[Senate Hearing 116-276]
[From the U.S. Government Publishing Office]
S. Hrg. 116-276
ACCESS TO CARE:
HEALTH CENTERS AND PROVIDERS IN
UNDERSERVED COMMUNITIES
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING ACCESS TO CARE, FOCUSING ON HEALTH CENTERS AND PROVIDERS IN
UNDERSERVED COMMUNITIES
__________
JANUARY 29, 2019
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
41-388 PDF WASHINGTON : 2020
--------------------------------------------------------------------------------------
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
LAMAR ALEXANDER, Tennessee, Chairman
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming PATTY MURRAY, Washington
RICHARD BURR, North Carolina BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky MICHAEL F. BENNET, Colorado
BILL CASSIDY, M.D.,Louisiana TAMMY BALDWIN, Wisconsin
PAT ROBERTS, Kansas CHRISTOPHER S. MURPHY, Connecticut
LISA MURKOWSKI, Alaska ELIZABETH WARREN, Massachusetts
TIM SCOTT, South Carolina TIM KAINE, Virginia
MITT ROMNEY, Utah MARGARET WOOD HASSAN, New Hampshire
MIKE BRAUN, Indiana TINA SMITH, Minnesota
DOUG JONES, Alabama
JACKY ROSEN, Nevada
David P. Cleary, Republican Staff Director
Lindsey Ward Seidman, Republican Deputy Staff Director
Evan Schatz, Minority Staff Director
John Righter, Minority Deputy Staff Director
C O N T E N T S
----------
STATEMENTS
TUESDAY, JANUARY 29, 2019
Page
Committee Members
Alexander, Hon. Lamar, Chairman, Committee on Health, Education,
Labor, and Pensions, Opening statement......................... 1
Murray, Hon. Patty, Ranking Member, a U.S. Senator from the State
of Washington, Opening statement............................... 4
Witnesses
Freeman, Dennis, Ph.D., Chief Executive Officer, Cherokee Health
Systems, Knoxville, TN......................................... 7
Prepared statement........................................... 8
Summary statement............................................ 14
Waits, John B., M.D., F.A.A.F.P., Residency Director, Cahaba
Family Medicine Residency, Chief Executive Officer, Cahaba
Medical Care, Centreville, AL.................................. 14
Prepared statement........................................... 16
Summary statement............................................ 19
Anderson, Andrea, M.D., F.A.A.F.P., Director of Family Medicine,
Unity Health Care, Inc., Core Faculty, Wright Center for
Graduate Medical Education in conjunction with Unity Health
Care, Inc., Washington, DC..................................... 20
Prepared statement........................................... 21
Summary statement............................................ 26
Trompeter, Thomas, President and Chief Executive Officer,
HealthPoint, Renton, WA........................................ 27
Prepared statement........................................... 28
Summary statement............................................ 30
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.
Jones, Hon. Doug:
American Academy of Family Physicians, Prepared statement.... 53
American College of Osteopathic Family Physicians, Joint
statement.................................................. 59
ACCESS TO CARE:
HEALTH CENTERS AND PROVIDERS IN
UNDERSERVED COMMUNITIES
----------
Tuesday, January 29, 2019
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10:00 a.m. in
Room SD-430, Dirksen Senate Office Building, Hon. Lamar
Alexander, Chairman of the Committee, presiding.
Present: Senators Alexander [presiding], Murray, Romney,
Braun, Cassidy, Scott, Murkowski, Casey, Hassan, Jones, Rosen,
Murphy, Baldwin, Warren, and Kaine.
OPENING STATEMENT OF SENATOR ALEXANDER
The Chairman. Good morning.
The Senate Committee on Health, Education, Labor, and
Pensions will please come to order. Senator Murray and I will
each have an opening statement and then we will introduce the
witnesses. After their testimony, Senators will each have five
minutes of questions. I am going to take just two, three
minutes longer than I usually do in my opening remarks, which I
hope everybody will allow me to do this morning because this is
our first hearing of the year.
I want to begin by welcoming new Members of the Committee.
Senator Romney from Utah, welcome, former Governor--always glad
to have a former Governor in our midst, if I may say that. Mike
Braun from Indiana is also a new Member of the Committee. We
welcome him--he has a background in business. Jacky Rosen from
Nevada is also a new Member of the Committee--we welcome you,
Jacky.
I think you will find this a spirited Committee dealing
with lots of difficulties, and on a fairly regular basis, we
find ways, thanks to Senator Murray and her staff and our
staff, to work together and come up with some pretty good
results. So, we are proud of that. This is the first hearing,
as I said--and let us talk about what we hope to accomplish in
the next two years. In my view, number one, reducing health
care costs--not just health insurance, but the overall health
care cost. Number two, making sure a college degree is worth
students' time and money.
On health care costs, we have had five hearings on reducing
health care costs towards the end of last year. We heard from
Dr. Brent James, a member of the National Academy of Medicine,
that up to half of health, spending in this country is
unnecessary and no one seems to contradict that. That startled
me and I hope it startles the American people. It is a massive
burden on family, businesses, state and Federal budgets. So, I
have sent a letter to experts, including witnesses at our five
hearings, asking to suggest to Senator Murray and me and our
Committee, specific recommendations to reduce health care
costs. And I would like to renew that invitation to anyone to
submit your comments by March 1, to lower healthcare costs, at
help.senate.gov.
The second priority is updating the Higher Education Act,
to ensure the expense of a college education is worth it for
students. The last time we did that seriously was in 2007, and
a lot has happened since then. For example, there was no iPhone
in 2007, a micro-blogging named Twitter had just gained its own
platform and started to scale globally, and Amazon released
something called Kindle in 2007. Tom Friedman, the New York
Times columnist puts his finger on 2007 as the technological
inflection point. So, we need to take a look at Federal support
for Higher Education that affects 20 million students, 6,000
institutions, and make sure we catch up with what is happening
in the world.
Our goal includes simplifying Federal Aid application, a
fair way for students to repay their loans, and a better system
of accountability for colleges. I have been visiting with
Members of the Committee, both Democrat and Republican Members,
to ask their advice. They have a number of good suggestions.
And we, over the last four years in Higher Education--actually,
there are a number of bipartisan bills that have been
introduced during that time that should be ready for us to
consider. Senator Murray and I sat down with the leaders of the
Finance Committee, Senator Grassley, Senator Wyden, on which a
number of Members on this Committee serve. We have shared
jurisdiction on much of healthcare, and we are trying to see,
are there things we can do to work together. I hope we can
complete our work on both, reducing healthcare costs and
updating higher education, in the first six months of this
year, so we can get something to the President before the end
of the year.
In addition, on the next few months, we need to reauthorize
the Older Americans Act, which supports the organization and
the delivery of social and nutrition services to older adults
and caregivers, and reauthorize the Child Abuse, Prevention and
Treatment Act.
Today's topic, extending Federal funding for community
health centers, as well as four other Federal health programs,
all of which are set to expire at the end of the year--they fit
into a larger topic, which is of great interest to this
Committee, which is primary healthcare.
There are more than 300,000 primary healthcare doctors in
the United States according to the American Medical
Association--that is, the doctor that most of us go to for our
day-to-day medical care. Our annual physical flu vaccine,
helping to manage a chronic condition, is our access to
healthcare, and a reference point usually for a specialist for
such things as an MRI or hip replacement. Adam Boehler, who
heads the Center for Medicare and Medicaid Innovation,
estimated that while primary care is only up to say 7 percent
of healthcare spending, it could impact at least half of
healthcare spending because that is how we get into the rest of
healthcare spending. So, we will be having a hearing next week
on how primary care can help control healthcare cost, but
today, we are talking about a primary example of primary
healthcare.
27 million Americans receive their primary care and other
services at community health centers. For example, in Lewis
County, Tennessee, the hospital closed. The closest emergency
room for 12,000 people was 30 minutes away, so the old hospital
building became Lewis Health Center, a community health center
which operates as something between a clinic and a hospital. I
visited there. It is a nice, clean place, a couple of doctors,
nurses. They believe they can deal with 90 percent of the
issues people walk in with every day. They have a full
laboratory. They run tests, perform X-rays, give IVs, and keep
an ambulance ready to take someone to a hospital if they need
that. Because Lewis Health Center is a community health center,
they charge based upon a sliding scale. Community health
centers like Lewis are one way American families can have
access to affordable healthcare close to home, and this
includes a wide range of healthcare, including preventive care,
which we hear in every hearing is the most important care,
helping to manage chronic conditions like asthma, high blood
pressure, vaccines, prenatal care--there are about 1,400
federally funded health centers that provide outpatient care to
approximately 27 million people, including 400,000 Tennesseans,
and about 12,000 sites across the United States. Those other
locations could be a mobile clinic, or a homeless shelter or
school. They have been especially important in battling the
Opioid Crisis.
Last year, the Department of Health and Human Services
provided over 350 million in funding specifically to support
community health centers, providing care for Americans in need
of substance use, disorder, or mental health services. These
centers accept private insurance, Medicare, and Medicaid, and
charge, based, as I said, up on the sliding scale. Community
health centers also receive Federal funding. In FY2019, that
was 4 billion in mandatory funds and 1.6 billion in
discretionary funds. We must act by the end of September in
Congress to make sure the community health centers receive this
Federal funding and keep their doors open. That is why two
weeks ago, Senator Murray and I took the first step by
introducing legislation that will extend funding for community
health centers for five years and $4 billion a year in
mandatory funding. The legislation also extends funding for
four additional Federal health programs set to expire in
September, the Teaching Health Center Graduate Medical
Education Program, the National Health Service Corps, Special
Diabetes Program, and Special Diabetes Program for Indians.
Today, we will hear about how the community health centers are
working, and how to insure 27 million Americans closer to home.
These centers rely on a well-trained workforce. Two
federally funded workforce programs, which train doctors and
nurses, expire this year. The Teaching Health Center Graduate
Medical Education Program is one. The National Health Service
Corps is another. More than half of those doctors choose to
work at one of the 12,000 community health centers and
affiliated sites. We look forward to hearing more about that
from witnesses.
Senator Murray.
OPENING STATEMENT OF SENATOR MURRAY
Senator Murray. Well, thank you very much Mr. Chairman.
Thank you to all of our witnesses who joined us today. We
appreciate it.
Mr. Chairman, my colleagues and I look forward to working
with you again this Congress on behalf of workers, and
communities, and families across our Nation, as we have under
your leadership for the past two Congresses. This is the first
time we have met since your announcement, and on behalf of all
of us, thank you for your bipartisan approach to the work we do
on this Committee and this institution. You and I, along with a
lot of Members in this room, have been able to work in a really
important bipartisan fashion to address a lot of the issues
that our families face, as you will know, to 21st-century
cures, Opioids epidemic, and a lot more. So on behalf of all of
us on this side of the dais, I hope we continue that tradition
and thank you for your tremendous work.
The Chairman. Thank you very much.
Senator Murray. I would also like to welcome our new
Members of the Committee. I look forward to having our new
colleagues, Senator Romney, welcome. Senator Braun, who has
joined us. Senator Rosen. You joined a long tradition in this
Committee of bipartisan work as we address, as the Chairman
outlined, the primary care cliff, higher education, healthcare
cost, retirement security, and many other issues. So, welcome
to this Committee, look forward to working with all of you. And
finally, I just want to say, I am really glad that President
Trump listened to the workers and families, and communities who
were harmed by this shutdown, and ended it. That pointless 35-
day shutdown not only cost a lot of damage but also wasted the
first month of this Congress. We have a lot of important work
to do starting with the topic of today's hearing of primary
care providers.
After hearing from families across my State of Washington
about the role that community health centers play in their
lives and visiting a lot of centers across my state to see the
good work that they do firsthand, I am really looking forward
to all of our witnesses' testimony and perspective on this
issue. Community health centers serve over 27 million patients
a year, many of them in rural and underserved communities. And
teaching health centers and programs, like the National Health
Service Corps, help bring qualified health professionals to
communities who are in need. These programs make it possible
for millions of patients and families to get the care they can
afford close to their home, and they play a critical role in
the local response to national health challenges like the
Opioid Crisis. But at this time last year, they were in the
middle of a different kind of crisis. Community health centers
were left waiting without funding, and uncertain when Congress
would extend funding for programs to support them and their
staff, and give patients access to the care that they rely on.
This time last year, community health centers across the
country were forced to cut back hours, and staff, and services,
and halt planned expansions like in Spokane, Washington, where
a new Opioid addiction treatment services initiated to combat
the Opioid epidemic was jeopardized by that funding freeze, or
out on our Olympic Peninsula, where plans to expand behavioral
health services was put on hold, or in Whatcom County where
they considered canceling construction plans for new medical,
dental, and behavioral healthcare facilities.
This time last year, community health centers were left
wondering how to pay their current staff and attract new
professionals. Ferry County is a rural area with fewer than
four people per square mile, where the funding uncertainty left
the center unable to sign annual contracts for needed medical
staff and managers. This time last year, some community health
centers had to figure out ways to cover basic but crucial
annual reoccurring expenses like renewing the lease for their
building.
In Yakima, Washington, clinics in some of our most
vulnerable communities were at risk of closing, and it was not
just Washington State. Senators across the country faced these
challenges. Elsewhere, a teaching health center closed, meaning
the residents there, the healthcare residents, healthcare
providers who were willing to forgo the draws of an academic
hospital, roll up their sleeves, and serve patients and
families and communities with severe professional shortages,
faced the harrowing prospects of having to scramble to find a
new residency program and possibly redo an entire year of their
residency.
Fortunately, one of our witnesses today, Dr. Waits, stepped
in and helped many of them to avoid that catastrophe and I hope
we will be able to hear more about that in his testimony today.
In the end, Congress was able to come together in a bipartisan
way to fund those community health centers and the other
critical primary care funding. But if funding runs out again
this year, we will be right back where we were a year ago that
I was just talking about.
It is clear to Members of both sides of this isle, we need
to do more to provide stability for communities and the health
centers they depend on. So, I am very glad that Chairman
Alexander and I were able to introduce legislation to do just
that. Whilst it is not the bill either one of us would have
written on our own, it lays down a very clear bipartisan marker
for providing these programs with long-term funding. Our
bipartisan bill will provide five years of stable funding for
our community health centers and give them the certainty that
they need to bring on new, skilled staff, and offer new
services, and make sure patients have the care that they need
close to their home. And as the Chairman said, it extends
funding for teaching health centers and the National Service
Corps, which encourages medical students and doctors to work in
underserved communities and fund at least one entire cycle of a
family medicine residency.
Funding these programs for the next five years will give
health centers greater confidence. They can recruit the
professionals that they need and medical students, residents,
and others to have greater confidence in their decision to work
in an underserved community. So, I am very pleased that we were
able to introduce this. I very much look forward to the hearing
today, Mr. Chairman, and thank you for all that.
The Chairman. Thank you Senator Murray, and thank you for
your leadership on this legislation and for your remarks at the
beginning of your statement. I suggest to people in Tennessee
that they look at Washington, D.C. sometimes as a split screen
television, and I said look at October, there you had the
Kavanaugh hearing on one side with mud going on every
direction, but on the other side you had 72 Senators working
with Senator Murray and me, both sides of the aisle, on
landmark Opioid legislation that helped nearly every community,
which was then signed into law by the President the next month.
We know how to get things done, despite differences of
opinion, and one reason we are able to do that is because of
Senator Murray's skill and leadership at getting results, and
the respect she has on her side of isle, but on our side of
isle as well, and I thank her for that. This is an example of
it, this bill--this is what we call a bipartisan hearing--that
means we agree on who the witnesses are, we agree on what the
subject is, and we hope to agree on a result.
I welcomed the other new Senators before, Senator Braun, it
was just before you walked in and I want to welcome you as
well. Well now, we will hear from our witnesses and then
Senators, I am sure, will have questions. I would ask each of
you summarize your remarks, please and within five minutes that
will give us more time for conversation.
The first witness is Dr. Dennis Freeman, a licensed
psychologist--he is the Chief Executive Officer of Cherokee
Health Systems in Knoxville, Tennessee. It has 23 clinics in 14
counties in Tennessee and offers a full range of services,
including primary care, behavioral health, and dental services
to over 70,000 patients. Senator Jones, would you like to
introduce the next witness?
Senator Jones. Yes, thank you Mr. Chairman and Ranking
Member Murray. I am pleased to introduce Dr. John B. Waits this
morning. Dr. Waits is the Co-founder and Chief Executive
Officer of the Cahaba Medical Care, which is a community health
center and teaching health center training program in Alabama.
Dr. Waits opened his health center in rural Bibb County, which
is just south of Birmingham, in 2004, and has since expanded to
seven delivery sights in six different counties throughout
central Alabama. He brings a unique perspective to our hearing
because he trains residents and treats patients in both rural
and urban underserved settings. I have had the pleasure of
visiting the Bibb County facilities and seeing firsthand the
impact, his team has on their community, and I am grateful for
him being here with us today. Dr. Waits, thank you, we look
forward to hearing your testimony.
The Chairman. Thank you, Senator Jones. The third witness
is Dr. Andrea Anderson, Director of Family Medicine at Unity
Medical Center, a system of community health centers around
Washington, D.C.--she is chair of the Washington, D.C. Board of
Medicine. She serves as a core faculty member with the Wright
Center for Graduate Medical Education. And finally, Senator
Murray would you like to introduce our fourth witness?
Senator Murray. Thank you very much Mr. Chairman. This
morning I really have the pleasure of introducing a fellow
Washingtonian, Thomas Trompeter. He is the President and CEO of
HealthPoint. It is an organization which runs health centers
and communities across our state to provide affordable care in
underserved areas. Last year HealthPoint served tens of
thousands of people. Almost two-thirds of their patients relied
on programs like Medicaid and CHIP, and many had no insurance
at all. Mr. Trompeter himself has helped families and
communities in the northwest stay healthy for years for the
past two decades at HealthPoint, and at the Northwest Regional
Primary Care Association a decade before that.
Thank you, Mr. Trompeter, for your ongoing dedication to
making sure families across our state can find healthcare close
to home regardless of their ability to pay. And thank you again
for traveling all the way out here from, what we call, the
better Washington to this Washington----
[Laughter.]
Senator Murray.----to be here today.
The Chairman. Thank you, Senator Murray. Dr. Freeman, why
don't you begin.
STATEMENT OF DENNIS FREEMAN, PH.D., CHIEF EXECUTIVE OFFICER,
CHEROKEE HEALTH SYSTEMS, KNOXVILLE, TN
Dr. Freeman. Mr. Chairman and my great Senator, Lamar
Alexander, Ranking Member Murray, and Members of the Committee,
it is an honor to be asked to share my views on the Health
Center Program. I am Dennis Freeman, a psychologist and Chief
Executive Officer of Cherokee Health Systems, a health center
in Tennessee.
Before sharing my perspectives, I want to acknowledge the
past support of this Committee, on a bipartisan basis, for
community health centers. We are truly grateful for that
support. Today I intend to share some insights gleaned from my
long experience participating in the Health Center Program. I
have submitted written testimony, which expands on the comments
I am going to make, and I hope you will read my written
testimony and consider me a resource in your ongoing
discussion.
By mission and by law, health centers serve the Nation's
least fortunate residents in the Nation's most remote and
economically challenged communities. At Cherokee, we speak of
going where the grass is browner, and we feel blessed to have
this mission, knowing in many cases we are caring for those who
really have few if any other, healthcare alternatives. Cherokee
began providing services in 1960. Last year, we saw 70,000
people--30 percent were uninsured, 40 percent were on Medicaid.
Many years ago, we recognized that primary care is really the
most common access point for people with behavioral health
concerns. And so, we began blending behavioral health into the
primary care team. We have pioneered this work and we have
shared our model of care with health centers across the
country.
Our commitment to the provision of both, medical and
behavioral healthcare in a truly integrated model, allows us to
provide comprehensive care to patients who present with
complex, chronic medical and psychiatric conditions. This model
works well for patients suffering substance use disorders,
including Opiate addictions--additions are clearly a complex
disorder, and in most circumstances, chronic disorders. This
Committee has recognized that health centers are in a unique
position to lead the treatment response to the Nation in the
Opioid Crisis, and have provided resources for us to do so. At
Cherokee, we have used these grant funds to organize care teams
to care for these patients. I do however want to caution
against a singular focus on the Opioid addiction alone--both in
terms of treatment approach and in terms of funding in
inflexible, narrow funding streams. Addiction to opioids is
commonly mingled with other addictions, other substances, not
to mention the serious medical consequences that follow in the
wake of addiction. So, health centers really need comprehensive
clinical teams to address the complexity of addiction.
