[Senate Hearing 113-009]
[From the U.S. Government Publishing Office]






                                                        S. Hrg. 113-009

    SUCCESSFUL PRIMARY CARE PROGRAMS: CREATING THE WORKFORCE WE NEED

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

                                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 SUCCESSFUL PRIMARY CARE PROGRAMS

                               __________

                             APRIL 23, 2013

                               __________

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


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          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 Smith, Staff Director

        Lauren McFerran, Deputy Staff Director and Chief Counsel

               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, APRIL 23, 2013

                                                                   Page

                           Committee Members

Sanders, Hon. Bernard, Chairman, Subcommittee on Primary Health 
  and Aging, Committee on Health, Education, Labor, and Pensions, 
  opening statement..............................................     1
Burr, Hon. Richard, a U.S. Senator from the State of North 
  Carolina, opening statement....................................     3
Warren, Hon. Elizabeth, a U.S. Senator from the State of 
  Massachusetts..................................................     4
Murphy, Hon. Christopher S., a U.S. Senator from the State of 
  Connecticut....................................................     4
Roberts, Hon. Pat, a U.S. Senator from the State of Kansas.......    14

                            Witness--Panel I

Spitzgo, Rebecca, HRSA Associate Administrator, Bureau of 
  Clinician Recruitment and Service, and Director of the National 
  Health Service Corps, U.S. Department of Health and Human 
  Services, Rockville, MD........................................     5
    Prepared statement...........................................     6

                          Witnesses--Panel II

Rust, George S., M.D., MPH, FAAFP, FACPM, Professor of Family 
  Medicine at the Morehouse School of Medicine And Co-Director of 
  the National Center for Primary Care, Atlanta, GA..............    18
    Prepared statement...........................................    20
Hawkins, Daniel R., Jr., Senior Vice President, Public Policy and 
  Research at the National Association of Community Health 
  Centers, Washington, DC........................................    25
    Prepared statement...........................................    26
Cunningham, Paul R.G., M.D., FACS, Dean and Senior Associate Vice 
  Chancellor for Medical Affairs at the Brody School of Medicine, 
  East Carolina University, Greenville, NC.......................    31
    Prepared statement...........................................    33
Wachtel, Deborah, NP, MPH, MSN, President of the Vermont Nurse 
  Practitioner Association and Vermont State Representative for 
  The American Association of Nurse Practitioners, Essex, VT.....    35
    Prepared statement...........................................    37
Koeppen, Bruce, M.D., Ph.D., Founding Dean of the Frank H. Netter 
  MD School of Medicine at Quinnipiac University, Hamden, CT.....    49
    Prepared statement...........................................    51

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Ray E. Stowers, DO, American Osteopathic Association (AOA)...    66
    Association of American Medical Colleges (AAMC)..............    70
    American Academy of Physician Assistants (AAPA)..............    76
    Physician Assistant Education Association (PAEA).............    79
    National Rural Health Association (NRHA).....................    82

                                 (iii)

  

 
    SUCCESSFUL PRIMARY CARE PROGRAMS: CREATING THE WORKFORCE WE NEED

                              ----------                              


                        TUESDAY, APRIL 23, 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 a.m. in 
room SD-430, Dirksen Senate Office Building, Hon. Bernie 
Sanders, presiding.
    Present: Senators Sanders, Murphy, Warren, Burr, and 
Roberts.

                  Opening Statement of Senator Sanders

    Senator Sanders. OK. We have a lot of work to do. Let's get 
going.
    I would like to thank all of you for being here today to 
discuss an issue of enormous consequence. It is no great secret 
that the American health care system faces enormous challenges, 
and not the least of which is our primary health care system.
    I want to take this opportunity to thank our witnesses for 
being here, and I will be talking to Ms. Spitzgo in a moment. 
We thank her for the fine work that she has done.
    In January, this subcommittee held a hearing on the primary 
care crisis in our country. In that hearing, we covered the 
extent of the primary care shortage. We noted that 1 in 5 
Americans lives in an area where there are too few primary care 
providers. We learned that we already have, today, a 
significant shortage, and by 2025, we will need over 50,000 new 
primary care physicians and thousands and thousands of other 
providers, including nurse practitioners and physician 
assistants, to ensure access to the cost-effective primary care 
services people need.
    The fact of the matter is that as a result of the primary 
health care crisis in this country, we are losing tens of 
thousands of people every single year who die because they do 
not get to a doctor when they should. We are seeing people 
ending up in hospitals when they could have been treated 
earlier because they did not gain access to medical care when 
they needed it and when it was appropriate.
    We are also, as a Nation, spending almost twice as much per 
capita on health care as any other Nation. And I think it is 
important to understand that in America today, our ratio of 
primary care physicians to specialists is 30 to 70; 30 percent 
primary care, 70 percent specialists. That is exactly the 
reverse than what we are seeing around the rest of the world, 
and I think that is one of the reasons we end up spending quite 
as much as we do compared to other countries.
    Instituting major reforms in primary care and enabling 
people to see a doctor when they need one will save lives. It 
will ease suffering and allow our Nation to save billions of 
dollars in health care costs.
    Let me just touch on a few of the areas that, I believe, we 
have got to address as we go forward in tackling this serious 
problem.
    First, clearly, we need to substantially increase the 
number of primary care practitioners. We must implement a 
change in the culture of medical schools, which train many 
people into medicine with an interest in primary care, but 
ultimately choose specialties. Why is that? Why is it that a 
lot of young people come in with the desire to be primary care 
physicians, but end up not being so?
    Needless to say, as part of that process, we also need to 
change the salaries and the reimbursement rates which strongly, 
at the present moment, incentivize medical students with high 
debt loads to go into the well-paying specialties rather than 
primary care.
    I mean at the end of the day, we have to ask ourselves why 
some medical professionals who work harder end up earning 
substantially less than others. We need to have schools, 
medical schools, around the country to create a culture within 
their student body emphasizing the importance of primary care.
    While some medical schools, in fact, do an excellent job--
and we are going to hear some of that in our second panel--do a 
great job in educating and training primary care physicians, 
the truth is that some medical schools do relatively little. 
Some, in fact, do nothing; virtually nothing at all.
    We should be taking, in my view, a hard look at why we are, 
through Medicare, providing $10 billion a year to training 
hospitals without really knowing what they are producing in 
terms of primary care physicians.
    Furthermore, we need to greatly expand, in my view, the 
Federally Qualified Health Center program. We are going to hear 
some of that discussion today. In my view, FQHCs provide 
extremely high quality, cost-effective health care to millions 
of people in 50 States around this country, and it is a program 
that we have expanded in recent years. I think we need to do 
more.
    We also need to start training more primary care residents 
in health centers through the Teaching Health Center program. 
This program, which is set to expire in 2015, only received 
$230 million over the last 5 years, a small amount compared to 
the over $50 billion going to train residents in traditional 
hospital-based settings over this period.
    We know that these community-trained providers are more 
likely to continue serving the areas that need them the most. 
So expanding the number of Teaching Health Centers is good 
policy that Congress should support.
    Last, but not least, we will obviously be hearing more 
about this from Ms. Spitzgo. In my view, we need to greatly 
expand the National Health Service Corps. In recent years, we 
have expanded that program. A lot more young people are now 
graduating medical school and dental school, and are able to 
serve in underserved areas in primary health care because of 
the National Health Service Corps. We made some good steps 
forward. We have more to do.
    With that, let me thank our Ranking Member, Senator Burr, 
for being with us, and ask him if he wants to make an opening 
remark.

                   Opening Statement of Senator Burr

    Senator Burr. Thank you, Mr. Chairman, and I look forward 
to working with you on this subcommittee, and I thank you for 
holding this hearing today.
    Ms. Spitzgo, thank you for being here, and to our other 
witnesses, especially Dean Cunningham from the Brody School of 
Medicine at East Carolina University; a very special facility 
in North Carolina.
    I appreciate the chance to discuss today the primary care 
workforce challenges that we are facing, and the possible 
solutions to addressing such critical issues.
    The issue of improving the access to primary care services 
particularly for those in rural and underserved areas, through 
targeted efforts, is an important challenge that we must 
address. As we work to identify the programs with proven track 
records of success from which we can build upon, we must also 
take a closer look at the programs where there are 
opportunities to strengthen accountability, to ensure 
appropriate stewardship of taxpayer dollars.
    Today's hearing represents an important opportunity to hear 
from our witnesses about what they think is working well, and 
where there are opportunities for improvements. Their ideas for 
solutions to build and improve our primary care workforce and 
to discuss ways in which we can ensure accountability for 
programs on behalf of patients and taxpayers.
    Programs such as community health center programs 
administered by the Health Resources and Services 
Administration, can be an effective model for delivering 
primary care services to uninsured and the underinsured.
    Research has shown that preventative care, care 
coordination for the chronically ill, and continuity of care, 
all of which are hallmarks of the primary care medicine, lead 
to improved outcomes and potential cost savings.
    Additionally, programs like the National Health Service 
Corps were established to help address unmet primary health 
care needs particularly in rural and underserved areas. Through 
the National Health Service Corps recruitment program, we have 
made steady strides in increasing access to primary care for 
underserved populations. But more can be done in our efforts to 
accomplish this goal, and to retain a robust primary care 
workforce especially in the rural and underserved areas.
    As Congress explores ways in which we can better target and 
enhance existing programs to address the workforce challenges 
impacting our Nation's patients, it is critical that we 
understand and examine the root causes and barriers patients 
face in accessing primary care, as well as the best metrics for 
judging success.
    It is critical that we build upon the successful models of 
care delivery and ensure the accountability of existing 
workforce programs in order to maximize their success and its 
benefit to our patients.
    Our witnesses here today provide a unique opportunity to 
learn how Congress can help to build a stronger primary care 
workforce that meets the needs of individuals across our 
Nation.
    I thank the chair.
    Senator Sanders. Senator Burr, thank you very much.
    Senator Warren.

                      Statement of Senator Warren

    Senator Warren. Thank you, Mr. Chairman. Thank you, Ranking 
Member. Thank you for holding this hearing today.
    We are here to talk about educating and training health 
care professionals, but before I get to my questions, I want to 
take a moment to publicly recognize the first responders, the 
doctors, the nurses, and everyone at our world-class hospitals 
for their heroic work in responding to the attacks in Boston on 
April 15, and for their ongoing work since this terrible 
tragedy.
    I also want to commend all of the race volunteers, the 
bystanders, the marathon runners who set aside their own 
individual roles that day and became part of Boston's health 
care force.
    We now have lost four people to this cowardly act of 
terrorism, but the courage, the strength, the perseverance of 
our entire health care workforce helped to ensure the survival 
of many individuals who, otherwise, would have perished in this 
attack.
    So to every one of the doctors, the nurses, EMS, support 
teams, and volunteers who literally made the difference between 
life and death, I want to start this morning just by saying 
thank you, publicly.
    Thank you, Mr. Chairman.
    Senator Sanders. Senator Murphy.

                      Statement of Senator Murphy

    Senator Murphy. Thank you very much, Mr. Chairman.
    And let me add my thanks to those of Senator Warren to the 
amazing acts of heroism performed by her constituents, and the 
lives that have been saved through a health care system that 
responded in ways that we hope that the health care systems 
respond to a tragedy like this. And Senator Warren, thank you 
for your leadership, for your State, and for your Nation on 
these last difficult days.
    Mr. Chairman, thank you for having this hearing. As someone 
who spent my career in public health policy, there is nothing 
more important than talking about primary care.
    I am very excited that on the second panel today, we will 
hear from a number of people who can talk to us about really 
great programs that are pushing more students into primary 
care, including my friend Bruce Koeppen from Quinnipiac 
University who, as he will tell you, has really focused their 
new medical school on the issue of primary care.
    I guess what I hope that our panelists will talk about is 
not just what we can do within those schools to try to 
incentivize more students to go into primary care, but what we 
can do once they leave school because the fact is, is that we 
have two problems here. We have one problem that involves 
schools not doing enough to incentivize students to look at 
primary care.
    But second, the job just is not as attractive as it used to 
be. It does not pay as much relative to other professions, and 
that becomes a bigger and bigger problem as the cost of 
education goes up. And second, it is just not as interesting as 
the work once was as more of the cutting edge medical work is 
done in the specialties; there is less prestige than there used 
to be involved in primary care.
    While I know our focus will mainly be on great programs 
that can get students into primary care, I think that we will 
hopefully acknowledge today that it is not just about the 
educational pathway. It is about really answering students' 
questions about the rate they are going to be paid if they 
choose primary care, and the kind of work that they are going 
to do. And if we solve for both problems, the pathway and then 
the job itself, then I think we will get to where we all want 
to get to.
    Thank you, Mr. Chairman.
    Senator Sanders. OK. Now, let's hear from our first 
witness.
    Rebecca, Becky Spitzgo is the Associate Administrator of 
HRSA's Bureau of Clinician Recruitment and Service, heading a 
staff of over 200 civilian and commissioned Corps personnel. 
She serves as the Director of the National Health Service 
Corps. Ms. Spitzgo has more than 30 years of Federal experience 
in grants management, system development, and project 
management with the Department of Health and Human Services and 
the Department of Education.
    Thanks very much for being with us.

  STATEMENT OF REBECCA SPITZGO, HRSA ASSOCIATE ADMINISTRATOR, 
 BUREAU OF CLINICIAN RECRUITMENT AND SERVICE, AND DIRECTOR OF 
 THE NATIONAL HEALTH SERVICE CORPS, U.S. DEPARTMENT OF HEALTH 
               AND HUMAN SERVICES, ROCKVILLE, MD

    Ms. Spitzgo. Thank you. Mr. Chairman, members of the 
committee.
    Thank you for the opportunity to testify today on behalf of 
the Health Resources and Services Administration about the 
National Health Service Corps.
    For over 40 years, the National Health Service Corps has 
helped to build healthy communities by supporting health care 
providers dedicated to working in areas of the United States 
with limited access to health care.
    Thanks to historic investments from the Affordable Care Act 
and the Recovery Act, the number of clinicians in the National 
Health Service Corps is at all-time highs from 3,600 in 2008 to 
nearly 10,000 in 2012. Today, Corps clinicians are providing 
primary medical, dental, and mental health care to more than 
10.4 million people who live in rural, urban, and frontier 
communities in all 50 States, the District of Columbia, Puerto 
Rico, and other U.S. territories.
    The National Health Service Corps programs provide 
scholarships and repay educational loans for primary care 
physicians, dentists, nurse practitioners, physician 
assistants, behavioral health providers, and other primary care 
providers who agree to practice in areas of the country that 
need them most.
    I have talked with doctors who have said they would have 
never been able to go into medicine without the National Health 
Service Corps scholarship program because they could not, they 
simply could not afford the costs of medical school.
    For most of the National Health Service Corps clinicians, 
we know it is not just about the money. We have found that more 
than 55 percent of the clinicians continue to practice in 
communities where they are needed most 10 years after they have 
completed their service commitment.
    Dr. Abbott is one of these amazing clinicians. He received 
a National Health Service Corps scholarship and began his 
service commitment in July 1983. Today, nearly 30 years later, 
Dr. Abbott is still providing pediatric health care and was 
recently appointed the Chief Medical Officer for the Family 
Health Centers of Baltimore where he began his career.
    Dr. Abbott is just one of many stories that underscores the 
return on investment of the National Health Service Corps, and 
how this program ensures that communities have access to 
quality health care both today and in the future.
    There are currently more than 1,000 students and residents 
preparing to go into practice who are receiving support through 
the scholarship program. As part of the National Health Service 
Corps's commitment, these future care providers will serve in 
communities where they are needed most.
    Approximately 45 percent of the 10,000 Corps clinicians are 
currently providing care in rural communities. To better meet 
the needs of rural and frontier communities, HRSA has expanded 
the Corps to include critical access hospitals and supports the 
growing use of telemedicine.
    The National Health Service Corps scholarship and loan 
repayment programs remain highly competitive. In fiscal year 
2012, the National Health Service Corps was able to fund 41 
percent of the applications for new loan repayment, and 15 
percent of the applications for scholarships.
    At its heart, the National Health Service Corps is about 
bringing primary care to communities in need. The Corps is able 
to do this by removing financial barriers for clinicians and 
the next generation of clinicians who are interested in primary 
medical, dental, and mental health care.
    Removing these barriers enables dedicated clinicians and 
students to pursue a fulfilling, mission-driven, community-
based career.
    Thank you, again, for providing me the opportunity to share 
HRSA's and the National Health Service Corps's mission with you 
today, and I am pleased to respond to your questions.
    [The prepared statement of Ms. Spitzgo follows:]
                 Prepared Statement of Rebecca Spitzgo
    Mr. Chairman and members of the committee, thank you for the 
opportunity to testify today on behalf of the Health Resources and 
Services Administration (HRSA) about the National Health Service Corps 
programs. HRSA focuses on improving access to health care services for 
people who are uninsured, isolated or medically vulnerable. HRSA's 
mission is to improve health and achieve health equity through access 
to quality services and a skilled health care workforce. There are 
approximately 80 different programs administered by HRSA.
    One of these programs is the National Health Service Corps. For 
over 40 years, the National Health Service Corps has helped to build 
healthy communities by supporting qualified health care providers 
dedicated to working in areas of the United States with limited access 
to health care.
    Thanks to historic investments from the Affordable Care Act and the 
Recovery Act, the numbers of clinicians in the National Health Service 
Corps are at all-time highs. The number of providers serving in the 
National Health Service Corps has nearly tripled from 3,600 in 2008 to 
nearly 10,000 in 2012, and they are providing care for millions more 
patients than the Corps was able to serve just 3 years ago.
    The National Health Service Corps programs provide scholarships and 
repay educational loans for primary care physicians, dentists, nurse 
practitioners, physician assistants, behavioral health providers, 
residents and other primary care providers who agree to practice in 
areas of the country that need them most. Across this country, nearly 
10,000 National Health Service Corps clinicians are providing care to 
more than 10.4 million people who live in rural, urban, and frontier 
communities.
    Serving at National Health Service Corps approved sites that 
include local rural health clinics, community health centers, Tribal 
sites and other primary care sites, National Health Service Corps 
clinicians are working every day to not just treat illness or injury, 
but also to keep people healthy and prevent them from getting sick. 
They are providing check-ups for children, filling cavities, managing 
diabetes, providing mental health care, and monitoring chronic 
conditions for seniors.
    Today, there are Corps clinicians providing primary medical, dental 
and mental health care in all 50 States, the District of Columbia, 
Puerto Rico, the U.S. Virgin Islands and other U.S. Territories. 
Physicians are the largest single discipline in the National Health 
Service Corps representing 26 percent of the nearly 10,000 Corps 
providers. And, National Health Service Corps mental and behavioral 
health care providers (Health Service Psychologists, Licensed Clinical 
Social Workers, Licensed Professional Counselors, Marriage and Family 
Therapists, and Psychiatric Nurse Specialists) have nearly quadrupled 
since 2008, increasing from approximately 700 to 2,800.
    The full-time option under the National Health Service Corps Loan 
Repayment Program offers up to $60,000 in loan repayment for 2 years of 
full-time service. At the end of 2 years, Corps members can apply to 
continue their service and receive additional loan repayment. National 
Health Service Corps scholars commit to serve in the Corps upon 
completion of their training, providing 1 year of service for each year 
of support (with a minimum 2-year service obligation). The Students to 
Service Loan Repayment Pilot Program provides loan repayment assistance 
of up to $120,000 to medical students (Medical Doctor and Doctor of 
Osteopathic Medicine) in their last year of school, in return for a 
commitment to provide primary health care services in communities of 
greatest need for at least 3 years.
    I have talked with doctors and nurses who say that they would never 
have been able to go into medicine or nursing without the National 
Health Service Corps Scholarship Program, because they and their 
families simply could not afford the cost of health professions 
training otherwise.
    For most of our Corps clinicians, we know it is not just about the 
money. We have done the research and found that more than 55 percent of 
clinicians continue to practice in the communities that need them most 
10 years after completing their service commitment. For example, Dr. 
Abbott is one of these amazing clinicians who has stayed long beyond 
his initial service commitment. Dr. Abbott was born in Brooklyn, NY, 
and attended Howard University College of Medicine. He completed his 
pediatric residency at Howard University Hospital and the District of 
Columbia Hospital. Dr. Abbott received a National Health Service Corps 
scholarship and began his service commitment at South Baltimore Family 
Health Center in July 1983. Nearly 30 years later, Dr. Abbott is still 
providing pediatric health services at this health center and was 
recently appointed to chief medical officer for the Family Health 
Centers of Baltimore. Dr. Abbott's story is just one of many stories 
that underscore the return on the investment of the National Health 
Service Corps and how this program helps ensure that communities have 
access to quality health care both today and in the future.
    In addition to National Health Service Corps clinicians currently 
providing health care, the Corps also invests in the training of the 
next generation of providers through scholarships and the Students to 
Service Loan Repayment Pilot Program. There are currently more than 
1,000 students and residents preparing to go into practice who are 
receiving support from these programs. As part of their National Health 
Service Corps' commitment, these future primary care providers will 
serve in communities where they are needed most.
    The National Health Service Corps scholarship and loan repayment 
programs are highly competitive. In fiscal year 2012, with data as of 
September 30, 2012, the National Health Service Corps Loan Repayment 
Program received 5,715 new applications and funded 2,342 new awards, 
which represents 41 percent of submitted applications. In addition, 
there were 1,925 continuation contracts, extending service for another 
year. Taken with these continuation contracts, the Loan Repayment 
Program invested $169 million in the primary care workforce. The 
National Health Service Corps Scholarship Program received 1,373 new 
applications and funded 212 new awards, which represents 15 percent of 
submitted applications. Overall, the Scholarship Program issued 222 
awards (212 new and 10 continuation contracts) totaling $42 million.
    National Health Service Corps providers serve in National Health 
Service Corps approved sites, which are sites that meet defined 
criteria demonstrating their need and that expand access to care by 
providing services regardless of a patient's ability to pay. There are 
currently more than 14,000 approved National Health Service Corps 
sites, and site administrators regularly report that eligibility for 
the National Health Service Corps programs are a valuable recruitment 
tool for health care providers.
    In 2012, HRSA launched the interactive National Health Service 
Corps Jobs Center to allow National Health Service Corps sites to post 
key information to recruit prospective job applicants, such as services 
offered, community information, photos, and site brochures, so the 
prospective applicant can learn not only about the specific site, but 
also about the community they will serve. The launching of the NHSC 
Jobs Center has significantly increased the number of prospective job 
applicants interested in positions in eligible communities. We are 
looking forward to providing all NHSC sites with robust recruitment 
opportunities with access to thousands of primary care providers 
through the Jobs Center.
    With 45 percent of the nearly 10,000 Corps clinicians currently 
providing care in rural communities, HRSA has adapted to better meet 
the need for primary care providers in rural and frontier areas. For 
example, HRSA expanded eligibility for the National Health Service 
Corps sites to Critical Access Hospitals in fiscal year 2012. As of 
October 2012, 134 Critical Access Hospitals had been approved as 
National Health Service Corps service sites, and an additional 71 
applications were under review as part of this initiative. 
Additionally, in fiscal year 2013, the National Health Service Corps 
began allowing providers practicing in eligible sites to offer 
telemedicine services to patients at distant sites. Designed to extend 
the reach of National Health Service Corps providers while minimizing 
patients' travel distances to seek care, this initiative has been 
particularly significant in increasing access to mental and behavioral 
health services in rural areas.
    In addition to encouraging a geographically well-distributed 
primary care workforce, the National Health Service Corps supports a 
racially and ethnically diverse primary care workforce. According to 
the most recent self-reports by the nearly 10,000 Corps clinicians 
currently providing care--13 percent are African-American, 10 percent 
are Hispanic, 7 percent are Asian or Pacific Islander, and 2 percent 
are American Indian or Alaska Native. In fiscal year 2012, African-
American physicians represented 17 percent of the Corps physicians, 
which exceeds their 6.3 percent representation within the national 
physician workforce. Hispanic physicians represented 16 percent of the 
Corps physicians, exceeding their 5.5 percent representation in the 
national physician workforce.
    Also, according to these self-reports, more than half of the nearly 
1,000 Corps scholars in the pipeline, currently in school or residency 
training, are racial and ethnic minorities--26 percent are Hispanic, 19 
percent are African-American, 12 percent are Asian or Pacific Islander, 
and 2 percent are American Indian or Alaska Native.
    At its heart, the National Health Service Corps is about bringing 
primary care to communities in need. The Corps is able to do this while 
making it possible for those with a passion and commitment to serve to 
pursue their dreams. The National Health Service Corps removes 
financial barriers for clinicians and students interested in practicing 
a primary care discipline, enabling them to pursue a fulfilling, 
mission-driven, community-based career.
    Thank you again for providing me the opportunity to share HRSA's 
and the National Health Service Corps' mission with you today. I am 
pleased to respond to your questions.

