[Senate Hearing 113-831]
[From the U.S. Government Publishing Office]
S. Hrg. 113-831
ADDRESSING PRIMARY CARE ACCESS AND WORKFORCE CHALLENGES: VOICES FROM
THE FIELD
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON PRIMARY HEALTH AND AGING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
ON
EXAMINING PRIMARY CARE ACCESS AND WORKFORCE CHALLENGES: VOICES FROM THE
FIELD
__________
APRIL 9, 2014
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.gpo.gov/fdsys/
U.S. GOVERNMENT PUBLISHING OFFICE
22-609 PDF WASHINGTON : 2017
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800;
DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC,
Washington, DC 20402-0001
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
TOM HARKIN, Iowa, Chairman
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington MICHAEL B. ENZI, Wyoming
BERNARD SANDERS (I), Vermont RICHARD BURR, North Carolina
ROBERT P. CASEY, JR., Pennsylvania JOHNNY ISAKSON, Georgia
KAY R. HAGAN, North Carolina RAND PAUL, Kentucky
AL FRANKEN, Minnesota ORRIN G. HATCH, Utah
MICHAEL F. BENNET, Colorado PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin MARK KIRK, Illinois
CHRISTOPHER S. MURPHY, Connecticut TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts
Derek Miller, Staff Director
Lauren McFerran, Deputy Staff Director and Chief Counsel
David P. Cleary, Republican Staff Director
______
Subcommittee on Primary Health and Aging
BERNARD SANDERS (I), Vermont, Chairman
BARBARA A. MIKULSKI, Maryland RICHARD BURR, North Carolina
KAY R. HAGAN, North Carolina PAT ROBERTS, Kansas
SHELDON WHITEHOUSE, Rhode Island LISA MURKOWSKI, Alaska
TAMMY BALDWIN, Wisconsin MICHAEL B. ENZI, Wyoming
CHRISTOPHER S. MURPHY, Connecticut MARK KIRK, Illinois
ELIZABETH WARREN, Massachusetts LAMAR ALEXANDER, Tennessee (ex
TOM HARKIN, Iowa (ex officio) officio)
Sophie Kasimow, Staff Director
Riley Swinehart, Republican Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
WEDNESDAY, APRIL 9, 2014
Page
Committee Members
Sanders, Hon. Bernard, Chairman of the Subcommittee on Primary
Health and Aging, opening statement............................ 1
Burr, Hon. Richard, a U.S. Senator from the State of North
Carolina, opening statement.................................... 3
Warren, Hon. Elizabeth, a U.S. Senator from the State of
Massachusetts.................................................. 13
Murphy, Hon. Christopher, a U.S. Senator from the State of
Connecticut.................................................... 14
Witness--Panel I
Spitzgo, Rebecca, Associate Administrator Bureau of Health
Professions, Health Resources and Services Administration, U.S.
Department of Health and Human Services, Rockville, MD......... 5
Prepared statement........................................... 7
Witnesses--Panel II
Brock, Stan, Founder and President, Remote Area Medical,
Rockford, TN................................................... 17
Prepared statement........................................... 18
Wiltz, Gary, M.D., Executive Director and Clinical Director,
Teche Action Clinic, Franklin, LA.............................. 19
Prepared statement........................................... 21
Flinter, Margaret, APRN, Ph.D., c-FNP, FAAN, FAANP, Senior Vice
President and Clinical Director, Community Health Center, Inc.,
Middleton, CT.................................................. 24
Prepared statement........................................... 25
Dobson, L. Allen, Jr., M.D., President and CEO, Community Care of
North Carolina, Raleigh, NC.................................... 29
Prepared statement........................................... 30
Nichols, Joseph, M.D., MPH, Family Medicine Resident, MedStar
Franklin Square Family Health Center, Baltimore, MD............ 36
Prepared statement........................................... 38
Kohn, Linda T., Ph.D., Director of Health Care, Government
Accountability Office, Washington, DC.......................... 43
Prepared statement........................................... 45
Edberg, Deborah, M.D., Program Director, McGaw Northwestern
Family Medicine Residency Program, Erie Family Health Center;
Assistant Professor of Clinical Family and Community Medicine,
Northwestern University Feinberg School of Medicine, Chicago,
IL............................................................. 51
Prepared statement........................................... 53
Hotz, James, M.D., Clinical Services Director, Albany Area
Primary Care, Albany, GA....................................... 55
Prepared statement........................................... 57
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Letter from Margaret Flinter, APRN, Ph.D., c-FNP, FAAN, FAANP
in Response to question from Senator Warren................ 73
Response to questions of Senator Warren by:
Joseph S. Nichols, M.D., MPH............................. 75
James Hotz, M.D.......................................... 76
(iii)
ADDRESSING PRIMARY CARE ACCESS AND WORKFORCE CHALLENGES: VOICES FROM
THE FIELD
----------
WEDNESDAY, APRIL 9, 2014
U.S. Senate,
Subcommittee on Primary Health and Aging,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10 a.m., in
room SD-430, Dirksen Senate Office Building, Hon. Bernard
Sanders, chairman of the subcommittee, presiding.
Present: Senators Sanders, Burr, Murphy, and Warren.
Opening Statement of Senator Sanders
Senator Sanders. Thank you all very much for being here for
what is, I think, going to be a very interesting and important
hearing. It is a busy day here in the Senate, and I think
you're going to see members gravitating in and out, but we want
to thank all of the panelists who are here with us.
The issue that we're dealing with today is of profound
importance and, I think, addresses some of the significant
problems facing our dysfunctional healthcare system. The first
issue that I would raise and that I hope we'll get some good
discussion on today is how it happens that the United States of
America ends up spending almost twice as much per person on
healthcare and yet our end results, our healthcare outcomes are
not particularly good compared to many other countries around
the world.
I think one of the reasons for that, that virtually every
study that I have seen tells us, is that we are much, much
weaker in terms of primary healthcare, and we put much less
resources into primary healthcare, comparatively speaking, than
do most other nations. Today, in fact, 60 million people in the
United States, nearly one in five, live in areas where there is
a shortage of primary care providers.
In fact, while the problem we're discussing is clearly a
national problem, it is even more so a rural problem, in that
there are many, many rural communities in this country where it
is very hard for people, especially people who do not have a
lot of money, to find a doctor or to find a dentist. In fact,
we are going to be hearing later this morning from Stan Brock,
who founded a wonderful organization called Remote Area
Medical, RAM, that sets up free medical clinics at fairgrounds
and stadiums in underserved areas to provide healthcare and
dental care to people who cannot otherwise find a doctor or a
dentist.
A couple of weeks ago, at our most recent subcommittee
hearing, we saw some of the photographs where in the United
States of America, people are waiting hours, and sometimes they
sleep overnight in their cars in order to gain access to free
healthcare or dental care. I hope that we can all agree that in
this Nation, presumably the wealthiest nation on earth, this
should not be happening.
But the issue is not only one of healthcare and what
happens to people when they get sick who cannot access a doctor
or a healthcare provider--what happens to those people? And the
answer is pretty obvious. They get sicker and sicker, and then
they end up either in the emergency room or in a hospital at
far more cost to the system than otherwise would have been the
case if they could have accessed healthcare when, in fact, they
needed it.
One of the great ironies of the moment is that while there
are some people who think we save money by cutting back on
public health programs, whether it's Medicare, Medicaid, or
whatever it may be, the truth of the matter is we end up
spending more money by not providing access to healthcare and
dental care when people actually need it. So it's a question of
easing suffering, human suffering; it's a question of
preventing death; it's a question of preventing serious
illness; and it is a question of saving money.
To compound the problem that we have right now, by 2025, we
will need over 50,000 new primary care physicians in our
country and thousands of other providers, including dentists,
nurse practitioners, and physician assistants, to ensure access
to the cost-effective primary care services people need. And
that comes from the Annals of Family Medicine.
How do we educate those practitioners? How do we get them
to the places that we need? It's not just the question of
needing more doctors. Frankly, we don't need more doctors on
Park Avenue in New York. We do need more doctors in rural
underserved areas in the country. How do we educate those
people? How do we get them to the areas where we need them?
Here's a startling fact that I hope we will have serious
discussion about. In 2011, about 17,000 doctors graduated from
American medical schools. Despite the fact that over half of
patient visits are for primary care--half of patient visits are
for primary care--only 7 percent--7 percent--of the Nation's
medical school graduates now choose a primary care career--7
percent. Why is that? How do we turn that around? And to
compound that issue, the average primary care physician in the
United States is 47 years of age today, and one-quarter are
near retirement. So why that is going on and how we transform
it is an issue I hope we will discuss today.
I think some of the answers are fairly obvious. First, we
need to change the culture in our medical schools. Medical
schools, in my view, especially given the fact that they
receive substantial sums of Federal money, should be training
and graduating doctors to serve in areas where they are most
needed. That should be a major focus. Frankly, many medical
schools are doing a good job, but many others are doing a very,
very poor job in making sure that we get those health care
providers to the areas where we need them.
Second, we are almost unique in the world in saying to
young people,
``If you want to go to medical school, fine. If
you're smart enough, you can go to medical school. But
guess what? On average, you're going to graduate
$160,000 in debt, and a third of you are going to
graduate with more than $200,000 in debt.''
That's the system we now have.
Well, guess what? If you are a young person graduating with
$200,000 of debt, and you want to have a family, you are
probably not going to go to rural Vermont or rural North
Carolina to practice--probably not. You're going to probably
figure out where you can make the most money possible in order
to pay back that debt, and that becomes a huge disincentive in
terms of getting doctors to the places where we need them.
In the midst of all of those serious problems, here's some
good news, and I look forward to hearing Rebecca Spitzgo talk
about this. In recent years, we have made significant progress
in increasing funding in a variety of ways to those entities
who are doing a really, really good job in addressing some of
the problems that we're talking about.
I am very proud that in the Affordable Care Act and in the
stimulus package--and I worked particularly hard in those
areas--we have doubled funding for federally qualified health
centers, and we're going to hear about what they are doing all
over America. More and more people are now able to access them.
The President's new budget is, I think, a good budget in
helping us to expand that. Let's talk about that.
But what Ms. Spitzgo is going to talk about in a moment is
also one of the important ways that we improve primary
healthcare in America, addressing the problem of students
graduating with deep debt, and that is the National Health
Service Corps. And I look forward to hearing Ms. Spitzgo talk
about some of the successes that we've had and where we should
be going in the future.
Another issue that I hope we will talk about today is that
we need to change the salaries and reimbursement rates, in my
humble opinion. Primary healthcare is as important as any other
area of medicine, and we have got to reward those people who go
into primary healthcare. That means changing reimbursement
rates.
Fourth, we have got to address the fact that Medicare has
promoted the growth of residencies in specialty fields rather
than primary healthcare by providing over $10 billion each year
to teaching hospitals without requiring any emphasis on
training primary care physicians.
Those are some of the issues that I hope we will be
addressing today. And, again, I want to thank all of our
panelists and Ms. Spitzgo for being here. Now, I'll give the
mic to Senator Burr.
Statement of Senator Burr
Senator Burr. Thank you, Mr. Chairman. Thank you for
holding this hearing, which I believe is vitally important. And
I appreciate the opportunity to continue our discussion
regarding primary care and workforce challenges. I'd like to
thank the witnesses for being here today, particularly Allen
Dobson, who is a family physician in North Carolina and
president and CEO of Community Care of North Carolina, an
entity that's known far outside of North Carolina with a great
track record thus far. With so many witnesses today, I suspect
we'll hear a wide range of perspectives from the primary care
trenches. And I'm glad that Allen is here to help share our own
experiences from North Carolina.
As we've discussed before, the issue of improving access to
primary care services, particularly those in rural and
underserved areas, is an important challenge we must address.
At our primary care hearing last year, I noted the importance
of identifying programs with a proven track record of success
from which we can build upon, as well as the importance of
taking a closer look at the programs to ensure accountability
and appropriate stewardship of taxpayer dollars.
Therefore, I am particularly pleased to welcome Linda Kohn
with the Government Accountability Office to hear an update on
the recent work to look at healthcare workforce programs,
including those which seek to address primary care access and
workforce challenges.
GAO's report last fall highlighted how four departments,
Health and Human Services, Veterans Affairs, Defense, and
Education, obligated $14.2 billion for healthcare vouchers for
the healthcare workforce training programs for postsecondary
training or education for direct care professionals in 2012.
HHS funds the bulk of these programs, many of which HRSA
administers. Yet by HRSA's own projections, the demand for
primary care physicians will grow more rapidly than the
physician supply, resulting in a projected shortage of
approximately 20,400 physicians in 2020, a mere 6 years from
now.
HRSA's analysis indicated that even with the increased use
of nurse practitioners, of physician assistants, the primary
care provider workforce is not prepared to meet the coming
needs. As of January 1 of this year, HRSA had 6,000 designated
primary care health professional shortage areas, 6,000. In
other words, we aren't meeting current demand, much less are we
preparing for what's coming at us.
As the Nation faces increasing primary care challenges,
it's essential that we take an honest assessment of the factors
driving and exacerbating these challenges. Have we properly
aligned incentives to encourage individuals to not only pursue
primary care medicine but practice it and practice it in those
areas with the greatest and hardest to reach needs? Are
incentives driving volume or quality? What can we learn from
patient-centric medical home models, such as Community Care of
North Carolina?
As Congress explores ways in which we can better target and
enhance existing programs to address the workforce challenges
impacting our Nation's patients, it is critical that we
understand and examine the root causes and barriers patients
face in accessing primary care as well as the best metrics for
judging success. I look forward to hearing from our witnesses
today about the specific metrics necessary to assess what is
and is not working to address our Nation's primary care needs.
It's clear from the projections of current and increasing
unmet needs that we cannot afford to continue on the current
course. I look forward to hearing suggestions from our
witnesses today regarding how we can address primary care
access and workforce challenges while ensuring accountability
for programs on behalf of patients and on taxpayers.
Thank you, Mr. Chairman. I yield.
Senator Sanders. Thank you very much, Senator Burr.
Senator Warren.
Senator Warren. I'd like to just go straight to the
witnesses. I don't need to do an opening statement. Thank you,
Mr. Chairman.
Senator Sanders. Senator Murphy.
Senator Murphy. I'm good.
Senator Sanders. You're all witnessing something very
unusual.
[Laughter.]
Senator Burr. But, hopefully, a trend.
Senator Sanders. Our first witness is Rebecca H. Spitzgo,
Associate Administrator of HRSA's Bureau of Health Professions.
She provides national leadership in the development,
distribution, and retention of a diverse health workforce. From
2009 through 2013, Ms. Spitzgo was the Associate Administrator
of HRSA's Bureau of Clinician Recruitment and Service, where
she oversaw the operations of the National Health Service
Corps.
Ms. Spitzgo, thanks very much for being with us.
STATEMENT OF REBECCA SPITZGO, ASSOCIATE ADMINISTRATOR, BUREAU
OF HEALTH PROFESSIONS, HEALTH RESOURCES AND SERVICES
ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES,
ROCKVILLE, MD
Ms. Spitzgo. Good morning. Mr. Chairman and members of the
subcommittee, thank you for the opportunity to testify on
behalf of the Health Resources and Services Administration.
My name is Rebecca Spitzgo. I am the Associate
Administrator for the Bureau of Health Professions in HRSA,
which is an agency of the Department of Health and Human
Services. HRSA's mission is to improve health and achieve
health equity through access to quality services and a skilled
healthcare workforce. HRSA supports the training of nurses,
physicians, dentists, and other clinicians and encourages
providers to work in areas of the country where health
resources are scarce.
Across this country in every State, the District of
Columbia, and Puerto Rico, there is a student or a clinician
whose future in primary care is being made possible by HRSA's
workforce programs. HRSA's grant, scholarship, and loan
repayment programs support the healthcare workforce across the
entire training continuum from academic training to programs
that support clinicians currently providing care to individuals
in underserved rural and urban communities.
In recent years, Congress and the administration have
strengthened the primary care workforce by funding additional
training and educational opportunities, by encouraging
community-based residencies and teaching hospitals, by
expanding training for a range of primary care providers, and
by the historic growth of the National Health Service Corps. To
date, the Affordable Care Act has supported the training of an
additional 1,700 primary care providers, including physicians,
advanced practice nurses, and physician assistants, as well as
200 behavioral health providers.
This academic year, the Teaching Health Center Graduate
Medical Education Program is expanding residency training for
more than 300 primary care residents and dentists in community-
based settings in 21 States, including HRSA funded health
centers. For the upcoming academic year, we expect nearly 600
FTEs will be supported by the Teaching Health Center GME
Program. In exchange for scholarship and loan repayment, nearly
8,900 National Health Service Corps clinicians are providing
care to millions of patients at more than 5,000 National Health
Service Corps sites in urban, rural, and frontier areas.
The fiscal year 2015 President's Budget includes a new
workforce initiative that will help support the residency
training of approximately 13,000 new physicians by the year
2024 and grow the number of the National Health Service Corps
clinicians to an annual field strength of 15,000 in fiscal year
2015 through 2020. This new investment will increase the supply
and the distribution of the healthcare workforce, which, when
coupled with the adoption of new, more efficient models of
care, will significantly increase access to care.
This new targeted support for the Graduate Medical
Education Program will emphasize primary care and will include
support for residency training in high-need specialties. The
targeted support for the GME Program will support residency
training with a strong focus on ambulatory and preventive care
and the goal of driving higher value healthcare that reduces
long-term costs.
In addition, the fiscal year 2015 President's Budget
includes funding for both rural physician training and for
inter-professional training, which will increase the capacity
of the primary healthcare teams to deliver quality,
coordinated, and efficient care to patients, families, and
communities.
Our health workforce programs in HRSA support a wide range
of primary care disciplines, including behavioral health and
oral health providers. Roughly one in three National Health
Service Corps clinicians provide behavioral health services,
and more than 1,300 provide oral health services. We are
partnering with the Substance Abuse and the Mental Health
Services Administration to train and provide placement
assistance to approximately 3,500 new behavioral health
professionals and paraprofessionals to meet the needs of young
people age 16 to 25.
