[Senate Hearing 113-314]
[From the U.S. Government Publishing Office]
S. Hrg. 113-314
30 MILLION NEW PATIENTS AND 11 MONTHS TO GO: WHO WILL PROVIDE THEIR
PRIMARY CARE
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON PRIMARY HEALTH AND AGING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING PRIMARY CARE
__________
JANUARY 29, 2013
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
Available via the World Wide Web: http://www.gpo.gov/fdsys/
?
______
U.S. GOVERNMENT PRINTING OFFICE
78-675 WASHINGTON : 2014
____________________________________________________________________________
For sale by the Superintendent of Documents, U.S. Government Printing Office,
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, U.S. Government Printing Office. Phone 202�09512�091800, or 866�09512�091800 (toll-free). E-mail, [email protected].
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
TOM HARKIN, Iowa, Chairman
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington MICHAEL B. ENZI, Wyoming
BERNARD SANDERS (I), Vermont RICHARD BURR, North Carolina
ROBERT P. CASEY, JR., Pennsylvania JOHNNY ISAKSON, Georgia
KAY R. HAGAN, North Carolina RAND PAUL, Kentucky
AL FRANKEN, Minnesota ORRIN G. HATCH, Utah
MICHAEL F. BENNET, Colorado PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin MARK KIRK, Illinois
CHRISTOPHER S. MURPHY, Connecticut TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts
Pamela J. Smith, Staff Director
Lauren McFerran, Deputy Staff Director
David P. Cleary, Republican Staff Director
__________
Subcommittee on Primary Health and Aging
BERNARD SANDERS, (I) Vermont, Chairman
BARBARA A. MIKULSKI, Maryland RICHARD BURR, North Carolina
KAY R. HAGAN, North Carolina PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin MICHAEL B. ENZI, Wyoming
CHRISTOPHER S. MURPHY, Connecticut MARK KIRK, Illinois
ELIZABETH WARREN, Massachusetts LAMAR ALEXANDER, Tennessee (ex
TOM HARKIN, Iowa (ex officio) officio)
Sophie Kasimow, Staff Director
Riley Swinehart, Republican Staff Director
(ii)
?
C O N T E N T S
----------
STATEMENTS
TUESDAY, JANUARY 29, 2013
Page
Committee Members
Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health
and Aging, Committee on Health, Education, Labor, and Pensions,
opening statement.............................................. 1
Enzi, Hon. Michael B., a U.S. Senator from the State of Wyoming.. 4
Warren, Hon. Elizabeth, a U.S. Senator from the State of
Massachusetts.................................................. 6
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin.. 6
Franken, Hon. Al, a U.S. Senator from the State of Minnesota..... 7
Murphy, Hon. Christopher S., a U.S. Senator from the State of
Connecticut.................................................... 8
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of
Pennsylvania................................................... 9
Prepared statement........................................... 9
Hagan, Hon. Kay R., a U.S. Senator from the State of North
Carolina....................................................... 10
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode
Island......................................................... 11
Witnesses
Mullan, Fitzhugh, M.D., Murdock Head Professor of Medicine and
Health Policy at the George Washington University School of
Public Health and Professor of Pediatrics at the George
Washington University School of Medicine, Washington, DC....... 12
Prepared statement........................................... 14
Kuenning, Tess Stack, CNS, MS, RN, Executive Director, Bi-State
Primary Care Association, Montpelier, VT....................... 19
Prepared statement........................................... 21
Decklever, Toni, MA, RN, Government Affairs, Wyoming Nurses
Association, Cheyenne, WY...................................... 25
Prepared statement........................................... 27
Wilper, Andrew P., M.D., MPH, FACP, Acting Chief of Medicine, VA
Medical Center, Boise, ID...................................... 30
Prepared statement........................................... 32
Reinhardt, Uwe, Ph.D., James Madison Professor of Political
Economy and Professor of Economics and Public Affairs,
Princeton University, Princeton, NJ............................ 37
Prepared statement........................................... 39
Fegan, Claudia M., M.D., CHCQM, FACP, Chief Medical Officer, John
H. Stroger, Jr. Hospital of Cook County, Chicago, IL........... 51
Prepared statement........................................... 52
(iii)
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
American Academy of Family Physicians (AAFP)................. 66
American Academy of Physician Assistants (AAPA).............. 69
American Association of Colleges of Osteopathic Medicine
(AACOM)................................................... 73
Association of American Medical Colleges (AAMC).............. 75
Society of General Internal Medicine (SGIM).................. 81
The American Occupational Therapy Association, Inc. (AOTA)... 83
30 MILLION NEW PATIENTS AND 11 MONTHS TO GO: WHO WILL PROVIDE THEIR
PRIMARY CARE?
----------
TUESDAY, JANUARY 29, 2013
U.S. Senate,
Subcommittee on Primary Health and Aging,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:03 a.m. in
Room 430, Dirksen Senate Office Building, Hon. Bernie Sanders,
chairman of the subcommittee, presiding.
Present: Senators Sanders, Casey, Hagan, Franken,
Whitehouse, Warren, Baldwin, Murphy, and Enzi.
Opening Statement of Senator Sanders
Senator Sanders. Let's begin our hearing, which is going to
cover, I believe, an enormously important issue.
I want to thank Ranking Member Mike Enzi for his work. He
and I have worked together on a number of issues over the
years, and I look forward to a productive working relationship.
Vermont is a rural State. I know something about rural
problems. His State is a lot more rural, so we will see how we
can go forward together.
Let me thank all of our panelists for being here. We have a
great set of panelists from all over the country, and we very
much appreciate them being here, and we thank them for the work
they do every day, providing health care and doing research.
In our country today, I think as many people know, we spend
almost twice as much as do the people of any other country per
capita on health care. That is about 18 percent of our GDP, and
yet our health care outcomes in terms of life expectancy,
infant mortality, and disease prevention are not particularly
good in terms of international comparisons.
One of the reasons for that is that we have a major crisis
regarding primary health care access, which results in lower
quality health care for our people and greater expenditures.
Lower quality health care, and yet we end up because of the
crisis in primary health care, spending substantially more than
we should.
Today, 57 million people in the United States, 1 in 5
Americans, cannot see a doctor when they need to. Lack of
access to a primary care provider is a national problem, but
those who are most impacted are people who are low-income,
minority, seniors, and people who live in rural communities
whether it is Vermont or Wyoming.
As we have seen time and time again with dental care,
mental health, and other health care issues, the groups that
need health care the most are the least likely to receive it.
The good news is that just 11 months from now, we will be
providing health insurance to 30 million more Americans through
the Affordable Care Act. The bad news is that we don't know how
we are going to be providing primary health care to those
Americans who now will have health insurance.
Let me just rattle off some statistics that, I think,
should be of concern to the Congress and, in fact, to all
Americans.
Not widely known, but maybe Dr. Wilper will talk about this
when he testifies, approximately 45,000 people every single
year die in the United States of America because they do not
have health insurance and they do not get to a doctor on time;
45,000 Americans.
According to the Health Resources and Service
Administration, we need 16,000 primary care practitioners to
meet the need that exists today with the ratio of 1 provider to
2,000 patients. Over 52,000 primary care physicians will be
needed by 2025.
In 2011, about 17,000 doctors graduated from American
medical schools despite the fact that over half of patient
visits are for primary care, only 7 percent of the Nation's
medical school graduates now choose a primary care career; 7
percent. Nearly all of the growth in the number of doctors per
capita over the last several decades has been due to a rise in
the number of specialists. Between 1965 and 1992, the primary
care physician to population ratio grew by only 14 percent,
while the specialists to population ratio exploded by 120
percent.
The average primary care physician in the United States is
47 years of age, and one-quarter are near retirement.
In 2012, it took about 45 days for new patients to see a
family doctor, up from 29 days in 2010. In other words, even if
you can find a provider, it often takes a lot longer than it
should to see him or her.
Only 29 percent of U.S. primary care practices provide
access to care on evenings, weekends, or holidays as compared
to 95 percent of physicians in the United Kingdom. In other
words, our culture is, ``Don't get sick on Saturday, Sunday, or
at night. 9 o'clock to 5 o'clock works pretty good.''
Half of emergency room patients would have gone to a
primary care provider if they had been able to get an
appointment at the time one was needed. In other words, we are
wasting billions of dollars because people end up in the
emergency room for non-
urgent care because they cannot find a primary health care
physician.
In my view and, I think, the view of all of the experts who
have studied the issue, primary care is intended to be, and
should be, the foundation of the U.S. health care system. In
2008, Americans made almost 1 billion office visits to the
doctor, 50 percent of those visits were to primary care
doctors; half. According to virtually every study done on this
issue, access to primary health care results in better health
outcomes, reduced health disparities, and lower spending by not
only reducing emergency room visits, but when you get people to
the doctor when they should, they don't get sicker than they
otherwise would be and end up in the hospital at great cost.
The problem we are discussing is clearly a national problem
existing in 50 States in the country, but it is even worse for
particular geographic regions. The ratio of primary care
doctors in urban areas is 100 per 100,000 people, double the
ratio in rural communities where it is 46 per 100,000. So urban
communities clearly have problems, rural communities have even
greater problems.
Of primary health care professional shortage areas, 65
percent are in rural counties. In my own State, we do much
better than the rest of the country in terms of primary health
care providers per 100,000. And yet, I can tell you that in the
State of Vermont, people often have difficulty getting to the
primary care provider they need. Although 20 percent of
Americans live in rural areas, only 9 percent of physicians
practice there.
One of the significant differences between the U.S. health
care system and the health care systems of other highly
developed countries--which could significantly explain why we
spend so much more than other countries around the world--is
the ratio of primary care physicians to specialists. In the
United States, roughly speaking, 70 percent of our
practitioners are specialists, 30 percent are primary health
care providers. Around the rest of the world, that number is
exactly the opposite, about 70 percent of their practitioners
are primary health care providers, 30 percent are specialists.
What can Congress do to address this very serious issue?
Let me just rattle off a few points, and give the microphone
over to Senator Enzi.
First and foremost, clearly, we must address the issue of
primary care reimbursement rates. Specialists earn as much as
$2.8 million more than primary care providers for their
lifetime of practice. So if you are going into medicine, if you
are a specialist, you can earn throughout your lifetime almost
$3 million more than a primary care practitioner. Radiologists
and gastroenterologists, for example, have incomes more than
twice that of family physicians.
The system for setting physician reimbursement in this
country is largely determined by the 31 physicians who sit on
the American Medical Association Committee called the Relative
Value Scale Update Committee, generally called the RUC. The
RUC, whose payment recommendations are accepted by the Centers
for Medicare and Medicaid services over 90 percent of the time
and are adopted by many private insurers, is dominated by
specialists. So specialists sitting on the committee determine
reimbursement rates. We have to look at that issue.
Medicare has promoted the growth of residencies in
specialty fields rather than primary health care by providing
significant sums, $10 billion each year to teaching hospitals,
without requiring any emphasis on training primary care
doctors; a serious issue.
Third, unlike other nations which provide significant
financial support for medical school education we, by and
large, do not do this in this country, and the result is the
median debt for medical students upon graduation is more than
$160,000 and almost one-third of medical school graduates leave
school more than $200,000 in debt. Now, if you are leaving
school $200,000 in debt, what are you going to do? You are
going to try to figure out how I make as much money as possible
to deal with that debt, and you are going to gravitate toward
those fields which pay you higher incomes.
If we are going to attract young people into primary health
care, we must make that profession more financially attractive.
In other words, we must address the issue of how reimbursement
rates are set for Medicare, which impacts reimbursement rates
for all physicians.
In recent years--and I have worked on this issue, other
members have worked on this issue--we have greatly expanded
community health centers around the country, and community
health centers provide very good quality, cost-effective health
care. We need to do more than that. We have made progress. We
need to make more progress.
In addition, we have significantly increased funding for
the National Health Service Corps, which says to somebody that
if you are graduating medical school $200,000 in debt, we are
going to help you address that debt and help you pay it off if
you practice in underserved areas. It is working. It has
worked. We have made progress. We need to make more progress in
that.
Teaching Health Centers: studies have shown that residents
trained at community health centers or rural communities are
more likely than those trained in other settings to make a
career practicing in underserved or rural areas. The THC
program was an important new investment in graduate medical
education in the Affordable Care Act, and the 5-year funding
was only $230 million. We have got to expand that concept.
We have also got to take a hard look at the role of allied
health providers, nurse practitioners, and others. How do we
better utilize those people in the provision of health care?
We have a very, very serious problem; the lives of
thousands of people depend upon what we do. I am very excited
about the wonderful panelists that we have at this hearing.
Now, I would like to hear from Senator Enzi, who has done
so much work in this area.
Opening Statement of Senator Enzi
Senator Enzi. Thank you, Mr. Chairman. Thank you for
holding this hearing, and I am glad to be joining you for my
first hearing as Ranking Member of this subcommittee, and I
look forward to working with you.
I would also like to thank the witnesses for taking time
out of their schedules to be with us. I would particularly like
to welcome Toni Decklever from Cheyenne. She has worked with me
and my staff on health care workforce issues for a number of
years, and I appreciate that she made the long trip across the
country to be here. It is a pleasure to welcome all the
witnesses to our hearing.
The issue of improving access to primary care services, and
aligning our health care workforce, is one that is important to
all of us, but one that is especially significant given the
obstacles that people face in Wyoming.
Nearly the entire State is considered a frontier or rural
county. Forty-seven percent of the population lives in a county
with fewer than six residents per square mile. According to the
Wyoming Department of Health, approximately 200,000 residents
live in health professional shortage areas with inadequate
access to primary or dental care.
There are serious access challenges in Wyoming that require
creative solutions to resolve. We have one hospital that is
served by a physician that, every time we lose that physician,
the hospital closes. To that end, the State has developed a
number of programs that are tailored to meet the specific needs
of a frontier State where distance presents the biggest barrier
to accessing a doctor. We say that we have miles and miles of
miles and miles, and recruiting health care professionals to
live and work there is an ongoing challenge.
The Wyoming Department of Health operates its own Health
Professional Loan Repayment Program along with a Physician
Recruitment Grant Program. These programs work to reduce the
high cost of health professional graduate and training
programs, which is often a deterrent to working in primary care
or other lower income medical fields. The Wyoming Health
Resources Network represents another innovative approach to
improving access and reducing primary care workforce shortages.
This collaborative arrangement between the major medical
and health professional societies, the University of Wyoming,
and other key partners maintains an extensive data base on
Wyoming health care facilities and their need for
professionals. Sharing information more effectively allows for
a better allocation of resources and manpower at a time when
the fiscal climate limits our ability to spend money on the
problem.
There is more that can be done to better align Federal
programs to meet the needs of rural and frontier States. The
criteria that determine eligibility for Federal funds to
support rural health programs are based on factors that make it
difficult to prove the needs of the underserved in rural and
frontier areas. For example, one provider for 3,500 people in
New York City is entirely different than 3,500 people living in
Fremont or Campbell County.
In addition, we need to think more creatively about how to
use technology services to improve telemedicine capabilities,
so that where a person lives has less impact on the level of
care they are able to receive. The advancement of more powerful
wireless technology has substantial potential to remotely link
individuals across the country to deliver health care in more
accessible settings. We have had quite a bit of success with
that with some of the veterans outreach clinics, where they use
telemedicine extensively with nurse practitioners being in
charge of handling the equipment and a doctor on the other end
of the telemedicine.
I hope this hearing will make it clear that we need to
think more creatively and figure out ways in which all
Americans can better access primary care services, and ways to
ensure health care professionals are employed where they are
most needed.
I look forward to hearing from our witnesses on what needs
to be done to solve these problems at the Federal, State, and
local level.
Again, I want to thank the witnesses for their
participation. I want to thank the Chairman for his great list
of suggestions on things that need to be done. And I am sure
that we have the capability to come up with some solutions
through this committee.
Senator Sanders. Senator Enzi, thank you. Thank you very
much.
Senators will get 5 minutes. Senator Warren was here first.
Senator Warren.
Statement of Senator Warren
Senator Warren. I just want to thank you very much for
holding this hearing, Mr. Chairman.
I am very interested in the question about how we equalize
access for all of our citizens, and particularly interested in
the question about how we make the right investments to lower
the overall cost of health care. I think the Chairman said it
best when he said,
``What we are looking for is better outcomes at lower
costs, and that that is the peculiar role that the
Federal Government can take if it makes the right up
front investment.''
So I am looking forward to hearing from each of the panelists.
I also want to thank the Ranking Member. I think the
comments about access, and the reminder that it is very
different in a large city than it is from a very rural area are
comments that are well-taken and one for us to remember
carefully.
Also, the reminder that that can have very different
consequences, even in a State like Massachusetts where,
obviously, we have very extensive health care services in some
areas, but it still leaves us with parts of the population in
Massachusetts, with difficulties in accessing care. Sometimes
distance is less the challenge, but costs can remain the
challenge and transportation, even within close areas, can be a
serious challenge. So I appreciate the reminder of the
diversity of issues that we face in making sure that all of our
citizens have good access.
Thank you, Mr. Chairman.
Senator Sanders. Thank you very much, Senator Warren.
Senator Baldwin.
Statement of Senator Baldwin
Senator Baldwin. Thank you, Mr. Chairman.
I will not use the allotted time in its entirety, and
apologize to the panel that I am going to have to sneak out to
attend another committee meeting and return, I hope, for the Q
and A. But I appreciate, Mr. Chairman, your focus on this
broad, but very critical, issue that has so much relevance
seeing through the implementation of the Affordable Care Act.
I represent a State that has urban concentrations as well
as, perhaps not as large spaces of rural areas as Vermont, but
certainly has the array of challenges that are the subject of
this hearing, and I appreciate the attention that is going to
be focused on it.
One of the things that I hope that we will hear some
elaboration on, aside from issues that compensation plays in
this, is the question of lifestyle for primary care
practitioners; things like the differences between the amount
of time that somebody might be on-call as a specialist versus a
primary care physician. As we look at larger payment reforms,
how the flexibility in their practice of being able to spend
the adequate time with a patient, for example, with multiple
chronic conditions that is necessary versus seeing folks in 15-
minute increments, et cetera. What impact will those policy
changes have on the number of primary care practitioners in
this country?
Mr. Chairman, thank you for focusing attention on this
issue, and I hope to return to hear more from the witnesses and
ask my questions.
Senator Sanders. Thank you very much.
Senator Franken.
Statement of Senator Franken
Senator Franken. Thank you, Mr. Chairman, for this
incredibly important hearing.
We will have 30 million more Americans covered, we hope, if
Medicaid expansion is adopted by the States, leaving some
people still uninsured. I read the testimonies last night, and
it is very clear that when you insure people their health care
outcomes are better. It actually costs us money when people
aren't insured.
Sometimes you hear, ``Well, we have health care in this
country. You can just go to the emergency room.'' Well, that is
the most expensive health care and it doesn't mean that you get
treated after the emergency room. It doesn't mean that you get
what you need to treat a chronic condition. All of your
testimonies put the lie to that, and I appreciate that.
In Minnesota, we do health care, relative to the rest of
the Nation, extremely well. HHS has rated us No. 1 in high
quality health care. And we, like Wisconsin, have kind of a
combination of urban centers and not the miles and miles of
miles and miles, but we have miles and miles. The Ranking
Member, who I would like to welcome to this subcommittee and I
am looking forward to his partnering on this. I admire his work
on rural health, which is so important in my State because
there are people that are underserved.
One of the things that the Chairman talked about was the
student loans and graduating from medical school with a typical
loan debt of $160,000 sometimes more. And then talking about
the tendency for doctors who have just graduated to say, ``How
am I going to make this money?''
And we have MedPAC, and this is an issue that you talk
about in your testimony. In our country, we pay specialists a
ratio more than primary care physicians than they do in other
countries that do their health care very successfully, and
cheaper, and less expensively than we do.
One of the things about student loans, to me, is that there
is nothing good about the high cost of college and of graduate
school in my mind, except that the only probably good thing is
that it creates some tool for us to motivate people to go into
the things that we need. One question that I would like the
panel to think about is--I know you are going to give your
testimony, and we are going to do the questions--what is the
return on investment?
If we say to doctors graduating medical school, we are
offering some loan forgiveness. We are especially offering loan
forgiveness for primary care physicians in a rural area or an
underserved urban area. But what would be the return on
investment if we really, really encouraged--by loan
forgiveness--doctors to go into primary care? In other words,
what is the calculus there? What is the equation? If we say,
``My goodness, it is such a benefit to society and such a cost
benefit to have a higher ratio of primary care physicians,''
that if we said, ``For anybody who goes into primary care
medicine we will, it's $100,000 right there.'' Boom. What is
the cost benefit there?
It is good to see you, Dr. Reinhardt. Dr. Reinhardt and I
have talked a number of times. He is a health care economist,
so maybe that is something you can mull over.
Thank you, Mr. Chairman, for this unbelievably important
hearing. Thank you.
Senator Sanders. Thank you, Senator Franken.
Senator Murphy.
Statement of Senator Murphy
Senator Murphy. Thank you very much, Mr. Chairman.
I am excited to be a member of this committee and excited
to be here with a fantastic panel. I will get out of the way,
so that you can provide us with your testimony.
Let me just say this. Having chaired the health committee
in the State legislature in Connecticut for years, we grappled
with this problem year after year. I remember specifically one
meeting that I had with about maybe 15 or 20 medical students
at the University of Connecticut. At some point in the meeting
we were, I think, talking about the Affordable Care Act and how
it could help medical students. We were talking a lot about
this issue of the high level of indebtedness.
I asked them, ``How many of you are considering, not
committed to, but considering going into primary care?'' And of
the 15 students around the table, one of them raised their
hand. Only one was even considering it.
Then we started to examine this question as to why they
didn't even have it on their mind, and certainly the dollars
were the first thing that they mentioned. All of them are going
to have extreme levels of indebtedness, even coming out of a
State university. They just really could not figure out how
they were going to make that work with the salary that they
were going to make as a primary care physician.
But as you started to tease a deeper answer out from each
one of them, the second thing that came up was prestige. That
they didn't feel that there was real prestige any longer in
being a primary care physician. That if you really wanted to
practice cutting edge medicine that you had to go into the
specialties, and they all had an ego to them that wanted to put
them on the frontlines of new medicine.
I hope that that's part of our hearing as well today, how
do we put the practice of medicine back into primary care? How
do we allow them to be more than just gatekeepers? I think that
there is a perfect opportunity as we start to rollout these new
delivery system models, as we envision a world where
accountable care organizations and interconnected
multispecialty practices are the rule rather than the exception
while we invest in things like medical home models. You allow
for primary care physicians to, once again, control a lot more
medicine than they used to control. The prestige comes back,
maybe not so much in the medicine that they are practicing, but
in the control they have over the health care system writ
large.
So I think that as we build a new delivery system it is an
opportunity not just to address what I think is still the most
critical question which is, how do they just make their
family's budget work, if they decide to go into primary care,
but how do they get to feel really good about the medicine that
they are practicing, and the value that they are adding to
their profession? Because that has been lost as well over the
years, as the prestige has moved to the specialists rather than
the primary care doctors, and I imagine we will examine that
topic today as well.
Thank you very much, Mr. Chairman.
Senator Sanders. Thank you, Senator Murphy.
Senator Casey.
Statement of Senator Casey
Senator Casey. Mr. Chairman, I will submit a statement for
the record.
I just want to thank you for calling this hearing. It is a
critically important issue, and we are grateful that you did
the work.
I guess the one quick comment I would make is when we go to
the Attending Physician as Members of Congress, we have a
doctor available to us here in the Capitol, and that doctor, in
a sense, is our quarterback who can make determinations about
our health and can refer us to all kinds of specialists and
others that help us.
And we hope that one of the conclusions that results, or
one of the goals here I guess is a better way to say it of all
this work in this hearing and otherwise, is that everyone has
that primary care doctor, that quarterback in their life who
can treat them, but also get them access to specialists and the
best care.
Thanks.
[The prepared statement of Senator Casey follows:]
Prepared Statement of Senator Casey
I want to thank Chairman Sanders for scheduling this
important hearing today and for his work in this area,
especially around Community Health Centers. His commitment to
guarantee that health care is available for everyone is a model
for all of us. I would also like to welcome our new Ranking
Member, Senator Enzi, and I look forward to working with him.
Ensuring an adequate health care workforce is an issue that
is important to Pennsylvania and one of the key aspects of this
issue is having a strong primary care workforce. The Health
Resource Services Administration estimates that 16,000 primary
care practitioners are currently needed today in shortage areas
around the country and 52,000 additional primary care
physicians will be needed by 2025. To meet these needs we must
not only protect our current training programs, but also look
for new and creative ways to provide primary care training.
In 2011, the baby boom generation started turning 65 and by
2030, all 78 million will have reached that age. Guaranteeing
our older citizens have access to primary care is a key part of
ensuring we have the workforce to care for an aging America.
The Affordable Care Act ensured every Medicare beneficiary
could have an annual physical. For our older citizens, having
the medical home a primary care provider affords is paramount
to staying healthy and active. And this is our responsibility.
We must ensure this generation that fought in our wars, worked
in our factories, taught our children and who gave us life and
love are cared for. This will require an investment in the
health care workforce that was begun under health care reform
and must continue into the coming decades.
Another area I have spent time working on is the pediatric
workforce and the role of freestanding children's hospitals and
the Children's Hospital Graduate Medical Education (CHGME)
program. Prior to the enactment of CHGME, the number of
residents in children's hospitals' residency programs had
declined over 13 percent. The enactment of CHGME has enabled
children's hospitals to reverse this trend and to increase
their training by 35 percent. Pediatricians are the primary
care providers for our children who we must nurture and care
for as they are our future. Accordingly, we have an obligation
to work to ensure this program continues and remains strong.
I look forward to hearing from our witnesses today on where
we are and what more we must do to ensure we have the workforce
we need and to continuing to work on this important issue.
Senator Sanders. Thank you very much, Senator Casey.
Senator Hagan.
Statement of Senator Hagan
Senator Hagan. Thank you much, Mr. Chairman and Ranking
Member Enzi. Thank you for holding this hearing today.
I think this is a critical issue facing our country today.
I know that in my State of North Carolina, we have more than a
million people who don't have access to primary health care
because of a shortage of providers. I know that when patients
can see a primary health care doctor, they frequently end up
getting care, obviously. But what happens when they don't have
that access, they go to the hospital and that is where
emergency care and treatment is so expensive, and it is
currently helping to drive up the cost of health care. Also, if
you have a chronic disease and you can manage that disease, it
is much less costly, because otherwise they will develop into
acute care episodes.
I know that there are innovations going on in this area,
and one of them is in North Carolina: the Blue Ridge Community
Health Services, which is a community health center in the
western part of our State. It received a grant just this past
November under the Teaching Health Center Program. In the Blue
Ridge, they have served 20,000 patients last year through
70,000 encounters with two primary care sites, four school-
based health centers, and one dental center, and they do
outreach at a local domestic violence shelter.
This funding that they were given has allowed them to
increase the number of residents at this facility in
Hendersonville. I think those new residents are really critical
to helping with providing more primary health care physicians.
Blue Ridge is one of 34 federally qualified health centers in
North Carolina that do provide that high quality, cost-
effective care to so many people across our State.
I know that there is another provision that is important,
and that is the Rural Physicians Pipeline Act that was included
in the Affordable Care Act. It gives the medical schools the
resources to recruit students from rural communities. So much
of this primary care access is lacking in our rural
communities. If we can train physicians from those rural
communities, they tend to stay in rural communities, which I
think is certainly a highlight of this provision. So programs
like that, I think, have a significant role to play in
relieving this current primary care shortage.
I am delighted to have this committee hearing. I look
forward to hearing the testimony of all of our witnesses today.
Thank you.
Senator Sanders. Thank you, Senator Hagan.
Senator Whitehouse.
Statement of Senator Whitehouse
Senator Whitehouse. Thanks very much, Senator Sanders, for
holding this hearing. You have drawn a big crowd, I think,
because it is an important issue.
We are all gearing up here in Washington for ``Son of
Fiscal Cliff,'' which is going to be coming in a couple of
weeks. With that looming, we are beginning to hear the usual
refrain about how important it is to cut Medicare benefits, and
to limit access to Medicare for seniors, and that that is the
responsible thing to do to save money; which, of course, is a
preposterous and ill-informed idea, particularly in the context
of a health care system that is 100 times more expensive than
it was in 1960.
If you look at the graph, it is an accelerating curve of
upward costs. When you look at a $2.7 trillion annual
expenditure on health care that is probably 50 percent higher
because of the inefficiency of our health care delivery system;
there is a 50 percent inefficiency penalty that we pay in the
United States compared to all of our industrialized
competitors. Our most inefficient industrialized competitor
spends 12 percent of its GDP on health care; we spend 18
percent of GDP on health care. It is $800 billion a year spent
unnecessarily.
You look at the scope of this, you look at the
accelerating, skyrocketing pace of the increase and you think
you are going to solve that by cutting Medicare? It is simply
not right. As the CEO of Kaiser Permanente, George Halvorson
said, ``That is an inept way of thinking about health care.''
He said, ``It's not just wrong, it's so wrong, it's almost
criminal.''
Hearings like this point out that there really is a problem
with costs and with the delivery system in the United States,
and that we really have to address that problem if we are not
going to misdiagnose what we have. Once you have a
misdiagnosis, you usually don't get the right cure.
It is really important that we not throw seniors and
Medicare under the bus because we have failed to address the
real problem in health care, which is wild inefficiencies and
skyrocketing costs that aren't just in Medicare. Indeed,
Medicare is probably the most efficient deliverer of health
care in our health care system.
If we get this right, 40 percent of the savings will come
back into the Federal budget, but the rest will go to Kaiser,
to Blue Cross, to United, to businesses and families all across
the country.
We have a real fight on our hands to try to make sure we
steer this in the right direction. And I hope this hearing
helps make sure we make the right choice.
Senator Sanders. Senator Whitehouse, thank you very much.
I want to remind members of the Senate and viewers on C-
SPAN that the report that we have done, ``Primary Care
Access,'' is available at my Web site www.Sanders.senate.gov.
Panelists, you have been extremely patient, but the good
news is that what you have seen today is that there is an
enormous amount of interest in this issue. We are delighted
that you are here and we thank you, again, for the work that
you do.
Let's begin with Dr. Fitzhugh Mullan. Dr. Mullan is the
Murdoch Head Professor of Medicine and Health Policy at the
George Washington University School of Public Health, and
professor of pediatrics at the George Washington University
School of Medicine.
Dr. Mullan, thanks so much for being with us.
STATEMENT OF FITZHUGH MULLAN, M.D., MURDOCK HEAD PROFESSOR OF
MEDICINE AND HEALTH POLICY AT THE GEORGE WASHINGTON UNIVERSITY
SCHOOL OF PUBLIC HEALTH AND PROFESSOR OF PEDIATRICS AT THE
GEORGE WASHINGTON UNIVERSITY SCHOOL OF MEDICINE, WASHINGTON, DC
Dr. Mullan. Thank you, Chairman Sanders, Senator Enzi, and
colleagues. It is a great privilege to be here.
As a primary care physician and pediatrician who was in the
first class of the National Health Service Corps in 1972,
subsequently ran the National Health Service Corps, it is not
only a privilege but an astounding development in history to
hear a committee of the U.S. Senate speak with such clarity
about the often orphan issues of primary care and service
delivery in poor, rural, and underserved communities. So if I
can get over my daze, I will try to be cogent, but thank you so
much for convening and for the thought that has gone into this.
