the Caribbean. In many small countries the
physician ``brain drain'' is the largest and most destabilizing aspect
of their health sector. We are not the only country to rely on foreign
trained physicians, of course. At one point, Nelson Mandela personally
appealed to Tony Blair to stop ``poaching'' South Africa's doctors.
Recently, global attention has turned to the question of health system
strengthening to fight AIDS and end poverty, and yet everywhere one
turns the brain drain of doctors and nurses stands as an impediment to
improved health in developing countries. Some have called it ``reverse
foreign aid.''
Heavy reliance on international medical graduates to fill residency
positions and undergird the Nation's physician workforce is neither
good domestic policy nor good foreign policy. Going forward, public
policy makers and medical educators should work toward self sufficiency
in medical education. This boils down to a single simple principle:
U.S. medical schools should graduate approximately the number of
students required to fill the first year residency positions offered in
the country.
In that regard, the current initiation of new medical schools and
expansion of class sizes at existing schools is a positive development.
These new U.S. students will undoubtedly find residency positions upon
graduation, decreasing our need to draw on the rest of the world to
meet our medical needs. This will be an asset in our efforts to promote
the United States as a good global citizen and also provide an overdue
opportunity for more U.S. students to go to medical school in the
United States.
Reform in the Three Sectors of the Physician Workforce
MEDICAL SCHOOLS
The principal Federal legislation impacting medical schools since
1963 has been the series of programs authorized under Title VII of the
Public Health Service Act. From 1963 to 1976 the principal investments
were designed to increase the number of medical schools and medical
school graduates. Construction grants, capitation funds, and student
loans were all used as stimuli for medical schools. The result was more
than a doubling of the Nation's annual medical school graduating class
from approximately 7,500 students a year in 1960 to 16,000 students a
year in 1980. This was an extraordinary achievement of public policy
and medical education.
The problems with medical education, however, that concerned
policymakers even in those early years went beyond absolute numbers. It
was growingly clear that physicians were not equally distributed in the
country nor were medical students reflective of the diversity of the
population of the United States. The term ``primary care'' was first
used in the 1960s to focus on yet another problem with medical
graduates--the increasing specialization of physicians such that many
parts of the country had little access to generalist care.
The result was a new growing set of programs authorized under Title
VII of the Public Health Service Act to promote community practice,
rural practice, primary care, and opportunities for minorities and
disadvantaged students. These included the Area Health Education
programs, support for family medicine, general internal medicine, and
general pediatrics, the Health Careers Opportunity Program and funding
for physician assistants. During this same period, funding for nursing
and, particularly, new nurse practitioner programs was similarly
increased under Title VIII of the Public Health Service Act.
In the early 1970s, the funding for title VII programs reached over
$2.5 billion (2009 dollars) (see Figure 5). In the mid-1970s, the
consensus changed with the belief that we were training enough (some
thought too many) physicians and title VII authorizations and
appropriations were throttled back. The title VII programs have
functioned in the very modest $200-300 million/year range from that
time until the present.
In the latter years of the Bush administration, serious efforts
were made to eliminate all title VII funding including support for
primary care, minorities in medicine, rural placements and workforce
tracking. During the same period, medical school revenues from NIH
research funding have risen from $2.4 billion in 1970 to $16.3 billion
in 2004 (all 2009 dollars), creating a robust culture of research at
medical schools that dominates medical school finances, faculty values
and school culture (see Figure 6).
Any serious proposal to reform medical practice in the United
States must start with reinventing and reinvigorating title VII funding
to medical schools for the purpose of creating incentives and
educational pathways that will select and train students for primary
care, rural health, diversity, and social mission. Parallel support for
nurse practitioners and physician assistants is important as well.
In the past, critics of title VII have proposed high standards of
measurement, asking, ``how do we know title VII funds make a
difference?'' This is a difficult problem for programs with small
funding streams that function within large institutions with many
contrary incentives. Nonetheless, an impressive series of studies have
shown that title VII funds affect physician careers positively in
regard to primary care, rural placement and minority opportunities.
There are many ways in which title VII could be augmented and
strengthened. One of those would be an initiative which provides
incentives for the creation of ``teaching community health centers''--
creating funded linkages between medical schools and Federally
Qualified Health Centers (FQHCs) for the purpose of training. Another
area in which title VII needs strengthening is in the ability to
collect important data and produce useful policy analyses on the
workforce. A national center for workforce studies should be given
serious consideration in augmenting title VII authorities and funds.
Funding for the education of physician assistants and nurse
practitioners should be continued and augmented to help provide the
build-up of flexible clinicians for health reform.
While the National Health Service Corps (NHSC) it is not an
educational program, it is a brilliant but underfunded asset available
to redistribute health professionals--physicians, NPs, PAs and others.
I say brilliant, since it matches the needs of individual health
science students/professionals with national needs for practitioners in
underserved areas. The program has been ``tested'' since 1971 and works
to the benefit of clinicians and communities. Many clinicians have
remained in their assigned communities for long periods or full
careers. At times, however, the NHSC has received criticism for not
having as high ``retention rates'' as some would like. There are
American communities that for reasons of geography or economy have
never been able to retain physicians. To the degree that the NHSC can
meet service needs with serial placements in these communities, the
program is a success. The principal problem with the NHSC is its size.
There are many more communities eager for NHSC help and many more
clinicians interested in scholarships or loan repayment opportunities
than can be met given the program's budget. Major investment in the
NHSC would do a great deal to increase access to health services in
some of our poorest and most rural communities.
A word should also be said about Community Health Centers which are
not teaching institutions but have a stellar record of providing
learning sites and supervision for clinical students--often without
recompense. Good data now shows that in many communities CHCs are
struggling to find sufficient primary care providers to meet their
staffing needs. Expansion of the NHSC and support through title VII and
Medicare GME for CHC-based teaching activities will be essential to
allow them to expand to meet the growing needs of the uninsured and
underinsured populations of our country.
GRADUATE MEDICAL EDUCATION
Graduate medical education (GME) grew significantly through the
1980s and early 1990s and leveled off at about 100,000 residents and
fellows a year in GME from the late 1990s to the early 2000s. In recent
years there has been a small increase in the total number of residents
and fellows. Residency programs are unevenly distributed throughout the
country, with history playing an important role. The locations of the
earliest residency programs 100 years ago are the areas of the largest
residency concentrations today including Boston, New York City,
Philadelphia and Washington, DC. In general, the resident physician-to-
population ratio is highest in cities in the Northeast, lower in
Southern and Western States, and lowest in rural areas.
The most important financial policy and educational instrument in
graduate medical education is Medicare GME. While Medicare has paid for
a portion of GME since its inception, the current system was
established in 1983 as part of the prospective payment reforms of
Medicare. The current system reimburses hospitals that train residents
for two costs:
1. Direct costs (DGME) associated with residents, such as salaries,
teaching time of faculty, administrative costs; and
2. Indirect costs (IME), which are intended to subsidize the higher
cost of patient care in teaching hospitals related to both higher
patient care acuity and the presence of residents in the hospital.
The calculation for direct and indirect payments is different, but
both are based on the number of residents at a given teaching hospital
and, as such, are a form of capitation payment--the more residents, the
higher the payment. In 2006, direct GME payments totaled $2.8 billion
and indirect GME payments totaled $5.8 billion, a total of $8.6
billion. This total amount represents only 2 percent of Medicare's
expenditures in 2006 and, perhaps, receives less public debate than it
might. On the other hand, $8.6 billion is far and away the largest
Federal expenditure related in any way to medical education.
As part of Medicare, these funds function as an entitlement and are
allocated based on established formulas. Medicare legislation requires
no community or regional physician needs assessment to qualify a
hospital for GME payments, sets no targets for the number or type of
resident physicians that a hospital trains and requires no
accountability for the type or sufficiency of physicians in the
hospital's city, county or State. Concerned with the cost of the
program and its potential to escalate, Congress capped the number of
federally funded residents in the Balanced Budget Act of 1997. In the
last 5 years, the total number of residents in the country has grown
slowly presumably due to the addition of ``off-cap'' residents and the
selection of specialties with longer training periods.
While Medicare GME in its current form has provided a large and
stable source of income for teaching hospitals that is understandably
of enormous value to those important institutions, it is effectively a
Federal payment without a deliverable--a subsidy. The resident
compliment of any given hospital is determined by the staffing needs of
that particular hospital with, presumably, the input of the chiefs of
the clinical services. There is no requirement that the particular
hospital or the medical school with which it is affiliated make any
judgments about the workforce needs of their community, region or
State. The result is that the annual graduates of the over 9,000
residency programs at nearly 1,100 teaching hospitals in the United
States comprise the workforce of the country with no regard to
specialty selection, practice location or regional needs.
Effectively, we are addressing the health care needs of the country
with a physician staffing pattern based on hospital needs. This is a
core problem for workforce reform. There are many ways in which
Medicare GME could be reconceptualized and redirected. For the purpose
of this testimony, let me suggest two levels of reform that might be
considered. The first I will entitle ``modest'' and the second
``major''.
Modest reforms to current Medicare GME would entail modifications
in the rules governing the use of GME funds. Currently, there are a
variety of financial disincentives to offsite training. Hospitals stand
to lose GME payments, both DGME and IME, for residents who spend time
offsite (for instance in Community Health Centers, office-based
practices, or local public health departments.) The sites, in turn,
face either complicated negotiations to obtain GME pass-through funds
or the prospect of training residents without receiving the benefit of
GME financing.
There is much that could be done to make Medicare GME more user-
friendly to primary care and community-oriented training. Reforms in
this area would be helpful but would do little to change the basic
problem of hospital staffing patterns dictating the Nation's physician
workforce.
A major reform would require reconstituting the current policy
thinking that governs Medicare GME. Rather than seeing GME as a
convenient vehicle for teaching hospital support, Medicare GME should
be seen as the principal instrument to shape the physician workforce of
the country. This perspective would require teaching hospitals to
undertake community or regionally oriented analyses of physician
workforce needs and make application for training positions based on a
fiduciary responsibility to train a complement of residents that
corresponds to agreed upon regional needs. This approach might also
call for rebalancing regional and sectional allocations of GME funding
and therefore physicians to provide a more balanced landscape of GME
training.
One problem with envisioning a system of this sort is that many
teaching hospitals who are current recipients of GME funding are not
large and do not have a large number of teaching programs. In fact,
many larger hospitals have specific foci such as cancer or children or
surgery that do not equip them to address regional needs. An answer to
this problem is the formation of independent consortia of teaching
institutions that would, when working together, represent training
capacity that could address regional needs in a much more comprehensive
fashion. A variant approach would be State-based GME organizations that
might (or might not) have a link to State government. In either case,
the consortium would be able to represent regional needs and work with
the Center for Medicare and Medicaid Services (CMS) on residency
training targets and GME funding.
A consortium system would require the establishment of many new
arrangements within the medical teaching sector. It might also mean
that teaching hospitals would have to modify their complement of
residency programs in ways that might not be popular with the chiefs of
service or the hospital administration. Strong political objection
would predictably be mounted against any such reform, but if this most
crucial link in the construction of the physician workforce in the
United States--graduate medical education--is to be modified to meet
the needs of an efficient and effective health system in the future,
changes will need to be made in the way the Federal Government does
business with the teaching hospitals of the country.
MEDICAL PRACTICE
Re-incentivizing and re-directing primary care in the pipeline
(medical schools and GME) will amount to little if parallel reforms are
not achieved in support for primary care practice. Physicians are smart
and ambitious enough that, if the current reimbursement inequities and
structural disincentives to primary care practice remain in place, many
will abandon primary care during their practice years despite excellent
primary care education and support for primary care in their training
years. The key areas in the practice environment that will help are
practice reimbursement, practice organization, and health information
technology.
Primary care physician average annual incomes are currently less
than half those of their specialty colleagues. Given high medical
school debt, late entry into an economically productive life and
demands of the job, it is not hard to understand why primary care
careers are severely disadvantaged in comparison to more lucrative
specialty options that often have more controlled lifestyles. While
physicians receive payment from many sources, the Medicare fee schedule
is the primary determinant of physician reimbursement and is a
candidate for major restructuring.
The organization of primary care practice is another area of major
reform potential. The preponderance of primary care providers still
work in solo practice or small groups. This minimizes the opportunity
to develop a full-service primary care team benefiting from new
information technologies or relating in an effective way to specialty
consultants. Larger team-based practices with excellent information
systems such as medical homes or accountable care organizations offer
the promise of a new platform for health care delivery. Incentivizing
and supporting these forms of practice stands to do a great deal to
improve the overall health system, particularly promoting primary care,
whose currency is patient well-being over time linked to episodes of
care provided by other practitioners. Health IT will organize and
empower the primary care practitioner in ways that will make the
practice of primary care much more effective. Investments in these
areas are crucial.
ACTION ITEMS
In closing, I want to emphasize three areas for legislative action
that would move the healthcare workforce of the United States in the
direction needed to provide universal coverage built on a strong
primary care base. The areas are the following:
1. The 1 percent National Health Service Corps
Increase investments in NHSC scholarships and loan repayment such
that there are 8,000 physicians and others in the field by 2012--
something approaching 1 percent of the physicians currently practicing
in America. A field strength of this size would help staff the
expanding network of community health centers and other community sites
and begin to address the medical needs of many newly insured Americans.
Additionally, modifications will need to be made in the current NHSC
law to allow NHSC clinicians to engage in teaching and medical
leadership functions.
2. Teaching Health Centers
A reform effort focused on all three sectors of the physician
workforce is the Teaching Health Center. Patient care in the United
States increasingly occurs in ambulatory settings. Yet medical
education (both undergraduate and graduate) is overwhelmingly based in
hospitals--creating a mismatch between the skills obtained during
training and those needed in practice, promoting specialization over
primary care careers and inhibiting recruitment and retention in
ambulatory sites, particularly those serving rural and underserved
communities. Establishing Teaching Health Centers would address all of
these by augmenting the current training system with increased training
directed by and occurring in health centers (including FQHCs, FQHC
look-alikes and public health department). While education does
currently occur in these settings, current laws and regulations are
prohibitive. Legislation to support the Teaching Health Center could
include:
Medicare GME funding paid directly to health centers to
support these training programs.
Title VII and title VIII grants to support faculty and
curriculum development.
Section 330 grants to support facility expansion and
faculty time costs.
Changes in National Health Service Corps to support a
teaching role within the NHSC service obligation.
3. A National Health Workforce Commission
Underlying reform efforts in all three sectors of the physician
workforce is the need for national level analyses and guidelines for
workforce policies. Policy changes aimed at reforming the three sectors
to address the health care needs of the Nation can not be successful
without clear workforce objectives, which require the ability to
collect important data and produce useful policy analyses on the
workforce. A National Health Workforce Commission, established as an
independent congressional agency, could serve in this function and
advise Congress and the Secretary on the alignment of Federal programs
including Medicare GME with national health workforce goals. Also
recognizing the complexities of data collection and the varying
geographic needs at the local level, State Level Health Workforce
Councils could support the National Commission--collecting and
analyzing State level data and implementing national level policies at
the local level.
CONCLUSION
In order to reform the delivery of health care in the United States
in a way that is more effective and constrains costs, a number of
changes need to be made in the workforce since the workforce is an
essential governing component of the functionality, quality and cost of
the system as a whole.
The number of physicians entering practice in the United States
currently is in a zone of adequacy. Many of these physicians are
trained abroad and measures should be taken to increase U.S. medical
school output so as to decrease our dependence on foreign-trained
physicians. The training and use of nurse practitioners and physician
assistants should be augmented to absorb increased demand in the system
due to an aging population.
The current system heavily favors fragmented specialty care, making
it inefficient and expensive. Moreover, it is unevenly distributed,
raising serious concerns of access and equity. Major investments in the
pipeline at the medical school and GME level will be essential to
rebalancing the system. At the GME level, in particular, where a large
investment already exists, modifications need to be made in the system.
In the practice sector, primary care is currently severely
disadvantaged and reforms in payment systems and practice support will
be needed to re-incentivize and restructure the practice of primary
care across the country.
It goes without saying that this is an important moment in the
history of health care in the United States. The Congress has an
unprecedented opportunity to lead in the reform of the system for the
benefit of all Americans. I very much appreciate the opportunity to
testify before you and I remain available to provide assistance in
whatever way I can.
Thank you.
References
1. National Association of Community Health Centers, Robert Graham
Center, George Washington University. Access Transformed: Building a
Primary Care Workforce for the 21st Century. August 2008.
2. Hauer KE, Durning SJ, Kernan WN, et al. Factors Associated with
Medical Students' Career Choices Regarding Internal Medicine. JAMA.
2008;300:1154-64.
3. Colwill JM, Cultice JM, Kruse RL. Will Generalist Physician
Supply Meet Demands of an Increasing and Aging Population. Health
Affairs. 2008;27:232-241w.
4. Salsberg E, Rockey PH, Rivers KL, Brotherton SE, Jackson GR.
U.S. Residency Training Before and After the Balanced Budget Act. JAMA.
2008;300:1174-1180.
Senator Sanders. Thank you very much, Dr. Mullan. When we
talk about health care, sometimes we forget dental care, which
is a huge problem in my State of Vermont. We are very pleased
to have Caswell A. Evans, Jr., who is the Associate Dean for
Prevention & Public Health Sciences, University of Illinois, at
Chicago College of Dentistry.
Dr. Evans, thanks very much for being here with us.
STATEMENT OF CASWELL A. EVANS, Jr., D.D.S, M.P.H., ASSOCIATE
DEAN FOR PREVENTION & PUBLIC HEALTH SCIENCES, UNIVERSITY OF
ILLINOIS AT CHICAGO COLLEGE OF DENTISTRY, CHICAGO, IL
Mr. Evans. Senator Sanders, thank you very much for having
me and Senator Brown, very nice to see you again and I
appreciate your comments, and our other distinguish elected
leaders. It is a pleasure to be here with you.
I am here this morning representing the American Dental
Education Association, which represents the dental education
network and 58 dental schools in the United States, all its
faculty and residency programs and other training programs.
It's important to point out and I want to echo your
comments, Senator, that we often overlook the fact that oral
health is inextricably linked to general health and the jaw
bone is connected to the toe bone. It's a connection we
unfortunately miss, and infections that occur in the jaw bone,
in effect, eventually will affect the toe bone and all in
between.