Over the years, the partnership between the Federal
Government and the health center community has been enormously
effective in improving health outcomes and in boosting access
to comprehensive primary care, including behavioral health and
substance use disorders. Our organization and every health
center in the country is dependent on the core financial
support we receive in our annual grant from HRSA. While we are
able to generate much of our revenue from patient services and
other sources, the 330 funding is the solid rock of our funding
base.
Over the past several years, health centers have faced
uncertainty over the renewal of this funding on several
occasions. While demand for our services was always
unrelenting, we were restrained from making investments in
staff and programs to meet that demand. So, I am really
grateful to learn legislation has been introduced by Members of
this Committee, including Chairman Alexander, to assure that
the Federal funding base for health centers is there in place
for five years. When health centers are financially secure, we
are able to respond to national concerns like the crisis of
Opiate abuse and the pernicious problem of childhood obesity.
I am truly grateful for the opportunity to speak with you
today, and I look forward to your questions.
[The prepared statement of Dr. Freeman follows:]
prepared statement of dennis freeman
Chairman Alexander, Ranking Member Murray and Members of the
Committee.
It is an honor to be asked to share my views on the Federally
Qualified Health Center Program (Health Centers) and the National
Health Service Corps (NHSC) with you today. I am Dennis Freeman, a
psychologist and Chief Executive Officer of Cherokee Health Systems, a
Health Center in Tennessee. In 2018 Cherokee served 70,000 patients in
23 clinics located in 14 Tennessee counties.
Cherokee operates clinics in isolated, rural mountain hamlets, mid-
size east Tennessee communities and inner city Memphis, Knoxville and
Chattanooga. Our staff outreaches into area schools, public housing
complexes, homeless shelters, hospital emergency departments and
patient's homes. Thirty present of our patients are uninsured and forty
percent are on Medicaid.
Before I share my perspective on today's topic, I briefly want to
acknowledge and recognize the depth of support that has been shown by
this Committee, on a bipartisan basis, for the three programs we will
discuss today. Thanks to that support, 1,400 health center
organizations now serve 28 million patients in over 11,000 communities
nationwide. The investments you've made have had a profound impact on
the patients and communities we serve, not to mention the healthcare
system as a whole, and for that we are truly grateful.
Cherokee Health Systems--A Federally Qualified Health Center
Cherokee Health Systems began providing services as a Community
Mental Health Center in 1960. As was customary for Mental Health
Centers in those days we did outreach into other parts of the
healthcare delivery and social services sectors. Through our outreach
into primary care we quickly saw primary care was the most common
access point for people seeking help for behavioral health concerns.
Our clinicians began circuit riding to area primary clinics on a
regularly scheduled basis so we could increase access to behavioral
health services to residents in our service area. After a few years we
recognized that many portions of our service regions had a critical
shortage of primary care providers so we began opening primary clinics
with behavioral health professionals working in close collaboration
with their primary care colleagues. When an opportunity to apply for a
grant to become a Health Center presented itself in 2002, we seized
upon it. Thankfully, our application was successful and we have been
proud and contented member of the Health Center community ever since.
The graph below shows clearly how Cherokee's growth has been
buoyed, but not totally dependent upon, our annual Health Center grant.
Our overall revenue has grown at a faster pace over time than our
federal Health center grant has. As expected, our trend line of
patients in care parallels our growth in revenue. The graph shows that
our grant has covered a good share of the amount of sliding fee
discounts we offer our low income patients in many years. During
economic hard times people lose employment, employers stop providing
insurance and more people show up on our doorstep needing healthcare
they can afford. As you can see, our grant has not covered our charity
care the last two years and the widening gap is worrisome.
The increases in our grant over the years have been for expansions
into new geographic areas or for new programs. The increases have
allowed us to open new offices in underserved areas and expand or start
new programs. For example, we have opened a clinic to serve homeless
residents in Knoxville. We have opened services near public housing
complexes. We have opened specialized services to treat patients
addicted to opiates. Most of these grants fueled program expansions
that decreased the percentage of our patients who had any healthcare
coverage to pay for their care.
At Cherokee we act on our expansion strategy of going where the
grass is browner. The program expansions cited above are fully in line
with that development strategy. Typically, the increases in our grant
are a critical piece but do not fully fund these expansions. We make
the program work financially by being frugal and efficient. Our reward
is reaching many of our neighbors who are in desperate need of care.
I expect a Member of Congress will look at the graph above and feel
good about the government's investment. Our grant is a relatively small
percent of our financing (currently 13.5 percent) but it spurs the
growth, and helps sustain the operation, of an effective and efficient
healthcare system. I'm quite sure the Cherokee picture is not unique
but is replicated by the community of Health Centers who are extending
primary care access into many, but by no means all, underserved areas
of our country. Additional investment in Health Centers is needed in
order to reach populations and communities not yet served by a Health
Center.
Cherokee's Clinical Model
At Cherokee we have blended behavioral health services into our
primary care clinical model and embedded behavioral health
professionals in our primary care teams for many years. This approach
to care is known, of course, as integrated care. This model of care is
rapidly gaining traction across the country, especially among Health
Centers. Without question, access to appropriate and timely care is the
greatest challenge facing the mental health and substance misuse
treatment sectors of the nation's healthcare system. In our experience
providing access to behavioral health assessment and intervention
within primary care goes a long way toward reducing the access barrier
to behavioral healthcare so prevalent across the country.
Primary care is the front door to the health care system. It's the
primary access point for all healthcare concerns and medical
conditions, including behavioral health issues. In addition to the
frequent presentation of psychiatric conditions and substance use
disorders in primary care, the personality and the lifestyle of the
patient are always factors in a patient's healthcare outcomes. Personal
health habits; a history of trauma; and resiliency in response to
stress all influence the etiology, the response to treatment and the
prognosis of all medical conditions that are presented in primary care.
The patient's behavioral health is a factor in every primary care
patient visit. This is especially true for patients coping with chronic
medical conditions. Encouraging these patients to adopt appropriate
health behaviors is the key to the medical management of complex and
chronic conditions. The presence of behavioral health professionals
within the primary care setting brings a clearer focus on the
psychosocial factors which influence health status. The integrated care
strategy has broadened the scope of primary care and enhanced the
effectiveness and efficiency of primary care practice.
Over the past few years the Patient-Centered Medical Home (PCMH)
model has come to be considered the best practice when it comes to
primary care delivery. At Cherokee we have embraced this model and have
enhanced it in a number of ways. We embed uniquely skilled behavioral
health professionals, referred to as Behavioral Health Consultants
(BHC), in the primary care team. BHCs are available to their primary
care colleagues for consultation at the point of care. They provide
assessment and intervention with patients during their primary care
visit. Community Health Coordinators are available to help patients
negotiate social determinates of health. In effect, they extend the
exam room into the community. When indicated, psychiatric consultation
is also available, in real time, to the primary care team. Psychiatric
consultation is one of the telehealth services Cherokee makes available
across its network of clinics. All providers on the team share an
electronic health record, treatment planning and the responsibility for
the overall care of all the patients on the panel.
Patients appreciate the comprehensiveness of the integrated care
model. Our primary care providers are enthralled with the support the
behavioral health and community-based staff provide them. The
integrated care team lightens the individual burden on primary care
providers and enhances their satisfaction with their work. Insurance
companies are pleased because the overall cost of care declines. Best
of all, patient outcomes improve.
The integrated Patient-Centered Medical Home is the best practice
model for treating patients with chronic conditions. Patient with a
chronic condition rarely present with only one chronic condition. This
is especially true with persons suffering a psychiatric or substance
use disorder. In our experience more than two-thirds of these patients
have one or more co-existing medical problems that need treatment. The
recent national attention on opioid addiction has illuminated the need
to identify effective treatment models and has brought additional focus
on integrated primary care as an effective treatment approach.
Treatment of Opioid Addiction in Context
The opioid epidemic has garnered the nation's attention for a
number of very good reasons. Few if any families have been spared the
devastating impact of a family member addicted to opioids. Healthcare,
law enforcement, the courts, social services--every sector of our
society has felt the impact. Death rates from opiate overdoses have
skyrocketed, medical providers have been indicted for over prescribing
and state Attorneys General are suing pharmaceutical companies for
misleading marketing and advertising strategies. Obviously, bringing
the opioid epidemic under control will require a multi-faceted approach
beginning with more public awareness of the dangerous, addictive
potential of these drug and much broader availability of effective
treatment for those who become addicted.
It is tempting to isolate on opiate addiction as a singular problem
and formulate overly simplistic treatment and financing strategies to
address the problem. This has led to some targeted funding streams
narrowly restricting providers in how grant funds may be use and how
third party payers reimburse for services. Some grants will only
support the treatment of patients with a specific diagnosis of opiate
addiction; some grants require that certain medications which block the
effect of opioids be part of the treatment; and some grants and payers
limit reimbursement to those clinical activities that take place in the
exam room.
Successful treatment of addiction, including treatment of those
addicted to opiates, requires a more comprehensive approach. Most
patients who present with opiate addiction are abusing other substances
as well. Many have co-occurring psychiatric conditions that need
treatment. Most have serious co-morbid medical conditions that need
immediate attention, conditions that are the direct result of their
substance abuse or an outcome of their unhealthy lifestyle. Many with
addictions have alienated their families and are without positive
social support. Addiction is a complex condition. The words of
Cherokee's Director of Addiction Medicine, Dr. Mark McGrail, are
instructive, ``cross addiction is a real phenomenon and patients who
suffer from addiction will find something to fill the void if we ``just
take the opioids away''.
At Cherokee we have adapted our integrated medical home model to
treat patients presenting with opioid addiction. We provide
accelerated, walk-in access because we know this is critically
important for some patients. We use medication assisted treatment as
appropriate. Patients participate in group treatment and receive
additional individual behavioral health services when indicated. Most
patients participate in an Intensive Outpatient Program which meets
several times a week for several hours at each session. We've had a 30-
day retention in treatment of 68 percent for these patients compared
with national data cited in the professional literature in the 35-40
percent range. We have teams to care for women who are pregnant and
abusing drugs and/or alcohol. We're beginning to incorporate pediatric
care into the model in order to provide concurrent care for mother and
infant after delivery. We always seek to become the healthcare home for
these patients, just as we are for patients living with other serious
chronic conditions. In 2018 Cherokee saw 6571 patients with a Substance
Use Disorder, including 2003 with a diagnosis of Opioid Use Disorder.
The integrated medical home has proven effective for the care of our
patients with addictions, including those abusing or addicted to
opiates.
The National Health Service Corps
Payment of educational debt by the National Health Service Corps is
life changing for clinicians who receive it. I frequently hear heart-
warming stories from a Cherokee staff member who speak passionately
about how being relieved of their debt allowed them to see their way
clear to follow their heart and work with their population of choice.
Concerns about purchasing a home and starting a family are eased. The
prospect of a financially secure future seems possible. At any point in
time Cherokee has a couple dozen clinicians who are receiving loan
repayment. Currently, seven clinicians are in the process of applying.
The majority stay on after their loans are paid and many envision long
careers at Cherokee. Cherokee has benefited greatly from the service of
clinicians who have received scholarships or have had educational loans
repaid by the NHSC.
Despite the success of the program, as an employer we are reluctant
to use the NHSC as a recruiting tool when funding for the program
remains uncertain. While the possibility for the payment of educational
debt is there for a prospective hire, to dangle the NHSC before them is
to ask them to make a leap of faith. In the black and white world of
personal finance that would be unfair to the applicant. Every year
there are many more applicants for NHSC slots than the program is able
to pay for at the current funding level. We should be doing more to
help support the recruitment of these applicants who have the will to
practice in medically underserved communities. In order to maximize the
effectiveness of the program we need to see long term, stable
investment in the program as well as the opportunity for growth so more
providers can be accepted into the program. It would be enormously
beneficial if Health Centers had designated NHSC slots they could use
as actual tools in recruiting clinicians.
Cherokee's Teaching Mission
At Cherokee Health Systems we consider training the next generation
of healthcare providers a core part of our mission. We want
professionals-in-training to have a good experience working in
underserved areas and providing care to a needy population. We know
most who enter the health professions do so with the motivation to help
others. Given a positive experience of working alongside highly
competent professional mentors who are committed to this work, many
will make a commitment to follow suit. We partner with area academic
institutions to train psychologists, nurses, nurse practitioners,
social workers, pharmacists and primary care physicians.
Cherokee does not participate in HRSA's Teaching Health Center
program, though we have been a wistful observer of the program and
wished that it had the size and the stability of funding to make the
impact needed in the Health Center community. At this point in time it
would be hard to find a Health Center that doesn't have available
positions for physicians.
Shortages in the workforce of Health Centers extends to other
professions besides physicians. Dentists, pharmacists and behavioral
health professionals are especially difficult to recruit for most
Health Centers. Dentists willing to work with underserved populations
seem to be in short supply. As we all know, professionals tend to stay
in the environments where they trained. I'm not aware of many health
centers who are training dentists and pharmacists. Heretofore, most
behavioral health professionals trained in behavioral health settings
and upon graduation went to work in behavioral health organizations.
These new graduates had neither the vision nor the skills to
contemplate a career in a Health Center working as a member of a
primary care team.
Fortunately, the education of healthcare professionals is changing.
More training is occurring in team-based models and, when that is the
case, the setting is usually in primary care. Health Centers are active
in these training opportunities. A couple of small but visionary
federal programs, the Graduate Psychology Education program (GPE) and
the Area Health Education Center's program (AHEC), are leading the
team-based training agenda and provide support for training of health
professionals in settings serving underserved populations.
The Area Health Education Center program (AHEC) was developed by
Congress in 1971 to recruit, train and retain a health professions
workforce committed to underserved populations. The AHEC program helps
bring the resources of academic medicine to address local community
health needs. The mission of AHEC is to enhance access to quality
healthcare, particularly primary and preventive care, by improving the
distribution of healthcare professionals via strategic partnerships
between academic programs and community organizations. Recently, the
national AHEC program has intensified its focus on multidisciplinary
training. In September 2007 Cherokee Health Systems entered into a
partnership with Meharry Medical College to serve as the east Tennessee
Area Health Education Center. In 2017 Cherokee expanded its role with
Meharry and is now the regional center for both east and west
Tennessee.
The GPE program prepares doctoral level psychologists to provide
behavioral healthcare, including substance abuse prevention and
treatment services, in settings that provide integrated primary and
behavioral health services to underserved and/or rural populations.
This program supports the inter-professional training of doctoral level
psychology interns and postdoctoral fellows while also providing
behavioral health services to underserved populations such as older
adults, rural populations, children, those suffering from chronic
medical conditions, veterans, victims of trauma and victims of abuse.
Grants are provided to accredited psychology internships and
fellowships. Cherokee's training of psychologists is partially
supported by a GPE grant.
Cherokee began an internship for psychologists in 2003 and started
accepting psychology postdoctoral fellows in 2013. To date we have
graduated 55 interns and 20 fellows with nine more currently in
training. More than a third of the interns have stayed with us upon
completion of their internship year. Nearly two thirds chose to work in
safety net organizations. Most of the fellows accepted staff positions
at Cherokee and the few who left all went to work with underserved
populations. We have demonstrated, as has been shown many times over in
many settings, training providers is the best recruitment strategy.
Internship Postdoctoral Fellowship
Current Trainees 5 4
Graduates 55 20
Stayed with Cherokee following 35 percent 85 percent
graduation
Working with Underserved Populations 65 percent 100 percent
Received NHSC Loan Repayment 20 percent 35 percent
Conclusion
I commend the Committee for their review of the Teaching Health
Centers, the National Health Service Corps and the Health Center
program. These vital programs, and the synergy among them, have an
important impact on the health of the nation and a profound impact on
isolated, remote and disadvantaged communities. Without these programs
many of our fellow citizens would not have access to timely and
affordable health care.
I'm grateful to learn legislation was introduced and supported by
Members of this Committee, including Chairman Alexander, to assure the
federal funding base of these critical programs for an additional five
years. If secured, this will enable us to continue to thrive and remain
a trusted partner of the Federal Government to address the nation's
healthcare challenges.
I encourage you to continue to build upon the prior investments you
have made in these programs and assure the benefits they bring to the
communities we serve. Your continued support is vital.
______
[summary statement of dennis freeman]
Mr. Chairman and my Senator, Lamar Alexander, Ranking Member Murray
and Members of the Committee,
It is an honor to be asked to share my views on the Health Center
program. I am Dennis Freeman, Chief Executive Officer of Cherokee
Health Systems, a Health Center in Tennessee. Before sharing my
perspectives, I want to acknowledge the past support shown by this
Committee, on a bipartisan basis, for Community Health Centers. We are
truly grateful.
Today I intend to share some insights gleaned from my experience
participating in the Health Center Program. I have submitted written
testimony which expands on the comments I will make this morning. I
hope you will read my written testimony and consider me a resource in
your ongoing discussion.
Cherokee Health Systems began providing services in 1960. Many
years ago we recognized that primary care was the most common access
point for people with behavioral health concerns and began blending
behavioral health professionals into the primary care team. We've
pioneered this work and have shared our model of care with our Health
Center colleagues across the country.
Our commitment to the provision of both medical and behavioral care
in a truly integrated model allows us to provide comprehensive care to
patients who present with complex, chronic medical and psychiatric
conditions. This model works well with patients suffering substance use
disorders, including opiate addictions. This Committee has recognized
that Health Centers are in a unique position to lead the treatment
response to the nation's opioid epidemic and has provided resources to
enable us to do so. At Cherokee we have these grant funds to organize
care teams to care for these patients. I want to caution against a
singular focus on opiate addiction alone. Addiction to opioids is
commonly mingled with addiction to other substances, not to mention the
other serious medical complications that follow in the wake of
addiction. Health Centers need comprehensive clinical teams to address
the complexity.
Over the years, the partnership between the Federal Government and
the health center community has been enormously effective in improving
health outcomes and boosting access to comprehensive primary care,
including behavioral health and substances use disorder services. Our
organization, and every Health Center in the country, is dependent on
the core financial support we receive in our annual grant from HRSA.
While we are able to generate much of our revenue from patient services
and other sources, 330 funding is the solid rock of our funding base.
Over the past several years Health Centers have faced uncertainty
over the renewal of federal 330 grant support. While the demand for our
services was unrelenting, we were restrained from making investments in
staff and programs to meet the demand. I'm grateful to learn
legislation was introduced by Members of this Committee, including
Chairman Alexander, to assure the federal funding base for Health
Centers for five years. When Health Centers are financially secure, we
are able to respond to national concerns like the crisis of opiate
abuse and the pernicious problem of childhood obesity.
I'm truly grateful for the opportunity to speak with you today. I
look forward to your questions.
______
The Chairman. Thanks, Dr. Freeman.
Dr. Waits.
STATEMENT OF JOHN B. WAITS, M.D., RESIDENCY DIRECTOR, CAHABA
FAMILY MEDICINE RESIDENCY, CHIEF EXECUTIVE OFFICER, CAHABA
MEDICAL CARE, CENTREVILLE, AL
Dr. Waits. Chairman Alexander, Ranking Member Murray, and
distinguished Members of the Committee thank you for inviting
me to speak about the Teaching Health Center Graduate Medical
Education Program. I am here on behalf of the American
Association of Teaching Health Centers, as long with executives
and clinicians from many of the Nation's teaching health
centers and several medical residents who are in the audience.
I am a family physician and the CEO of Cahaba Medical Care,
a federally qualified health center with 10 locations in
Alabama. I also direct the Cahaba Family Medicine Residency.
Cahaba is Alabama's only teaching health center and started its
inaugural class in 2013. 71 percent of our graduates are now
practicing in medically underserved areas, a rate almost three
times higher than in traditional residency programs. We were
honored to host Senator Jones at our Centreville campus, and
are grateful that he is a leader on this issue.
Our experience proofs that the Teaching Health Centers
Program works and deserves an extension. Without Congressional
action, however, as has been alluded to, the program will lapse
again on September 30th. So it is great that you are holding
such an early hearing and that the Chairman and Ranking Member
have introduced bipartisan legislation to extend it for five
years. Cahaba employs 266 people, including over 50 healthcare
providers, 31 of whom have utilized the National Health Service
Corps loan repayment as a crucial incentive.
We have grown from 2,100 patients in 2012 to over 17,000
unique patients served and over 80,000 patient encounters in
2018. Each of our sites sits within a health professional
shortage area and offers comprehensive care. 46 percent of our
patient population lives at or below the Federal poverty level,
and 15 percent are uninsured. There is also a high burden of
uncontrolled chronic diseases. The Teaching Health Centers
Program helps us respond to these medical needs. For example,
before we opened a new clinic in 2015, the small rural town of
Maplesville, Alabama had not seen a new physician in over 50
years, and its one physician was active only part-time and
nearing retirement.