I am going to run through. Chairman Sanders, you gave my
talk. I was supposed to be the expert. You are clearly the
expert, so I will stint on some of the things that I was going
to bring up, but try to focus on the issues of education and
system-building around primary care.
The demand clearly is in front of us--the aging of the
population, the advent of the Affordable Care Act and the
terrific entitlement that it provides, but that does present us
with a challenge. Just a few demographics.
We have about 280 physicians per 100,000 in the United
States, which puts us in the middle, roughly, of the developed
world. UK and Canada have less; Germany and France, for
instance, have more. But we are roughly in the middle.
We have about 800,000 physicians, but additionally, we have
190,000 nurse practitioners, physician assistants, and
certified nurse midwives. So we have almost a 25 percent add-on
of providers that did not exist 30 or 40 years ago. And a point
on that, important to remember, when our workforce was lean, I
am talking in the 1960s and 1970s, we were very short. And
everybody including the U.S. Congress agreed and began a
variety of programs that have lived on very powerfully today.
Among those were the development of the nurse practitioner
and the physician assistant that did not exist before, and the
National Health Service Corps. Lean is not necessarily bad in
terms of how we function, if we want a more efficient system.
There are systems that are used to the payments that they
currently get, and they are not going to change until there is
a real sense of need, and we are at that point. While I am not
for holding where we are now, I think we need to think about
the advantages, perhaps, and the creativity that can come from
this period.
In terms of the primary care challenge, I look at it in two
ways. One is within the factory, the medical school, the
teaching hospital, and the other is in the market. Clearly, we
have had eloquent testimony as to the pay parity gap that
exists. In simple general terms, a specialist will make twice
what a generalist makes, a generalist being a pediatrician,
family doctor, general internist, and other disciplines that
are generalist in nature and poorly paid. That is a huge
problem.
While education and training is very important, what I do
believe in, is that you can do the best education and training,
and if you put them out in the market with those kind of
incentives, you will get what we are getting now. We have got
to deal with that.
Speaking on the educational side, the challenges are both
at the medical school level and the residency level. As you
know, this prolonged adolescence we call residency is very
important, and also very influential, in the nature of the type
of physician and the location of the physician that comes out
of the education pipeline.
There is in medical schools a culture that is heavily, at
this point in time, specialty focused; a natural dominance of
the more research-oriented and the subspecialty sciences, which
are well represented for good reasons, in medical school. But
the primary care culture is often put in the back of the bus,
and you will not find a primary care physician who hasn't been
told at some point in their training career by a professor,
``You're too intelligent. You're too smart to go into primary
care.'' That culture is toxic, and it is out there, and we need
to worry about it.
The young doctor today is, as suggested, drawn to lifestyle
specialties. This is a problem too, with limited hours, clear
and rather refined knowledge requirements, and a predictable
life. One can understand those draws, but we need to work on
that.
Then finally, you have the sense of social purpose and
social mission. Our medical schools have been well-treated by
the NIH that provides about $17 or $18 billion a year to
research in medical schools; by Medicare, which provides $10
billion a year to teaching hospitals for residency programs,
$10 billion a year about $100,000 per resident; very, very
strong influence with no requirements in terms of workforce
product at the other end. And given those two pay streams, we
put about $300 million into primary care, family medicine,
nurse practitioners, PAs, and about $300 million into the
National Health Service Corps.
So you have $27 billion on one side that is generally
specialty-oriented and about $600 million that is promoting
primary care careers. A huge imbalance, again, not surprising
the outcome that results from that.
The teaching health centers, which have been referenced, a
very important innovation; it moves the paradigm out of the
hospital into the community. And importantly, it needs to
guarantee a pay stream. You cannot run a residency without
predictability. That is a very, very important outcome and it
is something that needs attention.
The nurse practitioner, PA, is a very important asset. As I
say, almost 190,000. We need more. They are more nimble. They
are more easily trained in larger numbers, and that is a very,
very important feature as we look at scaling up quickly our
workforce.
Finally, data and planning. We have a National Health Care
Workforce Commission finally voted in through the ACA. It has
not been funded. It has not met. We need a better brain in our
somewhat anencephalic system; our system without a good brain
to lead it. That would be very helpful.
In conclusion, we have a moral triumph in the ACA in the
entitlements that it brings, but also a technical challenge. In
terms of legislative issues, the main permanence of the THCs is
important. The full funding and greater funding of the National
Health Service Corps will be essential. Bringing the National
Health Care Workforce Commission to life is important. And
perhaps most important, is Medicare GME, we need to get a
handle and use that $10 billion in a more constructive, pro-
primary care fashion.
Thank you.
[The prepared statement of Dr. Mullan follows:]
Prepared Statement of Fitzhugh Mullan, M.D.*
My name is Fitzhugh Mullan. I am a professor of Health Policy and a
professor of Pediatrics at the George Washington University. The first
23 years of my medical career were spent as a Commissioned Officer in
the United States public health service, beginning as a National Health
Service Corps physician in a community clinic in northern New Mexico.
Subsequently, I served as Director of the National Health Service
Corps, Director of the Federal Bureau of Health Professions, and
Secretary of Health and Environment for the State of New Mexico. In
recent years, I have studied and written about medical education,
health professions workforce, and health equity. I am pleased to be
here today to talk about the challenges of primary care as set within a
changing health care system. I will address health workforce adequacy,
the National Health Service Corps, Teaching Health Centers, nurse
practitioners, physician assistants, certified nurse midwives, and
workforce data and planning.
---------------------------------------------------------------------------
* The author wants to thank Hannah Wohltjen, MA, for her assistance
in the preparation of this testimony.
---------------------------------------------------------------------------
GETTING IT RIGHT: CHALLENGES TO BUILDING A STRONG HEALTH WORKFORCE
We are facing a period of enormous challenge in building our health
care system to improve access and quality while managing costs. All
evidence points to the demands on the current system rising appreciably
based on the aging of our population and the extension of health
insurance to 30,000,000 Americans under the Affordable Care Act. What
does this mean for our health care workforce and where do we stand now?
The United States has about 280 physicians/100,000 people, which
puts us in the middle ranks of developed nations--somewhat above Canada
and the UK and somewhat below Germany and France. Roughly one third of
our physicians work in primary care, which makes us disproportionately
specialist-heavy as compared to many other developed nations (Figure
1).
Additionally, and importantly, we have approximately 106,000 nurse
practitioners, 70,000 physician assistants, and 13,000 certified nurse
midwives providing clinical services side-by-side with 835,000
physicians.\1\ \2\ \3\ This means that for every four physicians we
have one non-physician clinician providing services as well--a rich
asset that no other nation enjoys. A critically important and much
debated question today is whether we have an adequate number of
clinicians to meet our national needs. There has been a lot of
scholarly debate on this issue. In my judgment, we have a reasonable
range of clinical providers (physicians and non-physician clinicians)
to address our current needs. These needs will increase slowly as our
population grows and ages and there will clearly be an appreciable
increase in demand for service in 2014 when the insurance provisos of
the ACA kick in. All of these challenges will call on us to be
resourceful and strategic in the use of our current resources and will
require us to consider new and different strategies to address
educational and practice needs to build our future clinician workforce.
Toward that challenge, we should plan gradual and thoughtful growth in
our physician workforce aiming to increase the number of physicians
entering practice in high need specialties.
---------------------------------------------------------------------------
\1\ AHRQ. Primary Care Workforce Facts and Stats No. 2. October
2011. Retrieved from http://www.ahrq.gov/research/pcwork2.htm.
\2\ American Midwifery Certification Board, http://www.midwife.org/
Essential-Facts-about-Midwives.
\3\ Kaiser Family Foundation. Total professionally active
physicians, November 2012. Retrieved from http://
www.statehealthfacts.org/comparemaptable.jsp?ind=934&cat=8.
---------------------------------------------------------------------------
However, well-established evidence points to the fact that pure
increases in physician numbers are associated with higher costs and not
associated with better distribution of physicians or improved patient
outcomes. In fact, our national experience points to certain benefits
of a ``leaner'' physician workforce. Examples of this include the
development of the physician assistant and nurse practitioner
professions as well as the legislative birth of the National Health
Service Corps during earlier periods of physician shortage. Moreover,
the experience of organized health systems, ranging from Kaiser
Permanente to the Mayo Clinic that employ significantly fewer
physicians per population than the national average, suggest that
excellent care can be provided by better practice organization and
payment incentives.
THE PRIMARY CARE CHALLENGE--MEDICAL SCHOOL REFORM NECESSARY
BUT NOT SUFFICIENT
The education and maintenance of a strong primary care sector is
important to all aspects of excellence in health care--access, quality,
and affordability. Robust and consistent data from the United States
and global studies affirm the association of strong primary care
systems with better outcomes, lower costs, and better patient
satisfaction.
The United States has traditionally undervalued primary care in
both education and practice, which is a core problem that needs
resolution as part of overall health care reform. Our current physician
reimbursement system is effectively hard-wired to Medicare payment
policies--policies that compensate specialists (on average) twice as
much as primary care physicians. The culture of medical education is,
likewise, tilted toward specialties, both because of Federal funding
streams and the predominance of specialists on faculty. Primary care
physicians report time after time that, when they were medical
students, faculty members told them they were ``too smart to go into
primary care.'' Ten of our elite medical schools yet today do not have
family practice departments despite the panoply of specialties
represented on their campuses.\4\
---------------------------------------------------------------------------
\4\ Krupa, C. (2012, December 17). Will physician shortage raise
family medicine's profile? American Medical Association American
Medical News. Retrieved from http://www.ama-assn
.org/amednews/2012/12/17/prl11217.htm.
---------------------------------------------------------------------------
In addition to the lower pay for primary care work, many medical
students and young physicians consider primary care practice hard work
and are opting in large numbers for what are euphemistically called
``lifestyle specialties.'' These are medical specialties that have
predictable hours, well-bounded knowledge requirements, and good pay.
The challenges that bedevil primary care--pay equity, medical
school culture, and ``lifestyle'' preferences--represent long-term
problems that will not be corrected by a single reform or strategic
initiative. Rather, there will need to be a variety of approaches
undertaken at a governmental level as well as at institutional and
individual levels in an effort to rebalance our provider complement and
maintain a strong primary care presence. This cannot be done in medical
schools alone. Pro-primary care reforms in medical schools will not be
sufficient if the ``pay equity gap'' in practice is not narrowed. In
the United Kingdom, for instance, where specialists and general
practitioners have similar career earnings, there are no problems
filling the ranks of the Nation's general practitioners. The advent of
the Affordable Care Act and the aging of the baby boom generation
represent a challenge to the Nation--but also an opportunity for
medical educators to revisit the mission of their institutions,
examining opportunities to promote primary care and the general social
mission of medical education. There are a number of established
features of medical schools that are associated with recruiting and
graduating physicians who are more likely to work in shortage areas, to
choose primary care careers, and to address issues of prevention and
population health. A commitment by the Nations' medical schools and
teaching hospitals to promote the social mission of medical education
and practice would launch more graduates into careers dedicated to the
oncoming problems of access, quality, and affordability.
TEACHING HEALTH CENTERS--INNOVATION IN GRADUATE MEDICAL EDUCATION
The Teaching Health Center Program (THC), initially enacted in the
ACA, is a new residency model that will promote better training of more
physicians in community-based primary care settings. The principal
funding source for residency programs has been Medicare Graduate
Medical Education (GME) payments, which are paid to hospitals based
largely on the number of residents that they train. Not surprisingly,
hospitals recruit residents who fulfill the needs of the hospitals.
This tilts residency heavily toward medical and surgical specialties
and subspecialties. The vast majority of trainees spend little or no
time outside of the walls of the hospital. Studies have demonstrated
that only 1 percent of patients are hospitalized in major teaching
hospitals in any 3-month period and yet that is where virtually all
teaching and role modeling take place.
THCs are community-based. Residents are recruited to community
health centers that, in turn, arrange teaching rotations in regional
hospitals. The teaching program itself, the clinical training provided,
and values imparted are all community-oriented. THCs are funded through
modest, dedicated ACA support for 5 years. To date 22 THC residency
programs training 140 residents are up and running. Another 17 health
centers have recently received awards and it is anticipated that THCs
will soon be graduating almost 200 community-trained primary care
physicians annually. However, despite enormous interest and major
reform implications, the THC program, as currently legislated, is
effectively a demonstration program whose funding ends in 2014. The
absence of Medicare or Medicare-like permanent funding jeopardizes this
small but enormously important new model of primary care education.
This is a critical, near-term legislative challenge.
NATIONAL HEALTH SERVICE CORPS--TRIED, TRUE, AND ESSENTIAL
The National Health Service Corps, enacted in 1970, has proven to
be a powerful instrument for primary care career development and a
brilliant example of service learning in the national interest. Using
scholarships and loan repayments as incentives, the program has been
able to match large numbers of primary care clinicians to shortage-area
delivery sites, year after year. Thanks to the leadership of Senator
Sanders and the ACA, the NHSC has doubled its annual appropriation from
$150,000,000 to $300,000,000 (Figure 2) and, as we speak, deploys
almost 10,000 physicians, nurse practitioners, physician assistants,
social workers, mental health workers, and others in thousands of sites
in every State in the Nation.
In return for educational debt relief, National Health Service
Corps health care workers are ``doctors'' to resource-poor communities
all over the country. The 40,000 clinicians who have served in the NHSC
over 40 years is a tribute to good legislation and good will.\5\ With
the advent of the ACA, the program will need to expand its clinical
participants and communities served.
---------------------------------------------------------------------------
\5\ National Health Service Corps. Retrieved from http://
nhsc.hrsa.gov/corpsexperience/aboutus/index.html.
---------------------------------------------------------------------------
NURSE PRACTITIONERS, PHYSICIANS ASSISTANTS, AND CERTIFIED NURSE
MIDWIVES
Nurse practitioners (NPs), physicians assistants (PAs), and
certified nurse midwives (CNMs) are key providers of health care in
general and primary care in particular throughout the country.
Currently, as noted above, there are estimated to be 190,000 of them
working clinically throughout the country. It is estimated that 52
percent of NPs and 43 percent of PAs work in primary care.\6\ CNMs are
important providers of women's health in general. Scope of practice
laws and prescriptive authority have expanded over time in most States
with the result that NPs and PAs can provide, augment, and supplement
services that were previously limited to physicians. This availability,
as well as the spectrum of clinical capabilities within these groups of
clinicians, makes them extremely important resources in service
delivery in all settings. Moreover, the length and expense of their
training is less than that of physicians and they are able to choose
and modify their career courses in a far more nimble fashion than
physicians. Their presence, skills, and numbers are an important
contribution to primary care today and the ability to expand their
educational programs quickly will make them crucial players over the
next decade as the demand for services increases. As documented above,
the majority of PAs and a growing number of NPs are working in
specialty settings. I believe this to be an important asset for the
health system and not, as some believe, an abdication of their
``primary care role.'' If we are to develop a balanced workforce where
specialty services are used appropriately, NPs and PAs are positioned
to support specialists and perform clinical tasks in a way that
attenuates the need to train larger numbers of specialty physicians.
This will be an important contribution to recalibrating the specialist/
generalist mix of the workforce of the future.
---------------------------------------------------------------------------
\6\ AHRQ. Primary Care Workforce Facts and Stats No. 2. October
2011. Retrieved from http://www.ahrq.gov/research/pcwork2.htm.
---------------------------------------------------------------------------
THE WORKFORCE WILL NOT MANAGE ITSELF
Generalist and specialist physicians as well as NPs, PAs, and CNMs
require lengthy basic education, including graduate level practice-
focused training. Key clinicians such as these cannot be produced
quickly, and their education and training require educational
``infrastructure'' (schools, specialized classrooms and labs, faculty,
and clinical training sites) and substantial educational financing (for
schools, faculty, and students). Public policies relating to practice
are also important and, often, intricate. New practice models (Primary
Care Medical Homes and Accountable Care Organizations), reimbursement
policies, scope of practice laws, and loan repayment options--to name a
few--have an impact on career choices and service patterns of
physicians and other clinicians.
While many career decisions will be made by individuals and will
call on them to use their own financial resources, public policy at the
Federal and State level will contribute greatly to individual choices
about where and how to practice. The pressures of the system in the
near future will reinforce the importance of the public role in health
workforce policy. However, the history of public planning in the area
of health workforce is spotty at best. No senior agency of government
is charged with policy planning in this area. Data on health
professions workforce is limited and dispersed among Federal agencies
(HRSA's National Center for Health Workforce Analysis, the Bureau of
Labor Statistics, the Veterans' Administration), private associations
(AMA, AAMC, AACON), and State boards of nursing and medicine.
As a first step to providing better Federal leadership in health
workforce planning, the ACA enacted a National Health Care Workforce
Commission charged with the responsibility of drafting and promulgating
periodic reports on the workforce as a whole and specific workforce
issues in particular. It was to bring focus to the many issues of
health workforce analysis and planning. The State of that endeavor is
that Commissioners were appointed but no funds have been appropriated
to allow the commission to meet or function. The continued absence,
then, of any focal effort in workforce planning at the national level
will only become more problematic as the challenges of access, quality,
and cost continue to increase as the demographics of the country evolve
and the programs of the ACA come into play.
CONCLUSION
This is an exciting time. We are at the brink of expanding the
benefits of health insurance to most of those currently uninsured in
our population. This is a moral triumph but also a technical challenge.
Meeting this need will require educational and clinical resourcefulness
and both public and private investment. There are a number of areas in
which Federal legislative action will be needed including the
conversion of the THCs to a permanent program, extending and expanding
the NHSC, operationalizing the National Healthcare Workforce
Commission, funding HRSA's National Center for Health Workforce
Analysis so that it becomes the robust center that is required for
incisive public policymaking. A serious examination of Medicare GME is
overdue in regard to what can be done to make the program more
accountable and responsive to national physician workforce needs.
I hope that these remarks have helped to point out the
opportunities and challenges that face us. I very much appreciate the
chance to testify today, and would be happy to be of assistance to you
and the committee in any way I can in the future.
Thank you.
[Note: The author wants to thank Hannah Wohltjen, MA, for her
assistance in the preparation of this testimony.]
Senator Sanders. Thank you very much, Dr. Mullan.
In order for us to have a good, vigorous question and
answer period, if people could keep their remarks to 5 or 6
minutes, that would be appreciated.
The next witness is Tess Kuenning. She is the executive
director of Bi-State Primary Care Association, whose members
include the Federally Qualified Health Centers in Vermont and
New Hampshire.
Ms. Kuenning, thanks very much for being with us.
STATEMENT OF TESS STACK KUENNING, CNS, MS, RN, EXECUTIVE
DIRECTOR, BI-STATE PRIMARY CARE ASSOCIATION, MONTPELIER, VT
Ms. Kuenning. Chairman Sanders, Ranking Member Enzi, and
distinguished members of the subcommittee.
My name is Tess Kuenning, and I am the executive director
of Bi-State Primary Care Association located in Montpelier, VT
and Concord, NH. On behalf of the entire health center
community, including more than 22 million patients nationwide,
and the National Association of Community Health Centers, I
want to thank you for the opportunity to testify on the role of
community health centers in addressing our Nation's pressing
primary care access needs.
As the committee is aware, two important events have
significantly altered the health care financing and delivery
systems of our Nation, the Patient Protection and Affordable
Care Act, and the Supreme Court's decision about the same.
As a result of these events, it is estimated that as many
as 30 million Americans will gain coverage through Medicaid
and/or the health insurance exchange. Yet another 30 million
will still remain uninsured.
We strongly support these coverage expansions, which open
the door to a broader health care system for many of our
patients. However, we know well that coverage alone does not
equate to access. It is access to regular care that makes
coverage meaningful.
We also believe to achieve a truly reformed health system,
our Nation needs sustainable solutions to increase our primary
care capacity, lower and manage our health care costs, and
assure quality outcomes. It is for this reason, in my view,
that any efforts to increase access to insurance must grow and
expand our primary care infrastructure.
Community health centers offer a unique and proven solution
to these challenges. By statute and mission, community health
centers are located in medically underserved areas, and serve
medically underserved populations and care for everyone
regardless of your ability to pay. Community health centers
also are directed by patient majority boards insuring care is
locally controlled and responsive to each individual
community's needs.
It might surprise you to learn that the Community Health
Center of Burlington in Burlington, VT provides translation for
patients from the Sudan, Bosnia, Somalia, Burundi, Tibet and
Nepal, Bhutan and Burma, to name only a few. The ability to
receive care in one's native language removes a major access
barrier and improves the health of these families and our
communities.
From my years of clinical practice as a nurse in Nepal, I
am able to speak Nepali with our increasing immigrant and
refugee population from Nepal and Bhutan, and I see firsthand
the benefits of this type of enhanced provider-patient
relationship can yield.
Without access to primary care many people, including these
families, might delay seeking treatment until they are
seriously ill and require hospitalization or care in the
emergency room at a much higher cost to themselves and to the
health care system.
The literature backs up these real world experiences. For
example, ``The Journal of Rural Health'' article found that
counties with a community health center had 25 percent fewer
emergency room visits. Other data demonstrates that the
community health centers save the entire health system,
including government and taxpayers, approximately $24 billion
annually by keeping patients out of these costlier health care
settings.
Fortunately Congress, with the leadership of this
subcommittee's Chair, had the foresight to include mandatory
funding to expand the reach of the Nation's community health
centers in the Affordable Care Act to ensure that the promise
of coverage was met with the reality of care. We believe that
seeing this plan through is essential. Unfortunately, the
community health center expansion is not currently on-track.
A recent HRSA solicitation for New Access Point grants
anticipates spending only $20 million of the $300 million in
new fiscal year funding for fiscal year 2013. The
administration has instead proposed spreading out the community
health center growth over a much longer period of time, and we
urge that the full Affordable Care Act provided increase for
fiscal year 2013 be immediately extended to care for 2\1/2\
million new patients as Congress intended.
The demand for community health centers continues to
outpace the growth, and more than 60 million Americans still
lack access to primary care. In Vermont and New Hampshire in
the near term, all of our 19 health centers have identified
needs in their areas.
I would be remiss if I failed to cite another vital program
that supports the goal of creating medical homes for
underserved Americans and that is the National Health Service
Corps. The Corps places trained health professionals in health
shortage areas and remains a key partner in ensuring that
community health centers can meet the demand for primary care
that is looming just around the corner with the ACA
implementation.
Community health centers around the country are ready,
they're willing, they're able to be leaders in reforming our
health system community by community from the ground up.
We appreciate your leadership and look forward to your, and
the committee's, continued support as we work to provide
meaningful health care access to all.
Thank you, Mr. Chairman.
[The prepared statement of Ms. Kuenning follows:]
Prepared Statement of Tess Stack Kuenning, CNS, MS, RN
INTRODUCTION
Chairman Sanders, Ranking Member Enzi, and distinguished members of
the subcommittee, my name is Tess Kuenning, and I am the executive
director of Bi-State Primary Care Association located in Montpelier,
VT, and Concord, NH. On behalf of the entire health center community,
including more than 22 million patients served by Community Health
Centers, as well as the National Association of Community Health
Centers, I want to say thank you for the opportunity to testify today
before the committee on the efforts of Community Health Centers to
provide and expand access to primary care services in medically
underserved communities.
PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010
Two important events have radically altered the health care
financing and health care delivery systems of our Nation: The Patient
Protection and Affordable Care Act (ACA) which was signed into law on
March 23, 2010; and the Supreme Court's June 28, 2012, landmark
decision about same. It is estimated that 30 million people will gain
public coverage through Medicaid and/or the Health Insurance Exchanges.
There will be increased coverage through a number of mechanisms, but
another 30 million will remain uninsured.
In my view, any efforts to increase access to insurance must also
include investments to grow and expand the primary care safety net
infrastructure. Primary and preventive care must be central to any
efforts to achieve its goals of increasing
access, managing total patient costs and producing quality patient
outcomes.
As this committee is aware, the ACA created significant Federal
investments in expanding public coverage and private insurance reforms.
However, coverage does not equate to access. It is access that makes
coverage real. We need sustainable
solutions to increase our primary care capacity, lower and mange our
health care costs and assure quality outcomes, patient satisfaction and
patient accountability.
Community Health Centers are the Nation's primary and preventive
health care safety net. Community Health Centers hold the promise to
fulfill access to care for our Nation's communities. Community Health
Centers historically have, and will continue to care for all patients
in their community, but will extend their expertise in caring for our
most vulnerable; the uninsured and the Medicaid population.
HEALTH CENTERS--GENERAL BACKGROUND
Community Health Centers are community-owned non-profit entities
providing primary medical, dental and behavioral health care. In
addition, many Community Health Centers also provide pharmacy and a
variety of enabling and support services. To date, there are over 1,200
Community Health Centers located at more than 9,000 urban and rural
locations nationwide serving as patient-centered medical homes for more
than 22 million patients. For over 45 years, the Nation's Community
Health Center infrastructure has grown.
In 2000, Vermont had only 2 Community Health Centers with 7 sites
serving just over 18,000 patients. Currently, Vermont has 8 Community
Health Centers with 43 clinical sites in 12 counties caring for the
whole family from prenatal care to pediatrics, to adult and elder
health care, providing a medical home over the past 3 years to more
than 158,000 Vermonters. Vermont Community Health Centers have a
significant market share serving one in four Medicaid, one in four
uninsured, one in five Medicare enrollees and one in eight commercially
insured Vermonters. Over the past 10 years in New Hampshire, Community
Health Centers have grown to 12 organizations across the State serving
approximately 76,000 patients in underserved areas.
By statute and mission, Community Health Centers are located in
medically underserved areas or serve a medically underserved population.
Community Health Centers see patients regardless of their ability to
pay or insurance status and offer services based on a sliding fee
discount; thereby, easing one of the greatest barriers to care, the
financial burden.
Community Health Centers are also directed by patient-majority
boards. This unique model ensures care is locally controlled,
responsive to each individual community's needs and, at the same time,
reducing barriers to accessing health care through various services. In
some communities, Community Health Centers provide or arrange for
transportation to ease the geographic barriers. In other communities,
Community Health Centers provide care targeted to reduce various cultural
barriers by providing culturally competent care including translation
services.
At the Community Health Centers of Burlington in Burlington, VT,
they provide translation for patients from the Sudan, Bosnia, Somalia,
Burundi, Tibet, Nepal, Bhutan and Burma to name a few. At the
Manchester Community Health Center in Manchester, NH, of their 8,000
patients, only 51 percent speak English. There are 62 languages spoken
and 49 require interpretation. My training as a nurse and my various
roles in clinical practice has allowed me a greater appreciation to
understand a successful patient/clinician relationship. From my years
of clinical practice in Nepal, I am able to speak Nepali with our
increasing immigrant and refugee population from Nepal and Bhutan. I
have found myself in Community Health Center waiting rooms speaking
Nepali to children, teens, parents and grandparents. They greet this
with wonderment and genuine gratitude that someone knows their
language. All care at Community Health Centers is tailored to assure
patients are welcome and treated with respect.
Community Health Centers are more than a safety net, they have a
demonstrated track record of improving the health and well-being of
their patients using a locally tailored health care home model designed
to coordinate care and manage chronic disease. This distinctive model
of care has enabled us to save the entire health
system, including the government and taxpayers, approximately $24
billion annually by keeping patients out of costlier health care
settings, such as emergency departments.\1\ As a result of their timely and
appropriate care, Community Health Centers save $1,263 per person per year,
lowering costs across the delivery system--from ambulatory care settings to
the emergency department to hospital stays.\2\ Nationally, approximately 39
percent of Community Health Center patients are covered by Medicaid and
another 36 percent are uninsured.\3\ In return, Community Health Centers bring
significant value to the Medicaid program, serving 14 percent of Medicaid
patients for only 1 percent of Medicaid spending.\4\
In addition to reducing health care costs, Community Health Centers
can also serve as small businesses and economic drivers in their
communities. In 2012, Community Health Centers employed 153,000
individuals \5\ and in 2009 generated $20 billion in total economic
benefits in poor urban and rural communities.\6\ Vermont Community
Health Centers employed 753 individuals and generated nearly $108
million in total economic benefits; while New Hampshire Community
Health
Centers employed 537 individuals and generated over $77 million in
total economic benefits in their communities.
COMMUNITY HEALTH CENTERS CAN IMPROVE HEALTH CARE OUTCOMES AND REDUCE
HEALTH CARE COSTS
Numerous published studies over many decades have demonstrated that
Community Health Centers are a proven cost saver. Studies have also
proven that Community Health Centers improve the health status in
communities, reduce emergency room use and eliminate barriers to health
care.
A recent Journal of Rural Health article entitled: Presence of
Community Health Center and Uninsured Emergency Department Visit Rates
in Rural Counties, written by Dr. George Rust, et al., found that
counties with a Community Health Center site had 25 percent fewer
uninsured emergency department visits.\7\ Without access to primary
care, many people delay seeking health care until they are seriously
ill and require inpatient hospitalization or care at an emergency room
at a much higher cost. Community Health Centers can help reduce those
unnecessary costs by serving as health care homes for the underserved.
Barriers to care make it difficult for individuals to access
primary care and the demand for primary care far exceeds the supply
across the Nation, but Community Health Centers can play a role in
solving this crisis. The National Association of Community Health
Centers (NACHC) recently released a report entitled: Health Wanted, the
State of Unmet Need for Primary Health Care in America (``Health
Wanted''),\8\ which states that barriers to accessible care include
affordability, accessibility and availability can diminish access to
primary care. Health Wanted shows when Community Health Centers are
located in these medically underserved areas, communities are able to
overcome these barriers to care and are able to improve health care
outcomes, as well as reduce health care costs. However, the demand for
Community Health Centers continues to outpace growth. Health Wanted
also highlights the fact that at least 25 percent of U.S. counties in
greatest need do not have a Community Health Center.
Underserved communities all across the country are seeking
competitive Federal grant support to build or expand their primary care
infrastructure. In Vermont, there are three communities that are fully
poised to apply for competitive Federal funding to bring medical,
dental and behavioral health services to communities in need. As well,
of the eight current Vermont Community Health Centers, seven of them
have plans to further expand their medical, dental and behavioral
health services to either their existing sites or to new towns if only
there were sufficient Federal funding. This scenario plays out the same
in New Hampshire, in that each of the 12 Community Health Centers could
expand their primary and preventive services to thousands more patients
if resources were available.
GROWTH OF THE COMMUNITY HEALTH CENTER PROGRAM
Community Health Center expansion, championed by Members of
Congress and Presidents of both parties, has improved access to primary
care in rural and urban medically underserved communities in every
State and territory and brought enormous economic value and improved
health to the entire system. Since 2002, Community Health Centers have
expanded care from 11 million patients to 22 million patients through
the efforts of both Republicans and Democrats. Despite the growth of
the Community Health Center program over the years, more than 60
million Americans still lack access to a primary care provider.\9\
Our most recent expansion under the Affordable Care Act (ACA) was
championed by the distinguished Chairman of this subcommittee, Senator
Sanders. The Health Center Trust Fund provides $9.5 billion in funding
to support the expansion of Community Health Centers across the country
to reach and serve an additional 40 million people.\10\ The expansion
of the Community Health Center program to new sites and for expansion
of services at existing locations will continue until 2015. The goal of
the Trust Fund is to ensure that existing Community Health Centers are
thriving and new Community Health Centers are ready to provide primary
care access to the newly insured in 2014.