HRSA's workforce programs also play a critical role in
supporting a diverse and culturally competent workforce across
the country. Last year, underrepresented minorities and
individuals from disadvantaged backgrounds accounted for
approximately 45 percent of those who completed HRSA's health
profession training and education programs. And, according to
self-reporting, more than half of the nearly 1,100 National
Health Service Corps scholars and residents in the pipeline are
minorities.
Taken together, HRSA's workforce programs emphasize the
training of the next generation of primary care providers,
strengthens the primary care training and development
infrastructure, and provides incentives for students and
healthcare professionals to choose primary care and to practice
where the Nation needs them most. To meet the health needs of
Americans, HRSA will continue to make training, recruitment,
and retention of primary care professionals a priority.
Thank you again for providing me the opportunity to share
HRSA's primary care workforce priorities with you today. I am
pleased to respond to your questions.
[The prepared statement of Ms. Spitzgo follows:]
Prepared Statement of Rebecca Spitzgo
Mr. Chairman and members of the subcommittee, thank you for the
opportunity to testify today on behalf of the Health Resources and
Services Administration (HRSA). My name is Rebecca Spitzgo, and I am
the Associate Administrator of the Bureau of Health Professions in
HRSA, which is an agency of the Department of Health and Human Services
(HHS).
HRSA focuses on improving access to health care services for people
who are economically, geographically or medically vulnerable. Our
mission is to improve health and achieve health equity through access
to quality services and a skilled health care workforce. HRSA's
programs support the health care workforce across the entire training
continuum, from academic training to programs that support clinicians
currently providing care to individuals in underserved and rural
communities across the United States. HRSA supports the training of
nurses, physicians, and other clinicians, and encourages providers to
work in areas of the country where they are needed most.
In accomplishing our goals, we collaborate with colleagues across
the Federal Government and with State and local governments, as well as
a range of other partners in the private sector, including: community-
based organizations, health care providers and academic institutions.
Together with these key partners, we are working hard to meet the needs
of the American people and to prepare for changes in the health care
system to help ensure access to quality, efficient care.
I have been asked to speak to you today about HRSA's activities
regarding the primary care workforce and the Nation's needs in this
area. We appreciate your ongoing interest in HRSA programs and welcome
the opportunity to discuss them with you, Mr. Chairman, and the
subcommittee.
strengthening the primary care workforce through recent investments
To date, the Affordable Care Act has supported the training of an
additional 1,700 primary care providers, including physicians, advanced
practice nurses, and physician assistants, as well as 200 behavioral
health providers. And, with historic investments from the American
Reinvestment and Recovery Act of 2009 (ARRA) and the Affordable Care
Act, the numbers of clinicians in the National Health Service Corps
have more than doubled from 3,600 in 2008 to nearly 8,900 in 2013.
National Health Service Corps clinicians, who are located in every
State, are providing care to approximately 9.3 million medically
underserved people at more than 5,100 National Health Service Corps
approved sites in urban, rural, and frontier areas. Approximately 50
percent of NHSC clinicians serve in HRSA-funded health centers.
The Affordable Care Act also provided $230 million over 5 years to
fund the Teaching Health Center Graduate Medical Education (GME)
program. This funding has expanded residency training for primary care
residents and dentists in community-based ambulatory patient care
settings, including HRSA-funded health centers. This program supported
more than 300 primary care resident full-time equivalents (FTEs) in 21
States in Academic Year 2013-14. The number of residency programs and
resident FTEs supported through this program has doubled each academic
year since 2011, and we expect nearly 600 FTEs to be supported in
Academic Year 2014-15. There is evidence that physicians who receive
training in community and underserved settings are more likely to
practice in such environments.
HRSA's recent investments in nursing programs promote the supply,
skills and distribution of qualified nursing personnel needed to
improve the health of the public. These training programs increase
nursing education opportunities for individuals from disadvantaged
backgrounds; improve nurse education, practice and retention while
increasing quality of care; assist veterans with transition from
military service to nursing school and civilian nursing careers;
provide financial support to individuals pursuing an advanced nursing
education/training; and, provide financial support to schools of
nursing to increase the number of qualified nurse faculty. And, through
our scholarship and loan repayment programs, today there are nearly
1,600 advanced practice nurses in the National Health Service Corps and
nearly 2,600 nurses in the NURSE Corps working in high-need
communities.
building a primary care workforce for tomorrow
The fiscal year 2015 President's Budget includes a new workforce
initiative that will help support the residency training of
approximately 13,000 new physicians by 2024 and grow the number of
National Health Service Corps Clinicians from 8,900 health care
providers in 2013 to an annual field strength of 15,000 in fiscal years
2015-20. This new investment in our health care workforce will increase
the supply and distribution of the health care workforce, which when
coupled with the adoption of new, more efficient models of care, will
significantly increase access to primary care and other specialty
services.
This new residency training program, the Targeted Support for GME
program, will emphasize primary care, but will also include support for
residency training in high-need specialties. Building on the Teaching
Health Center GME program, it will focus on supporting residency
training in ambulatory, preventive care delivered in team-based
settings.
The Targeted Support for GME program aims to support residency
training with a strong focus on ambulatory and preventive care and the
goal of driving higher value health care that reduces long-term costs.
In addition, residency programs will be held accountable for training
residents and retaining them in primary care service in underserved
areas, as well as providing a broad range of training experiences that
include team-based care, expanded use of technology, and new, efficient
models of care.
The new program includes a $100 million set-aside for children's
hospitals annually in fiscal year 2015 and fiscal year 2016 to be
distributed via formula that will continue to support the same types of
disciplines currently funded through the Children's Hospitals GME
program. Children's hospitals and current awardees in the Teaching
Health Center GME program will be eligible to compete for funding
through the new program. The fiscal year 2015 President's Budget also
includes appropriations language that would make current Teaching
Health Center GME balances available until expended and thereby would
avoid having these funds expire at the end of fiscal year 2015.
The fiscal year 2015 President's Budget also builds upon the
historic investments through ARRA and the Affordable Care Act that have
more than doubled the National Health Service Corps. With more than 85
percent of Corps clinicians continuing to serve in high-need areas
after they fulfill their service commitment, the National Health
Service Corps helps ensure underserved rural and urban communities have
access to quality health care both today and in the future.
Other HRSA investments also emphasize the importance of providing
care in underserved communities. For example, 43 percent of individuals
who graduated from or completed HRSA-funded health professions training
and education programs reported working or pursuing further training in
medically underserved communities one year after graduation or
completion of their program.
In addition, the fiscal year 2015 President's Budget includes $10
million for a new Clinical Training in Interprofessional Practice
program which will support community-based clinical training in
interprofessional, team-based care to increase the capacity of primary
health care teams to deliver quality, coordinated, safe and efficient
care to patients, families and communities.
The fiscal year 2015 President's Budget also recognizes the special
need for primary care providers across rural America. The Budget
includes $4 million for the Rural Physician Training Grant program to
provide support for medical schools to recruit and train students
interested in rural practice and to develop training curriculum that
focuses on the unique needs of preparing medical students for rural
practice. These grants will focus on recruiting and training health
physicians in rural settings with the ultimate goal of increasing the
number of medical school graduates who practice in rural communities.
supporting a diverse workforce
HRSA's workforce programs also play a critical role in supporting a
diverse workforce across this country. Underrepresented minorities and
individuals from disadvantaged backgrounds accounted for approximately
45 percent of those who completed HRSA's health professions training
and education programs during the 2012-2013 Academic Year. According to
self-reporting, more than half of the nearly 1,100 National Health
Service Corps scholars and residents in the pipeline are minorities. As
part of their National Health Service Corps commitment, these future
primary care providers will serve in communities where they are needed
most to provide culturally competent care.
And, when we look at specific disciplines, the impact of these
programs is even more evident--a diversity not yet achieved in the
national health care workforce. For example, in fiscal year 2013
African-American physicians represented 17.8 percent of the Corps
physicians, which exceeds their 6.3 percent representation within the
national physician workforce, and Hispanic physicians represented 15.7
percent of the Corps physicians, exceeding their 5.5 percent
representation in the national physician workforce.
training for comprehensive primary care
HRSA's investments in the behavioral health disciplines are also
significant. National Health Service Corps providers that include
Health Service Psychologists, Licensed Clinical Social Workers,
Licensed Professional Counselors, Marriage and Family Therapists, and
Psychiatric Nurse Specialists have more than tripled since 2008,
increasing from approximately 700 to 2,440 in 2013. When we add in
psychiatrists, psychiatric physician assistants, and psychiatric nurse
practitioners, roughly one of every three clinicians in the National
Health Service Corps (more than 2,800 out of nearly 8,900 as of
September 30, 2013) provides behavioral health services.
HRSA and the Substance Abuse and Mental Health Services
Administration (SAMHSA) have been partnering to address critical needs
in behavioral health professionals and paraprofessionals trained to
address the needs of transition-age youth (ages 16-25). This
partnership will train and provide placement assistance for
approximately 1,800 additional behavioral health professionals and
1,700 behavioral health paraprofessionals. Last week, HRSA and SAMHSA
issued funding opportunities for this initiative.
In addition, HRSA funds several programs that support training and
education for health professionals to improve the integration of oral
health into primary care. And, in the National Health Service Corps
approximately 75 percent of the more than 1,300 dentists and dental
hygienists are working at health centers or health center look-alikes.
HRSA also is helping to meet the need for new dental providers by
expanding the dental workforce training and education programs, as well
as by supporting State development and implementation of innovative
programs to address dental workforce needs in underserved areas.
strengthening america's health workforce
Taken together, HRSA's workforce programs emphasize the training of
the next generation of primary care providers, strengthening up the
primary care training and development infrastructure, providing
incentives for students to choose primary care and to practice where
the Nation needs them most, and repaying loans for primary care
providers willing to work in some of the Nation's most underserved
areas. To meet the health needs of Americans, HRSA will continue to
make the recruitment, training and retention of primary care
professionals a priority.
Thank you again for providing me the opportunity to share HRSA's
primary care workforce priorities with you today. I am pleased to
respond to your questions.
Senator Sanders. Thank you very much for your testimony and
for the good work that you do. I think you have heard from
Senator Burr and myself and, I think, from a whole lot of folks
that we have a crisis in primary healthcare.
In recent years, we have doubled funding for the community
health center program. We have tripled funding for the National
Health Service Corps. Are those investments working?
Ms. Spitzgo. I would say yes, they are working. We have
doubled the size of the National Health Service Corps since
2008, when we had a little over 3,600 clinicians working there.
Now, we have over 8,900 clinicians working in underserved and
rural communities.
We know from talking to our National Health Service Corps
sites and our community health centers that it's a huge
recruitment tool for them. They are really able to attract very
talented providers to come and work in those centers by the use
of the loan repayment.
Our scholars, when they finish their training, are highly
sought after, and everyone says, ``I just wish you had more.
Bring me all the physicians you can, train all the physicians,
and I know we can place them.'' I think they have made a
tremendous difference.
Senator Sanders. I know that you are not a policymaker.
You're an administrator. And it seems clear to me that we have
made progress. More and more young people are now taking
advantage of the National Health Service Corps, because we have
more opportunity out there. If you had your druthers, and you
were sitting up here, and you understood the scope of the
problem, how much more would we be providing for the National
Health Service Corps?
Ms. Spitzgo. I certainly know from our folks and from the
interest in our programs and from talking to our sites that are
always actively recruiting for clinicians--it just is a
continuous process for them--they would like to see us be able
to support all of the folks who are interested in being a part
of the program, because it is that huge recruitment
opportunity. They would love for us to have more scholars that
are graduating and finishing our program.
I think as we look at that, the program is very
prestigious. There is tremendous interest, not only from
students as they go through school, but tremendous interest
from the sites that would employ them.
Senator Sanders. So what you are saying is that you think
if we increased funding, you would be able to attract more
young people to get into primary healthcare or dental care. Am
I hearing that?
Ms. Spitzgo. Yes. I think there is an interest, yes.
Senator Sanders. All right. Explain a little bit--maybe we
have kind of jumped the gun, because I'm not sure that
everybody knows what the National Health Service Corps is
about. Go into a little bit of detail--the bottom line here is
that if I am prepared and agree to work in an underserved area,
the NHSC is going to repay my debts. But can you go into some
detail about how that actually works?
Ms. Spitzgo. Sure. There's actually two main components to
the National Health Service Corps. First is our loan repayment
program, which is for fully trained, educated, and licensed
clinicians who may be coming out of school looking for that job
and has that educational debt. If they go to work in a health
professional shortage area and work at one of our approved
sites, they can qualify for loan repayment. The initial loan
repayment in a high-need area is $50,000 for a 2-year service
commitment. So they agree to work in that high-need area for 2
years.
Then they do have the opportunity to continue in the
program. If they have additional qualifying educational debt,
they can continue to work there until they actually have paid
off all of their student loans.
Senator Sanders. So if I graduated school $200,000 in debt,
how many years am I obliged to work in an underserved area?
Ms. Spitzgo. To completely pay off your debt, if you have
$200,000, I'm just going to roughly say I think we're talking 7
or 8 years with the continuations and continuing to stay in the
program. But we do prioritize--once you're in the program, we
fund our continuations first, so you do typically stay if
you're interested.
Senator Sanders. And you also have a scholarship program,
do you not? Say a word about that.
Ms. Spitzgo. We do. The scholarship program is for students
who are entering medical school or entering a nurse
practitioner or physician assistant program to get their
degree. And for every year of funding they receive for their
education, they have a 1-year service commitment when they
complete their degree, with a minimum of a 2-year service
commitment. So if you only got 1 year of funding, you would
still have a 2-year service commitment.
For our physicians, we're talking about typically a 4-year
service commitment. But they could start in their sophomore
year. They could start in their junior year. It doesn't have to
be in their entry year of medical school. And we do assist in
our scholarship program those who go to our highest-need areas,
and we do assist with placement and relocation expenses and
very much, of course, hope that they have a 4-year commitment,
and by the time that commitment is complete, they'll stay.
Senator Sanders. But we are not just talking--so everybody
understands, this is about physicians. We're talking about
dentists and what other providers?
Ms. Spitzgo. We're talking physicians--for a scholarship
program, nurse practitioners, physician assistants, dentists,
and dental hygienists all qualify.
Senator Sanders. Thank you very much.
Senator Burr.
Senator Burr. Ms. Spitzgo, thank you for being here and
thank you for the job that is done at HRSA within HHS. Senator
Sanders pointed to success and used the taxpayer investment as
an example of the commitment. Let me ask you--what metrics do
we have in place that you can point to that show the success of
this program?
Ms. Spitzgo. I think the metrics we have in place is, one,
we have an extremely low default rate, less than 1 percent, for
our loan re-payers. So not only when they get the money to pay
back their loans, they complete their service commitment.
We also know that not only do they complete their service
commitment, but when they've paid all their loans back, they
stay in underserved and rural areas. After completing the
program, over 80 percent of the folks continue to work in
underserved areas after immediately completing the program. And
we've done a 10-year study that shows that after 10 years, we
still have 55 percent of those National Health Service Corps
clinicians still working in underserved and rural areas.
Senator Burr. Last year, the GAO found that 91 Federal
programs obligated $14.2 billion toward healthcare workforce
training programs across four departments, HHS, DOD, VA, and
the Department of Education. How is HHS working with these
departments to ensure that these collective efforts are
coordinated without duplications and reflective of the most up-
to-date workforce projections as provided by HRSA?
Ms. Spitzgo. We work very closely with our colleagues,
first starting, I would say, within Health and Human Services
and, for example, CMS. With some of our Graduate Medical
Education programs that we fund through HRSA, we work very
closely and do audits to make sure that CMS funds are not
funding the same residents that were using HRSA funds.
We also work with the Indian Health Service in supporting
tribal communities and their workforce programs to make sure
that we are complementing each other's efforts. In addition, as
we work with Education, they have some loan repayment programs
if you work in underserved areas. So our guidances show very
much if you have that commitment that you can't be doing the
National Service Corps and also have a commitment somewhere
else.
So we do track with them very closely to make sure that we
don't have what we call double-dippers and that we're not using
funds for the same person more than once. We also work with VA
to look at their programs, to leverage the good work they're
doing, to see how they are running workforce programs, and to
see what we can learn from them, as well as to work very
closely together and not to duplicate.
Senator Burr. As you know, HRSA oversees the Children's
Hospital Graduate Medical Education Program, which provides
training for pediatricians across the country. As you noted in
your testimony, the President's budget has proposed
consolidating that funding under a new residency training
program called Targeted Support for GME.
Ms. Spitzgo. Yes.
Senator Burr. This new program will provide funding for the
Children's Hospital Graduate Medical Education Program until
2016, at which time children's hospitals will need to compete
for funding under the new targeted support program. Just this
week, the bipartisan Children's Hospital Graduate Medical
Education Reauthorization Act was signed into law, a signal
from Congress that this program is working well.
As we work to strengthen our healthcare workforce, do you
believe that the President's proposed new framework will
support the pediatric workforce and ensure that we're making
the appropriate investment in training pediatricians?
Ms. Spitzgo. Yes. We do think the new program will also be
able to address that, as well as address the primary care
residency and the need for those. So the targeted support for
the Graduate Medical Education Program is very much geared at
supporting primary care residency as well as other high-need
residencies where we have a documented shortage.
The program is also looking to take an innovative approach
to how we do residency training, and not to just have a payment
program, but to also have a discretionary program where we can
really have requirements that we're looking for our grantees to
meet so that we're using innovative models of care. We're doing
team-based care. We're utilizing electronic health records in a
way that really assists to provide a higher quality of care to
the patients that are being served.
By having innovative approaches to the way we train our
residents, we think that will lead to innovative approaches to
the way we deliver care. Those residents will go out and,
hopefully, spread that, and all of that will lead to lower
costs.
Senator Burr. Ms. Spitzgo, I didn't misinterpret in any way
what we're doing. We're changing and we're making children's
hospitals compete, which does not assure us of the investment
in pediatricians. Am I accurate?
Ms. Spitzgo. We feel like the structure of the targeted GME
Program is a community-based setting, and many of the hospitals
are already operating and run their programs in a community-
based setting. We've also moved the funding from a year-by-year
discretionary funding to a mandatory funding cycle which will
bring more assurance that the funding will continue. So there's
2 years of $100 million that's set aside for the Children's GME
in 2015 and 2016, and then we think they will be very well-
positioned to compete and also then move into providing some
innovative models of care as they do residency training.