We purchased a building and renovated it into a modern
primary care clinic, equipped with X-ray and in-house lab,
then, a graduating resident from Cahaba's first Teaching Health
Center class, Dr. Andrea White who is in the audience, joined a
nurse practitioner and provides primary care in that community.
Since then, Cahaba has been able to serve 50 percent of the
low-income population within Maplesville and has also helped
revitalize the economy and the small downtown square.
As you know, our Nation faces a severe doctor shortage. By
2030 the U.S. will require nearly 50,000 more primary care
physicians, and the shortage is felt most deeply in health
professional shortage areas and medically underserved areas. As
many as 84 million people experience disparities in health care
access because they are uninsured, or because they live in
rural and urban areas without enough primary care physicians.
While patient care increasingly occurs in ambulatory
settings, such as community health centers, traditional medical
education in the U.S. occurs mainly in inpatient hospital
facilities. Hospital-based training produces a health care
workforce whose skills and experiences are often poorly matched
to the primary care needs of the ambulatory population, and who
rarely choose to practice in rural or underserved urban
locations. By contrast, the Teaching Health Center model uses
community-based ambulatory health centers to train primary care
residents who will practice in urban and rural underserved
communities during their training and after they complete their
residencies.
Evidence has shown that resident physicians who train in
health center settings are nearly three times as likely to
practice in underserved settings after graduation. Only
investment in the community health workforce pipeline will
overcome recruiting difficulties and meet the demand.
We were very grateful that in 2018 Congress generously
brought the per-resident allocation back up to a more
sustainable level, but the last two reauthorizations were each
for two years and did not always provide sufficient certainty
for teaching health centers to make binding three-year
commitments to the recruits we were authorized to hire and
train. We are so glad that Chairman Alexander and Ranking
Member Murray have listened so carefully to our concerns over
the years, and have expressed strong support for Teaching
Health Centers by offering legislation to extend funding five
years. What a difference it will make if Congress gives us
stable funding for five years. We can budget more efficiently,
keep our doors open. The Alexander-Murray bill recognizes that
the Teaching Health Centers Program will improve medical
education and save lives in many of our communities.
I also want to encourage the Committee to consider
reauthorization legislation that we are working on with
Senators Collins and Jones, which would fund three of our other
needs. First, we need to restore some resident slots that were
authorized by HRSA but not filled during the last couple of
years of uncertainty. Second, we need a very modest increase in
the per-resident allocation because our clinics and residency
programs will face rising costs during this five-year
authorization period.
Lastly, the Collins-Jones bill would fund an expansion of
the Teaching Health Center Program to meet pent-up demand in
many communities for residency programs such as Cahaba's. Thank
you for giving me the time to testify this morning.
[The prepared statement of Dr. Waits follows:]
prepared statement of john b. waits
Chairman Alexander, Ranking Member Murray, and Distinguished
Members of the Committee.
Thank you for inviting me to speak to you about the Teaching Health
Center Graduate Medical Education Program, which we call ``THCGME.'' I
am a family physician and serve as the Chief Executive Officer of
Cahaba Medical Care (``CMC''), a Federally Qualified Health Center with
ten locations serving Bibb, Chilton, Perry, and Jefferson Counties. I
am also the Residency Director of the Cahaba Family Medicine Residency,
based in Centreville, AL. Cahaba Family Medicine Residency is Alabama's
only Teaching Health Center and started its inaugural class in 2013. I
am pleased to share that 71 percent of our graduated residents are now
practicing in a Medically Underserved Area, a rate almost three times
higher than in traditional residency programs.
As you can see, Cahaba's experience is proof that the THCGME
program works and deserves to be extended this year. In 2018, Congress
enacted a two-year reauthorization of the THCGME program through Fiscal
Year 2019, getting us back to a more sustainable level of $150,000 per
resident by providing $126.5 million in appropriations per year for
FY18 and FY19. Without Congressional action, the program will lapse
again on September 30, so I am very grateful that the Committee is
holding such an early hearing and that the Chairman and Ranking Member
have introduced bipartisan legislation to provide a five-year
extension. The leadership shown by Chairman Alexander and Senator
Murray in recognizing the need for a robust extension of our program is
greatly appreciated by the many teaching health center representatives
here in the Committee room and our medical residents here and across
the nation.
Members of the Committee can best understand why reauthorization is
so critical, please permit me to share some background about our own
teaching health center programs, our residents, and our patients.
Cahaba Medical Care--Teaching Health Centers in Alabama
CMC serves a portion of central Alabama that includes Bibb, Perry,
Chilton, and Jefferson Counties and currently employs 266 people. Prior
to becoming a FQHC/THC, CMC employed 11 people. Today, CMC employs over
50 providers, including physicians, resident physicians, physician
assistants, nurse practitioners, and licensed behavioral health
counselors. Since the National Health Service Corps program is also the
subject of today's hearing, I want to note that over 30 Cahaba
providers, including faculty physicians, have utilized the National
Health Service Corps loan repayment as a crucial incentive, since there
are often salary constraints for physicians working in an non-profit
setting.
The growth CMC experienced on the employee side has logically
enabled us to serve far more patients, increasing from approximately
2,100 patients in 2012 to over 17,000 unique patients served and over
80,000 patient encounters in 2018. Each of CMC's 10 sites sits within a
Health Profession Shortage Area for medical, dental, and behavioral
health and offers comprehensive care to everyone no matter their
insurance status. In our service area, 46 percent of the population
lives at or below the federal poverty level, and 15 percent are
uninsured. Among the patients seen by CMC, 17 percent are uninsured, 35
percent are Medicaid and 25 percent are Medicare. Also, there is a high
burden of uncontrolled chronic diseases such as diabetes, hypertension,
heart disease, mental health conditions, kidney disease, and late
presentation of diseases such as lung and colon cancers. In order to
meet the wide array of medical conditions that are also often
coexistent with significant social, emotional, financial, and
transportation barriers to receiving adequate care, CMC also employs a
team of social workers and counselors to help address the patients care
holistically.
CMC serves eight distinct communities, each of which has its own
story, its own strengths, its own challenges, and its own gaps in the
healthcare and other industries. One such community is Maplesville, AL,
a small rural town in Chilton County. Prior to our opening a new clinic
in 2015, Maplesville hadn't seen a new physician enter the community in
over 50 years, and the one physician in the community was active only
part time and nearing retirement. CMC purchased three buildings in the
historic, but antiquated, downtown, and renovated them into a modern
primary care clinic, fully equipped with a x-ray and in-house lab
capabilities. Patient care began in late 2015 with a nurse
practitioner. Then, a graduating resident from CMC's first THCGME
Residency class, Dr. Andreia White, DO, originally from Marengo County,
AL, joined as the second provider in August of 2016. Since that time,
according to the Federal Uniform Data Services Mapper (UDSMapper), CMC
has served over 50 percent of the low income population within
Maplesville and has also helped to revitalize the small downtown
square.
We were honored to host Senator Doug Jones at our Centreville
campus after he had heard this and other stories about the communities
we serve. During his visit, he learned more about our FQHC and the
integral part the Teaching Health Center has played in training,
recruiting, and retaining Family Medicine physicians to underserved
communities in Alabama.
The Primary Care Physician Shortage and Teaching Health Centers
Beyond the borders of Alabama, the entire nation also faces a
severe doctor shortage. In fact, by 2030 we will need more than 120,000
physicians to meet the growing demand for health care services across
the country. According to the Association of American Medical Colleges,
by 2030, the United States will require nearly 50,000 primary care
physicians, and the shortage is being felt most deeply in health
professional shortage areas (HPSAs) and medically underserved areas
(MUAs). As many as 84 million people living in these areas experience
disparities in health care access either because they are uninsured, or
because they live in rural, urban, or suburban areas without enough
primary care physicians. Additionally, we are reaching a critical time
when the number of medical school graduates will be greater than the
number of residency slots. Without a residency, medical school
graduates are unable to obtain a medical license.
While patient care increasingly occurs in ambulatory settings, such
as community health centers, medical education occurs mainly in
inpatient hospital facilities, funded primarily by CMS under a Medicare
formula. This hospital-based training produces a health care workforce
whose skills and experiences are poorly matched to the primary care
needs of the population, and who rarely choose to practice in rural or
underserved areas. In order to address the changing healthcare system
and address the disparities in the health care workforce, the THCGME
model uses community-based ambulatory health centers, such as nonprofit
community health centers and community consortia, to train primary care
residents who will practice 21st century care in urban and rural
underserved communities during their training and after they complete
their residencies. During their residency training, THC residents
practice in the approved primary care specialties of Family Medicine,
General Internal Medicine, Obstetrics and Gynecology, Pediatrics,
Psychiatry and General Dentistry.
According to the 20th Report of the Council on Graduate Medical
Education (COGME), ``the shortage in primary care providers,
particularly those capable of caring for adults with chronic disease
(Family Medicine and General Internal Medicine), overshadows the
deficits in all other specialties.'' One way to address the physician
workforce shortage is to train resident physicians in underserved
settings, based on the precept that training providers in areas of need
will produce the workforce with the necessary skills to serve in
underserved areas. Evidence has shown that resident physicians who
train in health center settings are nearly three times as likely to
practice in underserved settings after graduation. They are also 3.4
times more likely to work in a health center, compared to residents who
did not train in health centers. The difficulties in recruiting
community-based primary care physicians is also well documented; only
investment in the community health care workforce pipeline will help
meet the workforce demands. By moving primary care training into the
community, THCGME programs are on the leading edge of innovative
educational programming dedicated to meeting future health care
workforce needs.
Analysis of the THCGME programs continue to show promising results:
Reauthorization Legislation
With the looming primary care shortage on the horizon, investments
in graduate medical education training will be critical to meet the
needs of the evolving healthcare delivery system. The THCGME program is
one of the most reliable training models for primary care physicians
and has an overwhelming documented success, but has been critically
underfunded and is at the brink of collapse. Without immediately
strengthening and expanding, the program will unravel just as it is
beginning to produce the urban and rural primary care workforce that is
desperately needed.
As I noted earlier, we were very grateful that as an initial step
last year, Congress provided sufficient funding to bring the per
resident allocation back up to a more sustainable level. We are very
heartened that the Alexander-Murray bill would provide another element
of sustainability by reauthorizing the THCGME program for five years.
The last two reauthorizations were each for two years and did not
always provide sufficient certainty for teaching health centers to make
binding three-year commitments to all the recruits that they were
authorized to hire. The longer timelines are so important because the
training itself three years in duration and the medical student
recruiting process starts one to two years prior to the training, and
certainty of sustainable funding for training is utterly essential to
recruit qualified medical graduates into Teaching Health Centers. We
are so glad that Chairman Alexander and Ranking Member Murray have
listened so carefully to our concerns and have expressed such strong
support for THCGME by offering legislation to extend funding through
FY24. What a difference it will make if Congress gives us stable
funding for five years! We can budget more efficiently and ensure that
we can keep our doors open for enthusiastic future doctors who are
committed to practicing medicine in underserved communities. Primary
care saves lives and saves money and it is clear that the Alexander-
Murray five-year reauthorization bill recognizes how the Teaching
Health Center Graduate Medical Education program helps solve our
primary care crisis. Simply put, the Alexander-Murray reauthorization
proposal will improve medical education and save lives in many of our
communities.
In addition to the Alexander-Murray proposal, I want to encourage
the Committee to consider reauthorization legislation that the teaching
health centers have worked on with Senators Collins and Jones, which
would augment the $126.5 million current funding level by adding some
additional appropriations to meet three of our other needs. We are
grateful to Senators Collins and Jones for their willingness to work
with supporters of the Teaching Health Centers. We are hopeful that
Congress will consider favorably any proposal to help THCs restore some
resident slots that were authorized by HRSA but not filled during the
last couple years of uncertainty. Second, we are hopeful that Congress
will include funding for a very modest increase in the per resident
allocation to help offset inflation over the next five years. While
Congress was very generous in restoring the $150,000 PRA in last year's
law, our clinics and residency programs facing rising costs and we are
hopeful that Congress can find some funds to help us preserve our
purchasing power during this five-year reauthorization period.
Lastly, we are hopeful that Congress will include additional
funding for expansion of the THCGME program to meet pent-up demand in
many communities for a residency program such as Cahaba's. It has been
five years since HRSA last approved a new Teaching Health Center in
2014 and many potential sponsors of such centers have reached out to
our association asking for advice on how they can obtain such a
designation and the accompanying funding. HRSA has correctly
prioritized trying to sustain existing Centers for the past two years
and we are hopeful that this reauthorization process will include
additional funds that permit HRSA to solicit proposals and approve
entirely new centers or expansion of programs offered at existing
centers. Every dollar spent on expansion will generate tangible
benefits for your communities and those of other Senators. Lives will
be saved, economic growth generated, and we will make a dent in the
medical care shortage that plagues too many parts of our country to
this day.
Thank you for giving me the time to testify this morning.
______
[summary statement of john b. waits]
Chairman Alexander, Ranking Member Murray, and Distinguished
Members of the Committee: Thank you for inviting me to speak about the
Teaching Health Center Graduate Medical Education Program.
I am here on behalf of the American Association of Teaching Health
Centers. Cahaba is Alabama's only Teaching Health Center. 71 percent of
our graduated residents are now practicing in Medically Underserved
Areas, a rate almost three times higher than in traditional residency
programs. Many of them are in Alabama, in underserved areas that
haven't seen a new physician come to town in decades.
Our experience is proof that the THCGME program works and deserves
extension. Without Congressional action, the program will lapse again
on September 30.
In 2018, Congress gave us a two-year extension and a more
sustainable level of $150,000 per resident by providing $126.5 million
in appropriations per year. The Alexander-Murray bill would further
sustain us by reauthorizing the THCGME program for five years. The last
two reauthorizations were each for two years and did not always provide
sufficient certainty for teaching health centers to make binding three-
year commitments to all the recruits that they were authorized to hire.
The Alexander-Murray reauthorization proposal will improve medical
education and save lives in many of our communities.
Additionally, legislation that the AATHC has worked on with
Senators Collins and Jones, would add funding to meet three of our
other needs.
1. restoring some resident slots that were authorized by HRSA
but not filled during the last couple years of uncertainty.
2. a very modest increase in the per resident allocation to
help offset inflation because our clinics and residency
programs will face rising costs
3. funding expansion of the THCGME program to meet pent-up
demand in many communities for a residency program such as
Cahaba's. HRSA last approved a new Teaching Health Center in
2014 and many potential sponsors of such centers have reached
out to our association asking how they can obtain such a
designation and the accompanying funding.
Every dollar spent on expansion will generate tangible benefits for
communities with a new THC. Lives will be saved, economic growth
generated, and we will make a dent in the medical care shortage that
plagues too many parts of our country to this day.
______
The Chairman. Thank you, Dr. Waits.
Dr. Anderson, welcome.
STATEMENT OF ANDREA ANDERSON, M.D., DIRECTOR OF FAMILY
MEDICINE, UNITY HEALTH CARE, INC., CORE FACULTY, WRIGHT CENTER
FOR GRADUATE MEDICAL EDUCATION, WASHINGTON, DC
Dr. Anderson. Good morning. My name is Dr. Andrea Anderson,
and I am a Family Physician, with Unity Health Care here in
Washington, D.C. In addition to caring for my patients, as the
Medical Director of Family Medicine, I direct clinical policy
for the care of all of our patients. I signed my National
Health Service Corps contract in 1997, as a young medical
student, and came to Unity in 2004 to fulfill my obligation. I
subsequently became an NSHC loan repayer, and I have stayed
ever since - a total of nearly 22 years with the NHSC. I am
proud to care for multiple generations of families through all
the phases of life. In addition to carrying for them medically,
I advocate for my patients, helping them to navigate their way
through a complex healthcare system. I have held my patients as
newborns, visited them in the hospital, cared for their
pregnancies, celebrated their birthdays and graduations, and
mourned at their funerals.
I run into them at the grocery store and the playground,
and smile when they wave and rush over to me to report how they
are heeding my advice to eat more vegetables, or to walk more,
or whatever the small victory of the moment is. Even in a big
city, I can enjoy the personal relationships that one might
only imagine possible in a small town. The NHSC has a national
reach with an individual face. By making it possible for
physicians like me to serve these populations, the NHSC
addresses provider workforce shortages, health disparities, and
the social determinants of health. I am proud to be part of
such a profound legacy.
Since it is founding, the NHSC has placed more than 50,000
providers in underserved communities, with more than 10,000
placements in the last year alone. Despite this level of
service, it would still take more than 20,000 additional
providers to meet the existing need across the country. The
NHSC supports a wide variety of primary care providers,
including physicians like me. It includes PAs, NPs, dentists,
mental and behavioral health professionals, just to name a few.
Our providers serve in more than just FQHCs. We are in critical
access hospitals, mental health centers, prisons, Indian health
service, and rural health clinics--places where primary care is
needed most.
I also provide that NHSC providers tend to reflect the
communities they serve. Underrepresented minority students are
often the very ones who are more likely to serve populations
similar to their cultural background, and studies show that
having providers in underserved communities has a positive
benefit on the health outcomes of the patients, especially the
patients of color.
In addition, their presence is impactful and inspirational
to the next generation, fostering a positive cycle of
representation and encouragement. I am here today to ask your
help funding this incredibly important program. In October
2017, funding for the NHSC expired and the program's future was
uncertain. Without Congressional, before this October the NHSC
will once again face a funding cliff.
We are very thankful for the introduction of legislation
that has already shown the bipartisan support for the NHSC,
including S. 192 and S. 106 in this Congress, and S. 1441 in
the last Congress. And we look forward to working with this
Committee to ensure that the NHSC is stable and strengthened
for years to come. To accomplish this goal, we ask you to
consider expanding the funding for the NHSC to ensure all
current applicants are funded. There are clinicians across this
country ready and willing to serve in our highest need areas.
It is imperative to the health of our Nation that we do not
miss this opportunity. Today, the NHSC is only able to fund 10
percent of the scholarship applications, and less than half of
the loan-repayment applicants. To fund all these clinicians who
are ready to serve, and on behalf of the 41 national
organizations and the friends of the NHSC coalition, I would
ask you to consider a systematic doubling of the current
funding for the program.
It is clear the need exists today. This would be
tremendously beneficial to the program, to primary care
clinicians, but mostly, to the families and the friends, I
serve each day. They have hopes and dreams. They are the babies
that I welcome to this world and the wrinkled hands that I hold
as they exit this same world. They are the present and the
future of America, and I know this program works for all of us.
I appreciate the opportunity to testify before you today, and
we thank you for making the National Health Service Corps a
priority. I would be glad to answer any questions that you
have.
[The prepared statement of Dr. Anderson follows:]
prepared statement of andrea anderson
Chairman Alexander, Ranking Member Murray, and Members of the
Committee,
Thank you for inviting me to speak to you today on this very
important topic. My name is Dr. Andrea Anderson, a Family Physician,
and the Medical Director of Family Medicine at Unity Health Care here
in Washington DC. Unity is the largest federally qualified health
center network in the District, and I have had the honor of serving
patients there since 2004. I came Unity in fulfillment of my National
Health Service Corps (NHSC) scholarship, subsequently became a NSHC
loan repayor, and I have stayed ever since - a total of nearly 15
years. I am here today on behalf of the Association of Clinicians for
the Underserved (ACU), the American Academy of Family Physicians
(AAFP), and 39 other organizations that participate in the Friends of
the NHSC Coalition. In all, these organizations represent thousands of
physicians, nurse practitioners, physician assistants and other health
related professionals who are united in their support for this crucial
program.
As you know, the NHSC was created 45 years ago in a bipartisan
manner, and since then has proven to be a highly effective program
placing quality health care providers in the highest need areas of our
country. As both a NHSC Scholar and Loan Repayor, I am honored to be
here today to give you a firsthand perspective of the significance this
program has on medical students, health professionals, underserved
communities, your constituents, and ultimately the country as a whole.
Personal History/Mission
I deeply believe in the mission and purpose of the National Health
Service Corps. As you can see in my background document, I have served
many roles at Unity in addition to delivering primary care to my
patients for close to 15 years. Currently, I serve as the Director of
Family Medicine. In this capacity I direct clinical policy for over 80
Family Medicine clinicians. I am the former Medical Director of the
Upper Cardozo health center, the largest of our 13 community health
centers serving approximately 25,000 active patients. Previously, I
directed Student and Resident placements at Unity for over 300 learners
who passed through our doors during my tenure. Finally, I also directed
our Health Literacy and Cultural Competency program and our Reach Out
and Read Early Childhood literacy program because we know that research
demonstrates direct and indirect effects on health outcomes, especially
in vulnerable communities. In addition to delivering care to my
patients, I also to help train the next generation of providers in my
work as a core faculty member for the National Family Medicine
Residency, a Teaching Health Center program with the Wright Center for
GME. In this way I am actively involved with molding the next
generation of culturally competent, community minded, dedicated, and
committed members of the physician workforce. So I am a NHSC provider,
at a Federally-Qualified Health Center, who teaches at a federally-
supported Teaching Health Center. I am very happy to see the Committee
take up all three programs today as I can positively attest to how they
all work together to help us fill the shortage areas of the country and
truly enable everyone to have access to primary care.