I want to point out that academic dental institutions are
significant safety net providers in their communities. They
provide care to populations that unfortunately do not have
access otherwise to the health system, with the exception of
our community health centers. And we know these populations
well. They are low income, racially and ethnically diverse,
disabled, institutionalized patients, HIV/AIDS patients, and a
long list of those who did not have access to care.
We know that vulnerable populations are more at risk for
unmet oral health needs compared to other populations and the
same populations that, again, make up the service community and
recipients of services at community health centers, also seek
care in our schools of dentistry.
One of the issues facing dentistry is its lack of diversity
of the workforce. While we take African-Americans and Hispanics
collectively, they represent approximately 25 percent currently
of the U.S. population. Only 3 percent of dentists are Hispanic
and only 3 percent of dentists are African-American. So we look
at that as a potential barrier to access to care, much less the
issue of role modeling in terms of profession and recruiting
individuals into the profession.
I want to take just a moment to illustrate some of the
things we are doing at the University of Illinois at Chicago
College of Dentistry, because I think they are illustrative to
this particular issue.
In a course that is requisite and for credit and for all of
our senior students, we have 64 students per class. All senior
students now spend between 60 and 80 days in community centers,
in terms of gaining their clinical experience. We have a group
of specifically selected students, 16 in all, who spend half of
their senior year in community-based sites. These sites include
community health centers, FQHCs, Federally Qualified Health
Centers in both rural and urban environments. They also include
philanthropically supported health centers, a clinic serving
the developmentally disabled only, local health departments, a
union run clinic, Veterans Administration Hospital, and other
hospitals.
These clinical rotations are intended to provide an
experience in terms of access to care and health disparities
for these students and we find that they are resonating well to
that and many of them are seeking employment in community
health centers and we think that's a very significant model for
training and sensitizing our dental student cadre.
Thank you.
[The prepared statement of Dr. Evans follows:]
Prepared Statement of Caswell A. Evans, Jr., D.D.S, M.P.H.
SUMMARY
Good morning, Mr. Chairman and members of the committee. I am Dr.
Caswell Evans, Associate Dean for Prevention and Public Health
Sciences, at the University of Illinois at Chicago College of
Dentistry.
The American Dental Education Association represents all 58 dental
schools in the United States, in addition to more than 700 dental
residency training programs and nearly 600 allied dental programs, as
well as more than 12,000 faculty who educate and train the nearly
50,000 students and residents attending these institutions.
Academic Dental Institutions as safety net providers. Academic
dental institutions 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 key referral resources 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.
Vulnerable populations are more at risk for unmet oral health
needs. The same people that make up the largest proportion of Community
Health Center patients, namely low-income families, members of racial
and ethnic minority groups, the uninsured and rural residents,
experience more unmet oral health care needs than other groups and
suffer greater losses to their overall health and quality of life as a
result.
Multiple approaches are needed to improve access to dental care,
including improving access to community health centers. Evolution in
dental education to involve a more diverse student body, greater
attention to public health, and collaboration with other oral health
providers as well as primary care providers will help improve access to
oral health care in the long term.
Health centers are important providers of oral health care to
vulnerable populations who otherwise would go without. In 2005, 73
percent of existing federally funded health centers provided oral
health services onsite and all new federally funded health centers are
now required to assure the availability and accessibility of oral
health care services. About half of all NHSC providers are at community
health center sites. In order to meet the medical staffing needs of
underserved communities, including hundreds of vacancies at community
health centers, the NHSC must be expanded. Scholarship and loan
repayment programs ease provider shortages with approximately 20
percent of loan repayment awards currently going to dentists.*
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* Ruddy G ``Health Centers'' Role in Addressing the Oral Health
Needs of the Medically Underserved. ``Report'' National Association of
Community Health Centers, Washington, DC, August 2007.
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University of Illinois at Chicago College of Dentistry. The
University of Illinois at Chicago College of Dentistry (UIC COD) has
made an unwavering commitment to community-based service-learning as a
fundamental element of its curriculum. The average class size is
approximately 64 students. In the context of a requisite and for-credit
course structure, all fourth-year (senior) students spend at least 60
days in community sites providing care. A specifically selected group
of 16 students gain half of their clinical education and training
experience in community settings. The community sites include FQHC's
(Federally Qualified Health Centers) in urban and rural locations,
philanthropically supported health centers, a clinic serving the needs
of developmentally disabled patients only, local health departments, a
union-run health clinic, a Veterans Administration hospital and other
local hospital-based clinics. These clinical rotation experiences are
intended to expose students to issues of access to care, health
disparities, practice models beyond private practice, and the ``real
world'' of health care delivery and the related challenges. The
didactic aspect of the course provides an opportunity to explore these
issues in a scholastic manner as well. These educational experiences
have also proven to be an opportunity as more students, upon
graduation, have sought to initiate their careers in community health
centers, the Indian Health Services, or through the National Health
Service Corps supported positions.
In conclusion, Mr. Chairman, I thank the committee for considering
the American Dental Education Association's recommendations regarding
Primary Care Access Reform. 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.
______
Good morning, Mr. Chairman and members of the committee. I am Dr.
Caswell Evans, Associate Dean for Prevention and Public Health
Sciences, at the University of Illinois at Chicago College of
Dentistry. I currently serve on the Legislative Advisory Committee of
the American Dental Education Association (ADEA) on whose behalf I am
honored to appear before you to offer recommendations with regard to
primary health care access reform.
The American Dental Education Association represents all 58 dental
schools in the United States, in addition to more than 700 dental
residency training programs and nearly 600 allied dental programs, as
well as more than 12,000 faculty who educate and train the nearly
50,000 students and residents attending these institutions. It is at
these academic dental institutions that future practitioners and
researchers gain their knowledge, where the majority of dental research
is conducted, and where significant dental care is provided. ADEA
member institutions serve as dental homes for a broad array of racially
and ethnically diverse patients, many who are uninsured, underinsured,
or reliant on public programs such as Medicaid and the Children's
Health Insurance Program for their health care.
U.S. academic dental institutions (ADI) 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. Academic dental institutions
play an essential role in conducting research, 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 to 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, academic dental institutions 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 key referral resources 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.
DENTAL ACCESS
Access to oral health care is a growing challenge in the United
States. As many as 130 million American adults and children lack dental
insurance, nearly three times as many as lack medical insurance. Now
more than ever, academic dental institutions are a critical source of
oral health services to those with the highest burden of disease and
unmet need. The disparities in oral health care are stark: 100 million
Americans lack adequate fluoridated drinking water and only 10 percent
of the highest risk children have dental sealants. Yet, fluoridation
and sealants have been shown to prevent dental disease and reduce
health care costs over time. Dental caries remains the single most
common disease among children in America, with five times as many
sufferers as asthma. Half of all children have untreated tooth decay by
age 9 and 70 percent have at least one cavity by 18. Thirty percent of
Americans over the age of 65 have no teeth. In the face of these
alarming realities, academic dental institutions are working to reduce
the burden of oral health disease.\1\
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\1\ Ruddy G ``Health Centers'' Role in Addressing the Oral Health
Needs of the Medically Underserved. ``Report'' National Association of
Community Health Centers, Washington, DC, August 2007.
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Many Americans do not have access to dental services given a lack
of dental providers in their areas, or a lack of dentists who are
willing to accept insurance. Over 2,000 counties or partial counties
have been designated dental Health Professions Shortage Areas (D-HPSA),
where individuals suffer from an absolute lack of dental providers.
Less than half of these are served by safety net providers. Many
dentists do not accept patients insured by public insurance, such as
Medicaid.\2\ This was the case of a 12-year-old Maryland boy whose
untreated infected tooth resulted in his death. His death could have
been avoided by simply removing his tooth, a procedure costing about
$80. Though covered by Medicaid, the boy's family was unable to find a
dentist willing to take new Medicaid patients. The implications of not
having access to oral health care can be severe and even fatal.
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\2\ Ruddy G ``Health Centers'' Role in Addressing the Oral Health
Needs of the Medically Underserved. ``Report'' National Association of
Community Health Centers, Washington, DC, August 2007.
---------------------------------------------------------------------------
Currently a number of dental schools are taking it upon themselves
to address dental workforce issues around the lack of diversity and
lack of providers for underserved communities. The Arizona School of
Dentistry and Oral Health at A.T. Still University is a new school with
a focus toward social responsibility. Students spend their fourth year
in a residency at a health center, Indian Health Service site, or
Veterans Affairs facility.\3\ The school was founded to help meet the
staggering need for dental care in Arizona and to avert a significant
shortage of dentists--given that 2,000 more dentists are retiring each
year than entering practice in the State.\4\ Some 200 applicants vie
for 62 spots each year. The dental school graduated its first class in
2007. Graduates are specifically trained to be culturally competent,
community-responsive general dentists who are able and willing to serve
as a resource in their community for dental public health issues.
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\3\ 3 Krause B. ``State Efforts to Improve Children's Oral
Health,'' Issue Brief, Center for Best Practices, National Governor's
Association, Washington, DC, November 20, 2002.
\4\ Ruddy G ``Health Centers'' Role in Addressing the Oral Health
Needs of the Medically Underserved. ``Report'' National Association of
Community Health Centers, Washington, DC, August 2007.
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Additionally, other dental schools in California, Kentucky,
Missouri, New Mexico, and Oklahoma are exposing students during their
training to patients covered by Medicaid or the State Children's Health
Insurance Program (SCHIP). The Illinois at Chicago College of
Dentistry, the University of Michigan School of Dentistry and the
College of Dental Medicine Columbia University go further and link
students to underserved communities in an effort to encourage
subsequent work with low-income and other vulnerable populations.\5\
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\5\ Ryan J. Improving Oral Health: Promises and Prospects. National
Health Policy Forum Background Paper. Washington, DC, June 2003.
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Pipeline, Profession and Practice is a 3-year-old program funded by
the Robert Wood Johnson Foundation that now involves 27 percent of U.S.
dental schools. Each school is slated to establish a community-based
clinical education program and develop recruitment and retention
programs directed at underrepresented minorities and those from low-
income backgrounds. Even before graduation, students are in a position
to improve access to oral health care.
DENTAL WORKFORCE
The representation of minorities in the health care workforce has
not increased in over a decade. Black, Hispanics and American Indians
represent more than 25 percent of the U.S. population, yet comprise
less than: 9 percent of nurses, 6 percent of physicians and 5 percent
of dentists. The U.S. Bureau of Labor Statistics (BLS), which placed
the number of practicing dentists at 161,000 in 2006,\6\ 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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\6\ 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.
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.\7\ 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.
---------------------------------------------------------------------------
\7\ U.S. Bureau of the Census, http://www.census.gov/population/
www/popclockus.html, accessed February 5, 2008.
---------------------------------------------------------------------------
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 \8\ dental
hygienists, 280,000 \9\ dental assistants and 53,000 \10\ 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.
---------------------------------------------------------------------------
\8\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/pdf/
ocos097.pdf, accessed February 5, 2008.
\9\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/
ocos163.htm, accessed February 5, 2008.
\10\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/
ocos238.htm, accessed February 5, 2008.
---------------------------------------------------------------------------
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, 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 (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 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 4,048 in 2008. In
1993, HRSA estimated 1,400 dentists were needed in these areas; by
2008, the number grew to 9,432. Nearly 48 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.
ORAL HEALTH AND COMMUNITY HEALTH CENTERS
Over 2,000 counties or partial counties have been designated dental
Health Professions Shortage Areas where individuals suffer from an
absolute lack of providers in addition to all of the other barriers
facing the uninsured and publicly insured. Less than half (875) of
these dental HPSAs are served by federally qualified health centers
(837), FQHC look-alikes (6), or rural health clinics (32). Many
counties eligible for dental HPSA status have not applied for the
designation, whether because of the administrative burden or for other
reasons.
There are over 7,000 community health centers (CHC); 52.8 percent
are in rural communities.\11\ In calendar year 2007 16 million patients
were served. The CHC dental workforce includes 6,899 oral health
professionals: 2,107 dentists, 806 hygienists and 3,986 assistants.\12\
---------------------------------------------------------------------------
\11\ Health Resource Service Administration. Accessed May 2007.
\12\ Uniform Data System, 2007 Data.
---------------------------------------------------------------------------
Currently, community health centers are providing dental services
to over 2.3 million patients, a growth of 77 percent since 2000. Most
new dental care patients are likely to be those who lacked access to
care prior to seeking it at a health center, therefore more likely to
suffer from caries and periodontal disease and require more intensive
services than simple preventive care. The people who make up the
largest proportion of community health center patients, namely low-
income families, members of racial and ethnic minority groups, the
uninsured and rural residents, experience more unmet oral health care
needs than other groups, and suffer greater losses to their overall
health and quality of life as a result. Research shows that the
provision of preventive dental care is cost-effective.\13\
---------------------------------------------------------------------------
\13\ Ruddy G ``Health Centers'' Role in Addressing the Oral Health
Needs of the Medically Underserved. ``Report'' National Association of
Community Health Centers, Washington, DC, August 2007.
---------------------------------------------------------------------------
Of existing community health centers 73 percent provide oral health
services and all new community health centers are now required to
provide comprehensive oral health care. But challenges persist as these
centers continue to expand their capacity to better meet the oral
health needs of their patients. Community health centers cannot bridge
the gap between the supply and demand for oral health care alone. They
will continue to depend on the important contributions of the large,
private dentistry workforce as they work to provide dental care for the
medically underserved.
CHC STATE-BY-STATE ANALYSIS
Appendices A, B, and C provide state-by-state data on the
proportion of community health centers providing oral health services,
community health center dental staff, and related patients and visits
in 2005. As Appendix A demonstrates, 100 percent of community health
centers in Vermont and Nevada provide all four major dental service
categories--preventive, restorative, emergency, and rehabilitative, and
100 percent of the community health centers in three other States
(Delaware, Missouri, and New Mexico) provide three out of the four
services (preventive, restorative, and emergency).
Appendix B provides for each State information on patients who rely
on community health center dental services. Not surprisingly, these
centers in eight large States (California, Florida, Massachusetts,
Michigan, New York, Pennsylvania, Texas, and Washington) account for
half of all community health center dental patients. While nationally
17 percent of all health center patients use health center dental
services, more than 25 percent of health center patients in six States
(Connecticut, Michigan, Missouri, Nebraska, Vermont, and Washington)
receive health center dental services.
Last, Appendix C provides a close look at community health center
dental services staffing and visits per dentist and dental hygienist by
State. Although nationally the average dentist provided 2,719.5 visits
last year, health centers in three States (California, Florida, and
Wyoming) provided over 3,000. In addition, the average dental hygienist
in four States (Connecticut, Maryland, Michigan, and Oregon) and Puerto
Rico provided over 1,600 visits, compared to the national average of
1,279.8.
ORAL HEALTH AND THE NATIONAL HEALTH SERVICE CORPS
The National Health Service Corps (NHSC) has been important to the
oral health of the underserved for more than 26 years as it positively
addresses two public health concerns:
(1) enabling underserved populations to access qualified, high-
skilled health care practitioners; and
(2) facilitating continued interest in serving these special
populations after participants have left NHSC. It is more important
than ever that the NHSC embrace a bold proactive health agenda. Due to
the increased focus on children's oral health, the findings reported in
the U.S. Surgeon General's Report on Oral Health, and increasing
research data linking oral health to systemic health, the NHSC is of
paramount importance.
The National Health Service Corps dispatches clinicians to urban
and rural communities with severe shortages of health care providers.
Currently, more than 4,000 NHSC clinicians, including dentists,
physicians, nurse practitioners, physician assistants, nurse midwives,
and behavioral health professionals, provide health care services to
nearly 5 million Americans. About half of all NHSC providers are at
community health center sites. In order to meet the medical staffing
needs of underserved communities, including hundreds of vacancies at
community health centers, the NHSC must be expanded. Scholarship and
loan repayment programs ease provider shortages with approximately 20
percent of loan repayment awards currently going to dentists.\14\
---------------------------------------------------------------------------
\14\ Ruddy G ``Health Centers'' Role in Addressing the Oral Health
Needs of the Medically Underserved. ``Report'' National Association of
Community Health Centers, Washington, DC, August 2007.
---------------------------------------------------------------------------
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. The American Dental Education Association 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 of the future dental workforce. Specifically, we
recommend:
Evolution in dental education to involve a more diverse,
representative student body, greater attention to public health, and
collaboration with dental hygienists as well as primary care providers
will help improve access to oral health care in the long term;
Financial, administrative and clinical support incentives
will increase the likelihood that dentists at both ends of their
careers will choose to care for the underserved. Reimbursement and
remuneration may also need to more closely reflect those in the private
sector if more dentists are to choose to care for the underserved;
Innovative programs involving public-private partnerships
in several States have improved dentist participation in Medicaid and
increased take-up by eligible persons. These programs provide templates
for other States to devise solutions to challenges around use;
Maintain Support and restore adequate funding for Title
VII General and Pediatric Dentistry Residency Training programs;
Strengthen and Improve Medicaid;
Prioritize Dental Access in Rural Health Clinics;
Bolster Prevention to Eradicate Dental Caries; and
Establish Dental Homes for Everyone.
CONCLUSION
In conclusion, the American Dental Education Association thanks the
committee for considering our recommendations with regard to addressing
access 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.