Senator Burr. Thank you.
Senator Sanders. Thank you, Senator Burr.
Senator Warren.
Statement of Senator Warren
Senator Warren. Thank you, Mr. Chairman. I think we all
agree that access to primary care is essential for keeping
people healthy. I want to talk just briefly about a program
that Massachusetts has to improve the Commonwealth's primary
care workforce by offering loan repayment programs to help
doctors with medical school debt.
The University of Massachusetts Medical School, which is
ranked by U.S. News and World Report as the fifth best medical
school in the country for primary care, has a learning contract
that allows students to waive two-thirds of their tuition in
exchange for 4 years in primary care or as a specialist in an
underserved area. Massachusetts also has a State loan repayment
program grant from the National Health Service Corps that
provides the commonwealth with Federal funds to match our
investment in loan repayment programs for those who work in
underserved communities, including doctors, nurse
practitioners, and physician assistants.
I wondered, Ms. Spitzgo, if you could just briefly discuss
the importance of State programs and, more critically, the role
that the Federal Government can play to better support those
programs to help us get more primary care physicians.
Ms. Spitzgo. Yes. Thank you. You mentioned the National
Health Service Corps State Loan Repayment Program. I think
that's an excellent example of one of the programs we've had.
We've actually done a lot of retooling of that program so that
it is flexible for the States to really direct it to their
needs.
So it is a program where they receive a grant from HRSA,
and there is a one-to-one matching required. But at that point,
the State works within the framework of the National Health
Service Corps Loan Repayment Program, but can really customize
that program. So they may want to target it to a particular
area of the State. They may want to target it to all
disciplines in primary care, or they may want to narrowly focus
it to just dentists because they really have a shortage.
So we've really tried to emphasize the value of that. It
really does give them that flexibility to meet their own needs
as well as to meet the needs that--maybe through the national
program they're not getting the number of loan repayments they
want there. So it can really be a great tool to supplement
that.
I think we continue to work with the States. They are our
partners as well as local governments. HRSA has a wide
portfolio of programs, but we also can only do so much. We have
our partners, and we have foundations, and State and local
governments have an important role as well.
Senator Warren. I appreciate you pointing that out. Some
States have worked hard to recognize the shortage in primary
care and to try to do something about it. But I think it's
clear that there is still a very big shortage. So we have the
opportunity at the Federal level to do more to invest in
programs that permit more creativity and more effectiveness on
the ground. Thank you.
I also want to turn to a 2007 study from the International
Journal of Health Services that found that if the United States
increased the primary care workforce by 10 physicians per
100,000 people, we could improve health outcomes and avoid 49
deaths per year for each one of these groups. This is probably
because many costly conditions like hypertension and high
cholesterol are mostly managed by primary care doctors, as was
confirmed by the Journal of the American Board of Family
Medicine study earlier this year.
So it seems obvious that part of our long-term strategy to
improve outcomes at lower costs in our healthcare system would
be to increase the number of doctors trained in primary care.
Now, one promising approach is the Teaching Healthcare Center
Graduate Medical Education Program, a 5-year initiative
established by the Affordable Care Act that trains doctors to
treat complex patients in the community, and it costs only $230
million. But this program will expire at the end of 2015.
I wanted to ask you, Ms. Spitzgo, could you speak to the
return on investment that we get from investing in training a
primary care resident in a community health center as opposed
to a traditional residency?
Ms. Spitzgo. Yes. Thank you. As we look at the Teaching
Health Center, we feel that program has been extremely
successful. It's a relatively new program, but we've seen the
doubling of supporting--the number of slots double each year,
and it continues to grow. So there is tremendous interest in
the community in providing residency care at community-based
settings.
We feel like as residents train and they provide care in
community-based settings where the bulk of Americans do receive
their care, they are very well-trained, and they understand and
can appreciate the value of primary care and the need for it
and the challenges that go with the delivery of primary care.
We are already starting to see some of our graduates that are
coming out of that very much going into underserved areas as
well as rural areas and are staying in primary care.
Senator Warren. That's very good to hear. It's important to
continue to support traditional residencies, but it's also
critical that we support new efficient programs like these. And
I'm committed to making sure that our health centers are fully
supported and that our training programs don't lose critical
funding in 2016. Now is the time to invest in our future, and
this is how we should do it.
Senator Sanders. Thank you, Senator Warren.
Senator Murphy.
Statement of Senator Murphy
Senator Murphy. Thank you very much, Mr. Chairman.
Thank you, Ms. Spitzgo, for being here. I just want to
associate myself for 2 seconds with the remarks of Senator
Warren. We have one of these community health center residency
programs in Connecticut, run actually by a former Congressman
from Connecticut, Jim Maloney, in Danbury.
It has worked enormously well, and he points out regularly
to me and others that the data suggest that a physician trained
in a community health center is 300 percent more likely to stay
in an underserved area than someone who is trained in a
traditional residency program. That is not, just as Senator
Warren said, to create an advertisement for divesting in
traditional residency programs. But you get a really good
return on your investment in community health centers.
Ms. Spitzgo, I sort of wanted to talk about the problem
rather than the treatment at the beginning. I had the chance a
couple of years ago to sit down with a group of University of
Connecticut medical students who were in their first year.
Maybe there were 15 students around the table, and I asked
them, ``How many of you are considering going into primary
care?'' One of the fifteen raised their hand, and, of course,
that's a stunning number given that it wasn't so long ago that
half of the kids graduating from medical school would go into
primary care.
I asked them what was the reason. And, clearly, the first
reason was this subject of most of our discussion today, that
they just didn't believe they were going to get paid at a level
that would allow them to pay back their loans. But they also
talked about the fact that there was a sense that there was
much less prestige involved in going into primary care than
there was going into other specialties, and they wanted to be
on the cutting edge of medicine, and they were better off to go
into cardiology or orthopedics or neurosurgery.
Can you just talk a little bit about why we have a shortage
in primary care? And is it simply a matter of reimbursement
levels, or are there other things that we should be considering
doing or the profession should be considering doing to, I
guess, create that level of attraction that used to be there
for primary care?
Ms. Spitzgo. I think we have many factors that are driving
those decisions. I do believe it starts in the education. It
starts with understanding, I think, and valuing primary care
and valuing preventive care and the difference that it can make
overall in our healthcare systems. It also comes, I think, from
the experiences that our students are able to have as they're
going through school and the exposure that they can get to
working in an underserved area, working in a rural area,
mentoring with a primary care physician who may share those
experiences and those challenges.
I think the other part of that goes to where are innovative
approaches and our new ways of delivering care? Where does it
feel like there's the ability to have some creativity and to
think about doing it differently, which is where I think our
new residency program really wants to go. We want to drive some
innovation.
This isn't just seeing a patient every 10 minutes. This is
about really being able to provide the level of care and the
interaction and working as a team and really looking at new
things and new challenges and population health. How do you
work all of that into your practice and bring that? And I think
that's very exciting, and that's the message we need to get to
our students to start having them think differently and
appreciate, I think, the value of delivering primary care.
Senator Murphy. To the extent that reimbursement is an
issue, as you know, the ACA made a pretty significant
investment in raising Medicaid rates for primary care
physicians. We've seen a remarkable transformation in
Connecticut. I'll just give you the quick statistics.
From 2012 to 2013, we went from 235 APRNs practicing in the
Medicaid arena to 578. We went from 1,300 physicians to 2,400
physicians. We went from 25 PAs to 236 PAs. Clearly, that tells
us that if you pay physicians in the Medicaid program and you
pay practitioners in the Medicaid program close to what it
actually costs them to do the work, they're going to start
taking Medicaid clients, many of which are in the underserved
areas.
How important do you think it is that we maintain these
rates? The ACA only picks up the tab from a Federal perspective
for the first 2 years. How important is it for underserved
areas and Medicaid populations, in particular, to keep these
Medicaid rates for primary care pegged at the Medicare number
going forward?
Ms. Spitzgo. I think we do hear regularly, obviously,
reimbursement rates can help us drive change and really drive
innovation in the healthcare delivery. As we look at our sister
agency, CMS, and their innovation models that they are
currently funding and testing out, many of them include
workforce and looking at rates and really looking at what will
drive those changes. So I think as we continue, having the data
that you just shared with us and looking at those outcomes and
what the difference has made as we've made adjustments will
very much help to pave the path forward, hopefully, on what is
a workable solution.
Senator Murphy. Thank you, Mr. Chairman.
Senator Sanders. Ms. Spitzgo, thank you so much for your
testimony.
Now we'll bring up our second panel. We have a great panel,
and I want to thank all of the panelists for being here. We
think that at 11 o'clock--although around here, one is never
100 percent positive--there will be a vote. So people will
disappear and the chair will rotate a little bit. But we will
try to get back--I will get back, for sure, to continue the
discussion.
Our first panelist is Stan Brock. Mr. Brock is the founder
and president of the nonprofit healthcare organization, Remote
Area Medical, called RAM, based in Rockford, TN. He has a very
diverse resume.
He worked as a cowboy in the Amazon and later hosted the
television wildlife series, Wild Kingdom. After organizing
volunteers to deliver medical care in remote villages around
the world, he saw the great need here in the United States and
founded RAM, which has held over 700 free healthcare
expeditions since 1985.
Mr. Brock, thank you for your work and thank you for being
here this morning.
STATEMENT OF STAN BROCK, FOUNDER AND PRESIDENT, REMOTE AREA
MEDICAL, ROCKFORD, TN
Mr. Brock. Thank you, Mr. Chairman and distinguished
members of the committee. Welcome to America, number 37 in the
World Health Organization's country rankings. I am a voice for
more than half a million patients that Remote Area Medical,
RAM, has treated free of charge in 723 mobile medical clinics
during the last 28 years.
I know what it is like to be poor and without help. I am
one voice of the millions of people who are not a part of our
healthcare system. They have been left behind and forgotten. I
speak for them today.
I came from a place where there was no doctor, living with
the Wapishana Indians in the upper Amazon. Their only recourse
when faced with catastrophic injury or sickness was a tribal
witch doctor. But at least they had that. Some of the sick that
we see here in the United States have nowhere to turn. That is
why I created Remote Area Medical.
When I suffered a serious injury, one of the Indians said,
``The nearest doctor is 26 days on foot from here.'' I felt
then what so many in our Nation feel today when they need a
doctor and cannot get care. For millions of Americans, they
might as well be 26 days on foot from the nearest doctor. In
fact, one of our patients recently walked 15 miles because he
was desperate for medical attention.
Healthcare in America is a privilege of the well-to-do and
the well-insured. That leaves about 50 million people flat out
of luck. These families live in fear of injury and sickness
with no insurance or not enough of it. The predicament of these
millions of marginalized Americans raises questions of
morality, injustice, and education.
Poor education begets poor health. Poverty feeds on poor
nutrition which creates obesity, diabetes, heart disease, and
cancer. The vicious cycle lies in wait for each child enslaved
in poverty as they pass from beneath the security of State and
Federal programs into the barren wastes of adulthood. Many,
nursing mouthfuls of decayed and abscessed teeth or suffering
from fading vision, will inevitably join the long lines of
desperate patients at a RAM free clinic.
I have looked into the distraught faces of Americans
imprisoned by poverty, from child to grandparents, all
generations lining up by the hundreds in places as diverse as
Los Angeles or a fairground in the mountains of southwest
Virginia. I have seen our elderly in makeshift wheelchairs,
people clutching precious numbered scraps of paper, their RAM
free clinic ticket to relief from unnecessary agonizing pain
and sickness. They cannot afford healthcare.
This leads some of our American families, with their
children, to sleep in tents and cars, often for over 24 hours,
waiting for a RAM event to open its door. Blindfolded, you can
stick a pin on a map of America and wherever it lands, you will
find hundreds, if not thousands, of sick hurting people in need
of care that they cannot obtain.
Our people are living in sickness and pain and in need of
basic medical attention. At RAM clinics, dental care is the
greatest demand with vision services a close second. Eighty-
five million Americans do not have dental insurance, and half
of those can't afford to pay for a dentist without it.
What are they to do? Hospital emergency rooms don't do
dentistry and they don't make glasses. In most cases, Medicaid
does not cover dentistry or vision for adults, and finding a
Medicaid practitioner to provide treatment can be a real
challenge.
RAM is not a solution to the American healthcare crisis. We
need to be in places like Haiti, not Tennessee and California.
RAM bridges the gap for those suffering needlessly in our
system. A RAM event is logistically strained at 1,200 patients
a day, and we are forced to turn away hundreds and sometimes
thousands of sick people.
Our healthcare system has failed our people because they
either do not have access or they cannot afford it. As a result
of the great need of those who are sick or injured, we have
reached out to legislators for help. In 1995, RAM asked the
State of Tennessee to change the law to allow out-of-State
licensed practitioners to provide free care to underserved
patients in Tennessee. This highly successful program attracts
60 percent or more of the medical volunteers at RAM events from
out of State. A total of 12 States have now adopted the
Tennessee model, but this process has taken 20 years.
Doctors are still calling me to say that it is easier to
volunteer their services in places like Guatemala than it is
here in the United States. I have two pictures here that I'd
just like to hold up. Is this 1936 picture of a depression-era
mother in California any more revealing than this 2012 picture
of a thousand Americans holding up their hands appealing for
healthcare before daybreak at a RAM free medical event in
Bristol, TN? Where have we gone wrong in the last 76 years that
separates these iconic images?
Thank you.
[The prepared statement of Mr. Brock follows:]
Prepared Statement of Stan Brock
Welcome to America--No. 37 in the World Health Organization's
country rankings! I am a voice for more than half a million patients
that REMOTE AREA MEDICAL (RAM) has treated free of charge in 723
mobile medical clinics during the last 28 years. I know what it is like
to be poor and without help. I am one voice of the millions of people
who are not a part of our healthcare system. They have been left behind
and forgotten. I speak for them today.
I came from a place where there was no doctor, living with the
Wapishana Indians in the upper Amazon. Their only recourse, when faced
with catastrophic injury or sickness was a tribal witch doctor. But at
least they had that. Some of the sick that we see here in the United
States have nowhere to turn. That is why I created RAM. When I
suffered a serious injury, one of the Indians said, ``The nearest
doctor is 26 days on foot from here.'' I felt then what so many in our
Nation feel today, when they need a doctor and cannot get care. For
millions of Americans, they might as well be 26 days on foot from the
nearest doctor. In fact, one of our patients recently walked 15 miles
because he was desperate for medical attention. Health care in America
is a privilege of the well-to-do and the well-insured; that leaves
about 50 million people flat out of luck. These families live in fear
of injury and sickness with no insurance or not enough of it.
The predicament of these millions of marginalized Americans raises
questions of morality, injustice and education. Poor education begets
poor health. Poverty feeds on poor nutrition which creates obesity,
diabetes, heart disease and cancer. The vicious cycle lies in wait for
each child enslaved in poverty as they pass from beneath the security
of State and Federal programs into the barren wastes of adulthood.
Many, nursing mouthfuls of decayed and abscessed teeth or suffering
from fading vision, will inevitably join the long lines of desperate
patients at a RAM free clinic. I have looked into the distraught faces
of Americans imprisoned by poverty, from child to grandparents, all
generations lining up by the hundreds in places as diverse as Los
Angeles, or a fairground in the mountains of southwest Virginia. I have
seen our elderly in makeshift wheelchairs, people clutching precious
numbered scraps of paper, their RAM free clinic ticket to relief from
unnecessary agonizing pain and sickness. They cannot afford healthcare.
This leads some of our American families, with their children, to sleep
in tents and cars, often for over 24 hours, waiting for a RAM event to
open its door. Blindfolded, you can stick a pin on a map of America and
wherever it lands, you will find hundreds, if not thousands of sick
hurting people in need of care that they cannot obtain.
Our people are living in sickness and pain and in need of basic
medical attention. At RAM clinics, dental care is the greatest demand
with vision services a close second. Eighty-five million Americans do
not have dental insurance and half of those can't afford to pay for a
dentist without it. What are they to do? Hospital emergency rooms don't
do dentistry and they don't make glasses. In most cases, Medicaid does
not cover dentistry or vision for adults, and finding a Medicaid
practitioner to provide treatment can be a real challenge. RAM is not
a solution to the American healthcare crisis. We need to be in places
like Haiti, not Tennessee and California. RAM bridges the gap for
those suffering needlessly in our system. A RAM event is logistically
strained at 1,200 patients a day and we are forced to turn away
hundreds and sometimes thousands of sick people.
Our healthcare system has failed our people because they either do
not have access or they cannot afford it. As a result of the great need
of those who are sick or injured, we have reached out to legislators
for help. In 1995, RAM asked the State of Tennessee to change the law
to allow out-of-state licensed practitioners to provide free care to
underserved patients in Tennessee. This highly successful program
attracts 60 percent or more of the medical volunteers at RAM events
from out-of-state. A total of 12 States have now adopted the Tennessee
model, but this process has taken 20 years. Doctors are still calling
me to say that it is easier to volunteer their services in places like
Guatemala than it is here in the United States! Is this 1936 picture of
a depression-era mother in California any more revealing than this 2012
picture of a thousand Americans holding up their hands appealing for
health care before daybreak at a RAM free medical event in Bristol,
TN? Where have we gone wrong, in the last 76 years that separates these
iconic images?
Senator Sanders. Thank you very much.
Our second witness is Dr. Gary Wiltz. He is a board
certified internist and currently serves as CEO of Teche Action
Clinic, a network of community health centers based in
Franklin, LA, that serves six parishes in southwest Louisiana.
He is also the current Chairman of the Board of the National
Association of Community Health Centers, which represents more
than 1,200 health center organizations nationwide.
Thank you so much for being with us, Dr. Wiltz.
STATEMENT OF GARY WILTZ, M.D., EXECUTIVE DIRECTOR AND CLINICAL
DIRECTOR, TECHE ACTION CLINIC, FRANKLIN, LA
Dr. Wiltz. Good morning, and thank you, Chairman Sanders,
Ranking Member Burr, and Senator Murphy and Senator Warren.
Thank you for that kind introduction, so I won't repeat that.
Just one more fact about NACHC--we represent all of the
Nation's community health centers, and we are serving some 22
million people nationwide in nearly 9,000 rural and urban
settings.