    Senator Sanders. Thank you very much for your testimony, 
and thanks, again for being here.
    Let me begin by asking you this. One of the reasons, in 
fact, I voted for the Affordable Care Act is that there were 
great, significant expansions in the Federally Qualified Health 
Center programs and in the National Health Service Corps. My 
understanding is that you are now providing some help, 
financial support, to about 10,000 clinicians, three times more 
than you did in 2008.
    Is that correct?
    Ms. Spitzgo. That is correct, yes.
    Senator Sanders. So we have seen some significant 
expansions, but clearly that is not enough. The average medical 
school student, as I understand it, graduates school with about 
$160,000 in debt.
    Is that roughly right?
    Mr. Spitzgo. That seems to be what we see coming across in 
our applications. Yes.
    Senator Sanders. Based on your extensive experience with 
the program, if you had your druthers, what kind of support 
would you need to make sure that we can move more aggressively 
in terms of helping those students who want to practice primary 
care in the underserved areas?
    What kind of budget would you need?
    Ms. Spitzgo. As you know, Senator Sanders, HRSA will take 
whatever dollars we are given and put them to our best use, and 
try to make them go as far as we possibly can.
    Our average award amount for a loan repayment is about 
$52,000 right now. The average scholarship is about $200,000. 
We do have a new program that we recently started, the Student 
to Service Loan Repayment Program, which is about $120,000 and 
this actually goes to clinicians in their fourth year of 
training.
    Senator Sanders. No, I am asking you what the need is out 
there. The function of this hearing today is to try to figure 
out how we address a major crisis. Part of the solution will be 
programs like the National Health Service Corps.
    If we want to get more young people into primary health 
care in underserved areas, clearly, we need to expand the 
program. Can you give us some ideas about that?
    Ms. Spitzgo. I think we can look at the number of 
applications that we are not able to fund. We get about 5,700 
applications a year almost consistently for the last 3 to 4 
years. This year we will fund about 2,000 of those loan 
repayment awards, that is where your average amount is about 
$52,000 for a loan repayment award.
    Senator Sanders. You are funding significantly less than 
half of the applicants.
    Ms. Spitzgo. Yes. Yes, sir. And then for scholarships, we 
will get about 1,300 applications, and we will fund about 200 
of those.
    Senator Sanders. All right.
    Ms. Spitzgo. So there is----
    Senator Sanders. So what you are telling us is that the 
need is out there.
    Ms. Spitzgo. Yes.
    Senator Sanders. There are a lot more young people who 
would like that support, and if they got that, that is what 
would be in the primary care business.
    Ms. Spitzgo. Yes.
    Senator Sanders. OK. Let me ask you this. One of the 
concerns that we have in States like Vermont is you are basing 
your funding on needs in communities around the country.
    In Vermont right now, my understanding is we have many, 
many needs, but apparently they are less than other parts of 
the country. We may, in fact, be getting no National Health 
Service Corps money. That is true in other States as well.
    What do we do to make sure that we continue to have a 50-
State program where all States get at least some funding?
    Ms. Spitzgo. I think right now, the way the program works 
and our statute is written is to look at the program from a 
national approach, which is using our health professional 
shortage area scores, and we look across the Nation and that is 
the funding preference that we provide as we go down those 
orders.
    Needs within States, all States, I think, have significant 
needs that they are not able to fill or attract clinicians. But 
when we look at it from across the Nation, those do not 
necessarily find themselves within the 50 States; we find 
different levels of need. So as we fund down the order of the 
applications we receive, we do that until we run out of funding 
and are not necessarily looking at a State distribution.
    The other option that we do have through our program is the 
State loan repayment program that allows States to come in and 
provide a matching, to meet very specific State needs, which is 
different, similar but a bit different than the national.
    Senator Sanders. But Ms. Spitzgo, am I correct in assuming 
that unless we increase funding, there will be a number of 
States in this country which have needs, significant need, but 
will not be receiving National Health Service Corps dollars?
    Ms. Spitzgo. That is probably correct. We do not know each 
year how far we are able to go down the HPSA. Last year, we 
went into a Health Professional Shortage Area score of 13.
    Senator Sanders. And let me ask you this, as a result of 
actions taken a few years ago, you are looking at a cliff 
coming soon, a financial cliff?
    Ms. Spitzgo. Our cliff right now for continuations, this 
year, will fund approximately 2,600 continuations. That is the 
most we have ever had to fund and that is the result of 2011; 
we made almost 4,500 new awards. We fund our continuations 
first, and then we use the remaining funds to fund new awards.
    Our current funding goes through fiscal year 2015 with the 
Affordable Care Act.
    Senator Sanders. What happens if we don't do something 
about it? What happens in 2016?
    Ms. Spitzgo. If we don't do something about that, if we 
don't have an annual appropriation, then the program would not 
be able to continue, obviously, without funding.
    Senator Sanders. OK.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    Ms. Spitzgo, your testimony notes that there are 
approximately 80 different programs administered by HRSA.
    How many of HRSA's programs are Work Force programs?
    Ms. Spitzgo. How many? I would be glad to get you the exact 
number.
    I have within my organization, I have six of those 
programs, and we have a Health Professional Bureau, a Bureau of 
Health Professions that administer programs that go to schools 
and organizations as opposed to individuals, and we will be 
glad to get you what that number is.
    Senator Burr. To your knowledge, has HRSA done any type of 
a review to see if there is duplication of Work Force programs 
within HRSA?
    Ms. Spitzgo. Yes, we have significantly spent time talking 
about, ``Is there overlap and is there duplication?'' and 
trying to minimize that. As well as working very hard to 
leverage our programs and make sure that they are working 
together.
    Senator Burr. I am going to ask you, if you will, to 
provide for the committee, the comprehensive list of those Work 
Force programs and their stated objectives, if you will.
    Ms. Spitzgo. Be glad to.
    Senator Burr. Your testimony also notes that a number of 
providers serving in the National Health Service Corps has 
nearly tripled from 3,600 in 2008 to 10,000 in 2012.
    Since the change in law to provide for waiver of full-time 
requirements, what percentage of the providers in the National 
Health Service Corps is serving in a part-time capacity?
    Ms. Spitzgo. About 10 percent of our workforce comes in for 
part-time, and of that, about two-thirds of those do 2-year 
agreements with us, and one-third does a 4-year agreement. So 
the 2-year commitment seems to be the preference.
    Senator Burr. What is the attrition rate for individuals 
that commit to service through one of the National Health 
Service Corps programs but do not fulfill the full term of that 
agreement?
    Ms. Spitzgo. Currently, the loan repayment program has a 
default rate that is less than 1 percent, and we have about a 3 
percent default rate with our scholarship program.
    Senator Burr. OK. The National Health Service Corps Web 
site highlights short- and long-terms retention rates for the 
Corps noting an increase of 28 percent in the short-term 
retention rate and an increase of 6 percent in the long term 
retention rate, and this is 2000 to 2012.
    Ms. Spitzgo. Yes.
    Senator Burr. Is there any difference in these retention 
rates for full- and part-time clinicians?
    Ms. Spitzgo. At this point, we don't know. The first time 
we offered a part-time was in 2010, so the current retention 
study would not have taken that into account at all, the part-
time option that we have now. So that would be something we 
would be able to start taking a look at.
    We do an annual survey of our clinicians and capture short-
term retention data, as well as the 10-year, long term. So we 
will shortly have some data on that.
    Senator Burr. What is the average length of retention after 
a clinician fulfills their initial service contract?
    Ms. Spitzgo. The average length? I am going to have to--we 
look at the short term. We have about 80, over 82 percent, so 4 
out of 5 folks continue to work in underserved communities 
after they complete their commitment, and obviously then as you 
go further out, we looked at that short term and we looked at 
the long term.
    I would have to go back to the report to see if we can get 
you what the average is. My guess would be 2 to 3 years, at 
least, but we will be glad to get you----
    Senator Burr. Provide that for us, if you would.
    Ms. Spitzgo. Yes.
    Senator Burr. Your testimony states that HRSA has done 
research and found that more than 55 percent of clinicians 
continue to practice in the communities that need them the most 
10 years after completing their service commitment.
    Does your research show that these clinicians continue to 
practice in communities in which they fulfilled their service, 
or in other communities with health professional shortages?
    Ms. Spitzgo. That is for working in community with health 
professional shortages. So they are all within in a HPSA, and 
some of those would be still within the community where they 
did their service. Others do certainly change and move to work 
in other shortage areas.
    Senator Burr. Could I ask you to share with the committee 
the research and do it as a followup to today's hearing?
    Ms. Spitzgo. Be glad to.
    Senator Burr. Thank you Mr. Chairman.
    Senator Sanders. Thank you, Senator Burr.
    Senator Warren.
    Senator Warren. Thank you, Mr. Chairman.
    And thank you, Ms. Spitzgo for updating us on the work of 
the National Health Service Corps, and what you are doing to 
provide access to primary care in underserved communities. And 
I want to thank you for all the work you are doing to help 
educate the next generation of health care professionals.
    Equal access to health care and primary care, regardless of 
where you live, whether it is a rural community, a suburban 
community, or in an urban center is essential to assuring that 
Americans have an equal opportunity to full and healthy lives.
    And I recognize that equal access means that we have to 
have a strong workforce that is trained to practice in our 
evolving health care system, a system that is becoming more 
integrated, and more coordinated over time.
    I am proud to support the Medicare GME-funded residency 
programs at hospitals around the country, and especially our 
world-class hospitals in Massachusetts. But I recognize that we 
also need strong support for other Federal workforce 
development programs, including the Corps.
    Across the board, these programs are dramatically 
underfunded, and they can have stringent eligibility 
requirements that leave many extraordinary programs without 
adequate funding.
    Now, people talk a lot about rising health care costs and 
how concerned they are about those costs.
    Can you explain how access to primary care reduces the 
overall cost of health care for individuals who are able to see 
a provider before they develop expensive complications?
    Ms. Spitzgo. Yes. I think what we see, and often read 
about, is that getting care as soon as you have symptoms, and 
not letting them progress further into the point where you need 
a much more serious treatment or a much more series of 
treatment really is very much less expensive.
    You can go and get on a routine whether it is--you look at 
diabetes. If you catch that early, you can get some training on 
lifestyle adjustments, and you can learn how to manage it, and 
potentially never even end up on medication. As opposed to if 
it goes unchecked, and you are very far and much further down 
the path of complications with diabetes, then you are going to 
be on medications. You may be having problems, vision problems, 
you may have issues with your feet. I have seen my brother go 
through this who went through it unchecked.
    So the costs you are incurring, and the medical tests and 
the routine, whether it is vision or it is being hospitalized 
to deal with some of these issues, or the medications 
themselves, certainly greatly add to the cost of care.
    Senator Warren. So it is fair to say that early care, 
primary care, integrated care may reduce the overall cost of 
health care in the system.
    Is that fair?
    Ms. Spitzgo. Yes, I think that is fair and----
    Senator Warren. Good.
    So the question I want to ask you, then, is if we doubled 
the support for the National Health Service Corps, what impact 
would that have on overall quality of health for Americans and 
on costs to the health care system?
    Ms. Spitzgo. I think the cost, I cannot give you a number 
right off, but I think what we can see from a quality 
perspective and just access, being able to have people 
available.
    We often heard from our sites that it is difficult for 
folks to get appointments; there are long waiting times to get 
an appointment, their ability just to find the providers. Often 
when a physician leaves, they may be 12 or 18 months recruiting 
a new physician. So not having someone there, obviously, 
someone else is taking up that slack because you still have 
patients to care for even once you have lost providers.
    By being able to recruit and using the National Health 
Service Corps as a huge recruitment tool, we hear this from our 
sites all the time. They say, ``I don't know what I would do 
without the National Health Service Corps. That is what brings 
me providers.'' And the more providers they can get as we place 
our scholars, they say, ``Give me more physicians. I can use as 
many physicians as you can give me.'' All of those things allow 
them to serve patients more.
    We have quality, significant quality of care being provided 
by our community health centers, and about 50 percent of our 
clinicians work in those community health centers. So we know 
that many more would also land in community health centers if 
we had more providers that we could support.
    Senator Warren. Thank you very much.
    Every time someone talks about the rising cost of health 
care, I hope they will stop to remember that we have paths open 
to us to reduce the costs of health care. We know how to get 
better outcomes at lower costs, but to do that, we have to make 
sensible, up front investments.
    In this case, investing in the medical education of our 
health care workforce can give us all a great return. We can 
get better outcomes at lower costs. So I just want to say thank 
you very much. I want to express my support.
    And to say, Mr. Chairman, I apologize. There is a banking 
hearing going on at exactly the same time, so I am going to 
have to miss this second panel.
    Thank you.
    Senator Sanders. OK. Thank you very much, Senator Warren.
    Senator Roberts.

                      Statement of Senator Roberts

    Senator Roberts. Before Senator Warren leaves, let me 
associate myself with her remarks. And thank you.
    Mr. Chairman, thank you for your leadership on these 
workforce issues. Thank you for holding this hearing.
    Ms. Spitzgo, thank you for your work you are doing. Stay in 
there.
    Ms. Spitzgo. OK.
    Senator Roberts. We will do the best we can.
    This has always been a particular interest of mine and a 
focus. In Kansas, we have 105 counties and in many of those 
counties, we don't have any health care professionals: no 
pharmacists, no nurses, no doctors, certainly no doctors, no 
dentists. So you have to travel in some cases, 100 miles, and 
then you see a nurse practitioner, and then we have the 
regional centers but sometimes that is a long, long ways away 
too.
    In Title VII, and Title VIII of the Public Health Service 
Act, we have done some really good work to address these 
issues, and I thank you for that. You have my support for these 
programs.
    But with all of the successes that we have, we still have 
Kansans who are traveling hours to access care, and are also 
simply unable to find a health professional in their area.
    I am concerned about the Affordable Health Care Act from 
one aspect--well, I am concerned about it in general but--one 
aspect especially. It proposes a way to get more patients and 
families access to care, but we have 7 million people, at 
least, that we were supposed to bring into the new Affordable 
Care Act programs.
    We just had a big discussion in the Finance Committee on 
who is a navigator. Who is going to help these people? There 
are 21 pages that you have to fill out to apply and 61 pages to 
supplement. I even tried wading through all of that, so we are 
going to have to have some pretty expert navigators to make 
this work.
    But there is a growing concern that there won't be enough 
providers on hand to treat and care for the patients, even if 
they gain access to coverage.
    What do you think about that? What is your general view on 
that challenge?
    Ms. Spitzgo. I think we continue to look for new ways to 
deliver care, whether we are doing team-based care. There are 
many new and innovative ways to do that. And we really do need 
to take some different looks at how to provide care to ensure 
that everyone who is seeking care is able to get an appointment 
and be seen in a reasonable amount of time.
    Senator Roberts. I would like to visit with you sometime 
about these new ways and get into the specifics.
    I am concerned, too, because we have programs in Kansas 
where we have seen some success, and it largely involves 
students who go to medical school in Kansas, especially the 
University of Kansas, and then they return to their rural 
roots. There is a lot of positive feelings, toward, we call it 
sort of the homegrown approach. I would like to see if these 
new innovative ways could build off of those programs. In other 
words, we could reinvent some wheels, but let's not forget the 
wheels that are working.
    At any rate, I was interested in your response to Senator 
Burr that you have indicated that folks will stay 10 years if 
we can get them interested in going to school, come back to 
their hometowns for their home areas. That has not been my 
experience and I am just saying it on an anecdotal basis.
    I used to be a bucket-toter around here, a staff member, 
both in the Senate and the House. One of my duties was to be a 
recruiter, and we would hear of somebody that might be a doctor 
that would come to a special program, or working with 
immigration, or working with a refugee program, or whatever. 
And we really would go out and recruit, and we had to recruit 
against Nebraska and Oklahoma. It was like football or 
something.
    I would get on the phone to a young man or woman and 
encourage them to come to Kansas, and that they would be 
welcomed, and the whole community, however small it was, would 
welcome them.
    Sometimes we would be successful, and they were most 
welcomed and I think they enjoyed their stay; 3 years and gone. 
And I think about primarily folks from Asia, from India, and 
from Africa. It worked for a while, but in 3 years that is very 
different from the homegrown approach that I am talking about 
as well.
    Now, you have indicated that, yes, it is 10 years, but it 
is 10 years in a workforce area or a rural area as opposed to 
that first hometown. I would sure like to get folks to stay in 
an area for 10 years. That would be wonderful if we could do 
that in many rural areas of Kansas.
    Would you like to comment on that?
    Ms. Spitzgo. Yes, I think we would like to see that same 
thing very much, and we work really hard with our placements as 
we work with clinicians, our scholars so that they find that 
good fit. Because we found from our research, if we can make 
that match, and they go, and they start that first job 
somewhere where they really want to be. It is a good fit for 
them; it is a good fit for the community.
    If they have a family, often our sites will say, ``I really 
need to recruit the husband or wife more than I need to recruit 
the clinician.''
    Senator Roberts. Right.
    Ms. Spitzgo. ``They will work anywhere.'' But the families 
have to be happy. We have to take all those needs into account.
    One of the things we did in the last year is launch our 
National Health Service Corps Job Center out on the Internet. 
And not only does it list vacancies, but it really tells the 
stories about our sites.
    ``What is it like to work at this site? Here are some 
pictures. Here is what kind of populations it serves. Here are 
the types of languages it speaks, the size that it is. Here is 
what is available in the area.'' So that it really helps folks 
as they are looking for a job to find that job which will be 
not for a year or two, which will be for a long-term placement. 
And hopefully, we will retain them and they will stay there for 
at least 10 years.
    Senator Roberts. I thank you for your response.
    Thank you, Mr. Chairman.
    Senator Sanders. Senator Murphy.
    Senator Murphy. Thank you very much, Mr. Chairman.
    Ms. Spitzgo, thank you so much for your fantastic work and 
for all of your office's fantastic work.
    I just wanted to get the numbers right here. The commitment 
is for 2 years.
    Ms. Spitzgo. For loan repayment.
    Senator Murphy. For loan repayment, and the maximum loan 
repayment is for?
    Ms. Spitzgo. As long as they continue to have qualifying 
educational debt, they can continue in the program. And after 
that, it is a 1 year renewal, and they can continue on until 
their debt is paid.
    Senator Murphy. I wanted to follow along the same line of 
questions as Senator Roberts and Senator Burr, which is, 
questions about how we can get a bigger bang for our buck 
because I appreciate the fact that about half the people are 
staying there after 10 years. But that means that half the 
people are not staying there for after 10 years. And it is a 
pretty substantial investment to perhaps get somebody to stick 
around for only 2 or 3 years.
    The question is: how can we make the amount of money we are 
spending here go further? Are we sure we have the commitment 
timeframe right? Given the fact that we have twice as many 
applicants on the loan repayment side as we have slots to fill, 
does that suggest that we could actually increase the amount of 
time that we are asking someone to commit to these areas, and 
you wouldn't necessarily have fewer applicants than you have 
slots?
    Have we talked about expanding the commitment time?
    Ms. Spitzgo. We do continue to look at that each year.
    For our new program, our Student to Service Loan Repayment 
Program, which is just in its second year, that is a 3-year 
commitment. It is kind of in between a regular loan repayment 
where they have already finished school and are licensed and 
these folks are in their last year of training is the 
qualification for that and educational debt, where our 
scholarship program is 2 to 4 years, so some of those folks 
have a 4-year commitment. We do continue to look at that.
    We also have the part-time program where we have seen much 
less interest in a 4-year part-time than a 2-year part-time. 
And what we know from monitoring and working with our 
clinicians, once they are in service is that life does happen. 
Things change. Maybe they need to move to a new area and there 
might not be a National Health Service Corps site there. If 
they have care issues for their parents or they need something 
different for their children.
    We do continue to look at that whether 2 years or 3 years 
might be--2 years is what is in our statute, and we follow 
that, and then we do the 1 year increments after that.
    But we do continue to also look at the amounts of loan 
repayment to figure out, How do we make that money go further? 
And we have adjusted those amounts over the course of the last 
couple of years.
    Senator Murphy. We in Connecticut had a crisis with respect 
to access to pediatric dentistry, not unlike other States, and 
we had two ways to go.
    One we could try to directly attract more people into that 
field through loan repayment or through direct grants to people 
who committed to stick around. Or, we could just increase rates 
and hope that the market, then, would respond to the fact that 
we were going to pay more on a fee-for-service basis for the 
service provided.
    We increased rates and almost overnight, the market 
responded. And we had an influx of pediatric dentistry to the 
extent that we have largely solved the access problem in 
Connecticut.
    As someone who works in this field, we have a bucket of 
money to spend, and in this case, we are spending it on direct 
subsidies to physicians, or doctors, or health professionals to 
get them to come to underserved areas.
    Another way to do it is to take that amount of money that 
we have and use it to increase the rates that are being paid in 
those underserved areas to all physicians. So as to make it 
clear that if you come to this area, regardless of whether you 
are a member of Job Corps or not, you are a member of the 
Service Corps or not, you are going to be rewarded for 
practicing in an underserved area.
    What is your perspective on how we should approach whether 
it is better to direct money specifically to individuals who 
are going to make a potentially short-term time commitment to 
that area? Or, whether we would be better served to take money 
and put it into overall rate increases to anyone who goes to 
that area and hopefully have the market respond to the 
differentiation we have made in rates paid in underserved areas 
versus non-underserved areas?
    Ms. Spitzgo. I think right now, we actually have the bonus 
payment that is provided by the Center for Medicare and 
Medicaid for underserved areas. So we are doing some of that 
direct payment to folks who do work in those areas already.
    Senator Murphy. So you are talking with the physicians 
here.
    Does that make a difference?
    Ms. Spitzgo. I think I would have to go to see what the 
data is that CMS has on that. I am not familiar. I just know 
that there is that program to help attract, but we still know, 
even with that 10 percent bonus payment, we still have 
significant shortages in these areas.
    We also know, and I think another thing we wrestle with on 
retention is, what is the benchmark? How long is it typical for 
any type of physician to retain employees? And people move 
around frequently, and we continue to look for that benchmark. 
So someone staying there 55 percent for 10 years or staying 
their 2-year commitment or maybe their 3- or 4-year commitment. 
We do not actually start counting retention until they are no 
longer receiving funding from the program.
    We are not incentivizing them to stay any longer, unlike 
some of the programs where we talk about retention from a 
military perspective where we are giving retention bonuses. We 
actually have finished providing all financial support.
    I think what we see are these people do stay in underserved 
communities. They are there and they are very mission-driven. 
Some may make choices to maybe not be providing direct care and 
they may go into other lines of work that still support 
underserved communities, but they would not necessarily be 
counted in the retention numbers.
    In general, the folks we see in the program and that come 
there very much stay in the program. They benefit greatly. They 
are not necessarily, they said they would not be able to have 
gone to underserved and work in that environment without the 
financial support.
    I do not know if increasing the rates would directly get to 
the clinicians. I do believe most of our clinicians are paid a 
competitive rate for that area. Whether that would get passed 
on to them through their employer and who they work for, an 
increase? I think that would vary across the board how that 
might be implemented.
    Senator Sanders. Thank you. Ms. Spitzgo, thank you very 
much. Keep up the great work, and we have another panel to 
follow.
    Ms. Spitzgo. OK. Thank you.
    Senator Sanders. OK, if our second panel could please come 
to the table.
    [Pause.]
    Let me thank all of our panelists for being here today. It 
is an exceptionally good panel and I look forward to hearing 
the testimony. Let's begin.
    Dr. George Rust. Dr. Rust is a professor of family medicine 
and co-director of the National Center for Primary Care at 
Morehouse School of Medicine. Before that, he served 6 years as 
Medical Director for the West Orange Farm Workers Health 
Association in Central Florida. He is board certified in both 
family practice and preventative medicine. Dr. Rust is the 
author of over 70-peer reviewed publications related to primary 
care, health disparities, and underserved populations. His 
career as a family physician and scholar has consistently 
focused on primary health care for those in greatest need.
    Dr. Rust, thanks so much for being with us.

STATEMENT OF GEORGE S. RUST, M.D., MPH, FAAFP, FACPM, PROFESSOR 
 OF FAMILY MEDICINE AT THE MOREHOUSE SCHOOL OF MEDICINE AND CO-
 DIRECTOR OF THE NATIONAL CENTER FOR PRIMARY CARE, ATLANTA, GA

    Dr. Rust. Chairman Sanders, thank you for your leadership 
and for the committee's leadership as well, Ranking Member Burr 
and Senator Murphy. Thank you so much for allowing me to be 
here today.
    I am Dr. George Rust and I am a professor of family 
medicine at the National Center for Primary Care at Morehouse 
School of Medicine. I am also a family physician who trained in 
the inner city, practiced in a rural small town, and now teach 
and do community health outcomes research at an historically 
Black medical school. I learned to do team-based primary care 
for culturally diverse patients in the Cook County Hospital 
Family Medicine Residency Program, which was funded by HRSA 
primary care residency training grants. Their neighborhood 
clinics were early models of the teaching community health 
center, again, funded by HRSA CHC funding. And I am a veteran 
of the National Health Service Corps, which helped sustain my 
commitment to practice primary care in a community that really 
needed me.
    Early in my career, I saw firsthand the powerful impact of 
comprehensive, culturally relevant, team-based primary care 
offered and migrant and community health centers where I 
practiced. Since then, our research has confirmed that there is 
a 33 percent higher rate of uninsured emergency department 
visits in rural counties that do not have a community health 
center.
    Now, the nationwide cost of uninsured emergency room visits 
for ambulatory care, sensitive conditions is $65 billion. 
Community health centers not only provide emergency department 
diversion, but emergency department prevention. Patients 
survive, and rural hospitals can thrive when they do not have 
that burden of indigent care.
    The same is true in urban areas. Over half of visits to an 
urban public hospital's emergency department are for primary 
care-treatable or preventable conditions. Research by Dr. 
Starfield and others has shown that the more primary care 
clinicians a community has, the better people's health outcomes 
are, and the most cost-
effective the health care system is. Primary care matters.
    Now, for the past 21 years, I have been blessed to teach 
and research primary care and community health at the Morehouse 
School of Medicine, which was recently ranked No. 1 in the 
Nation for achieving a social mission based on our track record 
of producing the doctors that America really needs. Doctors 
that practice primary care, that serve in underserved rural and 
inner city communities, and who reflect the diversity of the 
American people.
    How do we do it? First, we work hard to find the right 
students. Students with reality tested idealism, a track record 
of community service, and a commitment to making a difference 
in the world. We train students from the first day in the 
community as well as the classroom, and we nurture that 
commitment to serve.
    We teach teamwork and people skills needed for students to 
deliver humane and effective care. And we nurture and value our 
primary care faculty, and we practice what we teach in the 
patient-centered primary care medical home.
    Unfortunately, we are swimming upstream against huge 
obstacles and financial disincentives. The HRSA-funded primary 
care training grants have been cut to the bone and they cap our 
overhead costs at 8 percent, which our dean compares to 
research grants with indirect cost rates of 40 to 50 percent. 
So the incentive is to expand lab research, not to expand 
primary care training programs.
    Subspecialty faculty generates more clinical revenues than 
primary care faculty. So which should our School hire more of?
    Graduate medical education support comes through hospital-
based Medicare IME and DME funding. So where is the support for 
community based residency education that keeps people out of 
the hospital?
    It takes a moral commitment for us to train primary care 
physicians for underserved areas because every decision we make 
to do the right thing flies directly in the face of the 
financial incentives built-in to the largest sources of medical 
education funding.
    So based on my experience and on the research and skipping 
past the obvious payment reform issues, let me offer three 
small suggestions.
    First, reconnect academic centers with community based 
practice starting with sustainable, direct, long-term funding 
for a large number of teaching community health centers.
    Second, we must increase dramatically the funding for title 
VII and title VIII support for primary care health professions 
training. These are solid investments in the primary care 
workforce.
    And third, unlink graduate medical education from hospital-
based specialty care unless you want to keep producing absurd 
proportions of subspecialists and hospitalists. Instead, let's 
create direct, sustainable funding for community based, 
outpatient residency programs that train doctors to keep people 
out of the hospital.
    We need your help. Morehouse School of Medicine and others 
have taken heroic risks to stay on mission, sometimes risking 
our own sustainability. Enough with the heroics; let's support 
primary care and let's reap the benefits in lower health care 
spending, more appropriate care, and better health outcomes for 
all Americans.
    Thank you very much.
    [The prepared statement of Dr. Rust follows:]
     Prepared Statement of George S. Rust, M.D., MPH, FAAFP, FACPM
    Good morning, Ranking Member Burr and Chairman Sanders, and members 
of the subcommittee. My name is Dr. George Rust, and I am a Professor 
of Family Medicine and Co-Director of the National Center for Primary 
Care at Morehouse School of Medicine.
    My testimony will focus on the importance of primary care in 
assuring the Nation's health, the benefits of supporting a robust 
primary care capacity (especially in underserved communities), and the 
ways in which we can support medical schools to produce the primary 
care physicians that America needs.
    Why is primary care so important? Published studies have 
demonstrated the positive impact of primary care on a variety of health 
outcomes, including decreased mortality (death rates) from cancer, 
heart disease, stroke, and all-causes combined. Primary care clinician 
capacity is also associated with fewer low birth weight births, 
increased life expectancy, and improved self-rated health. The dose of 
primary care can even be measured--an increase of one primary care 
physician per 10,000 population was associated with an average 
mortality reduction of 5.3 percent, or 49 per 100,000 per year.\1\
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    \1\ Macinko J, Starfield B, Shi L. Quantifying the health benefits 
of primary care physician supply in the United States. Int J Health 
Serv. 2007;37(1):111-26.
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    Primary care is where you go for your flu shots and blood pressure 
treatment, and where your kids go for school physicals and 
immunizations, but it's also where you go to say ``Doc, I just don't 
feel right. Something's wrong.'' Research by Dr. Barbara Starfield and 
others has shown for decades that the more primary care a community 
has, the better people's health outcomes are, and the more cost-
effective the healthcare system is. In other words, primary care 
matters!
    A June 2009 article in the Journal of the American Medical 
Association opens with this statement: ``Primary care is the essential 
foundation for an effective, efficient, and equitable health care 
system.'' \2\
---------------------------------------------------------------------------
    \2\ Grumbach K, Mold JW. A health care cooperative extension 
service: transforming primary care and community health. JAMA 2009; 
301(24): 2589-90.
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    Think of the successes we have achieved as a nation in improving 
America's health. Death rates due to heart attack and stroke have 
declined by more than 50 percent. Public health outreach and screening 
campaigns related to blood pressure as ``the silent killer'' were 
clearly a part of the success story, but only when coupled with the 
routine screening and treatment of high blood pressure all day long in 
primary care practices all across the country. Cervical cancer death 
rates have declined by more than 75 percent, a success attributable in 
large part to nurse practitioners and nurse midwives and physician 
assistants and doctors in primary care practices doing Pap smears and 
finding pre-cancers that can be eliminated even before cancer takes 
hold.
    In our own research at the National Center for Primary Care, we 
analyzed all the major successes in America's health over the last 
half-century. Among all the leading causes of death from 1950 to 2000, 
we found nine major causes of death that showed at least a 50 percent 
reduction in death rates from their 50-year peak level. Seven of those 
nine conditions demonstrated a pattern that we called triangulating on 
success \3\--three major components, including research innovation 
distributed through both medical care (especially primary care) and 
public health. Similar outcomes were achieved by our Nation 
triangulating on success for heart attack and stroke, for cervical 
cancer, for TB and syphilis, for influenza and pneumonia, and for HIV/
AIDS.
---------------------------------------------------------------------------
    \3\ Rust G, Satcher D, Fryer GE, Levine RS, Blumenthal DS. 
Triangulating on success: innovation, public health, medical care, and 
cause-specific U.S. mortality rates over a half century (1950-2000). Am 
J Public Health. 2010 Apr 1;100 Suppl 1:S95-104. doi: 10.2105/AJPH.2009
.164350. Epub 2010 Feb 10.
---------------------------------------------------------------------------
    We have also studied how primary care can prevent unnecessary use 
of the emergency department. Using data from the National Health 
Interview Survey, we showed that people who experience simple barriers 
in timely access to primary care, such as difficulty getting through on 
the telephone or getting an appointment during an acute illness, were 
significantly more likely to have an emergency room visit.\4\ The 
emergency room becomes the safety valve when primary care access or 
capacity is inadequate.
---------------------------------------------------------------------------
    \4\ Rust G, Ye J, Baltrus P, Daniels E, Adesunloye B, Fryer GE. 
Practical barriers to timely primary care access: impact on adult use 
of emergency department services. Arch Intern Med. 2008 Aug 
11;168(15):1705-10. doi:10.1001/archinte.168.15.1705.
---------------------------------------------------------------------------
    This is even more important for underserved segments of the 
population, which benefit most from access to primary care, especially 
the kind of primary care offered by community health centers--
comprehensive, community-owned, culturally relevant, team-based care. 
We compared rural counties in Georgia that had a community health 
center clinic site with those that did not, and found that there was a 
33 percent higher rate of uninsured emergency department visit rates in 
counties without a community health center. Some of this could be 
considered emergency department diversion--acute illness events or 
injuries treated in the community health center rather than the 
emergency department. But some of the difference also represented 
emergency department prevention, not diversion. ED visit rates for 
ambulatory care sensitive conditions (including chronic conditions such 
as asthma, hypertension, and diabetes) showed a 37 percent excess in 
communities with no CHC.
    This not only benefits the uninsured clients who are getting more 
of the right care in the right setting at the right time, but also 
benefits the community hospitals which reduce their indigent care 
costs, which could mean the difference between a rural hospital 
thriving or closing its doors. Using HCUP data from the Agency for 
Healthcare Research and Quality (AHRQ), we can estimate hospital 
charges due to uninsured hospitalizations across the Nation to be $64.8 
billion per year. Reducing this by a third in every community across 
the country which does not have a community health center or has 
inadequate primary care capacity, could potentially save tens of 
billions of dollars per year. Primary care matters!
    The same is true in urban areas.\5\ Over half of visits to an urban 
public hospital's emergency department are for primary care treatable 
or primary care preventable conditions. In other words, a primary care 
health home helps assure that each patient gets the right care in the 
right setting at the right time. Instead of treating a stroke in the 
ICU, we can treat high blood pressure right in the patient's own 
neighborhood. This primary care must be team-based care to achieve 
better outcomes for the whole patient. This includes re-connecting the 
head & the heart, by integrating mental health / behavioral health and 
primary care. Several years ago, our Morehouse School of Medicine 
National Center for Primary Care sponsored a summit of best-practice 
champions at the request of over a dozen Federal agencies, in order to 
bring this model to wide-spread adoption, which is now happening all 
across the country. Community-Oriented Primary Care (COPC) combines the 
one-on-one caring for patients in a primary care clinical practice with 
the larger perspective of improving overall community health outcomes.
---------------------------------------------------------------------------
    \5\ Rust G, Baltrus P, Ye J, Daniels E, Quarshie A, Boumbulian P, 
Strothers H. Presence of a community health center and uninsured 
emergency department visit rates in rural counties. J Rural Health. 
2009 Winter;25(1):8-16.
---------------------------------------------------------------------------
    I had the privilege of working as a family physician of a HRSA-
funded, community-owned migrant and community health center for 6 years 
in Central Florida early in my career. My career commitment to primary 
care in an underserved setting was nurtured and protected by a National 
Health Service Corps scholarship, and sustained by section 329/330 
health center funding. As medical director, I dealt with incredible 
challenges in recruiting and retaining clinicians to meet the 
community's needs when the Corps was de-funded in the 1980s, and so I 
am thrilled to see a revitalization of the National Health Service 
Corps, with a new flexibility in recruiting and a stronger commitment 
to retention.
    This primary care workforce is essential, and we must connect them 
with the communities where they are needed most. I was blessed to 
receive my residency training in Chicago's Cook County Hospital family 
medicine residency training program, which helped me to become an 
expert in primary care for the underserved and for culturally diverse 
populations. That program was supported by HRSA primary care residency 
training grants as well as primary care faculty development grants. 
They nurtured my idealism and fine-tuned my clinical skills in one of 
the earliest and best examples of a teaching community health center. 
My residency primary care continuity clinic experience was delivered in 
a federally funded community health center that served a culturally 
diverse, high-volume, low-income patient population. I was fortunate to 
train in a setting where primary care was a team sport, delivered in 
partnership with physician assistants and nurse practitioners and 
pharmacists and social workers and psychologists.
    For the past 21 years, I have had the privilege to teach and 
research primary care and community health at the Morehouse School of 
Medicine, which was recently ranked #1 in the Nation in social mission, 
based on our track record of producing the doctors that America really 
needs--doctors that practice primary care, doctors that serve in 
underserved rural and inner city communities, and doctors that better 
represent the diversity of the American people.
    Training primary care clinicians is broader than just training 
physicians, but medical schools are an expensive and essential 
component, so for the moment let me focus on what it takes for 
Morehouse School of Medicine and other institutions to be medical 
schools that excel in training the doctors America actually needs. How 
do we do it? On the positive side, we work hard to find the right 
students in the admissions process--students with reality-tested 
idealism, a track record of community service, and a commitment to 
making a difference in the world. We train students from day one in the 
community as well as in the classroom, and we nurture their commitment 
to serve and to make a difference. We have state-of-the-art clinical 
training labs with actors as standardized patients to assure that 
students have both the clinical skills and people skills to deliver 
humane and effective care. We nurture and value our primary care 
faculty, cultivate partnerships with local community health centers in 
our neighborhoods, and we work together to build excellence in models 
of the patient-centered primary care medical home.
    At the same time, our medical school is swimming upstream against 
incredible obstacles and financial incentives which lead most medical 
schools to run away from such a mission. Morehouse School of Medicine 
relies heavily on HRSA-funded primary care and diversity training 
grants, which have experienced significant cuts. Our training grants 
provide 8 percent indirect overhead cost rates, while NIH research 
grants offer indirect cost rates of 40-50 percent--so the financial 
incentive is to expand investigator-initiated research, not to expand 
primary care training programs. Sub-specialist faculty can generate 
dramatically higher clinical revenues than primary care faculty--so 
which should our school hire more of? Graduate medical education 
support comes through hospital-based Medicare IME/DME payments--so 
where is the support for community-based residency education that keeps 
people out of the hospital? Is it any surprise that only one out of 
third-year internal medicine residents plan to practice as general 
internists after graduation? The rest will choose to pursue sub-
specialty fellowships in specialties that are already over-subscribed, 
or if they remain generalists, to do hospitalist medicine, rather than 
outpatient primary care? It takes a moral commitment for a medical 
school to train primary care physicians for underserved areas, because 
every decision to do the right thing flies directly in the face of the 
financial incentives built into the largest sources of medical 
education funding. Do we choose mission over margin? Do we risk the 
very survival of our own institution in order to keep our commitment to 
train primary care clinicians for communities in need? Is that a choice 
America wants us to have to make?
    It is not by accident that the top 10 schools for research funding 
are not in the top 10 for training diverse students to become primary 
care physicians serving communities in need. Medical school research 
and medical school training has too often become disconnected from the 
real world community-based primary care clinical practice, and 
disconnected from training the doctors we most need for the communities 
where they are most needed. Our research must translate into real 
results--so we need more primary care and patient-centered research. To 
quote Dr. Larry Green, ``if we want more evidence-based practice, we 
must generate more practice-based evidence.'' Translational research, 
whether funded by NCATS or other institutes, must find a more even 
balance between bench-to-bedside T1 translation and the T2 real-world 
implementation research that moves innovation out to curbside and 
countryside, where the free-range humans live.
    Ultimately we need to re-balance our professional compensation 
scales so that there is not a ``half-the-pay for twice the work'' 
penalty associated with being a primary care physician. We need to 
reward patient care and community health outcomes more than we reward 
cranking out high-volume visits and procedures, so that primary care is 
not hamster-wheel medicine (running from exam room to exam room all day 
to achieve 30-40 visits), but rather is practiced in a humane, caring, 
and effective manner to achieve optimal care and outcomes for all our 
patients.
    We also need to radically re-configure our financial support for 
medical schools to assure that we are getting an excellent return on 
our taxpayers' investment, as measured by training the kind of doctors 
America needs for the communities that need them most. We can no longer 
maintain the disproportion of hospital-based GME funding at 20-times 
the levels at which we fund title VII and title VIII primary care 
training programs. We need new mechanisms that train physicians to 
practice in teams in community-based settings to provide the right care 
in the right setting at the right time. COGME has suggested that title 
VII needs to jump tenfold from $50 million to $500 million, and still 
it would represent only 5 percent of the amount currently passed 
through Medicare to hospitals for GME. So we must test ways to 
disconnect the CMS graduate medical education payments from hospital-
based specialty care, and fund community-based outpatient training 
programs that train clinicians to offer the right care in the right 
setting at the right time. Why pay to train doctors we don't need to 
practice in places where they are not needed?
    Finally, we need to re-connect academic medical centers with real-
world primary care and community health outcomes. A good start would be 
robust funding of the teaching community health centers model, 
connecting training and service for every medical student in schools 
that receive Federal funding. Health professions funding should have a 
directly measurable ROI, and I can even imagine funding formulas pro-
rated to the production of the clinicians America actually needs, 
clinicians who represent the diversity of the American people, who 
engage in community-oriented, team-based primary care, and who serve in 
communities of greatest need. Morehouse School of Medicine and other 
leading institutions have taken heroic risks with their own survival to 
prove that it can be done. Let's train the clinicians America actually 
needs. Let's be smart about paying for health professions education 
that gives us a good return on our investment, and then reap the 
benefits in lower healthcare spending, more appropriate care, and 
better health for all Americans.
    Thank you.
  
