[Senate Hearing 110-833]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-833

         ADDRESSING HEALTHCARE WORKFORCE ISSUES FOR THE FUTURE

=======================================================================

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                                   ON

   EXAMINING THE WAYS TO ADDRESS HEALTHCARE WORKFORCE ISSUES FOR THE 
             FUTURE, FOCUSING ON PRIMARY CARE PROFESSIONALS

                               __________

                           FEBRUARY 12, 2008

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut     MICHAEL B. ENZI, Wyoming,
TOM HARKIN, Iowa                     JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland        LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico            RICHARD BURR, North Carolina
PATTY MURRAY, Washington             JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island              LISA MURKOWSKI, Alaska
HILLARY RODHAM CLINTON, New York     ORRIN G. HATCH, Utah
BARACK OBAMA, Illinois               PAT ROBERTS, Kansas
BERNARD SANDERS (I), Vermont         WAYNE ALLARD, Colorado
SHERROD BROWN, Ohio                  TOM COBURN, M.D., Oklahoma
           J. Michael Myers, Staff Director and Chief Counsel
                 Ilyse Schuman, Minority Staff Director

                                  (ii)



                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                       TUESDAY, FEBRUARY 12, 2008

                                                                   Page
Sanders, Hon. Bernard, a U.S. Senator from the State of Vermont, 
  opening statement..............................................     1
    Prepared statement...........................................     3
Kennedy, Hon. Edward M., Chairman, Committee on Health, 
  Education, Labor, and Pensions, opening statement..............     6
    Prepared statement...........................................     8
Murkowski, Hon. Lisa, a U.S. Senator from the State of Alaska, 
  statement......................................................     9
Murray, Hon. Patty, a U.S. Senator from the State of Washington, 
  statement......................................................    11
    Prepared statement...........................................    12
Brown, Hon. Sherrod, a U.S. Senator from the State of Ohio, 
  statement......................................................    13
Allard, Hon. Wayne, a U.S. Senator from the State of Colorado, 
  statement......................................................    14
Steinwald, A. Bruce, Director, Healthcare, Government 
  Accountability Office, Washington, DC..........................    15
    Prepared statement...........................................    17
Grumbach, Kevin, M.D., Director, UCSF Center for California 
  Health Workforce Studies, Professor and Chair, UCSF Department 
  of Family and Community Medicine, San Francisco, CA............    27
    Prepared statement...........................................    27
Hooker, Roderick S., Ph.D., P.A., Director of Research, 
  Rheumatology Section, Medical Service Department of Veterans 
  Affairs, Dallas VA Medical Center, Dallas, TX..................    35
    Prepared statement...........................................    35
Salsberg, Edward S., M.P.A., Director, Center for Workforce 
  Studies, Association of American Medical Colleges, Washington, 
  DC.............................................................    38
    Prepared statement...........................................    39
Swift, James Q., D.D.S., Board President, American Dental 
  Education Association, Professor, University of Minnesota 
  School of Dentistry, Minneapolis, MN...........................    46
    Prepared statement...........................................    47
Auerbach, Bruce, M.D., President-Elect, Massachusetts Medical 
  Society, Vice President and Chief of Emergency Medicine, Sturdy 
  Memorial Hospital, Attleboro, MA...............................    60
    Prepared statement...........................................    61
Landon, Beth, M.H.A., M.B.A., Director, Alaska Center for Rural 
  Health, University of Alaska, Anchorage, AK....................    69
    Prepared statement...........................................    69
Laurent, Jennifer, M.S., FNP-BC, President, Vermont Nurse 
  Practitioner Association, Family Nurse Practitioner, Cambridge, 
  VT.............................................................    76
    Prepared statement...........................................    77
Maupin, John E., Jr., D.D.S., M.B.A., President, Morehouse School 
  of Medicine, Atlanta, GA.......................................    84
    Prepared statement...........................................    85
Enzi, Hon. Michael B., a U.S. Senator from Wyoming, prepared 
  statement......................................................   110

                                 (iii)


                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Senator Bingaman.............................................   113
    Senator Clinton..............................................   114
    American College of Physicians...............................   115
    Response of Bruce Steinwald to questions of:
        Senator Kennedy..........................................   117
        Senator Bingaman.........................................   118
        Senator Sanders..........................................   119
        Senator Mikulski.........................................   119
        Senator Enzi.............................................   119
        Senator Murkowski........................................   120
    Response of Kevin Grumbach, M.D. to questions of:
        Senator Kennedy..........................................   120
        Senator Mikulski.........................................   121
        Senator Bingaman.........................................   121
        Senator Clinton..........................................   123
        Senator Sanders..........................................   123
        Senator Enzi.............................................   127
        Senator Murkowski........................................   127
    Response of Roderick S. Hooker, Ph.D., P.A. to questions of:
        Senator Mikulski.........................................   129
        Senator Sanders..........................................   129
        Senator Enzi.............................................   130
        Senator Murkowski........................................   130
    Response of Edward S. Salsberg, M.P.A. to questions of:
        Senator Mikulski.........................................   131
        Senator Bingaman.........................................   133
        Senator Clinton..........................................   134
        Senator Sanders..........................................   135
        Senator Enzi.............................................   136
        Senator Murkowski........................................   137
    Response of Beth Landon, M.H.A., M.B.A. to questions of:
        Senator Mikulski.........................................   137
        Senator Enzi.............................................   138
        Senator Murkowski........................................   138
    Response of Jennifer S. Laurent, M.S., FNP-BC to questions 
      of:
        Senator Sanders..........................................   140
        Senator Mikulski.........................................   141
    Response of HRSA to questions of:
        Senator Mikulski.........................................   141
        Senator Bingaman.........................................   141
        Senator Brown............................................   142
        Senator Enzi.............................................   142
        Senator Murkowski........................................   142



  

 
         ADDRESSING HEALTHCARE WORKFORCE ISSUES FOR THE FUTURE

                              ----------                              


                       TUESDAY, FEBRUARY 12, 2008

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 2:34 p.m. in Room 
SD-106, Dirksen Senate Office Building, Hon. Bernard Sanders, 
presiding.
    Present: Senator Sanders, Kennedy, Murray, Brown, 
Murkowski, and Allard.

                  Opening Statement of Senator Sanders

    Senator Sanders. Thank you all very much for coming for 
what is going to be a very important hearing. I want to very 
much thank Chairman Kennedy and Ranking Member Enzi for helping 
us put together this meeting on what I consider to be one of 
the most important issues facing the United States in terms of 
the healthcare crisis.
    As everybody knows, what this hearing today will focus on 
is the future supply of essential primary care providers--
physicians, nurse practitioners, physician assistants, and 
dentists. While the scope of this hearing is limited to these 
health professions, we are all aware that the problem goes 
beyond those particular professions. Therefore, we have invited 
additional health professions, groups, to submit written 
statements that will be made part of the record of this 
hearing.
    [The information referred to can be found in additional 
material.]
    Senator Sanders. We have also received the testimony from 
the Administration, whose witness is unable to attend, but 
their testimony will also, of course, be part of the record.
    [The information referred to can be found in additional 
material.]
    Senator Sanders. After the opening remarks from the 
Senators, what we will hear is 2 minutes from each of the 
panelists, and then we will be able to engage in an informal 
discussion as to what the root causes of the problem are and 
how we can resolve it.
    Now my view--and few will disagree, regardless of their 
political persuasion--our country faces a major healthcare 
crisis. There are 47 million people who are uninsured. Even 
more are underinsured. Costs of healthcare keep going up, and 
we end up spending twice as much per person on healthcare as do 
the people of any other Nation.
    In addition, when we look at our healthcare crisis and all 
that we spend, it is important to understand that many of the 
important indices, like infant mortality or longevity, we fall 
behind dozens and dozens of other countries.
    When people look at this crisis, they sometimes think that 
the only issue is universal healthcare. Well, I happen to be a 
strong advocate of a national healthcare program. In my view, 
if tomorrow, magically, we had healthcare for all of our 
people, we would still continue to have a major healthcare 
crisis in terms of accessibility of many people, from one end 
of this country to another, to doctors and dentists.
    We have got to focus and what today's hearing is about is 
focusing on accessibility. Today, in America, over 56 million 
Americans do not have adequate access to primary healthcare 
services. My guess is that the number of people who lack access 
to dental care is even higher.
    Fewer and fewer U.S. medical and dental students are 
choosing primary care as their area of specialty. One of the 
issues that we have got to look at--it is not just the number 
of doctors out there or the number of dentists--what kind of 
practices do they have? Are they all specialists? Are there 
rural areas like my State of Vermont, where we have a whole lot 
of specialists in Burlington, but in the rural areas, you can't 
find the number of physicians that you need.
    When you are looking at dentists, we all know that dentists 
want to make us smile better and clean up our teeth and make 
them look all white and lovely. What about the people all over 
this country, working people who don't have front teeth and 
can't find a dentist to help them, or the kids who are 
suffering today because they can't find dentists to fill their 
cavities.
    I can go on and on with anecdotes. I will just mention one. 
Several years ago, I had a hearing on dental care in the State 
capital, Montpelier, VT. A woman gets up who works in a school, 
a low-income school. She said a kid in my school has teeth 
rotting in his mouth. He is in pain. She got on the phone. 
Called up everybody from the governor's office on down. She 
could not find a dentist to take care of that child.
    In the last few years in Vermont, we have had some success. 
We have built a number of clinics. The problem that remains in 
Vermont and all over this country is very severe.
    Further, when we talk about this crisis, we have to ask 
ourselves an important question. That is that while there has 
been an increase in the overall number of primary care 
physicians, it is troubling to me that the number of Americans 
pursuing a career in primary care has declined. Why is that? We 
hope that you will help us get some answers to that problem.
    As a nation, as the wealthiest Nation in the history of the 
world, for whatever reason, we are increasingly dependent on 
international medical school graduates to meet our needs. Why? 
Why can't the United States of America educate enough of our 
own physicians?
    Now, one of the problems about being dependent upon the 
international community is that we are depleting their 
healthcare talent, whether it is doctors or nurses in poor 
countries, being trained in those countries, and now coming to 
the United States of America. Is that fair to those countries?
    Let me just conclude, before I introduce Senator Kennedy 
and then Senator Murkowski, with a few thoughts as to where we 
should be going. I would like others to be thinking about this. 
We need to reauthorize title VII, our major health professions 
training act, with improvement in funding levels for grants, 
scholarships, and loan repayment that support needed 
professional development and community-based initiatives.
    We need to, in my view--and I know Senator Murkowski has 
legislation to do just this--double the funding and size of the 
National Health Service Corps. We need to, in my view, assure 
accessible care in underserved communities by significantly 
increasing the appropriations level each year for community 
health centers, a program that Senator Kennedy started a number 
of years ago, which has a huge impact all over this country in 
providing primary healthcare to tens of millions of Americans.
    Further, we need to reform the way the $8 billion that 
Medicare spends in support of graduate medical education to 
reward training models that address public health needs and 
allow flexibility for training to occur outside of the 
traditional limited number of sites of care.
    Last, we need to correct the disparity in Medicare and 
Medicaid reimbursement that favors specialty care over primary 
care. Those are some of my thoughts. We will discuss those 
ideas and many others in a few minutes. I will put my whole 
statement in the record.
    [The prepared statement of Senator Sanders follows:]

                 Prepared Statement of Senator Sanders

    I would like to call this hearing to order. I wish to thank 
Chairman Kennedy and Ranking Member Enzi for arranging a 
hearing on this critical topic. Today's hearing will explore a 
long neglected area of health care delivery. It will 
concentrate on the future supply of essential primary care 
providers: physicians, nurse practitioners, physician 
assistants, and dentists. While the scope of this hearing is 
limited to these health professions, I know full well that 
shortage issues affect many other health professions as well. 
Therefore, we have invited additional health professions groups 
to submit written statements that will be made part of the 
record of this hearing. We have also received testimony from 
the Administration whose witness is unable to attend. We will 
enter that testimony into the record as well. I thank and 
welcome the witnesses who are here today.
    I look forward to a fruitful exchange with them that will 
highlight not just the problems, but that will also offer us 
potential solutions to what I see as a crisis that will worsen 
in the future if nothing is done.
    The truth is that the American health care system is badly 
deteriorating for more and more Americans. The crisis in health 
care coverage is well-documented with over 47 million Americans 
now uninsured, and untold millions of others with increasingly 
inadequate coverage. It is unfathomable to me that, unlike 
every other industrialized nation in the world, we do not 
provide health care to all, as a right of citizenship.
    In addition, while we spend more as a society on health 
care per capita than any other nation, our outcomes in terms of 
many health status measures rank below even many developing 
countries. Over 30 nations have better infant mortality rates 
and longer life expectancy than the United States.
    Many assume wrongly that, by providing health care coverage 
to all, we would solve the problem. While I am a strong 
advocate that health care should be a right of citizenship for 
all Americans, I also realize that this is just part of the 
solution to achieving access to care for all. Let me be 
perfectly clear, if universal health care coverage were 
miraculously achieved tomorrow, it alone would not solve the 
access problem.
    Today, in America, over 56 million Americans do not have 
adequate access to primary health care services, (CHART) 
according to a study by the National Association of Community 
Health Centers. In terms of oral health, the number of 
Americans without access to dental care is even higher.
    Even though many of these Americans have insurance 
coverage, they live in communities with too few primary care 
providers.
    Fewer and fewer U.S. medical and dental students are 
choosing primary care as their area of specialty. There are 
simply not enough primary care providers now and the situation 
will become far worse in the future unless something is done. 
Clearly, we have a crisis when community health centers, 
generally recognized for their ability to provide 
comprehensive, cost-effective care, are unable to fill over 750 
vacancies in their physician staffing.
    To give a couple of examples of the difficulty that many 
face in accessing care: the small town of Island Pond, in the 
most isolated and rural part of northern Vermont, is fortunate 
to have a federally qualified health center that offers dental 
care to all regardless to ability to pay. It regularly receives 
calls from Vermonters from all over the State seeking dental 
care because either their towns do not have a dentist or 
because the few dentists they have are overbooked and not 
accepting patients.
    Sadly, little has changed since the time the State Welfare 
Office in Brattleboro, VT called to ask if the Island Pond 
dental practice would see some of their clients if they bused 
them there. Brattleboro is 165 miles away from Island Pond!
    For those who would deny this is a crisis, consider this: 
another community health center in Hardwick, VT got an urgent 
call from Walter Reed Hospital. A wounded returning veteran 
from Iraq was ready to be discharged to return home to Vermont, 
but, because of his need for ongoing medical treatment, he 
could not be discharged unless he had a local primary care 
provider. There were none available where he lived, so even 
though he was far from the Hardwick Health Center service area, 
the health center agreed to take him as a patient so that he 
could return home. Such situations should not exist in America 
and Congress should do all it can to correct this appalling 
situation.
    While I understand that there has been an increase in the 
overall number of primary care physicians, it is troubling to 
me that the number of Americans pursuing a career in primary 
care has declined. Therefore, the growth has been totally due 
to the number of international medical students training in 
America. We are increasingly dependent on international medical 
school graduates to meet our needs. Currently, one in four new 
physicians in the United States is an international medical 
graduate. (CHART)
    And, in America's underserved communities, international 
medical graduates make up 3 out of 5 of all physicians, 60 
percent! This is shameful. It is beyond my comprehension that 
the richest Nation in the history of the world is not able to 
graduate the kinds of health professionals we need. Instead, we 
are dependent on medical students trained abroad, whose 
education is often supported by their home countries.
    We ought to be able to encourage and develop enough primary 
care providers and not have to import doctors from countries 
that have arguably greater needs and fewer resources to care 
for their populations. It is morally wrong that we are 
depleting the number of health care providers from the poorer 
countries of the world. It is extremely important that we 
understand why we are not educating the kinds of doctors and 
dentists we need, and I look for this panel to provide us with 
information to correct this.
    We can debate forever whether the current supply of primary 
care doctors and dentists is sufficient. But I have no doubt 
that future demand will exceed supply. First year medical 
school enrollment per 100,000 people has declined since 1980. 
(CHART) At the same time, the number of elderly will double 
over the next 20 years. (CHART) With over one-third of active 
physicians over the age of 55 and likely to retire by 2020, we 
are looking at a major crisis.
    So, today's hearing and what we do as a result of it, is of 
extreme and urgent importance. As I stated earlier, I am 
looking for the panel to provide ideas for solving this 
problem. This is quite timely since the HELP Committee will be 
reauthorizing Title VII of the Public Health Service Act, which 
supports the major health professions training programs funded 
by the government. There is also action pending in the Senate 
to reauthorize the National Health Service Corps.
    I believe part of the solution lies in making medical, 
dental, and nursing education affordable for all Americans, not 
just for those with means. I applaud the efforts of Senators 
Kennedy and Enzi in the recently passed Higher Education bill, 
which will allow for loan forgiveness for those who work for 10 
years in the public or non-profit sector. This represents a 
good start, but I am committed to doing more. I look forward to 
working with my colleagues to:

    1. Reauthorize title VII, our major health professions 
training act, with improvement in funding levels for grants, 
scholarships, and loan repayment that support needed 
professional development and community-based initiatives. This 
vital program, funded at about $195 million, is targeted to be 
eliminated in the President's 2009 budget. This must not 
happen.
    2. Double the funding and size of the National Health 
Service Corps, as called for in a bill introduced by Senator 
Murkowski that I am pleased to be an original co-sponsor of. 
Funding for this program is currently $125 million and 
incredibly has actually declined in the past several years. And 
once again, the President would cut its funding in 2009 by $3 
million.
    3. Assure accessible care in underserved communities by 
significantly increasing the appropriation level each year for 
community health centers. This program, funded at just under $2 
billion, has been judged by the Office of Management & Budget 
to be one of the most efficient in using taxpayer dollars. If 
adequately funded over the next several years, it could 
increase the number of people in underserved areas who receive 
comprehensive primary care services from 16 million to 30 
million.
    4. Reform the way the $8 billion that Medicare spends in 
support of Graduate Medical Education to reward training models 
that address public health needs and allow flexibility for 
training to occur outside of the traditional, limited numbers 
of sites of care.
    5. Correct the disparity in Medicare and Medicaid 
reimbursement that favors specialty care over primary care, and 
rebase the Medicare FQHC reimbursement cap, as was promised 
when the program began in 1991, but which has never occurred.

    In the face of this compelling health professions shortage 
crisis, I look forward to an exchange of your ideas as to how 
to correct this worsening situation.

    Senator Sanders. Now let me introduce the Chair of this 
committee, who, as everyone knows, has been a leader in the 
U.S. Congress in so many areas in fighting the fight for 
healthcare for all Americans.
    Senator Kennedy.

                  Opening Statement of Senator Kennedy

    The Chairman. Thank you. Thank you very much, Senator 
Sanders, for chairing this hearing. Thank you, Senator 
Murkowski, for being so constructive and helpful to this 
committee about the needs that we are facing in the health 
profession in underserved areas, and in the challenges that 
underserved areas have just generally. It is a pleasure as well 
to be with Patty Murray, who has been so involved in health and 
education issues as well.
    Our Chairman Sanders has outlined, a central concern that 
we are facing as a country and as a Nation. There is a great 
debate that is taking place about this country trying to deal 
with the core challenge that we are facing, and that is to 
develop a comprehensive universal healthcare system.
    Well, it starts right where we are today, with the type of 
personnel that we are going to have. They are going to be able 
to help develop such a system. If we don't have it right in 
terms of the medical personnel, the allied health, the health 
professions, family physicians, and all the attendant kind of 
health assistants, we are just not going to get there.
    As we find individuals that are criss-crossing the country 
talking about healthcare and healthcare reform, this hearing is 
of the most importance because your ideas, your suggestions are 
absolutely indispensable not only for local communities, for 
what is happening in rural areas, and for what is happening in 
urban areas in the country, but also in terms of system reform, 
your comments are enormously helpful. I hope you will give us 
some of your guidance on this.
    I can remember having a similar hearing on this about 35 
years ago, I date myself. We had the strong representation of 
the AAMC and wonderful panels, and I always remember what I was 
told at that time. It still may be true, although, hopefully, 
we are getting away from it. That was in terms of medical 
schools, freshmen, by and large, when they enter medical 
schools, they want to be primary care physicians, and then the 
system begins to work against them.
    The indebtedness, primarily the indebtedness, works so that 
by the time they are graduating, they have a debt, what is 
piled on in terms of their college debt now $20,000, depending 
where you are, in what part of the country, and you add that to 
the medical school debt, and you are up to, what, $110,000, 
$120,000, perhaps even more. That drives their decisions in a 
very important way and skews and changes these issues.
    Last year here, in the Senate, we passed legislation to put 
a limitation on what individuals have to repay each year and 
put a limitation that no more than 15 percent of their income, 
no matter how indebted they are, would be required, with the 
hope that this might have some impact in terms of health 
professions. It is not the answer. We are going to hear a lot 
of different suggestions today. But at least we are going to 
try to begin to answer. You have other ideas in terms of how 
this is skewed. I hope you are going to help us.
    I hope you are going to help us understand why we always 
give short shrift to dental care and eye care. As someone who 
has been interested in education, when we were developing the 
SCHIP program, Senator Hatch and myself, trying to model it 
after what had happened up in Massachusetts. It was 
interesting. When we went to the floor of the U.S. Senate, we 
couldn't mandate eye care or dental care.
    Even though if children don't have dental care, as Senator 
Sanders points out, they are going to get sick, and they are 
going to be unable to go to school. If they can't see the 
blackboard, they are not going to be able to learn. If they 
can't hear the teacher, they are not going to learn. We give 
short shrift to dental care and to eye care as well. We have to 
understand we are talking about what do we really need in 
personnel to have a healthy Nation, a healthy country, a 
healthy population? That is what we are really interested in.
    I won't review because you know the facts about what is 
happening. What is happening in my State is we are trying to 
deal with a newer kind of healthcare system and how that is 
being skewed because of the lack of health personnel in the 
right areas. We need well-trained, well-led personnel, but we 
need them in the right areas professionally and in the right 
areas geographically. This is a constant issue and a constant 
question.
    Quite frankly, I don't intend this to be a partisan 
comment. But when you have an administration that sends a 
budget up here that zeroes out title VII and slashes title 
VIII, and then talks about trying to do something about 
healthcare and the personnel, it just rings hollow.
    This is going to take resources, and it is going to take 
also understanding the changes, which are taking place in the 
whole health delivery system. We need that kind of guidance 
that this panel can give. Let me just give you the assurance 
that we consider this to be an immensely important hearing 
today, and we will certainly share with our colleagues on this 
committee and with others as well.
    I thank Senator Sanders so much. He has been relentless, 
relentless. That is saying something when you say that about 
Senator Sanders, that he is relentless in his commitment and 
dedication on this issue. I thank again Senator Murkowski for 
all of her constructive help in terms of rural areas and the 
communities, and Patty Murray, who always adds a special 
dimension on health issues and education.
    I will put my whole statement in the record, and I thank 
you very much.
    [The prepared statement of Senator Kennedy follows:]

                 Prepared Statement of Senator Kennedy

    I want to thank Senator Sanders for his dedication to this 
topic and for working so hard on this hearing today. I also 
want to thank Senators Enzi and Murkowski for their work on 
this issue.
    To create a healthy nation we must not only have health 
care professionals that are excellently trained--we need health 
care professionals that are excellently trained in the right 
fields and practicing in the communities that need them the 
most. Over the years, experts have predicted a physician 
shortage, only to change those projections years later. We've 
heard of shortages in one specialty or another, only to have 
that prediction change as well. But one thing that has remained 
constant is the need for a strong network of primary care 
providers.
    The health of our Nation depends on a strong primary care 
system. And that system can not run without an adequate supply 
of primary care physicians, nurse practitioners, physician 
assistants and other providers. In implementing health reform 
in Massachusetts one thing has become very clear--comprehensive 
health reform can not take place without appropriate access to 
primary care providers. Unfortunately, we are facing a crisis 
in primary care. Family medicine residency positions have 
dropped by 50 percent since 1997 and the growth in the supply 
of primary care physicians for adult patients is now lagging 
behind the rate of growth of adults. Community health centers 
continue to report significant vacancies for primary care 
providers.
    We must take the steps needed to ensure a strong primary 
care workforce. One of those steps is making sure that the 
title VII health professions training programs are adequately 
funded. Amazingly, President Bush dramatically cut these 
programs in his budget. It is incomprehensible to me that 
President Bush would cut funding for these important programs 
in the face of primary care physician and other provider 
shortages. He even eliminated the health professions diversity 
programs that help to create a culturally competent diverse 
workforce that will serve in communities that need care the 
most.
    This hearing will inform our committee as we move forward 
on our work to reauthorize the title VII and title VIII 
programs. I want to thank all of our witnesses that have joined 
us today. They will provide us with a wealth of knowledge on 
the current state of affairs with the primary care workforce, 
including the challenges in rural and frontier areas and the 
importance of diversity in the health professions. There are 
also other primary care providers that we were not able to 
accommodate at this hearing, but we have asked for their 
official testimony to be included in the record so we can 
receive their important input.
    I also want to acknowledge that while this hearing focuses 
on primary care providers, I am aware of the profound nursing 
shortage in our country and I will be working with Senator 
Mikulski and other members of the committee in the coming 
months to address that issue as well.
    We know that primary care helps to reduce healthcare cost 
and results in a better quality of care of patients and I look 
forward to hearing more about what we can do to support our 
Nation's primary care providers.

    Senator Sanders. Thank you very much, Senator Kennedy.
    Senator Murkowski has, in fact, been a leader in the Senate 
on rural healthcare. Senator Murkowski, thanks very much for 
being with us.

                     Statement of Senator Murkowski

    Senator Murkowski. Well, thank you. I want to thank all 
that have assembled to join us here today on the panel and also 
in the audience. I don't know if you all noticed, but there was 
a group of about 20-some odd young people who came in, listened 
for about 5 minutes, and then they left. I wish that they had 
stayed because I need to recruit each and every one of them to 
come to the State of Alaska or to rural Vermont.
    We have a crisis in access to healthcare in this country in 
our medically underserved areas, and I am very pleased, Mr. 
Chairman, that you and Senator Enzi have kept your commitment 
certainly to Senator Sanders and myself to hold this very 
important hearing on healthcare workforce issues.
    With the panel that we have today, we are going to hear as 
they speak on the primary care shortages. That includes the 
physicians. It includes the dentists, the nurse practitioners, 
the physician assistants. We are going to hear from folks today 
who have come from all across the country. I have a constituent 
from Alaska that I am proud to welcome today.
    We are going to hear their comments about how important it 
is to reauthorize the funding for title VII and title VIII 
programs not just for rural America, but also for the so many 
economically disadvantaged urban areas. We know that while many 
of these areas aren't rural, they are medically underserved. 
They are equally affected by some of the very persistent 
shortages that we have in the workforce out there.
    As you have mentioned, Chairman Kennedy, the President has 
zeroed out funding for all of the title VII programs in this 
2009 budget and has said that they were ineffective. I 
absolutely disagree. Title VII, title VIII programs have a long 
and successful history. They go back to 1963 with the Health 
Professions Education Assistance Act that we passed to address 
the projections of the health professional shortages.
    This legislation sought to establish education and training 
programs for the primary healthcare workforce and has continued 
to do so by providing grants to the students, to the health 
professions, to the institutions, the community organizations, 
to provide the education, the training in primary care 
medicine, whether it is internal medicine, or general 
pediatrics. As a result, we have a larger number of individuals 
from rural and underserved communities, economically 
disadvantaged backgrounds, and diverse groups that have been 
entering that primary care profession.
    We know that these programs have been successful. We have 
seen reports out there, 70 to 80 percent of students are 
returning to serve as healthcare professionals in their 
communities. These are the kinds of statistics that we need to 
keep seeing.
    I am hoping that the testimony from those of you today 
includes recommendations to help deal with the primary care 
shortages that face nearly 62 million Americans living in rural 
and medically underserved areas.
    Senator Sanders, you have mentioned my legislation, some of 
the things that we are promoting in the Physician Shortage 
Elimination Act. I look forward to hearing from the panel 
members on some of the issues such as the integrated rural 
training track that will provide the graduate medical education 
or the GME reimbursement for residency training that is 
obtained in a non-hospital setting, as well as funding 
community health centers to enable them to provide shared 
residency training time with a teaching hospital.
    The third issue--and, Senator Sanders, you mentioned this--
is that my legislation will double the funding to $300 million 
annually for the National Health Service Corps. This is an 
immensely successful program that places primary healthcare 
workers in rural and medically underserved areas. 
Unfortunately, due to the reductions in funding, we turn away 
nearly 80 percent of program applicants every year from this--
80 percent.
    In Alaska, we are undoubtedly suffering from the most 
severe primary care vacancy rates, particularly in our rural 
and our frontier areas. We have unfulfilled physician assistant 
job openings at about 25 percent. Our family nurse practitioner 
jobs openings are at about 36 percent.
    Alaska, many of you think that it is this State with a 
young population. We are young, but we also have the fastest-
growing elderly population in the country, behind Nevada. We 
have got a very young, young population. In many of our 
villages, the average age is 18. Then we have the second 
fastest-growing elderly population in the country.
    There is not a day--seriously, there is not a day that 
doesn't go by when one of my offices around the State or back 
here in Washington, DC, doesn't get a phone call from an 
elderly constituent or from a son or a daughter who is calling, 
some of them in tears, searching for someone to provide for a 
level of care because the healthcare providers are not 
accepting Medicare.
    This is what reduced Medicare reimbursements to primary 
care providers in rural America brings about. Zero access to 
primary care healthcare services for the most vulnerable 
population, and that is the disabled and the elderly.
    I am going to end with a statistic that is really 
compelling when we talk about rural health disparities. Sixty-
two million Americans, this is about 20 percent of the U.S. 
population, live in designated medically underserved areas, 
many of them rural. Yet only 9 percent of the Nation's 
physicians practice there.
    Clearly, this situation deserves the Congress's attention. 
I look forward to hearing the comments and the suggestions from 
all of you and I appreciate your work, collaboratively, 
together and with the committee as well.
    Thank you.
    Senator Sanders. Thank you, Senator Murkowski.
    Senator Patty Murray has long been a leader on healthcare 
issues in the Senate.
    Senator Murray.

                      Statement of Senator Murray

    Senator Murray. Mr. Sanders, thank you so much for holding 
this hearing. You and Senator Murkowski are just right on 
target on bringing everybody together.
    I will submit my opening statement to the record.
    Just let me say this. I have been holding a series of 
roundtables around my State to focus on the issue of healthcare 
providers and the lack of access and how it is impacting the 
cost of healthcare. Because, as more and more people are 
getting older and needing healthcare, there is fewer and fewer 
healthcare workers. Access is becoming harder. It is driving up 
the cost, and it is an issue that all of us have to deal with.
    I have heard of how our nursing shortage is becoming very 
acute, yet even the University of Washington doesn't have 
enough slots to fill because they don't have enough faculty to 
teach nurses. Rural healthcare training and helping our rural 
healthcare folks is a huge issue in my State. Primary care 
physicians, lack of primary care physicians going into that 
field is really very, very worrisome to all of us.
    It is a very timely hearing. I am very concerned about the 
President's budget. As has been stated, I am sorry that we 
don't have a witness from the Department of Health and Human 
Services. I understand they could not show up today so we could 
talk about that.
    Focusing all of us on providing the type of people who need 
to go in all the career fields of healthcare will help us with 
access and, in turn, help us with bringing down the cost of 
healthcare, which I know is a goal of every single business, 
every single community, every single government agency that we 
have in this country today.
    Thank you very much.
    [The prepared statement of Senator Murray follows:]

                  Prepared Statement of Senator Murray

    I want to thank Senator Sanders and Senator Kennedy for 
organizing this hearing.
    The shortage of doctors, nurses, and workers across the 
health care field is one of the most serious workforce 
challenges our country faces. And as the baby boomers retire, 
the problem is only going to get worse.
    Experienced health care professionals are set to retire in 
large numbers in the near future--just as the baby boom 
generation will begin to need more care. The problem is already 
acute in some rural communities where it's increasingly 
difficult to recruit and retain doctors and nurses.
    Senator Sanders, I've been concerned about this issue for 
many years, as I know you have. Like you, I believe we must 
make building our health care workforce a national priority, so 
I'm glad we're having this hearing today.
    In the last year, I've held roundtables across my home 
State of Washington so I could talk to health care 
professionals and others experiencing this challenge firsthand, 
and learn more about what we can do to address this problem.
    I know that what we're seeing in Washington State is 
similar to what is going on across the country. So I wanted to 
share just a few things I've heard at those roundtables:

     In the next 10 years, the need for new nurses will 
spike dramatically as our experienced nurses retire.
     At the same time, colleges--including the 
University of Washington--say they don't have the capacity to 
accept all the qualified nursing applicants, and they are 
struggling to recruit and retain nursing faculty.
     Several health care executives have told me that 
the number of medical students interested in primary care is 
dropping across the board, making it difficult to recruit 
primary care doctors.
     And there is a great need to find better ways to 
get more skills training and education for workers. Health care 
workers in rural areas say this is especially challenging--
either because there aren't enough opportunities--or because 
they can't afford to leave work to get training or go back to 
school.

    Given how severe this problem is, I have to say I was 
extremely disappointed to see that--instead of taking action 
and planning for the future--the President proposed significant 
cuts in this area in his fiscal year 2009 budget. He cut the 
overall health professions budget by $252 million. That's an 80 
percent cut to one of the few government programs that could 
address this shortage.
    Despite the fact that the Bureau of Labor Statistics 
reports that between 2004 and 2014, registered nursing will 
have the second greatest job growth of all U.S. professions, 
the Administration slashed the budget for nurse training. For 
example, the President zeroed out the $61 million Advanced 
Education Nursing program and several others.
    I know we were expecting a witness from the Department of 
Health and Human Services to attend this hearing. I was sorry 
to hear no one was able to make it today because I have several 
questions for the Administration on this subject.
    But I'm looking forward to hearing from our excellent panel 
of witnesses about what they think we can do to address these 
workforce challenges. Finding a way to train and recruit 
workers to the health care field--and to keep them in those 
jobs--must be a priority.
    Thank you.

    Senator Sanders. Thank you very much.
    Senator Sherrod Brown has been a leader when he was in the 
House and in the Senate on quality healthcare for all 
Americans. Senator Brown, thank you.

                       Statement of Senator Brown

    Senator Brown. Thank you, Senator Sanders, and thank you, 
Senator Murkowski. Dr. Auerbach, nice to see you. There always 
seems to be a lot of Massachusetts representation in the 
witness panels here. I may be confused about that, but nice to 
see you.
    In the last year, during my first year in the Senate, I 
have been part of about 80-plus roundtables in 55 Ohio 
counties, made up of a cross-section of people in these 
communities. In almost every single one of these 50-plus 
counties, I have heard from a hospital administrator or a nurse 
or a physical therapist or a public health official that we 
have shortages in all kinds of healthcare services.
    We all know that. In Cincinnati, at Cincinnati Children's, 
it was made very clear to me we don't train enough pediatric 
nurses in my State or in this country. In southeast Ohio, I 
repeatedly heard we don't have enough dentists, and 
particularly dentists that accept Medicaid, to take care of the 
basic needs, the basic needs particularly for children. We know 
how that affects those children long-term.
    In Mansfield, OH, the town I grew up in, I met with some 
community health workers, high school graduates that are being 
trained. Some were GED and had gotten their high school diploma 
that way. They are trained in doing outreach, and particularly 
in two zip codes in Mansfield, a town of about 50,000. One zip 
code was predominantly white, Appalachia. One was predominantly 
black. This zip code had, in the past several years, a rate of 
about 21 or 22 or 23 percent low-birth weight babies in these 
two zip codes.
    After these community health workers began to go into the 
community whenever they knew of a pregnant woman and met with 
them and get them to an OB/GYN, the percentage of low-birth 
weight babies dropped--in the space of about 3 years, dropped 
to under 5 percent, which is the national average. That is what 
these professions can do, particularly community health workers 
and physician assistants and nurses aides and all that Senator 
Murkowski was talking about.
    That is why title VII and title VIII are so important to 
this country. That is why we are incredulous that President 
Bush would choose to give a tax cut of literally $51 billion 
for 2009 to people making over $1 million a year--$51 billion--
and then cut GME training and title VII and title VIII and 
refuse to sign a children's health insurance bill. Clearly, our 
priorities are wrong in this country, and we have to go to in a 
very different direction on healthcare.
    One last point on this, which perhaps, is also a moral 
question: we see more and more America bringing people from 
across the ocean to be nurses, to be other healthcare 
professionals. To me, there is a bit of a moral question there. 
I certainly don't judge the people that come across the ocean, 
who want to be in our country and get a middle-class standard 
of living and a decent lifestyle and take care of their kids. I 
also think that we should be training our own physicians, our 
own nurses, our own healthcare providers so that the training 
that those countries do, wherever it is, especially nurses and 
especially other kinds of healthcare workers like that, that 
they can stay in their country and do the kind of work that 
their people paid for to train them.
    We have a lot of work to do. Cutting title VII and title 
VIII is not the way to go. That is the importance of this 
hearing. I thank Senator Murkowski and Senator Sanders.
    Senator Sanders. Thank you, Senator Brown. Senator Wayne 
Allard of Colorado has joined us. Thank you very much.
    Senator Allard.

                      Statement of Senator Allard

    Senator Allard. Thank you, Mr. Chairman.
    I know that this hearing is on primary care in the health 
profession, but I also want to speak from my experience as a 
veterinarian. Veterinarians are on the front line. I once 
diagnosed bubonic plague in cats who lived daily with the 
family; I may have saved that family because I made that 
diagnosis.
    We have diseases such as toxoplasmosis and rabies and 
encephalitis. As a veterinary health officer, I was out there 
on the front line dealing with encephalitis outbreaks in the 
community in which I practiced. I just ask that you not forget 
about the veterinary profession. Veterinarians play a critical 
role in public health.
    We have had testimony before this committee from the Food 
and Drug Administration, from the Department of Agriculture, 
and various agencies which simply do not have enough 
veterinarians on their staff to fulfill their missions. 
Veterinarians are highly trained in laboratory and research 
techniques, playing a key role in approval of drugs. For 
instance, they play a key role in public health diseases with 
the CDC.
    I just ask that you keep these things in mind when we have 
this discussion. I certainly think we need to recognize that 
the veterinarians do play a key role in public health.
    Thank you, Mr. Chairman.
    Senator Sanders. Thank you very much. OK. Thank you very 
much, Senator.
    We are prepared to begin the discussion. The format will 
begin with Bruce Steinwald, who is the Director of Healthcare 
for the GAO, the Government Accountability Office. He will have 
5 minutes. Then we will just go around, and people will have 2 
minutes. Then we will just open it up for questions and 
comments.
    Mr. Steinwald, if you could begin, please?

       STATEMENT OF A. BRUCE STEINWALD, DIRECTOR, HEALTH-

            CARE, GOVERNMENT ACCOUNTABILITY OFFICE,

                         WASHINGTON, DC

    Mr. Steinwald. Thank you, Senator Sanders and members of 
the committee. Thank you for inviting me to participate in this 
discussion.
    In my prepared testimony, I have provided information on 
three areas. First, the recent trends in the supply, training, 
and demographics of primary care professionals. By that, I mean 
physicians, physician assistants, nurse practitioners, and 
dentists. I am sorry, not veterinarians, Senator Allard. Sorry.
    Second, projections of the future supply of primary care 
professionals. And third, how primary care services are 
undervalued by our payment systems in the United States. I will 
try to tie those points together as I go on.
    Please direct your attention to the first exhibit behind 
me, which, for the audience, is a variation on Table 1 on page 
7 of the written statement. For all categories of primary care 
professionals, over a recent period of roughly 10 years, the 
average annual growth has been positive with some categories, 
especially nurse practitioners and physician assistants, 
growing faster than others.
    Over a 10-year period, we do find an increase in primary 
care professionals. We have found that the supply of primary 
care physicians grew faster than the supply of specialists from 
1995 to 2005. Looking to the future, we examined trends among 
participants in primary care training programs in the United 
States. In the interest of time, I will focus my remarks on 
residency programs for physicians only.
    From 1995 to 2006, the number of primary care residents 
increased 6 percent. At the same time, the number of residents 
in specialty training increased 8 percent. These increases 
compare with population growth of about 15 percent over that 
same period.
    Underlying the data on physicians is a change in the 
composition of residents. If you will turn your attention to my 
second exhibit, which is based on Table 4 on page 10 of the 
written statement, you will notice that looking at primary care 
residents, there has been a decline in the proportion, as you 
pointed out, Senator Sanders, in the proportion that are U.S. 
medical school graduates and an increase in the proportion that 
are either international medical graduates or doctors of 
osteopathy.
    This decline in U.S.-trained primary care residents is 
often cited as a reason to be concerned about how our system 
undervalues primary care services. When looking at the 
demographic information and, in particular, minority 
representation, we found little data specific to primary care. 
What we did find is an increase, a modest increase in minority 
representation among all of the professional groups, but only a 
modest increase.
    When identifying projections of future supply, we again 
found little information specific to primary care 
professionals. Most workforce projections focus on physician 
supply, and we identified two projections that were specific to 
primary care doctors--those of HRSA and of the American Academy 
of Family Physicians. Both projections indicate that we may 
face a shortage of primary care physicians by around the year 
2020, depending on underlying assumptions.
    Our third finding has to do with the valuation of primary 
care services, which may be a factor in future supply. This 
finding is mostly about physicians and draws on information 
from the Medicare program. Our current system is predominantly 
a fee-for-service system, and fees are generally sensitive to 
the complexity of resources required to perform a service.
    As an example of how the system undervalues primary care 
services, please turn your attention to Exhibit 3. Now I would 
like to say I have nothing against diagnostic colonoscopies. In 
fact, according to my primary care doctor, I am due to have one 
when I get around to scheduling it. I could have picked from 
hundreds of other comparable diagnostic and other kinds of 
services.
    Anyway, you will note that in Boston, Medicare's fees for 
two services of similar duration--a diagnostic colonoscopy and 
a complex office visit--are vastly different. Because of the 
way the services are valued, specialists are already way ahead 
of the game. In this instance, the payment to a doctor for 
roughly a half an hour's work varies by a factor of four.
    Exacerbating the disparity between primary care doctors and 
specialists are technological innovations and improvements that 
enhance the ability of specialists over time to provide more 
services and more complex services and, thereby, increase their 
revenues. On the other hand, most primary care physicians, 
whose principal services are office visits, have little ability 
to improve efficiency and save time and provide more services. 
There are limits to how much he or she can reduce the time 
spent with patients without compromising quality of care.
    Furthermore, this undervaluing of primary care services 
appears to be counterproductive, given the vast literature 
describing the relationship between primary care costs and 
quality. In fact, we note several findings in our testimony on 
the benefits of primary care medicine. When I say that primary 
care services are undervalued, this doesn't mean that just 
increasing the prices paid for primary care is the solution.
    I will wrap up now. As you are aware, though, we face 
unsustainable trends in the Medicare program and our health 
system as a whole. Just as payment incentives are misaligned in 
primary care, they are misaligned in specialty medicine as 
well. The reforms that we need are not just a question of 
raising fees for primary care services, but for recalibrating 
fees and evaluating costs and benefits of different modes of 
healthcare delivery as well as financing.
    Mr. Chairman, this concludes my prepared remarks, and I 
look forward to your questions and to hearing the views of the 
other panelists.
    [The prepared statement of Mr. Steinwald follows:]
   Prepared Statement of A. Bruce Steinwald, Director of Health Care
                               Highlights
                         why gao did this study
    Most of the funding for programs under title VII of the Public 
Health Service Act goes toward primary care medicine and dentistry 
training and increasing medical student diversity. Despite a 
longstanding objective of title VII to increase the total supply of 
primary care professionals, health care marketplace signals suggest an 
undervaluing of primary care medicine, creating a concern about the 
future supply of primary care professionals--physicians, physician 
assistants, nurse practitioners, and dentists. This concern comes at a 
time when there is growing recognition that greater use of primary care 
services and less reliance on specialty services can lead to better 
health outcomes at lower cost.
    GAO was asked to focus on (1) recent supply trends for primary care 
professionals, including information on training and demographic 
characteristics; (2) projections of future supply for primary care 
professionals, including the factors underlying these projections; and 
(3) the influence of the health care system's financing mechanisms on 
the valuation of primary care services.
    GAO obtained data from the Health Resources and Services 
Administration (HRSA) and organizations representing primary care 
professionals. GAO also reviewed relevant literature and position 
statements of these organizations.
                             what gao found
    In recent years, the supply of primary care professionals 
increased, with the supply of nonphysicians increasing faster than 
physicians. The numbers of primary care professionals in training 
programs also increased. Little information was available on trends 
during this period regarding minorities in training or actively 
practicing in primary care specialties. For the future, health 
professions workforce projections made by government and industry 
groups have focused on the likely supply of the physician workforce 
overall, including all specialties. Few projections have focused on the 
likely supply of primary care physician or other primary care 
professionals.
    Health professional workforce projections that are mostly silent on 
the future supply of and demand for primary care services are 
symptomatic of an ongoing decline in the Nation's financial support for 
primary care medicine. Ample research in recent years concludes that 
the Nation's over reliance on specialty care services at the expense of 
primary care leads to a health care system that is less efficient. At 
the same time, research shows that preventive care, care coordination 
for the chronically ill, and continuity of care--all hallmarks of 
primary care medicine--can achieve improved outcomes and cost savings. 
Conventional payment systems tend to undervalue primary care services 
relative to specialty services. Some physician organizations are 
proposing payment system refinements that place a new emphasis on 
primary care services.

                                      Supply of Primary Care Professionals
----------------------------------------------------------------------------------------------------------------
                                                                 No. of primary care  No. of primary
                                                                    professionals          care
                                                               ----------------------  professionals    Average
                                                                                        per 100,000     annual
                                                                                          people      percentage
                                                                Base year    Recent  ---------------- change per
                                                                              year     Base   Recent    capita
                                                                                       year    year
----------------------------------------------------------------------------------------------------------------
Primary care physicians.......................................    208,187    264,086      80      90        1.17
Physician assistants..........................................     12,819     23,325       5       8        3.89
Nurse practitioners...........................................     44,200     82,622      16      28        9.44
Dentists......................................................    118,816    138,754      46      47        0.12
----------------------------------------------------------------------------------------------------------------
Sources: GAO analysis of data from HRSA's Area Resource File and organizations representing primary care
  professionals.
Notes: Data on primary care physicians are from 1995 and 2005. Data on physician assistants are from 1995 and
  2007. Data on nurse practitioners are from 1999 and 2005. Data on dentists are from 1995 and 2007. Data for
  identical time periods were not available. The average annual percentage change is not sensitive to these time
  period differences.

    GAO discussed the contents of this statement with HRSA officials 
and incorporated their comments as appropriate.
                               __________
    Mr. Chairman and members of the committee, I am pleased to be here 
today as you prepare to consider the reauthorization of health 
professions education programs established under title VII of the 
Public Health Service Act.\1\ Most of the funding for title VII 
programs goes toward primary care medicine and dentistry training and 
increasing medical student diversity.
---------------------------------------------------------------------------
    \1\ 42 U.S.C. Sec. Sec. 292-295 p.
---------------------------------------------------------------------------
    Despite a longstanding objective of title VII to increase the total 
supply of primary care professionals, health care marketplace signals 
suggest an undervaluing of primary care medicine, creating a concern 
about the future supply of primary care professionals. As evidence, 
health policy experts cite a growing income gap between primary care 
physicians and specialists and a declining number of U.S. medical 
students entering primary care specialties--internal medicine, family 
medicine, general practice, and general pediatrics. Moreover, the 
Federal agency responsible for implementing title VII programs, the 
Health Resources and Services Administration (HRSA), notes that 
physician ``extenders''--namely, physician assistants and nurse 
practitioners--may also be choosing procedure-driven specialties, such 
as surgery, cardiology, and oncology, in increasing numbers.\2\ \3\
---------------------------------------------------------------------------
    \2\ Physician assistants are health care professionals who practice 
medicine under physician supervision. Physician assistants may perform 
physical examinations, diagnose and treat illnesses, order and 
interpret tests, advise patients on preventive health care, assist in 
surgery, and write prescriptions. Unlike physician assistants, nurse 
practitioners are licensed nurses who work with physicians and have 
independent practice authority in many States. This authority allows 
them to perform physical examinations, diagnose and treat acute 
illnesses and injuries, administer immunizations, manage chronic 
problems such as high blood pressure and diabetes, and order laboratory 
services and x-rays with minimal physician involvement.
    \3\ For the purposes of this testimony, we considered primary care 
physicians to be those practicing in family medicine, general practice, 
general internal medicine, and general pediatrics. Some physician 
groups, such as the American Medical Association (AMA), consider 
physicians practicing in obstetrics/gynecology to also be primary care 
physicians. In addition, we considered general dentists and pediatric 
dentists to be primary care dentists. We defined primary care physician 
assistants as those practicing in family practice, general practice, 
general internal medicine, and general pediatrics. We defined primary 
care nurse practitioners as those practicing in adult, family, and 
pediatric medicine. Other types of health professionals, such as 
registered nurses, can provide primary care services in a variety of 
settings, but they were outside the scope of our review.
---------------------------------------------------------------------------
    A paradox commonly cited about the U.S. health care system is that 
the Nation spends more per capita than all other industrialized nations 
but ranks consistently low in such quality and access measures as life 
expectancy, infant mortality, preventable deaths, and percentage of 
population with health insurance. Moreover, experts have concluded that 
not all of this spending is warranted, and overutilization of services 
can, in fact, lead to harm.\4\ These findings come at a time when there 
is growing recognition that greater use of primary care services and 
less reliance on specialty services can lead to better health outcomes 
at lower cost.
---------------------------------------------------------------------------
    \4\ For example, noted studies show that Medicare spending for 
physician services varies widely by geographic areas and is unrelated 
to beneficiary health status. Elliott S. Fisher and H. Gilbert Welch, 
``Avoiding the Unintended Consequences of Growth in Medical Care: How 
Might More Be Worse?'' Journal of the American Medical Association, 
vol. 281, no. 5 (1999), 446-453; E.S. Fisher, et al., ``The 
Implications of Regional Variations in Medicare Spending. Part 1: The 
Content, Quality, and Accessibility of Care,'' Annals of Internal 
Medicine, vol. 138, no. 4 (2003), 273-287; E.S. Fisher, et al., ``The 
Implications of Regional Variations in Medicare Spending. Part 2: 
Health Outcomes and Satisfaction with Care,'' Annals of Internal 
Medicine, vol. 138, no. 4 (2003), 288-298; and Joseph P. Newhouse, Free 
for All? Lessons from the RAND Health Insurance Experiment (Cambridge, 
Mass.: Harvard University Press, 1993).
---------------------------------------------------------------------------
    To examine the supply of primary care professionals in more detail, 
you asked us to provide information related to the current and future 
supply of these professionals. My remarks today will focus on: (1) 
recent supply trends for primary care professionals, including 
information on training and demographic characteristics; (2) 
projections of future supply for primary care professionals, including 
the factors underlying these projections; and (3) the influence of the 
health care system's financing mechanisms on the valuation of primary 
care services.
    To discuss the recent supply trends for primary care 
professionals--including information on training and demographic 
characteristics--we obtained data from HRSA's Area Resource File; the 
American Academy of Physician Assistants (AAPA); and the American 
Academy of Nurse Practitioners (AANP). In addition, we reviewed 
published data from AMA, the American Association of Colleges of 
Nursing (AACN); and the American Dental Education Association 
(ADEA).\5\ We also obtained published annual estimates from the U.S. 
Census Bureau on the noninstitutionalized, civilian population.
---------------------------------------------------------------------------
    \5\ We obtained the most recently available data on supply for each 
professional group, the groups' training programs, and the groups' 
demographic characteristics. We compared the most recent data to a 
prior data point, in many cases 10 years earlier. For primary care 
physicians, we obtained data on supply for 1995 and 2005 from the Area 
Resource File and information on training and demographics from 
published AMA data for 1995 and 2006. For physician assistants, we 
obtained data on supply and demographic characteristics from AAPA for 
1995 and 2007. For nurse practitioners, we obtained data on supply and 
demographic characteristics from AANP for 1999, 2003, and 2005 and 
information on training from published AACN data for 1994 and 2005. For 
dentists, we obtained data on supply for 1995 and 2007 from the Area 
Resource File and information on demographics from published ADEA data 
for 2000 and 2005.
---------------------------------------------------------------------------
    To obtain information about projections of future supply of primary 
care professionals, we reviewed relevant literature and the position 
statements of organizations representing primary care professionals, 
including the American Academy of Family Physicians (AAFP) and the 
American College of Physicians (ACP). We also interviewed officials 
from HRSA, AAPA, AANP, the American Dental Association (ADA), and the 
Association of American Medical Colleges (AAMC). In selecting workforce 
supply projections for review, we focused on the projected estimates of 
national supply for primary care professionals from the past decade.
    To obtain information on the influence of the health care system's 
financing mechanisms on the valuation of primary care services, we 
reviewed relevant literature on Medicare's resource-based physician fee 
schedule and the influence of primary care supply on costs and quality 
of health care services.
    We assessed the reliability of HRSA's Area Resource File data by 
interviewing officials responsible for producing these data, reviewing 
relevant documentation, and examining the data for obvious errors.\6\ 
We assessed the reliability of the data provided by the AAPA and the 
AANP by discussing with association officials the validation procedures 
they use to ensure timely, complete, and accurate data. We determined 
the data used in this testimony to be sufficiently reliable for our 
purposes. We discussed a draft of this testimony with HRSA officials. 
They provided technical comments, which we incorporated as appropriate. 
We conducted this work from December 2007 through February 2008, in 
accordance with generally accepted government auditing standards.
---------------------------------------------------------------------------
    \6\ Data from the AMA Masterfile and the American Osteopathic 
Association (AOA) Masterfile--on which data on physicians in the Area 
Resource File is based--are widely used in studies of physician supply 
because they are a comprehensive list of U.S. physicians and their 
characteristics.
---------------------------------------------------------------------------
    In summary, in recent years, the supply of primary care 
professionals increased, with the supply of nonphysicians increasing 
faster than physicians. The numbers of primary care professionals in 
training programs also increased. Little information was available on 
trends during this period regarding minorities in training or actively 
practicing in primary care specialties. For the future, health 
professions workforce projections made by government and industry 
groups have focused on the likely supply of the physician workforce 
overall, including all specialties. Few projections have focused on the 
likely supply of primary care physician or other primary care 
professionals.
    Health professional workforce projections that are mostly silent on 
the future supply of and demand for primary care services are 
symptomatic of an ongoing decline in the Nation's financial support for 
primary care medicine. Ample research in recent years concludes that 
the Nation's over reliance on specialty care services at the expense of 
primary care leads to a health care system that is less efficient. At 
the same time, research shows that preventive care, care coordination 
for the chronically ill, and continuity of care--all hallmarks of 
primary care medicine--can achieve improved outcomes and cost savings. 
Conventional payment systems tend to undervalue primary care services 
relative to specialty services. Some physician organizations are 
developing payment system refinements that place a new emphasis on 
primary care services.
                               background
    Among other things, title VII programs support the education and 
training of primary care providers, such as primary care physicians, 
physician assistants, general dentists, pediatric dentists, and allied 
health practitioners.\7\ HRSA includes in its definition of primary 
care services, health services related to family medicine, internal 
medicine, preventative medicine, osteopathic general practice, and 
general pediatrics that are furnished by physicians or other types of 
health professionals. Also, HRSA recognizes diagnostic services, 
preventive services (including immunizations and preventive dental 
care), and emergency medical services as primary care. Thus, in some 
cases, nonprimary care practitioners provide primary care services to 
populations that they serve.
---------------------------------------------------------------------------
    \7\ Allied health professionals include, for example, audiologists, 
dental hygienists, clinical laboratory technicians, occupational 
therapists, physical therapists, medical imaging technologists, and 
speech pathologists.
---------------------------------------------------------------------------
    Title VII programs support a wide variety of activities related to 
this broad topic. For example, they provide grants to institutions that 
train health professionals; offer direct assistance to students in the 
form of scholarships, loans, or repayment of educational loans; and 
provide funding for health workforce analyses, such as estimates of 
supply and demand.\8\ In recent years, title VII programs have focused 
on three specific areas of need--improving the distribution of health 
professionals in underserved areas such as rural and inner-city 
communities, increasing representation of minorities and individuals 
from disadvantaged backgrounds in health professions, and increasing 
the number of primary care providers. For example, the Scholarships for 
Disadvantaged Students Program awards grants to health professions 
schools to provide scholarships to full-time, financially needy 
students from disadvantaged backgrounds, many of whom are minorities.
---------------------------------------------------------------------------
    \8\ For fiscal year 2007, funding for the title VII health 
professions programs was about $183 million. This excluded funding for 
student loans, which did not receive funds through the annual 
appropriation process.
---------------------------------------------------------------------------
Primary Care Education and Training Programs
    After completing medical school, medical students enter a multi-
year training program called residency, during which they complete 
their formal education as a physician. Because medical students must 
select their area of practice specialty as part of the process of being 
matched into a residency program, the number of physician residents 
participating in primary care residency programs is used as an 
indication of the likely future supply of primary care physicians. 
Physician residents receive most of their training in teaching 
hospitals, which are hospitals that operate one or more graduate 
medical education programs. Completion of a physician residency program 
can take from 3 to 7 years after graduation from medical school, 
depending on the specialty or subspecialty chosen by the physician. 
Most primary care specialties require a 3-year residency program. In 
some cases, primary care physicians may choose to pursue additional 
residency training and become a subspecialist--such as a pediatrician 
who specializes in cardiology. In this case, the physician would no 
longer be considered a primary care physician, but rather, a 
cardiologist.
    According to the AAPA, most physician assistant programs require 
applicants to have some college education. The average physician 
assistant program takes about 26 months, with classroom education 
followed by clinical rotations in internal medicine, family medicine, 
surgery, pediatrics, obstetrics and gynecology, emergency medicine, and 
geriatric medicine. Physician assistants practice in primary care 
medicine, including family medicine, internal medicine, pediatrics, and 
obstetrics and gynecology, as well in surgical specialties.
    After completion of a bachelor's degree in nursing, a nurse may 
become a nurse practitioner after completing a master's degree in 
nursing. According to the AACN, full-time master's programs are 
generally 18 to 24 months in duration and include both classroom and 
clinical work. Nurse practitioner programs generally include areas of 
specialization such as acute care, adult health, child health, 
emergency care, geriatric care, neonatal health, occupational health, 
and oncology.
    Dentists typically complete 3 to 4 years of undergraduate 
university education, followed by 4 years of professional education in 
dental school. The 4 years of dental school are organized into 2 years 
of basic science and pre-clinical instruction followed by 2 years of 
clinical instruction. Unlike training programs for physicians, there is 
no universal requirement for dental residency training. However, a 
substantial proportion of dentists--about 65 percent of dental school 
graduates--enroll in dental specialty or general dentistry residency 
programs.
 supply of primary care professionals increased; little data available 
                       on minority representation
    In recent years, the supply of primary care professionals 
increased, with the supply of nonphysicians increasing faster than 
physicians. The numbers of primary care professionals in training 
programs also increased. Little information was available on trends 
during this period regarding minorities in training or actively 
practicing in primary care specialties.
In Recent Years, Supply of Primary Care Professionals Increased
    In recent years, the number of primary care professionals 
nationwide grew faster than the population, resulting in an increased 
supply of primary care professionals on a per capita basis (expressed 
per 100,000 people). Table 1 shows that over roughly the last decade, 
per capita supply of primary care physicians--internists, 
pediatricians, general practice physicians, and family practitioners--
rose an average of about 1 percent per year,\9\ while the per capita 
supply of nonphysician primary care professionals--physician assistants 
and nurse practitioners--rose faster, at an average of about 4 percent 
and 9 percent per year, respectively. Nurse practitioners accounted for 
most of the increase in nonphysician primary care professionals. The 
per capita supply of primary care dentists--general dentists and 
pediatric dentists--remained relatively unchanged.
---------------------------------------------------------------------------
    \9\ Allopathic medicine is the most common form of medical 
practice. Graduates of allopathic medical schools receive doctor of 
medicine (M.D.,) degrees. Osteopathic medicine is a form of medical 
practice similar to allopathic medicine that also incorporates manual 
manipulation of the body as a therapy. Graduates of osteopathic medical 
schools receive doctor of osteopathic (D.O.) medicine degrees. The 
number of primary care physicians includes both M.D.'s and D.O.'s.