I want to talk to the subcommittee today--and thank you for
focusing on this issue--about the critical issue of primary
care access. I'd like to focus my remarks on the tremendous
strides that we've made in community health centers in
providing access to primary care to millions of people in this
country. And at the same time, I want to highlight a looming
funding crisis that threatens the program's very existence.
Last year, Teche Clinic provided care to more than 18,000
underserved Louisianans, 97 percent of whom are low-income.
Nearly half of our patients are uninsured, and a third are
covered by Medicaid. These are patients that I know very well.
You see, I began my service at Teche Action Clinic in 1982 as a
National Health Service Corps scholar, and some 32 years later,
I'm still there seeing patients every day.
It is from that perspective that I want to speak about what
access to care really means. Access is a term that's being
frequently used in our healthcare dialog and discussion, but
there's little agreement on what it really means. To those of
us who serve on the front lines of healthcare delivery, access
is more than just having an insurance card. It is more than
getting care in an emergency room.
Access is having a place to go for regular, reliable, high-
quality preventive and primary care. By its very design, the
locally controlled nonprofit health center model breaks down
the barriers to healthcare access, including those created by
geography and income.
Health centers are also economic engines in some of the
most economically depressed communities in the Nation. At our
health center in Franklin, we're one of the largest employers
in the community. We provide over 150 good-paying jobs, all
above minimum wage.
Not only do health centers deliver effective care, but,
nationally, we save the health system $24 billion by keeping
patients out of costly healthcare settings such as emergency
departments. At our health center, we're open 6 days a week, 7
a.m. to 7 p.m. We have demonstrated a decrease in inappropriate
emergency room usage by 40 percent.
Just recently, an uninsured man--as Senator Warren alluded
to earlier--an uninsured man came to our center on a Saturday
evening at 6 o'clock after he knocked off from work, suffering
from headaches due to uncontrolled hypertension. We were able
to diagnose and treat his problem that evening, saving him from
having to stay in an emergency room for hours and a costly $800
bill. More importantly, he was able to return to work the next
day without missing that day's pay.
Despite the history of strong bipartisan support from
Congress, many communities in need still lack primary
healthcare access. Even in communities with a health center,
significant unmet need remains. A recent report from NACHC and
the Robert Graham Center found that as many as 62 million
Americans lack regular access to primary care. So, clearly, our
work continues and is not done.
Yet without deliberate congressional action, both health
centers and primary care workforce programs--unless we get this
remedied, they're going to face a threat to their very
existence. Next year, the mandatory Health Center Fund, which
currently accounts for more than half of all health centers'
dollars, will end unless it is reauthorized. At that point,
health centers face a 70 percent reduction in grant funding,
leading to significant cuts to operations and elimination of
healthcare access in some of the Nation's most vulnerable
communities, even as demand for our care continues to grow.
I mentioned earlier that we are soon to open two more new
community health centers and two new sites. If these cuts come
into effect, not only will we not be able to open those two new
sites, but it would force me--and I'm CEO of these community
health centers--to lay off over 10 percent of my staff. And,
most importantly, 3,000 of our current patients would go
without services.
In addition to health centers, the National Health Service
Corps, of which I am a proud alumni, and the Teaching Health
Center programs also face a funding cliff. The Corps is a vital
program that provides scholarships and loan repayments to
providers who commit to serving in underserved areas, as I have
done for my entire career.
The Teaching Health Center program is an innovative effort,
as alluded to earlier, to grow the supply of primary care
providers trained in community-based settings. I know my
colleagues on the panel will speak more about these workforce
programs, but let me just say this. The funding cliff that
faces these programs threatens the stability and sustainability
of our healthcare system.
Failing to fix this cliff would send the country in the
wrong direction by reducing primary care capacity and sending
costs spiraling. We strongly urge Congress to address this
problem this year so that access to care in our communities can
become a reality for years to come. I look forward to your
questions.
[The prepared statement of Dr. Wiltz follows:]
Prepared Statement of Gary Wiltz, M.D.
Chairman Sanders, Ranking Member Burr and members of the
subcommittee, thank you for the opportunity to join you today to
discuss such an important--and urgent--topic: the persistent and
growing need for access to primary care in communities across this
country. My name is Gary Wiltz. I am a board-certified internist and
currently serve as chief executive officer of Teche Action Clinics, a
network of soon-to-be 10 community health centers serving six parishes
in southwest Louisiana whose home base is in Franklin, LA.
I also currently serve as chairman of the board of the National
Association of Community Health Centers (NACHC), which represents the
more than 1,200 Health Center organizations nationwide. Health centers
currently provide care in more than 9,000 rural and urban underserved
communities and serve some 22 million patients, which is a direct
result of broad, bipartisan support for the Health Center Program in
Congress. This support, which extends back decades and has been
embraced by presidential administrations of both parties, has led to
continued and expanded investment in our model of care. On behalf of
all of America's community health centers, I want to thank you, Mr.
Chairman and each member of the subcommittee and Congress for your
unwavering focus on this issue. The reason I am here to talk with you
today is to discuss the positive impact and tremendous strides
Community Health Centers have made in providing access to primary care
services to millions of vulnerable Americans throughout the country as
well as highlight a looming funding crisis that threatens the very
existence of the Health Center Program.
I came to Teche Action Clinic in 1982 as a National Health Service
Corps (NHSC) Scholar with a 3-year service commitment, and 32 years
later I am still there, serving patients every day. It is from that
perspective that I want to speak to the subcommittee today about the
notion of access to care. ``Access'' is a term that gets used
frequently in our national health care discussion, but with varying
interpretations of its meaning. For some, access means merely having
health insurance coverage. Others have suggested that a local emergency
room constitutes sufficient access. To those of us who serve on the
``front lines'' of health care delivery, access is more than just
having an insurance card. It is more than getting care in an emergency
room. Access is having a place to go for regular, reliable, high-
quality preventive and primary care.
Teche Action Clinic is just such a place. In 2013, we provided
access to care to more than 18,000 underserved Louisianans, more than
97 percent of who are low-income. Nearly half of our patients are
uninsured and nearly a third are covered by Medicaid. We provide not
only primary medical care but also oral health, behavioral health,
onsite pharmacy, lab, WIC, nutrition counseling, diabetes education,
chronic disease management and enabling services including
transportation, translation and enrollment services. Like all health
centers, our doors are open to everyone regardless of ability to pay.
We are a Joint Commission certified Patient-Centered Medical Home,
meaning our care is delivered in a coordinated manner by an
interdisciplinary team with a focus on increasing safety, improving
health and reducing costs.
Community Health Centers like the one where I serve are locally
controlled, non-profit entities. By its very design, the health center
model breaks down barriers to health care access, including those
created by geography and income. Health centers are also economic
engines in some of the most economically depressed communities in the
Nation. In 2009 alone, Health Centers generated $20 billion in economic
impact and were responsible for nearly 200,000 jobs. My health center
is one of the largest employers in our community providing over 150
good paying jobs, all above minimum wage.
Community health centers not only deliver effective care, but we
have a demonstrated track record that shows that we're a smart
investment of public funds. Nationally, we save the entire health
system approximately $24 billion annually by keeping patients out of
costlier health care settings, such as emergency departments. At our
Franklin site we are open 6 days a week 12 hours a day 7:30 a.m. to
7:30 p.m., and we have been able to decrease inappropriate ER visits in
my community by over 40 percent. Just recently, one of my patients, who
is employed but uninsured, came to the health center on a Saturday
evening after he got off work at 6 p.m. He was suffering from a severe
headache due to dangerously high blood pressure. We were able to get
him in, diagnose the problem and treat him that evening, which saved
him from waiting for hours to be seen at an emergency room and paying
over $800.00. Our ability to see him and provide him with services when
he needed care also allowed him to go to work the next day.
In addition to providing the right care at the right time at the
right price, Health Centers have established an impressive record of
delivering high-quality care to our patients. Research has shown that
Health Centers provide equal or better care compared to other primary
care providers, all while serving communities with more chronic illness
and socioeconomic complexity. Health center patients receive more
preventive services, such as immunizations, health education,
mammograms, pap smears, and other screenings, than patients seen in
other settings.
Unfortunately, many of the residents in my State, both the
uninsured and insured, are unable to access critical primary and
preventative care services because they just can't afford it or do not
have access to a health center or other primary care providers. Clearly
our work is not done. Despite the strong bipartisan support and the
history of investment in our capacity, many communities in need still
lack a Health Center or any other form of basic primary care. Even in
communities with a Health Center, demand often far exceeds supply and
significant unmet need remains due to limited resources. Many Health
Centers struggle to recruit and retain a primary care workforce that is
prepared to address the challenges of providing care to the medically
underserved.
A recent report issued by NACHC and the Robert Graham Center for
Policy Studies indicates that as many as 62 million Americans lack
regular access to primary care. Access barriers such as geography,
income, and insurance status--and the provider shortages that
exacerbate them--lead to poorer health outcomes and increased costs for
taxpayers. Yet at the very time that this need for expanded access is
most necessary, without deliberate congressional action both Health
Centers and vital primary care workforce programs face a threat to
their very existence. I want to focus the remainder of my testimony on
this issue--which we have taken to calling the Primary Care Cliff--and
the urgency of addressing it as soon as possible.
The Health Center grant, which supports the operations of the more
than 1,200 federally funded health center organizations nationwide, is
financed through a mix of annual discretionary appropriations and
mandatory funding appropriated through the Health Centers Fund. In the
coming fiscal year, if the health centers program were to maintain
discretionary funding at current levels and to fully utilize the last
remaining year of funding in the mandatory health center fund, we would
build the capacity to serve as many as 11 million new patients.
In fiscal year 2016, however, Health Centers face a funding cliff:
the mandatory funding, which currently accounts for more than half of
all health center dollars, will end unless it is reauthorized. With
only discretionary funding at current levels, Health Centers would see
up to 70 percent reductions in grant funding, leading to significant
cuts to operations and reduction or elimination of health care access
in some of the Nation's most vulnerable communities. This would occur
just as the demand for the type of care Health Centers provide is
growing. I mentioned earlier that my center is soon to be 10 sites as
we will be opening two new sites in a high-need parish in the next 2
months. If these cuts are to come to fruition, not only would I be
unable to open these two new sites, I would be forced to close two
additional sites, lay off over 10 percent of my staff and more
importantly over 3,000 of my current patients would no longer have
access to primary care services in Franklin.
In addition to Health Centers, the National Health Service Corps
and Teaching Health Center programs also face looming funding cliffs.
The National Health Service Corps is a vital program that provides
scholarships and loan repayment to providers that commit to serving in
underserved areas, as I have done for my entire professional career.
The Teaching Health Center program is an innovative effort focused on
growing the supply of primary care providers trained in community-based
settings.
I know my colleagues on the panel will be speaking in more depth
about these workforce development programs, but let me just say this:
taken together, the funding cliff that faces these three programs
threatens the stability and sustainability of our health care system.
Failing to fix this cliff would send the country in the wrong direction
by reducing primary care capacity and sending costs spiraling upward.
There is no way we can absorb a 70 percent cut. Instead it will force
Health Centers to close sites and lay off workers, meaning a major
reduction critical access for the patients and communities we serve.
We strongly urge Congress to address this problem this year--so
that health centers and our current and future clinicians can plan for
the future knowing that access to care in our communities can be a
reality for years to come. I know each of us, as well as the
organizations we partner with and represent, is eager to work with you
to address this problem. Thank you for your time and I look forward to
your questions.
Senator Sanders. Dr. Wiltz, thank you very much.
If you will forgive me, Senator Murphy has to leave, and he
wanted to introduce Dr. Flinter. So I'm going to kind of jump
over and we'll go to Dr. Flinter.
Senator Murphy.
Senator Murphy. Thank you very much, Mr. Chairman, for your
courtesy. I'm just pleased to have my good friend, Margaret
Flinter, here with us today. She's the senior vice president
and clinical director of Community Health Center, Inc. It's the
largest FQHC in Connecticut, serving about 130,000 patients in
13 practice settings.
But her expertise here today is really about all the great
work that she's done to develop a model of formal postgraduate
residency training programs for new nurse practitioners that
are committed to practice as primary care providers,
particularly in community health centers. This model now has 15
sites all around the country. For this committee's purposes,
there are sites in Massachusetts, Pennsylvania, South Carolina,
and Washington State.
She's a great friend, but also a real expert in the field
of primary care, and I'm delighted to have her join us this
morning.
Senator Sanders. Dr. Flinter, can you live up to all of
that?
Ms. Flinter. I don't know what else I can say.
Senator Murphy. And I would just add that she is
testifying, despite the fact that she has been up 2 nights in a
row watching the UConn Huskies win two national championships.
[Laughter.]
Ms. Flinter. Go Huskies. And they did a great job.
Senator Sanders. Dr. Flinter.
STATEMENT OF MARGARET FLINTER, APRN, Ph.D., c-FNP, FAAN, FAANP
SENIOR VICE PRESIDENT AND CLINICAL DIRECTOR, COMMUNITY HEALTH
CENTER, INC., MIDDLETOWN, CT
Ms. Flinter. Thank you so much, Senator Murphy. Good
morning, Chairman Sanders and Senator Burr and Senator Warren
as well. We are so pleased to have the honor to testify before
you today.
Primary care has been the defining focus of my entire
career, from the time I started as a young public health nurse
in rural Connecticut and Georgia and then as a family nurse
practitioner primary care provider and a leader at the
Community Health Center. I came there in 1980, newly graduated,
ink barely dry on my diploma from the Yale School of Nursing,
because the National Health Service Corps had the good sense to
assign me to what was then a storefront clinic on Main Street,
USA, in Middletown, CT.
It was my great good fortune to find a band of deeply
committed visionary community organizers and clinicians who are
as committed to community health and primary care as I was. And
as Senator Murphy has said, from those humble beginnings, we
care for 130,000 patients--medicine, dentistry, behavioral
health--in community health centers, but also in our school-
based health centers around the State, which numbers nearly
200.
Today I want to address three questions that are the focus
of so much of my work and I know on your minds. Who wants to be
a primary care provider? Second, how do we attract these
providers to the areas that need them most, both rural and
urban? And, third, how do we retain them once they're there?
First, the workforce shortage issue. You are hearing and
will hear compelling testimony from my colleagues. I'll tell
you in advance that I've read their testimony, and I support
their recommendations, and, in particular, the Teaching Health
Center reauthorization, which recognizes, as I do, that it's
both about training to the complexity of the care we deliver in
primary care and in health centers, but it's also about
training to a model of care that is patient-centered and data-
driven that focuses on quality and delivering care where people
live and work.
You will hear many statements about why there is a shortage
of primary care physicians. But I'm going to ask you to step
back and ask not just why don't more physicians choose primary
care, but who else wants to be a primary care provider, and how
do we support them in that choice.
My response is that nurse practitioners still
overwhelmingly choose primary care as their specialty. Eighty
percent of nurse practitioners specialize in a primary care
specialty, and 70 percent are in primary care today. We can
attract them and support them and assure their successful
transition to the role of a primary care provider by giving
them the opportunity for formal postgraduate residency training
programs in community health centers. In 2007, I and my
colleagues at the health center launched the country's first
program after many years of recognizing the need for such a
program.
GME legislation has been so successful in preparing
physicians, but it has never included nurse practitioner
residency training. We can't afford to lose new NPs from
community health centers, where the first year of practice can
rightly be described as one of shock and awe, or deter them
from coming to our setting simply because we haven't done the
work required to facilitate a successful transition from
brilliant education to practice.
We are now in our seventh year. Our applicants come from
all over the country. Twenty-seven of our twenty-eight
graduates are practicing as primary care providers all across
America. Fifteen other health centers have started programs
like ours, and 14 more residency programs will come online in
2014. It now extends beyond the community health centers to
include nurse-managed health centers and even large health
systems such as, Senator Burr, the Carolina healthcare system
in your home State where we've had the pleasure of meeting such
wonderful leaders.
We've come together. We've created a national nurse
practitioner residency training consortium to set standards and
to work for a sustainable stream of funding, such as that
that's available to physicians. And we will seek a legislative
commitment based on the fact that in 2010, Congress authorized
grants of up to $600,000 a year to implement NP residency
training programs in community health centers. But the
authorization expires this year, and no grants were ever
awarded because the program was never funded. We ask that it be
done and reauthorized and funded for 5 years.
My second question: How do we recruit providers to
underserved areas, both rural and urban? And I will simply
state what others have said: ``Expand the National Health
Service Corps.'' It worked for me in 1978. It worked for 40 of
my 200 clinicians on my staff, who at one time in their career
were National Health Service Corps, and that cuts across all
the disciplines.
And, finally, I want to answer the question: How do we
retain the best and the brightest? We do it by not making
coming to practice in a community health center a choice
between a stimulating career in practice and research and
training and being involved in leadership, but rather we can
make our health centers the locus of those activities.
That's what the Weitzman Institute at the Community Health
Center does, whether it's through our Project ECHO model of
connecting primary care providers to specialists around the
country to focus on the most pressing and difficult issues in
primary care, things like the management of chronic pain,
dealing with opioid and heroin addiction, managing HIV and
hepatitis C, and primary care. We can create these kinds of
innovations. We can use technology. We can have our research
within the health centers. And we can truly improve the health
and the healthcare of all Americans.
I thank you very much for the opportunity to be here today.
[The prepared statement of Ms. Flinter follows:]
Prepared Statement of Margaret Flinter, APRN, Ph.D., c-FNP, FAAN, FAANP
Good morning, Chairman Sanders, Senator Burr, and distinguished
members of the Subcommittee on Primary Health and Aging. It is an honor
to speak to you today on the issues of healthcare access and workforce
challenges across the United States.
Thank you, too, Senator Murphy for your kind introduction, and for
all of your efforts to ensure access to high-quality health care for
all Americans, first as our State Representative in Connecticut, then
as a Congressman, and now as a U.S. Senator.