We believe the continued expansion of Community Health Centers is
essential to ensuring access to primary care in medically underserved
communities. Unfortunately, efforts to continue that expansion have
faltered recently. The President's proposed fiscal year 2013 Health
Resources and Services Administration (HRSA) budget provides $1.58
billion in discretionary funding for the Community Health Centers
program. Together with the $1.5 billion in fiscal year 2013 mandatory
ACA funding available, Community Health Centers could receive a net
increase of $300 million in total programmatic funding for fiscal year
2013 equaling total funding of $3.1 billion.
We strongly support the President's proposed funding level of $3.1
billion for Community Health Centers, but we are concerned about the
Administration's proposal to hold back $280 million of the total
proposed increase of $300 million and instead spread out health center
growth over a longer period of time.
HRSA's January 16, 2012 solicitation for New Access Point grants
will only expend $20 million of the $300 million in available funding under
the ACA to establish 25 new Community Health Centers and only expand care
to 60,000 new patients. Instead of holding back funding, we propose that the
entire increase be used immediately to provide for the expansion of care to
2.5 million new patients. This planned minor expansion will fall far
short of addressing the pressing need for primary care services that
has clearly been demonstrated in communities nationally and will not
provide the access to primary care that was promised in the ACA. Next
year, when several critical provisions of the ACA begin, we should do
all we can to assure we have a strong, stable and growing primary care
infrastructure with additional sites for patients to access care.
I would be remiss if I failed to cite another vital program that
supports the goal of creating medical homes for underserved Americans,
the National Health Service Corps (NHSC). The NHSC, which places
trained health professionals in Community Health Centers and other
settings located in shortage areas, continues to serve
as a vital partner to the Community Health Center program. Half of the
approximately 10,000 health professionals placed by the NHSC are at
Community Health Centers. That program, too, was expanded in the ACA
thanks to your leadership, Mr. Chairman, with $1.5 billion provided to
it over 5 years, enough to train and place some 17,000 health
professionals by 2015. And even though it also
suffered a reduction in funding last year, the NHSC has been, and
remains, a key partner in the expansion of care in preparation for the
coming coverage expansions under the ACA.
CONCLUSION
Without their local Community Health Center, many communities and
patients would often be without any access to primary care. Community
Health Centers have proven time and time again that access to a health
center translated to improved health outcomes for our most vulnerable
Americans and reduced health care expenditures for this Nation. Continued
expansion of our program will result in the ability for Community Health
Centers to reach a sizable portion of the medically underserved individuals
who would otherwise be forced to seek care in emergency departments, or delay
care until hospitalization is the only option.
Mr. Chairman, we stand ready to meet the demand among those in need
of primary care. However, Community Health Centers can only meet these
primary care demands if we can provide access to care. This means
leveraging the funds available under the ACA to expand the number of
Community Health Centers throughout the country to ensure we are able
to address the Nation's primary care shortage.
We look forward to working with you and the other members of this
subcommittee to accomplish our shared goal of improving access to
primary care while reducing overall health care costs across the
country.
Thank you, Mr. Chairman.
References
1. Ku L, et al. Strengthening Primary Care to Bend the Cost Curve:
The Expansion of Community Health Centers Through Health Reform. Geiger
Gibson/RCHN Community Health Foundation Collaborative at the George
Washington University. June 30 2010. Policy Research Brief No. 19.
2. Ku L, et al, 2010.
3. Ku L, et al, 2010.
4. Hing E, Hooker RS, Ashman JJ. Primary Health Care in Community
Health Centers and Comparison with Office-Based Practice. Journal of
Community Health. 2010
5. Bureau of Primary Health Care, Health Resources and Services
Administration, DHHS. 2011 Uniform Data System.
6. Capital Link. Community Health Centers as Leaders in the Primary
Care Revolution. August 2010. www.nachc.com/research-data.cfm.
7. Rust George, et al. ``Presence of a Community Health Center and
Uninsured Emergency Department Visit Rates in Rural Counties.'' Journal
of Rural Health Winter 2009 25(1):8-16.
8. National Association of Community Health Centers and the Robert
Graham Center. Help Wanted: The State of Unmet Need for Primary Care in
America. March 2012. www.nachc.com/client//HealthWanted.pdf.
www.nachc.com/client//Health
Wanted.pdf.
9. National Association of Community Health Centers. Primary Care
Access: An Essential Building Block of Health Care Reform. March 2009.
http://www.nachc
.com/client/documents/pressreleases/PrimaryCareAccessRPT.pdf.
10. National Association of Community Health Centers. Community
Health Centers: The Local Prescription for Better Quality and Lower
Costs. 2011.
Senator Sanders. Thank you, Ms. Kuenning.
Senator Enzi is going to introduce our third witness.
Senator Enzi. Thank you, Mr. Chairman.
It is my pleasure to introduce Miss Toni Decklever. She is
a resident of Cheyenne, which is our biggest city. It is 66,000
people. We have 259 towns, but we only have 14 towns where the
population exceeds the elevation.
[Laughter.]
She is familiar with all of those, and she currently wears
several different professional hats. She is the Government
Affairs Liaison for the Wyoming Nurse's Association, and has
visited Washington, DC previously to advocate for her fellow
nurses.
Ms. Decklever is the State director for SkillsUSA, helping
improve the country's workforce by recruiting and preparing
individuals for careers in trade, technical, and skilled
service occupations including health occupations.
Finally, she is an independent consultant who helps train
individuals in CPR, first aid, medication administration, and
how to become first responders.
She has a Bachelor of Science degree in Nursing from the
University of Northern Colorado in Greeley, and is a certified
EMT. She has received a number of awards for outstanding
service on behalf of Wyoming's nurses and workforce development
groups, and we are pleased to have her here today. And I know
from my weekly trips to Wyoming, that it took 13 hours in
airplanes and airports for you to be able to get here.
Senator Sanders. Ms. Decklever, thanks very much for being
with us.
STATEMENT OF TONI DECKLEVER, MA, RN, GOVERNMENT AFFAIRS,
WYOMING NURSES ASSOCIATION, CHEYENNE, WY
Ms. Decklever. Good morning, Chairman Sanders and Ranking
Member Enzi, members of the committee. Thank you for the
opportunity to testify today.
As Senator Enzi stated, I do represent the Wyoming Nurses
Association. I have been a registered nurse for almost 30
years, and I have worked in acute care, long-term care,
education, and administration.
Wyoming is the ninth largest State in the United States
with almost 100,000 square miles of land, but population is the
smallest in the Nation with just a little over half a million
people. Wyoming's frontier and rural environment impacts our
health care system. Wyoming has 25 hospitals with 16 designated
as critical access hospitals, 25 beds or less. There are also
two veteran's hospitals, and 16 rural health clinics. Wyoming
has eight community health centers, three are special
population health centers, and three are satellites of larger
health care centers.
When dealing with the expanded number of patients and the
barriers to care for these patients, several components need to
be considered. One is the ability for providers to be able to
practice to the full scope of their education and licensure.
Another is addressing the shortage of providers due to
retirement, and a shortage of qualified faculty to educate new
providers. Others include the perception of quality of care and
support funding for rural areas.
With Baby Boomers turning 65 at the rate of 10,000 a day,
there will be an increase in the demand for health care in
traditional acute care settings along with expansion of
nonhospital settings, such as home health care and long-term
care.
Wyoming's Nurse's Practice Act allows Advanced Practice
Nurse Practitioners to practice independently in our State.
This ability helps nurses provide patients in rural areas
access to primary care. Unfortunately, some Federal laws and
regulations limit the nurse's ability to practice at their full
scope.
A quirk in Medicare law has kept APRN's from signing home
health plans of care and from certifying Medicare patients for
a home health benefit. In areas where access to physicians is
limited, this prohibition has led to delays in home health
services. Moreover, the delays in care inconvenience patients
and their families, and can lead to increased costs to the
Medicare system. This occurs when patients are unnecessarily
left in institutional settings or readmitted after discharge
because they did not receive proper home care.
A sufficient supply of nurses is critical in providing our
Nation's population with quality health now and into the
future. Registered nurses and Advanced Practice Nurses are the
backbone of hospitals, community health clinics, school health
programs, home health, and long-term care programs, and serve
patients in many roles and settings.
According to the 2008 National Sample of Surveyed
Registered Nurses, over 1 million of our Nation's 3.1 million
nurses are over the age of 50 with one-quarter of these nurses
over the age of 60. Much like world populations and that of
Wyoming, the provider population is aging and near retirement
age. This runs counter to the increasing need of growing older
population and a regional or sporadic growth of younger
populations. Studies have identified the retirement of
providers as one of the obstacles to providing comprehensive
care.
Wyoming responded to the increasing need for nurses by
creating a funding stream that would assist nurses to continue
their education and work as faculty at the community colleges
and university. This allowed the nursing programs to increase
their enrollment numbers and thus educate more registered
nurses. RN's are encouraged to continue their education into
the Advanced Practice Nursing level.
Wyoming has a small amount of State incentives and loan
repayment money for students, but the dollar amounts do not
meet the demand through each biennium. To fill this void in
funding, some students are able to receive funds from title
VIII and title VII.
The perception that health care also is delivered in bigger
health centers equals quality is not easily overcome. Many
residents are using health services in surrounding States who
could have been served in Wyoming. To address this issue, one
report suggested ways to re-characterize the system by:
(1) having a stable supply of primary care providers,
(2) have appropriately located tertiary centers,
(3) integrate services at the point of care--medical home
concept--collaborative planning and policy implementation,
(4) effective use of pooled financial services or
resources,
(5) shared reasonability for achieving goals for individual
health, and
(6) organized leadership that keeps the State responsive to
changing needs.
Federal designations provide eligibility for Federal
programs like HRSA 330 funding and enhanced reimbursements to
rural health clinics. Health provider shortage areas, medically
underserved areas, and medically underserved populations are
based on factors that make it difficult to prove the needs of
the underserved in rural and frontier areas. As noted by
Senator Enzi, one provider per 3,500 people in an urban setting
is entirely different than 3,500 people living in a county that
is almost 10,500 miles of land mass.
Wyoming's economy is based primarily on energy production,
coal, natural gas, oil, uranium, and even wind making it a boom
and bust economy. Many people working in the energy industry
make a sufficient salary when they work, but in some cases,
these salaries are significant enough that it can skew the
average income for families based on statewide data. Though
some families do very well financially, there is still a number
of people struggling to make ends meet. This income disparity
can be another challenge to meeting designation guidelines.
Committee members, thank you for your time and attention to
this very, very important matter, and I look forward to any
questions you may have.
[The prepared statement of Ms. Decklever follows:]
Prepared Statement of Toni Decklever, MA, RN
It is well known that Wyoming is the eighth largest State in the
United States with almost 100,000 square miles of land, but has the
Nation's smallest population of a little over half a million people.
Wyoming's frontier and rural environment impacts our health care
systems. The State is a patchwork of rural health clinics, county-owned
critical access hospitals, for-profit hospital networks, and a handful
of community health centers. Wyoming does not have a medical college at
the University, but through partnerships with other State education
programs, medical students can receive their education. In terms of
other healthcare educational opportunities, Associate, Bachelor and
Advance Practice nursing programs are offered through the Wyoming
Community College network and the State's only university.
Wyoming has 25 hospitals, with 16 designated as critical access
hospitals. There are also 2 veteran's hospitals and 16 rural health
clinics--half of which are associated with hospitals in their
communities. Wyoming has eight community health centers, three are
special population health centers and three are satellites of larger
health centers. Even with these safety-net providers, many small towns
and huge areas of Wyoming are without access to primary care.
Distance to medical care is one of the biggest barriers of access
to care for many people in the State. This also includes the
considerations of terrain and weather. For instance, Sweetwater County
is the largest county, having 10,490 square miles within the county
lines. This is approximately the same size as the entire State of
Massachusetts. There are two major towns of over 10,000 people, and
more than 10 ``tiny towns'' (population under 200) in this county.
These residents have to travel, over some 120 miles to reach healthcare
services from a town closest to the eastern border of the county.
Many of Wyoming's residents who live in these small towns have the
same issues of needing to travel to care. A small town near the
Colorado border had a rural health clinic with an automated pharmacy
that provided medications for the common problems like providing
antibiotics for ear infections. The residents of this community were
used to traveling to a larger Colorado town for care beyond the basics.
Last summer the road washed out, resulting in longer travel to other
Wyoming towns to access care. The road was under repair for many
months.
Wyoming's health care system is fragile. Outmigration of medical
care to larger regional medical centers within Wyoming and to
neighboring States is a common occurrence. A report done for the
Wyoming Health Care Commission in 2007 by the Rural Policy Research
Institute (RUPRI) Center for Rural Health Policy Analysis stated:
``One of Wyoming's advantages in health care delivery is an
adequate array of facilities offering inpatient services,
hospitals and skilled nursing facilities (nursing homes).
Despite the availability of these institutional services and
the presence of qualified clinical personnel, our analysis
shows that many Wyoming residents are using health services in
[surrounding states] who could have been served in Wyoming. We
recommend convening a health care provider group to assess
patient migration patterns and implement a plan to achieve
optimal use of services in Wyoming (including across locations
in the state).''
http://www.wyominghealthcarecommission.com/images/reports/07-24-
07RUPRI%
20Summary%20Report%20Final%20July%2019,%202007.pdf.
The perception that health care delivered in bigger health centers
equals quality is not easily overcome. That should not stop leaders at
all levels of government from examining ways to support health care
systems internal and external to State borders.
As the only non-legislative coalition to address comprehensive
health issues in the State, the Wyoming Health Care Commission was
legislatively founded in 2003 and sunsetted in 2009. The Commission
compiled volumes of research by national experts and heard hours of
discussion and testimony by State leaders and stakeholders on important
facets of healthcare including patient safety, provider recruitment and
retention, including specific nursing shortages, and expanding health
insurance coverage in rural health settings. In spite of this work, not
one policy recommendation from the Health Care Commission became law.
In spite of many analysts' recommendations that the research and
coalition work continue to make Wyoming stronger and more efficient,
the Wyoming Legislature has again taken its place as the only
organization to tackle health care issues. Wyoming's citizen
legislature meets as a body only 60 days in the biennium and has some
interim study opportunities. As a result, it should not be surprising
that many individual legislators work from a piecemeal understanding of
health care. If they do not have the opportunity to serve on a health
committee or attend national health-focused conferences like National
Council of State Legislatures, they often do not understand the
complexity of this system.
In the RUPRI report, the following (in order) was suggested as ways
``to re-characterize the State's health care delivery system by 2030:
A stable supply of health care professionals to support
primary and secondary care everywhere in the State (including dental,
behavioral, and geriatric health providers).
Appropriately located tertiary care services in Wyoming
that are preferred (as compared to the same services in neighboring
States) by residents of the State.
Integration of services at the point of care; all
providers involved in any episode of care are fully informed of the
actions of other providers and disparate services are bundled for
purposes of patient-centered care and reasonable payment.
Collaborative planning and policy implementation within
regions of the State that include all services affecting health,
including but not limited to education, criminal justice,
transportation, economic development and land use planning.
Effective use of pooled financial resources to extend
financial access to all citizens.
Shared responsibility for achieving goals for individual
and population health among public and private organizations and with
individuals who are responsible for their own health.
Organized leadership, through a public-private
partnership, that keeps the State responsive to changes in national
policy, health care practice, and the demographics of the State.''
http://www.wyominghealthcarecommission.com/images/reports/07-24-
07RUPRI%20Summary%20Report%20Final%20July%2019,%202007.
pdf.
Across the State, there is a shortage of primary care providers.
Using Sweetwater County as an example, the large majority of people who
qualify for Medicaid and/or who have Medicare have no access to
providers within the county. Much of the research completed by the
Wyoming Health Care Commission is still on the Commission's Web site,
but efforts like the statewide Health Professionals Database have not
been updated since 2009. The database was one of the first efforts to
quantify the availability of providers in each of the 23 counties
undertaken by the Commission and is crucial to any ongoing decisions
about recruitment and retention of health care providers. Many
legislative and ad hoc discussions have centered on what would help
small Wyoming communities recruit physicians and mid-level
practitioners.
Much like all rural populations and that of Wyoming, the provider
population, is aging and nearing retirement age. This runs counter to
the increasing needs of a growing older population and a regional or
sporadic growth of younger populations. Studies have identified the
retirement of providers as one of the obstacles to providing
comprehensive care. According to a study by the National Rural Health
Association, ``nonmetropolitan areas typically can neither afford the
duplication necessary to bridge an expected transition in health
workforce, such as the retirement of a provider, nor the fluxuation or
innovation of new service requirements.''
http://www.ruralhealthweb.org/index.cfm?objectid=153C1CCF-3048-651A-
FEB0361
2F7316078.
Wyoming has a small amount of State incentive and loan repayment
money, and the dollar amounts do not meet the demand through each
biennium. It is less than effective for recruitment when the Web site
announcing the grant program becomes inactive in the second year of
biennium because the funds have been expended. Federal incentives for
recruitment and retention that focuses on rural States could help in
this area.
The Health Care Commission studied nursing staffing issues and in a
report in 2008 projected nursing demand:
``Assuming no changes to the current policy scenario, R&P
projections show that Wyoming's health care industry will need
a total of 3,307 more nurses by 2014 than were employed in 2006
(estimated at 3,145) to fill the projected demand. This
represents more than double the number of RNs working in health
care between 2006 and 2014. Assuming that growth as a result of
recent staffing pattern trends can be held constant at current
levels through policy changes, Wyoming's health care industry
will need only an additional 2,935 nurses by 2014 to fill
projected demand. The policy change scenario represents a
savings of approximately 400 nurses.''
http://www.wyominghealthcarecommission.com/images/reports/
nursing_demand_08.pdf.
Wyoming responded to this by creating a funding stream that would
assist nurses wanting to continue their education and work as faculty
at the community colleges and university. This allowed the nursing
programs to increase their enrollment numbers, and thus educate more
registered nurses. RN's are encouraged to continue their education into
the Advanced Practice Nursing level. The Wyoming Nurse Practice Act
does allow Advanced Nurse Practitioners to practice independently in
the State, which helps with access to primary care. However, there are
still underserved areas and many people that still struggle to find a
primary care provider.
Wyoming's population and demographics do not adequately represent
health care barriers when measured by practices, certifications and
Federal designations. For example, in the report on recruitment and
retention by the National Rural Health Association, quality
measurements and Patient Centered Medical Home certifications are
different in rural communities:
``One component of health quality is dependent upon the
entirety of the system and is particularly interwoven in a
collaborative nature in rural systems. This may be particularly
amplified in rural areas due to the relative lack of
duplication of services and the coexisting relationships among
the local health care providers themselves. For this reason,
providers find natural collaboration within models that may
look similar to modern concepts such as the Patient Centered
Medical Home while the administration of such models may appear
different. Creativity and flexibility have been necessary to
develop what works best in individual community circumstances
while serving similar purposes.''
http://www.ruralhealthweb.org/index.cfm?objectid=153C1CCF-3048-651A-
FEB0361
2F7316078.
The Wyoming Integrated Network (WY-ICN) is one effort to network
health care systems and is a hospital and provider driven effort that
offers patients in Wyoming information about cost and quality of
primary care. This ongoing effort recently received Federal funding
through the Health Care Innovation grant to expand efforts across the
State by educating communities about the Medical Home model. It is
anticipated that initial outcomes will provide useful information to
our State and other rural States.
Federal designations that provide eligibility for Federal programs
including HRSA 330 funding, enhanced Medicare and Medicaid
reimbursement like Health Provider Shortage Areas, Medically
Underserved Areas and Medically Underserved Populations are based on
factors that make it difficult to prove the needs of the underserved in
rural and frontier areas. For example, one provider (physician or mid-
level) per 3,500 people in an urban setting is entirely different than
3,500 people living in Sweetwater County, which is over 10,000 square
miles of land mass.
Wyoming is also not ethnically diverse as measured by the Federal
guidelines. Only one county, which is home to the Wind River
Reservation, has a large number of non-white residents. Based on how
grants are scored, this would prevent Wyoming from meeting these
guidelines.
Wyoming's economy is based primarily on energy production, coal,
natural gas, oil, uranium, and even wind, making it a ``boom and bust''
economy. Many people working in the energy industry make a sufficient
salary when they work. In some cases, these salaries are significant
enough that it can skew the average income for families based on
statewide data. Though some families do very well financially, there
are still a number of people struggling to make ends meet. This income
disparity can be another challenge to meeting designation guidelines.
Additionally, younger retirees have an impact on the overall
income, which is a measure of underserved designations. Working with
rural organizations to better define ``rural'' as it applies to health
care and eligibility for Federal designations would be one way to more
effectively provide safety-net care.
These are some but not all of the current and past efforts to
address access to health care for all Wyoming residents. Considerable
time has been put forth to create programs and provide funding in an
attempt to meet the needs of the citizens of Wyoming. Progress has been
made in some areas and the work continues in many others. The
geographical terrain accompanied by the low population is challenging,
but not impossible. Wyoming will continue to develop programs and
interventions that will provide our citizens with the care they need.
Senator Sanders. Miss Decklever, thank you so much for
being with us, and thanks for your testimony.
Our fourth witness is Dr. Andrew Wilper, he is the acting
chief of medicine at the VA Medical Center in Boise, ID. Dr.
Wilper is a practicing general internist. He is the associate
program director for the Boise Internal Medicine Residency
program and the assistant director of the Boise VA Center of
Excellence in Primary Care Education.
Dr. Wilper, thanks very much for being with us.
STATEMENT OF ANDREW P. WILPER, M.D., MPH, FACP, ACTING CHIEF OF
MEDICINE, VA MEDICAL CENTER, BOISE, ID
Dr. Wilper. Thank you, Chairman Sanders, Ranking Member
Enzi, and members of the committee. It is a great honor to be
able to testify here today.
I was asked by Senator Sanders about my insight, two
insights specifically. One about the lack of health insurance
in the United States and its effect on health and health care
outcomes, and also to share my thinking on practical solutions
to the primary-care physician workforce shortage that we face.
To start off, there is an enormous literature that has
accrued over decades demonstrating that a lack of health
insurance is associated with decreased access to health care
and worse health outcomes.
The Institute of Medicine summarized these findings in a
six-
volume series earlier this century and the conclusions were
quite clear. Subsequent work has built on this evidence,
including some of my own that Senator Sanders mentioned in his
opening statement, specifically, a paper we published in 2009
in ``The American Journal of Public Health,'' linking lack of
insurance to nearly 45,000 deaths among adults in the United
States annually. The research is consistent: health insurance
leads to significant benefits and is good for your health.
Gaining health insurance does not guarantee access to
medical care, which is the second part of my testimony, nor
does it control costs. And perhaps the singular intervention
that we could make at the national level to reduce costs and
improve outcomes in our country with regard to health is to
bolster our primary care workforce.
Now, there is an additional massive body of literature
supporting the idea that primary care improves all sorts of
health outcomes and lower costs. Nevertheless, we have not seen
systematic changes to alleviate the shortage of PCP's in the
United States in decades.
I will talk a little bit about three policy levers that I
see that this committee could consider to increase the number
of physicians entering into the primary care workforce, some of
which have been referred to by Professor Mullan.
First, at the medical school level, this is the period of
time after which people graduate from college and are in their
undergraduate medical training. We could introduce additional
educational debt reduction, change Federal funding streams to
emphasize primary care, and increase funding for the National
Health Service Corps. In addition, we could direct support to
community health centers to incentivize third and fourth year
medical students to enter into primary care careers.
Second point would be the area of graduate medical
education. First, title VII funding as specifically earmarked
to go toward primary care programs. These are continuously
under threat of congressional cut, and have been cut
dramatically in the past 10 years. Reemphasizing that funding
would be an important step.
Another piece would be direct payment by Medicare to
teaching hospitals to offset the expense of training
physicians. As we have heard today, nearly $10 billion is spent
by the Federal Government to support these hospitals, but
currently we have no planning in place to actually meet the
needs of our population in the United States with regard to a
physician workforce.
Medicare should direct funding to residency programs for
education, instead of directing it through hospitals. Medicare
should also require assessments of community and regional
physician workforce for hospitals to qualify for this funding.
In its current form, graduate education is run by teaching
hospitals to meet their own staffing needs or their historical
staffing needs, and graduates select their field of practice
based on their personal interests, to emphasize a point that
Senator Murphy made moments ago. I have been personally told by
a residency director that his concern is the professional
desires of his trainees rather than population health needs.
Perhaps the most important policy reform that we could make
to reinvigorate primary care would be to address the pay
disparity between primary care physicians and specialists. This
could be done by raising primary care physicians' pay or by
decreasing that of specialists, and I feel that it is really
the disparity that is the driving force in this workforce
problem that we are facing today. Indeed, the American
Association of Medical Colleges has declared that education and
training cannot overcome the intense market incentives that
influence physician choices.
A focal point for payment reform has been mentioned: a
subcommittee of the American Medical Association called the
Relative Value Scale Update Committee. This is a secretive
group of doctors that wields tremendous influence over Medicare
reimbursement rates and CMS adopts nearly all of their
recommendations.
At a minimum, the public deserves transparency in
decisionmaking from the RUC. Better yet, we should establish a
process for rate-setting that is not encumbered by conflicts of
interest and does not favor narrow specialties. A rational
observer might conclude that the Federal Government and AMA are
colluding to bring an end to the primary-care physician
workforce in the United States.
In summary, it is eminently clear that health insurance
affords better health outcomes including a decreased risk for
death. Despite this, our current reform efforts through the
Affordable Care Act will leave 30 million uninsured.
In closing, I have worked for over a decade in medical
education as a student, resident, fellow, and now faculty
member hospital and residency program leader. And it is my
conviction that publicly sponsored training should be planned
to meet the health care needs of our population rather than the
staffing needs of hospitals or the lifestyle preferences of
young doctors.
Thank you.
[The prepared statement of Dr. Wilper follows:]
Prepared Statement of Andrew P. Wilper, M.D., MPH, FACP
My name is Andrew Wilper. I am a practicing primary care physician
(PCP) and researcher. In addition, I have substantial experience in
medical education and care for the underserved. I am grateful to have
been asked by Senator Sanders about my insights into the lack of health
insurance in the United States and its effect on access to health care
and health outcomes. I have also been asked to share my thinking on
practical solutions to the primary medical care workforce shortage. I
have divided my testimony into two parts. First, I will address the
evidence that lack of health insurance impedes access to health care
and degrades health outcomes. Second, I will discuss the primary care
physician shortage in the United States and strategies to increase the
number of primary care physicians.
I. THE EFFECT OF LACK OF HEALTH INSURANCE ON ACCESS TO CARE AND HEALTH
OUTCOMES IN THE UNITED STATES
For decades, researchers have demonstrated the ill effects of the
lack of health insurance on access to medical care. This body of
literature is enormous, and the signal is clear; lack of insurance is
definitively associated with decreased access to medical care and
poorer health for those without such access. The Institute of Medicine
(IOM) summarized these findings and their implications in a six-volume
series in the early part of this century, identifying three mechanisms
by which insurance improves health:
1. Getting care when needed.
2. Having a regular source of care.
3. Continuity of coverage.\1\ \2\ \3\ \4\ \5\ \6\
Research by myself and others has built on this work. The evidence
continues to paint a clear and unambiguous picture. Lack of health
insurance is associated with worse health status, decreased likelihood
of having a usual source of medical care, and death.\7\ \8\ \9\ \10\ In
a 2009 article, we updated an older estimate produced by the IOM,
linking 44,789 deaths in 2005 with lack of insurance, more than were
estimated to die that year as a result of renal failure. Contrary to
the popular notion that most uninsured are young and healthy, we found
that roughly one-third of the uninsured had a chronic medical condition
that would require medical care, and that the uninsured are more likely
to suffer undiagnosed, and therefore untreated, chronic illness.\8\
\11\ The uninsured are more likely to go without needed care than the
insured, and to be admitted to the hospital for illness that could be
prevented.\12\ \13\ The data also supports the notion that when
previously uninsured individuals gain coverage through Medicare, their
decline in health reverses.\14\ \15\ The research is consistent: health
insurance leads to significant benefits and is good for your health.
These findings are borne out in my clinical practice. I have cared
for many patients who delayed care as a result of lack of insurance.
Perhaps the most poignant case was Mr. A, who worked as a delivery man.
He was also a diabetic. I cared for this gentleman while I was in my
residency training in Portland, OR. He was admitted to the hospital for
a hypertensive crisis, which is usually the result of longstanding
hypertension that has not been adequately treated. His blood pressure
was so high that he bled into his eyes. The damage extended to his
kidneys. We were able to stabilize and send him home with new
medications. It turned out that his employer had dropped his coverage
prior to our meeting in the hospital. As a result, he could no longer
afford to go to his primary care doctor. He had been ordering his
insulin from Canada, which would arrive by mail. He was using this
without proper supplies or monitoring, and was without his blood
pressure medications. This led to our meeting. Ultimately, his kidney
function became so compromised that he needed permanent dialysis. As
you know, this is an extremely expensive treatment, costing
approximately $80K per year. What I find so shocking about this story,
is that as a society we were willing to pay for his dialysis treatments
through the Medicare End Stage Renal Disease program, but were not able
to treat his chronic conditions that likely would have allowed us to
avoid dialysis in the first place. This case drove home the fact that
even routine treatments are out of reach for people who are uninsured.
Mr. A. was not simply the victim of bad luck, nor was he an outlier.
His situation was a result of policies that have left millions of
Americans without insurance and access to medical care.
II. PRIMARY CARE IN THE UNITED STATES
Background
Good evidence supports the myriad benefits of a robust primary care
workforce. Within the United States, States with larger proportions of
specialists actually have lower quality care.\16\ Others have
demonstrated that increased proportions of PCPs are associated with
significant decreases in health care costs.\17\ Primary care is also
linked to lower all-cause mortality, infant mortality, fewer low-birth
weight babies, improved self-reported health, decreased costs, and
decreased racial disparities.\18\ Studies suggest an association
between the availability of primary care and decreased emergency
department (ED) use. Many patients using the ED report that they would
be willing to use another source of care were one available.
Nevertheless, we have not seen systematic changes to alleviate the
shortage of PCPs in the United States. This is in spite of widespread
calls for reform. Indeed, in 2006 the American College of Physicians
predicted that without comprehensive reform by Congress and Centers for
Medicare and Medicaid Services (CMS), primary care, the backbone of the
U.S. Health care system, may collapse.\19\
The proportion of U.S. physicians practicing in primary care is low
compared to other industrialized nations. The Kaiser Family Foundation
estimates a total of 834,000 practicing physicians in the United States
in 2012.\20\ The proportion of physicians practicing in primary care in
the United States is approximately 40 percent, with the remaining 60
percent practicing in sub-specialties. This specialist-dominated
distribution has been linked to the high costs and poor health outcomes
in the United States. This misdistribution occurs in the context of
what many describe as a physician shortage. The Association of American
Medical Colleges (AAMC), American College of Physicians, and the
Council on Graduate Medical Education all estimate current shortages in
the tens of thousands, and predict that these will continue to
grow.\21\ \22\ \23\
Medical School
Numerous strategies exist to increase the number of medical
students entering primary care. These include educational debt
reduction, changes in Federal funding streams to emphasize primary
care, and increased funding to the National Health Services Corps. In
addition, direct support for Community Health Centers participating in
teaching medical students would support our Nation's most vulnerable
populations while training future PCPs.
Graduate Medical Education
Graduate medical education (GME) has been the focus of many
federally supported programs to increase the primary care workforce.
Funding for title VII programs, which support training for PCPs, is
continuously threatened by congressional cuts. Only the title VII
programs provide money directly to primary care training programs.