                                 Table 1.--Supply of Primary Care Professionals
----------------------------------------------------------------------------------------------------------------
                                                                 No. of primary care  No. of primary
                                                                    professionals          care
                                                               ----------------------  professionals    Average
                                                                                        per 100,000     annual
                                                                                          people      percentage
                                                                Base year    Recent  ---------------- change per
                                                                              year     Base   Recent    capita
                                                                                       year    year
----------------------------------------------------------------------------------------------------------------
Primary care physicians \1\...................................    208,187    264,086      80      90        1.17
Physician assistants \2\......................................     12,819     23,325       5       8        3.89
Nurse practitioners \3\.......................................     44,200     82,622      16      28        9.44
Dentists \4\..................................................    118,816    138,754      46      47        0.12
----------------------------------------------------------------------------------------------------------------
Sources: GAO analysis of data from HRSA's Area Resource File, AAPA, AANP, and the U.S. Census Bureau.
Notes: Data on primary care professionals for identical time periods were not available. The average annual
  percentage change is not sensitive to these time period differences.
\1\ Data on primary care physicians include numbers for both M.D.'s and DOs. Data for M.D.'s are from 1995 and
  2005, and for D.O.'s are from 1995 and 2004.
\2\ Data on physician assistants are from 1995 and 2007. Data on the total number of physician assistants were
  obtained from AAPA, then weighted by using the percentage of physicians assistants who practiced primary care
  according to the 1995 AAPA membership survey and the 2007 AAPA physician assistant census survey.
\3\ Data on nurse practitioners are from 1999 and 2005. Data on the total number of nurse practitioners were
  obtained from AANP, then weighted by using the percentage of nurse practitioners who practiced primary care
  according to the AANP.
\4\ Data on dentists are from 1995 and 2007.

    Growth in the per capita supply of primary care physicians outpaced 
growth in the per capita supply of physician specialists by 7 
percentage points in the 1995-2005 period. (See Table 2.)

                  Table 2.--Supply of Primary Care and Specialty Care Physicians, 1995 and 2005
----------------------------------------------------------------------------------------------------------------
                                                                  No. of physicians       No. of
                                                               ---------------------- physicians per
                                                                                          100,000     Percentage
                                                                                          people      change per
                                                                   1995       2005   ----------------    capita
                                                                                       1995    2005
----------------------------------------------------------------------------------------------------------------
Primary care physicians.......................................    208,187    264,086      80      90         12
Specialty care physicians.....................................    468,843    553,451     181     189          5
All physicians................................................    677,030    817,537     262     280          7
----------------------------------------------------------------------------------------------------------------
Source: GAO analysis of data from HRSA's Area Resource File.
Note: Numbers do not add to totals due to rounding.

    By definition, aggregate supply figures do not show the 
distribution of primary care professionals across geographic areas. 
Compared with metropolitan areas, nonmetropolitan areas, which are more 
rural and less populated, have substantially fewer primary care 
physicians per 100,000 people. In 2005, there were 93 primary care 
physicians per 100,000 people in metropolitan areas, compared with 55 
primary care physicians per 100,000 people in nonmetropolitan 
areas.\10\ Data were not available on the distribution of physician 
assistants, nurse practitioners, or dentists providing primary care in 
metropolitan and nonmetropolitan areas.\11\
---------------------------------------------------------------------------
    \10\ Specialty care physicians are even more concentrated in 
metropolitan areas. In 2005, there were 33 specialty care physicians 
per 100,000 people in nonmetropolitan areas, compared with 200 
specialty care physicians per 100,000 people in metropolitan areas. In 
total, there were 87 physicians per 100,000 people in nonmetropolitan 
areas and 293 physicians per 100,000 people in metropolitan areas in 
2005.
    \11\ One researcher, analyzing HRSA data, reported that in 2007 
more than 30 million people were living in areas with too few dentists. 
Shelly Gehshan, ``Foundations' Role in Improving Oral Health: Nothing 
to Smile About,'' Health Affairs, vol. 27, no. 1 (2008).
---------------------------------------------------------------------------
Number of Primary Care Professionals in U.S. Training Programs 
        Increased from 1995 to 2006
    For two groups of primary care professionals--physicians and nurse 
practitioners--the number in primary care training has increased in 
recent years. Over the same period, the number of primary care training 
programs for physicians declined, while programs for nurse 
practitioners increased. Comparable information for physician 
assistants and dentists was not available.
    From 1995 to 2006, the number of physician residents in primary 
care training programs increased 6 percent, as shown in Table 3. Over 
this same period, primary care residency programs declined, from 1,184 
programs to 1,145 programs.

Table 3.--No. of Physicians in Residency Programs, in the United States,
                              1995 and 2006
------------------------------------------------------------------------
                                            No. of resident
                                              physicians      Percentage
                                         --------------------   change
                                            1995      2006
------------------------------------------------------------------------
Primary care residents..................    38,753    40,982          6
Specialty care residents................    59,282    63,897          8
All physician residents.................    97,416   104,526          7
------------------------------------------------------------------------
Sources: AMA, ``Appendix II: Graduate Medical Education,'' Journal of
  the American Medical Association (JAMA) vol. 276, no. 9 (September
  1996) and ``Appendix II: Graduate Medical Education, 2006-2007,'' JAMA
  vol. 298, no. 9 (September 2007).
Note: Primary care residencies include those for family medicine,
  internal medicine, pediatrics, internal medicine/family practice, and
  internal medicine/pediatrics.

    The composition of primary care physician residents changed from 
1995 to 2006. A decline in the number of allopathic U.S. medical school 
graduates (known as USMD) selecting primary care residencies was more 
than offset by increases in the numbers of international medical 
graduates (IMG) and doctor of osteopathy (D.O.) graduates entering 
primary care residencies.\12\ Specifically, from 1995 to 2006, USMD 
graduates in primary care residencies dropped by 1,655 physicians, 
while the number of IMGs and D.O.'s in primary care residencies rose by 
2,540 and 1,415 physicians respectively. (See Table 4.)
---------------------------------------------------------------------------
    \12\ Physicians who enter U.S. residency programs include graduates 
of both U.S. medical schools and foreign medical schools. Physicians 
from foreign medical schools--international medical graduates--can be 
citizens of other countries or U.S. citizens who attended medical 
school abroad.

        Table 4.--Number of Physicians in Residency Programs, by USMDs, IMGs, and D.O.'s,  1995 and 2006
----------------------------------------------------------------------------------------------------------------
                                                                    1995                         2006
                                                       ---------------------------------------------------------
                                                          USMDs     IMGs     D.O.'s    USMDs     IMGs     D.O.'s
----------------------------------------------------------------------------------------------------------------
Primary care residents................................    23,801    13,025    1,748    22,146    15,565    3,163
Specialty care residents..............................    45,300    11,957    1,585    47,575    12,611    3,466
All physician residents...............................    69,101    24,982    3,333    69,721    28,176    6,629
                                                       ---------------------------------------------------------
  Total (USMDs + IMGs + D.O.'s).......................              97,416                      104,526
----------------------------------------------------------------------------------------------------------------
Sources: AMA, ``Appendix II: Graduate Medical Education,'' JAMA vol. 276, no. 9 (September 1996) and ``Appendix
  II: Graduate Medical Education, 2006-2007,'' JAMA vol. 298, no. 9 (September 2007).
Note: Primary care residencies include those for family medicine, internal medicine, pediatrics, internal
  medicine/family practice, and internal medicine/pediatrics.

    From 1994 to 2005, the number of primary care training programs for 
nurse practitioners and the number of graduates from these programs 
grew substantially. During this period, the number of nurse 
practitioner training programs increased 61 percent, from 213 to 342 
programs. The number of primary care graduates from these programs 
increased 157 percent from 1,944 to 5,000.
Little Information Available Regarding Minorities in Training or 
        Actively Practicing In Primary Care Specialties
    Little information was available regarding participation of 
minority health professionals in primary care training programs or with 
active practices in primary care.\13\ Physicians were the only type of 
primary care professional for whom we found information on minority 
representation. We found information not specific to primary care for 
physician assistants, nurse practitioners, and dentists identified as 
minorities, which may be a reasonable substitute for information on 
proportions of minorities in primary care.
---------------------------------------------------------------------------
    \13\ HRSA's Health Careers Opportunity Program defines 
underrepresented minorities as racial and ethnic groups that are 
underrepresented in the health professions relative to their numbers in 
the general population. According to HRSA, African-Americans, 
Hispanics, American Indians, and Alaska Natives are underrepresented in 
the health professions. During the period we examined, minority 
representation increased among the general population. Specifically, 
from 1995 to 2006, the proportion of African-Americans in the general 
population increased from 12.0 percent to 12.3 percent; the proportion 
of Hispanics increased from 10.3 percent to 14.8 percent; and the 
proportion of American Indian/Alaska Natives increased from 0.7 percent 
to 0.8 percent.
---------------------------------------------------------------------------
    For physicians, we used the proportion of minority primary care 
residents as a proxy measure for minorities in the active primary care 
physician workforce. From 1995 to 2006, the proportion of primary care 
residents who were African-American increased from 5.1 percent to 6.3 
percent; the proportion of primary care residents who were Hispanic 
increased from 5.8 percent to 7.6 percent. Data on American Indian/
Alaska Natives were not collected in 1995, so this group could not be 
compared over time; in 2006, 0.2 percent of primary care residents were 
identified as American Indian/Alaska Natives.
    Minority representation among each of the other health professional 
types--overall, not by specialty--increased slightly. AAPA data show 
that from 1995 to 2007, minority representation among physician 
assistants increased from 7.8 percent to 8.4 percent. AANP data show 
that from 2003 to 2005, minority representation among nurse 
practitioners increased from 8.8 percent to 10.0 percent. ADEA data 
show that from 2000 to 2005, the proportion of African-Americans among 
graduating dental students rose slightly from 4.2 percent to 4.4 
percent, while the proportion of Hispanics among graduating dental 
students increased from 4.9 percent to 5.9 percent. The proportion of 
Native American/Alaska Native among graduating dental students grew 
from 0.6 percent to 0.9 percent.
    Other demographic characteristics of the primary care workforce 
have also changed in recent years. In two of the professions that were 
traditionally dominated by men in previous years--physicians and 
dentists--the proportion of women has grown or is growing. Between 1995 
and 2006, the proportion of primary care residents who were women rose 
from 41 percent to 51 percent. Growth of women in dentistry is more 
recent. In 2005, 19 percent of professionally active dentists were 
women,\14\ compared with almost 45 percent of graduating dental school 
students who were women.
---------------------------------------------------------------------------
    \14\ American Dental Association, ``Survey and Economic Research on 
Dentistry: Frequently Asked Questions'' (Chicago, Ill.: American Dental 
Association), http://www.ada.org/ada/prod/survey/faq.asp (accessed Jan. 
7, 2008).
---------------------------------------------------------------------------
    uncertainties exist in projecting future supply of health care 
    professionals; few projections are specifically for primary care
    Accurately projecting the future supply of primary care health 
professionals is difficult, particularly over long time horizons, as 
illustrated by substantial swings in physician workforce projections 
during the past several decades. Few projections have focused on the 
likely supply of primary care physician or nonphysician primary care 
professionals.
History of Physician Workforce Supply Predictions Illustrates 
        Uncertainties in Forecasting
    Over a 50-year period, government and industry groups' projections 
of physician shortfalls gave way to projections of surpluses, and now 
the pendulum has swung back to projections of shortfalls again. From 
the 1950s through the early 1970s, concerns about physician shortages 
prompted the Federal and State governments to implement measures 
designed to increase physician supply. By the 1980s and through the 
1990s, however, the Graduate Medical Education National Advisory 
Committee (GMENAC), the Council on Graduate Medical Education (COGME), 
and HRSA's Bureau of Health Professions were forecasting a national 
surplus of physicians. In large part, the projections made in the 1980s 
and 1990s were based on assumptions that managed care plans--with an 
emphasis on preventive care and reliance on primary care gatekeepers 
exercising tight control over access to specialists--would continue to 
grow as the typical health care delivery model. In fact, managed care 
did not become as dominant as predicted and, in recent years, certain 
researchers, such as Cooper,\15\ have begun to forecast physician 
shortages. COGME's most recent report, issued in January 2005, also 
projects a likely shortage of physicians in the coming years and,\16\ 
in June of 2006, the AAMC called for an expansion of U.S. medical 
schools and federally supported residency training positions.\17\ Other 
researchers have concluded that there are enough practicing physicians 
and physicians in the pipeline to meet current and future demand if 
properly deployed.\18\
---------------------------------------------------------------------------
    \15\ Richard A. Cooper, et al., ``Economic and Demographic Trends 
Signal an Impending Physician Shortage,'' Health Affairs, vol. 21, no. 
1 (2002).
    \16\ COGME, ``Sixteenth Report: Physician Workforce Policy 
Guidelines for the United States, 2000-2020'' (January 2005).
    \17\ AAMC, ``AAMC Statement on the Physician Workforce'' (June 
2006).
    \18\David Goodman, et al., ``End-Of-Life Care At Academic Medical 
Centers: Implications For Future Workforce Requirements,'' Health 
Affairs, vol. 25 no. 2 (2006) and Jonathan P. Weiner, ``Prepaid Group 
Practice Staffing And U.S. Physician Supply: Lessons For Workforce 
Policy,'' Health Affairs, Web Exclusive (Feb. 4, 2004).
---------------------------------------------------------------------------
Few Projections Address Future Supply of Primary Care Professionals
    Despite interest in the future of the health care workforce, few 
projections directly address the supply of primary care professionals. 
Recent physician workforce projections focus instead on the supply of 
physicians from all specialties combined. Specifically, the projections 
recently released by COGME point to likely shortages in total physician 
supply but do not include projections specific to primary care 
physicians.\19\ Similarly, ADA's and AAPA's projections of the future 
supply of dentists and physician assistants do not address primary care 
practitioners separately from providers of specialty care. AANP has not 
developed projections of future supply of nurse practitioners.
---------------------------------------------------------------------------
    \19\ COGME does not currently hold a position on the appropriate 
ratio of primary care physicians to specialty physicians. This is in 
contrast to the position COGME held from 1992 through 2004, which 
recommended that half of all physicians should be primary care 
physicians.
---------------------------------------------------------------------------
    We identified two sources--an October 2006 report by HRSA and a 
September 2006 report by AAFP--that offer projections of primary care 
supply and demand, but both are limited to physicians.\20\ HRSA's 
projections indicate that the supply of primary care physicians will be 
sufficient to meet anticipated demand through about 2018, but may fall 
short of the number needed in 2020. AAFP projected that the number of 
family practitioners in 2020 could fall short of the number needed, 
depending on growth in family medicine residency programs.
---------------------------------------------------------------------------
    \20\ U.S. Department of Health and Human Services, HRSA, Bureau of 
Health Professions, ``Physician Supply and Demand: Projections to 
2020'' (October 2006) and AAFP, ``Family Physician Workforce Reform (as 
approved by the 2006 Congress of Delegates) Recommendations of the 
AAFP'' (September 2006).
---------------------------------------------------------------------------
    HRSA based its workforce supply projections on the size and 
demographics of the current physician workforce, expected number of new 
entrants, and rate of attrition due to retirement, death, and 
disability. Using these factors, HRSA calculated two estimates of 
future workforce supply. One projected the expected number of primary 
care physicians, while the other projected the expected supply of 
primary care physicians expressed in full-time equivalent (FTE) units. 
According to HRSA, the latter projection, because it adjusts for 
physicians who work part-time, is more accurate.\21\ The agency 
projected future need for primary care professionals based largely on 
expected changes in U.S. demographics, trends in health insurance 
coverage, and patterns of utilization. HRSA predicted that the supply 
of primary care physicians will grow at about the same rate as demand 
until about 2018, at which time demand will grow faster than supply. 
Specifically, HRSA projected that by 2020, the nationwide supply of 
primary care physicians expressed in FTEs will be 271,440, compared 
with a need for 337,400 primary care physicians. HRSA notes that this 
projection, based on a national model, masks the geographic variation 
in physician supply. For example, the agency estimates that as many as 
7,000 additional primary care physicians are currently needed in rural 
and inner-city areas and does not expect that physician supply will 
improve in these underserved areas.
---------------------------------------------------------------------------
    \21\ The FTE projection takes into account an expected decrease in 
the number of hours worked by physicians due to demographic workforce 
changes, including a greater share of female physicians and older 
physicians, some of whom are likely to work less than full-time.
---------------------------------------------------------------------------
    In a separate projection, AAFP reviewed the number of family 
practitioners in the United States. AAFP's projections of future supply 
were based on the number of active family practice physicians in the 
workforce and the number of completed family practice residencies in 
both allopathic and osteopathic medical schools. AAFP's projections of 
need relied on utilization rates adjusted for mortality and 
socioeconomic factors. Specifically, AAFP estimated that 139,531 family 
physicians would be needed by 2020, representing about 42 family 
physicians per 100,000 people in the United States. To meet this 
physician-to-population ratio, AAFP estimated that family practice 
residency programs in the aggregate would need to expand by 822 
residents per year.
    Both reports noted the difficulties inherent in making predictions 
about future physician workforce supply and demand. Essentially, they 
noted that projections based on historical data may not necessarily be 
predictive of future trends. They cite as examples the unforeseen 
changes in medical technology innovation and the multiple factors 
influencing physician specialty choice. Additionally, HRSA noted that 
projection models of supply and demand incorporate any inefficiencies 
that may be present in the current health care system.
 move toward primary care medicine, a key to better quality and lower 
 costs, is impeded by health care system's current financing mechanisms
    Health professional workforce projections that are mostly silent on 
the future supply of and demand for primary care services are 
symptomatic of an ongoing decline in the Nation's financial support for 
primary care medicine. Ample research in recent years concludes that 
the Nation's over reliance on specialty care services at the expense of 
primary care leads to a health care system that is less efficient. At 
the same time, research shows that preventive care, care coordination 
for the chronically ill, and continuity of care--all hallmarks of 
primary care medicine--can achieve better health outcomes and cost 
savings. Despite these findings, the Nation's current financing 
mechanisms result in an atomized and uncoordinated system of care that 
rewards expensive procedure-based services while undervaluing primary 
care services. However, some physician organizations--seeking to 
reemphasize primary care services--are proposing a new model of 
delivery.
Payment Systems That Undervalue Primary Care Appear To Be 
        Counterproductive
    Fee-for-service, the predominant method of paying physicians in the 
United States, encourages growth in specialty services. Under this 
structure, in which physicians receive a fee for each service provided, 
a financial incentive exists to provide as many services as possible, 
with little accountability for quality or outcomes. Because of 
technological innovation and improvements over time in performing 
procedures, specialist physicians are able to increase the volume of 
services they provide, thereby increasing revenue. In contrast, primary 
care physicians, whose principal services are patient office visits, 
are not similarly able to increase the volume of their services without 
reducing the time spent with patients, thereby compromising quality. 
The conventional pricing of physician services also disadvantages 
primary care physicians. Most health care payers, including Medicare--
the Nation's largest payer--use a method for reimbursing physician 
services that is resource-based, resulting in higher fees for 
procedure-based services than for office-visit ``evaluation and 
management'' services.\22\ To illustrate, in one metropolitan area, 
Boston, Massachusetts, Medicare's fee for a 25- to 30-minute office 
visit for an established patient with a complex medical condition is 
$103.42 \23\; in contrast, Medicare's fee for a diagnostic 
colonoscopy--a procedural service of similar duration--is $449.44.\24\
---------------------------------------------------------------------------
    \22\ Evaluation and management (E/M) services refer to office 
visits and consultations furnished by physicians. To bill for their 
service, physicians select a common procedural terminology (CPT) code 
that best represents the level of E/M service performed based on three 
elements: patient history, examination, and medical decisionmaking. The 
combination of these three elements can range from a very limited 10-
minute face-to-face encounter to a very detailed examination requiring 
an hour of the physician's time.
    \23\ The fee for this service in Boston, MA, is represented on the 
fee schedule as CPT code 99214.
    \24\ The fee for this service in Boston, MA, is represented on the 
fee schedule as CPT code 45378.
---------------------------------------------------------------------------
    Several findings on the benefits of primary care medicine raise 
concerns about the prudence of a health care payment system that 
undervalues primary care services. For example:

     Patients of primary care physicians are more likely to 
receive preventive services, to receive better management of chronic 
illness than other patients, and to be satisfied with their care.\25\
---------------------------------------------------------------------------
    \25\ A.B. Bindman, et al., ``Primary Care and Receipt of Preventive 
Services,'' Journal of General Internal Medicine vol. 11, no. 5 (1996); 
D.G. Safran, et al., ``Linking Primary Care Performance to Outcomes of 
Care,'' Journal of Family Practice, vol. 47, no. 3 (1998); and A.C. 
Beal, et al., ``Closing the Divide: How Medical Homes Promote Equity in 
Health Care: Results From The Commonwealth Fund 2006 Health Care 
Quality Survey'' (The Commonwealth Fund, June 2007).
---------------------------------------------------------------------------
     Areas with more specialists, or higher specialist-to-
population ratios, have no advantages in meeting population health 
needs and may have ill effects when specialist care is unnecessary.\26\
---------------------------------------------------------------------------
    \26\ B. Starfield, et al., ``The Effects Of Specialist Supply On 
Populations' Health: Assessing The Evidence,'' Health Affairs web 
exclusive (2005).
---------------------------------------------------------------------------
     States with more primary care physicians per capita have 
better health outcomes--as measured by total and disease-specific 
mortality rates and life expectancy--than States with fewer primary 
care physicians (even after adjusting for other factors such as age and 
income).\27\
---------------------------------------------------------------------------
    \27\ B. Starfield, et al., ``Contribution of Primary Care to Health 
Systems and Health,'' Milbank Quarterly, vol. 83, no. 3 (2005).
---------------------------------------------------------------------------
     States with a higher generalist-to-population ratio have 
lower per-beneficiary Medicare expenditures and higher scores on 24 
common performance measures than States with fewer generalist 
physicians and more specialists per capita.\28\
---------------------------------------------------------------------------
    \28\ K. Baicker and A. Chandra, ``Medicare Spending, the Physician 
Workforce, and Beneficiaries' Quality of Care,'' Health Affairs web 
exclusive (2004).
---------------------------------------------------------------------------
     The hospitalization rates for diagnoses that could be 
addressed in ambulatory care settings are higher in geographic areas 
where access to primary care physicians is more limited.\29\
---------------------------------------------------------------------------
    \29\ M. Parchman, et al., ``Primary Care Physicians and Avoidable 
Hospitalizations,'' Journal of Family Practice, vol. 39, no. 2 (1994).
---------------------------------------------------------------------------
Some Health Care Reform Proposals Seek to Re-emphasize Primary Care 
        Medicine
    In recognition of primary care medicine's value with respect to 
health care quality and efficiency, some physician organizations are 
proposing a new model of health care delivery in which primary care 
plays a central role. The model establishes a ``medical home'' for 
patients--in which a single health professional serves as the 
coordinator for all of a patient's needed services, including specialty 
care--and refines payment systems to ensure that the work involved in 
coordinating a patient's care is appropriately rewarded.
    More specifically, the medical home model allows patients to select 
a clinical setting--usually their primary care provider's practice--to 
serve as the central coordinator of their care. The medical home is not 
designed to serve as a ``gatekeeper'' function, in which patients are 
required to get authorization for specialty care, but instead seeks to 
ensure continuity of care and guide patients and their families through 
the complex process of making decisions about optimal treatments and 
providers. AAFP has proposed a medical home model designed to provide 
patients with a basket of acute, chronic, and preventive medical care 
services that are, among other things, accessible, comprehensive, 
patient-centered, safe, and scientifically valid. It intends for the 
medical home to rely on technologies, such as electronic medical 
records, to help coordinate communication, diagnosis, and treatment. 
Other organizations, including ACP, the American Academy of Pediatrics 
(AAP), and AOA, have developed or endorsed similar models and have 
jointly recommended principles to describe the characteristics of the 
medical home.\30\
---------------------------------------------------------------------------
    \30\ AAFP, AAP, ACP, AOA, ``Joint Principles of the Patient-
Centered Medical Home'' (March 2007).
---------------------------------------------------------------------------
    Proposals for the medical home model include a key modification to 
conventional physician payment systems--namely, that physicians receive 
payment for the time spent coordinating care. These care coordination 
payments could be added to existing fee schedule payments or they could 
be included in a comprehensive, per-patient monthly fee. Some physician 
groups have called for increases to the Medicare 
resource-based fee schedule to account for time spent coordinating care 
for patients with multiple chronic illnesses. Proponents of the medical 
home note that it may be desirable to develop payment models that blend 
fee-for-service payments with per-patient payments to ensure that the 
system is appropriately reimbursing physicians for primary, specialty, 
episodic, and acute care.
                        concluding observations
    In our view, payment system reforms that address the undervaluing 
of primary care should not be strictly about raising fees but rather 
about recalibrating the value of all services, both specialty and 
primary care. Resource-based payment systems like those of most payers 
today do not factor in health outcomes or quality metrics; as a 
consequence, payments for services and their value to the patient are 
misaligned. Ideally, new payment models would be designed that consider 
the relative costs and benefits of a health care service in comparison 
with all others so that methods of paying for health services are 
consistent with society's desired goals for health care system quality 
and efficiency.
    Mr. Chairman, this concludes my prepared statement. I will be happy 
to answer any questions that you or members of the committee may have.

    Senator Sanders. Thank you very much, Mr. Steinwald.
    In no particular order, let us begin with Dr. Grumbach, who 
is the Director of the University of California at San 
Francisco Center for California Health Workforce Studies.
    Thank you very much for being with us, Dr. Grumbach. Please 
take 2 minutes.

 STATEMENT OF KEVIN GRUMBACH, M.D., DIRECTOR, UCSF CENTER FOR 
CALIFORNIA HEALTH WORKFORCE STUDIES, PROFESSOR AND CHAIR, UCSF 
 DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE, SAN FRANCISCO, CA

    Dr. Grumbach. Thank you for inviting me, Senator Sanders, 
members of the committee. I would like to honor the brevity of 
the requests for these opening remarks. I want to just hit on a 
couple of points.
    One, the Senators have identified the key issues. There is 
a crumbling infrastructure of primary care. It hits hardest in 
the most underserved communities of our Nation. What I would 
like to impress upon you is our research and research of 
colleagues that make it clear that certain Federal programs are 
quite effective in achieving their goals.
    There is now a very solid research base to support with 
good evidence the effectiveness of title VII training programs, 
that institutions that get title VII funding are more likely to 
have their graduates work in primary care, to serve in 
underserved areas, to work at community health centers, to join 
the National Health Service Corps, about 50 percent more likely 
yield of physicians who will work at community health centers.
    When asked the question, a simultaneous program of 
expansion of community health centers without investment in the 
pipeline that actually preferentially feeds physicians in the 
health centers.
    Second, there is a good evidence basis for the effects of 
the National Service Corps that have lasting effect on 
underserved communities, a very solid research base there.
    The last thing I would like to emphasize is the distorted 
incentives in the Medicare program and to pick up on Mr. 
Steinwald's comment. One way Federal policies can influence 
this is through proactive policies, such as title VII, title 
VIII, National Service Corps, but the other key problem is 
looking at the Medicare program, which has incentives in 
everything from GME to physician payment policies that pull 
people away from primary care. That without addressing the 
incentives of the Medicare program, It will be impossible to 
fully correct some of the deficits in primary care and people 
working in underserved communities.
    Thank you.
    [The prepared statement of Dr. Grumbach follows:]
               Prepared Statement of Kevin Grumbach, M.D.
                                Summary
    1. Primary care is the essential foundation of a well-performing 
health system.--Health systems built on a solid foundation of primary 
care deliver more effective, efficient, and equitable care than systems 
that fail to invest adequately in primary care.
    2. The primary care infrastructure in the United States is 
crumbling, and patient access to primary care is suffering throughout 
the Nation.--From 1997 to 2005, the number of U.S. medical school 
graduates entering careers in family medicine residencies dropped by 50 
percent, as did the number of internal medicine residents planning 
careers in primary care rather than specialty medicine. In a 2006 
survey of 92 large- or medium-sized physician groups, 94 percent of the 
respondents ranked internists or family physicians as the most 
difficult to recruit. Federally funded community health centers 
reported more than 750 vacant positions for primary care physicians in 
2004. In 2007, 29 percent of Medicare beneficiaries reported a problem 
finding a primary care physician, up from 24 percent in 2006.
    3. The Federal Government can address the crisis in primary care 
through:

    a. Targeted health professions primary care training programs such 
as title VII programs.--Research evidence demonstrates the 
effectiveness of these programs, finding that institutions receiving 
Title VII Section 747 Primary Care Training Grants are more likely to 
produce graduates who enter primary care fields, work at Community 
Health Centers, and participate in the National Health Service Corps.
    b. Reform of Medicare Graduate Medical Education funding.--Medicare 
GME funding policies tie funds to hospital-based settings emphasizing 
specialty training and hospital service priorities, rather than the 
public's workforce needs. Medicare GME funding needs to be reformed to 
become more aligned with primary care workforce needs and less rigidly 
tied to hospital-based training sites.
    c. The National Health Services Corps.--Research has shown that 
many NHSC participants remain in service to the underserved after 
completing their service obligations, and that temporary placement of 
NHSC physicians in rural underserved areas positively impacts the long-
term non-NHSC physician supply in those areas. In 2006, there were over 
4,200 vacant positions in underserved areas for NHSC physicians, yet 
only 1,200 funded NHSC positions to fill these slots.
    d. Medicare physician payment reform.--Between 1995 and 2003, the 
real take home income of primary care physicians decreased by 10.2 
percent, and the gap in earnings between primary care and specialist 
physicians widened considerably. From 1997 to 2006, Medicare 
expenditures for specialty-oriented physician services (e.g., surgery, 
imaging studies) increased 36 percent faster than expenditures for 
primary care-oriented evaluation and management (E&M) services. In 
2006, non-E&M services accounted for 86 percent in the overage in 
Medicare physician expenditures above the overall SGR target. To 
reverse the current disincentives for primary care practice, Medicare 
payment reforms should include:

     i.  Splitting the SGR and creating separate SGR accounts for E&M 
and non-E&M services,
     ii.  Adding a medical home care coordination payment, in addition 
to fee-for-service payments,
    iii.  Subsidies for capital investment to modernize the medical 
home through EMR installation and related IT, training and hiring of 
primary care office staff for innovative chronic and preventive care 
programs, and other infrastructure needs, and
     iv.  Greater performance-based payment incentives linked to 
achieving progress on quality and access targets.
                                 ______
                                 
    Senator Kennedy, Senator Enzi, and members of the Senate Committee 
on Health, Education, Labor, and Pensions, thank you for inviting my 
testimony today on this hearing on the health care workforce. My name 
is Dr. Kevin Grumbach. I am a family physician and Professor and Chair 
of the Department of Family and Community Medicine at the University of 
California, San Francisco. I also am Director of the Center for 
California Health Workforce Studies and Co-Director of the Center for 
Excellence in Primary Care at UCSF. My testimony today will focus on 
the crisis in the Nation's primary care physician workforce.
    There are three main points I would like to emphasize:

    1. Primary care is the essential foundation of a well-performing 
health system.
    2. The primary care infrastructure in the United States is 
crumbling, and patient access to primary care is suffering throughout 
the Nation.
    3. The Federal Government can address the crisis in primary care 
through:

        a.  Targeted health professions primary care training programs 
        such as title VII programs,
        b. Reform of Medicare Graduate Medical Education funding,
        c. The National Health Services Corps, and
        d. Medicare physician payment reform.

    Let me review the evidence in support of each of these points.
   1. primary care is the essential foundation of a well-performing 
                             health system
    A primary care home serves as the patient's door into the health 
care system and the patient's guide through the system. Patients and 
families can choose a family physician, general internist, or 
pediatrician to be their primary care physician. Working closely with 
these physicians, nurse practitioners and physician assistants also 
deliver primary care. When people say, ``I'm going to see my personal 
physician,'' they are usually talking about their primary care 
physician. Primary care has the job of preventing illness; treating 
acute problems; caring for the millions of people with chronic 
conditions such as high blood pressure, arthritis, and diabetes; 
providing compassionate care at the end of life; and coordinating 
specialty and other referral services.
    Research evidence makes it clear that health systems built on a 
solid foundation of primary care deliver more effective, efficient, and 
equitable care than systems that fail to invest adequately in primary 
care:

     Costs.--Patients with a regular primary care physician 
have lower overall costs than those without. Compared with specialty 
medicine, primary care provides comparable quality of care at lower 
cost for a variety of conditions such as diabetes, hypertension, and 
low back pain. In comparisons of regions and States in the United 
States, increased primary care physician to population ratios are 
associated with reduced hospitalization rates and lower overall health 
care costs.
     Quality.--States with more primary care physicians per 
capita--but not specialists--have better population health indicators 
such as total mortality, heart disease and cancer mortality, and 
neonatal mortality. Medicare patients in these States also receive 
better quality of care, including more appropriate care for heart 
attacks, diabetes, and pneumonia. Patients with a primary care home are 
more likely to receive appropriate preventive services such as cancer 
screening and flu shots.
     Equity.--Racial disparities are reduced when patients 
receive care from a well-functioning medical home.
 2. the primary care infrastructure in the united states is crumbling, 
 and patient access to primary care is suffering throughout the nation
    From 1997 to 2005, the number of U.S. medical school graduates 
entering careers in family medicine residencies dropped by 50 percent.


    A similarly large decrease has occurred in the number of internal 
medicine residents planning careers in primary care rather than 
specialty medicine.


    An analysis performed by Dr. Jack Colwill and colleagues at the 
University of Missouri indicates that the growth in the supply of 
primary care physicians for adult patients is now lagging behind the 
rate of growth in the adult population, with the gap projected to widen 
dramatically over the next decade.


                SOURCE: J Colwill, unpublished data, 2007.
                NOTES: ``aging of pop'' based on visits per age group; 
                ``Adjusted supply''--adjusted for age and gender. 
                Graduate decline''--extends the 2001-2004 rate of 
                decline of graduates through 2007.
    The human resource crisis in primary care is apparent in the 
difficulties faced by health organizations in recruiting primary care 
physicians. In a 2006 survey of 92 large- or medium-sized physician 
groups, 94 percent of the respondents ranked internists or family 
physicians as the most difficult to recruit. Federally funded community 
health centers reported more than 750 vacant positions for primary care 
physicians in 2004.
    These workforce trends are having a deleterious effect on patients. 
Lack of access to primary care physicians is becoming an alarming 
problem in communities throughout the Nation, not just in traditionally 
underserved rural and inner city communities. In 2007, 29 percent of 
Medicare beneficiaries reported a problem finding a primary care 
physician, up from 24 percent in 2006. Soon after Massachusetts began 
implementing its universal coverage plan, it confronted the glaring 
deficiency of having an insufficient supply of primary care physicians 
to provide medical homes to the patients newly insured by the State 
health plan.
   3. federal policies to address the primary care workforce crisis: 
             an evidence-based approach to effective policy
    Research evidence supports the critical influence of Federal 
policies on the State of the Nation's primary care workforce, and 
points to effective interventions to address the current crisis.
a. Targeted Health Professions Primary Care Training Programs: Title 
        VII Programs
    Title VII Section 747 Primary Care Training Grants are intended to 
strengthen the primary care educational infrastructure at medical 
schools and residency programs and to encourage physicians-in-training 
to pursue careers working with underserved populations. Research shows 
an association between title VII grants to medical schools and 
increased production of primary care physicians and a greater 
likelihood that graduates will practice in underserved areas. In 
addition, a study of title VII grants to family medicine residency 
programs in nine States found that graduates of title VII residencies 
were more likely to practice in rural and low-income areas than their 
counterparts trained at residencies that did not receive title VII 
grants.
    Recent research conducted by our own team at UCSF, led by Dr. Diane 
Rittenhouse, has documented the importance of title VII grants for 
strengthening the educational pipeline producing primary care 
physicians who work at federally qualified community health centers and 
join the National Health Service Corps. Physicians who graduated from 
title VII-funded U.S. medical schools were 50 percent more likely to be 
practicing at a CHC in 2001-03 than physicians who graduated from 
medical schools that did not receive title VII funding. As the figure 
below indicates, 3.0 percent of graduates of title VII-funded medical 
schools were working at CHCs in 2001-03, compared with 1.9 percent of 
graduates of schools not funded by title VII. Similar results were 
found for title VII-funded residency programs. Of family physicians who 
trained at title VII-funded residencies, 6.8 percent worked at CHCs in 
2001-03, compared to 5.0 percent of family physicians who trained at 
residencies not funded by title VII.



    These same patterns were found for the association between title 
VII funding and physician participation in the National Health Services 
Corps. For example, family physicians who attended title VII residency 
programs were 50 percent more likely to participate in the NHSC Loan 
Repayment Program than family physicians who trained at residencies not 
funded by title VII.
    This recent research provides evidence that the title VII section 
747 grant program supports the training of primary care physicians who 
are more likely to staff CHCs and participate in the NCHS. These 
findings have important implications for Federal policy decisions, 
including the recent major reduction in title VII section 747 funding. 
Reductions in title VII destabilize institutions that 
disproportionately serve as the pipeline for producing primary care 
physicians who participate in the NHSC and/or work at CHCs, undermining 
the Federal effort to improve access for the underserved through CHC 
expansion. Ongoing Federal investment in the medical education pipeline 
to prepare and motivate physicians to participate in the NHSC and to 
work in CHCs should be considered an integral component of efforts to 
improve access to care for the underserved.
b. Reforming Medicare Graduate Medical Education Funding
    Medicare GME funding policies tie funds to hospital-based settings 
emphasizing specialty training and hospital service priorities, rather 
than the public's workforce needs. Medicare GME funding needs to become 
more aligned with primary care workforce needs and less rigidly tied to 
hospital-based training sites. The minutes of the September 2008 
meeting of the Council of Graduate Medical Education summarize draft 
recommendations on GME funding that are consistent with the priorities 
identified by many medical educators as fundamental to more rational 
GME funding that corrects current disincentives for primary care 
training. These include:

     Broadening the definition of ``training venue'' beyond 
traditional training sites,
     Removing regulatory barriers limiting flexible GME 
training programs and training venues, and
     Making accountability for the public's health the driving 
force for graduate medical education, including by:

          developing mechanisms by which local, regional or 
        national groups can determine workforce needs, assign 
        accountability, allocate funding, and develop innovative models 
        of training which meet the needs of the community and of 
        trainees;
          linking continued funding to meeting pre-determined 
        performance goals.

    Deliberations about altering the current funding formulae for 
Medicare GME allocations to reduce overall Medicare GME funding must 
carefully consider the potential impact on vulnerable primary care 
residency training programs. Funding formulae should not be revised 
without considering the types of principles under discussion by the 
Council of Graduate Medical Education to create a more accountable and 
rational approach to GME funding.
c. National Health Services Corps
    National Health Service Corps physicians comprise a substantial 
proportion of physicians staffing CHCs. Research indicates that after 
completing their NHSC obligation, a large proportion of NHSC 
participants remain in service to the underserved. In addition, 
temporary placement of NHSC physicians in rural underserved areas 
positively impacts the long-term non-NHSC physician supply in those 
areas. Unfortunately, the demand for NHSC physicians far exceeds the 
supply. In 2006 there were over 4,200 vacant positions in underserved 
areas for NHSC physicians, yet only 1,200 NHSC physicians available to 
fill these slots.
    The NHSC is an effective strategy to provide incentives to 
physicians in training to enter primary care and provide service where 
it is most needed.
d. Medicare Physician Payment Reform
    One of the major disincentives for physicians in training to pursue 
careers in primary care is the widening gap in earnings between primary 
care physicians and physicians in subspecialty fields. The income of 
primary care physicians, adjusted for inflation, decreased by 10.2 
percent from 1995 to 2003. Median specialist income in 2004 was 180 
percent of primary care income. Unadjusted for inflation, specialist 
income grew almost 4 percent per year from 1995 to 2004, while primary 
care income grew 2 percent per year. A specialist spending 30 minutes 
performing a surgical procedure, a diagnostic test, or an imaging study 
is often paid three times as much as a primary care physician 
conducting a 30-minute visit with a patient who has diabetes, heart 
failure, headache, or depression.
    Although Medicare is only one payor among many in the U.S. health 
system, Medicare has a dominant influence on physician payment policies 
for all payors. Most private health plans base their payment policies 
on Medicare's relative value unit system. Thus, Medicare physician 
payment policy is physician workforce policy. Changes to Medicare 
physician payment policies that reverse the financial disincentives for 
primary care practice can play a powerful role in addressing the crisis 
in the primary care workforce.
            i. Splitting the Sustainable Growth Rate (SGR)
    From 1997 to 2006, Medicare expenditures for specialty-oriented 
physician services (e.g., surgery, imaging studies) increased 36 
percent faster than expenditures for primary care-oriented evaluation 
and management (E&M) services. In 2006, non-E&M services accounted for 
86 percent in the overage in Medicare physician expenditures above the 
overall SGR target.




    Although there are valid reasons for Medicare to use some type of 
SGR approach to control overall physician expenditures, the specific 
manner in which the SGR has been implemented has had a 
disproportionately adverse impact on Medicare payments to primary care 
physicians. Because there is one conversion factor for all services, 
primary care physicians are essentially penalized when large increases 
in expenditures for specialized services drive down the conversion 
factor that is applied to E&M and non-E&M services alike.
    A simple policy that could mitigate much of this unintended effect 
of the SGR that disproportionately penalizes primary care physicians 
would be to use a split SGR system for E&M and non-E&M services, such 
that the conversion factor for each category of service would rise or 
fall based on expenditure trends within that category of service.
    We have modeled the implications of a split SGR. In our modeling 
scenario, we allowed total Medicare physician expenditures to increase 
from 1997 to the actual observed 2006 level of $93.7 billion. However, 
instead of allowing total expenditures to increase more rapidly in the 
non-E&M service category than in the E&M category, as historically 
occurred, we kept the 1997	2006 rate of expenditure increase (90 
percent) equivalent within each of the E&M and non-E&M SGR pools. Under 
this scenario, E&M spending in 2006 would have been $37.5 billion 
rather than $34.4 billion, and fees for E&M services would have been 9 
percent greater in 2006 than they actually were. Non-E&M spending in 
2006 would have been $56.2 billion rather than the actual $59.3 
billion. The conversion factors in 2006 under the high growth scenario 
would have been 41.3 for E&M services and 35.9 for non-E&M services. 
These compare with the actual 2006 conversion factor of 37.9 for both 
E&M and non-E&M services. This modeling exercise indicates how 
implementation of a split SGR could allow Medicare to provide more 
incentives for primary care services without increasing overall 
Medicare expenditures.
            ii. Adding a Medical Home Care Coordination Payment, in 
                    Addition to Fee-for-Service Payments
    Providing comprehensive care to patients with chronic illnesses and 
complex medical problems requires that physicians spend considerable 
time coordinating services, communicating with patients and caregivers 
by phone and e-mail, and devoting effort to similar types of activities 
not reimbursed under the traditional ``piecemeal'' payment approach of 
fee-for-service. The Patient Centered Primary Care Collaborative, a 
coalition of large employers and primary care physician associations, 
has called for payors to add a monthly care coordination payment ``for 
the physician work that falls outside of a face-to-face visit and for 
the heath information technologies needed to achieve better outcomes. 
Bundling of services into a monthly fee removes volume-based incentives 
and promotes efficiency. The prospective nature of the payment 
recognizes the up-front costs to maintain the required level of care. 
Care coordination payments should be risk-adjusted to ensure that there 
are no inherent incentives to avoid the treatment of the more complex, 
costly patients.''
    An example of the cost-effectiveness of such a care coordination 
payment is illustrated by the experiences of North Carolina's Medicaid 
management program, known as Community Care of North Carolina. To 
qualify for a monthly coordination payment of $5.50 per Medicaid 
patient per month, primary care practices must agree to use evidence-
based guidelines for at least 3 conditions, track tests and referrals, 
and measure and report on clinical and service performance. The program 
spent $8.1 million between July 2002 and July 2003, but saved more than 
$60 million over historic expenditures. In the second year of the 
program $10.2 million were spent but $124 million was saved. In 2005 
the savings grew to $231 million.
            iii. Subsidies for Capital Investment to Modernize the 
                    Medical Home Through EMR Installation and Related 
                    IT, Training and Hiring of Primary Care Office 
                    Staff for Innovative Chronic and Preventive Care 
                    Programs, and Other Infrastructure Needs
    Specialist physicians who spend a large amount of their work time 
in hospitals benefit from the capital investments and staffing paid for 
by hospitals. Hospitals pay for installation of hospital-based 
electronic medical records, operating room equipment, and the nurses 
and other personnel to staff operating rooms and intensive care units. 
Primary care physicians are largely on their own when it comes to 
finding resources for capital improvement and staffing support. The 
work of primary care occurs mainly in the physician's office. 
Investments in purchasing an EMR or hiring a health educator to assist 
patients to learn how to manage their chronic illnesses come out of the 
physician's own practice earnings. In an environment where real net 
income for primary care physicians is falling, there is little margin 
in practice revenues to pay for such practice improvements.
                               conclusion
    Primary care is essential, and it is in crisis. Decisive action is 
required by the Federal Government to avert the collapse of primary 
care and its catastrophic consequences for the public. Many leaders in 
the private sector, such as large employers, are already taking action 
on issues such as physician payment reform to support new models of 
primary care.
    Research provides evidence of strategies that are of proven 
effectiveness in strengthening the primary care workforce and providing 
incentives for primary care practice. Some of these strategies, such as 
implementing a split SGR for Medicare physician payment or reforming 
Medicare GME payments, do not require new funds but rather a 
reconsideration of how existing funds are allocated. Other strategies, 
such as a reasonable level of funding for the Section 747 Title VII 
Primary Care Training Grants Program, require small investments. For 
example, restoring title VII section 747 funding to its 2003 level of 
$92.4 million would represent an annual investment equivalent to 0.02 
percent of the annual Medicare budget. Such investments in the future 
of the Nation's primary care physician workforce are a cost-
effective investment in the Nation's health care infrastructure and in 
the health of the public.
    Thank you.

    Senator Sanders. Thank you very much.
    Dr. Roderick Hooker is the Director of Research, 
Rheumatology Section, Medical Service Department of Veterans 
Affairs at the Dallas VA Medical Center.

   STATEMENT OF RODERICK S. HOOKER, Ph.D., P.A., DIRECTOR OF 
 RESEARCH, RHEUMATOLOGY SECTION, MEDICAL SERVICE DEPARTMENT OF 
     VETERANS AFFAIRS, DALLAS VA MEDICAL CENTER, DALLAS, TX

    Mr. Hooker. Thank you, Senator Sanders and others on the 
committee.
    Senator Sanders. Is your mike on, sir?
    Mr. Hooker. I, too, want to keep my remarks brief so we can 
have a richer discussion around the table.
    Approximately little over 35 years ago, an experiment was 
begun in the United States at three different locations--at 
Duke University, at University of Washington, and University of 
Colorado. These were experiments in trying to deliver primary 
care without the use of doctors for every visit. Physician 
assistants was that experiment. It is now over 65,000 P.A.s 
have graduated. Over 60,000 are in some sort of clinical role.
    They are widely dispersed throughout Alaska and many other 
States. Most States except Vermont have P.A. programs. It seems 
to be working. It works very well for a number of reasons. They 
are economically trainable. They get out into primary care at a 
greater percentage than physician ratios, and they seem to 
deliver very high numbers of primary care visits.
    I believe that there are opportunities here to expand on 
this, especially coupled with the other noble experiment that 
began little over 35 years ago with family medicine. These two 
professions have pretty much grown alongside each other with 
the benefit of title VII. I believe that title VII can be 
enhanced to try to expand this particular endowment of the 
United States that is now being emulated in seven other 
countries around the world, and many others are looking to the 
experience here as well.
    With that, I will conclude my opening remarks and pass on.
    [The prepared statement of Mr. Hooker follows:]
         Prepared Statement of Roderick S. Hooker, Ph.D., P.A.
    Good morning. Thank you, Senators Kennedy, Enzi, and other members 
of the committee for the opportunity to provide comments this morning 
on the primary health care workforce. I will address the implications 
for reauthorization Title VII Health Professions Programs under the 
Public Health Service (PHS) Act.
    My name is Roderick Hooker. My role in health care began many years 
ago as a Hospital Corpsman in the U.S. Navy. I have been a physician 
assistant for 30 years. In addition, I hold an MBA in Health Care 
Management and Organization and a Ph.D. in Health Policy. I am a 
physician assistant in the Department of Veterans Affairs Medical 
Center in Dallas, TX. I am also an Associate Professor at the 
University of North Texas, School of Public Health, and the University 
of Texas Southwestern Medical School. My research career has focused on 
the medical workforce and organizational efficiency in health care 
delivery.
    I am particularly interested in the critical role of physician 
assistants (PAs) and nurse practitioners (NPs) and how they expand 
access to primary health care. The research shows that absent a PA or 
NP, some populations would have no access to health care.
    Today, I'd like to briefly share my thoughts on the supply and 
demand of PAs and NPs in the United States. There is a critical need to 
reinvigorate the title VII program's investment to increase the supply, 
diversity, and distribution of PAs in medically underserved 
communities. (NP programs receive Federal funding support through title 
VIII of the PHS Act.)
                          physician assistants
    Physician assistants are licensed health professionals. They:

 practice medicine as a team with their supervising physicians;
 exercise autonomy in medical decisionmaking; and
 provide a comprehensive range of diagnostic and therapeutic 
    services, including physical examinations, taking patient 
    histories, ordering and interpreting laboratory tests, diagnosing 
    and treating illnesses, suturing lacerations, assisting in surgery, 
    writing prescriptions, and providing patient education and 
    counseling.

    PA educational preparation is based on the medical model. They 
practice medicine as delegated by and with the supervision of a doctor. 
Physicians may delegate to PAs those medical duties that are within the 
physician's scope of practice and the PA's training and experience, as 
allowed by law. A physician assistant provides health care services 
that were traditionally only performed by a physician.
               overview of physician assistant education
    All physician assistant programs provide students with a primary 
care education that prepares them to practice medicine with physician 
supervision. PA programs are located at schools of medicine or health 
sciences, universities, teaching hospitals, and the Armed Services. All 
139 PA educational programs are accredited by the Accreditation Review 
Commission on Education for the Physician Assistant and offer a 
bachelor or master's degrees.
               title vii support of pa education programs
    The title VII support for PA educational programs is the only 
Federal funding available, on a competitive application basis, to PA 
programs.
    Targeted Federal support for PA educational programs is authorized 
through section 747 of the Public Health Service Act. The program was 
reauthorized in the 105th Congress through the Health Professions 
Education Partnerships Act of 1998, P.L. 105-392, which streamlined and 
consolidated the Federal health professions education programs. Support 
for PA education is now considered within the broader context of 
training in primary care medicine and dentistry.
    P.L. 105-392 reauthorized awards and grants to schools of medicine 
and osteopathic medicine, as well as colleges and universities, to 
plan, develop, and operate accredited programs for the education of 
physician assistants with priority given to training individuals from 
disadvantaged communities. The funds ensure that PA students have 
continued access to an affordable education and encourage PAs, upon 
graduation, to practice in underserved communities. These goals are 
accomplished by funding PA education programs that have a demonstrated 
track record of: (1) placing PA students in health professional 
shortage areas; (2) exposing PA students to medically underserved 
communities during the clinical rotation portion of their training; and 
(3) recruiting and retaining students who are indigenous to communities 
with unmet health care needs.
    The title VII program works as intended.

     A review of PA graduates from 1990-2006 demonstrates that 
PAs who have graduated from PA educational programs supported by title 
VII are 59 percent more likely to be from underrepresented minority 
populations and 46 percent more likely to work in a rural health clinic 
than graduates of programs that were not supported by title VII.
     A study by the UCSF Center for California Health Workforce 
Studies found a strong association between physician assistants exposed 
to title VII during their PA educational preparation and those who ever 
reported working in a federally qualified health center or other 
community health center.

    The PA programs' success in recruiting underrepresented minority 
and disadvantaged students is linked to their ability to creatively use 
title VII funds to enhance existing educational programs. For example, 
a PA educational program in Iowa used title VII funds to target 
disadvantaged students, providing mentoring opportunities for students, 
increasing training in cultural competency, and identifying new family 
medicine preceptors in underserved areas. PA programs in Texas use 
title VII funds to create new clinical rotation sites in rural and 
underserved areas, including new sites in border communities. They 
establish non-clinical rural rotations to help students understand the 
challenges faced by rural communities. One Texas program developed web-
based and distant learning technology and methodologies so students can 
remain at clinical practice sites. A PA program in New York, where over 
90 percent of the students are ethnic minorities, used title VII 
funding to focus on primary care training for underserved urban 
populations. They did this by linking with community health centers, 
expanding the pool of qualified minority role models that engage in 
clinical teaching, mentoring, and preceptorship for PA students. 
Several other PA programs use title VII grants to leverage additional 
resources to assist students with the added costs of housing and travel 
that occur during relocation to rural areas for clinical training.
    Without title VII funding, many special PA training initiatives 
would be eliminated. Institutional budgets and student tuition fees are 
not sufficient to meet the special, unmet needs of medically 
underserved areas or disadvantaged students. The need is very real, and 
title VII is critical in leveraging innovations in PA training.
    The clinical training opportunities that are made available through 
the section 747 program are substantial and documented. They result in 
the delivery of essential health care services in medically underserved 
communities that would otherwise not be available.
      title vii and the distribution of health care professionals
    The Health Resources and Services Administration (HRSA) estimate 
the need for an additional 7,802 health professionals to remove the 
Primary Care Health Professional Shortage Areas (HPSAs) designation 
nationwide.
    The title VII programs are the only Federal education programs that 
are designed to address the supply and distribution imbalances in the 
health professions. Since the establishment of Medicare, the costs of 
physician residencies, nurses, and some allied health professions 
training has been paid through Graduate Medical Education (GME) 
funding. However, GME funding has never been available to support PA 
education. More importantly, GME was not intended to generate a supply 
of providers who are willing to work in the Nation's medically 
underserved communities.
    There is compelling evidence that race and ethnicity correlate with 
persistent, and often increasing, health disparities. Further evidence 
substantiates the need for increasing the diversity of health care 
professionals. Title VII programs recruit providers from a variety of 
backgrounds.
    Changes in the health care marketplace reflect a growing reliance 
on PAs as part of the health care team. The supply of physician 
assistants is inadequate to meet the needs of society; demand for PAs 
is expected to increase. Title VII continues to provide a crucial 
pipeline of trained PAs to underserved areas. The U.S. Bureau of Labor 
Statistics, US News and World Report, and Money magazine all speak to 
the growth, demand, and value of the PA profession. Medically 
underserved communities need additional assistance to attract health 
care professionals who are in high demand in the private market.
     need for increased title vii support for pa education programs
    Despite the increased demand for PAs, funding has not increased for 
title VII programs. More is needed to educate and place physician 
assistants in underserved communities. Nor has title VII support for PA 
education kept pace with increases in the cost of education. In fact, 
title VII support has decreased sharply. A review of HRSA section 747 
grants reveals that 42 PA educational programs received a total of 
$7,011,443 million in fiscal year 2005, compared to $3,292,535 million 
awarded to 27 grantees in fiscal year 2006, and just $2,616,129 awarded 
to 15 grantees in fiscal year 2007.
                  recommendations for reauthorization
    The Title VII Health Professions Programs needs to be reauthorized 
by the 110th Congress. Little needs to be tweaked or substantially 
changed during the reauthorization process. I do, however, believe that 
title VII needs to be reinvigorated, valued, and recognized as 
providing an important public good. Evidence now supports the notion 
that title VII has lived up to the expectations of its early creators.
    Support for the education of primary care providers is sorely 
needed. There is a pressing need to recruit underrepresented minorities 
and disadvantaged populations. Doing so provides quality health care in 
medically underserved communities; a cornerstone.
    Finally, an increased emphasis must be placed on support for PA 
educational programs through the reauthorization process. The current 
funding for primary care medicine and dentistry has been at the expense 
of funding support for PA education. I believe that PA educational 
programs must be eligible to participate in all title VII programs. In 
particular:

 Section 738 (a)(3) Loan Repayments and Fellowships Regarding 
    Faculty Positions;
 Section 736(g)(1)(A) Programs of Excellence in Health 
    Professions Education for Under-represented Minorities; and
 Sections 701-720 Health Education Assistance Loan (HEAL) 
    Program.

    I appreciate the opportunity to provide comments during the 
committee's roundtable discussion.
    Thank you.

    Senator Sanders. Thank you very much, Dr. Hooker.
    Edward S. Salsberg, M.P.A., is Director, Center for 
Workforce Studies, Association of American Medical Colleges in 
Washington.

 STATEMENT OF EDWARD S. SALSBERG, M.P.A., DIRECTOR, CENTER FOR 
 WORKFORCE STUDIES, ASSOCIATION OF AMERICAN MEDICAL COLLEGES, 
                         WASHINGTON, DC

    Mr. Salsberg. Thank you, Senator Sanders. The AAMC 
appreciates the opportunity to talk to you today. I am going to 
very briefly summarize some of the comments in my submitted 
testimony.
    The AAMC is particularly concerned these days with the 
likely shortage, major shortage of physicians in the coming 
years. This shortage is really going to be driven by the 
increasing U.S. population, the aging of the U.S. population 
and, in fact, many of the advances in medicine that are keeping 
people alive longer and using services, along with an aging 
physician workforce and a younger generation of physicians that 
aren't working the same long hours that physicians did in the 
past.
    We have recommended a 30 percent increase in medical school 
enrollment, and we are seeing some progress. The reality is 
that that increase is really not going to be enough to meet all 
of the needs of Americans. We really have to look at how we 
redesign the healthcare system, how we use other health 
professionals, how we use our physicians more efficiently and 
effectively.
    We are already concerned about the problems of 
distribution, and the reality is if we face major shortages of 
physicians and other health professionals, unfortunately, it is 
likely to be the rural and poorer communities, the inner city 
areas that are going to really feel those shortages most 
severely.
    We think it is absolutely essential, in addition to 
increasing the supply of physicians, that we support programs 
that are going to address the maldistribution problem. There 
are some programs that we know work. The National Health 
Service Corps has an excellent track record, and we know that 
there are more applicants than there are awards. We support 
very strongly an increase in the funding for the National 
Health Service Corps.
    We know that title VII has been a complex and comprehensive 
program with a lot of parts, and those parts are designed to 
address a number of these problems of access, distribution, 
supply, and diversity. We think those programs are clearly 
essential to a comprehensive strategy.
    Clearly, title VII alone isn't going to solve this problem, 
but we can't see how you can solve the problem without those 
pieces that are supported by title VII. That doesn't mean that 
there isn't room for improvement of title VII, and AAMC would 
be happy to work with the committee in exploring how we might 
strengthen and improve the program.
    [The prepared statement of Mr. Salsberg follows:]
             Prepared Statement of Edward Salsberg, M.P.A.
                                Summary
     The Nation is likely to face a major shortage of 
physicians in the future due to a growing and aging population; 
advances in medicine leading to longer life; an aging physician 
workforce; and shorter work hours for younger physicians in practice.
     Between 1980 and 2005, the U.S. population grew by more 
than 70 million people (31 percent) while medical school enrollment was 
essentially flat.
     Shortages are likely to be greatest in poor and rural 
communities and other communities that historically have had a 
difficult time recruiting and retaining physicians.
     It takes at least a decade to increase the supply of 
American educated physicians; therefore action is needed now to assure 
access and to prevent a crisis in the future.
     AAMC recommends a 30 percent increase in medical school 
enrollment by 2015 and funding for additional graduate medical 
education (GME) positions.