I am Margaret Flinter of the Community Health Center of
Connecticut, and primary care has been the defining focus of my career,
first as a young public health nurse in rural Connecticut and rural
Georgia, then as a family nurse practitioner, primary care provider,
and executive leader of one of the country's finest community health
centers. I came to the Community Health Center, Inc. in 1980, newly
graduated from the Yale School of Nursing as a family nurse
practitioner and ready to begin my ``service obligation'' as a National
Health Service Corps scholar. It was my great good fortune that the
NHSC assigned me to what was then a small storefront on Main Street in
Middletown, CT, where I found a small band of visionary and passionate
community organizers and clinicians, like founder and CEO Mark
Masselli, and family physician Dr. Carl Lecce, all of whom shared my
own vision and passion for primary care and community health.
We put our shoulders to the wheel in building a remarkable
community health center first in Middletown, but over time and in
response to requests from community leaders in cities all over
Connecticut, we developed community health centers in 12 cities across
our State. Through our W.Y.A. or ``Wherever You Are'' philosophy of
going where the need is, we have also pioneered the expansion of
statewide, school-based health centers and primary care services in
homeless shelters. Today, our Community Health Center has over 130,000
active patients throughout the State. We are known for our clinical
excellence but also for our commitment to innovation in addressing
complex issues in primary care; for our formal research; and for
training the next generation of qualified health care providers.
Today I want to address three questions that are the focus of much
of my work and your area of interest today. First: who wants to be a
primary care provider? And what must we do, now, to support those who
make the affirmative commitment to become primary care providers?
Second: how do we entice those providers to practice in underserved
areas, both rural and urban, to care for our most vulnerable
populations? Third, and just as important: how do we retain these
talented, brilliant, and committed individuals in community health
centers over the long haul? In answering these questions, I will speak
to what we can and are doing, ``in the field,'' and also, how you are,
and can, help us continue to do so.
First, let me address the workforce issue, and particularly the
shortage of primary care providers. You are hearing compelling
testimony today from my colleagues on this subject, and in particular,
the need and strategies for attracting, training, and retaining more
physicians in primary care. I support their recommendations and
testimony. I am particularly supportive of the Teaching Health Center
reauthorization and program, which recognizes, as I will emphasize in
my testimony, that we must train the next generation not only to the
clinical complexity of primary care in community health centers, but to
our model of care--and that is best accomplished by FQHC-based
residency training. You are well familiar with the many challenges that
contribute to the shortage of primary care physicians--the low
percentage of medical school graduates who choose primary care vs.
specialties, the salary discrepancies between primary care and
specialties, the burden of debt, and the deep frustration with primary
care practice of the past few decades, which I believe we are fully
capable of reversing--and I will speak to strategies to address that
shortly.
But I want to step back. Instead of asking only why more physicians
don't choose primary care, why not ask this broader question: Who else
wants to be a primary care provider, and how can we support them in
that choice and ensure that they will stick with it--particularly in
the complex setting of community health centers?
My response is that nurse practitioners still overwhelmingly choose
primary care as their preferred specialty, and we can attract, support,
and assure their successful transition to the role of primary care
provider in community health centers and other complex settings by
giving them the opportunity for formal, post-graduate residency
training programs in federally qualified health centers and nurse-
managed health clinics.
In 2007, I and my colleagues at CHC, Inc. launched the country's
first formal post-graduate residency training program for new nurse
practitioners who aspire to practice careers as primary care providers
in community health centers. We did this after many years of observing
the very difficult transition of brilliantly educated and fiercely
committed new NPs as novice primary care providers in the very busy,
immensely complicated settings of community health centers. The need
and call for residency training for new NPs had been written about,
talked about, and studied for years but the brick wall of GME
legislative language failed to include NP residency training and
impeded its development. We cannot afford to lose new NPs in community
health centers--or deter them from coming to our setting--simply
because we have not done the work required to facilitate their
successful transition from university to practice.
We decided that someone had to build the model for NP residency
training, and so we did. This NP Residency Training Program is full-
time for 12 months. It is very intensive training that addresses the
clinical complexity of health problems suffered by often uninsured,
low-income health center patients, and trains these NPs to a model of
high performance primary care--team-based, and integrated with
behavioral health; person-focused but also driven by actionable data to
achieve better and better outcomes.
We are now in our 7th year and have expanded to eight residents per
year. Our applicants come from all over the country--we have had
applicants from all but two States--and I can tell you that 27 of our
28 graduates to date are practicing as primary care providers in
community health centers and safety net settings all across America,
from Louisiana to Iowa, as well as in Illinois, Massachusetts,
California and Washington State.
From the time we started and in response to our first published
article on the model, we have been asked by others to help them develop
NP residency training programs. Today there are 15 NP residency
training programs for primary care NPs across the country, and 14 more
that will come on line in 2014. They include community health centers,
nurse-managed health clinics, and the Veterans Administration's Five
Centers of Excellence in Primary Care Education--plus the Jesse Brown
VA Medical Center in Chicago. We have over 60 organizational members
nationwide, with six participating facilities in Massachusetts alone--
in Belmont, Boston, Cambridge, Charlestown, Leominster and Worcester;
another NP residency training site has been established at the Fay
Whitney School at the University of Wyoming in Laramie; and now even
large health/hospital systems such as the Carolinas Healthcare System
in Senator Burr's home State--with six NP residency training sites--are
joining this national movement.
To advance the model of NP residencies, I and my colleagues created
the National Nurse Practitioner Residency Training Consortium, which
has brought together the leaders of the movement to advance the
development of NP residency training nationwide. Our goal is to set and
maintain appropriate standards for these residencies and work for a
sustainable stream of Federal funding similar to that available for
physicians and dentists under GME. In short, we seek a legislative
commitment to NP residencies, and we believe we are almost there. In
2010, Congress gave the Secretary of HHS the ability to award grants of
up to $600,000 a year to eligible health centers seeking to implement
NP residency training programs. However, that authorization expires
this year and no grants have ever been awarded because the program was
authorized but never funded. It is our request that, this year, the
previously enacted provision be reauthorized and funded for another 5
years, because this program is absolutely critical to address the
looming primary care workforce shortage we face over at least the next
10 years. While our consortium is growing due to the tremendous need in
our communities, many of the existing participants advise that they may
be unable to continue the training without the provision of Federal
funds moving forward. For example, the nationally renowned Penobscot
Community Health Center in Bangor, ME, just advised me that although
they will maintain the program next year, it will be cut by two-thirds.
They implemented the program and spread information concerning NP
residencies within the State but unfortunately say they will be
educating at reduced capacity, compared to what they could have done,
due to lack of funding.
My second question asked how we can recruit providers to
underserved areas, both rural and urban. The National Health Service
Corps, originally and brilliantly championed by Senator Warren G.
Magnuson of Washington State, has stood the test of time as an
effective, efficient, and elegant way to meet multiple critical needs:
the need of the new clinician to obtain financial support; the need of
the newly graduated clinician to obtain help with loan repayment; and
the dire need of communities to acquire primary care providers. Since
1972, the Corps has done just this. I know this first hand. When I made
the decision, after several years as a public health nurse, to attend
graduate school at Yale, the financial challenge was daunting. In 1978,
I was fortunate that the NHSC accepted me as a NHSC scholar, and I
gratefully committed myself to a future period of obligated service.
Why wouldn't I? All I wanted--as I have seen with subsequent
generations of NHSC scholars and loan forgiveness recipients--was a
chance to practice, as a primary care provider, with people and in a
community that needed my care.
In preparing for today's testimony, it occurred to me that I really
didn't have a firm handle on how many members of my medical, dental,
and behavioral health staffs had ever been in the NHSC during their
careers. I posed that question by email to the staff and invited people
to share the ``where and when'' of their service--but also what it
meant to them. Time does not permit me to read all 40 of the responses
I received. These respondents are all ``alums'' of the NHSC and include
physicians, nurse practitioners (both primary care and psychiatric
specialist), PAs, Licensed Clinical Social Workers, Licensed Clinical
Psychologists, Dentists and Dental Hygienists. Perhaps most tellingly,
while some are currently in their period of obligated service, the
majority completed their NHSC service many years ago but chose to stay
and work in primary care. As one NP wrote,
``In my experience, the NHSC provided me with the financial
support that allowed me to focus my attention directly on the
clinical concerns of my patients and connected me with other
like-minded clinicians. I remain forever grateful for the
opportunity afforded to me by the Corps. For this reason, I
would encourage all efforts to increase ongoing support for
this wonderful program, and I applaud the NHSC for taking so
many steps in recent years to `modernize' their rules,
procedures and policies to reflect changing times.''
Finally, I would like to answer my third question: what do we need
to do to retain the best and the brightest, the most committed
clinicians in primary care? For this, we must look to the cutting edge
innovations and opportunities that create an exciting, stimulating, and
vibrant career path for clinicians choosing primary care in community
health centers. We can't have a path that says to practice primary care
in a community health center, you must forego any thoughts about
research, teaching, and mastery of complex challenges through on-going
exposure to the best specialists that academic medical centers might
offer. Instead, our health centers provide exactly that rich
environment. I have had the opportunity to see this through the
creation of our Weitzman Institute, founded in 2005 as the Weitzman
Center for Innovation in Primary Care, which is an institute with a
core focus on delivery system research, applying the science of quality
improvement in primary care, and training. And I have seen how powerful
a force it is for us at CHC in both attracting--and retaining--our best
clinicians.
Finally, I want to speak to overcoming the isolation that can be
inherent in primary care as we face some of the most vexing problems.
One example is ``Project ECHO''--an evidence-based, distance learning
approach developed by Dr. Sanjeev Arora at the University of New Mexico
and replicated by CHC for FQHCs around the country. Project ECHO-CT.
connects a team of specialists, by video, with groups of primary care
providers all over the country. Practitioners in the field present
their most challenging cases and get expert clinical guidance by
telemedicine and, in the process, become expert over time themselves.
Nowhere is this more important than in two critical areas of primary
care: the diagnosis and management of chronic pain and--sadly, but
closely related--the management of heroin and opioid addiction. We all
recognize the danger and precipitous rise in death by opioid overdose,
both prescription pill and heroin, in our communities. Dealing with
issues like this--alone and without expert support and guidance--is the
kind of isolating and frustrating experience that drives people out of
primary care. Connecting primary care providers with specialists and
each other to treat and manage these complexities is of enormous value,
and I would be happy to speak more about this if time permits.
In summary, I answer my three questions again. Who wants to be a
primary care provider? Nurse practitioners do, and seek the opportunity
for further intensive training appropriate to the complex setting of
community health centers. How can we attract the best, brightest and
most committed young providers across the medical/dental/behavioral
health disciplines? By growing the National Health Service Corps. And
finally, how do we retain these providers? Our responsibility, in the
field, is to make our health centers not JUST centers of clinical
excellence, but also the loci of research, training, and the
advancement of science in primary care.
We greatly appreciate your leadership and look forward to your
continued support for these initiatives.
Senator Sanders. Thank you very much.
Senator Burr is going to introduce Dr. Dobson.
Senator Burr. Mr. Chairman, I'm pleased to introduce Dr.
Allen Dobson, the present CEO of Community Care of North
Carolina. He's a family physician. He currently serves as the
vice president of Clinical Practice Development at Carolina's
Medical Health System in Charlotte, and he is a visiting
scholar at the Engelberg Center for Healthcare Reform at the
Brookings Institute here in Washington, DC.
Let me just say on a personal note that Allen has been
instrumental in reshaping the delivery of healthcare to the
most vulnerable in North Carolina and I think nationally. His
effort to create and to implement community care has been a
model many have tried to figure out and replicate, if not in
total, in part.
Dr. Dobson.
STATEMENT OF L. ALLEN DOBSON, Jr., M.D., PRESIDENT AND CEO,
COMMUNITY CARE OF NORTH CAROLINA, RALEIGH, NC
Dr. Dobson. Thank you, Chairman Sanders and Senator Burr
and members of the committee. It is a great pleasure to be with
you today, and, as Senator Burr said, I'm a family physician. I
actually started practice 30 years ago in a rural health clinic
in a small town, and I still live there, despite the number of
jobs--probably too many.
Let me just say that building and supporting a strong
primary care infrastructure must be the top priority in health
policy today. We believe Community Care is an important model,
and just let me say that we spent the last 15 years in North
Carolina building a strong community-based primary care system.
Ninety percent of our North Carolina primary care workforce
participates in Medicaid, far better than most States. That's
private, community health centers, and others. Why? Because we
started paying better for Medicaid, and Community Care was
built to provide an infrastructure to support our primary care
doctors.
I think the last time I was here, Senator Sanders, I said
Community Care is a virtual community health center for all
primary care physicians. It's built on those principles. We
provide health informatics and care management services in the
community to enable our primary care doctors to better
coordinate care and really do true population management in the
rural communities and urban communities that they serve.
As a public-private partnership, it's an infrastructure
that covers all 100 counties. We've achieved one of the lowest
growth rates of Medicaid spending in the country. We've saved
the State money by avoiding wasteful spending. In fact, over a
4-year period, actuaries have said up to a billion dollars.
Our model is flexible and it serves both urban and rural
equally well. What does it do? It helps support primary care
doctors in getting PCMH certified. It works in collaboration
with the Office of Rural Health, Area Health Education Centers,
our Community Health Center organizations, the Division of
Medical Assistance and Public Health. We're the fabric for the
primary care workforce. All our FQHCs, rural health clinics,
residency programs, public health departments--all are members
of Community Care.
So why is primary care important? Well, it's delivering
basic preventive care. It's also maximizing that 80 percent of
care that can be provided at a low-cost setting for our
population. And it's really coordinating the care of people
with the most complex diseases and needs. The primary care
workforce is where that needs to occur.
The upheaval in healthcare over the last 2 to 3 years has
actually made things worse, and we all are here to testify
about the pipeline and the primary care infrastructure. From
our experience in North Carolina, let me just offer maybe four
basic thoughts.
One is we really need to create an effective primary care
pipeline in medical education. It starts with GME, looking at
how we can get outcomes, but really focusing on training at the
site where we know it will make a difference. We know in North
Carolina if a med student is trained in a North Carolina
medical school, and, more importantly, if they do their
training in a North Carolina residency, they're likely to stay.
The corollary is if they train in a rural area they will most
likely stay.
We need to support our community-based AHECs and
particularly support our Teaching Health Centers. It's a great
model. Our early results--we have several in North Carolina.
They are great partners. It's three or four times more likely,
people who train there will stay and get a job at a community
health center.
Physician-led medical homes and medical homes, in general,
can help control cost and improve outcomes if supported with an
adequate care management infrastructure and an effective
population health infrastructure. We've got to do something
about the 10-minute visit. You can't handle this in a 10-minute
visit.
The second thing is that we really need to accelerate
payment reform supporting primary care. We've talked about it,
but it's pretty inadequate. We need to create incentives for
physicians to see and engage patients and handle the most
complex and high-risk populations. We need to make sure the
Medicaid rates stay at 100 percent of Medicare.
We need to help States build the capacity in the rural
areas and support independent practices. Two-thirds of our
Medicaid population in North Carolina are served by some 900
independent practices and FQHCs mostly in rural areas. The care
management infrastructure we give for the primary care
providers in North Carolina really helps them manage those
high-cost patients efficiently.
We also need to decrease the fragmentation that occurs by
multiple payers doing it in multiple ways. The Federal
Government is no exception. We need to support multi-payer
efforts that align the efforts around the delivery system
transformation, particularly in primary care, to allow such
things as the multi-payer advanced primary care demo to be
continued, because that funding allows the primary care
workforce to really deliver effectively. So we would ask to
support that.
North Carolina has found that if you really support the
primary care system and residency training in local settings,
the return on investment is there. It has led to local
collaboration and care improvement and ultimately improved
quality and cost control.
We really need policymakers to help enable our community-
based infrastructures to become strong. That includes not just
workforce, but health informatics and care management. We think
we have pieces that will help inform the national dialog, and
we can achieve long-lasting and widespread reform, but it
starts with primary care.
Thank you very much for the opportunity to be here.
[The prepared statement of Dr. Dobson follows:]
Prepared Statement of L. Allen Dobson, Jr., M.D.
Chairman Sanders, Senator Burr and members of the committee, it is
a great honor to be with you today to discuss health policy issues that
are critical to our future, both in terms of access to quality
healthcare and the overall strength of our healthcare system and
economy.
My name is Allen Dobson. I am a family physician in North Carolina
and president and CEO of Community Care of North Carolina (CCNC).
In North Carolina, as in most of the country, there has been a
whirlwind of change with new payment structures, new technologies,
market consolidation, new regulatory requirements, and a new industry
of healthcare ``consultants'' who tell us they have the latest
innovation or technology that will fix it all. Despite all of this,
building and supporting a strong primary care base remains the top
priority in healthcare policy.
Over the last 15 years, North Carolina has built a strong,
community-based primary care system. Over 90 percent of North
Carolina's primary care workforce participates in CCNC, a Medicaid
participation rate far higher than most States. This is the result of
North Carolina paying a somewhat higher rate for reimbursements than
other States and the support provided to primary care doctors by CCNC.
This includes health informatics and low-cost care management platforms
that enable the application of population management across CCNC's
entire statewide footprint and improve the quality of care delivered.
This unique public-private infrastructure, which covers all 100 of
the State's counties, has helped to give North Carolina the lowest
Medicaid growth rate in the country (see Figures 1 and 2), making it a
national model for quality improvement and cost control. In an
independent actuarial study, Community Care was shown to save nearly a
billion dollars over a 4-year period in our Medicaid program. CCNC's
system works equally well in rural, underserved and urban areas (See
Figure 3 for geographic distribution of primary care facilities).
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Our model has improved care by building capacity at the provider
and community level and linking providers together through a statewide
infrastructure that links providers together. We provide support for
practices seeking recognition as a Patient Centered Medical Home (PCMH)
support and other needed help in collaboration with the North Carolina
Office of Rural Health, North Carolina Area Health Education Centers
(AHEC), North Carolina Division of Medical Assistance and others.
We have thrived on innovation, fostering change, and establishing a
culture of collaboration with all our partners around a common goal,
improving the care delivered to our most vulnerable citizens.
Upheaval in the healthcare landscape, however, has accelerated
rapidly over the last 2-3 years and our doctors are reeling. Our
primary care medical homes are under stress and this will have a
significant impact on the future primary care workforce and accesses to
quality healthcare for our citizens.
If you are a primary care physician in North Carolina:
You have probably just bought and implemented an
electronic medical record and are now figuring out how to meet
meaningful use requirements. You may be with vendors who have promised
a Ferrari and delivered a Yugo. Many EHRs still are not capable of
providing needed reports or communicating with other systems
effectively.