______
Appendix A.--Percent of Community Health Center Grantees Providing
Dental Services Onsite* by State, 2005
----------------------------------------------------------------------------------------------------------------
Dental Dental Dental Dental
# Health preventive restorative emergency rehabilitative
State center onsite onsite onsite onsite
grantees [percent] [percent] [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Alabama.......................................... 15 73.3 73.3 66.7 40.0
Alaska........................................... 24 66.7 58.3 58.3 25.0
Arizona.......................................... 14 92.9 85.7 100.0 64.3
Arkansas......................................... 12 75.0 75.0 75.0 50.0
California....................................... 97 74.2 72.2 72.2 44.3
Colorado......................................... 15 80.0 80.0 80.0 73.3
Connecticut...................................... 10 90.0 90.0 90.0 70.0
Delaware......................................... 3 100.0 100.0 100.0 33.3
District of Columbia............................. 3 66.7 33.3 33.3 33.3
Florida.......................................... 36 69.4 66.7 69.4 47.2
Georgia.......................................... 23 65.2 52.2 52.2 34.8
Hawaii........................................... 11 54.5 54.5 54.5 27.3
Idaho............................................ 10 70.0 70.0 70.0 60.0
Illinois......................................... 33 75.8 66.7 69.7 45.5
Indiana.......................................... 13 61.5 61.5 53.8 53.8
Iowa............................................. 9 77.8 77.8 77.8 66.7
Kansas........................................... 9 55.6 33.3 44.4 33.3
Kentucky......................................... 14 64.3 64.3 57.1 28.6
Louisiana........................................ 18 66.7 66.7 55.6 44.4
Maine............................................ 16 75.0 62.5 62.5 50.0
Maryland......................................... 13 76.9 69.2 69.2 46.2
Massachusetts.................................... 33 72.7 69.7 66.7 51.5
Michigan......................................... 26 76.9 73.1 73.1 61.5
Minnesota........................................ 12 66.7 66.7 66.7 33.3
Mississippi...................................... 19 84.2 78.9 84.2 36.8
Missouri......................................... 17 100.0 100.0 100.0 82.4
Montana.......................................... 12 75.0 66.7 58.3 41.7
Nebraska......................................... 5 80.0 80.0 80.0 20.0
Nevada........................................... 2 100.0 100.0 100.0 100.0
New Hampshire.................................... 8 62.5 62.5 50.0 50.0
New Jersey....................................... 17 76.5 70.6 70.6 64.7
New Mexico....................................... 14 100.0 100.0 100.0 78.6
New York......................................... 47 91.5 89.4 85.1 63.8
North Carolina................................... 24 75.0 75.0 75.0 37.5
Oregon........................................... 21 61.9 52.4 57.1 28.6
Pennsylvania..................................... 29 86.2 79.3 82.8 62.1
Rhode Island..................................... 7 100.0 100.0 85.7 42.9
South Carolina................................... 21 33.3 28.6 33.3 28.6
South Dakota..................................... 7 57.1 42.9 42.9 28.6
Tennessee........................................ 22 50.0 45.5 50.0 27.3
Texas............................................ 43 88.4 86.0 88.4 48.8
Utah............................................. 11 90.9 72.7 72.7 63.6
Vermont.......................................... 3 100.0 100.0 100.0 100.0
Virginia......................................... 21 57.1 47.6 57.1 28.6
Washington....................................... 23 95.7 95.7 87.0 52.2
West Virginia.................................... 27 44.4 37.0 37.0 22.2
Wisconsin........................................ 15 80.0 73.3 73.3 73.3
Wyoming.......................................... 5 80.0 20.0 20.0 0.0
----------------------------------------------------------------------------------------------------------------
United States**................................ 952 73.4 68.7 68.8 46.4
----------------------------------------------------------------------------------------------------------------
North Dakota..................................... 4 25.0 25.0 25.0 0.0
Ohio............................................. 23 73.9 69.6 73.9 56.5
Oklahoma......................................... 9 44.4 44.4 44.4 22.2
----------------------------------------------------------------------------------------------------------------
* ``Onsite'' includes services rendered by salaried employees, contracted providers, National Health Service
Corps Staff, volunteers, and others such as out-stationed eligibility workers who render services in the
health center's name. Grantees may also provide these services through formal referral arrangements.
** U.S. totals include American Samoa, Fed. States of Micronesia, Guam, Marshall Islands, Virgin Islands, and
Palau.
Note: Includes only federally-funded health centers, and therefore may underreport the volume of health care
delivered by health centers.
Source: Bureau of Primary Health Care, HRSA, DHHS, 2005 Uniform Data System.
Appendix B.--Community Health Center Dental Services Patients,
Visits per Patient, and Percent of Total Patients by State, 2005
----------------------------------------------------------------------------------------------------------------
Total patients using
State Total dental services Average dental visits dental services
patients per dental patient [percent]
----------------------------------------------------------------------------------------------------------------
Alabama.............................. 42,057................. 1.6.................... 15
Alaska............................... 16,243................. 1.9.................... 21
Arizona.............................. 40,353................. 2.2.................... 14
Arkansas............................. 18,565................. 1.7.................... 15
California........................... 285,460................ 2.8.................... 14
Colorado............................. 65,018................. 1.9.................... 16
Connecticut.......................... 58,046................. 1.7.................... 29
Delaware............................. 3,874.................. 2.1.................... 18
District of Columbia................. 13,851................. 1.9.................... 18
Florida.............................. 102,464................ 1.9.................... 16
Georgia.............................. 24,137................. 1.4.................... 10
Hawaii............................... 13,480................. 2.1................... 16
Idaho................................ 13,599................. 2.0.................... 15
Illinois............................. 66,582................. 1.9.................... 9
Indiana.............................. 22,089................. 1.8.................... 14
Iowa................................. 16,715................. 2.0.................... 18
Kansas............................... 4,689.................. 1.5.................... 8
Kentucky............................. 21,424................. 1.7.................... 11
Louisiana............................ 27,780................. 1.7.................... 22
Maine................................ 20,604................. 1.5.................... 16
Maryland............................. 27,574................. 1.6.................... 16
Massachusetts........................ 86,305................. 2.4.................... 20
Michigan............................. 113,385................ 1.5.................... 27
Minnesota............................ 29,804................. 1.9.................... 24
Mississippi.......................... 41,031................. 1.7.................... 15
Missouri............................. 71,510................. 2.1.................... 24
Montana.............................. 18,287................. 1.5................... 24
Nebraska............................. 5,989.................. 2.2.................... 17
Nevada............................... Data Unavailable....... Data Unavailable....... Data Unavailable
New Hampshire........................ 4,550.................. 1.1.................... 8
New Jersey........................... 57,914................. 2.0.................... 22
New Mexico........................... 53,839................. 2.1.................... 24
New York............................. 196,811................ 2.1.................... 18
North Carolina....................... 52,196................. 1.9.................... 17
North Dakota......................... 3,726.................. 1.8.................... 17
Ohio................................. 53,171................. 1.9.................... 17
Oklahoma............................. 10,184................. 1.9.................... 12
Oregon............................... 41,620................. 1.8.................... 21
Pennsylvania......................... 72,543................. 2.1.................... 16
Puerto Rico.......................... 27,699................. 1.7.................... 7
Rhode Island......................... 19,724................. 1.7.................... 21
South Carolina....................... 11,319................. 1.6.................... 4
South Dakota......................... 7,353.................. 2.0.................... 15
Tennessee............................ 29,648................. 1.7.................... 12
Texas................................ 117,025................ 1.9.................... 18
Utah................................. 13,169................. 1.8.................... 16
Vermont.............................. 10,526................. 1.6.................... 30
Virginia............................. 21,803................. 1.8.................... 11
Washington........................... 174,972................ 2.2.................... 30
West Virginia........................ 23,653................. 1.5.................... 8
Wisconsin............................ 37,513................. 1.9.................... 24
Wyoming.............................. 4,779.................. 1.6.................... 25
--------------------------------------------------------------------------
United States*..................... 2,340,710.............. 2.4.................... 17
----------------------------------------------------------------------------------------------------------------
* U.S. totals include American Samoa, States of Micronesia, Guam, Marshall Islands, Virgin Islands, and Palau.
Note: Includes only federally-funded health centers, and therefore may underreport the volume of health care
delivered by health centers.
Source: Bureau of Primary Health Care, HRSA, DHHS, 2005 Uniform Data System.
Appendix C.--Community Health Center Dental Services Staffing and
Visits by State, 2005
--------------------------------------------------------------------------------------------------------------------------------------------------------
Dental
State Dentist visits Visits per FTE hygienist Visits per FTE Dental support Total dental Total dental
dentist visits hygienist staff* FTE services FTE services visits
--------------------------------------------------------------------------------------------------------------------------------------------------------
Alabama...................... 67,204.......... 2,941.1......... 19,945.......... 1,360.5......... 36.8........... 74.3........... 87,149
Alaska....................... 31,210.......... 2,100.3......... 3,429........... 546.0........... 29.2........... 50.3........... 34,639
Arizona...................... 88,994.......... 2,604.4......... 21,737.......... 1,232.3......... 96.5........... 148.3.......... 110,731
Arkansas..................... 31,030.......... 2,800.5......... 5,486........... 1,284.8......... 24.3........... 39.7........... 36,516
California................... 808,672......... 3,239.2......... 28,780.......... 1,100.6......... 497.6.......... 773.4.......... 837,452
Colorado..................... 122,860......... 2,642.7......... 22,624.......... 1,147.3......... 102.9.......... 169.1.......... 145,484
Connecticut.................. 100,335......... 2,837.5......... 45,555.......... 1,867.0......... 58.6........... 118.4.......... 145,890
Delaware..................... 8,278........... 1,851.9......... 1,646........... 1,266.2......... 5.7............ 11.5........... 9,924
District of Columbia......... 25,756.......... 2,846.0......... 0............... 0.0............. 11.8........... 20.8........... 25,756
Florida...................... 195,566......... 3,177.9......... 34,402.......... 1,284.1......... 126.2.......... 214.5.......... 229,968
Georgia...................... 34,186.......... 2,387.3......... 8,682........... 1,205.8......... 22.2........... 43.7........... 42,868
Hawaii....................... 28,702.......... 1,807.4......... 2,122........... 742.0........... 28.0........... 46.8........... 30,824
Idaho........................ 26,655.......... 469.2........... 5,342........... 1,077.0......... 19.2........... 35.4........... 31,997
Illinois..................... 128,316......... 3,050.1......... 12,073.......... 1,223.2......... 73.0........... 124.9.......... 140,389
Indiana...................... 39,730.......... 2,579.9......... 11,668.......... 1,511.4......... 29.0........... 52.1........... 51,398
Iowa......................... 34,056.......... 2,742.0......... 5,985........... 1,031.9......... 31.5........... 46.7........... 40,041
Kansas....................... 7,177........... 2,648.3......... 1,866........... 790.7........... 6.0............ 11.1........... 9,043
Kentucky..................... 37,280.......... 2,782.1......... 9,184........... 1,111.9......... 24.6........... 46.2........... 46,464
Louisiana.................... 48,409.......... 2,384.7......... 2,746........... 888.7........... 30.4........... 53.8........... 51,155
Maine........................ 31,140.......... 2,077.4......... 25,309.......... 1,202.3......... 30.4........... 66.4........... 56,449
Maryland..................... 45,259.......... 2,935.1......... 5,994........... 1,927.3......... 24.3........... 42.9........... 51,253
Massachusetts................ 205,754......... 2,870.1......... 37,419.......... 1,514.3......... 94.8........... 191.2.......... 243,173
Michigan..................... 174,784......... 2,703.5......... 79,163.......... 1,663.1......... 114.1.......... 226.4.......... 253,947
Minnesota.................... 56,932.......... 2,564.5......... 14,316.......... 944.3........... 28.6........... 66.0........... 71,248
Mississippi.................. 68,943.......... 2,496.1......... 7,991........... 1,225.6......... 40.9........... 75.1........... 76,934
Missouri..................... 148,374......... 2,582.2......... 20,709.......... 1,320.7......... 108.0.......... 181.1.......... 169,083
Montana...................... 27,351.......... 2,811.0......... 7,146........... 1,791.0......... 16.5........... 30.2........... 34,497
Nebraska..................... 13,359.......... 2,515.8......... 1,332........... 672.7........... 11.7........... 19.0........... 14,691
Nevada....................... Data Unavailable Data Unavailable Data Unavailable Data Unavailable Data Data Data
Unavailable. Unavailable. Unavailable
New Hampshire................ 5,145........... 2,198.7......... 3,969........... 1,160.5......... 2.5............ 8.3............ 9,114
New Jersey................... 116,724......... 2,824.2......... 6,497........... 1,486.7......... 65.6........... 111.3.......... 123,221
New Mexico................... 110,404......... 2,455.1......... 28,684.......... 1,221.6......... 92.2........... 160.7.......... 139,088
New York..................... 408,533......... 2,468.0......... 78,776.......... 1,558.1......... 251.2.......... 467.3.......... 487,309
North Carolina............... 96,581.......... 2,530.3......... 18,872.......... 1,217.5......... 71.2........... 124.8.......... 115,453
North Dakota................. 6,777........... 2,823.8......... 1,337........... 568.9........... 5.6............ 10.3........... 8,114
Ohio......................... 103,027......... 2,762.9......... 15,728.......... 1,012.7......... 72.4........... 125.3.......... 118,755
Oklahoma..................... 19,325.......... 2,049.3......... 3,233........... 829.0........... 15.9........... 29.2........... 22,558
Oregon....................... 73,311.......... 2,260.6......... 24,353.......... 1,742........... 63.4........... 109.8.......... 97,664
Pennsylvania................. 154,850......... 2,517.5......... 33,388.......... 1,239.8......... 97.1........... 185.5.......... 188,238
Rhode Island................. 32,567.......... 2,649.9......... 19,375.......... 1,490.4......... 31.4........... 56.7........... 51,942
South Carolina............... 18,227.......... 2,112.1......... 4,494........... 1,129.1......... 13.6........... 26.2........... 22,721
South Dakota................. 14,358.......... 2,033.7......... 3,845........... 1,248.4......... 14.7........... 24.8........... 18,203
Tennessee.................... 49,224.......... 2,507.6......... 4,359........... 736.3........... 26.4........... 51.9........... 53,583
Texas........................ 224,858......... 2,543.6......... 46,622.......... 1,185.4......... 186.1.......... 313.8.......... 271,480
Utah......................... 23,232.......... 2,242.5......... 3,176........... 1,549.3......... 17.8........... 30.2........... 26,408
Vermont...................... 16,881.......... 2,718.4......... 10,030.......... 1,297.5......... 12.1........... 26.1........... 26,911
Virginia..................... 40,317.......... 2,599.4......... 2,660........... 537.4........... 33.4........... 53.9........... 42,977
Washington................... 391,782......... 2,893.3......... 30,543.......... 1,000.4......... 333.3.......... 499.2.......... 422,325
West Virginia................ 36,623.......... 2,886.0......... 10,689.......... 1,138.3......... 26.9........... 49.0........... 47,312
Wisconsin.................... 72,454.......... 2,575.7......... 17,672.......... 979.1........... 57.3........... 103.5.......... 90,126
Wyoming...................... 7,779........... 3,758.0......... 4,065........... 2,032.5......... 4.1............ 8.2............ 11,844
Puerto Rico.................. 45,797.......... 2,346.2......... 5,382........... 2,152.8......... 28.3........... 50.3........... 51,179
--------------------------------------------------------------------------------------------------------------------------
United States*............. 4,728,590....... 2,719.5......... 834,042......... 1,297.8......... 3,268.2........ 5,649.6........ 5,562,632
--------------------------------------------------------------------------------------------------------------------------------------------------------
FTE = Full-time employed.
* Includes Dental Assistants, Aids, and Technicians.
** U.S. totals include American Samoa, States of Micronesia, Guam, Marshall Islands, Virgin Islands, and Palau.
Note: Includes only federally-funded health centers, and therefore may underreport the volume of health care delivered by health centers.
Source: Bureau of Primary Health Care, HRSA, DHHS, 2005 Uniform Data System.
Senator Sanders. Dr. Evans, thank you very much. Yvonne
Davis is a board member with the Community Health Center in
Florence, SC. And one of the interesting aspects about
federally qualified community health centers is they are run by
the community, itself, and Ms. Davis, thank you so much for
being with us.
STATEMENT OF YVONNE DAVIS, COMMUNITY HEALTH CENTER BOARD
MEMBER, FLORENCE, SC
Ms. Davis. Thank you, Mr. Chairman. To my own Congressman
Clyburn, and members of the committee as well, for the
invitation to speak to you today. This is a topic that I care
deeply about and I appreciate the chance to share my thoughts
with you.
My name is Yvonne Davis, I'm from Florence, SC. I have been
employed at Francis Marion University as a Resource and
Acquisitions Coordinator for about 28 years. Today I am here as
a community health center patient, advocate and consumer board
member. I have been a part of the community health center
movement for about 18 years now, as both a health center
patient and a community board member at Health Care Partners of
South Carolina, Incorporated.
I have never been more excited for the world to witness and
hear what our community health center is and to learn what it
is all about.
I come from Marion, SC. It's my home, which is a very small
town about 45 miles north of Myrtle Beach. Communities there
are close knit, and of course, gatherings there are still alive
and well. My home town, at one time, was booming with many
jobs, and life was good. Then as years passed, they all seemed
to just disappear; no jobs, no insurance, no unemployment
benefits means no health care.
Having the health center in our community has made it
possible for people who have lost their jobs to still receive
access to quality care, purchase medicine at a reduced price,
and be educated about preventive measures they can take to live
a normal and productive life.
The story I would like to share with you is about my
brother, Dwayne. After being laid off from his job of 20-plus
years, and suffering a series of personal tragedies, as if he
had no reason to live, Dwayne went into a state of depression.
One day I went to visit him and found him in a condition I
couldn't believe.
I took him to our community health center for a complete
examination. The doctor called me and informed me that my
brother had suffered a heart attack. What a shocker. Luckily,
he survived.
Now my brother receives health care at the health center
and is sharing the information about the center with his
friends who are in need as well. And he says to me quite often,
``Thank you.''
Since that time I have vowed to advocate for community
health centers. We are truly blessed to have access to a place
like Health Care Partners in our community and receive the
comprehensive care that they provide.
Now, my role as a community health center board member.
Consumer board members in my center go out to church services,
civic meetings, and town functions and share information about
the services provided by our health center. We don't want
anyone to go without care simply because they're not aware of
our health center.
I am thinking about an instance I am particularly proud of,
and that is when we worked with one of our local high schools
there--we housed a school-based plan and saw their numbers of
teenage pregnancy, STD's, and other conditions decrease. That
pride turned to disappointment when we could no longer provide
the services due to limited funds.
There is an emergency call from the community for us to
return. So we must find a way to answer their call.
I have witnessed the power of community health centers
firsthand, and I know that all across the country America's
health centers are ready to lead the way in health reform by
providing high quality, affordable, accessible primary and
preventive care to anyone in need. Thank you.
[The prepared statement of Ms. Davis follows:]
Prepared Statement of Yvonne Davis
SUMMARY
I'm here as a community health center patient, advocate and
community board member.
I've been a part of the community health center movement
about 18 years now, as both a health center patient for 16 years and a
community board member for 18 years at Health Care Partners of South
Carolina, Inc.