I signed my contract with the NHSC as a first-year medical student
at Brown University because I believed as much then as I do now, and if
not more today, in the mission and ideals of this program. The
knowledge that I had committed to serving my community after school
shaped the way I approached my studies and enhanced my outlook as a
young student physician who would ultimately be assigned to an area
somewhere in America in high need of health care professionals. By
addressing the primary care shortage, NHSC physicians and other health
professionals ensure access to healthcare for everyone, regardless of
their ability to pay. We prevent disease and illness as we care for the
most vulnerable people who have limited access to health care and might
otherwise go without needed primary health care services.
As a Family Physician, I received rigorous training to care for
children, adults, and pregnant women during my residency and Chief
Resident/Academic Fellowship year at Harbor-UCLA in Southern
California. Family physicians care for patients of all genders and
every age through an ongoing, personal patient-physician relationship.
Family doctors conduct one out of every five office visits - about 192
million visits annually. I am proud as a family physician to provide
front line medical care to people of all socioeconomic strata and
experiences.
In my time at Unity Health Care, I have cared for thousands of
patients, walking with them through the challenges and choices of life
and everything in between. I am proud to care for multiple generations
of families through all the imaginable phases of this thing we call
life. In addition to caring for them medically, I advocate for my
patients, helping them navigate their way through a complex community
and health care system. I have held my patients as newborns, visited
them in the hospital, cared for their pregnancies, attended their
school recitals and career days, celebrated their birthdays and
graduations, and mourned at their funerals. I run into them at the
grocery store and the barber shop and smile when they wave and rush
over to me to report how they are heeding my advice to eat more
vegetables, or to walk more, or whatever the small victory of the
moment is. Even in a bustling metropolis, I can enjoy the personal
relationships that one might only imagine possible in a small town. The
NHSC has a national reach with an individual face. By making it
possible for physicians like me to serve these populations, the NHSC
addresses provider workforce shortages, health disparities and the
social determinants of health. I am proud of be a part of such a
profound legacy and urge you to continue the funding that would make it
possible for the NHSC to continue recruiting top primary care providers
to serve your constituents and all Americans.
Current Status of NHSC Funding
Beginning in 1972, funding for the NHSC had been through regular,
annual appropriations. This changed under the American Recovery and
Reinvestment Act (ARRA) and the Affordable Care Act (ACA). Both of
these laws provided new mandatory funding to expand the program to
additional communities. However in FY2011, recognizing this new program
funding stream, Congress dramatically decreased the regular
appropriation. By FY2012, all regular appropriations had been
eliminated and the program became 100 percent reliant on the mandatory
trust fund created under the ACA. When that initial funding stream
expired at the end of FY2015, Congress extended the fund for two
additional years within the Medicare Access and CHIP Reauthorization
Act (MACRA) of 2015. Unfortunately that funding expired in October of
2017 without a new agreement, sending the program into turmoil and
unable to make any new awards. By February of 2018 Congress was able to
extend funding for the NHSC for another two years, through FY2019. That
bill, the Bipartisan Budget Act of 2018, maintained level funding for
the NHSC at $310 million.
Without Congressional action before October of this year, the NHSC
will once again face the prospect of losing the $310 million currently
provided through the mandatory trust fund. We are very thankful for the
introduction of S. 192, by Chairman Alexander and Ranking Member Murray
that shows your clear support for extending NHSC funding for an
additional five years. This kind of stability is critical to the
program's future. In addition, we are very grateful for S. 106,
introduced by Senators Blunt and Stabenow, which calls for increased
funding for the NHSC over the same five year period. We are also aware
that other Senators on this very Committee previously introduced
legislation calling for even more rapid growth for the NHSC, meeting
the need in all shortage areas across the country. We are very grateful
for this bipartisan show of support and look forward to working with
Congress and the Administration to ensure the NHSC is stable and
strengthened.
NHSC Background
The NHSC program, established in 1972, is designed to incentivize
primary care professionals to work in urban, rural, and frontier
communities designated as having a health professional shortage. Since
its founding, the NHSC has placed more than 50,000 providers in
underserved communities, with more than 10,000 placements in the last
year alone. In exchange for their service, the program helps to
alleviate the burden of debt accumulated during the course of their
education through scholarship and loan repayment programs.
The four NHSC programs are:
The Scholarship Program (SP)--Provides a full scholarship for
eligible medical, dental, mental and behavioral health students in
exchange for service after their training in high need health
professional shortage areas (HPSAs). Awards are very competitive, with
the program only able to fund 10 percent of current applications. They
look for students who have a real interest in delivering care to
underserved communities, and have a high probability of success in
their primary care careers. There are about 1,000 scholars now, who
will be serving in the field in the years ahead.
The Loan Repayment Program (LRP)--This is by far the largest part
of the NHSC program, with over 8,800 of the current field strength
receiving loan repayment. The program helps students repay school loans
in exchange for service, starting with a two year commitment at $25,000
per year. In order to fund the highest need areas, the program awards
loan repayment contracts to applicants serving in the highest scoring
HPSAs first. Last year the program was only able to fund applicants
down to a HPSA score of 16.
The State Loan Repayment Program (SLRP)--This program provides
matching funds for qualifying state loan repayment programs. Not all
states take advantage of this program, but there are 1,350 placements
in the field through the state loan repayment programs. This is a very
cost-effective program from a federal perspective because of the state
matching requirement. In addition, since the state is putting up half
the funding, they also have more flexibility on how they structure
their program within their state. Some fund lower scoring HPSAs and
others fund additional provider types not currently eligible under the
federal loan repayment program, such as pharmacists and nurses.
The Students to Service Program (S2S)--The Students to Service
program is the most recent addition to the NHSC toolbox, and the
smallest in terms of field strength. However, it is a critical link
between the scholarship program and the loan repayment program. The S2S
program enables those students who are at a key decision point in their
education to be able to choose the primary care path with financial
support from the NHSC program.
NHSC placements are made at approved sites providing primary
medical, dental and/or mental and behavioral health services. All NHSC
providers must be open to all, regardless of ability to pay. Eligible
facilities include:
Federally-Qualified Health Centers
Indian Health Facilities
Correctional or Detention Facilities
Certified Rural Health Clinics
Critical Access Hospitals
Community Mental Health Centers
State or Local Health Departments
School-Based Clinics
Certain Private Practices
Mobile Units
Free Clinics
Current provider types include:
35 percent.......................... Nurse practitioners, physician
assistants, certified nurse-
midwives
9 percent........................... Mental and behavioral health
professionals
20 percent.......................... Physicians
16 percent.......................... Dentists and dental hygienists
The NHSC has proven to be a successful, sustainable solution to the
shortage of providers in thousands of communities across the United
States. According to HRSA, 82 percent of NHSC clinicians who complete
their service obligation continue to practice in a shortage area up to
one year later, and a majority continue to practice in a shortage area
for more than 10 years after completing their service obligation.
Despite this level of service, it would still take more than 20,000
additional providers to meet the existing need in the more than 15,000
federally-designated HPSAs across the country.
NHSC Impact on Clinicians and Communities
I can say without hesitation that the more you dig into the
statistics on the NHSC, the more supportive you will be. I want to
highlight a few more things that I believe show the value of the
program as well. First of all, NHSC providers tend to reflect the
communities they serve. This means that NHSC placements in rural areas
tend to come from other rural areas, underrepresented minority
communities tend to see more of their NHSC providers with similar
cultural and geographic backgrounds. This is because the NHSC gives
students a chance to see themselves as clinicians, whether that be a
PA, a dentist, or a physician. The Scholarship program enabled me to
envision how I could finance my path to become a doctor. The Loan
Repayment program enables literally thousands of students to afford to
repay their loans and work in the communities that they care about and
are committed to. Over the years, medical school debt has increased
some 20-fold. According to the Association of American Medical
Colleges, the median four-year cost to attend a public medical school
is about $240,000 and a private medical school degree can be more than
$340,000. The average medical school graduate comes out carrying about
$190,000 or more in debt. Fourteen percent start their residency
training owing $300,000 or more. These debt levels are larger than most
mortgages. I can tell you first hand that my family could not have
afforded to send me through medical school alone. When I was in high
school I couldn't even imagine how I could possibly afford to be a
doctor. Like most physicians, I was a top student. I was accepted into
several highly competitive universities. I was accepted to an eight-
year combined medical program out of high school at Brown University.
Fortunately, I learned of the NHSC from an advisor at Brown when I was
an undergraduate. I already had a desire to work in community medicine
and public health with underserved populations and I was glad to know
that there was a way this could be possible. I had to apply, and I was
so grateful to be accepted as a scholar to fund my attendance of the
Warren Alpert Medical School of Brown University. We know that the NHSC
is a resource for all providers, regardless of their background who are
committed to serving the most vulnerable communities. However, one
hidden benefit of the NHSC is the opportunity that it affords for
educationally or economically disadvantaged students. Research shows
that among students who incur debt, Underrepresented Racial Minority
(URM) students face similar levels of total debt. However, URM students
are twice as likely to carry some educational debt because they are
often more likely to hail from low-income families.
These astute student doctors are often the very ones who are more
likely to serve populations similar to their cultural background and
studies show that having these doctors in communities actually has a
positive benefit on the health outcomes of the patients, especially the
patients of color. In addition, their presence is impactful and
inspirational to the next generation, fostering a positive cycle of
representation and encouragement. Having the NHSC Scholarship Program
available was one of the things that encouraged me and allowed me to
see myself as a physician. I know it helps diversify the field of
clinicians among all the eligible provider types.
In addition to enabling lower-income, rural, urban, and
underrepresented minority students to become clinicians, there is one
other aspect I would like to emphasize for the Committee. As you know,
many times rigid structures discourage our best and brightest from
helping those most in need. It is easier to take a job in a well-off
community, often making much more in salary alone, than to fight your
way through the red-tape in order to help an underserved community.
Fortunately, with some urging from Congress, the NHSC has enabled more
and more part-time placements. This flexibility has enabled a new
generation of providers to serve in high need areas, while maintaining
the mission of the program. For example, the part-time commitment
allows participants to care for a new family, obtain a public health
degree, or work in academia or health policy enacting research or
policies that can reach a wider breath and impact these communities
while providing face to face clinical care part-time. More importantly,
this improves and extends retention and increases patient access to
their regular primary care provider. There is still room for
improvement, but these communities also benefit by ensuring that the
next generation can participate in the NHSC, by extending their
commitment concomitant to their part-time status.
NHSC Funding Request
While thankful for the support shown by this Committee, we remain
very concerned about the base funding for the program provided through
the trust fund. As evident during the last extension debate, even
strong bipartisan support may not enable passage before October. The
loss of this base funding will cause even greater damage to the program
as people lose faith in the stability of the program. This will result
in a dramatic decrease in field strength, jeopardizing access to care
for millions of people.
We understand that our country faces record debt levels and there
are nearly continuous negotiations on federal spending levels. However,
I truly believe that based on the merits of the program, the NHSC can
withstand any kind of debate that focuses on value, impact, and long--
term savings. We know that access to primary care saves lives and saves
money, and the NHSC is designed to increase access to primary care
services where we need it most. For this reason, we urge the Congress
to fund the NHSC at a level that would enable it to fund at least the
current applicants for the program.This is possible through a
systematic doubling of the current funding for the program.
Doubling the funding for the NHSC would enable an additional 11
million people to have access to primary care. We know the need far
exceeds this, with more than 72 million people living in primary care
shortage areas, 54 million living in dental shortage areas, and more
than 111 million living in mental health shortage areas. We know there
are thousands of applicants already looking to serve.
The current funding level for the program allows for only 40
percent of Loan Repayment applicants and a mere 10 percent of
scholarship applicants to be granted awards. I mention this to bring
attention to the fact that although it is usually difficult to recruit
primary care clinicians to these shortage areas, the NHSC is clearly an
effective and popular way to overcome this difficulty. As we look for
ways to increase access to primary care, we have literally thousands of
passionate health professionals applying to the NHSC to serve in our
most needed areas of the country. I would urge you to fund as many of
these applicants as possible and help our rural and underserved
communities get the primary care access they need today.
Conclusion
Today, more than 10,000 NHSC clinicians serve 11 million people
across the country. I stand before you proud to be one of them. We are
hopeful that we can strengthen and grow the program to help address the
urgent need of millions of people for primary health care services.
These millions of people have faces and names. They have hopes and
dreams. They are my patients that I see every day. They are our
neighbors. They are your constituents. They are the babies that I
welcome to this world and the wrinkled hands that I hold as they exit
that same world. They are you and they are me. They are the present and
the future of America. Without action by Congress, $310 million in
funding for the NHSC will expire later this year. The NHSC program has
proven time and time again to be an effective program, and I can assure
you, as an alumnus, in my opinion, that the NHSC is one of the best
programs this country has devised to incentivize primary care medical
providers to be able to choose primary care and to serve in underserved
communities. I appreciate the opportunity to testify before you today,
and we thank you for making the National Health Service Corps a
priority. I would be glad to answer any questions you may have.
______
[summary statement of andrea anderson]
My name is Dr. Andrea Anderson, a Family Physician, and the Medical
Director of Family Medicine at Unity Health Care here in Washington DC.
Unity is the largest federally qualified health center network in the
District, serving over 100,000 patients. I have had the honor of
serving patients there since 2004, and I am proud to care for multiple
generations of families through all imaginable phases of life. I came
to Unity in fulfillment of my National Health Service Corps (NHSC)
scholarship, subsequently became a NSHC loan repayor, and I have stayed
ever since--a total of nearly 15 years. I deeply believe in the mission
and purpose of the NHSC program; a program with a national reach and an
individual face. By making it possible for physicians like me to serve
high need communities, the NHSC addresses provider workforce shortages,
health disparities and the social determinants of health. I am here
today on behalf of the ACU, AAFP, and 39 other organizations that
participate in the Friends of the NHSC Coalition.
Since its founding, the NHSC has placed more than 50,000 providers
in underserved communities, with more than 10,000 placements in the
last year alone. Despite this level of service, it would take an
additional 20,000 providers to meet the existing needs across the
country. In exchange for their clinical service in high need areas, the
NHSC helps to alleviate the burden of debt accumulated during the
course of their education through scholarship and loan repayment
programs. The program includes the Scholarship Program, the Loan
Repayment Program, the Students to Service Program and the State Loan
Repayment Program. Eligible providers include nurse practitioners,
physician assistance, certified nurse-midwives, mental and behavioral
health professionals, physicians, dentists and dental hygienists.
Eligible organizations include Health Centers, IHS facilities, rural
health clinics, critical access hospitals, community mental health
centers, correctional facilities and more.
NHSC providers tend to reflect the communities they serve.
Underrepresented Racial Minority students are often the very ones who
are more likely to serve populations similar to their cultural
background and studies show that having these doctors in communities
actually has a positive benefit on the health outcomes of the patients,
especially the patients of color. In addition, their presence is
impactful and inspirational to the next generation, fostering a
positive cycle of representation and encouragement.
We know that access to primary care saves lives and saves money,
and the NHSC program has proven time and time again to be an effective
federal program. Unfortunately, without Congressional action before
October of this year, the NHSC will once again face the prospect of
losing the $310 million currently provided through the mandatory trust
fund. Additionally, the NHSC is only able to fund 10 percent of
scholarship applicants and less than half of loan repayment
applications today. For these reasons, we urge Congress to extend and
increase the funding available for the NHSC to enable all current
applicants to receive awards. This would be possible through a
systematic doubling of the current funding for the program.
We are very thankful for the introduction of legislation that has
already shown the bipartisan support for the NHSC (S. 192, S. 106, and
S.1441 in the 115th Congress) and look we forward to working with this
Committee to ensure the NHSC is stable and strengthened for years to
come.
______
The Chairman. Thank you, Dr. Anderson, and Mr. Trompeter,
welcome.
STATEMENT OF THOMAS TROMPETER, PRESIDENT AND CHIEF EXECUTIVE
OFFICER, HEALTHPOINT, RENTON, WA
Mr. Trompeter. Chairman Alexander, Ranking Member Murray
and Members of the Committee, thank you for the opportunity to
provide testimony in support of the Community Health Center
Fund, the National Health Service Corps, and the Teaching
Health Center program, and to address the importance of fixing
the primary care funding cliff we face this year.
My name is Thomas Trompeter, and I am the President and
Chief Executive Officer for HealthPoint. We are a federally
qualified health center, serving people in need in suburban
King County, outside the City of Seattle.
We provide the full spectrum of primary medical, dental,
and behavioral health care through ten full-service clinics,
three school-based clinics, three out-stationed primary care
clinics, and a mobile medical van that focuses on the homeless.
In 2018, we took of 89,000 people, 17 percent of whom had no
insurance, and 65 percent of whom relied on Medicaid and CHIP
for their coverage.
In addition to emphasizing the essential role our base
federal grant plays, I would like to thank you for the recent
supplemental funding for integrated mental health and substance
use disorder services. The opioid epidemic in our area
continues to increase. This funding allows us to expand
services for existing as well as new patients and has allowed
us to add a behavioral health consultant, a chemical dependency
counselor, and a psychiatric nurse practitioner.
Like many health centers, we participate in the National
Health Service Corps Loan Repayment Program. We also
participate in Washington's own Health Professions Loan
Repayment Program, which is made possible by federal matching
funds. These programs support medical and dental providers,
behavioral health providers, and pharmacists working at
HealthPoint. 20 percent of our current workforce receives this
support. Another 30 percent has received this support in the
past--so that is half our providers relying on these programs,
this is key.
Loan repayment is our most effective tool to introduce new
clinicians to our work and to keep them in that work for the
long haul. We are also a teaching health center through The
Wright Center National Family Medicine Residency Consortium. We
have graduated three classes of residents--that is 11 new
physicians. Of that 11, seven are working in community health
centers, including four at HealthPoint and two other at other
Washington community health centers. Here is a great success
story. In 2017, we graduated from our residency a woman who
began her journey as one of our patients. She was inspired by
her primary care provider, and after completing her
undergraduate degree and her medical degree, entered our
residency and is now a practicing physician in our community.
For the last two authorization and appropriation cycles,
HealthPoint and health centers everywhere have experienced
serious uncertainty because of the cliff. In the fall of 2017,
when funding for all three programs expired and we actually
went over the cliff, we scrambled to make sure that we would
not have to cut services or disrupt the education of our future
doctors. This was especially acute for our family medicine
residents and the faculty who were really afraid that we would
renege on our promise to complete their education.
It is understandable that some might question the ongoing
need for Federal grant support in a state like Washington with
our adoption of the Medicaid expansion. However, like the other
health centers in Washington, we serve a significant number of
people with no insurance--over 15,000 every year. And many of
our insured patients are still low-income and have insurance
plans that have copays and deductibles that are simply not
affordable for them. In addition to all that, we provide a wide
array of wraparound services that are not reimbursed by most
insurances, including things like interpretation services and
care coordination. Our support through the Federal program also
helps us leverage other needed grant support. Like all the
health centers, we are supported with a patch-work quilt of
grants and reimbursements, all of which are critically
important to our ability to serve the underserved. The Federal
330 grant is the essential support for our ability to provide
care to these uninsured and underinsured patients--it is often
the seal of approval that others look to, to provide us with
support.
We must arrive at a more durable solution and provide
stable and adequate long-term funding for the care we provide.
Without your continued support, all this work is in serious
jeopardy.
I am grateful that the Chairman and Ranking Member, who
just happens to be my own Senator, have introduced legislation
to extend funding for the Community Health Center Fund, the
National Health Service Corps, and the Teaching Health Centers
program for an additional five years. I know other Members of
the Committee have also sponsored legislation to extend long
term funding and we are grateful for all of this support. I
urge the HELP Committee to move this legislation forward in
order to provide stable and full funding for the health center
programs and to prevent a repeat of the uncertainty and
disruption that occurred in the last two authorization and
appropriation cycles. Our staff, our patients, and our
community are counting on you. Thank you.
[The prepared statement of Mr. Trompeter follows:]
prepared statement of thomas trompeter
Chairman Alexander, Ranking Member Murray and Members of the
Committee, thank you for the opportunity to provide testimony in
support of the Community Health Center Fund, the National Health
Service Corps, and the Teaching Health Center Graduate Medical
Education program, as well as the importance of addressing the Primary
Care Funding Cliff we face in Federal Fiscal Year 2020.