          While this is a necessary step it will not be 
        sufficient to assure access in the future; systems redesign, 
        improvements in productivity, greater use of non-
        physician clinicians and more effective use of physicians is 
        also essential.

     Increasing the physician supply alone will also not 
address the problems of geographic and specialty mal-distribution. More 
than 30 million Americans live in areas designated as having shortages. 
The AAMC recommends a doubling of annual NHSC awards and increased--not 
decreased--support for title VII.
     The financing of graduate medical education has a major 
impact on the physician workforce.

          Existing funding is threatened in the President's 
        budget request and by the proposed rule prohibiting Federal 
        Medicaid payments for GME. The AAMC supports legislation (S. 
        2460) to extend the current moratorium prohibiting action on 
        the proposed rule.
          Current GME regulations (Medicare) penalize 
        outpatient/primary care training.
           aamc recommendations for title vii reauthorization
     The AAMC strongly recommends continuation of programs 
authorized under Title VII of the Public Health Service Act with 
modifications. This program has numerous components designed to improve 
access, distribution, effectiveness and equity.
     Retain diversity programs as currently structured at a 
higher authorization level, and create a new program to support 
demonstration projects designed to increase the number of 
underrepresented minority faculty. Increasing the diversity of the 
health workforce should be a national priority. Title VII programs are 
critical to this effort.
     Improve data collection and program evaluation by 
increasing the authorization for regional workforce analysis centers 
and authorizing a new national workforce database to track the supply 
and location of health professionals.
     Improve the alignment between title VII grants and service 
in underserved areas by restructuring the primary care programs to 
preferentially award grants to applicants entering a formal 
relationship with providers in underserved areas.
     Create a new program to award grants for schools or 
departments to administer demonstration projects to improve the quality 
and efficiency of primary care.
     Address inefficiencies in the title VII loan programs.
                                 ______
                                 
    My name is Edward Salsberg, and I am the Director of the Center for 
Workforce Studies at the Association of American Medical Colleges 
(AAMC). Thank you for the opportunity to speak to you today regarding 
the physician workforce and the response of America's medical schools 
and teaching hospitals to a growing concern about potential future 
physician shortages.
    The AAMC is a nonprofit association representing all 126 accredited 
U.S. allopathic medical schools; nearly 400 major teaching hospitals 
and health systems, including Department of Veterans Affairs medical 
centers; and 94 academic and scientific societies. Through these 
institutions and organizations, the AAMC represents 109,000 faculty 
members, 67,000 medical students, and 104,000 resident physicians.
    Our mission is to improve the health of the public by enhancing the 
effectiveness of academic medicine. Together with our members we pursue 
this mission through the education of the physician and medical 
scientist workforce, the discovery of new medical knowledge, the 
development of innovative technologies for prevention, diagnosis and 
treatment of disease, and the delivery of health care services in 
academic settings.
    The AAMC is committed to promoting an adequate supply of well-
educated physicians sufficient in number and competencies to assure 
access to high quality medical care in the future. To this end, the 
AAMC established its Center for Workforce Studies in 2004 to enhance 
and make publicly available comprehensive data and analyses regarding 
the supply of and demand for physicians. The Center is committed to 
providing the medical education community (medical schools, medical 
students, residency programs and teaching hospitals), the public, and 
policymakers with superior information on current and likely future 
physician workforce needs. The Center does this through original 
research, analysis of existing data, collaboration with other 
associations representing physicians and through an annual conference 
on physician workforce research. In recent months, the Center has 
updated a number of documents including our ``2007 State Physician 
Workforce Databook'' and a listing of ``Recent Reports and Studies of 
Physician Shortages in the United States.'' These reports accompany 
this statement and are available along with additional information on 
the Center on our Web site, http://www.aamc.org/workforce.
    In my comments today, I want to provide you with some basic 
background on the physician workforce, why we are concerned about the 
likelihood of a future physician shortage, what the AAMC is 
recommending in terms of physician workforce policies, and finally, how 
the Nation's medical schools and teaching hospitals are responding. I 
also want to specifically address the importance of the title VII 
program in addressing physician workforce needs of the Nation.
                 background on the supply of physicians
    The vast majority of licensed physicians in the United States are 
educated in allopathic medical schools--those that confer an M.D. 
degree--and residency training programs in the Nation's teaching 
hospitals accredited by the Accreditation Council for Graduate Medical 
Education (ACGME). Allopathic medical schools and their affiliated 
teaching hospitals also are a critical source of research, new medical 
knowledge, and clinical care, and are a vital part of the Nation's 
medical safety net.

     Physicians in the United States can practice medicine only 
after completion of a medical degree (``undergraduate medical 
education'' or UME), and several years of post-graduate training in an 
accredited residency program (``graduate medical education'' or GME).
     Each year approximately 16,000 physicians graduate from 
U.S. medical schools with an M.D. degree; these graduates fill roughly 
two-thirds of first-year residency positions in training programs--such 
as internal medicine, general surgery, pediatrics, and others--that are 
accredited by the Accreditation Council for Graduate Medical Education 
(ACGME).
     In 2006-07, nearly 6,800 graduates of foreign medical 
schools, generally referred to as international medical school 
graduates or IMGs, entered residency training, representing about 27 
percent of the new residents that year; of those, about 1 in 4 were 
U.S. citizens who attended schools outside of the United States.
     Graduates of osteopathic medical schools (D.O.'s) 
represent about 11 percent of all physicians entering graduate training 
each year. More than half of D.O.'s enter ACGME accredited residency 
programs.
     Physicians in the United States are licensed by individual 
States, all of whom require an M.D. or D.O. degree, as well as some 
level of accredited graduate training (GME).
     In 2006, there were almost 870,000 physicians active in 
medicine in the United States, of which 56,000 were osteopaths. This 
figure includes just under 105,000 physicians in residency training. 
About 25 percent of active physicians in the United States are 
graduates of non-U.S. medical schools.
                   why a physician shortage is likely
    The expected future shortage of physicians is driven by likely 
changes in both the supply and the demand for physicians. On the demand 
side, key factors include: (1) the growing U.S. population (more than 
25 million each decade). In fact, between 1980 and 2005, the U.S. 
population grew by more than 70 million people (31 percent) while 
medical school enrollment remained essentially flat; (2) the rapid 
increase in the number of people over the age of 65 (who use twice as 
many physician services per capita each year than those under 65); (3) 
advances in medicine that prolong life and improve the quality of life 
for millions of Americans; and (4) the rising expectations of Americans 
along with increasing wealth that will motivate and enable them to use 
more services. On the supply side, key factors include: (1) the aging 
of the physician workforce (36 percent of active physicians are over 55 
and most will retire by 2020); and (2) a new generation of physicians, 
who value lifestyle and do not appear willing to work the long hours 
that prior generations of physicians have worked. At current levels of 
training, the physician-to-population ratio will peak before 2020 and 
then fall, just as the baby boomers begin to reach 75 years of age.
    Since 2002, there have been at least 35 studies showing current or 
future physician workforce needs of a State or specialty.\1\ An October 
2006 report by the Health Resources and Services Administration (HRSA) 
predicts that the demand for physicians will exceed the supply by 
2020.\2\ The underserved and elderly populations are most likely to be 
affected. These shortages are likely to exacerbate the existing lack of 
access for the 20 percent of Americans that live in government-
designated Health Professional Shortage Areas (HPSA).\3\ Many rural and 
urban communities, economically disadvantaged and underrepresented 
minority populations are likely to remain medically underserved for the 
foreseeable future, and certainly will be more underserved if a 
national shortage emerges.
---------------------------------------------------------------------------
    \1\ http://www.aamc.org/workforce/recentworkforcestudies2007.pdf.
    \2\ HRSA Bureau of Health Professions. Physician Supply and Demand: 
Projections to 2020. October 2006. http://bhpr.hrsa.gov/
healthworkforce/reports/physiciansupplydemand/default.htm. Accessed: 
February 5, 2008.
    \3\ http://bhpr.hrsa.gov/shortage/.
---------------------------------------------------------------------------
                        the supply of physicians
    For the last 50 years, the physician-to-population ratio has been 
growing steadily. This reflects a doubling in medical school enrollment 
in the 1960s and 1970s. However, with the report of the Graduate 
Medical Education National Advisory Commission (GMENAC) in the late 
1970s predicting a large surplus of physicians, medical school 
enrollment stabilized. In fact, the number of graduates from U.S. 
medical schools has been virtually flat since 1980. As a result, a very 
large number of active physicians now are nearing retirement age. In 
2005, a little more than 12,000 active physicians reached age 63; by 
2017, this number will grow to more than 24,000.
    The near-zero growth in U.S.-M.D. graduates has translated to a 
decrease in the number of medical school slots per population in 
America. In fact, between 1980 and 2005, the U.S. population grew by 
more than 70 million (31 percent) \4\ while there was no growth in 
allopathic enrollment; this has led to a significant and steady decline 
in enrollment per 100,000 population. In addition to the large number 
of physicians approaching retirement age, there are growing reports 
that the newest generation of physicians do not want to work the long 
hours of physicians in the past. Gender also plays a role. While only 
10 percent of practicing physicians were female in 1980, they are now 
about 50 percent of the medical students. While this trend is 
encouraging from a societal perspective, it has implications for the 
physician workforce because women tend to work fewer hours than their 
male counterparts do. Moreover, there are growing reports that many of 
today's young physicians, male and female, are choosing to work fewer 
hours than their older counterparts regardless of their gender. As a 
result, the future physician workforce may effectively be 10 percent 
lower than their aggregate numbers may suggest.
---------------------------------------------------------------------------
    \4\ U.S. Census Bureau.
---------------------------------------------------------------------------
    In order to be able to forecast future supply of physicians more 
accurately, the AAMC, in collaboration with physician specialty 
societies and the American Medical Association (AMA) undertook two 
major surveys: one of more than 9,000 physicians over 50, the other of 
4,100 physicians under 50. The ``Over 50 Survey'' was designed to 
understand factors influencing retirement patterns and plans; the 
``Under 50 Survey'' was designed to assess whether in fact younger 
physicians are working fewer hours than physicians in the past. The 
surveys confirmed the likelihood of future physician shortages.
                 aamc workforce policy recommendations
    While there are already shortages in many communities and for some 
specialties today, the potential major nationwide shortages loom in the 
future. However, we need to be concerned today as it takes at least a 
decade to impact the supply of U.S.-educated physicians due to the time 
to develop additional capacity and the length of education and 
training. An appropriate supply of well-educated and trained physicians 
is an essential element to assure access to quality health care 
services for all Americans. The recommendations of the 2006 AAMC 
Position Statement on the Physician Workforce are intended to better 
assure an appropriate supply of physicians while increasing medical 
education opportunities for Americans. The AAMC recommendations 
include:

     Enrollment in LCME-accredited medical schools should be 
increased by 30 percent from the 2002 level by 2015. This expansion 
should be accomplished by increased enrollment in existing schools as 
well as by establishing new medical schools.--The United States medical 
education community has spent decades developing standards and methods 
to help assure that schools meet appropriate minimum standards and that 
physicians that graduate from these schools have the skills and 
knowledge necessary to provide high quality care. The nation is better 
served when a greater, not lesser, proportion of future physicians are 
held to these standards. Moreover,

          There are large numbers of Americans who aspire to 
        attend U.S. medical schools but have been unable to gain 
        admission due in part to limited capacity. Many are so 
        committed that they are willing to pay high tuitions at schools 
        with varying standards and leave the United States for several 
        years to reach their goal. We estimate that more than 3,000 
        U.S. citizens enter medical school outside of the United States 
        each year;
          There is growing international concern that English-
        speaking countries may be draining valuable human resources 
        from less-developed countries. Increasing U.S. medical school 
        graduates will reduce the ``pull'' of physicians from less 
        developed countries without creating barriers for individual 
        migration.

    Achieving the desired growth in medical school graduates will 
require an increase in enrollment at most existing schools as well as 
the creation of new medical schools. Increases in enrollment are 
particularly appropriate in areas of the country where the population 
has grown rapidly over the past 25 years and areas where the population 
is projected to grow rapidly in future years. In addition, States with 
low medical school enrollment per capita, with numerous underserved 
areas and States with large and growing elderly populations may also be 
appropriate areas for medical school enrollment growth.

    The AAMC is making every effort to inform the medical education 
community about the growing likelihood of a physician shortage but does 
not control the number of medical student enrollments or training 
positions available. The AAMC's recommendation to increase enrollment 
has not gone unnoticed. The 2007 entering class to U.S. medical schools 
is the largest in the Nation's history. The number of first-year 
enrollees totals almost 17,800 students, a 2.3 percent increase over 
2006. More than 42,300 individuals applied to enter medical school in 
2007, an increase of 8.2 percent over 2006. Nearly 32,000 were first-
time applicants, the highest number on AAMC record. According to a 2007 
survey of medical school deans, 100 of the Nation's 126 medical schools 
already have increased their enrollment or plan to increase their 
enrollment by five or more students within the next 5 years, when 
compared to their baseline 2002-2003 enrollment. Data from this survey 
projects that first-year enrollment will grow to 19,909 in 2012 from 
16,488 in 2002, an increase of nearly 21 percent. It appears that our 
member institutions will reach the 30 percent increase in enrollment 
goal from both existing and new schools by 2017.

     The aggregate number of graduate medical education (GME) 
positions should be expanded to accommodate the additional graduates 
from accredited medical schools.--U.S. medical schools face many 
challenges in increasing the number of medical school graduates. A 
primary goal of this expansion is to increase the supply of physicians 
available to assure access to services in the future. Since all 
physicians must complete accredited graduate training to become 
licensed in the United States, the number of GME positions is a 
critical choke point to increase the supply of physicians available to 
care for Americans.
    We strongly urge Congress to preserve Medicare support for GME. The 
AAMC also recommends that Congress eliminate the current limit on the 
number of Medicare-funded residency positions. This will allow GME 
programs to expand in response to increased medical school enrollment 
and other physician workforce dynamics. The AAMC welcomes the 
opportunity to work with the committee to educate the public and 
policymakers about the importance of stabilizing and expanding GME 
support in the context of an impending physician shortage.
    The AAMC believes the Resident Physician Shortage Reduction Act of 
2007 (S. 588) is a useful beginning in meeting the Nation's needs for 
future physician services. We express support for this important first 
step in what we hope will be a systematic and rapid process to 
eliminate the Medicare resident cap. However, we do wish to be clear 
that financing this legislation from other cuts in Medicare in which we 
have any interest will be self-defeating and unacceptable.
    On a related matter, the President's fiscal year 2009 budget 
proposes, over 5 years, to cut indirect medical education (IME) 
payments to teaching hospitals by a total of $21.75 billion. The 
Administration would accomplish this by reducing the add-on payment 
from 5.5 percent to 2.2 percent over 3 years, as well as eliminating 
IME payments to hospitals treating Medicare Advantage beneficiaries. We 
ask Congress to reject these proposals, which are shortsighted in light 
of the looming physician shortage.
    Additionally, the AAMC strongly urges Congress to preserve Medicaid 
support for GME. As you know, CMS has issued a proposed rule that would 
reverse a long-standing policy of providing Federal matching funds for 
State Medicaid GME payments. The AAMC asks you to delay further action 
on this proposed rule by immediately taking up and passing S. 2460, 
which extends by 1 year a current moratorium prohibiting CMS from 
moving forward with these Medicaid GME cuts.
    The AAMC also asks Congress to take up legislation to remove 
regulatory barriers that penalize GME programs that train residents in 
outpatient settings such as community-based primary care offices. We 
also encourage Congress to continue funding programs that offer higher 
reimbursement levels for physicians who practice in underserved areas.

     The AAMC should continue to advocate for and promote 
efforts to increase enrollment and graduation of racial and ethnic 
minorities from medical school; and promote the education and training 
of leaders in medical education and health care from racial and ethnic 
minorities. Studies repeatedly have shown that medical students from 
racial and ethnic minority groups are more likely to practice in 
underserved communities and to care for a disproportionate number of 
disadvantaged patients. This information, coupled with other compelling 
arguments, underlies the AAMC's strong advocacy for greater diversity 
in medical education. The implementation of lawful, race- and 
ethnicity-conscious decisionmaking in medical school admissions and in 
faculty recruitment and retention is essential to meet society's need 
for a physician workforce capable of caring optimally for our 
increasingly diverse population.
    In the fall of 2006, the AAMC launched the AspiringDocs.org 
campaign, which seeks to encourage well prepared African-American, 
Hispanic/Latino, and Native American college students from all 
undergraduate majors to pursue medicine as a career. U.S. medical 
schools and teaching hospitals have a decades-long commitment to 
building diversity in medicine. To complement efforts to increase the 
pipeline of prospective students, the AspiringDocs.org campaign takes a 
new approach--career marketing--to reach an untapped segment of 
potential minority student applicants in America's colleges and 
universities that was revealed by an innovative AAMC analysis.
     The J-1 visa is the most appropriate visa for non-U.S. 
citizen graduates of foreign medical schools entering graduate medical 
education programs in the United States and should be encouraged.--The 
primary purpose of graduate medical education is education. The J-1 
program's purpose is educational and its administration by the 
Educational Commission for Foreign Medical Graduates (ECFMG) assures 
that J-1 residents and fellows possess valid educational credentials, 
have successfully passed Steps 1 and 2 of the United States Medical 
Licensing Examination (USMLE), and that their country of origin needs 
the knowledge and skills that they will obtain through their education 
in the United States. No other immigration program or visa category is 
as consistent with the aims of U.S. graduate medical education or 
offers an equal assurance of the quality of entrants.
    The H-1 visa (an employment visa) is not appropriate for physicians 
coming to the United States for education and training purposes. At the 
national level, consideration should be given to clarifying and 
expanding the types of visas available for physicians seeking GME in 
the United States.
     The National Health Service Corps (NHSC) has played an 
important role in expanding access for underserved populations, and 
continued expansion of this program is strongly recommended.--The NHSC 
is a program sponsored by the Department of Health and Human Services 
(HHS) that helps place physicians and other health care providers in 
communities where they are most needed, both through scholarships and 
through loan repayment. The NHSC has a proven track record of serving 
the underserved in both rural and urban settings; 60 percent of its 
clinicians are located in rural areas, while the remainder serve urban 
populations in settings such as Community Health Centers (CHC), health 
departments, and other critical access facilities. A recent report in 
the Journal of the American Medical Association by Rosenblatt and 
colleagues demonstrates the reliance of CHCs on NHSC scholars and loan 
repayment recipients and the inability of these safety net sites to 
recruit an adequate number of physicians.\5\
---------------------------------------------------------------------------
    \5\ Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of 
medical personnel at community health centers: implications for planned 
expansion. JAMA. 2006; 295(9):1042-9.
---------------------------------------------------------------------------
    Since its creation, the NHSC consistently has received 
significantly more applications for positions than it is able to 
support with the funding provided by Congress. Funding for the NHSC has 
decreased by $47 million (27 percent) since fiscal year 2003, when its 
budget was $171 million. Limited funding has reduced new NHSC awards 
from 1,570 in fiscal year 2003 to an estimated 947 in fiscal year 2008, 
a nearly 40 percent decrease.
    The growing debt of graduating medical students is likely to 
increase the interest and willingness of U.S. medical school graduates 
to apply for NHSC funding and awards. The scholarship program funds 
tuition and other fees for over 150 medical students annually. 
Moreover, almost 80 percent of the NHSC budget funds loan repayments 
(numbering about 1,200 annually) for physicians that agree to serve 
underserved communities after the completion of residency training. The 
AAMC has recommended increasing annual NHSC awards by 1,500 to allow 
more graduates to practice in underserved areas. A NHSC appropriation 
of at least $400 million is necessary to sustain current NHSC levels 
and the AAMC-recommended increase.
           aamc recommendations for title vii reauthorization
    While we are encouraged by the response of the medical education 
community to our call for an increase in medical school enrollment, the 
AAMC and our constituents recognize that increasing the supply of 
physicians will not in and of itself address the problems of 
geographical and specialty mal-distribution. Having an adequate 
national supply of physicians is necessary but not sufficient to assure 
access to health care services for all Americans. The AAMC believes 
that Title VII of the Public Health Service Act is an essential part of 
the elements needed to assure access.
    Federal funding for the title VII health professions training 
programs administered by the Health Resources and Services 
Administration (HRSA) has been instrumental in increasing the supply of 
the primary care workforce and in addressing the needs of the 
underserved. Title VII programs support the training and education of 
health care providers through loans, loan guarantees, and scholarships 
to students, and grants and contracts to academic institutions and non-
profit organizations.
    The statutory authority for these programs provided by the Health 
Professions Education Partnerships Act of 1998 [P.L. 105-392] expired 
in September 2002. Each year, the community, in its efforts to preserve 
funding for these programs, faces opposition from the Office of 
Management and Budget, and in fiscal year 2006, the programs sustained 
a 51.5 percent cut in Federal funding. The President's budget request 
for fiscal year 2009 recommends eliminating all funding for the title 
VII programs.
    Recognizing that a new approach to the title VII programs is needed 
to strengthen them and improve their prospects for long-term survival, 
the AAMC in September 2004 appointed a committee to review the missions 
and effectiveness of the programs and propose recommendations as 
Congress considers reauthorization. The AAMC Committee agreed that the 
programs' shared goals should continue to be enhancing primary care, 
bringing care to underserved areas, and improving the diversity of the 
health care workforce. The committee also agreed that the 
reauthorization of the title VII programs should improve accountability 
of the programs by creating outcomes measures and enhancing the 
collection and analysis of data to monitor the programs' impact.
    The committee set forth a series of recommendations to align 
current funding streams with these goals and enhance the future 
viability of the programs. A copy of the AAMC Committee's final report 
accompanies this statement.

     Diversity (Sections 736-739).--The AAMC recommends the 
programs under Sections 736-739 of the Public Health Service Act be 
retained in their current structure, which includes the following 
programs: Centers of Excellence, Health Careers Opportunity Program, 
Faculty Loan Repayment Program, and the Scholarships for Disadvantaged 
Students. They should be funded at $155 million. Additionally, the AAMC 
notes the need for increased emphasis on the development of 
underrepresented minority faculty, as these mentors create an 
environment that allows minority health professions students to succeed 
and graduate to provide care in their communities. The AAMC recommends 
the creation of a new program to support demonstration projects 
designed to increase the number of underrepresented minority faculty. 
The program should receive $5 million of the $155 million recommended 
for sections 736-739.
     Health Workforce Information and Analysis (Section 761).--
Despite the emphasis of title VII programs on bringing care to 
underserved areas, there continues to be a dearth of information on 
their impact on workforce distribution. Additional funding is needed to 
establish and maintain a system for linking physician practice location 
and their medical education and graduate training experiences. A 
national workforce-tracking database is needed to identify where title 
VII-trained professionals are practicing and to produce benchmark data 
to be used in evaluating the programs and determining preferences for 
the granting process.
    The Regional Centers for Health Workforce Studies supported by HRSA 
have led the way in conducting health workforce studies and collecting 
data to inform State and national programs regarding State and regional 
health workforce needs. In addition, the Regional Centers have been 
able to leverage Federal funding to obtain additional State and private 
support. Yet, this component of title VII has remained unfunded since 
fiscal year 2006. The AAMC supports the continuation and expansion of 
these Centers, by reauthorizing section 761 at $2 million for the six 
regional centers and authorizing $3 million for a new national 
workforce database to track the location of health professionals 
educated and trained in programs receiving title VII support.
     Primary Care (Section 747).--Primary care is an effective 
and necessary investment that benefits the health of all people. Title 
VII funding is key to producing primary care providers and improving 
their education. The section 747 programs are guided by two agendas: 
caring for the underserved and preserving and promoting primary care.
    The AAMC recommends a new structure, in which grants are 
preferentially awarded to applicants who enter into a formal 
relationship and submit a joint application with a Federally Qualified 
Health Center (FQHC), an FQHC Look-Alike, Area Health Education Center 
(AHEC), or a clinic located in a HPSA or MUA or a clinical practice 
setting in which at least 40 percent of its patients are either 
uninsured or supported by Medicaid. The AAMC recommends the 
continuation of the funding priorities and preferences included in the 
current statute.
    Additionally, the AAMC proposes the creation of a new program under 
section 747 in which grants will be awarded to schools or departments 
to administer demonstration projects centered on improving the quality 
of primary care in selected emphasis areas. A funding level of $198 
million is recommended for section 747, with the distribution among the 
disciplines and between undergraduate and graduate programs to remain 
the same.
     Address Inefficiencies in title VII loan programs.--The 
title VII student loan programs offer long-term, low interest loans for 
economically disadvantaged and underrepresented minority students in 
the health professions. The average medical student participating in 
the title VII student loan programs will save over $50,000 when 
compared to current Stafford loans. Unfortunately, many medical 
students will not accept a Primary Care Loan (PCL) due to the extended 
service requirement and harsh default penalties. Students' avoidance of 
the PCL program has resulted in a large portion of available funds 
going unawarded each year, undermining the original intent of the 
program, and thereby subjecting the program to annual Federal 
rescissions.
    In addition to reducing these harsh default penalties, the AAMC 
recommends that the eligibility requirements for all HHS title VII and 
title VIII health professions loan programs be amended to allow for the 
waiver of parental financial information in extraordinary 
circumstances.
    Currently, the HHS Student Financial Aid Guidelines (section 
101.3.142) indicate that ``institutions still must take parents' 
information'' into account to determine students' eligibility PCL, 
HPSL, LDS, and Nursing Student Loan (NSL) programs. In other Federal 
financial aid programs--for instance, under the auspices of the 
Department of Education--financial aid officers have the ability to 
adjust this parental financial information requirement to reflect an 
individual's specific situation; however, HHS regulations state that 
the requirement to include parental data ``cannot be waived.''
    There are compelling instances in which it would be appropriate for 
financial aid officers to use professional judgment to waive parental 
data for one or both parents, such as when a parent is incarcerated or 
incapacitated during long-term hospital care, or when a parent's 
whereabouts are unknown. Permitting financial aid officers to use their 
professional judgment to waive this requirement in appropriate cases 
would afford them greater flexibility in ensuring that scarce resources 
are best targeted to those students who are truly in need. Furthermore, 
the AAMC believes this is a more appropriate interpretation of the 
Federal regulations that require the consideration of the ``expected 
contribution from parents.'' (42 CFR Part 57.206).
    Report language accompanying the FY 2007 Senate Labor-HHS-Education 
Appropriations bill (S. 3708, S. Rept. 109-287) encouraged ``HRSA to 
omit the consideration of parental income from the fiscal year 2007 
competitions as well as from future guidance and methodology'' for 
administering the title VII student loan programs. As you are aware, 
discrepancies in availability of parental financial information have 
disqualified already disadvantaged students from obtaining these 
affordable loans. The AAMC has been working with HRSA to ensure that 
students' fiduciary abilities are more appropriately represented in the 
student aid process by granting financial aid administrators greater 
professional discretion. The AAMC believes congressional direction 
through title VII reauthorization will help ensure that title VII funds 
are more appropriately allocated in the future.

    The issues surrounding the physician workforce and potential 
shortages are complex. The AAMC and our member institutions are 
committed to assuring an adequate supply of well-educated physicians to 
ensure that the future needs of Americans are met.

    Senator Sanders. Thank you very much, Mr. Salsberg.
    James Q. Swift, D.D.S., is Board President of the American 
Dental Education Association, and he is a professor at the 
University of Minnesota School of Dentistry. Dr. Swift, thanks 
very much for being with us.

STATEMENT OF JAMES Q. SWIFT, D.D.S., BOARD PRESIDENT, AMERICAN 
    DENTAL EDUCATION ASSOCIATION, PROFESSOR, UNIVERSITY OF 
         MINNESOTA SCHOOL OF DENTISTRY, MINNEAPOLIS, MN

    Mr. Swift. Thank you, Senator Sanders. Thank you to the 
committee for allowing me to be here. I represent the American 
Dental Education Association, which represents 15,000 dental 
educators, dental students, residents, and educators and 
students in allied dental health programs.
    I would like to focus on three specific areas of my 
testimony. The one relates to our diversity mission. In the 
dental education environment, there is a significant shortage 
of underrepresented minorities in education programs for the 
dental profession. We do think that this needs to be addressed 
because the future of the profession is dependent and critical 
upon achieving optimum oral health for racial and ethnic 
minority groups, which experience a higher level of oral health 
problems and have limited access to dental care. We must 
address that specific issue.
    In addition, there is a significant access to dental care 
problems, as illustrated by Senator Sanders and Senator Kennedy 
earlier on. We need to get beyond the semantics of the concept 
of dentist shortages or maldistributions. There is a 
significant problem out there with access to oral health care, 
as illustrated by the cases that you had mentioned.
    There are millions of Americans, especially children, that 
don't have access to oral health care, and there are several 
solutions that have been proposed and several solutions that 
can be influenced or impacted by this committee. I look forward 
to working with you to determine that.
    Last, there is a significant problem in the dental 
education environment with dental faculty. This was also 
referenced earlier in the testimony. It is difficult to entice 
dentists after they graduate from dental school with a debt 
somewhere between $175,000 on the average, depending on whether 
you attend a private dental school or a publicly funded dental 
school, in addition to the predoctoral costs prior to getting 
to that point, makes it financially unable for these 
individuals to be able to go out into some of these underserved 
areas and work for lower income, when they have that type of 
debt to face.
    I look forward to giving further testimony and comments on 
how we can perhaps achieve some solutions to these problems. 
Thank you for letting me be here.
    [The prepared statement of Mr. Swift follows:]
Prepared Statement of the American Dental Education Association (ADEA), 
                  Presented by James Q. Swift, D.D.S.
                                summary
    The testimony of the American Dental Education Association (ADEA) 
is presented by Dr. James Q. Swift, ADEA President and Professor and 
Director of the Division of Maxillofacial Surgery at the University of 
Minnesota School of Dentistry. The testimony speaks to the primary 
challenges faced by academic dentistry, the dental profession, and 
Congress.
    Chief among the challenges that we face together is the need to 
increase diversity among professionally active dentists and allied 
dental professionals, which are at the present time predominately White 
non-Hispanic. The low number of African American, Hispanic, and Native 
American students in dental schools remains disproportionate to their 
numbers in the U.S. population.
    Although the U.S. population is mostly homogenous, there is growing 
diversity for which we are unprepared. Increasing diversity in the 
dental profession is vital to the future of the profession and it is 
central to achieving optimal oral health for racial and ethnic minority 
groups, which experience a higher level of oral health problems and 
have limited access to dental care.
    Furthermore we need to move past the semantics of dentist 
``shortage'' or dentist ``maldistribution.'' There can be no doubt that 
there is a significant access problem for millions of Americans. We 
must acknowledge that the current dental workforce is unable to meet 
present day demand and need for dental care. Millions of Americans 
experience dental pain daily and cannot afford to buy dental insurance 
or pay for dental care out-of-pocket. The dental safety-net as well as 
charity dental care provided by dentists cannot solve the problem.
    Interest in the dental profession remains high and competition to 
enter dental school is robust. Several new dental schools are scheduled 
to open across the country to meet individual State workforce and 
access needs. This will exacerbate the current shortage of dental 
faculty to educate and train the future dental workforce. We face a 
crisis if resources are not dedicated to help recruit and retain 
faculty for the Nation's dental schools.
    ADEA suggests several straightforward steps that Congress can take 
to immediately address the challenges we face. The answers lie in 
prioritizing resources both in terms of manpower and funding to tackle 
these challenges. Some are fairly simple and pragmatic while others, 
admittedly, will require coordination among multiple interested parties 
and compromise. ADEA stands ready to work with Congress and our 
colleagues in the dental community to ameliorate the access to dental 
care problems the Nation faces and to meet the needs for the future 
dental workforce.
                              introduction
    The American Dental Education Association (ADEA) \1\ welcomes the 
committee's examination of issues related to the dental workforce and 
diversity of the profession. I am Dr. James Q. Swift, Professor and 
Director of the Division of Maxillofacial Surgery at the University of 
Minnesota School of Dentistry. I appear before you this morning as the 
President of ADEA and am honored to share my views with you.
---------------------------------------------------------------------------
    \1\ The American Dental Education Association (ADEA) represents all 
57 U.S. dental schools, 714 dental residency training programs, 285 
dental hygiene programs, 271 dental assisting programs, and 21 dental 
laboratory technology programs, as well as the faculty, dental 
residents and dental allied dental students at these institutions as 
well as 10 Canadian dental schools. It is at academic dental 
institutions that future practitioners and researchers gain their 
knowledge, the majority of dental research is conducted, and 
significant dental care is provided. Our member institutions serve as 
dental homes to thousands of patients, many of whom are underserved 
low-income patients covered by Medicaid and the State Children's Health 
Insurance Program.
---------------------------------------------------------------------------
    Profound disparities in the oral health of the Nation's population 
have resulted in a ``silent epidemic'' of dental and oral diseases 
affecting the most vulnerable among us. These disparities, in 
combination with the current shortage of dental school faculty, the 
scarcity of underrepresented minority dentists, and the need for 
targeted incentives to draw dentists to practice in rural and 
underserved communities, make this committee's examination timely and 
necessary.
    The challenge to Congress and the dental community is not only how 
to expand the capacity of the dental workforce, but also how to improve 
access to oral health care. According to Delta Dental Plans Association 
and the National Association of Dental Plans, 134 million Americans do 
not have dental insurance. The lack of insurance is a significant 
barrier to receiving needed preventive and restorative care. Having 
insurance, however, does not guarantee quick access to dental care; 
even insured Americans can wait weeks for appointments with their 
general dentists and/or specialists.
    Despite concerted efforts by Congress and the dental community to 
address access to dental care, there has been little genuine progress 
made since the untimely death of 12-year-old Deamonte Driver, 1 year 
ago. Deamonte was a young Maryland boy who died from infection caused 
by an abscessed tooth that spread to his brain. All of us know this 
tragedy could have been avoided if his Medicaid coverage had not lapsed 
and if he had had better access to dental care. I do congratulate 
Congress for having approved a guaranteed dental benefit in the bill to 
reauthorize the State Children's Health Insurance Program (SCHIP), even 
though the bill was twice vetoed. ADEA and the entire oral health 
community pledge to work for passage of this important bill in the next 
Congress.
        the dental and oral disease burden in the united states
    It has been 7 years since the first-ever U.S. Surgeon General's 
report \2\ was published which comprehensively examined the status of 
the Nation's oral health (Table 1 provides a summary of the report's 
major findings). The report identified oral health as integral to 
general health stating that ``Oral health is a critical component of 
health and must be included in the provision of health care and the 
design of community programs.'' It also declared that ``oral health is 
essential to the general health and well-being of all Americans.'' 
Unfortunately, millions are left wanting and needing dental care. There 
are ``profound and consequential oral health disparities within the 
population,'' the Surgeon General concluded, particularly among its 
diverse segments ``including racial and ethnic minorities, rural 
populations, individuals with disabilities, the homeless, immigrants, 
migrant workers, the very young, and the frail elderly.''
---------------------------------------------------------------------------
    \2\ U.S. Department of Health and Human Services. Oral Health in 
America: a Report of the Surgeon General. Rockville, MD: U.S. 
Department of Health and Human Services, National Institute of Dental 
and Craniofacial Research, National Institutes of Health, 2000.
---------------------------------------------------------------------------
    Over the past 55 years, discoveries stemming from dental research 
have reduced the burden of dental caries (tooth decay) for many 
Americans. However, the Surgeon General's report declared dental 
carries to be America's most prevalent infectious disease, five times 
more common than asthma and seven times more common than hay fever in 
school children. The burden of the disease, in terms of both extent and 
severity, has shifted dramatically to a subset of our population. About 
a quarter of the population now accounts for about 80 percent of the 
disease burden. Dental caries remains a significant problem for 
vulnerable populations of children and people who are economically 
disadvantaged, elderly, chronically ill, or institutionalized. This 
high-risk group includes nearly 20 million low-income children (nearly 
all are eligible for Medicaid or SCHIP). Early childhood caries is 
found in children less than 5 years of age. It is estimated that 2 
percent of infants 12-23 months of age have at least one tooth with 
questionable decay whereas 19 percent of children 2-5 years of age have 
early childhood caries in the United States.\3\ It should be noted that 
the American Academy of Pediatric Dentistry recommends that all 
children visit a dentist in their first year of life and every 6 months 
thereafter, or as indicated by the individual child's risk status or 
susceptibility to disease. ADEA concurs with this recommendation.
---------------------------------------------------------------------------
    \3\ Savage MF, Lee JY, Kotch JB. Early Preventive Dental Visits: 
Effects on Subsequent Utilization and Costs. Pediatrics 2004;(114)4.

      Table 1.--Major Findings of the U.S. Surgeon General's Report
------------------------------------------------------------------------
 
-------------------------------------------------------------------------
 Oral diseases and disorders in and of themselves affect health
 and well-being throughout life.
 Safe and effective measures exist to prevent the most common
 dental diseases--dental caries and periodontal diseases.
 There are profound and consequential oral health disparities
 within the U.S. population.
 More information is needed to improve America's oral health and
 eliminate health disparities.
 The mouth reflects general health and well-being.
 Oral diseases and conditions are associated with other health
 problems.
 Scientific research is key to further reduction in the burden
 of diseases and disorders that affect the face, mouth and teeth.
 Each year, millions of productive hours are lost due to dental
 diseases. Children miss 51 million hours of school due to treatment
 problems. Workers lose 164 million work hours because of dental
 disease.
 Lifestyle behaviors that affect general health such as tobacco
 use, excessive alcohol use, and poor dietary choices affect oral and
 craniofacial health as well.

              the u.s. population and the dental workforce
    The U.S. Bureau of Labor Statistics (BLS), which placed the number 
of practicing dentists at 161,000 in 2006,\4\ projects a 9 percent 
growth in the number of dentists through 2016. This rate would bring 
the total number of practicing dentists to 176,000.
---------------------------------------------------------------------------
    \4\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/
content/ocos072.stm, accessed February 5, 2008.
---------------------------------------------------------------------------
    About 80 percent of dentists are solo practitioners in primary care 
general dentistry while the remaining dentists practice one of nine 
recognized specialty areas: (1) endodontics; (2) oral and maxillofacial 
surgery; (3) oral pathology; (4) oral and maxillofacial radiology; (5) 
orthodontics; (6) pediatric dentistry; (7) periodontics; (8) 
prosthodontics; and (9) public health dentistry.

  Table 2.--Approximate Number of Dentists in the United States in 2006
------------------------------------------------------------------------
 
------------------------------------------------------------------------
General Dentists...........................................     136,000
Specialists:                                                     34,878
  Orthodontists............................................       9,400
  Oral and Maxillofacial Surgeons..........................       7,700
  Pedodontists.............................................       4,978
  Prosthodontists..........................................       3,300
  Periodontists............................................       5,100
  Endodontists.............................................       4,400
  Other dentists and specialists...........................       5,756

    The vast majority of the 176,634 professionally active dentists in 
the United States are White non-Hispanic. At the present time the U.S. 
population is 303,375,763. \5\ At the time of the last census, when 
there were 22 million fewer people, the largest segment of the U.S. 
population was White (75 percent) but an increasing percentage was 
minority with 35.3 million (13 percent) Latino, and 34.6 million (12 
percent) Black or African-Americans (see Table 3).
---------------------------------------------------------------------------
    \5\ U.S. Bureau of the Census, http://www.census.gov/population/
www/popclockus.html, February 5, 2008.

  Table 3.--U.S. Population by Race and Hispanic Origin for the United
                            States: 2000 \6\
------------------------------------------------------------------------
                                                              Percent of
     Race and Hispanic or Latino Number           Number         total
                                                              population
------------------------------------------------------------------------
Race:
  One race..................................     274,595,678        97.6
  White.....................................     211,460,626        75.1
  Black or African-American.................      34,658,190        12.3
  American Indian and Alaska Native.........       2,475,956         0.9
  Asian.....................................      10,242,998         3.6
  Native Hawaiian and Other Pacific Islander         398,835         0.1
  Some other race...........................      15,359,073         5.5
  Two or more races.........................       6,826,228         2.4
                                             ---------------------------
    Total population........................     281,421,906       100.0
                                             ---------------------------
Hispanic or Latino:
  Hispanic or Latino........................      35,305,818        12.5
  Not Hispanic or Latino....................     246,116,088        87.5
                                             ---------------------------
    Total population........................     281,421,906       100.0
------------------------------------------------------------------------
\6\ Source: U.S. Census Bureau, Census 2000 Redistricting (PL 94-171)
  Summary File, Tables PL1 and PL2, http://www.census.gov/prod/2001pubs/
  c2kbr01-1.pdf, February 5, 2008.

     dental hygiene, dental assisting, dental laboratory technology
    The allied dental workforce, comprised of dental hygienists, dental 
assistants and dental laboratory technologists, is central to meeting 
increasing needs and demands for dental care. About 167,000 \7\ dental 
hygienists, 280,000 \8\ dental assistants and 53,000 \9\ dental 
laboratory technologists were in the U.S. workforce in 2006. Both 
dental hygiene and dental assisting are among the fastest growing 
occupations in the country with expected growth of 30 percent and 29 
percent respectively through 2016 bringing the total numbers of dental 
hygienists to about 217,000 and dental assistants to 361,000. Only 
about 2,000 dental laboratory technologists will be added to the 
workforce by 2016. The ability to increase the number is limited. At 
the present time there are only 21 accredited training programs.
---------------------------------------------------------------------------
    \7\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/pdf/
ocos097.pdf, accessed February 5, 2008.
    \8\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/
ocos163.htm, accessed February 5, 2008.
    \9\ U.S. Bureau of Labor Statistics, http://www.bls.gov/oco/
ocos238.htm, accessed February 5, 2008.
---------------------------------------------------------------------------
    Dental hygienists are licensed professionals who perform a variety 
of clinical tasks while dental assistants work alongside dentists 
during dental procedures and provide assistance. However, both dental 
hygienists and assistants perform substantial routine preventive and 
certain other radiographic and treatment services in compliance with 
State practice acts. Dental laboratory technicians fill prescriptions 
from dentists for crowns, bridges, dentures, and other dental 
prosthetics and may specialize in one of five areas: orthodontic 
appliances, crowns and bridges, complete dentures, partial dentures, or 
ceramics.
                  dentist shortage or maldistribution
    Some say we have a dental shortage. Others say we have a 
maldistribution of dentists to meet the Nation's oral health needs. No 
matter how one defines it, there can be no doubt that there is a 
significant access problem for millions of Americans. We must 
acknowledge that the current dental workforce is unable to meet present 
day demand and need for dental care.
    If every man, woman and child were to have a dental home and were 
covered by dental insurance, then the Nation would clearly have an 
insufficient number of dentists to care for the population. We are not 
close to being at this point but we aspire to get there as quickly as 
possible so everyone who needs and wants dental care is able to achieve 
optimal oral health. The need and demand for dental services continues 
to increase; in large measure this is due to the population explosion. 
Also, Baby Boomers as well as the geriatric population, are retaining 
more teeth and there is a growing focus on increasing access and 
preventative dental care.
    Each year academic dental institutions (ADIs), including dental 
schools, allied dental programs and postdoctoral/advanced dental 
education programs), graduate thousands of new practitioners to join 
the dental workforce. About 4,500 predoctoral dental students graduate 
annually. About half of these new graduates immediately sit for a State 
licensure exam before beginning private practice as general dentists, 
or they join the military, the U.S. Public Health Service, or they 
advance their education in a dental specialty. Approximately 2,800 
graduates along with hundreds of practicing dentists apply to residency 
training programs. Nearly 23,000 allied dental health professionals 
graduate from ADIs each year and join the dental workforce. 
Approximately 14,000 dental hygiene students, 8,000 dental assistants, 
and 800 dental laboratory technologists graduate annually.
    According to the U.S. Surgeon General, the ratio of dentists to the 
total population has been steadily declining for the past 20 years, and 
at that rate, by 2021, there will not be enough active dentists to care 
for the population. The number of Dental Health Professions Shortage 
Areas (D-HPSAs) designated by the U.S. Health Resources and Services 
Administration (HRSA) has grown from 792 in 1993 to 3,527 in 2006. In 
1993, HRSA estimated 1,400 dentists were needed in these areas; by 
2006, the number grew to 9,164. Nearly 47 million people live in D-
HPSAs across the country. Although it is unknown how many of these 
areas can financially support a dentist or attract a dentist by virtue 
of their infrastructure or location, it is clear that more dentists are 
needed in these areas.
    Modified and updated criteria for Dental HPSAs designation has been 
in ``clearance'' at the U.S. Department of Health and Human Services 
for more than 2 years. At the present time the HPSA criteria require 
three basic determinations for a geographic area request: (1) the 
geographic area involved must be rational for the delivery of health 
services, (2) a specified population-to-practitioner ratio representing 
shortage must be exceeded within the area, and (3) resources in 
contiguous areas must be shown to be over-utilized, excessively 
distant, or otherwise inaccessible. HPSA designation is used by a 
variety of purposes by Federal programs. \10\
---------------------------------------------------------------------------
    \10\ Several Federal programs utilize the Federal HPSA designation 
in the administration of their programs including the National Health 
Service Corps and the U.S. PHS Grant Programs administered by HRSA-BHPr 
gives funding preference to title VII and VIII training programs in 
HPSAs.
---------------------------------------------------------------------------
                      need/demand for dental care
    Need for oral care is based on whether an individual requires 
clinical care or attention to maintain full functionality of the oral 
and craniofacial complex. The disproportionate burden of oral diseases 
and disorders indicates that specific population groups are in greater 
need of oral health care. Demand is generally understood as the amount 
of a product or service that users can and would buy at varying prices.
    Americans spent roughly $91.5 billion on dental procedures in 2006, 
the vast majority of this amount was paid out of pocket ($40.6 billion) 
or through private insurance ($45.3 billion) while $5.5 billion was 
paid through public programs, Medicare ($0.1 billion) and Medicaid/
State Children's Health Insurance Program ($5.3 billion). \11\ Mostly 
this was spent on fillings, crowns, implants, and high-end restorative 
procedures. The extent of oral health care disparities clearly 
indicates that many of those in need of oral health care do not demand 
oral health care.
---------------------------------------------------------------------------
    \11\ Catlin, Aaron, Cowan, Cathy et al., Health Spending in 2006, 
Health Affairs, 2008, 27 (1): page 14-29.
---------------------------------------------------------------------------
    Unfortunately millions of Americans experience dental pain daily 
and cannot afford to buy dental insurance or pay for dental care out-
of-pocket. Since few oral health problems in their early stages are 
life-threatening, people often delay treatment for long periods of 
time. Often, when they do seek care, it is hospital emergency rooms or 
others in the dental safety-net system--ADIs, community health centers, 
school-based clinics, and municipal clinics. This system of care is 
inadequate to effectively deal with the magnitude of the problem.
    Additionally, charity dental care provided by dentists cannot solve 
the problem. Each year, ADIs eagerly join with dentists in the 
community and others to participate in Give Kids a Smile Day, a 
national initiative by the American Dental Association to focus 
attention on the epidemic of untreated oral disease among disadvantaged 
children. The 5th annual Give Kids A Smile Day held on February 1, 2007 
provided care to 751,000 children at more than 2,000 locations across 
the country. Approximately $72 million in dentistry was provided at no 
charge to patients. Taking part were 14,315 volunteer dentists and 
38,000 others including dental school faculty and students. While this 
event is noteworthy for all care it provides, it is not a cure for the 
problem. State dental societies regularly organize Missions of Mercy in 
which thousands of people receive free care in temporary dental 
``hospitals'' and about 74 percent of dentists routinely provide free 
or discounted care to people who otherwise could not afford it. Charity 
has exceeded $1.5 billion annually. \12\
---------------------------------------------------------------------------
    \12\ American Dental Association, ``Insuring Bright Futures: 
Improving Access to Dental Care and Providing a Healthy State for 
Children'' statement to Energy and Commerce Committee hearing March 27, 
2007.
---------------------------------------------------------------------------
    While dental care demands are higher than many other health care 
demands, many people in the United States do not receive basic 
preventive dental services and treatment. Most oral diseases are 
preventable if detected and treated promptly. Preventative care is 
essential to contain costs associated with oral health care treatment 
and delivery. Children who have early preventive dental care are more 
likely to continue using preventive services. Those who wait to visit a 
dentist are more likely to visit for a costly oral health problem or 
emergency.
            access to care and academic dental institutions
    U.S. academic dental institutions are the fundamental underpinning 
of the Nation's oral health. As educational institutions, dental 
schools, allied dental education, and advanced dental education 
programs are the source of a qualified workforce, influencing both the 
number and type of oral health providers. U.S. academic dental 
institutions play an essential role in conducting research and 
educating and training the future oral health workforce. All U.S. 
dental schools operate dental clinics and most have affiliated 
satellite clinics where preventative and comprehensive oral health care 
is provided as part of the educational mission. All dental residency 
training programs provide care to patients through dental school 
clinics or hospital-based clinics. Additionally, all dental hygiene 
programs operate on-campus dental clinics where classic preventive oral 
health care (cleaning, radiographs, fluoride, sealants, nutritional and 
oral health instruction) can be provided 4-5 days per week under the 
supervision of a dentist. All care provided is supervised by licensed 
dentists as is required by State practice acts. All dental hygiene 
programs have established relationships with practicing dentists in the 
community for referral of patients.
    As safety net providers, ADIs are the dental home to a broad array 
of vulnerable and underserved low-income patient populations including 
racially and ethnically diverse patients, elderly and homebound 
individuals; migrants; mentally, medically or physically disabled 
individuals; institutionalized individuals; HIV/AIDS patients; Medicaid 
and State Children's Health Insurance Program (SCHIP) children and 
uninsured individuals. These dental clinics serve as a key referral 
resource for specialty dental services not generally accessible to 
Medicaid, SCHIP, and other low-income uninsured patients. ADIs provide 
care at reduced fees and millions of dollars of uncompensated care is 
provided each year.
      no professors--no profession: strains on academic dentistry
    The math is simple on this equation. There is an increasing need 
and demand for dental care. There is a current shortage of dental 
faculty to educate and train the future dental workforce. Several new 
dental schools are scheduled to open across the country to meet 
individual State workforce and access needs. We face a crisis if 
resources are not dedicated to help recruit and retain faculty for the 
Nation's dental schools.
    The number of vacant budgeted faculty positions at U.S. dental 
schools increased throughout the 1990s, with a peak of 358 positions in 
2000. Following this peak, the number of vacancies declined, falling to 
275 in 2004-2005. Since that time, there has been a rapid increase in 
the number of estimated vacancies, reaching 417 in 2005-2006, falling 
slightly to 406 in 2006-2007. Competition for this scarce resource of 
faculty will be exacerbated by the opening of new academic dental 
institutions across the country.
    At the present time there are 57 U.S. dental schools in 34 States, 
the District of Columbia and Puerto Rico. There are 714 dental 
residency training programs located in 44 States, the District of 
Columbia and Puerto Rico. There are 285 dental hygiene programs in all 
50 States and the District of Columbia, 271 dental assisting programs 
located in 47 States and Puerto Rico and 21 accredited dental 
laboratory technology programs located in 21 States.
    Growing demand for dental care in certain areas of the country has 
precipitated the opening of seven new dental schools. In 2003 the 
Arizona School of Health Sciences, the University of Nevada Las Vegas 
in 2002, and the Nova Southeastern University in Florida in 1997. 
Midwestern University in Glendale, AZ will open a dental school in 
August 2008 with an enrollment of 100 students per class. The dental 
school is part of Midwestern's expansion plan to address the State of 
Arizona's health care workforce shortages. Western University of Health 
Sciences in Pomona, CA plans to open a dental school in 2009. The 
University is in the preliminary phase of the accreditation process. 
The North Carolina State legislature plans to open a dental school at 
East Carolina University in Greenville, NC to focus on rural dentistry. 
The school plans to operate 10 student dental clinics in underserved 
communities throughout the State enrolling 50 students per class. Very 
recently New Mexico Governor Bill Richardson included funding in his 
fiscal year 2009 budget for construction of a facility at the 
University of New Mexico for a dental residency program and to begin 
planning for a new dental school.
               academic dental institutions and research
    Oral health is an important, vital part of health throughout life, 
and through dental research and education, we can enhance the quality 
and scope of oral health. Despite tremendous improvements in the 
Nation's oral health over the past decades, the benefits have not been 
equally shared by millions of low-income and underserved Americans. 
Dental research, the underpinning of the profession of dentistry, is 
needed to identify the factors that determine disparities in oral 
health and disease. Translational and clinical research is underway to 
analyze the prevalence, etiology, and impact of oral conditions on 
disadvantaged and underserved populations and on the systemic health of 
these populations. In addition, community- and practice-based 
disparities research, funded by the National Institute of Dental and 
Craniofacial Research (NIDCR) and the Centers for Disease Control and 
Prevention's Oral Health Programs, can help to identify and reduce 
risks, enhance oral health-promoting behaviors, and help integrate 
research findings directly into oral health care practice.
            applications, diversity and the dental pipeline
    Interest in the dental profession remains high and competition for 
first-year positions is robust. The application cycle for 2008 is still 
in process, but it appears that applicant to enrollee ratio is about 
3:1. The number of applicants increased from 4,644 in 1960 to 15,734 in 
1975, a dramatic increase of 239 percent. A precipitous decline 
followed that peak, falling to 4,996 in 1989. Applicants increased 97 
percent between 1989 and 1997, to 9,829; falling again over the last 2 
years to 9,010. First-year enrollments varied less during these time 
periods, increasing 76 percent between 1960 and 1978, from 3,573 to 
6,301. First-year enrollments declined then through 1989 to 3,979. 
Since 1989, first-year enrollment has increased nearly 20 percent.
    The number of African-American, Hispanic, and Native American 
students in dental schools remains disproportionate to their numbers in 
the U.S. population. In 2006, underrepresented minority (URM) students 
comprised 12.4 percent of the applicants and 11.6 percent of first-year 
enrollees. Asian/Pacific Islanders and whites comprised 69.7 percent of 
applicants and 71.1 percent of first-year enrollees. The proportion of 
URM applying and enrolling in U.S. dental schools is far less than the 
proportion of URM in the communities served by the dental school. For 
example, during the 2003-2004 academic year, 7 percent of dental 
students enrolled at the University of California Los Angeles and the 
University of Southern California were Hispanic, while 46.5 percent of 
the Los Angeles population were Hispanic. Also in 2003-2004, total 
African-American enrollment at all U.S. dental schools was 5.41 
percent, while 12.8 percent of the U.S. population were black. The 
proportion of URM dentists also remains significantly lower than the 
proportion of URM in the U.S. population. Currently, about 6.8 percent 
of professionally active dentists are URM, while 27.9 percent of the 
U.S. population are URM.
    Increasing diversity in the dental profession is vital to the 
future of the profession and it is central to achieving optimal oral 
health for racial and ethnic minority groups, which experience a higher 
level of oral health problems and have limited access to dental care. 
Recognizing that enrollment of underrepresented minorities (URM) had 
remained largely stagnant, ADEA has become actively engaged in 
supporting programs that bolster underrepresented minority recruitment 
and retention into dentistry and partnered with foundations and others 
to make headway:

     The ``Pipeline, Profession, and Practice: Community-Based 
Dental Education'' program sponsored by the Robert Wood Johnson 
Foundation (RWJF). This program has also been supported by the 
California Endowment and the W.K. Kellogg Foundation. The 5-year 
initiative launched in 2003 was to help increase access to oral health 
care. This program provided institutions with grants to link their 
schools to communities in need of dental care and to boost their URM 
and low-income (LI) student enrollment numbers. Dental Pipeline I 
successfully concluded with 15 dental schools participating. Dental 
students and residents in the program provided care to thousands of 
low-income patients through partnerships with 237 community-based 
clinics. The success of the first Pipeline has spurred the RWJF and the 
California Endowment to continue the program with Pipeline II, adding a 
mentoring portion to the curriculum. Awards will soon be announced.
     The ``Summer Medical and Dental Education Program 
(SMDEP)'' is a collaborative program administered by ADEA and the 
Association of American Medical Colleges and funded by the Robert Wood 
Johnson Foundation-RWJF. The program will run from summer 2006 through 
summer 2009 and offer academic enrichment for disadvantaged 
undergraduate freshmen/sophomores. The curriculum includes classes in 
organic chemistry, physics, biology and pre-calculus/calculus. Students 
gain learning and communication skills; get exposure to medicine and 
dentistry issues and get clinical exposure. Finally, students have a 
financial planning workshop to learn about financial strategies and 
issues. Nearly 1,900 students have participated (333 dental and 1,564 
medical). Seventy-one percent of the participants have been women, 48 
percent have been Black or African-American, 21 percent have been 
Hispanic or Latino, and two percent have been American Indian.
     ADEA has received a grant from the Josiah Macy, Jr. 
Foundation to increase the diversity of the dental workforce in the 
United States. ADEA is serving as the host organization and 
coordinating committee of the program entitled Moving Forward: Bridging 
the Gap. The grant funds the planning process to implement a flexible 
7-year dental curriculum, modeled after one currently used in medicine, 
to prepare a new cadre of underrepresented minority and low-income 
(URM/LI) students for the practice of dentistry. The program aims to 
move toward the implementation of a 7-year curriculum that will 
significantly increase the number of URM students that receive a dental 
education and then enter the workforce as dental school graduates.
         recommendations to address dental workforce challenges
    There are several straightforward steps that Congress can take to 
immediately address the challenges we face. The answer lies in 
prioritizing resources both in terms of manpower and funding to tackle 
these challenges. Some are fairly simple and pragmatic while others, 
admittedly, will require coordination among multiple interested parties 
and compromise. ADEA stands ready to work with Congress and our 
colleagues in the dental community to ameliorate the access to dental 
care problems the Nation faces and to meet the needs for the future 
dental workforce. Specifically, we recommend:
1. Strengthen and Improve Medicaid
    Early intervention is the key to assuring that children have good 
oral health. While children enrolled in Medicaid have a Federal 
guarantee for access to dental services through the Early Periodic 
Screening Diagnosis and Treatment program (EPSDT),\13\ accessing 
services is often difficult due to low reimbursement rates and the 
number of participating dentists. Other barriers include a lack of 
community-based oral health projects and public outreach. Unfortunately 
millions of children covered by Medicaid are not getting regular dental 
care. Many dentists decline Medicaid patients because of low 
reimbursement levels and complain about Medicaid paperwork. We urge 
Congress to work with States to increase reimbursement rates and to 
simplify and streamline the application, enrollment and recertification 
process for Medicaid, and lessen the administrative burden associated 
with this program. These actions would significantly increase access to 
care for children insured by Medicaid.
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    \13\ Medicaid statutes, P.L. 101-239, Section 6403, require that 
dental services for children shall at a minimum, include relief of pain 
and infection, restoration of teeth, and maintenance of dental health. 
Medicaid guarantees medically necessary services, including preventive 
dental care, under its EPSDT provision.
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    Children covered by Medicaid have access to excellent care. 
Medicaid regulations \14\ define dental as diagnostic, preventive, or 
corrective procedures provided by or under the supervision of a dentist 
in the practice of his or her profession, including treatment of: (1) 
the teeth and associated structures of the oral cavity and (2) disease, 
injury or impairment that may affect the oral or general health of the 
recipient.
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    \14\ 42 CFR 440.100.
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2. Include Dental Guarantee in SCHIP
    Congress can improve the Nation's oral health and increase access 
to dental care for vulnerable children covered by the State Children's 
Health Insurance Program (SCHIP) by: (1) Establishing a Federal 
guarantee for dental coverage in SCHIP; (2) Developing a dental wrap-
around benefit in SCHIP; (3) Facilitating ongoing outreach efforts to 
enroll all eligible children in SCHIP and Medicaid; and (4) Ensuring 
reliable data reporting on dental care in SCHIP and Medicaid. These 
objectives are supported by ADEA and the entire dental community and 
were strongly advocated during the recent congressional action on the 
Children's Health and Medicare Protection Act (H.R. 3162--CHAMP Act).
    Presently dental coverage is an optional benefit in SCHIP. Dental 
care sits atop the list of parent-reported unmet needs. For children 
with special needs dental care is the most prevalent unmet health care 
need surpassing mental health, home health, and all other services. 
Dental coverage is often the first benefit cut when States seek 
budgetary savings. SCHIP lacks a stable and consistent dental benefit 
that would provide a comprehensive approach to children's health while 
reducing costly treatments caused from advanced dental disease. 
Congress can help stabilize access to oral health care services by 
improving funding for the SCHIP program.
3. Establish Dental Homes for Everyone
    Ideally everyone should have a continuous and accessible source of 
oral health care--a dental home--established early in childhood and 
maintained throughout one's life. Having an established dental home 
makes oral health care accessible, continuous, comprehensive, 
coordinated, compassionate, and culturally effective. The dental home 
should be able to provide the following: (1) An accurate risk 
assessment for oral diseases and conditions; (2) An individualized 
preventive dental health program based on risk assessment; (3) 
Anticipatory guidance about growth and development issues; (4) A plan 
for emergency dental trauma; (5) Information about proper care of 
patients', infants' or children's teeth and soft tissues; (6) 
Information about proper nutrition and dietary practices; (7) 
Comprehensive dental care in accordance with accepted guidelines and 
periodicity schedules for general and pediatric dental health; and (8) 
Referrals to other dental specialists when care cannot be provided 
directly within the dental home.
4. Reauthorize and Fund the Dental Health Improvement Act
    The Dental Health Improvement Act (DHIA), championed by Senators 
Susan Collins and Russ Feingold, is up for reauthorization. The program 
assists States in developing innovative dental workforce programs. The 
first grants were awarded to States last Fall 2006 and are being used 
to increase hours of operation at clinics caring for underserved 
populations, to recruit and retain dentists to work in these clinics, 
for prevention programs including water fluoridation, dental sealants, 
nutritional counseling, and augmenting the State dental offices to 
coordinate oral health and access issues. Eighteen States were among 
the inaugural cohort awarded.
5. Establish a Dental Disproportionate Share (DDS) Program
    The capacity of ADI clinics to meet the needs of publicly insured 
and uninsured patients is compromised by inadequate payments from 
Medicaid and other Federal and State programs which threaten their 
financial viability as critical dental safety net providers. ADEA urges 
Congress to establish a Medicaid allotment for each State and territory 
that would be distributed in quarterly payments to qualified dental 
clinics operated directly by ADIs or those with an affiliation 
agreement with an ADI. Federal payments made to qualified clinics 
should require State matching funds. Qualified dental clinics would be 
required to have a pediatric Medicaid, SCHIP, and uninsured dental 
patient load equal to or more than a specified threshold compared to 
the total of their pediatric patients. Payments from the allotment 
would be based on a specified percentage of Medicaid payments for 
children's dental services in the previous quarter. ADEA is eager to 
explore this proposal with the committee.
6. Pass Deamonte's Law, H.R. 2371
    This legislation would authorize $10 million for two pilot programs 
that would greatly assist academic dental institutions and community 
health centers to address access issues. The bill calls for $5 million 
for grants to accredited dental education programs to support training 
that enhances and strengthens skills of dental students, dental 
residents and dental hygiene students in the provision of oral health 
care to children. Funding could be used to support continuing education 
for practicing dentists and dental hygienists in pediatric dentistry. 
Additionally, the bill would authorize $5 million for grants to 
federally qualified community health centers (CHC) to increase access 
to oral health care for patients seeking treatment. Funding could be 
used to hire dentists, purchase of dental equipment and construction of 
dental facilities. Also, funding could be used to support contractual 
relationships between CHCs and surrounding private practice dentists.
7. Pass the Essential Oral Health Act, H.R. 2472
    The legislation aims to improve the delivery of dental services 
through a variety of measures. It would provide each State an option to 
accept an increase in its Federal Medical Assistance Percentage rate 
for its dental Medicaid and SCHIP programs provided certain access to 
care provisions are met. States that increase the percentage of plan 
users and participating dentists will continue to receive the enhanced 
match. It would authorize grants to pilot the Community Dental Health 
Coordinator (CDHC) position which will work in underserved communities, 
in collaboration with health and community organizations and schools to 
provide community-focused oral health promotion. The CDHC will also 
connect residents with limited dental care access to dentists. The bill 
would authorize grants for volunteer dental programs by community-based 
organizations, State dental associations, dental schools, and hospitals 
with postdoctoral dental education programs to provide free dental care 
to underserved populations. Finally, the legislation would encourage 
dentists to provide additional donated dental services by providing a 
$5,000 tax credit for free and discounted services provided.
8. Pass the Special Care Dentistry Act
    This legislation introduced in previous Congresses aims to provide 
dental care to the most vulnerable citizens, poor children, aged, blind 
and disabled. This includes developmentally disabled and mentally 
retarded, disabled, the aged frail elderly and medically compromised 
elderly as well as medically compromised patients. Across the country 
there are approximately 31 million such patients. The bill would permit 
flexibility for States allowing them to either make provision for 
special care dentistry coverage through a State's existing EPSDT 
program or by creating a separate program for Aged, Blind or Disabled 
Adults.
9. Restore Dental Graduate Medical Education for Programs in Non-
        Hospital 
        Settings
    Congress should bolster support for dental residency training in 
both hospitals and non-hospital sites through Medicare Graduate Medical 
Education (GME). While all medical residency training positions are 
supported by Medicare GME only some dental residencies are. No dentist 
may practice a specialty without having first successfully completed 
residency training. The current number of positions and funding is 
woefully insufficient for all dental graduates to participate in a year 
of service and learning in an accredited program. ADEA encourages 
dental graduates to pursue postdoctoral dental education in either 
general dentistry, advanced dental education program or a dental 
specialty. To accommodate advanced education in general dentistry and 
specialties additional supported training positions are needed. Meeting 
this challenge would help to strengthen the dental workforce and would 
help provide access to care.
10. Make Dentistry Eligible for Title VII Administrative Academic 
        Units, Predoctoral Training, Faculty Development
    At the present time academic dental institutions are ineligible to 
compete for three important programs within the title VII primary care 
medicine and dentistry cluster; namely the Academic Administrative 
Units in Primary Care (AAU), Faculty Development in Primary Care (FD), 
and Predoctoral Training (PDTP) Programs. Congress should broaden 
eligibility to include dentistry and increase funding to accommodate 
this eligibility. In its November 2001 report to Congress, the HRSA 
Advisory Committee on Training in Primary Care Medicine and Dentistry 
(ACTPCMD) also recommended this modification.