I come from a very small town about 45 miles north of
Myrtle Beach, SC. My hometown at one time was booming with many jobs
for the citizens of Marion as well as the connecting counties, and life
was good. Then as years passed they all just seem to have disappeared;
no jobs, no insurance, no unemployment benefits, means no health care.
Having the health center is critically important to our community
and it has been to me personally.
I've had allergy problems since I was a kid. It was our
physician at the community health center who taught me how to live a
more comfortable life during the high allergy season. I no longer felt
like it was a waste of time to seek a physician's help when my eyes
were always running and red all the time and I spent little or no time
outside.
My brother Dwayne was very ill and actually suffered a
heart attack after years of not seeing a doctor. His experience
motivated me to advocate for community health centers because there are
many more cases just like my brother's: people who, if they had access
to the right care at the right time, could avoid the pain and cost of
hospitalization.
As a board member, I make it a priority to get out in the community
and spread the word on health centers.
Volunteer consumer board members at my center make it a
point to get out to church services, civic meetings and town functions
and share information about the services provided by our community
health center.
We don't want anyone to go without care simply because
they aren't aware of the health center.
Funding constraints have limited our ability to advertise,
but the good news is that there is no better advertisement than
recommendations coming from community leaders that are now patients of
the center.
Because of the recession we're facing serious problems
with providing coverage for the higher demand. Patients are constantly
calling asking for more office hours.
I have witnessed the power of community health centers first hand
as a patient and board member. I know that all across the country,
America's Health Centers are ready to lead the way in health reform,
providing high-quality, affordable, accessible primary and preventive
care to anyone in need.
______
Good morning. Thank you, Mr. Chairman and members of the committee,
for the invitation to speak to you today. This is a topic that I care
deeply about, and I appreciate the chance to share my thoughts with
you.
My name is Yvonne G. Davis of Florence, SC. I've been a State
employee for 28 years at Francis Marion University as the Resource &
Acquisitions Coordinator for the library.
Today I'm here as a community health center patient, advocate and
community board member. I've been a part of the community health center
movement about 18 years now, as both a health center patient for 16
years and a community board member for 18 years at Health Care Partners
of South Carolina, Inc. I have never been more excited for the world to
witness and hear what community health centers are all about.
I come from a very small town about 45 miles north of Myrtle Beach,
SC. Communities there are close knit and family gatherings are still
alive and well. My hometown at one time was booming with many jobs for
the citizens of Marion as well as the connecting counties, and life was
good. Then as years passed they all just seem to have disappeared; no
jobs, no insurance, no unemployment benefits, means no health care.
Having the health center in our community has made it possible for
people who have lost their jobs to still receive access to quality
care, purchase medicine at a reduced price, and be educated about
preventive measures they can take to live a normal and productive life.
You see, I've had allergy problems since I was a kid, and if any of
you suffer from them, then you know where I'm coming from. It was our
physician at the community health center who taught me how to live a
more comfortable life during the high allergy season. I no longer felt
like it was a waste of time to seek a physician's help when my eyes
were always running and red all the time and I spent little or no time
outside. What a difference it makes when your doctor makes you feel as
if he or she really cares. The service at my health center is excellent
and I would recommend the center to any of my family members. My mother
who at the time lived in St. Petersburg, FL had a serious stroke and
could no longer take care of herself; once we relocated her to the
Carolina's, we immediately registered her as a patient at the health
center.
She was diagnosed with several serious conditions: hypertension,
renal failure, diabetes, congestive heart failure, etc. This was a big
adjustment for my family and we really didn't know what to expect. It
was the assistance of the center's staff and other specialists that
made life a little easier for us and we're so grateful. The quality of
care she received was just unreal. If you can please my mother, then
you must be doing something right.
But the real story is about my brother Dwayne. I remember so
clearly the day when Dwayne, who is just 11 months older than me, was
laid off from his job of 20+ years. Not only did he lose his job, but
within a 16-month timeframe, his only son was killed in a car accident,
our oldest brother who was a disabled veteran died of medical problems,
our mother had a stroke, and Dwayne's wife was diagnosed with a lung
disease then later died. It was if he had no reason to live. Dwayne
went into a state of depression like never before, and it was like we
had lost another family member.
In August 2007, I attended the National Association of Community
Health Center's (NACHC) annual Community Health Institute conference in
Dallas, TX and had invited my brother Dwayne to travel with me just to
get him away. For a life-long Dallas Cowboy fan to quickly turn me down
was shocking. I immediately went to visit him and found him in a
condition I couldn't believe. I promised myself and him that he was my
candidate for take a love one to the doctor day, and I did just that.
After a complete examination and several tests the Doctor called me
in and informed me that he thought my brother suffered a heart attack
and the ambulance was on its way. What a shocker. I saw the look on his
face from the news and knew that he was afraid. He was afraid for
several reasons, one, because he didn't have any insurance and wasn't
sure what would happen because he had no money. After completing
applications for public assistance, patient care services, etc., he was
finally admitted to the hospital then immediately put into the
intensive care unit. A quadruple bypass operation was recommended after
a series of tests. He had 96.5 percent blockage.
After spending about 14 days in the hospital, we all know who ended
up paying for that bill: yes, taxpayers. His excuse for not seeing a
doctor earlier was after paying his utility and other bills he just
didn't have the money. My brother is now sharing the information about
the community health center with his friends that may be in the same
shape he was in, and says to me, thank you. ``That Health Center is
alright with me,'' I didn't know they had it like that.
Since that time I have vowed to advocate for Community Health
Centers because there are many more cases just like my brother's:
people who, if they had access to the right care at the right time,
could avoid the pain and cost of hospitalization. We truly are blessed
to have access to a place like Health Care Partners in our community,
and to receive the comprehensive care they provide, regardless of the
ability to pay.
I would also like to speak a little about my role as a community
board member. Volunteer consumer board members at my center make it a
point to get out to church services, civic meetings and town functions
and share information about the services provided by our community
health center. We don't want anyone to go without care simply because
they aren't aware of the health center. Funding constraints have
limited our ability to advertise, but the good news is that there is no
better advertisement than recommendations coming from community leaders
that are now patients of the center. Because of the recession we're
facing serious problems with providing coverage for the higher demand.
Patients are constantly calling asking for more office hours. With your
help we can make that happen. The need of our people is why we're here.
In thinking about an instance I am particularly proud of, I think
one example is when one of the local high schools where we housed a
school-based clinic saw their numbers of teenage pregnancy, STDs, and
other conditions decrease during the time we were on campus. That time
of being proud turned to disappointment when we could no longer provide
these services within the school. There is an emergency call from the
community for us to return, so we must.
I have witnessed the power of community health centers first hand
as a patient and board member. I know that all across the country,
America's Health Centers are ready to lead the way in health reform,
providing high-quality, affordable, accessible primary and preventive
care to anyone in need.
Senator Sanders. Thank you very much, Ms. Davis.
John Matthew is a physician and the director of the health
center in Plainfield, VT. In Vermont, we have gone, in the last
6 years, from two community health centers, FQHCs, to eight.
And John, at Plainfield, is doing an outstanding job. Dr.
Matthews, thank you very much for being here.
STATEMENT OF JOHN D. MATTHEW, M.D., THE HEALTH CENTER,
PLAINFIELD, VT
Dr. Matthew. Thank you, Senator Sanders, Representative
Clyburn and members of the committee. Thank you for having us
here today.
I have been practicing primary care medicine in rural
Vermont for 36 years. When good, accessible primary care is
available, it still is most costly when provided in a
multispecialty setting. It's almost as expensive in the hands
of internal medicine physicians, and is much less costly in
family medicine practices. The care is most economical, with
equal outcomes, in community health centers, just published in
Health Affairs, this very week, same as it was a decade ago.
When care is unavailable, those who lack access pay the price
and society pays the bill.
Rural communities, suburbs and city neighborhoods, all
would do well to have accessible good health care through
FQHCs. These services, I want to emphasize, are not only for
the poor, the uninsured or the Medicaid population. FQHCs
provide care to all persons, regardless of their ability or
inability to pay. We do not discriminate against those who are
insured.
At our health center, we have a motto, we do ``Health Care
the Way it Ought to Be,'' everyday for every one.
Our organization, The Health Center in Plainfield,
functioned for years as a freestanding nonprofit rural health
center. It was a struggle to keep the organization afloat. We
had to scrimp and save all the time to break even at each
year's end. We were always restrained by very tight finances.
Since becoming an FQHC 2 years ago, we've been able to
expand the number of uninsured persons we see, and our active
patient population has increased from 7,800 to 9,400 persons.
By this fall, our staff will have grown from 34 full-time and
19 part-time employees to 47 full-time and 30 part-time
employees. We anticipate that we will be able to take care of
1,200 to 1,800 more medical patients, 2,000 more dental
patients and 2,400 kids and adolescents around the State with a
mobile dental program. We have consolidated our fiscal position
and are poised to do more in behavioral health, mental health,
dental health, access to 340b pharmacy and physical therapy,
which is now in-house.
It is an enormous relief as head of the agency to be on a
more solid financial footing. And as a physician, it's
extremely gratifying to be able to provide a broader scope of
services and to care for all of our patients, and to offer more
sliding scale and nominal charge care to the unfortunate, the
downtrodden and the marginalized, and now with the newly
unemployed and uninsured who are suffering in the current great
recession.
Many of these improvements and our ability to address our
community's needs would be impossible without our having become
a FQHC. Others would have occurred only slowly and
incrementally because tight finances would constrain innovation
and the starting of new or expanded services, despite these
being badly needed by the population.
Expansion of funding for FQHCs and for the National Health
Service Corps has the potential to help reverse the decline of
primary care and bring excellent, accessible care to all in all
of our communities.
This is the essence of health care reform. This is what
America needs, not just for the poor and uninsured, but for all
of us. Health care for all.
[The prepared statement of Dr. Matthew follows:]
Prepared Statement of John D. Matthew, M.D.
SUMMARY
Good, accessible primary care is the essential foundation of all
health care and for any hope of constraining the costs of health care
for the Nation. But primary care is, and has been for a decade or more,
in precipitous decline, with some 60 million Americans now unable to
find a personal physician. Arresting and reversing this decline must be
a matter of the highest priority.
When primary care is available, it is most costly when provided in
multi-specialty settings. It is almost as expensive in the hands of
Internal Medicine physicians, and it is much less costly in Family
Medicine practices. But care is most economical, with equal outcomes,
in Community Health Centers (Federally Qualified Health Centers or
FQHCs).
When care is unavailable, those who lack access pay the price and
society pays the bill.
Rural communities, suburbs, and city neighborhoods, to have
accessible care for all, need to have an FQHC in their area. These
services are not only for the poor, the uninsured, or the medicaid
population. FQHCs provide care to all persons regardless of their
inability--or ability--to pay. We do not discriminate against those who
are insured or economically better off.
We do ``Health Care the Way it Ought to Be'' every day, for
everyone.
Our organization, The Health Center in Plainfield, VT, functioned
for years as a freestanding nonprofit Rural Health Clinic. It was a
struggle to keep the organization afloat, We had to scrimp and save all
we could to break even at each year's end. We were always restrained by
very tight finances.
Since becoming an FQHC 2 years ago, we have been able to expand the
number of uninsured persons we serve on sliding scale and our active
patient population has increased from 7,800 persons to 9,400 persons.
By this fall our staff will have grown from 34 full-time and 19 part-
time employees to 47 full-time and 30 part-time staff members. We are
consolidating our fiscal position and are poised to do much more, with
more medical, dental, and behavioral health patients and more persons
accessing our 340b pharmacy program, all with sliding scale discounts
for uninsured persons with incomes below 200 percent of the federally
determined level of poverty.
To accommodate the unmet need, we will add a physician and a
physicians assistant this summer. We anticipate taking care of about
1,200 to 1,800 more medical patients with this summer's staff
additions, with eventual growth to 12,000 patients. Adding two dentists
this fall and another in December will allow our staffing a dental care
mobile in six locations around the State and will allow our caring for
about 2,000 more patients in the dental service of the center. We will
also see substantial growth in our behavioral health and 340b pharmacy
services.
It is an enormous relief as head of the agency to be on a more
solid financial footing. And as a physician it is extremely gratifying
to be able to provide a broader scope of services and care to all our
patients and to offer more sliding scale and nominal charge care for
the unfortunate, the downtrodden, and the marginallized--and now for
the newly unemployed and uninsured who are suffering in the current
great recession.
Many of these improvements in our ability to address our
community's needs would be impossible without our having become an
FQHC. Others would only occur slowly and incrementally, because tight
finances would constrain innovation and the starting of new or expanded
services, despite those being badly needed by the population.
Expansion of funding for FQHCs and for the NHSC has the potential
to help reverse the decline of primary care and to bring excellent,
accessible care to all--in all of our communities.
This is the essence of health care reform.
This is what America needs.
Not just for the poor or the uninsured--but for all of us.
Health Care for All.
The Coming Crisis in Primary Care is Soon Upon Us
Vermonters were pleased recently to have been told we live in the
healthiest State in the Nation. The State launched the new Catamount
health plan, an ambitious effort to reduce the number of persons
without health insurance in the State. The UVM School of Medicine was
rated very highly for its education of primary care physicians. The
past 2 years have seen the expansion in Vermont of Federally Qualified
Health Centers chartered to serve all persons in their geographic area,
regardless of their ability to pay.
But these recognitions, innovations, ratings, and successes have
occurred in circumstances that, beneath the radar of most of the public
and many policymakers, threaten to undermine our collective efforts to
make health care available to all, especially in rural areas. In fact,
the very structure of our health care system, if it should be called a
system, is threatened by the coming collapse of primary care, which is
the foundation of quality and any hope of economy in this realm.
There is a substantial and worsening lack of physicians and
dentists to work in primary care nationwide, with rural areas suffering
disproportionate shortages. While our need for these essential
professionals is projected to grow by as much as 40 percent in the
coming decade, the number of medical students moving on to primary care
residencies after graduation has fallen by about 50 percent in the last
10 or 12 years. Our cadre of primary care providers, both medical and
dental, is aging and not being replaced. If this trend continues--and
it appears to be accelerating--we will find ourselves in a circumstance
with 50 percent of our present supply trying to provide care for 140
percent of our present demand. This may understate the problem, since
the aging population, in little more than 20 years, will need about
seven times the present number of geriatric physicians, a group already
available at half of current need.
About half of the estimated 56 million Americans who now have no
primary care doctor have health insurance but still can find no source
of primary care. We are already seeing many practices in Vermont closed
to new patients and the professionals working longer hours to take care
of those enrolled in their practices. In Vermont, and across the
Nation, increasing numbers of patients are being seen and experiencing
worsening delays in our emergency rooms. This trend has been aggravated
in other States by the closure of many ERs by for-profit hospitals
which have discovered that these services lose money, particularly as
they attract the uninsured and the down and out. The care that people
without a regular source of primary care receive, if they do receive
care, is almost certain to be much more costly, in both the short and
the longer run, in financial and in human terms.
Primary care is one of the most challenging disciplines in
medicine, requiring broad scientific knowledge and exceptional
interpersonal ``soft'' skills. It is also one of the most rewarding,
involving long-term relationships with individuals and families which
many other specialties do not offer. It is also the most cost-effective
component of our system. But primary care is in trouble.
Many primary care physicians, feeling under appreciated and under
reimbursed compared to their professional colleagues in other fields,
report diminished satisfaction with their professional work. After
working more and more un-reimbursed hours contending with Medicare
pharmacy program companies and an unending stream of prior approval
forms, changing formularies, and barriers to care, some are getting out
of practice. They are not recommending similar careers to their
children or others, and increasingly report feeling undervalued,
overworked, and taken for granted.
There are many disincentives to choosing primary care that devolve
from our medical education system, including what sort of person is
chosen to be admitted to medical school, how they are influenced by the
role models and practice organizations in academic medical centers, and
the great costs they confront to get through college, medical school,
and residency training before starting practice. Medical students
graduate with substantial debt after 4 years of college and 4 years of
medical school, so they are apt to opt for specialties that provide
higher incomes after residency training. For the same time in training
and no less work, primary care incomes are often half or a third of
what other specialists earn.
We not only have half as many graduating doctors choosing primary
care post-graduate training but also find that half of the new
residents in family medicine programs are graduates of foreign medical
schools, half of whom are foreign nationals. We do not seem to be able
to manage to attract and educate enough of our own bright young people
to take care of our own population.
Unlike attorneys, physicians can not bill for telephone work or
most paperwork, so roughly 35 percent of the regular working hours of
primary care physicians are not reimbursed. The average family
physician, prior to the extra hours demanded by managed care and
pharmacy benefits management companies, worked a 54-hour week, not
including the hours on call with a beeper on their belt or a phone on
the bedside table. More and more ``free'' work is the result of
companies, often for profit companies, requiring physicians and their
staff to complete forms, answer questionnaires, or make telephone calls
to justify their decisions in order to have their patients receive
care.
The private physicians still attempting to survive in unsubsidized
situations are trying to make ends meet with increasing numbers of
persons in the expanded Medicaid program, which nickels and dimes
providers at every turn. Medicaid also has its own formulary program,
which adds to the difficulty of caring for these patients. Quite a
number of these physicians are limiting or ceasing enrollment of
Medicaid patents in their practices, because of the poor reimbursement.
One of the great ironies of our present circumstance is that State
government, the State colleges, and some of our leading and more
successful companies reduce their operating costs by insuring with
Cigna, which, when patient management fees are taken into account, pays
primary care providers in the fee-for-service sector less than Medicaid
pays. The State and some employers often appear to be surprised and
even mystified by the shrinking supply of doctors for their
beneficiaries and employees, but some simple accounting would solve the
mystery. (It's the reimbursement, stupid.)
The public, where primary care is still available, seems unaware of
the accelerating crisis in access that faces all of our citizens. If
they knew the true situation, there might be a clamor for solutions,
but any of these, when adopted, will take years to change the supply of
doctors for the population. Things are virtually certain to get much
worse before getting better, if that is going to happen. The primary
care system, with dwindling numbers of providers contending with
increasing patient loads and expanding mandates, dictates, expectations
and demands, including those of such laudable quality initiatives as
the Vermont Blue Print for Health, is much closer to breaking down than
most people realize.
Those leading the march to health care reform run the risk of
turning around to discover that there are no primary care physicians
and dentists behind them in the parade. Those who do continue in the
work--some would say the calling--of taking care of the sick will all
be entirely too busy with patients who are aging and have more complex
illnesses, while trying to get pharmaceuticals and tests approved by
companies which increase their profits--or non-profit insurers which
must try to compete with those companies--by reducing access to care.