My name is Thomas Trompeter. I am the President and Chief Executive
Officer for HealthPoint. HealthPoint is a Federally Qualified Health
Center, founded in 1971, serving people in need in suburban King
County, outside the City of Seattle.
In 2018, we provided care to underserved communities in King County
through 10 ``full service'' health centers, 3 school based clinics, 3
out-stationed primary care clinics, and a mobile medical van which
focuses on serving people who are homeless. We provide the full
spectrum of primary medical, dental, and behavioral health care.
Here are a few key metrics for HealthPoint in 2018:
We served 89,000 patients
16 percent of our patients have no insurance
65 percent of our patients are covered by Medicaid/
CHIP
We provided $8.5 million in care that was not paid
for by our patients or their insurance
In addition to emphasizing the essential role our base federal
grant plays in providing high quality primary care to underserved
communities, I would like to thank you for the recent supplemental
funding for increased access to critical integrated mental health and
substance use disorder services. With funding through the recent AIMS
and SUDS service expansions, HealthPoint has added (and is adding) new
personnel to expand access to integrated SUD and MH treatment for our
patients. The opioid epidemic in our service area continues to
increase, with no end in sight. As a Federally Qualified Health Center,
HealthPoint is at the forefront of responding to this community-wide
crisis. We are dedicated to meeting the challenge by removing barriers
and providing opportunities for more high-risk patients to access care.
With the epidemic creating the need for increased staff capacity, these
supplemental awards provide critical funding needed to better respond
to this crisis. Our increase in integrated SUD and MH personnel
(Behavioral Health Consultant, Chemical Dependency Counselor and a
Psychiatric Nurse Practitioner) will expand access to services for
existing as well as new patients and strengthen our capacity and
commitment to making sure that care is within reach for everyone who
seeks help.
Like many health centers across the country, we participate in the
National Health Service Corps Loan Repayment Program, as well as
Washington State's own health professions loan repayment program, which
is made possible by federal matching funds. These programs provide
support for medical and dental providers, behavioral health providers
and pharmacists working at HealthPoint.
About 20 percent of this workforce at HealthPoint is
currently receiving support through these programs.
Nearly 50 percent of all our providers are either
currently receiving support or have received support in the
past.
This is key. Loan repayment is an essential recruiting tool for
HealthPoint and for health centers in general. It is the most effective
tool we have at HealthPoint to introduce new clinicians to our work. It
is not uncommon for providers--once exposed to the rewarding work we
do--to decide that working in a Health Center is a truly worthwhile
career and to stay with us.
We are also deeply engaged in training the next generation of
health center providers. We are a community campus of the AT Still
School of Osteopathic Medicine in Arizona (SOMA). 79 percent of our
graduates pursue residencies in primary care--a percentage that is far
greater than in most medical schools.
We are a Teaching Health Center through The Wright Center National
Family Medicine Residency Consortium. We have graduated 3 classes of
residents for a total of 11 new physicians. Of that 11:
7 are working in Community Health Centers--4 at
HealthPoint, 2 at other Washington CHCs, and one in a
California CHC
Of the remaining 4, 3 are working in our local area
and 1 is practicing out of state.
It is worth noting that for each of the three years we have
operated the residency program, the number of graduates choosing to
work in a Health Center has increased. We are thrilled with the
Teaching Health Center program.
I would like to offer one example of the success of our involvement
with the Teaching Health Center program. In 2017, we graduated from our
residency a woman who was a patient at HealthPoint. She was inspired by
her HealthPoint provider and, after completing her undergraduate
degree, entered our SOMA community campus and then was accepted into
our residency program. She is now a practicing physician in our
community.
I am grateful that the Committee is holding this hearing to discuss
the importance of resolving the Primary Care Funding Cliff. For the
last two authorization and appropriation cycles, HealthPoint and CHCs
in Washington State and around the nation have experienced serious
uncertainty due to the challenges we have faced with the Cliff. We must
arrive at a more durable solution and provide stable and adequate long
term funding for the critical care we provide for underserved
communities.
In the fall of 2017, when funding for all three programs expired
and we actually went over the cliff, we at HealthPoint scrambled to
make sure that we would not have to curtail services to people in need
and to the medical students and residents who rely on us. Fortunately
for us, the gap in funding was ultimately resolved prior to the end of
our own grant budget period, thereby saving us from having to make even
more difficult decisions. Nonetheless, the level of uncertainty created
serious difficulty for us as an organization. And, while I remained
relatively confident that a solution would be found, I cannot say the
same for our staff. Perhaps the most powerful example of the effects of
this uncertainty is with our Family Medicine Residents and faculty. Our
residents were understandably concerned that the promise we made to
them would be unfulfilled due to loss of THC funding. Our faculty were
understandably concerned that we would be forced to renege on our
commitment to these future Family Physicians. This, then, created
serious concern that our Federal Government would abandon a program
that has shown great promise in helping to address the shortage of
primary care physicians dedicated to caring for underserved
populations.
It is understandable that some might question the need for federal
grant support in a state like Washington with our adoption of the
Medicaid expansion under the Affordable Care Act. However, like the
other CHCs in Washington, HealthPoint still serves a significant number
of people with no insurance. 17 percent of our patients have no
insurance. In addition to that, many of our insured patients are still
low-income with policies that have copay and deductible provisions that
are not affordable for them. The federal 330 grant is the essential
support for our ability to provide care to these uninsured and
underinsured patients.
I would also point out that in many ways--our support through the
federal CHC program helps HealthPoint leverage other needed grant
support. Like all CHCs, we are supported by a ``patch-work quilt'' of
grants and reimbursements--all of which are critically important to our
ability to serve our communities. Chief among these sources is the
support we receive through the CHC programs--it is in many ways the
seal of approval that our other sources of support look to as an
assurance that we are a high quality organization worth their
investment.
All the programs I have briefly described here--whether directly
supported with federal funding or indirectly supported because of the
foundation that federal support provides--are made possible by the
stable and adequate funding we have historically received through the
CHC programs portfolio. Without your continued support, all this work
is in serious jeopardy.
I am grateful that the Chairman and Ranking Member, who just
happens to be my own Senator, have introduced legislation to extend
funding for the Community Health Center Fund, the National Health
Service Corps, and the Teaching Health Centers program for an
additional five years. I know other esteemed Members of this Committee
have also sponsored legislation to extend long term funding. On behalf
of health centers in Washington and across the country I want to thank
you all for these efforts. I urge the HELP Committee to move this
legislation forward in order to provide stable and full funding for the
CHC programs, and to prevent a repeat of the uncertainty and disruption
that occurred in the last two authorization and appropriation cycles.
Our staff, our patients, and our community our counting on you.
______
[summary statement of thomas trompeter]
HealthPoint is a Federally Qualified Health Center, founded in
1971, in King County, Washington.
10 ``full service'' health centers; 6 ancillary
sites; one mobile van
Full spectrum of primary medical, dental, and
behavioral health care.
89,000 patients; 17 percent uninsured; 65 percent
Medicaid/CHIP
$8.5 million in care that was not paid for by our
patients or their insurance
Our base federal grant is critical to our ability to care for the
uninsured and underinsured
The opioid epidemic in our service area continues to increase, with
no end in sight. Recent expansions funds have let us add needed staff
and expand services.
NHSC is a critical resource for HealthPoint. It provides (a) direct
assistance and (b) leverages resources for a state program that also
provides similar assistance;
20 percent of our provider workforce currently
receives support; 50 percent of all our providers are current
or past recipients
Loan repayment is the most effective tool recruitment
we have, and recipients often stay.
We are a community campus of the AT Still Medical School and a THC
through The Wright Center National Family Medicine Residency
Consortium.
79 percent of our medical school graduates pursue
residencies in primary
Our residency has graduated 11 new physicians. Of
that 7 are in CHCs
In the fall of 2017, when funding for all three programs expired
and we actually went over the cliff, we at HealthPoint scrambled to
make sure that we would not have to curtail services to people in need
or to the Family Medicine Residents who rely on us. For HealthPoint,
the level of uncertainty created serious difficulty. The effects of
this uncertainty were especially acute with our Family Medicine
Residents and faculty. Our residents were understandably concerned that
the promise we made to them would be unfulfilled due to loss of THC
funding.
Our 330 grant is essential to our ability to provide care to
uninsured and underinsured people. It also leverages other resources
for our ``patch work quilt'' of support--it is the seal of approval for
other funders.
Without your continued support, all this work is in serious
jeopardy.
I am grateful that the Chairman and Ranking Member, who just
happens to be my own Senator, have introduced legislation to extend
funding for the Community Health Center Fund, the
National Health Service Corps, and the Teaching Health Centers
program for an additional five years. I know other esteemed Members of
this Committee have also sponsored legislation to extend long term
funding.
On behalf of health centers in Washington and across the country I
want to thank you all for these efforts. I urge the HELP Committee to
move this legislation forward in order to provide stable and full
funding for the CHC programs, and to prevent a repeat of the
uncertainty and disruption that occurred in the last two authorization
and appropriation cycles. Our staff, our patients, and our community
are counting on you.
______
The Chairman. Thank you, Mr. Trompeter and all the
witnesses, thank you very much. We will now begin a round of
five-minute questions. Senator Cassidy.
Senator Cassidy. Hey, thank you all for your good work. My
work as a physician was in an inner-city hospital, so I applaud
what you do. Dr. Anderson, my wife did her residency at Harbor-
UCLA. A good friend of hers was probably one of your part-time
faculty. So anyway, just to say that and I did mine at a big
County. So anyway, I am going to probe, and I probe not to do
anything but to be able to explain this program better to
others. Dr. Waits, you mentioned the $150,000 per position per
year. Now, the average resident earns about $57,000 a year,
maybe 20 percent benefits will move it up to $65,000 because of
the delta there. Now obviously you have to pay faculty, but
faculty are also billing. So, if I am defending the program to
others, how do I defend that delta between the average salary
of a resident and the $150,000 we are allocating per year?
Dr. Waits. Well, thanks for the question. I guess the first
thing I would say is a lot of the delta is very understandable,
with fringe benefits----
Senator Cassidy. From 25 percent right?
Dr. Waits.----and then their malpractice insurance and the
efficiency of a resident in a health center that is already
seeing uninsured patients and nonprofit--our interns typically
see three patients in a half day, whereas a faculty member
might see 15 or 20. And so they are just cost to the
institution that it takes to host an accredited training
program. This number was independently assessed in the peer-
reviewed literature by George Washington University and it is
it is consistent with the cost of graduate medical education in
the CMS program that has been somewhat standard for decades.
Senator Cassidy. Sounds great.
Dr. Waits. Yes.
Senator Cassidy. Mr. Trompeter, are these grants kind of
stackable if you will? Can someone get loan forgiveness, but
also fill a slot that is financed by the--whenever I say THC I
think of THC meaning something else--but THC Graduate Medical
Education Program. Can you have somebody who is loan forgiven
and then put into one of those slots?
Mr. Trompeter. I am not quite following the question.
Senator Cassidy. Can we have two different incentive
programs to try and move people to these areas? Maybe Dr. Waits
should be the one to answer. And in the question--ideally, they
were both operating independently, but if we have the loan
forgiveness program that would attract somebody, but we attract
them into a residency position, which is otherwise financed by
the THCGME, then you are using two different incentive programs
to attract one person. I do not know the answer. That is why--
--
Mr. Trompeter. Well let me try and maybe Dr. Waits can help
me out here. The loan repayment program is for providers who
are hired on as full-time staff providers. They are not
residents----
Senator Cassidy. I see. That is not the residency that
comes out.
Mr. Trompeter. That is correct.
Senator Cassidy. Okay. Got you. Okay and that helps me
tremendously. I assume you all are 340b providers?
I see a lot of his nodding behind you. Dr. Freeman, how
does that 340b program interact with what you all are doing? I
say that because obviously, that could be a source of revenue.
Do you pass those savings on to your patient if you have a
drug, which is coming to you to at a below cost?
The Chairman. Microphone, please.
Dr. Freeman. Yes. In our state with Medicaid patients the
revenue really is subbed out to a subcontractor. So we are paid
only a filing fee on Medicaid patients. You know, it is a great
benefit to our patients to give them lower-cost prescriptions.
Senator Cassidy. Dr. Waits, Mr. Trompeter, do you all also
pass those savings on to your clients?
Dr. Waits. Absolutely. It is a crucial revenue stream to
pass on the savings on the cost of medications to our uninsured
patients from our in-house dispensaries.
Senator Cassidy. If you bill insurance, do you similarly
pass those savings on to the insurance company? I see, Mr.
Trompeter, 16 percent of your patients are insured.
Mr. Trompeter. 17 percent are uninsured, Senator Cassidy.
We do pass those savings on to our patients. It is the tool
that allows us to provide medications to our uninsured patients
at a sliding scale discount.
Senator Cassidy. Got you. Yes, but also to the insurance
company? I am sorry. I got the wrong percentage, but a certain
percent of your patients do have private commercial insurance,
at least as I was trying to figure out your statistics. Are
those savings passed on to them as well?
Mr. Trompeter. We normally do not use the 340b program for
those patients.
Senator Cassidy. Oh, really?
Mr. Trompeter. Yes.
Senator Cassidy. An honest man, so I just say most----
Mr. Trompeter. Well and they will go to a commercial
pharmacy. It is a very small portion of our patients.
Senator Cassidy. Got it. Okay. Mr. Chair, thank you for
deferring to me. I appreciate that. I yield back.
The Chairman. Thank you, Senator Cassidy, for your usual,
well-informed questions.
Senator Murray.
Senator Murray. Thank you. And thank you to all of our
witnesses--really appreciate again your testimony and being
here today. It really seems to me that our community health
centers are sort of the backbone of our country's primary care
infrastructure. And Mr. Trompeter, you talked a little bit
about it, but can you speak more broadly to the importance of
the community health center grants and how they have supported
your mission in strengthening communities in Washington and
providing access to all?
Mr. Trompeter. Sure. The grants, as I said, really are the
fundamental support that we have for taking care particularly
of the uninsured, but also the underinsured and for our whole
program. They also help us provide services that are not
covered by most insurances, including Medicaid and these
include things like care coordination, social work, referral
coordinator, interpretation services. There is a wide variety
of sort of wrap-around services that, particularly the patients
that we all take care of, really need in order for the medical
and dental care that we provide to be effective.
Senator Murray. Okay, and can you describe for us the
impact of the lapse in funding that occurred last year on your
day-to-day operations and strategic planning? Just tell us what
happened.
Mr. Trompeter. Sure. We had a lot of conversation. It
really did throw things into uncertainty, and like I said in my
testimony it was particularly acute with our teaching health
center folks who were really very nervous. Our faculty was also
very nervous that we were going to have to renege on a promise
that we made in order to help people complete their medical
education. From a strategic planning standpoint, it made us
just kind of step back and say we are not really ready to make
certain kinds of expansion decisions or service depth decisions
until we are more confident that we have actually got the
support that we need in order to do these things. It created
enough uncertainty that it was kind of like no way to run a
business, and it really did make us slow down and reconsider
things that we knew we needed to do in order to serve our
communities.
Senator Murray. Thank you for that. Dr. Waits, thank you
for being here. My home state has six teaching health centers,
and I have really seen the importance of how they helped get
physicians into rural communities as a result of those teaching
centers. From your experience, talk a little bit about how
training providers in rural areas better prepare them to
actually practice in those kinds of settings.
Dr. Waits. Well, thank you. A rural area or an inner city
under-resourced clinic is challenging. I have been in practice
in central Alabama for 15 years and it is very different when
you are the doctor in the hospital or in the clinic, and maybe
the only one that is on call for a weekend in a county of
25,000 people and your nearest consultant is an ambulance ride
or a helicopter away, and that is often daunting for someone
that has trained for a decade of their medical education in a
university-based, city-based training program. The beauty of
these teaching health centers that are situated in rural or
urban community health centers is that it matches the training
to the very needs that our society needs. And so a graduate of
a teaching health center would not be deterred from practicing
in a community health center environment, either rural or urban
because they were not trained in that environment. So there is
a degree of nervousness that is alleviated from choosing that
job and that career path.
Senator Murray. Okay. Thank you. Dr. Anderson, thank you
for your testimony. The National Health Service Corps is so
important, providing loan repayments and scholarships, and I
think I heard you in your testimony talk about how you yourself
were helped by the National Health Service Corps. Can you
describe how that got you involved and what it has meant for
you?
Senator Murray. I--turn on your mic there.
Dr. Anderson. Thank you. I always had a heart to serve the
underserved. When I signed my contract in 1997, I made a pledge
to serve these communities. I graduated in the year 2000 from
Brown University and I took an oath. I brought it with me
today. It is scratched up and tattered, but it talks about my
commitment to serve humanity regardless of their social
standing, and the National Health Service Corps made it
possible for me to serve to the truest letter of this promise
that I made 22 years ago. I signed that contract eight years
before I was even in the workforce and I came to Unity Health
Care, as I mentioned. I served in a community health center,
and I now teach in a teaching health center residency. Some of
my residents are behind me today and I can say that I would
send any one of my family members to those residents because I
am confident that they have the skills and the passion to serve
and to stand in the gap of what America's healthcare needs are
today.
Senator Murray. Okay, thank you. Thank you very much. Thank
you to all of our witnesses.
The Chairman. Thank you Senator Murray, and welcome to the
residents of Dr. Anderson.
Senator Romney.
Senator Romney. I am going to ask my first question to Mr.
Trompeter, but then ask a question to all of you from Mr.
Trompeter on down. First, I just wonder how you were able to
make this patchwork of financial resources fill the gap when
the Federal Government backed away. You said you had to
scramble. Just what did you do? But then we let me turn with a
second question for you and for the other Members of the panel,
and this may be particularly attuned to you and also to Dr.
Freeman, but that is, to what extent is their involvement on
the part of the state for the program that you administer, and
what coordination is there between Federal and state dollars
and direction? And is that a help? Is that a hindrance? I know
that we on this side of the dais, and I mean on this side of
the bench all the way around, sometimes we are overwhelmed with
all the programs that exist--my guess is that you have to, not
only deal with us but the states and counties and so forth. So
what is the involvement of the state, and how coordinated is
that with what is happening at the Federal level? But first,
how did you make it work? How did you make that patchwork work
when things fell through at the Federal level?
Mr. Trompeter. Senator, fortunately, our grant period was
outside the bubble of the cliff, when the cliff happened the
last time around. Many of my colleagues were not in that
position. Nonetheless, we were still very nervous about whether
the cliff would actually get fixed until it actually did get
fixed. And there is a certain amount of faith that all of us
have got to have in order to do this work. And frankly, this
Committee is one of the reasons we get to have that faith
because this Committee has done such a good job of working in a
bipartisan way to make sure that the folks that we take care of
are getting taken care of. So personally, I had faith and I was
by hook or by crook, we are not going to close our doors. We
are going to make sure that they stay open.
Like I said earlier, I think it was--the conversations were
the most involved with the folks who were relying on us for
their medical education because they are new in the world here
and they are still uncertain about who is going to fulfill
their promise and how that is going to happen. And when they
hear all of the news and the talk around that cliff, you made
them very nervous. So I spent a lot of time calming people
down, which kind of goes with the territory. So we made it, but
that way. And I do know that some of the examples that Senator
Murray spoke to early on are very close to us. I know those
folks and I know that they went through them. I know that bank
loans were denied. I know that bank loans were put on hold. I
know that expansions were delayed and I know that providers who
were looking to come to work in some of those health centers
decided to go to work elsewhere because they read the news and
they did not understand whether they were going to have a
secure job.
The recruitment cycle for physicians particularly is long,
and if people are uncertain, it creates not just an immediate
problem but a problem further on down the road. So I just want
to emphasize that this was no small thing that we faced there.
With regard to the answer for the state, we are fortunate to
live in a--I am fortunate and Senator Murray is fortunate to
live in a state with a really great state government and a
really great health care approach. And we are well coordinated
with the state. We do not get state grant dollars. So the
coordination that we do with the state is really through the
Medicaid program. But yes, I think we have had the good fortune
of working with folks in our state both at the governor's
office, and the legislature on both sides of the aisle, and
with the healthcare authority, who understand the work that we
do and really try to be additive to that work rather than
duplicative.
