[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
FULL COMMITTEE HEARING ON
THE PROJECTED PHYSICIAN SHORTAGE
AND HOW HEALTH CARE REFORMS
CAN ADDRESS THE PROBLEM
=======================================================================
HEARING
before the
COMMITTEE ON SMALL BUSINESS
UNITED STATES
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
HEARING HELD
July 8, 2009
__________
Small Business Committee Document Number 111-034
Available via the GPO Website: http://www.access.gpo.gov/congress/house
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
----------
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Washington, DC 20402-0001
HOUSE COMMITTEE ON SMALL BUSINESS
NYDIA M. VELAZQUEZ, New York, Chairwoman
DENNIS MOORE, Kansas
HEATH SHULER, North Carolina
KATHY DAHLKEMPER, Pennsylvania
KURT SCHRADER, Oregon
ANN KIRKPATRICK, Arizona
GLENN NYE, Virginia
MICHAEL MICHAUD, Maine
MELISSA BEAN, Illinois
DAN LIPINSKI, Illinois
JASON ALTMIRE, Pennsylvania
YVETTE CLARKE, New York
BRAD ELLSWORTH, Indiana
JOE SESTAK, Pennsylvania
BOBBY BRIGHT, Alabama
PARKER GRIFFITH, Alabama
DEBORAH HALVORSON, Illinois
SAM GRAVES, Missouri, Ranking Member
ROSCOE G. BARTLETT, Maryland
W. TODD AKIN, Missouri
STEVE KING, Iowa
LYNN A. WESTMORELAND, Georgia
LOUIE GOHMERT, Texas
MARY FALLIN, Oklahoma
VERN BUCHANAN, Florida
BLAINE LUETKEMEYER, Missouri
AARON SCHOCK, Illinois
GLENN THOMPSON, Pennsylvania
MIKE COFFMAN, Colorado
Michael Day, Majority Staff Director
Adam Minehardt, Deputy Staff Director
Tim Slattery, Chief Counsel
Karen Haas, Minority Staff Director
.........................................................
(ii)
STANDING SUBCOMMITTEES
______
Subcommittee on Contracting and Technology
GLENN NYE, Virginia, Chairman
YVETTE CLARKE, New York AARON SCHOCK, Illinois, Ranking
BRAD ELLSWORTH, Indiana ROSCOE BARTLETT, Maryland
KURT SCHRADER, Oregon TODD AKIN, Missouri
DEBORAH HALVORSON, Illinois MARY FALLIN, Oklahoma
MELISSA BEAN, Illinois GLENN THOMPSON, Pennsylvania
JOE SESTAK, Pennsylvania
PARKER GRIFFITH, Alabama
______
Subcommittee on Finance and Tax
KURT SCHRADER, Oregon, Chairman
DENNIS MOORE, Kansas VERN BUCHANAN, Florida, Ranking
ANN KIRKPATRICK, Arizona STEVE KING, Iowa
MELISSA BEAN, Illinois TODD AKIN, Missouri
JOE SESTAK, Pennsylvania BLAINE LUETKEMEYER, Missouri
DEBORAH HALVORSON, Illinois MIKE COFFMAN, Colorado
GLENN NYE, Virginia
MICHAEL MICHAUD, Maine
______
Subcommittee on Investigations and Oversight
JASON ALTMIRE, Pennsylvania, Chairman
HEATH SHULER, North Carolina MARY FALLIN, Oklahoma, Ranking
BRAD ELLSWORTH, Indiana LOUIE GOHMERT, Texas
PARKER GRIFFITH, Alabama
(iii)
Subcommittee on Regulations and Healthcare
KATHY DAHLKEMPER, Pennsylvania, Chairwoman
DAN LIPINSKI, Illinois LYNN WESTMORELAND, Georgia,
PARKER GRIFFITH, Alabama Ranking
MELISSA BEAN, Illinois STEVE KING, Iowa
JASON ALTMIRE, Pennsylvania VERN BUCHANAN, Florida
JOE SESTAK, Pennsylvania GLENN THOMPSON, Pennsylvania
BOBBY BRIGHT, Alabama MIKE COFFMAN, Colorado
______
Subcommittee on Rural Development, Entrepreneurship and Trade
HEATH SHULER, Pennsylvania, Chairman
MICHAEL MICHAUD, Maine BLAINE LUETKEMEYER, Missouri,
BOBBY BRIGHT, Alabama Ranking
KATHY DAHLKEMPER, Pennsylvania STEVE KING, Iowa
ANN KIRKPATRICK, Arizona AARON SCHOCK, Illinois
YVETTE CLARKE, New York GLENN THOMPSON, Pennsylvania
(iv)
C O N T E N T S
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OPENING STATEMENTS
Page
Velazquez, Hon. Nydia M.......................................... 1
Graves, Hon. Sam................................................. 2
WITNESSES
Harbaugh, Dr. Robert E., Professor and Chair, Department of
Neurosurgery, Penn State University, On behalf of the American
Association of Neurological Surgeons & Congress of Neurological
Surgeons, Hershey, PA.......................................... 3
Sheldon, Dr. George F., Professor of Surgery and Social Medicine,
Department of Surgery, The University of North Carolina at
Chapel Hill, On behalf of the American College of Surgeons,
Chapell Hill, NC............................................... 5
DiMarco, Dr. Carlo, Professor and Regional Dean of Clinical
Medicine, Lake Erie College of Osteopathic Medicine, President,
American Osteopathic Association, Erie, PA..................... 7
Heim, Dr. Lori, President Elect, American Academy of Family
Physicians, Laurinburg, NC..................................... 9
Kauk, Dr. Bruce A., Northland Internal Medicine, Gladstone MO.... 11
APPENDIX
Prepared Statements:
Velazquez, Hon. Nydia M.......................................... 25
Graves, Hon. Sam................................................. 27
Harbaugh, Dr. Robert E., Professor and Chair, Department of
Neurosurgery, Penn State University, On behalf of the American
Association of Neurological Surgeons & Congress of Neurological
Surgeons, Hershey, PA.......................................... 29
Sheldon, Dr. George F., Professor of Surgery and Social Medicine,
Department of Surgery, The University of North Carolina at
Chapel Hill, On behalf of the American College of Surgeons,
Chapell Hill, NC............................................... 35
DiMarco, Dr. Carlo, Professor and Regional Dean of Clinical
Medicine, Lake Erie College of Osteopathic Medicine, President,
American Osteopathic Association, Erie, PA..................... 45
Heim, Dr. Lori, President Elect, American Academy of Family
Physicians, Laurinburg, NC..................................... 50
Kauk, Dr. Bruce A., Northland Internal Medicine, Gladstone MO.... 59
Statements for the Record:
American College of Physicians................................... 62
Metropolitan Medical Society of Greater Kansas City.............. 79
National Rural Health Association................................ 106
American Academy of Physician Assistants......................... 109
(v)
FULL COMMITTEE HEARING ON
THE LOOMING CHALLENGE
FOR SMALL MEDICAL PRACTICES:
THE PROJECTED PHYSICIAN SHORTAGE
AND HOW HEALTH CARE REFORMS
CAN ADDRESS THE PROBLEM
----------
Wednesday, July 8, 2009
U.S. House of Representatives,
Committee on Small Business,
Washington, DC.
The Committee met, pursuant to call, at 9:35 a.m., in Room
2360, Rayburn House Office Building, Hon. Nydia M. Velazquez
[Chair of the Committee] presiding.
Present: Representatives Velazquez, Moore, Dahlkemper,
Altmire, Bright, Griffith, Graves, Bartlett, Luetkemeyer, and
Thompson.
Chairwoman Velazquez. Good morning, everyone. This hearing
is now called to order.
American health care is a complex system. To properly
function, it requires a myriad of interworking components, from
hospital infrastructure to insurance companies and drug
researchers. But the most critical element cannot be built or
tested in a laboratory. It is the men and women who make the
system run.
General practitioners are the backbone of the medical
field. They offer basic care and are responsible for half of
all patient visits. But in many parts of the country these
small business practices are becoming an endangered species.
Today, we will examine the current physician workforce
shortage and discuss its potential impact on health care
reform. This issue is of particular concern to our Committee,
not just because most general practices are small firms. For
one, it affects doctors in all areas, from surgeons to
pediatricians. Physician shortfalls also hinder our efforts to
control costs for entrepreneurs and have the potential to
undermine our work towards universal coverage.