Also missing from the parade will be the numerous Physician's
Assistants and Nurse Practitioners who are essential and capable
components in our primary care efforts. They too will be overwhelmed as
more and more need confronts our shrinking numbers, physicians and
``physician extenders'' alike.
There will be increasing numbers of foreign medical graduates
filling out the ranks of America's primary care providers, but leaving
their native lands with even less care in a global brain drain to the
more affluent United States. Hospitals will increasingly employ primary
care providers, subsidizing their practices by shifting income from
imaging and surgery services to attract and retain primary care
doctors, whose value is not as obvious until they are not available in
their communities.
President Bush may be proven to have been inadvertently prescient
when he stated recently that all Americans have access to health care
because they can go to the emergency room. More and more, this will be
the health care entry point of necessity: crowded, expensive, and
poorly suited to attend to the tasks of primary care. It is a chaotic
and worrisome picture to contemplate.
______
Mr. Chairman, members of the committee, my name is John Matthew. I
am a primary care physician. I have been practicing primary care
medicine in rural Vermont for the past 36 years. I appreciate the
opportunity to offer to you my insights and opinions concerning the
crisis in primary care access and the potential that Community Health
Centers and The National Health Service Corps offer to address this
core challenge in our present circumstances and to any health care
reform program the Nation may undertake.
Good, accessible primary care is the essential foundation of all
care and for any hope of constraining the costs of health care for the
Nation. But primary care is, and has been for a decade or more, in
precipitous decline, with some 60 million Americans now unable to find
a personal physician. The causes and consequences of this situation are
multiple and complex. I addressed some of these last year in the
appended article, ``The Coming Crisis in Primary Care is Soon Upon
Us,'' which provides some detail concerning the dynamics of this
accelerating calamity.
Arresting and reversing this decline must be a matter of the
highest priority. Without an adequate supply of primary care providers,
located and organized to make accessible, high quality care available
to all residents in all of our communities, good health care is in
jeopardy. Care will not just be less and less available, it will, when
accessed, be of lower quality and of much greater cost, in human and in
economic terms. Without primary care the population delays care, visits
emergency rooms as sources of basic care, and often uses medical sub-
specialists in lieu of those trained to provide primary care.
When primary care is available, it is most costly when provided in
multi-specialty settings. It is almost as expensive in the hands of
Internal Medicine physicians, much less costly in Family Medicine
practices, and most economical, with equal outcomes, in Community
Health Centers (Federally Qualified Health Centers or FQHCs). There are
also short- and long-term impacts on health and on health care costs
that devolve from primary care quality and availability, or the lack of
these, played out in other settings and for years to come. Early
intervention, preventive medicine, and risk factor control are key
parts of good primary care. Those who lack access pay the price and
society pays the bill.
The days of physicians setting up shop in small communities and
suburbs, even if we did train a sufficient number to care for the
population, are going fast, if not gone. No primary care physician has
set up a private practice in Central Vermont in many years. Most
physicians now are not entrepreneurs: they seek employment in which
they can practice on a salary and without investing in buildings,
equipment, and staff. Rural communities, suburbs, and city
neighborhoods, if they are to have accessible care would do very well
to have an FQHC in their area, providing an organizational structure,
economies of scale, economies of scope, efficient use of providers
organized in teams of physicians and mid-level practitioners,
integration of behavioral health services, well-equipped dental units,
community outreach and social services, and access to less costly
prescription medications. With a community board of directors in
charge, the program of each FQHC can be tailored to the needs of its
particular community. These services are not only for the poor, the
uninsured, or the medicaid population. FQHCs provide care to all
persons regardless of their inability--or ability--to pay. We do not
discriminate against the insured or better off in our population. We
take pride in providing care as good as or better than that which
insured persons might find anywhere else to everyone, whatever their
insurance status.
Just as all politics is local, so is all health care, whether in an
exam room or in the community. Every community is different in some
way. We need flexible, locally controlled institutions such as FQHCs to
organize and operate the structures which can tailor their programs to
meet local needs. These established agencies can then better attract
professionals to provide the primary health services--medical, dental,
mental health, and medications--needed in every community, rural or
otherwise. FQHCs are the prototypical patient-centered medical homes,
committed to patient participation in their care and viewing health
care as far more than a series of episodic or periodic office visits.
Informing and empowering people are key concepts of the community
health center movement.
Our organization's evolution and the value of our becoming a
Federally Qualified Health Center to the people whom we serve is
illustrative. At the start we established The Health Center as a non-
profit corporation, which employs the staff and owns the practice. We
have always had a board of directors made up of community members and
it has always been our mission to provide care for everyone from our
area who wants to come to the center, whatever their insurance status.
We functioned for years as a freestanding Rural Health Clinic (RHC).
The RHC caps for cost-based reimbursement were always too low. We lost
money on every Medicare and Medicaid office visit and it was a struggle
to keep the organization afloat, though we always did. Our sliding
scale was self-funded, in the sense that we had no outside monies to
support the un-reimbursed care we provided for the less fortunate. We
had to know where every nickel was and to scrimp and save all we could
to pay our staff and operating costs and still break even at each
year's end. We were always constrained by very tight finances. But for
a very dedicated core staff putting in extraordinary hours, we might
well have floundered and folded up shop. We did good work, but in a
very crowded facility, and our margin was far too tight for comfort. I
spent as many sleepless nights concerned about our finances as I did up
admitting patients to the hospital and taking after hours calls.
When we became an FQHC--after once having our application receive a
grade of ``95'' but not be funded--higher reimbursement caps provided
more income than we had received as an RHC for the very same work. We
reduced our losses on Medicare visits, though the caps still cause us
to receive less than our costs, and were able to recoup our costs for
Medicaid visits. Our 330 grant has allowed us to have community
resources persons on staff, to expand the hours of our operations
manager to coordinate fund raising for and construction of an expanded
facility, to have the luxury of time free for program development, and
to expand the number of uninsured persons we serve on a sliding scale.
We are enabled to provide not just one-on-one care in a series of
office calls and hospital visits, but also to innovate, to collaborate,
and to reach out to our community and to other agencies and local
systems that compliment the provision of these services.
In the past 2 calender years our active patient population has
increased from 7,800 persons to 9,400 persons. By this fall our staff
will have grown from 34 full-time and 19 part-time employees to 47
full-time and 30 part-time staff members. We are consolidating our
fiscal position and are poised to do more, with more medical, dental,
and behavioral health patients and more persons accessing our 340b
pharmacy program, all with sliding scale discounts for uninsured
persons with incomes below 200 percent of the federally determined
level of poverty.
We are expanding our medical and our dental staff to meet the unmet
medical and dental needs in the area. All of the local medical
practices, other than the Health Center, have been closed to new
patients for most of the past few years. And no local dental practice
accepts medicaid patients except on a very limited basis. Our medical
practice has about 45 percent medicare and medicaid patients. Our
dental practice does 65 percent or more of total work for medicaid
patients. There is a region-wide need for more dental care for medicaid
and uninsured patients.
To accommodate the unmet need, we will add a physician and a
physicians assistant this summer. We anticipate taking care of about
1,200 to 1,800 more medical patients with this summer's staff
additions, with eventual growth to 12,000 patients, or 20 percent of
the county population as we find another physician and another PA or
nurse practitioner.
We have moved from five to nine dental chairs and are now going to
add four more. We are expanding our in-house dental program and
cooperating with other FQHCs in an innovative mobile dental program for
rural kids and youth. Adding two dentists this fall and another in
December will allow our staffing the dental care mobile in six
locations around the State and will allow our caring for about 2,000
more patients in the dental service of the center.
Our ``mental health'' staff, with added counseling, PTSD treatment,
behavioral neurology, rehabilitation, and onsite psychiatric skills is
growing to meet a large unmet need. We have teamed with other FQHCs to
set up a tele-psychiatry link for consultations with the University of
Vermont child and adolescent psychiatrists. We have submitted a request
for a Change of Scope to allow our contracting for child and
adolescent, general, and geriactric psychiatric consultations for our
medicaid and uninsured patients who otherwise have substantial problems
receiving this care.
We have been able to bring 340b pharmacy services to our patients
in a collaborative effort with four other FQHCs, including an automated
dispensing unit--effectively a branch of the pharmacy--in our center.
We have brought two staff members on to expand our outreach and
case management efforts. We are taking on more medical students for
teaching in the practice, improving continuing education for our
professionals, and strengthening our community health education
efforts.
This fall we will, through a cooperative agreement with the local
transportation agency, start to offer transportation to patients who do
not have reliable private transportation. We are already open 60 hours
a week. We will add another evening medical clinic and more evening
dental hours this fall.
It is an enormous relief as head of the agency to be on a more
solid financial footing and to have more adequate support staff in the
business and operations components of the center, necessary to our
addressing the needs of those whom we serve.
It is an equal relief as a physician to be able to provide more
sliding scale and nominal charge care for the unfortunate, downtrodden,
and marginallized--and now for the newly unemployed and uninsured who
are suffering in the current great recession. We wish that we could
provide a sliding scale fee schedule to persons or families with
incomes under 300 percent of FLP, as we did when we were a Rural Health
Clinic.
It is heartening to be able to expand our dental program. We have
become the de facto dental practice for those seen in our local
emergency room with dental pain. We draw dental patients from a large
geographic region. This includes many persons who have medicaid dental
coverage but no other practice which will see them. We have always
understood dental care to be an integral part of the promise of good
heath care. To be able to deliver on this promise is very heartening.
We have always been very comfortable and capable, nearly unique
amongst practices in our region, caring for behavioral heath problems
in our practice, but we have always recognized the need for other
skills in this domain. We are very pleased to have been able to offer
more services on site, where they are more accessible and affordable
for our patients.
And it is a very substantial benefit to providers and patients
alike to have access to more affordable medications through the
collaborative 340b program. For some patients the postal delivery of
these medications is about as helpful as the lower prices, since
getting to the drug store, often several times a month due to PBM
restrictions, and waiting for overworked pharmacists has been a burden
and a barrier that we did not recognize before we had the 340b option
in house and by mail.
And, I am sleeping better, concerned with service delivery rather
than with survival.
Many of these improvements in our ability to address our
community's needs would be impossible without our having become an
FQHC. Others would only occur slowly and incrementally, because tight
finances would constrain innovation and the starting of new or expanded
services, despite these being badly needed by the population.
To staff the FQHCs that we envision being established across the
Nation, as well as other primary care settings in every corner of the
country, we will need to attract a very much larger proportion of the
graduates of our medical schools to work in primary care. Slowing and
then reversing the trend to fewer and fewer graduates entering primary
care will require a multifaceted and multi-year effort. One important
step will be to relieve physicians who undertake primary care training
of some of the substantial debt that they accumulate as they pursue
their professional education and post graduate studies. It is telling
that our community, with most practices closed to new patients and
having lost three primary care doctors in the past year, has been
unable to recruit replacements. The last primary care M.D. brought to
our area by the local hospital and the new physician who will join our
organization this summer are both veterans with years of practice and
experience, not the 30-year-olds fresh out of residency training. These
veterans will not practice forever, nor will my physician colleagues at
The Health Center, nor will I, as much as we enjoy most aspects of our
practice lives. The same limits apply to the very fine Physicians
Assistants and nurses who work with us every day.
Expansion of the National Health Service Corps will be one
mechanism to address the need to replace the Nation's aging cadre of
primary care medical and dental providers. Knowing that NHSC loan
forgiveness or scholarships are available will help attract students to
primary care. Having the NHSC professionals located in various
communities will provide professional staffing for the interval of the
professional's commitment. And some will remain to dedicate their
professional lives to the communities which they get to know as NHSC
members.
Expansion of funding for FQHCs and for the NHSC has the potential
to help reverse the decline of primary care and to bring excellent,
accessible care to all--not just the poor or uninsured--in all of our
communities. This is the essence of health care reform. This is what
America needs. Not just the poor or the uninsured--all of us. All
Americans.
Senator Sanders. Dr. Matthew, thank you very much.
Lisa Nichols, who is the Executive Director of Midtown
Community Center, Ogden, UT. Ms. Nichols, thanks very much for
being with us.
STATEMENT OF LISA NICHOLS, EXECUTIVE DIRECTOR, MIDTOWN
COMMUNITY CENTER, OGDEN, UT
Ms. Nichols. Thank you. Thank you for having us here today.
I'm very proud to be part of the community health center
movement and to tell you all about our health center and health
centers in general.
My name is Lisa Nichols. I am the Executive Director of
Midtown Community Health Center, and a board member of the
Association for Utah Community Health.
Midtown serves underserved community residents from Weaver,
Morgan and Davis counties located in northern Utah. Midtown has
experienced tremendous growth fueled by community need, Federal
funding opportunities and private partnerships.
In 1999, Midtown served 6,500 patients from a single site.
Services were limited to comprehensive primary care. Oral
health care services and mental health services were not
provided. We now operate from six sites in four different
cities, providing comprehensive primary, oral and mental health
services to nearly 26,000 patients.
The most dramatic growth has come over the past 3 years.
Midtown relocated its Ogden site to a new facility in 2006.
This $3.2 million facility was funded through Federal funds and
private dollars, with $2.9 million raised from our community.
The new facility is more than twice the size and should
have allowed for 5 years of growth. We were turning an average
of 20 patients away because demand exceeded resources daily.
The patient population has grown by over 11,000, and we still
turn an average of 20 patients away daily.
Midtown received new Federal access point funding in 2007
to open a site in Davis County. Over 1,000 residents from Davis
County were traveling to Midtown's Ogden site to receive
subsidized services. We opened in 2007 with a goal of adding
4,300 users by 2010. Over 5,800 patients are served and the
need continues to grow.
One of Midtown's most successful partnerships is with
Weaver State University's Oral Hygiene Program. Midtown
provides a dentist to supervise the students, while providing
dental services to Midtown patients. The University provides
space, equipment and students to care for the oral hygiene
needs of patients. This arrangement allows 2,500 individuals to
receive care annually at an average cost of $62 compared to the
national benchmark of $139.
Federal funding to Midtown has grown by 685,000 since 2006,
allowing for $62 per user. This is a cost-effective model,
giving that the average cost of serving a patient in other
settings ranges upwards to $700.
Midtown, along with other community health centers,
decreases overall health care costs. Midtown's work with
InterMountain Health Care, our local hospital, to transfer
uninsured patients seeking non-emergent care through the
emergency department to a community health center. A decrease
from an average of six visits per patient to less than one per
year has been realized.
Midtown's largest challenge is in medical provider
staffing. It is difficult to compete with the generous wage and
benefits packages of larger organizations. The National Health
Service Corps' loan repayment program has been vital to our
success. We have retained medical providers hired in 1994
through this program.
Community needs continue to grow beyond our resources to
meet it. An additional 37,000 individuals in Weaver, Morgan and
Davis counties have limited health care access. We will strive
to meet this need through new Federal funds and new community
partnerships. Thank you.
[The prepared statement of Ms. Nichols follows:]
Prepared Statement of Lisa Nichols
SUMMARY
The following written statement contains an overview of community
health centers in Utah. It includes a profile of each of the 11
federally qualified health centers along with their 2008 data, as
reported in the Federal Bureau of Primary Health Care Uniform Data
System. My remarks to the committee will focus primarily on specifics
related to the Midtown Community Health Center (MTCHC), of which I am
the executive director.
MTCHC has operated in northern Utah since 1970 serving underserved
community residents from Weber, Morgan and Davis Counties. MTCHC has
experienced tremendous growth fueled by community need, Federal funding
opportunities and private partnerships over the past 10 years. In 1999,
MTCHC served 6,504 patients from a single site located in Ogden, UT.
Currently, MTCHC operates from six sites in four different cities,
providing comprehensive primary health care, oral health care services
and mental health services to 25,969 individuals.
Midtown relocated its Ogden site to a new facility in the spring of
2006. This facility, at a cost of $3.2 million, was funded through a
combination of Federal funds and private dollars. Nearly $2.9 million
was raised from the residents of northern Utah. The new facility is
more than twice the size of the former facility. It was anticipated
that the site would allow for 5 years of growth. Midtown added a
pharmacy and radiology services along with additional medical
providers. The patient population has grown by over 11,000 and we still
turn an average of 20 patients away daily.
Sixty-eight percent of the patients served by MTCHC are uninsured.
This is in contrast to the national benchmarks for urban health centers
of 41 percent. Only 31 percent of Midtown's funding comes from the
Bureau of Primary Health Care. Midtown is able to serve such a large
uninsured population and manage tremendous growth by managing resources
cost-effectively and developing community partnerships.
Midtown's largest challenge in meeting the on-going needs of the
underserved is in finding adequate medical provider staffing. Midtown
competes with larger health care facilities in recruiting efforts. It
is through the National Health Service Corps loan repayment program
that Midtown is able to keep the clinic fully staffed. Midtown has
retained medical providers hired in 1994 through this program. It is
vital to our success.
Community need continues to grow despite MTCHC's efforts to meet
it. It is estimated that an additional 37,000 individuals in Weber,
Morgan and Davis Counties have limited health care access. MTCHC will
strive to meet this need through new Federal funds and new community
partnerships.
______
Mr. Chairman and members of the committee, my name is Lisa Nichols.
I am the executive director of the Midtown Community Health Center in
Ogden, UT and a board member of the Association for Utah Community
Health (AUCH). On behalf of Utah's 11 not-for-profit community health
center corporations (CHCs), we appreciate the opportunity to
demonstrate the cost-effective provision of comprehensive primary and
preventive medical, dental, and mental health services being offered at
29 health care home delivery sites in Utah. While the National
Association of Community Health Centers (NACHC) speaks to the
contribution of the Nation's CHCs providing service in more than 7,000
communities nationwide, AUCH will present information on Utah CHCs. The
CHC response to Utah health care reform efforts is also included.