     Academic Administrative Units in Primary Care grants 
establish and improve primary care units so that they are equal to 
other departments or divisions in the medical school. Resources may be 
used to enhance the ability of the primary care unit to significantly 
expand their primary care mission in teaching, research and faculty 
development. ADEA suggests general and pediatric dentistry and dental 
public health units be added within the dental school.
     Faculty Development in Primary Care grants help to plan, 
develop, and operate programs, and pay stipends, for training of 
physicians who plan to teach in family medicine, general internal 
medicine and general pediatrics training programs. Four grant types: 
Type I Primary Care Clinician Researchers; Type II Primary Care Master 
Educators; Type III Primary Care Community Faculty Leaders; and Type IV 
Community Preceptors. ADEA suggests training for dentists who plan to 
teach in general and pediatric dentistry and public health dentistry be 
added.
     The Predoctoral Training grants help to plan, develop, and 
operate or participate in predoctoral programs in family medicine, 
general internal medicine and general pediatrics. ADEA suggests that 
both general and pediatric dentistry and public health dentistry be 
added.
11. Maintain Support for Title VII General and Pediatric Dentistry
    Support for title VII programs is essential to expanding existing 
or establishing new general dentistry and pediatric dentistry residency 
programs. Title VII general and pediatric dental residency training 
programs have shown to be effective in increasing access to care and 
enhancing dentists' expertise and clinical experiences to deliver a 
wide range of oral health services to a broad patient pool, including 
geriatric, pediatric, medically compromised patients, and special needs 
patients. Title VII support increases access to care for Medicaid and 
SCHIP populations. The value of these programs is underscored by 
reports of the Advisory Committee on Training in Primary Care Medicine 
and Dentistry and the Institute of Medicine. Without adequate funding 
for general dentistry and pediatric dentistry training programs it is 
anticipated that access to dental care for underserved populations will 
worsen.
    General Dentistry and Pediatric Dentistry Residency Training 
programs are essential to building and the primary care dental 
workforce are effective in increasing access to care for vulnerable 
populations including patients with developmental disabilities, 
children and geriatric patients. These programs are safety net 
providers of oral health care and generally include outpatient and 
inpatient care and afford residents with an excellent opportunity to 
learn and practice all phases of dentistry including trauma and 
emergency care, comprehensive ambulatory dental care for adults and 
children under the direction of experienced and accomplished 
practitioners.
12. Restore Funding for Title VII Diversity Programs
    The only Federal programs whose goal it is to strengthen and 
diversify the health professions are the Title VII Centers of 
Excellence (COE) and Health Careers Opportunity Program (HCOP). These 
programs work in diverse communities to achieve this national goal. 
After several years of cuts to these programs saw small increases; 
however, they remain woefully underfunded. Congress should restore 
their funding to fiscal year 2005 levels.

           Table 4.--COE and HCOP Funding by Fiscal Year (FY)
                        [In millions of dollars]
------------------------------------------------------------------------
                                      FY 2005  FY 2006  FY 2007  FY 2008
------------------------------------------------------------------------
COE.................................      $35      $12   $11.88   $12.77
HCOP................................       33        4      3.9      9.8
------------------------------------------------------------------------

    These programs assist institutions in developing a more diverse 
applicant pool, establishing and strengthening the academic performance 
of under-represented minority students enrolled in health professions 
schools, improving institutional academic, research and library 
capacity, and enhancing pipeline efforts to undergraduate and pre-
college students. Also, HCOP makes grants to community-based health and 
educational entities to support student pipeline and other academic 
activities.
13. Limit Graduating Student Loan Debt Is Key to Access and Career 
        Choice
    Students are graduating from dental school with increasing amounts 
of educational debt. In 2007 the average for all graduates with debt 
averaged $172,627, those graduating from a public school averaged 
$148,777 while those graduating from private/State-related schools 
averaged $206,956. This level of debt places a great deal of pressure 
on new dentists. Many new graduates who wish to further their education 
in a specialty or general dentistry forgo the option. New dentists who 
might otherwise choose a career in the U.S. Public Health Service or 
Armed Forces shun the option. By virtue of the staggering debt new 
dentists have upon graduating, many seek practice opportunities in 
relatively affluent areas where they are likely to earn higher 
salaries. This cycle has repeated itself year after year leaving 
underserved areas chronically understaffed. Congress can alleviate the 
debt burden new dentists face upon graduating by doing the following:

    1. Restore nearly $50 million taken through rescissions from the 
title VII and VIII revolving health professions student loan programs 
\15\. These low-interest loan programs designed and authorized by 
Congress to address shortages in the health professions workforce help 
limit borrowing from higher cost private loan programs. No Federal 
funds are required to maintain these programs and they receive no 
annual appropriation, thereby posing no burden on taxpayers. They are 
funded with the interest from student/graduate repayment, creating a 
self-sustaining revolving fund designed by Congress to address 
shortages in the health professions workforce.
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    \15\ As part of the Labor-HHS-Education Appropriations for FY 2005 
and FY 2006, Congress rescinded the ``unobligated balances'' from the 
title VII and VIII student loan programs. Consequently, HRSA returned 
$21 million to the U.S. treasury in 2005 and $26.5 million in 2006. 
HRSA administers the loan programs authorized under Titles VII and VIII 
of the Public Health Service Act: (1) the Health Professions Student 
Loan (HPSL) program awards funds to accredited schools of dentistry, 
optometry, pharmacy, podiatric medicine, and veterinary medicine; (2) 
The Loans for Disadvantaged Students (LDS) program awards funds to HPSL 
and Primary Care Loan eligible students who are from a disadvantaged 
background as defined by HHS; (3) The Primary Care Loan (PCL) program 
awards funds to accredited schools of allopathic and osteopathic 
medicine for medical students who agree to enter and complete residency 
training in primary care within 4 years after graduation and practice 
in primary care for the life of the loan; and (4) The Nursing Student 
Loan (NSL) program awards funds to accredited schools of nursing under 
title VIII.
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    2. Increase the aggregate unsubsidized Stafford Loan limits \16\ 
that dental and medical students use. The current annual cap is $38,500 
while the aggregate is limited to $189,125. The cap forces dental and 
medical students into less favorable loan options such as the GradPLUS 
or private student loans. This needlessly drives up graduating debt.
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    \16\ The aggregate combined Stafford Loan limit for health 
professions should be adjusted to reflect the annual unsubsidized 
Stafford Loan limits. The aggregate combined Stafford Loan limit for 
health professions students has remained stagnant for over a decade, 
does not account for increases in annual unsubsidized Stafford Loan 
limits or reflect programs of different duration, and is not defined in 
regulation. The ``Deficit Reduction Act of 2005'' (DRA) increased the 
annual unsubsidized Stafford Loan limit for graduate/professional 
students from $10,000 to $12,000 (effective July 1, 2007). This 
increased the annual combined Stafford Loan limit from $18,500 to 
$20,500. Certain health professions students in 9-month and 12-month 
programs are eligible for an additional $20,000 and $26,667 in 
unsubsidized Stafford Loans per year, respectively. The current 
aggregate combined Stafford Loan limit for health professions is 
$189,125. The justification for this figure is defined in the Federal 
Student Aid handbook as: This increased aggregate loan limit would 
permit a student to receive the current maximum Stafford annual loan 
limits for 4 years of undergraduate study ($6,625 + $7,500 + $10,500 + 
$10,500) and 4 years of graduate/professional study ($18,500 x 4), plus 
the maximum increased unsubsidized loan limit for an academic year 
covering 9 months for 4 years of graduate/professional study ($20,000 x 
4). However, this current aggregate limit does not reflect the 
increased annual unsubsidized loan limits mandated by the DRA nor does 
it recognize the annual increases allowed for health professions 
students in 12-month programs.
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    3. Congress should immediately and permanently restore the Economic 
Hardship Deferment option that was eliminated when Congress passed the 
College Cost Reduction and Access Act.\17\
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    \17\ On September 27, 2007, President Bush signed the ``College 
Cost Reduction and Access Act'' (CCRAA, H.R. 2669, H. Rpt. 110-317). 
The measure included a change to the definition of economic hardship 
deferment, which has the potential to eliminate the pathway that most 
hospital-based dental residents as well as most medical residents use 
to qualify for the program. CCRAA changed the definition of economic 
hardship deferment. The new definition does not include the debt-to-
income pathway, which is the most common means by which hospital-based 
dental residents and most medical residents obtained eligibility. Under 
the new definition, a borrower's income cannot exceed the greater of 
either the minimum wage rate or 150 percent of the poverty line 
applicable to the borrower's family size. For an independent single 
student the maximum qualifying monthly income will be $1,276.
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14. Increase Access for Native American and Alaska Native Populations
    Congress should increase the award size for the Indian Health 
Service (IHS) loan repayment program and make both the loan repayment 
and the IHS scholarship programs tax free. By taking this action 
Congress would help to boost the number of dentists and other health 
care providers in Indian country. Eliminating taxation of IHS 
scholarship and loan repayment programs would be equivalent to 
increasing the programs' appropriations substantially without costing 
any additional money. Equalizing the programs will enhance the IHS 
competitiveness for health care providers seeking loan repayment in 
exchange for service in eligible sites. The current playing field 
between IHS and the National Health Service Corps and Department of 
Defense scholarship and loan repayment programs \18\ are not 
competitive. Also, unlike other Federal scholarship and loan repayment 
programs, IHS scholarship stipends are subject to income and FICA 
taxation so the IHS pays up to 20 percent of Federal taxes directly to 
the Internal Revenue Service (IRS). As a result in fiscal year 2006 IHS 
withheld 27.65 percent of each scholarship recipient's stipend to pay 
taxes. An additional 7.65 percent of the IHS contribution to the FICA 
tax also comes from the scholarship program funds. IHS had to use $2.3 
million (17.5 percent) of its fiscal year 2006 appropriation to pay 
taxes rather than award scholarships to deserving NA/IA health 
professions students.
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    \18\  P.L. 107-16, Section 413, the Economic Growth and Tax Relief 
Reconciliation Act of 2001, which provides for the scholarship 
programs, and P.L. 108-357, Section 320, the American Jobs Creation Act 
of 2004, provides for the loan repayment programs.
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15. Prioritize Dental Access in Rural Health Clinics
    Delivery of health care in rural America is changing rapidly; 
however, one thing remains constant: rural communities across America 
rely on rural health clinics to provide care to everyone including 
those who are uninsured or underinsured. Full-service community 
hospitals in rural areas are safety net providers providing basic 
health services but often oral health care is unavailable. To improve 
the oral health status of rural America, Congress should incentive 
rural health clinics to add preventive and restorative dental services 
to the list of core services they provide on-site or under arrangement.
16. Increase Funding for Dental and Craniofacial Research and 
        Disparities Research
    Funding for dental research must be both reliable and increased. 
Oral health researchers funded by the National Institute of Dental and 
Craniofacial Research (NIDCR) have built a base of scientific and 
clinical knowledge that has been used to improve oral health. NIDCR is 
the only Institute within the NIH that is committed to oral health 
research and training. Institute-sponsored research continues to link 
oral infection to such systemic diseases as diabetes, cardiovascular 
disease (heart attack and stroke) and adverse pregnancy outcomes (pre-
term birth and low-birth weight). Dental research is advancing 
investigations in bone formation and craniofacial development, 
treatment of facial pain, salivary gland disorders. The Institute 
remains the primary public agency that supports dental behavioral, 
biomedical, clinical, and translational research. Research is needed to 
identify the factors that determine disparities in oral health and 
disease. These factors may include proteomic, genetic, environmental, 
social, and behavioral aspects and how they influence oral health 
singly or in combination. Translational and clinical research is 
underway to analyze the prevalence, etiology, and impact of oral 
conditions on disadvantaged and underserved populations and on the 
systemic health of these populations. In addition, community- and 
practice-based disparities research, funded by the NIDCR and the 
Centers for Disease Control and Prevention's Oral Health Programs, can 
help to identify and reduce risks, enhance oral health-promoting 
behaviors, and help integrate research findings directly into oral 
health care practice.
17. Bolster Prevention to Eradicate Dental Caries
    Congress could make great strides in reducing dental caries if they 
focused on preventive strategies that can save millions of dollars. The 
cost of providing restorative treatment is much higher than providing 
preventive services. Among the most immediate and effective strategies 
would be to establish a national water fluoridation standard. This is 
the best and safest public health measure to prevent dental disease. 
The CDC reports that approximately one-third of Americans lack access 
to a community fluoridated water supply. Other strategies to reduce 
dental caries include: (1) applying pit and fissure sealants (plastic 
coating that are applied to the grooves and fissures of primary and 
permanent teeth) to patients at high-risk for dental caries. Only 18.5 
percent of children have at least one sealed tooth. A nationally based 
dental sealant program in the public schools is an ideal way to deliver 
cost-effective services to children; (2) increasing dietary and hygiene 
counseling for patients at high-risk for dental caries; and (3) 
professionally applying topical fluoride 1-2 times annually for 
patients at high-risk for dental caries.
    The Centers for Disease Control and Prevention (CDC) found that 
delivering sealants to all children attending low-income schools was 
the most cost-effective strategy in significantly reducing as child's 
risk of having untreated dental disease. Combining oral health 
promotion and education with prevention strategies will improve the 
oral health of children who are at a higher risk for dental disease. 
Almost as importantly, these programs save money. Delta Dental, a 
private dental insurer estimates that preventive care, early detection, 
and treatment of oral health conditions save $4 billion annually in the 
United States. According to the Children's Dental Health Project, 
dental costs for children who receive preventative dental care early in 
life are 40 percent lower than costs for children whose oral health is 
neglected. The American Dental Hygienists Association estimates that 
for every $1 spent on prevention in oral health care, $8 to $50 are 
saved on restorative and emergency dental procedures.
18. Adequately Fund the Centers for Disease Control and Prevention 
        (CDC) Division of Oral Health
    Congress should continue to support this important program. The 
Centers for Disease Control and Prevention Oral Health Program expands 
the coverage of effective prevention programs by building basic 
capacity of State oral health programs to accurately assess the needs 
in their State, organize and evaluate prevention programs, develop 
coalitions, address oral health in State health plans, and effect 
allocation of resources to the programs. CDC's funding and technical 
assistance to States is essential to help oral health programs build 
capacity.
                               conclusion
    In conclusion, I thank the committee for considering ADEA's 
recommendations with regard to addressing access to dental care and 
dental workforce issues. A sustained Federal commitment is needed to 
meet the challenges oral disease poses to our Nation's citizens 
including children, the vulnerable and disadvantaged. Congress must 
address the growing needs in educating and training the oral health 
care and health professions workforce to meet the growing and diverse 
needs of the future. ADEA stands ready to partner with you to develop 
and implement a national oral health plan that guarantees access to 
dental care for everyone, eliminates oral health disparities, bolsters 
the Nation's oral health infrastructure, eliminates academic and dental 
workforce shortages, and ensures continued dental health research. I am 
happy to answer any questions you may have.

    Senator Sanders. Dr. Swift, thank you very much.
    Bruce Auerbach, M.D., is President-Elect, Massachusetts 
Medical Society, Vice President and Chief of Emergency Medicine 
at Sturdy Memorial Hospital in Attleboro, MA. Dr. Auerbach, 
thanks very much.

      STATEMENT OF BRUCE AUERBACH, M.D., PRESIDENT-ELECT, 
  MASSACHUSETTS MEDICAL SOCIETY, VICE PRESIDENT AND CHIEF OF 
  EMERGENCY MEDICINE, STURDY MEMORIAL HOSPITAL, ATTLEBORO, MA

    Dr. Auerbach. Thank you, Senator Sanders and members of the 
committee, for allowing us to be here and participate in this 
very important hearing.
    We are all in agreement today that unless we take the 
necessary steps to increase the number of physicians, 
particularly those going into primary care, our goal to 
increase access to quality healthcare and reduce costs will 
fail.
    As Senator Sanders mentioned earlier, even if we 
instantaneously snapped our fingers and had universal 
healthcare tomorrow, that would not solve the access problem. 
The experiment that we are doing in Massachusetts proves that. 
We are adding hundreds of thousands of residents that were 
previously uninsured into the system. It has really not done 
anything except worsen the primary care shortage or the 
perception of the primary care shortage.
    The Massachusetts Medical Society has chronicled for 
several years the deterioration in the workforce in 
Massachusetts. During the last 2 years, we experienced for the 
first time critical shortages to severe shortages in primary 
care. Primary care physicians have a unique role in managing 
and coordinating care. When you consider that all of the 
national studies have shown that the healthcare systems that 
provide the best and lowest cost care to those with the most, 
are those with the most robust primary care systems, the 
imperative is clear.
    I would like to make three main points that, hopefully, we 
will discuss more fully. National and State data confirm that 
we are in or at least on the verge of a primary care crisis. 
The critical role of these physicians in providing cost-
effective quality care is without dispute. The key focus of 
much of our work in Massachusetts, as we implement our new 
State law, is to correct this issue.
    Second, the title VII program is one of the only federally 
funded programs designed specifically to increase the number of 
primary care providers, particularly in underserved areas. Our 
experience in Massachusetts, confirmed by national data, shows 
that these dollars have been very effective in training 
physicians who continue to practice in community health centers 
and underserved areas. It is essential that title VII be 
reauthorized and well funded.
    There are several steps the Federal Government could take 
to address these issues and two I would like to highlight. 
First, a more accurate count of full-time practicing 
physicians. Current databases rely on the number of medical 
licenses and misrepresent the number of physicians taking care 
of patients full time. Second, we need to have a focus on 
medical student debt relief and other financial incentives for 
physicians--or students who pursue primary care.
    I thank you very much and I'm looking forward to working 
with you on this issue.
    [The prepared statement of Dr. Auerbach follows:]
               Prepared Statement of Bruce Auerbach, M.D.
    Good Morning. I am Dr. Bruce Auerbach, President-Elect of the 
Massachusetts Medical Society and Vice President and Chief of Emergency 
and Ambulatory Services at Sturdy Memorial Hospital in Attleboro, MA. 
It is my distinct pleasure to represent the Massachusetts Medical 
Society at today's hearing on the ``Health Care Workforce Shortages for 
the Future'' and reauthorization of Title VII of the Public Health 
Services Act. The Massachusetts Medical Society represents over 19,000 
physicians, students and residents and is dedicated to improving the 
health and welfare of the residents of the Commonwealth.
    At the outset I want to emphasize the fundamental importance of the 
title VII program and why we at the Massachusetts Medical Society 
believe these programs are imperative to achieve our overall goal of 
universal access to quality health care for all Americans. The title 
VII program is one of only two federally funded programs specifically 
designed to increase the number of primary care physicians and 
providers, particularly in underserved areas. The importance of the 
primary care physician in the medical home is without dispute. There is 
strong evidence to demonstrate the effectiveness of physicians who 
provide first contact, comprehensive, longitudinal care, and 
coordination of care. Countries with strong primary care systems have 
lower health care costs than those with weaker primary care systems. In 
this Nation we know that States with more primary care resources tend 
to mirror these lower costs and have better health care outcomes.
    And yet at a time when health care reform is a priority on national 
and State agendas, and efforts to increase access to care are 
intensifying, we face burgeoning shortages of physicians, including 
primary care physicians. The American College of Physicians recently 
warned that ``primary care, the backbone of the Nation's health care 
system, is at grave risk of collapse.'' (Bodenheimer, ``Primary Care--
Will It Survive? NEJM August 31, 2006) (Appendix I) It is a fundamental 
truth--which we are learning the hard way in Massachusetts--
comprehensive health care reform cannot work without appropriate access 
to primary care physicians and providers. In this context it is clear 
that the need for title VII funds is perhaps even greater than when the 
program was originally conceived. When you consider that all the 
national studies have shown that the health care systems providing the 
best and lowest cost care to their populations are those with the most 
robust primary care systems, the imperative is clear.
    My testimony today will focus on three areas: (1) outlining the 
primary care crisis in Massachusetts and our efforts to address this 
problem; (2) review the successes and history of title VII programs and 
the impact on primary care, including community health centers; and (3) 
share our recommendations for title VII and related programs.
           i. primary care crisis--massachusetts perspective
    For nearly a decade the Massachusetts Medical Society has 
systematically studied and documented changes in our physician 
workforce and medical practice environment. The need for this data was 
clear. While our physicians and patients reported increasing stresses 
to the system, others maintained that the Commonwealth suffered from an 
oversupply of physicians. To this end the Massachusetts Medical 
Society, in consultation with outside consultants, initiated two annual 
studies that profile changes in the medical practice environment and 
physician workforce.
    The first of these two studies, the Physician Practice Environment 
Index report (Appendix II) was first published in 1997 and is a 
statistical indicator of nine selected factors that impact the delivery 
of patient care in Massachusetts and the United States. The indicators 
are as follows:

    1. Applications to medical schools,
    2. Percent of physicians over 55 years of age,
    3. Median physician income levels,
    4. Ratio of median housing prices to median physician income,
    5. Mean number of hours spent on patient care activities,
    6. Physician cost of doing business,
    7. Number of visits per emergency department,
    8. Change in average malpractice rates, and
    9. Number of advertisements for physician employment in the New 
England Journal of Medicine.

    This year's report published in April 2007 shows a decline in the 
Massachusetts medical practice environment for the 13th consecutive 
year. Further, the rate of deterioration in Massachusetts was 26 
percent faster than in the United States as a whole over the 14-year 
period from 1992-2006. This lengthy deterioration is one principle 
cause of accelerating physician shortages and reflects the growing 
imbalance between high costs of medical practice relative to a low rate 
of reimbursement in a State dominated by managed care. This economic 
imbalance is particularly harmful to primary care practices where 
revenues are historically proportionally much lower than costs.
    The second report, The Massachusetts Medical Society Physician 
Workforce Study (Appendix III) was developed with the input of 
prominent labor economists and chronicles changes in physicians supply. 
In addition to ongoing shortages in several specialties, the 2007 
Workforce Report shows severe to critical shortages in primary care for 
the second year in a row. The impact of shortages in primary care 
physicians is of great concern given the unique role primary care 
physicians serve in managing individual patient care.
    Among its findings, the study found that in 2006, 53 percent of 
patients were able to see primary care physicians within a week of 
contacting the physicians. In 2007, however, that rate dropped to 42 
percent. Moreover, 17 percent of survey respondents with a serious, but 
not life threatening medical problem say the wait for a doctors 
appointment was a problem in 2007, an increase of 7 percent from 2006. 
Hospitals and physician practices report increasing delays in their 
ability to recruit or retain primary care providers. In my own 
community, where I am on the Board of the large multispecialty group 
practice, the time to recruit primary care physicians has doubled and 
tripled in the last 5 years. The impact of the shortages on patients 
and physicians ability to provide quality care is multifold. In 
addition to significantly longer waiting times, physicians are forced 
to see many more patients in less time.
    The Massachusetts Medical Society workforce study concluded ``The 
task before those concerned about workforce issues is to educate 
policymakers about how changes in the physician workforce will affect 
cost, access and quality and impress upon them that serious efforts to 
promote quality of care and reduce costs will not be effective unless 
qualified physicians are there to provide care.'' Taking heed of this 
statement is more important than ever as Massachusetts implements 
universal health care and attempts to provide affordable insurance to 
hundreds of thousands of previously uninsured residents.
    These numbers are reflected nationally. The 2006 American Academy 
of Family Physicians Workforce study reports that in 2005 there were 
31.2 family physicians per 100,000 people in the United States. The 
study found that meeting the Nation's anticipated need for primary care 
in 2020 will require a workforce of 139,531 family physicians, or a 
ratio of 41.6 family physicians per 100,000 people. To achieve the 2020 
target, the AAFP concluded that 3,725 family physicians will need to be 
produced annually by ACGME-accredited family medicine residencies and 
714 annually by AOA-accredited family medicine residencies. As such, 
the typical ACGME-accredited family medicine residency would need to 
expand from an average of 21.7 residents to 24 residents.
    Portending worse shortages for the future, the AAMC reported the 
number of family medicine residency positions available in the 2007 
Match (2,603) continued to decline this year--100 fewer positions 
available than in 2006, and more than 500 fewer than were available in 
the 2000 Match. As the following charts dramatically illustrate, the 
escalating trend with resident's choices over the past 8 years has been 
away from primary care.


    It is important to underscore that the impact of shortages in 
primary care physicians is exacerbated in terms of their impact on 
community health centers. Like most health care providers, 
Massachusetts' community health centers are facing staffing shortages 
of primary care physicians and non-clinical staff. The Massachusetts 
League of Community Health Centers estimates that a total of 100 
physicians will be required in the current year to meet the needs of 
existing patients as well as newly insured patients seeking care at 
community health centers under health care reform. That number is 
expected to be the same in each of the next 2 years. At the national 
level a 2006 JAMA Article, Shortages of Medical Personnel at Community 
Health Centers, concluded that while primary care physicians 
constituted 89 percent of physicians working in Community Health 
Centers, there were 428 vacant funded full-time equivalent for family 
physicians and 376 vacant FTEs for registered nurses. There were 
vacancies for 13.3 percent of family physicians positions, 20.8 percent 
of obstetrician's gynecologist's positions and 22.6 percent for 
psychiatrists. Of particular note, the study concluded that physician 
recruitment in CHS was heavily dependent on National Health Service 
Corps scholarships, loan repayment programs and international medical 
gradates with J-1 visa waivers.
    While a number of factors contribute to the primary care shortages, 
most agree that rising medical student debt is particularly formidable 
to those interested in practicing primary care. The AAMC reports that 
in 2006 medical school graduates owed on average about $130,000, with 
estimates for Massachusetts medical schools estimated to be about 10 
percent higher. This figure is expected to increase as both private and 
public institutions face increasing costs in all areas, and 
accordingly, must raise tuitions. Median tuition and fees for the 
school year ending in 2004 increased 5.7 percent at private schools 
over the previous year, and 17.7 percent at public institutions. The 
burden of medical school debt, coupled with undergraduate debt, 
compounded by interest rates is a significant detriment to primary care 
where predicted revenues are 30 percent lower than the mean.
    The Massachusetts Medical Society is working on a number of 
initiatives to address the primary care shortage and to better 
understand factors influencing medical student's decision as to career 
choice. The previously referenced NEJM article also noted that it is 
generally believed that lifestyle concerns also play a role, as primary 
care physicians often experience heavy loads of after hours call with 
little or no reimbursement. Furthermore it notes that primary care 
physicians typically receive less reimbursement both in terms of 
resources and prestige when compared to specialists. On the global 
level, it is clear that reimbursement reform for primary care 
physicians will be necessary to allow for financial stability for these 
practices. In addition to increasing reimbursement, payment methodology 
should reflect the nature and value of primary care practices which are 
based on cognitive skills, longitudinal management and prevention.
    At the State level, the Massachusetts Medical Society is currently 
surveying medical students to determine the factors which most 
influence their decision in choosing a specialty or primary care. The 
Massachusetts Medical Society is also working closely with the State 
Commission on Workforce, Secretary of Heath and Human Services Bigby, 
and Mayor of the City of Boston Thomas Menino on various task forces 
and commission to develop recommendations to address the primary care 
problems. The Massachusetts Medical Society supports legislation that 
was recently reported out of committee (House Bill 4514) which will 
provide loan forgiveness for physicians choosing to practice primary 
care. The Medical Society has proposed amendments which are referenced 
in my attached testimony (Appendix III). Internally the Medical Society 
has convened several internal workgroups to focus on physician's 
shortages, primary care shortages and medical student debt relief.
       ii. title vii: health professions education assistance act
    Since 1978, the Bureau of Health Professions, via section 747 of 
title VII, has been a critical source of support for medical education 
in primary care. In fact, given the absence of a Center for Primary 
Care at the NIH, relatively small and static funding at AHRQ, and 
ongoing decreases in Medicare GME reimbursement, Title VII is one of 
the only outside sources of funding to stimulate medical education, 
residency education, faculty development, and academic development in 
Primary Care. Title VII funds are often currently linked to training 
physicians to work in underserved communities. Several programs in 
Massachusetts are recognized as leaders in the training of medical 
students and residents within federally funded Community Health 
Centers--an important goal of title VII programs. These include: (1) 
the Family Medicine Residency at Boston University Medical Center which 
utilizes Community Health Centers to train residents, (2) University of 
Massachusetts Medical School in Worcester which enjoys a national 
reputation for its development of education/service models within 
federally funded CHC's; and (3) the Greater Lawrence Family Health 
Center which is the only Community Health Center in the country that 
serves as the primary sponsor of a Family Medicine Residency Program.
    Community Health Centers play a vital role in ensuring access to 
health care and are a priority for health care reform initiatives. 
There are 52 non-profit community health centers in Massachusetts which 
serve one out of nine (700,000) State residents. In 2006, these health 
centers provided more than 3 million outpatient visits. Massachusetts 
health centers care for patients of all ages and racial and ethnic 
backgrounds, and represent a major source of care for medically 
underserved women and children. Health center patients are 
disproportionately low-income, publicly insured or uninsured, and are 
at higher risk for contracting chronic and complex diseases. There are 
dozens of national studies which document the cost effectiveness and 
quality of care provided by community health centers.
    While the Federal Government has made significant investments in 
the growth of Community Health Centers, as noted previously, it has not 
made a companion investment in the training of physicians who work in 
these health centers (Rosenblatt et al., Shortages of Medical Personnel 
at Community Health Centers). There are significant data to show that 
title VII funding has a direct impact on Community Health Center 
staffing. As the following chart details, medical schools and primary 
care residency programs funded by title VII, section 747 
disproportionately serve as the medical education pipeline that 
produces physicians who go on to work in CHCs and participate in NHSC. 
This finding is particularly true among family physicians.


    The authors of this study concluded that exposure to Title VII, 
Section 747, funds during medical school is strongly associated with 
subsequent work in community health centers. Almost 4,000 family 
physicians and general practitioners were exposed to title VII funding 
during medical school and subsequently chose to work in a CHC. If these 
physicians had not been exposed to title VII funds the authors 
anticipate over 750 fewer family physicians would have been working in 
a CHC in 2003. A recent JAMA article (March 1, 2006) shows currently 
600 vacancies for family physicians in CHCs. Without title VII dollars 
we would expect there to be twice as many vacancies. These are 
conservative estimates: data are from Medicare so pediatrics is 
underrepresented.
    The same finding applied to the impact of title VII funds during 
medical school on participation in the National Health Service Corps. 
This association is true for all physicians, but it is even stronger 
among primary care physicians, family physicians and general 
practitioners. As the following chart details, almost 2,500 family 
physicians were exposed to title VII funding during medical school and 
subsequently participated in the National Health Service Corps. Without 
title VII funding, it is expected that only 350 physicians have served 
in the NHSC.


                          massachusetts models
    As noted previously, several primary care training programs in 
Massachusetts receive title VII funds. The successes of the 
Massachusetts programs in training family physicians who demonstrate a 
long-term commitment to practicing in a community health setting are 
significant and dramatic. The impact of these programs coupled with the 
national data should dispel any debate as to the efficacy and import of 
title VII funds.
University of Massachusetts Medical School (Worcester)
    Learning contract: Since graduating its first class in 1974, the 
University of Massachusetts Medical School has maintained a Learning 
Contract that provides for partial tuition waivers for medical students 
who agree to: (1) return to Massachusetts to practice a Primary Care 
specialty, or (2) return to Massachusetts to practice a specialty with 
a focus on providing care for vulnerable populations. Failure to do so 
triggers a payback.
    Training in underserved communities produces physicians who 
practice in underserved communities: In 1976, Umass established the 
State's first Family Medicine training program, which graduated 454 
Family Physicians through 2005, training in four tracks--a Community 
Health Center (Family Health Center of Worcester), a rural health 
center (Barre Family Health), an urban site (Hahnemann Family Health 
Center), and a small urban area (Fitchburg Family Practice). The 
results from the program are impressive.

     50 percent of graduates have remained to practice in 
Massachusetts; 65 percent practice in New England;
     44 percent of graduates from the CHC track went on to 
practice in a Health Professions Shortage Area (HPSA); and
     Graduates from the rural training site are more likely to 
practice in a rural area.

    Recent approach.--Establishment of an Office for Primary Care: In 
2007, UMass Medical School and UMass Memorial Health Care established 
an Office for Primary Care. This office is charged with ensuring that 
the hospital system and the medical school will maintain a robust 
primary care network. Strategies include:

     Program development to stimulate student interest in 
primary care careers;
     Working with payers to Develop new models for primary care 
practice that enhance quality while improving both patient and 
physician satisfaction;
     Developing a longitudinal curriculum devoted to quality 
improvement in patient safety (funded through title VII). This first-
of-a-kind project will impact curricula across all 4 years of the 
medical school, the residency programs at the three primary care 
disciplines, and will provide training programs for primary care 
attendings, physicians, and faculty who interact with students and 
residents on a regular basis.
Greater Lawrence Family Health Center
    Using title VII funds, the Greater Lawrence Community Health Center 
teamed up with Lawrence General Hospital to sponsor the first community 
health center residency program in the country. At the time Lawrence 
was considered one of the most underserved communities in the State 
with a severe shortage of primary care physicians. At that time the 
Community Health Center took care of about 10,000 to 12,000 patients 
out of community of 75,000. Using title VII primary care funds, the 
Community Health Center partnered with Lawrence General Hospital for a 
unique residency program. As a result of their partnership the 
Community Heath Center sees about 45,000 patients and is no longer 
considered an acutely underserved area. The infant mortality rate in 
Lawrence, once in the high teens, has now been dramatically reduced to 
single digits, even though the risk factors for infant mortality 
continue. In terms of workforce issues, about half of the physicians 
from the program have continued to work at the Community Health Center, 
while the other half have continued their work for the underserved in 
other areas. The success of the program and the collaboration between 
the Hospital and Community Health Center was cited by then-Secretary of 
HHS Donna Shalala as a national model.
Family Medicine Residency at Boston University Medical Center
    The Family Medicine Residency at Boston University Medical was 
established in 1997 with funding from title VII grants which have been 
critical to its success. By establishing and maintaining a strong link 
between the residency programs, hospital and community health canter, 
this program has significantly increased the number of family 
physicians who practice in the community health centers, while 
improving coordination and access to care between the hospital and 
centers. The BU program currently provides inpatient services for 12 of 
the 15 Health Net community centers with each attending providing care 
to about 40 to 50 patients at any one time. Their physicians provide 
inpatient services for about half of the ob-gyn and nursery where 
overall deliveries have increased from about 1,600 to 28,000, mostly 
from community health center patients. In one center, these physicians 
also serve as hospitalists throughout the year, thus allowing the 
physicians to continue to care for their patients during their 
hospitalization. Although the acuity of these patients' illness is 
generally more severe, the length of stay for their patients is about a 
3.4 day shorter. The advantage of this approach is significant--two 
thirds of the graduates who have trained in this program either 
practice in a community health center in Massachusetts or elsewhere. By 
linking the community health centers with the hospital, the program has 
arguably improved the quality of care provided while increasing the 
physician's satisfaction that care for their patients throughout the 
continuum. From a policy perspective it is significant, that these 
programs graduate family physicians that stay committed to primary care 
and choose to practice in needed areas.
                          iii. recommendations
    As noted previously there are a number of barriers to increasing 
the number of primary care physicians. These recommendations focus on 
efforts specific to title VII and boarder policy areas.
1. Reauthorize Title VII With Significant Increases
    Absent reauthorization in the past several years, title VII 
programs have experienced a decrease in funding. For example, in fiscal 
year 2005 Massachusetts received $3,558,576 in Section 747 Primary Care 
Grants. In fiscal year 2006, funding was reduced by $1,992,863 for a 
total of $1,565,713. Given data to show the positive impact of these 
programs, and the growing shortage of primary care providers, we 
recommend that Congress reauthorize the title VII programs with 
increases commensurate with the projected needs.
2. Improved Methodology To Determine Number and Location of Practicing 
        Physicians
    Surprisingly one of our biggest challenges continues to be the 
creation of a national data base that records the number of practicing 
physicians in each State and location of their practice. It is our 
understanding that current Federal data bases which are used for these 
designations count the number of physicians with medical licenses. 
These figures do not accurately reflect those physicians who actively 
practice medicine on a full-time basis and the true number of hours 
devoted to patient care. Thus, in areas such as Massachusetts with a 
significant number of academicians and researchers, the data base is 
grossly misleading. An additional flaw is that the information may 
reflect a physicians' homes address, as opposed to where he/she 
practices medicine, further compounding the problem of accurately 
defining underserved areas. Reliable data bases will require better 
coordination with State and county medical societies to ensure accuracy 
and timeliness of the information.
    While Medicare has created a number of shortage designations we 
believe eligible counties are not being recognized given the faulty 
data base. When the Medicare Modernization Act created new categories 
for physicians' shortages, compared to the number of Medicare 
beneficiaries, we were stunned that several counties in Massachusetts 
did not qualify. One area was on the Cape, where the percentage of 
Medicare beneficiaries to physicians is very high and waiting times to 
see a physician were becoming legendary. In our experience, the 
national data base was seriously outdated and based on the licensed, as 
opposed to practicing physicians, in the area. It was only after 
several attempts and a great deal of grassroots work by the 
Massachusetts Department of Public Health and the local hospital--
literally calling physicians to determine how many hours they practiced 
and where their office was located--did the region qualify for national 
shortage dollars. Our experience suggested this problem was not unique.
3. New Approach To Defining Shortage Areas
    Given the growing shortages of primary care physicians across the 
board, we would encourage a creative look at the definitions of 
shortage areas. Historic definitions have not kept pace with the 
increasing shortages in primary care physicians nationally. This being 
said, it is not our intent to disrupt or divert funding from those 
areas and programs which are historically considered health 
professional shortages. These localities must continue to receive 
additional funds to address acute problems. However, we do believe 
Congress should develop additional funding programs to help those areas 
which are also experiencing significant problems but have not qualified 
under historic definitions. While the concept of new dollars may seem 
irresponsible against soaring budget deficits, we would encourage you 
to consider the cost savings that will accrue from primary care.
4. Medical Student Debt Relief And Other Financial Incentives For 
        Medical Students Who Pursue Primary Care
    Given the significant burden of medical school debt, we recommend 
funding a demonstration project for a new type of grant program to 
forgive federally funded medical student loans. Eligible physicians who 
commit to practicing primary care in the demonstration grant States 
would have a portion of their Federal loan forgiven. In order to 
encourage primary care physicians to practice in community health 
centers, consider forgiving a greater percentage or all of the debt for 
those who commit to practicing in a community health center.
    The model differs from the current National Health Service Corps 
program in several respects. The demonstration project program would 
allocate funds to post-
medical school pre-residency physicians who have chosen to practice 
primary care in the demonstration grant State for a determined period 
of time. The NHSC focuses on medical students who, at times, have 
changed their preference for primary care during medical school. 
According to testimony presented at the State by the University of 
Massachusetts, ``national data have consistently indicated that most 
physicians will establish their practice within 50 miles of where they 
complete their residency regardless of where they attended medical 
school. Furthermore, residents are nearer to the completion of their 
training, and so investments in individual residents will yield 
measurable results, in terms of the numbers of practicing primary care 
physicians much sooner than investments in incoming first year medical 
schools.'' In addition, this program would not be tied to current 
definitions of underserved areas. As noted previously, the current 
Federal definitions of shortage designation are extremely narrow thus 
preventing otherwise qualified counties from participating. The Medical 
Society is pursing a similar strategy at the State level suggesting 
that a Federal-State partnership for the grants might be advisable.
5. Overall Payment Reform
    There is no question that ultimately Congress will need to address 
comprehensive payment reform for all physicians and health care 
providers. While not under the jurisdiction of this hearing, it is 
important to underscore that we believe the above recommendations will 
address temporarily acute problem areas in primary care. At a minimum, 
reform for primary care physicians should focus on increased value for 
cognitive and preventive services, comprehensive longitudinal 
management of patients and proposals to incent quality and the medical 
home. While it would be impossible here to detail all the provisions 
necessary for such a systemic change, one thing is clear--without a 
sound financial model that incents quality care and a robust physician 
workforce, our efforts to improve access to health care and to reduce 
costs, will fail.
    On behalf of the Massachusetts Medical Society, I want to thank you 
for holding this hearing on an extremely important issue. We look 
forward to working closely with you on this and other health care 
issues facing our Nation.

    Senator Sanders. Thank you very much, Dr. Auerbach.
    Beth Landon is an M.H.A., M.B.A., Director of the Alaska 
Center for Rural Health, University of Alaska in Anchorage. 
Thank you very much for being with us.

  STATEMENT OF BETH LANDON, M.H.A., M.B.A., DIRECTOR, ALASKA 
  CENTER FOR RURAL HEALTH, UNIVERSITY OF ALASKA, ANCHORAGE, AK

    Ms. Landon. Thank you, Senator Sanders.
    Rural America faces a growing crisis. In Alaska, since this 
committee's field hearing, we have learned that at least 15 
percent of our primary care positions are vacant, often for up 
to 3 years. Projections indicate this will only get worse.
    On behalf of the Alaska Center for Rural Health, the 
National Rural Health Association, national AHEC organization, 
and others, I ask Congress to work with us in developing our 
future health workforce. Addressing the projected health 
workforce shortages requires a multifaceted approach through 
sustained and collaborative efforts. It is good for the 
economy. It is good for the community.
    It starts with recruitment of young people into the health 
professions, beginning as young as elementary school. It 
continues through clinical education and then programs to 
retain our health professionals. What I have just described for 
you is what area health education centers do every day and do 
well.
    In Alaska, I have seen how our very new, 2-year-old program 
is already successful. Youth are choosing careers in 
healthcare, and clinical students are selecting employment in 
our frontier communities.
    Senator Sanders, Senator Murkowski, other distinguished 
members of this committee, I thank you for your continued 
commitment to the health workforce needs of rural America and 
efforts to address this crisis.
    [The prepared statement of Ms. Landon follows:]
           Prepared Statement of Beth Landon, M.H.A., M.B.A.
                                summary
    Rural America faces a looming health professions workforce crisis. 
Already in my State of Alaska, rural primary care positions have 
vacancy rates of almost 15 percent. Surveys show that many of these 
vacancies last up to 3 years. The crisis is only going to get worse as 
the baby boomer generation gets older and a large percentage of current 
health professionals begin to retire. Rural America cannot wait; we 
must begin to train the future health care workforce today.
    We know how this can be accomplished. Studies show that students 
from rural areas and/or those who were exposed to rural practice while 
in school are more likely to pick sub-specialties in communities that 
are in the most need. Programs such as Area Health Education Centers 
and other programs within the title VII and VIII lines are essential in 
providing rural students the skills they need to go to medical school. 
Other programs such as the National Health Service Corps have been and 
should continue to be used to help pay for the education of these 
students that are considering practicing in underserved communities. 
Finally, graduate medical education should be reoriented so that more 
students are exposed to rural training and residency programs.
    We can and must meet the needs of rural America by providing a 
health workforce of tomorrow that is stronger, more diverse and better 
geographically dispersed. We need Congress to act to remove some of the 
many barriers to the realization of this goal.
                                 ______
                                 
    On behalf of the National Rural Health Association (NRHA) and as 
the director of the Alaska Center for Rural Health, Alaska's Area 
Health Education Center (AHEC) in Anchorage, AK, thank you for this 
opportunity to testify before the committee on the looming health 
workforce crisis unfolding in rural America. The NRHA is a national, 
non-profit membership organization whose mission is to improve the 
health of rural Americans. The NRHA provides leadership on rural health 
issues through advocacy, communications, education and research.
    Although my comments will specifically address the looming 
shortages in my home State of Alaska, interactions with my colleagues 
across the country and the data included in my testimony make clear 
that similar trends are occurring throughout our Nation. In short, 
while over 62 million Americans call rural home (slightly over 20 
percent of the Nation's population), less than 10 percent of the 
Nation's physicians practice there. Other health professions have 
similar, if not higher disparities. Studies show that rural areas 
consistently had the largest gap between predicted need for nurses and 
numbers employed. This will grow worse, the Bureau of Labor Statistics 
estimates, within 15 years there will be over a million nurse openings, 
most will be in rural areas. Frontier States, those with the most rural 
of populations like my own, are in even worse shape. Taken together, 
rural Americans cannot continue to expect access to health care without 
a concerted effort of all stake holders to address workforce shortages.
    As will be clear throughout my testimony, the Federal Government is 
not the only stakeholder addressing this situation. However, the 
Federal Government is a very important one. Without the efforts of a 
number of government agencies and programs, States like my own cannot 
expect to continue to provide basic levels of health care for our 
citizens, leaving our economic future to the hopes of miracle cures or 
a post-illness society. Our concern is primarily that without a large 
Federal investment in our future, we cannot assume that our children 
will have access to health care in rural America.
               introduction--the health workforce crisis
    This committee is well acquainted with the health workforce crisis 
and the unique challenges of rural Alaska due to the field hearing that 
you held in Alaska in 2007. I would like to thank Chairman Kennedy, 
Ranking Member Enzi and Senator Murkowski for this commitment to our 
State and to the workforce challenges throughout the Nation. As was 
made clear during that hearing, the health workforce crisis faced by 
Alaska and the rest of rural America is growing and acute. Twenty 
percent of the U.S. population lives in rural America, yet only 9 
percent of the Nation's physicians are practicing in these areas. This 
is not a new problem, shortage of physicians, in rural areas of the 
country, represents one of the most intractable health policy problems 
in the past century. As a result of these deficiencies, rural patients 
are often denied both access to care and high quality care. All told, 
over 50 million Americans, many of them rural, live in areas that have 
a shortage of physicians to meet their basic needs.
    This will only get worse. Experts predict that by 2030, when over a 
fifth of our Nation's population is over 65 years of age and needing 
increasing levels of care, the Nation will have shortages of at least 
100,000 physicians and perhaps as many as 200,000. With demands for 
health care increasing rapidly, our Nation is producing the same number 
of medical school graduates as we did 25 years ago. Yet, we are slated 
to see a huge number of retirements in the coming years. A third of the 
Nation's active physicians are older than 55 and likely to begin 
retiring in the next few years. In fact, by 2020, physicians are 
expected to hang up their stethoscopes at a rate nearly 2\1/2\ times 
the retirement rate of today.
    It is no wonder then that States like my own are beginning to show 
major cracks. Last year, my center, the Alaska Center for Rural 
Health--Alaska's AHEC, conducted a statewide survey of workforce 
vacancies across the State. We found that in all types of health 
providing agencies--hospitals, private and non-profit clinics, dental 
offices, physician offices, imaging centers, mental health centers, 
school districts and across 119 different health occupations, that 1 
out of 10 positions were unfilled. For key primary care occupations, 
vacancy rates were much higher. Over 15 percent for family physicians, 
20 percent for general internists, nearly 25 percent for pharmacists 
and around 19 percent for family nurse practitioners (FNPs) and 
physician assistants (PAs). All of these numbers were higher in rural 
and frontier areas--PAs over one-quarter of positions and for FNPs over 
36 percent. Looking at our tribal health organizations, which serve an 
extremely vulnerable and primarily remote population, the average 
vacancy rate climbed to 16.5 percent, with notable spikes of 42 percent 
for pharmacists and over 50 percent for dentists. Further, the survey 
revealed that it was not uncommon for a position to go unfilled for 3 
or more years.
    Similar to national trends, the ``Last Frontier'' State will face 
growing challenges in the years to come. While it may seem odd for such 
a frontier State to complain about a growing population, ours will 
cause major challenges in the years to come. Alaska has the second 
fastest increasing elderly population in the Nation behind only Nevada. 
Each of these seniors will place increasing demands on the Alaska 
health care system, especially the rural underserved system. This is 
worrisome because the study found that one of the top reasons for 
vacancies was population growth and an increased need/burden for health 
services were the reasons for causing strain for the few practicing 
physicians Alaska has.
    In rural Alaska this is of particular concern as there is not an 
option of simply driving elsewhere in the State for these services. 
Despite an area larger than the combined sizes of California, Texas and 
Montana, Alaska has fewer miles of road than any other State. This 
means that even in the best weather conditions, over 150,000 people in 
230 communities, including our State capital of Juneau, can only access 
services outside their area by air or water transportation. A health 
care workforce that is able to provide all aspects of basic care is 
necessary in these communities that cannot reach urban areas in a 
timely or cost-effective manner. Unfortunately, this is not currently 
the case as rural Alaska has the worst physician to population ration 
in the Nation. But even in the rest of the Nation, rural citizens 
deserve the ability to access care in their own communities. And Alaska 
is not unique in the challenges of weather and distance that would make 
such travel impractical and dangerous.
    Our partners in the Washington, Wyoming, Alaska, Montana and Idaho 
(WWAMI) region are also facing major challenges. Since we share a 
medical school, this means that we are all in it together to generate 
enough health care providers. But none of us are. For instance, the 
State of Washington with the largest population in the region has 
entire counties with not a single physician. Ferry County, population 
of over 7,300 people, has a single doctor. This leaves the State's 
population without access to even basic care. Statewide, Washington 
lags behind even my own State of Alaska in the percentage of 
pediatricians, family practitioners, obstetric providers and surgeons 
to the population. Similarly the State is experiencing nurse vacancies 
of up to 10 percent of all positions. The workforce crisis is 
throughout the northwest and we must work together to deal with it.
            meeting the challenge--growing our own workforce
    Despite the gathering crisis, we know how we can get ourselves out 
of this hole--we must train our own workforce in rural and frontier 
America. One reason that we must train our own professionals is the 
value they provide to our rural communities. Health care is a vital 
segment of the rural economy, usually the second largest employer in 
the community. Quality health care in rural America not only provides 
for the health of the community, but creates jobs, infuses capital into 
the local economy, attracts businesses and encourages families and 
seniors to maintain residency within the community. The health folks 
call this ``ensuring access to culturally competent care'' and the 
business folks call it ``economic development.''
    Health professionals who live, train and work in rural areas feel 
appreciated by the communities in which they serve and know that they 
are making a difference in people's lives. The difficulty is in getting 
health professionals to give rural areas a try. Studies have 
consistently shown that providers who are most willing to practice in 
rural and underserved areas come from those same areas. In addition, 
evidence shows that rural residency rotations, brief perceptorships in 
rural areas, and graduation from residency programs that emphasize 
rural, underserved health care have the most promise in preparing 
physicians for rural practice and in lengthening the time that they 
serve in rural communities.
    We acknowledge that as rural communities we have a role in this. In 
Alaska, we have reviewed the literature and found that in addition to 
training our own health professions, we must commit ourselves to making 
our communities more attractive to other health professionals. This 
simply has to do with numbers. Our State recently expanded from 10 to 
20 medical slots a year at a jointly sponsored WWAMI Medical School and 
another 12 residency spots; compared to the nearly 100 physicians we 
would need to train annually just to keep pace with our current 
insufficient supply of health professionals. Some key recruitment 
strategies we employ include considering the needs of the entire 
family, being willing as a community to open up and accept health 
professionals that have ``outsider'' status and finding creative ways 
to provide clinical, professional and financial support. Once the right 
person is found, there needs to be continual work to retain that person 
through community inclusion and support. Otherwise, the high costs of 
recruitment and training will be spent again with turnover.
    Finally, nationwide, there is a body of evidence that family 
practice and osteopathic physicians, which constitute a majority of 
rural primary care physicians, are more likely to distribute themselves 
in proportion to the population compared to specialists as long as 
payment methodology is fair for rural and underserved areas. 
Unfortunately, payment methodology is not fair and medical school 
students are growing more unlikely to choose general practice compared 
with subspecialties. While there are a variety of theories for these 
choices, including following the higher pay, less emphasis on primary 
care during school, and lack of perceived prestige, it is unclear to 
what extent each of these play in the individual choices of medical 
students. What is needed is for Congress to place a priority in public 
policy to encourage medical students to make the choice to serve their 
communities and country by serving rural and underserved areas.
  public policy priority one: title vii and viii reauthorization and 
                               expansion
    As stated, the workforce shortages faced by my State and the Nation 
are the direct result of the individual choices made by medical 
students. However, policymakers and educators cannot simply walk away 
and say that it is an individual's choice. Too many factors play a 
major role in whether a rural student even has the option to serve 
their community as a health professional. By the time a student enters 
medical school, they must have years of math and science training. Many 
rural schools are economically disadvantaged when it comes recruiting 
these teachers making it difficult for even an eager student to take 
the classes required for admission to advance programs. Further, many 
students that may want to become health professionals do not have the 
mentorship of people from their community to explain the necessity of 
math and science. Rural communities therefore at an early age often 
have a large gap between the desire to serve their community and the 
ability to do so.
    At the Federal level, a group of 40 programs have been developed to 
help fill this niche. They are known collectively as the Title VII and 
Title VIII Health Professions and Nursing Education Training Programs. 
These programs each focus on different facets of the challenge of 
training health professionals who will serve rural and underserved 
communities, and minority populations. Like many collective groups of 
programs, there are some issues of overlap and missing links, but as a 
whole, the title VII and VIII programs provide support to students, 
programs, departments and institutions to improve racial and ethnic 
diversity, accessibility especially to rural areas and the quality of 
the health care workforce.
    While each of the 40 programs deserve your full attention, I would 
like to focus my remarks on the Area Health Education Centers (AHECs) 
that I know best. AHECs are the workforce development, training and 
education machine for the Nation's health care safety-net programs. In 
my own experience, I have seen firsthand how our new program, just over 
2 years old, is already making a difference in Alaska. We are 
successfully encouraging youth to pursue careers in health care, and 
health professions students who participate in our frontier clinical 
rotations are selecting employment in those communities. Nationwide, 
AHECs develop and support the community-based training of health 
professions students, particularly in rural and underserved areas. They 
recruit a diverse and broad range of students into health careers, and 
provide continuing education, and other learning resources that improve 
the quality of community-based healthcare for underserved populations 
and areas.
    The Area Health Education Center program is effective and provides 
vital services and national infrastructure. Nationwide, in 2006, AHECs 
introduced over 308,000 students to health career opportunities, and 
over 41,000 mostly minority and disadvantaged high school students 
received more than 20 hours each of health career programs and academic 
enhancement. AHECs support health professional training in over 19,000 
community-based practice settings, and over 111,000 health professional 
students received training at these sites. Further, over 368,000 health 
professionals received continuing education through AHECs.
    Together with the other title VII and VIII programs, AHECs have 
proven their effectiveness. Congress, together with this 
Administration, has shown a commitment to the Community Health Center 
program to provide safety-net care. This has been a noble approach 
which the NRHA supports to provide resources to provide care for our 
Nation's most vulnerable populations. But while these resources have 
facilitated an expansion in CHC facilities, there is a huge shortage of 
professionals to actually work in them. In fact, it has been shown that 
CHCs have over 400 physician shortages today for the current health 
center, not to mention further expansion or retirements in the years to 
come. In the past, these professionals would have been trained in title 
VII and VIII programs. Today, over 60 percent of CHC physicians were 
exposed to title VII funding during their time in medical school. 
Likewise, over 57 percent of National Health Service Corp physicians 
(detailed in the next section of this testimony) were exposed to this 
funding during school. Where will our Nation's safety net physicians 
come from if Congress continues recent trends of underfunding and 
defunding title VII and VIII programs?
    One more word is needed on the effectiveness of the title VII and 
VIII programs. The Bush administration, using their Program Assessment 
Rating Tool (PART), has labeled these collective programs as 
ineffective. This is both deceptive and unfair. While each of the 40 
individual programs has their own program goals and objectives, they 
were lumped together for a single evaluation. Programs like AHECs were 
not considered on their own merits. In fact, the PART assessment even 
singled out AHECs as a program that may be working if they had their 
own assessment. Second, the long-term measures that the programs were 
asked to meet were blatantly unfair. The PART measure selected was the 
``proportion of persons who have a specific source of reliable, 
continuing healthcare.'' This measure is impacted by a myriad of 
factors including insurance coverage, income, geographic location and a 
host of other factors. Surely, Congress does not expect training 
programs to be able to cover all of these separate policy 
considerations. Compare this, as the Administration did, with the 
National Health Service Corp measures that evaluate the number of 
patients served by NHSC physicians and the placement and retention into 
underserved areas. These are factors that the NHSC has control over. 
Title VII and VIII programs also deserve to have measures relevant to 
the program goals, so that our proven effectiveness is demonstrated to 
the Administration and Congress.