Remarkably, for every title VII dollar there are about $1,000 Medicare
GME dollars, and these Medicare GME dollars push training efforts
toward inpatient and subspecialty care. Medicare spending for GME is
directed toward hospitals, which is heavily tilted toward hospital-
based specialty care.\24\ Medicare should direct funding to residency
programs for education instead of directing it through hospitals.
Medicare should also require assessments of community and regional
physician workforce for hospitals to qualify for GME funding. In
effect, Medicare should begin requiring accountability in its
subsidization of teaching hospitals. Remarkably, the Federal Government
spends nearly $10 billion annually to produce a physician workforce
without a workforce plan. As part of his testimony before the House
Energy and Commerce Subcommittee on Health, Dr. Fitzhugh Mullan called
for ``requir(ing) teaching hospitals to undertake community or
regionally oriented analyses of physician workforce needs and make
application for training positions based on a fiduciary responsibility
to train a complement of residents that corresponds to agreed upon
regional needs.'' \25\ In its current form, GME is run by teaching
hospitals to meet their own staffing needs, and graduates select their
field of practice based on their personal interests. I have been
personally told by a residency program director that his concern is the
professional desires of his trainees, rather than population health
needs. Given the annual income of certain physician types, Medicare
could consider limiting or defunding training programs that do not meet
population needs, or that could be reasonably funded via trainee loans
given future income expectations.
Practice and Payment Reform
Payment reform is the most critical element of change needed to re-
invigorate primary care. Remarkably, it is explicit Federal Government
policy to direct oversized payment toward specialists and thereby skew
workforce statistics. Efforts to reform the payment system in an effort
to address the maldistribution of physicians by specialty have failed.
The resource-based relative values scale has grossly distorted relative
physician reimbursement since 1992. Now PCP compensation is 30 percent
to 60 percent less than subspecialists.\24\ Without payment reform, it
is unlikely that efforts targeting medical students and residents will
succeed in bolstering the primary care workforce. Indeed, the AAMC has
declared that ``education and training cannot overcome the intense
market incentives that influence physician choices.'' \25\ The income
disparity could be addressed by increasing PCP reimbursement or by
decreasing that of subspecialists.
A focal point for payment reform is a committee of the American
Medical Association called the Relative Value Scale Update Committee,
known as the RUC. This group of 31 doctors wields tremendous influence
over physician pay in the United States, with CMS following nearly all
of its recommendations. One estimate has the RUC directing $54 billion
in Federal spending annually. Yet the group has no government
oversight. This opaque group benchmarks reimbursement rates for
physician services in the United States and does so in a way that
favors surgeons and specialists. Only three seats on the committee are
designated for primary care specialties.\26\ Critics argue that RUC
decisions are based on suspect data leading to systematic overstatement
of time and work that favors surgery and subspecialty physicians. \27\
\28\ The playwright George Bernard Shaw commented that ``any sane
nation, having observed that you could provide for the supply of bread
by giving bakers a pecuniary interest in baking for you, should go on
to give a surgeon a pecuniary interest in cutting of your leg, is
enough to make one despair of political humanity.'' \29\ We have gone a
step beyond what Shaw feared by allowing physicians to set their own
rates. At a minimum, the public deserves transparency in decisionmaking
from the RUC. Better yet, we should establish a process for rate
setting that is not encumbered by conflicts of interest and does not
favor narrow specialties.
Expanded patient access to PCP services could be achieved through
strategies that reform current practice models. Expanded insurance via
the Affordable Care Act will stress primary care supply. In the 2 years
following health reform in Massachusetts, waits to see PCPs increased
by 82 percent.\30\ This has been linked to a mismatch between the
supply and demand for primary care services. Policy efforts to
implement the Patient Centered Medical Home will focus on risk-adjusted
capitated payments, non-traditional visits such as telephone and email
care, in addition to delegating physician decisionmaking to non-
physician team members. This will require changes in our reimbursement
system, workforce and the culture of medicine.
In summary, it is eminently clear that health insurance affords
better patient outcomes, and that it has been associated with decreased
risk of mortality. Despite this, our current reform efforts in the
Affordable Care Act will leave as many as 30 million uninsured. The
physician pipeline recommendations above have been made for years by
health policy and workforce experts. Nonetheless, efforts to increase
the number of PCPs have been frustrated by the funding mechanisms for
medical education in the United States. This current system of funding
is at best inefficient, meeting the needs of a narrow group of teaching
hospitals and subspecialists. At its worst, the current GME funding
stream acts as a principal driver for a workforce that meets the
interests of physicians and hospitals rather than the health needs of
the population. In addition, Medicare's grossly unequal fee payments to
specialists and PCPs continues to discourage trainees from primary care
careers. I have worked for over a decade in medical education as a
student, resident, fellow, faculty member and residency program and
hospital leader. My conviction is that publically sponsored training
should be planned to meet the health care needs of our population
rather than the staffing needs of hospitals or the lifestyle
preferences of young doctors.
Thank you.
End Notes
1. Insuring America's Health: Principles and Recommendations.
Washington, DC: The National Academies Press; 2004.
2. Care without Coverage: Too Little, Too Late: Principles and
Recommendations. Washington, DC: The National Academies Press; 2002.
3. Health Insurance is a Family Matter: Principles and
Recommendations. Washington, DC: The National Academies Press; 2002.
4. Hidden Costs, Value Lost: Uninsurance in America: Principles and
Recommendations. Washington, DC: The National Academies Press; 2003.
5. Coverage Matters: Insurance and Health Care: Principles and
Recommendations. Washington, DC: The National Academies Press; 2001.
6. A Shared Destiny: Community Effects of Uninsurance: Principles
and Recommendations. Washington, DC: The National Academies Press;
2003.
7. Finkelstein A, Taubman S, Wright B, et al. The Oregon Health
Insurance Experiment: Evidence from the First Year. NBER Working Paper
No. 17190. Issued July 2011.
8. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH,
Himmelstein DU. A national study of chronic disease prevalence and
access to care in uninsured U.S. adults. Ann Intern Med. 2008 Aug
5;149(3):170-6.
9. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH,
Himmelstein DU. Health insurance and mortality in U.S. adults. Am J
Public Health. 2009 Dec;99(12):2289-95.
10. Sommers BD, Baicker K, Epstein AM. Mortality and access to care
among adults after State Medicaid expansions. N Engl J Med. 2012 Sep
13;367(11):1025-34.
11. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH,
Himmelstein DU. Hypertension, diabetes, and elevated cholesterol among
insured and uninsured U.S. adults. Health Aff (Millwood). 2009 Nov-
Dec;28(6):w1151-9.
12. Lurie N, Ward NB, Shapiro MF, Brook RH. Termination from Medi-
Cal-does it affect health? N Engl J Med. 1984;311:480-84.
13. Weissman JS, Gatsonis C, Epstein AM. Rates of avoidable
hospitalization by insurance status in Massachusetts and Maryland.
JAMA. 1992;1992;268:2388-94.
14. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of
previously uninsured adults after acquiring Medicare coverage. JAMA.
2007;298:2886-94.
15. McWilliams JM. Health consequences of uninsurance among adults
in the United States: recent evidence and implications. Milbank Q. 2009
Jun;87(2):443-94.
16. Baicker K, Chandra A. Medicare spending, the physician
workforce, and beneficiaries' quality of care. Health Aff (Millwood).
2004 Jan-Jun;Suppl Web Exclusives:W4-184-97.
17. Kravet SJ, Shore AD, Miller R, Green GB, Kolodner K, Wright SM.
Health care utilization and the proportion of primary care physicians.
Am J Med. 2008 Feb;121(2):142-8.
18. Starfield B, Shi L, Macinko J. Contribution of primary care to
health systems and health. Milbank Q. 2005;83(3):457-502.
19. American College of Physicians. The Impending Collapse of
Primary Care Medicine and Its Implications for the State of the
Nation's Health Care: a report from the American College of Physicians.
January 2006.
20. United States: Physicians. The Kaiser Family Foundation. http:/
/www.statehealthfacts.org/profileind.jsp?cat=8&sub=100&rgn=1, accessed
January 24, 2013.
21. American Association of Medical Colleges. Physician Workforce
Policy Recommendations. September 2012. https://www.aamc.org/download/
304026/data/2012aamcworkforcepolicyrecommendations.pdf, accessed
January 24, 2013.
22. How Is a Shortage of Primary Care Physicians Affecting the
Quality and Cost of Medical Care? A comprehensive Evidence Review.
American College of Physicians, 2008 http://www.acponline.org/advocacy/
where_we_stand/policy/primary_shortage.pdf, accessed January 24, 2013.
23. Physician Workforce Policy Guidelines for the United States,
2000-20. Council on Graduate Medical Education. January 2005. http://
www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/
sixteenthreport.pdf, accessed January 24, 2013.
24. Thomas Bodenheimer, M.D., Kevin Grumbach, M.D., and Robert A.
Berenson, M.D.A. Lifeline for Primary Care. N Engl J Med 2009;
360:2693-96.
25. Mullan, Fitzhugh. Testimony before the House Energy and
Commerce Subcommittee on Health. http://sphhs.gwu.edu/departments/
healthpolicy/dhp_
publications/pub_uploads/dhpPublication_14EBB1B9-5056-9D20-3D27A281209
EB378.pdf, accessed January 24, 2013.
26. RUC Members Effective July 1, 2012. American Medical
Association. http://www.ama-assn.org/resources/doc/rbrvs/ruc-members-
current.pdf, accessed January 24, 2013.
27. Wilde, A., McGinty, T. (2010, October 26). Physician Panel
Prescribes the Fees Paid by Medicare. Wall Street Journal. Retrieved
from http://online.wsj.com/article/
SB10001424052748704657304575540440173772102.html .
28. Jerry Cromwell, Sonja Hoover, Nancy McCall and Peter Braun.
Validating CPT Typical Times for Medicare Office Evaluation and
Management (E/M) Services. Med Care Res Rev 2006 63: 236.
29. George Bernard Shaw, The Doctors Dilemma, New York: Brentano's,
1911.
30. Amireh Ghorob, A., Bodenheimer, T. Sharing the Care to Improve
Access to Primary Care. N Engl J Med 2012; 366:1955-57. May 24, 2012.
Senator Sanders. Thank you very much, Dr. Wilper.
My understanding is that Senator Franken has to leave, and
you wanted to ask a brief question of Dr. Wilper, is that
correct?
Senator Franken. Thank you, Mr. Chairman. You are talking
about compensation. You probably heard my comment earlier about
the return on investment in terms of loan forgiveness for
primary care physicians. What would that look like? I know we
do some loan forgiveness in ACA. We do it for people serving in
underserved communities. What would that look like, and how
could you compute that in terms of what value you would get
back over the course of a physician's career? If you said,
``OK. If you're a GP, boom, $100,000 off of your loan.'' Have
studies been done to do that? Has that been looked at?
Dr. Wilper. Senator Franken, thank you for the question.
To my knowledge, there is no systematic review of that
specific question. I know in my State of Idaho, which is a
neighbor to Wyoming and also exceptionally rural, we do have
programs in place to help offset educational debt related to
medical education, and those have been somewhat successful.
I would defer to my panelist to my left, Dr. Reinhardt, who
may be able to comment on that question.
Senator Franken. Dr. Reinhardt, since you are a medical
economist, may I ask you that?
Dr. Reinhardt. If you have more primary care physicians,
that will improve access. And the Institute of Medicine's
studies that were cited shows that that will produce better
health and life years, and we economists can covert that into
quality adjusted life years. And usually, the assumption is a
value is imputed to that.
Normally, I know David Cutler and others use $100,000 just
to put a value on it. And then say by having more physicians in
that field and providing better access, how many ``qualies''
have you produced, life years saved, or better quality of life,
and you would get the return. I suspect it would be fairly
high.
Senator Franken. I would love if that could be done.
Dr. Reinhardt. It would be a nice senior thesis. I will ask
a student.
Senator Franken. Since I just have 2 minutes left, then I
will just go.
Senator Sanders. That's all you have left anyhow.
Senator Franken. That's what I meant.
Senator Sanders. You're not doing us a great favor here.
Senator Franken. I was making the same point. I would like
those 3 seconds back.
I would like, to Senator Murphy's question or comment about
the status, I think your status is partly determined by your
salary. So I do think that the Relative Value Board that you
were talking about, I cannot remember the name right off, in
other countries what is the compensation like in terms of
general practitioner to specialist? Is it different? Is it
lower? I mean, is the ratio higher from GP to specialist in
other countries versus here?
Dr. Reinhardt. Specialists do earn more I know, for
instance in Germany, but not as much as they do here. So GP's
generally do have lower pay and occasionally protest about
that. It happens over there. But I don't think the ratio is
quite as large as it is here.
Senator Franken. Yes.
Dr. Reinhardt. There's also a huge----
Senator Franken. They have lower health costs and as good
outcomes, if not better, right?
Dr. Reinhardt. Yes, about half, yes.
Senator Franken. The health care costs. OK. I just wanted
to do this.
Senator Murphy, again, brought this up, Accountable Care
Organizations, which we have a lot of in our State and health
care homes, medical homes, would they elevate the role of
general practitioner in that model? In the sense that they
would be sort of organizing this team that does the care?
Does anybody have an opinion on that?
Dr. Wilper. Specifically with regard to ACO's, unless fee
for service payment mechanisms are changed, and there is a
proposal to do that in these new medical home models to move to
a capitated system, there is some chance that that would move
the needle in terms of primary care physician reimbursement.
I would caution, however, I know this research fairly well.
There is very limited evidence that patient-centered medical
homes are actually going to reduce costs. I think that that
intervention, while worthy--and we are working on it at the
State level and within the VA--is still, in my view,
experimental.
Senator Sanders. OK.
Senator Franken. Well, OK. I'm sorry. Thank you, rather,
Mr. Chairman for that. And I just wanted, just one last thing.
Miss Decklever, I thought it was really off-base for the
Ranking Member to use your willingness to come here to testify
to moan about his weekly commute.
[Laughter.]
Senator Sanders. Let me introduce a man who has already
spoken--reintroduce him--and that is Dr. Uwe Reinhardt. He is
the James Madison Professor of Political Economy, and professor
of economics and public affairs at Princeton University, and
contributing writer to ``The New York Times'' economics blog.
Dr. Reinhardt, thanks very much for being with us.
STATEMENT OF UWE E. REINHARDT, Ph.D., JAMES MADISON PROFESSOR
OF POLITICAL ECONOMY AND PROFESSOR OF ECONOMICS AND PUBLIC
AFFAIRS, PRINCETON UNIVERSITY, PRINCETON, NJ
Mr. Reinhardt. Thank you, Mr. Chairman for inviting me to
this committee. I am very honored by it.
I should have added to my CV that I was delivered by a
midwife and, of course, my mother. I once told that to a member
of the American Medical Association and he said, ``Well, it
shows.'' And I'm not sure what he meant.
I divided my written statement into three parts. First, is
our current workforce efficiently used? And I think you have
already heard from the panel; the answer is no.
The second is, what public policy levers does the Congress
have given that we want more primary care physicians to move
them into that field and also to the practice where they are
needed?
Then the third question is, to what extent can financial
incentives be used, which you have already answered and talked
about.
The traditional model of workforce forecasting has been the
focus on physician population ratios, as if all the other
people who work in the primary care team didn't matter. My
whole career has been to say we should use non-physician
workers far more imaginatively and let them practice
independently in full competition with physicians. That was
very controversial many years ago, less so now. Many States
actually already allow that.
Congress has played a very large role in innovating in this
field by funding the training of nurse practitioners and
physician assistants, and also creating community health
centers in other settings where they have very, very
effectively been used.
There are issues of licensing that Congress could address.
Usually licensing is excused, professional licensing, with an
appeal to a patient's safety and quality. Usually the violins
come out when I hear that. I think it is mainly over economic
turf. It always has been.
I remember the fight over whether optometrists could dilate
pupils. I think it was settled years ago, but those were the
issues. It is almost like an insurgent war that has to be
fought. I think Congress should simply make sure that licensing
is driven by clinical and patient quality, and not by economic
turf.
There is an issue of the SOP's, Scopes of Practice, which
now States dominate and there are huge variations in that. I
believe there should be. I agree with the nursing profession,
there should be a standard SOP for the Nation which, in my view
as I said, should allow nurses to practice independently.
Physicians Assistants, by their nature, actually are supervised
by physicians.
On the second question of how can you drive physicians to
the extent you definitely need them in these teams into primary
care, there is the issue of prestige; Senator Murphy mentioned
that.
My view on that is the new models of primary care, medical
home, the ACO's, et cetera, will quite naturally enhance the
professional power. It is not just money, it is also power
because they are not gatekeepers, but they are, nevertheless,
traffic cops. And I think in those settings their prestige will
rise.
I told that to our daughter, who is an internist,
yesterday. I said, ``I would be very excited to be a primary
care physician now.'' The entrepreneurial opportunities are
limitless there; much less in other specialties.
On the final point, I had some probably controversial
things. Compensation is clearly an issue. Mr. Chairman, you
mentioned that over a lifetime, a specialist gets $2 to $3
million more. Actually, it is such a small sum when you think
of a Goldman managing director, if that were the annual bonus,
they would be offended by it. But that probably would do
something because it sort of signals value to people.
Debt forgiveness, I think, that should definitely be done.
It is really sort of like the National Health Service Corps. I
would say for every year you practice--or you could say, ``If
you go into a specialized field in primary care, we'll forgive
you, say, $80,000 up front. And then for every year you
specialize in a location that we would like you to go, we'll
forgive you $20,000,'' sort of to have that incentive out
there.
Finally, I thought when I think that we are actually
allowing private equity managers to take what is really just
earned income, a commission, and get capital gains taxes on it,
carried interest, I said, ``Why don't we honor primary care
physicians in America as we honor private equity managers, and
give them the same rate if, say, they go to rural areas?'', et
cetera. The precedent exists. Congress says, ``Well, carried
interest. We want to encourage capital formation.'' Well, that
is capital. Physicians are human capital, and we want to
encourage them.
Thank you, Mr. Chairman.
[The prepared statement of Mr. Reinhardt follows:]
Prepared Statement of Uwe E. Reinhardt, Ph.D.
My name is Uwe E. Reinhardt. I am the James Madison Professor of
Economics and Public Affairs at the Woodrow Wilson School of Public and
International Affairs and the Department of Economics of Princeton
University, Princeton, NJ.
My research over the last several decades has focused primarily on
health economics and--policy, although I also teach or have taught at
Princeton University general economics, financial accounting and
financial management. Throughout my career, I have had an interest in
issues surrounding the health workforce.
I would like to thank you, Mr. Chairman, and your colleagues for
inviting me to testify before this committee on a matter of importance
to the successful implementation of the Affordable Care Act (ACA) of
2010--the ability of our health system to absorb the additional demand
for health-care services likely to be triggered by the extension of
health-insurance coverage to an estimated 30 million or so Americans
who would otherwise have remained uninsured.\1\
---------------------------------------------------------------------------
\1\ Association of American Medical Colleges. The Impact of Health
Care Reform on the Future Supply and Demand for Physicians Updated
Projections Through 2025 (June 2010).
---------------------------------------------------------------------------
That challenge should prompt us once more to explore the following
questions that have hovered over workforce issues in this country for
at least half a century, to wit:
I. Is our current health workforce--especially in primary care--
used as effectively and efficiently as it could be?
II. What public-policy levers are there to influence the choice of
physicians on:
a. what medical specialty to enter, and
b. where to practice?
III. To the extent that financial incentives play a role in the
choice of specialty and location, what policy levers are there in this
respect?
I will order my remarks along this outline. Before proceeding,
however, I would like to summarize here my various recommendations.
1. As an economist I have long favored the independent clinical
practice of primary care by properly trained nurse practitioners
without supervision by a physician, either in free-standing, nurse-led
clinics of the sort pioneered by Mary Mundinger \2\ or, better still in
clinically integrated settings where the idea ``supervision by a
physician'' would be replaced by ``collegial collaboration with a
physician.''
---------------------------------------------------------------------------
\2\ Mary O. Mundinger et al. ``Primary Care Outcomes in Patients
Treated by Nurse Practitioners or Physicians: A Randomized Trial,''
Journal of the American Medical Association (January 5, 2000)
283(1):59-68. http://jama.jamanetwork.com/
article.aspx?articleid=192259#qun
defined.
---------------------------------------------------------------------------
2. I endorse the idea put forth by the Advanced Practice Nurse
Practitioners (APNP) Consensus Working Group and the National Council
of State Boards of Nursing to develop for use by the States a national
scope of practice (SOP) for the nursing profession, to limit or perhaps
even eliminate the current variation in SOPs across the States.
3. Evidently, the standardized national SOP should reflect the
expertise of both, physicians and nurse practitioners. But, to avoid
the inherent economic conflicts of interest both professions have in
the matter, the standardized SOP should be developed by a carefully
selected board that is not dominated by either nurse practitioners or
physicians, and that has significant representation by patients and
those who pay for health care, including public payers.
4. As even the authoritative Medicare Payment Advisory Commission
(Medpac) could not find a theoretical foundation for the existing
payment differentials for identical primary care services rendered by
primary care physicians and by non-physician primary care givers, I
support calls for eliminating these differentials in public insurance
programs and for calling upon private health insurers, whose clients
also lament a shortage of primary care physicians, to recognize the
role of non-physician primary care givers and to eliminate the payment
differentials as well.
5. If Congress sincerely believes that there is and will be an
acute shortage of primary care physicians, it should realign the levels
of compensation of physicians under Medicare and Medicaid more in favor
of primary care physicians. If Congress would like to see that
realignment, it has no choice but to lead the way, as individual
private insurers would find it difficult to effect the realignment by
themselves.
6. Congress should fund experiments with rewarding the choice of a
career in primary care, or to practice in an area with an acute
shortage of primary care physicians, by forgiving for every year the
physician works full-time in primary care part of the debt medical
graduates have accumulated during their education and training.
7. As long as carried interest paid from long-term capital gains is
accorded the dubious tax preference Congress has accorded it, Congress
should extend that privilege also to primary care professionals, at
least for some time of their careers.
I. EFFECTIVE AND EFFICIENT USE OF THE HEALTH WORKFORCE
Primary health care is still thought of among the laity as the
health care rendered by a particular subset of physicians who tend to
serve as the patient's primary contact with the health-care system. It
naturally leads to hand-wringing over projected physician-population
ratios for physicians in primary care.
A much superior definition of primary care has been offered by the
Institute of Medicine in a report ``Primary Care: America's Health in a
New Era \3\:
---------------------------------------------------------------------------
\3\ Molla S. Donaldson, Karl D. Yordy, Kathleen N. Lohr and Neal A.
Vanselow, eds. Primary Care: America's Health in a New Era (1996).
Washington, DC: Committee on the Future of
Primary Care, Institute of Medicine, 1996. http://www.nap.edu/
openbook.php?isbn=03090
53994.
Primary care is the provision of integrated, accessible
health care services by clinicians who are accountable for
addressing a large majority of personal health care needs,
developing a sustained partnership with patients, and
---------------------------------------------------------------------------
practicing in the context of family and community.
This definition undoubtedly leans on the even more expansive
definition offered in the World Health Organization's Declaration of
Alma Alta of 1978:
Primary health care is essential health care based on
practical, scientifically sound and socially acceptable methods
and technology made universally accessible to individuals and
families in the community through their full participation and
at a cost that the community and country can afford to maintain
at every stage of their development in the spirit of self-
reliance and self-determination. It forms an integral part both
of the country's health system, of which it is the central
function and main focus, and of the overall social and economic
development of the community. It is the first level of contact
of individuals, the family and community with the national
health system bringing health care as close as possible to
where people live and work, and constitutes the first element
of a continuing health care process.\4\
---------------------------------------------------------------------------
\4\ World Health Organization, Declaration of Alma-Ata
International Conference on Primary Health Care, Alma-Ata, USSR, 6-12
September 1978. http://www.who.int/publications/
almaata_declaration_en.pdf.
I recite these definitions of primary care--presumably very well
known to members of this committee--to highlight the fact that the
provision of primary care in a community and in the Nation should be a
team effort, ideally within an organizational structure that encourages
teamwork and the efficient delegation of tasks among members of the
team.
Physician-Population Ratios: Research over the years has shown that
there is actually much more flexibility in the substitution among types
of health professionals than has traditionally been presumed among
health workforce planners who think in terms of ideal physician-
population ratios.
Indeed, it is remarkable how widely physician population ratios
vary among advanced economies and even within countries. Figure 1
illustrates this phenomenon for the United States with data published
by the American Association of Medical Colleges (AAMC) in its report
2011 State Physician Workforce Data Book.\5\
---------------------------------------------------------------------------
\5\ American Association of Medical Colleges (AAMC). 2011 State
Physician Workforce Data Book. Washington, DC: AAMC, November 2011.
https://www.aamc.org/download/263512/data/statedata2011.pdf.
The map overleaf, taken directly from the AAMC report, illustrates
the geographic pattern of the ratio of primary care physicians to
population. Evidently, the northeastern States are relatively much
better endowed with primary care physicians than are many of the
southern States. Yet in these States one also constantly hears laments
over a prevailing or impending physician shortage.
Figure 2--Map of Primary-Care Physicians per 100,000 population,
2010
The AAMC data raise the following question. If the ideal endowment
with primary care physicians is to be gauged by some ideal physician-
population ratio, which of the many different ratios across the United
States should it be? How should one arrive at the answer?
I addressed myself to this question years ago in my doctoral
dissertation with the now politically incorrect title Physician
Productivity and the Demand for Health Manpower, at a time when the
earlier enactment of Medicare gave rise to laments of a serious overall
physician shortage.\6\ Using a cross-section data base on medical
practices, I found that the feared shortage could be substantially
mitigated through more judicious task delegation from physicians to
support staff with clinical training short of a physician's, but also
with much lower costs per hour of work.
---------------------------------------------------------------------------
\6\ Uwe. E. Reinhardt, Physician Productivity and the Demand for
Health Manpower. Boston, MA: Ballinger Publishing Company, 1975.
---------------------------------------------------------------------------
In the meantime, modern technology and improved training of non-
physician clinical personnel has made possible even more extensive task
delegation. Most prominently mentioned among the non-physician health
professionals are advanced practice nurse practitioners (APRNs or
simply NPs) and physician assistants (PAs). A more comprehensive
definition would include pharmacists providing pharmaceutical care
services and certified nurse midwives. Some would include even
dentists.
The Growing Role of Non-Physician Primary-Care Professionals: The
consensus in the literature \7\ is that the traditional primary care
model relying almost exclusively on primary care physicians is a thing
of the past.\8\ It had physicians perform many task for which, in
effect, they were overqualified, as has been vividly described by
primary care physician Lawrence P. Casalino in his ``A Martian's
Prescription for Primary Care: Overhaul the Physician's Workday.'' \9\
---------------------------------------------------------------------------
\7\ For syntheses of this literature, see Robert Wood Johnson
Foundation, Primary care workforce in the United States. Policy Brief
No. 22. July 2011, or Julia Paradise, Cedrik Dark and Nicole Bitler,
Improving Access to Adult Care in Medicaid: Exploring the Potential
Role of Nurse Practitioners and Physician Assistants. Washington, DC:
Kaiser Commission on Medicaid and the Uninsured. March 2011, http://
www.kff.org/medicaid/upload/8167.pdf or Mary D. Naylor and Ellen T.
Kurtzman, ``The Role of Nurse Practitioners in Reinventing Primary
Care.'' Health Affairs. (May 2010) 29(5): 893-99.
\8\ David Margolius and Thomas Bodenheimer, ``Transforming Primary
Care: From Past Practice to the Practice of the Future.'' Health
Affairs. (May 2010) 29(5): 779-84.
\9\ Lawrence P. Casalino, ``A Martian's Prescription for Primary
Care: Overhaul the Physician's Workday.'' Health Affairs (May 2010)
29(5): 785-90.
---------------------------------------------------------------------------
The traditional model is being replaced by new models of primary
care in which advance practice registered nurses, physician assistants
and other professionals will play a much larger role. Some authors have
recently argued that the perceived primary care shortage could be all
but eliminated through the use of primary care teams relying heavily on
non-physicians and modern electronic communication.\10\
---------------------------------------------------------------------------
\10\ Linda V. Green, Sergei Saving and Yina Lu, ``Primary Care
Physician Shortages Could Be Eliminated Through the Use of Teams,
Nonphysicians and Electronic Communication.'' Health Affairs. (January
2013). 32(1): 11-19.
---------------------------------------------------------------------------
In fact, non-physician primary care professionals have been by far
the fastest growing component of the primary care workforce in this
country. During 1995-2005, for example, the number of primary care
physicians per capita grew by only 1.1 percent per year while that of
nurse practitioners grew by 9.4 percent and that of physician
assistants by close to 4 percent. To be sure, physicians still made up
three-quarters of the primary care workforce by 2005,\11\ but only
about 60 percent by 2009.\12\ That fraction is bound to fall further in
the decades ahead as models relying on non-physician primary care
professionals develop further and proliferate, especially in areas less
popular with primary care physicians. In those areas non-physician
primary care professionals already make up a greater share of the
primary care workforce.\9\
---------------------------------------------------------------------------
\11\ A. Bruce Steinwald, Primary Care Professionals: Recent Trends,
Projections, and Valuation of Services. Washington, DC: General
Accountability office, February 12, 2008: Table 1, p. 7.
\12\ Julia Paradise, Cedrik Dark and Nicole Bitler op. cit.: 3.
---------------------------------------------------------------------------
Although the barriers to greater reliance on non-physician primary
care professionals do not strike me as overwhelming, there remain some
that could and should be removed by government. These barriers are (a)
State-regulated scopes of practice (SOPs) and (b) differential payment
levels.
Scope of Practice (SOP) Restrictions: Like any other health
professionals, nurse practitioners, physician assistants and other non-
physician professionals working in primary care--e.g., pharmacists
providing a valuable service called ``pharma-care'' or ``pharmaceutical
care services (PCS) \13\--are subject to formal scopes of practice
(SOPs) that require a specified content of education and training,
prescribe limits on the scope of services the professional may deliver
and also dictate whether or not they may practice independently of a
physician or must be supervised by a physician.\14\
---------------------------------------------------------------------------
\13\ Carole W. Cranor, Barry A. Bunting and Dale B. Christensen,
``The Asheville Project: long-term clinical and economic outcomes of a
community pharmacy diabetes care program.'' Journal of the American
Pharmaceutical Association. (May-April 2003) 43(2): 173-84. http://
healthmaprx.com/yahoo_site_admin/assets/docs/Cranor31.90105431.pdf.
\14\ American Medical Association, AMA Scope of Practice Data
Series. (October 2009). http://www.tnaonline.org/Media/pdf/apn-ama-sop-
1109.pdf.
---------------------------------------------------------------------------
Society has traditionally granted licensed physicians an
extraordinarily wide SOP, including the off-label prescription of
potentially harmful drugs that have not been approved for these off-
label indications by the Food and Drug Administration.
The SOPs for non-physician primary care givers are reasonably
narrower than those granted physicians--as the former undoubtedly would
be the first to agree. But for reasons that evidently have much more to
do with a penchant for protecting economic turf and the political power
of State medical societies than with safety standards of patient care,
the SOPs for non-physician primary care professionals still vary
considerably among States \15\--and that in the land that originally
invented and grew powerful on the idea that ``one-size-fits-all''
(think of McDonalds, the Holiday Inn, and the many other national and
now global franchises for which America is famous.) Furthermore, in
some States these restrictions are narrower than they need to be.\16\
---------------------------------------------------------------------------
\15\ Joanne M. Pohl, Charlene Hanson, Jamesetta A. Newland and
Linda Cronenwett, ``Unleashing Nurse Practitioners' Potential to
Deliver Primary Care and Lead Teams.'' Health Affairs. (May 2010):
29(5): 90-905.