Dr. Anderson. I would say that any degree of uncertainty in
any of these programs causes a ripple effect. I would say from
the perspective of the National Health Service Corps,
especially for loan repayment extenders--so the way the program
works is you get a certain lump sum the first two years, but
then you have the option to continue to extend it as long as
you have a loan balance. And so, this creates stability within
the community when your patients have the same doctor that they
come to for years and years. I am fortunate to have taken care
of multiple generations of patients. Some patients I saw for
their school physicals, and now I am taking care of their
children 15 years later. So the importance of the funding
cannot be emphasized enough. That in order to capture the
talent, the providers, the medical students, to interest them
to stay in these communities, we need consistent sustained
funding, especially for the residents. Funding that will cover
their entire residency and not be renewed every day every two
years. So we thank you for your support in keeping this funding
stable.
The Chairman. I am afraid the five minutes has expired.
Maybe the two of you will have a chance to answer Senator
Romney's question a little later.
Senator Casey.
Senator Casey. Mr. Chairman, thank you very much. I want to
thank you and the Ranking Member for the legislation that you
have--I guess it is Senate Bill 192--and the work you have
done. Dr. Anderson, I will direct my questions to you
principally. I wanted to ask you about teaching health centers
generally, but in particular, to use by way of example as a--I
guess a predicate for my question. We are joined today by
individuals from my hometown of Scranton who are here from the
Wright Center, Dr. Thomas Hemak and two residents here with
this on this side of the room--I am sorry, that side of the
room. And the Wright Center in Scranton is well known as both,
a community health center and a teaching health center. They
have been able to respond to and serve the specific needs of
that particular community. They have programs to assist
patients with addiction, with pain management, and also with
counseling, to help patients adhere to their medication
program. So my first question to you is, can you discuss how
teaching health centers are able to both adapt their programs
to meet those unique needs of a community, and also how they
are able to train residents to respond to those particular
needs? I know some of this you may have provided by way of your
testimony, which I was not here for, at least the oral version
of the testimony.
Dr. Anderson. Yes. Thank you. The teaching health center
program is incredibly important to train the next generation of
physicians who are interested and willing to stay in these
types of communities. Actually, the program that I teach is
also a part of the Wright Center. It is the National Family
Medicine Residency Program. It is a consortium model that
happens in four sites throughout the country including a
HealthPoint. So these residents have signed on to train in the
community health centers. And even in our current graduating
class alone, there are seven graduates coming out, five have
signed contracts to stay at our center. So this shows that this
is a pipeline where students are willing to stay in these
communities, and I would agree this is a skill set that is
learned. It is incredibly daunting for a physician who has
trained in a site where they do not have any type of experience
with patients or underserved patients who do not have
insurance, patients who might speak another language, patients
who have an addiction or mental health challenges, or any of
these things that we deal with every day in the community
health center. So by training these residents in these
settings, they are more likely to stay in these settings
afterward.
Senator Casey. Do you have, in particular, any specific
examples of models or good examples for us to follow?
Dr. Anderson. Training models?
Senator Casey. Right.
Dr. Anderson. For example, our site employees group visits.
Now this is a very important innovation where instead of me
telling each individual person one after the other about
healthy eating for example or weight loss, we can combine the
patients together in a group of 10 or 12 and the residents can
be part of that, thus employing the expertise of the medical
professional and the collective wisdom of the group. So for
example, if I say, hey, everyone has to eat more vegetables,
and one of the other patients might say, oh I tried it and look
I have lost 10 pounds, and then the other patient says, oh,
yes, and these vegetables are on sale this week at Safeway, and
the other patient says, oh, yes, let's all go afterwards.
[Laughter.]
Dr. Anderson. You know, that kind of community model is
what these centers are invested in. It is said that once you
see one community health center, you see one community health
center because we are trained to respond to the individual
needs of those patients and be flexible in adapting our
training to the needs that the patients are exhibiting at that
time.
Senator Casey. Dr. Waits, anything on this that you would
want to add?
Dr. Waits. Yes. Thank you for the question. I would just
add that the Teaching Health Center Program itself is an
innovation. You know, as we have alluded to, it is such an
accountable program. It has such transparent outcomes of--it is
targeting the training to the exact location where the
workforce need is the greatest in our community health centers.
We have got great outcomes of graduates staying with the
program, being comfortable in taking care of patients in the
program, and it is a transparent program where you can see
those outcomes. And I think that is innovation itself, and it
is a reproducible model. That looking at this reauthorization,
there could be more teaching health centers to do what we all
have done.
Senator Casey. Before I wrap up and you can answer it more
fully in a written form, but as you know, we have had--recent
events have proved we are really good at stopping, starting
government. The Congress now has expertise in short term,
really short-term government. And one of the problems here is
of course the authorization period. We have had a lot of
examples of two-year authorization periods, so maybe, for a
fuller written version--I will just present the question now,
you can answer in writing--but the positive impact, which I
will assume, of a five-year authorization, reauthorization as
opposed to the shorter term. So I will leave that for the
record. Thanks to Chairman.
The Chairman. Thank you, Senator Casey.
Senator Murkowski.
Senator Murkowski. Thank you. Mr. Chairman, and I want to
thank you and the Ranking Member for your introduction of this
package that focuses on our community health centers, and the
training, and our National Health Service Corps. My colleagues
here on the Committee know very well that when I ask, questions
are always very Alaska centric because I listened with great,
almost envy, that we have these opportunities for some training
facilities, the teaching health centers, the opportunities to
really work to build this is workforce of professionals, but we
struggle in Alaska to be able to attract those good folks that
you are training up, whether they are in Alabama or whether
they are in Tennessee, wherever they may be, we would like to
have them up north----
[Laughter.]
Senator Murkowski.----and we don't have our own medical
school and that is not going to happen anytime soon. And so you
point to a real reality, Dr. Waits, that when you have somebody
who has been trained and in perhaps a more urban setting and
when they get the Alaska bug and they decide they want to have
this great adventure up there, they get into a setting where
they are it. They don't have any support that you have
mentioned, Dr. Anderson, and it is not that they are an
ambulance away or an airlift there. They are hours, perhaps
even days, from being able to be with anybody else that can
help them with this particular issue. So you really have to be
an independent individual. So I am recruiting for independent,
smart people----
[Laughter.]
Senator Murkowski.----who really want to practice medicine.
Dr. Freeman. You will be pleased to know Senator, we lost a
really good physician who moved to Alaska.
[Laughter.]
Senator Murkowski. Loving it. Thank you. Thank you, we will
keep them coming, but my question to you and the challenge is,
what more can we be doing? We have looked at National Health
Service Corps as an opportunity to again be able to attract
those individuals into these medically underserved areas. Is
there more partnering that we can do--we do a lot of partnering
obviously with the State of Washington, our closest neighbor
with some of the training and the residencies--but what more
can we do? What more can you offer us in these very remote,
often frontier practice areas? And I throw that out to any one
of you. I am looking for good ideas, help me.
Dr. Anderson. I would go back to the as you know, we are
asking for a doubling of funding for the National Health
Service Corps, and even if we could have a tripling of funding
because right now we are only able to fund 10 percent of the
scholarship applicants and have less than half of the loan
repayment applicants----
Senator Murkowski. 10 percent of scholarship applicants?
Dr. Anderson. Right. And had less than half of the loan
repairs. So there might be great people who want to go back to
Alaska but they don't get the scholarship that year, or they
don't get the loan repayment, and what cannot be
underemphasized is that these health professional shortage
areas, the money goes to the highest need and then it trickles
down until the funding runs out. That doesn't mean that the
numbers at the bottom of the list don't have need----
Senator Murkowski. Right.
Dr. Anderson.----they do but we cannot fund them. And so
those areas go--the needs go unmet. And I just want to
emphasize the recruitment tool of having a provider, let us say
from Alaska, who grows up in Alaska, sees a doctor who is from
Alaska come back to Alaska--that is inspirational for a young
boy, a young girl who is thinking, you know what, I can be a
doctor too, I can do this too. I can come back and serve my
community, and there is a way for them to do it.
Senator Murkowski. Other ideas?
Dr. Waits.
Dr. Waits. I would just add additionally from the
educational standpoint, in terms of the reproducibility of the
teaching health center model, this legislation, the Alexander-
Murray legislation and the Collins-Jones legislation, goes a
long way. This five-year reauthorization is so critical. So if
we were going to set up a teaching health center in Alaska, the
organization itself would need to know if we take the two or
three years to get accredited as a teaching institution and
then we start recruiting first, second, third year medical
students. Well, we have used that five-year reauthorization
building the program and looking at medical students and
convincing them to come train with us. And so the stability,
the permanence, and the growth of this program, that again is
so accountable, has such good outcomes. I think that is one of
your key models right there. It could be done if there was
stability for that funding.
Dr. Freeman. Here is a suggestion. You know, with the
National Health Service Corps, great program, life-changing for
people who receive it but when we are recruiting providers, we
cannot promise them that they are going to receive it. You
know, we can tell them about it. They can apply, but if Alaska
health centers had slots and your providers could say this is
loan repayment. This is part of the deal. You know, I think
that would really help in the recruitment there. I have been of
your health centers. We have done consulting. I have been in
Talkeetna. I have been in the Kenai Peninsula. Wonderful
places, wonderful providers. You can get them there. I think
you can keep them there. But if they could use the core as a
certain recruitment tool, I think that would really help
recruit providers.
Senator Murkowski. Thank you.
Mr. Chairman.
The Chairman. Thank you, Senator Murkowski. Senator Hassan.
Senator Hassan. Thank you, Mr. Chairman and Ranking Member
Murray for holding this hearing. And thank you to all the
witnesses for being here, but also for all that you do to help
people throughout our country.
I think there is a question for each of you. As I am sure
you all know, we are experiencing a significant healthcare
workforce shortage, particularly when it comes to the
behavioral health workforce in my home State of New Hampshire.
Communities are especially in need of help to fill shortage of
behavioral health. Professionals community health centers in
New Hampshire have played a key role in addressing the deadly
fentanyl, heroin, and Opioid Crisis that has devastated our
communities, and they have done it in part by incorporating
medication-assisted treatment into each of the eleven health
centers in our state. Last Congress I worked with Democrats and
Republicans on this Committee to help pass the Support Act,
which included a provision I helped to introduce, to expand
access to substance use disorder services by taking steps to
increase the number of behavioral health professionals who can
provide those services. It is an important step, but we
obviously have a lot more to do.
Maybe starting with you, Dr. Freeman, I am interested in
hearing from all of you about how additional funding for
community health centers could be used to address the need for
behavioral health services and professionals, particularly in
those states hardest hit by the Opioid epidemic?
Dr. Freeman. It is interesting--we trained behavioral
health professionals typically in behavioral health settings--
--
Senator Hassan. Right.
Dr. Freeman. They generally then go to work in behavioral
health settings. The primary point of access though, for folks
who have behavioral health needs, are in primary care.
Senator Hassan. Right.
Dr. Freeman. If we did more training, a behaviorist within
primary care settings--many, many more would stay in those
settings----
Senator Hassan. Yes.
Dr. Freeman.----and the efficiency of practice would be
much greater than if they were in isolated behavioral health
silos. There are a few programs that are kind of like the
Teaching Health Center Program. There is a Graduate Psychology
Education Program. It really trains--psychologists, who work in
primary care settings--the AHEC program is another model--where
we could get more behavioral health training and primary care
psychology internships. You know, any of these models where we
train--I have got some data in my written testimony that shows
kind of when we train interns or fellows in psychology at
Cherokee, we retain a high percentage of them and I would to
see those programs expand to community health centers.
Senator Hassan. Thank you. Does anybody else quickly want
to add anything to that?
Dr. Anderson. I can add as a provider, as a family
physician, in a community health center. It is invaluable to my
practice to have a mental health provider working alongside me.
About 10 years ago in our clinic, we abolish the mental health
department and we co-located those providers along with the
primary care. This takes off the stigma for someone to have to
go to mental health department and we teach our patients their
brain is a part of their body. So it is the same kind of
illness and we are here to help them take care of their total
health. And so it is invaluable if the patient gets up the
courage to reveal depression, to reveal an addiction, to their
primary care provider, I can say, you know what, thank you for
telling me that. I want to help you with that. Here is my
colleague right down the hall and I can walk you down the hall
and do what we call a warm handoff.
Senator Hassan. Right.
Dr. Anderson.----here, we are going to help you together
and the patient feels taken care of as a member of the team. So
it is not just me as the physician caring for the patient. It
is the entire brevity of the healthcare staff.
Senator Hassan. Thank you.
Mr. Trompeter.
Mr. Trompeter. Senator, I would simply add to what my two
colleagues have said, we train postdoc psychologists and it is
the kind of thing that we are able to do when we have a stable
base to work from.
Senator Hassan. Yes.
Mr. Trompeter. The first thing you could do is fund the
health centers, and then I think additional resources would be
great. But the first thing is to make sure we are working on a
stable base.
Senator Hassan. Thank you. And Dr. Waits, did you have
anything to add?
Dr. Waits. Just echoing that point--the stability is
important. This is something that we are training our residents
to do as well. And so as we begin to co-locate behavioral
health and primary care, reducing that stigma, taking care of
addiction and depression, and these sorts of things. Just a
reduction in sometimes the regulatory burden of reporting--are
you a mental health facility? Are you primary care facility? We
are bringing down these barriers and so that can be an
important point as well.
Senator Hassan. Thank you. I think you are all echoing the
need for the right treatment, at the right place, at the right
time. And so I appreciate it. You all anticipated my second
question, which was about the need for stability for the
program and funding, so thank you for touching on that as well.
Thank you. Mr. Chair.
The Chairman. Thank you Senator Hassan.
Senator Braun.
Senator Braun. Thank you. First of all, it is a real
pleasure to be on this Committee. I told you that in my own
backyard of Southern Indiana, health care delivery through my
own company has been a challenge in a taken on the effort and
mantle to try to do the best we can through employer-provided
insurance, and have really been looking into different ways to
make this more effective. I was in Indiana last week and spoke
to the folks that--they have 196 health center delivery sites
there and was surprised the voids that they were filling in to
provide services in underserved areas. In all my discussions on
this and anything else, it is such a complicated dynamic where
health care delivery is going in his country. You know, it is
way too large percentage of our GDP.
It has got to be more effective. You got to cover pre-
existing conditions and no cap on coverage, generally speaking,
and you got to fill the voids that are in many places. You had
mentioned, and I am going to be interested in revenue sources,
if you could whoever feels comfortable with it, describe--you
mentioned patient services--and tell me how much revenue you
generate, and you don't have to get detailed but generally,
from folks that are not availing themselves of something that
would be supplemented through government? Patient services--
somebody referred to that earlier in terms of what component
that is. Anyone that feels comfortable with it?
Dr. Freeman. Let me tell you a little bit about how our
revenue comes. We are a $60 million company.
Senator Braun. Yes.
Dr. Freeman. You know, we get a Federal grant of a little
bit over $8 million. So, 13.5 percent of our revenue comes from
our HRSA grant. We get a few other Federal grants, but the bulk
of the revenue comes from patient services. You know, 30
percent of our patients are uninsured. You know, our minimum
fee for those patients is $30--$20, I am sorry. We sometimes
collect that. If we have homeless folks, we don't charge any
fee at all. 40 percent of our patients are Medicaid. Medicaid
is our best payer. There is some Federal regulation that helps
support--a special rate for us to get basically a cost base
rate with Medicaid. About 15 percent of our patients are
commercially insured. We negotiate those contracts as best we
can, and about 15 percent are Medicare. With almost all of our
contracts now, we have value-based provisions--so that if we
show good clinical outcomes, if we can reduce the total cost of
care, we will sometimes earn bonus dollars from the insurer.
Senator Braun. To tally that up. It was roughly 83 percent.
Do you get some folks that just come in and pay a fee because
they are not income constrained but need the service because it
is in an underserved area?
Dr. Freeman. We do--we get some full fee patients. Yes.
Yes, but it's 40 percent Medicaid, 30 percent uninsured, 15 and
15, I think 100 percent, right----
Senator Braun. Of the 13.5 percent were the grant source,
and that is going towards uninsured. So what makes up the
difference between the 13.5 percent and the 30 percent that is
uninsured? How do you fill that gap?
Dr. Freeman. Of the payer base--I gave you that break down
which is 100 percent of how those patients are classified. The
Federal grant, basically, underwrites the sliding fee scale
discounts.
Senator Braun. Okay, very good, I get that. One other
question on recruiting, I understand how we are getting
residents and doctors into the system. What do you do with
other staff? How hard is it to staff locations outside of the
doctor or resident? Is that tougher? Is it easy to staff?
Dr. Freeman. Go ahead.
Dr. Waits. It is tough as well. And we have, I think, each
of us in our own way. For example, we have created a medical
assistant orientation program where we start with the high
school health professions courses, where they volunteer some of
their time and take coursework, and we work with them in the
sciences and in the health professions education. And some of
them stay on. And typically, their first six months, to
sometimes a year or two, it takes to take to train them to be
able to assist the providers, and it is difficult to staff each
of the positions.
Senator Braun. Thank you.
The Chairman. Thank you, Senator Braun.
Senator Jones.
Senator Jones. Thank You, Mr. Chairman. And Mr. Chairman, I
would like to submit two statements for the record. First is a
statement from the American Academy of Family Physicians in
support of the Teaching Health Center Graduate Medical
Education Program, the National Health Service Corps Program,
and the Community Health Center Program. The second is a
statement from the American Osteopathic Association, the
American College of Osteopathic Family Physicians, the American
College of Osteopathic Internist, the American College of
Osteopathic OBGYNs--surreal osteopathic class for sure.
[Laughter.]
Senator Jones. The American College of Osteopathic
Neurologists and Psychiatrists, and the American College of
Osteopathic Pediatricians in support of the Teaching Health
Center Graduate Medical Education Program.
[The following information can be found on pages 53 and 59
in the Additional Materials:]
The Chairman. Order.
Senator Jones. Thank you. Mr. Chairman. Dr. Waits, thank
you so much for being here again. I really appreciate it, and I
have been so impressed with what you have been able to do in
Alabama. And we have still got a long way to go, particularly
in our rural areas in underserved areas. I particularly want to
thank you for mentioning the bill that Senator Collins and
Tester and Capito and I will be introducing, the Training The
Next Generation Of Primary Care Doctors Act of 2019, which will
increase the authorization for the Training Health Center
Graduate Medical Education Program and reauthorize it for five
years, and I would like to ask you about that a little bit. I
would like for you, if you would, just to explain to the
Committee a little bit more about how your teaching health
center could benefit from an increase in funds over the next
five years. How do you use those funds to help folks in the
areas in Alabama, would you expand? And how the bill would
allow for the creation of new teaching health centers
throughout the area, because Alabama is certainly one of those
states that is beginning to suffer from a drain of physicians
and a drain of health centers in our rural areas. So I will
just give you the floor for a little bit.
Dr. Waits. Well, thanks. So the increase in your debt
legislation would be critical. There is rising cost of
inflation for our centers, for our residents, for the Residency
Education Program, all costs go up. And so this rising a little
bit over the course of the five years is critical for our
bottom line and for us to run a good non-profit business and
educational center. In terms of the five-year authorization, it
is so critical. We are persuading medical students to follow
through on their dream. Often in the application to medical
school you write a personal statement saying that you want to
go to an underserved area, you want to take care of the least
of these, and we feel like we get to wake up every day and live
out the dream that we wrote in our medical school personal
statements. As you get to the end of medical school, as in the
third or fourth year, you find yourself with often on average
$200,000-$250,000 in debt. And if you look at training in a
program that may not have funding for two more years and you
may find yourself in the middle of a training program without
funding, it becomes daunting when you think about your family
and your career. So that is just speaking to the fact that the
five-year reauthorization is so critical. And then, was there
another question that you had----
Senator Jones. I think you covered most of that. I am
assuming that you would consider expanding, much like you did
in Maplesville, to help folks down in those areas. If we can
get this reauthorized for five years?
Dr. Waits. Right. And you know the last the last teaching
health center that was funded with 2014 and we have heard from
the Senator from Alaska, and there are many places in Alabama
that could open a teaching health center. It is such a
reproducible model. The new funding for new centers is really
something that could speak to the health workforce crisis that
we have in this country.
Senator Jones. Just out of curiosity, do you assume, even
though it is primary care, you probably still see a lot of
women who come in who are pregnant who are having babies and
there is a need for that in those rural areas. Would that be
correct?
Dr. Waits. That is right.
Senator Jones. You handle that as well those centers?
Dr. Waits. That is right. Among our 54 healthcare
providers, seven of us are family doctors who deliver babies.
In our center, we have three different labor and deliveries
that we help staff, one of them rural, and so it is definitely
a part of family medicine, especially underserved rural family
medicine--delivering babies, taking care of women and children.
Senator Jones. Well, we are going to be looking at some
legislation dealing with that, too. So thank you very much
again for being here. Thank you all for being here, by the way.
Thank you very much. Thank you.