In overhauling health care, we are looking to provide
coverage that is both affordable and accessible, but we cannot
do that without the necessary workforce.
In the last decade the availability of doctors has dropped
off considerably, even for those with gold-plated policies. If
current trends continue, the gap between supply and demand may
reach 125,000 by the year 2025. Fewer physicians mean longer
lines in waiting rooms, greater difficulties scheduling
appointments, and less time with the doctors themselves. These
challenges are more than an inconvenience. Some patients may
choose to avoid checkups all together. That will be a dangerous
consequence, one that could blunt the benefits of universal
coverage and drive up costs over time.
Primary care is preventative care and an effective means
for reining in costs. That is because a person who gets regular
checkups is less likely to develop serious conditions down the
road; and, considering that 75 percent of health care
expenditures go towards treating chronic illnesses, primary
care is critical.
The current physician shortage is already posing a
significant threat to reform. Reform will bring more uninsured
Americans into the fold, but it will not create more doctors to
treat them. Take the 46 million newly insured, add an aging
baby boomer population, and that could very well be a recipe
for disaster.
As with anything related to health care, there is no silver
bullet solution. Still, a number of possible fixes are under
consideration, including provisions to expand health services
in underserved communities, the regions suffering most from the
current shortage.
This body will soon take steps to transform our broken
health care system. I think most of us will agree that it is
about time. But in moving towards reform, we need to be sure
our foundation is strong. It is critical that we have a solid
pool of medical professionals to see the process through.
Today, I hope we can look for ways to make that happen.
I would like to thank all of today's witnesses in advance
for their testimony, and I am so pleased that they could join
us and look forward to hearing from all of you.
And let me say the hearing was scheduled to start at 10,
but the Small Business Committee has a bill on the floor, and
they sent a late note last night that the hearing needed to be
much earlier.
With that, I will yield to Ranking Member Graves for his
opening statement.
Mr. Graves. Thank you, Madam Chair, and thank you for
calling this hearing on the supply of physicians here in the
United States. And I want to extend a special thanks to all of
our witnesses who are here today.
A 2008 University of Missouri study found that the U.S.
Could face a shortage of up to 44,000 family physicians,
general internists, and general pediatricians in the next 20
years. Many of these professionals operate solo or in small
group practices, small businesses. It is underserved urban and
rural areas, such as parts of my district in Missouri.
With our growing and aging population, there is an
increasing demand for health care services, and there is a
trend towards the coordinated and continuous care provided by
primary care physicians and internists. However, during the
past decade the supply of generalist physicians has fallen by
22 percent, partly due to the reliance on physician
specialists, which makes our health care more expensive and
less efficient. The decline in generalists continues as fewer
medical students are choosing to practice in family care. In
addition, there is evidence that physician assistants and nurse
practitioners may also be choosing to specialize in fields such
as cardiology and oncology.
According to the Government Accountability Office,
conventional payment systems undervalue primary care compared
to specialty care. There is a growing income gap between
primary care physicians and specialists. Several physicians'
organizations have recommended altering compensation structures
to encourage medical students to become generalists.
The Kaiser Family Foundation reported that in 2007 U.S.
health care expenditures exceeded $7,026 per person. Yet
surveys on satisfaction with health care are mixed. Some
experts believe that there is an over-reliance on specialists
and a greater use of primary care providers and internists
would lead to better outcomes at lower costs. These physicians
focus on prevention, wellness, coordinated care, and chronic
disease coordination. Studies show that these services can save
money over the long term.
I want to add a final word about health care reform. I
strongly oppose employer mandates and a government-run health
care system. These alternatives could cause as many as 120
million Americans to lose their current coverage, drive
companies out of the market, and require substantial tax
increases on the small businesses we are depending on to create
jobs. I hope Congress will consider these points during our
debate.
Again, Madam Chair, thank you for holding this hearing. I
look forward to hearing from our panelists.
Chairwoman Velazquez. Thank you, Mr. Graves.
Chairwoman Velazquez. Let me welcome Dr. Robert Harbaugh.
He is a neurosurgeon at Penn State University in Hershey,
Pennsylvania. He serves as the Director of the Penn State
Institute of Neurosciences. Dr. Harbaugh is testifying on
behalf of the American Association of Neurological Surgeons and
the Congress of Neurological Surgeons. The Association is
dedicated to advancing the specialty of neurological surgery.
Welcome, sir. You have 5 minutes to make your presentation.
STATEMENT OF ROBERT E. HARBAUGH, M.D.
Dr. Harbaugh. Good morning, Chairwoman Velazquez, Ranking
Member Graves, members of the Committee. Thank you for inviting
me to appear today to discuss the current workforce shortage
that is facing surgical specialty medicine and, specifically,
neurosurgical care.
Recently and understandably, a great deal of attention has
been paid to the shortage of primary care physicians, but
little attention has been paid to the shortage of surgeons. The
Association of American Medical Colleges estimates a shortage
of 46,000 primary care physicians and 41,000 surgical
specialists by 2025; and while plans are being considered to
address the primary care deficit, little is being done to
address the shortage of surgical specialists.
The Bureau of Health Professions projects a 19 percent
increase in primary care physicians by 2020, based on some of
the actions that are planned, but continued and significant
decreases in the number of surgical specialists over the same
time.
At present, there are fewer than 3,500 practicing board
certified neurosurgeons in the United States serving a
population of more than 300 million people. And as the
population ages, more of our citizens face devastating problems
such as stroke, degenerative spine disease, Parkinson's
Disease, and brain tumors that neurosurgeons treat. This
supply/demand mismatch will become ever more acute.
In addition, the effectiveness of things like deep brain
stimulation for treating movement disorders and obsessive
compulsive disorders makes it very likely that we are on the
verge of a minimally invasive and effective neurosurgical
treatment for things like obesity and addiction; and because of
the prevalence of these disorders, many more neurosurgeons will
be needed to meet the demand for their neurosurgical
treatments.
We already have an acute neurosurgical workforce problem in
the subspecialty areas of pediatric neurosurgery and trauma and
emergency neurosurgery. There are less than 200 surgeons
certified by the American Board of Pediatric Neurological
Surgery, and within the next 10 years more than 40 percent of
the current pediatric neurosurgical workforce is likely to
retire.
On the supply side, there are less than 10 trainees who
enter pediatric neurosurgery fellowship training each year.
There is also a shortage of neurosurgeons to provide
neurosurgical emergency and trauma care. Closure of trauma
centers in Pennsylvania, Tennessee, Missouri, Illinois, Texas,
and Florida were due in part to shortages of neurosurgeons. And
the National Foundation For Trauma Care reports that, after
trauma surgeons, neurosurgeons are the specialists with the
highest percentage of trauma care.
According to this same report, physician shortages, caused
by a variety of factors, including medical liability expense,
decreasing reimbursement, represent one of the major reasons
for the closure of trauma centers. And with estimates that 10
to 20 percent of the Nation's 600 regional trauma centers may
be forced to close within 3 years, it appears that neurosurgeon
shortages are affecting the availability of trauma care in the
United States, despite the fact that more than 90 percent of
practicing neurosurgeons participate in emergency call
coverage.
Many neurosurgeons must provide emergency care at more than
one hospital at a time, and that places our citizens at risk of
delayed care for neurological emergencies such as head, spine,
and nerve trauma and cerebral hemorrhage from ruptured
intercranial aneurysm and other causes.
While there are many complex factors that lead medical
students to select one specialty over another, there are
several reasons for the present and impending shortages in the
neurosurgical workforce. One of these is medical liability.
Neurosurgeons continue to face increased professional liability
insurance costs, which in some areas of the country now
approach $300,000 per year.
According to a survey we conducted a few years ago, medical
liability issues contributed substantially to neurosurgeons
limiting their availability for emergency and trauma care and
eliminating treatment of high-risk patients; and medical
liability reform would clearly help address this part of the
physician workforce shortage.
Lifestyle issues must also be considered as a contributing
factor in the shortage of surgical specialists. The AMC
projects that physician practice patterns are likely to be
different in the future because of a greater concern for
lifestyle issues among young physicians and because of the
intensity of the neurosurgical practice. With frequent
emergencies requiring long hours of neurosurgical care,
lifestyle issues will contribute to a shortage of available
neurosurgeons.