\16\ Mary D. Naylor and Ellen T. Kurtzman, ``The Role of Nurse
Practitioners in Reinventing Primary Care.'' Health Affairs. (May 2010)
29(5): 896.
---------------------------------------------------------------------------
The most contentious issue in this regard is the clinical
independence of nurse practitioners. The conceptual model for the work
of physician assistants has always been to work with and under the
supervision of a physician, and the profession seems comfortable with
that restriction. Nurse practitioners, on the other hand, could and do
practice independently of physicians and in quite a few States as can
be seen in this map taken directly from the previously cited Kaiser
Commission on Medicaid and the Uninsured.\9\
The foregoing leads me to the following recommendations:
As an economist I have long favored the independent clinical
practice of primary care by properly trained nurse
practitioners without supervision by a physician, either in
free-standing, nurse-led clinics of the sort pioneered by Mary
Mundinger \17\ or, better still in clinically integrated
settings where the idea ``supervision by a physician'' would be
replaced by ``collegial collaboration with a physician.''
---------------------------------------------------------------------------
\17\ Mary O. Mundinger, et al. ``Primary Care Outcomes in Patients
Treated by Nurse Practitioners or Physicians: A Randomized Trial,''
Journal of the American Medical Association (January 5, 2000)
283(1):59-68. http://jama.jamanetwork.com/
article.aspx?articleid=192259#qun
defined.
---------------------------------------------------------------------------
I endorse the idea put forth by the Advanced Practice Nurse
Practitioners (APNP) Consensus Working Group and the National
Council of State Boards of Nursing to develop for use by the
States a national scope of practice (SOP) for the nursing
profession, to limit or perhaps even eliminate the current
variation in SOPs across the States.
Evidently, the standardized national SOP should reflect the
expertise of both, physicians and nurse practitioners. But, to
avoid the inherent economic conflicts of interest both
professions have in the matter, the standardized SOP should be
developed by a carefully selected board that is not dominated
by either nurse practitioners or physicians, and that has
significant representation by patients and those who pay for
health care, including public payers.
Payment for Non-Physician Primary-Care Givers: Most economists
probably would subscribe to the principle that the same price should be
paid for identical goods or services, regardless of who produced it. A
truly competitive market of textbook fame would actually yield that
result.
The available research suggests that the quality of the care
rendered by nurse practitioners--measured along several dimensions,
including process, clinical outcome and patient satisfaction--is as
good as that rendered by primary care physicians for the services
allocated to nurse practitioners under existing SOPs.\18\ That
circumstance suggests that nurse practitioners should receive for the
services they render the same fees paid to physicians for those same
services.
---------------------------------------------------------------------------
\18\ Julia Paradise, Cedrik Dark and Nicole Bitler, op cit.: 3-4.
---------------------------------------------------------------------------
In fact, however, the current practice has been to pay nurse
practitioners less. Medicare and Medicaid, for example, pay them 75 to
85 percent of the comparable physician fee, unless the nurse
practitioner practiced under the direct supervision of a physician in
which the payment is 100 percent.
Could such a differential in payment be defended? The only
explanation I can think of is that with a visit to a physician, the
patient purchases two things: (a) the delivery of the service in
question and (b) a conveniently available stand-by capacity in the form
of the physician's wider technical competence in health care. The
higher fee paid physicians thus could be construed as payment for that
stand-by capacity. This may not be a convincing argument, but it is
that, that presumably has driven the differential payment.
Do private insurers have a more sophisticated approach in this
regard? On the contrary. According to the literature, many of them
erect much higher financial barriers to nurse practitioners by refusing
to recognize and credential them as primary care providers or, if they
do credential them, paying them less than they pay physicians.\19\
---------------------------------------------------------------------------
\19\ Tine Hansen-Turton, Ann Ritter and Rebecca Torgan, Insurers'
Contracting Policies on Nurse Practitioners as Primary Care Providers :
Two Years Later. Policy Politics Nursing Practice 2008 9(4): 241-8.
As even the authoritative Medicare Payment Advisory
Commission (Medpac) could not find a theoretical foundation for
the existing payment differentials for identical primary care
services rendered by primary care physicians and by non-
physician primary care givers, I support calls for eliminating
these differentials in public insurance programs and for
calling upon private health insurers, whose clients also lament
a shortage of primary care physicians, to recognize the role of
non-physician primary care givers and to eliminate the payment
---------------------------------------------------------------------------
differentials as well.
Government's Role in Primary-Care Innovation: Although popular
folklore has it that government rarely innovates in health care--even
though it was the first to introduce bundled payments for health care
in the form of DRGs and developed the Medicare fee schedule whose
underlying relative-value scale is now used by most private insurers--
Medicare, Medicaid and several State governments actually have been
quite progressive in supporting the development of the more modern
primary care models.
On the supply side, the Federal Government as early as the 1960s
started to provide financial support to the education and training of
non-physician primary care professionals through the National Health
Service Corps (NHSC) which also, of course has supported physicians. It
can be argued that the NHSC has never been as large as it should have
been, or ought to be in the future; but it was important in recognizing
early the value of these non-physician health professionals.
The ACA of 2010 further enhances Federal institutional support to
expand the supply of these professionals, along with individual support
through the NHSC program.
Finally, the U.S. Veterans Administration health system has long
demonstrated the successful use of non-physician primary care
professionals in the delivery of health care.\20\ \21\
---------------------------------------------------------------------------
\20\ Perri M. Morgan, David H. Abbott, Rebecca B. McNeil and
Deborah A. Fisher, ``Characteristics of primary care office visits to
nurse practitioners, physician assistants and physicians in U.S.
Veterans Health Administration facilities, 2005 to 2010: a
retrospective cross-sectional analysis.'' Human Resources for Health.
2012. 10: 42. http://www.human-resources-health.com/content/pdf/1478-
4491-10-42.pdf.
\21\ D. Buzdi, S. Lurie and R. Hooker, ``Veterans' perceptions of
care by nurse practitioners, physician assistants, and physicians: a
comparison from satisfaction surveys.'' Journal of the American Academy
of Nurse Practitioners. (March 2010) 22(3): 170-6.
---------------------------------------------------------------------------
On the payment side the Medicare program at the Federal level and
the Medicaid program at the State level have since the 1970s recognized
the role of these professionals in primary care, in contrast to private
health insurers. As noted, however, they do pay nurse practitioners
lower fees for given services than they pay physicians.
On the delivery of primary care, the Federal and State Governments
have encouraged the development of nurse-led clinics in primary care
which, as noted, I endorse. That development is further encouraged in
the ACA through demonstration projects.
The Federal Government also has long supported the establishment of
qualified community health centers of which the Nation now has over
2,000. They have demonstrated their value in making primary care
accessible especially to otherwise underserved, low-income populations.
Non-physician primary care givers play important roles in these
centers.
The ACA of 2010 encourages the further development of the Patient
Centered Medical Home, thought of as a clinically integrated primary
care facility that should facilitate collaboration among teams of
primary care professionals and would facilitate further by the use
modern electronic information systems. Part of these establishments
task would be maintenance of a personal electronic health record.
Finally, a number of State governments have been active on their
own in promoting innovative primary care models that rely heavily on
non-physician primary care workers--e.g., Minnesota, Pennsylvania and
Vermont.\22\ Vermont's Blueprint for Health legislation created
Community Health Teams of nurses, social workers and behavioral
counselors that work with participating medical practices to help
coordinate and monitor the primary care of patients. They now serve
over half of the State's population in this capacity.
---------------------------------------------------------------------------
\22\ Robert Wood Johnson Foundation, How Nurses are solving some of
primary care's most pressing challenges. Policy Brief No. 18 (July
2012) http://www.pcpcc.net/2012/08/21/rwjf-
report-how-nurses-are-solving-some-primary-cares-most-pressing-
challenges.
---------------------------------------------------------------------------
All told then, although high-performing private-sector health-care
delivery systems also have experimented and innovated in this area--
e.g., Kaiser Permanente or the Virginia Mason health system \23\ to
mention but two of many--it is fair to say that governments at both the
Federal and State levels have actively encouraged innovation in
enhancing the supply of primary care services through innovative models
of health care delivery. It is appropriate and fair to acknowledge from
time to time this role of government as an innovator in U.S. health
care.
---------------------------------------------------------------------------
\23\ C. Craig Blackmore, Jordan W. Edwards, Carly Searles, Debra
Wechter, Robert Mecklenburg, and Gary S. Kaplan, ``Nurse Practitioner--
Staffed Clinic at Virginia Mason Improves Care and Lowers Costs for
Women with Benign Breast Conditions.'' Health Affairs. (January 2013).
32(1): 20-6.
---------------------------------------------------------------------------
II. INFLUENCING THE SPECIALTY AND LOCATIONAL CHOICES OF PHYSICIANS
Even if innovation in the delivery of primary care that relies on
non-physician professionals were pushed to the acceptable limit, there
would undoubtedly remain the need for a sizable supply of primary care
physicians. There is the possibility that the future demand for such
physicians would still outstrip the future supply of them--certainly in
traditionally underserved inner-city and rural areas.
It raises the question what public-policy levers there are to
influence the specialty and locational choices of physicians in
general, and especially of primary care physicians.
A very comprehensive survey on this question can be found in a 2009
report by the Josiah Macy, Jr. Foundation, which specializes in health
workforce issues.\24\ The report notes that specialty and location
choices are related in complex ways to many factors other than
financial incentives, among them the characteristics of medical
students themselves, the mentoring of students during residency
training and the medical school attended.
---------------------------------------------------------------------------
\24\ Josiah Macy, Jr. Foundation, Specialty and Geographic
Distribution of the Physician Workforce: What Influences Medical
Students and Resident Choices? (March 2, 2009). http://www.graham-
center.org/online/etc/medialib/graham/documents/publications/mongraphs-
books/2009/rgcmo-specialty-geographic.Par.0001.File.tmp/Specialty-
geography-compressed.pdf.
---------------------------------------------------------------------------
Women graduates appear to be less likely to practice in rural
areas, and men less likely in primary care. Other things being equal,
however, rural birth, a declared interest in serving underserved
populations, and residency training in inner-city
facilities increase the likelihood that graduates will choose primary
care and locate in underserved areas. Students graduating from public
medical schools appear to be more likely to chose primary care.
Finally, medical graduates are more likely to choose primary care if
during training they had mentors encouraging that choice or, in
general, if the culture of their medical education encouraged it.
Beliefs about and attitudes on the control over life style implied by
different career choices also have been found to be highly
influential.\25\
---------------------------------------------------------------------------
\25\ E. Ray Dorsey, David Jarjoura and Gregory W. Rutecki,
``Influence of Controllable Life Styles on Recent Trends in Specialty
Choice by US Medical Students.'' Journal of the American Medical
Association. (September 3, 2003) 290(9): 1173-8.
---------------------------------------------------------------------------
Remarkably, research on the influence of accumulated debt by
medical graduates on career choice has yielded mixed results.\24\ One
would have thought it to be a major factor driving career choices.
Because the compensation of primary care physicians is
substantially lower than that of most medical specialists, there does
seem to be wide agreement that financial incentives could be used to
influence these choices. There certainly is empirical support for that
theory.\26\ As the authors of a Josiah Macy, Jr. Foundation report
conclude:
---------------------------------------------------------------------------
\26\ James Thornton, ``Physician choice of medical specialty: do
economic incentives matter?'' Applied Economics. 2000. vol. 32:1419-28.
The income gap between primary care and subspecialists has an
impressively negative impact on choice of primary care
specialties and of practicing in rural or underserved settings.
At the high end of the range, radiologist and orthopedic
surgeon incomes are nearly three times that of a primary care
physician. Over a 35-40 year career, this payment disparity
produces a $3.5 million gap in return on investment between
primary care physicians and the midpoint of income for
---------------------------------------------------------------------------
subspecialist physicians.
There is something odd in the fact that for at least two decades
health-workforce experts and health-policymakers have wrung their hands
over an acute shortage of primary care physicians, all the while paying
primary care physicians so much less than is paid their specialist
colleagues. To an economist, it comes across as insincerity over the
alleged shortage. If primary care physicians are deemed so essential to
the health of Americans, why are they not paid more?
Be that as it may, in the next section I explore how the financial
incentives facing medical graduates could be changed in favor of
primary care.
III. CHANGING FINANCIAL INCENTIVES TO ENCOURAGE A CHOICE OF PRIMARY
CARE
Although economists recognize the complex set of factors that drive
choices of a medical specialty and a practice location, it is natural
that they concentrate on financial incentives.
A compact way to model the impact of these financial incentives, in
the minds of economists, is to think of the choice of a professional
career as the perfect analogue of any other investment decision that
requires an initial investment in the hope of a positive subsequent
return on that investment. Figures 2 and 3 illustrate this so-called
``human capital'' model as it is exposed in the classroom.
In Figure 2 it is imagined that a medical-school graduate is aware
of the two lines in that graph. The top line represents the typical
future net cashflow, after practice expenses and income taxes, from
practice in a medical specialty. The bottom line represents the
analogous cashflow faced by a primary care physician. It is assumed
here that a specialist career requires some additional years of low-
paying residency training. The foregone income that could have been
earned in primary care is the up-front investment in a specialist
career, relative to a primary care career.
The decision to enter a specialist career, rather than one in
primary care, can then be represented by subtracting the primary care
cashflow from the specialist cashflow, to obtain the differential
cashflow shown in Figure 3. It is the cashflow from which one
calculates the net-present-value (NPV) or the internal rate of return
(IRR) of the decision to become a specialist rather than enter primary
care practice. Economists believe that medical graduates respond to
these summary metrics in choosing their specialty.
It is immediately apparent from figures 2 and 3 that to enhance the
financial attractiveness of a career in primary care, other things
being equal, one could either shift down the projected cashflow to
specialists or by shifting up the life-cycle cashflow to primary care
or do both. The effect would be to shift down the cashflow line in
Figure 3, that is, to decrease the relative financial attractiveness of
specialty training.
How could that be done?
Changing compensation: The most obvious method of doing so would be
either to raise the compensation of primary care physicians (fees,
capitation, or salaries), or to lower the compensation of specialists,
or to do both.
It has been attempted before, most notably when Congress
established the Medicare fee schedule in 1992. At that time the fees of
primary care physicians were raised substantially and those to many
specialists were lowered relative to the previously prevailing fees.
For some reasons, however, it has proven difficult to maintain this
tilting of the fee schedule over time, for reasons many observers
attribute to the manner in which the relative value scale underlying
the Medicare physician-fee schedule has proceeded.\27\ It is in good
part a problem of intra-medical-profession politics and power, and also
one of congressional politics.
---------------------------------------------------------------------------
\27\ In this connection, see Uwe E. Reinhardt, ``The Little-Known
Decision-Makers for Medicare Physician Fees.'' The New York Times
Economix (December 10, 2010). http://economix
.blogs.nytimes.com/2010/12/10/the-little-known-decision-makers-for-
medicare-physicians-fees/.
---------------------------------------------------------------------------
It can be asked next why private insurers have not led the way to
raise the fees they pay primary care physicians relative to those paid
specialists. Many and probably most of them simply have adopted the
Medicare relative value scale underlying their fee schedules, although
their absolute level of fees may be higher than Medicare fees.
Insurance executives answer this question by pointing out that
Medicare must lead the way. First, private insurers cannot act in
unison, as that would violate antitrust laws. Second, if one of them
individually raised substantially the payments to primary care
physicians, that insurer would have a cost disadvantage relative to
competitors and yet would not be able to move the overall supply of
primary care physicians. On the other hand, if the individual insurer
wanted to achieve cost neutrality by paying specialists less, the
insurer's enrollees might lose access to specialty care and move to
competing insurers. I find that reasoning persuasive.
Lowering the Amortization of Medical-School Debt: In other
industrial nations, tuition in medical school is low or zero. By
contrast, American medical students pay substantial annual tuition
charges, ranging in 2012-13 from a median of $32,414 in public medical
school to a median of $50,309 in private medical schools.\28\ Including
other costs of attendance, but excluding the much higher opportunity
cost of not earning a regular income in another job, the total cost of
attending medical school ranged from a median of $53,685 in public
medical school to a median of $72,344 in private medical schools.
---------------------------------------------------------------------------
\28\ Association of American Medical Colleges, Medical Students
Education: Debt, Cost and Loan Repayment Fact Card. (October 2012).
https://www.aamc.org/download/152968/data/debtfactcard.pdf.
---------------------------------------------------------------------------
Over 85 percent of medical students borrow to finance part or all
of this huge investment in human capital. In 2012, 17 percent of them
had an accumulated debt of $250,000 or more upon graduating from
medical school. The average accumulated debt per graduate was $166,750
and the median $170,000.\24\
It may be noted in passing that the amortization of this huge
investment in human capital cannot be deducted from taxable income as
would be an investment in physical capital--e.g., in a haberdashery.
Our tax code has a distinct bias in favor of physical capital, even
though it is now widely agreed that the wealth of modern nations
depends crucially on its human capital.
Curiously, as already noted, the literature on the influence of
debt on the career choices of medical-school graduates has yielded
mixed results.\24\ It does not seem to be a major factor-driving career
choices. Even so, it may be worth exploring what potential policy
levers a medical graduate's accumulated debt might offer.
Table 1 below illustrates the fraction of a physician's pretax net
practice income (or salary) that would be absorbed by the amortization
of debt for a hypothetical medical school graduate choosing either a
primary care career or entering a specialty.
Table 1--Percentage of Pretax Net Practice Income Absorbed by Annual
Debt Repayments under 20-Year Amortization
(Assumed annual growth in practice income 3.5 percent; Borrowing rate
7.9 percent)
------------------------------------------------------------------------
Starting annual income $150,000 $300,000
------------------------------------------------------------------------
Growing Growing
payments payments
Equal at 3.5 Equal at 3.5
Year payments percent payments percent
[percent] per year [percent] per year
[percent] [percent]
------------------------------------------------------------------------
1........................... 10.1 7.8 5.1 3.9
10.......................... 7.2 7.8 3.6 3.9
20.......................... 5.1 7.8 2.5 3.9
------------------------------------------------------------------------
It is assumed in this table that debt amortization takes place over
20 years with either fixed annual loan repayments or, alternatively,
payments that grow annually at 3.5 percent, the same rate at which the
net practice income (or salary) of both types of physicians is assumed
to grow. The assumed borrowing rate is 7.9 percent.
The tables show the absorption rates, in percent of net income, in
practice years 1, 10 and 20. As would be expected, these absorption
rates are sensitive to the borrowing rate students must charge on their
debt. At a borrowing rate of only 4 percent, for example, the entries
in the table would be as those in Table 2 below.
Table 2--Percentage of Pretax Net Practice Income Absorbed by Annual
Debt Repayments under 20-Year Amortization
(Assumed annual growth in practice income 3.5 percent; Borrowing rate
7.9 percent)
------------------------------------------------------------------------
Starting annual income $150,000 $300,000
------------------------------------------------------------------------
Growing Growing
payments payments
Equal at 3.5 Equal at 3.5
Year payments percent payments percent
[percent] per year [percent] per year
[percent] [percent]
------------------------------------------------------------------------
1........................... 7.4 5.4 3.7 2.7
10.......................... 5.2 5.4 2.6 2.7
20.......................... 3.7 5.4 1.8 2.7
------------------------------------------------------------------------
Evidently, one way to enhance the future cashflow from primary care
relative to that accruing to a specialty career would be to mitigate
the burden of this debt amortization.
It could be done by lowering the borrowing rate for primary care
physicians, but not for specialists.
An alternative would be a loan-forgiveness program contingent on
practicing full-time in primary care. For example, for every year a
physician works full-time in primary care, X amount of dollars of his
or her debt would be forgiven.
There might be arguments by specialists that some of their work
involves primary care as well, for which they would seek pro-rated loan
forgiveness; but such objections should not stand in the way of the
general idea. One could work around it or simply reject the argument.
Manipulating the tax code: A final method to alter the future life
cycle cashflow from a choice of primary care, relative to that from a
specialty career, would be changes in the tax code, much as economists
dislike, as a matter of principle, the now widely practiced use of the
tax code for social engineering, in lieu of more forthright
subsidization of activities preferred by government.
As one such manipulation of the tax code, Congress has long
extended to the managers of private equity funds and hedge funds the
tax-preference under which carried interest stemming from the long-term
capital gains earned by the fund for investors in the fund is taxed at
the low capital gains rate. Carried interest is distinct from any long-
term capital gains these managers have earned on whatever their own
investment in the fund may be. Carried interest basically is a cash
bonus paid by other investors to the managers of funds for superior
management of the funds. This tax preference has always been justified
on the ground that it encourages capital formation, although like other
economists,\29\ \30\ I personally find that justification unpersuasive.
---------------------------------------------------------------------------
\29\ Alan S. Blinder, ``The Under-Taxed Kings of Private Equity.''
The New York Times. (July 29, 2007). http://www.nytimes.com/2007/07/29/
business/yourmoney/29view.html?ei=5090&en
=973b345a4a0b4227&ex=1343361600&adxnnl=1&partner=rssuserland&emc=rss&_r=
0.
\30\ N. Gregory Mankiw, ``The Taxation of Carried Interest.'' Greg
Mankiw's Blog. (July 19, 2007). http://gregmankiw.blogspot.com/2007/07/
taxation-of-carried-interest.html.
---------------------------------------------------------------------------
But as long as this dubious tax preference continues to exist, it
might as well be used in health policy. In one of my posts on The New
York Times blog Economix \31\ I had proposed that, if policymakers
really do believe that the Nation faces an acute shortage of primary
care physicians, they might come around to the view that this
particular type of human capital is socially as meritorious as is
general physical capital, be it factories or golf resorts. On that
notion, the practice income of primary care physicians might be taxed,
at least for some duration, as if it were the equivalent of carried
interest.
---------------------------------------------------------------------------
\31\ Uwe E. Reinhardt, ``If Primary-Care Doctors Were Taxed Like
Hedge-Fund Managers.'' The New York Times Economix (October 26, 2012).
http://economix.blogs.nytimes.com/2012/10/26/if-primary-care-doctors-
were-taxed-like-hedge-fund-managers/.
---------------------------------------------------------------------------
To sum up at section III of this statement on financial incentives.
In view of the foregoing discussion, I would recommend that:
If Congress sincerely believes that there is and will be an
acute shortage of primary care physicians, it should realign
the levels of compensation of physicians under Medicare and
Medicaid more in favor of primary care physicians. If Congress
would like to see that realignment, it has no choice but to
lead the way, as individual private insurers would find it
difficult to effect the realignment by themselves.
Congress should fund experiments with rewarding the choice of
a career in primary care, or to practice in an area with an
acute shortage of primary care physicians, by forgiving for
every year the physician works full-time in primary care part
of the debt medical graduates have accumulated during their
education and training.
As long as carried interest paid from long-term capital gains
is accorded the dubious tax preference Congress has accorded
the managers of private equity and hedge funds, Congress should
extend that privilege also to primary care professionals, at
least for some time of their careers.
Senator Sanders. Dr. Reinhardt, thank you very much.
And last, but very much not least, is Dr. Claudia Fegan.
She is the chief medical officer for the John H. Stroger, Jr.
Hospital, Cook County in Chicago, often referred to as Cook
County Hospital. She was previously the associate chief medical
officer for the Cook County Ambulatory and Community Health
Network, and interim chief medical officer of the Cook County
Bureau of Health Services. Dr. Fegan served as past president
of Physicians for a National Health Program. She received her
undergraduate degree from Fisk University, and her medical
degree from the University of Illinois College of Medicine.
Dr. Fegan, thanks so much for being with us.
STATEMENT OF CLAUDIA M. FEGAN, M.D., CHCQM, FACP, CHIEF MEDICAL
OFFICER, JOHN H. STROGER, JR. HOSPITAL OF COOK COUNTY, CHICAGO,
IL
Dr. Fegan. Thank you, Senator Sanders, Senator Enzi, and
other distinguished Senators for affording me this opportunity
to address the issue of inadequate access to primary care in
the United States.
As the chief medical officer of John H. Stroger, Jr.
Hospital in Chicago, known to most people outside of Chicago as
Cook County Hospital, I confront on a daily basis our country's
failure to provide universal access to health care as a right
to which, I believe, everyone is entitled.
Every single day, people without a physician line up across
the street from our hospital to be seen in our walk-in clinic.
Hundreds of people a week, tens of thousands a year, stand out
in the wee hours of the morning hoping to be one of the 120 to
200 people who will be seen that day. And even better, hoping
to be one of the 12 patients who will be assigned a primary
care physician and given an appointment so they won't have to
come back; they hope to be one of the lucky ones who will be
given a physician of their very own.
Our current influenza epidemic highlights the
vulnerabilities of our current patchwork for health care
delivery. Too few people in this country have access to a
primary care provider. Their primary care provider could have
educated them about influenza and the need for influenza
vaccine, especially to vulnerable populations and those in
contact with those populations. Then their primary care
provider could have given them that vaccine. Instead, we are
witnessing tens of thousands of people presenting to our
emergency rooms sick and looking for help. At the peak, our
emergency room at Stroger was seeing 450 people a day while
hospitals around the city, and the country I might add, closed
their doors and went on bypass. At Cook County we never go on
bypass. We never close our doors.
We created the RBVS system to compensate physicians for
their cognitive effort in the care of patients. It was hoped
that that would begin to level the playing field between
primary care physicians and procedure-based specialists. Yet,
the RVS Update Committee, which is tasked annually, was
reviewing how Medicare compensates physicians for care
provided, has only a paltry few seats allocated for primary
care when setting reimbursement rates.
We want to increase the number of primary care physicians,
but when Medicare funds graduate medical education in
hospitals, we disperse the same amount for a plastic surgeon as
a primary care physician. If we increase hospital reimbursement
for primary care physicians in training over specialists in
training, we will have more primary care physicians. You could
do that.
I have to say I have the privilege of being a primary care
physician myself. I love taking care of patients. It is one of
the most fun things I do. My patients invite me into their
lives as I teach them how to take care of themselves and get
what they need.
The daughter of a labor union organizer and a social
worker, I could have never been able to afford medical school.
I was fortunate enough to be a member of the National Health
Service Corps, which paid for my medical education. So I was
free to make a decision to follow my passion and become a
primary care physician without having to worry about how I
would pay off my loans.
I would say to you if medical students know before they
begin medical school they will have no debt upon completion of
their studies, they will be more likely to make a decision to
pursue a career in primary care rather than more highly
compensated specialties.
The administrative burden we have placed on physicians is a
product of our Nation's fragmented, dysfunctional system of
financing health care with multiple private and public payers,
including hundreds of private insurance plans each with its own
set of rules, the costly paperwork and headaches inflicted upon
our physicians, including primary care physicians is enough to
drive many to distraction or exit from our profession.
If we would enact a single-payer national health care
program where everyone was entitled to health care as a right,
we could focus on delivering the best care in the world to our
patients, and relieve physicians of the administrative hassles
required to ensure proper billing services are provided.
The stresses on primary care physicians are tremendous,
with the implementation of the Electronic Health Record that
forced them to spend more time looking at the computer than at
their patients. Most EHR systems today were designed to enhance
efficient billing, not patient care. As a result, EHR has
created a hideous documentation burden that robs precious time
from the physician that they would rather spend engaging with
their patients and understanding their needs. There is no
question if we had designed the EHR to further clinical care,
we would have developed a very different tool.
While it is true there are elements of EHR that will
improve patient safety, they are far overshadowed by the
demands for administrative documentation. We lose the narrative
of the individual patient to improve the point-and-click
documentation and make billing more efficient.
I urge you to work to make a difference, not for me or you,
but for the patients I have the privilege of serving, who
desperately need elected officials to care about what happens
to them.
Thank you.
[The prepared statement of Dr. Fegan follows:]
Prepared Statement of Claudia M. Fegan, M.D., CHCQM, FACP
Thank you Senator Sanders, Senator Enzi and other distinguished
Senators for affording me this opportunity to address the issue of
inadequate access to primary care in the United States.
The lack of adequate access to primary care speaks to the much
larger issue of inadequate access to health care in this country as a
whole.
As the chief medical officer of John H. Stroger, Jr. Hospital in
Chicago, known to most people outside of Chicago as Cook County
Hospital, I confront on a daily basis the reality of our country's
failure to provide universal access to health care as a right to which
I believe everyone is entitled.
Every single day, people without a physician line up across the
street from our hospital to be seen in our walk-in clinic. Hundreds of
people a week--tens of thousands a year--stand in line in the wee hours
of the morning, hoping to be 1 of the 120-200 people who will be seen
that day and even better, hoping to be one of the 12 patients who will
be assigned to a primary care physician and given an appointment so
they won't have to come back.
They hope to be one of the lucky ones who will be given a physician
of their very own, who will get to know them and take care of them and
be available when they have a problem or question, someone to help them
meet their medical needs, someone to help them navigate our complicated
health care system to get what they need. I have to admit I hesitate to
refer to health care delivery in this country as a system, because so
little is connected to anything else.
Every day I look at the charts of patients admitted to our public,
safety net hospital who were told by another hospital to come to us
because they are uninsured. They come from distances great and small. I
see patients who come from other cities, other counties, other States,
other countries and patients who come from just a few blocks away.
Sometimes they come with their films or slides and have been told
they need surgery or chemotherapy or a diagnostic study and they would
be better off at ``the County.'' These patients come to us in a state
of desperation with great expectations. We take care of them and do the
best we can with the limited resources we have. This is as we prepare
to absorb the beginning of the phaseout of Disproportionate Share Funds
for Safety Net Hospitals on October 1 of this year. The elimination of
DSH funds with the presumption that everyone will be insured is just
another challenge as we continuously struggle to meet the needs of all
who come to our doors.
I know the Affordable Care Act promises to provide insurance
coverage to more Americans, but I know there will still be 30 million
people who will remain uninsured even after the Affordable Care Act is
fully implemented. So I know the need for the safety net and places
like Cook County will remain. I also know there are not enough primary
care providers to care for all the patients who will need them.
Whereas in 1930 the ratio of generalists or primary care physicians
was about 80:20, today that ratio is reversed. It's not an exaggeration
to say we are facing a crisis in this vital area.
Research show that primary care is the foundation of any high
functioning health system. A well-developed primary care infrastructure
makes access to care easier and more efficient; it contains cost, such
as identifying and treating problems before they become more severe or
advanced. It improves the coordination of resources and care; and most
important, it yields better medical outcomes than when such an
infrastructure is missing. It saves lives. I might add, studies have
noted more expensive for-profit hospitals, do not have better outcomes
than our public safety net hospitals. There is no correlation between
the amount of money we spend on care and the quality of the outcomes.
Our current influenza epidemic highlights the vulnerabilities of
our current patchwork for health care delivery. Too few people in this
country have access to a primary care provider. Their primary care
provider could have educated them about influenza and the need for
influenza vaccine, especially in vulnerable populations and those in
contact with those populations. Then their primary care provider could
have provided them with that vaccine.
Instead we are witnessing tens of thousands of people presenting to
our emergency rooms sick and looking for help. At the peak, our
emergency room at Stroger was seeing 450 patients a day while hospitals
around the city closed their doors and went on bypass. At Cook County,
we never go on bypass, we never close our doors.