Despite buying into technology, doctors are inundated with
paperwork and clerical tasks often turning physicians into data entry
clerks. A recent national survey demonstrated doctors spend 22 percent
of their time on paperwork; that is equivalent to 1 day a week of work.
You may have been promised enhanced reimbursement for
becoming an accredited Patient Centered Medical Home and may have
invested $30,000 to $40,000 and hundreds of staff hours and have yet to
recoup your investment. Promised payment reforms have been slow to
come, leaving primary care doctors a volume-based payment system while
being told they must prove their value before payment changes can be
considered.
Physicians now have to decide whether to join (or become)
an Accountable Care Organization. A recent national survey of emerging
ACOs put the price tag for startup costs at $4M to $10M. The decision
of independent physicians to join larger ACOs may be based on money
rather than performance.
There is rapid consolidation of our hospital systems,
leaving independent physicians little choice but to take on salaried
positions with large health systems. The number of independent
hospitals has dropped from 142 to 24. From personal communications I
have had with the North Carolina Medical Society and North Carolina
Hospital Association, it appears that the number of independent
cardiology practices in North Carolina has dropped from 196 to 4 in
just the last 2 years.
While some notable integrated delivery systems have
increased healthcare value for purchasers, consolidation also decreases
competition and may actually decrease local collaboration and
innovation as the systems becomes more competitive and proprietary.
There has also been rapid growth in healthcare technology
platforms that promise to activate patients, provide remote monitoring,
and control costs. Our State legislators and North Carolina Department
of Health and Human Services staff are inundated with information from
vendors promoting the latest app or care management solution and
promises of savings and return-on-investment. Without a State
infrastructure or larger reform plan, more fragmentation will occur.
Unfortunately, this chaos is also having an impact on
recruiting medical students and residents into primary care. While we
have increased the number of medical student slots in North Carolina,
only 19 percent are choosing primary care specialties (See Figure 4).
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
I believe that policy options that strengthen primary care are the
most important element to a s successful national healthcare reform
effort. Primary care is essential for delivering preventive care,
providing a significant portion of a healthcare needs in a low-cost
setting and effectively coordinating care of patients with multiple
chronic diseases.
Here are three recommendations from our experience in North
Carolina that may be helpful:
1. Create an effective primary care pipeline. We need a continuous
and coordinated medical education strategy with both undergraduate and
graduate medical education policies that increase the supply off
primary care doctors in rural areas.
In North Carolina, as in many parts of the country, there is not
just a doctor shortage; there is a misdistribution of primary care
doctors (along with general surgeons and psychiatrists). While the
focus has been on adding more medical school positions (we have added
177 slots in the past 2 years), there is likely to be little impact on
the other end of the pipeline unless we tie GME funding to outcomes. In
2005, out of 408 medical students in North Carolina, only 21 percent
went into primary care and just 2 percent went on to practice primary
care in a rural area. (See Figure 5.)
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
However, in-state training and community-based GME programs will
increase the primary care physician supply:
a. Students who both went to school in North Carolina and completed
residency in North Carolina, were more likely to practice in North
Carolina (69 percent vs. 42 percent)
b. Residents who trained in community-based AHECs were more likely
to practice in North Carolina compared with those trained in
conventional GME settings (46 percent vs. 31 percent) and more likely
to practice primary care (53 percent vs. 31 percent).
c. We now have two teaching health centers based out of FQHCs in
North Carolina and a CCNC practice site; we believe this to be an
effective workforce strategy. Residents trained in an FQHC are 3.4
times more likely to choose a job in a community health center.
d. CCNC works with all North Carolina primary care residency
programs and North Carolina AHEC
e. CCNC-involved practice are more likely to be involved in
education.
We must support and build capacity in primary care in order to
improve access in rural area as and control costs. The evidence based
around population health is teaching us that physician-led medical
homes, supported with care management and effective population health
strategies and infrastructure can help control costs and improve
outcomes.
However, medical homes cannot function under a reimbursement model
where physicians must see patients every 10-12 minutes. Payment
structures that incentivize team-based care, population management,
quality data reporting, and accountable care are a start; but we are
finding that our independent practices are struggling to participate in
these new models.
One of our pediatricians said,
``I met with my office manager and my accountant, and we
figured out that it costs me $87 an hour to be involved in
quality work. I'm not rewarded for it. Doing quality work
actually costs me at this point. None of my partners are
particularly interested in doing it and they take home more
than I do. I do it because it is right and because I see it
coming. I also get ulcers when things are not running
efficiently and doing quality work has really improved our
ability to not let patients fall through the cracks. Some
things that used to keep me up at night don't anymore since we
have these processes in place. We are delivering better care--
no doubt.''
2. Payment reform is needed now and on a larger scale. It should
focus on incentives that allow primary care doctors--especially those
in independent practices and FQHCs--to form continuous relationships
that engage and activate patients to change behaviors and allow
physicians to manage at risk populations. The Direct Primary Care model
where some or all primary care services are capitated with a flat fee
is one example that shows promise.
3. States need structures to support and build capacity in rural
areas and for independent practices. In the CCNC program, two-thirds of
our Medicaid population is cared for in approximately 900 independent
practices. In fact, despite the consolidation of the last few years,
over 60 percent of the Medicaid population is still cared for by
independent physicians and FQHCs, the majority in the rural areas of
North Carolina. Our independent practices, like FQHCs, take care of a
complex case mix and are our higher performers in total cost of care,
hospitalization rates and readmission rates. With the exploding costs
of ``practice overhead,'' we need lower cost utilities for practices to
subscribe to that will allow them to participate in value-based care.
In North Carolina, we have built a statewide informatics
infrastructure that supports our practices and has enabled our
practices to identify ED super utilizers, patients who are not getting
their medications filled, and those with chronic disease who are
missing needed tests like hemoglobin A1Cs. Our platform also allows
them to compare their clinical quality data with that of their peers
and motivates local clinical management entities to improve population
health.
We are now working with our partners including FQHCs to knit
together a statewide health information exchange that will allow
practices to report quality data and identify populations that need
more intensive care management and will allow physicians to use
healthcare resources more efficiently.
summary
In North Carolina, we have found that supporting primary care and
residency training in local settings has led to local collaboration and
care improvement--and ultimately improved quality and cost control. We
look to policymakers to help enable community-based infrastructures
such as health informatics and care management supporting primary care
that will further improve population health outcomes. Highly functional
integrated health systems play an important role, but there will be a
need for State-based ``utilities'' to support rural and independent
practices to achieve lasting and widespread reform of our healthcare
system.
Thank you for the opportunity to testify before this committee.
Senator Sanders. Thank you very much, Dr. Dobson.
Here's what we're going to do. We have a very important
vote on the floor. That's why some members have disappeared and
why Senator Burr and I are going to have to disappear. So we're
going to halt this meeting for a few minutes. We will be up as
soon as we can. We thank you for your patience.
[Whereupon, at 11:13 a.m., the committee recessed, to
reconvene at 11:25 a.m., the same day.]
Senator Sanders. My apologies again. But here in the
Senate, there's usually about six things happening
simultaneously, and that's the way it is.
We just heard from Dr. Dobson. Senator Burr is going to be
returning in a minute. And now we'd like to hear from Dr.
Nichols.
Dr. Nichols is a Family Medicine Resident at MedStar
Franklin Square Family Health Center in Baltimore. He
specializes in family medicine and community health
epidemiology, focusing on population health management for
medically complex and disadvantaged patients.
He has served on the American Academy of Family Physicians
Commission on the Health of the Public and Science. Dr. Nichols
is a graduate of the University of Texas School of Public
Health and Baylor College of Medicine.
Thanks so much for being with us, Dr. Nichols.
STATEMENT OF JOSEPH NICHOLS, M.D., MPH, FAMILY MEDICINE
RESIDENT, MEDSTAR FRANKLIN SQUARE FAMILY HEALTH CENTER,
BALTIMORE, MD
Dr. Nichols. Good morning, Chairman Sanders, Senator
Warren. I want to thank all the Senators present and not
present today for putting aside lingering NCAA rivalries to sit
down and talk about this very important issue today. I'm Joseph
Nichols, and my path to a primary care career began at the age
of three, when I was diagnosed with acute lymphoblastic
leukemia, kindling a lifelong interest in medicine as a means
to help others in need.
Early on, I entered a pipeline that started at the South
Texas High School for Health Professions and continued all the
way through the Premedical Honors College--an 8-year full
tuition and fees scholarship to the University of Texas Pan
American and Baylor College of Medicine. So you can imagine how
excited I was to tell my pediatric oncologist about my plan to
follow in his footsteps as a doctor for children with cancer.
To my surprise, this wise subspecialist physician, whose
life's work saved my life, told me not to subspecialize like
him, but instead to go where the need was now greatest, as he
had done at the beginning of his career so many years ago. And
to him, the need was now greatest for primary care physicians.
I took his advice seriously.
Primary care is something everyone needs and deserves, and
yet it has a constituency of no one. Nobody raises their hand
and says, ``I have primary care disease.'' A majority of first-
year medical students enter medical school considering careers
in primary care, but, as Senator Sanders mentioned, about 7
percent of U.S. medical graduates will go on to practice
primary care.
At my school, at Baylor, students gave a variety of reasons
for following other career paths. But in almost every case, my
classmates worried about their student loans. Even at the least
expensive private medical school in the country, many medical
students abandon plans of becoming primary care doctors because
of student loan debt. Moreover, most medical students are
turned off to the prospect of primary care practice early in
their training.
Our first intimate experience with primary care usually
comes in our family medicine clerkships as third-year medical
students. Most family medicine clerkships expose students to
dysfunctional and outdated models of primary care delivery,
often in settings where the fewest resources are available and
yet where the sickest and poorest patients often seek care
because they have no other place to go.
My family medicine clerkship and later experiences with a
Title VII-funded Care of the Underserved Track at Baylor were
exceptions that proved the rule, and I'm happy to elaborate on
why.
But as medical students, we had abundant opportunities to
interact with subspecialist physicians who were leading their
respective fields, but we had almost no opportunities to be
mentored by primary care physicians providing cutting edge
care. I was drawn to underserved care because I wanted to
discover a better way to care for these patients.
Many of us in the safety net toil day after day trying
desperately to rescue patients from a rapidly flowing stream of
suffering, saving them one by one from drowning. Meanwhile,
what our healthcare system most acutely and keenly lacks is the
ability to work effectively upstream, addressing the forces
like poverty, social isolation, and racism that push Americans
into the river of disability and poor health every day.
I looked for a family medicine program where I would spend
most of my days trying to pull patients out of the river, but
with regular opportunities to venture upstream. At Franklin
Square, I met patients like Mr. Simms, a loving husband and
father who used to support his family until he lost his job as
a result of his diabetes. Unfortunately, with the loss of his
job, he also lost his health insurance.
There are other patients in our practice like Mr. Simms,
including his own son, who already shares many chronic
illnesses with his father. And although little Regi is 25 years
younger than Mr. Simms, his disease progression lags behind his
father's by only 5 years or so.
Children are supposed to be healthy enough to care for
their aging parents. If we do not take swift and decisive
action to grow the primary care workforce, already strained
safety nets may break, failing from the weight of caring for
multiple generations of sick patients simultaneously for the
first time in history.
More patients surge down the river and become tangled in
the net every day. We must recognize that my patient, his son,
and others like them are afflicted primarily by poverty.
Although poverty often masquerades as chronic diseases like
diabetes, hypertension, addiction, or depression, we must not
be distracted by this ruse. We must commit ourselves to moving
upstream to prevent others from becoming sick, even as we tend
to the sickness that is already upon us.
So what then must we do? We must make the total cost of
medical education more affordable for students committed to
careers in primary care. Programs like the National Health
Service Corps Scholarship Programs and loan repayment programs
are especially critical, accountable, and effective. We must
identify students likely to enter primary care careers early
on, as early as high school, and support these students with a
long-range pipeline leading to primary care practice.
We must ensure that students receive their first exposure
to primary care in innovative and effective training sites,
like revamped academic primary care practices in medical
schools or Teaching Health Centers. We must support and expand
the Teaching Health Center program. The most vulnerable and
most disadvantaged patients continue to fall into the river of
disability and illness every day.
Rather than baptizing medical students in the river, let's
give them a boat. The Teaching Health Center is a boat with a
motor. Other students deserve to benefit from the excellent
sort of training opportunities that I had.
I pray that one day, I'll live to see the day when a former
patient will share with me her ambition to follow in my
footsteps. I pray that I will be able to say to her that the
problem to which I dedicated my life has mostly been fixed. I
pray that she'll be able to devote her energies to a different
challenge, to whatever is then the most pressing matter of her
day.
Thank you, and be well.
[The prepared statement of Dr. Nichols follows:]
Prepared Statement of Joseph Nichols, M.D., MPH
Good morning Chairman Sanders, Ranking Member Burr, and members of
the subcommittee. My name is Joseph Nichols, and I am a Family Medicine
resident at the MedStar Franklin Square Family Health Center in
Baltimore, MD.
I'm grateful for the opportunity to share with you today the
perspective of a young primary care physician anticipating a long
career of service to the poor and underserved. My testimony today will
focus on the pipeline that led me to become a primary care physician,
my view from the front lines of primary care training, and some
concrete actions that the subcommittee can take right now to grow the
primary care workforce this country so desperately needs and deserves.
I was born and raised in Harlingen, TX, a small community on our
Nation's southernmost border with Mexico. My family's world was upended
when, at the age of 3, I was diagnosed with acute lymphoblastic
leukemia. While I would not wish a diagnosis of cancer on anyone, in
retrospect it led to the best things that have ever happened to me. It
kindled a lifelong interest in medicine as a means to help others in
need, and it helps me to identify with the suffering of patients and
families that I treat. I did fine with my treatment, and I went on to
enjoy about as normal a childhood as I suspect I could, growing up in
that unique part of the world.
Given my lifelong interest in medicine, when the time came, I
applied to the South Texas High School for Health Professions, a public
magnet high school which offers students a high quality educational
experience focused on pursuing careers in health-related fields. ``Med
High'', as it is affectionately known, results from a novel
partnership, since 1984, between Baylor College of Medicine and the
South Texas Independent School District. Med High has been repeatedly
ranked among the top 100 high schools in the Nation by Newsweek and
U.S. News & World Report and has demonstrated consistent success in
producing health care professionals. Three other students in my
graduating medical school class also shared the stage with me at my
high school commencement, including our high school salutatorian. Other
members of my graduating high school class went on to become dentists,
pharmacists, nurses, public health workers, physician assistants,
doctoral level researchers, and a variety of other health and
nonhealth-related professionals as well.
Until the end of high school, it was my ambition to return to South
Texas as a pediatric oncologist. I looked for every opportunity to
follow this dream, and so I applied to the Premedical Honors College,
what was at the time an 8-year full tuition and fees scholarship
offered by the University of Texas Pan American and Baylor College of
Medicine.
A number of changes have affected the scholarship program and its
sponsoring institutions since my time there. The Premedical Honors
College was founded in 1994 as a Hispanic Center of Excellence, with
Federal dollars from the Division of Disadvantaged Assistance at HRSA.
The Premedical Honors College soon opened it its doors to students from
all ethnic backgrounds, losing Federal funding. It was for a time
supported by funds from both institutions and by a small group of
generous private foundations. However these private donors eventually
shifted focus to other worthy endeavors. Meanwhile, the endowments of
both institutions were hit very hard in the recession. Despite funding
challenges, both sponsoring institutions remain committed to the
success of the Premedical Honors College, even as The University of
Texas Pan American reorganizes itself as the University of Texas Rio
Grande Valley, in order to better serve the educational needs of
students from the southernmost region of south Texas, and increasingly,
Hispanic students from across the Nation.
When I was admitted to medical school as a high school senior, you
can imagine how excited I was to tell the pediatric oncologist who
inspired my career choice. When I shared with him my hope to follow in
his footsteps as a doctor for children with cancer, he expressed great
pride for my accomplishments. But to my surprise, he discouraged me
from this career path. He explained that he entered the field as a
young resident feeling that the abandonment of children with cancer and
their families constituted the greatest injustice in medicine of his
time. I should state that my doctor not only entered into the field
pediatric oncology; he pioneered it. He led the team that produced the
first cures for childhood leukemia. By the time I was treated for
cancer, his work and the work of many others brought survival rates for
several types of childhood cancer above 90 percent, whereas when he was
starting his career, many of these diseases had been a death sentence.
More work on childhood cancer remains to be done, but as his career
began to wane, he had the satisfaction of seeing other challenges rise
to prominence.
This wise physician, whose life's work saved my life, encouraged me
not to follow in his footsteps, but instead to go where the need was
now greatest, as he had done at the beginning of his career. To him,
the need was now greatest for primary care physicians. Moreover, he
felt that all the compassion and dedication that had been borne into me
as a cancer survivor would make me exceptionally well suited for this
equally noble career path.
I took his advice seriously. It occurred to me that primary care is
a necessity hiding in plain sight. Primary care is something needed and
deserved by everyone, and yet it has a constituency of no one. Nobody
raises her hand and says, ``I have primary care disease.'' This would
be the field where I would leave my mark.
The quality and rigor of the advanced placement program at my
health careers-oriented high school allowed me to complete almost an
entire year of college coursework as a high school junior and senior.
So I was fortunately able to finish my undergraduate degree in only 3
years. I invested my year before starting medical school in studying
epidemiology at the University of Texas School of Public Health, in
Houston.
In public health school, I learned how to think about health in
terms of populations. I learned, paraphrasing the words of another
physician champion of social justice, that people live not only in
bodies, but also in families, neighborhoods, communities and
populations. The physical and social environments have a profound
impact not only on our health, but also on our potential for health,
even at the genetic level. Health is largely a product of where and how
people live, learn, work, worship, and play. Those of us working
together in the fields of public health medicine cannot therefore
meaningfully alter the health or health potential of a person or a
group without partnering with people beyond the exam room and the
hospital. And the most effective interventions are those which focus
not on doing things to people or for people, but rather with people,
building on their inherent strengths, and working together to build
healthier environments and practice healthier behaviors.