In some areas of medicine, physicians assistants and
advanced practice nurses may be able to address a shortage of
physicians, but there is no good substitute for well-trained
neurosurgeons for patients with head, spine, and nerve
injuries, brain tumors, stroke, hydrocephalus, and other
neurosurgical emergencies.
After graduating from medical school, most neurosurgeons
train for 7 years or more before entering practice; and there
are less than 100 neurosurgical training programs in the United
States, with many programs training only one resident per year.
Compounding this problem, the Accreditation Council for
Graduate Medical Education has established work hour
restrictions for residents; and due to the time and intensity
required to adequately train a neurosurgeon, restricting weekly
work hours will require lengthening the period of training if
we want to continue to have well-trained neurosurgeons.
Over the past several years, we have heard repeatedly that
reimbursement is contributing to the shortage of primary care
physicians because more medical students choose higher-paid
specialties rather than primary care. However, there is also a
risk that reducing surgical specialty reimbursement in the face
of medical liability and lifestyle issues that inhibit students
from entering a surgical specialty will exacerbate the current
shortage of surgical specialists.
In conclusion, the convergence of declining reimbursements,
rising practice expense, less time for non-work-related
activities may deter young physicians from becoming
neurosurgeons. This will exacerbate already acute problems with
access to neurosurgical care, and I think these problems will
be compounded by effective neurosurgical treatments for common
disorders and an aging population that requires more
neurosurgical services.
Thank you for this opportunity to speak with you today. I
would be happy to answer any questions.
Chairwoman Velazquez. Thank you, Dr. Harbaugh.
[The statement of Dr. Harbaugh is included in the
appendix.]
Chairwoman Velazquez. Our next witness is Dr. George
Sheldon. Dr. Sheldon is a Professor of Surgery and Social
Medicine in the Department of Surgery at the University of
North Carolina in Chapel Hill. He is also the Director of the
American College of Surgeons Health Policy Research Institute.
Dr. Sheldon is testifying on behalf of the American College
of Surgeons. The ACS is a scientific and educational
Association of surgeons that was founded in 1913.
Welcome.
STATEMENT OF GEORGE F. SHELDON, M.D.
Dr. Sheldon. Thank you very much, Chairman Velazquez and
Mr. Graves, ranking member, members of the Committee. We are
also pleased to be here, and I would make several points on the
going in.
Neither candidate during the last election could put
forward any of the details about one of the big problems in
health care that has already been mentioned by Dr. Harbaugh is
a shortage. And I think if we pick just one specialty to try to
stimulate, it is sort of like putting a finger in a dyke that
has got 10 holes leaking. We have got to do it for everybody.
And I know we hear a lot about the problems with American
medicine and all the things, and we all agree, and we are all
committed to health reform. But I would call your attention to
a July 4 publication of Lancet, the respected British medical
journal. They published a comparison of cancer deaths in the
United Kingdom, 11 countries, and the United States, using
World Health Organization databases. Cancer mortality in the
United Kingdom, which has a federal program, as everybody
knows, were 23 percent higher than six European countries and
31 percent higher than in the United States. So my hope, among
other things, is that whatever we do for health reform, we
don't throw the baby out with the bath water. There have been
some good things happen over the years.
We are encouraged by the book by Ezekiel Emanuel. Dr.
Ezekiel Emanuel, who is a White House advisor, has a very good
outline of a plan that might be done.
In a similar void and on the other side, the June 2
publication by the Council of Economic Advisors of the White
House embraced the concept of a 30 percent overage that could
be money saved in health care costs by reduction in regional
variation by what they call input changes and also by using the
False Claims Act. This is, of course, based on the Dartmouth
work, respected investigators.
But there is four other groups, including ours, that find
different types of data. And that would be Dr. Robert Berenson
of the Urban Institute, Dr. Richard Cooper of the Wharton
School of Business for the University of Pennsylvania, and our
data from Dr. Ricketts. In short, while there is some regional
variation, they are only comparing Medicare; and Medicare is
only 50 percent of the payers. So it is like comparing apples
and oranges. It is not agreed upon enough to be a premise for
health care reform.
The rest of my comments will deal with shortage of
surgeons. There are shortages in every specialty of surgery
today. We have done population maps and showed that some States
are worse off than others, but there is not a single State in
the Union that has more surgeons than they did 10 years ago,
and that's also shown in the Dartmouth atlas.
One-third of all surgeons are over 55 years of age; and
specialization of surgery, as instrumentation and other types
of technology increased, has been monumental. But to give some
data, the general surgeon is sort of the generalist in the
group. He is usually head of the trauma centers, does a lot of
the transplant surgery, does a lot of the cancer surgery.
And we have fewer general surgeons now practicing than we
did in 1980. The American Board of Surgery, of which I was
chairman at one time, in 1981 certified 1,047 people. Last
year, it was 1,032. And, in the meantime, the population of the
country has grown by 25 million each decade.
Rural America, with about 20 percent of the population, 59
million people, require on surgical services to keep their
hospitals open. That is what allows the hospital to provide the
other services. It is the backbone of the rural hospital.
There is 1,300 critical access hospitals in the United
States, and 300 of them don't even have a surgeon living in the
county. If a surgeon is not available, the other services
pretty much go away.
A further example of the shortage is cardio-thoracic
surgery. Cardiac disease is the commonest killer in the 20th
century and will predictably be for the first part of the 21st.
Only 50 U.S. medical school graduates applied for training
in cardio-thoracic surgery this past year. So who is going to
do our heart surgery as we go forward? There aren't going to be
people around to do it.
My closing comments would just say that I would believe
that we have a shortage in all specialties, primary care and
all the surgical fields. And we think that there ought to be
access to the public programs like Title VII, the National
Health Service Corps, of the dish provisions that are provided
for primary care and others. These things ought to be made
available for all specialties, not just primary care.
Thank you very much for your attention, and I am certainly
available to provide maps of all these States and everything if
you would like to see them. In fact, you have one map with you,
I think.
Chairwoman Velazquez. Thank you, Dr. Sheldon.
[The statement of Dr. Sheldon is included in the appendix.]
Chairwoman Velazquez. Now the Chair recognizes the
gentlelady from Pennsylvania, Mrs. Dahlkemper, for the purpose
of introducing our next witness.
Mrs. Dahlkemper. Thank you, Madam Chair.
It is my pleasure to welcome Dr. Carlo DiMarco to the Small
Business Committee today. Dr. DiMarco is from my hometown of
Erie, Pennsylvania. He is the 112th President of the American
Osteopathic Association. He is also a Professor and Regional
Dean of Clinical Medicine and Director of Ophthalmology
Residency Program at the Lake Erie College of Osteopathic
Medicine in Erie, which we call LECOM.
Aside from his duties at LECOM, Dr. DiMarco is part of
Medical Associates of Erie, a network of multi-specialty
physicians who practice throughout Erie County and teach in
affiliation with LECOM.
Welcome, Dr. DiMarco.
STATEMENT OF CARLO J. DiMARCO, D.O.
Dr. DiMarco. Thank you, Chairman Velazquez and Ranking
Member Graves and Representative Dahlkemper and members of the
Committee. I thank you for the opportunity to testify today.
As President of the American Osteopathic Association, which
represents 67,000 osteopathic physicians across the country,
and as Professor and Regional Dean of the Lake Erie College of
Osteopathic Medicine, I am acutely aware of the challenges of
addressing our Nation's physician workforce shortage,
particularly in the field of primary care.
At LECOM, our mission is to educate physicians in the
osteopathic tradition of competent and compassionate whole
person care. The percentage of our graduates who pursue careers
in primary care is 67 percent, placing LECOM at eighth in the
Nation for training primary care physicians. But despite this
commitment to primary care, the challenges facing our
profession and our students are increasingly prohibitive.
Three central factors contribute to our current and
projected primary care workforce shortage, and these factors
also apply to general surgery: the Medicare physician payment
system, graduate medical education, reimbursement policies and
time-consuming administrative burdens that shift attention away
from patient care.