    Recommendations: Reauthorize and expand Title VII and VIII Training 
Programs including Area Health Education Centers that have been proven 
to be highly effective in training health professionals who will 
practice in rural and underserved areas. This reauthorization should be 
for at least 5 years. Further, these programs have been underfunded and 
cut since at least fiscal year 2005. Congress must appropriate adequate 
funding levels for these programs to continue success in training the 
future rural health workforce. Finally, the PART assessment of these 
programs should look at each program individually in a way that will 
actually measure the mission and goals of the individual program.
        public policy priority two: reauthorization of the nhsc
    For more than 35 years, the National Health Service Corps (NHSC) 
has been recruiting health professionals to serve in communities where 
needs are greatest. We thank this committee in acknowledging this 
important program this past fall and urge that the reauthorization is 
quickly taken up by the full Senate. The communities served by the 
program include both rural areas, where the nearest clinic may be miles 
away, and in inner-city neighborhoods, where economic and cultural 
barriers prevent people from seeking and receiving the health care they 
deserve. To qualify for a NHSC physician or other health professional, 
the community must be located in a primary care health professional 
shortage area (HPSA). Currently, 4,000 NHSC clinicians provide care to 
nearly 6 million people nationwide. Tragically, this leaves some 50 
million Americans residing in a primary care HPSA without access to the 
care they need. While the NHSC has been essential in making sure that 
some of these communities are and will continue to be served in the 
years to come, more help is needed.
    The program was originally created as a scholarship program for 
those in medical school. For a year of scholarship support, a NHSC 
scholar agreed to dedicate a year working in an underserved area. The 
experience with this has been that many of the scholars go on to serve 
underserved communities their entire careers. More recently, more 
emphasis has been placed in a loan repayment program. This has been 
effective in introducing medical school graduates to underserved 
communities and allowed more participation at a lower cost to the 
Federal Government. However, our experience with the two programs shows 
us that the scholarship program is more likely to generate longer terms 
of service due to an upfront commitment than the loan repayment 
programs.
    But no matter which portion of the program a student takes 
advantage of, rural communities need this program to be reauthorized, 
expanded and slightly modified. Currently, over 80 percent of NHSC 
applicants are turned down in a given year. The current appropriations 
of approximately $130 million is not enough. Senator Murkowski 
introduced a bill last year that would have expanded authorization to 
$400 million annually. The NRHA strongly endorses these efforts.
    In terms of modifications, the rural experience with primary health 
care shows that not all primary care disciplines are included in the 
NHSC program. For instance, pharmacists and optometrists are often 
front line workers on primary care issues in our communities. In 
Alaska, pharmacy services are often mentioned in our survey as one of 
the most difficult provider types to recruit with a quarter of all 
positions vacant. The list of primary care providers should be 
expanded. Second, the most rural of communities, frontier, are often at 
a disadvantage in acquiring and keeping a HPSA score that would allow 
them to recruit NHSC providers. This has to do with the population size 
being served factored into the equation. Due to the lack of population 
in rural and frontier communities, our scores often lag behind urban 
areas. Further, in communities that are able to acquire a single NHSC 
provider, they often lose their HPSA designation since the number of 
providers now exceeds the number that would make sense in an urban 
area. This means many frontier communities can only have one provider 
to be a HPSA, leaving that person with no coverage if they take a week 
off. This can be disastrous if that provider leaves the community as 
they are unable to immediately recruit a provider that will receive 
loan assistance. Frontier communities must have automatic HPSAs that 
protect them from these formulaic mistakes.
    In addition, when the Senate considers reauthorization of the NHSC 
and other programs like Community Health Centers, the 330A Outreach and 
Network grant programs should be included. These grant programs have a 
track record of improving quality and access to care in rural 
communities by allowing communities to tackle unique health challenges 
in their own community. These grants have been used for a variety of 
health challenges, including health information technology networks, 
diabetes prevention, school-based health care and workforce challenges. 
Despite the variety of uses for the program, a quarter of the grants 
are used annually on workforce projects. This is clearly relevant to 
the work of this committee. These programs should be reauthorized as 
they have been very effective as 85 percent of the recipients continue 
the project after grant funding has run out.

    Recommendations: The NHSC is an essential program in providing 
health professionals to underserved communities. It needs to be 
expanded, fully funded and slightly modified to allow a more 
appropriate list of primary care providers and communities that are in 
most need of the program to participate despite flaws in formula. In 
addition, 330A Grant Programs (Outreach and Network Grants) should be 
reauthorized.
           other priorities: rural graduate medical education
    This next two topics may be outside the scope of both this hearing 
and this committee's jurisdiction, so I will be brief, but no workforce 
discussion is complete without at least mentioning the problems with 
our graduate medical education and reimbursement structures in this 
country. First, medical education in the United States has become 
specialized, centralized and urban, embracing uniform standards of 
patient care, education and research. While this has led to a higher 
quality of care than in the old apprentice style system, it has led to 
a sharp decrease in the availability of health care in some parts of 
the country. As has been outlined previously, rural students are more 
likely to practice in rural communities. In fact, studies show that 
over half of medical students will practice within 100 miles of their 
medical school, and usually in a similar practice environment to where 
they trained. Public policy necessitates that medical schools do 
training in rural communities and recruit from across their States to 
make sure they have a diverse workforce that serves all communities. 
However, urban medical schools often favor continuing high quality 
research and cutting edge procedures at the expense of training a 
workforce for their State that will practice throughout their State.
    Alaska is largely impacted by this trend. We have no medical school 
in the State. We have recently increased to 20 slots annually through a 
joint project with WWAMI Medical School that enables Alaskans to study 
three out of the four medical school years in Alaska. In addition, we 
have 12 residency slots a year in the Anchorage area. Thankfully this 
has been extraordinarily successful as 75 percent of the graduates of 
the Alaska Family Residency Program have remained in Alaska, with the 
vast majority working in underserved communities or with underserved 
populations. Unfortunately, the program is too small to meet the 
growing needs of rural Alaska. And our State is not alone.
    Policies must change to encourage medical schools to train more 
health professionals who will practice in rural communities. At the 
Federal level, you have two levers that you can easily pull to help 
make this change a reality. First, Congress has already placed in 
statute a waiver to Graduate Medical Education (GME) payment caps to 
those programs that included integrated rural training tracks (IRTT). 
Unfortunately, since Congress never defined IRTT, CMS has not 
implemented this waiver. Congress needs to go back and define what they 
meant by IRTT so students that are exposed to rural practice and are 
trained in primary care, obstetrics, pediatrics, emergency medicine and 
community health are not held to the same cap as Congress implemented 
for specialty training. Second, Congress should take advantage of the 
relatively small number of medical schools in this country that operate 
rural residencies to streamline reporting and payment so that rural 
residencies get the money directly from Medicare. This would increase 
efficiency and accountability and make it more likely that rural sites 
could and would participate in residency training programs.
    To compound the difficulty in training a rural health workforce, 
the cost of going to medical school continues to rise. Even in public 
medical schools, the cost has risen 900 percent in the last 25 years. 
Rural students and those that will go into rural medicine cannot afford 
these levels of debt as they will get paid less than sub-specialists 
and those that choose to practice in urban settings. Congress should 
continue to examine ways to reduce this debt burden either through the 
previously mentioned NHSC program, more GME payments to reduce tuition 
or other tax incentives. These should be predicated on a commitment to 
practicing in rural, underserved areas.

    Recommendations: Graduate medical education in this country has 
become specialized, centralized and urban. Congress should work to make 
sure that medical education continues to train rural practitioners by 
defining IRTT and encouraging more rural residency programs. Finally, 
the debt level of medical school graduates is out of control and needs 
to be reigned in for students that choose to practice in underserved 
areas.
             other priorities: fair reimbursement structure
    Finally, without fair payment for rural health professionals, many 
will choose to either reduce or eliminate the number of Medicare 
patients they see, relocate their practices to areas of the country 
where they are paid better, retire earlier than they intended, or a 
combination of all three. These inequalities must be addressed.
    While payment structures are complicated and diverse, there is one 
element of the Sustainable Growth Rate for physicians that further 
complicates the ability to recruit and retain rural physicians--the 
Work Geographic Practice Cost Index. There are a number of indices that 
factor in different costs of operating a practice in different areas 
including the extra costs of rent in urban areas. But the index that 
adjusts for work costs is both imprecise and unfair. Physicians have 
the choice of practicing all across this Nation. Pay must be comparable 
in a rural community for them to even consider these facilities. It is 
the same work. It should be paid the same. It is unfair and bad public 
policy to pay better served communities more. Due to these unfair 
payment structures, in Alaska, Medicare payments only reflect about 40 
percent of serving a Medicare patient. This is both not sustainable, 
nor is it fair for our rural communities.
    We would have a better understanding of how these decisions have 
impacted rural America if the Medicare Payment Advisory Commission 
(MedPAC) had proportional rural representation. Current law states that 
the Commission must be ``balanced'' between urban and rural 
commissioners, yet only 2 of the 17 commissioners have rural 
credentials. With one rural commissioner departing this spring, we face 
having only one rural commissioner on MedPAC when 27 percent of the 
Medicare population resides in rural America.
    In addition to Medicare, rural communities disproportionately rely 
on the Medicaid and State Children's Health Insurance Programs. While 
the stereotype of those covered by these public programs may be the 
urban poor, 32 percent of rural kids were on one of these public 
programs, compared with only 26 percent of those in urban America. Any 
Federal changes to Medicaid and SCHIP need to take this into 
consideration, so that rural providers continue to accept these payment 
rates to take care of our most vulnerable kids.

    Recommendations: Enact legislation that fixes the Medicare 
physician payment system so that it realistically reflects physician 
practice costs and does not unfairly pay less to those providers that 
serve these communities that need their help the most. Second, ensure 
proportional representation on MedPAC. Finally, protect payments to 
Medicaid and SCHIP that cover rural children.
                               conclusion
    Over the next 20 years, this Nation's health professions workforce 
shortage will reach the crisis proportions being experienced today in 
rural, frontier, and other underserved areas. My State of Alaska is 
already in the midst of it. We know from experience that this will 
force us to try new things--we have already heavily invested in health 
information technology both as a means of training our health 
professionals and to monitor patients from a distance. But this will 
not solve all of our problems.
    We must have culturally competent health professionals in our 
communities. We must have more providers in our CHCs so that the most 
vulnerable population is served. We want to make sure that our 
grandparents are able to receive the care they deserve in the community 
that they have spent their lives. We also want to make sure that our 
children are able to receive the checkups early in life that they need 
to be productive citizens. But this will not happen if we do not begin 
training the future rural health workforce today.
    In rural and frontier States all across this Nation, including my 
own of Alaska, we are willing and able to begin to make the changes 
necessary to train and recruit this workforce. But a number of barriers 
are in our way. Congress must act appropriately and eliminate the 
barriers at a Federal level, and invest in our future. Without these 
efforts and funding for title VII and VIII programs, the National 
Health Services Corp, graduate medical education and a fair 
reimbursement structure, we will not be able to train the professionals 
we know we need. We look forward to working with you to make sure that 
the predicted crisis does not come to pass.
                                sources
Alaska Center for Rural Health, ``2007 Alaska Health Workforce Vacancy 
    Study Research Summary,'' August 2007.
Frederick M. Chen, M.D., MPH, Meredith A. Fordyce, PhC, and L. Gary 
    Hart, Ph.D., ``WWAMI Physician Workforce 2005,'' Working Paper #98, 
    WWAMI Center for Health Workforce Studies, May 2005.
Health Professions and Nursing Education Coalition, ``Health 
    Professions Programs: Over 1,000,000 Trained and Counting,'' 2007.
Health Resources and Services Administration, ``Nursing Education in 
    Five States,'' 2005.
Joshua Freeman, M.D. and Jerry Kruse, M.D., MSPH, ``Title VII: Our 
    Loss, Their Pain,'' Annals of Family Medicine, 2006.
National AHEC Organization, ``Response to the OMB Performance and 
    Management Assessment of the Health Professions Program,'' April 
    2003.
National Rural Health Association, Issue Paper, ``Recruitment and 
    Retention of a Quality Health Workforce in Rural Areas,'' March 
    2005.
National Rural Health Association, Policy Brief, ``Health Professions: 
    Title VII of the Public Health Service Act Reauthorization,'' 
    January 2004.
United States Senate, Health, Education, Labor and Pensions Committee 
    Field Hearing, February 20, 2007 in Alaska.

    Senator Sanders. Thank you very much.
    Jennifer Laurent is an M.S., FNP-BC, President of the 
Vermont Nurse Practitioner Association. She is a family nurse 
practitioner in Cambridge, VT. Thanks for being with us.
    Turn the mike on and hold it close to your mouth.

STATEMENT OF JENNIFER LAURENT, M.S., FNP-BC, PRESIDENT, VERMONT 
  NURSE PRACTITIONER ASSOCIATION, FAMILY NURSE PRACTITIONER, 
                         CAMBRIDGE, VT

    Ms. Laurent. Closer, there we go. Thank you, Senator 
Sanders, committee members, for asking me, inviting me to be 
here.
    As Senator Sanders said, I am a nurse practitioner, and I 
consider myself on the front lines of primary care, where I 
work seeing patients. I would like to acknowledge the 
importance that nurse practitioners play in answering a lot of 
the primary care shortage. Sixty-three percent of nurse 
practitioners are in a primary care setting, and there is room 
for many more nurse practitioners to be added to the primary 
care workforce, except for barriers such as title VIII cuts 
that are anticipated.
    My recommendation is that it is vital that we have that 
title VIII funding and increase that funding. There are three 
reasons for that. One is, we all know that there is a nursing 
shortage. As there is a nursing shortage, there is going to be 
a nurse practitioner shortage, which means that we are going to 
really have a crunch in many ways. We are not going to have 
access to primary care, and there is also not going to be 
enough nurses out there.
    The title VIII funding, especially in Vermont, is vital to 
answering the primary care crisis. From my standpoint, we are 
in a crisis. There are several people who call my practice on a 
regular basis, almost daily, that are turned away because they 
are two counties away from us, and they can't get primary care 
in their counties. They are looking for primary care in my 
county. We are a very small, rural practice, and that is pretty 
consistent with most of Vermont, except for Burlington.
    That would be one recommendation that I would have. The 
other one is, and it is actually not in my testimony, but it is 
a bill that I came across. It is Senate bill 2112, looking at 
nurse-run managed health centers and funding to add to current 
nurse managed health centers to allow them to continue to serve 
the underserved. These people are serving the majority of 
people who don't have insurance and are self-pay.
    Those are two recommendations that I have. In closing, I 
would just like to say that there are actually nurse 
practitioners out there who would like to be primary care 
providers, but cannot find a job even given the primary care 
shortage.
    Thank you.
    [The prepared statement of Ms. Laurent follows:]
        Prepared Statement of Jennifer S. Laurent, M.S., FNP-BC
                                Summary
    Thank you for inviting me to participate in this hearing on 
healthcare workforce issues, its impact on access to primary care 
services for the United States, and the role of the nurse practitioner 
in meeting this need.
    Nurse practitioners are primary care and specialty clinicians who 
practice in ambulatory, acute and long-term care settings. According to 
their practice specialty they provide nursing and medical services to 
individuals, families and groups. In addition to diagnosis and 
management of acute episodic and chronic illness, NPs emphasize health 
promotion and disease prevention. Services include but are not limited 
to ordering and interpreting diagnostic tests, prescribing therapeutic 
medications and non-medication therapies. Teaching and counseling are a 
major part of nurse practitioner care.
    Nurse practitioners currently practice autonomously and 
collaboratively with other health care professionals, under their own 
license and with their own provider number. They serve as healthcare 
researchers, interdisciplinary consultants and patient advocates.
    Research indicates that when nurse practitioners (NPs) practice 
within their areas of expertise, there are no important differences 
between NPs and primary care physicians regarding quality of care, 
number of visits per patient, use of the emergency room, and 
prescribing practices. Furthermore it is well-documented in the 
literature through randomized clinical trials and meta-analyses that 
there is no major difference in patient outcomes and some research 
indicates higher patient satisfaction with NP over physician (M.D.) 
care.
    Outcome studies consistently demonstrate increased satisfaction, 
comparable outcomes to physician-provided care, and both direct and 
indirect cost savings. National databases demonstrate patient safety 
with NP directed and managed care in all States including those 
currently practicing autonomously.
    In my home State of Vermont, available and accessible primary care 
services are inadequate. Eight of Vermont's 14 counties fall below 
Federal standards for the ratio of primary care physicians to area 
residents. Nineteen percent of family physicians and 27 percent of 
internists are not accepting new patients. In Washington County this 
percentage rises to 54 percent. As fewer medical students seek primary 
care residencies and the population of the elderly grows 
disproportionately, accessible healthcare services will decline. 
Vermont NPs are a stable workforce, providing care for a primarily 
rural population.
    The obvious need for accessible quality healthcare, healthcare cost 
control, and provisions for health promotion presents an optimal 
opportunity for nurse practitioners meet the critical demand. The 
following recommendations are made:

    1. Reauthorization and increased funding of title VIII to encourage 
an increase in the number of faculty that will be required to support 
the demand for nurse practitioners in primary care. This is the only 
Federal funding source for these programs since they have no access to 
graduate medical (GME) funds.
    2. Support S. 1795 to improve access to workers' compensation 
programs for injured Federal employees by adding nurse practitioners to 
the list of providers authorized to provide services under this 
statute.
    3. Federal support at State levels to increase access and 
reimbursement to nurse practitioner services for all individuals.

    I welcome the opportunity to provide further information should you 
have questions. Please do not hesitate to contact me if the need 
arises.

    (Jennifer S. Laurent, M.S., FNP-C, 281 Shelburne Street, 
Burlington, Vermont 05401, [email protected] (802) 644-5114.)
                                 ______
                                 
    Thank you for inviting me to participate in this hearing on 
healthcare workforce issues, its impact on access to primary care 
services for the United States, and the role of nurse practitioner in 
meeting this need.
    Nurse practitioners are playing a critical role in meeting the 
workforce needs of the Nation's primary care healthcare providers. My 
comments are organized into the following areas:

    1. The Professional Role of Nurse Practitioners
    2. Quality of Nurse Practitioner Care
    3. Nurse Practitioner Care and Patient Safety
    4. Nurse Practitioner Cost Effectiveness
    5. Barriers to Accessing Primary Care Services: An Example from the 
Rural State of Vermont
    6. Recommendations
                           professional role
    Nurse practitioners are primary care and specialty clinicians who 
practice in ambulatory, acute and long-term care settings. According to 
their practice specialty they provide nursing and medical services to 
individuals, families and groups. In addition to diagnosis and 
management of acute episodic and chronic illness, NPs emphasize health 
promotion and disease prevention. Services include but are not limited 
to ordering and interpreting diagnostic tests, prescribing therapeutic 
medications and non-medication therapies. Teaching and counseling are a 
major part of nurse practitioner care.
    Nurse practitioners currently practice autonomously and 
collaboratively with other health care professionals, under their own 
license and with their own provider number. They serve as healthcare 
researchers, interdisciplinary consultants and patient advocates.
                   quality of nurse practitioner care
    Research indicates that when nurse practitioners (NPs) practice 
within their areas of expertise, there are no important differences 
between NPs and primary care physicians regarding quality of care, 
number of visits per patient, use of the emergency room, and 
prescribing practices. \1\ Furthermore it is well documented in the 
literature through randomized clinical trials and meta-analyses that 
there is no major difference in patient outcomes and some research 
indicates higher patient satisfaction with NP over physician (M.D.) 
care. This is true in European studies as well.
---------------------------------------------------------------------------
    \1\ Phillips, R.L., Jr., Harper, D.C., Wakefield, M., Green, L.A., 
& Fryer, G.E., Jr. (2002). Can Nurse Practitioners And Physicians Beat 
Parochialism Into Plowshares? Health Aff, 21(5), 133-142.

     Studies show that NPs rate high in consumer 
satisfaction.\2\ \3\ \4\
---------------------------------------------------------------------------
    \2\ Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic 
review of whether nurse practitioners working in primary care can 
provide equivalent care to doctors. BMJ, 324(6), 819-823.
    \3\ Kinnersley, P., Anderson, E., Parry, K., Clement, J., Archard, 
L., Turton, P., et al. (2000). Randomised controlled trial of nurse 
practitioner versus general practitioner care for patients requesting 
``same day'' consultations in primary care. BMJ, 320(7241), 1043-1048.
    \4\ Hooker, R.S., & McCaig, L.F. (2001). Use of physician 
assistants and nurse practitioners in primary care, 1995-1999. Health 
Aff, 20(4), 231-238.
---------------------------------------------------------------------------
     The congressional OTA reviewed studies comparing NPs and 
M.D.'s: NPs appear to have more effective communication, counseling, 
and interviewing skills than M.D.'s.\5\
---------------------------------------------------------------------------
    \5\ Congressional Budget Office (1979). Physician extenders: Their 
current and future role in medical care delivery. Washington, DC: U.S. 
Government Printing Office.
---------------------------------------------------------------------------
     NPs score higher in areas such as depth of discussion 
regarding preventive health and wellness and child health care; amount 
of advice, therapeutic listening and support offered; completeness of 
history and follow-up on history findings; completeness of physical 
exam and interviewing skills; and patient knowledge and comprehension 
regarding the plan of care given to them by the NP.\6\
---------------------------------------------------------------------------
    \6\ Prescott, P.A. & Driscoll, L. (1980). Evaluating nurse 
practitioner performance. Nurse Practitioner, 1 (1), 28-32.
---------------------------------------------------------------------------
     80 percent to 90 percent of adult primary care and up to 
90 percent of pediatric primary care can be provided by NPs. Large 
randomized studies show that these services were provided as safely and 
effectively as when provided by M.D.'s.\7\
---------------------------------------------------------------------------
    \7\ Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, 
W.Y., Cleary, P.D., Friedewald, W.T., Siu, A.L., & Shelanski, M.L. 
(2000). Primary care outcomes in patients treated by nurse 
practitioners or physicians: A randomized trial. JAMA, 283 (1), 59-68.
---------------------------------------------------------------------------
     In regards to measurement of diagnosis, treatment, and 
patient outcomes, several studies show that the quality of care 
provided by NPs is equal to that of physicians.\8\ \9\ \10\ \11\
---------------------------------------------------------------------------
    \8\ Roblin, D.W., Becker, R., Adams, E.K., Howard, D.H., & Roberts, 
M.H. (2004). Patient satisfaction with primary care: Does type of 
practitioner matter? Medical Care, 42 (6).
    \9\ Horrocks, S., Anderson, E., Salisbury, C. (2002). Systematic 
review of whether nurse practitioners working in primary care can 
provide equivalent care to doctors. BMJ, 324, 819-823.
    \10\ Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, 
R., & Sibbald, B. (2006). Substitution of doctors by nurses in primary 
care. Cochrane Database of Systematic Reviews. 2006, Issue 1.
    \11\ Lenz, E.R., Mundinger, M.O., Kane, R.L., Hopkins, S.C., & Lin, 
S.X. (2004). Primary care outcomes in patients treated by practitioners 
or physicians: Two-year follow-up. Medical Care Research and Review 61 
(3), 332-351.
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     NPs tend to provide a more relaxed atmosphere where 
patients feel more comfortable to ask questions that they regard as too 
trivial for physicians.\12\
---------------------------------------------------------------------------
    \12\ Robyn, D. & Hadley, J. (1980). National health insurance and 
the new health occupations: Nurse practitioners and physicians. J 
Health Polit Policy Law.
---------------------------------------------------------------------------
     A large randomized study found that NPs made appropriate 
referrals when further intervention was necessary.\13\
---------------------------------------------------------------------------
    \13\ Spitzer, W.O., Sackett, D.L., Sibley, J.C., Roberts, R.S., 
Gent, M., Kergin, D.J., et al. (1990). 1965-1990: 25th anniversary of 
nurse practitioners: The Burlington randomized trial of the nurse 
practitioner Journal of the American Academy of Nurse Practitioners, 
2(3), 93-99.
---------------------------------------------------------------------------
               nurse practitioner care and patient safety
    Outcome studies consistently demonstrate increased satisfaction, 
comparable outcomes to physician provided care, and both direct and 
indirect cost savings. National databases demonstrate patient safety 
with NP directed and managed care in all States including those 
currently practicing autonomously.

     The National Practitioner Data Bank (NPDB) and the 
Healthcare Integrity and Protection Data Bank (HIPDB), were established 
to protect the public from and increase awareness of potentially 
harmful healthcare providers. the NPDB assists in preventing 
incompetent practitioners from moving State to State without disclosure 
or discovery of previous damaging or incompetent performance. This data 
provides total accumulated reports of malpractice and adverse actions 
of healthcare providers in the United States.\14\ Reports accessed from 
the NPDB, August 1996 through September 2005, demonstrate the safety of 
NP-provided care independent of autonomous practice level. Filings for 
physicians are far higher than 8:1, the average ratio of physicians to 
NPs in the United States.\15\ \16\ Autonomous practice States 
demonstrate very low rates of NPDB filings nationally compared to other 
States with practice agreements.
---------------------------------------------------------------------------
    \14\ National Practitioner Data Bank (2004). NPDB 2004 annual 
report. Retrieved March 16, 2006, from http://www.npdbhipdb.com/pubs/
stats/2004_NPDB_Annual_Report.pdf.
    \15\ National Practitioner Data Bank (2006). Healthcare integrity 
and protection data bank. Retrieved April 15, 2006, from http://
www.npdbhipdb.com/hipdb.html.
    \16\ Pearson, L. (2006). The Pearson report. The American Journal 
for Nurse Practitioners 10(1), 1-163.
---------------------------------------------------------------------------
     The HIPDB reports total number(s) of accumulated adverse 
action reports, civil judgments, and criminal conviction reports for 
NPs, physicians, and Doctors of Osteopathic Medicine in the United 
States. This includes licensure actions and any other adverse actions, 
findings, or adjudicated actions.\17\ Reported filings of NP misconduct 
are extremely low and consistent with the NPDB reports for all States.
---------------------------------------------------------------------------
    \17\ National Practitioner Data Bank (2006). Healthcare integrity 
and protection data bank. Retrieved April 15, 2006, from http://
www.npdbhipdb.com/hipdb.html.
---------------------------------------------------------------------------
     In 1990, the Canadian Burlington Randomized Trial 
demonstrated NPs safely and effectively manage 67 percent of their 
patient visits without physician consultation, the remaining 33 percent 
of patients were referred appropriately to other providers for 
care.\18\
---------------------------------------------------------------------------
    \18\ Spitzer, W.O., Sackett, D.L., Sibley, J.C., Roberts, R.S., 
Gent, M., Kergin, D.J., et al. (1990). 1965-1990: 25th anniversary of 
nurse practitioners: The Burlington randomized trial of the nurse 
practitioner. Journal of the American Academy of Nurse Practitioners, 
2(3), 93-99.
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                 nurse practitioner cost effectiveness
    NPs are a proven response to the evolving trend towards wellness 
and preventative health care driven by consumer demand. For over four 
decades, NPs have been proven to be cost-effective providers of high-
quality care.
    Over 25 years ago, the Office of Technology Assessment \19\ 
conducted an extensive case analysis of NP practice and reported that 
NPs provided equivalent or improved medical care at a lower total cost 
than physicians. The authors determined that NPs could manage up to 80 
percent of adult primary care and 90 percent of pediatric primary care 
needs at that time. NPs in a physician-practice were found to have the 
potential to decrease the cost per patient visit by as much as one-
third, particularly when seeing patients in an independent, rather than 
complementary manner. Since that time, continued reports have supported 
ongoing cost-effectiveness of NP practice. When OTA later re-examined 
the role of NP practice, the positive analysis was confirmed.\20\
---------------------------------------------------------------------------
    \19\ Office of Technology Assessment (1981). The Cost and 
Effectiveness of Nurse Practitioners. Washington, DC: U.S. Government 
Printing Office.
    \20\ Office of Technology Assessment (1986). Nurse Practitioners, 
Physician Assistants, and Certified Nurse Midwives: A policy analysis. 
Washington, D.C.: U.S. Government Printing Office.
---------------------------------------------------------------------------
     In 1981, the OTA reported that the hourly cost of an NP 
was one-third to one-half the cost of a physician. The median total 
compensation for primary care physicians in 2004 ranged from $130,000 
to $208,700, depending on type and size of practice.\21\ The median 
2004 salary for NPs across all specialties who practiced full-time was 
$71,000, with a mean of $73,630.\22\ NP preparation currently costs 20-
25 percent that of physician preparation.\23\ When productivity 
measures, salaries, and costs of education are considered, NPs are 
cost-effective providers of health services.
---------------------------------------------------------------------------
    \21\ Lowes, R. (2005). Exclusive survey: The earnings freeze--now 
it's everybody's problem. Medical Economics, Sept 16, 2005.
    \22\ AANP (2004). 2004 national NP sample survey, Part III: NP 
income and benefits. JAANP, 18 (1), 2-5.
    \23\ AACN (2000). Nurse Practitioners: The growing solution in 
health care delivery. Accessed online at: http://www.aacn.nche.edu/
Media/FactSheets/npfact.htm.
---------------------------------------------------------------------------
     A recent study of 26 capitated primary care practices with 
approximately two million visits by 206 providers determined that the 
practitioner labor costs per visit and total labor costs per visit were 
lower in practices where NPs and physician assistants (PA) were used to 
a greater extent.\24\
---------------------------------------------------------------------------
    \24\ Roblin, D.W., Howard, D.H., Becker, E.R., Adams, E., & 
Roberts, M.H. (2004). Use of midlevel practitioners to achieve labor 
cost savings in the primary care practice of an MCO. Health Services 
Research, 39 (3), 607-26.
---------------------------------------------------------------------------
     A cost analysis comparing the cost of providing services 
at an NP managed center for homeless clients with other community 
alternatives showed earlier and less costly interventions by the NP-
managed center.\25\ NPs delivering care in Tennessee's State-managed 
MCO, TennCare, delivered health care at 23 percent below the average 
cost of other primary care providers with a 21 percent reduction in 
hospital inpatient rates and 24 percent lower lab utilization rates 
compared to physicians.\26\ Jenkins & Torrisi performed a 1-year study 
comparing a family practice physician-managed practice with an NP-
managed practice within the same managed care organization.\27\ The NP 
managed practice had 43 percent of the total emergency department 
visits, 38 percent of the inpatient days, and a total annualized per 
member monthly cost that was 50 percent that of the physician practice.
---------------------------------------------------------------------------
    \25\ Hunter, J., Ventura, M., & Kearns, P. (1999). Cost analysis of 
a nursing center for the homeless. Nursing Economics, 17 (1), 20-8.
    \26\ Spitzer, R. (1997). The Vanderbilt experience. Nursing 
Management, 28 (3), 38-40.
    \27\ Jenkins, M. & Torrisi, D. (1995). NPs, community nursing 
centers and contracting for managed care. Journal of the American 
Academy of Nurse Practitioners, 7 (3), 119-23.
---------------------------------------------------------------------------
    A study conducted in a large HMO setting found that adding an NP to 
the practice could virtually double the typical panel of patients seen 
by a physician. The projected increase in revenue was $1.28 per member 
per month, or approximately $1.65 million per 100,000 enrollees per 
year. \28\
---------------------------------------------------------------------------
    \28\ Burl, J., Bonner, A., Rao, M. (1994). Demonstration of the 
cost-effectiveness of a nurse practitioner/physician team in primary 
care teams. HMO Practice, 8 (4), 156-7.
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     Chenowith et al. analyzed the health care costs associated 
with an innovative on-site NP practice for over 4,000 employees and 
their dependents.\29\ Compared with claims from earlier years, the NP 
care resulted in significant savings of $.8 to $1.5 million, with a 
benefit-to-cost ratio of up to 15 to 1. Paez and Allen compared NP and 
physician management of hypercholesterolemia following 
revascularization. Patients in the NP-managed group were more likely to 
achieve their goals and comply with prescribed regimen, with decreased 
drug costs.\30\
---------------------------------------------------------------------------
    \29\ Chenowith, D., Martin, N., Pankowski, J., & Raymond, L.W. 
(2005). A benefit-cost analysis of a worksite nurse practitioner 
program: First impressions. Journal of Occupational and Environmental 
Medicine, 47 (11), 1110-6.
    \30\ Paez, K. & Allen, J. (2006). Cost-effectiveness of nurse 
practitioner management of hypercholesterolemia following coronary 
revascularization, Journal of the American Academy of Nurse 
Practitioners, 18 (9), 436-444.
---------------------------------------------------------------------------
    When comparing the cost of physician-only teams with the cost of a 
physician-NP team in a long-term care facility, the physician-NP team's 
cost were 42 percent lower for the intermediate and skilled care 
residents and 26 percent lower for those with long-term stays. The 
physician-NP teams also had significantly lower rates of emergency 
department transfers, shorter hospital lengths of stays, and fewer 
specialty visits.\31\
---------------------------------------------------------------------------
    \31\ Hummel, J., Pirzada, S. (1994). Estimating the cost of using 
non-physician providers in an HMO: Where would the savings begin? HMO 
Practice, 8 (4), 162-4.
---------------------------------------------------------------------------
    A collaborative NP/physician team was associated with decreased 
length of stay and costs and higher hospital profit, with similar 
readmission and mortality rates.\32\ \33\ Larkin cites a number of 
studies supporting decreased costs, complication rates, and lengths of 
stay associated with NP-managed care.\34\ For instance, he cites 
University of Virginia Health System's 1999 introduction of an NP model 
in the area of neuroscience, resulting in over $2.4 million savings the 
first year and a return on investment of 1,600 percent. The NP model 
has been expanded in this system, with similar savings and improved 
outcomes documented. Another example cited includes an NP model 
introduced at Loyola University Health System's cardiovascular area, 
with a decrease in mortality from 3.7 percent to 0.6 percent and over 9 
percent decreased cost per case (from $27,037 to $24,511).
---------------------------------------------------------------------------
    \32\ Cowan, M.J., Shapiro, M., Hays, R.D., Afifi, A., Vazirani, S., 
Ward, C.R., et al. (2006). The effect of a multidisciplinary 
hospitalist/physician and advanced practice nurse collaboration on 
hospital costs. The Journal of Nursing Administration, 36 (2), 79-85.
    \33\ Ettner, S.L., Kotlerman, J., Abdemonem, A., Vazirani, S., 
Hays, R.D., Shapiro, M., et al. (2006). An alternative approach to 
reducing the costs of patient care? A controlled trial of the multi-
disciplinary doctor-nurse practitioner (MDNP) model. Medical Decision 
Making, 26, 9-17.
    \34\ Larkin, H. (2003). The case for nurse practitioners. Hospitals 
and Health Networks. Aug. 2003, 54-59.
---------------------------------------------------------------------------
    Direct-cost savings estimated by the Department of Health and Human 
Services of an office visit with an NP was 10-40 percent less than 
comparable services provided by physicians.\35\ According to the 
American College of Nurse Practitioners, nurse practitioners cost 40 
cent less per U.S. dollar than physicians and provide value-added 
effects. Advanced practice nurses are particularly cost-effective with 
their expertise in counseling, education and case management in 
administering preventive care.\36\ Some estimates suggest that up to 
8.75-billion U.S. dollars could be saved in long-term costs by fully 
utilizing nurse practitioners.\37\
---------------------------------------------------------------------------
    \35\ Fitzgerald, M., Jones, E., Lazar, B., McHugh, M., & Wang, C. 
(1995). The Mid-level Provider: Colleague or Competitor? Patient Care, 
23-37.
    \36\ Appleby, C. (1995). Boxed in? Hospitals and Health Networks, 
28-34.
    \37\ Canadian Nurses Association. (2002). Cost effectiveness of the 
nurse practitioner role: Fact sheet. Retrieved April 15, 2006, from 
http://72.14.203.104/search?q=cache:Ubt5MfCIeV0J: 
www.cna-nurses.ca/CNA/documents/pdf/publications/
FS10_Cost_effectiveness_Nurse_ 
Practitioner.
---------------------------------------------------------------------------
barriers to accessing primary care services: an example from the rural 
                            state of vermont
    Available and accessible primary care services in Vermont are 
inadequate. Eight of Vermont's 14 counties fall below Federal standards 
for the ratio of primary care physicians to area residents. Nineteen 
percent of family physicians and 27 percent of internists are not 
accepting new patients. In Washington County this percentage rises to 
54 percent. As fewer medical students seek primary care residencies and 
the population of the elderly grows disproportionately, accessible 
healthcare services will decline.\38\ Vermont NPs are a stable 
workforce, providing care for a primarily rural population. Removing 
the restrictive language linking NP workforce to physician involvement 
will provide the citizens of Vermont access to necessary, high quality 
healthcare. Increased access to preventative services will greatly 
reduce morbidity and mortality of Vermont's highest ranking health 
problems: diabetes-related death, colorectal cancer, obesity, and 
hypertension.\39\
---------------------------------------------------------------------------
    \38\ Dritschilo, G & Palmer, R. (2006). Patients struggling to find 
local physicians. Retrieved on April 2, 2006 from http://
www.rutlandherald.com/apps/pbcs.dll/article?AID=/20060305/NEWS/
603050377/1024.
    \39\ Pearson, L. (2006). The Pearson report. The American Journal 
for Nurse Practitioners, 10(1), 1-163.
---------------------------------------------------------------------------
    In 2002 there were 451 practicing NPs in the State of Vermont. Of 
that number 63 percent were in a primary care setting. Sixty-five 
percent of NP workforce has been in practice for 5 or more years and 93 
percent possess prescriptive authority. Seventy-three percent of NPs 
hold a masters degree or higher. Most NPs work in a physician/NP group 
setting (34 percent), a hospital-based setting (33 percent), or a 
community health center (17 percent).\40\ Pearson reports Vermont NPs 
are among the lowest in the Nation for reported misconduct, reflecting 
their safety in providing healthcare. \41\ Vermont advanced practice 
nurses may apply for hospital privileges and are recognized as primary 
care providers for Vermont Medicaid.
---------------------------------------------------------------------------
    \40\ Vermont Department of Health (2004). Advanced practice 
registered nurses: 2002 statistical report and survey. In Vermont 
Department of Health (Ed.): State of Vermont.
    \41\ Ibid.
---------------------------------------------------------------------------
    The current language of the Administrative Rules obligates a 
professionally educated, trained, and nationally board certified NP to 
sign a practice agreement with a physician prior to being endorsed by 
the Board of Nursing as a nurse practitioner in the State of 
Vermont.\42\ This has created barriers to practice, which could be 
interpreted as barriers to accessing care for the people of Vermont. 
Examples of this include:
---------------------------------------------------------------------------
    \42\ Vermont State Board of Nursing (2004). Board of nursing 
administrative rules (March 4 ed., pp. 55 0957): State of Vermont.

     NPs are having difficulty locating physicians willing to 
enter into and maintain collaborative agreements. NPs who wish to 
practice in areas such as Franklin County, a rural federally designated 
underserved area, and are unable to open their own practice due to 
inability to find a physician to sign a practice agreement;
     Certified nurse mid-wives (CMNs) and NPs who must pay up 
to $8,000.00 annually to a physician for a written practice agreement 
which makes practicing economically unfeasible for the NP;
     Perpetuates confusion for insurers who continue to resist 
recognizing NPs as primary care providers, therefore refusing to 
reimburse for delivered services;
     Physicians are fearful that they will be held liable if 
they sign an agreement with an NP.
     Physicians can at anytime sever an agreement.
     NPs cannot abandon patients when a collaborative agreement 
is severed, yet cannot legally under the current statute continue to 
provide care to patients.
     NPs will continue to be seen as ``extenders'' of the 
medical model and remain virtually invisible at the policy reform 
table;
     NPs who are comfortable in their current practice 
arrangements are not aware of the implications that this outdated 
language has on provision and reimbursement of health services and the 
vulnerability of NP reliance on M.D.'s choice to support or not support 
NP practice.\43\ It is important to recognize ultimately that the 
language change does not affect scope of practice, including the 
ability to collaborate.
---------------------------------------------------------------------------
    \43\ Edmunds, M. (2000). NPs face systematic opposition from 
physicians. The Nurse Practitioner, 25(12), 65 0968.

    ``Given that no health care professional practices independently 
any longer, statutory language, professional organization policies, and 
even separate ethical principles may be outdated for both professions 
[NPs and M.D.'s] .'' \44\ As a better understanding evolves as to how 
to reconfigure the health care system to address the changing needs of 
our society, legislated barriers to collaboration should be removed and 
replaced by cooperative model practice acts.\45\
---------------------------------------------------------------------------
    \44\ Phillips, R.L., Jr., Harper, D.C., Wakefield, M., Green, L.A., 
& Fryer, G.E., Jr. (2002). Can nurse practitioners and physicians beat 
parochialism into plowshares? Health Aff, 21(5), 133-142, p. 139.
    \45\ Ibid.
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                            recommendations
    While the healthcare system appears in dire straits, the 
identification of problems as central and urgent as the frail U.S. 
healthcare system is not enough to warrant a place on the healthcare 
policy agenda. Problems which drive policy formation depend on ``public 
salience and the degree of group conflict surrounding it '' \46\ and 
the feasibility of such solutions. Potential solutions to identifiable 
problems must be available. The Clinton Health Security Act of 1993 
proposed to reform healthcare through cost control and provision of 
universal healthcare. This proposal was never enacted.\47\ Other 
possible solutions may be targeted towards increasing the population of 
primary care physicians through incentives. This does not address 
either healthcare cost control or the current need for services.
---------------------------------------------------------------------------
    \46\ Longest, B. (2002). Health Policymaking in the United States 
(3rd ed.). Chicago: Health Administration Press, p. 131.
    \47\ Ibid.
---------------------------------------------------------------------------
    Since the birth of the NP, a wealth of literature exits in support 
of NP-provided care. A recent study concluded NPs could safely provide 
75 percent of primary care, 90 percent of pediatric primary care, 65 
percent of routine anesthesia care, 85 percent of rural anesthesia 
care, and 98 percent of routine obstetrical care if the appropriate 
workforce was available.\48\
---------------------------------------------------------------------------
    \48\ Brooten, D., Youngblut, J., Kutcher, J., & Bobo, C. (2004). 
Quality and the nursing workforce: APNs, patient outcomes and 
healthcare costs. Nursing Outlook, 52, 45 0952.
---------------------------------------------------------------------------
    The obvious need for accessible quality healthcare, healthcare cost 
control, and provisions for health promotion presents an optimal 
opportunity for nurse practitioners to meet the critical demand. The 
following recommendations are made:

Reauthorization and Increased Funding of Title VIII
    In the presence of spiraling medical care costs and the shortage of 
professional nurses and primary care providers, the need to prepare 
quality, cost effective clinicians such as nurse practitioners 
continues to be acute. The need for primary care providers to serve 
vulnerable populations, increase the public health infrastructure and 
serve as first responders in the presence of national disasters has 
been clearly articulated by both Congress and the Administration. Nurse 
practitioners are primary care providers who can meet all of these 
national needs.
    Nurse practitioners have been demonstrated to provide high quality, 
cost-effective care in whatever environment they practice. It is 
important that the proper preparation of enough of these providers is 
maintained to meet health care needs identified in these current 
national priorities. This cannot be accomplished if educational 
programs are unable to be funded at higher levels. Only a limited 
number of programs are able to be funded each year at the current 
funding levels. Increases are needed for nurse practitioner educational 
programs and traineeships to work toward this need. This is the only 
Federal funding source for these programs since they have no access to 
graduate medical (GME) funds.
    Nurse practitioners want to help meet the growing health needs of 
the Nation, but they will need assistance to do it. This means that 
nurse practitioner educational programs and scholarship funding needed 
to be maintained and increased in the Federal budget. Reauthorizing and 
increasing funding for title VIII will improve the workforce of primary 
care nurse practitioners by providing and educating the faculty that 
will be needed to accomplish this goal.
Support S. 1795 To Improve Access To Workers Compensation Programs for 
        Injured Federal Employees by Adding Nurse Practitioners to the 
        List of Providers Authorized to Provide Services Under This 
        Statute
    While nurse practitioners have been recognized and reimbursable 
providers in the Federal Employees Health Insurance Program for nearly 
20 years, they have not been identified as authorized providers in the 
Federal Employee Workers Compensations Program.
    Nurse practitioners diagnose and treat injuries and illnesses 
currently covered by the Federal Employees Workers Compensation 
Program. Because nurse practitioners are not listed as covered 
providers, patients must seek care from other providers, often in more 
costly practice sites such as emergency rooms, adding cost and lapsed 
time prior to appropriate and necessary treatment. Nurse practitioners 
have long been demonstrated to provide safe and responsible care to the 
patients they serve. They have expert knowledge and skills that allow 
them to provide high quality care to patients needing care under the 
provisions of this statute. Yet they are not among the list of 
providers (often with more limited scopes of practice) authorized under 
this legislation. Nurse practitioners have been recognized as a cost-
effective source of high quality care that should be authorized to 
provide care under the provisions of this statute.
    Currently nurse practitioners provide reimbursable services to 
Federal employees under the Federal employees health plan. Likewise in 
approximately half of all States, nurse practitioners are authorized to 
sign for and provide workers compensation services. This bill will 
provide consistency with both Federal health care insurance laws and 
State workers compensation laws.
Federal Support at State Levels to Increase Access and Reimbursement to 
        Nurse Practitioner Services for all Individuals
    Nurse practitioners face similar barriers to those of physician 
primary care providers such as increasing administrative demands, 
sicker patients, growing patient panels, and decreasing reimbursement. 
Exacerbating the growing burden of providing primary care for NPs is 
the restrictive practice guidelines set forth decades ago limiting 
patient access to available high quality primary care providers.
    Nursing has been and remains a distinct, self-regulating profession 
like law and medicine. As a profession, nursing has the authority and 
responsibility to define its standards of practice. NPs are not 
``junior physicians'' or ``underlings'' of the physician. NPs will 
increase access to cost-effective, high quality primary healthcare by 
removing workforce dependency on physician collaboration, practice 
agreements, and/or physician oversite.
    Given that only one out of four medical school graduates select 
residencies in the primary care specialties,\49\ NPs present an 
available, stable, and high quality workforce to address the health 
care needs of the Nation.
---------------------------------------------------------------------------
    \49\ Dritschilo, G. & Palmer, R. (2006). Patients struggling to 
find local physicians. Retrieved on April 2, 2006 fromhttp://www. 
rutlandherald.com/apps/pbcs.dll/article?AID=/20060305/NEWS/603050377/
1024.
---------------------------------------------------------------------------
                                summary
    I would like to thank Senators Sanders, Kennedy, Enzi, and their 
staff for this opportunity to discuss how nurse practitioners are vital 
in solving the primary care shortage in the United States. Nurse 
practitioners provide different healthcare services and products than 
that of physicians. NPs place emphasis on health promotion, disease 
prevention, self-management of chronic disease, education, and health 
for the individual, family, and/or community. We are skilled at 
improving the knowledge base and the level of physical functioning of 
individuals, families, and their communities. We provide comfort and 
assist in adapting to loss or change. Nurse practitioner care is 
holistic. The ``value-added'' NP effects result in indirect cost 
savings, increased satisfaction, and improved outcomes for our patients 
and society. With your support and assistance, nurse practitioners will 
go a long way in addressing the primary care shortage for the Nation.
    Note: For more information please contact author.\50\
---------------------------------------------------------------------------
    \50\ Jennifer S. Laurent, MS, FNP 09C, 281 Shelburne Street, 
Burlington, Vermont 05401, phone 802.644.5114, e-mail: 
[email protected].

    Senator Sanders. Thank you very much.
    Dr. John Maupin, D.D.S, M.B.A., is the President of the 
Morehouse School of Medicine in Atlanta. Dr. Maupin, thanks 
very much for being with us.

  STATEMENT OF JOHN E. MAUPIN, JR., D.D.S, M.B.A., PRESIDENT, 
           MOREHOUSE SCHOOL OF MEDICINE, ATLANTA, GA

    Mr. Maupin. Thank you for allowing me to be here today. 
First, I represent one of four historically black medical 
schools, also the Association of Minority Health Professions 
Schools, which represents 12 historically black institutions 
that train physicians, dentists, veterinarians, pharmacists, 
and nurses.
    Collectively, we have trained over 50 percent of all 
African-Americans or black health professionals in this 
country. Much of our success has come from the support of the 
title VII programs and particularly the diversity programs. Our 
success has always been demonstrated by our graduates. Over 70 
percent practice in underserved communities. They work in 
federally qualified community health centers, public health 
departments. They work in their own private practices in areas 
where there are predominantly uninsured and underinsured 
individuals.
    This is the front line of the safety net group that 
continues to serve this country in many ways. It is because of 
those programs that the institutions have been successful, and 
much of that has to do with their mission.
    When your mission is about training primary care, when your 
mission is serving a disproportionate share of uninsured, when 
your mission is not on research focus, and when you have 
patients who will not become your wealthy donors, then you are 
forced, in many ways, to depend on these programs to survive in 
today's environments that are capital intense and very 
competitive.
    The diversity programs in particular, and title VII in 
general, have allowed us to connect with AHECs, to work with 
federally qualified community health centers, to provide 
training experience. This success rate is not by accident. It 
is by design.
    I am one of those. I came to Meharry Medical College in 
1968. I was exposed to a federally qualified community health 
center in Los Angeles, Watts Community Health Center. I was 
there. In 1970, I was allowed to go to Baltimore and train in 
an externship in the hospital. Across the street was a 
federally qualified community health center. That community 
health center led me to believe that should be my career.
    We talked about it back in Nashville in my training. We 
were exposed to it, both my medical colleagues, my dental 
colleagues, and others. It is where you train and how you train 
that determines where you go to serve. These institutions can 
carry that mission out and make a great contribution, but right 
now, quite frankly, they are faced with a daunting future.
    When you cut back on Medicaid, when you reduce GME, when 
you want to talk about eliminating DSH funding, and all of 
those things that support any institution, and then you zero 
out title VII, you are asking for them to close and not 
participate at all in the future.
    Thank you, sir.
    [The prepared statement of Dr. Maupin follows:]
       Prepared Statement of John E. Maupin, Jr., D.D.S., M.B.A.
    Mr. Chairman and members of the committee, thank you for the 
opportunity to discuss the critical importance of diversity in the 
health professions, and specifically the health professions training 
programs at the Health Resources and Services Administration (HRSA).
    I am Dr. John E. Maupin, President of the Morehouse School of 
Medicine (MSM) in Atlanta, GA, MSM is one of only four historically 
Black medical schools in the country, and one of twelve (12) 
Historically Black health professions institutions that compromise the 
Association of Minority Health Professions Schools (AMHPS). 
Historically, the small number of schools have collectively trained 50 
percent of the African-American physicians and dentists in this 
country. Sixty percent of African-American pharmacists, and 75 percent 
of African-American veterinarians. Many have called our institutions a 
national resource, and they are correct. These schools go a long way in 
making the healthcare workforce look like America. I want you to know 
that it is not lost on me that I am making this statement to your 
committee in February, Black History Month. I think this is as 
appropriate a time as any to have a discussion about health disparities 
in America, and hopefully we can agree on a legislative solution. Mr. 
Chairman, I understand that the historically Black institutions are not 
the only ones who are combating health disparities. I have provided the 
committee with a list of all institutions which were able to compete 
well for the key programs which support the training of minority health 
professionals, when those programs were funded more robustly.
    In 1997, then as President of Meharry Medical College (MMC) in 
Nashville, TN, I testified before this committee, and discussed the 
challenges of health disparities in America. There have been some 
improvements, thanks to the work this committee did to reauthorize, 
restructure, and empower certain programs that created and strengthened 
a pipeline of minority health professionals. Those health professionals 
have dedicated themselves to serving in the areas where they are most 
needed--rural and urban medically and underserved communities. The 
diversity cluster of the title VII health professions training 
programs: Minority Centers of Excellence (COE), Health Careers 
Opportunity Program (HCOP), Scholarships for Disadvantaged Students 
(SDS), and Faculty Loan Repayment Program are the programs that made 
the training of a diverse healthcare workforce possible, and they are 
the lifeblood of institutions like Morehouse School of Medicine, 
Meharry, and our sister institutions at AMHPS. Unfortunately, the 
funding for these programs was dramatically cut in fiscal year 2006, 
and the programs have struggled to regain that funding. Shortly, I will 
explain the unique mission of our small set of institutions, the reason 
why the aforementioned programs are so important, and what this 
committee can do to make sure we continue to produce quality primary 
care health professionals.
                    the health status of minorities
    Mr. Chairman, in 2005 the Centers for Disease Control and 
Prevention (CDC) still claimed that ``non-Hispanic blacks bear a 
disproportionate burden of disease, injury, death, and disability.'' It 
is still fair to say that African-Americans and other minorities suffer 
a disproportionately low health status when compared to their non-
minority counterparts in our country. In a 1985 landmark study 
conducted by the U.S. Department of Health and Human Services, The HHS 
Secretary's Task Force Report on Black and Minority Health, confirmed 
this national problem. Allow me to share updates on some of the 
highlights from that report:

     African-American infants are nearly 2\1/2\ times more 
likely to die before their first birthday than white infants.
     African-Americans are twice as likely to die from a stroke 
as Caucasians. The rate of first strokes in African-Americans is almost 
double that of Caucasians.
     African-Americans who died from HIV-AIDS had approximately 
11 times as many age-adjusted years of potential life lost before age 
75 years per 100,000 population as non-Hispanic whites. African-
Americans also had substantially more years of potential life lost than 
non-Hispanic whites for homicide (nine times as many), stroke (three 
times as many), prenatal diseases (three times as many) and diabetes 
(three times as many).
     Cancer is the second leading cause of death for African-
Americans.
     Only 56 percent of African-Americans have private health 
insurance coverage. Medicaid covers an additional 21 percent, but 
almost one quarter (23 percent) are uninsured. The uninsured rate for 
African-Americans is more than 1\1/2\ times the rate for white 
Americans.
     Of African-American families, 24.7 percent lived below the 
poverty level, including 46 percent of African-American children.