COMMUNITY HEALTH CENTERS IN UTAH
The first health center established in Utah was the Wayne Community
Health Center in the rural town of Bicknell (January 1978), followed by
the Salt Lake Community Health Center in 1979. The contrast in the two
locations is striking--one, a relatively isolated rural setting and the
other within the large metropolitan area of the State. Fourteen of
Utah's counties are classified as ``Sparsely Populated/Frontier,'' with
less than six persons per square mile. There are 14 health center
delivery sites within these counties. Approximately 89 percent of Utah
residents live in metropolitan areas where 15 health center delivery
sites are located. The diverse nature of the populations/locations
served by CHCs in Utah is a testimony to the versatility and
suitability of the model to successfully provide comprehensive, high
quality primary care in a reformed health care system. Appended to this
document are profiles of Utah's CHCs together with 2008 data as
reported to the Federal Bureau of Primary Health Care (BPHC). Important
in describing CHCs in Utah is the comprehensive nature of the services
provided to over 100,000 individuals, which include the following:
Pediatric, adult and family medicine, including chronic
disease management;
Obstetrics/gynecology;
Dental care;
Supporting social services;
Specialty referrals;
Immunizations;
School-based health locations;
Laboratory services;
Mental health/substance abuse counseling;
In-patient care;
Pharmacy (including access to 340B pricing);
Smoking cessation and prevention; and
Public health programs.
Additionally, CHCs in Utah are connected through video technology,
helping to mitigate the considerable geographic distances between the
29 sites. This capacity allows for educational/informational
presentations for both CHC providers and patients from a variety of
sources, e.g., Moran Eye Center and other University of Utah
departments, the Utah Department of Health, Utah Women's Information
Center, private providers. Teleophthalmology services for diabetic
retinopathy screenings are provided collaboratively between all Utah
CHCs and contracted screening providers. Teleradiology services are in
place for most Utah CHCs, as well.
Utah CHCs have quantified the economic impact on the communities
they serve. A 2006 report by Capital Link and AUCH found that the CHCs
had an overall impact of $71.1M and supported more than 846 jobs during
the 2005 study period. The impact included $42.6M in operational
expenditures injected into local economies and $28.5M in indirect and
induced economic activity. Additionally, the report estimated that the
economic output on Utah's CHCs included $39.2M in aggregate gain of
household incomes within the communities that CHCs served.
Staffing of CHCs with adequate numbers of primary care providers
remains a challenge, however. Currently, there are 10 CHC-posted
vacancies in Utah with the National Health Service Corps, a primary
recruitment source.
community health center role in a reformed health care delivery system
Utah's CHC presented the following response to a United Way's
Financial Stability Council Straw Man Reform Proposal in 2008. The
response includes a number of cost-effective CHC practices that
highlight the appropriateness of community health centers as
centerpieces within health care reform efforts.
------------------------------------------------------------------------
Guiding principles Health center alignment
------------------------------------------------------------------------
Contain Costs:
We must make difficult choices that will An emphasis on preventive
make health care more affordable and care, such as
equitable, stem rapidly rising health immunizations, disease
care costs, simplify administration and screenings, and health
encourage the implementation of health education provides for
information technology. Incentives in screening and early
the system must be realigned to focus identification of
on quality, value, best practices, and conditions that are
personal responsibility. considerably more expensive
to treat if not addressed
early.
Evidence-based chronic
disease maintenance and
monitoring slow the
progression of conditions
such as diabetes and heart
disease, and minimize the
need for costly
hospitalization for these
conditions. For example, if
everyone with diabetes were
screened for eye disease
and received the
recommended care and
treatment, a savings of
$470 million could be
created for the health care
system nationally.\1\
Utah's health centers
currently provide retinal
screenings for their
diabetic patients.
Many of Utah's health
centers provide primary
care services using Nurse
Practitioners or Physician
Assistants, which is a cost-
effective method of care
delivery that has proven
results.
The total medical care
services cost per medical
encounter in Utah health
centers averages $110. This
compares with the average
encounter charge in an
emergency department for a
medical condition which
could more appropriately
have been treated in a
primary care setting of
$347-$572,\2\ depending on
the degree of delay by the
patient and subsequent
severity.
Following Federal health
information technology best
practice guidelines, health
centers in Utah monitor
health outcomes and track
key measures. CHCs are
adopting integrated
electronic medical records
technology, and many sites
have also implemented
telehealth technology.
Shared Responsibility:
Individuals, employers, providers, The model of health centers
insurers, State government and the has always been based on
Federal Government share responsibility shared responsibility. The
to make high-quality, cost-effective clinics do not provide
health care available to everyone. charity or free care, but
Within this framework, Utahns should provide a reasonable fee
decide what health care solutions work schedule that is based on
best for them. an individual's ability to
pay for the services. In
2006, $4.4 million was
collected directly from
health center patients for
care rendered.\3\
In addition to patient
revenue, the health center
model leverages a
combination of contract and
grant funding from Federal,
State, local, and private
sources to ensure adequate
access to high-quality care
for all health center
patients. Shared
responsibility is inherent
in the diverse funding
sources that are brought
together to serve each
community in which health
centers operate.
Support For Market-Based Solutions:
Effective and fair competition in a CHCs are full participants
responsibly regulated free-market in the existing health care
system will deliver greater value for market. Patients are
both employers and individuals. rigorously screened for
Competition should be focused on insurance eligibility.
effectiveness, outcomes, efficiency, Health centers participate
and overall quality and value. in all available health
Consumers should have the information plans. Insurers, including
and incentive to choose health care Medicare and Medicaid, are
options based on value. billed according to
established methodologies.
The quality of care at CHCs
is assured by the rigorous
standards required to
annually maintain their
Federal designation and
Joint Commission on
Accreditation of Healthcare
Organizations (JCAHO)
ambulatory care
accreditation.
Endorse Wellness and Prevention:
Healthy lifestyles and preventive care Health centers receive
form the cornerstone of good health. significant UDOH funding
Individuals must take responsibility ($348,000) to engage in
for their health and be provided with preventive care activities,
incentives that reward responsible including funding from
behavior. Heart Disease and Stroke
Prevention, Immunization,
and Tobacco Control to
implement programs in their
patient base.
Health centers adhere to
national quality measures
in the treatment of
individuals with chronic
conditions such as diabetes
and heart disease.
Health centers leverage
funding sources to improve
access for preventive
screening technology, such
as the use of a shared
retinal camera for diabetic
screenings.
Health centers continue to
emphasize wellness
practices as an essential
component of good health
care. Services offered may
include health education,
parenting education, and
lifestyle change practices.
Through the services offered
by health centers, patients
gain an understanding of
the impact that current
decisions have on their
subsequent health status.
Be Compassionate:
Society must devote appropriate Health centers in Utah and
resources to care for the most needy in nationally have continued
our community. In addition, population- to follow a vision that
specific differences in the presence of places the patient first,
disease, health outcomes and access to regardless of their
health care should be eliminated. economic, insurance, or
geographic situations.
As an example, Utah's health
centers provided care to
over 53,000 uninsured
Utahns in 2006 (61 percent
of the total patient base,
and 17.6 percent of the
total uninsured in the
State). Utah's health
centers also provided care
to over 83,000 individuals
living at or below 200
percent of the poverty
level. (94.4 percent of
total patient base)\4\
Access to health center
services is designed to
accommodate any person in
need of health care
services. The use of a
sliding fee scale based on
income provides one
indication of the
commitment to access that
health centers share.
Significant resources are
expended in health centers
to assist patients.
------------------------------------------------------------------------
\1\ National Association of Chronic Disease Directors, An Urgent
Reality: The Need to Prevent and Control Chronic Diseases, undated.
\2\ Utah Office of Health Care Statistics, Utah Department of Health.
Primary Care Sensitive Emergency Department Visits in Utah, 2001.
April, 2004. http://health.utah.gov/hda/Reports/
Primary_Care_ERvisits_Utah2001.pdf.
\3\ U.S. Department of Health and Human Services, Health Resources and
Services Administration, Bureau of Primary Health Care, Uniform. Data
System Calendar Year 2006 Utah Rollup Report, available on request.
AUCH Health Care Reform Action Plan--April 2008.
\4\ U.S. Department of Health and Human Services, Health Resources and
Services Administration, Bureau of Primary Health Care, Uniform. Data
System Calendar Year 2006 Utah Rollup Report, available on request.
The following information includes a brief profile of each health
center organization in Utah.
BEAR LAKE COMMUNITY HEALTH CENTER, INC.
The mission of BLCHC is to provide access to quality primary and
urgent health care for the residents and visitors of the Bear Lake
Valley and surrounding communities on an ability-to-pay basis. The
center takes a holistic approach to maintaining a healthy community
through education, prevention, and a community networking system.
In 2008, the clinics of BLCHC served 5,138 individual patients, and
provided 15,819 patient visits during the year while supporting 28
full-time equivalent positions in its clinic communities.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race
Insurance [percent] [percent] Age groups [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 33........................ 100 percent or < FPL: Age 0-4: 11............ Hispanic/Latino: 7
10.
CHIP: 0.............................. 101-150 percent FPL: 2. Age 5-19: 25........... Not Hispanic/Latino: 93
Medicaid: 9.......................... 151-200 percent FPL: 1. Age 20-44: 38.......... Asian/Pl: < 1
Medicare: 6.......................... > 200 percent FPL: < 1. Age 45-64: 19.......... Black: < 1
PCN/Other: 0......................... Unknown: 87............ Age 65+: 7............. NA/AI: < 1
Private: 52.......................... ..................... ..................... White: 92
> One race: 7
Unreported: < 1
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Carbon Medical Services Association, Inc.
Carbon Medical Services Association, Inc. (CMSA) was originally
founded in 1952 to serve the needs of the local coal miners and their
families. Since 1992, CMSA has been operating as a Federally Qualified
Health Center. CMSA operates two clinic sites, and serves Carbon County
and the northeast region of Emery County.
In 2008, the clinics of CMSA served 3,058 individual patients, and
provided 9,651 patient visits during the year while supporting over 19
full-time equivalent positions in its clinic communities.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race
Insurance [percent] [percent] Age groups [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 33........................ 100 percent or < FPL: Age 0-4: 5............. Hispanic/Latino: 15
33.
CHIP: 1.............................. 101-150 percent FPL: 11 Age 5-19: 14........... Not Hispanic/Latino: 85
Medicaid: 12......................... 151-200 percent FPL: 3. Age 20-44: 37.......... Asian/PI: < 1
Medicare: 18......................... > 200 percent FPL: 2... Age 45-64: 30.......... Black: <
PCN/Other: 0......................... Unknown: 51............ Age 65+: 14............ NA/AI: < 1
Private: 36.......................... ..................... ..................... White: 92
> One Race: 0
Unreported: 7
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Community Health Centers, Inc.
The mission of CHC, Inc. is to provide quality patient-centered
primary health care services to individuals regardless of their ability
to pay. It is CHC's vision that culturally relevant primary health care
is available, affordable, appropriate, adequate and acceptable to all
community members, particularly for individuals, families and groups
who are vulnerable and underserved.
In 2008, the clinics of CHC, Inc. served 31,096 individual
patients, and provided 99,432 visits during the year while supporting
152 full-time equivalent positions in its clinic communities.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race
Insurance [percent] [percent] Age groups [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 63........................ 100 percent or < FPL: Age 0-4: 20............ Hispanic/Latino: 73
61.
CHIP: 2.............................. 101-150 percent FPL: 18 Age 5-19: 32........... Not Hispanic/Latino: 27
Medicaid: 18......................... 151-200 percent FPL: 5. Age 20-44: 33.......... Asian/PI: 3
Medicare: 2.......................... > 200 percent FPL: 1... Age 45-64: 12.......... Black: < 1
PCN/Other: 0......................... Unknown: 15............ Age 65+: 3............. NA/AI: 3
Private: 15.......................... ..................... ..................... > One Race: < 1
Unreported: 5
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Utah Farm Worker Health Program
In 1990, Community Health Centers, Inc. (CHC) received Federal
funding to provide health services to Utah's migrant and seasonal farm
workers and their families. CHC provides medical, dental, health
education, and outreach services through the Utah Farm Worker Health
Program (UFWH). UFWH also refers patients to other existing health care
providers and resources.
In 2008, UFWH served 5,531 individual patients, and provided 7,088
patient visits during the year through the Brigham City clinic site
(Clinica de Buena Salud) and mobile van services.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race
Insurance [percent] [percent] Age groups [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 92........................ 100 percent or < FPL: Age 0-4: 13............ Hispanic/Latino: 98
92.
CHIP: 1.............................. 101-150 percent FPL: 5. Age 5-19: 78........... Not Hispanic/Latino: 2
Medicaid: 4.......................... 151-200 percent FPL: 1. Age 20-44: 6........... Asian/PI: 2
Medicare: < 1........................ > 200 percent FPL: < 1. Age 45-64: 2........... Black: 1
PCN/Other: 0......................... Unknown: 2............. Age 65+: < 1........... NA/AI: 1
Private: 3........................... ..................... ..................... > One Race: 0
Unreported: 11
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Enterprise Valley Medical Clinic
The Enterprise Valley Medical Clinic (EVMC), established in 1983,
provides primary and preventive care to a service area spanning a 40-
mile radius in rural southwest Utah. EVMC serves individuals living in
the Washington County towns of Enterprise, Central, Brookside, and Veyo
and the Iron County towns of Beryl, New Castle, Modena, and Lund.
In 2008, the EVMC served 2,465 individual patients, and provided
6,619 visits during the year while supporting over nine full-time
equivalent positions in its clinic community.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race
Insurance [percent] [percent] Age groups [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 45........................ 100 percent or < FPL: Age 0-4: 11............ Hispanic/Latino: 14
29.
CHIP: 2.............................. 101-150 percent FPL: 17 Age 5-19: 29........... Not Hispanic/Latino: 86
Medicaid: 10......................... 151-200 percent FPL: Age 20-44: 29.......... Asian/PI: < 1
100.
Medicare: 9.......................... > 200 percent FPL: 37.. Age 45-64: 19.......... Black: < 1
PCN/Other: 1......................... Unknown: 7............. Age 65+: 12............ NA/AI: 1
Private: 33.......................... ..................... ..................... White: 89
> One Race: 0
Unreported: 9
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Green River Medical Center
The Green River Medical Center (GRMC) provides a full range of
healthcare services to eastern Emery and northern Grand counties in
southeastern Utah. GRMC not only provides care to the local residents
but also provides the bulk of emergency medical services for those
individuals traveling on the isolated stretch of Interstate 70 running
through central Utah.
In 2008, GRMC served 1,527 individual patients, and provided 4,804
patient visits during the year while supporting almost seven full-time
equivalent positions in its clinic community.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race
Insurance [percent] [percent] Age groups [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 38........................ 100 percent or < FPL: Age 0-4: 6............. Hispanic/Latino: 17
41.
CHIP: 2.............................. 101-150 percent FPL: 11 Age 5-19: 26........... Not Hispanic/Latino: 83
Medicaid: 14......................... 151-200 percent FPL: 3. Age 20-44: 33.......... Asian/PI: < 1
Medicare: 13......................... > 200 percent FPL: 3... Age 45-64: 22.......... Black: < 1
PCN/Other: 0......................... Unknown: 42............ Age 65+: 14............ NA/AI: 22
Private: 33.......................... ..................... ..................... White: 75
> One Race: 0
Unreported: 1
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Midtown Community Health Center
Midtown Community Health Center's (MTCHC) mission is to provide
excellent and safe health care to the residents of northern Utah,
especially those with economic, geographic, cultural, and language
barriers. MTCHC is recognized for its high level of cultural competency
and ability to provide affordable, quality health care.
In 2008, the clinics of MTCHC served 25,969 individual patients,
and provided 60,060 visits during the year while supporting over 76
full-time equivalent positions in its clinic communities.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race (2007)
Insurance [percent] [percent] Age groups [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 68........................ 100 percent or < FPL: Age 0-4: 16............ Hispanic/Latino: 60
36.
CHIP: 2.............................. 101-150 percent FPL: 12 Age 5-19: 26........... Not Hispanic/Latino: 40
Medicaid: 13......................... 151-200 percent FPL: 3. Age 20-44: 38.......... Asian/PI: < 1
Medicare: 3.......................... > 200 percent FPL: < 1. Age 45-64: 16.......... Black: 1
PCN/Other: 0......................... Unknown: 48............ Age 65+: 4............. NA/AI: < 1
Private: 15.......................... ..................... ..................... White: 35
> One Race: < 1
Unreported: 62
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Mountainlands Community Health Center
The mission of MCHC is ``Health professionals providing and
collaborating with other partners to assure high-quality health care
for everyone in our community.'' MCHC is the only provider in Utah
County that offers comprehensive primary medical, dental, and mental
health services on a sliding fee scale.
In 2008, MCHC served 10,111 individual patients, and provided
32,397 patient visits during the year while supporting almost 51 full-
time equivalent positions in its clinic communities.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race
Insurance [percent] [percent] Age groups [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 75........................ 100 percent or < FPL: Age 0-4: 14............ Hispanic/Latino: 78
64.
CHIP: 2.............................. 101-150 percent FPL: 20 Age 5-19: 19........... Not Hispanic/Latino: 22
Medicaid: 11......................... 151-200 percent FPL: 3. Age 20-44: 46.......... Asian/PI: 1
Medicare: 3.......................... > 200 percent FPL: 1... Age 45-64: 16.......... Black: 3
PCN/Other: 0......................... Unknown: 11............ Age 65+: 5............. NA/AI: < 1
Private: 9........................... ..................... ..................... > One Race: 0
Unreported: < 1
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Southwest Utah Community Health Center
The mission of the SWUCHC is to make lives better in southwest Utah
by providing accessible, quality health care, regardless of financial,
language, or cultural barriers. SWUCHC serves a five-county area in
southwestern Utah, and is the only provider of care in the St. George
area that offers medical, dental, and mental services on a sliding fee
scale.
In 2008, the SWUCHC served 4,805 individual patients, and provided
13,585 visits during the year while supporting over 18 full-time
equivalent positions in its clinic community.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race
Insurance [percent] [percent] Age groups [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 57........................ 100 percent or < FPL: Age 0-4: 17............ Hispanic/Latino: 66
64.
CHIP: 2.............................. 101-150 percent FPL: 18 Age 5-19: 17........... Not Hispanic/Latino: 34
Medicaid: 24......................... 151-200 percent FPL: 5. Age 20-44: 44.......... Asian/PI: 1
Medicare: 4.......................... > 200 percent FPL: 3... Age 45-64: 18.......... Black: 1
PCN/Other: 0......................... Unknown: 11............ Age 65+: 5............. NA/AI: 2
Private: 13.......................... ..................... ..................... White: 48
> One Race: 51
Unreported: < 1
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Wayne Community Health Centers, Inc.