People don't understand that influenza vaccination is not just
about you and whether you get sick, but about everyone you encounter
and the risk you will infect them. After we had a patient in our
hospital infected by a visitor and a pregnant patient who wound up on a
ventilator, we were forced to limit access to the hospitals in our
System for visitors who might be sick. People are dying, dying from
influenza, a preventable disease. This is an example of our tendency in
this country to be pennywise and pound foolish in our funding of health
care.
There is no doubt that for many years we have undervalued primary
care. It shows up in a variety of ways.
As a nation we provide little incentive for young physicians to
become primary care providers. By contrast there are strong incentives
for young clinicians to pursue higher compensated specialties.
A medical education is expensive and most young physicians leave
medical school with hundreds of thousands of dollars in debt. Because
primary care physicians are the lowest compensated of physicians, and
because the prospect of a heavy, long-term debt is so unappealing,
medical students find themselves gravitating away from primary care
toward higher paid specialties.
We say we value primary care physicians and yet we pay them half as
much as we pay specialists. We say we appreciate the cognitive skills
of primary care physicians so necessary to see patients as a whole and
make decisions in the best interests of each individual, but we make it
financially difficult for young clinicians to take this path.
Another example: We created the RBVS system to compensate
physicians for their cognitive effort in the care of patients. It was
hoped this would begin to level the playing field between primary care
physicians and procedure-based specialists. Yet the RVS Update
Committee, which is tasked with annually reviewing how Medicare
compensates physicians for care provided, has only a paltry few seats
allocated for primary care when setting reimbursement rates.
We want to increase the number of primary care physicians, but when
Medicare funds graduate medical education in hospitals, we disburse the
same amount for a plastic surgeon as a primary care physician. If we
increase hospital reimbursement for primary care physicians in training
over specialists in training, we will have more primary care
physicians. You could do that.
I have to say that I have the privilege of being a primary care
physician myself--previously in private practice and now at a large
public hospital--and I love taking care of patients. It is one of the
most fun things I do. My patients invite me into their lives as I teach
them how to take care of themselves and get what they need. These
experiences are often deeply moving and rewarding and they remind me
why I chose medicine as a profession.
The daughter of a labor union organizer and a social worker, I
would have never been able to afford medical school. I was fortunate
enough to be a member of the National Health Service Corps, which paid
for my medical education, so I was free to make the decision to follow
my passion and become a primary care physician without having to worry
how I would pay off my loans.
While the National Health Service Corps still exists, it is a
shadow of its former self; more students receive funding in the form of
loan repayment.
I would say to you: if medical students know before they begin
school that they will have no debt upon completion of their studies,
they are more likely to make the decision to pursue a career in primary
care rather than a more highly compensated specialty.
There are other ways to make primary care more attractive to the
next generation of physicians too.
The administrative burden we have placed on physicians is the
product of our Nation's fragmented, dysfunctional system of financing
care through multiple private and public payers, including hundreds of
private insurance plans, each with its own rules. The costly paperwork
and headaches inflicted on our physicians, including primary care
physicians is enough to drive many to distraction or exit from our
profession.
If we would enact a single-payer national health care program,
where everyone was entitled to health care as a right, we could focus
on delivering to our patients the best care in the world and relieve
our physicians of the administrative hassles required to ensure proper
billing for services provided.
As a primary care provider myself, I feel the external control in
the exam room with me and my patient as I struggle to make sure I have
completed all the required elements on the computer screen, sometimes
at the cost of neglecting to ask what the patient's concerns are today.
Because of this onerous administrative burden, primary care
physicians have lost something of their precious connection with their
patients. Lifting that burden would help strengthen the doctor-patient
relationship.
The stresses on primary care physicians are tremendous with the
implementation of the electronic health record (EHR) that force them to
spend more time looking at a computer screen than looking at the
patient. Most EHR systems today were designed to enhance more efficient
billing, not patient care. As a result, EHR's create a hideous
documentation burden that robs precious time from physicians that they
would rather spend engaging with their patients and understanding their
needs.
There is no question, if we had designed the electronic health
record to further clinical care we would have developed a very
different tool. While it is true there are elements of the EHR that
will improve patient safety, they are far overshadowed by the demands
for administrative documentation. We lose the narrative of the
individual patients to improve the point and click documentation and
make billing more efficient.
It's just one more example of where we expect primary care doctors
to address more and more issues, even as we expect them to see more and
more patients.
I would say to the members of this committee, as Members of
Congress you have the opportunity to increase the number of primary
care providers in this country.
1. Adjust the funding for graduate medical education to reimburse
hospitals more for the primary care physicians than specialists.
2. Insist the American Medical Association increase primary care
representation on the RVS Update Committee.
3. Increase the National Health Service Corps scholarship program.
I urge you to work to make a difference, not for me or you, but for
the patients I have the privilege of serving, who desperately need
their elected officials to care about what happens to them.
Senator Sanders. Dr. Fegan, thank you very, very much.
Let me begin the questioning. I want to ask two brief
questions in my 5 minutes. My understanding is that if I have
the flu or a non-urgent type of illness, and I walk into an
emergency room, it will cost Medicaid something like 10 times
more than me walking into a community health center to visit my
primary health care physician.
My understanding is that there are millions of Americans
who hesitate, I know this is true in Vermont. People get sick.
They think it is going to get better. They don't go to the
doctor. They wait months and months, they wait a year, they
walk-in to a doctor. The doctor says, ``Why weren't you here 6
months ago? You're really ill. I've got to get you to the
hospital.''
My question is how much money does it cost and how much
human suffering is taking place in this country because people
are unable to walk into a doctor's office when they need to?
Who wants to respond to that?
Dr. Fegan.
Dr. Fegan. I can just tell you about the faces of the
patients who line-up to be seen at our walk-in clinic on a
daily basis, and I don't know how you measure the cost of human
suffering. But we see always--people come to County because you
can see things you will never see anywhere else in the world,
such advanced stages of disease, and people who with everything
from brain tumors to breast lesions that are eroding from the
skin. I mean, and you say, ``Why did you stay home?'' And they
didn't have to.
I am going to tell you, these people are working folks.
These are taxi drivers. They are college professors. They are
accountants. They are attorneys. And the first thing they say
to me is, ``I never thought I'd be here. I never thought I'd be
at the County.'' So I would say it has to be, and no
exaggeration, millions of dollars we lose in workforce
productivity, as well as in the suffering.
I see so many patients who get cancer, particularly breast
cancer, and lose their jobs, and then wind up coming to us to
get further treatment. And they've lost their homes, many of
them, by the time they get to us, and we are trying to figure
out how to get them started on their chemotherapy and find them
some place to live.
Senator Sanders. Other comments on that?
Ms. Kuenning.
Ms. Kuenning. Yes, thank you. I know from the stories from
the community health centers just in Vermont, I can't put a
dollar equation to it, but we have so many stories. We have a
farm worker program that actually goes out to farms and works
with, not only seasonal farmers, but actually our farmers who
aren't coming in for care.
We have a 50-year-old farmer who has a history in the
family of diabetes and has never seen a doctor, comes in and
actually doesn't know that they can get care at the community
health center on a sliding fee discount because of their
income.
So I think a lot of it is outreach and enrollment into
understanding both their cultural issues, as well as being able
to get them into care.
Senator Sanders. OK. Let me switch gears for a moment and
touch on another very important issue in terms of how we
determine reimbursement rates for physicians. And that is the
RUC, which I think probably is not a household word throughout
America, and yet is an organization which plays an enormously
important role in determining how much specialists will make,
how much primary care physicians will make.
And apparently, we have an organization which is kind of
loaded, top heavy, with people in the specialties and weak in
terms of representing primary care physicians. Is this an
important issue?
Dr. Mullan, do you want to take a shot at that?
Dr. Mullan. I do. A key issue, when we talk globally about
the idea of pay inequity, how do we get a handle on it?
Since Medicare is the largest single payer, and
historically many private payers key off Medicare in a variety
of ways, managing the Medicare conundrum around the pay gap
would be central to reforming the whole system, and the RUC is
at the center of it. It is well-wired in the sense that it has
been this way a long time, and there are a variety of
approaches to it, but I think just sunshine, daylight
featuring, focusing on this.
You have lurking under it the question of, do you raise the
floor or bring the ceiling down? Both will raise all kinds of
issues for people involved, and philosophically, and
politically as well.
I believe it is both. I mean, the point is we are not going
to pay all our primary care physicians $500,000 a year. But I
must say as a physician and a citizen, when I hear about a
physician making $500,000 or $1 million a year, yes, there are
people in business from their college class, et cetera, etc. I
think it is a moral argument we need to engage as a country.
Senator Sanders. Dr. Wilper, you had some strong words on
that, and then we will get to Dr. Reinhardt.
Dr. Wilper. Thank you. So I do have some additional
thoughts on this, and specifically the process by which the RUC
evaluates billing codes between the different subspecialties
and primary care. This process could be improved by
reevaluating the evaluation and management, what are called,
CPT codes.
An example of this is as follows: an ophthalmologist will
bill the same code, a 99214, for a 10 minute exam with very
little followup needed. A PCP, a Primary Care Physician, who
bills the same code generally spends 25 to 30 minutes with a
patient, face-to-face, has 25 to 30 minutes' post-care
documentation and followup at an estimated 20 to 30 minutes
between visits for the same patient. Now, the reimbursement for
those two services are identical.
So what we need are new E&M codes in primary care. We need
to update our knowledge base regarding this issue as current
time estimates for these codes are actually outdated and are
dated to the 1980s, 20-25 years old, and they are based on very
small sample sizes.
A proposal would be to develop an independent process for
reviewing these codes that is transparent, peer-reviewed, and
based on real world data.
Senator Sanders. Dr. Reinhardt, do you want to comment?
Briefly, please.
Dr. Reinhardt. Yes, the RUC determines relative values, not
absolute levels, but it is a zero sum game if it is budget
neutral.
One could put more primary care members on that board, and
I think that would be a good idea. But MedPAC had also proposed
that there be an outside committee, an independent committee of
stakeholders who kind of audit and review the RUC
recommendations. I don't know if that ever went anywhere, but I
would encourage you to look at it, and maybe go that way.
Senator Sanders. OK. Thank you very much.
Senator Enzi.
Senator Enzi. Thank you, Mr. Chairman.
I will begin by asking Miss Decklever. In your testimony,
you described some of the challenges that frontier States face
in qualifying for Federal grants to improve primary care access
and increase the health professional workforce.
What needs to be done at the Federal level to improve that
grant process, and what can we do to make the process better?
Ms. Decklever. Senator Enzi, members of the committee, the
information that I received from the community health centers
refers back to the number when they are looking at
designations. So it is the number of people per provider rather
than the amount of space where those people are located in.
The other thing that sometimes is a bit of a disparity is
in States like ours where we have lower minority populations,
just by the nature of our State that sometimes by those
designations we are put out of the running, as it were, because
we just don't have a high enough percentage of minority or
different types of ethnic backgrounds.
And then, again, the wage disparity where the average
statewide data, States that are the designated areas are
financially in pretty good shape. But if you were to look at
the overall where we have many people that are making a lot of
money, and then some that are making very little, it skews the
average. And to maybe look at that type of data and those types
of figures as far as designation goes.
Senator Enzi. Thank you.
This is a question of you and Ms. Kuenning. What needs to
be done to enhance and improve the coordination and
collaboration between the Federal Government and the State
government agencies to most effectively deploy the resources?
How can we avoid duplication of efforts?
Ms. Kuenning. Thank you.
At least I can speak to Vermont and New Hampshire in terms
of accepting, not the National Health Service Corps loan
repayment to providers, but actually a loan repayment dollar.
There are restrictions on how you use those resources. They
have to be within health professional shortage areas rather
than MUA's and MUP's.
If we could get a change from that in the Federal
Government, then States like Vermont and New Hampshire who
don't take any Federal funding for loan repayment--they have
State loan repayment, but no Federal loan repayment--that
actually would be very favorable.
Senator Enzi. Thank you. Were you going to comment on that,
Miss Decklever?
Ms. Decklever. Senator Enzi, I do not have enough
information to be able to give you an intelligent answer, but I
would be more than happy to do some research on that and get
back to you.
Senator Enzi. OK. I do have some other questions for
everybody on the panel that I hope they will answer in writing.
Dr. Mullan, what needs to be done to ensure that effective
oversight and financial controls are in place to ensure that
Federal funding is being used effectively, and helps ensure
professional resources are being allocated more efficiently?
Dr. Mullan. Thank you, Senator Enzi.
The array of Federal programs is quite different. I have
spoken to the issue of Medicare GME, which I think--you would
not issue a contract without a deliverable, without
specificity. And I think oversight there is actually quite lax.
I realize that is not the jurisdiction of this committee, but
it inevitably speaks to this issue.
In regard to the title VII programs, these would be
programs that support educational activities for primary care
physicians, for physician assistants, and the title VIII
programs for nurse practitioners, they are actually managed
fairly tightly. They use an NIH-type grant award system, with
Federal project officers, and I think there is good
supervision. In fact, from the perspective of the schools,
often, they feel it is too tight. It is very hard to move when
things are highly stipulated.
The National Service Corps is a relationship, of course,
with the individuals. And happily over the years, there used to
be many individuals who bought out, simply didn't serve. That
has been tightened with the help of Federal legislation. There
is extra indemnity if you don't serve on the scholarship, and
with loan repayment, that is managed quite tightly.
So I think in this area in general there is pretty good
accountability across the programs, and no doubt, room for
improvement, but in general, it is pretty good.
Senator Enzi. Thank you. My time has expired.
Senator Sanders. Thank you, Senator Enzi.
Senator Warren.
Senator Warren. Thank you.
Like Senator Enzi, I would like to followup with some
questions about community health centers as a vehicle for
delivering primary health care, and it is their impact on
access, on costs, and on disparity.
I am very interested. I read through all of the testimony,
and am very impressed by the work you have done, Ms. Kuenning.
It is terrific work.
I was very glad to hear, Ms. Decklever, about the work that
is done out in Wyoming and that you've got community health
centers there.
But what I would really like to know is, what else do we
know about them in any of those dimensions? As I said, it is
about cost. It is about access. It is about reducing disparity.
Can anyone speak to that?
Dr. Wilper, your head snapped up, so I am guessing it is
you.
Dr. Wilper. Sorry for that.
Senator Warren. No, no. I like it.
Dr. Wilper. In addition to my work at the VA, I also work
at a community health center in Boise, ID called Terry Reilly
Health Systems.
In my experience, the CHC's provide a critical safety net
for the uninsured of our Valley. I live in the Treasure Valley.
The un-
insurance rate for this population is nearly 50 percent, which
is actually second highest in the Nation.
My experience as a clinician working in that clinic is that
despite the access that it provides, oftentimes what we end up
providing is care that, at least in my other job at the VA, we
would not find acceptable because we don't have other resources
to offer to these patients seen in our community health center
because they don't have insurance. So even though they have a
foot in the door to the clinic at the community health center,
oftentimes patients are unable to access additional services
that would be standard of care in any other system in the
United States.
Senator Warren. Very helpful. Yes, ma'am.
Dr. Fegan. Cook County also pairs with many other community
health centers, and what we find is that when we provide access
to primary care, we uncover specialty needs. One of the big
problems that we have as a hospital, or one of our major
challenges, is that these patients in between the health
centers have nowhere to go to receive those services, and they
refer them to us.
So I think that community health centers are invaluable
because they offer care in the community where people live and
they are likely to be more flexible in their hours and in their
pay scale. People who don't normally have access to care will
receive access. But then, they have nowhere to send them, and
we are the safety net, and it is a continuous tension we have
with capacity in meeting those needs.
Senator Warren. Dr. Mullan, did you want to add?
Dr. Mullan. Yes. Thanks, Senator Warren.
I had the privilege of working for 12 years at a community
health center, the Upper Cardozo part of the Unity Network; it
is about 2 or 3 miles from here. And what one saw there, what I
saw there day to day was a population that, were it not for
that health center, would be in the emergency room.
There were not private providers in the neighborhood and to
the extent there were, they weren't really prepared to deal
with the clinical needs, the language needs, the support needs
of this population. Health centers, Unity here in DC and others
around the country, have built-in, hardwired in social work,
mental health, and a variety of services that typify the kinds
of needs that our population had.
So it represents, at its best, a one-stop shop which is the
spirit of primary care, but particularly attuned to the kind of
neighborhood, the kind of population that you are working with.
Without that, the emergency room would have been the recourse
if care was to be delivered at all.
Senator Warren. Thank you. Miss Kuenning.
Ms. Kuenning. Yes, thank you.
I would characterize that what we're doing in Vermont is,
working toward a redesign of both the finance and the delivery
system, and the community health centers are really part of
that. There were acts that came out of the State house and all
of them made primary care centric.
Part of that is the financing, which is you are going to do
some kind of shared savings, or a global payment, or bundled
payment. Then you are also going to change, with regard to the
delivery system, in terms of ACO's, and that is your
relationship with mental health and specialists so that you are
not aligning in terms of your governance, but you are aligning
with regard to the total medical expense. So you are
responsible for that patient's expense, and it is changing the
way that we do business. That we are not really doing it based
on the volume of care, but doing it and being paid based on
value. And that whole system is being done at many community
health centers across the Nation.
Actually, Blackstone Valley is a great example. I am sorry
the Senator left, but it is a great example of how they
redesigned the visit to actually have the providers working at
the top of their scope, bringing in more assistants to the
nurses and to the health centers' physicians, and they saved
over 1 year, $1 million just at one community health center
looking at total medical expense. But that requires having
electronic medical records and claims data so that you can
actually see where your patients go. Because when you are at
the health center, you have a medical record of where they have
come to see you, but you don't have any experience of where
they are going in terms of the hospital, or to the emergency
room, or to mental health.
So this whole concept of ACO, as long as it is primary care
centric, really aligns the thinking about both financing and
delivery for our patients so that we are thinking about the
total medical expense, and making interventions in the primary
care that will matter both in terms of their outcomes and the
finances.
Senator Warren. Thank you. Enormously valuable. So it is an
estimate. I am sorry, Mr. Chairman.
This estimate that we've got a $24 billion savings from the
current community health centers, in part is coming from
keeping people out of emergency rooms, in part is coming, I
assume, from integrated care. As Dr. Reinhardt talks about
different kinds of providers. But it is also coming from these
innovative approaches to care.
Ms. Kuenning. Right, and a lot of the patients under
medical home work--in Vermont we have a concept that is called
the Blueprint, and it is really thinking about chronic care
management. How do you really take somebody that has a higher
prevalence of diabetes, or hypertension, or asthma and really
manage their care to keep them out of the emergency room, keep
them out of the hospital and they are inpatient, as well as
returning to the hospital? So it is about really focusing in on
the patient rather than the delivery system.
Senator Warren. Thank you very much.
Senator Sanders. Thank you, Senator Warren.
Senator Baldwin.
Senator Baldwin. Thank you, Mr. Chairman. Again, thank you
for the focus of this hearing. The title sort of speaks
volumes, ``30 Million New Patients and 11 Months To Go.''
Certainly our States have different experiences as we move
forward in terms of the level of uninsuredness, the level of
preparation with primary care providers, the distribution of
those providers throughout the State.
I apologized earlier for having to step out to attend
another organizational meeting of one of my other committees,
and so, I missed some of your testimony. But I hinted in my
opening statement that I would like to hear a little bit more
about your opinions and the level of knowledge on the impact of
the non-remunerative factors in increasing the supply of
primary care practitioners.
I think about the anecdotal information I hear as medical
students are going through their rotations and observing the
specialties, as well as joining primary care settings. And they
are observing mentors and teachers with different levels of
autonomy, different levels of flexibility. I think about the
difference in experience that one might have if they are in a
setting where they are modeling a patient-centered medical home
versus other settings that would be for service, more
traditional payment systems. You know, how much is their mentor
and teacher on-call? Every other night, is it more reasonable?
So I am wondering about the level of knowledge of how these
non-compensatory factors play into the decisionmaking to
specialize or to go into primary care as students have these
observations and are looking to the future of the way we design
medicine?
Dr. Mullan, I understand you did raise that briefly in your
testimony. I wonder if you would start.
Dr. Mullan. Thank you, Senator Baldwin. Could we spend the
afternoon on it? It is an important topic.
Senator Baldwin. I would love to.
Dr. Mullan. I will be very quick.
The culture, as I have called it, of medical schools and
teaching hospitals over the years, for good reasons, has
developed a very reductionist, research-oriented, subspecialty-
oriented culture. All of our medical schools have that element
to them. Some do better in terms of local accountability, local
focus.
I would like to see every medical school have a workforce
plan. I travel often to medical schools and say, ``What is your
geography? What is your catchment area?'' State schools do a
little better. They say, ``Our State,'' but even that is kind
of vague. When a school has a fiduciary, a focus, they do much
better and there are a number of schools who do that, Southern
Illinois being an example.
A very new model of changing the culture is an osteopathic
medical school in Phoenix, the A.T. Still College of Medicine.
They now do 1 year on campus for the basic sciences. They take
their class, then for the last 3 years and distribute them to 1
of 11 community health centers, and they do all their teaching,
all of their clinical medicine in a community health center
working with local or regional hospitals. That is really
breaking the mold; one school doing that.
There are other experiments underway, but we have 10 of our
leading universities that don't even have family practice
departments that are sort of saying, ``That is somebody else's
problem.''
These issues are core to the economy of this country, the
health of this country, and the nature of the physicians that
we produce. And I think, in general, medical schools have not
taken this as a challenge. There is a great deal that could be
done and we could spend the afternoon on it, but that is just a
sample of possibilities.
Senator Baldwin. I don't know if any of our other witnesses
would like to comment on this. I am particularly interested in
knowing how much do we know about this rather than the
anecdotal sharing that we hear?
Professor Reinhardt.
Dr. Reinhardt. The Macy Foundation in 2009, or even later,
published a really comprehensive report on this issue, on the
whole workforce issue and listed these nonfinancial factors.
One of them is the background of the student. That people
from rural areas are more likely to go there from inner city,
or people who sort of demonstrate that they are interested in
this. And so through the admissions process, you could probably
rearrange the classes; no guarantee, but nevertheless, you
could go there.
Part of it is, of course, the culture. I have read about
that also that one of the Senators mentioned, ``You're too
smart; you shouldn't go into primary care.''
One way, perhaps, to do this is through the graduate
medical education support. Most economists don't actually think
it is warranted. That actually these residents are cheap labor
to a hospital, but you could differentiate and give a teaching
hospital more if they develop programs that specifically
acculturize students into this. So that the residency is in
community centers and that there are first rate faculties who
do mentor them.
I think medical schools react very much like everyone else
to the money, which is through the direct graduate medical
education and indirect at them without really asking much in
return.
Senator Sanders. Thank you, Senator Baldwin.
Senator Murphy.
Senator Murphy. Thank you very much, Mr. Chairman.
I worry a little bit about our ability to micromanage this
problem, and I think a lot of the ideas we are talking about
are incredibly important. But whether it is rate setting or
loan forgiveness programs, I am sometimes more attracted to
ideas that sort of reset the marketplace itself, to give the
marketplace more reason to invest in primary care.
One of the themes we have talked about is that this new
delivery system that is potentially based on bigger systems of
care, accountable care organizations, more physicians working
for salary rather than for fee-for-service, may help solve this
prestige issue. Because if you are in charge of specialists
instead of just referring out to specialists then you feel a
little bit better about your work.
But there is probably also a theory that says that if you
have more primary care doctors working for organizations rather
than working on their own, and you have an ACO that is getting
a big bundled payment to take care of a big group of patients,
then the ACO is going to actually be incentivized to pay its
primary care physicians more. Because that is going to help
them manage their costs, and help them keep the delta of
whatever they save, and you already see that happening. You see
more primary care physicians now going to work for hospitals.
At least in Connecticut, you are seeing hospitals starting to
buy up primary care groups, and you are starting to see more of
them working for salary.
I guess I pose that as the question here, is there a
potential that as you shift a delivery system to have more
integrated systems of care, more accountable care
organizations, that there will be an incentive for the
organizations to pay primary care doctors more, separate and
aside from decisions that we may make on reimbursement?
Maybe I will put this to the economist first as to what,
Dr. Reinhardt, what you think ultimately the shift in delivery
system may mean for the kind of rates that primary care doctors
get paid?
Dr. Reinhardt. Well, the great hope is that it will do
exactly that, that a bundled payment, ideally there should be
capitation for chronic or bundled payment for episodic care.
That somebody is in charge of managing the money from that
bundle, and will realize that having a heavy component of
primary care is cost minimizing, and therefore profitable in
that way.
I once talked to a group, North Texas Medical Group, and
they were an integrated IPA, connected with a computer, who
took risks. The hospital piece was done by Pacific Health Care
and they did the medical piece; I think also the drugs. They
told me, they had already tilted the fee schedule internally of
primary care substantially and paid the specialists less
because they were at-risk for a capitation that they got.
It might be worth it to talk to them. They are now,
actually, an ACO. They were one of the first pioneer ACO's. It
might be interesting to talk to them or invite them to tell you
what they experienced.
Senator Murphy. Dr. Wilper, you expressed skepticism based
on the literature as to the cost savings medical home models
may provide. ACO's are a little bit different.
What do we know about the ability for ACO's with perhaps
primary care specialists, primary care doctors, elevated to get
cost savings that maybe we have not seen in some of the early
rollouts of medical home models?
Dr. Wilper. To my knowledge we know, actually, very little
about how ACO's will reduce costs or what their effects on
costs will be.
What we could look to is the model of care where I
practice, which is in the VA, which is sort of the ultimate
integrated care model, right. We have people for life after
they return from service and do a very good job taking care of
them. It is my understanding, although I do not know this
literature in its entirety, that we provide care that is of
similar or better quality to most private institutions in the
United Stats at costs that are much lower.
Senator Murphy. One final question to you, Dr. Wilper.
You've got a provocative statement at the end of your testimony
about the interests that the AMA may be serving here. Can you
elaborate a little bit on that?
Dr. Wilper. Happy to, thank you.
My personal position on this is that this subcommittee of
the AMA wields inordinate power over physician rate setting,
and I know we are trying to get away from remuneration, but the
Federal Government is sending a very clear price signal to
students about what they want them, what the Federal Government
would like them to practice in. And I think to minimize that is
a little bit dangerous.
My personal view is that physician groups treat public
payers as though they were their own entitlement programs
rather than a source of coverage for the U.S. population.
Senator Sanders. Thank you, Senator Murphy.
Senator Casey.
Senator Casey. Thank you, Mr. Chairman.
I have two questions. One would be more specific, and the
second is more broad-based for the whole panel. We appreciate
your testimony here today.
The specific question--and I will direct it to Dr. Mullan
and Dr. Fegan or anyone in between who wants to comment on
this--relates to health care as it relates to children. Our
child advocates always remind us that in the context of health
care and otherwise, children are not small adults. They are
different. We have to treat them differently and have
strategies that recognize that reality.
When we were going through the debate about health care in
this committee in the summer of 2009, Senator Dodd and I worked
together, and he was really the lead on this, to design
elements in the bill that would speak directly to that reality.
We had one, in particular, that spoke to the workforce. I
am looking at section 5203, Health Care Workforce Loan
Repayment Programs, ``Establishing a loan repayment program for
pediatric subspecialists and providers of mental and behavioral
health services to children and adults who will be working in
health professional shortage areas,'' and it goes on from
there. But that was our intent. We were successful in that.
But I am wondering, now that we are beyond just the
theoretical stage, and we have a piece of legislation which is
in place and continuing to be implemented in this broader topic
of primary care, are there steps we need to take to make sure
that that primary care physician, and the services and
treatments that come with it, are available for children?
Doctor, I don't know if you have a thought about that.
Dr. Mullan. Thank you, Senator Casey.
Your observations about children are, of course, on point.
Children are more vulnerable, they are poorer, and they are
more underserved than the rest of the population as a matter of
analysis of the benefits that come to children. We are
definitely weighted toward the elderly in terms of benefits,
public benefits, and that creates a challenge, particularly
with the ACA principles of trying to be inclusive and bring
kids in.
I think we are all optimistic that, particularly with the
Medicaid expansion where it occurs, kids will get good benefits
or better benefits than they have in the past.
The specific issues in pediatrics, generally the notion of
primary care does not include subspecialties. I think probably
the correct notion is underserved or under-populated
disciplines, which primary care is the heart of it, but there
are some others. General surgery, for instance, we have a
growing trend of shortage.
Pediatric subspecialties, the argument is made and I do not
know the arguments well, but they have been pretty well
substantiated that there is not the tendency of pediatricians
to subspecialize. There aren't as many training programs, and
we probably do need more. So the spirit of the legislation that
was encouraging that, makes sense in terms of workforce
development.
I would not want to see the profile where well over two-
thirds of adult internists are specializing and going into
hospital medicine. Hospitalists, which is a good development,
but it takes them out of the primary care field. So there is
that challenge.
By and large, though, pediatrics has had a good market.
Medical students like it. They tend to go into it in good
numbers. So pediatrics overall is not short, but some of the
subspecialties are.
Senator Casey. Doctor, from the vantage point of Chicago
and the pediatric workforce.
Dr. Fegan. The issue of pediatric specialists, it is
because pediatrics tends to be a loss leader for hospitals. So
the number of specialists that are pediatric specialists that
are available at general hospitals is very low.
In Chicago, we actually have, I would say, a glut of
pediatric hospitals and so the specialists are generally
available. But I know that in a more rural community, this is a
tremendous challenge in terms of providing access for those
children, complicated children who need multidiscipline
support. Providing those services for them is increasingly
difficult today and encouraging people not only to the
specialties, not that they are underrepresented, but they are
poorly distributed in terms of where the areas of need are for
that.
Senator Casey. I will hold my second question, but anyone
in the 15 seconds we have want to comment on this question or
not?
Senator Sanders. Thank you, Senator Casey.
Let me conclude by thanking all of the Senators who
participated in this hearing. I think the large turnout tells
you how seriously many of us feel about this issue.
Most importantly, I want to thank all of our panelists for
their wonderful testimony and to tell you that we are going to
listen very seriously to what you had to tell us. And I
especially want to thank those who came from such far
distances, Ms. Decklever and Dr. Wilper, but thank you all very
much for your help.
This hearing is adjourned.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of the American Academy of Family Physicians (AAFP)
The American Academy of Family Physicians (AAFP), which represents
105,300 family physicians and medical students, is pleased to submit
the following statement for the record of the Health, Education, Labor,
and Pensions Committee's subcommittee hearing entitled, ``30 Million
New Patients and 11 Months to Go: Who Will Provide Their Primary
Care?''
According to the Institute of Medicine, primary care is defined as:
The provision of integrated, accessible health care services
by clinicians who are accountable for addressing a large
majority of personal health care needs, developing a sustained
partnership with patients, and practicing in the context of
family and community.
Unfortunately, our current health care system is not consistent
with this definition. Instead, the system is fragmented, uncoordinated,
wasteful and expensive.
Every day, family physicians and other primary care doctors see the
results of our poorly functioning system of care. Duplicative and
unnecessary tests are ordered. Diseases remain undiagnosed and
untreated until they result in acute conditions. Patients with multiple
chronic illnesses are shunted from one specialist to another, each one
of whom treats only one of the diseases. And far too little attention
is paid to prevention and wellness services.
That is why the AAFP consistently has supported efforts to increase
the role of primary care physicians in the delivery of health care.
Primary care provides high-quality, coordinated, cost-effective care to
patients employing a whole-person approach.