With respect to physician reimbursements, studies show that
income disparities have a significant negative impact on the
choice of primary careers over specialties among the Nation's
young physicians. This is not surprising, given that the
average of income of a primary care physician is approximately
one-third of a specialist, while practice costs are often even
higher.
Unless Congress takes immediate action to establish a more
equitable physician payment system, a predicted workforce
shortage can only worsen. We urge Congress to enact financial
incentives for primary care physicians to provide a bonus of at
least 10 percent for primary care services, with mandated
annual increases to achieve market competitiveness.
As you know, the instability of the current physician
payment system stemming from the flawed sustainable growth rate
formula results in the threat of annual costs and cuts. We
appreciate Congress's yearly interventions to avert these
drastic cuts, but a Band-Aid approach does nothing to alleviate
the underlying systemic problems driving physicians out of
medical practice. The unpredictability forces small primary
care practices with limited revenues and narrow margins to make
difficult decisions about whether to lay off staff, reduce
their Medicare patient population, defer investments or retire
early.
Medicine is calling, but the business of medicine, in
general, is a small business. No business can survive when its
expenses exceeds its revenues.
Administrative burdens create additional strains on primary
care physicians, resulting in the significant decline in
professional satisfaction and hampering recruitment efforts. In
fact, 60 percent of primary care physicians would not recommend
a career in medicine.
While physicians in all other specialties face unnecessary
and costly administrative hassles, the burden on primary care
physicians in small practices is particularly excessive,
detracting from the time available for patient care. Primary
care physicians' role in coordinating care and making needed
referrals to specialists typically involves frequent
interaction with Medicare and other third-party payers to
obtain required approvals, services, and payments, and
resulting in paperwork and overhead expenses at almost twice
that of other physicians.
A typical primary care physician must coordinate care for
Medicare patients with 229 other physicians working in 117
different offices, yet receives no compensation for these care
coordination services. The AOA supports the development of a
new delivery and payment model such as the patient centered
medical home that will allow primary care physicians to provide
comprehensive, continuous patient care.
Reforms to the graduate medical education training system
are also an essential component of workforce development.
First, the current graduate medical education system is not
capable of meeting increases in enrollment in the Nation's
colleges of osteopathic medicine and colleges of medicine. We
support a modification of current limits on the number of
funded residency training positions through a one-time increase
in the number of funded positions by 15 percent.
Additionally, we support modifications that allow for
collaboration through consortiums, such as the Osteopathic
Postgraduate Training Institutes, or OPTIs. These consortiums
allow several teaching locations to share resources, thus
enhancing the educational opportunities for the resident
physician.
Finally, research has shown that physicians who are trained
in the community health centers, for example, are twice as
likely to work in underserved settings and four times more
likely to work in health centers after completing their
residencies. However, Medicare does not reimburse for most time
spent in outpatient settings. We urge Congress to enact
legislation that will create new training opportunities in non-
hospital settings and clarify existing regulations governing
such training.
Providing residents with the opportunities in real-world
settings offers greater exposure to primary care specialties
and increases the likelihood that residents will choose to
practice in these settings and in small physician practices
that make up the backbone of our primary care system.
On behalf of the AOA, I would like to thank you for drawing
attention to this important issue, and we look forward to
continuing to work with you in addressing the physician
workforce shortage. Thank you very much.
Chairwoman Velazquez. Thank you, Dr. DiMarco.
[The statement of Dr. DiMarco is included in the appendix.]
Chairwoman Velazquez. Our next witness is Dr. Lori Heim.
She is President-elect of the American Academy of Family
Physicians. Dr. Heim advocates on behalf of family physicians
and patients nationwide to inspire positive changes in the U.S.
health care system. The American Academy of Family Physicians
is one of the largest national medical organizations, with more
than 93,000 members.
Welcome.
STATEMENT OF LORI HEIM, M.D.
Dr. Heim. Thank you, Chairwoman Velazquez and
Representative Graves and members of the Small Business
Committee.
I am Lori Heim, President-elect of the American Academy of
Family Physicians, which now represents over 94,000 members
across the U.S.; and I am pleased to be here to testify on
physician workforce needs as Congress considers health care
reform.
As you know, the vast majority of family physicians
themselves are small businesses, delivering care in communities
across the Nation. Nearly 38 percent of family doctors practice
in solo or two-physician practices. Studies indicate that more
Americans depend on family physicians than on any other
specialty. We see up close the hardship of the uninsured, and
we struggle along with those patients who are insured but then
who face coverage denials.
We consider an expanded primary care physician workforce
essential to the success of health reform. Unfortunately, while
the supply of primary care physicians is far from adequate, the
projections are truly alarming. Primary care has been described
as the base of the health care workforce pyramid. But the U.S.
physician profile is only 31 percent primary care and 69
percent specialty.
The AAFP supports the steps necessary to build the primary
care workforce to at least 45 percent of all practicing
physicians. To restore stability, we must adopt workforce
policies that ensure an adequate number of primary physicians
who are trained to practice in the comprehensive patient-
centered primary care medical home model. That model of care
provides patients with preventive care, as well as coordinates
their chronic disease and appropriate care for acute illness.
To realize the quality and efficiency benefits of the
patient-centered medical home, we must have an adequate supply
of primary care doctors, particularly family physicians.
The reasons for the inadequate supply of primary care are
many, and we must address each one of these. The first and most
critical step has already been mentioned, and that is to
increase the payment for primary care. This will encourage more
student interest in primary care, as well as allow for the
redesign of existing practices to improve quality and access.
Next, Congress should provide targeted incentives such as
scholarships, loan forgiveness or other forms of debt relief
for medical students who choose primary care and family
medicine.
Also, we are recommending opportunities in programs such as
the National Health Service Corps. Congress should reauthorize
and adequately fund Title VII health professions training grant
programs for primary care medicine.
AAFP has also called for reforms to graduate medical
education payments to ensure that we are training the primary
care physician workforce that we need. However, we would
suggest caution with respect to the expansion of residency
slots. We recommend that unused residency slots be dedicated to
primary care before an overall expansion of the number of
residency slots is considered.
We are grateful to the House discussion draft that
addresses the primary care physician workforce shortage with
provisions including the bonus payment for primary care
services provided in health profession shortage areas,
reauthorization and mandatory funding for Title VII section
747, the Health Professions Primary Care Medicine Training
Program, and the National Healthcare Workforce Commission to
study and recommend appropriate numbers and distribution of
physicians.
We look forward to continuing to work on workforce and
other key elements of health care reform. Now is the time to
provide affordable, high-quality health care coverage. The
status quo is not working, neither for the physicians nor for
the patient. We urge Congress to invest in the health care
system that we want, not the one that we have now.
Thank you very much.
Chairwoman Velazquez. Thank you, Dr. Heim.
[The statement of Dr. Heim is included in the appendix.]
Chairwoman Velazquez. The Chair recognizes the ranking
member, Mr. Graves, for the purpose of introducing our next
witness.
Mr. Graves. Thank you, Madam Chair.
Madam Chair, I am pleased to introduce Dr. Bruce Kauk, M.D.
He is a fellow Missourian from Gladstone. Dr. Kauk has been in
private practice with Northland Internal Medicine in Gladstone
since 1979. He is board certified in internal medicine and
geriatrics. A graduate of the University of Nebraska Medical
Center in Omaha, Dr. Kauk served his internship and residency
at Southern Illinois University in Springfield.
Dr. Kauk has been President of the Clay County Medical
Society and President of the North Kansas City Hospital Medical
Staff Credentials Committee, and he is a founding member and
chairman of the Clay County Senior Services in Gladstone.
Thanks, Doctor, for coming in all the way from Missouri.
STATEMENT OF BRUCE A. KAUK, M.D.
Dr. Kauk. Good morning. Thank you.
Madam Chairman, Ranking Member Graves, members of the
Committee, I appreciate this opportunity to talk to you. I do
not represent any society or any other specialty group. I think
I come to give you the passion and the soul of what we all do
every day, which is not quite the flavor of what my other
colleagues have told you. They are more concerned about the
facts, and there are other issues to this issue.
I am particularly glad to come to this Committee because
most physicians traditionally have been small businessmen. One
of the issues is, though, that we are seeing that change
dramatically. In my community, we are down to about a 50/50 mix
of internal medicine and family practice being self-employed.
Most of them have joined some organization.