So I was excited after my year at public health school to enter
medical school and begin learning how to go about helping people to
achieve this thing called health. You can imagine my disappointment
when I found that we spent almost our entire time talking about
diseases, when clearly health is so much more than merely the absence
of disease. Few of my other classmates seemed to notice, or to be
bothered by this.
We know that a majority of first year medical students enter
medical school considering careers in primary care. Unfortunately we
are also aware that far fewer than the majority of medical school
graduates will go on to practice primary care. This forces us to
consider what we're doing, or not doing, to lose students to other
specialties that may not address the pressing workforce needs of our
Nation. An important part of medical education is what has been termed
the ``hidden curriculum''--the inculcation of attitudes and belief
systems that are distinct from procedural and intellectual knowledge.
This hidden curriculum contains some of the most noble features of our
profession, namely compassion, altruism, honesty, and the value of hard
work. Unfortunately, the hidden curriculum in many medical schools
turns students away from careers in primary care, due to the
misperceptions it perpetuates about our specialty, its practitioners
and our patients.
You have no doubt heard many other primary care physicians recount
stories of attending physicians and classmates discouraging their
choice of specialty. In all honesty, I don't recall being harassed for
pursuing a career in primary care while at Baylor College of Medicine.
In fact, a good number of my classmates confided in me that they wished
they could practice primary care as well. These students gave a variety
of reasons for following other career paths.
Some of my classmates said that the breadth and depth of knowledge
underlying primary care was too vast and difficult to master. Other
students said they lacked or could not develop the social skills
necessary to manage long-term relationships with patients in the
context of these patients' families and communities. But in almost
every case, my classmates who opted toward subspecialty training and
away from primary care did so in part because they worried they could
not afford to repay their student loans as a primary care physician.
I'm certain that this point has been made to the subcommittee
before. But to show how extraordinary this part of my story is, allow
me to tell it another way. Even at the least expensive private medical
school in the country, many medical students abandon plans of becoming
primary care doctors because of student loan debt.
So I applied myself in my clinical years, training in the full
variety of different types of hospitals available to BCM students,
including a large inner-city public hospital, a freestanding children's
hospital, a Catholic hospital, a well-endowed private hospital, and the
largest Veterans Administration hospital facility. I received excellent
preparation for providing high-quality primary care to socially
disadvantaged and medically complex patients at Baylor College of
Medicine. However I also understand why medical schools struggle in
producing primary care physicians, especially for the poorest and
sickest patients where primary care doctors are most desperately needed
now.
Most students completing a family medicine clerkship are exposed to
dysfunctional and antiquated models of primary care delivery, often in
settings where the fewest resources are available, and yet where the
sickest patients by necessity seek care. Medical students keenly sense
the frustration and helplessness, often thinly veiled, of providers
trapped in inefficient and inadequate systems.
My family medicine clerkship was an exception that proved the rule.
Through some advanced planning and extra effort, I arranged to spend my
month-long family medicine clerkship 2 hours east of Houston, training
in a 100-year-old rural practice, run by a third-generation primary
care physician who was an immediate past president of the Texas Academy
of Family Physicians. This practice cared mostly for sick and elderly
rural patients who had no other reliable source of primary care
available in the rural Texas Hill Country, and they did so by building
a practice perfectly suited to the needs of their patients. Doctors
there anticipated the need for an electronic medical record in the mid-
1990s, and they were already using their EMR to its full capabilities a
full 10 years ahead of our more recently determined meaningful use
deadlines. These physicians served various key roles in the community,
including school board member, trustee of the local bank, director on
the board of the local critical access hospital, high school sports
team physician, radio talk show host, and local county health officer.
Almost all the characteristics of the patient-centered medical home
that so many practices are struggling to embrace, even today, were
already present in this practice, simply because this seemed like the
right way to do things, and because the doctors working there had the
capability and commitment to make things better, from one day to the
next.
My experiences with an innovative, rural Texas family medicine
practice stood in stark contrast to those of my colleagues who stayed
in Houston, placed in dysfunctional urban family medicine clinics,
where patients were more often than not swept downriver further and
further each day, despite the most heroic efforts of the providers.
Even though as medical students we trained in nearly every kind of
hospital commonly encountered in the healthcare landscape of the United
States, our outpatient primary care experiences were, by comparison, an
afterthought. We had every opportunity to interact with many
subspecialist physicians who were leading their respective fields, but
we had almost no opportunities to be mentored by primary care
physicians providing cutting edge care. It was possible for only a
small motivated minority of students, like myself, to experience the
sort of advanced model of primary care practice in training that is
vital for meeting our country's needs.
Many of us in the so-called safety net toil day after day, trying
desperately to rescue patients from a rapidly flowing stream of
suffering, saving them one by one from drowning. Meanwhile, what our
health care system most keenly lacks is the ability to work effectively
upstream, addressing the forces like poverty, social isolation, and
racism that push Americans into the river of disability and poor health
every day.
Somehow I survived medical school. I must take a moment to thank
the then-Dean of Students at BCM. He is a kind and wonderful man who
was and is incredibly supportive of his students, and of me in
particular. He went out of his way to encourage each student selecting
a career in primary care, confiding in us that he (a Harvard educated
surgeon who had graduated with honors from medical school at Baylor)
did not feel personally capable of undertaking a career path as
challenging as primary care. ``You are the real doctors,'' he told me,
summarizing his admiration for primary care. As wonderful as it was to
hear the Dean of Students affirm my career choice, it saddens me that
he shared this message with me privately, and at the end of my third
year of medical school, after all of my classmates had selected our
medical specialties, rather than at the very beginning of our training
and over the course of our difficult first few years.
I decided to pursue my family medicine training in a residency
program where I would spend most of my days trying to pull patients out
of the river, but with regular opportunities to venture upstream. At
the MedStar Franklin Square Family Health Center, we take primary care
to our patients. We follow some patients in the nursing home. We
sometimes go on house calls for patients that cannot make it into the
office to see us, often bringing along reinforcements from our
multidisciplinary care management team, including a nurse care
coordinator, medical and clinical social workers and a pharmacist,
along with medical and pharmacy students from a variety of schools,
including Johns Hopkins School of Medicine. In between, my journeys
upstream have taken me to our local county health department, the
Maryland State health department, the governing body of the American
Academy of Family Physicians, the Robert Graham Center, and the U.S.
Capitol, on more than this one occasion.
I met patients like Mr. Simms, whose story I'm sharing with you
today with his permission. Mr. Simms is a loving husband and father,
who used to support his family working 12 hour shifts 5 or more days a
week as the manager of a chain restaurant serving 24-hour breakfast. An
unfortunate combination of eating too much of his restaurant's food,
not getting enough exercise outside of working such long hours, and a
genetic predisposition resulted in Mr. Simms developing diabetes in the
prime of his working years. His disease was advanced by the time it was
diagnosed, and he needed insulin therapy from the beginning. His long
and irregular schedule, and the lack of a refrigerator at work where he
could safely store his insulin, prevented him from giving himself the
medications he needed to manage his disease.
He soon lost his job after he developed a serious infection of one
of his feet, requiring amputation of several toes. This would be the
first of many surgeries and complications to befall Mr. Simms as a
result of his diabetes. Unfortunately, with the loss of his job, he
also lost his health insurance. I met Mr. Simms almost 20 years after
his diagnosis. He was uninsured and had nearly been bankrupted by his
medical bills. And like many Americans, he was nearly underwater on his
mortgage. His wife continued working, and she made just enough money to
prevent him from being eligible for many of the more common forms of
public assistance. Mr. Simms worked out a deal with the bank that
enabled him to keep his house; however he was required to maintain very
strict limits on his debt, which any further medical bills would upset,
resulting in the loss of his home.
Caring for Mr. Simms, and patients like him, I became adept at
considering the myriad social and economic forces that affect health in
America. On some rare occasions, I can even use these forces to my
advantage. For instance, the great majority of medications that I use
routinely are found on the $4 list of medications available from big-
box store pharmacies. These medicines are tried-and-true, and I take
two of them myself every morning. It is tempting to believe that this
is an affordable way of providing patients with good quality medical
care. Four dollars for a 30-day supply of medicine suddenly becomes
expensive for patients living on a fixed income who need to fill six or
more of these prescriptions every month. Meanwhile many essential
medications remain absent from these lists.
My patient, Mr. Simms, is a personal hero of mine. Despite multiple
partial amputations of both feet, prolonged hospitalizations and
nursing home stays, and the recent loss of an eye to a complication of
diabetes, he remains cheerful, and he continues to teach our residents
and our care coordination staff about the needs of patients like him.
There are already other patients in our practice like Mr. Simms,
including his own son. Little Regi, as everyone knows him, already
shares many chronic illnesses with his father. Although Little Regi is
25 years younger than Mr. Simms, his disease progression lags behind
his father's by only 5 years or so. The moral of this story: If we do
not take swift and decisive action to grow the primary care workforce
and to empower it with the tools it needs to address the upstream
causes of chronic disease, already strained safety nets may break,
failing from the weight caring for multiple generations of medically
complex patients simultaneously, for the first time in history.
More patients surge down the river and become tangled in the net
every day. We must recognize that my patient, his son, and others like
them are afflicted primarily by poverty. Although poverty often
masquerades as a chronic disease like diabetes, hypertension,
addiction, or depression, we must not be distracted by this ruse. We
must commit ourselves to moving upstream to prevent others from
becoming sick, even as we tend to the sickness that is already upon us.
So what then must we do?
First we must shorten the path to medical training. BCM and other
medical schools have previously successfully experimented with a 3-year
medical school curriculum, during a time in the past when a shortage of
physicians was feared. We have the opportunity to refocus medical
education not on learning everything that one needs to know, but rather
on learning how to learn. Recognizing that medical school is simply a
stepping stone into a lifelong process of learning, empower each
graduate with the tools that she will need to tailor a lifetime of
learning and practice to meet the needs of her patients.
Next we must make the total cost of medical education more
affordable for students committed to careers in primary care. In doing
so, we must consider the total cost of training, from undergraduate
education through the duration of residency. Programs like the National
Health Service Corps Scholarship Programs and Loan Repayment Programs
are especially critical, linking students and residents to training in
primary care specifically for the disadvantaged and underserved.
Next we must identify students likely to enter careers in primary
care early on, as early as high school, and support these students with
a long range pipeline approach leading to medical school admission and
to eventual primary care careers. Invest in novel and effective
educational programs, such as health professions magnet high schools,
as key sections of this pipeline. Patch the pipeline along every
section with extra support and advisement for students from
disadvantaged backgrounds, helping the students that will be most
likely to practice and be effective at delivering primary care to
disadvantaged patients in the future. This investment will pay great
returns in the future. In the meantime, we need to increase primary
care production now, so the early experiences of students entering
medical school in the next few years present a critical opportunity to
retain trainees in the primary care pipeline.
Encourage the development and expansion of advanced primary care
training sites in academic medical centers through grants for research
and training, especially targeted at the academic primary care
practices where most students receive their first exposure to primary
care. Create the same opportunity for medical students early in their
training to emulate primary care innovators as they have to be
impressed by subspecialists. While we must continue to advance all
fields of medicine, in the near future we should focus funding for
research and training especially on primary care, which has urgent
catching up to do.
Support and expand the Teaching Health Center program as a better
approach to caring for and training with the medically underserved. The
most vulnerable and most disadvantaged patients continue to fall in the
river of illness and disability every day. Rather than baptizing
students in the river, let's give them a boat. The Teaching Health
Center is a boat with a motor. The students and residents that train in
Teaching Health Centers will receive the specialized training they need
to become the primary care physicians that must, in the coming years,
right the inequities that underlie the majority of the excess
healthcare costs that we as a nation collectively bear. And while we
set about growing the primary care workforce we need and deserve, our
sickest patients will benefit from improved medical care in the mean
time.
I want to conclude by saying that my education does not belong to
me; I did not purchase it or win it. It's rather something with which I
have been entrusted. Like all medical students, my education was
heavily subsidized by Federal and State funds, in addition to the
numerous scholarships which I also received from public and private
sources. I feel a profound responsibility to use my education and
skills in service to society, and to pass these skills and knowledge on
to the next generation of physicians, who will care for myself, my
family and my neighbors in the future. I want nothing more or less than
to belong to my community, to dedicate my labors to its health and
well-being, and for us to care for one another.
Even though my story may seem exceptional, I am not. While it
requires a lot of hard work to get where I am today, I also had a
tremendous amount of help from a great number of people and programs.
I'm a living example of a well-researched finding that individuals
coming from socially or educationally disadvantaged backgrounds are
more likely to pursue careers in primary care. I'm also confident that
without the ongoing support of a number of unique programs stretching
back to high school, I would not have been able to achieve admission to
medical school, and I would not have been able to pursue this goal.
Other students deserve to benefit from the excellent sort of training
opportunities that I had, and these sorts of programs show great
promise for growing the primary care workforce our country needs and
deserves.
And I pray I live to see the day when one of my former patients
will share with me her ambition to follow in my footsteps, helping
others as I once helped her. I pray that I may have the satisfaction of
saying that the problem to which I have dedicated my life has been
vastly improved. I pray that she will devote her energies to a
different challenge, what is then the most pressing matter of her day.
Thank you, and be well.
Senator Sanders. Thank you, Dr. Nichols.
Senator Burr.
Senator Burr. Mr. Chairman, I have the pleasure today to
introduce Dr. Linda Kohn, Director of GAO's office that has the
healthcare team where she works on issues related to public
health, health information, technology, and quality management.
I want to thank her today for the work that that group has done
to help us navigate where we should go based upon the
assessments that they've made.
And, Linda, GAO does incredible work, work that is
invaluable to the Congress and, I think, to the American
people. Would you please convey to your colleagues there how
grateful we are--especially your team, and to the rest--how
grateful we are for the work that they do. In many cases, you
bring reports out that enlighten us on things we didn't know,
are not always what everybody wants to hear, but are the facts
that are best used to foundationally fix what's broken. Thank
you.
STATEMENT OF LINDA T. KOHN, Ph.D., DIRECTOR OF HEALTH CARE,
GOVERNMENT ACCOUNTABILITY OFFICE, WASHINGTON, DC
Ms. Kohn. Thank you very much for that kind introduction.
Chairman Sanders, Ranking Member Burr, members of the
committee, I'm pleased to be here today to discuss our work on
Federal investments in health workforce training and the
availability of data related to the supply of and demand for
healthcare professionals.
Last fall, we issued a report that identified Federal
programs that support postsecondary education for direct
healthcare professionals in fiscal year 2012. Shortly after
that, we issued another report that examined HRSA's actions to
project the future supply of healthcare professionals,
including physicians, physician assistants, and advanced
practice nurses.
My statement today is based on those two reports. Together,
they provide a snapshot of the Federal efforts in ensuring that
a well-trained and diverse healthcare workforce is available to
provide care in this Nation.
Our first report that identified Federal training programs
is fairly limited in scope. It represents a first cut at trying
to compile as comprehensive a list as possible for the Federal
programs that provide support for training of healthcare
professionals. So we tried to identify the programs, and for
each one identified, the number of trainees in the program and
the Federal obligations for 2012.
As noted before, we found that four departments, HHS, VA,
DOD, and Education, supported 91 training programs for direct
healthcare professionals and obligated a total of about $14
billion in 2012. The largest amount of money went for
postgraduate residency training for physicians, dentists, and
others, commonly known as Graduate Med Ed or GME. We identified
seven programs that totaled about $11 billion or 78 percent of
the $14 billion total. That was through HHS, mainly Medicare
and Medicaid, but VA and DOD also supported GME programs.
So if $14 billion was spent in total, and $11 billion of
that went to GME, that leaves about $3 billion or 22 percent of
the pie for all the other 84 programs that we identified. Some
of those programs provide financial assistance, such as
scholarships or loans. Others, as we heard, provide financial
assistance in exchange for a commitment to work in a specific
facility or location.
Some of the programs supported primary care, but not all of
them. Overall, HRSA administered the most programs. But the
most money went through CMS for GME.
We identified several challenges in compiling comprehensive
information about the scope of the programs, and, partially,
it's because these programs do cross multiple departments and
multiple agencies within a department. So getting comparable
information was not always possible for us. For example, we
identified programs at HHS, VA, and DOD where the number of
trainees was not available, or maybe we could only get the
information at an aggregate level. We couldn't break it down at
a program level.
The Department of Education has several programs that
support postsecondary training for various types of students,
including health professionals. But those programs aren't
specifically targeted for health professionals. So we weren't
able to break it down in terms of how many health professionals
were also included in those programs, even though we know those
programs are there.
Our second report focused on HRSA efforts to produce
workforce projections. HRSA is the agency responsible for
monitoring the supply and demand for healthcare professionals.
And we reported in September 2013 that HRSA last published its
workforce projections in 2008, based on data from 2000.
Since 2008, HRSA awarded five contracts for studies to
support updated projections, but had not published any of those
projections at the time of our work, although four were
planned. After we issued our report last fall, HRSA published
the projections for the primary care workforce to 2020.
We recognize the challenges in producing workforce
projections, but there is a long lead time for any policy
changes, such as altering the number or mix of training to
affect the supply of healthcare professionals. And HRSA has
also acknowledged the long lead time for any interventions that
might be possible.
But together, these two reports aimed to shed some light on
what might be considered fairly basic information: What is the
Federal investment in workforce training programs for direct
healthcare professionals? How many programs are there? How much
money is being expended? What is known about how many health
professionals we need? We hope this underlying information
contributes to your discussions.
That concludes my prepared remarks, and I'm happy to
respond to any questions. Thank you.
[The prepared statement of Ms. Kohn follows:]
Prepared Statement of Linda T. Kohn, Ph.D.
HEALTH CARE WORKFORCE--Federal Investments in Training and the
Availability of Data for Workforce Projections
Summary
why gao did this study
A well-trained and diverse health care workforce is essential for
providing Americans with access to quality health care services,
including primary care services. To help ensure a sufficient supply of
physicians, nurses, dentists, and other direct care health
professionals for the Nation, the Federal Government has made
significant investments in health care workforce training through
various efforts. As Congress considers funding existing or additional
training programs that would address any potential shortages of health
care professionals, timely and up-to-date estimates of future supply
and demand for health care professionals are critical.