    Mr. Chairman, if improving upon these health disparities is a 
national priority, the need for an aggressive Federal commitment to 
address these problems still very much exists.
   the need for strengthening and funding federal health professions 
                           training programs
    The national priority to improve the health status of minorities, 
by doing so all Americans, rests in large part on our ability to train 
competent and dedicated individuals to serve our Nation's underserved 
and disadvantaged areas. Currently, Mr. Chairman, eventhough African-
Americans represent about 13 percent of the U.S. population, only 2-3 
percent of all physicians, dentists, pharmacists, veterinarians, and 
allied health professional are African-Americans. There is also a wide 
body of research demonstrating that language, communication patterns, 
socioeconomics barriers, and diverse health/disease belief systems play 
a major role in eliciting history, establishing diagnoses, obtaining 
the help and cooperation of family and friends, and influencing the 
patients' compliance with a recommended course of treatment. There are 
also ethnic and racial differences in response to drugs and how 
diseases manifest themselves. Therefore, Federal health professions 
training programs support targeted to institutions that significantly 
influence the number of under represented minorities practicing in 
these areas is critical not only to addressing issues of access to care 
but to the quality of healthcare provided as well.
    Every credible study ever conducted demonstrates that an individual 
who comes from a disadvantaged background or underserved area is much 
more likely to serve in underserved areas as a health professional. 
Increasing the numbers of health professionals that serve in an 
underserved areas can and does improve health status. Many of the 
health professions training and institutional support programs being 
reviewed today have, and continue to have a dramatically positive 
impact on the ability of our schools to train the health professions 
workforce that will serve in underserved areas and improve the health 
status of disadvantaged and minority populations. Those programs have a 
positive impact when they are well-funded.
  the role of historically minority institutions in training african-
                     american health professionals
    Collectively, the goal of historically minority institutions has 
been to train African-Americans to serve in medically underserved 
areas. As demonstrated by the figures outlined in the opening part of 
my statement, this small contingent of schools has been hugely 
successful in accomplishing this mission. Yet, in spite of our proven 
success in training minority health professionals, our institutions 
endure a financial struggle that is inherent in our mission to train 
disadvantaged individuals to serve in underserved areas. That is why we 
say that MSM, like Meharry and our other sister institutions, is a 
private institution with a public mission.
    The financial plight of the majority of our students has affected 
our schools in numerous ways such that we are not able to depend on 
more traditional means of support such as annual gifts and generous 
endowment contributions. Additionally, the patient populations served 
by the AMHPS institutions have historically been poor, uninsured and 
under-insured, therefore our institutions have not generated revenue 
from the process of much more lucrative patient care at the 40-50 
percent level achieved by majority schools. In other words, as a 
colleague of mine says, our schools have grateful patients, but not 
wealthy, grateful patients.
    With regard to student financial assistance, there is a desperate 
need for this committee to understand that scholarship support is the 
only way to a health professions education for severely disadvantaged 
students. Student aid officers tell us time and time again that poor 
students will not agree to incur debt for tuition cost that is about 
twice the level of their family's annual household income. The effect 
of wiping out scholarship support is to ensure that poor people do not 
become health professionals. Further, that almost guarantees that the 
poor will not be well.
    The very nature of our mission directs us to admit students that do 
not come from affluent backgrounds. In fact, at MSM, 72 percent of 
entering MSM are classified as disadvantaged. Because of the lack of a 
sizable financial base at most historically minority institutions, we 
are unable to provide scholarship assistance to our students at the 
same level of other institutions. For example, at MSM:

     Only 25 percent of the scholarships awarded annually are 
from endowment funds.
     The remaining 75 percent are non-endowed scholarships and 
are funded by sources that are cyclical in nature so that the numbers 
and amounts of scholarships fluctuate annually and are therefore less 
stable sources of funding.
     The average annual scholarship award is $9,480, which 
comprises only one-third of the College's tuition and fees for medical 
students. More significantly, this average award represents only one-
fourth of the total cost of a medical education at MSM.
     Because MSM's scholarships only cover 25 percent of the 
educational costs, the students must secure the remaining 75 percent of 
the funding from loans. When they graduate, the students have often 
amassed debt which exceeds the national averages for students entering 
similar professions.

    Therefore, targeted Federal scholarship support is crucial to the 
fulfillment of our missions. Scholarship support is the most important 
way to assist the health professions education of severely 
disadvantaged students. The program that accomplishes this is the 
Scholarships for Disadvantaged Students (SDS).
    Health professions training grants, targeted towards our 
institutions and authorized by this committee, have helped our schools 
level the playing field by a small measure. They have also allowed us 
to continue to address the critical disparity needs. Make no mistake, 
without such programs as the Minority Centers of Excellence (COE), MSM 
would be a much different place. Health professions training programs 
represent life blood for our institutions.
    However, that life blood, like the pipeline of health 
professionals, has been choked off. In fiscal year 2006, the Congress 
passed a Labor-Health and Human Services (HHS)-Education Appropriations 
bill that severely cut the funding stream for the programs that fund 
our institutions' core activities. The programs cut were COE (funded in 
fiscal year 2005 at $33.6 million, funded in fiscal year 2008 at 
$12.773 million), HCOP (funded in fiscal year 2005 at $35.647 million, 
funded in fiscal year 2008 at $9.825 million), Faculty Loan Repayment 
Program (funded in fiscal year 2005 at $1.302 million, funded in fiscal 
year 2008 at $1.266 million), and Scholarships for Disadvantaged 
Students (funded in fiscal year 2005 at $47.128 million, funded in 
fiscal year 2008 at $45.842 million). I appreciate the fact that the 
HELP Committee is an authorizer, but the negative impact of this low 
level of funding for these programs cannot be understated. In terms of 
the COE program, the funding level is so low that MSM cannot compete 
for a grant. MSM is adversely affected by our inability to compete for 
COE and the low level of HCOP funding which inhibits our outreach 
efforts towards students in primary education, especially the poor, to 
show them which math and science courses to take to begin the road to 
the health professions. Secondly, MSM boasts the No. 1 rated program in 
the Nation for producing minority medical school faculty. That program, 
previously funded by our COE grant, is in serious jeopardy of closing. 
Like MSM, that program is a national and State treasure. It is fair to 
say that if these programs continue to be funded at these low levels, 
many of the minority health professions institutions may not exist in 
their current form, furthering the disparity of minority health 
professionals. These are the kinds of ramifications that occur when the 
core funding stream for our programs and institutions are drastically 
reduced.
    This has occurred at a particularly sensitive time for the minority 
health training community. Our institutions face the threat of loss of 
Graduate Medical Education (GME) funding, financing our residency 
programs, withdrawn unless the moratorium on the CMS rule is extended.
    No matter the vehicle this committee chooses to reauthorize the 
diversity cluster of the title VII health professions training 
programs--either as a portion of Senator Kennedy's Minority Health 
Improvement and Health Disparities Elimination Act (S. 1576) or a title 
VII reauthorization bill--our institutions are in favor of adding an 
evaluation component to each program. Some criticize these programs for 
not having enough evidence of effectiveness. Mr. Chairman, our students 
disproportionately dedicate themselves to practicing in the medically 
underserved areas. That is a direct result of the programs I mentioned 
above. Morehouse School of Medicine and its sister HBCU health 
professions schools, only 12 in all, have historically trained about 
half of the black health professionals in the country. I don't know how 
much more evidence anyone needs to appreciate the impact of these 
institutions and the importance of these Federal programs in responding 
to their needs.
   recommendations for the reauthorization of the health professions 
                           training programs
    Mr. Chairman, we urge that the committee move quickly to 
reauthorize the Centers of Excellence, Health Careers Opportunities 
Program, Scholarships for Disadvantaged Students, and Minority Faculty 
Loan Repayment Program to respond to the unwarranted criticism that it 
is difficult to link the effectiveness of these programs. Please do 
incorporate a strong evaluation and data collection component into the 
reauthorization.
    We also encourage each member of this committee to advocate for the 
full restoration of funding for COE, HCOP, Faculty Loan Repayment, and 
Scholarships for Disadvantaged Students in the fiscal year 2009 L-HHS 
Appropriations bill. The full funding of these programs gives 
institutions like MSM the opportunity to compete and invest in the 
education of the Nation's future health professionals that will 
actively combat racial and ethnic health disparities in the United 
States.
    Mr. Chairman, I hope these suggestions are helpful to the 
committee. Thank you for the opportunity to present views of the 
Association of Minority Health Professions Schools and Morehouse School 
of Medicine.

    Senator Sanders. Thank you very much.
    Why don't we begin? Let me start off with a question, and 
then we will go to the other Senators. Everybody jump in, and 
Senators jump in, and we will go where we will go and keep this 
moving.
    Let me start off with what is a fairly dumb-bunny question, 
I must confess. This is the richest country in the history of 
the world, and people all over the world would find it hard to 
understand why, in this Nation, we are not educating and 
sending forth the number of primary care medical professionals 
that we should. The result being that tens of millions of 
people lack access to primary healthcare.
    This is the simple question. Why is this? Very briefly, how 
do we resolve that crisis? Who wants to begin, okay, Dr. 
Grumbach?
    Dr. Grumbach. You know, there is a saying that every system 
is perfectly designed to achieve the outcomes it is achieving. 
We have a perfect system to provide all the incentives for 
physicians, for nurses, for others to practice in highly 
specialized, highly centralized areas. Again, Mr. Steinwald 
showed you can make four times more per hour doing procedural 
work than you can working in a primary care area, and that is 
not lost on people going into the field.
    Unless you look at the incentives, drawing people into 
where they are not as needed as they might otherwise be, you'll 
never tackle the problem. It is not a lack of money, as you 
point out. It is ultimately not even a lack, truly, that we 
have a shortage overall of personnel. It is just all the 
incentives are to not have somebody practice in a community 
health center in rural Alaska. It is to do specialized medicine 
in Beverly Hills, in downtown San Francisco.
    Unless you address that, you will just keep seeing the same 
patterns.
    Mr. Steinwald. Let me add to that, if I may, Senator? It is 
absolutely true that the incentives are paramount, and we have 
this paradox of plenty existing side by side with shortage. The 
incentives are our payment systems--not just Medicare, but most 
private insurances--to do more and do more complex procedures. 
That, in turn, generates revenue.
    As has been pointed out, medical students are not blind to 
that. Those that have substantial debt can see the difference 
in earning potential between primary care and specialty care. 
The paradox is extended when you consider that the systems that 
do exist in this country that emphasize primary care tend to 
get better outcomes at lower cost. That includes not only 
closed systems like our staff model HMOs, it also includes 
certain areas of the country where there are fewer specialists, 
more primary care doctors tend to deliver quality services at a 
lower cost.
    Senator Sanders. Other thoughts?
    Dr. Maupin.
    Mr. Maupin. I would say that not only the payment system to 
the individual physician or provider, whether it be a dentist 
or other, but also the reimbursement or the payment system for 
graduate medical education, which comes through Medicare and 
sometimes Medicaid.
    When you look at a hospital with a high number of 
subspecialty services and a high number of Medicare patients, 
you will find that they are reimbursed at a higher rate than 
you will find a public hospital trying to serve the 
underserved. There is just no way that they can survive in 
today's environment under the current payment system and 
reimbursement system.
    Senator Sanders. Dr. Auerbach.
    Dr. Auerbach. Yes, in addition to these issues, which have 
been brought up repeatedly by people, the issue of medical 
student debt, is a very significant factor. In most of the rest 
of the world, students that graduate from medical school 
graduate with virtually no debt.
    I actually was in medical school in France for a couple of 
years, and it cost me $100 a year as a non-national to go to 
medical school, let alone, it was $20 a year for the French 
medical students. It is a huge difference between getting your 
schooling for free, essentially, and getting your schooling for 
$40,000, $50,000 a year, which, as Senator Kennedy indicated, 
students are graduating with $140,000 to $160,000 worth of 
debt.
    At the Mass Medical Society, we have actually been going to 
the medical schools and interviewing the medical students 
around the issue of primary care. When we asked them the 
question how many of you are going to be choosing your 
specialty because of the amount of debt you are leaving medical 
school with, more than 50 percent of the hands go up. It is a 
very clear equation when you think about the relative 
difference in reimbursement.
    Senator Sanders. Dr. Swift.
    Mr. Swift. In the dental environment, there actually is a 
preponderance of primary care people educated through the 
educational system. Of the dental school graduates, 80 percent 
go into general dental practice, and a few more go into 
pediatric dental practice, which is a primary care type of 
situation.
    The challenge, however, is the disregard for oral health or 
dental health as a component of overall general health. It has 
existed for decades. As a result, it is difficult for anyone to 
get reimbursement for any type of dental treatment procedure, 
whether it be the Medicaid program.
    We attempted to get a dental benefit, dental guarantee in 
the SCHIP, and as you all know, SCHIP didn't go. We were 
hopeful that that would be something that would be passed. That 
was the first time, that we are aware of, that dentistry was 
carved out as a specific area in any bill that addressed the 
issues related to oral healthcare.
    It is a relative problem that is related to reimbursement 
rates, access to care, and the identity that oral health and 
the oral systemic connection is an important feature of overall 
general health.
    Senator Sanders. Mr. Salsberg.
    Mr. Salsberg. One of the problems, we think, is again we 
are not producing enough U.S.-medical school graduates. We 
graduate about 16,000 physicians each year, but we have 25,000 
first-year residency positions. And then comes into play the 
system's incentives, which say they can get higher rewards and 
benefits going into other specialties.
    Increasing the number of U.S.-medical school graduates 
would be one step. Obviously, having the system rewards and 
incentives in the right place is also critical. And then having 
a delivery system that is well designed, that is interesting 
and challenging for the primary care physician is critical. We 
think we need to do more in terms of interdisciplinary care and 
treatment and education. A physician should learn through the 
education process that they work with nurse practitioners, 
P.A.'s, and others, and we deliver care in a team setting.
    Senator Sanders. OK. Yes, Doctor?
    Mr. Maupin. I want to take this opportunity to highlight 
something, an experience I had. I served in Desert Shield and 
Desert Storm, and one of my assignments during Desert Shield, 
as a dentist, was to prepare the National Guard for their 
service. The No. 1 issue of calling them noncombat ready was 
their oral health status, their oral health status. It is so 
widespread that the access to care for people who work in jobs 
and don't have insurance and the ability to find practitioners 
willing to serve in Medicaid, high Medicaid areas and uninsured 
areas is so great that it is not only a shame for the country, 
but it is a challenge for our military issues and strengths 
across this country.
    Senator Sanders. Ms. Laurent.
    Ms. Laurent. I just wanted to acknowledge the under 
utilization of nurse practitioners as primary care providers in 
the Nation. I am happy to say in the State of Vermont, nurse 
practitioners are recognized as primary care providers by 
Medicaid. But, that is not really true for the Nation as a 
whole.
    Nurse practitioners are educated with pretty much the sole 
purpose of health promotion, disease prevention, in a cost-
effective, high-quality role. The barriers that presents to the 
Nation by not reimbursing these primary care providers by 
Medicaid really is a significant barrier to access and quality 
of care.
    As we all are now learning, health promotion is really 
where it needs to be. It doesn't need to be in treating people 
after they have had their third or fourth MI or heart attack. 
It needs to be, you know, diet and exercise and counseling, and 
really, that is where nurses and nurse practitioners excel.
    Utilizing those providers to their maximum extent really 
has far-reaching consequences in the Nation, as we all get 
older and the healthcare crisis continues.
    Thank you.
    Senator Sanders. Let me move on now to Senator----
    Senator Allard. Mr. Chairman?
    Senator Sanders. Yes? Sure.
    Senator Allard. While we are on this subject, I would like 
to ask a question if I might. Scientific programs are generally 
finding it more difficult to recruit good quality students. Are 
we seeing that in medicine, where we have maybe not as much 
interest in going to the healthcare sciences as you maybe had 
20, 30 years ago? Anybody want to respond to that?
    Senator Sanders. Mr. Salsberg.
    Mr. Salsberg. The AAMC tracks this for medical schools, and 
we work closely with the osteopathic community. Actually, the 
last 5 years, applications to medical schools has been up. It 
was down from the mid-1990s to about 5 years ago, but it has 
been up over the last several years. We believe we are getting 
very well-qualified students applying for medical school and 
osteopathic schools.
    Senator Allard. It is about two applicants for every one 
slot, right?
    Mr. Salsberg. Yes.
    Mr. Hooker. It is now more difficult to get into P.A. 
school than it is to medical school. Our challenge is reaching 
out to underrepresented minorities and other disadvantaged 
populations because our experience in some States, especially 
in Alaska, where we can bring those people from the community, 
train them as P.A.'s, they tend to go back to those communities 
and stay in those communities.
    The big challenge for us is not the quality of the 
applicants, which is as good as it gets. These applicants can 
go into medical school, law school, any school that they want. 
It is trying to get the people that the communities really 
need, the rural underserved areas, and getting people like that 
to get into P.A. school.
    Senator Sanders. Ms. Landon.
    Ms. Landon. To echo Dr. Hooker, it is the title VII 
programs that are exposing youth, especially youth of minority 
and disadvantaged backgrounds, to the health professions. The 
area health education centers, the AHEC and the HCOPs, really 
take the lead in that. They are really the Federal programs in 
the country that are exposing these youth to health career 
opportunities.
    Not just exposure, but structured programming. Last year, 
the area health education centers supported, over 300,000 
youth, exposed them to health careers, and 41,000 of those 
youth had 20 hours or more of structured programming to expose 
them and get them interested in health careers.
    It doesn't stop there. They have got to be academically 
prepared. They need ongoing mentoring support to get in, to 
matriculate into and continue through.
    Senator Sanders. Dr. Swift.
    Mr. Swift. With the dental school environment, it is 
approximately three to one for application for a position at 
the time, which is a high for us compared to what it was about 
a decade ago. The challenge, however, is the underrepresented 
minority. That is the issue.
    We have about 6 percent or 7 percent of the dental 
workforce a underrepresented minorities. We have been able to 
get that up to about 12 percent first-year enrollment now in 
dental schools, underrepresented minorities, through a couple 
of programs that the American Dental Education Association has 
supported.
    One is called Pipeline Profession and Practice. It is 
sponsored by the Robert Wood Johnson Foundation, W.K. Kellogg, 
and the California Endowment. It is a 5-year initiative that 
was started in 2003, limited to 15 dental schools across the 
country. What they did was establish--or increase the numbers 
of underrepresented minorities and low-income students within 
the environment. As a result of that, they provided care to 
over 237 community-based clinics. This program was so popular 
and efficacious that the California Endowment agreed to fund it 
again for this next phase.
    In addition, we have the Summer Dental Education Program, a 
collaborative effort with the AAMC, and this has been running 
for approximately 3 years. It is an academic enrichment program 
for disadvantaged undergrad freshmen and sophomores, where they 
get classes in courses like organic chemistry and calculus, 
physics, biology, and then they have improvement of their 
communication skills and exposure to the health professions.
    We, at the current time, have run this program through for 
1,900 students. Sixteen hundred that are anticipating going 
into medical school, 300 into dental school. Seventy-one 
percent of this group are females. Forty-eight percent are 
black or African American. Twenty-one Hispanic or Latino, and 2 
percent American Indian. There will be some success with that.
    Senator Sanders. Senator Murray, did you want to jump in 
and ask a question?
    Senator Murray. I am curious, we talked a lot about primary 
care physicians and nurses that we all know there is a shortage 
on. When I did the roundtables in Washington State, I heard a 
lot about the support professions--lab technicians, dental 
hygienists, people that are almost sort of behind the scenes. 
Very real shortage, particularly in rural areas. Could anybody 
comment on that?
    Mr. Hooker. As I go around visiting rural areas, this is 
really a critical area, regardless of what State that you go 
in. All of the allied health disciplines are suffering to some 
extent. I don't know to what extent, but they all are.
    Senator Sanders. Mr. Salsberg.
    Mr. Salsberg. Yes, what we are seeing has really been a 
significant increase over the past two decades in the demand 
for health services, a lot of it driven by the aging of the 
population and the shortages we are beginning to feel across a 
whole wide range of professions.
    Perhaps in ways medicine and dentistry have an advantage. 
We certainly have no shortage of applicants. We have to look at 
expanding our educational capacity. There is a lot of interest 
in a whole wide range of professions, and there have been some 
good programs developed to try and build pipelines for 
individuals into a wide range of programs.
    One of the benefits of title VII is that it has tended to 
look across professions and not be focused on just any one 
profession.
    Senator Sanders. Ms. Landon.
    Ms. Landon. Senator Murray, in Alaska, last year we looked 
at vacancy rates for 119 health occupations. It definitely 
delved quite far into the allied health professions. Overall, 
the vacancy rate across those 119 occupations across the State 
was a little over 10 percent.
    I have the data on the specific allied health occupations, 
any one you would like to know about. Anecdotally, I recall 
that for the therapy programs--PT, OT, speech path--the vacancy 
rates were between 25 and 30 percent. If that isn't staggering 
enough, those vacancies can endure 3 years, if you can imagine 
that?
    Senator Sanders. Yes, Dr. Maupin.
    Mr. Maupin. While our poor applicant pool has gone up 
slightly, I want to reiterate the issue of the minority 
applicant, qualified applicant. What I am concerned about most 
is the recent reductions in title VII support for many of our 
outreach programs. We are beginning to see where that is taking 
its toll on our ability to go out and reach out, participate in 
summer programs, reach out to counseling in the undergraduate 
programs.
    We are going to continue to be very challenged. We have had 
to cut, lay off people in certain areas, which means that we 
really won't be able to continue the kind of success we have 
had in the past with the outreach for minority students in the 
health professions. That is across all of our schools.
    The other point I would make is that if we had an increase 
in the number of applicants, we brought all this together, and 
there is a challenge for us to add, expand our class size so we 
can increase the numbers of people and to address the looming 
shortages. One of the concerns is the residency training 
programs won't be available.
    I may be able to increase the class size, but I won't have 
a place for them to train in the residency training programs. 
That is extremely concerning, and especially the support for 
the primary care programs that need expansion and need special 
attention.
    Senator Sanders. Let me turn to Senator Murkowski now.
    Senator Murray. Could we have Dr. Swift answer that? I want 
to hear from the dental side.
    Senator Sanders. Sure.
    Mr. Swift. Yes, there are a couple of novel programs that 
have been proposed by the American Dental Hygiene Association, 
a workforce model in that particular situation or environment, 
and also by the American Dental Association. They are, at the 
current time, in the process of funding trials, pilot projects 
to determine how those particular--what the roles of those 
individuals will be and how they might integrate into the 
community.
    Senator Sanders. Senator Murkowski.
    Senator Murkowski. Thank you. Dr. Hooker, you have 
mentioned the role that P.A.s, certainly the role that they 
play in the State. Ms. Laurent, certainly in the State of 
Vermont the role of the nurse practitioner there. Mr. 
Steinwald, this actually came from your report about the 
statistics on the per capita supply of primary care physicians 
rising at about an average of 1 percent a year, but while for 
the P.A.s they are rising at about 4 percent, nurse 
practitioners at about 9 percent.
    The question to you all is do you see that investing in the 
P.A. programs, the N.P. programs is a more rewarding benefit, 
if you will, than investing in recruiting the physicians? In 
Alaska and Idaho, Montana, Wyoming, we don't have medical 
schools, but we do have the mid-level programs. Is this where 
we should be focusing more of our attention?
    If we can speak to it from the medical school perspective, 
too, is it more effective to expand the residency slots, or do 
we build more medical schools? I am going in two different 
directions there, but I know everyone is going to be raising 
their hands, and I won't be able to interject here. Dr. Hooker, 
why don't we start with you?
    Mr. Hooker. Well, first of all, let me just also touch on 
the experiments that are underway. Alaska is a very good 
example of where they have introduced dental therapists, and 
this is a very exciting thing for Alaska to have this sort of 
experiment and seeing if some other service other than a 
dentist can deliver some aspect of healthcare service.
    The idea of introducing nurse practitioners and P.A.s into 
the American landscape was a good one, and we don't really know 
how far we can extend that. It is still new territory. We do 
know, after 40 years of examination, that when there is team-
based approach to care, when the doctor and the P.A., the 
doctor and M.P.E., or all three of them, and in group model 
HMOs, like Group Health Cooperative of Puget Sound or Kaiser 
Permanente, where you have modules working together, you find 
that the healthcare of those populations really improve 
substantially.
    There are opportunities to enhance that team approach. I 
don't know what the right formula is. It is one of the 
questions that Professor Grumbach and Mr. Salsberg and I get 
asked all the time. What is the right ratio of doctor to P.A. 
to M.P.E. to population?
    Well, it is one of those ``it depends,'' and it depends on 
many, many things; and how rural or healthy the population is. 
Elderly people tend to be in higher concentrations in rural 
areas. There is ample room--ample, ample room to embark on 
many, many experiments in this area and that we should open our 
opportunities to try to look at them.
    Senator Murkowski. Dr. Grumbach.
    Dr. Grumbach. I would echo a lot of what Dr. Hooker said. 
It is all about team care. I wouldn't see it as an either/or 
question. It is time we can say, well, if the docs are bailing 
out of primary care, if we could just get some more nurse 
practitioners, physician assistants, they all need each other, 
and you need a whole team working in concert.
    What we are also seeing is the same incentives are drawing 
nurse practitioners and physician assistants away from primary 
care. I don't know if Dr. Hooker wants to comment, but the data 
I have seen show a plummeting number of P.A.s that are working 
in the primary care sector because they can get, again, much 
more attractive jobs doing orthopedic physician assistant work 
in hospitals.
    You all really have to look at the whole picture of primary 
care and think of how do we assemble a cadre of workers that 
are physician assistants, nurse practitioners, allied health 
workers, physicians to really address this problem. There is 
not going to be an easy fix of, well, if one group is dropping 
out, we can just rely on another group because it is the same 
endemic problems they are facing.
    In terms of residency and medical schools, what we have 
right now is about 25 percent more first-year residency 
positions than the number of U.S. medical school graduates 
every year, and that is what is being filled largely by 
international medical school graduates. Many of us who aren't--
I'm not sure we necessarily need an overall output increase in 
physicians in the United States. We could certainly close the 
gap by training more of our own.
    That gets into some of these issues around domestic 
production, particularly if we focused on underrepresented 
groups in medicine. Really, if we coupled that with an 
expansion of medical school size, that would close the gap and 
lessen our reliance on foreign-trained physicians to come in.
    What many of us have emphasized, ultimately, it is about 
distribution, not just about total numbers. It is not just 
about how many residency positions, but it is in what fields. 
Because you could train a whole lot more physicians, and they 
would all practice in the same areas that are being 
overserviced, high cost, poor outcomes, and isn't going to 
address the fundamental problem.
    Many of us think it is not so much counting the numbers as 
how do we align the incentives, how do we restructure primary 
care and really build that infrastructure so critical to our 
Nation's health?
    Senator Murkowski. Mr. Salsberg.
    Mr. Salsberg. I would agree that it is not an either/or. 
Nurse practitioners and physician assistants and other health 
professionals have a major role to play. If you are a State 
that does not have a medical school, then adding educational 
capacity for an N.P. or P.A. program can be a good viable 
strategy.
    We actually know we have an excellent program at the 
University of Washington, the WAMI program, which links the 
medical school there, the academic medical center there with 
several States, and that is an excellent model to look at the 
branch campuses of medical schools that can be located in a 
more rural or less populated area.
    I agree with what Dr. Grumbach said about graduate medical 
education. You do want to look at undergraduate and graduate 
medical education together. Adding more residency slots without 
adding more medical school capacity will probably be an 
incentive to recruit more international medical school 
graduates.
    We are increasing U.S. medical school capacity. We should 
be clear that we called for a 30 percent increase. The 
osteopathic community is also increasing. We do forecast at 
this point that medical school graduates will be up 20 percent 
by 2012. We will have them. We will need more residency 
training positions.
    The ability to train physicians in ambulatory settings and 
settings outside of the major academic medical centers are an 
important part of the strategy. It may be that for a State like 
Alaska or Vermont, getting more training programs in primary 
care in those underserved communities may be one way of 
introducing primary care physicians to those communities.
    Senator Murkowski. Mr. Swift, in Alaska, we have instituted 
the dental health therapist program. It has been successful, 
and it is an effort to get to that mid level. Is the American 
Dentistry Association considering mid-level practitioners, if 
you will, within that area to help address some of the concerns 
that we have heard here today?
    Mr. Swift. Yes, thank you for the question. The American 
Dental Education Association does not have a pilot or program 
for a mid-level provider. The American Dental Association does. 
Actually, two different types of providers. The American Dental 
Hygiene Association has one. Then the third model that has been 
discussed is the one that does exist in Alaska with the dental 
health aide therapist.
    The concern is that can the dental health aide therapist 
provide services to the degree that they need to in their 
environment? That is the question that remains. As you know, 
there were a lot of concerns and issues related to that. We 
think that there are ways to integrate mid-level providers 
within an environment, provided the training programs are 
exceptionally good and provided that they are essentially 
embraced in the team concept as well. That has already been 
mentioned.
    Also, potentially, unlike medicine, in the dental 
environment we actually have more applicants than we have 
positions in primary care or residency training programs, both 
the advanced education and general dentistry program and the 
general practice residency program. We could utilize the 
additional funding that originally provided some with the 
Dental Health Improvement Act, championed by Senator Collins 
and Feingold. Also, other title VII programs would be a benefit 
as well.
    Senator Murkowski. Dr. Auerbach.
    Dr. Auerbach. Yes, again, to support the issues that have 
been raised about the team concept, where certainly the primary 
care, all the primary care specialties are pursuing the concept 
of the medical home, which is basically a team concept and is a 
physician working in concert with their physician assistants, 
nurse practitioners, and other allied health professionals is 
certainly something that we need to consider.
    Again, these are all people, each individual and each 
entity has an appropriate place in the healthcare delivery 
system, but working together is the way that we are going to 
achieve the most gain for our population.
    Certainly increasing the residency slots is not going to 
resolve the issue if we don't change the incentives for 
reimbursement around our system because as was included in our 
testimony from an article that was in the New England Journal 
of Medicine relatively recently, in 1998, more than 50 percent 
of the third-year internal medicine residents were choosing 
careers as specialists. In 2005, that number was about 18 
percent.
    Increasing the number of residency slots is not necessarily 
going to change the number of people that are actually going 
into practice primary care. In terms of utilizing services and 
resources, and particularly taking advantage of title VII 
resources in underserved areas, one of the examples that we 
have in Massachusetts is a community health center in the city 
of Lawrence, which is a heavily underserved area. In using 
title VII resources, they have really developed a robust 
program to the point where they are now the primary sponsor for 
a family medicine residency program.
    That has really been a great boon to that community. We 
have seen a tremendous improvement in healthcare outcomes and 
drop in low birth weight infants and infant mortality and the 
like. It really has been a model program that has been done 
under the auspices of the title VII program.
    Senator Murkowski. Can I ask, those doctors who train in 
the community health centers, do they end up staying in those 
more rural communities?
    Dr. Auerbach. To a large degree. I can't remember exactly, 
but it is somewhere in the neighborhood of 80 percent of the 
physicians that have come up through the ranks, particularly 
through title VII programming. At least that has been the 
experience in Massachusetts with the three programs that we 
have at UMASS, BU medical school, and in Lawrence. About 80 
percent of them are staying in community health center practice 
or practice in underserved areas, even if they leave the 
primary area where they trained.
    Senator Murkowski. So, providing residency training or 
hands-on job experience in those rural communities will help to 
get more?
    Dr. Auerbach. That is absolutely correct.
    Mr. Maupin. That was more of what I was trying to focus on. 
We really are having trouble with the residencies in special 
areas, not just open up all residencies.
    The other, I would say what is interesting here is the 
title VII, title VIII programs recognize the need to support 
and balance everything. The trouble has come from the 
appropriations side, not the authorization. The appropriation 
and zero funding then puts one against the other for who can 
have the most pressure to make something happen now.
    We need to reauthorize and then focus heavily on making 
sure that the right level of appropriation is there because 
these programs work. They work to give balance, recognition of 
team, all the unique issues are put together through these 
programs, and they just have not been funded appropriately. We 
need to make sure they are reauthorized. The lack of 
reauthorization gives people strength to say, ``well, why 
should we fund them?''
    Senator Sanders. I would like to throw out a question that 
comes from a slightly different direction. Many of us, 
including myself, have mentioned the fact that we are filling 
the gap in terms of the lack of primary care healthcare 
practitioners--doctors, nurses, and others--by bringing in 
people from other countries. Many of the people are coming from 
countries that are quite poor.
    Do any of you have information as to what is the impact on 
those countries if we are bringing thousands of nurses in from 
the Philippines or physicians from India or other countries?
    Now it seems to me that if you are a poor country and you 
are educating a medical practitioner--doctor or nurse or 
whatever--you are spending a lot of limited resources, you are 
probably not terribly enthusiastic that after education that 
person is leaving for the United States, and it is probably 
having a negative impact on the healthcare in that person's 
native country.
    Do we have any information about the impact on those 
countries drawing primary healthcare professionals into this 
country?
    Dr. Hooker.
    Mr. Hooker. We should be careful which continent we are 
talking about. If we are talking about Sub-Saharan Africa, It 
is a profound effect, and some of our colleagues are now doing 
a very good job of documenting the effect of that.
    If we are talking about places like India that have schools 
purposely training doctors for export, or Philippines that are 
training nurses for export, or places like Taiwan that have 
surplus of nurses, then I don't think it is an issue. The 
English-speaking countries primarily have been the ones that 
have imported the most number of doctors from many of these 
areas, and we use the term ``brain drain,'' of course, to 
describe this phenomenon.
    Many of us wonder why we can't train our own? That is 
really the heart of the question.
    Senator Sanders. Other comments on that?
    Dr. Auerbach. Just to support what Dr. Hooker said, I know 
a number of years ago, my hospital was in a severe nursing 
shortage and got involved with an organization that was 
basically recruiting Filipino nurses that were coming out of 
schools that were specifically training nurses for export. It 
really was an export industry for the country.
    Because the nurses, when they came over here, sent so much 
money back home that it was actually beneficial to the 
government. In an area like that, it was not necessarily 
strapping them from their resources. As was mentioned, there 
are other parts of the country, where we are basically stealing 
their resources that they have spent their money training them.
    Senator Sanders. Other thoughts on that? Yes?
    Mr. Salsberg. Well, I will just note, unfortunately, that 
the number of international medical school graduates has been 
increasing over the past decade. It is up about 25 percent per 
year. It demonstrates the need that we need to continue to 
encourage an increase of U.S. medical school production.
    I share the comments, in some countries it clearly is more 
likely to be having a major impact. The numbers, for instance, 
from Sub-Saharan Africa are not necessarily significant 
compared to the 25,000 new physicians we have each year. We 
bring in 300 to 400 from Africa. For those countries, they are 
very significant.
    And so, there is growing concern. We are really just 
beginning to try and track that migration a little better. Some 
really good work done by Dr. Fitzhugh Mullen that has tracked 
the migration patterns, and the numbers are significant.
    By the way, I should note a different perspective on this. 
The largest single source country is India, which we bring in 
about 1,500 physicians each year from India. While some of 
those may be coming from schools that are targeted for export, 
many are coming from across the spectrum of schools in India.
    As India develops economically over the next 10 or 20 
years, I begin to get concerned can we even count on the steady 
flow, as we know that India has about one-third as many 
physicians per population as we have. We know that there will 
be needs there, and as the country becomes wealthier, I am sure 
there will be more opportunities.
    Again, that speaks for us doing more to educate our own 
supply. Especially when we know medicine is such a valuable 
career for young people and that many young people want to 
become physicians, it seems like we should be offering them 
that opportunity.
    Senator Sanders. Ms. Landon.
    Ms. Landon. I would like to speak to another part of the 
country that is losing its workers, and that is rural America. 
Our youth go off to the big city for college. They get their 
health professions training in an urban facility. They get 
their clinical rotations training at a teaching hospital across 
the street, and rural America, frontier America loses those 
minds.
    By using the title VII programs, such as AHEC and HCOP, and 
supporting those youth to go into health careers and supporting 
clinical rotations, opportunities in those rural and other 
underserved areas, we are able to bridge the gap and keep the 
rural youth in those communities, getting them to go back to 
those communities.
    Senator Sanders. Yes, Dr. Grumbach.
    Dr. Grumbach. I just want to pick up on Ms. Landon's 
comments because the parallels are profound if we are thinking 
about our own domestic problems. Because it is a search for 
policy solutions. When you look at the international migration 
issue, it is fundamentally about the infrastructure of 
healthcare in those countries and the lack of infrastructure to 
retain their own health professionals.
    It is very challenging to try to regulate movement when the 
incentives are so strong to move out of the country and come 
here. That is the same thing in rural America. It is the same 
thing in primary care. That is what I would like to emphasize. 
It is about the infrastructure. It is the infrastructure when 
you are talking about international migration and what our 
Nation will do to help support the infrastructure of developing 
nations to build a healthcare system that will retain their own 
workers.
    It is about primary care. How do we invest in the primary 
care infrastructure so our graduates, no matter how many 
programs we have, don't flee away from that, but really serve 
where the need is greatest in the types of positions where the 
need is greatest? The same in how do we build the rural 
healthcare infrastructure to attract and retain the best of our 
health professionals?
    It is a multidimensional question, which is, we need title 
VII. We need title VIII. We need these programs, but we need 
them to think much more comprehensively about how do we do what 
you alluded to, Senator Sanders. How do we change the whole 
thrust of our healthcare system so that it is not driven so 
much by where the opportunity is around technological 
imperatives, where the financial system provides so many 
incentives? It seems so contrary to an efficient, cost-
effective health system that produces good health for all 
Americans.
    That is going to take some serious deliberation about what 
are the incentives? How do we invest in electronic medical 
records that we can put into rural communities, that we can put 
into primary care offices? How do we look at medical education?
    Maybe my caution is it, unfortunately, won't be just one 
program and one appropriation. It will be a fundamental 
rethinking of what is really the priority for reform of this 
healthcare system and----
    Senator Sanders. I fear not only serious deliberations, but 
heavy-duty political struggle on this issue as well.
    Dr. Hooker.
    Mr. Hooker. I have heard a phenomenon that is being 
predicted. Of course, any prediction is as good as the people 
giving it. There are now Canadians who are recruiting and 
successfully recruiting family practice doctors to go to Canada 
for various reasons--lifestyle, salary, low bureaucracy, and 
40-hour week. They can work as doctors. They don't have to 
worry about the insurance infrastructure.
    Some people are saying that Generation Y may be part of 
this, that there will be more and more healthcare workers that 
now want to bring their careers to the global stage to be able 
to offer them to other countries instead of dealing with the 
bureaucracy of the United States because of all the 
administrative requirements.
    Senator Sanders. You are raising a whole other issue which 
I don't know that we have the time to get into and that is, in 
certain respects, not only the issue of financial incentives 
and the infrastructure, but the fact that physicians and nurses 
and people within the healthcare profession are pulling out 
their hair, sick and tired of filling out forms and dealing 
with bureaucracy.
    They went to graduate school or whatever to practice 
medicine, to help people, not to be arguing with insurance 
adjusters. That is another issue, I guess.
    Senator Murkowski.
    Senator Murkowski. Well, Senator Sanders, one of these 
days, I need to sit down with you. We have got a program in 
Alaska through the South Central Foundation that has taken a 
lot of these concepts that we are talking about, the delivery, 
how do you return a quality of life to the practitioner? How do 
you integrate the nurse practitioner, the P.A., the primary 
care guy, the guy that is dealing with the insurance? Allowing 
for a system that reduces costs as well as provide for real 
meaningful access to the patient.
    It is an innovative model. Oregon has taken it up, I think 
it is called Care Oregon. They talked about it as a paradigm 
shift, if you will. If what we are going to be able to provide 
in this country is a level of healthcare that we all want for 
ourselves and for our family, and we want to encourage people 
to go into the profession for the right reasons, we are going 
to have to change how we are doing business.
    It is kind of interesting listening to all of you around 
the table. In terms of those in Government programs that have 
proven effective, universally everyone is saying title VII is 
essential. Title VIII is essential. The graduate medical 
education, the ways that we can help move people in the right 
direction. The challenge for us then is how you get them to 
stay in these areas where that demand is so great?
    Aside from these programs that we have talked about here 
today, does anybody have any really great new ideas, any 
wonderful brainstorm that you want to present here today that 
can help us? Mr. Steinwald, you haven't talked much beyond your 
initial comments about how we value the care that is provided. 
What else do we need to be doing?
    Mr. Steinwald. Since you addressed me, Senator, I will try 
to respond. I am an economist by training, and so you don't 
want me to provide any suggestions of a clinical nature.
    [Laughter.]
    Senator Murkowski. OK. That is fair.
    Mr. Steinwald. I do spend most of my time looking at the 
numbers and about the financial incentives that underlie them. 
The technological imperative that someone, maybe it was Dr. 
Grumbach, mentioned earlier, is a fact of life in our 
healthcare system in the United States. It disadvantages 
primary care because of the way it promotes specialization and 
volume and complexity of care.
    We waste an awful lot of money in this country on 
unnecessary tests. We see huge variability across the country, 
State by State or region by region, in how much we spend per 
capita with no evidence that the areas that are spending the 
most are, in any way, benefiting from it.
    To me, that says that we have got enough money in our 
system. We would like to hold the rate of growth at a slower 
pace. We are increasing our healthcare spending per capita at 
GDP plus 2.5 percent, and we cannot sustain it.
    There are a lot of advantages to primary care and to 
accomplishing a lot of the objectives that go with that, 
services in underserved areas, by the paradigm shift that has 
been mentioned here before. That takes away some of the rewards 
for increasing volume and complexity of services and rechannels 
those dollars to a more, to me, rational way of providing 
healthcare that is team based, that emphasizes primary care.
    You know, it has been pointed out that we have an aging 
society. The baby boomers are aging into entitlement for 
Medicare. There will be many, many more people with multiple 
chronic illnesses. That is where a lot of the money is spent, 
and that is where the benefits of a team approach to medicine 
can be realized.
    A lot can be accomplished just by rechanneling the money 
that we spend in the direction that we believe it is most 
needed.
    Senator Murkowski. Who else?
    Dr. Auerbach.
    Dr. Auerbach. Yes, we have been talking about this all 
afternoon, that the realignment of incentives is very clearly 
an extremely important issue. The whole concept of team-
building, we probably need to understand more from the people 
that are currently practicing in those environments what they 
like about it and find a way to duplicate that.
    The other thing that is important is that we need to take 
advantage of other technologies. We have talked about 
technologies that are helping to drive up the cost of 
healthcare with high-tech imaging studies and so on and so 
forth. There are other technologies that can bring a greater 
depth of practice and more enjoyment in being in a rural 
practice, like telemedicine.
    Where you can have someone that doesn't have to feel--a lot 
of the reason that when we talk to students and when we talk to 
residents about going into underserved areas and going and 
practicing in rural areas, most of them don't like the 
isolation. They don't like the isolation from their colleagues.
    Physicians tend to--like the rest of us are quite 
gregarious, and we like to be able to communicate. We like to 
be able to share with colleagues. Things that we can do to 
encourage the use of those kinds of technologies so that a 
physician practicing out in a rural setting still can feel like 
they are part of the academic center or the other training 
center where they developed their skill set, could be very 
helpful in getting people to go and stay in those areas.
    Senator Murkowski. Ms. Landon.
    Ms. Landon. I appreciated your suggestion for new ideas, 
thinking about it, it is a privilege to live in Alaska, where 
people are so open to innovation and always willing to try a 
new idea. In the context of this discussion, what we should 
talk about is increasing funding for title VII programs.
    Looking at the GAO report from February 2006, title VII 
funding increased only 27 percent between 1999 and 2005, and 
AHEC was essentially flat-funded during that period. Increasing 
the funding is critical to meeting the need because these 
programs are effective.
    Think about the community health center line item. That has 
been increasing. The number of sites are increasing. The JAMA 
report, Journal of the American Medical Association, from a 
little over a year ago documented the shortage of primary care 
providers in the community health centers. AHECs are the ones 
that are feeding the clinical rotations opportunities from the 
academic facilities to those centers.
    We need to be strengthening the title VII programs to 
support that linkage. That is even before we talk about the 
aging of America.
    Thank you.
    Senator Murkowski. Ms. Laurent.
    Ms. Laurent. I would have to echo the comments of Ms. 
Landon and really emphasize the importance of increasing 
spending where--in title VIII, where it matters in the health 
promotion area. As with the other panelists, I am in agreement 
that the reimbursement is misaligned, and we need to really 
kind of take a step back and think about how we can actually 
prevent things from happening.
    With title VIII funding and increasing funding, we have no 
shortage of nursing applicants. We are turning away 33 percent 
of people who are applying for undergraduate nursing. We are 
turning away more for people who are trying to become nurse 
practitioners. We have no faculty to train these people. We 
have the access, but we do not have the faculty.
    It is a trickle-down effect. If you don't have people 
focusing on health promotion, we can do everything in the 
world, but it is going to cost more and more money. If we can 
kind of look back to where the cost-saving is, it is all about 
preventing these things from happening and taking advantage of 
the collaborative practice between physicians, nurse 
practitioners, and nurses in primary care. It really is 
realigning and focusing our needs on training healthcare 
providers that are in primary care.
    And title VIII is vital. I work at UVM as well, University 
of Vermont, and every semester the question is where are we 
going to find the faculty to teach these people? It is a 
scramble every semester.
    Senator Sanders. Let me just jump in and respond to that by 
saying that in the higher education bill, which is meandering 
its way around here, there is a provision that some of us 
worked on, which would provide $3,000 per pupil to nursing 
schools as they increase their student numbers. We think that 
is----
    Ms. Laurent. To encourage more faculty?
    Senator Sanders. Exactly. So the schools can hire more 
faculty because one of the problems is that faculty in nursing 
schools are now running to hospitals, where they can make a 
heck of a lot more money than they can as faculty in a nursing 
school.
    Dr. Grumbach.
    Dr. Grumbach. I really appreciate your challenge, Senator 
Murkowski, and I would echo everybody who said, I mean, 
attention to title VII and title VIII. Let me go ahead and push 
it to the next level because what there needs to be is more 
Federal attention to demonstration projects about the ideal 
medical home.
    To put out those models that then can inspire everybody 
else and show how it can be done, which is to think much more 
creatively, and you are talking about the types of models in 
Alaska and other areas. It is about aims. It is about bringing 
in community health workers to teach self-management, being 
able to think about how to staff a primary care team. It is 
about how to then implement electronic technology, both for 
telemedicine, but also for patients. So patients can get access 
to their own test results or their medical records. So they can 
e-mail with their clinician and communicate like that.
    There are some demonstration projects under Medicare and 
Medicaid in sort of the modernized medical home, and I would 
really look at those because that is what we need. We need to 
say the Federal Government is helping to point the way toward 
what a modernized future patient-responsive primary care 
medical home will look like. And really come up with those 
experimental models that will then get away from some of the 
traditional reimbursement formulas.
    There is talk about then you needing a care coordination 
fee, an additional fee-for-service. It is not always about just 
a lot more money. It is about reusing some of the money you 
have and getting out of some of the regulatory things that 
handicap the ability to work creatively.
    For example, right now, you can't bill--if you are a health 
worker or a patient educator in the practice who sees a 
patient, but a nurse practitioner or a physician or a dentist 
doesn't--you can't bill Medicare, you can't bill Medicaid. It 
is getting out of that to the idea it is really the team having 
responsibility for care.
    Maybe it is better that they see the health worker that can 
work with them to take care of their diabetes. If you do an 
electronic visit by e-mail or by phone, that is not 
reimbursable.
    It is re-altering, maybe not changing the overall pool all 
the time, but how to allow more flexibility and really to work 
with the American College of Physicians, the American Academy 
of Family Physicians, the American Academy of Pediatrics, Nurse 
Practitioner Associations, the Osteopaths, all have put forward 
this idea that we are ready to leap forward into much more 
sophisticated models of the medical home that will really meet 
patients' need.
    We just need a sense that the Government is there, seeing 
that they would like to look at these test models to point the 
way toward the future. And then that will excite people, 
whether it is nurses, physicians, to say, ``boy, I see how this 
could be a satisfying career, that you could really do what you 
want to do as a health professional.'' There are models out 
there that really could be a fulfilling practice and allow us 
to do what we want to do. It would change the whole dynamic and 
some of the disincentives that are out there.
    Senator Murkowski. Mr. Salsberg.
    Mr. Salsberg. Yes, and I want to echo that Dr. Grumbach's 
ideas are really excellent. I would add not only 
demonstrations, but valuation and dissemination because there 
are some really good models--we mentioned the WAMI model--to 
understand how that works and what pieces could be replicated 
most easily.
    It is in terms of new ideas, it is not really a new idea, 
but we are looking at how the academic medical centers can play 
a greater role in addressing distribution problems in 
underserved urban and rural areas, whether it is telemedicine, 
whether it is distance clinics, whether it is medical student 
rotations or residency training sites, that our major medical 
centers can play a role in helping address the distribution 
problem.
    There are also some strategies--again, I fully appreciate 
the idea of what new ideas are out there. It is a little 
frustrating sometimes when we know we have some good ideas 
about what works. You get something like the National Health 
Service Corps and many of the programs under the title VII, and 
particularly the diversity programs, we know that if you 
support the corps, you can get physicians and other 
practitioners in underserved areas.
    We know that if we increase diversity, we will get 
physicians and practitioners going into underserved areas. We 
know some things that work, and we need to do more to support 
that, combine that with the valuation of new ideas and 
assessment of what is out there so that we can disseminate to 
the rest of the community the strategies that work.
    Mr. Swift. We shouldn't forget the concept of the dental 
home as well. And not dissociated from the medical home, by any 
means, but there have been some successes along those lines in 
academic and dental institutions establishing clinics in 
outreach areas.
    At my own institution, the University of Minnesota, we have 
seven current outreach sites. Eighty percent of the patients 
are public program patients or uninsureds that we manage in 
that environment, with the cooperation of the community 
practitioners in those areas that are wanting to have that type 
of opportunity or experience. So that does work.
    In addition, another story about one of our dental schools, 
member institutions. The Arizona School of Dentistry and Oral 
Health is a relatively new dental school. In fact their first 
class, graduating this spring, was built on that model of doing 
outreach clinics as the clinical component of their training.
    A large number of them, a majority of the class, has made a 
commitment to spend time managing patients in underserved areas 
and providing dental services for patients based upon that 
model through their educational training process. There are 
some things out there, obviously, the academic dental 
institutions can't meet the needs of all the dental patients 
that are underserved in the country. It is a way to go.
    Senator Murkowski. Dr. Hooker.
    Mr. Hooker. Title VII, in many aspects, has been met with 
success. The creators must surely be looking at many aspects of 
title VII with pride and said we have achieved what we set out 
to achieve. We now know that many of the experiments and 
demonstration projects have turned out to be successful. They 
need more funding.
    One of the areas that I echo other people at this table, 
though, is that there has been a great lack of documentation. 
There has not been enough assessment. We don't exactly know how 
effective these programs are. We just know. Some of it is 
anecdotal that we have mentioned today from our own experience. 
Some of it has reached the public domain. Clearly, more needs 
to be done to be able to document just how successful it is.
    Senator Sanders. Let me jump in and ask another question. I 
know what the answer will be, but I want to ask it anyhow. 
Senator Murkowski and I are working on legislation to double 
the amount of money for the National Health Service Corps. Is 
that a good idea? What has been your experience with the 
National Health Service Corps?
    Dr. Hooker.
    Mr. Hooker. I just read a dissertation on this, and the 
loan repayment seems to be highly successful. It does what it 
supposedly intends to do. The scholarship program takes a much 
longer time to repay. It is a yes/no. It is a binary answer 
that the loan repayment is highly motivating for people to go 
into those underserved areas and work off their loan.
    Senator Sanders. Dr. Auerbach.
    Dr. Auerbach. Yes, the National Health Service Corps is a 
wonderful program. I will go back to a comment that I made in 
my opening remarks, which is that we need to be sure that we 
have accurate data about the physicians that are actually in 
practice. In areas and States and in parts of the country where 
there are large academic centers, you have huge numbers of 
physicians that are still calculated based on their presence of 
a medical license that are involved in research and other 
activities and are not actually delivering patient care, 
potentially making it look like that area is overserved, rather 
than underserved with physicians.
    That is a critical issue if we are going to be doing 
anything to increase funding to National Health Service Corps.
    Senator Sanders. Your concern is that the numbers may not 
be correct in terms of how we define an underserved area?
    Dr. Auerbach. That is correct.
    Senator Sanders. Ms. Landon.
    Ms. Landon. Several things to comment on. I agree that the 
National Health Service Corps is an extremely effective 
program. AHECs work arm-in-arm with them, works closely as part 
of the safety net with the community health centers.
    There is a problem with the designation of underserved 
areas. Frontier areas are underrepresented because of the 
population to provider ratio requirement, which we can't meet. 
If we even came close to meeting it, the burnout from call 
coverage for 24-7, well, it is just killing the providers.
    I did want to add also it is interesting that the State 
loan repayment program is perceived to be so effective. That is 
great. Alaska and Vermont do not participate in the State loan 
repayment program at this time. If you increase the funding, we 
will be more competitive to do so.
    Senator Sanders. Yes, Dr. Maupin?
    Mr. Maupin. The National Service Corps program works. I 
would only comment that all of these programs work when they 
are in good partnership with each other. I was a community 
health center director, and I recruited a number of National 
Health Service Corps folks. The people that stayed after their 
commitment were the people that came out of many of the 
community-based medical schools across this country.
    And so, there is this cycle. We have a group of schools 
that have done a great job. They are extraordinarily dependent 
upon many of these programs. I would say, to the question of 
can we do something different, they usually are dependent upon 
filling the gaps because there is an economic imbalance in 
their mission with a host of issues, whether it is research, 
the level of patient care, the extraordinary number of 
uninsured and Medicaid patients, lack of subspecialty, more 
generalist training, not part of a major medical center.
    All of these community-based medical schools are challenged 
economically, and they end up surviving by the many different 
kinds of programs that they are dependent upon. Each of these 
individual programs kind of get picked off or flat funded.
    Probably the next idea is to say we ought to figure out how 
to fully fund a community-based medical school, which is also 
one of the key components that partners with AHEC. They partner 
with National Health Service Corps. They partner with federally 
qualified community health centers. The Centers of Excellence 
program is one of the funded programs that if they are a 
participant in that program, they get endowment funding for 
research so they can participate in community-based 
participatory research with community health centers.
    There are so many things that are connected around their 
mission focus that we haven't--and they are the ones that seem 
to be always left out and having to go to all these desperate 
programs to fill the gaps.
    Senator Sanders. Let me pick up on your comment and ask 
this. Medicare spends about $8 billion in graduate medical 
education.
    Mr. Maupin. Mm-hmm.
    Senator Sanders. Do we make enough demands of those medical 
schools that, in fact, are going to be graduating physicians 
who are going to serve in underserved areas? No?
    Mr. Maupin. Well, I would say no, but at the same time, I 
would say that that is a difficult way to go about it. In other 
words, to make a demand, I have a school that spends more--a 
lot of our resident time is spent in community health centers 
in the community, and we are connected to a public institution.
    That institution, the Grady Hospital, is not receiving the 
same level of Medicare funding. There are others that will. 
Their focus is in subspecialty care. Their focus is different. 
It is the incentives from the manner in which it is paid. We 
have talked about it is how you align the incentives in any of 
these programs. I wouldn't say you have this amount of money. 
It really is how do you redistribute the incentives so that 
they go to the right places?
    If I want to start a program in a rural community and want 
to be connected to a rural hospital and a rural community 
health center, how do they participate in a training program? 
How are they funded when they don't get the same level of 
funding, yet they have the same needs for housing for 
residents, for students, for all of the things, the 
complexities that go with it?
    Again, I wouldn't put something against and demand on 
someone, I would look at are we missing out on how we fund 
residency programs and other training opportunities in the 
first place? The new model of medical education funding needs 
to be looked at. We are so connected in so many different 
unusual ways to get funding some place that it is easy for them 
to get distorted when one starts to talk about it.
    I remember a conversation that said, that one government 
official, and I won't name where, but said, ``You have other 
ways to get money. You don't need this money.'' Well, they 
really didn't understand the complexity of all the funding 
mechanisms that are tied up in so many odd ways that when we 
decouple them a little bit and then really place them in the 
right purity, if you will, and with the right incentives, I 
think we have it.
    I would be a little hesitant to say punish someone for not 
doing something when they said, ``Look, we are here to do this 
in the first place.'' It really wasn't their fault that the 
funding came there. I don't blame my colleagues at Emory 
because there is more money in graduate medical education for 
Crawford Long Hospital, even though they also participate at 
Grady Hospital, and it is funded less per resident because of 
the severity and also the mix of Medicare patients.
    Senator Sanders. Senator Murkowski.
    Senator Murkowski. This is more a rhetorical question. 
Great agreement around the table here today in terms of some of 
the things that we can do, continue to do, and some new 
approaches about how we have been doing business.
    In the State of Alaska, we talk about the urban/rural split 
in my State. I would imagine that in many rural States in this 
country, you have those same tensions over funding. You have 
got the population centers that get it all. They get the 
research. Everything goes to them, and the rural areas remain 
underserved.
    In looking at the President's budget and what he is 
proposing with the programs that we have been discussing here 
today, we all seem to understand the situation that we are 
facing in rural America and our medically underserved areas. Do 
the rest of them just not get it, or what is happening?
    I don't mean to be flip with that, but I look at this as an 
impending crisis. In some parts of the country, we can say is 
in crisis. What is causing this giant divide here? Is it 
nothing more than an urban/rural split that we are seeing 
around the country? Mr. Grumbach, you are shaking your head no?
    Dr. Grumbach. No.
    Senator Murkowski. Do they not get it? Or do they not 
believe that it is as acute as you and I believe it is?
    Dr. Grumbach. Yes, the crisis is just becoming adequately 
apparent. It is easy to marginalize it when it is a rural 
community or it is a minority inner city. Until it hits middle-
class America, it doesn't become a problem that galvanizes 
political attention.
    We see that. We see in 2006, 24 percent of Medicare 
beneficiaries said they had a problem finding a primary care 
physician. Last year, it was up to 29 percent. That is what is 
probably--that wave--the canary in the mine is rural Alaska.
    Senator Murkowski. Tell me.
    Dr. Grumbach. It is Compton, L.A. It is Grady Memorial 
Hospital. That is just the warning signs of a problem that is 
starting to affect, middle America, and that is going to compel 
some attention. I can only wonder along with you why this 
crisis, as now unfolding in middle America, is not captivating 
some of our political leadership to really understand that 
action needs to be taken?
    Senator Murkowski. It is starting to come.
    Senator Sanders. They get it perfectly well. They get what 
they want to get, and this is a political issue. It is an issue 
of ideology, in my view. You have a President who, among other 
things, doesn't believe in government and would prefer to give 
tax breaks to billionaires than adequately fund programs that 
have been demonstrably successful year after year.
    Senator Murkowski and I are trying to double, as I 
mentioned a moment ago, the National Health Service Corps. This 
is all of $125 million a year increase, $125 million a year 
increase. Compare that to the tax breaks that are going to 
billionaires. Do they get it? I think they get it just fine. It 
just is a philosophical divide in this country.
    Mr. Steinwald.
    Mr. Steinwald. Yes, I would like to actually answer your 
earlier question. The $8 billion, it is not as big as the tax 
break that you just mentioned, but it is certainly a nice big 
number. I don't think there is sufficient accountability.
    You are not going to achieve greater access in rural 
communities with that $8 billion and you are not going to 
achieve greater access on primary care services. There is very 
little accountability for how those dollars are spent.
    The incentives that we talk about in a fee-for-service 
system drive right on down to, the medical education system, 
and I will let Ed comment on that as well. Because you have 
faculty practice plans, you have deans of medical schools 
trying to fund clinical areas. The fees from services go in the 
direction of funding those programs, in addition to providing 
positions for doctors in training, who are selecting among 
primary care versus specialty services and then seeing a 
difference in remuneration as a result.
    The whole system plays in one direction against what we 
believe is our policy objectives toward primary care in 
underserved areas. The accountability for that $8 billion just 
isn't there.
    Senator Sanders. Dr. Auerbach.
    Dr. Auerbach. Yes, I don't know this for sure in terms of 
whether they get it or not, as you proposed, Senator Murkowski. 
It would be important to recognize that there is an industrial 
medical complex that puts a very significant spin on this as 
well. The specialists and subspecialists work with a huge 
industrial medical complex that generates a very significant 
amount of money in this country.
    Not paying so much--primary care physicians don't really 
participate in that very much not only from a reimbursement 
perspective, but also from encouraging the continuation of that 
complex. Whereas, specialists and subspecialists are heavily 
invested in--not personally invested, but heavily invested in 
making that industrial medical complex grow. That certainly 
could be another factor in people not being willing to pay much 
attention to the primary care crisis.
    I know we have been talking title VII, a critical issue. I 
would like to go back to another issue that I raised earlier 
and was mentioned in your opening statements, Senators, which 
does have the potential also to help with propagating primary 
care in rural America, which is the issue of medical student 
debt.
    We are working both on the State level as well as working 
with some of our Federal partners around some potential 
demonstration projects for Federal loan and Federal debt 
forgiveness above and beyond that in the National Health 
Service Corps for not students, but residents that are agreeing 
to go into primary care and working in areas where the need is 
the greatest.
    Senator Sanders. Dr. Auerbach, I am sure that you are all 
aware that just recently one of the better pieces of 
legislation passed last year was the Higher Ed----
    Dr. Auerbach. Yes.
    Senator Sanders [continuing]. Reconciliation act, which 
will provide not only for people in the healthcare 
professionals, but for all people who work for Government or in 
public service. After 10 years, their debts will be forgiven.
    Dr. Auerbach. Yes.
    Senator Sanders. You see that as a step forward, I guess?
    Dr. Auerbach. Absolutely. Because--and again, if we get 
people to go and practice in those areas and they remain for 
that time period, when their debt is repaid, even though they 
still may have the opportunity to earn more in another area, 
they are probably not going to leave because they are going to 
be hooked into the community.
    Senator Sanders. Yes?
    Mr. Maupin. One, I want to echo support for that comment 
and to talk really that we do need to look at debt forgiveness 
and the issues around the students and the residents that 
decide to stay in these communities. I wanted to, before we get 
off--I don't want to miss one item.
    As we look through all of what we do, I am also aware that 
there are some critical specialties that we are having real 
problems with in various States. You talk about healthcare is 
always local. Looking at the State of Georgia, for example, the 
lack of general surgeons is becoming extremely critical. We are 
going to have to look at how all of these programs that we may 
want to support don't also hurt something that may, in fact, be 
a critical specialty that is needed in key areas. We don't want 
to forget that issue.
    Senator Murkowski. Ms. Landon, did you want to comment on 
that? Because I know that in Alaska, there is a concern about 
how we are able to provide for that surgical care.
    Ms. Landon. Yes, and in fact, Fairbanks Memorial Hospital 
just last month submitted an application to the University of 
Washington to have seats for residency for general surgeons. 
They will have 10 rotating up each year on rotation to start to 
meet that need.
    Senator Sanders. OK, Senator Murkowski.
    Senator Murkowski. I just wanted to make sure that Senator 
Enzi's statement was going to be entered into the record.
    [The prepared statement of Senator Enzi follows:]