Again, I say I am a traditional internist. That means I do
everything. I go to the hospital. I have an office practice. I
have a nursing home practice. Recently, because of some of the
budget issues, I have added a long-term acute care practice.
So I know you are all aware that physicians are in
evolution and internists are in evolution, particularly. We
have hospitalists. We have people who just do office work. We
have people who do none of that, who don't practice active
care. There are many things that physicians can do now. There
are many other opportunities competing for active practice.
Again, I think it is important to focus that we
traditionally have been businessman, that we employ four to
five people per practice. We pay taxes. We pay insurance for
those people. For a two-man practice, my health insurance costs
for my employees are $72,000 a year.
I bring evidence to you that this shortage has been going
on since the 1950s, when my retired partner got a call after
the funeral of one of his patients saying, one of your patients
died. Can I come to your practice?
So that brings us to the shortage. I think we all agree
there is a shortage--I am happy to hear that--in all parts of
medicine but particularly primary care.
Why has that happened? I think there are a number of
factors: the evolution, the competition, other venues, the
number of hours worked. I would give you mine, but you wouldn't
believe them.
Quality of life becomes an extremely important issue for
all of us. We look at comparison to medical peers. That has
been talked about. The difference between primary care and such
specialty reimbursement is $3.5 million over your working
lifetime.
You look at comparison of my neighbors. They all work a 40-
hour week. I work a 60-hour week, and then I am on call. I am
responsible every minute, 80 hours. That is a great difference
in quality of life. Then we wonder why people don't want to go
to medicine, don't want to go into primary care.
On top of that, we are asking people in primary care to do
a great deal of gate-keeping. I have to personally sign
numerous documents allowing other people to be paid. This takes
approximately 30 minutes every day. I have to employ one full-
time employee to take care of medicine issues, pre-
authorization with insurance companies. A study has been done
that shows each primary care physician expends $60,000 to deal
with these kind of issues. That is one-third of my salary. It
cost me 1 percent of my salary to come here today on my own
dime.
So how do we fix that? What do we do about it?
We have said that physician extenders haven't been helpful.
They go on into subspecialties. We are working on equalizing
reimbursement, but the budget is an issue.
How do we retain present physicians? One of the things is
decreasing costs. Primary care can do that. They have been
shown to do that. Maintaining quality, again, primary care has
been shown to do that. There are multiple studies documenting
that, that those communities with more primary care physicians
have a longer life span, fewer re-admissions, all the things
that increase costs.
Prevention is another major issue in our society, in our
country. I listened to Tommy Thompson, previous Health and
Human Services Secretary, some 10 to 12 years ago say, we are
missing the boat. We have got to do preventive care. Well, we
are still missing the boat. There is a lot of work to be done
there; and, from my point of view, that is the major area where
cost savings can be entertained.
Chairwoman Velazquez. Dr. Kauk, time has expired. And since
we have a bill on the floor, I would like to go to the
questions. And then in the question and answer period, if you
want to expand on any thoughts that you might not have been
able to share, you will be welcome to do so.
Dr. Kauk. Thank you.
[The statement of Dr. Kauk is included in the appendix.]
Chairwoman Velazquez. Thank you very much.
I would like to address my first question, if I may, to Dr.
Heim. You note that more medical training, must have greater
flexibility if we are going to increase the presence of primary
doctors in our health care system. How do we go about
accomplishing this goal in a balanced way without creating new
challenges for our medical education system?
Dr. Heim. Thank you. If I understand your question, are you
asking how do we balance the number of slots or the types of
specialties that people go into, ma'am?
Chairwoman Velazquez. Well, you are saying that we need
more medical training and, in order to achieve that, that we
must have greater flexibility if we are going to increase the
presence of primary doctors. What I am asking is, how can we
achieve that goal without impacting or dismantling or affecting
or posing new challenges for our medical education system?
Dr. Heim. The slots that we have right now, we have asked
that those--the numbers of slots available for training in
residency programs, those right now are, as you noted in your
remarks, being--primarily, most of the education is done in the
hospital. So there are a couple of factors.
One is, we have to realign the actual slots for training so
that more of those go to primary care. That is a redistribution
issue.
The other component is then paying for the care that is
done in the community. Part of this is a regulation change that
can occur at CMS having to do with voluntary preceptors.
The third component is that we believe that, right now,
funding for training is primarily through government products--
Medicare, Medicaid. Our policy is that everybody should
contribute to that, whether or not it is funding for any of the
GME slots; and in that way then I think it becomes much more
balanced.
Chairwoman Velazquez. Dr. Sheldon, do you have any thoughts
on that?
Dr. Sheldon. Well, I think the Balanced Budget Act of 1997
froze reimbursement under Medicare, and that needs to be taken
off.
It is important to note that there are only four
specialties that had more applicants than they do slots. And
when you talk about unfilled slots, most of those are in
primary care fields; and redistributing back to primary care, I
don't know if that would solve it or not.
Chairwoman Velazquez. Dr. Harbaugh, the shortage of
physicians is expected to intensify if health reform passes. As
we learned in Massachusetts, there is no guarantee that
patients will be able to see a doctor if they have health
insurance. How do we avoid these problems to ensure access to
care doesn't become a major problem?
Dr. Harbaugh. I think all of us have addressed that. There
clearly is a shortage of physicians, and that includes primary
care physicians but certainly is not restricted to primary care
physicians. There are acute shortages of surgical specialists,
and we can't simply say we have to shift everything to primary
care and that will take care of the problem, because it will
exacerbate the surgical shortages.
Some of the things that I think would be very helpful, one
would be to revise the cap on Medicare support for resident
training, and that is an important issue. We are creating more
medical students right now. There is a lot of investment going
into new medical schools and enlarging medical school classes.
But if we don't enlarge the residency training pool, we are
simply going to take students that are trained in the United
States and they will displace students that are trained in
other countries' medical schools that now do their residency
training here, and at the end of the pipeline we will have the
same number of doctors coming out.
So increasing the number of medical school slots without
residency slots doesn't help, and I think we have to recognize
that that increase must go across all specialties. We can make
things worse by focusing solely on primary care and now having
an exacerbated crisis in the surgical specialties, a crisis
that already exists.
Chairwoman Velazquez. There is no easy solutions, right?
I would like for any of the members of the panel to respond
to this question.
Medical liability is a major concern for the medical
profession. It seems clear the health reform cannot be achieved
without addressing this issue. Short of placing a cap on
medical claims, the President has stated he believes this
should be addressed as part of reform. What measures should
Congress consider to reduce the costs of malpractice insurance?
Dr. DiMarco?
Dr. DiMarco. Next to caps. Except for caps. Well,
unfortunately, the caps are a great part, because industry knew
right away in the early days that Workmen's Comp--they knew how
to deal with the--set their prices the way they needed it for
those injuries.
But without caps, in Texas, for instance, when they passed
a law on caps, the malpractice insurance dropped by 12-1/2
percent the next day. Now it is down by 25 percent since the
passage of caps. So I think that caps are an important part of
physician liability reform, and that is necessary to attract
students into specialties that reimburse less.
Chairwoman Velazquez. Okay. Dr. Sheldon.
Dr. Sheldon. I think the only answer is a cap like the
California law. Three years ago, West Virginia's liability got
so high that all the acute patients with trauma had to be
transferred to Pennsylvania by helicopter. The same thing
happened in Nevada. An emergency session of the legislature was
called to provide some.
It won't work unless you cap like California did. And we
appreciate the House has passed this many times. It is the
Senate that doesn't seem to like it.
Dr. Harbaugh. I think the caps are an important piece.
Other things that could be considered would be alternatives to
civil litigation, early disclosure, compensation offers,
administrative determination of compensation where you have a
health court model that would determine compensation.
I think we can also do things like provide medical
liability protection for physicians who follow established
evidence-based practice guidelines. If you are practicing to
the standard of care, even if there is a bad outcome, then that
shouldn't be a liability issue.
Some minor things would be to protect physicians who
volunteer their services in a disaster or local emergency
situation. And I think, going back to the cap, some reasonable
cap on noneconomic damages, not on the economic damages to the
patient but a cap on noneconomic damages is a very important
piece of the puzzle.
Chairwoman Velazquez. Dr. Kauk.