  
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 
    

    Senator Sanders. Thank you very much, Dr. Rust.
    Our second witness is Dan Hawkins, senior vice president, 
Public Policy and Research at the National Association of 
Community Health Centers. During his tenure at the NACHC, 
Federal support for health centers has grown from $350 million 
to over $1.6 billion annually, and the number of people served 
by health centers has grown from 5 million to over 20 million.
    Mr. Hawkins, thanks so much for being with us.

  STATEMENT OF DANIEL R. HAWKINS, JR., SENIOR VICE PRESIDENT, 
   PUBLIC POLICY AND RESEARCH AT THE NATIONAL ASSOCIATION OF 
            COMMUNITY HEALTH CENTERS, WASHINGTON, DC

    Mr. Hawkins. Thank you and good morning, Mr. Chairman, 
Ranking Member Burr, and distinguished members of the 
subcommittee.
    On behalf of the National Association of Community Health 
Centers and the American health center community, I thank you 
for this subcommittee's strong bipartisan support of health 
centers, and for the opportunity to join today's discussion of 
the primary care workforce challenges.
    Today, there are over 1,200 community health centers 
located at more than 9,000 urban and rural locations nationwide 
serving as health care homes for more than 22 million 
Americans. By statute and mission, health centers are located 
in medically underserved areas and care for patients regardless 
of their ability to pay.
    Health centers have experienced significant growth over the 
last decade, and are projected to continue growing with funding 
provided under the Affordable Care Act. And thanks to your 
leadership, Mr. Chair.
    With this growth, however, they also face challenges in 
recruiting sufficient numbers of clinicians. To address this 
problem, health centers have adopted and embraced a grow our 
own strategy, training all types of health professionals right 
in our health centers to address the team approach to health 
care delivery. Nurse practitioners, physician assistants, 
certified nurse midwives, dentists, dental hygienists, and 
behavioral health professionals are key members of our health 
home teams.
    Today, I will focus on physician training.
    Health centers have a long history training medical 
residents. Some have residents through for a few short weeks, 
others for longer periods of time, and still others serve as 
the home for a resident's full ambulatory care training 
experience. To date, we know of at least 57 health centers 
nationally engaged in significant residency training activity.
    Now, these programs have proven to be most beneficial for 
everyone and especially for rural communities. Health center 
trained residents are four times more likely to remain at 
health centers and more than two-thirds of them report working 
in underserved communities following graduation, nearly double 
the rate for those trained elsewhere.
    Yet, a lack of dedicated and reliable funding for this 
training has prevented many interested health centers from 
pursuing it, and saddled those that are so engaged with 
significant financial losses.
    To that end, we were very pleased when the Teaching Health 
Centers, or the THC program, was created within the ACA, the 
first-ever Federal effort to directly fund community-based 
organizations to provide primary care training. Communities, 
after all, are where most of their primary care providers will 
actually spend the rest of their careers.
    This new program was funded at $230 million for a 5-year 
period through fiscal year 2015. We estimate there are over 300 
residency slots currently at the nearly 40 THC funded programs 
across the country.
    Under current law, the THC funding authority, as you noted, 
expires in fiscal 2015. However, current grantees face a more 
immediate threat, because they will soon be expected to recruit 
the class that starts July 1 of next year. And yet, they may 
have no funding to support the completion of that training 
cycle. This could literally leave incoming and even existing 
residents with no place to complete their training.
    For this reason, we urge the committee to promptly 
reauthorize this program for 5 years and to fully fund it 
through that period. My written statement also includes some 
additional recommendations.
    I would also like to highlight another vital program, the 
National Health Service Corps which, since 1970, has been an 
essential tool for addressing disparities that affect 
underserved and provider-short communities.
    Since Ms. Spitzgo has already testified, I will simply note 
that the NHSC serves as a vital partner to health centers and 
she noted, with approximately half of its 10,000 assignees 
working there today. Like the THC program and, for that matter, 
the Health Centers' program, it also faces a funding cliff in 
fiscal 2016. We want to work with you to ensure that all these 
programs remain strong and intact now and post-2015.
    Finally, I want to salute an incredibly innovative program 
that is changing the training of primary care. More than a 
decade ago, my organization partnered with the A.T. Still 
University to establish a health center focused dental school. 
And then 5 years later, partnered again to open one of 
America's newest osteopathic medical schools. These two 
programs are growing the next generation of health center 
providers having already produced more than 300 practicing 
dentists and over 300 medical students whose education is 
currently embedded in a health center.
    Thank you, Mr. Chairman, and members of the subcommittee, 
and I would be happy to answer any questions.
    [The prepared statement of Mr. Hawkins follows:]
              Prepared Statement of Daniel R. Hawkins, Jr.
                              introduction
    Chairman Sanders, Ranking Member Burr, and distinguished members of 
the subcommittee, my name is Dan Hawkins, and I am the senior vice 
president for Public Policy and Research at the National Association of 
Community Health Centers. On behalf of the American health center 
community, including the more than 22 million patients served 
nationwide by health centers, the 131,660 full-time health center 
staff, and countless volunteer board members who serve our centers as 
well as the National Association of Community Health Centers, we thank 
you for this subcommittee's strong bipartisan support of health 
centers. I also wish to thank you for the opportunity to testimony for 
the committee as you continue to discuss the primary care workforce 
challenges facing our country.
                   health centers--general background
    Community Health Centers (CHCs) are community-owned non-profit 
entities providing primary medical, dental, and behavioral health care 
as well as pharmacy and a variety of enabling and support services. To 
date, there are over 1,200 CHCs located at more than 9,000 urban and 
rural locations nationwide serving as health care homes for more than 
22 million patients.
    By statute and mission, CHCs are located in medically underserved 
areas or serve a medically underserved population. CHCs see patients 
regardless of their ability to pay or insurance status and offer 
services based on a sliding fee discount.
    CHCs are also directed by patient-majority boards; this unique 
model ensures care is locally controlled and responsive to each 
individual community's needs, while also reducing barriers to accessing 
health care though our various services.
    The Nation's health centers have experienced significant growth 
over the last decade and received strong bipartisan support thanks to 
their cost-effective model which brings access to care and improved 
health to communities nationwide. The health center infrastructure is 
projected to continue to grow with the expansion of CHCs contained 
within the Affordable Care Act (ACA). Through the ACA's Health Center 
Fund, CHCs were allocated $9.5 billion over 5 years for operational 
expansions including the opening of new sites as well as expansions of 
medical and other services. This capacity expansion was designed to 
allow health centers to meet the needs of the newly insured, many of 
whom are expected to seek care at our Nation's health centers, 
beginning in 2014. That expansion has been slowed significantly due to 
a sizable reduction to health center funding in fiscal year 2011, but 
growth has resumed in the last 2 fiscal years.
    With this operational growth, however, will come an additional 
strain on health centers that already face challenges in recruiting 
sufficient numbers of clinicians from a limited supply of primary care 
providers nationally. Many CHCs face challenges in filling provider 
vacancies across provider types including physicians, nurse 
practitioners, physician assistants, certified nurse midwives and 
nurses, pharmacists, dentists, and other clinical staff. In order to 
address the challenges of developing a sufficient primary care 
workforce for underserved communities, CHCs have embraced a strategy we 
like to call ``grown our own,'' by stepping up and training health 
professionals right in our health centers.
    Health centers have a long history of training the full complement 
of primary care providers, but for the purposes of this hearing I am 
going to focus largely on physician training.
                 health centers and residency training
    Health Centers have a long history training medical residents in 
our centers at a variety of levels. Some centers may have residents 
rotate through for a short few weeks, others for longer periods of 
time, and still others serve as the primary ambulatory care site (or 
``continuity clinic'') for the resident's training experience. These 
programs have proven to be beneficial to the health centers in which 
they are located, to the residents, to the partnering institutions, and 
the medical colleges or hospitals. Through these partnerships, health 
centers are able to provide additional care for patients and recruit 
providers and residents who are more inclined to work in underserved 
areas after their exposure to these unique training opportunities.
    To date, we know of at least 57 health center engaged in 
significant residency training activity. Many of these health centers 
are engaged in residency training at the continuity clinic level, 
beyond offering elective rotation experience.
    Each health center residency program is unique to the community in 
which it is located and there are many variations on the arrangements 
health centers have with their partnering institutions. However, there 
are many universal benefits and challenges these programs face.
    Residency training in health centers has proven to be a successful 
way for health centers to recruit providers and to them practicing in 
medically underserved areas. In fact, health center trained residents 
are four times more likely to work in health centers. In addition, more 
than two thirds of health center-trained residents reported working in 
underserved settings following graduation--nearly double the rate of 
non-health center-trained graduates. These training benefits are 
particularly significant in rural areas of the country where access to 
academic medical centers are limited.\1\
---------------------------------------------------------------------------
    \1\ Morris, C., Kim, S., Chen, F. Training Family Physicians in 
Community Health Centers: A Health Workforce Solution, Health Services 
Research. 2008; 40 (4): 271-275.
---------------------------------------------------------------------------
    Yet, a lack of dedicated and reliable funding for this community-
based training at the continuity level prevents many interested health 
centers from pursuing it. Even for those engaged in these activities, 
funding is often tenuous and many programs result in a financial loss 
for the health center. Partnering institutions often do not provide 
enough reimbursement and patient revenue does not generate enough 
funding to offset the direct and indirect costs faced by health centers 
engaging in this training. Some financing to cover the costs of 
training is provided by Medicare and Medicaid reimbursement from 
patients whose care is supervised by physician preceptors and resident 
billing for patients seen, but unreimbursed indirect costs are 
particularly significant. Many residency programs cover some of the 
direct costs incurred by CHCs, but such funding is often unreliable and 
CHCs generally do not receive adequate resources to support their 
indirect costs such as additional space, supplies and staff time 
commitments that residency training requires.\2\
---------------------------------------------------------------------------
    \2\ National Association of Community Health Centers. Health 
Centers' Contributions to Training Tomorrow's Physicians: Case Studies 
of FQHC-Based Residency Programs and Policy Recommendations for the 
Implementation of the Teaching Health Centers Program. August 2010. 
http://www.nachc.com/client/THCReport.pdf.
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                   the teaching health center program
    Until health reform, efforts to coordinate and fund residency 
training in community based settings such as CHCs had been accomplished 
on a very limited scale. Efforts within the Affordable Care Act focused 
on unique ways to foster and more reliably fund primary care training 
in community-based settings.
    Given the role health centers play across the country in training 
various health professionals, health centers were uniquely positioned 
to help meet what we believe is an important goal of health reform to 
``flip the pyramid'' and move our Nation toward a broader base of 
primary care instead of the inverse specialty care driven system we 
have today.
    To that end, we were very pleased when the Teaching Health Centers 
Graduate Medical Education (THCGME) program was created within ACA. 
This represented Congress' first direct investment in primary care 
training in the community, where the vast majority of primary care 
providers will actually practice upon completion of their training. The 
ACA authorized and appropriated $230 million in total funding for a 5-
year (fiscal year 2011-15) payment program to support accredited 
primary care residency training programs operated by community-based 
entities, including health centers.
    The THCGME statute also authorized but did not appropriate $125 
million in developmental grants for developing THCs. The goal of these 
grants was to help defray the cost of establishing a THC, including 
curriculum development, recruitment, training and retention of 
residents and faculty, accreditation, faculty salaries, and technical 
assistance.
    Currently, our estimates are that there are over 300 residency 
slots at nearly 40 THCGME-funded programs across the country. Eligible 
training programs are accredited graduate medical education residency 
training programs in: family medicine, internal medicine, pediatrics, 
internal medicine-pediatrics, obstetrics and gynecology, psychiatry, 
general dentistry, pediatric dentistry, and geriatrics.
    While the program is still in its early stages, it is already 
starting to change the paradigm of residency training by putting 
community-based entities in the driver's seat for the first time.
     current challenges for the teaching health center gme program
    The $230 million in ACA funding allocated for the THCGME program 
expires in fiscal year 2015 at the end of the program's 5-year 
authorization. However, current grantees are facing a more immediate 
threat to their programs.
    The traditional residency year begins July 1, and while varying by 
discipline, most residencies run at least 3 years. Grantees will be 
recruiting this summer and fall for the class that will start July 1, 
2014 and will be in the midst of their residency training when THC 
funding expires. Absent some certainty by this summer or fall, these 
programs will face the untenable situation of recruiting a resident 
class for which they may have no funding to support completion of those 
residents' training. Instead, many have indicated they will not recruit 
a next class absent the assurance of continued funding. For those 
programs that were created specifically with THCGME funding, in 
particular, this could mean their programs enter a ``death spiral.'' If 
no new class is recruited, faculty may leave and existing residents may 
also want to do so, but in an environment where most hospital-based 
programs are at their GME cap, these residents could be orphaned.
    For this reason, and to ensure this innovative new program is not 
extinguished before it has even had the opportunity to make its mark on 
the way our Nation trains its primary care providers, we urge this 
committee to promptly reauthorize this program for 5 additional years 
and to fully fund it through that period.
                        issues for consideration
    The THC program, as designated by the ACA, is essentially a capped 
entitlement, providing a fixed ``direct'' or mandatory appropriation 
for operating teaching health centers. Due to this construction, HRSA 
is obligated, as long as funds are available, to fund all programs that 
apply and meet the program requirements. As such, HRSA must continue to 
fund all programs meeting the requirements of the program for as many 
qualifying programs as requested as long as funding is available.
    Absent an annual limitation on funding, a surge in interest in the 
program could deplete the program's total funding in a very short 
timeframe, possibly even a single year, making an annual funding cap 
prudent and likely essential for long-term sustainability. With an 
annual cap in place, we believe it is equally important that there be 
some mechanism, such as a minimum per resident amount, in place to 
ensure that there is reliability for those operating the programs. In 
effect, we propose a ceiling be established for annual program funding, 
which make necessary the construction of a floor in terms of a minimum 
per-resident amount.
          the national health service corps and health centers
    While the Teaching Health Center GME Program aims to address the 
critical issue of the supply of primary care providers in medically 
underserved communities, another vital program, the National Health 
Service Corps (NHSC) has since 1970 been an essential program in 
addressing provider distribution disparities that affect the 
underserved and provider-short communities where health centers and 
other key health care systems are located.
    With my colleague Rebecca Spitzgo here with me today, I will not 
cover the full landscape of how critically important the NHSC is. 
However, I would be remiss if I failed to note that the NHSC serves as 
a vital partner to the Health Centers program. According to the most 
recent numbers I have seen, approximately half of the approximately 
10,000 health professionals currently placed by the NHSC are working at 
CHCs--and those providers make up almost one-fifth of the health center 
clinician staff nationally.
    The NHSC has been an incredibly successful recruitment tool for 
health centers seeking to attract providers to our safety-net settings. 
According to NHSC clinician retention surveys, many NHSC providers stay 
at their service site, another NHSC site, or in an underserved area 
after completing their service obligation. A 2012 HRSA NHSC retention 
survey found that 82 percent of NHSC clinicians who completed their 
service commitment in the Corps continued to practice in underserved 
communities up to 1 year after their service completion and 55 percent 
of National Health Service Corps clinicians continue to practice in 
underserved areas 10 years after completing their service 
commitment.\3\
---------------------------------------------------------------------------
    \3\ Bureau of Primary Health Care, Health Resources and Services 
Administration, DHHS. NHSC Clinician Retention: A Story of Dedication 
and Commitment. December 2012. http://nhsc.hrsa.gov/currentmembers/
membersites/retainproviders/retentionbrief.pdf.
---------------------------------------------------------------------------
    The NHSC was expanded in the ACA, with $1.5 billion in mandatory 
funds provided over 5 years, enough to train and place some 17,000 
health professionals by 2015. Due to a fiscal year 2011 reduction 
however, that expansion has been significantly scaled back. In 
addition, starting in fiscal year 2011 and continuing through the 
present, the NHSC's entire budget has been tied solely to the ACA 
mandatory fund and, like the Teaching Health Center Program, and the 
Health Centers program, for that matter, it also faces a funding cliff 
in fiscal year 2016.
    The NHSC has been, and remains, a key partner, particularly for 
CHCs, in the expansion of care prior to the coming coverage expansions 
under the ACA. We want to work with you in the years ahead to ensure 
that it remains strong and intact now and post-2015.
    true innovation in primary care training: a.t. still university 
                         partnership with chcs
    I would also like to briefly touch on an incredibly innovative 
program that is at the forefront of training primary care 
practitioners. The A.T. Still University (ATSU) has long had a 
commitment to providing medical care for those most in need that 
started with its founder. Doctor Andrew Taylor Still followed in his 
father's footsteps by bringing care to the most isolated, vulnerable 
and needy--regardless of their ability to pay.
    Today, ATSU has four campuses with the School of Osteopathic 
Medicine (SOMA) and dental school located in Mesa, AZ. From its 
inception, ATSU has focused on community-based care and educating the 
next generation of osteopathic physicians in the communities that those 
campuses serve. This made for a natural partnership with health 
centers. Recognizing the need to increase the number of primary care 
providers, my organization, NACHC, partnered with ATSU more than 11 
years ago to establish a health-center focused osteopathic dental 
school--and then 5 years later, partnered again to open one of 
America's newest medical schools--that are each not only growing the 
next generation of health center providers, but also challenging the 
notion of how medical training is structured.
    Today, ATSU's partnership with NACHC continues through Contextual 
Learning Campuses at health centers throughout the country. In this 
first-of-its-kind model, students begin their clinical observations in 
health centers at the start of their second year instead of waiting 
until the third year as in most traditional programs. Third- and 
fourth-year students complete their clinical rotations at health 
centers and in Community Campus associated hospitals, as well as with 
affiliated healthcare providers and at select healthcare institutions.
    ATSU's work with health centers is already making impressive 
strides toward improving the number of community-based care providers. 
To date, our partnership has produced more than 300 practicing 
dentists, one-half of whom are working at health centers today, with 
more than 30 of those graduates serving as health center dental 
directors. Moreover, there are 315 medical students whose education is 
currently embedded in a health center. ATSU has 200 health center 
affiliated clinical agreements and over 1,500 CHC shadowing or clinical 
rotations per year.
    This very successful partnership is providing osteopathic dental 
and medical students with significant exposure to the unique challenges 
of working in an underserved setting and making them better providers 
along the way.
                               conclusion
    Today, 60 million Americans lack regular access to primary care, 
even as the Nation is preparing to provide health coverage for as many 
as 30 million newly insured Americans. Health centers stand ready to do 
our part to meet these enormous challenges of providing a health care 
home for these individuals.
    We believe--and indeed we know from experience--that training 
residents in health centers offers the opportunity to both improve the 
supply of primary care providers in our Nation and to better distribute 
those providers to meet the needs and demands of medically underserved 
communities.
    Common-sense programs like the THCGME program and the National 
Health Service Corps are essential to these efforts--addressing both 
the supply and distribution issues currently vexing our primary care 
workforce.
    We know that growing our primary care workforce and expanding 
primary care access is the only way we will achieve true health care 
reform that provides Americans the right care, in the right place, at 
the right time.
    We look forward to working with you and the other members of this 
subcommittee to accomplish this shared goal. We simply cannot afford to 
fail.
    Thank you, Mr. Chairman and members of the subcommittee.

    Senator Sanders. Thank you very much, Mr. Hawkins.
    Senator Burr is going to introduce our next panelist.
    Senator Burr. Mr. Chairman, it is indeed a pleasure to 
welcome and to introduce Dr. Paul Cunningham, the Dean and 
Senior Associate Vice Chancellor for Medical Affairs at the 
Brody School of Medicine at East Carolina University in 
Greenville, NC.
    Dean Cunningham joined East Carolina as dean of the Brody 
School in the fall of 2008, and Dean Cunningham comes to North 
Carolina by way of Jamaica and New York City, not the 
traditional route that people find their way to our State. But 
we are pleased he chose Greenville as his home.
    Before his role as dean of the Brody School of Medicine, 
Dr. Cunningham held a number of positions including among them 
Professor of Surgery at ECU, Chief of Staff at Pitt County 
Memorial Hospital, and is currently serving as Governor of the 
American College of Surgeons.
    Dr. Cunningham is board certified in general surgery, and 
currently has a focus in the areas of trauma and bariatric 
surgery.
    Thank you, Dr. Cunningham, for taking the time to travel to 
be here with us today. I am glad that you will have the 
opportunity to share with my colleagues the success that you 
have helped achieve at the Brody School of Medicine, Dr. 
Cunningham.
    Senator Sanders. Dr. Cunningham, thank you very much for 
being with us. Please.

STATEMENT OF PAUL R.G. CUNNINGHAM, M.D., FACS, DEAN AND SENIOR 
  ASSOCIATE VICE CHANCELLOR FOR MEDICAL AFFAIRS AT THE BRODY 
  SCHOOL OF MEDICINE, EAST CAROLINA UNIVERSITY, GREENVILLE, NC

    Dr. Cunningham. Mr. Chairman and Ranking Member Burr, thank 
you very much for the opportunity to represent the Brody School 
of Medicine at East Carolina University at this hearing and to 
submit this statement for the record. I want to thank you for 
this invitation.
    The Brody School of Medicine at East Carolina University 
has roots that go back to the early 1970s when the North 
Carolina General Assembly appropriated $43 million to build a 
full-fledged medical school at East Carolina University.
    Legislatively mandated at the time, the mission of the 
Brody School of Medicine was, and continues to be, 
intentionally tripartite in nature. To educate primary care 
physicians, to provide access to careers in medicine for 
minority and disadvantaged students, and to improve health care 
in eastern North Carolina. As a result of that, the Brody 
School of Medicine is setting the pace for the Nation in some 
very important ways.
    It is the highest ranking school in the percent of 
graduates from 1996 to 2000 practicing in rural areas, 95 
percentile in graduates practicing in primary care according to 
the 2013 AAMC mission management tool. It is the highest 
ranking school in the percent of graduates from 1996 to 2000 
practicing in underserved areas, 95th percentile in graduates 
practicing primary care according to the 2013 AAMC mission 
management tool, 96th percentile for graduates practicing 
primary care.
    The highest ranking school in the percent of graduates from 
2007 to 2009 entering training in family medicine, 100th 
percentile, the highest ranking school in the percent of 
graduates practicing family medicine.
    The highest ranking school in the percent of graduates, 
from 2004 to 2009, who are American Indian or Native American; 
98 percentile ranking nationally for graduate who are Native 
American, according to the 2013 AAMC mission management tool.
    The highest ranking school in the percent of graduates from 
2004 to 2009 who are Black or African-American, 98th percentile 
ranking nationally for graduates who are Black or African-
American according to the AAMC 2013 mission management tool.
    Achieved the lowest ranking amongst all schools in cost of 
attendance for a 2012 graduate, where low cost is desirable. 
For the 4 years, $119,891.
    Achieved the lowest ranking among all schools in average 
debt of 2010 graduates, $92,413. At the 4th percentile 
nationally for average debt of graduates according to the 2013 
AAMC mission management tool.
    For the current year, and for many, many years preceding, 
the Brody School of Medicine has the lowest combined rate for 
tuition and fees of all public medical schools in the 50 
States.
    We are bending the health curve in East North Carolina in a 
positive manner. A 20-year trajectory for age adjusted 
mortality rates show an 18 percent decrease that tracks 
favorably with the rest of the State, and a couple of 
percentage points more favorable than the Nation overall.
    Although this was not stated as a part of the mission, it 
is important to note the transformative economic effect to 
Greenville, where we live, and the surroundings of the 
establishment and growth of Brody School of Medicine, we have 
been an important economic engine for the region.
    These accomplishments have been realized despite successive 
permanent State budget cuts of approximately 17 percent since 
fiscal year 2008-9.
    How do we accomplish these goals? We accomplish them in a 
number of ways. We are embedded in the most rural part of North 
Carolina and the communities that we serve. We are closely 
affiliated with, but do not own, a large teaching hospital: 
Vidant Medical Center. The cause is noble, and the faculty who 
are selected are authentic in their mentorship. Our faculty, 
and staff, and students display a visible and palpable 
commitment to the mission of the School.
    There has never been 1 day of mission drift as the winds of 
time change with respect to physician production models or 
other changes in the health care system. The mission of the 
School precisely aligns with the needs of the communities that 
we serve.
    Our curriculum is aligned in a manner that provides early 
clinical experience with primary care physicians and embeds 
primary care training and exposure throughout the 4 years of 
training. There is immediate gratification at the professional 
and personal level when the work that is being accomplished 
shows visible evidence of success, and there are measurable 
changes in the lives of those that we serve.
    We actively select individuals with the competencies and 
the capacities to serve the mission and the needs of the 
citizens. And over time, the aspirations and behaviors have 
become internalized, and now drive performance and have created 
lifelong habits.
    In terms of the future, the commitment of other medical 
schools across the Nation is no different, but in the past, the 
development of their strategies and missions were predicated on 
different reward models and strategies.
    The Government has a responsibility to help with the 
transitions that are necessary to align payment and rewards 
with the current and future needs of our citizens. Current 
health care debates are critical, but should not deter us from 
progress.
    The focus will need to be on what we should do, rather than 
on what we can do. This is a reality that recognizes that 
people are not succumbing to chronic diseases as in the past 
and that they are negotiating their way through an even more 
vastly complex health care system. Acknowledging that, and 
creating teams of health professionals to put around patients 
and families to help coordinate their care with the patient at 
the center of decisionmaking is critical for success.
    It remains unclear as to the method by which we will be 
able to successfully up scale the current educational 
enterprise, or export the positive outcomes to other cultures 
or geographic locations. We could easily grow and produce more 
of the excellent outcomes we have achieved, but need to have 
primary care and other residencies in which to send students 
after medical school.
    We sense an advantage locally, since we are co-located and 
fully collaborative with the most prolific school of nursing in 
the State; a prestigious College of Allied Health; the newest 
and most innovative school of dental medicine; a robust area 
health education system; and a cooperative community college 
system.
    We are prepared to join in future conversations, in depth, 
and across the Nation, so as to bring greater enlightenment.
    Thank you again for the opportunity.
    [The prepared statement of Dr. Cunningham follows:]

         Prepared Statement of Paul R.G. Cunningham, M.D., FACS

    As Dean, I am pleased to represent the Brody School of Medicine at 
East Carolina University at this hearing and to submit this statement 
for the record. I want to thank Chairman Sanders and Ranking Member 
Burr for holding this hearing on such an important topic and for 
extending to me an invitation to testify.
                                history
    The Brody School of Medicine at East Carolina University has roots 
that go back to the early 1970s, when the North Carolina General 
Assembly appropriated the $43 million to build a full-fledged medical 
school at East Carolina University.
    Legislatively mandated at the time, the mission of the Brody School 
of Medicine was, and continues to be, intentionally tripartite in 
nature:

     To educate primary care physicians.
     To provide access to careers in medicine for minority and 
disadvantaged students.
     To improve health care in eastern North Carolina.
                                results
    The Brody School of Medicine is setting the pace for the Nation in 
some very important ways:

     Highest ranking school in percent of graduates from 1996-
2000 practicing in rural areas; 95th percentile in graduates practicing 
primary care according to the 2013 AAMC Missions Management Tool.
     Highest ranking school in percent of graduates from 1996-
2000 practicing in underserved areas; 95th percentile in graduates 
practicing primary care according to the 2013 AAMC Missions Management 
Tool.
     96th percentile for graduates practicing primary care.
     Highest ranking school in percent of graduates from 2007-9 
entering training in family medicine; 100th percentile--highest ranking 
school--in percent of graduates practicing Family Medicine.
     Highest ranking school in percent of graduates from 2004-9 
who are American Indian or Native American; 98th percentile ranking 
nationally for graduates who are Native American according to the 2013 
AAMC Missions Management Tool.
     Highest ranking school in percent of graduates from 2004-9 
who are Black or African-American; 98th percentile ranking nationally 
for graduates who are Black/African-American according to the 2013 AAMC 
Missions Management Tool.
     Achieved the lowest ranking among all schools in cost of 
attendance for a 2012 graduate (where low cost is desirable); $119,891.
     Achieved the lowest ranking among all schools in average 
debt of 2010 graduates; $92,416. At the 4th percentile nationally for 
average debt of graduates according to the 2013 AAMC Missions 
Management Tool.
     For the current year--and for many, many years preceding--
the Brody School of Medicine has the lowest combined rate for tuition 
and fees of all public medical schools in the 50 States.
     We are bending the health curve in eastern North Carolina 
in a positive manner--a 28 year trajectory for age-adjusted mortality 
rates shows an 18 percent decrease that tracks favorably with the rest 
of the State, and a couple of percentage points more favorable than the 
Nation overall.
     Although this is not a stated part of the mission, it is 
important to note the transformative economic effect to Greenville and 
surroundings of the establishment and growth of Brody School of 
Medicine. We have been an important ``economic engine'' for the region.
     These accomplishments have been realized despite 
successive permanent State budget cuts of approximately 17 percent 
since fiscal year 2008-9.
               method used to achieve a positive outcome
    We accomplish these goals in a number of ways.