The Chairman. Thank you, Senator Jones. Let me pose a
question to all of you, in our hearings on reducing health care
costs last year, as I mentioned, the uniform testimony was as
much as one half of healthcare spending in the United States is
unnecessary. And Senator Murray and I, Senator Grassley and
Wyden sat down recently and I said look, if that is even close
to true given the positions we have here, we ought to be able
to agree on something to help reduce the cost of healthcare,
which is an enormous tax on family's budgets, states, Federal
Government. And one of the obvious ways into that seems to be
through primary care, because while primary healthcare is only
2 points to 7 percent of the total spending the access, the
access that most of us have to healthcare is through our
primary healthcare doctors, which includes many of the people
who are part of your part of your systems.
One of the things we hear most frequently is that well we
need more transparency. If people just knew what the prices
were of everything, prices would go down. Well, I wonder about
that because most people who are sick or who are busy, get a
bunch of information about healthcare and they are not likely
in a very good position to do anything about it. Others might
say, well if this hip replacement costs more, it might be like
going to Harvard, if it costs more, it is a better place to go
and so they don't go for the lower price. Again, the primary
healthcare doctor is a person who might help if you want to use
a Papa John's Pizza analogy, looking for better outcomes,
better experience, lower cost, your primary healthcare doctor
should be the person who might be able to help you do that. So,
let me ask you based on your experience. What could we do to
remove barriers or create incentives so the primary healthcare
doctors throughout our country, so the 300,000, I am including
those at your centers, can help us help patients, get better
outcomes, better experience, but at a lower cost? Doctor
Freeman.
Dr. Freeman. Yes, I know the data is really clear. You
know, the systems in other countries that stress utilization of
primary care have lower costs. Australia is a good example--it
is often written about. There is really good data to show that
health centers are cost-effective. There is published data that
health centers are cheaper than other primary care system.
The Chairman. A lot of that is, as Dr. Anderson was saying,
eat your vegetables type of advice as a primary care doctor.
Dr. Roizen at the Cleveland Clinic will tell you that 80
percent of the costs of chronic conditions has to do with
wellness.
Dr. Freeman. Certainly, the patient is the most important
person in the primary care team, so getting patient engagement
in their care and really helping.
The Chairman. But what can we do in Congress to remove
barriers or create incentives that would make the primary care
doctor more effective in creating better outcome, better
experience, lower costs? What specifically can we do? Any of
you.
Mr. Trompeter. Senator, I would urge you to support the
models that we already know work.
The Chairman. Such as?
Mr. Trompeter. Teaching Health Centers, Community Health
Center Program, the National Service Corps. If we are to
build----
The Chairman. You cannot think of anything that we could be
doing?
Mr. Trompeter. I would expand on it.
The Chairman. Just more of what we are doing?
Mr. Trompeter. Double down on it.
The Chairman. Yes.
Mr. Trompeter. We know that this works. We know that we
don't have enough primary care in this country. It is true that
most people with what we would normally consider regular
insurance, get access to care through their primary care
physician. It is also true that a lot of folks who are
underserved don't have access to a primary care physician,
unless they are coming to a health center and they get their
care through an emergency room. And that is more expensive in
the system and less effective for health. We also know that the
health centers help people address, what Dr. Anderson termed
the social determinants of health. This has to do with what you
spoke about, diet, exercise, and things like that, which are
harder to come by and underserved communities. So I think if we
really want to start bending the cost curve, we in that portion
of the primary care system that is really shown to be effective
in helping bend that curve and in the communities that probably
need it most.
The Chairman. Okay. I have got another 40 seconds.
Dr. Freeman. I am not sure what the mechanism is, but
anyway that you can help get healthcare data to the primary
care provider. You know, when we start getting information on
our patients from insurance companies, we are shocked about the
doctor hopping that is going on--the referrals out to
specialists that we don't know anything about.
The Chairman. Well, that is something we can do. And one of
the problems I have had my own mind is if we make that data
available, generally many people don't know what to do with it.
Dr. Freeman. Yes.
The Chairman. Primary care doctors should know what to do
with it.
Dr. Freeman. They should and what has to happen is--it is
very complicated and so really healthcare systems really have
to have data analytics. You know, so we modified our electronic
health record so that when a chart is open on a primary care
patient, our primary care provider can see was that patient in
the hospital--where they recently in the emergency room--what
other kinds of claims, information, do we have from the
insurer? So I think first data has to flow from the payer to
the system, and then there has to be some massaging of that
data so it comes to the providers at the point of care. They
say they see what their patient has had and what their patient
needs.
The Chairman. Thank you very much. Senator Smith--Senator
Rosen, excuse me, Senator Rosen.
Senator Rosen. Thank you. Thank you Chairman Alexander.
Thank you. Thank you. I appreciate that. And I thank you
Ranking Member Murray, I want to tell you how thrilled I am to
be part of this Committee and excited for our first hearing and
I really appreciate everything that you have done for your
patients, for your communities, and for this Nation, it really
makes a huge difference.
I want to tell--I am from Nevada, my home state. We ranked
48th in the nation in terms of primary care physicians per
capita, but community health centers have made a tremendous
contribution for us, not only in our low income population, but
also in our rural and underserved communities in Nevada, and we
serve over 93,000 patients each year, including more than
29,000 children. So I am really deeply concerned about the
pending primary healthcare cliff and its impact on Nevada and
across our Nation. I know we have talked a lot about what we
can do, the funding, how much more robust we can make it, how
you can plan a long-term strategic planning, and funding really
makes a difference for people and removing that uncertainty.
But I want to go in just a little bit different way to expand
on what I like to think of as our people pipeline. So, of
course you have the physician, my husband is a physician, and
so that is one kind of provider. There is nurses, there is a
respiratory tax. There is people who wrap your arm if you break
it----
[Laughter.]
Senator Rosen. But across the medical spectrum, there are a
variety of jobs from A to Z. No one-job being more important
than the other--a person who draws your blood as important as
the person who does the surgery, you need it all. So you have
these wonderful models of the community health centers, the
teaching health centers and in underserved communities that
often have issues with people getting good paying jobs that are
going to last or being able to get trained for that. So, how
can we expand on this with some of our funding or do you think
that would be a good thing to do to grow that people pipeline?
Like you said, right from the community, giving those jobs
across the across the medical spectrum. How can we help you do
that, if you think that is a viable way to grow on these
healthcare teaching centers?
Dr. Anderson. I can say as a provider that in your state
there were 83 National Health Service Corps placements last
year. These providers are working in team-based models. In our
Center, we employ the patient-centered medical home model,
meaning that when the patient comes in they always have the
same person that registered them, the same doc, the same MA,
the same this, the same that. They develop a familiarity with
that team. Many times the patient might reveal something to my
MA that they don't tell me. It is part of the whole team based
model. So I think investing in all of those levels of the team
makes the center be solvent and makes for better healthcare
outcomes. Actually touching on what Senator Alexander had
mentioned, funding the community health centers funds proven
success because the community health centers have to report
everything. We have to account for every dollar. We have to
account for healthcare outcomes. We have to look at how are we
doing with diabetes? How are we doing with blood pressure? How
are we doing with this and with that, and make changes that
tweak even to the very point, one or point two of the
hemoglobin A1C, for example, for diabetes.
Senator Rosen. Right.
Dr. Anderson. Funding those models actually does result in
positive healthcare outcome. And what you said, it is a
pipeline for people in the community to see--I become an MA. I
can become a nurse. We have this all the time in the center.
They grow, they go to med-school, they come back to serve the
same community. And so it is a great cycle to invest in.
Senator Rosen. Thank you. I have one other question and you
were talking about sharing of electronic health records and all
of that information and course you are serving rural
communities, so we have the issue of course of rural broadband
across this Nation, and how that is going to impact your
ability to get data across platforms in, I guess we will say a
speedy fashion, or any fashion at all if you will. And so do
you think that an investment in rural broadband in telemedicine
would help amplify the ability of your community health centers
and teaching health centers to provide better and more access
to specialized care if necessary, or care in general?
Dr. Waits. It is absolutely critical for our electronic
medical records--they are often in the cloud. And so you need
any broadband just to access the patient's charts. We are
sending X-rays and other secure encrypted images of patients
broken bones and other images, so it is critical and the USDA--
there are some USDA programs that help with some rural
broadband, but definitely that level of investment would help,
not only the hospitals and the community health centers in
rural areas, but the education systems as well.
Senator Rosen. Thank you.
The Chairman. Thank you, Senator Rosen.
Senator Warren.
Senator Warren. Thank you. Mr. Chairman. Community health
centers provide essential services to our communities, but they
need Federal funding to do their work and they need that
funding to be predictable and sustainable. So exactly one year
ago right now, community health centers across the country were
running out of funding because Congress failed to reauthorize
critical programs before they expired--some of you may remember
that. For four uncertain months until Congress finally acted in
February of 2018, health centers and their patients were in
limbo. They held back on hiring new people, on replacement
staff. They deferred opportunities to make vital improvements
in their programs. And while most funding directed to health
centers was still flowing during the government shutdown that
ended last week, other vital funding sources that patients rely
on were cut off.
The next primary care cliff is only eight months away. So
today I wanted to dig into the impact of unpredictable funding
streams on the patients who are served by health centers. Mr.
Trompeter, your health center has several sites in Washington
State. Do many of your patients rely on federal food and
nutrition programs like SNAP and WIC, or Federal housing
vouchers all programs that were affected by the recent
government shutdown?
Mr. Trompeter. They do.
Senator Warren. How did your patients deal with the
uncertainty caused by the 35-day shut down?
Mr. Trompeter. Senator, we have seen an increase in anxiety
amongst our patients. Most of this is anecdotal at this
juncture, but we have queried our front desk who are usually
the folks who get told this stuff first, and we do know that a
lot of our patients, particularly those that rely on benefits
like SNAP and WIC, have been worried about whether or not they
were going to have the nutrition that they needed in order to
follow that advice of their doctors. I am also aware of two
patients, and this is small-scale stuff, but who made what we
might consider short-term smart financial decisions, maybe not
so much in the long term. One of our patients just decided that
he was going to stop paying his bills for a while.
If you don't pay your rent, sometimes you don't have a
house. Another patient decided that he would just use his
credit card in the meantime, and we have tried to counsel these
folks, but in the face of the kind of uncertainty that they
were facing, it is really kind of futile.
Senator Warren. Yes. I understand. These are people who
don't have a lot of financial alternatives. Now, health centers
also saw other impacts. In Massachusetts, on Cape Cod, one
health center was not able to pay the bills on a critical
facility replacement projects because they were no longer
receiving funding allotted for the projects from the U.S.
Department of Agriculture. The shutdown also had indirect
effects on health centers in the DC area. Dr. Anderson many of
your patients livelihood depends on Federal Government
functioning, with some family members of your staff as Federal
employees. What impact did the shutdown have on your patients
and staff?
Dr. Anderson. Thank you, Senator Warren. I can definitely
say that anecdotally the shutdown did have an effect on both
staff and patients. Many staff members are married to Federal
workers who rely on that two-income household to live in the
Washington, D.C. area and pay their bills, but I would say also
for our patients, many of them rely on the foot traffic
generated by the Federal workers. So for example, I might not
be seeing the actual Federal worker, but I am seeing the person
they buy coffee from. I am seeing the person they stop and get
a hot dog from on the way in, or the person that maybe that is
a shoeshine guy or, there is the person that delivers food to
the to the corporate boardroom meeting those are the unseen
patients that we see and we give dignity to at the health
center level. And for so many of Americans, as we all know,
that live from paycheck to paycheck and don't have an emergency
plan, there was definitely a huge impact and a lot of anxiety
in our patients when that type of supplemental income was not
was not guaranteed.
Senator Warren. Thank you. Dr. Anderson. I appreciate that
and I am sure everyone has stories around this. You know, while
President Trump demanded a border wall and Republicans let him
hold our government hostage, American families were struggling
to make ends meet. I am glad that the government is open again,
but we cannot do this again in two and a half weeks when the
next deadline comes. And whether it is due to a shutdown or
because Federal programs aren't reauthorized until months after
funding expires, we cannot keep putting our community health
centers and their patients in these uncertain and unsustainable
positions. I am glad that Chairman Alexander and Ranking Member
Murray have proposed a five-year extension of primary care
programs so that health centers have more certainty and
predictability. Patients are depending on us to make sure that
they have consistent access to care.
Thank you. Mr. Chairman.
The Chairman. Thank you, Senator Warren.
Senator Murray do you have any other comments?
Senator Murray. No, thank you again. Mr. Chairman, for this
hearing and for working with us on this bipartisan legislation.
I think we have heard today how critical this certainty is, and
hopefully we can move this long get it through. And thank you
again to all of our folks who are here today testifying.
The Chairman. Senator Romney, I think you get the
attendance award for today coming early.
[Laughter.]
The Chairman. Do you have any other comments you would like
to make?
Senator Romney. Let me ask one closing question, that is I
am astonished by the idea that 50 percent of healthcare cost
might be unnecessary, but I am curious as to whether you and
your positions see that kind of unnecessary health care costs
or expenditure. And if not--and my guess is you are going to
tell me everything you do is entirely necessary--if not, where
do you think that kind of excess lies and why it might exist in
our system today?
Dr. Waits. You are right in anticipating that we would not
say 50 percent of our healthcare is unnecessary. But this is
the community health center program and the other programs is a
proven model. And let me make it granular from a patient care
standpoint. You know, when a community health center opens up
in a community, we often find dozens if not hundreds of
patients who have gone a decade without getting a pap smear or
taking care of their diabetes, and often what comes to the
floor is 20 years of undiagnosed diabetes or, God forbid, a
cancer case and all of that could have been prevented by
preventative care. That is why we recommended, not meaning to
be self-serving, but doubling down on this type of program.
Across the world primary care has been proven as reducing
health care costs as well as enhancing access and enhancing
quality of care. Having a patient center medical home, having a
primary care physician as your healthcare quarterback, can help
reduce unnecessary referrals. So if someone is in a rural area
without a reliable primary care physician and they are
commuting to different big cities, different emergency rooms,
getting unnecessary scans, and no one person is advising them
that we need to do this, you have already had this done, this
is how community health centers primary care physicians and
interdisciplinary teams can really make a dent in the
healthcare costs.
The Chairman. Thank you. Well thanks to the all four of you
and Senator Romney. I was startled to when that testimony came
from people who are affiliated with the National Academy of
Medicine about the estimate of as much as 50 percent
unnecessary, now I am not saying wasted, just saying
unnecessary. I asked all the other witnesses if they agreed
with that and they all did. They thought 30 to 50 percent was.
And so we began to ask for suggestions for what to do that
might create better outcomes, better experiences, and lower
cost, and obviously empowering primary care doctors to be more
effective in what they are able to do is one obvious way to do
that. So, Dr. Freeman has suggested better access to data. The
witnesses from Cleveland Clinic suggested tying employer
healthcare to wellness so that more people eat vegetables, keep
their weight under control, do other things that are proven to
lower costs. So we are looking for specific steps we can take
to remove barriers, create incentives, to do that. You have
been very helpful. If you have further suggestions, we would
like to have them in writing.
I want to thank Senator Murray for working, as she so often
does, in effective and bipartisan way to get ahead of the game
here introducing five-year legislation so there can be some
resolution of funding for our primary care community health
centers. So, you can plan ahead and do the things that you did,
so your testimony today will be very----
[Laughter.]
Mr. Chairman. I spoke too long.
[Laughter.]
Senator Kaine. Mr. Chairman, I yield my time back to you--
--
Mr. Chairman. No, I just gave Senator Romney the attendance
award for staying the whole time. But you are welcome to have
five minutes of questions if you would like to do that, Senator
Kaine, and then we will conclude the hearing.
Senator Kaine. Well, let me just jump in and I apologize
for being late because of an Armed Services hearing, but what I
am most interested in and you all have a wonderful perspective
on it, and I am sure you have talked a good bit about it
already is making sure we have an adequate healthcare
workforce, especially in rural Virginia. We have had real
challenges and obviously as part of the Higher Education Act
reauthorization will do will have an opportunity to deal with
programs like public service loan forgiveness that could impact
upon rural workforce. But I think, is it Dr. Freeman, your work
is in Tennessee and touches on Virginia, correct?
Dr. Freeman. Right.
Senator Kaine. Talk to me a little bit about some of the
workforce challenges that you guys grapple with and how you
deal with them in rural Tennessee and Virginia.
Dr. Freeman. I think what we found--is training is the best
recruitment. So, whenever we can get different health
professionals into our place and train--so we train a lot of
psychologists. We train social workers. We train nurse
practitioners, we train nurses and then we are able to keep
many of those. You know, we have looked wistfully at the
teaching health center program and if it had more stability in
funding longer-term, that is something else we might do. But I
think training within our workforce, if you look at people who
enter the health professions--they come in there because they
want to help. You know, they want to help other people and
there is often a lot of passion about going and helping those
who really need it the most--but then the cost of education is
so high--that especially positions are drawn to higher-paying
specialties so they can get those paid off. If we have got
training tracks--where--idealistic young medical students are
working with my colleagues here--and they see they see how
rewarding it is to work in that environment, they stay.
Senator Kaine. For each of you, how important is well-
designed public service loan forgiveness programs to attracting
health care professional, not just Physicians but all
healthcare professions, especially to underserved communities?
Dr. Anderson. Yes, thank you. I can say that I had the
National Health Service Corps scholarship when I was a medical
student. And then I also have the National Health Service Corps
loan repayment program after my scholarship commitment finished
and I can say that these programs are critical in recruiting
the workforce that we need to serve our communities. Even at my
site, I would say a large number of our providers have been
either currently in the program or in the past, and I would say
a majority of those also teach in our residency program. And so
continuing the pipeline like Dr. Freeman was saying, training
the next generation and showing people how it is possible to
help these communities.
Senator Kaine. Mr. Trumpeter, where you going to speak a
word about public service loan forgiveness also?
Mr. Trompeter. I was and it is, like Dr. Anderson said,
critical. 50 percent of our providers are either current
recipients or past recipients of loan repayment programs. It is
the way that we could get people and the way that we can keep
them.
Senator Kaine. Let me ask go switching to another topic, I
notice when I am in rural Virginia that there is a significant
percentage of doctors, especially, but some of their health
professionals, who are immigrants, who have come from other
countries and may be trained in other countries. Sometimes they
have done a medical training in other country and done a
residency after matching in the United States. And I have gone
through other parts of rural America and seen the same thing--
in terms of meeting our workforce needs, and I think Dr.
Anderson, you are bilingual, correct?
Dr. Anderson. Yes.
Senator Kaine. In meeting our workforce needs to deal with
a diverse population, isn't it important that we think about
the immigration topic--we often of the immigration topic as a
security issue, is not it also important that we really think
about workforce and the need especially in some harder hit
communities. The right immigration policy can help us even in
healthcare workforce. Would you not agree with that?
Dr. Anderson. I would say that the community health centers
serve everyone that comes to our doors regardless of their
ability to pay and we serve everyone in the community
regardless of where that community is. Earlier in the in the
testimony, I held up the oath that I took at Brown University
to serve patients and serve humanity and the National Health
Service Corps and the community health center program has made
it possible to serve all patients regardless of their ability
to pay or their social standing.
Senator Kaine. Let me focus on the work force though as I
conclude. Do you also believe that for the workforce that you
need to serve populations may be especially in rural America,
that thinking about immigration policy is one way of dealing
with meeting workforce needs in rural America?
Dr. Waits. Definitely, we are here representing the idea of
training local high school students that go through the
pipeline to medical school and to our training programs, but we
all definitely have colleagues who did medical school in
another country and have provided awesome service to our rural
communities to our inner city communities. We have had
colleagues that we were residency and did fellowship with that
were from other countries, and so a very clearly articulated
set of rules for our colleagues that did medical school in
other countries and come here to train and graduate medical
education and often choose to stay as a destination to serve--
this exact workforce need we are talking about--A clearly
articulated policy around that would be would be helpful in
terms of workforce.
Senator Kaine. Thank you.
Mr. Chairman.
The Chairman. Thank you Senator Kaine. The hearing record
will remain open for 10 days. Members may submit additional
information for the record within that time if they would like.
The Chairman. Our Committee will meet again on Tuesday at
10:00 a.m. for a hearing on how primary care affects health
care costs. Thank you for being here. The Committee will stand
adjourned.
Additional Material
American Academy of
Family Physicians.
Hon. Lamar Alexander, Chairman,
Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC 20510.
Hon. Patty Murray, Ranking Member,
Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC 20510.
On behalf of the American Academy of Family Physicians
(AAFP) thank you for the opportunity to submit this Statement
for the Record for the U.S. Senate Health, Education, Labor,
and Pensions Committee's hearing, Access to Care: Health
Centers and Providers in Underserved Communities.