Dr. Kauk. The other piece is that, in Kansas, there is as
equalization pool, my neighboring State. In Missouri, it is
present but not funded. I pay as much doing no procedures as a
gastroenterologist who is licensed in Kansas who does
procedures all day long. There needs to be more equity in the
way the premiums are determined.
Chairwoman Velazquez. Thank you.
Now I recognize Ranking Member Graves.
Mr. Graves. To kind of dovetail on medical malpractice, is
it--is medical malpractice insurance more expensive for--and
anybody can answer this--for general practitioners than it is
for specialists? No?
Dr. Heim. No, it is not. But one of the things goes to also
what you were saying. I used to do vasectomies in my practice.
However, when I applied for medical malpractice they gave me
the same rate, doing that one procedure, as if I were doing
urology with very extensive urological operations in the OR.
That made no sense. So I had to stop doing that service for my
community because I simply couldn't afford it.
So, in some ways, if we do the full gamut of what we have
been trained to do, then, actually, we are bound by the higher
cost, even though our rate of negative outcomes is obviously
then far less.
Dr. Harbaugh. I would like to address that from a local
standpoint. I mean, the private practice model of neurosurgery
in the Philadelphia area has gone away and it has gone away
because neurosurgeons are asked to pay $300,000 per year for
minimal liability coverage. That is their insurance fee. So by
the time they pay office rent and secretarial help and nurses
and record keepers and $300,000 off the top for an annual
insurance fee, they can't make ends meet. So they have become
hospital employees. They have joined large academic groups.
There are ways that they have adjusted to this. But the
malpractice premiums for some of the surgical specialties are
truly astonishing.
Mr. Graves. Next question. And, Dr. Harbaugh, you touched
on it. But is the shortage for all doctors? Is it interest? Is
it students? Or is it because what you said was it is
residency. It doesn't matter if we have bigger medical schools.
If we don't expand our residency programs, the outcome is going
to be the same. But do we have the students or the kids that
are interested in medicine out there? Do we have the numbers?
Dr. Harbaugh. I think there are always a lot more people
who apply to medical school than get accepted, so--and many of
the people who don't get accepted I think would make very fine
physicians and are qualified. So if we expand the number of
medical school training spots, we will turn out more medical
students who have gotten their M.D.
The problem right now is, in order to practice
independently, all of those students then need to go on and do
a residency. If we don't increase the number of residency
positions, we simply displace foreign medical graduates with
American medical graduates, but the number of practicing
physicians at the end of the day stays the same.
Dr. Sheldon. We studied this when I was chairman of the
Association of American Medical Colleges. Right now, only 64
percent of the doctors practicing in the United States actually
went to medical school here. There is 32 percent more position
physicians in residency than there are graduates of U.S.
medical students. Most of them come from India. The second
commonest group come from our offshore Caribbean schools. Those
eventually get licensed; and if they go to a health services
underrepresented area, 3 years they can get citizenship.
So if we leave the residency group alone right now, we
will--and not get some of the funding changed--that is the
bottleneck in the system at the moment.
Mr. Graves. Dr. Kauk.
Dr. Kauk. I think we have to make each subspecialty
appealing to people. There have been studies done that show the
amount of medical school debt implies one of the more
likelihood to go to a subspecialty. Most physicians come out of
medical school owing at least $100,000; and the kids these days
are smart enough to figure that math out and do what works out
economically, rather than maybe works for their heart.
In internal medicine 10 years ago, the number of people
going into primary care was 54 percent. Now it is down to 26
percent. So that is a dramatic change in the last 10 years.
How can we change the reimbursement, the quality of life,
the hassle factors? You know, at my hospital now, I have to
talk to two people before I can decide whether they can be
admitted or an observation. That has nothing to do with what I
do. It has to do with Medicare reimbursement. So it takes me
about twice as long to make hospital rounds now as it used to.
Mr. Graves. Dr. Heim.
Dr. Heim. I think there are two other components when you
are talking about students and medical school. One of it is we
know from prior studies that there are certain types of medical
students who are more likely to go into primary care and there
is actually ways that States have incentivized more students
going into primary care. Their demographics are known. Medical
school admissions committees who are aware of this can, thus,
increase the number of students who are interested in primary
care.
And, secondly, going to the mismatch, the currently
unfilled slots in family medicine and in primary care is true.
We have not been filling, which I think just highlights the
fact that we need to turn around those incentives for students
to go into primary care. But I would say that the current
proposals are such that you have made changes that will start
making students interested in primary care. So I would
encourage you to continue to move those unfilled slots to
primary care.
You have created the incentive for them to want to be
there. So don't then pull away the slots just at the time when
you are telling them that they have a right to be interested
and enthusiastic about primary care. Please keep those slots
available for them to go into.
Dr. Harbaugh. I appreciate the shortage in primary care,
but we have acute shortages in surgical care as well, which
will only get worse if we say that new residency spots must be
restricted to primary care. We may make primary care better. I
believe that would happen. But we will exacerbate what is
already a shortage of surgical specialists. And if you look at
the projections, the projected shortage of surgical specialists
by 2025 is almost identical to the projected shortage of
primary care physicians, and we can't make one problem
dramatically worse at the expense of fixing another one.
Chairwoman Velazquez. Mr. Griffith.
Mr. Griffith. Listening to this--my mentors were
neurosurgeons, David Klein and Peter Jannetta and George
Tindall at Emory, et cetera, but I am a radiation oncologist,
although I did 2 years of neurosurgery.
I must say that you are pointing out a real sensitive area
for me and where we as physicians have been asleep at the
switch. We show up only in Congress to be sure our
reimbursements are okay, but for the last three decades, we
have said nothing about the fact that we were in charge of--not
you, but we generic, us--have been in charge of recognizing
that the baby boomers were going to come through the system. We
were delivering them, but we didn't--it made no difference to
us in our medical schools. We didn't increase our numbers; we
didn't increase the number of medical schools, the number of
kids coming out, and now we are faced with an acute shortage.
We have got an acute shortage of general surgeons. We have got
an acute shortage of neurosurgeons, orthopedic surgeons,
because as they practice, they begin to cut back on their
trauma, their quality of life, they are ready in their 50s to
slow down a little bit. Our residency programs are full of non-
U.S. Graduates. And so we as a group, we M.D.s as a group, have
let us all down by not making enough noise, not participating
in the political system.
I am through preaching. What I will say is this: I don't
think we can pass any sort of health care reform without
malpractice reform. There is always four people in your room
when you are examining a patient. It is you, the patient, the
nurse and the plaintiff's attorney unseen is there, and if we
do not fix that, all of this reform, all of this reform, will
be for naught because we will not control costs, because as
Madam Chair said, if everyone has an insurance card, they still
can't see a doctor, because if we don't reform the number of
providers, and we continue to try to reform a system around a
scarcity, we create the black market, or we create--we create
the concierge medicine, and everybody else is over here
fighting to see someone.
So we have got a real problem on our hands, and I am afraid
that this rush to meet an artificial deadline on health care
reform may have some severe unintended consequences. So my
question to you or my plea to you is when you go back to see
your people that you represent, that have got to get interested
in the political process, you have got to tell them to get
interested because your fate is going to be sealed by those of
us on a panel like this who know very little about what you do.
But thank you each for coming. We really appreciate it.
Chairwoman Velazquez. Mr. Thompson.
Mr. Thompson. Well, first of all, I thank the Chairwoman
and the Ranking Member for this hearing. This is extremely
important. I came to Congress after 28 years as a health care
manager. And I appreciate the words my colleague just shared in
terms of the issue with medical liability, the cost of that out
of pocket for physicians; but the cost of the system with
frankly having a medical record to be able to defend yourself
with; that plaintiff attorney that is not seen but always
present; and the workforce issue, which is significant. And I
appreciate the panel being here.
It sounded a little bit like a family feud here the past
couple of questions, and there is a lot of competition for
future professionals, future providers.
I will start with Dr. Harbaugh, and then we will see if any
others have a good handle on--frankly, instead of competing--
right now it sounds like you are competing for these folks.
What is the estimated shortfall over the next 10 years of the
actual need of practitioners versus the supply given the
current trends in enrollment that are out there?