    1. We are embedded in the most rural part of North Carolina, and 
the communities that we serve.
    2. We are closely affiliated with, but do not own a large teaching 
Hospital--Vidant Medical Center.
    3. The cause is noble, and the faculty who are selected are 
authentic in their mentorship.
    4. Our faculty, staff and students display a visible and palpable 
commitment to the mission of the School. There has never been 1 day of 
mission drift as the winds of time change with respect to physician 
production models or other changes in the health care system.
    5. The mission of the School precisely aligns with the need of the 
communities that we serve.
    6. Our curriculum is aligned in a manner that provides early 
clinical experience with primary care physicians and embeds primary 
care training and exposure throughout the 4 years of training.
    7. There is immediate gratification at the professional and 
personal level when the work that is being accomplished shows visible 
evidence of success, and there are measurable changes in the lives of 
those that we serve.
    8. We actively select individuals with the competencies, and the 
capacities to meet the mission and the needs of the citizens that we 
serve.
    9. Over time, the aspirations, and behaviors have become 
internalized, and now drive performance, and have created lifelong 
habits.
    forecasting the future needs for rural eastern north carolina, 
                             and the nation
    1. The commitment of other medical schools across the Nation is no 
different, but in the past, the development of their strategies and 
missions were predicated on different reward models and strategies.
    2. The government has a responsibility to help with the transitions 
that are necessary to align payment and rewards with the current and 
future needs of our citizens.
    3. Current health care debates are critical, and should not deter 
us from progress.
    4. The focus will need to be on what we should do, rather than on 
what we can do. This is a reality that recognizes that people are not 
succumbing to chronic diseases as in the past, and that they are 
negotiating their way through in a vastly more complex health care 
system. Acknowledging that, and creating teams of health professionals 
to put around patients and families to help coordinate their care with 
the patient at the center of decisionmaking is critical for success.
    5. It remains unclear as to the method by which we will be able to 
successfully up-scale the current educational enterprise, or export the 
positive outcomes to other cultures or geographic locations. We could 
easily grow and produce more of the excellent outcomes we have 
achieved, but need to have primary care and other residencies in which 
to send students after medical school.
    6. We sense an advantage locally, since we are co-located and fully 
collaborative with the most prolific School of Nursing in the State; a 
prestigious College of Allied Health; the newest and most innovative 
School of Dental Medicine; a robust Area Health Education System; and a 
cooperative Community College System.
    7. We are prepared to join in future conversations, in depth, and 
across the Nation, so as to bring greater enlightenment.

    Thank you again for the opportunity to submit this statement for 
the record and for your interest and leadership in this important 
subject for the future of healthcare in our Nation.
    The Brody School of Medicine at East Carolina University stands 
ready to work with the Subcommittee to strengthen and improve the ways 
in which we train primary care physicians in the United States.

    [Editor's Note: The BSOM narrative report is maintained in the 
committee file.]

    Senator Sanders. Dr. Cunningham, thank you very much.
    Our fourth witness is a fellow Vermonter, Deborah Wachtel, 
who has served patients as a nurse practitioner since 1986, and 
as a registered nurse since 1975. She is pursuing a doctorate 
of nursing practice and holds a master's degree in nursing, a 
master's degree in public health, and a bachelor's degree in 
community health sciences.
    Thank you very much for being with us, Ms. Wachtel.

 STATEMENT OF DEBORAH WACHTEL, NP, MPH, MSN, PRESIDENT OF THE 
   VERMONT NURSE PRACTITIONER ASSOCIATION AND VERMONT STATE 
     REPRESENTATIVE FOR THE AMERICAN ASSOCIATION OF NURSE 
                    PRACTITIONERS, ESSEX, VT

    Ms. Wachtel. Thank you, Chairman Sanders, Ranking Member 
Burr, and members of the committee.
    I appreciate the opportunity to speak with you on behalf of 
the 155,000 nurse practitioners across the United States.
    As you know, my name is Deborah Wachtel. I have been a 
registered nurse since 1975, a nurse practitioner since 1986, a 
master's degree in public health, and a master's degree in 
nursing. As an adult nurse practitioner, my focus has always 
been primary care. First in women's health and now in chronic 
disease prevention and management, which includes diabetes, 
obesity, cardiovascular disease, and endocrine disorders.
    I currently serve as Vermont State representative for the 
American Association of Nurse Practitioners, which is the 
largest nurse practitioner association in the country with over 
43,000 members. In addition to my role with AANP, I am the 
president of the Vermont Nurse Practitioner Association, and a 
Governor-appointed commissioner on the Vermont Blue Ribbon 
Commission on nursing.
    NPs have been providing primary care for half a century and 
are rapidly becoming the health care provider of choice for 
millions of Americans. The vast majority of nurse practitioners 
throughout the United States are currently providing primary 
care services including adult, family, gerontologic, 
pediatrics, and women's health. In fact, 88 percent of NPs are 
prepared to be primary care clinicians and nearly 70 percent 
are currently practicing in a primary care setting.
    In Vermont where we have full practice authority, there are 
441 practicing NPs. As clinicians that blend clinical expertise 
in diagnosing and treating health conditions with an added 
emphasis on health promotion and disease prevention, NPs bring 
a comprehensive patient-centered perspective to health care.
    All NPs must complete a master's or doctoral degree and 
have advanced clinical training beyond their initial, 
professional registered nurse preparation. Didactic and 
clinical courses prepare nurses with specialized knowledge, 
clinical competency and training to provide primary, acute, and 
specialty healthcare service including diagnosis and treatment 
of acute and chronic illnesses from a straightforward 
pharyngitis to multiple, complex health problems. Ordering, 
performing, supervising, and interpreting diagnostic tests 
including lab tests and x-rays, prescribing medications and 
other treatments, and managing patients' overall health care. 
Outcome studies clearly demonstrate that NPs provide high 
quality, cost effective, primary care with high patient 
satisfaction ratings.
    I want to thank Senator Sanders, who has been a major 
supporter of the FQHC model of health care delivery in Vermont, 
which has shown great success in delivering primary care 
services.
    Currently, there are a total of 43 health centers serving 8 
counties where nurse practitioners provide primary care to the 
State's most vulnerable populations. It is important to note 
NPs within these practices also provide valuable preceptor 
opportunities for nurse practitioner and medical students.
    According to the American Association of Colleges of 
Nursing, since 2010, enrollments in master's and doctor of 
nursing practice programs grew by 33 percent. In my home State 
of Vermont, the University of Vermont has graduated nearly 300 
nurse practitioners, all of which are in primary care tracks. 
Ninety percent practice in primary care.
    Last year, the University had 84 students enrolled in 
primary care NP programs, yet turned away 48 qualified 
applicants. Nationally, we turned away 9,600 NP program 
applicants due to faculty shortages. It is critical that 
investments are made to reduce the barriers that prohibit 
schools of nursing from accepting primary care nurse 
practitioner students.
    The Health Resources and Services Administration reports 
that 6,333 Vermont residents are living in 30 primary care 
health professional shortage areas. Vermont's demand for 
primary care is emblematic of the need at the national level. 
NPs can help fill this need.
    I would be remiss if I did not take the opportunity to ask 
that the committee help to remove the barriers to care. There 
are many limitations in current law including the requirement 
that a physician must certify that: face-to-face visits by 
nurse practitioners have been completed in order for an NP to 
certify eligibility for home health care services. That only a 
physician may make the initial certification of patients for 
hospice care. That only a physician may certify the order for 
certain durable medical equipment. That only a physician may 
conduct the admitting physical exam and every other routine 
visit to patients in skilled nursing facilities. That a 
physician, rather than a nurse practitioner, must be onsite 
when cardiac and/or pulmonary rehab is being conducted, and 
only a physician may conduct the admitting physical exam of a 
rehab center.
    By removing such barriers and unnecessary redundancies to 
improve access to health care, we can best serve our patients' 
needs. Now, is the time to give consumers the freedom to choose 
among all qualified providers, just as we have in Vermont and 
16 other States.
    My nurse practitioner colleagues and I stand ready to serve 
our patients in all areas of health care, and look forward to 
working with this committee, and the Congress, to ensure 
patients' needs are met.
    Thank you very much.
    [The prepared statement of Ms. Wachtel follows:]
           Prepared statement of Deborah Wachtel NP, MPH, MSN
    Thank you Chairman Sanders, Ranking Member Burr, and members of the 
committee. I appreciate the opportunity to speak with you on behalf of 
the 155,000 Nurse Practitioners across the United States. I would also 
like to take this time to note that I currently serve as Vermont's 
State representative for the American Association of Nurse 
Practitioners (AANP), which is the largest nurse practitioner 
association in the country.
    My name is Deborah Wachtel. I have been a registered nurse since 
1975 and a nurse practitioner since 1986. I have a Bachelor's degree in 
Community Health Sciences, a Master's Degree in Public Health, and a 
Master's Degree in Nursing, and I am currently in a Doctor of Nursing 
Practice (DNP) program. My field of practice is as an adult nurse 
practitioner; my focus has always been toward primary care, first in 
women's health and now in chronic disease prevention and management. My 
current work as an nurse practitioner (NP) includes work with diabetes, 
obesity, cardiovascular disease, and endocrine disorders. In addition 
to my role with AANP, I am also the president of the Vermont Nurse 
Practitioner Association, a Governor-appointed commissioner on the 
Vermont Blue Ribbon Commission on Nursing, and represent NPs on the 
Vermont Action Coalition which focuses on advancing the Institute of 
Medicine (IOM) recommendations on the Future of Nursing.
    NPs have been providing primary care for half a century and are 
rapidly becoming the health care provider of choice for millions of 
Americans. The vast majority of nurse practitioners throughout the 
United States are currently providing primary care services. This 
includes adult, family, gerontological, pediatrics and women's health 
nurse practitioners. In fact, 88 percent of NPs are prepared to be 
primary care clinicians and nearly 70 percent are currently practicing 
in a primary care setting. Currently in Vermont there are 441 
practicing NPs. As clinicians that blend clinical expertise in 
diagnosing and treating health conditions with an added emphasis on 
health promotion and disease prevention, NPs bring a comprehensive 
perspective to health care. NPs are clinicians with advanced education 
and training who provide primary, acute and specialty healthcare 
service including diagnosis and treatment of acute and chronic 
illnesses--from a straightforward pharyngitis to complex multiple 
health problems--ordering, performing, supervising and interpreting 
diagnostic tests including laboratory tests and x-rays, prescribing 
medications and other treatments and managing patients' overall health 
care. I have attached AANP's NP Facts, Scope of NP Practice, Standards 
of Practice, Quality of NP Practice, and NP Cost-Effectiveness 
documents to my testimony for your reference.
    This comprehensive perspective is deeply rooted in our educational 
background. All NPs must complete a master's or doctoral degree 
program, and have advanced clinical training beyond their initial 
professional registered nurse preparation. Didactic and clinical 
courses prepare nurses with specialized knowledge and clinical 
competency to practice in primary care, acute and long-term health care 
settings. Growth in our Nation's nurse practitioner programs has 
steadily increased with the demand for primary care. According to the 
American Association of Colleges of Nursing (AACN), since 2010, 
enrollments in master's and doctor of nursing practice programs grew by 
33 percent yet more encouraging, since 2010, graduations from these 
programs increased by 40 percent. In the 2012 academic year, 46,353 
students were enrolled and 11,540 students graduated from nurse 
practitioner programs that prepared them as primary care providers. 
While this growth rate is critical to addressing the shortage of 
primary care providers, it is sobering to note that our schools of 
nursing also turned away 9,640 qualified applicants to primary care 
nurse practitioner programs due to faculty shortage, budget restraints, 
and lack of clinical sites. This represents a 54 percent increase in 
applicants turned away since 2010. In particular, the shortage of nurse 
faculty creates a bottleneck for sustainable growth in our NP programs. 
Across the country, nearly 1,800 vacant faculty positions were reported 
by AACN member schools in academic year 2011-12. It is critical that 
investments are made to reduce the barriers that prohibit schools of 
nursing from accepting primary care nurse practitioner students.
    In my home State of Vermont, the University of Vermont (UVM) 
responded to AACN's survey; which shows that the University graduated 
24 students and currently has 84 students enrolled in primary care NP 
programs. At the same time, the University turned away 48 qualified 
applicants; this is double the number of students graduated. According 
to Health Resources and Services Administration (HRSA), 6,333 Vermont 
residents are living in 30 primary care Health Professional Shortage 
Areas. Vermont's demand for primary healthcare is emblematic of the 
need at the national level. Nurse practitioners can help to meet that 
need.
    UVM has offered graduate level education for Primary Care NPs since 
1999. The NP program at UVM includes Family, Adult and Psychiatric-
Mental Health NPs. The vast majority of these graduates stay in Vermont 
to practice and approximately 90 percent practice in primary care 
settings. The NP students have applied for HRSA Graduate Traineeship 
funds, and the awards have been as much as $1,400 per year (per 
student) over the past 8 years, though many students received no award. 
In 2012, through the Affordable Care Act, UVM was awarded Traineeship 
funds for $350,000 for 2 years. This substantial increase in funds has 
helped to increase support for 48 students, whose awards ranged from 
$5,200 to $14,500 for this past year. We are hopeful that this HRSA 
funding will continue in subsequent years. UVM strives to increase 
diversity within their program, and all students are expected to 
participate in caring for populations in rural and underserved areas. 
Clinical rotations are spread throughout our rural State.
    Unfortunately, UVM faces the same faculty shortages felt across the 
Nation with one full-time tenure track NP position vacant for 4 years, 
despite searches for the position every year. Additionally, we have had 
a full-time clinical track NP position that has been filled by faculty 
for 2-3 years only, representing turnover of faculty and disruption of 
coverage for classes.
    To meet the demand for, and adhere to, the highest level of quality 
care standards, NPs undergo rigorous national certification, periodic 
peer review, clinical outcome evaluations, and observe a code for 
ethical practices. Continuing education and professional development 
are also essential to maintaining clinical competency. It is important 
to note that NPs are licensed in all States and the District of 
Columbia and practice under the rules and regulations of the State in 
which they are licensed. We provide care in many types of settings 
including clinics, hospitals, emergency rooms, urgent care sites, 
private physician or NP practices, nursing homes, schools, colleges, 
and public health departments. In the State of Vermont, NPs are able to 
practice at the full scope of their education and credential; patients 
have benefited from this privilege for over 2 years. Several States in 
my region including, Rhode Island, Maine, and New Hampshire have had 
autonomous practice for nearly two decades, and patients in those 
States have benefited from full and direct access to safe, high quality 
NP services.
    The vast majority of nurse practitioners in Vermont practice in 
rural, primary care settings, many in advanced primary care practices 
often referred to as ``the patient medical home.'' This innovative 
Vermont-born network of primary care practices is known as The Vermont 
Blueprint for Health. The growing network of practices, which number 
over 100, span the entire State and the numbers are increasing as new 
practices join. The focus is interdisciplinary and inter-professional 
primary health care, utilizing all providers and health care workers at 
the full extent of their credentials and education. Outcome data and 
benchmarking will drive the reimbursement schemes and focus of chronic 
disease prevention and management programs. There are approximately 122 
nurse practitioners currently practicing at these health centers. This 
is yet another example of how we can utilize a highly educated 
workforce to improve the health of our citizens in a cost-effective 
model of high quality, patient-centered care.
    A nurse owned and managed primary care health center opened its 
doors in southern Vermont on March 5, 2012, in response to 9,000 
patients who were without primary care providers. This NP practice saw 
approximately 2,000 patient visits in its first year. The NP sees 
between 25-40 patients daily with 33 percent on Medicaid, 35 percent on 
Medicare, 5 percent uninsured, and the rest with private insurance and 
is currently booking into July. In the last 6 years, this southern 
county lost 14 primary care physicians and will be losing 2 more this 
year. Having full practice authority has made it possible for the 
patients in this community to have access to high quality primary care 
but is not without remaining barriers. The limitation of NPs to order 
home care under current law has created a significant barrier for 
addressing patient needs adding additional expense and on occasion 
prolonged hospital stays or avoidable re-admissions.
    As an active member of AANP, I have a vast network of colleagues 
who practice in primary care settings. My experiences have made me 
acutely aware that providing high quality care in various settings 
provides patients with the best health care outcomes. I thank Senator 
Sanders, who has been a major supporter of the FQHC model of health 
care delivery in Vermont which has shown great success in delivering 
primary care services. Currently, there are a total of 29 health 
centers serving 8 counties where 32 NPs provide primary care to the 
States' most vulnerable population. It is important to note, NPs within 
these practices also provide valuable preceptor opportunities for nurse 
practitioner and medical students.
    Nationally, 87 percent of NPs care for Medicare beneficiaries. Even 
though enormous strides have been made, multiple barriers still exist 
in current law. These barriers contribute to increased costs, 
administrative burden and interfere with the provision of quality 
health care delivery to Medicare beneficiaries. There are many 
limitations in current law including:

     the requirement that a physician must certify that face-
to-face visits by nurse practitioners have been completed in order for 
an NP to certify eligibility for home health care services,
     that a physician must certify that a face-to-face visit by 
a nurse practitioner has been made in order for certain durable medical 
equipment to be ordered for patients,
     that a physician is required to conduct the admitting 
physical examination and every other routine visit to patients in 
skilled nursing facilities when a fully capable nurse practitioner is 
available to conduct those visits,
     that a physician rather than a nurse practitioner must be 
onsite when cardiac and/or pulmonary rehabilitation is being conducted,
     and a physician must conduct the admitting physical 
examination in a rehabilitation center.

    I bring these examples to your attention in order to emphasize 
these barriers and unnecessary redundancies to delivering care.
    Additionally, I would like to point out that the current Medicare 
Shared Savings Program limits the assignment of beneficiaries to those 
who receive primary care services from a physician. This makes it 
difficult to participant in and impossible for nurse practitioners in 
independent practices to establish Accountable Care Organizations (ACO) 
under the Shared Savings Program creating a disincentive for NPs and a 
challenge to patients who participate in these organizations. Removing 
these barriers can increase efficiency, create cost effective access to 
patient appropriate care and enhance the quality of the care that is 
being delivered more effectively by the health care workforce.
    An example of how these reimbursement barriers impact access to 
care was recently demonstrated in the New North End of Vermont in a 
private practice that included three physicians and one nurse 
practitioner. This practice provided care for a vulnerable and aging 
population where each provider had a roster of 1,000	1,500 patients. 
The three physicians left the practice. The nurse practitioner arranged 
with the University of Vermont to transform this practice into a UVM 
owned nurse managed health center which would accomplish multiple 
objectives: (1) the patients who wanted to remain with this practice 
would not be forced to travel out of their community to seek primary 
care services, (2) the practice would be managed by clinical faculty, 
all of whom are primary care NPs, (3) the practice would provide badly 
needed preceptors for NP and medical students, (4) the practice would 
provide fellowship positions for new NP grads under the guidance of 
experienced primary care NPs. The Director of the Vermont Blueprint 
agreed to include this practice in their network, which gave the 
patients immediate access to a highly skilled community care team. Even 
with all of the above noted support, unfortunately, two large insurance 
entities in the State refused to empanel the NPs without the presence 
of a physician in the practice. The practice has remained closed.
    In October 2010, the IOM released a lengthy document entitled The 
Future of Nursing: Leading Change, Advancing Health. This document 
describes how the nursing profession should be transformed and how 
harnessing the full potential of the profession can improve health care 
in the United States. The document recommends that nurses should 
practice to their full scope and should be full partners with 
physicians and other health care professionals in redesigning health 
care in the United States. I ask that you pay particular attention to 
recommendation I entitled: ``Remove scope-of practice barriers.'' My 
colleagues and I fully endorse the IOM finding and are striving for 
implementation at the State and national level. Chapter 7 of the IOM 
Report: Recommendations and Research Priorities, is attached for your 
reference.
    Vermont has embraced these recommendations in many areas. In 2011 
Vermont legislature adopted the National Council of State Boards of 
Nursing recommendations for nurse practitioner practice laws. The 
Vermont Blue Ribbon Commission on Nursing created a report of 
recommendations that was approved and signed by Governor Shumlin in 
2012. The Commission recommendations included adopting the IOM mandates 
which I have enclosed in my testimony, specifically targets seamless 
and cost-effective access to NPs, such as seeking Medicare waivers 
allowing NPs to order home health services for their patients.
    Now is the time to give consumers the freedom to choose among all 
qualified providers, just as we have in Vermont. By removing barriers 
to improve health care, we can best serve our patient's needs. My Nurse 
Practitioner colleagues and I stand ready to serve our patients in all 
areas of health care and look forward to working with this committee 
and the Congress to ensure patients' needs are met. At this time, we 
cannot afford to do less.
    In summary, I urge the committee to examine the contributions of 
Nurse Practitioners across the country in various settings providing 
primary care to diverse populations. Removing barriers will allow 
patients greater access to health care, keeping them out of higher cost 
settings. Our added emphasis on health promotion and disease prevention 
perfectly positions us to be leaders in the health care profession at 
this critical time. I would like to acknowledge the support that our 
legislators have demonstrated by supporting NPs in primary care. I 
encourage the committee to continue this dialog with the American 
Association of Nurse Practitioners, as we have a vast membership from 
which to draw. I thank the committee for this opportunity and look 
forward to serving as a resource.
    Attachments:

      1. AANP NP Facts
      2. AANP Scope of Practice for Nurse Practitioners
      3. AANP Standards of Practice for Nurse Practitioners
      4. AANP Quality of Nurse Practitioner Practice
      5. AANP Nurse Practitioners Cost-Effectiveness
      6. Institute of Medicine (IOM) Report, The Future of Nursing: 
Leading Change, Advancing Health. 269-84.
                              Attachments
  American Association of Nurse PractitionersTM
                                np facts
The Voice of the Nurse Practitioner
    There are more than 155,000 nurse practitioners (NPs) practicing in 
the United States.

     An estimated 11,000 new NPs completed their academic 
programs in 2010-11.
     93 percent of NPs have graduate degrees.
     97 percent of NPs maintain national certification.
     18 percent of NPs practice in rural or frontier settings.
     88 percent of NPs are prepared in primary care; 68 percent 
of NPs practice in at least one primary care site.
     87 percent of NPs see patients covered by Medicare and 84 
percent by Medicaid.
     43 percent of NPs hold hospital privileges; 15 percent 
have long-term care privileges.
     96.5 percent of NPs prescribe medications, averaging 20 
prescriptions per day.
     NPs hold prescriptive privilege in all 50 States, with 
controlled substances in 48.
     The early-2011 mean, full-time NP base salary was $91,310, 
with average full-time NP total income $98,760.
     60 percent of NPs see three to four patients per hour; 7 
percent see over five patients per hour.
     Malpractice rates remain low; only 2 percent have been 
named as primary defendant in a malpractice case.
     Average NP is female (96 percent) and 48 years old; she 
has been in practice for 12.8 years as a family NP (49 percent).

   Distribution, Mean Years of Practice, Mean Age by Population Focus
------------------------------------------------------------------------
                                                       Years of
                 Population                   Percent              Age
                                               of NPs  Practice
------------------------------------------------------------------------
Acute Care..................................      5.6       7.0       45
Adult+......................................     19.3      10.9       50
Family+.....................................     48.3       9.5       48
Gerontological+.............................      3.2      11.6       52
Neonatal....................................      2.0      12.3       47
Oncology....................................      1.0       8.3       47
Pediatric+..................................      8.5      13.3       49
Psych/Mental Health.........................      3.0       8.5       52
Women's Health+.............................      9.0      14.7       49
------------------------------------------------------------------------
+ Primary care focus.
Sources: AANP National NP Data base, 2010-2011; 2011 AANP national NP
  Compensation Survey; 2010 AANP National Practice Site Survey; 2009
  AANP Membership Survey; 2009-2010 AANP NP Sample Survey.
Additional information is available at the AANP Web site www.aanp.org.

               scope of practice for nurse practitioners

Professional Role

    Nurse practitioners (NPs) are licensed, independent practitioners 
who practice in ambulatory, acute and long-term care as primary and/or 
specialty care providers. According to their practice specialties, they 
provide nursing and medical services to individuals, families and 
groups. In addition to diagnosing and managing acute episodic and 
chronic illnesses, NPs emphasize health promotion and disease 
prevention. Services include, but are not limited to: ordering, 
conducting, supervising, and interpreting diagnostic and laboratory 
tests; and prescription of pharmacologic agents and non-pharmacologic 
therapies. Teaching and counseling individuals, families and groups are 
major parts of NP practice.
    As licensed, independent practitioners, NPs practice autonomously 
and in collaboration with health care professionals and other 
individuals to assess, diagnose, treat and manage the patient's health 
problems and needs. They serve as health care researchers, 
interdisciplinary consultants and patient advocates.

Education

    Entry-level preparation for NP practice is at the master's, post-
master's or doctoral level. Didactic and clinical courses prepare 
nurses with specialized knowledge and clinical competency to practice 
in primary care, acute care and long-term health care settings. Self-
directed continued learning and professional development beyond the 
formal advanced education is essential to maintain clinical competency.

Accountability

    The autonomous nature of the NP's advanced clinical practice 
requires accountability for health care outcomes. Insuring the highest 
quality of care requires national certification, periodic peer review, 
clinical outcome evaluations, a code for ethical practice, evidence of 
continuing professional development and maintenance of clinical skills. 
NPs are committed to seeking and sharing knowledge that promotes 
quality health care and improves clinical outcomes. This is 
accomplished by leading and participating in both professional and lay 
health care forums, conducting research and applying findings to 
clinical practice.

Responsibility

    The role of the NP continues to evolve in response to changing 
societal and health care needs. As leaders in primary and acute health 
care, NPs combine the roles of provider, mentor, educator, researcher 
and administrator. Members of the profession are responsible for 
advancing the role of the NP and insuring that the standards of the 
profession are maintained. This is accomplished through involvement in 
professional organizations and participation in health policy 
activities at the local, State, national and international levels.
             standards of practice for nurse practitioners

I. Qualifications

    Nurse practitioners are licensed, independent practitioners who 
provide primary and/or specialty nursing and medical care in 
ambulatory, acute and long-term care settings. They are registered 
nurses with specialized, advanced education and clinical competency to 
provide health and medical care for diverse populations in a variety of 
primary care, acute and long-term care settings. Master's, post-
master's or doctoral preparation is required for entry-level practice 
(AANP 2006).

II. Process of Care

    The nurse practitioner utilizes the scientific process and national 
standards of care as a framework for managing patient care. This 
process includes the following components.
    A. Assessment of health status
         The nurse practitioner assesses health status by:

          Obtaining a relevant health and medical history.
          Performing a physical examination based on age and 
        history.
          Performing or ordering preventative and diagnostic 
        procedures based on the patient's age and history.
          Identifying health and medical risk factors.
    B. Diagnosis
         The nurse practitioner makes a diagnosis by:

          Utilizing critical thinking in the diagnostic 
        process.
          Synthesizing and analyzing the collected data.
          Formulating a differential diagnosis based on the 
        history, physical examination and diagnostic test results.
          Establishing priorities to meet the health and 
        medical needs of the individual, family, or community.
    C. Development of a treatment plan
         The nurse practitioner, together with the patient and family, 
        establishes an evidence-based, mutually acceptable, cost-
        awareness plan of care that maximizes health potential. 
        Formulation of the treatment plan includes:

          Ordering and interpreting additional diagnostic 
        tests.
          Prescribing or ordering appropriate pharmacologic and 
        non-pharmacologic interventions.
          Developing a patient education plan.
          Recommending consultations or referrals as 
        appropriate.
    D. Implementation of the plan
         Interventions are based upon established priorities. Actions 
        by the nurse practitioners are:

          Individualized
          Consistent with the appropriate plan for care.
          Based on scientific principles, theoretical knowledge 
        and clinical expertise.
          Consistent with teaching and learning opportunities.
    E. Followup and evaluation of the patient status
         The nurse practitioner maintains a process for systematic 
        followup by:

          Determining the effectiveness of the treatment plan 
        with documentation of patient care outcomes.
          Reassessing and modifying the plan with the patient 
        and family as necessary to achieve health and medical goals.