                   Prepared Statement of Senator Enzi

    Thank you for holding this hearing and for providing an 
important forum for the committee to work from to identify and 
address the healthcare workforce issues that confront us. 
Today's hearing will give us all an opportunity to highlight 
not only those issues that are unique to our States but also 
those that affect our Nation's healthcare system as a whole.
    In my home State of Wyoming, one of our biggest challenges 
is providing timely access to healthcare providers. That kind 
of access has been hampered because Wyoming is currently facing 
a shortage of health care professionals--and I am not referring 
only to specialists. Clearly, that is a problem that needs to 
be addressed on more than one level.
    To begin with, to have access to more health care 
professionals, we need more than a new, more effective grant 
program to increase their numbers. We need real reform of our 
medical system as a whole. I have introduced a Ten Step bill 
that will, when it is adopted, greatly reduce the health 
professional crisis we are already seeing in States like 
Wyoming, Vermont, Alaska and Massachusetts.
    We will be focusing on the training of health 
professionals, today, but I want to make it clear that work-
force issues also include affordable medical insurance for 
patients, health information technology, better telehealth 
capabilities, and a liability environment for health care 
providers. Together, these foundations will help to make people 
feel more satisfied with their career choice, more fulfilled by 
the work they do, and ultimately attracted to not only begin, 
but pursue the call of medicine for many, many years.
    That is necessary because Wyoming has a long list of health 
care needs. We do not have enough primary care physicians, 
dentists, physician assistants and nurse practitioners. That is 
in addition to our shortage of subspecialists.
    Title VII of the Public Health Service Act is an important 
component of training our Nation's health care providers. Loan 
repayment, underrepresented minority programs, faculty 
training, and various other education programs are important 
programs that need to be continued. At the same time, we must 
coordinate the goals of the programs with the outcomes that we 
measure. We need to improve these programs and our health care 
delivery system. A few small tweaks are likely not sufficient. 
That would be like adding a new heel to an old shoe that we 
would be better off replacing with a new pair.
    I appreciate the efforts of Senator Kennedy, Senator 
Sanders and Senator Murkowski for beginning this conversation. 
I look forward to examining many aspects of our health work 
force training including how we plan and pay for our pre and 
post graduate training. Before that, we need to encourage more 
individuals to consider a career in health care and serving in 
areas that are currently underrepresented. It seems to me it is 
also important that we may need to broaden training sites to 
include more ambulatory care sites in rural areas.
    Recent experience in Wyoming shows that with concentrated 
effort almost 2/3 of the family practice physicians who train 
in Wyoming will stay in Wyoming.
    I am interested in our witnesses' thoughts on establishing 
a National Health Work Force Commission so that we can start 
addressing the shortages identified today in a comprehensive 
and coordinated way.
    Senator Murkowski. He wasn't able to attend. Apparently, he 
has--I don't know whether there are several questions for you, 
Ms. Landon, but he did want to ask that we keep the record open 
for 5 days.
    Senator Sanders. Well, we are going to do it for 10 days.
    Senator Murkowski. All right. That is right, get more 
questions in here. I want to thank you for your leadership, for 
the discussion that we have had here today. There is good 
consensus in terms of those areas where we need to be doing 
more. We need to make sure that the funding is there. We need 
to make sure that the accountability is there. We need to make 
sure that we are counting things right.
    I look forward to working with you, certainly, Senator 
Sanders, in making sure that we push on increasing funding for 
the National Health Service Corps. We have got to do that. The 
GME money for the training programs, the funding for the 
community health centers, so that we can get the residency 
training in there for this minimum period. We get people hooked 
into these areas where they will stay.
    Good suggestions, good input. I appreciate all that you are 
doing throughout the country, and we will keep working on it. I 
would just thank you all.
    Senator Sanders. Well, let me just conclude by thanking 
you, Senator Murkowski, and all of you. I want to thank you for 
the work that you are doing back in your respective areas. This 
is an issue of significance to tens of millions of Americans. 
Your comments have been extraordinarily illuminating. We look 
forward to working with you, and thank you very much for being 
here today.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                 Prepared Statement of Senator Bingaman

    Let me thank the Chairman for holding this important 
hearing on health professions supply. This deserves our serious 
attention.
    In New Mexico, 30 of our 33 counties are federally 
designated as health professions shortage areas or medically 
underserved areas.
    With a low per-capita income, and a high uninsured 
population, having a health provider in our towns can mean the 
difference between getting care while problems are manageable, 
or waiting until problems became so serious that they require 
hospitalization or worse.
    In New Mexico, we have worked on creative interdisciplinary 
models of health delivery, such as the Health Commons models 
that provide an enhanced primary care home, including medical, 
behavioral, and oral health, to our most needy populations.
    We train our health professionals in these venues, and they 
end up working in them at two to three times the rate of other 
trainees when they graduate. These programs work. Title VII 
funding supported their success. New Mexicans depend on these 
programs for health care.
    These programs are under severe threat. The President 
proposed eliminating title VII funding, severely cutting title 
VIII funding, and unilaterally changing Medicaid rules through 
CMS that will devastate training programs and will unravel our 
tenuous safety net in New Mexico, and across our Nation.
    We have witnessed the unprecedented growth of our uninsured 
under this Administration with 48 million Americans who are 
medically uninsured and over 100 million who lack oral health 
coverage.
    This would be exactly the wrong time to cut funding, as the 
President has proposed. While I support the President's call to 
expand community health center funding, it is cynical, it is 
illogical, to cut the funding of the title VII programs that 
assure staffing of those centers.
    While 21 percent of the U.S. population live in rural 
areas, only 10 percent of our physicians work in rural areas.
    Our population will grow by 25 million per decade, and 
those over age 65 will double by year 2030. Those over age 65 
have twice the number of doctor visits as younger individuals.
    Our Nation faces physician shortages which will grow to 
over 200,000 by 2020, while nursing shortages may exceed 1 
million. Currently, few dentists accept Medicaid and access is 
impossible for our uninsured.
    Let us focus our legislative attention on our pipeline of 
health professionals and the distribution of these graduates 
into the areas they are most needed.
    Let us support new interdisciplinary models of service and 
learning, with a balance of urban and community-based 
experience--addressing our Nation's most pressing health needs, 
while admitting health professions students more reflective of 
our Nation's diversity.
    It is time for us to pass measures, using funding 
mechanisms like GME and IME through Medicare and Medicaid, to 
assure training of health professions to address our current 
and future health workforce and access needs. CMS should not be 
cutting funding of these programs through rule changes that 
will blow up our pipeline supply when shortages are severe, and 
getting worse.
    Americans deserve, and should expect, better health 
professions outcomes and return on our Federal investment. We 
should expand funding to programs that produce the types of 
health professionals most needed, and that succeed in placing 
them in the cities and towns where we most need them.
    It is time for Congress to address these shortages, to 
support the hard-working health professionals both in our 
cities and in our small towns, and to fund programs that 
clearly and conclusively work, including title VII and title 
VIII physician, nurse and dental training, scholarship, 
diversity, and loan repayment programs.

                 Prepared Statement of Senator Clinton

    I look forward to working with my colleagues on the HELP 
Committee to reauthorize the title VII health professions 
program. These programs have a great impact on New York, both 
as a State with multiple health professions schools, and as a 
State that has underserved communities who benefit from these 
programs. Our State has 15 medical schools with over 15,000 
residents in training and 11 accredited nursing schools. Our 
rural and urban communities have critical needs for primary 
care physicians, dentists, nurses and other health 
professionals. Over 50 of New York's 62 counties have Medically 
Underserved Areas (MUA's) and many of those counties have 
multiple MUA designations, in both urban and rural areas. In 
some of our rural regions, there has been a significant decline 
in the number of health professionals filling demand, and at 
this point, we do not have enough primary care providers to 
meet the growing needs.
    In addition to ensuring adequate workforce for both rural 
and urban underserved areas, I believe that the title VII 
programs are an important tool in addressing the growing 
diversity of the U.S. population, which is not yet reflected in 
our health workforce. New York State has a minority population 
of 36 percent, yet enrollment in our medical schools by 
minority students lags far behind at 10 percent. This under-
representation is associated with poor health outcomes in 
minority communities, and I think that by improving the number 
of underrepresented minorities in the health professions, we 
can reduce health disparities. Title VII Health Professions 
Programs address these issues by providing educational 
pipelines that target minority students at all levels of 
education, helping them to gain interest in and pursue careers 
in health care.
    The President's proposed budget for New York health 
professions' programs this year is $13 million, compared to $29 
million only 5 years ago. Yet the shortage of primary care 
providers only continues to grow. If we are to meet the needs 
of underserved communities in New York and the Nation, we must 
increase our support for the title VII programs that are an 
essential component in improving access to care for all 
Americans.
    I believe that the title VII programs should be re-
authorized to a level that will make them effective in 
providing a pipeline to encourage a diverse range of 
participants to enter the health professions, retain a 
commitment, through years of training, and to serve in the 
urban and rural communities where they are most needed.
    We need to assure that training programs are aligned with 
healthcare needs. These programs should be amended to improve 
data collection in order to track health professionals, 
identify shortage areas, and evaluate specific outcomes.
    We need to address the primary care shortage by improving 
linkages between health professions schools to medically 
underserved areas.
        Prepared Statement of the American College of Physicians
    The American College of Physicians (ACP) is the largest medical 
specialty society in the United States, representing 125,000 doctors of 
internal medicine, residents and medical students. ACP commends 
Chairman Edward Kennedy for addressing the challenges in the training 
and supply of the healthcare workforce. The College is extremely 
concerned about the looming crisis in the supply of primary care 
physicians, particularly the pending undersupply of general internists 
and the potential impact on the health care of the United States 
population.
    There has been a steady decline of medical students and residents 
pursuing careers in primary care specialties and many areas of the 
country are already facing shortages. The College is very concerned 
that if current trends continue, there will not be an adequate supply 
of well-trained primary care physicians to treat an aging population--
especially those 65 and older--many of whom will have multiple chronic 
illnesses. Numerous studies show that the availability of primary care 
is positively associated with lower rates of preventable mortality 
(preventable deaths per 100,000 people) and fewer preventable hospital 
admissions for chronic diseases like diabetes, lower overall 
utilization of health care resources, and lower overall per capita 
health care expenditures.
    ACP is particularly concerned about the adequacy of the supply of 
general internists who provide care in outpatient settings. Many 
general internists are choosing to leave internal medicine, while 
others near retirement, are choosing to retire earlier than planned. 
Approximately 21 percent of physicians who were board certified in the 
early 1990s have left general internal medicine, compared to a 5 
percent departure rate for internal medicine subspecialists.\1\ 
Simultaneously, there has been a precipitous decline in the number of 
medical students and residents choosing to pursue careers in office-
based general internal medicine.\2\ If this trend continues, a shortage 
of primary care physicians will likely develop more rapidly than many 
now anticipate.
---------------------------------------------------------------------------
    \1\ Lipner RS, Bylsma WH, Arnold GK, Fortna GS, Tooker J, Cassel 
CK. Who is maintaining certification in internal medicine--and why? A 
national survey 10 years after initial certification. Ann Intern Med. 
2005;144:29-36.
    \2\ Popkave, CG. Research Associate, Office of Research, Planning, 
and Evaluation, American College of Physicians. Personal communication. 
February 2006. ITE Exam Survey Data.
---------------------------------------------------------------------------
    The College is in agreement with the GAO's findings submitted to 
the committee that primary care medicine is essential to better quality 
and lower costs. The College also agrees that the health care system's 
current financing mechanisms undervalue primary care services. However, 
the College believes that the GAO understates the developing shortage 
of primary care and feels that clarification is necessary on two 
issues:
      1. the number of primary care physicians per 100,000 people
    The GAO study states that the number of primary care physicians has 
increased from 80 primary care physicians per 100,000 people in 1995 to 
90 primary care physicians per 100,000 people in 2005. However, the 
Health Resources and Services Administration in its October 2006 
report, Physician Supply and Demand: Projections to 2020, projects that 
the estimated requirements in 2005 were 95 primary care physicians per 
100,000 people. In the same report HRSA estimates that the baseline 
primary care physician requirements per 100,000 people will increase to 
100 by 2020.\3\
---------------------------------------------------------------------------
    \3\ Health Resources and Services Administration. Physician Supply 
and Demand: Projections to 2020. October 2006.
---------------------------------------------------------------------------
    2. the number of residents training in primary care specialties
    The GAO Study states that there were 40,982 residents in primary 
care graduate medical training programs in 2006, based on data from the 
National GME Census that appears annually in the Journal of the 
American Medical Association. We believe that this number is misleading 
as this number represents all primary care residents on duty without 
regard to where they are in the training process. For example, while 
22,099 of the 40,982 primary care residents reported were internal 
medicine residents, it is important to consider that 3 years of an 
internal medicine residency is a pre-requisite for subspecialty 
training in cardiology, endocrinology, gastroenterology, hematology, 
infectious disease, nephrology, oncology, pulmonary disease, 
rheumatology and sports medicine.\4\ Many residents going on to careers 
in other specialties also first complete preliminary programs in 
internal medicine. It cannot be assumed that all 22,099 of those 
residents will go on to practice primary care. In fact, data from 
surveys of third-year internal medicine residents (chart below) 
suggests otherwise. In 2006, only 24 percent of third-year internal 
medicine residents surveyed stated that they intended to pursue careers 
in general internal medicine, down from 54 percent in 1998. The 
remainder indicated that they planned on pursuing careers in an 
internal medicine subspecialty or hospital medicine.
---------------------------------------------------------------------------
    \4\ Brotherton S. and Etzel S. Graduate Medical Education 2006-
2007. JAMA, 2005; 289 (9) 1081-1096.

       Trends in Career Plans of Third-Year Residents Enrolled in U.S. Categorical and Primary Care Internal Medicine Training Programs, 1998-2006
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                            Career plan (in percent)
                                                       -------------------------------------------------------------------------------------------------
                  Year                       No. of      General
                                          respondents   internal         Hospitalist         Subspecialty    Other           Undecided           Missing
                                                        medicine
--------------------------------------------------------------------------------------------------------------------------------------------------------
1998..................................          4008         54    N/A.....................         42           3    N/A.....................        1
1999..................................          4338         49    N/A.....................         47           2    N/A.....................        2
2000..................................          4562         44    N/A.....................         51           4    N/A.....................        2
2001..................................          4565         40    N/A.....................         54           4    N/A.....................        2
2002..................................          3495         28    4.......................         56           2    6.......................        4
2003..................................          4732         27    7.......................         57           2    6.......................        1
2004..................................          4974         24    8.......................         56           4    8.......................        0
2005..................................          4926         20    12......................         58           1    7.......................        1
2006..................................          4817         24    8.......................         63           1    4.......................        0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: Internal Medicine In-Training Examination Survey

    With this in consideration and assuming that many of the 7,964 
pediatric residents that were included in the 40,982 figure will also 
likely subspecialize, it is evident that the number of residents who 
choose to practice office-based primary care upon completion of 
training is actually far less than what the GAO study indicates.
    The GAO study found that preventive care, coordinated care for the 
chronically ill, and continuity of care can achieve better health 
outcomes and cost savings. These are the fundamental characteristics of 
the care that general internists provide. The study also found that 
States with more primary care physicians per capita have better health 
outcomes than States with fewer primary care physicians and that States 
with a higher generalist-to-population ratio have lower per-beneficiary 
Medicare expenditures. The GAO study confirms that the Nation's 
uncoordinated system of care, which has an over reliance on specialty 
care services, has led to a less efficient health care system that 
undervalues primary care services and rewards expensive procedure-based 
services. The College strongly agrees with the GAO's findings and is a 
strong proponent of the medical home model the GAO cited in its study.
                            recommendations
    As the education and training of new physicians takes at least 10 
years, immediate action is needed to assure access to care and to 
prevent a crisis in the future. The College feels strongly that special 
emphasis should be placed on increasing the supply of primary care 
physicians including general internists through modifications in 
Medicare GME funding, expansion of the National Health Service Corps, 
increased funding for primary care training and faculty development 
programs under title VII and expansion of program for student loan debt 
relief. According to the Association of American Medical Colleges, the 
average medical student debt in 2007 was $139,517. Those students with 
debt that exceed $150,000 are the least likely to select a primary care 
residency.\5\ Medical school scholarships and loan repayment programs 
in exchange for service in underserved areas for those pursuing careers 
in primary care are essential for those that are interested in careers 
in these critical but less remunerative specialties.
---------------------------------------------------------------------------
    \5\ Rosenblatt RA and Andrilla CHA. The Impact of U.S. Medical 
Students' Debt on Their Choice of Primary Care Careers: An Analysis of 
Data from the 2002 Medical School Graduation Questionnaire. Academic 
Medicine (2005) 80: 815-819.
---------------------------------------------------------------------------
    The College also urges improving the payment and practice 
environment of existing primary care physicians and advocates reforming 
Medicare payment policies so that physicians engaging in primary care 
can receive reimbursement that is commensurate with the value of their 
contributions. The College was encouraged by the GAO's findings that 
payments for services and their value to the patient are misaligned and 
that payment system reforms are necessary. Reducing existing income 
disparities would make the field more attractive and increase the 
number of physicians entering and continuing practice in primary care 
specialties.
    Additionally, the College strongly advocates adopting a patient-
centered primary care model of health care delivery. Patient-centered 
primary care will facilitate the ability of physicians, working in 
partnership with their patients, to implement a systems-based approach 
to delivering patient-centered services that have been shown to result 
in better quality, lower costs, and higher patient satisfaction. It 
will also avert an impending collapse of primary care medicine by 
restructuring payment policies to support the value of care provided by 
a primary care physician. Moreover, patient-centered primary care will 
extend the benefits of a patient-centered health care system to all 
Americans by taking immediate steps toward making affordable coverage 
available to the uninsured and by giving them direct access to 
coordinated care through a medical home.
                               conclusion
    The American College of Physicians appreciates the opportunity to 
provide the Committee on Health, Education, Labor, and Pensions with 
this summary of our views on the primary care workforce crisis. Without 
general internal medicine, the health care system will become 
increasingly fragmented, over-specialized, and inefficient--leading to 
poorer quality care at higher costs. Unless steps are taken now, there 
will not be enough general internists to take care of an aging 
population with growing incidences of chronic diseases. An insufficient 
supply of primary care physicians will also contribute to higher health 
care costs and poorer outcomes, especially for patients with multiple 
chronic diseases. Additional information on ACP's analysis and 
proposals can be found on our Web site: Creating a New National 
Workforce for Internal Medicine http://www.acponline.org/advocacy/
where_we_stand/policy/im_workforce.pdf; Medical Homes and Patient-
Centered Care http://www.acponline.org/advocacy/where_we_stand/
medical_home/.
Response to Questions of Senators Kennedy, Bingaman, Sanders, Mikulski, 
               Enzi, and Murkowski by Bruce A. Steinwald
                      questions of senator kennedy
    Question 1. In your testimony, you indicate that over the last 50 
years, government and industry groups predicted a shortage of 
physicians, then a surplus, and now they are predicting a shortage 
again. With this knowledge, what steps should we take now to address 
this situation, and prevent shortages from reaching severe levels?
    Answer 1. As we noted in our testimony, research in recent years 
has concluded that the Nation's over reliance on specialty care 
services at the expense of primary care leads to a health care system 
that is less efficient. We also note that the predominant form of 
payment to physicians--fee-for-service--and the conventional resource-
based pricing of services undervalues primary care. Ideally, payment 
system reforms that address this undervaluing of primary care services 
should not strictly be about raising fees but rather about 
recalibrating the value of all services, both specialty and primary 
care. It is unclear, however, whether there is currently a shortage of 
primary care physicians.

    Question 2. Your testimony indicates that the total supply of 
primary care professionals is going up, but that the supply of 
nonphysicians is increasing faster than the supply of physicians. To 
ensure adequate numbers of primary care providers, we will need to 
continue encouraging both physicians and non-physician providers to 
enter primary care specialties. What steps should we be taking now to 
encourage each of these groups to enter primary care specialties?
    Answer 2. As we noted in our testimony, the health care system's 
financing mechanisms result in an uncoordinated system of care that 
rewards specialty services and undervalues primary care services. For 
example, primary care physicians, whose principal services are patient 
office visits, are not able to increase the volume of their services 
without reducing the time spent with patients, thereby compromising 
quality. Moreover, the resource-based pricing system used by most 
health care payers, including Medicare, results in higher fees for 
procedure-based services performed by specialty physicians than for 
``evaluation and management'' services.
    Some physician organizations are proposing a new health care 
delivery model that establishes a primary care provider as the central 
coordinator of a patient's medical care. This ``medical home'' model 
allows patients to select a clinical setting--such as their primary 
care physician's practice--to act as the coordinator of their medical 
needs, including specialty care. These ``medical home'' proposals call 
for the primary care provider to be appropriately compensated for 
performing coordination duties.

    Question 3. Your testimony indicates that the conventional pricing 
of physician services undervalues primary care and appears to be 
counterproductive. Could you describe the system-wide financial benefit 
of investing in primary care?
    Answer 3. The benefits of primary care services that we noted in 
our testimony include:

     Patients of primary care physicians are more likely to 
receive preventive services, to receive better management of chronic 
illness than other patients, and to be satisfied with their care.
     Areas with more specialists, or higher specialist-to-
population ratios, have no advantages in meeting population health 
needs and may have ill effects when specialist care is unnecessary.
     States with more primary care physicians per capita have 
better health outcomes--as measured by total and disease-specific 
mortality rates and life expectancy--than States with fewer primary 
care physicians (even after adjusting for other factors, such as age 
and income).
     States with a higher generalist-to-population ratio have 
lower per-beneficiary Medicare expenditures and higher scores on 24 
common performance measures than States with fewer generalist 
physicians and more specialists per capita.
                     questions of senator bingaman
    Question 1. In reviewing the testimony you submitted in regard to 
Primary Care Professionals, and their valuation of services, you 
reported that fee for service payment provide no incentive for quality 
or outcomes, and also disadvantage primary care physicians. You also 
cite data that communities with higher generalist physician to 
population ratios have better outcomes. The number applying to family 
medicine and general internal medicine residencies has decreased when 
we need them most.
    Can you tell the committee about how you might create payment 
mechanisms to coordinate care in a primary care home?
    Answer 1. Some physician organizations are proposing the 
establishment of a medical home model for patients in which a single 
health professional coordinates all the services a patient needs, 
including specialty care. The medical home model would also include a 
refinement to current payment systems to ensure that the work involved 
in coordinating a patient's care is appropriately compensated.
    More specifically, the proposed medical home model allows patients 
to select a single primary care provider to serve as the central 
coordinator of their care. The medical home model seeks to ensure 
continuity of care and guide patients and their families through the 
complex process of making decisions about their treatments and 
providers. The proposal includes a key modification to conventional 
physician payment systems so that physicians receive payment for the 
time spent coordinating care. These care coordination payments could be 
added to existing fee schedule payments or included in a comprehensive, 
per-patient monthly fee.

    Question 2. Has MedPAC or the GAO made recommendations to institute 
payment to assure an adequate primary care workforce?
    Answer 2. During its March 2008 public meetings, MedPAC discussed 
potential payment adjustments for primary care physicians under the 
current Medicare payment system. Based on this discussion, MedPAC may 
be making recommendations to the Congress on payment for primary care 
services in its June 2008 report.
    The GAO, however, has not made recommendations about refining 
payment systems to ensure the adequacy of the primary care workforce.
                      questions of senator sanders
    Question 1. In your testimony, you point out that the total number 
of primary health care professionals has been increasing--yet the 
number of U.S.-trained medical graduates has decreased while the number 
of international medical graduates has increased. So in essence, the 
United States is not really increasing the number of primary care 
health professionals. Therefore, don't we have a shortage? What would 
it take for the United States to eliminate its reliance on 
international medical graduates?
    Answer 1. Our testimony notes that in recent years, the supply of 
primary care physicians grew faster than the population, resulting in 
an increased supply of primary care professionals on a per capita 
basis. Between 1995 and 2006, the composition of primary care physician 
residents did change. A decline in the number of allopathic U.S. 
medical school graduates (USMDs) selecting primary care residencies was 
offset by increases in the numbers of international medical graduates 
(IMGs) and doctor of osteopathy (DO) graduates entering primary care 
residencies.
    We did not evaluate the relative contributions of USMDs, IMGs, and 
DOs to the provision of primary care services in the United States.

    Question 2. In your investigation, you note that few projections 
directly address the supply of primary care professionals and instead 
focus on the supply of all physicians combined. In my mind, if you 
don't measure it, it's an invisible problem. Who should be responsible 
for collecting this data?
    Answer 2. The Health Resources and Services Administration (HRSA) 
collects and disseminates a significant amount of data on the health 
care professions. In our testimony, we relied on these data, as well as 
data from nongovernmental organizations that represent the health care 
professions.

    Question 3. In your testimony, you highlighted the concept of a 
``medical home'' as a means of reforming health care to reemphasize 
primary care. Would you provide specific suggestions for changes that 
Congress would need to enact to advance this medical home model?
    Answer 3. We do not have specific recommendations for the Congress 
to enact the medical home model. Other organizations, including MedPAC, 
are addressing the issue and may make recommendations to the Congress.
    During its March 2008 public meetings, MedPAC discussed a potential 
recommendation for the Congress to launch a medical home pilot project 
in Medicare. Under this draft recommendation, the medical homes would 
be required to meet ``stringent criteria,'' such as providing primary 
care; using health information technology; conducting case management 
services to coordinate services; maintaining 24-hour patient 
communication and access; keeping up-to-date records of advance 
directives by patients about their wishes if they become medically 
incapacitated; and being accredited or certified by an external 
accrediting body. The draft recommendation also states that physicians 
who provide medical home services should receive a modest per-
beneficiary payment.
    Some physician organizations have advocated for increases to the 
Medicare resource-based fee schedule to account for time spent 
coordinating care for patients with multiple chronic illnesses. 
Supporters of the medical home model contend that it may be desirable 
to develop payment models that blend fee-for-service payments with per-
patient payments to ensure that the system is appropriately reimbursing 
physicians for primary, specialty, episodic, and acute care.
                      question of senator mikulski
    Question. With the aging baby boomer generation and the shortage of 
geriatricians, what can be done to increase the number of 
geriatricians?
    Answer. In our study, physicians in general practice, family 
medicine and general internal medicine were regarded as providers of 
primary care services. While we did not specifically examine 
geriatricians, we would expect that all providers of primary care 
services would benefit from a re-evaluation of such services in 
Medicare's payment system.
                       questions of senator enzi
    Question 1. Recognizing that most resident physicians practice 
within a limited distance of their training site, and that the majority 
of current residency training programs exist in or near the major 
metropolitan cities on the East Coast, West Coast and Great Lakes 
areas, what should be done to equalize the distribution of residency 
training sites in the United States?
    Answer 1. We did not evaluate the distribution of residency 
training sites in the United States, or what effect the location of 
residency training sites have on where physicians choose to practice.

    Question 2. As the number of primary care doctors in proportion to 
the population has actually risen, will you discuss the cause of the 
perceived shortage of these physicians?
    Answer 2. We are not aware of any information that demonstrates a 
current shortage of primary care physicians.
    HRSA issued a report projecting that the current supply of primary 
care physicians will be sufficient to meet anticipated need through 
about 2018, but it may fall short of the amount needed in 2020. HRSA 
based its physician supply projections on the size and demographics of 
the current physician workforce, expected number of new entrants, and 
rate of attrition due to retirement, death, and disability.
    The American Academy of Family Physicians (AAFP) also issued a 
report projecting the number of family practitioners in 2020 could fall 
short of the number needed, depending on growth in family medicine 
residency programs.
                     questions of senator murkowski
    Question 1. I have heard concerns that HRSA's Healthcare work 
shortages designation in frontier areas are not accurately reflected by 
the area's HPSA scores. Do you think that HPSA scores accurately 
reflect shortage needs in frontier areas? Can you suggest ways to 
modify HPSA score formula or additional consideration that might be 
used to better measure shortages of health professionals in frontier 
areas?
    Answer 1. The Department of Health and Human Services (HHS) 
published a notice of proposed rulemaking regarding the designation of 
medically undeserved populations (MUPs) and health professional 
shortage areas (HPSAs) on February 29, 2008 (Federal Register, Vol. 73, 
No. 41, pp. 11232-11281). The proposed rule would revise and 
consolidate the criteria and processes for designating MUPs and HPSAs, 
designations that are used in a wide variety of Federal Government 
programs. The Federal Register notice discussed the impact of the 
proposed rule on (1) the distribution of designations by Metropolitan/
Non-Metropolitan and Frontier Status, and (2) the distribution of 
population of underserved area and underserved populations by 
Metropolitan/Non-Metropolitan and Frontier Status (see p. 11258).
    We have not evaluated HHS's proposed changes to the HPSAs and MUPs, 
or how these changes would affect the measurement of shortages of 
health professionals in frontier areas.

    Question 2. In discussing health care provider shortages in 
Wyoming, I have heard of health care providers who are always on call 
as they are the only health care provider in an area and I am concerned 
about this added stress. What is the best way to account for the strain 
of professional isolation on providers that geographic isolation causes 
in frontier areas?
    Answer 2. We have not evaluated the effects of professional 
isolation on health care providers in frontier areas.
Response to Questions of Senators Kennedy, Mikulski, Bingaman, Clinton, 
          Sanders, Enzi, and Murkowski by Kevin Grumbach, M.D.
                      questions of senator kennedy
    Question 1. Dr. Grumbach, in your testimony you say that we should 
take an evidence-based approach to developing effective Federal 
policies in health care. How would you suggest we target title VII 
funding to strengthen our primary care infrastructure?
    Answer 1. The primary care workforce goals for title VII funding 
should guide the targeting of title VII funds. In my view, 
reauthorization of title VII should make explicit the following two 
goals for the primary care components of this program: (1) preparing 
primary care physicians and physician assistants to transform the 21st 
Century primary care medical home into a modernized, high-quality, 
patient-centered practice model for all Americans, and (2) an 
additional special focus on preparing primary care physicians and 
physician assistants to care for underserved populations in the United 
States. The guidelines for targeting of title VII funds that logically 
follow from these goals are: (1) prioritize funding for training 
programs that demonstrate that they are preparing students and 
residents to lead innovative models of primary care (e.g., are 
providing training in applications of the Chronic Care Model, open 
access scheduling methods, use of electronic medical records, group 
medical visits, innovative team-based care models, etc.), and (2) 
prioritize funding for training programs that demonstrate that they are 
teaching skills in the care of underserved populations (e.g., working 
with interpreters, culture competence, integrating oral health care 
into primary medical care), recruiting individuals from underserved 
backgrounds (underrepresented minority, socioeconomically 
disadvantaged, and rural backgrounds), and having significant numbers 
of their graduates practicing in underserved communities and caring for 
vulnerable populations.

    Question 2. Dr. Grumbach, in your testimony you make the case that 
primary care is the foundation of a well-performing health system. 
Could you please tell us what the literature shows about the use of 
primary care in terms of quality, cost, and equity outcomes?
    Answer 2. Research evidence makes it clear that health systems 
built on a solid foundation of primary care deliver more effective, 
efficient, and equitable care than systems that fail to invest 
adequately in primary care:

     Costs: Patients with a regular primary care physician have 
lower overall costs than those without. \1\ \2\ \3\ Compared with 
specialty medicine, primary care provides comparable quality of care at 
lower cost for a variety of conditions such as diabetes, hypertension, 
and pneumonia. \4\ \5\ In comparisons of regions and States in the 
United States, increased primary care physician to population ratios 
are associated with reduced hospitalization rates and lower overall 
health care costs. \6\ \7\
     Quality: Counties and States with more primary care 
physicians per capita--but not specialists--have better population 
health indicators such as total mortality, heart disease and cancer 
mortality, and neonatal mortality. \8\ \9\ \10\ Medicare patients in 
these regions also receive better quality of care, including more 
appropriate care for heart attacks, diabetes, and pneumonia.\7\ 
Patients with a primary care home are more likely to receive 
appropriate preventive services such as cancer screening and flu shots. 
\11\ \12\
     Equity: Racial disparities are reduced when patients 
receive care from a well- functioning medical home. The Commonwealth 
Fund 2006 Health Care Quality Survey found that when adults have a 
health care setting that provides timely, well- organized care and 
enhanced access to the range of health providers, racial and ethnic 
disparities in access and quality are reduced or eliminated. With a 
medical home, minority patients are just as likely as whites to have 
care when needed, receive preventive screening, and have chronic 
conditions managed appropriately. \13\
                      question of senator mikulski
    Question. With the aging baby boomer generation and the shortage of 
geriatricians, what can be done to increase the number of 
geriatricians?
    Answer. The forces discouraging physicians from entering the field 
of geriatrics are the same forces discouraging physicians from entering 
primary care fields in general:

     inadequate promotion of geriatrics in institutions of 
medical education,
     inadequate reimbursement for the practice of geriatrics, 
which almost exclusively involves under-valued evaluation and 
management (E&M) services, and
     inadequate reforms in practice models to create and reward 
more team-based, innovative models of care for patients with chronic 
illness.

    Addressing any one of these problems in isolation is unlikely to 
solve the problem of the geriatrician workforce. For example, funding 
for title VII programs in geriatric training is a necessary, but 
insufficient, policy response. Such support must be coupled by reforms 
of Medicare physician payment to provide more incentive for physicians 
to practice geriatrics, such as by increasing fees for E&M services. In 
addition, Medicare should develop more creative approaches to 
supporting team-based primary care such as by adding a monthly care-
coordination payment and directly subsidizing hiring of case managers, 
health ``coaches'' to assist patients in self-management of chronic 
illness, and related staff for the comprehensive primary care team. 
Such a payment scheme has been proposed by Gorol, et al. (Fundamental 
reform of payment for adult primary care: comprehensive payment for 
comprehensive care. J Gen Intern Med. 2007;22(3):410-5).
                     questions of senator bingaman
    Question 1. Dr. Grumbach, thank you for your testimony, and for 
taking your valuable time to share your expert knowledge with the 
committee.
    In reviewing and hearing your testimony, I note that you have data 
that demonstrate that title VII funding is correlated with getting 
doctors to practice in areas where they are most needed. Can you 
discuss the data demonstrating title VII effectiveness?
    Answer 1. Our own study that I cited, led by Dr. Diane Rittenhouse 
and funded by the Bureau of Health Professions (HRSA), demonstrated 
that Title VII Section 747 Primary Care Training grants are 
significantly associated with physicians and physician assistants being 
more likely to work at federally funded Community Health Centers (CHCs) 
and join the National Health Service Corps. Ours was the most 
comprehensive study of title VII outcomes performed to date, utilizing 
comprehensive historical grant files from HRSA, a complete historical 
record of all NHSC participants, a national data base on all currently 
active U.S. physicians, and Medicare claims files.
    The key findings for CHCs are displayed in the following table:

       Number (%) of Physicians Exposed to Title VII Grants During Training That Worked in CHC (2001-2003)
----------------------------------------------------------------------------------------------------------------
                                                  All         [In                   [In       FP/GPs      [In
                                              specialties   percent]  PCPs only   percent]   only (6)   percent]
----------------------------------------------------------------------------------------------------------------
Medical School Exposure (3):
  Exposed During Medical School.............       5,934        3.0%      3,515       4.5%      2,258       6.2%
    AAU grant...............................         847      3.0           506     4.8           301     6.5
    Pre-doctoral grant......................       1,624      2.7           914     4.1           574     5.7
    Both grants.............................       3,465      3.1         2,095     4.6         1,383     6.4
  Not-exposed During Medical School.........       4,007      1.9         1,814     3.0           950     4.3
Residency Exposure (5,6):
  Exposed During Residency..................         N/A      N/A         3,130     4.4         1,698     6.8
  Not-exposed During Residency..............         N/A      N/A         3,629     3.5         1,710     5.0
----------------------------------------------------------------------------------------------------------------
All are significant at p<0.001 for comparisons between exposed and non-exposed physicians, using chi square
  tests.
 
(1) Includes all U.S. physicians who completed residency in 1977 or later.
(2) International and Canadian medical school graduates were excluded because they are not eligible for the
  NHSC.
(3) International and Canadian medical school graduates were excluded because they could not be exposed to title
  VII during medical school.
(4) Includes all U.S. physicians who completed residency in 1987 or later.
(5) Osteopathic physicians were excluded from residency analyses due to insufficient osteopathic residency data
  in the AMA Masterfile.
(6) General practitioners were excluded from residency analyses because they generally do not undergo full
  residency training.
 
Primary care = family medicine, general practice, general internal medicine, and general pediatrics.
Data source: 2004 AMA Physician Masterfile & Health Resources and Services Administration Title VII Training
  Program Grantee Database; CMS Outpatient Claims File, 2001, 2002, 2003; & HRSA Bureau of the Health
  Professions NHSC Participant Database.


    Prior published research has demonstrated an association between 
title VII grants to medical schools and increased production of primary 
care physicians (PCPs) \14\ \15\ \16\ \17\ and a greater likelihood 
that graduates will practice in underserved areas.\17\ \18\ The only 
published study to examine title VII grants to residency programs was 
limited to family physicians (FPs) in 9 States, and found that FPs who 
were exposed to title VII grants during residency training were more 
likely to practice in rural and low-income areas than other FPs.\18\
    I have also performed research on title VII programs focused on 
health professions diversity. I led a study, funded by the Bureau of 
Health Professions (HRSA) and completed in 2002, that reviewed all the 
research evidence on the effectiveness of educational pipeline 
interventions designed to increase the number of underrepresented 
minorities entering health and health science careers. This critical 
review concluded that while there had been a relative paucity of high 
quality, rigorous evaluations of pipeline programs conducted to date, 
those studies which had been conducted did consistently demonstrate a 
significant, positive effect of these interventions.

    Question 2. Can you tell the committee when you submitted these 
data or reports to HRSA, and how long it was before that data was 
released to the public?
    Answer 2. Our final report on our Title VII--Community Health 
Center--NHSC study was submitted to HRSA in April, 2006. To our 
knowledge, HRSA has not to date taken any action on this report. We 
have not received any formal comments from HRSA about our report, and 
the report has never been published by HRSA or released to the public.
    My report to HRSA on diversity pipeline programs was reviewed by 
staff in the Bureau of Health Professions in 2002, and we revised the 
report in response to this review. HRSA accepted our revised report and 
planned to publish the report as a government document, but a final 
review by the Office of the Secretary of Health and Human Services 
deemed the report inappropriate for publication and the report was 
never released by the Federal Government. A revised version of the 
report was published in 2003 under the sponsorship of a private 
foundation, The California Endowment.
                      question of senator clinton
    Question. In your testimony, you noted that the Title VII Primary 
Care Training Grants are ``more likely to produce graduates who enter 
primary care fields, work at Community Health Centers, and participate 
in National Health Service Corps.'' Given that the National Health 
Service Corps is having trouble filling all available positions, and 
that we are seeing fewer and fewer medical school graduates entering 
primary care, it is imperative that we work to support efforts to 
increase the supply of primary care professionals.
    Title VII programs have contributed to training thousands of New 
York students. Multiple experts and the research literature stress the 
importance of the programs, yet the Administration has criticized the 
effectiveness of these programs.
    The basis for such criticism is the use of the Program Assessment 
Rating Tool (PART), which does not accurately reflect the multiple 
goals of title VII programs.
    Given the success of these programs in increasing the number of 
primary care physicians, what outcome measures would you recommend as 
appropriate in evaluating the true impact of these valuable training 
programs?
    Answer. In my response above to the first question from Senator 
Kennedy, I alluded to goals and performance targets for title VII 
programs. More specifically, in terms of outcomes measures, I believe 
that many of the outcomes measures being collected by the Bureau of 
Health Professions as part of its Comprehensive Performance Monitoring 
System are very appropriate for evaluation of these programs. Among the 
valuable outcomes measures currently collected by BHPr are:

     The number of graduates of funded institutions entering 
careers in primary care fields,
     The number of students and residents from underrepresented 
minority and socioeconomically disadvantaged backgrounds enrolling and 
graduating from funded programs, and
     The number of program graduates entering practice in 
underserved communities and settings.

    In a report our research team recently submitted to BHPr for a 
contract examining approaches to evaluating BHPr programs (K Grumbach, 
et al., Pipeline Programs to Improve Racial and Ethnic Diversity in the 
Health Professions: An Inventory of Federal Programs, Assessment of 
Evaluation Approaches, and Critical Review of the Research Literature; 
submitted November 2008), we pointed out the need to invest resources 
to create more capacity in BHPr to perform more centralized and 
systematic evaluation of its programs, such as by enhancing BHPr 
capacity for matching program enrollee and graduate data bases with 
centralized data bases such as the AAMC files on national matriculation 
data for U.S. medical schools. In addition, when interpreting outcomes 
measures, it is important to not only examine outcomes in reference to 
some desired benchmark or target for performance, but to also give 
credit to programs and institutions that demonstrate improvement over 
time towards meeting such benchmarks, even if they still fall short of 
the actual benchmark.
                      questions of senator sanders
    Question 1. Over the years, projections regarding future physician 
supply and adequacy have proven to be less than accurate. I have a 
couple of basic questions about what goes into computing the need for 
physicians. What is the presumed optimal population to physician ratio 
on which projections are based? What factors are involved in 
determining an appropriate population to physician ratio? Have we got 
it right?
    Answer 1. Senator Sander's question cuts to the heart of how policy 
analysts define the adequacy of physician supply. First, I would 
respectfully suggest that the assertion ``projections regarding future 
physician supply and adequacy have proven to be less than accurate'' is 
only half true. Past projections of physician supply have actually been 
pretty much on target. For example, the forecast of physician supply 
for 2000 made by the national Graduate Medical Education Advisory 
Commission in the 1980s turned out to be very close to the actual 
number in 2000. The problem, therefore, in determining the adequacy of 
physician supply has not so much been due to inaccuracies in 
forecasting supply, but rather to disagreement about how many 
physicians the Nation actually requires.
    One approach to determining the adequacy of physician supply 
defines adequacy on the basis of ``demand'' for medical care. Adherents 
of this view point to the growing number of patient visits per capita 
and growth in the overall economy as signals that demand for physician 
services will significantly increase in coming years, and thus the 
Nation will need more physicians per capita. Critics of this demand-
based approach argue that health care does not operate as a true free 
market and that physicians are able to create demand for their own 
services, even if these services do not necessarily benefit the health 
of the public. These critics of demand-based planning argue that 
requirements should be based on assessments of population ``need'' for 
physicians, and include considerations of quality, affordability, and 
prioritization of health care services. My own perspective tends to be 
one of a needs-based approach to assessing physician requirements.
    When examining the question of whether more physicians are actually 
needed or the optimal supply of physicians, the research evidence shows 
a weak link between patient outcomes and physicians per capita, with 
the exception of studies of primary care physician supply. Health care 
regions are remarkably adaptable to 2- and 3-fold differences in 
overall physician supply across similar populations, achieving 
comparable outcomes despite large variation in supply.\19\ The 10 
percent ``shortfall '' in physicians per capita in 2020 predicted by 
the Council on Graduate Medical Education's demand-based models \20\ is 
dwarfed by the current 200 percent difference in the supply of 
physicians across Dartmouth Atlas of Health Care Hospital Referral 
Regions, adjusted for differences in population age and sex.\21\ 
Differences in patient needs do not explain variation in physician 
supply across locales. For example, the age-sex adjusted regional 
supply of cardiologists is unrelated to the incidence of acute 
myocardial infarction among Medicare beneficiaries.\22\ Studies 
examining outcomes associated with higher supply demonstrate that while 
a very low supply of physicians is associated with higher mortality, 
once supply is even modestly greater, patients derive little further 
survival benefit.\23\ \24\ \25\ \26\
    However, as noted above in response to Senator Kennedy's second 
question, research indicates that health systems with primary care as 
the foundation of care provide the best outcomes at the lowest costs. 
In these primary care-oriented systems and regions, Medicare 
beneficiaries have fewer specialists involved in an episode of care and 
more visits with primary care physicians, spend fewer hospital days in 
intensive care, and have lower health care costs. Such high performing 
health care systems include prepaid group practices, integrated 
delivery systems in fee-for-service payer environments, and other 
models organized around primary care.\27\
    In conclusion, to answer the question ``have we got it right?,'' 
the answer is definitely, ``No!'' We spend too much time preoccupied 
with counting the numbers of physicians on the head of a pin and 
conjecturing about the future demand for physicians, and not nearly 
enough time examining whether we are effectively deploying the existing 
physician workforce that we have in the United States. It is reasonable 
to set some floor for the minimum adequacy of physician supply. For 
example, current Federal policies consider a population-to-primary care 
clinician ratio of 3500-to-1 or greater to be one of the criteria for 
defining Health Professions Shortage Areas, which is a defensible 
policy. But research on the physician workforce makes it abundantly 
clear that there is wide variation in specialist physician supply 
across regions above such as minimum level of supply, with no evidence 
that regions with the highest supply have better health outcomes than 
those with more moderate levels--and may in fact have worse outcomes. 
What we do know is that having more of these physicians in primary care 
fields is associated with less costly and better quality care, and that 
incentives are needed to ensure that physicians are delivering the care 
that is most needed and delivering it with high quality and safety. As 
a health economist once commented about physician supply, ``Let's make 
sure we are stirring up the sugar already in our cup of tea before 
adding another spoonful.'' Determining the optimal number of physicians 
has a lot to do with how well we stir up the ``sugar already in the 
cup:'' our existing supply.

    Question 2. You noted that the National Health Service Corps is an 
effective strategy for increasing the number of primary care 
physicians. I strongly agree. What specific recommendations would you 
make to improve and expand the National Health Service Corps?
    Answer 2. I recommend:

     Doubling the number of loan-repayment positions,
     Allowing more flexibility in determining prioritization 
for NHSC placement sites,
     Creating a leadership training program as part of the NHSC 
to assist NHSC clinicians to become change agents in their practice 
settings, for example by becoming leaders of Bureau of Primary Health 
Care chronic care improvement collaboratives.

    Question 3. In your expert opinion, do we need more U.S. medical 
students and/or schools or do we only need to get more U.S.-medical 
school graduates to fill the increasing number of primary care 
residency slots that are not filled by U.S. graduates?
    Does it concern you that the increase in those pursuing primary 
care residencies is the result of international medical graduates? What 
are the implications of this?
    Answer 3. I support increasing the number of students graduating 
from U.S. medical schools, but I do not advocate a similar major 
expansion of graduate medical education (residency) slots in the United 
States. What I recommend would result in more opportunity for qualified 
U.S. students to become physicians, and less reliance on foreign-
educated physicians to fill U.S. residency training slots. Because the 
United States has about 25 percent more first-year residency positions 
than the number of annual U.S.-medical school graduates, there would be 
room to accommodate more U.S. graduates in the existing residency 
training slots. Over time, the increase in the number of U.S.-medical 
school graduates would reverse the trend of many primary care residency 
positions being filled by international medical school graduates, 
mitigating the ``brain drain'' of physicians from developing nations.

    Question 4. To prevent under- or over-supply of primary care 
physicians in the future, what should we be monitoring and what 
adjustments should be made to avoid subsequent crises in access?
    Answer 4. We should continue to monitor the overall supply of 
physicians in the United States. My own view is that we currently have 
a reasonable overall supply of physicians per capita, and should avoid 
either a large increase or decrease in this supply in the coming 
decades. We should also continue to assess the specialty distribution 
of the physician workforce, and implement policies to reverse what 
appears to be an impending substantial decrease in the proportion of 
physicians in primary care fields which has ominous implications for 
access to primary care and the overall functioning of the entire health 
system. We should also monitor the geographic distribution of 
physicians, and emphasize policies to promote more equitable 
distribution of physician supply for underserved rural and urban 
communities.
    We should also monitor data on patient reports of their access to 
care, such as the information obtained from the regular Medicare 
Beneficiary Surveys conducted by CMS. Recent data from this survey 
indicate that Medicare beneficiaries are reporting more difficulty 
accessing primary care physicians. In 2007, 29 percent of Medicare 
beneficiaries reported a problem finding a primary care physician, up 
from 24 percent in 2006. However, one caveat needs to be mentioned 
about interpretations of patient reports on access to care. Regional 
physician supply is only one factor among many that influence patients' 
access to care. Among the strongest influences are whether the patient 
has insurance, and whether physicians accept the patient's insurance. 
If low payment rates leads some physicians to no longer accept Medicare 
beneficiaries into their practice, Medicare beneficiaries may report 
problems in access to care even when there is adequate physician 
supply. In the case of access to primary care physicians, Medicare 
beneficiary reports of deteriorating access to care appears to be 
correlated with the falling off of the supply of primary care 
physicians for adults, particularly the decrease in new physicians 
entering general adult internal medicine, and less a matter of fewer 
primary care physicians accepting Medicare beneficiaries because of 
payment issues. An example of the payment issue is the findings of a 
recent study of patients' access to dermatologists. The study found 
that it was much easier for a patient requesting cosmetic treatment to 
get an appointment with a dermatologist than a patient requesting 
evaluation of a skin lesion that was suspicious for skin cancer. This 
study revealed how the existing supply of physicians in a particular 
specialty may not be deployed in a way that prioritizes access to care 
for the most pressing health concerns of the population.

    Question 5. In your testimony, you call for reform of how the 
Medicare Graduate Medical Education funding is directed. Are you able 
to provide specific language for the committee's consideration that 
would accomplish what you propose?
    Answer 5. The recommendations for reform of Medicare GME policies 
that have been drafted by the Council of Graduate Medical Education and 
will appear in the Council's 19th Report to be released in early April 
2008, provide an excellent template for legislative language in this 
regard. The draft recommendations published in the minutes of the 
Council's September 18-19, 2007 meeting (http://www.cogme
.gov/minutes09_07.htm), are as follow:

    Recommendation 1: Align GME with future healthcare needs.

    a. Increase funded GME positions by a minimum of 15 percent, 
directing support to innovative training models which address community 
needs and which reflect emerging, evolving, and contemporary models of 
healthcare delivery.

    Recommendation 2: Broaden the definition of ``training venue'' 
(beyond traditional training sites).

    a. Decentralize training sites.
    b. Create flexibility within the system of GME which allows for new 
training venues while enhancing the quality of training for residents.

    Recommendation 3: Remove regulatory barriers limiting flexible GME 
training programs and training venues.

    a. Revise current Centers for Medicare & Medicaid Services (CMS) 
rules that restrict the application of Medicare GME funds to limited 
sites of care.
    b. Use CMS's demonstration authority to fund innovative GME 
projects with the goal of preparing the next generation of physicians 
to achieve identified quality and patient safety outcomes by promoting 
training venues that follow the Institute of Medicine's (IOM) model of 
care delivery.
    c. Assess and rewrite statutes and regulations that constrain 
flexible GME policies to respond to emergency situations and situations 
involving institutional and program closure.

    Recommendation 4: Make accountability for the public's health the 
driving force for graduate medical education (GME).

    a. Develop mechanisms by which local, regional or national groups 
can determine workforce needs, assign accountability, allocate funding, 
and develop innovative models of training which meet the needs of the 
community and of trainees.
    b. Link continued funding to meeting pre-determined performance 
goals.
    c. Alter title VII in order to revitalize support for graduate 
medical education.

    Question 6. Similarly, you echo much of what Mr. Steinwald of the 
GAO advocated in terms of a ``medical home'' model that would 
reemphasize primary care in terms of Medicare payment reform. Are you 
able to provide the committee with specific language that would 
accomplish this?
    Answer 6. Two key payment reforms for Medicare to which I alluded 
in my testimony are (1) splitting the Sustainable Growth Rate (SGR), 
and (2) adding a medical home care coordination payment, in addition to 
fee-for-service payments for patient visits. The first proposal would 
begin to address what Mr. Steinwald refers to as the ``undervaluing'' 
of traditional fee-for-service Medicare payments to primary care 
physicians.
    The legislative language for a splitting of the SGR would need to 
include the following elements:

     Separating Evaluation and Management (E&M) payments codes 
and non-E&M codes into separate ``buckets,''
     Assigning SGR targets to each bucket,
     Calculating conversion factors for physician fees for each 
bucket based on the actual pattern of Medicare expenditures in each 
bucket relative to the SGR target for the bucket of services.

    This policy could be implemented in a manner that would be cost-
neutral for overall Medicare payments to physicians, while creating a 
more equitable distribution of payments between primary care and non-
primary care services. More details about such a policy and its 
implications for revaluing or primary care payments may be found in our 
analysis at http://www.ucsf.edu/cepc/_pdf/The%20Split%20SGR
%20Proposal.pdf.
    The medical home care coordination payment would provide a 
mechanism for compensating primary care physicians for the work that 
they perform in comprehensively caring for patients beyond the time 
spent in face-to-face visits. This type of care coordination payment is 
particularly important for primary care physicians caring for patients 
such as Medicare beneficiaries who have chronic illnesses requiring 
considerable physician time to coordinate referral and ancillary 
services, provide patient education on self-management, monitor 
patients' status at home, and perform similar tasks. The Web site of 
the Patient Centered Primary Care Collaborative, led by large 
employers, primary care professional organizations, and other members, 
provides more details about care coordination payments at http://
www.pcpcc.net/content/physician-payment-reform. The Centers for 
Medicare and Medicaid Services is considering this type of payment 
reform, in response to Section 204 of the Tax Relief and Health Care 
Act of 2006 which mandates that CMS establish a medical home 
demonstration to provide ``targeted, accessible, continuous, and 
coordinated family-centered care to high-need populations.'' Options 
being considered by CMS include a tiered coordination payment indexed 
to the level of illness of each patient, with monthly payments of $10, 
$20-25, and $54 for Tier I, II, and III patients, respectively. To 
receive these payments, physicians would have to document that their 
practice meets essential features of a well-functioning medical home, 
such as being able to produce registries of patients in the practice 
with chronic illnesses, generate reminders for services needed, provide 
coaching in patient self-management, assure accessibility when care is 
needed, etc.
    North Carolina's Medicaid management program, known as Community 
Care of North Carolina, successfully implemented a care coordination 
payment for primary care. For a payment of $5.50 per Medicaid patient 
per month, primary care practices in this Medicaid network use 
evidence-based guidelines, track tests and referrals, and measure and 
report on clinical and service performance. The program spent $8.1 
million between July 2002 and July 2003, but it saved more than $60 
million over historic expenditures. In the second year of the program 
$10.2 million were spent but $124 million was saved. In 2005 the 
savings grew to $231 million.
                       questions of senator enzi
    Question 1. Recognizing that most resident physicians practice 
within a limited distance of their training site, and that the majority 
of current residency training programs exist in or near the major 
metropolitan cities on the East Coast, West Coast and Great Lakes 
areas, what should be done to equalize the distribution of residency 
training sites in the United States?
    Answer 1. Several models of decentralized residency training have 
been successfully implemented in the United States, featuring rural-
based training sites linked to an academic hub at an urban medical 
school. Examples include the rural family medicine residency tracks 
affiliated with the University of Washington, University of Minnesota, 
and University of New Mexico. Rural health centers and Critical Access 
Rural Hospitals often serve as the training sites for these programs. 
Other family medicine residency programs have developed partnerships 
with federally funded community health centers to provide community-
based residency training as an alternative to centralizing all training 
at large urban teaching hospitals. One of the most important actions 
that the Federal Government could take to support these types of 
decentralized residency training models would be to reform Medicare GME 
payment policies so that these payments are not so tightly linked to 
teaching hospitals and could be deployed to support training at rural 
and urban health centers. (See my response to question three from 
Senator Sanders for more information about suggested reforms of 
Medicare GME.)

