[Congressional Record Volume 140, Number 21 (Wednesday, March 2, 1994)]
[Senate]
[Page S]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: March 2, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                          PRIMARY CARE ISSUES

  Mr. BAUCUS. Madam President, in this Olympic year, America's greatest 
winter athletes came together in the spirit of competition and 
sportsmanship to compete against the world's best. These young men and 
women come from all over the country, from various backgrounds, but 
they all share the desire to be the best. Who did we send to represent 
us? Who did we send to go for the gold? America's best. Our first team.
  We need the same commitment in health care. We want our first team in 
the rural areas where the need for basic, primary health care is 
greater than even before. We depend on the skills of primary care 
physicians for providing prevention and early detection services.
  Over two-thirds of the State of Montana is classified by the Federal 
Government as a health professional shortage area [HPSA]. Isolation, 
economics, and family issues have shrunk the pool of primary care 
doctors. Primary care physicians who do choose to work in rural areas 
face difficult circumstances--unreasonably long and stressful hours, 
and much lower salaries than their urban counterparts.
  Over the past few years, a consensus has emerged on the physician 
specialty imbalance. We now have 30 percent in primary care and 70 
percent in nonprimary care. The surplus of medical specialists drives 
up U.S. health care costs, which are already the highest in the world. 
We need to even the balance if we are to move toward meaningful health 
reform.
  As we have been over the past few weeks of Olympic competition, the 
difference between a gold medal and the rest of the field can be a 
fraction of a second. The difference between what I see as our gold 
medal primary care effort and tinkering around the edges of the problem 
is just as crucial.
  The President's Health Security Act and other health reform bills 
currently on the table offer several good alternatives geared toward 
improving the balance between the primary care and nonprimary care 
physician work force. The proposals would be even more effective in 
their goals if they would also take a more comprehensive approach to 
primary care reimbursements.
  I introduced legislation last September 20, S. 1473, the Primary Care 
Support Act of 1993, to address our country's severe shortage of 
primary care doctors. This bill would increase the number of primary 
care doctors practicing in the United States, increase the relative 
income of primary care doctors, and encourage our medical education 
system to train more primary care doctors.
  Let me take a moment to point out how I believe we can all come out 
winners when it comes to primary care. We must:
  Establish fairness in physicians' pay;
  Encourage more physician residency programs to train primary care 
physicians;
  Create a national council, such as the National Physician Work Force 
Commission, to monitor physician supply, identify areas of concern, and 
propose solutions; and
  Provide continued, increased support for the National Health Service 
Corps and other work force priority areas, as proposed by the Clinton 
administration.
  We must reach out to our health professional shortage areas located 
throughout rural and urban America if we want to achieve a 
comprehensive, and long-term solution to our primary care needs. And to 
do so, we must make sure that our health reform plans keep these 
elements intact.
  As I proposed in the Primary Care Support Act of 1993, and as the 
President has included in his health reform proposal, we must increase 
Medicare reimbursement to primary care physicians. We must work toward 
revising the resource based relative value scale that serves as the 
basis for Medicare reimbursements, looking beyond historically allowed 
charges and determining actual resource based practice costs more 
favorable to primary care. We need to follow up with timely 
implementation. Following from this, we need to work toward primary 
care physician pay parity in the private sector as well. We must also 
reform the payments in the Medicare Program for graduate medical 
education programs to emphasize primary care. While the public demands 
more primary care services, the market continues to provide powerful 
incentives to produce physicians narrowly trained in subspecialty 
fields. We need to revise the current incentives and establish a 
meaningful connection between the market for medical care and the 
market for medical education.
  Some people may argue that the market will eventually correct itself. 
It may. But I see no evidence that we are even moving in the right 
direction. Even if it were true, we do not have time to wait for this 
correction to come about. We need to take a pro-active approach to this 
situation by standardizing Medicare GME payment to hospitals. By basing 
reimbursement on a weighted national mean amount, we will put the 
various programs on an equal footing and encourage higher quality 
programs at hospitals that are currently underpaid.
  The Council on Graduate Medical Education currently provides national 
guidance on primary care issues based on expert advice and targeted 
research. Health reform plans now under consideration include 
provisions for the continued use of this council or the creation of a 
new one that assists in steering medical professionals toward primary 
care practice.
  Like the National Physician Work Force Commission that I proposed in 
my bill, a national committee would create proposals to allocate more 
residency positions to general physicians, and decrease the number of 
specialist residency positions to achieve an even distribution of 
generalist physicians and specialists.
  Physician recruitment and retention in HPSA's is still difficult and 
the number of HPSA's continues to grow. In Montana and other sparsely 
populated frontier States, however, the addition of just one or two new 
physicians can mean that an area loses its HPSA status.
  Thus financial incentives can function like a catch-22--helath 
providers are given financial incentives to a HPSA, but as soon as they 
get there the area loses its HPSA designation, and they never receive 
the financial incentives they were promised. For this reason, I believe 
we need multiple incentives that, enacted together, will maintain and 
build upon and maintain the primary care work force. We need to 
increase primary care reimbursement to get medical professionals into 
underserved areas, but also need to offer assurance that they will 
continue to receive additional compensation in cases where an area 
loses its HPSA designation.
  It is crucial to increase the incentives to practice medicine in 
health professional shortage areas by doubling the bonus payments in 
the Medicare Program for services in those areas. Under current law, 
physicians who furnish services to Medicare beneficiaries that live in 
health professional shortage areas receive a 10-percent bonus on top of 
the current geographically determined service reimbursement.
  This law has been somewhat helpful in encouraging physicians to serve 
in those areas, but more must be done. A doubling of this bonus to 20 
percent would go further in bridging the reimbursement gap.
  I also support continuing bonus payments to physicians who relocate 
to HPSA's for at least 10 years even if the area loses its HPSA 
designation. It would be unfair to induce physicians to move into a 
HPSA and then cut off the bonus payments shortly after they move there.
  Health reform will fail in Montana unless we address our shortage of 
primary care physicians. Without a comprehensive approach to the 
problem, the shortage will just keep getting worse, reducing access to 
care, reducing quality of care, and increasing costs. Montana needs 
primary care physicians and nurses. I will not be able to support a 
health reform proposal unless I am sure that it will meet Montana's 
needs. Neither the silver nor the bronze are good enough. Health reform 
demands our gold medal efforts.
  I will not settle for the silver or the bronze.
  Madam President, I yield the floor, and I suggest the absence of a 
quorum.
  The PRESIDING OFFICER. The clerk will call the roll.
  The legislative clerk proceeded to call the roll.
  Mr. MURKOWSKI. Madam President, I ask unanimous consent that the 
order for the quorum call be rescinded.
  The PRESIDING OFFICER. Without objection, it is so ordered.
  Mr. MURKOWSKI. Madam President, I understand we are in morning 
business.
  The PRESIDING OFFICER. The Senator is correct. We are in morning 
business until 3 p.m..
  Mr. MURKOWSKI. I thank the Chair.
  I ask unanimous consent that I may be allowed 5 or 6 minutes to make 
a statement.
  The PRESIDING OFFICER. The Senator is authorized to speak up to 10 
minutes under the order.
  Mr. MURKOWSKI. I thank the Chair.

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