As such, efficient and effective health systems result when primary
care physicians are the usual source of care for people. Family
physicians and other primary care physicians can help patients prevent
disease by improving their healthy behavior. They can aid them in
managing their chronic diseases, especially when the patient has more
than one chronic illness, and refer to a subspecialist, when necessary.
And family physicians and other primary care physicians can help
patients navigate the complex world of hospitals and other health
institutions.
Health delivery reform requires considering how our dysfunctional
health care system can become one that serves the patient by
coordinating care over time to prevent disease, managing chronic
conditions and providing immediate and targeted care for an acute
condition when it arises.
Consequently, the availability of an adequate primary-care
physician workforce is essential to achieving these aims.
Unfortunately, this workforce is stagnant, if not dwindling, which
raises significant concerns about the viability of the Nation's health
care system.
The Commission on Graduate Medical Education (COGME) in its 20th
report (December 2010) offered specific recommendations and goals for
building an adequate primary-care physician workforce.
COGME cited compelling evidence that health care outcomes and costs
in the United States are strongly linked to the availability of primary
care physicians. For each incremental primary care physician (PCP),
there are 1.44 fewer deaths per 10,000 persons. Patients with a regular
primary care physician have lower overall health care costs than those
without one.
As a result of a number of factors including compensation, practice
environments, and experience in medical school, there is a shortage in
the number of primary care physicians, particularly those with the
ability to care for adults and their associated chronic disease burden.
This shortage is especially critical now in the context of health care
reform objectives that will increase the need for primary care
physicians. As a result of passage of the Patient Protection and
Affordable Care Act (ACA), as many as 32 million previously uninsured
Americans will be eligible for coverage. Such an influx of previously
uninsured and likely underserved individuals will undoubtedly increase
the demand for primary care services nationwide.
At the present time, 32 percent of physicians in the United States
are primary care providers, of which 12.7 percent are family
physicians, 10.9 percent general internists, 6.8 percent general
pediatricians, and 1.6 percent in general practice. The current U.S.
primary-care physician workforce is in jeopardy of accelerated decline
because of decreased production and accelerated attrition. Decreased
production from graduate medical education is a reflection of the
choices made by young physicians and by teaching hospitals that are
associated with a growing income disparity between primary care
physicians and other specialties. Over the last several years, a
variety of policies have been adopted to reduce this disparity and the
new Affordable Care Act takes steps to reduce it even further.
Decreased medical student interest in primary care is caused by
multiple factors including heavy workload, insufficient reimbursement,
the subtle persuasion in medical school away from primary care, and a
lack of strong primary care role models.
Attrition also will be augmented as the primary-care physician
workforce continues to age. At the present, there are 242,500 primary
care physicians in the United States and almost one quarter (55,000)
are age 56 or older. The likelihood is that many of these physicians
will retire within the next decade.
The AAFP believes policies and programs should be implemented to
support the practice of primary care, and to increase the supply of
primary care physicians. Fee-for-service payment for physician services
is biased in favor of hospital-based and procedural services and does
not provide appropriate incentives for the practice of primary care, or
to increase the supply of primary care physicians. Policy changes
should be dramatic to remedy these legacy biases and have immediate
effect.
Specifically, policies should be implemented that raise the
percentage of primary care physicians (i.e., family physicians, general
internists, and general pediatricians) among all physicians to at least
40 percent from the current level of 32 percent, a percentage that is
actively declining at the present time. The achievement of this goal
should be measured by assessing physician specialty once in practice,
rather than at the start of postgraduate medical training.
In order to achieve the desired ratio of practicing primary care
physicians, the average income of these physicians must achieve at
least 70 percent of the median income of all other physicians.
Currently this average is in the 50 percent range. If primary care
physicians are paid differently and better, in the context of the
physician-led Patient Centered Medical Home, costs should decline.
Investment in primary care office practice infrastructure will also be
needed to cope with the increasing burdens of chronic care and to
provide comprehensive, coordinated care. Payment policies should be
modified to support both of these goals.
Accordingly, Congress, CMS, and private insurers should embrace
reimbursement mechanisms that enhance primary care physician income
including:
1. Preferential increases in fee-for-service payments for primary
care services.
2. Support for coordination in primary care practices through per-
member, per-month care management fees.
3. Financial rewards for improvements in performance measures.
4. Reward the Patient-Centered Medical Home (PCMH) financially when
its physicians meet the four essential functions (first contact access,
patient-focused care over time, comprehensive care, and coordinated
care) and the three corollary functions (family orientation, community
orientation, and cultural competency) and when measures of process and
quality are met and improved. The physician-led PCMH should be
supported as the construct for the practice environment that achieves
optimal care coordination and integration, for use of health
information technology, for enhanced access, and for appropriate
payment. Study levels of funding necessary to sustain the physician-led
PCMH model and its impact on costs in settings other than physicians'
offices.
5. Implement payment models that bundle payments for full-service
accountable care organizations and incentivize the development of
community health care organizations that provide the four essential
functions of primary care through collaboration of primary care
physicians, public health, care coordination organizations, and mental
health organizations.
Medical schools and academic health centers should develop an
accountable mission statement and measures of social responsibility to
improve the health of all Americans. This includes strategically
focusing and changing the processes of medical student and resident
selection and altering the design of educational environments to foster
a physician workforce of at least 40 percent primary care physicians
and a health system that meets societal needs.
In order to accomplish the transformation of the educational
environment, medical schools and academic health centers should:
1. Increase and sustain the involvement of primary care physicians
through all levels of medical training;
2. Support student primary care interest groups;
3. Recruit, develop, and support community physician faculty
members; and
4. Require student participation in rural, underserved, and global
health experiences.
5. Expand medical school class size strategically to address the
primary care physician deficit and maldistribution issues.
6. Reform admission processes to increase the number of qualified
students more likely to choose a primary care specialty and to serve
medically vulnerable populations.
7. Recruit and retain underrepresented minority students and
faculty members.
8. Require block and longitudinal experiences of sufficient length
that medical students clearly understand the essential functions of
primary care and the medical home.
9. Collaborate with local communities and distribute resident
training accordingly, support reductions in physician income
disparities, and lead in the development of new models of practice like
the physician-led PCMH.
The Federal and State Government contributions to this effort would
include:
1. Providing increased incentives for physicians who practice
primary care or other critical specialties in designated health
workforce shortage areas.
2. Substantially enhancing funding for scholarships, loans, loan
repayment, and tuition waiver programs to lower financial obligations
for students who plan and pursue careers in primary care.
Graduate Medical Education (GME) payment and accreditation policies
and a significantly expanded title VII program should also support the
goal of producing a physician workforce that is at least 40 percent
primary care.
To accomplish this objective, Congress, the Administration,
Department of Health and Human Services, and accrediting agencies
should:
1. Change regulations to support more training in outpatient
settings and experimentation with practice models to prepare residents
appropriately for an evolving contemporary health care environment;
2. Strategically increase the number of new primary care GME
positions and programs to accommodate the increased production of
medical school graduates and respond to the need for a workforce
composed of at least 40 percent primary care physicians;
3. Increase training in ambulatory, community, and medically
underserved sites by promoting collaboration between academic programs
and Federally Qualified Health Centers (FQHCs), rural health clinics
(RHCs), and the National Health Service Corps (NHSC);
4. Implement new methods of funding to include GME funding that is
not calculated according to Medicare beneficiary bed-days, and
substantial expansion of title VII funding specifically for community-
based training;
5. Provide financial incentives for GME that directs funding to
primary care residency programs, educational consortia, or non-hospital
community agencies to provide the proper incentives for ambulatory and
community-based training;
6. Explore augmenting payments for primary care residents,
including differentially higher salaries and early loan repayments, to
decrease the negative impact of educational debt on primary care
specialty choice;
7. Fund all primary care residency programs at least at the 95th
percentile level of funding for all programs (using total direct
medical education (DME) and indirect medical education (IME) payments
as a basis); and
8. Reward teaching hospitals, training programs, and community
agencies financially on the basis of the number of primary care
physicians produced, to be determined by specialty in practice and not
at the initiation of training.
Last, to enable policy development predicated on data and to
address geographic and socioeconomic maldistribution of physician
supply, Congress and the Administration should:
1. Ensure funding for the Healthcare Workforce Commission included
in ACA;
2. Ensure funding of the National Health Service Corps at the $1.15
billion amount authorized by the ACA so that the NHSC can recruit more
primary care physicians, provide greater support of scholarship
recipients, create special learning opportunities and networks for
scholarship recipients and early loan repayers, and forge formal
affiliations with academic institutions and training programs;
3. Increase substantially the funding for Title VII, section 747,
in Primary Care Medicine and Dentistry cluster grants;
4. Implement programs to increase funding by the Agency for
Healthcare Research and Quality (AHRQ), National Institutes of Health
(NIH), and private research enterprises for projects that stimulate
primary care and community-based research and emphasize methodologies
such as population-based ecological and cluster studies, qualitative
behavioral studies, and comparative effectiveness research; and
5. Increase funding for Community Health Centers (CHCs) that are
committed to training students and residents; and increase funding for
Area Health Education Centers (AHEC) programs to improve existing
programs, support new programs, and support innovative funding
proposals that promote the practice of primary care in medically
underserved areas.
The AAFP appreciates the opportunity to provide family medicine's
views on the importance of an adequate primary-care physician workforce
in the development of an efficient and effective U.S. health delivery
system. In particular, we agree with the evidence that suggests that
health system reform can be successful only if it is built on a base of
primary care physicians. To this end, we recommend:
1. Elimination of the flawed sustainable growth formula in the
Medicare physician fee schedule and support alternative delivery
systems including the physician-led patient-centered medical home;
2. Full funding for the National Physician Workforce commission,
title VII and the National Health Service Commission;
3. Increased availability of scholarships and loan repayment for
medical students choosing to practice as primary care physicians; and
4. Support for innovation in graduate medical education funding,
including allowing GME dollars to ``follow the resident'' and
reimbursement for residency sponsoring entities other than hospitals.
Thank you for the opportunity to provide recommendations on this
critical topic.
Prepared Statement of the American Academy of Physician
Assistants (AAPA)
SUMMARY
Physician assistants (PAs) are one of three healthcare professions
providing primary medical care in the United States today, and are an
integral part of the solution to healthcare workforce shortages.
In 2010, over 300 million patient visits were made to
physician assistants.
PAs practice in virtually every area of medicine.
Approximately one-third of all PAs practice in primary care. PA
education is based on the primary care model of care, providing greater
flexibility for PA practice upon graduation.
By design, PAs always work with physicians. Team-based,
patient-centered medical care is a hallmark of the PA profession and a
perfect fit for today's dynamically changing healthcare system.
PAs serve as medical directors in rural health clinics,
community health centers, and other federally qualified health centers.
In rural and other medically underserved communities, a physician
assistant may be the only health care professional available.
PAs provide first contact, continuous, and comprehensive
care for patients throughout the United States. PAs currently manage
care for patients in primary care, chronic care, and other areas of
medicine.
Studies show that in a primary care setting, PAs can
execute at least 80 percent of the responsibilities of a physician with
no diminution of quality and equivalent patient-care satisfaction.
By virtue of PA education in primary care and the ability
of PAs to work in all medical and surgical specialties, PAs expand
access to care in medically underserved rural and urban communities.
In addition to the need to produce more primary care physicians and
nurses, it is critical that Congress support PA educational programs as
they develop strategies for addressing healthcare workforce challenges.
The Title VII, Public Health Service Act's, Health
Professions Program is successful in training health care professionals
for practice in medically underserved communities. Funding for PA
educational programs through title VII should be a priority.
The single largest barrier to PA educational programs
educating more PAs is a lack of clinical training sites. Attention must
be directed to investing in the number of these sites, including loan
repayment for preceptors in primary care medical practices and/or the
increased use of VA facilities as clinical training sites for PA
educational programs.
Funds must be made available to increase the number of
faculty at PA educational programs. Eligible PA students are being
turned away because of the lack of faculty and clinical sites.
Federally supported student loans and increased
opportunities through the National Health Service Corps are key to
attracting PA students and clinicians to primary care.
Graduate medical education funding should be used to
support the educational preparation of physician assistants in
hospitals and outpatient, community-based settings.
The President's initiative to create a pathway for
veterans to PA education is particularly well-suited to support the
increased presence of PAs in rural areas. Veterans are
disproportionately from rural areas and are well-equipped to return to
rural communities and provide quality medical care as PAs. The
initiative is a good healthcare workforce development model that
warrants ongoing support.
Physician assistants are key to healthcare workforce shortages.
However, to be fully utilized and add maximum efficiency of team-based
medical care, technical changes must be made to Federal programs to
provide full transparency of the medical care (and cost of medical
care) provided by PAs. Additionally, current barriers to care that
exist in Federal law must be addressed.
Medicare and Medicaid must be updated to fully enroll PAs.
The Medicare statute must be amended to allow PAs to order
home health and hospice care, as well as to provide hospice care for
Medicare beneficiaries.
The Federal Employee Compensation Act needs to be updated
to allow PAs to diagnose and treat Federal employees who are injured on
the job.
______
On behalf of the nearly 90,000 certified physician assistants (PAs)
represented by the American Academy of Physician Assistants (AAPA),
thank you for the opportunity to submit written testimony for the
hearing record of the Senate Subcommittee on Primary Health and Aging,
Committee on Health, Education, Labor, and Pensions.
As one of three professions (medicine, nursing, and physician
assistants) with a primary role in healthcare delivery, the growth of
the physician assistant workforce is an integral part of addressing our
Nation's future needs.
The Affordable Care Act has brought unprecedented attention to
ensuring the supply of primary healthcare professionals is adequate to
address the future needs of patient care. When ACA is fully
implemented, up to 32 million currently uninsured patients will have
healthcare coverage, requiring an accompanying growth in the healthcare
workforce. The Bureau of Labor Statistics projects 39 percent increase
in demand for physician assistants from 2008 to 2018.
The PA profession with its generalist education, commitment to
team-based practice, and relatively short training is ideally
positioned to address both the short-term and long-term needs of the
Nation. However, those needs can be met by PAs only if the profession
is able to substantially increase the number of graduates over the next
10 years.
PHYSICIAN ASSISTANTS
Physician assistants are licensed health professionals, or in the
case of those employed by the Federal Government, credentialed health
professionals, who:
practice medicine in teams with physicians,
exercise autonomy in medical decisionmaking,
provide a comprehensive range of diagnostic and
therapeutic services, including performing physical exams, taking
patient histories, ordering and interpreting laboratory tests,
diagnosing and treating illnesses, assisting in surgery, writing
prescriptions, and providing patient education and counseling, and
may also work in educational, research, and administrative
settings.
PAs are located in almost all health care settings and in every
medical and surgical specialty. PAs are covered providers within
Medicare, Medicaid, Tri-Care, and most private insurance plans.
Additionally, PAs are employed by the Federal Government to provide
medical care, including the Department of Defense, the Department of
Veterans Affairs, the Public and Indian Health Services, the State
Department, and the Peace Corps.
AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS
The AAPA represents PAs throughout the United States, and is the
only national organization representing PAs in all medical specialties.
The mission of the Academy is to promote quality, cost-effective,
accessible health care, and to promote the professional and personal
development of physician assistants. The Academy assures competency of
PAs through active involvement in the development of educational
curricula and accreditation of PA programs, provides continuing medical
education, conducts PA-related research, and educates the general
public about the PA profession.
OVERVIEW OF PHYSICIAN ASSISTANT EDUCATION
The PA educational program is modeled on the medical school
curriculum, a combination of classroom and clinical instruction. The PA
course is rigorous and intense. The average length of a PA education
program is 27 months.
Admission to PA school is highly competitive. Applicants to PA
programs must have completed at least 2 years of college courses in
basic science and behavioral science as prerequisites, analogous to
premedical studies required of medical students.
PA programs are located at schools of medicine or health sciences,
universities, teaching hospitals, and the Armed Services. All PA
educational programs are accredited by the Accreditation Review
Commission on Education for the Physician Assistant, an organization
composed of representatives from national physician groups and PAs.
The first phase of the program consists of intensive classroom and
laboratory study, providing students with an in-depth understanding of
the medical sciences. More than 400 hours in classroom and laboratory
instruction are devoted to the basic sciences, with over 70 hours in
pharmacology, more than 149 hours in behavioral sciences, and more than
535 hours of clinical medicine.
The second year of PA education consists of clinical rotations. On
average, students devote more than 2,000 hours or 50-55 weeks to
clinical education, divided between primary care medicine and various
specialties, including family medicine, internal medicine, pediatrics,
obstetrics and gynecology, surgery and surgical specialties, internal
medicine subspecialties, emergency medicine, and psychiatry. During
clinical rotations, PA students work directly under the supervision of
physician preceptors, participating in the full range of patient care
activities, including patient assessment and diagnosis, development of
treatment plans, patient education, and counseling.
After graduation from an accredited PA program, the physician
assistant must pass a national certifying examination jointly developed
by the National Board of Medical Examiners and the independent National
Commission on Certification of Physician Assistants. To maintain
certification, PAs must log 100 continuing medical education credits
over a 2-year cycle and reregister every 2 years. Also to maintain
certification, PAs must take a recertification exam every 6 years.
The majority of PA educational programs offer master's degrees, and
the overwhelming majority of recent graduates hold a master's degree.
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 funds are
used to encourage PA students, upon graduation, to practice in
underserved communities. These goals are accomplished by funding PA
education programs that have a demonstrated track record of: placing PA
students in health professional shortage areas; exposing PA students to
medically underserved communities during the clinical rotation portion
of their training; and recruiting and retaining students who are
indigenous to communities with unmet health care needs.
The Title VII program works.
A review of PA graduates from 1990-2009 demonstrates that
PAs who have graduated from PA educational programs supported by title
VII are 67 percent more likely to be from underrepresented minority
populations and 47 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. 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.
need for increased targeted support for pa education
Federal support must be directed to PA educational programs to
stimulate growth in the PA profession to meet the needs of universal
health care coverage. Targeted funding should be directed to:
The use of title VII funds for recruitment and loan
repayment for faculty in PA educational programs.
Incentives to increase clinical training sites for PA
education.
Federally backed loans and loan repayment programs for PA
students.
Graduate Medical Education support for the education of
PAs in hospitals and community-based settings.
Expansion of the President's initiative to create a
pathway for veterans to PA educational programs.
ELIMINATING BARRIERS TO CARE IN FEDERAL LAW
Eliminating current barriers to medical care provided by PAs that
exist in the Medicare, Medicaid, and the Federal Employees Compensation
Act (FECA) laws would do much to expand access to needed medical care,
particularly for patients living in rural and other medically
underserved areas.
AAPA believes that the intent of the 1997 Balanced Budget
Act was to cover all physician services provided by PAs at a uniform
rate. However, PAs are still not allowed to order home health, or
hospice care, or provide the hospice benefit for Medicare
beneficiaries. At best, this creates a misuse of the patient's
physician's, and PA's time to find a physician signature for an order
or form. At worst, it causes delayed access to care and inappropriate
more costly utilization of care, such as longer stays in hospitals. For
patients at end-of-life, it creates an unconscionable disruption of
care. (A 2009 report by the Lewin Group estimates an overall cost
savings through implementation of the PA Medicare provisions.)
Most States recognize services provided by PAs in their
Medicaid Programs, but it is not required by law. Consequently, some
State Medicaid Directors pick and choose which services provided by PAs
they will cover. Others impose coverage limitations not required by
State law, such as direct supervision by a physician.
Although nearly all State workers' compensation programs
recognize the ability of PAs to diagnose and treat State employees who
are injured on the job, the Federal program does not. As a result,
Federal workers who are injured on the job may be rerouted to emergency
rooms for workers' compensation-related care, rather than to go to a
practice where the PA is the only available health care professional.
The Medicare, Medicaid, and FECA statutes create Federal barriers
to care that do not exist in State law. The barriers need to be
eliminated to promote increased access to the quality, affordable
medical care provided by PAs and to add efficiency to team-based care.
NEED FOR TRANSPARENCY IN THE MEDICARE CARE AND REIMBURSEMENT
FOR CARE PROVIDED BY PAS
PAs contribute a unique role as part of medical teams in virtually
all medical specialties and health care systems. However, the
contribution of PAs and the physician-PA team are rarely captured in
reporting systems. The AAPA strongly encourages Congress to encourage
the development of patient-centered comparative effectiveness research
to require that all public and private health care reporting systems
identify medical services and payment for medical services provided by
PAs. The Academy believes that a requirement of data systems to track
medical care provided by PAs is essential to track the clinical and
economic performance of PAs for issues related to cost-effectiveness,
quality, and outcomes research; practice patterns; and to determine the
volume of patient care services delivered for workforce projections.
To encourage transparency, as well as increased accountability for
medical care provided by PAs, AAPA recommends that:
PAs be fully enrolled in Medicare by amending the Medicare
statute to update payment services provided by PAs to allow for payment
to the PA, just as payment is allowed for virtually every other
healthcare professional recognized by Medicare;
All State Medicaid programs enroll PAs, as opposed to
reimbursing medical care provided by PAs through the physician; and
The Medicare claims system be modified to require the
identification of PA delivered services.
A baseline for medical care provided by PAs will be increasingly
important as the healthcare delivery system moves toward a model that
relies more on team-based delivery of care in order to better evaluate
the cost-effectiveness of team-based care.
Thank you for the opportunity to submit a statement for the hearing
record of 30 Million New Patients and 11 Months to Go: Who Will Provide
Their Primary Care?
American Association Colleges of Osteopathic Medicine (AACOM)
The American Association of Colleges of Osteopathic Medicine
(AACOM) is pleased to submit this statement for the record to the U.S.
Senate Health, Education, Labor, and Pensions (HELP) Subcommittee on
Primary Health and Aging for the January 29, 2013 hearing, ``30 Million
New Patients and 11 Months to Go: Who Will Provide Their Primary
Care?'' AACOM commends subcommittee Chairman Bernard Sanders for
convening this hearing on this extremely important issue.
AACOM represents the Nation's 29 colleges of osteopathic medicine
at 37 locations in 28 States. Today, more than 21,000 students are
enrolled in osteopathic medical schools. One in five U.S. medical
students is training to become an osteopathic physician. AACOM was
founded in 1898 to support and assist the Nation's osteopathic medical
schools, and to serve as a unifying voice for osteopathic medical
education.
OSTEOPATHIC MEDICAL EDUCATION AND PRIMARY CARE
Osteopathic medical education (OME) has a long history of
establishing educational programs for medical students and residents
that target the health care needs of rural and underserved populations.
Colleges of osteopathic medicine (COMs) have a standing commitment and
focus on training primary care physicians, and osteopathic physicians
have a special commitment to providing primary care, particularly to
the Nation's rural and underserved communities. All osteopathic medical
schools provide training in community-based settings, where students
spend time in community hospitals, physician offices, and health care
facilities such as Area Health Education Centers (AHECs) and Community
Health Centers (CHCs) in which they are integrated into those
communities. The majority of osteopathic medical schools are located
outside of urban areas and have particular missions related to the
underserved areas in which they are located.
OME plays an extremely strong role in training future primary care
physicians--many of whom will serve in workforce shortage areas. In
each of the last three cohorts of osteopathic medical school graduates
(2010-12), 32 percent of graduates indicated the intention to
specialize in the primary care specialties of family practice, general
internal medicine, and general pediatrics. For each year, an additional
11 to 12 percent planned to specialize in emergency medicine, and 5
percent in obstetrics and gynecology. From these same three classes,
one-third of graduates indicated plans to practice in areas that are
designated health care underserved/physician shortage areas.
AACOM strongly believes that primary care should be an essential
part of any foundation of a modern health care system. Any proposal
that would displace physicians from this role would disrupt the health
care delivery system and create obstacles to the development of the
integrated, team-based system needed to maximize value, access, and
quality. A medical education system that produces the kind of primary
care physicians that are needed to work in a value-driven health care
system should be a strong goal of medical education.
PHYSICIAN WORKFORCE
There are nearly 70,000 active osteopathic physicians (DOs)
practicing in the United States today, including those currently in
graduate medical education (GME) (or internships, residencies, and
fellowships). Of osteopathic physicians who have completed GME, 56
percent are practicing in the primary care specialties of family and
general practice, pediatrics and adolescent medicine, and general
internal
medicine (http://www.osteopathic.org/inside-aoa/about/aoa-annual-
statistics/Documents/2012-OMP-report.pdf).
Currently, more than 20 percent of new U.S. medical students are
training to be osteopathic physicians. By 2019, that number is expected
to grow to 25 percent. Many current osteopathic medical students will
pursue careers in primary care and many will practice in rural and
underserved areas; these are areas that already face shortages of
primary care providers.
AACOM believes that GME funding should be more closely associated
with specific workforce needs. With rising projections of physician
shortages to meet the health care needs of a growing and aging
population, AACOM supports the sustainable expansion of GME positions
in areas of specialty need (e.g., primary care, geriatrics, general
surgery) in which there are substantial current demand and anticipated
growing shortages--especially in rural and underserved areas. AACOM
believes that GME funding is critical to ensuring the stability and
continuity of both the Nation's medical residency training programs
that produce future physicians and the hospitals that provide care to
the Nation's citizens.
GRADUATE MEDICAL EDUCATION SUPPORTS PHYSICIAN WORKFORCE SHORTAGES
The current number of GME positions funded by the Centers for
Medicare & Medicaid Services (CMS) will not be sufficient to
accommodate the number of medical school graduates seeking positions or
the number of positions needed to offset projected physician workforce
shortages; there is growing evidence of the need for community-based
medical education to produce an outcome that will address the need for
a primary care-based health care system that provides access and value
to populations in rural and underserved areas, as well as to those
areas traditionally well-served. Since osteopathic medical students who
train in community-based institutions are more likely to practice in
these areas, AACOM continues to support GME programs that expand the
participation of community-based institutions. This is particularly
important at a time when the number of osteopathic medical school
graduates is growing and is expected to continue to grow in response to
physician workforce shortages that exist and are projected over the
next 5 to 15 years.
AACOM understands the necessity of evaluating the process of and
funding mechanism for future physician training, but we also firmly
believe Congress must take into consideration the full spectrum of
medical education in order to thoroughly understand the complexities of
GME as appropriate avenues of reform are explored.
THE ROLE OF INNOVATION IN TRAINING FUTURE PHYSICIANS
AACOM believes that there are many potential innovative solutions
that could address the challenges in the current GME system and
recognizes that training needs to support developments leading to a
patient-centered, team-based and value-driven system. It is important
to note the strong connection between osteopathic medical colleges'
training of students, which is patient-centered and geared toward
primary care in community-based and non-hospital settings, and
osteopathic GME programs, which are tied together through the oversight
of an Osteopathic Postdoctoral Training Institution (OPTI). OPTIs are
built upon partnerships between one or more teaching hospitals, a
medical school, and other medical training facilities. Additionally,
osteopathic medical schools are actively pursuing innovative approaches
to education with many students participating in interprofessional
education for team-based care, as well as utilizing problem- and case-
based curricular models.
AACOM supports the evaluation of Medicare GME funding as it
relates to need and supports expanded flexibility of current funding to
create an environment in which innovation can occur. Innovation,
partnership, and targeting of resources should help address need. The
current OME model links the osteopathic medical schools training to the
community where their student's learn. For instance, the number and
distribution of GME positions should be tied directly to the number and
type of positions needed, with an eye to geographic, demographic, and
specialty need; the development of more programs should be developed at
hospitals that do not fall under the GME cap; osteopathic medical
colleges should be enabled to work with their OPTIs on creative
development of more GME programs, in association with a variety of
institutions and funding mechanisms.
In addition, programs such as the Health Resources and Services
Administration's (HRSA) Teaching Health Center GME Program, which
provides funds to establish or enlarge primary care residency training
programs in community health centers, should continue to expand with
stable funding sources beyond those originally provided in the Patient
Protection and Affordable Care Act (P.L. 111-148). The HRSA Teaching
Health Center GME Program, currently in its third year, has provided a
model of innovation that produces primary care physicians in the
communities in which they are most needed. While approximately 10
percent of all U.S. GME programs are osteopathic programs, 21 of the 32
Teaching Health Center residencies are osteopathic consortia programs
accredited by the American Osteopathic Association (AOA), and three of
those programs are dually accredited by both the AOA and the
Accreditation Council for Graduate Medical Education (ACGME).
Sustainability for programs such as these is critical in addressing
physician workforce needs and has the potential to increase the number
of primary care physicians that serve the communities most in need.
Thank you again for the opportunity to submit this statement for
the record. AACOM looks forward to working with the subcommittee on
supporting quality patient care and a robust physician workforce that
will meet the demands of our Nation's complex and evolving health care
system.
Prepared Statement of the Association of American Medical
Colleges (AAMC)
The Association of American Medical Colleges (AAMC) is pleased to
submit this statement to the record for the January 29, 2013, hearing,
``30 Million New Patients and 11 Months to Go: Who Will Provide Their
Primary Care?'' of the Health, Education, Labor, and Pensions (HELP)
Subcommittee on Primary Health and Aging.
AAMC is a not-for-profit association representing all 141
accredited United States and 17 accredited Canadian medical schools;
nearly 400 major teaching hospitals and health systems, including 51
Department of Veterans Affairs medical centers; and nearly 90 academic
and scientific societies. Through these institutions and organizations,
the AAMC represents 128,000 faculty members, 75,000 medical students,
and 110,000 resident physicians.
The AAMC applauds subcommittee Chairman Bernard Sanders, and
Senators Mike Enzi and Rand Paul for convening this hearing on a timely
and important topic. Five years ago--nearly to the day--the AAMC
testified before the committee on this matter at a hearing chaired by
Senator Sanders, ``Addressing Healthcare Workforce Issues for the
Future.''
Much has changed in the 5 years that have passed. Enactment of the
Affordable Care Act (ACA, P.L. 111-148 and P.L. 111-152) ushered
historic reforms that will provide affordable health care coverage to
as many as 32 million more Americans; many of these people finally will
be able to access regular care for previously untreated health
conditions. The first Baby Boomers entered the Medicare program in
2011, and for the next two decades, another 10,000 Americans will turn
65 daily. The Nation's medical schools already have taken the first
critical step to address increased demand for physician services
expected as the number of Medicare beneficiaries soars and coverage
expands under the ACA: 15 new medical schools and 9 new osteopathic
medical schools have opened since 2008, with several more planned. In
combination with existing medical schools that have expanded
enrollment, the number of medical graduates is currently on track to
meet by 2016 the goal of a 30 percent increase in enrollment over 2002
levels.
Yet, despite this growing shift in demographics and the response of
the medical education community, the central challenge discussed at the
2008 HELP Committee hearing remains a challenge today: the Nation faces
a critical shortage of physicians. By 2020, the shortfall will reach
91,500 physicians, and grow to more than 130,000 by 2025. While medical
schools have taken action by graduating 30 percent more students, we
have not seen a proportionate increase in the number of residency
training or graduate medical education (GME) positions. The limited
availability of residency positions--the direct result of a cap
Congress imposed in 1997, freezing Medicare support for GME at 1996
levels--soon will preclude medical graduates from completing the
supervised training required for independent practice. In other words,
the best efforts of medical schools to increase the number of
matriculates will not curtail the physician shortages unless Congress
releases the bottleneck and lifts the Federal cap on residency training
support.
Underserved populations in both urban and rural areas will continue
to bear the greatest burden of workforce deficits, but extensive
shortages across a number of specialties are likely to impede access to
care for many Americans. The AAMC projects there will be 45,000 too few
primary care physicians by the end of the decade, hindering access to
preventive care for millions.