III. Care Priorities

    The nurse practitioner's practice model emphasizes:
    A. Patient and family education
         The nurse practitioner provides health education and utilizes 
        community resource opportunities for the individual and/or 
        family.
    B. Facilitation of patient participation in self care.
          The nurse practitioner facilitates patient participation in 
        health and medical care by providing information needed to make 
        decisions and choices about:

          Promotion, maintenance and restoration of health.
          Consultation with other appropriate health care 
        personnel.
          Appropriate utilization of health care resources.
    C. Promotion of optimal health
    D. Provision of continually competent care
    E. Facilitation of entry into the health care system
    F. The promotion of a safe environment

IV. Interdisciplinary and Collaborative Responsibilities

    As a licensed, independent practitioner, the nurse practitioner 
participates as a team leader and member in the provision of health and 
medical care, interacting with professional colleagues to provide 
comprehensive care.

V. Accurate Documentation of Patient Status and Care

    The nurse practitioner maintains accurate, legible and confidential 
records.

VI. Responsibility as Patient Advocate

    Ethical and legal standards provide the basis of patient advocacy. 
As an advocate, the nurse practitioner participates in health policy 
activities at the local, State, national and international levels.

VII. Quality Assurance and Continued Competence

    Nurse practitioners recognize the importance of continued learning 
through:

      A. Participation in quality assurance review, including the 
systematic, periodic review of records and treatment plans.
      B. Maintenance of current knowledge by attending continuing 
education programs.
      C. Maintenance of certification in compliance with current State 
law.
      D. Application of standardized care guidelines in clinical 
practice.

VIII. Adjunct Roles of Nurse Practitioners

    Nurse practitioners combine the roles of provider, mentor, 
educator, researcher, manager and consultant. The nurse practitioner 
interprets the role of the nurse practitioner to individuals, families 
and other professionals.

IX. Research as Basis for Practice

    Nurse practitioners support research by developing clinical 
research questions, conducting or participating in studies, and 
disseminating and incorporating findings into practice.
                 quality of nurse practitioner practice
    Nurse practitioners (NPs) are high quality health care providers 
who practice in primary care, ambulatory, acute care, specialty care, 
and long-term care. They are registered nurses prepared with 
specialized advanced education and clinical competency to provide 
health and medical care for diverse populations in a variety of 
settings. A graduate degree is required for entry-level practice. The 
NP role was created in 1965 and over 45 years of research consistently 
supports the excellent outcomes and high quality of care provided by 
NPs. The body of evidence supports that the quality of NP care is at 
least equivalent to that of physician care. This paper provides a 
summary of a number of important research reports supporting the NP.
    Avorn, J., Everitt, D.E., & Baker, M.W. (1991). The neglected 
medical history and therapeutic choices for abdominal pain. A 
nationwide study of 799 physicians and nurses. Archives of Internal 
Medicine, 151(4), 694-98. A sample of 501 physicians and 298 NPs 
participated in a study by responding to a hypothetical scenario 
regarding epigastric pain in a patient with endoscopic findings of 
diffuse gastritis. They were able to request additional information 
before recommending treatment. Adequate history-taking resulted in 
identifying use of aspirin, coffee, cigarettes, and alcohol, paired 
with psychosocial stress. Compared to NPs, physicians were more likely 
to prescribe without seeking relevant history. NPs, in contrast, asked 
more questions and were less likely to recommend prescription 
medication.
    Bakerjian, D. (2008). Care of nursing home residents by advanced 
practice nurses: A review of the literature. Research in Gerontological 
Nursing, 1(3), 177-85. Bakerjian conducted and extensive review of the 
literature, particularly of NP-led care. She found that long-term care 
patients managed by NPs were less likely to have geriatric syndromes 
such as falls, UTIs, pressure ulcers, etc. They also had improved 
functional status, as well as better managed chronic conditions.
    Brown, S.A. & Grimes, D.E. (1995). A meta-analysis of nurse 
practitioners and nurse midwives in primary care. Nursing Research, 
44(6), 332-9. A meta-analysis of 38 studies comparing a total of 33 
patient outcomes of NPs with those of physicians demonstrated that NP 
outcomes were equivalent to or greater than those of physicians. NP 
patients had higher levels of compliance with recommendations in 
studies where provider assignments were randomized and when other means 
to control patient risks were used. Patient satisfaction and resolution 
of pathological conditions were greatest for NPs. The NP and physician 
outcomes were equivalent on all other outcomes.
    Congressional Budget Office. (1979). Physician extenders: Their 
current and future role in medical care delivery. Washington, DC: U.S. 
Government Printing Office. As early as 1979, the Congressional Budget 
Office reviewed findings of the numerous studies of NP performance in a 
variety of settings and concluded that NPs performed as well as 
physicians with respect to patient outcomes, proper diagnosis, 
management of specified medical conditions, and frequency of patient 
satisfaction.
    Cooper, M.A., Lindsay, G.M., Kinn, S., Swann, I.J. (2002). 
Evaluating emergency nurse practitioner services: A randomized 
controlled trial. Journal of Advanced Nursing, 40(6), 771-730. A study 
of 199 patients randomly assigned to emergency NP-led care or 
physician-led care in the U.K. demonstrated the highest level of 
satisfaction and clinical documentation for NP care. The outcomes of 
recovery time, symptom level, missed work, unplanned follow-up, and 
missed injuries were comparable between the two groups.
    Ettner, S.L., Kotlerman, J., Abdelmonem, A., Vazirani, S., Hays, 
R.D., Shapiro, M., et al. (2006). An alternative approach to reducing 
the costs of patient care? A controlled trial of the multi-disciplinary 
doctor-nurse practitioner (MDNP) model. Medical Decision Making, 26, 9-
17. Significant cost savings were demonstrated when 1,207 patients in 
an academic medical center were randomized to either standard treatment 
or to a physician-NP model.
    Horrocks, S., Anderson, E., Salisbury, C. (2002). Systematic review 
of whether nurse practitioners working in primary care can provide 
equivalent care to doctors. British Medical Journal, 324, 819-23. A 
systematic review of 11 randomized clinical trials and 23 observational 
studies identified data on outcomes of patient satisfaction, health 
status, cost, and/or process of care. Patient satisfaction was highest 
for patients seen by NPs. The health status data and quality of care 
indicators were too heterogeneous to allow for meta-analysis, although 
qualitative comparisons of the results reported showed comparable 
outcomes between NPs and physicians. NPs offered more advice/
information, had more complete documentation, and had better 
communication skills than physicians. NPs spent longer time with their 
patients and performed a greater number of investigations than did 
physicians. No differences were detected in health status, 
prescriptions, return visits, or referrals. Equivalency in 
appropriateness of studies and interpretations of x-rays were 
identified.
    Laurant, M., Reeves, D., Hermens, R., Braspenning, J., Grol, R., & 
Sibbald, B. (2006). Substitution of doctors by nurses in primary care. 
Cochrane Database of Systematic Reviews. 2006, Issue 1. This meta-
analysis included 25 articles relating to 16 studies comparing outcomes 
of primary care nurses (nurses, NPs, clinical nurse specialists, or 
advance practice nurses) and physicians. The quality of care provided 
by nurses was as high as that of the physicians. Overall, health 
outcomes and outcomes such as resource utilization and cost were 
equivalent for nurses and physicians. The satisfaction level was higher 
for nurses. Studies included a range of care delivery models, with 
nurses providing first contact, ongoing care, and urgent care for many 
of the patient cohorts.
    Lenz, E.R., Mundinger, M.O., Kane, R.L., Hopkins, S.C., & Lin, S.X. 
(2004). Primary care outcomes in patients treated by nurse 
practitioners or physicians: Two-year followup. Medical Care Research 
and Review 61(3), 332-51. The outcomes of care in the study described 
by Mundinger, et al. in 2000 (see below) are further described in this 
report including 2 years of followup data, confirming continued 
comparable outcomes for the two groups of patients. No differences were 
identified in health status, physiologic measures, satisfaction, or use 
of specialist, emergency room, or inpatient services. Patients assigned 
to physicians had more primary care visits than those assigned to NPs.
    Lin, S.X., Hooker, R.S., Lens, E.R., Hopkins, S.C. (2002). Nurse 
practitioners and physician assistants in hospital outpatient 
departments, 1997-99. Nursing Economics, 20(4), 174-79. Data from the 
National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to 
identify patterns of NP and PA practice styles. NPs were more likely to 
see patients alone and to be involved in routine examinations, as well 
as care directed toward wellness, health promotion, disease prevention, 
and health education than PAs, regardless of the setting type. In 
contrast, PAs were more likely to provide acute problem management and 
to involve another person, such as a support staff person or a 
physician.
    Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M., Tsai, W.Y., 
Cleary, P.O., et al. (2000). Primary care outcomes in patients treated 
by nurse practitioners or physicians: A randomized trial. Journal of 
the American Medical Association, 283(1), 59-68. The outcomes of care 
were measured in a study where patients were randomly assigned either 
to a physician or to an NP for primary care between 1995 and 1997, 
using patient interviews and health services utilization data. 
Comparable outcomes were identified, with a total of 1,316 patients. 
After 6 months of care, health status was equivalent for both patient 
groups, although patients treated for hypertension by NPs had lower 
diastolic values. Health service utilization was equivalent at both 6 
and 12 months and patient satisfaction was equivalent following the 
initial visit. The only exception was that at 6 months, physicians 
rated higher on one component (provider attributes) of the satisfaction 
scale.
    Newhouse, R. et al (2011). Advanced practice nurse outcomes 1999-
2008: A systematic review. Nursing Economic$, 29 (5), 1-22. The 
outcomes of NP care were examined through a systematic review of 37 
published studies, most of which compared NP outcomes with those of 
physicians. Outcomes included measures such as patient satisfaction, 
patient perceived health status, functional status, hospitalizations, 
ED visits, and bio-markers such as blood glucose, serum lipids, blood 
pressure. The authors conclude that NP patient outcomes are comparable 
to those of physicians.
    Office of Technology Assessment. (1986). Nurse practitioners, 
physician assistants, and certified nurse midwives: A policy analysis. 
Washington DC: U.S. Government Printing Office. The Office of 
Technology Assessment reviewed studies comparing NP and physician 
practice, concluding that, ``NPs appear to have better communication, 
counseling, and interviewing skills than physicians have:'' (p. 19) and 
that malpractice premiums and rates supported patient satisfaction with 
NP care, pointing out that successful malpractice rates against NPs 
remained extremely rare.
    Ohman-Strickland, P.A., Orzano, A.J., Hudson, S.V., Solberg, LI., 
DiCiccio-Bloom, B., O'Malley, D., et al. (2008). Quality of diabetes 
care in family medicine practices: Influence of nurse-practitioners and 
physician's assistants. Annals of Family Medicine, 6(1), 14-22.  The 
authors conducted a cross-sectional study of 46 practices, measuring 
adherence to ADA guidelines. They reported that practices with NPs were 
more likely to perform better on quality measures including appropriate 
measurement of glycosylated hemoglobin, lips, and microalbumin levels 
and were more likely to be at target for lipid levels.
    Prescott, P.A. & Driscoll, L. (1980). Evaluating nurse practitioner 
performance. Nurse Practitioner, 1(1), 28-32. The authors reviewed 26 
studies comparing NP and physician care, concluding that NPs scored 
higher in many areas. These included: amount/depth of discussion 
regarding child health care, preventative health, and wellness; amount 
of advice, therapeutic listening, and support offered to patients; 
completeness of history and followup on history findings; completeness 
of physical examination and interviewing skills; and patient knowledge 
of the management plan given to them by the provider.
    Roblin, D.W., Becker, R., Adams, E.K., Howard, D.H., & Roberts, 
M.H. (2004). Patient satisfaction with primary care: Does type of 
practitioner matter? Medical Care, 42(6), 606-23. A retrospective 
observational study of 41,209 patient satisfaction surveys randomly 
sampled between 1997 and 2000 for visits by pediatric and medicine 
departments identified higher satisfaction with NP and/or PA 
interactions than those with physicians, for the overall sample and by 
specific conditions. The only exception was for diabetes visits to the 
medicine practices, where the satisfaction was higher for physicians.
    Sacket, D.L., Spitzer, W.0., Gent, M., & Roberts, M. (1974). The 
Burlington randomized trial of the nurse practitioner: Health outcomes 
of patients. Annals of Internal Medicine, 80(2), 137-42. A sample of 
1,598 families were randomly allocated, so that two-thirds continued to 
receive primary care from a family physician and one-third received 
care from a NP. The outcomes included: mortality, physical function, 
emotional function, and social function. Results demonstrated 
comparable outcomes for patients, whether assigned to physician or to 
NP care. Details from the Burlington trial were also described by 
Spitzer, et al. (see below).
    Safriet, B. J. (1992). Health care dollars and regulatory sense: 
The role of advanced practice nursing. Yale Journal on Regulation, 
9(2). The full Summer 1992 issue of this journal was devoted to the 
topic of advanced practice nursing, including documenting the cost-
effective and high quality care provided, and to call for eliminating 
regulatory restrictions on their care. Safriet summarized the OTA study 
concluding that NP care was equivalent to that of physicians and 
pointed out that 12 of the 14 studies reviewed in this report which 
showed differences in quality reported higher quality for NP care. 
Reviewing a range of data on NP productivity, patient satisfaction, and 
prescribing, and data on nurse midwife practice, Safriet concludes:

          ``APNs are proven providers, and removing the many barriers 
        to their practice will only increase their ability to respond 
        to the pressing need for basic health care in our country''--
        (p. 487).

    Spitzer, W.O., Sackett, D.L., Sibley, J.C., Roberts, M., Gent, M., 
Kergin, D.J., Hacket, B.D., & Olynich, A. (1974). The Burlington 
randomized trial of the nurse practitioner. New England Journal of 
Medicine, 290 (3), 252-56. This report provides further details of the 
Burlington trial, also described by Sackett, et al. (see above). This 
study involved 2,796 patients being randomly assigned to either one of 
two physicians or to an NP, so that one-third were assigned to NP care, 
from July 1971 to July 1972. At the end of the period, physical status 
and satisfaction were comparable between the two groups. The NP group 
experienced a 5 percent drop in revenue, associated with absence of 
billing for NP care. It was hypothesized that the ability to bill for 
all NP services would have resulted in an actual increased revenue of 9 
percent. NPs functioned alone in 67 percent of their encounters. 
Clinical activities were evaluated and it was determined that 69 
percent of NP management was adequate compared to 66 percent for the 
physicians. Prescriptions were rated adequate for 71 percent of NPs 
compared to 75 percent for physicians. The conclusion was that ``a 
nurse practitioner can provide first-contact primary clinical care as 
safely and effectively as a family physician'' (p. 255).
                 nurse practitioner cost-effectiveness
    Nurse Practitioners (NPs) are a proven response to the evolving 
trend toward wellness and preventive health care driven by consumer 
demand. A solid body of evidence demonstrates that NPs have 
consistently proven to be cost-effective providers of high-quality care 
for almost 50 years. Examples of the NP cost-effectiveness research are 
described below.
    Over three decades ago, the Office of Technology Assessment (OTA) 
(1981) conducted an extensive case analysis of NP practice, reporting 
that NPs provided equivalent or improved medical care at a lower total 
cost than physicians. NPs in a physician practice potentially decreased 
the cost of patient visits by as much as one third, particularly when 
seeing patients in an independent, rather than complementary, manner. A 
subsequent OTA analysis (1986) confirmed original findings regarding NP 
cost effectiveness. All later studies of NP care have found similar 
cost-efficiencies associated with NP practice.
    The cost-effectiveness of NPs begins with their academic 
preparation. The American Association of Colleges of Nursing has long 
reported that NP preparation cost 20-25 percent that of physicians. In 
2009, the total tuition cost for NP preparation was less than 1-year 
tuition for medical (MD or DO) preparation (AANP, 2010).
    Comparable savings are associated with NP compensation. In 1981, 
the hourly cost of an NP was one-third to one-half that of a physician 
(OTA). The difference in compensation has remained unchanged for 30 
years. In 2010, when the median total compensation for primary care 
physicians ranged from $208,658 (family) to $219,500 (internal 
medicine) (American Medical Group Association,2010), the mean full-time 
NP's total salary was $97,345, across all types of practice (American 
Academy of Nurse Practitioners [AANP], 2010). A study of 26 capitated 
primary care practices with approximately 2 million visits by 206 
providers determined that the practitioner labor costs and total labor 
costs per visit were both lower in practices where NPs and physician 
assistants (PAs) were used to a greater extent (Roblin, Howard, Becker, 
Adams, and Roberts, 2004). When productivity measures, salaries, and 
costs of education are considered, NPs are cost effective providers of 
health services.
    Based on a systematic review of 37 studies, Newhouse et al. (2011) 
found consistent evidence that cost-related outcomes such as length of 
stay, emergency visits, and hospitalizations for NP care are equivalent 
to those of physicians. In 2012, modeling techniques were used to 
predict the potential for increased NP cost-effectiveness into the 
future, based on prior research and data. Using Texas as the model 
State, Perryman (2012) analyzed the potential economic impact that 
would be associated with greater use of NPs and other advanced practice 
nurses, projecting over $16 billion in immediate savings which would 
increase over time.
    NP cost-effectiveness is not dependent on actual practice setting 
and is demonstrated in primary care, acute care, and long term care 
settings. For instance, NPs practicing in Tennessee's state-managed 
managed care organization (MCO) delivered health care at 23 percent 
below the average cost associated with other primary care providers, 
achieving a 21 percent reduction in hospital inpatient rates and 24 
percent lower lab utilization rates compared to physicians 
(Spitzer,1997). A 1-year study comparing a family practice physician-
managed practice with an NP-managed practice within an MCO found that 
compared to the physician practice, the NP-managed practice had 43 
percent of the total emergency department visits, 38 percent of the 
inpatient days, and 50 percent total annualized per member monthly cost 
(Jenkins and Torrisi,1995). Nurse managed centers (NMCs) with NP-
provided care have demonstrated significant savings, less costly 
interventions, and fewer emergency visits and hospitalizations (Hunter, 
Ventura, and Keams, 1999; Coddington and Sands, 2009). A study 
conducted in a large HMO setting established that adding an NP to the 
practice could virtually double the typical panel of patients seen by a 
physician with a projected increase in revenue of $1.28 per member per 
month, or approximately $1.65 million per 100,000 enrollees annually 
(Burl, Bonner, and Rao, 1994).
    Chenowith, Martin, Pankowski, and Raymond (2005) analyzed the 
health care costs associated with an innovative onsite NP practice for 
over 4,000 employees and their dependents, finding savings of $ .8 to 
1.5 million, with a benefit-to-cost ratio of up to 15 to 1. Later, they 
tested two additional benefit-to-cost models using 2004-2006 data for 
patients receiving occupational health care from an NP demonstrating a 
benefit to cost ratio ranging from 2.0-8.7 to 1, depending on the 
method (Chenowith, Martin, Pankowski, and Raymond (2008). Time lost 
from work was lower for workers managed by NPs, compared to physicians, 
as another aspect of cost-savings (Sears, Wickizer, Franklin, Cheadie, 
and Berkowitz, 2007).
    A number of studies have documented the cost-effectiveness of NPs 
in managing the health of older adults. Hummel and Prizada (1994) found 
that compared to the cost of physician-only teams, the cost of a 
physician-NP team long-term care facility were 42 percent lower for the 
intermediate and skilled care residents and 26 percent lower for those 
with long-term stays. The physician-NP teams also had significantly 
lower rates of emergency department transfers, shorter hospital lengths 
of stay, and fewer specialty visits. A 1-year retrospective study of 
1,077 HMO enrollees residing in 45 long-term care settings demonstrated 
a $72 monthly gain per resident, compared with a $197 monthly loss for 
residents seen by physicians alone (Burl, Bonner, Rao, and Kan, 1998). 
Intrator (2004) found that residents in nursing homes with NPs were 
less likely to develop ambulatory care-sensitive diagnoses requiring 
hospitalizations. Bakerjian (2008) summarized a review of 17 studies 
comparing nursing home residents who are patients of NPs to others, 
finding lower rates of hospitalization and overall costs for the NP 
patients. The potential for NPs to control costs associated with the 
healthcare of older adults was recognized by United Health (2009), 
which recommended that providing NPs to manage nursing home patients 
could result in $166 billion healthcare savings.
    NP-managed care within acute-care settings is also associated with 
lower costs. Chen, McNeese-Smith, Cowan, Upenieks, and Afifi (2009) 
found that NP-led care was associated with lower overall drug costs for 
inpatients. When Paez and Allen (2006) compared NP and physician 
management of hypercholesterolemia following revascularization, they 
found patients in the NP-managed group had lower drug costs, while 
being more likely to achieve their goals and comply with prescribed 
regimen.
    Collaborative NP/physician management was associated with decreased 
length of stay and costs and higher hospital profit, with similar 
readmission and mortality rates (Cowan et al., 2006; Ettner et al., 
2006). The introduction of an NP model in a health system's 
neuroscience area resulted in over $2.4 million savings the first year 
and a return on investment of 1,600 percent; similar savings and 
outcomes were demonstrated as the NP model was expanded in the system 
(Larkin, 2003). Boling (2009) cites an intensive short-term 
transitional care NP program documented by Smigieski et al. through 
which healthcare costs were decreased by 65 percent or more after 
enrollment, as well as the introduction of an NP model in a system's 
cardiovascular area associated with a decrease in mortality from 3.7 
percent to 0.6 percent and over 9 percent decreased cost per case (from 
$27,037 to $24,511).
    In addition to absolute cost, other factors are important to health 
care cost-effectiveness. These include illness prevention, health 
promotion, and outcomes. See Documentation of Quality of Nurse 
Practitioner Practice (AANP, 2013) for further discussion.
                               References
AANP (2010). Nurse practitioner MSN tuition analysis: A comparison with 
    medical school tuition. Retrieved February 7, 2013 from http://
    www.aanp.org/images/documents/research/NPMSNTuitionAnalysis.pdf.
AANP (2010). 2009-10 National NP sample survey: Compensation and 
    benefits. Author: Austin TX. Accessed March 20, 2013 at http://
    www.aanp.org/images/documents/research/2009-
    10_income_Compensation.pdf.
American Association of Colleges of Nursing (nd). Nurse Practitioners: 
    The Growing Solution in Health Care Delivery. Retrieved February 7, 
    2013, from http://www.aacn.nche.edu/media-relations/fact-sheets/
    nurse-practitioners.
American Academy of Nurse Practitioners (2010). Documentation of 
    Quality of Nurse Practitioner Care. Retrieved December 3, 2009 from 
    http://www.aanp.org.
American Medical Group Association (2009). 2009 Physician Compensation 
    Survey. Retrieved September 22, 2009 from http://
    www.cehkasearch.com/compensation/amga.
Bakerjian, D. (2008). Care of nursing home residents by advanced 
    practice nurses: A review of the literature. Research in 
    Gerontological Nursing, 1(3), 177-85.
Boling, P. (2000). Care transitions and home health care. Clinical 
    Geriatric Medicine, 25, 135-48.
Burl, J., Bonner, A., Rao, M., & Khan, A. (1998). Geriatric nurse 
    practitioners in long-term care: demonstration of effectiveness in 
    managed care. Journal of the American Geriatrics Society, 46(4), 
    506-10.
Chen, C., McNeese-Smith, D., Cowan, M., Upenieks, V., & Afifi, A. 
    (2009). Evaluation of a nurse practitioner led care management 
    model in reducing inpatient drug utilization and costs. Nursing 
    Economics, 27(3), 160-68.
Chenoweth, D., Martin, N., Pankowski, J., & Raymond, L.W. (2005). A 
    benefit-cost analysis of a worksite nurse practitioner program: 
    First impressions. Journal of Occupational and Environmental 
    Medicine, 47(11), 1110-6.
Chenoweth, D., Martin, N., Pankowski, J., & Raymond, L. (2008). Nurse 
    practitioner services: Three-year impact on health care costs. 
    Journal of Occupational and Environmental Medicine, 50(11), 1293-
    98.
Coddington, J. & Sands, L. (2008). Cost of health care and quality of 
    care at nurse-managed clinics. Nursing Economics, 26(2) 75-94.
Cowan, M.J., Shapiro, M., Hays, R.D., Afifi, A., Vazirani, S., Ward, 
    C.R., et al. (2006). The effect of a multidisciplinary hospitalist 
    physician and advanced practice nurse collaboration on hospital 
    costs. The Journal of Nursing Administration, 36(2), 79-85.
Ettner, S.L., Kotlerman, J., Abdemonem, A., Vazirani, S., Hays, R.D., 
    Shapiro, M., et al. (2006). An alternative approach to reducing the 
    costs of patient care? A controlled trial of the multi-disciplinary 
    doctor-nurse practitioner (MDNP) model. Medical Decision Making, 
    26, 9-17.
Hummel, J., & Pirzada, S. (1994). Estimating the cost of using non-
    physician providers in an HMO: where would the savings begin? HMO 
    Practice, 8(4), 162-4.
Hunter, J., Ventura, M., & Kearns, P. (1999). Cost analysis of a 
    nursing center for the homeless. Nursing Economics, 17(1), 20-28.
Intrator, 0., Zinn, J., & Mor, V. (2004) Nursing home characteristics 
    and potentially preventable hospitalization of long-stay residents. 
    Journal of the American Geriatrics Society, 52, 1730-36.
Jenkins, M. & Torrisi, D. (1995). NPs, community nursing centers and 
    contracting for managed care. Journal of the American Academy of 
    Nurse Practitioners, 7(3), 119-23.
Larkin, H. (2003). The case for nurse practitioners. Hospitals and 
    Health Networks, (2003, Aug.), 54-59.
Newhouse, R. et al. (2011). Advanced practice nurse outcomes 1999-2008: 
    A systematic review. Nursing Economic$, 29 (5), 1-22.
Office of Technology Assessment. (1981). The Cost and Effectiveness of 
    Nurse Practitioners. Washington, DC: U.S. Government Printing 
    Office.
Office of Technology Assessment. (1986). Nurse Practitioners, Physician 
    Assistants, and Certified Nurse Midwives: A Policy Analysis. 
    Washington, DC: U.S. Government Printing Office.
Paez, K. & Allen, J. (2006). Cost-effectiveness of nurse practitioner 
    management of hypercholesterolemia following coronary 
    revascularization, Journal of the American Academy of Nurse 
    Practitioners, 18(9),436-44.
Perryman Group (2012). The economic benefits of more fully utilizing 
    advanced practice registered nurses in the provision of care in 
    Texas. Author: Waco, TX. Accessed March 20, 2013 at http://
    www.texasnurses.org/associations/8080/files/
    PerrymanAPRN_UltilizationEconomicImpactReport.pdf.
Roblin, O.W., Howard, D.H., Becker E.R., Adams, E., & Roberts, M.H. 
    (2004). Use of midlevel practitioners to achieve labor cost savings 
    in the primary care practice of an MCO. Health Services Research, 
    39, 607-26.
Sears, J., Wickizer, T., Franklin, G., Cheadie, A., & Berkowitz, B. 
    (2007). Expanding the role of nurse practitioners: Effects on rural 
    access to care for injured workers. Journal of Rural Health, 24(2), 
    171-78.
Spitzer, R. (1997). The Vanderbilt experience. Nursing Management, 
    28(3), 38-40.
United Health. Group (2009). Federal health care cost containment: How 
    in practice can it be done? Options with a real world track record 
    of success. Retrieved February 7, 2013 from http://
    www.unitedhealthgroup.com/hrm/UNH_Working
    Paper1.pdf.
                   Institute of Medicine (IOM) Report
  the future of nursing: leading change, advancing health (pp. 278-79)
Recommendation 1: Remove scope-of-practice barriers. Advanced practice 
registered nurses should be able to practice to the full extent of 
their education and training. To achieve this goal, the committee 
recommends the following actions.

For the Congress:

     Expand the Medicare program to include coverage of 
advanced practice registered nurse services that are within the scope 
of practice under applicable State law, just as physician services are 
now covered.
     Amend the Medicare program to authorize advanced practice 
registered nurses to perform admission assessments, as well as 
certification of patients for home health care services and for 
admission to hospice and skilled nursing facilities.
     Extend the increase in Medicaid reimbursement rates for 
primary care physicians included in the ACA to advanced practice 
registered nurses providing similar primary care services.
     Limit Federal funding for nursing education programs to 
only those programs in States that have adopted the National Council of 
State Boards of Nursing Model Nursing Practice Act and Model Nursing 
Administrative Rules (Article XVIII, Chapter 18).

For State legislatures:

     Reform scope-of-practice regulations to conform to the 
National Council of State Boards of Nursing Model Nursing Practice Act 
and Model Nursing Administrative Rules (Article XVIII, Chapter 18).
     Require third-party payers that participate in fee-for-
service payment arrangements to provide direct reimbursement to 
advanced practice registered nurses who are practicing within their 
scope of practice under State law.

For the Centers for Medicare and Medicaid Services:

     Amend or clarify the requirements for hospital 
participation in the Medicare program to ensure that advanced practice 
registered nurses are eligible for clinical privileges, admitting 
privileges, and membership on medical staff.

For the Office of Personnel Management:

     Require insurers participating in the Federal Employees 
Health Benefits Program to include coverage of those services of 
advanced practice registered nurses that are within their scope of 
practice under applicable State law.

For the Federal Trade Commission and the Antitrust Division of the 
Department of Justice:

     Review existing and proposed State regulations concerning 
advanced practice registered nurses to identify those that have 
anticompetitive effects without contributing to the health and safety 
of the public. States with unduly restrictive regulations should be 
urged to amend them to allow advanced practice registered nurses to 
provide care to patients in all circumstances in which they are 
qualified to do so.

    Senator Sanders. Thank you very much.
    Senator Murphy, I know, wanted to be here to introduce Dr. 
Koeppen. I believe there are seven or eight hearings taking 
place at this particular moment. So you will forgive members if 
they are a little bit stretched out.
    I will introduce Dr. Koeppen, who is the founding dean of 
the new school of medicine at Quinnipiac University in 
Connecticut. He previously worked as a professor in the 
Departments of Medicine and Cell Biology on the faculty of the 
University of Connecticut School of Medicine, and then as dean 
for Academic Affairs.
    Dr. Koeppen has served on a number of State and national 
education-related committees and organizations, including the 
Accreditation Council for Continuing Medical Education.
    Dr. Koeppen, thanks so much for being with us.