WCHC has been offering full-time primary health care services in
Wayne County since 1978. Deep canyons and high mountains separate this
service area from any other primary or emergency care provider for 60
to 120 miles. WCHC has built a strong reputation for delivery of high
quality services to this economically depressed and isolated area.
In 2008, WCHC served 3,899 individual patients, and provided 15,068
patient visits during the year while supporting almost 26 full-time
equivalent positions in its clinic communities.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race
Insurance [percent] [percent] Age groups [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 42........................ 100 percent or < FPL: Age 0-4: 8............. Hispanic/Latino: 2
29.
CHIP: 7.............................. 101-150 percent FPL: 13 Age 5-19: 29........... Not Hispanic/Latino: 98
Medicaid: 5.......................... 151-200 percent FPL: 10 Age 20-44: 27.......... Asian/PI: < 1
Medicare: 7.......................... > 200 percent FPL: 39.. Age 45-64: 22.......... Black: < 1
PCN/Other: 0......................... Unknown: 9............. Age 65+: 14............ NA/AI: < 1
Private: 39.......................... ..................... ..................... White: 96
> One Race: 0
Unreported: 2
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Wasatch Homeless Health Care, Inc. Fourth Street Clinic
The Fourth Street Clinic helps homeless Utahns improve their health
and quality of life by providing high-quality health care and support
services. WHHC principles include the fact that good health is
necessary for maintaining a job and stable housing; that affordable
health care and housing are basic human rights; that compassionate and
respectful health care is delivered to all Fourth Street Clinic
patients; and that ensuring affordable health care, housing and other
basic life necessities will break and prevent the cycle of
homelessness.
In 2008, the Fourth Street Clinic provided health care to 5,723
individuals.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race [
Insurance [percent] [percent] Age groups [percent] percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 84........................ 100 percent or < FPL: Age 0-4: 4............. Hispanic/Latino: 19
93.
CHIP: < 1............................ 101-150 percent FPL: 1. Age 5-19: 6............ Not Hispanic/Latino: 81
Medicaid: 13......................... 151-200 percent FPL: < Age 20-44: 50.......... Asian/PI: 1
1.
Medicare: 3.......................... > 200 percent FPL: < 1. Age 45-64: 39.......... Black: 8
PCN/Other: 0......................... Unknown: 5............. Age 65+: 2............. NA/AI: 4
Private: < 1......................... ..................... ..................... White: 70
> One Race: 0
Unreported: 17
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Utah Navajo Health System, Inc.
The mission of UNHS is to make a difference in the quality of life
for all community members by providing high quality, comprehensive
primary and preventive health care in a culturally and linguistically
competent manner while maintaining fiscal viability. UNHS operates
clinics in San Juan County, Utah and Tonalea, AZ, and is a major
provider of health care to Navajo Tribal members living in southeast
Utah and adjacent ``Four Corners'' locations.
In 2008, UNHS served 11,760 individual patients, and provided
53,660 visits during the year while supporting over 129 full-time
equivalent positions in its clinic communities.
2008 Key Demographics
----------------------------------------------------------------------------------------------------------------
Poverty level Ethnicity/Race
Insurance [percent] [percent] Age groups [percent] [percent]
----------------------------------------------------------------------------------------------------------------
Uninsured: 44........................ 100 percent or < FPL: Age 0-4: 12............ Hispanic/Latino: < 1
62.
CHIP: 1.............................. 101-150 percent FPL: 11 Age 5-19: 28........... Not Hispanic/Latino: 99
Medicaid: 20......................... 151-200 percent FPL: 12 Age 20-44: 26.......... Asian/PI: < 1
Medicare: 8.......................... > 200 percent FPL: 13.. Age 45-64: 24.......... Black: < 1
PCN/Other: 0......................... Unknown: 2............. Age 65+: 9............. NA/AI: 76
Private: 28.......................... ..................... ..................... White: 24
> One Race: 0
Unreported: < 1
----------------------------------------------------------------------------------------------------------------
FPL = Federal Poverty Level
Senator Sanders. Ms. Nichols, thank you very much.
We have been joined by Senator Harkin of Iowa, and I want
him to say a few words because he has perhaps, more than
anybody else in the Senate over the years, been the leading
exponent for disease prevention and primary health care.
Welcome, Senator Harkin.
Senator Harkin. Thank you very much, Mr. Chairman.
Senator Sanders. Do you want to say a few words?
Senator Harkin. No. I don't want to interrupt. I am sorry I
am late. I had a previous engagement. I wanted to be here. This
is so important.
Senator Sanders. Let's just begin the discussion. Let's all
take a deep breath and we will do it informally. We're among
friends here.
[Laughter.]
Let me start off. I want to go to Dan Hawkins for a minute
because he made a very profound statement a few moments ago. He
talked about the potential of the saving of hundreds of
billions of dollars through the expansion of community health
centers as we keep our people well. People are healthier. The
system spends less money. It's kind of a no-brainer in terms of
wanting to go forward. Dan, why would we save so much money by,
if Representative Clyburn and I are successful, putting a
community health center in every underserved area in America?
Where does the savings occur?
Mr. Hawkins. Senator, where they occur most profoundly is
in the quality management of the care and the health of each
individual patient that they serve. Health centers, No. 1,
emphasize prevention, both for children, childhood check-ups,
immunizations, for women who are pregnant, good, quality
prenatal care, they have lower low-birth weight rates and lower
infant mortality rates. Studies have shown that rates are 40
percent lower in communities that have a health center than
they are in similarly situated communities that do not have a
health center.
And perhaps most importantly in this day and age, when
chronic illness is such a major cause of health care spending,
health centers have learned to engage the people they serve. I
don't like the word patient because it implies dependency. It's
really a co-dependency in a collaborative relationship between
a provider of care and the individual receiving care. The
individual receiving care has to understand their condition,
has to take charge of that condition, embrace it, and
understand if they have diabetes or high blood pressure,
congestive heart failure, they may well have--now HIV and many
forms of cancer, which instead of being a fatal diagnosis now
are more likely to be a lifelong condition diagnosis. Take
charge, embrace that condition, understand how to manage it, to
self-manage their care. Health centers provide glucometers to
diabetics, blood pressure cuffs to hypertensives, tell them to
go home and measure your particular indicators, call us every
day, provide that information, and come back for regular
planned visits and group visits. Actually, I think that John
Matthew and Lisa could probably speak more profoundly to this
from the real world, but this is what we know health centers
do. By doing that, they avoid the need for much of the
specialty care and repeat services that are needed. They avoid
the need for in-patient hospitalization and they take people
out of the emergency room, which is the absolute worst place
for people to receive primary or preventive care, most costly
and least effective.
Senator Sanders. OK. Why don't we stay on this issue.
Ms. Bascetta. I have a comment.
Senator Sanders. Yes.
Ms. Bascetta. I want to make three comments. One is that
there was a study done a few years ago that noted that while
health centers provide care that is equivalent to other
providers across the country, that in some situations in
chronic care, they weren't performing as well as some
integrated systems such as the VA, and the hypothesis was that
better health IT at the health centers would enable them to
perform better because that was the competitive advantage that
the VA has. So I would like to note that the stimulus does
provide money for IT. It's not a panacea, necessarily, but it's
a very important piece for measuring outcomes across the course
of a chronic disease.
The second thing I want to mention is that, and I sort of
hesitate to say this, but prevention--everybody wants to do
prevention. It's absolutely what you want to do. You do want to
avert the cost of failing to take care of people early in the
disease, but from a system perspective, overall, most of the
studies show that when you prevent certain diseases, people
eventually will live to develop something else. So it doesn't
necessarily control costs in the long run.
Senator Sanders. We all hope at 100 to develop something
else. I don't know if that's a criticism?
[Laughter.]
Ms. Bascetta. No, it's not. I just want to point it out.
The other thing that I would point out is that on the cost-
saving issue, it's correct that many of the studies show
important costs from things like emergency room diversion. We
have some concerns that the more that health centers expand,
the more Medicaid costs will increase. Now that's a good thing,
because it means people are getting care. So rather than think
only about the cost savings over all to the system, I would
prefer thinking about the importance of building on the
infrastructure that community centers have established to be a
vehicle for using the public insurance that we have, Medicaid
and Medicare.
Senator Sanders. Thanks very much. Further discussion?
John.
Dr. Matthew. Senator, I would make the point that I have
been around in medicine long enough to see preventive medicine
work. We now have a radically reduced rate of strokes and a
radically reduced rate of coronary heart disease, heart attacks
because of risk factor control. It's not a short term
phenomenon. It is years of good blood pressure control, good
cholesterol control, and salt control in the diet. The American
Heart Association says if everybody ate a no-added salt diet in
the whole Nation, we'd have 25 percent less cardiovascular
disease and stroke. If everybody ate fish twice a week or fish
oil every day, we would have 20 percent additional reduction in
cardiovascular disease and stroke. Middle-aged men who ate two
grams of fish oil a day reduced their risk of sudden death to
one-sixth of what it would be. Men with highest levels of
vitamin D who have prostate cancer, have one-sixth the chance
of dying from that cancer compared to men who have the lowest
levels. There is a lot of room to do preventive medicine.
Senator Sanders. And you feel that community health centers
are in a position to do that?
Dr. Matthew. Absolutely.
Mr. Evans. Senator, may I add an oral health point here? It
is somewhat indirect but it is rather pertinent.
Senator Sanders. Yes.
Mr. Evans. A recent study in California, indicated that in
California emergency rooms, there were over 200,000 dentally
related emergency visits. The cost translation to that
emergency room system of California hospitals was in the
multimillions of dollars. Again, were there are better points
of access, that would be a major cost savings.
I would also like to point out that that study indicates
that there are 51 million school days lost by children for
dentally related issues in our system and 146 workdays lost by
workers in the United States over dentally related issues. Were
there more access points in the system, many of those being
provided by community health centers, those statistics also
represent major savings in the United States, and in terms of
the workforce, increase the productivity of that workforce.
Senator Sanders. Representative Clyburn.
Representative Clyburn. Thank you very much, Senator. I
would like to make two quick points before I go back to the
other side. I don't want to wear out my welcome over here.
[Laughter.]
Two things. First of all is this. I am a former public
school teacher. I started out my career as a public school
teacher and I know dental care is something that we have to be
very concerned about. There is something we never talk about,
but that I have seen a profound impact on students being able
to do well in school. It's called vision care, and I think we
never talk about it. If you talk to any public school teacher,
especially first or second grades, they will tell you that a
lot of time students fall behind and never catch up simply
because they don't know that they can't see or don't see well.
So I want us to start a discussion, and community health
centers would be great with that.
Second, on yesterday, I met with my hospital association,
and I was shocked when they told me how much they are
supporting our efforts here, Senator Sanders. And they tell me
the main reason is because Federal law currently dictates that
their emergency centers must provide primary care for those who
can't afford it. And they said to me that is the worst possible
thing to take place. And they would love to get these people
out of the emergency rooms and out into the community health
centers. So my hospital association told me they are ready for
us to get these bills passed. Thank you, Mr. Chairman.
Senator Sanders. Other discussion?
Yes, Dr. Mullan.
Dr. Mullan. If I could say just say a word about the future
that we might envision with these bills passing. The
relationship between training and careers in community health
centers in the past has been a little shaky. For a long time
the National Health Service Corps and community health centers
ran on totally separate tracks. It's only been more recently
where there has been a vigorous effort to use the National
Health Service Corps to staff health centers.
The notion that we had far more National Health Service
Corps people in health centers, and that in fact, training
could take place in health centers, so it becomes not just
something that you do to pay off a loan, it's something that is
seen as a career, as a culture of medicine, not as a side bar,
but as a main line activity, is very, very important. And I
think running it at very low levels--National Health Service
Corps, as I mentioned before, I've always called it a pilot
program even though it is 40 years old. There are today 4,000
people in the field serving in that National Health Service
Corps, about half of those are physicians.
There are 800,000 physicians in America. So right now, one-
quarter of 1 percent of physicians are in the National Health
Service Corps. That is a pilot. That is a demonstration, and
that's after 40 years of proven effectiveness.
So what you envision in taking this out of the nice
experiment into the main line, with teaching, with residency
programs, with careers, with leadership training, really is
revolutionary and terribly important. I commend you for it, and
if we can get it, it would be terrific.
Senator Sanders. Thank you. Let me tell you a funny story.
Senator Harkin, you will be interested in this.
David Reynolds, who is sitting behind me, founded the first
federally qualified community health center in Vermont, and is
now on my staff. He and I went to Dartmouth Medical School a
few weeks ago, and our purpose was to explain to the medical
school that we tripled the funding for the National Health
Service Corps, and we would like them to do everything they
could to advertise that fact to their students to get them
involved in primary health care.
What we learned from some of the young students, medical
students was, they said that when they told their fellow
students that they were going into primary health care, their
fellow students looked at them in shock and assumed that they
were dummies doing bad on their tests. They could not
understand why would you go into primary health care and earn
substantially less money than those who were going into
specialties?
That's where we are today. The most important work is
disparaged. So I did want to mention that and certainly agree
with you, Dr. Mullan, we've got to get out of the pilot project
phase, which has now gone on for 40 years.
I would be remiss in not mentioning, obviously that the
founder of the whole concept of community health centers is not
with us today, but is the Chairman of this committee, Senator
Kennedy. His work is so greatly appreciated.
So getting physicians and getting dentists, of course, out
into areas where we need them is a major priority that many of
us are working on.
Senator Harkin.
Statement of Senator Harkin
Senator Harkin. Thank you very much, Mr. Chairman. And
thank you for calling this hearing. As we have discussed many
times, this is an intense area of interest of mine. As we are
looking ahead to having a health care reform bill this year, if
you could draft--not the whole bill perhaps--but if you could
draft a part that would be for prevention and wellness, which
is what I am doing with the working group, how would you fit in
these two elements: federally qualified community health care
centers and the National Health Service Corps? How would they
fit? How would they be structured so they could continue to not
only get operational money, but expansion money?
That's always been a battle, as you know, the money we
provide--if it's for new construction, then we don't put enough
money in there for the operational requirements for existing
centers. So how do we structure that to make sure that we can
grow federally qualified community health care centers, and
also keep the operational structure intact and supporting those
that are there? The ones that are there are going to need
increases every year, not just cost-of-living, but a lot of
them now need to expand their services to dental and a lot of
other things that they did not have in the past. That's one
element.
The second is just what we just touched on, and that's the
National Health Service Corps. How do you structure that in
health care reform?
I think that these are just two elements which we've got to
address. We are wrestling with it right now, on exactly how we
structure it.
So you are the experts. How would you structure it?
Dan.
Mr. Hawkins. Thank you, Senator. I have to say I know you
struggle every year, but I marvel at your success, in managing
to produce additional resources to grow these and many other
vital public health programs across the board, so my hat's off
to you, and the hard work that you do.
First of all, I think an important way to look at this, and
this in the context of health reform, is we are talking about
investments that produce a return. I mentioned earlier that
health centers last year saved the health care system $18
billion. I did point out that their expenditures at that point
were $8 billion. That's still a two-for-one return on
investment.
And by the way, more than a third of that was Medicaid
spending, that Ms. Bascetta mentioned, of which health centers
pulled down $3 billion in Medicaid revenues last year, and sent
back to Medicaid through State agencies and to the Federal
Government more than $6.5 billion. Again, a two-for-one return
on the payments that Medicaid agencies made for care provided.
We have to think about this. Our centers provide personal
health care. National Health Service Corps clinicians, by and
large, provide personal health care. But as I know you both
know, Senators Sanders and Harkin, and everyone at the table,
it's got to be about more than personal health. It's community
health. It's population health.
Right now, the first confirmed case of swine origin flu
was--a confirmed case now--was identified at a health center.
But I know my own health center in Brownsville, TX is sitting
on 30 cases of suspected flu. They are linked at the hip with
the local health department down there, ensuring that the
community is going to get preventive measures that they need to
avoid spreading that contagion further than it has already
spread, to track and contain it. You have to be about
population health.
One of the most important things Jack Geiger, one of the
founders of community health centers, said was, ``Yes, it's
care patient by patient, but it is so much broader than that.
It's got to be about the whole community.'' There are resources
you have to put in, Senator, but what you also look at is the
return you get.
Senator Harkin. I want to ask Dr. Mullan about this too,
the National Health Service Corps, and anyone else who has a
thought on this. We are going to have a national health
program. We are obviously going to have a lot of price plans
out there and whether there is a connector or not, like the
Massachusetts system, we don't know. But it's been my thinking
that we must insist that any plan that anyone might want to get
that comes into this system must provide that they can exercise
that plan at a community health center.
Mr. Hawkins. Oh, absolutely.
Senator Harkin. And that services are fully reimbursable at
any community health center--as it is now. As you know, anyone
can go to a federally qualified community health center now,
under a private plan, or whatever, and they will pay for that.
But we have to insist that somehow that's part of every plan
that is allowed into the system.
Mr. Hawkins. You are absolutely right. I mean I suspect
that reform would have network adequacy standards. And one of
the worst things that could be allowed in the absence of those
strict standards, is that some plans may choose not to contract
with community health centers as a way of redlining the very
people we are working----
Senator Harkin. You see, that's why we have got to have
that.
Mr. Hawkins. That's right. We can't allow that to happen.
It's a form of discrimination that occurs too much today in the
private insurance system. With insurers looking for young
healthy folks and avoiding in every way they can, folks who are
sicker and in need of greater care. That's one of the things
that we've got to do, and as you said, full participation and
adequate payment. Folks have got to recognize the kinds of
services health centers provide--I know John's center does,
Lisa's center does, Yvonne's center does--services like
outreach into the community, health and nutrition education. I
am talking about making the medical care they get effective.
Making it work. For a pregnant woman, understanding how to take
care of herself during pregnancy, in order to ensure a positive
outcome. That costs money. That's care management, it's patient
management, but oftentimes insurers, especially private
insurers, won't reimburse it.
So full participation is required and adequate payment,
that is vitally important. The only programs that do that
today, Senator, in response to your point about a public plan,
the only payers today that recognize the unique needs of the
people that health centers serve, and provide benefits
accordingly, and the only payers that recognize the unique
safety net role that health centers play and reimburse them
accordingly, are Medicare, Medicaid, and SCHIP, public
programs.
To me, and to all of us, there is great value.