    Question 2. The committee recognizes that there are many factors 
that contribute to the waning interest in primary care, including 
student debt, long hours, the physician fee schedule, a perceived lack 
of prestige, and lack of exposure to primary care mentors. Of these 
factors and others that may be present, can you rank these factors as 
to the ones that have the greatest impact and that we should focus the 
most resources on addressing?
    Answer 2. Factors may be classified as ``pull factors'' and ``push 
factors.'' Pull factors are those aspects of the practice environment 
that either attract or deter medical students and physicians in 
training from pursuing careers in primary care; these include earning 
potential, lifestyle considerations, job opportunities, and the quality 
of the practice environment. Push factors are factors in medical 
education, such as prestige, role models, indebtedness, and the 
training environment, that encourage or discourage individuals from 
pursuing careers in primary care. Evidence suggests that pull factors 
are most influential. It is therefore vital that Federal policies 
address one of the most critical pull factors--the widening gap in 
earnings between primary care and non-primary care physicians. Public 
and private payers should also invest in improvements in the primary 
care practice environment, such as by investing in installation and 
maintenance of electronic medical records in primary care practices, 
supporting the hiring of key support personnel for the primary care 
team, and providing technical assistance for implementing innovative 
practice models. At the same time, research I cited in my responses to 
Senator Bingaman indicates that push factors also play a role and need 
to be addressed. Title VII is one key mechanism for addressing push 
factors. NHSC loan repayment programs that help to mitigate medical 
student indebtedness are another important strategy.
                     questions of senator murkowski
    Question 1. I have heard concerns that HRSA's Healthcare work 
shortages designation in frontier areas are not accurately reflected by 
the area's HPSA scores. Do you think that HPSA scores accurately 
reflect shortage needs in frontier areas? Can you suggest ways to 
modify HPSA score formula or additional consideration that might be 
used to better measure shortages of health professionals in frontier 
areas?
    Answer 1. HRSA is currently in the process of modifying its 
approach to designating Health Professions Shortage Areas. The proposed 
new rules, published in the February 29, 2008 Federal Register, were 
developed through a lengthy analytic process conducted by experts at 
the Cecil G. Sheps Center of the University of North Carolina under 
contract to HRSA, with input from many stakeholders in the designation 
process. These proposed new rules should be carefully reviewed to 
assess whether they will adequately reflect shortage needs in frontier 
areas.

    Question 2. In discussing health care provider shortages in 
Wyoming, I have heard of health care providers who are always on call 
as they are the only health care provider in an area and I am concerned 
about this added stress. What is the best way to account for the strain 
of professional isolation on providers that geographic isolation causes 
in frontier areas?
    Answer 2. There are several ways to support providers who work in 
relative isolation in frontier communities. One way is to assist State 
rural health associations to coordinate locum tenens relief programs 
for rural providers, providing coverage for providers when they take 
much needed time off for vacations and professional development. 
Another way is to build virtual group practices through telemedicine. 
Telemedicine offers several ways to support frontier providers, such as 
by allowing specialists based at hub facilities to provide real-time, 
remote consultations for patients being seen in the frontier provider's 
office. Telemedicine can also provide a means to provide frontier 
providers access to continuing medical education programs hosted at 
urban sites through teleconferencing hook ups. The Federal 
Communications Commission is currently sponsoring a telemedicine 
initiative.
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Receipt of Preventive Services. J Gen Intern Med. 1996;11:269-276.
    12. Rosenblatt RA, Hart LG, Baldwin LM, Chan L, Schneeweiss R. The 
Generalist Role of Specialty Physicians: Is There a Hidden System of 
Primary Care? JAMA. 1998;279:1364-70.
    13. Beal AC, Doty MM, et al. (2007). Closing the Divide: How 
Medical Homes Promote Equity In Health Care. Results from the 
Commonwealth Fund 2006 Health Care Quality Survey.
    14. Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG. The 
Effect of Federal Grants on Medical Schools' Production of Primary Care 
Physicians. Am J Public Health. 1993;83(3):322-8.
    15. Alpert JJ, Bauchner H, Pelton SI, Siegel B, Levenson S, Vinci 
R. Career Choice in One General Pediatric Title VII--Supported 
Residency. Arch Pediatr Adolesc Med.1995;149(9):1019-21.
    16. Politzer RM, Horab S, Fernandez E, Gamliel S, Kahn N, Mullan F. 
The Impact of Title VII Departmental and Predoctoral Support on the 
Production of Generalist Physicians in Private Medical Schools. Arch 
Fam Med. 1997;6(6):531-5.
    17. Fryer GE, Jr., Meyers DS, Krol DM, Phillips RL, Green LA, Dovey 
SM, et al. The Association of Title VII Funding to Departments of 
Family Medicine With Choice of Physician Specialty and Practice 
Location. Fam. Med. 2002;34(6):436-40.
    18. Krist AH, Johnson RE, Callahan D, Woolf SH, Marsland D. Title 
VII Funding and Physician Practice in Rural or Low-Income Areas. J 
Rural Health. 2005;21(1):3-11.
    19. Goodman D, Grumbach K. Lack of Evidence That Having More 
Physicians Leads to Better Health System Performance. JAMA 2008;299.
    20. Council on Graduate Medical Education. Sixteenth Report 
Physician Workforce Policy Guidelines for the United States, 2000-2020. 
Washington, DC: 2005.
    21. Goodman DC. Trends: Twenty-Year Trends in Regional Variations 
in the U.S. Physician Workforce. Health Affairs 2004.--Suppl Web 
Exclusives:VAR90-7.
    22. Wennberg D. Dartmouth Atlas of Cardiovascular Health Care. 
Chicago, IL: American Hospital Association; 2000.
    23. Goodman D, Fisher E, Little G, Stukel T, Chang C, Schoendorf K. 
The Relation Between the Availability of Neonatal Intensive Care and 
Neonatal Mortality. N Engl J Med 2002;346:1538-44.
    24. Krakauer H, Jacoby I, Millman M, Lukomnik J. Physician Impact 
on Hospital Admission and on Mortality Rates in the Medicare 
Population. Health Services Research 1996;31191-211.
    25. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, 
Pinder EL. The Implications of Regional Variations in Medicare 
Spending. Part 2: Health Outcomes and Satisfaction With Care. Ann Int 
Med 2003;138:288-98.
    26. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, 
Pinder EL. The Implications of Regional Variations in Medicare 
Spending. Part 1: The Content, Quality, and Accessibility of Care. A 
Ann Int Med 2003;138:273-87.
    27. Starfield B, Shi L, Macinko J. Contribution of primary care to 
health systems and health. The Milbank Quarterly 2005;83:457-502.
    Response to Questions of Senators Mikulski, Sanders, Enzi, and 
                               Murkowski 
                   by Roderick S. Hooker, Ph.D., P.A.
                      question of senator mikulski
    Question 1. With the aging baby boomer generation and the shortage 
of geriatricians, what can be done to increase the number of 
geriatricians?
    Answer 1. The role of the geriatrician in American healthcare is 
vital, producing a number of benefits. However, it is difficult for 
geriatricians to thrive in the current reimbursement structure. An 
ideal ratio of geriatricians could be determined, followed by a planned 
effort to produce this ratio.
    When geriatricians team with physician assistants (PAs) and nurse 
practitioners (NPs), there is a significant effect in lowering 
hospitalization rates, lowering re-
admission rates, and improving satisfaction of patients and caregivers. 
A team of two geriatricians and five PAs/NP can be remarkably effective 
in cost containment and health outcomes. Vertically integrated prepaid 
health plans and the Veterans Health Administration are the proving 
grounds for the best use of geriatricians. The utility of geriatricians 
continues to be revealed by demonstration projects such as the Social 
HMO where the elderly are served in their homes instead of 
institutions.
                      questions of senator sanders
    Question 1. You made a compelling case for the role that Physician 
Assistants and Nurse Practitioners can play in improving access and 
overcoming shortages in the future supply of primary care 
professionals. Can you give me some idea about a substitution effect? 
For example, if we trained ``x number'' more PAs & NPs, we would need 
``y fewer'' primary care physicians?
    Answer 1. The ideal ratio of doctor to population is not yet known, 
outside of certain large health maintenance organizations and the 
military. A study performed 25 years ago determined that a PA can 
offset 85 percent of a primary care physician's workload. This type of 
study has not been repeated. What shapes this task transfer effect is 
multifactorial: an aging population, advancing technology, and the 
sustainability of chronic disease. Diabetes and rheumatoid arthritis 
are examples of diseases that benefit from tighter control, resulting 
in more office visits and laboratory monitoring (work that can be done 
by a PA/NP). Also, the workweek of a doctor is shrinking, for various 
reasons but sometimes due to employing PAs/NPs to ease their workload. 
Up to 90 percent of a family medicine doctor's tasks can be delegated 
to a PA or NP without compromising patient safety, and achieving 
comparable outcomes of care and satisfaction.

    Question 2. Are there any impediments or practice restrictions that 
limit the use of PAs and NPs? If so, what are they and how could they 
be overcome?
    Answer 2. Forty years ago, an experiment was conducted by 
introducing PAs and NPs into American society. The experiment was 
successful in employing a team approach, thus expanding access to care. 
Practice restrictions and impediments are lessening as research results 
report the safety and capability are published. Many States have 
adopted beneficial legislation for PAs. Progress for NP independent 
practice has been slower. A national policy analysis on the utility of 
PAs and NPs would give States better guidance.
                        question of senator enzi
    Question. Recognizing that most resident physicians practice within 
a limited distance of their training site, and that the majority of 
current residency training programs exist in or near the major 
metropolitan cities on the East Coast, West Coast and Great Lakes 
areas, what should be done to equalize the distribution of residency 
training sites in the United States?
    Answer. The WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) 
program for Family Medicine residencies is a regional attempt to better 
disperse residents. The WWAMI site in Casper, WY, is a model aimed at 
sharing faculty development and family practice experience in less-
centralized areas. Residency sites in non-metropolitan areas may be 
possible if leveraged with economic incentives. Creating areas of 
medical training excellence in family medicine, general pediatrics, and 
surgery in non-urban locations is possible through The National Area 
Health Education Center Organization. This organization supports and 
advances the Area Health Education Center (AHEC) network whose focus is 
improving the health of individuals and communities by transforming 
healthcare through education. Absent residency sites, PAs and NPs have 
found these to be prime locations for clinical training.
                     questions of senator murkowski
    Question 1. I have heard concerns that HRSA's Healthcare work 
shortages designation in frontier areas are not accurately reflected by 
the area's HPSA scores. Do you think that HPSA scores accurately 
reflect shortage needs in frontier areas? Can you suggest ways to 
modify HPSA score formula or additional consideration that might be 
used to better measure shortages of health professionals in frontier 
areas?
    Answer 1. Health Professional Shortage Area (HPSA) scores do not 
always reflect the geographical barriers (or enhancements) to primary 
care. A gorge or mountain in Oregon may separate a population from a 
clinic by time and/or distance 5 times longer than the air miles yet 
the HPSA score may be low. Conversely being close to an Interstate in 
east Texas may make healthcare access only 30 minutes away although the 
distance is far and the HPSA score high. The Rural-Urban Commuting Area 
Codes (RUCAs) is a new classification scheme that utilizes the standard 
Bureau of Census Urbanized Area. Its value is it uses population 
cluster definitions in combination with travel information to 
characterize all of the Nation's Census tracts regarding their rural 
and urban status and relationships. Matching HPSA with RUCAs offers a 
refinement for understanding health professional shortages areas and 
medically underserved areas.

    Question 2. In discussing health care provider shortages in 
Wyoming, I have heard of health care providers who are always on call 
as they are the only health care provider in an area and I am concerned 
about this added stress. What is the best way to account for the strain 
of professional isolation on providers that geographic isolation causes 
in frontier areas?
    Answer 2. Role fatigue is one of the pitfalls for many healthcare 
providers. Burnout occurs when the physician is ``on call'' all the 
time. Rural doctors in the Far West may be at risk more than others due 
to their scarcity and isolation. Coupling PAs and/or NPs with remote 
and isolated physicians may relieve this role stress by providing 
collegiality, respite and sharing the work burden. Medical 
anthropological research is needed to better understand how scattered 
populations in medical catchments and their providers view each other 
in these circumstances.
    Summary: Medical workforce research in the United States is only 
now emerging from a descriptive phase and poised to undertake large 
social experiments to improve care. Unfortunately innovative ideas and 
creative research in this area have not always been well funded. While 
the heterogeneity of the U.S. population present challenges for 
healthcare, successful models are emerging. Sharing and learning what 
works best under certain circumstances is critical. Finding the right 
balance between optimal care and cost (and sustaining the balance) is 
achievable. Flawed predictions were responsible for some of the 
shortages today. Fortunately improved methods of calculating labor 
supply and demands are now more reliable. Perhaps a central repository 
of knowledge and a national health workforce action plan could 
accomplish an improved understanding where emphasis is needed over 
different time periods.
Response to Questions of Senators Mikulski, Bingaman, Clinton, Sanders, 
           Enzi, and Murkowski by Edward S. Salsberg, M.P.A.
                     questions of senator mikulski
    Question 1. How can dental and medical schools be made more 
affordable for the middle class?
    Answer 1. The AAMC and its members share your concern with the 
rising medical education debt. While we believe medicine is still an 
excellent career choice for Americans, we too worry that some well-
qualified candidates may be discouraged from entering medicine and that 
some physicians may be less likely to go into practice in an 
underserved community. While we know of no easy solutions, the AAMC 
recommends three steps that can begin to help:

     Reinstate the 20/220 pathway of the Economic Hardship 
Deferment in the ongoing Higher Education Act reauthorization;
     Clarify that residency training qualifies as public 
service under the new loan forgiveness program established by P.L. 110-
84 and that this is tax-exempt income; and
     Significantly increase the number of awards given by the 
National Health Service Corps.

    The AAMC and its member institutions have for many years pursued a 
common commitment to increase diversity among students attending U.S. 
medical schools, based on a belief that including students from 
different backgrounds, experiences, and identities enhances the 
education of all medical students. While efforts have focused on 
achieving racial and ethnic diversity, there also is a concern that 
significant barriers confront students from all lower-income families. 
Over the last three decades, the distribution of medical students by 
family income has been remarkably consistent. The data suggests that 
approximately 70 percent of medical students have come from the highest 
two quintiles of family incomes (at least $57,660 in 2005).
    In 2007, new medical school graduates reported an average 
indebtedness of $140,000 and 87.6 percent graduated with some debt. 
Under a typical 10-year repayment schedule at the current fixed 6.8 
percent interest rate, the average medical resident can expect to have 
a monthly loan payment greater than $2,000. With an average first-year 
resident stipend of just over $3,700 a month, these sizeable loan 
payments pose a substantial burden on young physicians while they 
complete their medical training.
    The Economic Hardship Deferment allows medical residents to 
postpone repayment of their Federal student loans without penalty if 
they meet the debt-to-income ratio requirement. Medical residents 
qualify under this pathway (the ``20/220 pathway'') if: (1) they have 
monthly loan repayments greater than 20 percent of their monthly 
income; and (2) their monthly income minus their monthly loan payment 
is less than 220 percent of a Federal poverty designation.
    The recently enacted ``College Cost Reduction and Access Act'' 
(P.L. 110-84) eliminates this pathway requiring medical residents to 
enter forbearance or a new income-based repayment program. 
Unfortunately, the new income-based repayment program does not offer 
medical residents the option to postpone loan repayment during their 
initial years of residency. Rather, medical residents wishing to 
postpone repayment will be forced to enter forbearance, during which 
interest accrues on their entire Federal loan portfolio. On March 12, 
2008, the AAMC and the American Medical Association urged the education 
committees to re-instate the 20/220 pathway in the ongoing Higher 
Education Act reauthorization.
    P.L. 110-84 also creates a new public service loan forgiveness 
program. While it is unclear which physicians will qualify, we are 
pleased the program includes 501(c)(3) tax exempt organizations. It is 
our understanding that medical residency training in teaching hospitals 
will qualify as public service. We also urge Congress to clarify that 
public service loan forgiveness should be tax-exempt income similar to 
awards from the National Health Service Corps (NHSC).
    The NHSC has the potential to both help the economically 
disadvantaged and middle class medical students with the cost of 
medical school and it is a very effective strategy to address the needs 
of our most under-served communities through the service requirements. 
The NHSC provides scholarship and loan repayment awards in exchange for 
service in qualifying health professions shortage areas (HPSAs). 
Considering the average medical education indebtedness, the majority of 
physicians are able to forgive their entire educational debt after 5 
years of service. Since its creation, the NHSC consistently has 
received significantly more applications for positions than it is able 
to support with the funding provided by Congress (approximately 10 
applicants for every award). However, limited funding has reduced new 
NHSC awards from 1,570 in fiscal year 2003 to an estimated 947 in 
fiscal year 2008, a nearly 40 percent decrease. Funding for the NHSC 
has decreased by $47 million since fiscal year 2003, over 27 percent of 
its then $171 million 
budget. In its June 2006 Statement on the Physician Workforce, the AAMC 
recommended increasing annual NHSC awards to physicians by 1,500 to 
allow more graduates to practice in underserved areas.

    Question 2. With the aging baby boomer generation and the shortage 
of geriatricians, what can be done to increase the number of 
geriatricians?
    Answer 2. Increasing the number of geriatricians requires a multi-
faceted approach, including changes to the delivery, financing, and 
education systems. Raising the visibility of geriatrics among medical 
students can be challenging given the current shortage of academic 
geriatric faculty, who serve as important role models for medical 
students. Further, emphasis on interdisciplinary learning as the health 
system shifts to team-based systems of care is critical, particularly 
in geriatrics. Interdisciplinary teams, in which health professionals 
from multiple disciplines apply their special skills, knowledge and 
values to achieve common goals, can enhance innovation, improve the 
quality of patient care, and strengthen academic-clinical ties and 
partnerships among institutions and settings.
    Funding for the geriatrics programs under Title VII of the Public 
Health Service Act has been instrumental in confronting these 
challenges. The multidisciplinary geriatric education centers (GECs), 
geriatric training programs (GTPs), and Geriatric Academic Career 
Awards (GACAs) are effective in providing opportunities for health care 
personnel to develop skills for providing better, more cost-effective 
care for older Americans. Affiliated with educational institutions, 
hospitals, nursing homes, community-based centers for the aged, and 
veterans' hospitals, GECs include short-term faculty training, 
curriculum, and other educational resource development, and technical 
assistance and outreach. GTPs provide fellowships for medical and 
dental faculty and provide for curriculum development, faculty 
recruitment, and the first 3 months of fellowship training. GACAs 
support career development of geriatricians in junior faculty positions 
who are committed to academic careers teaching clinical geriatrics. In 
fiscal year 2008, funding for the title VII geriatrics training 
programs was $31 million, compared to $31.6 million in fiscal year 
2005. The President's fiscal year 2009 budget request eliminates 
funding for these programs. Increased support is necessary to allow the 
programs to continue to prepare the health care workforce to care for 
an aging population.
    The AAMC has been encouraging changes in the education of 
physicians to better prepare them to care for the elderly. Among other 
initiatives, from 1999-2004, the AAMC coordinated and managed a grants 
program for the John A. Hartford Foundation to enhance medical 
education in gerontology and geriatrics. Through the program, 40 U.S. 
medical schools received grants to develop and implement innovative 
curricula that re-inforce the relevance and importance of geriatrics 
throughout the 4 years of undergraduate medical education. The results 
of the development, implementation, and evaluation of the curricula 
were disseminated widely to all medical schools.
    In July 2007, the AAMC hosted a consensus conference to develop 
competencies in geriatrics education. The ultimate purpose of the 
conference was to develop a consensus about the evidence that supports 
the need for geriatrics education and establish standards for assessing 
those outcomes. The competencies were defined and are available, and a 
report of the consensus conference is in development. The AAMC and its 
members continue to work to ensure that newly trained physicians are 
well-schooled in providing high quality care for our senior population.
                      question of senator bingaman
    Question. Mr. Salsberg--thank you for your testimony. In reviewing 
your written testimony and hearing your brief comments, you mention the 
importance of retaining diversity programs in title VII. The number of 
rural applicants to medical school has remained the same, but the 
number accepted has decreased 40 percent. In addition, the percentage 
of underrepresented minority medical school graduates has remained 
relatively stable at 13 percent, while the percentage of our 
underrepresented minority population in the United States has grown to 
25 percent. Data suggest that underrepresented minorities and rural 
applicants are more likely to practice in rural and medically 
underserved areas.
    Does the AAMC have recommendations as to what we can do to increase 
the percentage of underrepresented minority that graduate and rural 
applicants that are accepted to our medical schools?
    Answer. While the AAMC and its members have undertaken a number of 
actions to address these issues, some of which are described below, we 
think the Federal Government has an essential role to play as well. 
Congress is at a critical juncture in terms of both rural residents and 
underrepresented minorities entering medicine and other health 
professions. As you know, the President has proposed eliminating all 
funding for the extremely valuable programs under title VII that were 
designed to address these issues. Assuring continued and adequate 
funding for such programs as Area Health Education Centers (AHECs), the 
Health Careers Opportunity Programs (HCOP) and Centers of Excellence 
(COE) should be a priority.
    The AAMC and its members have a decades-long commitment to building 
diversity in medicine because diversity--both geographic and racial/
ethnic--in medical education improves the medical education environment 
for all, and a more diverse physician workforce improves the Nation's 
health care. Academic medical centers across the country employ a 
spectrum of practices to build diversity in medicine, including 
outreach and career awareness activities, mentoring, and summer 
academic enrichment and research opportunities.
    The AAMC compiles data annually on the demographics of applicants 
and accepted students. The table below lists between 1992 and 2007 the 
percentage of accepted students who provided a rural county of 
residence when completing the American Medical College Application 
Service (AMCAS). In 1992, 49 percent of rural applicants were accepted 
to medical school, compared to 46 percent of rural applicants in 2007. 
This ratio has remained relatively stable over the last 16 years, 
fluctuating between 41 and 50 percent. These trends mirror those in the 
total applicant pool; 47 percent of all applicants were accepted in 
1992, compared to 45 percent in 2007, with acceptance percentages 
varying between 37 and 50 percent.

 
----------------------------------------------------------------------------------------------------------------
                                                                     Rural                               Total
                                                                   Accepted/                           Accepted/
               AMCAS Year                    Rural       Rural      Applied      Total       Total      Applied
                                          Applicants   Accepted       [in     Applicants   Accepted       [in
                                                                   percent]                            percent]
----------------------------------------------------------------------------------------------------------------
1992....................................       2,897       1,433         49%      37,402      17,465         47%
1993....................................       3,324       1,445       43         42,806      17,361       41
1994....................................       3,608       1,508       42         45,360      17,318       38
1995....................................       2,842       1,201       42         46,586      17,356       37
1996....................................       2,827       1,161       41         46,965      17,385       37
1997....................................       2,666       1,112       42         43,016      17,312       40
1998....................................       2,670       1,192       45         40,996      17,373       42
1999....................................       2,543       1,151       45         38,443      17,421       45
2000....................................       2,479       1,213       49         37,088      17,535       47
2001....................................       2,417       1,182       49         34,860      17,454       50
2002 *..................................       329 *       166 *       50 *       33,625      17,593       52
2003....................................       2,184       1,094       50         34,791      17,542       50
2004....................................       2,260       1,139       50         35,735      17,662       49
2005....................................       2,277       1,121       49         37,373      17,987       48
2006....................................       2,213       1,090       49         39,108      18,418       47
2007....................................       2,369       1,097       46         42,315      18,858       45
----------------------------------------------------------------------------------------------------------------
* Incomplete data for rural applicants and acceptances in 2002.

    As of 2006, 28.8 percent of the U.S. population was black/African-
American, Hispanic/Latino, or Native American, yet these groups 
accounted for 14.6 percent of medical school graduates. The 2007 
medical school applicant pool included more individuals from racial and 
ethnic minorities than the previous year. The number of black male 
applicants and Hispanic male applicants both increased by 9.2 percent 
(higher than the growth rate of the total applicant pool, 8.2 percent). 
The number of black males who ultimately were accepted and enrolled in 
medical school increased by 5.3 percent, a rate nearly double that of 
the first-year entrant increase overall. Hispanic male first-year 
enrollees remained at the same level as 2006.
    Outreach projects directed by the AAMC include a Minority Student 
Medical Career Awareness Workshop and Recruitment Fair, which attracts 
nearly 1,000 students annually, and AspiringDocs.org, a comprehensive 
marketing campaign to increase diversity in medicine. Launched in the 
fall of 2006, the AspiringDocs.org campaign takes a new approach--
career marketing--to encourage well-prepared 
African-American, Hispanic/Latino, and Native American college students 
from all undergraduate majors to pursue medicine as a career. The 
interactive Web site featuring information, support, and encouragement 
has logged 124,069 unique user visits and more than 3,373 registered 
undergraduate and college graduate visitors since 2006.
    Another reliable way to impact the applicant pool is to fortify the 
pipeline that leads to a health professions education. Pipeline 
programs, including those supported by title VII, play an important 
role in promoting a health professions education at an early age and 
helping to strengthen the math, science, and learning skills of 
aspiring health professionals. The Title VII Area Health Education 
Centers (AHECs), for example, offer an array of outreach activities for 
students in rural and other undeserved areas. Federal funding for the 
AHEC program, however, has slowly deteriorated over the last 9 years, 
dropping from $33.4 million in fiscal year 2001 to $28.2 million in 
fiscal year 2008.
    Similarly, the Title VII Health Careers Opportunity Programs (HCOP) 
and Centers of Excellence (COE) support the recruitment, retention, and 
advancement of underrepresented minorities and disadvantaged students 
in the health professions, through mentorship, academic and financial 
support, and other activities. Since fiscal year 2006, the programs 
have struggled to recover from virtual elimination of Federal funding 
in fiscal year 2006. Despite a slight increase in fiscal year 2008, 
funding for these programs remains well below fiscal year 2005 levels. 
The AAMC strongly supports restoration of funding to fiscal year 2005 
levels. The AAMC also recommends the creation of a new program under 
title VII to support demonstration projects designed to increase the 
number of underrepresented minority faculty. Underrepresented minority 
faculty help create an environment that can minimize attrition rates 
among minority health professions students through mentorship.
    Loans, loan guarantees, and scholarships provided through the title 
VII and other programs can play an instrumental role in diversifying 
the health workforce as well. As mentioned previously, the NHSC has 
demonstrated tremendous success in providing scholarships and loan 
repayment for physicians that agree to serve rural and urban 
underserved communities after completing residency training.
    From 1996-2005, the AAMC directed the Health Professions 
Partnership Initiative (HPPI). Funded by the Robert Wood Johnson and 
W.K. Kellogg Foundations, HPPI supported collaboration between medical 
and health professions schools, undergraduate institutions, and K-12 
public school systems to improve curricula, provide learning 
opportunities, and enhance academic performance among participating 
students. The AAMC also has had 20 years of experience with what is now 
the Summer Medical and Dental Education Program (SMDEP). SMDEP is a 12-
site summer academic enrichment program for underrepresented minority 
and disadvantaged undergraduate students funded by the Robert Wood 
Johnson Foundation and co-
directed by the AAMC and the American Dental Education Association. 
From 1989 to 2005, 16,575 students participated in SMDEP. Of those 
participants 60.9 percent (8,903) applied to medical school, and 64.3 
percent of those who applied (5,723) were accepted.
    Additionally, the AAMC is developing a comprehensive Holistic 
Review Project to develop, distribute, and promote information and 
tools to be used by medical schools in their efforts to create and 
sustain institutional diversity--a specific focus on application and 
admission processes linked to medical schools' missions and goals.
                      question of senator clinton
    Question. In your testimony, you note the importance of Title VII 
Primary Care Training Programs, specifically their role in 
strengthening diversity of the workforce and improving professional 
placements into under-resourced urban and rural communities.
    You recommend reauthorization at levels greater than previously 
funded. How do you recommend the funds be applied in order to maximize 
outcomes?
    Answer. Studies show that health centers and other clinics that 
provide care to the underserved need more primary care physicians, as 
well as physician assistants, and dentists. Primary care education 
programs would benefit by providing their trainees access to sites in 
underserved areas. The new structure proposed by the AAMC for the Title 
VII Primary Care Training Programs would award grants preferentially to 
applicants entering a formal relationship with one of these sites of 
care (Output program) and would create a new program for demonstration 
projects centered on improving the quality of primary care in selected 
emphasis areas (New Competencies program). The AAMC recommends a 
funding level of $198 million for the Primary Care Training Programs, 
with the distribution among the disciplines and between undergraduate 
and graduate programs to remain the same.\1\ A total of 80 percent of 
this funding is directed to the Output program ($158.4 million) and 20 
percent to the New Competencies program ($39.6 million).
---------------------------------------------------------------------------
    \1\ Level recommended by the HRSA Advisory Committee on Training in 
Primary Care Medicine and Dentistry.
---------------------------------------------------------------------------
    Within the Output program, the AAMC reaffirms the funding 
priorities and preferences outlined in existing statute and recommends 
reserving a certain percentage of funding (e.g., 50 to 70 percent) for 
already successful programs. The statute states: funding priority will 
be given to applicants that have a significant improvement in the 
percentage of providers entering primary care; preference will be given 
to applicants that have a high rate for placing graduates in practice 
settings having the focus of serving residents of medically underserved 
communities or during the preceding 2 years have achieved a significant 
increase in the rate of placing graduates in such setting.\2\ To 
encourage new applicants, the AAMC further recommends a certain amount 
of funding be reserved (e.g., 30 to 50 percent) for applicants that 
outline a plan with strong potential to improve the number of their 
students entering primary care and working in underserved areas.
---------------------------------------------------------------------------
    \2\ Public Health Service Act, Sections 747(c) and 791(a).
---------------------------------------------------------------------------
                      questions of senator sanders
    Question 1. Your Association is recommending a 30 percent increase 
in medical school enrollment by 2015. Does this assume that we will 
continue to rely on international medical graduates to be \1/4\ of our 
physician workforce? If so, what would the U.S. enrollment increase 
need to be to supplant our exploitation of poor countries?
    Answer 1. The primary goal of the AAMC recommendation for a 30 
percent increase in medical school enrollment is to promote an adequate 
supply of well-educated physicians to meet the growing needs for care 
in the United States. Based on the best available data, the Association 
concluded that demand is likely to be rising more rapidly than supply 
and steps are needed now to increase the total number of physicians 
that will be available in the coming decades to serve a growing and 
aging America.
    Currently, more than 6,500 international medical graduates (IMGs) 
enter the U.S. training system each year and nearly all stay to 
practice in the United States. About a quarter of these physicians are 
U.S. citizens who have gone abroad for medical education.
    The recommended increase in enrollment assumes a continued flow of 
international medical graduates into the United States. The recommended 
30 percent increase in enrollment is equal to about 5,000 additional 
graduates per year phased in between 2005 and 2015. This will not be 
sufficient to meet all of the medical care needs of the Nation. We will 
continue to need IMGs; the exact number is dependent on a number of 
factors, including our success in improving the performance of the 
delivery system. The Nation must also improve the efficiency and 
effectiveness of our health care delivery system to make better use of 
our physician supply. This includes increasing the supply of nurse 
practitioners and physician assistants.
    In the absence of major delivery system improvements, any 
significant decrease in the number of international medical school 
graduates would require significant additional increases in U.S. 
medical school enrollment to ensure an adequate supply of physicians.
    The AAMC is very concerned with the global need for physician 
services and the potential impact of physicians migrating to the United 
States from less developed countries. We believe America can and should 
be a good global citizen and leader. To that end, the AAMC supports 
efforts to improve medical education and health care throughout the 
world. Increasing the number of U.S.-medical school graduates will 
directly reduce the ``pull'' of physicians from less developed 
countries without creating barriers for individual migration.
    But there is more that needs to be done. The AAMC and its members 
have valuable knowledge, skills and resources that would be of great 
help to the medical community in less developed countries. Many AAMC 
members already have begun to work with institutions and organizations 
outside of the United States, demonstrating the commitment of the U.S.-
medical education community to improve health worldwide. These 
initiatives include a wide range of programs and can involve medical 
schools, teaching hospitals, medical students and physicians in 
training.
    As part of these efforts, the AAMC has joined with the Foundation 
for Advancement of International Medical Education and Research 
(FAIMER) and the Global Health Education Consortium (GHEC), to collect 
information about international activities at U.S. medical schools. 
More information on these programs is available at http://
www.faimer.org/resources/opportunities/index.html.

    Question 2. If we don't significantly increase U.S. enrollment, 
won't we be even more dependent on international medical graduates?
    Answer 2. Yes, given expected shortages of physicians in the United 
States, in the absence of a significant increase in medical school 
enrollment, the expected increase in need and demand is very likely to 
lead to an increasing demand for international medical graduates. We 
worry that if we fail to increase the number of U.S. medical school 
graduates and GME positions over the coming years, shortages will lead 
to pressure to recruit even more physicians from abroad.
                       questions of senator enzi
    Question 1. Recognizing that most resident physicians practice 
within a limited distance of their training site, and that the majority 
of current residency training programs exist in or near the major 
metropolitan cities on the East Coast, West Coast and Great Lakes 
areas, what should be done to equalize the distribution of residency 
training sites in the United States? (AG)
    Answer 1. The AAMC has called for an expansion of medical education 
and training in the United States, and medical schools are responding. 
However, the current restriction on Federal support of graduate medical 
education (GME) through the Medicare program instituted through the 
Balanced Budget Act of 1997 (P.L. 105-33) has severely limited the 
ability of residency programs to respond to the impending shortage of 
physicians. These shortages will be worse for those areas that are 
already underserved and efforts must also be made to improve the 
distribution of physicians nationwide.
    The ``Resident Physician Shortage Reduction Act of 2007,'' (S. 588) 
is a positive first step towards addressing the national shortage of 
physicians in training. The bill will allow those States whose training 
ratios fall below the national median level to begin the effort of 
increasing the number of GME slots. This would be particularly helpful 
to those areas of the country whose populations have grown most rapidly 
and those that are already faced with an inadequate infrastructure for 
training future physicians. While it is only a first step toward the 
important elimination of the Medicare cap, it is a step in the right 
direction.

    Question 2. Mr. Salsberg: As the number of primary care doctors in 
proportion to the population has actually risen, will you discuss the 
cause of the perceived shortage of these physicians?
    Answer 2. While the aggregate number of primary care physicians has 
been increasing over the past several decades, there are growing 
concerns with current and projected shortages of primary care 
physicians. There are several reasons for this.

     The need and demand for primary care services is rising. 
This reflects a variety of factors including the growing number of 
elderly and chronically ill who need far more primary care services 
than others. For example, according to the National Ambulatory Medical 
Care Survey, those over 65 make twice as many physician visits per 
person per year as those under 65. As America ages and the number of 
chronically ill increases we can expect total visits to physicians--
including primary care physicians--to continue to increase.
     While the number of primary care physicians is still 
growing, the U.S. population is growing more rapidly and may outpace 
the growth in the supply of primary care physicians.
     The length of an average visit also appears to be 
increasing. This in part reflects the fact that visits by the elderly 
take longer and their share of visits is increasing. Advances in 
medicine and a wider array of diagnostic tests and interventions may 
also be contributing to longer visits.
     The physician workforce is aging; more than a third of 
active physicians are now over the age of 55. This is important because 
physicians in general tend to start to cut back on their work hours 
slowly but steadily beginning in their early 50s.
     In the past, younger physicians could be counted on to 
pick up some of the extra demand; but the youngest generation of 
physicians appears to be less willing to work the long hours worked by 
earlier generations of physicians.
     As need and opportunities in sub-specialties rise, an 
increasing number of internal medicine and pediatric trainees are going 
on to sub-specialize. While this helps meet the need for specialists, 
it contributes to the shortage in primary care. An increasing number of 
internists are also becoming hospitalists, working full time in the 
hospital. While this may improve the quality of hospital care and 
assist the community primary care physician, it also reduces the number 
of physicians available to practice primary care in the community.

    The demand and need for primary care physicians is expected to 
continue to rise in the future for all of the reasons mentioned above. 
This along with the decreasing number of physicians now going into 
primary care, particularly among U.S.-medical school graduates, has 
contributed to the growing concerns.
                     questions of senator murkowski
    Question 1. I have heard concerns that HRSA's Healthcare work 
shortages designation in frontier areas are not accurately reflected by 
the area's HPSA scores. Do you think that HPSA scores accurately 
reflect shortage needs in frontier areas? Can you suggest ways to 
modify HPSA score formula or additional consideration that might be 
used to better measure shortages of health professionals in frontier 
areas?
    Answer 1. A proposed new methodology for the designation of 
Medically Underserved Areas (MUAs) and HPSAs (42 CFR parts 5 and 51c) 
was published as proposed rules in the Federal Register on February 29, 
2008. The Department of Health and Human Services is accepting comments 
on the proposed new rules until April 29.
    While we have not done an in-depth analysis of the proposed new 
methodology, it was designed to respond to some of the concerns 
expressed by rural communities. The proposed regulations were developed 
in part by a research team at the University of North Carolina Cecil 
Sheps Center. It appears that the new criteria will be more sensitive 
to the needs of rural communities.

    Question 2. In discussing health care provider shortages in 
Wyoming, I have heard of health care providers who are always on call 
as they are the only health care provider in an area and I am concerned 
about this added stress. What is the best way to account for the strain 
of professional isolation on providers that geographic isolation causes 
in frontier areas?
    Answer 2. Information technology and remote diagnosis and treatment 
guidance will be vital to maximizing the effect of current health care 
providers. In particular, strengthening linkages between providers in 
remote areas with academic medical centers (teaching hospitals and 
physicians) will better enable health professionals to utilize every 
available expert that will benefit underserved populations. Recreating 
these centers may not be feasible in every community; however, every 
effort should be made to improve access to cutting edge health care by 
patients and providers alike.
    Thank you again for the opportunity to testify. The AAMC and its 
member institutions look forward to working with Congress on this 
important topic.
    Response to Questions of Senators Mikulski, Enzi, and Murkowski 
                     by Beth Landon, M.H.A., M.B.A.
                      question of senator mikulski
    Question. With the aging baby boomer generation and the shortage of 
geriatricians, what can be done to increase the number of 
geriatricians?
    Answer. Senator, as you are aware the aging of ``baby boomers''--
compounded with longer life expectancies and expectations for quality 
of life--increasingly affect the delivery of health and social services 
in our country. The need for health care professionals with training in 
geriatrics will continue to grow in parallel. While there is ample 
recognition of this phenomenon, funding is scarce to support training 
in this arena. One noteworthy resource is the Geriatric Education 
Center Program (GEC). Within Title VII of the Public Health Service 
Act, GEC is legislatively required to develop the health professions 
workforce providing geriatric services. They achieve this purpose with 
programming in four areas:

    i. Continuing education and continuing medical education 
opportunities;
    ii. Development and dissemination of curricula for the treatment of 
health problems of elderly individuals;
    iii. Instruction in geriatrics through a faculty-training program; 
and
    iv. Student clinical training in geriatrics, including geriatric 
residencies, and traineeships.

    As Congress continues its deliberations for reauthorization of 
title VII programs, reauthorization of the GEC program, combined with 
increased funding, is critical to our Nation's capacity to provide 
competent geriatric health care.
                        question of senator enzi
    Question. Recognizing that most resident physicians practice within 
a limited distance of their training site, and that the majority of 
current residency training programs exist in or near the major 
metropolitan cities on the East Coast, West Coast and Great Lakes 
areas, what should be done to equalize the distribution of residency 
training sites in the United States?
    Answer. Senator, your question highlights one of the great needs 
for rural health in this country--rural training tracks for medical 
residents. Rural training tracks, especially family medicine training 
tracks, must be both developed and expanded. Family physicians 
constitute nearly 90 percent of all primary care rural physicians and 
are the only source of medical care in many remote rural communities. 
Training programs designed for rural training have a proven track 
record--76 percent of graduates of such programs are in rural 
communities, while 61 percent were in federally designated HPSAs. 
Despite this track record, only 29 of the 474 family medicine residency 
programs in this country have an accredited rural training track and 
only 143 programs offer a fellowship in rural medicine. Barriers exist 
in rural physician residency programs and much of the need in rural 
America for primary care is left unmet.
    One of these barriers is a direct reflection of the caps under 
Medicare Graduate Medical Education (GME) payments. To address rural 
shortages, Congress created in statute a waiver to GME payment caps to 
those programs that include integrated rural training tracks (IRTT). 
Despite statutory authority, CMS has never approved an application for 
this new training tract, claiming that Congress did not adequately 
define IRTT. Therefore, Congress should clearly define this new IRTT, 
thereby, exposing many more students to rural practice and receive 
critical training in primary care, obstetrics, pediatrics, emergency 
medicine and community health. This could have a large impact on the 
future of rural training by encouraging a number of medical schools to 
create these programs.
    Compounding the difficulty in training a rural health workforce in 
rural America is that the cost of going to medical school continues to 
rise. Even in public medical schools, the cost has risen 900 percent in 
the last 25 years. Rural students and those that will go into rural 
medicine cannot afford these levels of debt as they will get paid less 
than urban sub-specialists. Congress should continue to examine ways to 
reduce this debt burden for those committed to practicing in rural, 
underserved areas.
    A final way of addressing the barriers around training physicians 
and other health professionals in programs outside of the major 
metropolitan cities in this Nation is through title VII and VIII 
programs, such as Area Health Education Centers (AHECs). AHECs are 
authorized to assist health professional schools to improve the 
distribution, supply, quality, utilization and efficiency of health 
personnel in scarcity areas through the efficient use of regional 
educational resources. One way this is done is through AHEC Centers 
that have clinical rotations.
                     questions of senator murkowski
    Question 1. I have heard concerns that HRSA's Healthcare work 
shortages designation in frontier areas are not accurately reflected by 
the area's HPSA scores. Do you think that HPSA scores accurately 
reflect shortage needs in frontier areas? Can you suggest ways to 
modify HPSA score formula or additional consideration that might be 
used to better measure shortages of health professionals in frontier 
areas?
    Answer 1. Senator, you are correct--the current HPSA scoring and 
designation process do not accurately reflect shortages in frontier 
areas, primarily due to processes based on urban, not rural, 
communities. In fact, many of the most geographically-isolated 
populations, who reside in frontier locations, often are not 
categorized as a HPSA. These frontier regions are often ineligible for 
a geographic designation because they exceed the required population to 
provider ratio of 3,500:1. Receiving designation as a HPSA is critical 
for all frontier areas because it would allow them to participate in 
the NHSC program and other critical Federal programs.
    A ``frontier designation'' can and should be added to the Health 
Resource and Services Administration's list of HPSA designations. The 
NRHA has developed designation criteria for a frontier HPSA using the 
extensive input from health care leaders in seven frontier States. The 
criteria currently in place, as well as anticipated proposed methods, 
does not provide meaningful results in areas with sparse or 
geographically isolated populations.
    This new designation would establish ``Frontier'' as a geographic 
area with fewer than seven people per square mile across a service 
area, within which the time and/or distance to primary care is 
excessive for the residents. Such areas should qualify as frontier 
HPSAs whose populations are experiencing excessive time or distance to 
primary care, oral health and mental health care.
    It is important to note, that nearly all areas defined by this 
definition as frontier are without public transportation. Many 
experience dramatic seasonal fluctuations in population either for 
employment or recreation, and many have seasonal weather barriers to 
travel. For instance, the community of Unalaska, 800 air miles from the 
nearest hospital, is served by a single community health center with 
three and a half physicians and two mid-level providers. The population 
fluctuates between 5,500 and 10,000 with the dangerous fishing seasons. 
With this staffing, they are ineligible for consistent HPSA status, 
compromising their ability to recruit and retain providers.
    In addition to correcting HPSA inequities, other solutions exist to 
strengthen the health care safety net in rural areas. As you know, 
research consistently indicates that providers are more likely to work 
in rural or frontier areas if they are from those areas or have spent 
time in those areas. Title VII programs such as Area Health Education 
Centers (AHEC) and Health Careers Opportunities Program (HCOP) are 
specifically designed to support career exposure activities with youth 
in the remote areas, improving their likelihood of matriculation into 
those fields. AHECs prepare and socialize students to work in shortage 
areas, and serve as a feeder program for the NHSC. Moreover, AHEC 
supports health professions students to conduct part of their clinical 
training in the remote areas.
    For instance, as you know Senator Murkowski, one of the three AHEC 
Centers in your State is located in Bethel, 500 air miles from 
Anchorage in a region the size of Oregon with 25,000 residents living 
in villages unconnected by roads. Securing health professionals in this 
environment is extremely difficult. We know, from a study my office 
conducted in 2006, that rural health organizations spend an average of 
$106K to recruit a pharmacist and takes over 2.5 years (32.6 months) to 
fill that vacancy. Last year, the Bethel AHEC Center coordinated and 
funded 37 clinical rotations last year in medicine, dentistry, 
pharmacy, and nearly 35 in other occupations. These are providers 
recruited from programs in the Lower 48, since there is not an Alaskan 
medical school. As a direct result of their clinical experiences in the 
Bethel region, two of those pharmacy students have signed employment 
contracts and one has already started. It is too early in training for 
the medical or dental students to know if they will choose to return to 
practice but we plan to get them out to Bethel for another clinical 
rotation further along in their training. As we look at Alaska's 
workforce shortages, and our Nation's, AHECs are a great investment in 
providing residency training in rural and frontier communities.
    Unfortunately, despite the importance of AHECs and other Title VII 
Health Professions Programs to rural health care, Federal funding has 
consistently decreased. The President's fiscal year 2009 budget request 
eliminates funding for AHEC and other title VII programs. These 
programs need to be adequately funded with appropriate inflationary 
adjustments.

    Question 2. In discussing health care provider shortages in 
Wyoming, I have heard of health care providers who are always on call 
as they are the only health care provider in an area and I am concerned 
about this added stress. What is the best way to account for the strain 
of professional isolation on providers that geographic isolation causes 
in frontier areas?
    Answer 2. Senator, AHEC is designed to decrease professional 
isolation of practicing providers through programs that enhance 
education, continuing education and new support programs. Studies have 
shown that practitioners who serve as preceptors for health professions 
students are more satisfied in their professional roles. They have 
additional contacts with academic institutions through working with 
students. AHECs design and deliver continuing education programs for 
these providers. AHECs also provide support to these providers through 
information dissemination on practice management, electronic health 
records, and current best practices in clinical topics. AHECs work with 
providers, facilities and local communities to strengthen recruitment 
and retention of providers, as well as facilitating community planning 
for the local health care system.
    Mr. Chairman and other distinguished members of the committee, 
thank you for this opportunity to respond to your questions on the 
needs of a rural workforce. If you are in need of further follow-up or 
clarification, please feel free to contact myself or Maggie Elehwany, 
NRHA Vice President of Government Affairs and Policy (202-639-0550 or 
[email protected]).
        Response to Questions of Senators Sanders and Mikulski 
                  by Jennifer S. Laurent, M.S., FNP-BC
                      question of senator sanders
    Question. What restrictions exist nationwide that impede nurse 
practitioner practice? Are they State specific or do they lend 
themselves to action by Congress. What specifically would you recommend 
Congress to do?
    Answer. Rules and regulations for nurse practitioners (NPs) 
practice vary State to State. Currently in 11 States NPs practice 
independently (i.e. no physician involvement) they are ME, NH, AK, OR, 
AZ, ID, MT, WY, NM, WA and the District of Columbia. Of the remaining 
States restrictions vary from physician onsite oversite to written 
practice agreements. The Pearson Report \1\ provides a detailed 
overview of each State and their rules and regulations.
---------------------------------------------------------------------------
    \1\ Pearson, L. (2008). Retrieved on March 17, 2008 at http://
www.webnp.net/downloads/pearson_report08/ajnp_pearson08.pdf.
---------------------------------------------------------------------------
    Recognition of the value of NP high quality, cost-effective care by 
Congress sends a strong signal to the States. Supporting bill S. 59: 
Medicaid Advanced Practice Nurses and Physician Assistants Access Act 
of 2007 which ``specifies as primary care case managers any nurse 
practitioner, certified nurse-midwife, or physician assistant that 
provides primary care case management services under a primary care 
case management contract'' and ``revises the coverage of certain nurse 
practitioner services under the Medicaid fee-for-service program to 
remove the specification of certified pediatric nurse practitioner and 
certified family nurse practitioner in order to extend such coverage to 
services furnished by a nurse practitioner or clinical nurse 
specialist.'' \2\
---------------------------------------------------------------------------
    \2\ Library of Congress: Thomas. Retrieved on March 17, 2008 at 
http://thomas.loc.gov/cgi-bin/bdquery/z?d110:SN00059:@@@L&summ2=m&.
---------------------------------------------------------------------------
    The language in the Balanced Budget Act of 1997 is misleading and 
created new barriers for NPs. State-driven Medicaid programs have 
instituted Primary Care Case Management (PCCM) Programs. In many States 
NPs have been excluded from these program provider panels resulting in 
patients being denied access to NP services, primary care services, and 
dual eligible Medicare/Medicaid patients from obtaining vital 
prescriptions written by their NP. NPs are well recognized valuable 
health care providers in Medicaid Managed Care and SCHIP programs in 
the Nation and specifically in undeserved urban and rural communities. 
Authorization of S. 59 will ensure continued access to high quality, 
cost-effective primary care services for all individuals.\3\
---------------------------------------------------------------------------
    \3\ AANP (2008). Medicaid managed care and SCHIP fact sheet 
[electronic version]. Retrieved on March 14, 2008 at http:// 
www.aanp.org/NR/rdonlyres/ex312ckjf35s3pe5dlgqryyaxlxwmm
jedk2yhxzryd67tkv2ftfmarnxkgzkayhabrk6sgafg6ceowsj7h6gjmgrvzc/
Fact+Sheet+Medicaid+Man-
aged+Care+1-08.pdf.
---------------------------------------------------------------------------
    Support S. 1678: Home Health Planning Improvement Act of 2007. 
Currently, NPs are unable to order home health services for their 
patients thereby requiring a M.D. provider to initiate care for an 
unfamiliar patient potentially resulting in delay of necessary 
services. This bill provides increased access to NPs health services 
for Medicare beneficiaries which will expedite referrals for home care 
services to those who need them and, in turn, decrease undue burdensome 
paperwork for all parties.
    Support S. 54: Nursing School Clinics Act. This bill would allow 
Medicaid payment for services to NP faculty and students who provide 
direct patient care in clinics within academic institutions as is 
currently the model for medical residents.
    Full recognition of NPs as PCP on a national level will serve as a 
role model on State and local levels. Other recommendations include the 
following:

     Appointing NPs to national healthcare workgroups;
     Avoiding ``physician'' only language;
     Encouraging local legislators to follow Congresses lead.

    These straight forward approaches prevent barriers to NP care and 
enhance utilization of NPs as vital healthcare resources.
                      question of senator mikulski
    Question. With the aging baby boomer generation and the shortage of 
geriatricians, what can be done to increase the number of 
geriatricians?
    Answer. Nurse practitioners may specialize and receive board 
certification in gerontology. Gerontological nurse practitioners (GNP) 
are educated to diagnose and manage acute and chronic diseases using a 
holistic approach to meet the complex medical, psychosocial, and 
functional needs of older persons.
    Unlike medical residency programs, NP programs are turning away 
qualified NP applicants for several reasons.

     Lack of faculty necessary to educate students;
     Lack of funding for such programs;
     Lack of scholarship funding.

    Reauthorization and increased title VIII funding will improve the 
workforce of geriatric nurse practitioners by providing and educating 
the faculty that will be needed to accomplish the increased demand of 
the baby boomer generation.
    Thank you for the opportunity to provide further information. Nurse 
practitioners are a valuable, untapped resource who are primed to 
answer the primary care needs of the people by providing holistic, high 
quality, health care. Should you require further information please do 
not hesitate to contact me.\4\
---------------------------------------------------------------------------
    \4\ [email protected] or [email protected].
---------------------------------------------------------------------------
  Response to Questions of Senators Mikulski, Bingaman, Brown, Enzi, 
                         and Murkowski by HRSA
                      question of senator mikulski
    Question. With the aging baby boomer generation and the shortage of 
geriatricians, what can be done to increase the number of 
geriatricians?
    Answer. HRSA supports programs that provide direct primary care to 
individuals for all life cycles, including the geriatric cycle. For 
example, the 2009 HRSA budget supports funding for direct care services 
through the National Health Service Corps (NHSC), the Nursing Education 
Loan Repayment and the Nursing Scholarship programs.
    In order to improve the distribution of health professionals and 
improve the health of the underserved, the budget focuses on activities 
that fund placement of more doctors, nurses and other health care 
professionals in the regions of the country that face shortages.
    The NHSC is building on its success in increasing health care 
access for elderly and non-elderly residents of Health Professional 
Shortage Areas, removing barriers to care, and improving the quality of 
care to these underserved populations. The Nursing Education Loan 
Repayment Program is providing nurses who can immediately begin 
practicing in a health care facility with a critical shortage of 
nurses. The Nurse Scholarship Program is reducing the financial barrier 
to nursing education for professional nursing students, and thereby 
increasing the pipeline supply of nurses who will care for elderly and 
non-elderly patients. In addition to these programs, the fiscal year 
2009 request includes funding for the Comprehensive Geriatric Nursing 
program which will provide advanced practice nurses, registered nurses 
and certified nursing assistants with specialized education and 
training to care for the unique needs of the elderly.
                     questions of senator bingaman
    Dr. Duke, we were disappointed that HRSA did not attend our hearing 
on the health professions workforce. I and other committee members, 
including Senators Kennedy, Harkin, Clinton, Obama, Murray, Reed, 
Brown, Dodd, and Mikulski were disappointed that we were not provided 
the 18th and 19th Council on Graduate Medical Education Reports in 
advance of our hearing.
    It is our understanding that the final versions of these reports 
were submitted to HRSA in September 2007, and have yet to be forwarded 
on to Secretary Leavitt. Despite multiple phone calls, e-mails, and the 
formal request--those reports have yet to be released. One of our 
expert witnesses had data demonstrating title VII effectiveness that 
was delayed for many months. These data and reports are essential to 
informing health professions workforce data and legislation to address 
shortages especially in our rural and medically underserved areas.
    Question 1. Why does it take so many months for HRSA to forward the 
reports to the Secretary?
    Answer 1. HRSA provides this timeline for the COGME reports in 
question. On the last day of September, the 18th and 19th COGME reports 
were submitted as documents for printing. The printed reports were 
received the last week of December. During that period HRSA initiated 
reviewing the reports, preparing comments and transmittal documents for 
the HRSA Administrator to the Secretary. When HRSA completed its 
review, the Administrator formally transmitted the reports to the 
Office of the Secretary where pertinent components of this Office are 
allocated 30 days to review the reports and HRSA's comments. Formal 
release of these reports is expected in the near future.

    Question 2. The Administration has eliminated funding for title VII 
programs in the 2009 budget. Have HRSA staff been asked to delay 
release of data, reports or recommendations that support expansion or 
continuation of title VII programs?
    Answer 2. The COGME, as is customary with similar advisory 
committees, extends to the Department, i.e. the Secretary, the time 
necessary to review reports before they are sent to the congressional 
committees.
    HRSA staff were not asked to delay these data releases or reports.
                       questions of senator brown
    Question 1. I am aware the HRSA issued a report in May 2006 titled: 
The Critical Care Workforce: A study of the Demand for and Supply of 
Critical Care Physicians. The report concluded that there was a current 
shortage of critical care physicians and that the shortage is projected 
to worsen through 2020. The imbalance between supply and demand is 
caused largely by the growth in the aging population and its predicted 
increase use of critical care services. Do you agree with the findings 
of the HRSA report and if so, what policy steps should Congress be 
considering to address this physician shortage?
    Answer 1. (See answer 2.)

    Question 2. In your 2006 report on Physician Specialties, one of 
the featured trends was specialty shortages, with vascular surgery 
being the specialty with the least number of active physicians--2,452 
or one for every 121,600 Americans. The majority of their patients are 
Medicare beneficiaries and this population will be greatly increasing 
when the Baby Boomer generation starts turning 65. What are your 
recommendations for increasing the number of vascular surgeons and 
other physician specialties that predominantly treat diseases of the 
aged?
    Answers 1 and 2. Numerous studies, including HRSA's May 2006 study, 
have projected shortages for the physician primary care and 
subspecialty workforces. Generally speaking, HRSA's statutory grant-
making authorities do not include programs that target the subspecialty 
workforce. Funding through the Department of Education as well as 
partnerships with private and corporate entities is available to 
support health professions and meet anticipated needs.
                        question of senator enzi
    Question. Recognizing that most resident physicians practice within 
a limited distance of their training site, and that the majority of 
current residency training programs exist in or near the major 
metropolitan cities on the East Coast, West Coast and Great Lakes 
areas, what should be done to equalize the distribution of residency 
training sites in the United States?
    Answer. The National Health Service Corps (NHSC) does not address 
the distribution of residency training sites, but it does have an 
impact on where physicians ultimately practice. It has been very 
successful in placing and retaining clinicians in underserved areas 
throughout the country. The NHSC's retention rate, the rate at which 
clinicians remain in an underserved area at the conclusion of their 
service commitment, measured at 1 year after service completion is 
approximately 75 percent. The State Loan Repayment program, a matching 
grant program for States, also helps to draw clinicians to underserved 
areas in the United States by providing loan repayment to clinicians to 
work in one of the 33 participating States.
                     questions of senator murkowski
    Question 1. I have heard concerns that HRSA's Healthcare work 
shortages designation in frontier areas are not accurately reflected by 
the area's HPSA scores. Do you think that HPSA scores accurately 
reflect shortage needs in frontier areas? Can you suggest ways to 
modify HPSA score formula or additional consideration that might be 
used to better measure shortages of health professionals in frontier 
areas?
    Answer 1. In the current HPSA methodology, HRSA works to take into 
account the shortage needs in frontier and rural areas. One of the HPSA 
scoring factors is time and distance traveled which is significant in 
frontier and rural areas. Using this factor helps to portray a picture 
of actual access to care in these areas.
    On February 29, HRSA issued a Notice of Proposed Rulemaking (NPRM) 
to revise the designation methodology for HPSAs and for Medically 
Underserved Populations (MUP). The goal of the NPRM is to improve both 
the methodology and the process for obtaining HPSA and MUP 
designations. Under the NPRM, HRSA includes a population density factor 
which is intended to reflect the shortage needs in frontier and rural 
areas. HRSA realizes that frontier and rural areas face special issues 
in accessing care, and we have sought to address those issues under the 
current HPSA methodology and in our proposed methodology.

    Question 2. In discussing health care provider shortages in 
Wyoming, I have heard of health care providers who are always on call 
as they are the only health care provider in an area and I am concerned 
about this added stress. What is the best way to account for the strain 
of professional isolation on providers that geographic isolation causes 
in frontier areas?
    Answer 2. The Department of Health and Human Services has sought to 
recognize the strain of professional isolation for health professionals 
practicing in frontier and rural areas. For example, Medicare Incentive 
Payments provide an additional 10 percent in reimbursement than 
otherwise permitted to physicians practicing in HPSA-designated areas.
    In addition, telehealth programs can help to ameliorate 
professional isolation by supporting professional quality of life in a 
variety of areas. This includes supporting continuing education and 
facilitating technology-mediated peer relationships. HRSA's 2009 budget 
request includes $6.8 million for a range of telehealth activities, 
including training for health care providers.
    Last, higher education institutions can help prepare health-
professions students to practice in a variety of settings, including 
rural and frontier areas. Faculty with experience in such settings 
could be sought, and students with a rural background should be invited 
to share their insights. Also mentoring arrangements in the form of 
short-term student internships and more extensive training 
opportunities in rural areas could foster networking that can continue 
post-graduation.

    [Whereupon, at 4:41 p.m. the hearing was adjourned.]

                                    