 STATEMENT OF BRUCE KOEPPEN, M.D., Ph.D., FOUNDING DEAN OF THE 
FRANK H. NETTER MD SCHOOL OF MEDICINE AT QUINNIPIAC UNIVERSITY, 
                           HAMDEN, CT

    Dr. Koeppen. Good morning, Chairman Sanders, Ranking Member 
Burr, and members of the subcommittee.
    Thank you for inviting Quinnipiac University to testify 
today about our Frank H. Netter MD School of Medicine, which is 
being built to train primary care physicians and to foster 
collaborative team-based care.
    I have the privilege of serving as the founding dean of the 
School of Medicine and I am working with my fellow deans in the 
Schools of Nursing and Health Sciences to build at Quinnipiac a 
national model of inter-professional education of the primary 
care health care team.
    As you know, our country faces a significant physician 
shortage, especially in primary care disciplines. It is for 
this reason that Quinnipiac University made the decision to 
build its medical school. I was hired to lead the development 
of the medical school, and began that task on November 1, 2010. 
My charge was to build a medical school focused on primary care 
and to do this in collaboration with the Schools of Nursing and 
Health Sciences. I am pleased to say that this August, our 
charter class of 60 students will begin their studies.
    We have set as a goal to have at least 50 percent of each 
class go into a primary care specialty. To maximize our chances 
of achieving this goal, we have hired faculty who support and 
believe in the mission. Our admissions process is holistic and 
targets students more likely to practice primary care.
    The core curriculum has been designed to emphasize high 
impact diseases rather than the rare diseases that are more the 
domain of the subspecialist. It also emphasizes wellness, 
prevention, social determinants of health, and health 
disparities.
    We have included a curricular experience we call ``the 
medical student home.'' As part of this experience, each 
student will be paired with a primary care physician, and 
beginning in the fall of their first year and continuing for 3 
years, the student will spend one-half day each week seeing 
patients with that physician. We hope this intense and long 
lasting relationship will reinforce for the student the 
importance and value of primary care and establish a meaningful 
student-mentor relationship.
    We know that we have to address student indebtedness. That 
is why the University's Board of Trustees has established ``the 
primary care fellowship.'' The goal of this program is to offer 
a fellowship to any student we admit who says they want a 
career in a primary care discipline. The fellowship consists of 
a full tuition and fee waiver for all 4 years of medical 
school. We will track them through their residency training and 
into practice. If they practice primary care medicine for 4 
years, all of the waived tuition and fees are forgiven. If at 
any point in their training they change their mind, the waiver 
money is converted into a loan they must repay.
    Despite what we do, I still fear that we may fall short of 
our goal. There are several factors that can discourage a 
student from choosing a career in primary care. As you have 
heard today, most residency training programs are embedded in 
hospitals, the very site where subspecialty care is provided. 
Primary care takes place outside of the hospital.
    The teaching health center program is a good first step to 
change this model. It trains primary care residents in a 
primary care setting. However, it is not enough. If we are to 
meet the demand for services, there needs to be an expansion of 
federally funded residency programs, and these should be 
weighted toward primary care specialties, and take place in 
appropriate ambulatory settings.
    We must also embrace team medicine. Patient-centered 
medical homes and accountable care organizations are all about 
team medicine. We need to abandon the traditional model of the 
physician as the captain of the ship who directs the crew, and 
adopt the model of a NASCAR pit crew.
    The pit crew is a team of highly skilled individuals that 
bring their expertise to the care of the car. Now, replace the 
car with a patient and the pit crew with a team that consists 
of physicians, nurse practitioners, physician assistants, 
physical and occupational therapists, social workers, mental 
health counselors, and nutritionists. However, simply 
assembling the team is not enough. You have to let each member 
of that team practice at the top of their training, not just 
the top of their license. What do I mean?
    The members of the health care team are often trained at a 
higher level than the scope of practice laws in their State 
allow. If every member of the team can practice at the top of 
their training, then we have an exciting and fulfilling work 
environment for all. More importantly, it expands access and 
each patient will get better coordinated and better quality 
care. Done right, it will also lower total health care 
expenditures by keeping patients well longer.
    At Quinnipiac University, we believe we have the right 
environment to train the primary care health care team of the 
future, one that can function as I have just described. It will 
not be easy and we will need help, but we must succeed.
    Thank you for inviting me to testify, and thank you for 
your leadership in finding ways to successfully create the 
primary care workforce this country so desperately needs.
    [The prepared statement of Dr. Koeppen follows:]
          Prepared Statement of Bruce M. Koeppen, M.D., Ph.D.
    Good morning Chairman Sanders, Ranking Member Burr and members of 
the subcommittee, thank you for inviting Quinnipiac University to 
testify today about our Frank H. Netter MD School of Medicine. The 
principal mission of the School of Medicine is to train primary care 
physicians and to foster collaborative, team-based care. Our mission is 
to be the national model of interprofessional health professions 
education.
    I am Bruce Koeppen, founding Dean of the Medical School. I have 
been in academic medicine, and involved in medical student education, 
for more than 30 years. Prior to assuming my current position at 
Quinnipiac University I was on the faculty of the University of 
Connecticut School of Medicine. The School of Medicine will open its 
doors in August 2013. Our charter class will have 60 students, and over 
a 3-year period our class size will increase to 125. When at full 
capacity we will be the largest medical school in Connecticut.
    We must address our Nation's growing shortage of primary care 
physicians and other primary care health professionals. We also must 
restructure our health care system to advance models that provide high 
quality, cost-effective and patient-centered primary care. I am pleased 
that Quinnipiac University is at the forefront of both of these 
efforts.
                               background
    The Center for Work Force Studies of the Association of American 
Medical Colleges (AAMC) has projected a significant shortage of 
physicians.

 
----------------------------------------------------------------------------------------------------------------
                                                                     Physician       Physician       Physician
                              Year                                  supply (all     demand (all    shortage (all
                                                                   specialties)    specialties)    specialties)
----------------------------------------------------------------------------------------------------------------
2010............................................................         709,700         723,400          13,700
2015............................................................         735,600         798,500          62,900
2020............................................................         759,800         851,300          91,500
2025............................................................         785,400         916,000         130,600
----------------------------------------------------------------------------------------------------------------

    While this physician shortage is across all specialties, it is most 
significant in the primary care disciplines of Family Medicine, General 
Internal Medicine and General Pediatrics. According to the AAMC 
analysis the shortage of primary care physicians in 2020 will be 
45,400--and in 2025 this increases to 65,800.
    The causes for the overall physician shortage are multifactorial, 
and include the movement of Baby Boomers into the Medicare system 
(10,000/day); a group where 50 percent are already diagnosed with two 
or more chronic medical conditions. Added to this will be more than 30 
million individuals who will obtain health insurance through the 
Affordable Care Act.
    The reasons for the significant shortage of primary care physicians 
are also complex. Medical students are increasingly choosing non-
primary care specialties, and the reasons include perceptions that it 
is less prestigious, and more demanding in terms of breadth of 
knowledge and in life style. Also, the hard reality is that among the 
various medical specialties, primary care specialties are at the bottom 
of the income ladder.
    The provision of high quality patient-centered care is essential to 
the health of our citizens, and especially for the Nation to bend the 
health care expenditure curve. Doing more of the same in terms of 
medical student education will simply not get us to where we, as a 
Nation, and a health care system, need be. Simply put--What got us here 
. . . Won't get us there! We need new ideas and new approaches.
    The new medical schools being developed in our Nation offer a 
special opportunity to positively affect medical student education. We 
can innovate in ways that might be difficult in established medical 
schools. The new schools have the opportunity to define a mission, and 
then build to that mission from faculty recruitment, design of the 
space, and selection of the students. This is much easier than changing 
an existing institutional culture.
    Many new medical schools are not focused on primary care; at 
Quinnipiac University, it is our mission. We believe the provision of 
patient-centered primary care should be provided by a team of care 
givers, each of whom has the ability to practice at the top of their 
training. Quinnipiac University has committed itself to educating and 
training the primary care team of the future. We aim to change the 
traditional model, where the physician is viewed as the captain of the 
ship giving orders to the crew, to a model more akin to a NASCAR pit 
crew. Pit crews are highly efficient and effective teams, comprised of 
individuals with unique knowledge and expertise, all focused on the 
care of the racecar. We envision the primary care team in the same way; 
a team of highly trained and skilled professionals each bringing their 
expertise to the care of the patient.
                         quinnipiac university
    Quinnipiac University traces its roots to 1929 when the Connecticut 
College of Commerce was founded in New Haven, CT. In 1951, the name was 
changed to Quinnipiac College, and then to Quinnipiac University in 
2000. Today the university has established Schools of Business, 
Communications, Education, Health Sciences, Law, Nursing, and a College 
of Arts and Sciences, on three campuses located in Hamden and North 
Haven, CT.
    The School of Medicine resides on the 104-acre North Haven campus, 
housing the graduate programs in the School of Health Sciences, the 
School of Education, and the School of Nursing. Our Law School will 
relocate to the campus in 2014.
    Quinnipiac University began programs in allied health in the 1950s, 
formally established the School of Health Sciences in 1971, and today 
offers a wide range of undergraduate and graduate programs.

        Bachelor of Science
                Athletic Training
                Biomedical Sciences
                Diagnostic Imaging
                Health and Health Sciences
                Microbiology/Molecular biology
                Premedical Studies
        Master of Science
                Biomedical Sciences
                Cardiovascular Perfusion
                Medical Laboratory Sciences
                Pathologists' Assistant
                Physician Assistant
                Radiologist Assistant
                Occupational Therapy
                Anesthesia Assistant
        The School of Nursing, and offers the following degree 
        programs.
                Bachelor of Science in Nursing (BSN)
                Masters of Science in Nursing (MSN)
                Doctor of Nursing Practice (DNP)

    The School of Nursing is developing a nurse anesthetist program. In 
addition, master's degree programs in public health and social work are 
at an early stage of development.
    Given the collective strength of the health professions programs, 
Quinnipiac University saw the development of a medical school as an 
important addition to the existing educational programs.
                           school of medicine
    The School of Medicine has an emphasis on primary care and the 
training of the physician of the future as a member of an integrated 
care team.
    Our Frank H. Netter MD School of Medicine will be a model for 
educating diverse, patient-centered physicians who are partners and 
leaders in an inter-professional primary care workforce, responsive to 
healthcare needs in the communities they serve. The School of Medicine 
embodies the University's commitment to its core values of excellence, 
student-oriented education, and a strong sense of community. 
Accordingly, the School of Medicine values partnerships among our 
community that provide students with learning and service opportunities 
that also improve the health of the community. Beyond the local 
community, the School of Medicine works in collaboration with our 
global health program to promote primary care, patient education, 
community medicine and public health through international 
partnerships.
    To facilitate our efforts around inter-professionalism, we have 
designed and are building the Center for Medicine, Nursing, and Health 
Sciences. This 250,000 sf facility provides state-of-the-art student-
centered educational space for all of the health professions students 
at Quinnipiac University.


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



    We have also established a Center for Interprofessional Health 
Education, which serves as a think tank and coordinating point for 
identifying best practices for interprofessional education.
                         achieving our mission
    To achieve our mission relative to primary care we have developed 
the following strategies:

     Faculty that support the mission
     Holistic student admissions process
     Curricular content and experiences related to primary care
     Positive role models in primary care
     Targeted financial aid

    Faculty: Our school has a single basic science department focused 
on medical student education, rather than the typical spectrum of basic 
science departments seen at other schools, which were established to 
support research programs more so than medical student education. All 
basic science faculty were hired for their teaching expertise, rather 
than a research area of focus. They were also only hired if they 
supported our mission.
    Student Admissions: We have adopted a holistic admissions process. 
We have set a threshold for GPA and MCAT score, but the decision to 
accept or not a student for admission is based on how the student is 
judged in the following areas.

     Awareness of the school's primary care mission and vision
     Maturity
     Motivation
     Intellectual curiosity
     Interpersonal skills and non-verbal expression

    Curriculum and Role Models: The core curriculum has been designed 
to emphasize high impact diseases, rather than the rare diseases that 
are more the domain of the subspecialists. It also emphasizes wellness, 
prevention, social determinants of health, and health disparities. We 
have added two unique components. The first is what we call the Medical 
Student Home (MeSH). As part of this experience, beginning in the fall 
of their first year, each student is placed in the office of a primary 
care physician, and they go to that office one half-day each week for 
the next 3 years to see patients with the physician. This gives them a 
real life perspective on the provision of continuity of care, and 
allows them to see how chronic disease is managed. We hope these 
physicians serve as positive role models and mentors.
    We have also included in our curriculum a concentration and 
capstone experience, which we believe will help our student acquire the 
knowledge and skills in related professions, which they can apply in 
their roles as physicians. The areas of concentration we have developed 
involve the other schools at Quinnipiac, and include.

     Global, Public, and Community Health (Albert Schweitzer 
Institute)
     Health Policy Advocacy (School of Law)
     Health Management and Leadership (School of Business)
     Health Communication (School of Communication)
     Medical Education (School of Education)
     Medical Humanities (College of Arts and Sciences)
     Translational, Clinical and Basic Science Research

    Financial Aid: We believe that limiting the indebtedness of 
students tracking into primary care is important. As a result, the 
Board of Trustees has established the ``Primary Care Fellowship''. When 
fully funded, any student we admit, who says they intend to have a 
career in primary care medicine, will be offered one of these 
fellowships. The fellowship consists of a full tuition and fee waiver 
for all 4 years of medical school. The student will sign a contract 
that stipulates that they must practice primary care for at least 4 
years after they complete their residency training. If they do meet 
that commitment the waiver funds are forgiven. However, if they decide 
on a career in a subspecialty at any point in their training (medical 
school or residency), or do not practice primary care, the waived funds 
become a loan that must be repaid.
    We do not know how successful our approach will be, but we have set 
as a goal to have at least 50 percent of each graduating class become 
primary care clinicians.
                   challenges and potential solutions
    Residency Training: Medical schools can only do so much relative to 
building the primary care physician workforce, since every graduate 
must complete a residency program in order practice medicine. As 
currently organized, residency training typically takes place in 
tertiary care hospitals, which by definition is subspecialty care. 
Resident physicians may start out on a path to a primary care career, 
but may be diverted during the course of their residency training. An 
effort must be made to embed residency programs in the settings were 
high quality primary care is being provided. The ``Teaching Health 
Center'' program included in the Affordable Care Act is a good first 
step. It allows Community Health Centers to establish residency 
programs, to train physicians who would then stay on to practice 
primary care in that setting. Unfortunately it is only a 3-year grant 
funded program. To be truly successful I believe these need durable 
funding similar to what is currently provided to the majority of 
hospital-based residency programs. I would also advocate to expand the 
number of federally funded residency positions in the country, and 
weight those toward primary care disciplines. This is critical if we 
are to address the looming primary care physician shortage.
    Perceptions: Students often have the impression that the practice 
of primary care medicine is boring and not challenging. That it is just 
endless numbers of patients with colds, high blood pressure, etc., and 
that only the specialists see the interesting stuff. While there may be 
some truth to this impression, the real truth is those interesting 
patients often see the specialist by a referral from the primary care 
physician. More importantly, I believe establishing a primary care team 
changes this completely. If patient centered medical homes and 
accountable care organizations establish primary care teams that 
consist of physicians, nurse practitioners, physician assistants, 
occupational and physical therapists, nutritionists, behavior health 
specialists, and States allow these individuals to practice at the top 
of their training, rather than at the top of their license, then we 
have an exciting and fulfilling work environment for all. More 
importantly, the patient will get better coordinated, and better 
quality of care. I also believe it will lower total health care 
expenditures, by keeping patients well longer, and thus out of the 
hospital.
    Thank you for inviting me to testify and thank you for your 
leadership in finding ways to successfully create the primary care 
workforce this country so desperately needs.

    Senator Sanders. Dr. Koeppen, thanks so much.
    Let me just thank our panelists, not only for being here 
this morning, but for their life's work. Without exception, all 
of you are doing work that is enormously important to our 
country.
    Let me begin by asking, in a sense, a dumb bunny question, 
and that is, as a Nation, we spend almost twice as much per 
capita on health care as do the people of any other Nation, and 
yet our health care outcomes are not necessarily any better. In 
some cases, they are worse.
    We have 70 percent of our physicians who are specialists; 
30 percent, roughly speaking, are in primary health care. The 
rest of the world, generally speaking, is exactly the opposite: 
70 percent primary, 30 percent specialists.
    What is the relationship between the fact that we have so 
many specialists compared to the rest of the world, and we 
spend twice as much per capita on health care? Is there a 
relationship?
    Dr. Rust, do you want to start?
    Dr. Rust. Sure, and the answer is yes. And the answer is 
yes because you can look at the bottom line outcomes.
    And just as Dr. Starfield did earlier in her career looking 
at the number of subspecialists to primary care ratios, those 
sorts of things, and tie them to both health outcomes and to 
health care costs, but look also at how we reimburse 
specialists.
    We reimburse people on piecework. We reimburse people for 
procedures, and high-cost procedures disproportionate to the 
way we reimburse people who spend time with patients in 
relationship, helping coach them to better health.
    So when you pay people to do a significant number of 
procedures, when you train people to do hospital-based care and 
that is the environment in which they are comfortable, we tend 
to get the most expensive forms of care done exquisitely well 
in this country, but we do it way too much.
    And if you are able to move upstream, just as we saw with 
the 30 percent reduction in emergency room visits, by putting a 
community health center in that community. If we treat the high 
blood pressure, then the patient does not have a stroke. Look 
at what we have saved by doing that. If we treat the patient 
with diabetes and help them self-manage their condition so that 
they don't have a leg amputation, and so forth.
    So having more primary care allows you to practice in the 
most cost effective way. And one way to think about it is to 
get people the right care, in the right setting, at the right 
time.
    Senator Sanders. In other words, what you are saying is 
when we emphasize primary care, we are treating people when 
they need to be treated. We are keeping them out of the 
emergency room. We are keeping them out of the hospital if they 
get sicker than they otherwise should have. And we are saving 
substantial sums of money.
    Dr. Rust. Absolutely.
    Senator Sanders. OK. Let me ask Mr. Hawkins. We have made 
some progress in terms of expanding community health centers 
around the country. If we located a community health center in 
every community in rural or urban America that actually is 
medically underserved and needed it, that is going to cost us a 
bit of change. No question about that.
    But at the end of the day, picking up on Dr. Rust's point, 
if you make health care available to those people who need it, 
who then do not use an emergency room, who do not get 
unnecessarily sick, where you do disease prevention you, in 
fact, end up or not, saving money for the whole health care 
system.
    Mr. Hawkins. That is absolutely true, Mr. Chairman. We have 
already seen studies that show that even at their current 
level, community health centers save the health care system, 
taxpayers, private payers, all payers, between $20 and $25 
billion a year for the care that they provide today to the 22 
million people.
    There are 60 million Americans who do not have a regular 
source of primary care. I was just going to add my two cents to 
what Dr. Rust said. The flipside of the problem of having too 
many specialists is that we do not have enough primary care 
providers. And therefore, those who could use that care cannot 
find it and end up in the emergency room.
    It is a double whammy: too much spent on specialty care, 
not enough availability of primary care. So folks end up in the 
emergency room anyhow for what could have been treated in a 
primary care setting.
    As I noted, 60 million people today without a regular 
source of primary care. We look less at communities than at 
populations, and if we could grow the health center program to 
serve those 60 million people, roughly 3 times the number of 
people that they serve today, then it stands to reason that the 
savings would be trebled as well.
    Senator Sanders. OK. Let me ask--we are going to have 
another round as well--so let me just ask Dr. Cunningham, I 
think, an interesting question.
    One of the points you made is that your medical school is 
far less expansive than the national average.
    How do you do that?
    Dr. Cunningham. Chairman Sanders, we have created a group 
of missioners who actually have figured out that with their 
patient's care service, sending bills to patients, they can 
actually support the mission of our school.
    Somewhere between 70 and 75 percent of our budget is driven 
by our physicians' practice in Greenville. Only 20 percent of 
our medical school's budget is supported by the State 
Government. The rest comes from our tuition, which is, as I 
mentioned, the lowest in the Nation, tuition and fees, the 
lowest in the Nation at the moment.
    And then we have local philanthropists. The School is named 
for a family of successful businessmen called the Brody's, and 
we have Brody scholarships. We have a number of other 
scholarships that we use to supplement our budget so that we 
can actually have affordable tuition and fees for our students.
    Senator Sanders. Thanks very much.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    I find it a great loss that Ms. Spitzgo did not stick 
around to hear these witnesses because, I think, this is a 
fascinating opportunity to hear how different areas are 
succeeding, growing, exploring new areas that, I think, are 
absolutely crucial to somebody who has the responsibility to 
run programs that directly impact it.
    I am reminded, as I hear some of you respond, that this is 
not as much about one single type of delivery. It is not all 
about community health center. It is not all about this. But it 
is about a medical home model.
    It is about whether a person is in an un-served or 
underserved area, urban, maybe it is in one of the best health 
care delivery markets in the country. But if the perception is 
not that I need to go in for preventative care, then the 
likelihood is they end up as an emergency room patient just 
simply because they did not have that connection, that 
relationship to get in.
    Paul, let me ask you, if you will, can you share with us a 
few more details about East Carolina's embedding students in 
the most rural parts and the communities that you serve with 
different primary care training programs?
    Dr. Cunningham. Thank you, Senator.
    I think you have really focused on the complexity of 
creating the rural health care force that is going to serve the 
communities in the rural areas of this State.
    First of all, you recruit from the State of North Carolina 
and you recruit students from rural communities. They already 
have a propensity to want to return to those communities. Their 
families have lived there for generations, and that tends to be 
one of the retention formulas.
    The other thing is you then send them back into those 
communities to serve as medical students, and they develop a 
familiarity with the system, with the people. I like to say 
that they fall in love with their patients.
    There is more to motivating a physician than just the 
money. Some of that is their passion for the patients that they 
actually serve. So that, if you would, is a trick. We actually 
send them back to fall in love with the rural communities that 
they will need to serve in the future.
    May I mention a couple of thoughts that came up in the 
prior questioning? I am a general surgeon by training and, in 
fact, I consider that a prestigious discipline. But through 
education, we have recognized that family medicine is also a 
prestigious subspecialty as well. And so, it is a matter of 
reformatting our rhetoric in terms of supporting that as an 
initiative.
    Senator Burr. Great.
    Dr. Rust, in your testimony you stated, and I quote, 
``Medical school research and medical school training has too 
often become disconnected from the real world, community based 
primary care clinical practice, and disconnected from training 
the doctors we most need for the communities where they are 
most needed.''
    What suggestions would you offer on how to address this 
concern that they are not tied to or contingent upon Federal 
funding?
    Dr. Rust. I am sorry. You would like suggestions that are 
unrelated to the Federal funding mechanism.
    Senator Burr. How this concern that we are not tied to? 
Yes.
    Dr. Rust. There are a number of pressures in the 
environment that push medical schools in the direction of 
subspecialty care.
    We have heard about how clinical revenues are supporting an 
entire medical school at a 70 to 75 percent level. It is a lot 
easier to generate those clinical revenues with subspecialists 
than it is with primary care clinicians.
    So there is often a drift, even in medical schools that 
start with a charter focused on primary care, there is some 
sense of mission drift in many medical schools--and Brody being 
the wonderful exception--toward more subspecialty care models, 
toward more bench research and so forth.
    What I was suggesting in that testimony is that we do need 
to make a conscious, proactive effort to make sure that we are 
getting a return on the investment for the medical education 
dollars, whether they be State dollars or Federal dollars or 
other dollars that go into our medical schools. And that return 
on investment measured in producing the doctors that America 
actually needs and producing the other clinicians that America 
actually needs.
    Are they going to primary care? Are they going into 
underserved communities? Are they able to practice on teams 
where they respect and honor the high level performance of all 
the other members of that team? Do they represent the diversity 
of the American people?
    And if we are able to hold medical schools accountable in 
some way to producing that return on our investment, whether it 
be a Federal investment, a State investment, or whether it be 
the investment of patient care dollars that are supporting 
them.
    Senator Burr. It had not been that long since you went 
through medical school.
    Dr. Rust. Yes, sir.
    Senator Burr. Follow the current student as he completes 
his undergraduate degree, picks the medical school, goes to the 
bank, and the first word out of the loan officer's mouth is, 
``What specialty are you going into?'' And as soon as you say, 
``Primary care,'' the bank tells you about a neat bank down the 
street that is also open for business, because they look at the 
reimbursement and see the earnings capabilities of a primary 
care doctor.
    In the average medical school today, the payback of a 
student loan from medical school looks like the amortization 
for a home mortgage.
    Dr. Rust. Absolutely.
    Senator Burr. I think you alluded to it. You said that it 
is influenced by the reimbursement system.
    Dr. Rust. Right.
    Senator Burr. Now share with me, for a moment, I am going 
to go outside the box just a little bit.
    Dr. Rust. Sure.
    Senator Burr. Should we find it odd that the largest system 
that we have, Medicare, pays on a per incident basis? I mean, 
you go in, you get something, they pay the bill. You get 
something else, they pay the bill.
    Dr. Rust. That's right.
    Senator Burr. It is actually the private sector risk-takers 
today that are actually investing their own dollars to bring 
clinicians in to work with chronically ill patients because 
they recognize the fact that if they can keep them well, they 
cost less money. They are less risky.
    How do we get this model changed?
    Dr. Rust. From your lips to God's ear, Senator, I would 
love to see that happen. I would say that there are innovations 
both in the private and the public sector.
    In that space, we published a study on Medicaid disease 
management program from our State that we participated in that 
saved the State over $100 million in its first year of 
operation based on reducing the increasing cost line for 
Medicaid patients with serious chronic disease and multi-
morbidity, multiple chronic diseases at the same time. So 
whether it is private sector or public sector, I think the key 
is, are you getting the return on investment?
    And it seems clear to me that you have hit on the key 
point, which is, if you pay for volume, you get volume. If we 
pay for health outcomes, what will happen then is teams will 
begin to reconfigure themselves and get pretty smart about the 
fact that they need other people on teams besides doctors. 
Doctors, and nurse practitioners, and PA's, and psychologists, 
and social workers need to work together.
    We need to blur the boundaries of the clinic wall because 
people do not live in our patient centered medical homes. They 
are free range humans who live out in the countryside and do 
all manner of things. Community health workers, and navigators, 
and other individuals will become part of those teams.
    But if the payment is based on achieving optimal health 
outcomes for a set community, then we are in a much better 
position to make the right investments. There is enough money 
in the game. The amounts we are spending on health care are 
just disproportionate to what other countries find the need to 
spend.
    But right now, if a community health center invests in, for 
example, extra expenditures to invest in psychologists and 
mental health integration with primary care, or social workers 
to address some of the social complexities of their patients, 
they will not reap the benefit for that. The return on 
investment will come to the hospital, which has less indigent 
care admissions, uninsured admissions, the less uninsured 
emergency room visits.
    This disconnect between those who are able to influence the 
outcomes and where investments can be really strategic and 
where small investments can make a big difference, is 
completely disconnected from who will reap the benefit of that 
return on investment, right now, in the current system.
    Senator Sanders. OK. Let me continue down the line here.
    Ms. Wachtel, there is no question that nurse practitioners 
play an enormously important role in the provision of primary 
health care.
    Briefly describe the role that they are playing and what 
you would like to see them play in the future.
    Ms. Wachtel. I have an example of a health care shortage 
area in the southern part of the State. This will be an example 
of what nurse practitioners do in the State of Vermont.
    Over the past 6 years, 12 primary care physicians left that 
area and most of the patients were ending up in the emergency 
room. There were close to 9,000 patients that did not have any 
primary care provider.
    She opened a practice in March of last year. Since opening 
her doors, she's provided comprehensive primary health care to 
people with very complex health needs. Two-thousand patient 
visits in the first year that she opened her doors.
    She is now so busy that she is looking to hire another 
nurse practitioner to help with this because they are still 
underserved. That is one of our biggest underserved areas.
    If those patients were not seeing this nurse practitioner, 
they would be getting their care in the emergency rooms like we 
have been discussing. Or, they would not be going to the 
emergency rooms and their diseases, their medical problems 
would progress to the point where the cost of taking care of 
them would be so much higher.
    The only barriers that, in Vermont, because we are a full 
practice authority State, really the only barriers left are the 
barriers that I mentioned earlier in my testimony. So that 
there are still those barriers left all over the country.
    And in areas where you have discussed that nurse 
practitioners do not have full practice authority, they can 
still practice with the same level of competency as all nurse 
practitioners can. But it is their patients' ability to access 
their care which are creating the barriers.
    So removing those barriers as well, allowing nurse 
practitioners in this entire country to practice at the full 
scope of their education would bring the models that we are 
being successful with in Vermont, which is patient-centered, 
team-based nurse practitioners and others leading those teams 
to provide patients with excellent primary care.
    And if you read the outcome studies, you will see that 
nurse practitioners are providing very high quality care with 
cost savings.
    Senator Sanders. Dr. Koeppen, congratulations on your 
endeavor. It is extraordinary. Your hope is to have 50 percent 
of your graduates going into primary care, which is much, much 
higher than the national average. Let me ask you a hard 
question; others can pick up on it.
    We have medical schools out there that receive substantial 
sums of money from Medicare as part of the Graduate Medical 
Education program. We spend about $10 billion a year on that 
program, who are graduating almost no primary care physicians.
    What do you think we should do about that?
    Dr. Koeppen. I talk to a lot of different people about the 
challenges of building a brand new medical school from scratch. 
And truthfully, what worries me most is not what we are able to 
create at the medical school, but it is where our graduates 
will go.
    It is that GME environment that, I think despite all of our 
best efforts, can undo a lot of what we have tried to do during 
medical school.
    As I noted in my testimony, most Graduate Medical Education 
is embedded in a hospital full of specialists and a graduate 
entering into that is going to be pulled, actively recruited in 
many cases, into the subspecialties.
    The other thing that is happening is the Nation is trying 
to increase the number of U.S. medical school graduates through 
increasing class size of established schools and the founding 
of new medical schools. But there has been no substantial 
increase in the number of residency slots.
    So all we are heading for is a situation where a U.S. 
medical school graduate will not be able to get a residency 
position because they will not exist, and therefore cannot 
practice medicine.
    Senator Sanders. Medicare is spending $10 billion a year 
for resident training. We, in many ways, do not even know what 
they are producing with that $10 billion.
    Who wants to, Dr. Rust or Dr. Cunningham, do you want to 
jump in on that one?
    Dr. Cunningham. Sure, sir. Our hospital is an anomaly in 
that it is close to a 1,000 bed hospital in a town of 90,000 
people. That is a very strange situation.
    It also is what is called 50 percent over the cap. So it 
pays for half of the residents that are training at that 
facility. We, at the Medical School, actually contribute our 
share to the training of those medical students as well, the 
residents in the hospital, the GME component.
    I believe there is a statistic that is important. If a 
student goes through our medical school and does their 
residency within the hospital, 75 percent of those graduates 
stay in North Carolina, and we know that close to 60 percent of 
our graduates remain in primary care for the duration. So I 
believe that is an insight.
    The training center needs to be embedded in a rural 
community for it to work.
    Senator Sanders. OK.
    Dr. Rust, should I be concerned, should we be concerned 
that we spend $10 billion a year providing support to training 
hospitals, and we don't even know who they are graduating? We 
do not even have that basic information let alone demanding 
that they do more in primary care.
    Dr. Rust. Right. I think we have some data on that, but 
what you are referring to, I think, is the accountability 
metrics to be able to say that we expect the production to, in 
some way, match the need, whether it is geographic distribution 
or whether it is specialty distribution. Now, I will give you a 
specific example.
    Internal medicine residency training used to be considered 
a primary care discipline. Some medical schools when they 
report how many of their students choose primary care 
residencies will count internal medicine residencies among 
them.
    But more than 70 percent of those internal medicine 
residents are going to go into a subspecialty fellowship. 
Another 10 to 20 percent are going to now choose hospitalist 
medicine as opposed to outpatient primary care for their 
careers. You are left with 10 to 15 percent of the production 
of those residency programs, those so-called primary care 
residency programs, are actually going to become primary care 
residents.
    So there is this huge pool and if you were able to address 
that one thing aggressively and quickly, within 2 to 3 years, 
you have this huge pool of individuals who are going to make a 
choice between pursuing further subspecialty training or 
staying in a primary care discipline in which they have been 
trained.
    We have the opportunity to move the needle on that one 
fairly quickly if we were aggressive about holding our GME 
funding sources, and the people they fund, to accountability 
for training more of the clinicians that America needs.
    Ms. Wachtel. Excuse me, Senator. Can I just add something 
to that?
    Senator Sanders. Yes.
    Ms. Wachtel. I think that it is really important that what 
we have been talking about is in terms of getting primary care 
providers out there. And even though the vast majority of nurse 
practitioners that graduate go into primary care, there are 
long waiting lists to get into nurse practitioner programs.
    Senator Sanders. Right.
    Ms. Wachtel. And I think that channeling some of that 
funding to faculty.
    Senator Sanders. Right.
    Ms. Wachtel. Faculty loan repayment is incredibly important 
and channeling some of that funding to nurse-managed health 
centers where we can precept medical students, as well as nurse 
practitioner students, as well as nurses, because part of the 
problem is we don't have the preceptor sites either. And that 
is true for medical schools as well as nurse practitioner 
programs.
    Senator Sanders. Thank you.
    Ms. Wachtel. Thank you.
    Senator Burr. Mr. Chairman, I just want to give Dr. 
Cunningham a last opportunity.
    If there is a take away from what you have learned in the 
ECU model that has been successful in North Carolina, and could 
be replicated elsewhere in the country, share that with us.
    Dr. Cunningham. Sir, it is the focus on the mission. The 
mission that we were given early on was to create primary care 
physicians, and we have never deviated. We have never been 
distracted by the financial exigencies.
    We actually do not have many of the lucrative 
subspecialties as a part of the Medical School. We have no 
orthopedics, no anesthesia, no urology, no ENT in the Medical 
School. So we were created to do exactly what we produced.
    So if you create a system that is designed to do something, 
it is likely to do that, and that is exactly what we have done 
for the 40 years of our existence.
    Senator Burr. Mr. Chairman, I want to thank you again for 
this hearing and thank our witnesses.
    I do want to just say I think it is very dangerous that 
Congress look at ways that we can manipulate more primary care 
doctors. I remember back over my 19 years, so far, here. I 
think twice we have actually paid schools to decrease the 
number of students in their program, and then we have put those 
spaces back in there. And the fact is we are headed on a 
demographic formula that we are going to have a shortage, and I 
cannot tell you in which specialties they are going to be in.
    I can with some certainty tell you the shortage in primary 
care is going to continue because I can see the funnel, and the 
need, and know that there are not enough coming in. But it is 
also going to be in other areas.
    We are in a much better position if we let institutions 
determine how to handle this and we provide the support that 
allows the flexibility of institutions to focus. And if they 
want to do as East Carolina did, where they attract in a very 
small area of discipline, and they stay managed in that, that's 
great. Or as we startup new ones, we look at where the mission 
of that institution should be.
    I think at the end of the day, we have to continue to 
produce the professionals at all levels to make sure that we 
can meet the needs of the American people.
    I thank the Chair.
    Senator Sanders. Thank you, Senator Burr. Let me just ask 
my final question.
    According to HRSA, we need 16,000 more primary care 
practitioners to meet the needs that exist today and that 
number is going to go way up in the years to follow. And this 
problem is especially compounded by the fact that as a result 
of the ACA, we will have another 30 million Americans who will 
have health insurance, who have the, at least theoretically, 
the opportunity to walk-in to a doctor's office.
    How serious is that crisis?
    Mr. Hawkins. Mr. Chairman, it is dead serious. The 
experience of Massachusetts alone shows us and tells us that 
when we extend coverage to 30 million additional individuals, 
many of whom are not well today, and are holding off, and have 
held off on seeking care oftentimes until their illness is so 
bad, that they really do need very costly and complex care.
    If we give insurance cards, when we give insurance cards to 
those 30 million people, there is going to be such a huge 
surge. And in places where there is a large uninsured 
population, States like Texas, for example, today, that the 
resultant stress on the health care system is going to be all 
but overwhelming.
    I think that is where it is imperative that the health care 
system very quickly focus on--and I am looking at Ms. Wachtel 
here--because it is the training of the nurse practitioners. 
You guys have got to get off this bachelor's degree, 3-year 
requirement. I remember when we used to train them for 2 years 
of which 15 months was, or 9 months, at least, was a practicum 
at my health center back in the 1970s and 1980s.
    But we need to train more nurse practitioners, physician 
assistants, nurse midwives who can be trained in much less time 
to be part of a team. I believe that really team practice is 
what works. We need to move training as we have talked about 
and it is being done, and there are many, many more community 
health centers and other community-based organizations that are 
ready to engage, and in partnership with the residency programs 
at the medical schools in the training of community-based 
primary care physicians of the future.
    If we engage in those couple of practices, we are still 
going to have a problem come next year. But we can slowly ease 
that problem and create a workforce that is more in tune with 
the needs of the population that it is there to serve.
    Senator Sanders. Dr. Cunningham.
    Dr. Cunningham. Sir, we are not waiting for it to happen. 
We are creating innovation as we speak. Necessity is the mother 
of invention.
    We have a project called the PROSPER Project, which is 
attempting to turn the spigot off upstream. It involves the 
faith community. We are partnering with our community college 
system to create a curriculum to teach people in the community, 
so that we can mitigate some of this expansion of health care 
need in the future.
    We are also collaborating with the military, with the V.A. 
system in our region. We are the third largest area in the 
country where military dependents live, and therefore we are 
going all out everywhere to begin to mitigate this. The fastest 
growing component of our medical practice is the emergency 
department at this point. So there is pent-up need and it is 
coming at us right now.
    Senator Sanders. Dr. Rust.
    Dr. Rust. The first thing I would like to say is that the 
individuals who will be coming onto the insurance rolls are 
already in the health care system. But they are using it in a 
highly inefficient way because they are trying to defer care, 
and ending up with the sicker care and the more downstream and 
more expensive forms of care.
    Some of this is an issue of reallocation of resources, of 
preferentially shifting funds toward primary care and 
prevention, having your hospital-based care in these 
accountable care organizations and other models. Where people 
are looking at: what is the best way to get to a community 
health outcome? Not, what is the best way to fill up my 
hospital beds? And, what is the best way to generate procedure-
based income?
    So I think as we begin to move to those other payment 
models, you can get to a more efficient system, one that does 
not require every single contact with a patient to be a face-
to-face visit in the exam room because that is what makes a 
billable visit.
    If we are paying for outcomes rather than for volume, then 
what we find is that with the appropriate teams in the primary 
care setting, as well as in partnership with hospitals and 
specialists, we can develop cohesive systems of care that are 
more efficient, that can take care of larger panels of 
patients, and achieve better outcomes without necessarily 
having to have primary clinicians running from exam room to 
exam room all day long trying to generate the billable visits 
on the hamster wheel of current primary care.
    Senator Sanders. All right.
    With that, let me again, thank you all not only for being 
here today, but for the great work that you are doing.
    And with that, this hearing is ended.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                Prepared Statement of Ray E. Stowers, DO
    Chairman Sanders, Ranking Member Burr, and members of the 
subcommittee, on behalf of the American Osteopathic Association (AOA), 
thank you for the opportunity to provide a statement for the record on 
Successful Primary Care Programs: Creating the Workforce We Need.
              the osteopathic profession and primary care
    The American Osteopathic Association (AOA) proudly represents its 
professional family of more than 100,000 osteopathic physicians (DOs) 
and osteopathic medical students; promotes public health; encourages 
scientific research; serves as the primary certifying body for DOs; is 
the accrediting agency for osteopathic medical schools; and has Federal 
authority to accredit hospitals and other health care facilities.
    Osteopathic medicine's roots are in primary care medicine, and 
today, approximately 63 percent of osteopathic physicians are 
practicing in primary care specialties:

                                     Self-Identified DO Practice Specialties
----------------------------------------------------------------------------------------------------------------
                     Family and      General     Pediatrics         Obstetrics        Osteopathic      Other
                      general       internal         and                             manipulative    specialty
                      practice      medicine     adolescent                            medicine   --------------
       Year       -----------------------------   medicine   -----------------------     (OMM)
                                               --------------                       --------------   DOs     %
                     DOs     %     DOs     %     DOs     %        DOs         %       DOs     %
----------------------------------------------------------------------------------------------------------------
2012.............  22,363   37.9  7,618   12.9  3,373    5.7     2,727        4.6      946    1.6  22,003   37.3
----------------------------------------------------------------------------------------------------------------

                          osteopathic training
    While we fully support subspecialty practice, the osteopathic 
medical profession is designed to instill in students the rewards of a 
career in primary care medicine. As a result, our schools produce a 
large number of primary care physicians. The 2013 U.S. News & World 
Report ranking of medical schools reveals that six of the top seven 
medical schools with the highest percentage of graduates who enter 
primary care residencies are colleges of osteopathic medicine:

 
------------------------------------------------------------------------
                                                     Graduates entering
                                                        primary care
                                                    specialties (2009-11
                                                        average) [In
                                                          percent]
------------------------------------------------------------------------
Michigan State University (College of Osteopathic                  77.6
 Medicine)........................................
University of Pikeville...........................                 68.0
West Virginia School of Osteopathic Medicine......                 66.1
University of North Texas Health Science Center...                 65.8
University of Nebraska Medical Center.............                 65.0
University of New England.........................                 65.0
Lake Erie College of Osteopathic Medicine.........                 64.7
------------------------------------------------------------------------
Source: http://grad-schools.usnews.rankingsandreviews.com/best-graduate-
  schools/top-medical-schools/primary-care-residents-rankings.

    The profession also has a long-standing history of training 
physicians who practice in rural and underserved areas. Many of our 
colleges are located in geographic regions with acute physician 
shortages, such as western Washington, Arizona, and the full span of 
Appalachia where we have four schools. This commitment to establishing 
colleges and training opportunities in areas of need is key to meeting 
the health care needs of underserved communities and is indicative of 
the profession's commitment to this cause.
    For example, the University of New England College of Osteopathic 
Medicine (UNECOM) is located in Biddeford, ME. The maps below 
illustrate UNECOM's significant contributions to the primary care needs 
of Maine.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    To help address the emerging shortage of primary care physicians, 
the number of osteopathic medical schools in recent years has been 
growing at a remarkable rate. Our newer schools continue along the 
historical traditions by serving rural and urban underserved areas, 
including the University of Pikeville-Kentucky College of Osteopathic 
Medicine, which is located in eastern Kentucky in the heart of central 
Appalachia; the Edward Via Virginia College of Osteopathic Medicine in 
Blacksburg, VA; the Lincoln Memorial University-DeBusk College of 
Osteopathic Medicine in Harrogate, TN; and the Touro College of 
Osteopathic Medicine in Harlem, NY, to name a few.
    Drawing matriculates from their surrounding communities, these 
schools aim to provide primary care to rural and underserved 
populations.
    Today, osteopathic medicine has a total of 29 accredited colleges, 
offering instruction on 37 campuses in 29 States. The goal of many of 
these schools is to recruit from their local communities, conduct 
training in the local areas, and produce physicians who will return to 
practice osteopathic medicine, many as primary care providers, in those 
communities.
    Another osteopathic school worth noting for its innovation is the 
A.T. Still University--School of Osteopathic Medicine in Arizona (ATSU-
SOMA). Most medical schools use a ``2+2'' model to educate students--
the first 2 years on campus in didactic classes and second 2 years in 
clinical rotations in hospitals and ambulatory sites. In partnership 
with the National Association of Community Health Centers, ATSU-SOMA 
uses a ``1+3'' model to place students in underserved areas for 3 years 
of training. Their first year is on campus completing didactic 
coursework and using standardized and simulated patients. Beginning in 
year two, the students begin rotating in 1 of 11 community health 
centers around the Nation. Such exposure in community settings further 
instills the importance of primary care in these students and prepares 
them to enter it as a career.
    Another advancement in osteopathic training that helps to ensure a 
community focus is the creation and implementation of the Osteopathic 
Postdoctoral Training Institution (OPTI) concept in 1995. An OPTI is a 
community-based training consortium composed of at least one college of 
osteopathic medicine (COM) and at least one hospital, and it can 
include teaching health centers, clinics and other ambulatory training 
facilities. OPTIs are like large umbrellas that connect residency 
training programs to each other and to colleges of osteopathic 
medicine. All osteopathic medical schools and osteopathic residency 
training programs must be members of an OPTI.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    The OPTI enhances quality and efficiency in the delivery of medical 
education by sharing resources both in undergraduate medical education 
and graduate medical education (GME). Through this partnership with 
COMs and hospitals, OPTIs provide support for new program development 
contributing to a stronger primary care workforce. There are currently 
21 OPTIs across the United States, and each has a unique mission and 
vision to serve the needs of the patients and communities in their 
service areas.
               hrsa's teaching health center gme program
    While approximately 10 percent of U.S. GME programs are 
osteopathic, more than half (21 of 32) Health Resources and Services 
Administration (HRSA) Teaching Health Center residencies are 
osteopathic consortia programs accredited by the AOA.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Teaching health centers offer primary care residents the 
opportunity to train in community-based, ambulatory settings--the kinds 
of settings where they will take care of patients throughout their 
careers. Residents receive high-quality, hands-on training in venues 
that expand access to care for patients in urban and rural underserved 
areas. Training in these settings provides the residents with an 
opportunity to make a difference and motivates them to practice in such 
areas after they finish their training.
                 growth of aoa-accredited gme programs
    As a result of the growing national demand for additional residency 
training positions, the osteopathic medical profession increased its 
internship and residency training programs by 5.6 percent from academic 
year 2011 to academic year 2012.

 
------------------------------------------------------------------------
                                   2010-11 Training    2011-12 Training
                                       Programs            Programs
------------------------------------------------------------------------
    Total.......................                961                1015
------------------------------------------------------------------------

    The AOA will also continue its strategy of developing new residency 
training programs in community settings.
                    streamlining physician training
    In addition to location and primary care emphasis, another 
innovation in osteopathic medicine is the accelerated primary care 
program. Osteopathic medicine has embraced accelerated undergraduate 
educational programs as a method to address the national shortage of 
primary care physicians in the United States.
    Accelerated programs reduce the length of undergraduate education 
from 4 years to 3 years, saving the student money. In addition, 
students commit to entering osteopathic primary care residency programs 
directly after graduation and practicing primary care medicine for a 
minimum of 5 years following the successful completion of residency. 
These programs have been in operation at The Lake Erie College of 
Osteopathic Medicine's accelerated program since April 2006, and at the 
New York Institute of Technology College of Osteopathic Medicine's 
since December 2010.
    While our experience with accelerated programs has been positive, 
more innovation is needed if the national shortage of physicians is to 
be addressed. The AOA and the American Association of Colleges of 
Osteopathic Medicine (AACOM) have formed a Blue Ribbon Commission to 
guide the transformation of the osteopathic medical education system to 
meet the needs of the next generations of patients. This Commission is 
composed of the leading medical educators in osteopathic medicine who 
have been tasked with making recommendations so that the osteopathic 
medical education system can be a leader in producing physicians needed 
in the coming years. The physician of the future must understand the 
dynamics of team-based care and the role of each health care provider 
in the health of the patient. Importantly, medical education must be 
integrated and streamlined so that the overall lengths of undergraduate 
medical education and GME are reduced without sacrificing quality. We 
anticipate release of the Commission's findings and recommendations 
later this year.
                            recommendations
    The American Osteopathic Association (AOA) believes Congress 
should:

     Revise the cap on GME residency slots to provide a greater 
teaching capacity in our Nation's teaching hospitals.
     Specify that increases in funded GME residency positions 
should be targeted to primary care, general surgery, and other medical 
specialties most in need.
     Prioritize new residency slots to States with new medical 
schools and colleges of osteopathic medicine.
     Advance proposals that provide for transparency and 
accountability in the use of GME funding.
     Support new and innovative models for the financing of GME 
programs and distribution of GME dollars.
     Continue funding important programs including title VII 
and the HRSA Teaching Health Center GME Program.
     Advance proposals that would increase training 
opportunities in community-based settings. These settings are underused 
and viable training sites that are deserving of greater opportunities 
to train future physicians--especially those in primary care 
specialties.
     Examine options for targeted scholarship, loan deferment 
and loan forgiveness programs to encourage medical school graduates to 
invest in the small primary care practices so many communities are 
lacking. The average osteopathic medical school graduate has a debt 
nearing $200,000, and this can be a deterrent to their entering into 
primary care.
                               conclusion
    The AOA fully supports dialog on how to ensure an adequate primary 
care workforce. We believe we have innovative ideas that can be shared 
broadly. Our colleges and OPTIs are given the encouragement and support 
to prepare for the evolving needs of our patients. We hope this 
important dialog on the primary care workforce further facilitates and 
encourages innovative thinking.
    We applaud the subcommittee for their interest in addressing this 
important issue. Thank you again for the opportunity to submit our 
statement to the committee, and we look forward to a continued dialog. 
The osteopathic medical profession remains ready to ensure a strong 
physician workforce.