Accordingly, in a 2010 survey of medical school deans, 75 percent
(94 of 125 respondents) reported instituting or considering initiatives
to encourage primary care.
Less commonly reported, but equally troubling, is the parallel
shortage of more than 46,000 specialists, leaving patients with cancer,
Alzheimer's disease and dementia, hip fractures, and other ailments
without immediate access to necessary care. These trends are of
particular concern as the Nation ages and requires specialty care for
many age-related illnesses and disabilities.
Some have argued that policymakers should limit the number of
specialists, based on a study suggesting that places with more
generalists report lower Medicare spending and higher quality. These
findings repeatedly have been challenged and invalidated--most recently
in a January 2013 Working Paper for the Federal Reserve Board of
Governors' Finance and Economics Discussion Series--for neglecting to
adjust appropriately for socioeconomic factors. The recent analysis
clearly demonstrates that including the rate of uninsured and black in
the regression negates the original conclusion correlating workforce
composition with health care spending.
Indeed, prioritizing only one component of the workforce will be a
futile strategy, as the broad scope of the problem necessitates an
equally multi-faceted response. As the subcommittee discusses potential
solutions, the AAMC provides the following background principles about
graduate medical education and teaching hospitals, and offers policy
recommendations to consider in the interest of improving access to care
for all patients.
BACKGROUND PRINCIPLES
Medicare Supports GME to Ensure Access to Physicians and to Highly
Specialized Services for Medicare Beneficiaries
Physician training is inextricable from patient care, and Medicare
historically has paid for its share of the costs of training and the
highly sophisticated health services provided by teaching hospitals.
Medicare reimburses teaching hospitals for a portion of these costs
through two types of payments: Direct Graduate Medical Education (DGME)
and Indirect Medical Education (IME) payments.
DGME payments are intended to offset the direct costs of GME, such
as resident stipends and benefits; supervising faculty salaries and
benefits; and allocated institutional overhead costs. These payments
are tied directly to a program's ``Medicare share,'' an institution-
specific amount that reflects Medicare volume as a percent of patient
care days at the institution. According to fiscal year 2009 Medicare
cost reports (www.HealthData.gov), Medicare DGME payments reimbursed
less than one quarter of the total direct costs teaching hospitals
incurred in fiscal year 2009. The training costs above Medicare's share
are borne primarily by the program itself.
Medicare DGME payments are not limited to teaching hospitals;
currently, community health centers and other teaching settings are
eligible for DGME payments that, like teaching hospitals, are
calculated based on the facility's Medicare share. Congress repeatedly
has clarified that Medicare GME support should remain tied to the level
of Medicare services provided, rather than diverting limited Medicare
funds to providers that do not treat a substantial number of Medicare
beneficiaries.
Medicare IME payments, on the other hand, are patient care payments
that recognize the additional costs incurred by teaching hospitals
because they maintain specialized services and treat the most complex,
acutely ill patients. As stated in House and Senate report language
when Congress created the IME adjustment as part of Medicare's
Prospective Payment System (PPS) in 1983:
This adjustment is provided in light of doubts . . . about
the ability of the DRG case classification system to account
fully for factors such as severity of illness of patients
requiring the specialized services and treatment programs
provided by teaching institutions and the additional costs
associated with the teaching of residents . . . The adjustment
for indirect medical education costs is only a proxy to account
for a number of factors which may legitimately increase costs
in teaching hospitals. (House Ways & Means Committee Rept. No.
98-25, March 4, 1983, and Senate Finance Committee Rept. No.
98-23, March 11, 1983)
For example, AAMC-member teaching hospitals operate 80 percent of
Level 1 Trauma centers and provide a range of highly sophisticated
services not offered elsewhere in communities. IME payments are meant
to partially offset these costs. Providers that do not incur the unique
patient care costs associated with caring for highly complex, severely
ill inpatients (i.e., ambulatory sites that largely provide primary,
non-acute care) do not qualify for these payments.
The specialized services supported in part by IME payments extend
far beyond the locale of the recipient institution. Rather, in many
cases, major teaching hospitals provide life-saving care to the entire
region. Consider, for example, inpatient discharges for the University
of Colorado Health Systems. As depicted in the map below, patients
across the State of Wyoming, regions of Montana, New Mexico, and
several other States beyond Colorado rely on services offered by the
University of Colorado Health Systems.
Major Teaching Hospitals Offer A Comprehensive Range of Unique Services
to All Patients
As described above, AAMC-member teaching hospitals maintain the
vast majority of the country's critical standby units. In addition to
the trauma centers, AAMC members operate: 79 percent of all burn care
units; 40 percent of neonatal- and 61 percent of pediatric-ICUs; nearly
half of the surgical transplant services; over one-fifth of all cardiac
surgery services; and 44 percent of Alzheimer centers. These
institutions provide over one-third of all hospital charity care.
Compared with physician offices and other hospitals, major teaching
hospitals care for patients that are sicker, poorer, and more likely to
be disabled or non-white.
At nearly half of academic medical centers, the majority of
Medicare visits are provided in hospital-based clinics. Hospital
Outpatient Departments (HOPDs) serve as a safety net for vulnerable
populations, offering both primary care, and comprehensive and
coordinated care settings for patients with chronic or complex
conditions. Examples include access to pain centers, cancer clinics, or
psychiatric care, as well as wrap-around services, such as translation
and community-based services.
Academic medical centers also serve as vital partners to community-
based facilities. A 2010 study described the barriers that community
health centers (CHCs), which primarily provide primary care services,
face in securing specialty care for patients; 91 percent reported
difficulties in finding offsite specialists for uninsured patients, 71
percent for Medicaid patients, and 49 percent for Medicare patients,
though hospital affiliations eased the difficulty in some cases. These
findings suggest a major obstacle in ensuring timely treatment, as an
October 2007 study in Health Affairs reported that 25 percent of visits
to CHCs result in ``medically necessary referrals for services not
provided by the center.'' The Health Affairs study describes that those
CHCs affiliated with medical schools or hospitals report better access
to specialty services, and notes:
``If policymakers plan to extend access to primary care for
the uninsured by increasing the number of CHCs, they must also
address the problem of access to secondary and tertiary levels
of care.''
With major teaching hospitals treating a substantial and growing
percentage of Medicaid and/or financially disadvantaged patients, the
studies reinforce the importance of a comprehensive approach to
resolving access issues, rather than growing the capabilities of one
type of facility or specialty at the expense of others.
Teaching Hospitals Are Leading Innovative Efforts to Improve Care
Quality and Efficiency
The current caps on physician training were imposed at a time when
most researchers predicted that the delivery system would change
rapidly and drastically under the influence of tightly managed care.
Today, the health care delivery system is in a time of significant
transformation with numerous Federal, State, and private efforts under
way to improve coordination and quality of care, increase access, and
reduce cost--which may have a significant impact on demand for
physician services.
Major teaching hospitals are at the forefront of many of these
innovations in care delivery. AAMC member institutions account for less
than 6 percent of all hospitals but constitute a much larger percentage
of participants in reforms sponsored by the Centers for Medicare and
Medicaid Services (CMS). For example, AAMC members make up 44 percent
of Health Care Innovation Award grantees; 34 percent of the Innovation
Advisors Program; 18 percent of all CMS Accountable Care Organizations
(ACOs); 38 percent of Pioneer ACOs; and 17 percent of Medicare Shared
Savings Program participants.
Similarly, AAMC medical schools and teaching hospitals are
innovating to prepare the next generation of health professionals for
practice in a new delivery system. For example, AAMC has partnered with
other health education associations through the Interprofessional
Education Collaborative (IPEC) to focus on better integrating and
coordinating the education of physicians, nurses, pharmacists,
dentists, public health professionals, and other members of the patient
health care team to provide more collaborative and team-based care.
It is too early to know the short-or long-term effect these nascent
efforts will have on our future workforce needs, but these changes will
take years to come to fruition. In the interim, it would be
irresponsible to ignore the Nation's expanding health care needs. As
demonstrated in Massachusetts, expanding insurance coverage leads to an
initial increase in utilization of both primary and subspecialty care.
Influencing Specialty Choice: Studies Indicate Debt Plays a Minor Role
Many claim prohibitive debt levels lead medical students to choose
careers other than primary care, but surprisingly little evidence
supports this assertion. In fact, a thorough review of the academic
literature shows little to no connection between debt and specialty
choice. Rather, studies show specialty choice is a complex and personal
decision involving many factors. According to AAMC's annual survey of
graduating medical students, the most important factors are a student's
personal interest in a specialty's content and/or level of patient
care; desire for the ``controllable lifestyle'' offered by some
specialties; and the influence of a role model in a specialty. Student
debt consistently ranks toward the bottom of the list for this question
every year.
Further, Federal programs, such as the National Health Service
Corps (NHSC), offer incentives to help physicians manage their debt. A
January 2013 study in Academic Medicine found that,
``physicians in all specialties, including primary care, can
repay the current median level of education debt. At the most
extreme borrowing levels . . . options exist to mitigate the
economic impact of education debt repayment. These options
include an extended repayment term or Federal loan forgiveness/
repayment program, such as IBR, PSLF, and the NHSC.''
In addition to the NHSC, other programs at the Health Resources and
Services Administration (HRSA) have proven successful in guiding
students toward a career in primary care and underserved communities.
The title VII health professions programs offer support for educational
opportunities in these settings. Marking their 50th anniversary in
2013, these programs serve as a catalyst for innovations in education
and training, helping the workforce over the years adapt to the
Nation's changing workforce needs. Similarly, the Children's Hospitals
Graduate Medical Education program provides critical support to
strengthen the future primary and specialty care workforce for the
Nation's children.
The Teaching Health Center (THC) program is a new HRSA initiative,
established in the Affordable Care Act and funded with a mandatory
appropriation. The THC program provides payments of $150,000 per
resident, per year, to community-based, ambulatory patient care centers
that operate primary care residency programs. These payments are being
made at a far higher level than Medicare supports teaching hospitals.
AAMC continues to support HRSA funding for this new program, given that
the agency oversees the Federal health center program, health
professions workforce development programs, and other community-based
entities. We look forward to studying the outcomes of the initial
cohort of THCs, and how continued HRSA funding can sustain the higher
payments made to these facilities.
It should also be noted that past attempts to influence specialty
selection through Medicare GME payments have failed, leading the
Medicare Payment Advisory Commission (MedPAC) to promote other
mechanisms, such as clinical reimbursement, NHSC, and title VII
programs, instead. Since the mid-1990s, hospitals have received twice
the DGME payment for primary care and geriatrics residents as compared
to subspecialty fellowships, yet shortages persist. As observed by
MedPAC in its November 2003 report on the Impact of Resident Caps on
the Supply of Geriatricians, ``[f]actors other than Medicare's resident
caps may better explain the slow growth in the number of geriatric
physicians.'' The report further notes that:
``federal policies intended to affect the number, mix, and
distribution of the health care workforce should be implemented
through specific targeted programs rather than through
Medicare.''
POLICY RECOMMENDATIONS
Despite the best-implemented health care delivery reforms, the
growing and aging Nation will need a larger physician workforce. The
United States cannot afford to wait until the physician shortage takes
full effect, as the education and training of each physician takes more
than a decade. These recommendations are intended to clarify that an
adequate supply of physicians must be achieved both through more
efficient health care delivery models and by increasing physician
training positions. No single approach is sufficient; all of the
following are necessary to ensure an adequate supply of physicians:
1. The number of federally supported GME training positions should
be increased by at least 4,000 new positions a year to meet the needs
of a growing, aging population and to accommodate the additional
graduates from accredited medical schools. The medical education
community will be accountable and transparent throughout the expansion.
Training an additional 4,000 physicians a year would allow the
Nation to increase its expected supply of doctors by approximately
30,000 by the end of the decade--meeting approximately one-third of the
expected shortage. This represents an expansion of approximately 15
percent over current training levels, which would provide a sufficient
number of positions to accommodate U.S.-educated doctors while allowing
for international medical graduates (IMGs) to occupy about 10 percent
of training positions. Absent the necessary increases in residency
positions, per capita numbers of physicians will continue to fall as
the population grows and ages with rising per capita needs.
The AAMC believes that primary care is the foundation of a high-
performing health system, but it is equally important to increase the
supply of subspecialists in many areas. As patients age, incidence of
both chronic and acute conditions rises dramatically; U.S. health care
has made great advances in the care of these conditions. Cancer,
arthritis, diabetes, and other illnesses of adults will continue to be
treatable disorders that require the care of oncologists, surgeons,
endocrinologists, and other specialties. Children who previously would
have succumbed to their illnesses will survive into adulthood but
require decades of followup by primary care, pediatric subspecialists,
and adult subspecialists. Meeting these needs cannot be accomplished
without increasing the number of residency positions.
2. Current and future targeting of funding for new residency
positions should be planned with clear attention to population growth,
regional and State-specific needs, and evolving changes in delivery
systems. Today, approximately half (2,000) of these additional
positions should be targeted to primary care and generalist
disciplines; the remainder should be distributed across the dozens of
the approximately 140 other specialties that an aging nation relies
upon. Attempts to increase physicians in targeted specialties by
reducing training of other specialists will impede access to care.
Approximately half (or 13,000) of first-year residency training
positions are in family medicine, internal medicine, and pediatrics;
while many of these residents will go on to subspecialize, the number
of fellowship (or subspecialty) training positions accounts for
approximately 20 percent of all available GME slots. Even the largest
internal medicine subspecialty, cardiology, trains fewer than 1,000
physicians a year; fewer than 500 oncologists are trained annually.
Attempting to force physicians to forgo subspecialty training by
limiting fellowship opportunities would have limited effect and, even
if successful, would jeopardize timely access to care for patients who
require a subspecialist.
Wait times for access to subspecialists continue to grow,
necessitating that, in some cases, training capacity must be increased,
combined with efforts to more efficiently use subspecialty care. The
AAMC believes that the ideal team-based health care delivery and
utilization model should efficiently use human resources to improve
patient access to appropriate services. For example, some patients
managed by specialists can be directed back to primary care providers
with management plans for chronic conditions. Other providers in a
variety of settings could care for lower acuity patients now treated by
physicians. Optimizing utilization will help relieve both the burden on
patients seeking to access appropriate health care services and on
overwhelmed providers, but will not obviate the need to train more
doctors.
Physician shortages will persist even if the Medicare funding caps
are lifted today, given the severity of the problem and a likely modest
rate of change in the delivery and payment systems. Increasingly,
patient access to both primary and specialty care will be a challenge.
As health care is better integrated--team care expands and unnecessary
variations are reduced--newly insured patients will present in the
offices of primary care providers. For many of those patients, primary
care providers will need to coordinate the care of subspecialists for
complex illnesses. These needs will outstrip the supply of many
subspecialties at current levels, even if utilization rates are
significantly reduced.
It is unclear how extensive this increase in utilization will be
over the course of subsequent years. Therefore, it is imperative to
target the current and future increase in federally funded residency
positions through ongoing analysis of health care utilization and
estimates of future demand, rather than by prescribing a static
specialty composition that does not actively respond to a dynamic
health care environment.
3. In addition to expanding support for GME, policymakers should
leverage clinical reimbursement and other mechanisms to affect
geographic distribution of physicians and influence specialty
composition.
While the ACA took steps to increase reimbursement to primary care
providers, policymakers will need to reimburse cognitive and patient
management services in a way that makes these specialties more
attractive to new physicians. Similarly, programs like NHSC and title
VII have successfully improved distribution of primary care providers
to underserved areas, but policymakers must find ways to reward
physicians economically who serve geographically or economically
underserved communities. Education and training cannot overcome the
intense market incentives that influence physician choices.
Recent studies show 31 percent of physicians are not accepting new
Medicaid patients. Teaching hospitals and physician faculty are more
likely to serve poor and vulnerable populations and will be asked to
see more patients for whom reimbursement is less than the cost of
providing care. Physicians and other providers must be paid adequately
to ensure that patients have access to care.
4. The Federal Government should continue to invest in delivery
system research and evidence-based innovations in health care delivery.
Lifting the 15-year freeze in Federal support for physician
training by 15 percent only would meet one-third of the expected
shortage of physicians by the end of this decade, and is insufficient
to ensure access to care. Delivery system innovations that improve
efficiency, integrate care, and leverage other health professionals
also will be necessary.
The ACA created new opportunities for health care delivery reform
at the Federal level and for the States, which are now in the beginning
stages of implementation. AAMC institutions and faculty are working
with the Federal Government to improve delivery and payment by
participating in numerous initiatives. AAMC members are focused on the
transformation of health care delivery, including through the Patient-
Centered Outcomes Research Institute (PCORI).
AAMC teaching hospital members receive significant public funding
for their missions and are willing to be meaningfully accountable for
that support. The training of physicians and other health professionals
has changed significantly in the last 15 years and is increasingly
focused on teaching doctors to improve systems of care. As measures are
created, tested, and evaluated, these data will demonstrate the
increasing ability of new physicians to work in teams; facilitate
system changes to improve population health; and foster continuous
quality improvement.
Continued research will inform how providers, systems, and payers
can ensure access to care as well as optimal outcomes. Along with the
AAMC, the Federal Government should continually assess how these
delivery changes affect workforce needs and make the necessary
additional investments in training to provide an adequate physician
workforce.
Communities in all regions of the country rely on academic medical
centers for high-quality medical care, advanced research, job creation,
new business development, and education of medical professionals. As
the Nation faces an unprecedented demand for health care services,
continued support for medical schools and teaching hospitals will be
essential.
Thank you again for the opportunity to submit this statement for
the record and for your leadership in addressing this important
subject. The AAMC looks forward to working with the subcommittee in
strengthening access to health care for patients across the country.
Prepared Statement of the Society of General Internal Medicine (SGIM)
Mr. Chairman and members of the subcommittee, the Society of
General Internal Medicine is pleased to submit this statement for the
record associated with the subcommittee's January 29, 2013 hearing,
``Primary Care Access--30 Million New Patients and 11 Months to Go: Who
Will Provide Their Primary Care?''
SGIM is comprised of approximately 3,000 general internists who
provide patient care and conduct research and educational activities to
improve the health of individuals, many of whom suffer from complex,
multiple chronic illnesses. Our mission is rooted in the fact that
patients who have access to a robust primary care system experience
better health care quality and better outcomes at lower costs. For the
poor, the uninsured and the elderly, in particular, primary care
functions as a safety net by serving as the first, and often their only
source for medical care and treatment.
Primary care is the backbone of our health care system, but it is
under severe strain. Recent studies show that half of adults reported
problems obtaining access to care and nearly two-thirds experienced
problems with the coordination of their care by providers. Patients
often encounter extended waits for primary care services, with one in
five adults reporting a delay of 6 days or more to see a physician.
Lacking ready access to care, one in five chronically ill adults end up
visiting the emergency room for care they could have received from a
primary care physician.
With an estimated 30 million newly insured people set to enter the
health care market over the next 6 years, the demand for primary care
services will skyrocket. The current physician shortage and
maldistribution will be aggravated, and quality of care will be
threatened.
And unless our national leaders act soon, the situation will only
get worse. Within the next 10 years the demand for primary care
services in the United States will increase dramatically as 80 million
baby boomers age into the Medicare system, as the obesity epidemic
continues to grow and as the Affordable Care Act is fully implemented
across the United States.
Just as demand is growing dramatically, the supply of primary care
clinicians is dwindling, with projections of a shortage of 52,000
primary care physicians by 2025. At the same time, one-third of
generalist physicians will retire from medical practice. As a result,
by 2016 the number of adult primary care physicians leaving practice
will exceed the number who are entering.
What can be done to ensure greater access to primary care? Multiple
steps must be taken to right-size primary care.
ALIGN TAXPAYER SUBSIDIES WITH SOCIETAL NEEDS
Medicare is the Nation's single largest funder of graduate medical
education (GME), the training that medical school graduates receive as
residents in approximately 1,100 of the Nation's teaching hospitals. To
help overcome the current shortage of primary care practitioners,
Congress should consider policy changes that better align the Medicare
GME program with physician workforce needs. These would include:
Increasing the direct GME per resident payment for
trainees in primary care programs;
Providing bonus payments to hospitals for graduating
residents who practice primary care after their training is completed;
Expanding loan repayment programs for residents who
practice primary care;
Increasing salaries of primary care residents;
Raising the cap for funded GME positions by 3,000
positions annually for 5 years and allocating at least 80 percent of
the new slots for primary care training programs; and
Teaching hospitals should be encouraged to pursue funding
through the CMS's Center for Medicare and Medicaid Innovations to
develop innovative models to enhance the training of primary care
residents.
Equitable pay during residency could help reduce the financial
strain on many residents and enable them to make career and specialty
decisions that are not dictated by financial constraints.
REDUCE FINANCIAL BARRIERS
Low reimbursement rates have long threatened patient access to
primary care providers and services. While the ACA put in place a
modest 10 percent Medicare bonus for primary care services from 2010
through 2015, this is insufficient to appreciably address the workforce
shortage as the demand for primary care services increases. A much
larger increase that is not time limited is needed to change behavior
and increase the supply of primary care physicians. A primary care
physician's annual practice income would need to increase by 63
percent, for example, to generate the same lifetime earnings as that of
a cardiologist.
In 2008, median income for generalist physicians was 54 percent of
that for specialty physicians. This compares to almost 65 percent in
the early 1990s, when the compensation gap between generalists and
specialists narrowed, and we saw a 12 percent rise in the number of
students choosing primary care residencies.
So long as physician reimbursement rates for both existing and new
services are so severely skewed toward procedural services, primary
care will be undervalued and underinvested. Aligning incentives,
especially monetary ones, for current and future physicians with the
society's need for more primary care physicians would bring about the
desired change more quickly and dependably than will continue to
support the existing infrastructure that has contributed to the
maldistribution of physicians and shortages in primary care
specialties.
Since 1991, the Centers for Medicare and Medicaid Services (CMS)
has relied upon the recommendations of the American Medical
Association's Relative Value Scale Update Committee (RUC) to determine
the relative value units for physician services, including the
evaluation and management services billed by primary care providers.
Historically, CMS accepts over 90 percent of the RUC's recommendations.
While the RUC has recently added primary care members, the vast
majority of the 31 person panel is composed as specialists. Given the
influence of this committee over payment policy, more must be done to
increase primary care membership and the transparency of its
proceedings. The Affordable Care Act took the first step at
scrutinizing the RUC's work by including a provision to review mis-
valued codes, and CMS has awarded a contract to do this work. In 2011,
Representative Jim McDermott introduced legislation aimed at the RUC.
These were important first steps, but policymakers must further
scrutinize the work and composition of the RUC and change current
incentives in a fiscally prudent manner.
STRENGTHEN SUPPORT FOR TITLE VII PRIMARY CARE TRAINING AND ENHANCEMENT
Title VII of the Public Health Service Act authorizes the only
source of Federal funds for primary care training. In order to meet the
growing demands for primary care services, particularly in underserved
rural and urban communities, SGIM strongly urges Congress to support
the following HRSA programs with a proven track record of increasing
the supply of primary care physicians, including:
$150 million for Training in Primary Care Medicine to
support training and improved general competencies of primary care
professionals through grants to hospitals, medical schools and other
entities;
$30 million for Centers of Excellence designed to increase
the number of minority youth who pursue careers in the health
professions;
$30 million for the Health Careers Opportunity Program
(HCOP) to provide students from disadvantaged backgrounds an
opportunity to develop the skills needed to successfully compete, enter
and graduate from health professions schools; and
$3 million for the National Health Care Workforce
Commission to provide Congress and the executive branch with
comprehensive, unbiased recommendations on workforce goals, priorities
and policies.
SGIM stands ready to work with the subcommittee as it grapples with
these challenges.
Thank you for the opportunity to submit this statement.
______
The American Occupational Therapy Association,
Inc.,
Bethesda, MD 20814-1220,
February 11, 2013.
Hon. Bernard Sanders, Chairman,
Committee on Health, Eduation, Labor, and Pensions,
Subcommittee on Primary Health and Aging,
U.S. Senate,
Washington, DC 20510.
Hon. Michael B. Enzi, Ranking Member,
Committee on Health, Eduation, Labor, and Pensions,
Subcommittee on Primary Health and Aging,
U.S. Senate,
Washington, DC 20510.
Dear Chairman Sanders and Ranking Member Enzi: The American
Occupational Therapy Association (AOTA) is the national professional
association representing the interests of more than 140,000
occupational therapists, occupational therapy assistants, and students
of occupational therapy. We greatly appreciate the recent subcommittee
hearing, ``30 Million New Patients and 11 Months to Go: Who Will
Provide Their Primary Care?'' As the subommittee proceeds in forming
recommendations to improve the current healthcare system and promote
timely, cohesive, quality healthcare services, AOTA would like to
provide a brief explanation of the critical role occupational therapy
practitioners can play in primary care settings through promoting
wellness, coordinating care, and providing rehabilitative services to
individuals throughout the lifespan, thus reducing healthcare costs and
promoting a healthier nation.\1\
---------------------------------------------------------------------------
\1\ Journal of the American Medical Association, Vol. 278 (1997).
Occupational therapy for independent-living older adults: A randomized
controlled trial.
---------------------------------------------------------------------------
Occupational Therapy (OT) is a profession dedicated to the
improvement and maximization of function and performance--how, when and
how well people do the activities or ``occupations'' important to
them--so that people can live healthier, more productive and satisfying
lives. People define health in many ways but it is beyond being
disease-free. When people describe ``healthy'' it usually involves
being able to DO things: to work and care for oneself despite
conditions or age, being interested in the world, having energy and
vitality. All of this involves performance of activities of daily life
which ultimately contribute to quality of life.\2\ Including
Occupational Therapy as part of the team providing services and
interventions in a coordinated manner, is the way for people to live
life to its fullest.
---------------------------------------------------------------------------
\2\ British Medical Journal, Vol. 319 (1999) Population-based study
of social and productive activities as predictors of survival among
elderly Americans.
---------------------------------------------------------------------------
Primary care can be defined very narrowly, simply identifying
practitioners--physicians, nurse practitioners, and physician's
assistants, or it can be defined from the much broader view of primary
health care--comprehensive care that addresses the majority of a
patients needs over time including both preventative and curative
services. This latter, more broad view of primary care is essential to
improving health outcomes and reducing healthcare costs. We believe
that Occupational Therapy can be central to many aspects of a cohesive,
quality healthcare system.
PRIMARY CARE TEAMS
Primary care addresses basic health needs but must also include the
ability to effectively link to rehabilitative services that enable
individuals to become or stay healthy. Because of the holistic nature
of occupational therapy and expertise related to performance and
function across the lifespan, occupational therapy practitioners should
be utilized in primary care teams.
Occupational therapy's collaborative approach to the provision of
healthcare and focus on increasing client capacity and independence
make practitioners a valuable part of beneficiaries' primary care team
particularly in critical areas such as preventing falls for elderly
patients, working with individuals with diabetes on assuring their
lifestyles support health, monitoring child development to increase
early and appropriate intervention. Other areas where occupational
therapy can be useful in a coordinated model are in premature infants/
NICU, mental health (e.g., schizophrenia), and hand, wrist or shoulder
injuries to begin the rehabilitation process immediately or even avoid
more expensive treatments.\3\ \4\
---------------------------------------------------------------------------
\3\ The British Journal of Occupational Therapy, Vol. 132 (2008).
Audit of a therapist-led clinic for carpal tunnel syndrome in primary
care.
\4\ Occupational Therapy International, Vol. 15 (2008).
Effectiveness of a peer-support community in addiction recovery:
participation as intervention.
---------------------------------------------------------------------------
MEDICAL HOMES
Similar to the arguments for primary care participation, AOTA
supports the medical home concept and sees a unique role for
occupational therapy as part of the medical home team to help clients
get the right services to maximize their functional independence.
Additionally, occupational therapy interventions help clients with
compliance with their medical regimen delivering improved outcomes and
thus cost savings.
PREVENTION
Occupational therapy practitioners have the education, perspective
and knowledge base to be recognized as qualified providers of
preventative services. Occupational therapy practitioners have
expertise in falls risk assessment, smoking cessation, obesity
interventions and a variety of other lifestyle management techniques
important to the formulation and implementation of comprehensive,
successful personalized prevention plans. Research indicates that
preventative occupational therapy cost effectively slowed down the
declines associated with aging and improved health in the elderly or
simply prevented injuries (e.g., through preventable falls) and
improved lives.\5\ \6\ \7\
---------------------------------------------------------------------------
\5\ Journal of Gerontology: Psychological Sciences, Vol. 56 (2001).
Embedding health promoting changes into the daily lives of independent-
living older adults: Long-term followup of occupational therapy
intervention.
\6\ Journal of the American Geriatrics Society, Vol. 54 (2006). A
randomized trial of a multicomponent home intervention to reduce
functional difficulties in older adults.
\7\ Journal of Rehabilitation Medicine, Vol. 40 (2008). A single
home visit by an occupational therapist reduces the risk of falling
after hip fracture in elderly women: a quasi-randomized controlled
trial.
---------------------------------------------------------------------------
CARE COORDINATION
Occupational therapy practitioners bring a unique skill set and
expertise that can and should be a vital component of any new or
existing care coordination models to achieve optimal client outcomes
and deliver more targeted, effective care. Occupational therapy
addresses issues of daily living that are often ignored but are
critical to care coordination, particularly for individuals with
chronic conditions. Occupational therapy is particularly effective in
addressing children with disabilities like autism in school or in other
settings \8\ or families addressing Alzheimer's disease.\9\
---------------------------------------------------------------------------
\8\ American Journal of Occupational Therapy, Vol. 62 (2008).
Evidence-based review of interventions for autism used in or of
relevance to occupational therapy.
\9\ The Gerontologist, Vol. 41 (2000). A randomized controlled
trial of home environmental intervention to enhance self-efficacy and
reduce upset in family caregivers of persons with dementia.
---------------------------------------------------------------------------
CHRONIC CARE MANAGEMENT
Occupational therapy focuses on enabling individuals to participate
in productive and meaningful activities of daily life using approaches
that help individuals self-manage--vital to such things as appropriate
medication management skills, fall prevention, energy conservation,
self-care, and maintaining participation in key activities such as
work, family management or leisure. Savings can be achieved as people
maintain their health and independence through their own actions.
Practitioners achieve improved outcomes through active collaboration
with clients and their caregivers during the evaluation and
intervention process. Occupational therapy should be a part of chronic
care management teams for persons with traumatic brain injury, multiple
sclerosis, spinal cord injury, diabetes, autism, stroke among other
conditions.\10\ \11\
---------------------------------------------------------------------------
\10\ American Journal of Occupational Therapy, Vol. 63 (2009).
Changing face of stroke: Implications for occupational therapy
practice.
\11\ Multiple Sclerosis, Vol. 14 (2008). A longitudinal study on
effects of a 6-week course for energy conservation for multiple
sclerosis clients.
---------------------------------------------------------------------------
As stated throughout the subcommittee hearing, allied health
professionals have the potential to be a key component to reducing
healthcare spending costs if utilized properly. While considering new
and innovative ways to provide primary health care and improve outcomes
within our healthcare system, we strongly encourage you to consider the
important role that occupational therapy can play as part of the
healthcare solution.
Thank you for the opportunity to express our views to the
subcommittee. Should you have any questions or need additional
information about the role of occupational therapy practitioners in
primary care, please contact Heather Parsons at [email protected] or
(301) 652-6611 Ext. 2112.
Sincerely,
Christina Metzler,
AOTA Chief Public Affairs Officer,
American Occupational Therapy Association, Inc.
[Whereupon, at 11:58 a.m., the hearing was adjourned.]