Senator Harkin. Dan and Mr. Chairman, I would like to work
with you, to work together to make sure that in this health
reform it is adequately reimbursed, for any plan that comes in
has to have that in its plan.
I want to get into the National Health Service Corps.
That's another part.
Yes, Dr. Matthew.
Dr. Matthew. I would make the point that you have to invest
in efforts of community education. I put up on the dias behind
you sir--we have a newsletter, we have a series of the public
classes on topics of importance to the public. We have people
on our staff called community resources. We have always had a
dietician. You can not do all of the medical care on a one-on-
one encounter in an exam room or the one person who is in the
hospital. We have an effort by the staff to get people a ride,
to be sure they are signed up for their insurance. That sort of
thing. But on the other side, the public education and patient
education are terribly important.
Senator Harkin. Of course, I have another idea for that
that I am thinking of incorporating. And that is that we should
have a federally qualified community health center establish an
outreach program at every public school within its region. But
that's for another time. I hate to take any more time, but the
National Health Service Corps, how do we incorporate them in
this health care reform bill?
Mr. Mullan. The question is a good one because standard
medical education, as we all know, and dental education, is
fairly narrow and it tends less to the issues of prevention,
population health, and community health, both at the medical
school level and in residency. What the opportunity of an
enhanced National Health Service Corps, community health center
initiative affords is really impacting that education system in
several ways.
One is that traditionally it's been hard for the National
Health Service Corps to work with the people it gives awards to
until they actually come on site. But going back into the
pipeline, and doing a lot more power education where there
would be summer clerkships, and there would be residency
opportunities for people who are headed to health centers even
along the way.
The building of teaching community health centers where
population health would be part of what they learn, would be
essential to creating the kinds of doctors that we need.
And this finally gets to this whole notion of changing the
culture of medicine. This is the specialty, community health,
and this puts air under the wings of the idea that we would
really have a major part of health education in medicine,
dentistry, and nursing in this country, focusing on prevention,
outreach, population health for folks who are headed into that
practice setting with prestige. This gives you the opportunity
to really put a brand on what they're doing and not at
something, again, that they did just to pay the bills--it's
something they did because that's where they want to serve.
Senator Harkin. A cardiologist friend of mine said just
recently, ``Look, we really need more primary care doctors. And
the only way we are going to get them is you have got to pay
them more.''
There are two ways of payment, there's back-end payment and
front-end payment. We can control and we can do something about
the front-end payment. And that is, if you want more primary
care doctors, why don't we just pay for their education? Pay
for the whole thing? Pay for everything. That's front-end
payment.
That, I think is something else I would like to see
incorporated, but my time is up.
Senator Sanders. Senator Merkley.
Senator Merkley. Thank you very much, Mr. Chairman. I
wanted to explore a couple other points.
One is how the health care centers serve as a gateway to
more complicated medical treatment that might involve
specialists. Ms. Davis, your story may provide an example of
this. Your brother had a heart attack, if I understood
correctly?
Ms. Davis. Yes.
Senator Merkley. So he got care for that heart attack. I'm
imagining he did not have insurance. If that's the case, how
did the health center work with heart specialists to ensure
that he got the treatment that he needed, and how did the
finances around that work?
Ms. Davis. Actually, what happened was, when my brother was
diagnosed that he had had a heart attack, I immediately went to
the emergency room. I knew, he knew that he was uninsured. We
had no idea what was about to happen. I went there and asked
for the patient assistance program, and we had to sign
documents and complete the paperwork because they didn't want
to dismiss him. Well, actually, I was not going to take him
home--let him go home. And it turns out that he had a quadruple
bypass. He had a 96.7 percent blockage. The doctors told them
he would have lasted about 48 hours, but when they told him
what surgery he had to have, family members came in because we
knew he was only eligible for a certain amount of patient
assistance.
So instead of having to mortgage his home, his siblings--we
in turn--had to borrow money to help. But the rest of it, more
or less, was paid for by taxpayers because, unfortunately he
was in the intensive care unit for 6 days, and then in the
hospital for an additional 5 days. But that was the way--we had
no other choice. We had to put our necks on the line in order
to make the payment.
Senator Merkley. Yes, I want to broaden the discussion to
the issue of how--thank you very much for your personal
example. I think it really helps illuminate the issues that we
face and to broaden the question to other folks who would like
to comment on how this works, how it should work, how it can
work, how it does work currently?
Ms. Davis. I would also like to add that when he was
discharged from the hospital, the community health center made
arrangements for him to see a local internal physician, and
then he himself had a personal connection with a cardiologist,
and then they got it set up so that he could be treated by him
as well.
So it was this ongoing effort by the community health
center that helped him get what was locally available to him in
Marion. Because Marion County is without a lot of specialists,
so we had to do what we had to do to make it happen.
Ms. Nichols. We provide comprehensive primary care, but as
you might imagine, we often detect people who need specialty
care services. Our community has been enormously generous. We
have 370 specialty care providers in a volunteer provider
network who have each agreed to donate one to three visits
monthly and donate about $2 million in care annually. That's
wonderful, but that generosity can only go so far. For example,
we have an orthopedic surgeon, who spends 2 days a month in our
office and another 2 days of surgery donated by the hospital,
donated by him. We still have to pay his malpractice insurance.
It's a great benefit for the community, but we would love to
see services somehow expanded to include FTCA for specialty
care providers. That would just help us enormously.
Senator Merkley. The health care center plays a huge role
in facilitating donated services, and an individual, a poor
individual, would have no chance of knowing how to reach that
gateway, if you will, to access care for a complicated medical
circumstance.
Ms. Nichols. Exactly. We have case managers who do that. We
have to have them placed in the emergency department and in the
local school system.
Senator Merkley. Now, Ms. Nichols, I think you mentioned
that you had to turn away patients. How do you make decisions
as a health care center, who you provide services to, and who
you do not provide services to, when the demand exceeds the
capacity?
Ms. Nichols. It's very difficult. We have created some
priority groups. We always take children under the age of 19,
pregnant women, individuals with HIV/AIDS, individuals with
mental health issues. We are pleased that in August, because of
the stimulus funding, that we will be able to open our doors
again. We hope! We don't know how soon we will be turning
patients away again, but we will be opening our doors again.
Senator Merkley. You are completely closed down right now?
Ms. Nichols. Other than those groups that I mentioned.
Senator Merkley. He means opening the door to new people?
Ms. Nichols. Oh, I am sorry. Yes. Yes, we are not closed
down. We accept those patient populations that I described.
Other than that, we are referring them elsewhere.
Mr. Evans. I would like to offer an example, if I may,
Senator?
Senator Merkley. Please.
Mr. Evans. Health care centers also provide a unique
opportunity for physician-dentist interaction. Take, for
example, a diabetic patient, we know that there are
associations between periodontal diseases and diabetes, for
example. That diabetes exacerbates periodontal diseases, and
periodontal disease, in turn exacerbates diabetes in terms of
glycemic control. And that's understandable, as I said
previously, the jaw bone is connected to the toe bone. If you
think about it forming an infection anywhere in the body, that
will, in fact, exacerbate the effects of diabetes.
Health centers have the option of working with their
diabetic patients in terms of that referral and the results of
that referral, and that interaction is better control of
diabetic conditions, and consequently it is not only
lifesaving, it's morbidity saving as well, and cost saving, as
a further example. That interaction is also an important one, I
think, at the community health centers.
Senator Sanders. If I could just pick up on a point that
Congressman Clyburn raised and Dr. Evans raised a moment ago,
and that is getting primary health care to young people in
schools, school-based health.
I will tell you a personal experience. We started a dental
clinic in a low-income school in the city of Burlington, which
is now treating kids all over the city and has been hugely
successful. We have one in Bennington. We are expanding one in
the northern part of our State as well.
Does bringing health care and dental care to the kids at
school, so they do not miss the days that you were talking
about--stay home because of dental problems--is that something
that is worth exploring?
Ms. Davis, do you want to address that?
Ms. Davis. Yes. As I spoke about it earlier, school-based
clinics, when I was on the PTA at the high school in Marion.
One of the things that we're experiencing now is that, after we
met with the local hospital, we found that they are getting a
high number of teenaged pregnant students that go to the
hospital that are now almost in their fifth trimester, where
they've had no prenatal care. When we were in the high school
there, we educated the young girls and we talked about it.
Congressman Clyburn spoke about the vision care, we had all
means of expertise to come in with us.
Senator Sanders. This was an opportunity for a physician or
a medical person to come in and talk to young women about
sexuality and so forth.
Ms. Davis. Yes, and as a PTA person, we had the parents to
come in and they witnessed how the numbers dwindled as to the
success of the school-based clinic.
Senator Sanders. Excellent. Let's wait on that one.
Ms. Nichols.
Ms. Nichols. We actually just opened a school-based clinic
on April 6. We did that in conjunction with our local hospital,
Intermountain Health Care, who funded it because they
recognized that so many children were coming to the emergency
department for nonemergent needs. So we don't yet have a lot of
experience, but we are working closely with the school case
managers and counselors. Whenever a child misses school, we
will be on the phone with them scheduling an appointment and we
hope to have excellent outcomes.
Senator Sanders. John, you have a relationship with Cabot
High School, don't you?
Dr. Matthew. Yes, we have a school-based clinic and have
for about 16 or 18 years in Cabot for the school kids, but also
for anybody in the community that wants to come. So that puts
us out about 15 miles further into the hills.
I also want to point out that we are going to be the base
for a dental van, it's called the Care Mobile, that will go
around to other FQHC areas in our State to take care of kids
and teens who don't have dental care. In one of our rural
towns, about an hour from us, there are 1,200 kids with a
Medicaid card, good for all the dental care they need through
the age of 21 in Vermont, and no dentist to see them. So we are
going to be, quarterly, back in town, for about a month each
time.
Senator Sanders. Any additional thoughts on school-based
clinics?
Senator Merkley.
Senator Merkley. I wanted to take the conversation to a
different area.
Dr. Mullan, I believe you mentioned that we have enough
physicians, it's the challenge of re-deploying them. Did I hear
that correctly?
Dr. Mullan. Yes.
Senator Merkley. I wanted to turn to the issue of
recruiting providers, and I understand that the loan repayment
program and scholarship program, under NHSC, there are
currently a large number of vacancies for certified nurse
midwives, 62, nearly 1,000 vacancies for nurse practitioners,
64 vacancies for psychiatric nurse specialists. Are these
vacancies a result of a lack of funding for scholarships or
lack of applicants because we are under supplied?
Dr. Mullan. I did take the opportunity, as I mentioned, to
do some homework yesterday, talking to people in the program,
and they told me the following: in the last round of
scholarship and loan repayment awards, there were roughly 1,000
applicants--this is across disciplines--for scholarships and
they were able to award 100. And in loan repayment, there were
about 2,800 applications, they were able to award about 800.
There is an eagerness, and this is an environment which many
students know that there is relatively little chance they are
going to get an award. If there was a sense that there are
awards available, one suspects that the application numbers
would go way up.
Senator Merkley. In exchange for the loan repayment and the
scholarships, there is a service commitment. Could you describe
or elaborate on those types of commitment?
Dr. Mullan. On the scholarship, the law has been since the
beginning, it is a year for a year, with a minimum of 2 years.
You incur a year of obligation for every year of award. So
typically, if it's a 2-year award, you serve for 2 years,
although the evidence is that the majority of people placed by
the scholarship or loan repayment stay in the community longer,
sometimes for careers, and other times work at other health
centers or other underserved areas. So it's been quite positive
in terms of the movement of people from areas that are higher
density to ones that are lower density in general.
Senator Merkley. So this is a program we should really look
at trying to fund at higher levels?
Dr. Mullan. It would be, I think, critical both to the
success of the community health movement, and Dan could speak
to this better, but even at the current level, there are very
substantial vacancies in health centers for physicians,
dentists, nurses, and others, and at the expanded levels,
unless we have an instrument that will move personnel along
with building health centers, you are going to have great
buildings that are empty.
Senator Merkley. Thank you.
Senator Sanders. Well, Senator Merkley, I mentioned, as I
said earlier, in the stimulus package, we tripled funding for
the National Health Service Corps and the legislation that we
are discussing this morning we would increase it by 10 times.
Yes, Ms. Nichols.
Ms. Nichols. I know there is discussion of changing the
deadline dates of the National Health Service Corps. At this
point you can apply once a year, and that certainly has been a
barrier for us because those medical providers don't always
look for jobs just once a year.
Senator Sanders. That has changed. The reason for that is
they didn't have enough money to accommodate the applicants,
but right now I believe they will be around every 2 months. It
will be a rolling period. So I think you are going to be able
to apply at any time. Because now, they have the money to begin
to provide the debt forgiveness and the scholarships.
Mr. Evans. May I suggest that recruitment and the promotion
of those opportunities be very, very early because, per the
example you provided earlier, Senator, late in the educational
career is really too late. It has to be done day one, and it
should be done minus day one.
Senator Sanders. Absolutely. We're thinking of trying to
get the information out to college students who are thinking of
going to medical school or dental school.
Yes, Dr. Mullan.
Dr. Mullan. One other affiliated point. There are numerous
studies in medicine and in some of the other health professions
that show that students enter with high levels of idealism and
we beat it out of them.
[Laughter]
Senator Sanders. What a process.
Dr. Mullan. This goes in medicine, through medical school
and in through residency. I mean the low point of cynicism is
probably residency years and then it goes along wounded, and
late in the career you see the optimism and the positive
attitude that come up a little bit. That is a little bit of a
phenomena and careers and mortgages and all that, but a lot of
it is what we do, in the absence of opportunities to express
positive careers.
We see right now across the health professions an explosion
of interest in global health. People are sort of scratching
their heads, what is it? The globe has always been out there.
The illnesses have always been out there. The missionary spirit
has always been out there. I think that for a variety of
reasons, the seriousness of the HIV world, and what we see in
images coming back, it is picking of off the idealism.
But one of the reasons is, frankly, students don't see the
opportunities here. And what this double set of up-funding
promises is building, once again, a sense of, ``I can do this
in America.'' We have an unfinished mission and doing primary
care community health can make a huge difference. I don't need
to go to Botswana. I can do it in northern Vermont, etc. It's a
little bit of smarmi pictures, but I think it's very real.
Senator Sanders. One of the absurdities of the current
situation appropriately related to what you said, Dr. Mullan,
in terms of nursing. You talked about globalization. Do you
know where we get many of our nurses from right now? We get
them from the Philippines. So we are depleting struggling Third
World systems, taking their professionals into our country,
because we are not producing the doctors, the dentists, the
nurses that we need. So it's a reverse globalization, if you
like.
Mr. Hawkins. Senator, I also wanted to add, especially in
light of your point about what you heard from the students at
Dartmouth, and Senator Harkin's point about the question of how
do we re-elevate the value and the position of primary care
within our health care system? You talked about the 2,000 or
4,000 clinicians in the Corps today, but really if you think
about it in terms of medical school and residency fits, it's
not just one-quarter of one percent, but it might be less than
2 percent of residents across the country are actually on loan
repayment or scholarship.
But if you can grow the National Health Service Corps to
the size, Senator, that your bill portends, a much higher
proportion of--now they are going into medical schools. They
are going to go into medical schools and offer loan repayment
to those who didn't take scholarships before they begin their
residency, to pick them up in their third or fourth year of
medical school. What you will see is a much greater proportion
of medical students going into primary care as a residency and
career choice, and as you do that, Senator Harkin, yes, we've
got to improve the payment for primary care because it is well
below what it should be, just to be appropriate, but it won't
be a king's ransom that has to be paid. You will have more
folks coming out of the training pipeline, ready to go into
primary care. Several years ago we partnered with an
osteopathic medical school to create the first community health
center-focused dental school in America, in Arizona, that is
now pumping out over 60 dentists every year, the vast majority
going into practice at a health center in oral health.
Two years after that, we partnered with the same school to
create one of the most recent osteopathic medical schools in
America, with more than 100 students who spend 3 of their 4
years of medical education in a community health care center-
based setting. Although it hasn't graduated its first class,
and as a result its students didn't qualify for help from the
National Health Service Corps, it will next year. And more than
100 medical students every year will be coming out, going into
residency and we believe the vast preponderance, going into
practice in community health centers.
This is what we need to do, target the support that is
going to be provided as the National Health Service Corps does,
on two things: primary care; service in underserved
communities. Those are the two great needs.
Senator Sanders. Dr. Matthew.
Dr. Matthew. Senator, I make the point that we have got to
get at medical students very early on. Our doctors are all on
the faculty of the University of Vermont and I'm on the faculty
of Dartmouth. We get first-year students out for a thing called
``Doctoring in Vermont.'' They are obliged to come about six
times and then three times towards the end of the year. Some of
them come every week. We really try to track them and make them
feel welcome and include them in our medical staff, so to
speak. We also teach third and fourth year students, usually
for about 3\1/2\ weeks at a time, but I think that's a bit late
in the game. I think we need them early on so they get oriented
to this and know that there can be excellent practice in the
periphery. It's not all public health. It's having the
individual physician to be, recognize that can be good work,
done well, and that you don't have to be in an academic
institution to do that.
Senator Sanders. I think we are going to wind down, Senator
Harkin, do you have any last thoughts you want to share?
Senator Harkin. I want to thank everyone here. As we are
working on this health care reform we need your best
suggestions on how we structure this to accomplish the ends
that we've all talked about and that Senator Sanders has taken
the lead on. We don't want to miss this boat. This ship is
moving and we want to get onboard. We want to make sure that we
restructure it properly.
Senator Sanders. Let me just concur with Senator Harkin and
say this, I think because of the work that all of you have
done, and many thousands more around this country, there is a
growing understanding and we are seeing it manifested in the
funding levels here in Congress, that we need nothing less than
a revolution in primary health care. That it's absurd that 60
million Americans have no health care home, that even more lack
a dentist, that there is so much unnecessary human suffering
because of the crisis of primary health care, and then to add
insult to injury, we are wasting hundreds of billions of
dollars because we are not keeping people healthy, and giving
them access to primary health care. So I think we are beginning
to change the paradigm and as Senator Harkin indicated, we need
your continued help and support to move the ball forward. I
think this has been a productive hearing.
Senator Harkin, thank you very much for all of your
contributions, and all of the members of the panel, thank you
so much for being here.
Thank you.
[Whereupon, at 11:31 a.m., the hearing was adjourned.]