  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 April 23, 2013, hearing, 
``Successful Primary Care Programs: Creating the Workforce We Need,'' 
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 U.S.-medical schools 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 Chair Bernie Sanders and Ranking 
Member Richard Burr for continuing their attention to the gaps in 
access that will occur as the demand for health care services exceeds 
the supply of physicians and other health professionals over the next 
few years. As has been widely reported, and as was described in the 
subcommittee's January 29 hearing, the Nation faces a shortage of 
91,500 physicians in the next decade, a consequence of an aging patient 
population battling multiple chronic conditions; an influx of up to 32 
million newly insured individuals entering the health care system with 
previously untreated conditions; and attrition in the physician 
workforce as current practitioners near retirement.
    The deficit of physicians spans evenly across both primary and 
specialty care, with shortages of over 45,000 primary care physicians 
and 46,000 specialists expected by 2020. Medical schools already have 
taken the first critical step to address this increased demand, 
enrolling by 2016, 30 percent more students compared to 2002.
    Notwithstanding recent upticks in the number of medical graduates 
opting to pursue primary care, some have expressed concern about the 
level of interest in primary care careers (even among pre-medical 
students) and its implications, given projected shortages. In addition 
to the noteworthy efforts of The Brody School of Medicine at East 
Carolina University; the Frank H. Netter, M.D., School of Medicine at 
Quinnipiac University; and Morehouse School of Medicine, a number of 
AAMC-member institutions across the country have undertaken initiatives 
to facilitate interest in primary care careers. In accordance with the 
theme of this hearing, the AAMC offers through this statement a broad 
overview of these programs to supplement the testimony of the three 
witnesses from AAMC-member institutions. In light of the pressing 
health needs of the rapidly increasing Medicare population, the AAMC 
hopes the subcommittee next will schedule a subsequent hearing that 
explores the similarly surging demand for specialty care.
    Despite the best efforts of medical schools to increase the number 
of matriculates, such action will have a negligible effect on reversing 
physician shortages--in either primary or specialty care--unless 
Congress permits a proportionate increase in Federal support for 
graduate medical education (GME) training positions at teaching 
hospitals. 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.
    According to the National Resident Matching Program, in the 2013 
Match, 528 qualified U.S.-medical school graduates did not match to a 
residency training position and 99.4 percent of positions were filled. 
Only five family medicine positions, six internal medicine positions, 
two pediatrics positions, 10 preliminary general surgery positions, 
seven psychiatry positions, and 31 positions in a handful of other 
specialties remained unfilled at the conclusion of the Match and the 
Supplementary Offer and Acceptance Program. Regardless of a medical 
graduate's specialty choice, he or she will not be able to complete the 
training required for independent practice unless a sufficient number 
of training positions is available across specialties. Thus, 
successfully bolstering the number of both primary care and specialty 
care physicians will rely on congressional action to expand Medicare 
support for training positions at teaching hospitals.
    Accordingly, this statement also highlights legislation recently 
introduced in both chambers to release this bottleneck. The ``Resident 
Physician Shortage Reduction Act of 2013'' (S. 577/H.R. 1180) and the 
``Training Tomorrow's Doctors Today Act'' (H.R. 1201) will be a 
critical element of any comprehensive national workforce strategy. 
Other Federal programs also play a key role in promoting primary care 
practice. The AAMC encourages the subcommittee to continue its 
longstanding tradition of support for investments in the health care 
workforce and to work with the Senate Finance Committee, as well as the 
House Ways & Means and Energy & Commerce Committees, in advancing S. 
577/H.R. 1180/H.R. 1201, in the interest of improving access to care 
for all patients.
medical schools are actively responding to the nation's workforce needs
    In 2005, the Liaison Committee on Medical Education (LCME) fully 
accredited a new medical school for the first time since 1986, bringing 
the total number of medical schools to 125. Today, after two decades of 
no growth, the total number of medical schools stands at 141, 
paralleled by increases in class sizes at existing medical schools. The 
proliferation of medical education programs predates enactment of the 
Affordable Care Act (ACA, P.L. 111-48 and P.L. 111-52), rather 
reflecting a recognition that the Baby Boomers soon would confront 
ailments common to old age--ranging from Alzheimer's disease and 
dementia to heart disease to hip fractures--and the physician supply 
would not be sufficient to meet their needs. Extending health care 
coverage to as many as 32 million previously uninsured individuals 
through the ACA amplifies these looming physician shortages and 
heightens the urgency to address them.
    Guided by both the benefit and challenge of building a new 
educational program from scratch, the new medical schools are proving 
eager to pursue curricular innovations to help address both national 
and local needs. Prevalent themes among this new cohort include early 
clinical experiences for students, curricular structures that integrate 
the basic and clinical sciences, emphasis on interprofessional 
educational opportunities, and case-based learning. Schools also are 
reporting novel approaches to advancing their specific missions, such 
as Cooper Medical School of Rowan University, which requires students 
to complete 40 hours annually of non-medical community service in the 
school's neighborhood of Camden, NJ. While the mission of each medical 
school necessarily differs, many of the new schools report an emphasis 
on primary care.
    Profiles of these new institutions are featured in the November 
2012 AAMC report, A Snapshot of the New and Developing Medical Schools 
in the United States and Canada, available at: https://
members.aamc.org/eweb/upload/A%20Snap-
shot%20of%20the%20New%20and%20Developing%20Medical%20Schools%20in%20
the%20US%20and%20Canada.pdf. Continued study and analysis of their 
efforts over time will help inform opportunities to further shape 
medical education and the culture of medical practice.
    Existing medical schools also have implemented creative initiatives 
to address challenges as they evolve, including some specifically 
targeted to promoting primary care. In a 2010 survey of medical school 
deans, 75 percent (94 of 125 respondents) reported current or future 
plans to institute programs or policies to encourage student interest 
in primary care. Two-thirds of those 94 schools reported refined 
admissions criteria and 60 percent reported expanded primary care 
faculty and/or resources. Most also reported new or expanded 
extracurricular opportunities (87 percent); new, expanded, or modified 
clinical rotations (74-73 percent); modified pre-clinical curricula (71 
percent); and other activities (19 percent).
    The Duke University School of Medicine officially launched the 
Primary Care Leadership Track in 2011 after a 2-year pilot phase. The 
program combines community service, experience, and requires a year of 
community-engaged research, with a goal of preparing physicians to work 
with and learn from communities to improve care delivery and produce 
better outcomes. Similarly, the University of California, San Francisco 
(UCSF), School of Medicine administers the Program in Medical Education 
for the Urban Underserved (PRIME-US), an effort that is not a dedicated 
primary care track, though the majority of participants enter primary 
care disciplines. The program aims to produce leaders to care for urban 
underserved communities and embeds community-based participatory 
research among students' experiences.
    Some medical schools have established rural or small-town regional 
campuses that serve as fully functional branches of the main campus. 
Groups of students receive their entire 4 years of undergraduate 
medical education, or the bulk of their clinical experience, at the 
rural site. For example, the Columbia University College of Physicians 
and Surgeons in New York began accepting students in the fall of 2011, 
for a new rural medicine track in partnership with Bassett Healthcare 
System in the upstate New York village of Cooperstown. For the first 18 
months of medical school, students in the Columbia-Bassett program 
attend core ``foundations of medicine'' classes at Columbia's northern 
Manhattan campus, then move to Cooperstown, a town of only 2,000, for 
longitudinal clinical experiences. The University of Kansas School of 
Medicine, Indiana University School of Medicine, and the Texas Tech 
Health Sciences University in Lubbock--among others--boast similar 
programs.
    Other institutions are building new models for primary care in the 
face of changing demographics and health care challenges. The Warren 
Alpert Medical School of Brown University is developing a novel dual-
degree Primary Care and Population Health program to ensure graduates 
understand the clinical, behavioral, and public health contexts of 
patient care. Expected to begin in fall 2015, the 4-year M.D./Sc.M. 
program would allow students to follow patients through their various 
interactions with the health care system by engaging in 9-month, 
physician practice-based clerkships. The experiences are designed to 
help students learn not only the medical knowledge necessary for 
quality care, but also public health policy, leadership skills, and 
familiarity with practice as part of a broader patient-care team.
    At the national level, the AAMC has partnered with other health 
education associations through the Interprofessional Education 
Collaborative (IPEC) to focus on better integrating and coordinating 
the education of nurses, physicians, pharmacists, dentists, public 
health professionals and other members of the patient health care team 
to provide more collaborative and team-based care. A growing body of 
work demonstrates that shared learning experiences of this sort can 
improve health outcomes. Supported by funding from the Macy Foundation, 
IPEC recently awarded funding to 16 interprofessional teams to 
accelerate education content refinement and submission for peer review 
to AAMC's free, web-based MedEd-
PORTAL data base, which will serve as a national clearinghouse of 
competency-linked learning resources for IPE and models of team-based 
or collaborative care. To date, interest in IPEC's faculty development 
institutes has been so strong that registration reaches capacity only 
hours after opening.
    In graduate medical education, too, a number of institutions have 
successfully incorporated key attributes of the Patient-Centered 
Medical Home (PCMH) model of care into their delivery system while 
serving as a training site for medical residents and other health 
professionals. In early 2010, the AAMC, in collaboration with 
representatives of the Society of General Internal Medicine (SGIM) and 
the American College of Physicians (ACP), designed a survey that was 
distributed to AAMC member institutions, asking participants to 
identify residency programs that have integrated into their care system 
infrastructural or workforce transformations commonly associated with 
the medical home. Respondents to the survey described a high level of 
team-based care consisting of physician and non-physician clinicians, 
as well as care coordinators, social workers, PharmDs, and 
nutritionists. Practices also noted enhanced access and communication, 
significant quality monitoring and improvement activities, and near 
unanimous access to electronic health records technology. Seven high-
performing practices (including The Brody School of Medicine Department 
of Family Medicine) were profiled in the AAMC's November 2010 
publication, Moving the Medical Home Forward: Innovations in Primary 
Care Training and Delivery. The full report is available at: https://
members.aamc.org/eweb/upload/
Moving%20the%20Medical%20Home%20Forward.pdf.
    The examples cited here are by no means exhaustive. While all 
medical schools are committed to producing primary care physicians in 
accord with the Nation's needs, it is also important to note that each 
medical education program is responsible for establishing a curriculum 
aligned with its own institutional missions and educational objectives 
within the framework of general competencies required for accreditation 
by the LCME. Medical schools serve society in many ways--they conduct 
groundbreaking medical research that helps address the health needs of 
all patients; they provide vital community services such as geriatric 
care, nutrition counseling, health clinics, and free screenings for the 
uninsured and underinsured; and they work to improve medical care not 
only for Americans, but also for disadvantaged populations globally. 
Measuring their contributions to society solely through their efforts 
to cultivate interest in primary care overlooks the vital role that 
many of these institutions play in advancing other essential components 
of quality health care.
    Moreover, the AAMC strongly supports the ability of individual 
medical students and physicians to determine for themselves which area 
of medicine they wish to pursue. While medical schools actively carry 
out their responsibility to present an array of rich educational 
experiences across disciplines of medicine, ultimately, each individual 
student must determine the specialty that best suits his or her 
personal and career goals. Education and training cannot overcome the 
intense market incentives that influence physician choices.
 expanding the physician workforce relies on congress lifting the cap 
                             on gme support
    Before medical graduates can practice independently, they must 
complete advanced supervised training in the form of a residency at a 
teaching hospital. But, as described above, Congress has limited the 
availability of training positions by freezing Medicare support for GME 
at 1996 levels. Though medical schools will be graduating more medical 
students to respond to the increased demand, the overall number of 
physicians is likely to remain the same without congressional action. 
This bottleneck will thwart efforts to expand both the primary care and 
specialty care workforce.
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.
    Direct Graduate Medical Education (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 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.
    Teaching hospitals also receive Medicare Indirect Medical Education 
(IME) payments, but these 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. 
For example, AAMC member teaching hospitals operate 80 percent of Level 
1 Trauma centers, 79 percent of all burn care units, 40 percent of 
neonatal- and 61 percent of pediatric ICUs, nearly half of surgical 
transplant services, and provide a range of other highly sophisticated 
services not offered elsewhere in communities. 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. 
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 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. 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.
Legislation Introduced Recently Would Strengthen the Primary and 
        Specialty Care Workforce by Lifting the Freeze on Medicare GME 
        Support
    Senators Bill Nelson and Chuck Schumer and Majority Leader Harry 
Reid recently introduced the ``Resident Physician Shortage Reduction 
Act of 2013'' (S. 577) to expand physician training support. The 
measure is accompanied by a bipartisan companion (H.R. 1180) in the 
House, introduced by Reps. Joe Crowley and Michael Grimm, as well as a 
similar bill, the ``Training Tomorrow's Doctors Today Act'' (H.R. 
1201), introduced by Reps. Aaron Schock and Allyson Schwartz. While 
there are some differences among the bills, all three would increase 
the number of residency slots by 15,000 over 5 years, directing half of 
the newly available positions to training in shortage specialties. The 
bills also specify priorities for distributing the new slots, such as 
prioritizing States with new medical schools and hospitals that 
emphasize training in community health centers, community-based 
settings, or hospital outpatient departments.
    AAMC strongly supports these bills, which are consistent with the 
policy recommendations AAMC outlined in its statement submitted to the 
record for the subcommittee's January 29 hearing. With over 99 percent 
of current residency positions filled in the 2013 Match, any efforts to 
augment the number of practicing physicians of any specialty will rely 
on the availability of additional training positions. Further, 
proposals to undermine support to teaching hospitals threaten to weaken 
the Nation's physician training capacity at the most inopportune time.
    It also should be noted that 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. 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. 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, the National Health Service Corps (NHSC) and 
title VII health professions education and training programs, instead.
   investments are necessary in other federal programs that promote 
                              primary care
    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. Additional discussion of such influences is included in the 
recent report, AAMC Physician Education Debt and the Cost to Attend 
Medical School: 2012 Update, available at: https://www.aamc.org/
download/328322/data/statedebtreport.
pdf.
    Further, Federal programs, such as the 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 
Income Based Repayment, Public Service Loan Forgiveness, and the NHSC. 
Continued investment in the NHSC and other programs designed to 
encourage practitioners toward primary care practice is another key 
component to an optimal Federal workforce strategy.
National Health Service Corps (NHSC)
    Administered by the Health Resources and Services Administration 
(HRSA), the NHSC provides scholarships and loan repayment to health 
professionals in exchange for practicing primary care in federally 
designated health professions shortage areas (HPSAs). The program is 
widely recognized--both in Washington and in the underserved areas it 
helps--as a success on many fronts. The NHSC improves access to health 
care for the growing numbers of rural and urban underserved Americans; 
provides incentives for practitioners to enter primary care; and 
reduces the financial burden that the cost of health professions 
education places on new practitioners.
    By the end of fiscal year 2013, the NHSC expects to have provided 
scholarships and loan repayment to over 44,400 health professionals 
committed to providing care to underserved communities over its 41-year 
history. In 2012, NHSC clinicians working at NHSC sites provided 
primary health care to 10.4 million underserved people in HPSAs. In 
spite of the NHSC's success, there are still over nearly 55 million 
people living in 5,900 primary care HPSAs. It would take nearly 7,550 
physicians to eliminate these primary care HPSAs.
    The NHSC State Loan Repayment Program (SLRP) is a grant program 
which offers a dollar-for-dollar match for State loan repayment 
programs. Unfortunately, the NHSC SLRP is redundantly limited to 
matching the funding of State programs that address the same workforce 
shortages as the Federal program. The AAMC recommends expanding 
authorization of the NHSC SLRP to allow States to address their unique 
primary care service shortages.
    Thanks in large part to the efforts of the Chairman, the ACA 
provides crucial funding for the NHSC through fiscal year 2015. The 
steady, sustained, and certain growth established by this mandatory 
funding for the NHSC has resulted in program expansion and innovative 
pilots such as the Student to Service (S2S) Loan Repayment Program that 
incentivizes fourth-year medical students to practice primary care in 
underserved areas after residency training.
    The AAMC opposes any rescissions from or repeal of the NHSC Fund 
created under the ACA. The AAMC further requests that any expansion of 
NHSC eligible disciplines or specialties be accompanied by a 
commensurate increase in NHSC appropriations so as to prevent a 
reduction of awards to current eligible health professions. Despite 
growing health professional workforce shortages and an unprecedented 
access to health insurance, the NHSC Fund expires soon, leaving 
questions about how Congress will maintain the program after fiscal 
year 2015. The AAMC encourages the subcommittee to prioritize continued 
funding for NHSC beyond fiscal year 2015, while also preserving the 
full spectrum of other Federal health care workforce programs.
Title VII Health Professions Programs
    The HRSA programs authorized under Title VII of the Public Health 
Service Act are designed to provide education and training 
opportunities in high-need areas to aspiring health care professionals. 
With a focus on primary care, they are the only Federal programs 
designed to train providers in interdisciplinary, community-based 
settings to meet the needs of the country's special and underserved 
populations, increase minority representation in the health care 
workforce, and fill the gaps in the supply of health professionals not 
met by traditional market forces. Celebrating their 50th anniversary in 
2013, the programs' longstanding success can be attributed to their 
ability to help the workforce adapt to Americans' changing health care 
needs by advancing timely priorities.
    For example, HRSA data from the 2011-12 academic year show the 
number of title VII participants who practice in a medically 
underserved community (MUC) and/or a HPSA after graduation is 
increasing, and on average, 1 in 3 participants enter practice in a MUC 
or HPSA. Further, individuals who participate in title VII programs are 
more likely to join the NHSC and/or work in community health centers 
(CHCs).
    In addition to the title VII primary care medicine programs, the 
title VII Area Health Education Centers (AHEC) program, which provides 
interprofessional, community-based training opportunities, trained more 
than 28,000 medical students in rural and or underserved communities in 
the 2011-12 academic year alone. AHECs also provide academic enrichment 
to students and continuing education to providers on a variety of 
topics, including cultural competence, health disparities, diabetes, 
and issues affecting veterans.
    Similarly, the title VII diversity programs play an instrumental 
role in producing a workforce equipped to mitigate racial, ethnic, and 
socio-economic health disparities. For example, the most recent data 
show that the diversity pipeline Health Careers Opportunity Program 
(HCOP) trained 5,333 disadvantaged students, a 20 percent increase over 
the previous year, helping students successfully complete their 
coursework and helping to create a more competitive applicant pool to 
health education programs.
    Yet, despite the programs' successes in shaping the health care 
workforce, their relatively modest funding continually is under siege. 
The AAMC recommends $520 million in fiscal year 2014 for the title VII 
health professions programs and their nursing workforce development 
counterpart, title VIII.
Teaching Health Centers
    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. 
The law requires programs to meet the same accreditation criteria as 
other residency programs, and HRSA allows THCs to satisfy this 
requirement through participation in a consortium that includes a 
hospital/other entity that is listed as the institutional sponsor.
    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.
    Medical schools and teaching hospitals make unparalleled 
contributions to improving medical care in the United States and around 
the globe through their integrated missions of education, research, and 
patient care. As the Nation faces an unprecedented demand for health 
care services, continued support for these institutions 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 American Academy of Physician Assistants 
                                 (AAPA)
    On behalf of the more than 90,000 clinically practicing physician 
assistants (PAs) in the United States, the American Academy of 
Physician Assistants (AAPA) is pleased to submit comments to the Senate 
HELP Subcommittee on Primary Health and Aging following its April 23, 
2013 hearing, Successful Primary Care Programs: Creating the Workforce 
We Need.
    The Academy has been following the subcommittee's actions, and we 
appreciate the subcommittee's continued recognition of the physician 
assistant profession, as well as the subcommittee's support for primary 
care and public health.
    Nearly 30 million uninsured people are about to obtain medical 
coverage under the Patient Protection and Affordable Care Act beginning 
January 2014; yet, we have a projected shortage of 45,000 primary care 
physicians by 2020. The AAPA believes that the physician assistant 
profession is integral to addressing this shortage and improving access 
to care for those currently in the system, and for those who will seek 
care in 2014.
    The PA profession has grown dramatically since its first education 
program was launched nearly 45 years ago. With over 90,000 certified 
PAs and 6,000 newly graduated PAs joining their ranks this past year, 
PAs are one of the fastest growing healthcare professions in the United 
States. In fact, the Bureau of Labor Statistics predicted in 2010 a 30 
percent growth in PA jobs over the next decade.
    Furthermore, since the passage of the Patient Protection and 
Affordable Care Act in 2010, over 80 new PA education programs are 
expected to be accredited by mid-2016. With this substantial growth 
rate, it is projected that over 10,000 PAs will be entering the medical 
workforce per year by 2020 to help offset the growing shortage of 
physicians.
                          pas in primary care
    An estimated 30,000 PAs (30 percent of the profession) work in 
primary care across the Nation--37 percent work in private practice 
(both physician group and solo practices); 3.1 percent practice in 
community health centers, 2.7 percent practice in certified rural 
health clinics, and 2.1 percent work in a Federally Qualified Health 
Center.
    PAs are also one of three primary care providers who work in the 
National Health Service Corps (NHSC). The NHSC is an important Federal 
program with nearly 10,000 healthcare providers, like PAs, who benefit 
from the program's loan-forgiveness and scholarships awards to those 
providers and students who commit 2 years to provide medical, dental 
and mental healthcare in medically underserved areas.
    Additionally, an estimated 2,790 PAs proudly work in community 
health centers (CHCs) around the country, some as CHC medical 
directors. Community health centers provide cost-effective healthcare 
throughout the country and serve as medical homes for millions in 
medically underserved areas. CHCs offer a wide variety of healthcare 
services through team-based care, providing high quality healthcare to 
CHC patients and significantly reducing medical expenses.
                         how are pas educated?
    The PA educational program is modeled on the medical school 
curriculum, a combination of classroom and clinical instruction. The PA 
course of study is rigorous and intense. The average length of a PA 
education program is 27 months.
    Admission to a PA educational program is highly competitive. 
Applicants to PA programs must complete at least 2 years of college 
courses in basic science and behavioral science as prerequisites to PA 
school, analogous to premedical studies required of medical students. 
The majority of PA programs have the following prerequisites: 
chemistry, physiology, anatomy, microbiology, and biology. 
Additionally, most PA programs require or prefer that applicants have 
prior healthcare experience.
    PA education includes instruction in core sciences: anatomy, 
physiology, biochemistry, pharmacology, physical diagnosis, 
pathophysiology, microbiology, clinical laboratory science, behavioral 
science and medical ethics.
    PAs also complete more than 2,000 hours of clinical rotations, with 
an emphasis on primary care in ambulatory clinics, physician offices 
and acute or long-term care facilities. Rotations include family 
medicine, internal medicine and psychiatry.
    Practicing PAs participate in lifelong learning. In order to 
maintain national certification, a PA must complete 100 hours of 
continuing medical education every 2 years. Additionally, PAs must 
currently take a recertification exam every 6 years to maintain 
certification through the National Commission on Certification of 
Physician Assistants.
    Currently there are 173 accredited Physician Assistant education 
programs in the U.S., with 74 in the pipeline. The overwhelming 
majority of PA educational programs award master's degrees. Currently 
41 PA programs have a curriculum that prepares students specifically 
for a career in primary care, including PA educational programs 
represented by Senators on the subcommittee, such as: Christian 
Brothers University in Tennessee, Duke University, and the University 
of Maryland Eastern Shore. All PA educational programs are accredited 
by the Accreditation Review Commission on Education for the Physician 
Assistant.
    Many of these primary care mission-based PA programs benefit from 
grants from the Public Health Service Act Title VII Health Professions 
Program. These funds are awarded to programs that not only educate and 
guide PA students into primary care and underserved areas, but also 
recruit PA students from underrepresented minority populations to help 
improve the diversity of the healthcare workforce.
    An AAPA study of PA graduates from 1990-2009 revealed that PAs who 
graduated from a title VII supported program were 67 percent more 
likely to be from an underrepresented minority population and were 47 
percent more likely to work in a rural health clinic. The title VII 
program is the only Federal educational program designed to address the 
supply and distribution imbalances in the health professions.
    In 2010, 39 percent of all PA graduates went into primary care, 
which includes family medicine, general internal medicine, and general 
pediatrics. With the need for more primary care providers, it is 
crucial that we invest in the title VII program that supports PA 
educational programs in primary care. With title VII assistance, the PA 
profession is expected to grow 39 percent through 2018 to help meet the 
increasing demands for care.
                    current challenges in education
    Due to the rapid growth in the number of PA programs, title VII 
Health Professions grants are a necessary part of developing new 
curricula to address the needs of underserved populations, as well as 
faculty development for new and experienced faculty.
    Faculty development is crucial. The anticipated 74 new PA 
educational programs will require approximately 448 new faculty 
members, many of whom will likely transition from clinical practice 
with no teaching experience. In addition, the current PA educational 
grant has two new priorities for programs to address: developing a 
pathway for our Nation's veterans into PA educational programs and 
improving the quality of teaching at clinical training sites.
    As it is for other health professions, acquiring, maintaining and 
ensuring a high-level of quality clinical sites is a tremendous 
challenge for PA programs. Title VII grants help fill these gaps and 
ensure that PA curriculum and faculty are able to address the training 
needs of students, as well as to ensure well-trained clinicians to meet 
the Nation's growing health needs.
                      physician assistant practice
    Physician assistants are licensed health professionals who practice 
medicine as members of a team with a physician. PAs exercise autonomy 
in medical decisionmaking and provide a broad range of medical and 
therapeutic services to diverse populations in rural and urban 
settings.
    In all 50 States, PAs carry out physician-delegated duties that are 
allowed by law and within the physician's scope of practice and the 
PA's training and experience. Additionally, PAs are delegated 
prescriptive privileges in all 50 States, the District of Columbia, and 
Guam. This allows PAs to practice in rural, medically underserved areas 
where they are often the only full-time medical provider.
      unnecessary federal barriers to medical care provided by pas
    Over the last 45 years, the PA profession has emerged as a critical 
component of our Nation's healthcare workforce and was recognized in 
the Patient Protection and Affordable Care Act as one of three 
professions providing primary care. However, Federal laws and 
regulations created during the advent of the profession have not kept 
pace with the evolution of PA practice into the 21st century. 
Significant and unnecessary barriers to the quality medical care 
provided by PAs remain. Specifically, changes are necessary to allow 
PAs to provide hospice care to, and order hospice and home health care 
for, Medicare beneficiaries. Additionally outdated Medicare 
regulations, such as the inability of PAs to order fecal occult blood 
tests, must be addressed to allow PAs to practice as efficiently as 
possible.
    PAs were largely left out of the Medicaid electronic health record 
incentive (EHR) program in the Health Information Technology for 
Economic and Clinical Health (HITECH) Act of 2009. The absence of PAs 
in this program has created a disparity for patients served by PAs, 
particularly in underserved areas where PAs may be the sole primary 
care provider. Unless the PA a is the lead practitioner in a Federally 
Qualified Health Center or a Rural Health Clinic, their practice and 
their patients may be unable to obtain access to electronic health 
records due to the lack of funding. The Medicaid EHR incentive program 
is a significant boon to medical offices around the country, yet PAs 
are not able to access this incentive in the same manner as physicians 
and nurse practitioners, creating a financial disincentive for some 
practices to employ PAs.
           how does the quality of care provided by pas rate?
    PAs deliver high-quality care and enjoy high patient satisfaction. 
Studies have consistently shown that PAs provide high-quality care with 
outcomes similar to physician-provided care. Additionally, studies have 
shown that incorporating PAs into office or hospital practice can 
improve outcomes. For example, when a trauma center transitioned from a 
resident-assisted to PA-assisted trauma program, the quality of care 
improved, with a 1-day reduction in length of stay. A study published 
in the Journal of the American Geriatrics Society indicates that 
nursing homes that used PAs had lower hospitalization rates for 
ambulatory care sensitive conditions.
    Patients are consistently satisfied with PA-provided care. Studies 
have shown that patients are just as satisfied with medical care 
provided by PAs as with that provided by doctors and do not distinguish 
between types of care providers.
       how do pas increase the cost-effectiveness of healthcare?
    Studies have shown that PAs can increase the cost-effectiveness of 
healthcare. PA labor costs are more affordable. A practice employing a 
PA pays less in overhead costs for that PA compared to a physician, 
while having a healthcare provider on board who can provide most of the 
same services. A study examining a national sample of patients found 
that those who saw a PA for most of their yearly office visits had 
approximately 16 percent fewer visits per year than patients who only 
saw physicians.
    Additionally, PAs provide preventive services, which reduce the 
need for more costly acute care and chronic care management. Patient 
costs, in terms of actual payment, lost time from work and unnecessary 
pain, are decreased when patients can be seen promptly in the most 
appropriate setting. For example, it is always more cost-effective to 
get a flu vaccination than to be hospitalized for an influenza-related 
complication.
    PA education costs less and takes less time than physician 
education, which allows PAs to enter the workforce more quickly. 
Further, PAs can practice in any medical or surgical specialty, and 
they can perform almost all the duties that physicians perform. 
Therefore, PAs are cost-effective options for practices and hospitals 
looking to offset physician shortages and trim overhead.
   how do pas fit into healthcare reform and the patient protection 
                    and affordable care act (ppaca)?
    The intent of healthcare reform is to provide care for all 
Americans while reducing healthcare costs through adequate preventive 
care. PAs help extend physician care and can easily adapt to any care 
model. Their education prepares them to work in teams, and they help to 
coordinate care and provide preventive services.
    PAs were recognized by Congress and the President as crucial to 
improving U.S. healthcare. In the PPACA, Congress recognized PAs as one 
of three healthcare professions in primary care. PAs were also 
recognized as crucial to the Independence at Home model noted in the 
PPACA. Further acknowledging PAs' value in a reformed healthcare 
system, the Administration in 2010 committed additional money for the 
education of PAs.
    One example of an emerging care model that is strongly supported by 
health care reform is the patient centered medical home (PCMH). This 
model makes use of all healthcare providers' skills in ways that are 
most efficient and effective for patients and encourages open and 
continued communication with each provider and the patient.
    In a PCMH, clinicians work together to provide care that is 
comprehensive, ongoing and coordinated. The clinical team provides 
primary, acute and preventive medical care. The team also integrates 
specialty referrals and other services from the health system and 
community.
    Additionally, PAs play a vital role in chronic care management. 
Chronic care management programs may reduce hospital admissions, re-
admissions, specialty care and prescription drug use, in turn 
eliminating costly healthcare services. This model relies heavily on 
patient education and empowering patients to play an integral role in 
their healthcare.
    Thank you for the opportunity to submit comments for the hearing 
record on behalf of the American Academy of Physician Assistants.
  Prepared Statement of the Physician Assistant Education Association 
                                 (PAEA)
    On behalf of the 174 accredited physician assistant (PA) education 
programs in the United States, the Physician Assistant Education 
Association (PAEA) is pleased to submit these comments for the record 
on the recent hearing, ``Successful Primary Care Programs: Creating the 
Workforce We Need.''
                          primary care crisis
    The unmet need for primary care services in the United States is 
well documented, and only expected to grow as Baby Boomers age and the 
Affordable Care Act is fully implemented. Simultaneously, the very 
parameters of access and health care quality are rapidly evolving. Yet 
the one constant in our health care system remains the need for 
qualified health care providers in numbers sufficient to meet demand, 
and primary care has been clearly identified as the critical entry 
point into the health care system where that access must be guaranteed. 
PAs stand ready for the challenges in primary care, and could play an 
even larger role with appropriate financial support and through 
innovations in the PA education system.
    Like physicians, the PA profession also faces shortages that will 
hinder its ability to help address the primary care issue in the United 
States. Without new solutions, at the current output of approximately 
6,500 graduates from PA programs per year, these shortages will 
persist, particularly in the rural and underserved communities where 
care is needed the most. Title VII funding is the only opportunity for 
PA programs to apply for Federal funding and plays a crucial role in 
developing and supporting the PA education system's ability to produce 
the next generation of these critical advanced practice clinicians.
                    background on the pa profession
    Since the 1960s, PAs have consistently demonstrated they are 
effective partners in health care, readily adaptable to the needs of an 
ever-changing delivery system. Physician assistants are licensed health 
professionals who practice medicine as members of a team with their 
supervising physicians. PAs exercise autonomy in medical decisionmaking 
and provide a broad range of medical and therapeutic services to 
diverse populations in rural and urban settings. In all 50 States, PAs 
carry out physician-delegated duties that are allowed by law and within 
the physician's scope of practice and the PAs training and experience. 
Additionally, PAs are delegated prescriptive privileges by their 
physician supervisors in all 50 States, the District of Columbia, and 
Guam. This allows PAs to practice in rural and other medically 
underserved areas where they are often the only full-time medical 
provider.
          pa education: the pipeline for physician assistants
    There are currently 173 accredited PA education programs in the 
United States--a 23 percent increase over the past 5 years; together 
these programs graduate over 6,500 PA students each year. PAs are 
educated as generalists in medicine and their flexibility allows them 
to practice in more than 60 medical and surgical specialties. More than 
a third of PA program graduates practice in primary care.
    The average PA education program is 26 months in length and 
typically, 1 year is devoted to classroom study and approximately 12 
months is devoted to clinical rotations. Most curricula include 340 
hours of basic sciences and nearly 2,000 hours of clinical medicine.
    As of today, approximately 74 new PA programs are in the pipeline 
at various stages of development, moving toward accredited status. The 
growth rate in the applicant pool is even more remarkable. Since its 
inception in 2001 until the most recent application cycle, the 
Centralized Application Service (CASPA) used by most programs grew from 
4,669 applicants to over 19,000. In March 2009, there were a total of 
12,216 applicants to PA education programs; as of March 2013, there 
were 19,786 applicants to PA education programs. This represents a 54 
percent increase in CASPA applicants over the past 5 years.
    The PA profession is expected to continue to grow as a result of 
the projected shortage of physicians and other health care 
professionals, the growing demand for care driven by an aging 
population, and the continuing strong PA applicant pool. The Bureau of 
Labor Statistics projects a 39 percent increase in the number of PA 
jobs between 2008 and 2018. With its relatively short initial training 
time and the flexibility of generalist-trained PAs, the PA profession 
is well-positioned to help fill projected primary care shortages in the 
numbers of health care professionals--if appropriate resources are 
available to support the education system behind them.
                          areas of acute need
Faculty Shortages
    Faculty development is one of the profession's critical needs and 
educators are an often overlooked element to developing an adequate 
primary care workforce. In order to attract the most highly qualified 
individuals to teaching, PA education programs must have the resources 
to train faculty in academic skills, such as curriculum development, 
teaching methods, and laboratory instruction. Most educators come from 
clinical practice and these non-clinical professional skills are 
essential to a successful transition from clinical practice to 
teaching. Without Federal support, we will continue to cycle through 
faculty in the didactic and clinical portions of PA student education. 
Nearly 50 percent of PA faculty are 50 years or older so the profession 
faces large numbers of retirements in the next 10-15 years. An interest 
in education must be developed early in the educational process to 
maintain a continuous stream of qualified educators.
Clinical Site Shortages
    A lack of clinical sites for PA education is hampering PA programs' 
ability to produce the next generation of PAs at the pace needed to 
meet the demand for primary care in the United States. This shortage is 
caused by two main factors: a shortage of people willing to teach 
students as they are cycling through their rotations (preceptors), and 
a lack of sites with the physical space to teach.
    This phenomenon is experienced throughout the health professions, 
and is particularly acute in primary care. It has created unintentional 
competition for clinical sites and preceptors within and among PAs, 
physicians and advance practice nurses. Federal funding can help 
incentivize practicing clinicians to both offer their time as 
preceptors, and volunteer their clinical operations as training grounds 
for PAs and other health professionals. PAEA believes that 
interprofessional clinical training and practice are necessary for 
optimum patient care and will be a defining model of health care in the 
United States in the 21st century. We can only make that a reality if 
we begin to build a sufficient network of health professionals who are 
willing to teach the next generation of primary care professionals--
that approach will benefit PAs as well as the future physicians and 
nurses that comprise the full primary care team.
Enhancing Diversity
    Generalist training, workforce diversity, and practice in 
underserved areas are key priorities identified by HRSA. It is 
increasingly important that the health workforce better represents 
America's changing demographics, as well as addresses the issues of 
disparities in health care. PA programs have had success in attracting 
students from underrepresented minority groups and disadvantaged 
backgrounds using programs such as the National Health Service Corps 
(NHSC), Scholarships for Disadvantaged Students (SDS) and the Health 
Careers Opportunity Program (HCOP). Studies have found that health 
professionals from underserved areas are three to five times more 
likely to return to underserved areas to provide care. If we can 
provide resources to schools that are particularly poised to improve 
their diversity recruitment efforts and replicate or create best 
practices, we can begin to address this systemic need.
    Efforts to increase workforce diversity in the PA profession are 
enhanced when colleges and universities are able to leverage primary 
care training funds with other Federal programs that specifically 
target recruitment and retention of underrepresented minorities. PAEA 
therefore supports the restoration of funding for the Health Careers 
Opportunity Program, and increased funding for the Scholarships for 
Disadvantaged Students and National Health Service Corps. Historically, 
access to higher education has been constrained for individuals from 
disadvantaged backgrounds and these individuals are more likely to work 
in underserved areas addressing primary care needs.
Title VII Funding
    Title VII funding fills a critical need for curriculum development, 
faculty development, clinical site expansion and diversification of the 
primary care workforce. These funds enhance clinical training and 
education, assist PA programs with recruiting applicants from minority 
and disadvantaged backgrounds, and enables innovative programs that 
focus on educating a culturally competent workforce. Title VII funding 
increases the likelihood that PA students will practice in medically 
underserved communities with health professional shortages. The absence 
of this funding would result in the loss of care to patients with the 
most urgent need for access to care.
    Title VII support for PA programs was strengthened in 2010 when 
Congress enacted a 15 percent allocation in the appropriations process 
for PA programs. This funding will enhance capabilities to train a 
growing PA workforce and is likely to increase the pool for faculty 
positions as a result of PA programs now being eligible for faculty 
loan repayment. Huge loan burdens serve as barriers for physician 
assistant entry into academia.
Student Debt--The Looming Crisis
    The cost of higher education has risen in recent years.--The 
average cost of a master's degree for a resident in a public PA program 
is $36,739; for a non-resident, it is $62,984. For a private PA 
program, a student will pay $68,712. Debt influences the first job 
choice of many graduates. They may forgo primary care because they deem 
it easier to repay high levels of graduate and undergraduate debt by 
working in a specialty practice. PA faculty often have to counsel 
students to ``keep the faith'' by applying for, and hopefully 
receiving, NHSC loan repayment. NHSC programs are a conduit for primary 
care practitioners and educators. Here is what one former NHSC Scholar 
and current PA faculty member (Oregon Health Sciences University PA 
Program), Antoinette Polito, had to say about receiving an NHSC 
scholarship:

          ``I moved to Seattle, Washington . . . and began work at a 
        cooperative women's health collective. I was a medical 
        assistant and patient advocate. At the same time I returned to 
        school to take the science prerequisites I knew that I would 
        need to apply to a Physician Assistant program. I took that 
        leap in 1997, packed my bags again, and headed back across the 
        country to Duke University in Durham, North Carolina . . .
          I was so fortunate to apply for and receive a National Health 
        Service Corps Scholarship to support my studies at Duke. With 
        my longstanding commitment to provide care to the underserved, 
        the Scholarship was a wonderful acknowledgement and a gift in 
        so many ways. After graduating from the Duke University 
        Physician Assistant Program in 1999 with a Master of Health 
        Sciences, I joined a federally funded cooperative of primary 
        care offices in rural North Carolina as a National Health 
        Service Corps Scholar. I worked in Robeson County, along the 
        South Carolina border, in a designated medically underserved 
        area. The poorest county in North Carolina, Robeson's 
        population is divided just about equally among rural 
        Caucasians, African-Americans, and Lumbee Native Americans.
          The healthcare challenges in this area known as the ``stroke 
        belt'' for its high rates of cardiovascular disease, diabetes, 
        and tobacco abuse, were monumental. The county ``boasted'' one 
        of the highest rates of syphilis in the Nation. Care was 
        desperately needed and appreciated. My 3 years working at four 
        facilities in four small towns within the county limits was an 
        incredibly rewarding experience . . . The medicine was 
        challenging and the outcomes not always what I would have 
        wished. However, the lessons learned were priceless and the 
        impact on me substantial. I have the NHSC to thank for that . . 
        . I feel strongly that educating the next generation of primary 
        healthcare providers is the best way for me to contribute to 
        our future . . .''--Antoinette Polito, MHS, PA-C, Assistant 
        Professor, Oregon Health & Science University PA Program.

    With an ever-worsening shortage of primary care providers, the 
availability of well-trained PAs, who can practice with a significant 
level of autonomy, is critical to meeting the demands of patients. PAs 
are crucial to increasing access to care for rural and underserved 
communities, as they are often the only primary health provider in 
these areas. PAs play an important role in addressing the growing need 
for primary care and other health care areas in the United States in a 
cost-effective way; in many ways, they are ``just what the doctor 
ordered.''
   Prepared Statement of the National Rural Health Association (NRHA)
    A strong investment in rural training, placement, and retention 
programs is crucial to rural Americans' access to care and a wise 
investment of taxpayer dollars. The shortage of primary health care in 
rural America represents one of the most intractable health policy 
problems of the past century.
    This problem will only worsen. In just 20 years, 20 percent of the 
U.S. population will be 65 or older, a percentage larger than at any 
other time in our Nation's history. Just as this aging population 
places the highest demand on our health care system, we have some 
experts who predict a national shortage of physicians alone will be 
close to 200,000. If that becomes a reality, 84 million patients could 
be potentially left without a doctor's care. Rural patients are in 
desperate need of a renewed focus on physician training, placement, and 
retention.

     Rural Americans are, per capita, older, poorer, and sicker 
than their urban counterparts. According to the United States 
Department of Health and Human Services, ``rural areas have higher 
rates of poverty, chronic disease, and uninsurance, and millions of 
rural Americans have limited access to a primary care provider.''

     Rural residents have higher rates of age-adjusted 
mortality, disability, and chronic disease than their urban 
counterparts, according to the U.S. Department of Agriculture.
     Rural residents are more likely to be uninsured, more 
likely to have coverage through public sources, and less likely to be 
privately insured than residents of urban areas.
     Twenty percent of the U.S. population lives in rural 
America, yet they are scattered over 90 percent of the Nation's 
landmass. Geography, weather, and distances can make accessing care 
difficult; cultural, social, and language barriers compound rural 
health challenges.
     Seventy-seven percent of the 2,050 rural counties in the 
United States are designated as primary care Health Professional 
Shortage Areas (HPSAs). Nine percent of all rural counties in the 
United States have no doctors (MD or DO) at all.
     There, the ratio of primary care physicians per 100,000 
people in rural areas is less than half of that in urban areas.
     More than one-half of all patients in rural areas travel 
an average 60 miles to receive specialty medical care, compared to only 
6 percent of urban patients who do so.
     Payment equity for providers and hospitals remains 
critical to rural physician recruitment and retention, yet the 
President's budget proposes to reduce reimbursement to Critical Access 
Hospitals and eliminate the status for some facilities. The budget 
proposal does this in spite of the fact that 41 percent of these 
facilities already operate at a loss.

    The NRHA is a non-partisan and non-profit member driven 
organization with over 21,000 members nationwide, which includes a 
broad spectrum of the rural physician workforce. Our diverse membership 
represents a collection of individuals and organizations with a common 
dedication to addressing the health care needs of rural and underserved 
beneficiaries.

    [Whereupon, at 11:54 a.m., the hearing was adjourned.]

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