The AAFP appreciates the Committee's interest in examining
health care access and underserved communities. Consistent with
the World Health Organization's definition, the AAFP believes
that health is ``a state of complete physical, mental, and
social well-being and not merely the absence of disease or
infirmity.'' As the largest society of primary care physicians,
we are committed to helping patients achieve health and in
supporting initiatives that build healthy communities. It is
also our view that community health does not occur by
coincidence. Healthy communities develop through robust
research as well as investments from citizens, community-based
organizations, educational institutions, governments, and the
private sector.
Primary Care is Associated with Healthier Communities
The AAFP acknowledges that family physicians play an
important role in community health, both as clinicians, but
also as community partners who understand that factors outside
of the doctor's office (the social determinants of health)
impact patient health and the health of a community. Still,
primary care (comprehensive, first contact, whole person,
continuing care) is the foundation of an efficient health
system. It is not limited to a single disease or condition, and
can be accessed in a variety of settings. Primary care (family
medicine, general internal medicine and general pediatrics) is
provided and managed by a personal physician, based on a strong
physician-patient relationship, and requires communication and
coordination with other health professionals and medical
specialists. The benefits of primary care do not just accrue to
the individual patient. Primary care also translates into
healthier communities. For instance, U.S. states with higher
ratios of primary care physician-to-population ratios have
better health outcomes, including lower rates of all causes of
mortality: mortality from heart disease, cancer, or stroke;
infant mortality; low birth weight; and poor self-reported
health. This is true even after controlling for
sociodemographic measures (percentages of elderly, urban, and
minority; education; income; unemployment; pollution) and
lifestyle factors (seatbelt use, obesity, and tobacco use). \1\
---------------------------------------------------------------------------
\1\ Shi L, The relationship between primary care and life chances.
J Health Care Poor Underserved. 1992 Fall; 3(2):321-35
The dose of primary care can even be measured - an increase
of one primary care physician per 10,000 people is associated
with an average mortality reduction of 5.3 percent, or 49 fewer
deaths per 100,000 per year. \2\ High quality primary care is
necessary to achieve the triple aim of improving population
health, enhancing the patient experience and lowering per
capita costs. \3\
---------------------------------------------------------------------------
\2\ 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.
\3\ Shi L, Starfield B, Primary care, income inequality, and self-
rated health in the United States: a mixed-level analysis. Int J Health
Serv. 2000; 30(3):541-55.
Patients, particularly the elderly, with a usual source of
care are healthier and have lower medical costs because they
use fewer health care resources and can resolve their health
needs more efficiently. \4\ In contrast, those without a usual
source of care have more problems accessing health care and
more often do not receive appropriate medical help when it is
necessary. \5\ Patients with a usual source of care have fewer
expensive emergency room visits, unnecessary tests and
procedures. They also enjoy better care coordination. \6\ We
believe it is in the national interest to support programs with
the potential to help improve patient access for primary
medical care, particularly for vulnerable populations.
---------------------------------------------------------------------------
\4\ Gilfillan, R. J., Tomcavage, J., Rosenthal, M. B., Davis, D.
E., Graham, J., Roy, J. A., & Steele, J. D. (2010). Value and the
Medical Home: Effects of Transformed Primary Care. American Journal of
Managed Care, 16(8), 607-615
\5\ Ibid.
\6\ Liaw, W., Jetty, A., Petterson, S., Bazemore, A. and Green, L.
(2017), Trends in the Types of Usual Sources of Care: A Shift from
People to Places or Nothing at All. Health Serv Res. doi:10.1111/1475-
6773.12753
---------------------------------------------------------------------------
Primary Care Workforce and Underserved Communities
The current physician shortage and uneven distribution of
physicians impacts population health. A U.S. Centers for
Disease Control and Prevention study indicated that patients in
rural areas tend to have shorter life spans, and access to
health care is one of several factors contributing to rural
health disparities. \7\ The report recommended greater patient
access to basic primary care interventions such as high blood
pressure screening, early disease intervention, and health
promotion (tobacco cessation, physical activity, healthy
eating). \8\ The findings highlighted in the CDC's report are
consistent with numerous others on health equity, including a
longitudinal study published in JAMA Internal Medicine,
indicating that a person's zip code may have as much influence
on their health and life expectancy as their genetic code. \9\
Therefore, it is imperative that physician care is accessible
to all.
---------------------------------------------------------------------------
\7\ Moy E, Garcia MC, Bastian B, et al, Leading Cause sof Death in
Nonmetropolitan and Metropolitan Areas - United States, 1999 - 2014,
MMWR, Surveil Summ, 2017; 66 (No.SS-1); 1-8. DOI: https://www.cdc.gov/
mmwr/volumes/66/ss/ss6601a1.htm
\8\ MMWR, 2017
\9\ Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, Morozoff C,
Mackenbach JP, van Lenthe FJ, Mokdad AH, Murray CJL. Inequalities in
Life Expectancy Among US Counties, 1980 to 2014Temporal Trends and Key
Drivers. JAMA Intern Med. 2017;177(7):1003-1011. doi:10.1001/
jamainternmed.2017.0918
The current primary care physician shortage and
maldistribution remain significant physician workforce
challenges. An Annals of Family Medicine study projects that
the changing needs of the U.S. population will require an
additional 33,000 practicing primary care physicians by 2035.
\10\ A 2017 Government Accountability Office (GAO) report
indicates that physician maldistribution significantly impacts
rural communities. \11\ The patient-to-primary care physician
ratio in rural areas is only 39.8 physicians per 100,000
people, compared to 53.3 physicians per 100,000 in urban areas.
\12\ According to GAO, one of the major drivers of physician
maldistribution is that medical residents are highly
concentrated in very few parts of the country. The report
stated that graduate medication education (GME) training
remained concentrated in the Northeast and in urban areas,
which continue to house 99 percent of medical residents. \13\
The GAO also indicated that while the total number of residents
increased by 13.6 percent from 2001 to 2010, the number
expected to enter primary care decreased by 6.3 percent. \14\
---------------------------------------------------------------------------
\10\ http://www.annfammed.org/content/13/2/107.full
\11\ U.S. Government Accountability Office, May 2017, GAO 17-411,
http://www.gao.gov/assets/690/684946.pdf
\12\ Hing, E, Hsiao, C. US Department of Health and Human
Services. State Variability in Supply of Office-based Primary Care
Providers: United States 2012. NCHS Data Brief, No. 151, May 2014
\13\ GAO, 2017
\14\ Ibid
Primary care workforce programs, such as the Teaching
Health Center Graduate Medical Education Program and the
National Health Service Corp Program, are essential resources
to begin to increase the number of primary care physicians and
to ensure they work in communities that need them most. The
THCGME program appropriately trains residents who then stay in
the community. THCGME residents are trained in delivery system
models using electronic health records, providing culturally
competent care, and following care coordination protocols. \15\
Some are also able to operate in environments where they are
trained in mental health, drug and substance use treatment, and
chronic pain management. \16\ Residents who train in
underserved communities are likely to continue practicing in
those same environments. \17\
---------------------------------------------------------------------------
\15\ Candice Chen, Frederick Chen, and Fitzhugh Mullan. Teaching
Health Centers: A New Paradigm in Graduate Medical Education.''
Academic Medicine: Journal of the Association of American Medical
Colleges 87.12 (2012): 1752-1756. PMC. available at https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3761371/
\16\ David Mitchell, Residency Directors Tout Benefits of Teaching
Health Center GME Program, AAFP News, (September 6, 2013), available at
http://www.aafp.org/news/education-professional-development/
20130906thcroundtable.html
\17\ Elizabeth Brown, MD, and Kathleen Klink, MD, FAAFP, Teaching
Health Center GME Funding Instability Threatens Program Viability, Am
Fam Physician. (Feb. 2015);91(3):168-170. Available at http://
www.aafp.org/afp/2015/0201/p168.html
American Medical Association Physician Masterfile data
confirms that a majority of family medicine residents practice
within 100 miles of their residency training location. \18\ By
comparison, fewer than 5 percent of physicians who complete
training in hospital-based GME programs provide direct patient
care in rural areas. \19\ Thus, the most effective way to
encourage family and other primary-care physicians to practice
in rural and underserved areas is not to recruit them from
remote academic medical centers but to train them in these
settings. Similarly, the National Health Service Corps (NHSC)
offers financial assistance to recruit and retain health care
providers to meet the workforce needs of communities across the
nation designated as health professional shortage areas
(HPSAs). The NHSC is vital for supporting the needs of our
nation's vulnerable communities. The AAFP believes building the
primary care workforce is an important return on investment. We
also believe that workforce programs help ensure high quality,
efficient medical care is more readily available. By reducing
physician shortages and attracting physicians to serve in
communities that need them, these programs also help improve
the way care is delivered and help meet the nation's health
care goals.
---------------------------------------------------------------------------
\18\ E. Blake Fagan, MD, et al., Family Medicine Graduate
Proximity to Their Site of Training, Family Medicine, Vol. 47, No. 2,
at 126 (Feb. 2015).
\19\ Candice Chen, MD, MPH, et al., Toward Graduate Medical
Education (GME) Accountability: Measuring the Outcomes of GME
Institutions, Academic Medicine, Vol. 88, No. 9, p. 1269 (Sept. 2013).
Community health centers (CHCs) play an important role in
primary care graduate medical education as well. The nation's
9,800 CHCs provide care for 25 million patients, 71 percent of
whom are low-income. \20\ CHC facilities, along with other
safety net providers, are also valuable training settings for
THCGME residents who care for patients like those they are
likely to treat in primary care outpatient settings. Residents
who train in CHCs also have the unique opportunity to be
trained in delivery system models using electronic health
records, providing culturally competent care, and following
care coordination protocols. \21\ Some are also able to operate
in environments where they are trained in mental health, drug
and substance use treatment, and chronic pain management. \22\
Residents who train in underserved communities are likely to
continue practicing in those same environments. \23\ An
important, but unique element within the THCGME program is that
its accountability measures require an evaluation of the number
of physicians who continue practicing after residency and if
they continue serving in rural and underserved communities.
---------------------------------------------------------------------------
\20\ National Association of Community Health Centers, About Our
Health Centers, available at http://www.nachc.org/about-our-health-
centers/
\21\ Candice Chen, Frederick Chen, and Fitzhugh Mullan. Teaching
Health Centers: A New Paradigm in Graduate Medical Education.''
Academic Medicine: Journal of the Association of American Medical
Colleges 87.12 (2012): 1752-1756. PMC. available at https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3761371/
\22\ David Mitchell, Residency Directors Tout Benefits of Teaching
Health Center GME Program, AAFP News, (September 6, 2013), available at
http://www.aafp.org/news/education-professional-development/
20130906thcroundtable.html
\23\ Elizabeth Brown, MD, and Kathleen Klink, MD, FAAFP, Teaching
Health Center GME Funding Instability Threatens Program Viability, Am
Fam Physician. (Feb. 2015);91(3):168-170. Available at http://
www.aafp.org/afp/2015/0201/p168.html
We appreciate Senators Lamar Alexander and Patty Murray's
leadership in introducing S. 192, a bill that will reauthorize
the Teaching Health Center Graduate Medical Education program,
National Health Service Corps program, and Community Health
Centers programs. This five-year reauthorization will help lay
the foundation for much-needed stability and funding adequacy
for these important programs.
Family Physicians and Health Care for All
The AAFP also supports health care for all, consistent with
the public health mission of the specialty of family medicine.
The AAFP promotes health care for all in the form of a primary
care benefit design featuring the patient-centered medical
home, and a payment system to support it for everyone in the
United States. \24\ AAFP believes that all Americans should
have access to primary care services (e.g. in the case of
infants and children, immunizations and other evidence-based
preventive services, prenatal care, and well-child care),
without cost sharing. The AAFP believes that health care for
all should also include services outside the medical home (e.g.
hospitalizations) with reasonable and appropriate cost sharing
allowed, but with protections from financial hardship.
Supporting access to care for everyone in the United States is
consistent with the ``triple aim'' of improving patient
experience, improving population health, and lowering the total
cost of health care. Having both health insurance and a usual
source of care (e.g., through an ongoing relationship with a
family physician) contributes to better health outcomes,
reduced disparities along socioeconomic lines, and reduced
costs. \25\
---------------------------------------------------------------------------
\24\ AAFP, Health Care For All (2014), available athttp://
www.aafp.org/about/policies/all/health-care-for-all.html
\25\ See, e.g., The Robert Graham Center, The Importance of Having
Health Insurance and a Usual Source of Care, Am. Fam. Physician (Sept.
15, 2004), available at http://www.aafp.org/afp/2004/0915/p1035.html.
The AAFP urges each and every one of its members to become
involved personally in improving the health of people from
minority and socioeconomically disadvantaged groups. The
Academy supports: cooperation between local family physicians
and community health centers; promotion of health education in
schools, faith-based organizations, and community groups;
continuation of beneficial programs that serve to promote
health and disease prevention; simplified regulations and
improved payment to encourage the establishment and success
\26\ of physician practices in underserved areas; and
development of programs to encourage the provision of services
by physicians and other health care professionals in
underserved areas.
---------------------------------------------------------------------------
\26\ AAFP, Medically Underserved (2013), available at https://
www.aafp.org/about/policies/all/medically-underserved.html
Health care access is also a significant barrier,
especially for low-income individuals. The AAFP first adopted a
policy supporting health care coverage for all three decades
ago. For the past 28 years the AAFP has advanced and supported
policies that ensure a greater number of Americans enjoy the
security of health care coverage. The AAFP appreciates the
bipartisan support for the Medicare Access and CHIP
Reauthorization Act's (MACRA) landmark reforms that have the
potential for improving patient care outcomes by emphasizing
value over fee-for-service. We welcome the opportunity to work
with policymakers to evaluate MACRA's implementation process
---------------------------------------------------------------------------
and the potential to improve patient outcomes.
It is also important to acknowledge that passage of the
Patient Protection and Affordable Care Act represented a sea
change for millions of patients. We are pleased the Committee
has engaged in bipartisan hearings to examine ways to improve
the individual market as well as proposals to maintain cost-
sharing reduction payments. Medicaid expansion and the law's
Essential Health Benefits were particularly important for
vulnerable populations. Medicaid assists the most vulnerable
patients who are often members of minority groups, homeless,
formerly incarcerated, foster and former foster youth, mentally
ill, addicted, and/or in military families. Insurance coverage
rates among minorities are lower than rates among the non-
Hispanic white population. \27\ Minorities experience
disproportionate rates of illness, premature death, and
disability compared to the general population. \28\ In
addition, virtually all of the estimated individuals nationally
who are homeless could be eligible for Medicaid. Many in this
population would benefit from the mental health and addiction
treatment requirement included under the law. \29\ Forty
percent of our nation's veterans who are under 65 years of age
have incomes that could qualify them for Medicaid under the
ACA's expanded coverage. \30\ In general, family members of
veterans are not covered by the Veteran's Administration, but
may seek coverage through Medicaid or the marketplace. \31\
Many patients in this category are unaware that they qualify
for health benefits.
---------------------------------------------------------------------------
\27\ Center for Health Care Statistics (CHCS), Reaching Vulnerable
Populations Through Health Reform, April 2014, available athttp://
www.chcs.org/media/Vulnerable-Populations--April-2014.pdf
\28\ Center for Health Care Statistics, April 2014
\29\ Id.
\30\ Id.
\31\ Id.
A New England Journal of Medicine article indicates that
the law's coverage expansion was associated with higher rates
of having a usual source of care, greater access to primary
care access, and, higher rates of preventive health screenings.
\32\ Anecdotal evidence among family physicians also reveals
that health care access is saving lives and improving patient
health for those who are accessing much-needed care for chronic
diseases or detecting health challenges in their initial
stages. Again, achieving optimal health does not occur by
accident. Realizing the vision of healthy communities, like
other national priorities, requires that we identify goals,
invest resources, and eliminate barriers, especially for
vulnerable citizens.
---------------------------------------------------------------------------
\32\ Benjamin D. Sommers, M.D., Ph.D., Atul A. Gawande, M.D.,
M.P.H., and Katherine Baicker, Ph.D., N Engl J Med 2017; 377:586-593
---------------------------------------------------------------------------
Conclusion
The AAFP appreciates the opportunity to share these
comments on health access and vulnerable communities and
welcomes the opportunity to work with policy makers to achieve
positive outcomes on these and other policies. For more
information, please contact Sonya Clay, Government Relations
Representative, at 202-232-9033 or [email protected].
------
American College
of Osteopathic
Family Physicians
Hon. Lamar Alexander, Chairman,
Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC 20510.
Hon. Patty Murray, Ranking Member,
Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC 20510.
On behalf of the more than 145,000 osteopathic physicians
and medical students we represent, we applaud the Committee's
leadership and bipartisan effort to address the shortage in our
health care workforce. We are thankful for the Chairman and
Ranking Member for introducing legislation that would
reauthorize the Teaching Health Centers Graduate Medical
Education Program (THCGME). In anticipation of the upcoming
hearing, Access to Care: Health Centers and Providers in
Underserved Communities, we would like to highlight the need,
and encourage the Committee, to support funding for growth in
the reauthorization of the THCGME program to help address the
shortage in our health care workforce.
The majority of THCGME programs are currently accredited by
the AOA or are dually accredited (DO/MD) programs, supporting
nearly 800 osteopathic resident physicians through their
training since the program's inception. Located in 27 states
and the District of Columbia, THCGME programs train residents
in much-needed primary care fields that have the largest
shortages nationally, including family medicine, internal
medicine, pediatrics, obstetrics and gynecology, psychiatry,
geriatrics, and dentistry. It is a vital source of training for
primary care residents to help expand access to care in rural
and underserved communities throughout the country.
Osteopathic physicians (DOs) are fully-licensed to practice
in all specialty areas of medicine, with nearly 57 percent of
active DOs in primary care. Our training emphasizes a whole-
person approach to treatment and care, where we partner with
our patients to help them get healthy and stay well.
Osteopathic medical education also has a long history of
establishing educational programs for medical students and
residents that target the health care needs of rural and
underserved populations. Given this strong presence in primary
care, osteopathic medicine aligns naturally with the mission
and goals of the THCGME program that has proven successful in
helping address the existing gaps in our nation's primary care
workforce.
Residents who train in THC programs are far more likely to
specialize in primary care and remain in the communities in
which they have trained. Data shows that, when compared to
traditional postgraduate trainees, residents who train at THCs
are more likely to practice primary care (82 percent vs. 23
percent) and remain in underserved (55 percent vs. 26 percent)
or rural (20 percent vs. 5 percent) communities. It is clear
that a well-designed THCGME program not only plays a vital role
in training our next generation of primary care physicians, but
helps to bridge our nation's physician shortfall. The program
also tackles the issue of physician maldistribution, and helps
address the need to attract and retain physicians in rural
areas and medically underserved communities. In the 2016-2017
academic year, nearly all residents received training in
primary care settings and 83 percent of residents trained in
Medically Underserved Communities.
However, reauthorizing the THCGME program at its current
level funding, for the next five years, would lead to a
reduction of approximately 70 residency slots from the
currently funded 737 residency positions.
We respectfully ask the Committee to consider legislation
by Senators Susan Collins (R-ME), Doug Jones (D-AL), Shelley
Moore Capito (R-WV), Jon Tester (D-MT), and John Boozman (R-AR)
the ``Training the Next Generation of Primary Care Doctors Act
of 2019.'' In addition to reauthorizing the THCGME program for
the next five years, this bill also provides funding and a
pathway for growth in the number of residents trained in
underserved rural and urban communities. This represents a much
needed expansion to address the physician shortages in our
country.
We would also like to briefly highlight the broader role
osteopathic physicians have in reducing our nation's physician
shortage. Since 2010, the number of DOs has increased by 54
percent. Today, more than 65 percent of all DOs are under the
age of 45, and if current enrollment trends continue, DOs are
projected to represent more than 20 percent of practicing
physicians by 2030. Because of the whole-person approach to
patient care that is inherent in osteopathic medicine, the
increasing share of DOs in the physician workforce, and the
number of DOs in primary care specialties, we have a unique and
important perspective on the needs of our nation's health care
workforce and would welcome the opportunity to contribute to
your work on this issue.
We appreciate your bipartisan effort to address the
shortage in our country's health care workforce, and we stand
ready to assist in your effort.
Sincerely,
American College of Osteopathic Family Physicians
American College of Osteopathic Internists
American College of Osteopathic Obstetricians and
Gynecologists
American College of Osteopathic Neurologists and
Psychiatrists
American College of Osteopathic Pediatricians
American Osteopathic Association
[Whereupon, at 11:55 a.m., the hearing was adjourned.]
[all]