Dr. Harbaugh. Well, the numbers that I have heard is that
if you look by 2025, there is an estimated 46,000-person
deficit in primary care and about a 41,000 deficit in surgical
specialties. And I think nobody here is questioning the need to
support primary care physicians. The concern from the surgical
specialties is that if that is done at the expense of the
surgical specialties, which is what happens if you restrict
residency training and give special relief of debt repayment,
et cetera, et cetera, if you say we are only interested in
primary care, primary care is where all the focus has to be,
then I think you really run the risk of fixing that problem,
great, but exacerbating another problem.
And I think the surgical specialists are as important as
primary care for the overall health of the Nation, particularly
in areas like trauma, where it is not going to go away and you
need surgical specialists to be there right away, you know, a
life-threatening situation that to exacerbate the one problem
to fix the other doesn't make sense to me.
Dr. Sheldon. We had publications in Health Affairs about 2
years ago, and the numbers go between 20- and 40,000 of doctors
across the board. These numbers aren't going to be right
looking back, because medical schools are a target of 13
percent increase with now 130 medical schools as just the last
few years.
The problem, though, is at the residency level, because if
we don't get something fixed there, changing the Balanced
Budget Act and that, we are just going to be robbing countries
that can't afford to give us their people. I have worked all my
life in public hospitals, and that is what we are going to be
doing, and we ought to be able to have our workforce funding be
self-sufficient.
Mr. Thompson. That is a good segue to kind of part two of
my question, which is how do we fix this so we are not
competing back and forth; that we are growing enough future
professionals to meet all the needs? Because the need is
significant with the aging baby-boomer population, the
attrition of retirements that has been happening for some time
now, and it is going to intensify, plus the amount of need that
is going to be out there as the population ages.
Dr. Sheldon. Let me make one more comment. Dr. Griffith's
comments are germane in that if the number of medical schools
and residency growth had continued beyond 1997 at the pace that
it was before, we would probably be okay right now. But we
froze everything at that period of time with the Balanced
Budget Act and with the voluntary cap done by the medical
schools.
Mr. Thompson. Dr. DiMarco.
Dr. DiMarco. Yes, the graduate medical education, no one
has mentioned about the fact that Medicare--right now the
residents are reimbursed through the hospital in its convoluted
formula of direct and indirect payments. And meanwhile the last
two decades, Medicare funds have been going through independent
insurance companies, who don't contribute back to the graduate
medical education system. It is only on the back of Medicare
and Medicaid.
And I think that would increase the GME slots tremendously,
because at the medical school level we are all doing our job
trying to increase the class sizes by 15 percent on the
allopathic side, and we have doubled our schools on the
osteopathic side. But if you can't place your residents when
they are done--and the students vote with their feet. They are
not stupid. They see what is going on. They know business a
little bit. They can figure it out, and they say, I don't want
to do this because I can't make ends meet, but I can do this.
But if the GME slots were more available, some of the ones that
don't get filled, there would be others that would get filled.
Right now there is an understanding that the GME slots are
dedicated to certain specialties. They are not. They belong to
the hospital, and they can divvy them out any way they want.
And if you don't use them in 3 years, you lose them.
Mr. Thompson. Thank you, Madam Chairwoman.
Chairwoman Velazquez. Mrs. Dahlkemper.
Mrs. Dahlkemper. Thank you, Madam Chair. I want to thank
you for holding this very important and timely hearing today.
As we move towards universal coverage and health care reform,
it is essential that we address this future physician workforce
shortage.
The Council on Graduate Medical Education has predicted a
10 percent shortfall of physicians by 2020, and as we have seen
in Massachusetts, health care reform will only exacerbate this
impending decline. And health care reform must strive to not
only to expand health insurance coverage, but also to provide
everyone access to physicians.
These physician shortages are particularly troublesome in
rural areas such as my district in western Pennsylvania since
less doctors tend to be attracted to fill those positions in
the rural areas. In this vein I was pleased to see the
additional funding for the National Health Services Corps,
which was already mentioned today. And we also need to address
the debt which the students carry, which we just talked about.
But I wanted to ask you, Dr. DiMarco, if there is 2,500
hospitals in the United States that do not have a teaching
program, amenities are located in those rural and suburban
communities. As a solution to our workforce shortage problems,
the American Osteopathic Association recommends expanding the
number of teaching programs. What steps should be taken to
achieve this goal, and what kind of support would hospitals
need to build these programs?
Dr. DiMarco. Of course it is a brain-drain issue, but the
thing is that in the country today, with six States that are
responsible for 80 percent of the training, one of the
advantages we have noticed in the osteopathic professions, we
have opened schools in rural areas where there are hospitals
that never had interns and residents. Fortunately there is a
loophole in the Balanced Budget Act that says if it is a
hospital that has never had an intern or a resident, you can
cap that hospital at a new number first time, And that is what
we are achieving at this time.
We have hospitals in Colorado--in Colorado, in Denver; in
Mississippi; Yakima, Washington; in California where there have
never been residents and interns. And all our new schools have
all their slots already preordained prior to the first
graduating class, And that can be done across the whole
country.
Mrs. Dahlkemper. Would anyone else like to address this?
Dr. Sheldon.
Dr. Sheldon. I was a charter member of COGME, and,
candidly, they have been a part of the problem. They have said
there is a cap--there was a study done the second year of COGME
that not only talked about the primary care shortage, but about
six stress specialties, which included two in surgery. And
COGME is late coming around to recognizing the projected needs
for the future. There are a number of other groups that were
way ahead of them on that.
Mrs. Dahlkemper. Dr. Heim, did you want to--
Dr. Heim. I practice in actually the poorest county in
North Carolina right now and certainly appreciate the need to
have more attention paid to the rural areas. When I discharge a
patient from the hospital, I often cannot find anyone to take
care of that patient. So simply having insurance, even if their
bill gets paid, there is nobody there for me to refer to.
We also, as part of the Patient-Centered Medical Home
Demonstration Project, where we are looking with residencies in
a demonstration project to see new ways of doing training,
likewise have been moving residents from the traditional
tertiary big hospital out to small community hospitals as an
innovative way of improving their training, providing some
workforce to the rural, and also decreasing costs.
We also think that you have to change the payment system
and make sure that health care insurance is available for all,
because otherwise it is the small rural hospitals that are
really struggling when you have a very high proportion of your
population that gets admitted or comes to the emergency room
for which there is no then adequate reimbursement for them.
Mrs. Dahlkemper. Thank you.
I have one last question. Dr. Harbaugh, you were talking
about the foreign medical graduates, or maybe Dr. Sheldon was
addressing this, too. What percentage of those who take these
residency spots, what percentage of those are staying here, and
what percentage are actually leaving?
Dr. Harbaugh. To my knowledge, the vast majority stay in
the United States. Dr. Sheldon may have more accurate--
Dr. Sheldon. It is well over 60 percent. India now has more
medical schools than we do, and they will often send people
here with a plan to go back, and probably more of that is
happening now. But the number is way, way up.
Mrs. Dahlkemper. I was wondering just with the change in
kind of the global climate, and some of these countries may be
attracting more of their students back.
Dr. Sheldon. Like, sub-Saharan Africa has a real problem.
Guiana had, I believe, 1,200 graduates; half of them practice
in the United States today. And their ratios, if you look at
the World Health Organization chart, is just dismal. We
shouldn't be robbing the other countries to fill our own
residencies.
Mrs. Dahlkemper. Thank you very much.
Chairwoman Velazquez. Time has expired.
Mr. Luetkemeyer.
Mr. Luetkemeyer. Thank you, Madam Chairwoman.
With regards to the proposed health care plan that is being
discussed, part of that plan is rationed health care, and I was
just curious as to whether you had an opinion on this or
whether you would give us some insights as to what the feeling
of your group, Dr. DiMarco, would be. Or I see Dr. Kauk held
his hand up first. Why don't you go ahead.
Dr. Kauk. That is fine.
I work in internal medicine and geriatrics, so I deal with
hospice patients all the time. I have had multiple patients
tell me that this is not the American way. We do not limit
care, we do not ration care. If I get sick--Mom, I had this, I
want this--may have a revolt of our patients. I have had the
strongest outpouring from patients about this, And this is an
issue I deal with every day with my patients. Sixty-five
percent of my patients are on Medicare, and they are very
concerned about this very issue. The patients are. Physicians
are as well.
The impact upon myself and other peers, if we go to saying,
okay, I spend too much money, and I won't be in the program
anymore, this is what I do. How is that fair?
Mr. Luetkemeyer. Very good.
Dr. DiMarco.
Dr. DiMarco. We concur also. We do not support rationed
care in this country. It is just not the American way.
Mr. Luetkemeyer. Okay. I have a medical school in my
district, by the way. So, welcome.
Dr. Heim, everybody has got their hand up here. I must have
hit a hot topic here. Thank you.
Dr. Heim. I would just like to point out that I think under
our current system we do ration care. If you do not have health
insurance right now, you oftentimes delay or do not get care.
That is rationing.
I also think, though, that even those people who have
insurance currently, I see a disparity, and we all know that
there are disparities of care in this country. So I think that
when we develop health care reform, we have to look at whether
the disparities right now, what is the rationing that is
currently going on as we move forward to a different program.
But, sir, it exists out there right now, and I face it every
day in my active practice.
Mr. Luetkemeyer. Okay.
Dr. Sheldon. We have a safety net hospital. Eighteen
percent of our work is uncompensated, coming close to $300
million a year. Rationing is common in the public programs in
England and on the continent, and it is often pegged at a
patient's age. And unfortunately, with all of the patients,
everybody getting older in this country especially, that is
when most of the diseases come along that need care. And the
cancer statistics that I quoted earlier in my comments may well
in part be due to the fact that they have limitations what care
you can get at certain ages. It is hard to get it right. I
think if we follow the advisory of Council of Economic Advisors
that was in that June 2nd document from the White House, the
inevitable result will be losing public money and probably will
make this worse.
Mr. Luetkemeyer. Dr. Harbaugh.
Dr. Harbaugh. I think the specter of rationing is that
someone who doesn't know an individual patient will make a
determination that this particular patient cannot receive care
that may in that case be life-sustaining, and that scares
people to death. I don't think we need to go there. If we had
better research on what care is truly effective and what care
was futile or ineffective, we could take care of a lot of the
expense problems that we have now.
If you look at the Dartmouth health care maps--and I spent
a long time at Dartmouth, and it was part of their surgical
outcome s group. And if you look at the variability in the
number of surgical procedures done from region to region, what
you find is that where the indications for surgery are
ambiguous, you have a great deal of variability, and it tends
to follow the number of surgeons. On the other hand, when you
have very clear-cut indications for surgery, you find that the
rate of those operations is the same all over the country.
So we can do a much better job of finding out clear-cut
indications for surgical care, and I am sure the same is true
for other types of care, and the comparative effectiveness
approach, I think, if done right, has a lot of merit.
Mr. Luetkemeyer. Thank you very much.
Thank you, Madam Chairman.
Chairwoman Velazquez. Thank you.
Mr. Bartlett.
Mr. Bartlett. Thank you very much. Sorry that I was late.
I think in moving forward, we need to recognize that we
really do not have much of a health care system in this
country; we have a really, really good sick care system, the
best in the world probably. I hope that in moving forward that
we are focused a bit more on--a whole lot more on health care.
Maybe if we had a better health care system, we wouldn't need
to have such a big sick care system.
One of the problems that we have in rural areas, and I
guess in some of our inner cities, too, is that the government
now controls the health care for almost 50 percent of our
population: all of our military, all of our veterans, SCHIP
children, Medicare and Medicaid. And by design, the government
intends to pay less than the cost of health care. Obviously you
can't do this, or you can't stay in business. So there is a lot
of cost shifting going on.
How are you dealing with this problem in rural areas where
frequently large percentages of your patients--I have some
rural areas in my district, and I know that some of their
nursing homes are 90-odd percent all Medicaid. Tough to run an
institution when the person who is paying the bill intends to
pay less than the full cost of health care. How are you dealing
with this?
Dr. Harbaugh. Well, at a large academic medical center,
this is an acute problem because we do not refuse care to
anyone because of ability to pay. We are--our trauma patients
very frequently are Medicaid patients.
Now, we are luckily to live in a part of Pennsylvania that
also has a pretty good payor mix in other parts of the
population, and it is clearly cost shifting, that people who
have insurance are paying enough to care for the people who
don't cover their expenses with Medicaid.
Mr. Bartlett. You have to do this, or you are out of
business. Yes.
Dr. Kauk. I think it is really becoming an issue. I deal
with 65 percent Medicare patients, and realistically it is
coming to a point where I cannot any longer be a private
physician running my own business. After 30 years of doing
this, 30 years of being a very good, efficient, busy physician,
I have not been able to give my employees a raise for 5 years,
I have not funded my pension profit-sharing plan. I am looking
at other options for my practice at this point. I will probably
become an employed physician and will probably lose another
small business, and this at a time where I should be doing
well, not suffering.
And that is a personal story, but that is the way I think
most people are struggling with it, not very well, hoping they
get enough of the private insurance people who pay a little
better that they can keep going or looking for other people to
pay those bills. Studies have shown the average primary care
physician loses 80-some thousand dollars a year.
Mr. Bartlett. Dr. Heim.
Dr. Heim. There are a few things that I think we can look
to for models. One is in North Carolina we have the North
Carolina Community Care, which actually is built around
Medicaid patients right now, and as you said, you lose money on
your Medicaid patients. And so simply filling up your practice
usually with Medicaid, like any small business knows, that
volume doesn't work when each time you lose more money. But in
the North Carolina, the Community Care, what they have done is
it is a patient-centered medical home model, and the State has
paid the primary care physicians an additional payment per
Medicaid payment in order to coordinate the care specifically
across certain disease States. What that has done is it has
increased the payment for the primary care physician to a point
that they can afford to not only see these patients, but do the
coordination of care, and, in fact, to save the State over 250
billion in the length of the program.
The other thing that I agree, I think what we are seeing is
a change in primary care practices. They are starting to do
more procedures, which is not what we want, because the system
has driven people to simply do more things, rather than looking
at health outcomes. And we have also seen that there are a lot
of our members who are now selling out their practices and
starting to work for hospital systems, or they are starting to
leave and go into other practices.
Dr. Harbaugh. I would like to point out that I think not
only primary care physicians practice preventive care. Much of
what I do is preventive care. The patient with the symptomatic
carotid stenosis who is at risk of stroke, there is a very
effective surgical intervention to prevent a stroke and all of
the costs that go with that. The patient with the unruptured
intercranial aneurysm who is at risk of a devastating
hemorrhage, if that aneurysm is fixed before the hemorrhage
occurs, that saves an immense amount of cost in the system. And
as I have mentioned briefly in my system, I think there are
neurosurgical procedures just around the corner that would
offer a minimally invasive and effective treatment for things
like addiction, And that means addiction to tobacco and alcohol
and et cetera, and obesity. And that would be a neurosurgical
example of very effective preventive care that could save
immense amounts of money.
So when we talk about prevention, let us be clear that many
of us practice preventive medicine, even if we are surgical
specialists.
Dr. Sheldon. I was going to comment that colonoscopy and
early removal of polyps has a great impact on lowering colon
cancer mortality, which has already seen progress since that
has become more common.
Similarly, one of the differences that the United States
has led the world in is frequency of mammograms. Instead of
diagnosing a breast cancer at Stage 3, we are getting it at
Stage 1.
As far as programs that have been authorized by Congress,
they have a program in our State that has also been very
effective in helping with some of these things and making
access good.
Chairwoman Velazquez. Time has expired. Let me take this
opportunity to thank all of you for taking time to be here
today. This is a very important issue, and there is no doubt in
my mind that, as you stated, each one of you, you know, there
are--most medical practices are small businesses, and that is
why we wanted to hold this hearing today.
The House will be introducing its health care reform bill
this week, and it is expected to be marked up next week. I have
been meeting with some of the leaders dealing with the
committee of jurisdictions discussing some of the important
issues related to health care reform with small businesses. The
shortage of physicians is a very important issue. There is no
way that we can accomplish the goal of health care reform
without addressing this important issue.
So with that, let me say that I ask unanimous consent that
Members will have 5 days to submit a statement and supporting
materials for the record. Without objection, so ordered.
Chairwoman Velazquez. This hearing is now adjourned. Thank
you.
[Whereupon, at 10:55 a.m., the Committee was adjourned.]
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