This statement addresses (1) the scope of the Federal Government's
role in health care workforce training and (2) the availability of data
related to projecting health care workforce supply and demand. It is
based on findings from two recent GAO reports. The first report
identified Federal programs that supported postsecondary training and
education for direct care health care professionals in fiscal year
2012, including information about program purpose, funding, and
targeted health professionals. The second report examined actions HRSA
has taken to project the future supply of and demand for physicians,
physician assistants, and advanced practice registered nurses (APRN)
since publishing its 2008 physician workforce report. These products
used a variety of methodologies, which are detailed in each report.
what gao found
GAO found that there is substantial Federal funding for health care
workforce training programs but that obtaining comprehensive
information about the scope of such programs is challenging. In GAO's
August 2013 report on the Federal role in health care workforce
training, GAO found that four Federal departments--the Department of
Health and Human Services (HHS), the Department of Veterans Affairs
(VA), the Department of Defense (DOD), and the Department of Education
(Education)--administered 91 programs that supported postsecondary
training or education specifically for direct care health professionals
in fiscal year 2012. All together, the four departments reported
obligating about $14.2 billion for health care workforce training
programs in fiscal year 2012, with HHS funding the most programs (69)
and having the largest percentage of total reported funding (82
percent). The majority of funding for health care workforce training in
fiscal year 2012--about $11.1 billion, or 78 percent--was invested in
seven programs that supported postgraduate residency training for
physicians, dentists, and certain other health professionals, called
Graduate Medical Education. The remaining 84 programs administered by
HHS, VA, DOD, and Education accounted for obligations of about $3.2
billion and provided varying levels of assistance, ranging from
participation in short-term continuing education courses to full
support for tuition and books and a stipend for living expenses.
Compiling comprehensive information about the scope of Federal support
for health care workforce training is challenging because multiple
Federal departments administer such programs, and GAO found that the
departments did not always have comparable program information.
Lack of timely, regularly updated data creates challenges for
projecting health care workforce supply and demand. The Health
Resources and Services Administration (HRSA)--an agency within HHS--is
responsible for monitoring the supply of and demand for health care
professionals. At the time of its September 2013 report, GAO found
that, since publishing a 2008 report on physician supply and demand,
HRSA had awarded five contracts to research organizations to update
national health care workforce projections. However, HRSA had failed to
publish any new workforce projections. While HRSA created a timeline in
2012 for publishing a series of new workforce projection reports, the
agency missed its original goals for publishing them and had to revise
its publication timeline. HRSA's report on the primary care workforce
was published in November 2013, more than 3 years after the contractor
originally delivered its report to HRSA for review.
______
Chairman Sanders, Ranking Member Burr, and members of the
subcommittee: I am pleased to be here today to discuss our work on
Federal investments in health care workforce training and the
availability of data related to projections of supply and demand for
health care professionals. A well-trained and diverse health care
workforce is essential for providing Americans with access to quality
health care services, including primary care services. A number of
reports published by government, academic, and health professional
organizations have projected national shortages of some types of health
care professionals, which could result in patients experiencing delays
in receiving, or a lack of access to, needed care. To help ensure a
sufficient supply of physicians, nurses, dentists, and other direct
care health professionals for the Nation, the Federal Government has
made significant investments in health care workforce training through
various efforts.\1\ These efforts include Federal programs that train
health professionals directly, award grants or make payments to
institutions training health professionals, and provide financial
assistance to health professional students through stipends,
scholarships, loans, or loan reimbursement. In addition, as Congress
considers policy options to address health care workforce issues--such
as funding training programs that would address any potential shortages
of health care professionals--timely and up-to-date estimates of future
supply and demand for health care professionals are critical. The
Health Resources and Services Administration (HRSA)--an agency within
the Department of Health and Human Services (HHS)--is responsible for
monitoring the supply of and demand for health care professionals.
---------------------------------------------------------------------------
\1\ For the purposes of this statement, direct care health
professionals are those who deliver clinical or rehabilitative care to
patients, such as allopathic and osteopathic physicians, nurses,
dentists, pharmacists, physician assistants, podiatrists,
psychologists, and physical or occupational therapists.
---------------------------------------------------------------------------
This statement addresses (1) the scope of the Federal Government's
role in health care workforce training and (2) the availability of data
related to projected health care workforce supply and demand. It is
based on findings from two recent GAO reports. The first report, Health
Care Workforce: Federally Funded Training Programs in Fiscal Year 2012,
identified Federal programs that supported postsecondary training and
education for direct care health care professionals in fiscal year
2012, including information about program purpose, funding, and
targeted health professionals.\2\ The second report, Health Care
Workforce: HRSA Action Needed to Publish Timely National Supply and
Demand Projections, examined actions HRA has taken to project the
future supply of and demand for physicians, physician assistants, and
advanced practice registered nurses (APRN) since publishing its 2008
physician workforce report.\3\
---------------------------------------------------------------------------
\2\ GAO, Health Care Workforce: Federally Funded Training Programs
in Fiscal Year 2012, GAO-13-709R (Washington, DC.: Aug. 15, 2013).
\3\ GAO, Health Care Workforce: HRSA Action Needed to Publish
Timely National Supply and Demand Projections, GAO-13-806 (Washington,
DC.: Sept. 30, 2013).
---------------------------------------------------------------------------
Each of the reports cited in this statement provides detailed
information on our scope and methodology. This statement is based on
work that was conducted from March 2013 through September 2013 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
background
The U.S. health care workforce includes a spectrum of health
professionals requiring varying levels of postsecondary education and
training, ranging from diploma programs to graduate degrees and
postgraduate training.\4\ Some professionals who deliver direct health
care services to patients require clinical training through a health
care institution--such as internships, residencies, or fellowships--in
addition to completing graduate-level educational requirements before
being eligible for full licensure. These professionals include
physicians, certain pharmacists, podiatrists, clinical psychologists,
and dentists seeking a dental specialty.
---------------------------------------------------------------------------
\4\ Postsecondary education is education or training beyond the
high school level.
---------------------------------------------------------------------------
To maintain an adequate health care workforce, the future supply of
health care professionals must be projected and compared to the
expected demand for health care services to determine whether there
will be enough providers to meet the demand. Such projections can
provide advance warning of shortages or surpluses so that health care
workforce policies, such as funding for health care training programs,
can be adjusted accordingly. In its 2008 physician workforce report,
HRSA noted that due to the long time needed to train physicians and to
make changes to the medical education infrastructure, policymakers and
others need to have information on the adequacy of the physician
workforce at least 10 years in advance.\5\ We have also previously
reported that producing supply and demand projections on a regular
basis is important so that estimates can be updated as circumstances
change.\6\
---------------------------------------------------------------------------
\5\ Health Resources and Services Administration, The Physician
Workforce: Projections and Research into Current Issues Affecting
Supply and Demand (Rockville, Md.: 2008).
\6\ GAO, Health Professions Education Programs: Action Still Needed
to Measure Impact, GAO-06-55 (Washington, DC.: Feb. 28, 2006).
---------------------------------------------------------------------------
substantial federal funding for health care workforce training programs
exists, but obtaining comprehensive information about the scope of such
programs is challenging
In our August 2013 report, we found that four Federal departments--
HHS, the Department of Veterans Affairs (VA), the Department of Defense
(DOD), and the Department of Education (Education)--administered 91
programs that supported postsecondary training or education
specifically for direct care health professionals in fiscal year 2012.
All together, the four departments reported obligating about $14.2
billion for health care workforce training programs in fiscal year
2012, with HHS funding the most programs (69) and having the largest
percentage of total reported funding (82 percent).\7\ See table 1 for
additional details about the number of health care workforce training
programs administered by HHS, VA, DOD, and Education and the funds the
departments reported obligating for them in fiscal year 2012.
---------------------------------------------------------------------------
\7\ GAO asked department and agency officials to provide
obligations, including those for which expenditures have been made, for
each program in fiscal year 2012. The term obligation refers to a
definite commitment by a Federal agency that creates a legal liability
to make payments immediately or in the future. Agencies incur
obligations, for example, when they award grants or contracts to
private entities. An expenditure is the actual spending of money by the
issuance of checks, disbursement of cash, or electronic transfer of
funds made to liquidate a Federal obligation. The total reported
obligations do not include amounts obligated in prior years that were
expended in fiscal year 2012.
Table 1.--Health Care Workforce Training Programs Administered by Four
Federal Departments and Funds Obligated for These Programs in Fiscal
Year 2012
------------------------------------------------------------------------
No. of health care
Department workforce training Obligations
programs funded
------------------------------------------------------------------------
Department of Health and Human 69 $11.7 billion
Services.
Department of Veterans Affairs.. 12 $1.7 billion
Department of Defense........... 7* $0.9 billion
Department of Education......... 3 $2 million
------------------------------------------------------------------------
Source: GAO summary of Department of Defense (DOD), Department of
Education (Education), Department of Health and Human Services (HHS),
and Department of Veterans Affairs (VA) information.
Note: DOD, Education, HHS, and VA obligated a total of about $14.2
billion for health care workforce training programs in fiscal year
2012. Amounts listed in this table do not add to $14.2 billion because
of rounding.
* One of DOD's seven programs represents multiple clinical and
instructional health professions education programs. For the purposes
of this statement, we characterized them as a single program because
DOD could not provide consistent program-level information.
In total, across all four departments, the majority (78 percent) of
Federal funding for health care workforce training in fiscal year
2012--about $11.1 billion--went to seven programs that supported
postgraduate residency training for physicians, dentists, and certain
other health professionals, called Graduate Medical Education (GME)
(see fig. 1). Two programs administered by HHS's Centers for Medicare &
Medicaid Services (CMS)--Medicare payments to teaching hospitals and
other entities for Direct Graduate Medical Education (DGME) and
Medicare payments to teaching hospitals for Indirect Medical Education
(IME)--accounted for about 66 percent of total reported health care
workforce training funding.\8\ CMS's Medicaid program also made
payments to teaching hospitals for GME, and HRSA, another agency within
HHS, administered two programs that supported GME in settings other
than teaching hospitals.\9\ VA and DOD also administered GME programs;
however, the funding information VA provided to us accounted for
resident salaries and benefits, while the funding information provided
by DOD accounted for only certain administrative costs to operate its
GME program.
---------------------------------------------------------------------------
\8\ For the purposes of this statement, we considered Medicare DGME
payments and Medicare IME payments to be separate programs. Medicare
DGME payments cover the teaching costs of training residents, such as
resident stipends, administrative overhead, and supervisory physician
salaries. Medicare IME payments support the higher patient care costs
associated with training residents, such as the ordering of more tests
and increased use of emerging technologies.
\9\ Medicaid payments for GME and the two HRSA programs--the
Children's Hospitals GME Payment program and the Teaching Health Center
GME Payment program--provided funding for both direct costs of resident
training, such as resident salaries and benefits, and indirect funding
to reflect the higher patient care costs associated with resident
education.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The remaining Federal funding for health care workforce training--
about $3.2 billion--went toward 84 HHS, VA, DOD, and Education programs
---------------------------------------------------------------------------
that:
provided financial assistance to direct care health
professional students and professionals,
provided or supported instruction or clinical training for
direct care health professionals, or
provided a combination of these and other training support
services.
Across all 84 non-GME programs, trainees received differing levels
of assistance, ranging from participation in short-term continuing
education courses to full support for tuition and books and a stipend
for living expenses. These 84 programs targeted various types of health
professionals and eligible individuals. See table 2 for additional
information about the number of non-GME training programs targeting
various categories of health care professionals.
Table 2.--Number of Non-Graduate Medical Education (GME) Training
Programs That Target Certain Categories of Health Care Professionals
------------------------------------------------------------------------
No. of
Category of health care professionals targeted training
programs
------------------------------------------------------------------------
Students, professionals, or faculty in multiple health 47
professions\1\...............................................
Nurses only................................................... 18
Physicians or physician assistants only....................... 8
Dentists or dental hygienists only............................ 6
Behavioral health professionals only.......................... 4
Physicians and dentists only.................................. 1
---------
Total....................................................... 84
------------------------------------------------------------------------
Source: GAO summary of Department of Defense, Department of Education,
Department of Health and Human Services, and Department of Veterans
Affairs information.
Note: We included both programs that solely targeted direct care health
professionals and programs that targeted direct care health
professionals among other professionals if the program purpose or
objectives specifically identified direct care health professionals.
\1\ These programs targeted three or more types of health professionals.
Compiling comprehensive information about the scope of Federal
support for health care workforce training is challenging because
multiple Federal departments administer such programs, and we found
that the departments did not always have comparable program
information. For example, at the time of our review, we relied on a
multitude of sources to identify training programs and program
information in the absence of a comprehensive listing of such programs.
In some cases, the level of detail in the information we obtained from
the four departments varied or data were not available. For example,
HHS and VA were not able to account for the number of health
professional trainees supported by certain programs they administer. In
another example, DOD was unable to provide information about funds
obligated or the number of trainees supported by each of its multiple
non-GME clinical training and education programs for military medical
personnel. Therefore, we reported the number of trainees supported and
amount of funds obligated at an aggregate level for these DOD programs.
The funding information reported by DOD also did not include amounts
for salary and benefits of residents in its GME programs, whereas other
departments included these amounts in their reported GME funding.
The scope of our August 2013 review of Federal programs that
supported postsecondary training and education for direct care health
care professionals had some limitations. For example, we limited our
review to programs that specifically targeted postsecondary training
and education for direct care health care professionals in fiscal year
2012. There could be additional programs or funding that supported
health care workforce training that did not specifically target direct
care health professionals. For instance, in fiscal year 2012, Education
administered programs--such as the Subsidized and Unsubsidized Stafford
Loan Programs, the Direct PLUS and Perkins Loan Programs, Pell grants,
and Federal Work Study--that support postsecondary training or
education for various types of students, including direct care health
professionals. However, these programs do not specifically target
health professionals, and we could not determine the number of direct
care health professionals supported by these programs or the total
amount of funds from these programs that supported such training.
Additionally, there may be other programs that support health care
workforce training but that did not obligate funds in fiscal year 2012.
lack of timely, regularly updated data creates challenges for
projecting health care workforce supply and demand
In addition to administering 50 health care workforce training
programs, HRSA is responsible for monitoring the supply of and demand
for health care professionals and disseminating workforce data and
analyses to inform policymakers and the public about workforce needs
and priorities. The Bureau of Health Professions (BHPr) within HRSA has
multiple responsibilities related to workforce development, including
conducting and contracting for studies on the supply of and demand for
health care professionals. In 2006, we found that HRSA had published
few national workforce projections despite the importance of such
assessments to setting health care workforce policy, and we recommended
that HRSA develop a strategy and establish timeframes to more regularly
update and publish national workforce projections for the health
professions.\10\
---------------------------------------------------------------------------
\10\ GAO-06-55.
---------------------------------------------------------------------------
At the time of our September 2013 report, we found that HRSA had
awarded five contracts since 2008 to research organizations to update
national workforce projections but that HRSA had failed to publish any
new reports containing projections since those contracts had been
awarded. While HRSA created a timeline in 2012 for publishing a series
of new workforce projection reports, the agency missed its original
goals for publishing these reports and had to revise its timeline for
publishing them. (See table 3)
Table 3.--Health Resources and Services Administration's (HRSA) Original and Revised Timelines for Publishing
Updated Workforce Supply and Demand Projections, as of September 2013
----------------------------------------------------------------------------------------------------------------
Original goal for Revised goal for
Report Description publication publication
----------------------------------------------------------------------------------------------------------------
Primary care......................... Projects supply of and No goal date........... Fall 2013
demand for the primary
care workforce to
2020..
Clinician specialty.................. Projects supply of and December 2012.......... Summer 2014
demand for physicians,
physician assistants,
and certain advanced
practice registered
nurses\1\ (APRN) to
2025..
Nursing workforce.................... Projects supply of and September 2013......... Fall 2014
demand for nurses,
including APRNs, to
2030..
Cross-occupations.................... Projects supply of and 2013................... 2014
demand for more than
20 health professions
to 2030..
----------------------------------------------------------------------------------------------------------------
Source: GAO review of HRSA information.
\1\ Includes nurse practitioners, certified registered nurse anesthetists, and certified nurse-midwives.
Clinical nurse specialists are not included.
At the time of our September 2013 report, the most recent
projections from HRSA available to Congress and others to inform health
care workforce policy decisions--such as distributing physician
training slots to medical specialties that were projected to experience
shortages--were from the agency's 2008 report. That report was based on
data that were, at that time, more than a decade old.
As of July 2013, HRSA had received some of the contracted reports
for its review, and others were under development. The first report,
which included projections for the primary care workforce to 2020, was
delivered to HRSA in July 2010, but HRSA was still reviewing and
revising the draft when we released our study in September 2013. We
recommended that HRSA expedite the review of that report, and the
agency published its projection in November 2013.\11\
---------------------------------------------------------------------------
\11\ Health Resources and Services Administration, Projecting the
Supply and Demand for Primary Care Practitioners through 2020
(Rockville, Md.: 2013).
---------------------------------------------------------------------------
Chairman Sanders, Ranking Member Burr, and members of the
subcommittee, this completes my prepared statement. I would be pleased
to respond to any questions that you may have.
Senator Sanders. Dr. Kohn, thank you very much.
Our next panelist is Dr. Deb Edberg, program director at
the McGaw Northwestern Family Medicine Residency Program at the
Erie Family Health Center in Chicago. She is also an Associate
Professor of Clinical Family and Community Medicine at the
Northwestern University Feinberg School of Medicine.
Throughout her career, Dr. Edberg has worked at community
health centers in the Cook County Health System. She received
her medical degree from Jefferson Medical College and completed
her residency training in family medicine at the University of
Connecticut.
Thank you very much, Dr. Edberg, for being here.
STATEMENT OF DEBORAH EDBERG, M.D., PROGRAM DIRECTOR, McGAW
NORTHWESTERN FAMILY MEDICINE RESIDENCY PROGRAM, ERIE FAMILY
HEALTH CENTER; ASSISTANT PROFESSOR OF CLINICAL FAMILY AND
COMMUNITY MEDICINE, NORTHWESTERN UNIVERSITY FEINBERG SCHOOL OF
MEDICINE, CHICAGO, IL
Dr. Edberg. Thank you. Chairman Sanders, Ranking Member
Burr, Senator Warren, my name is Debbie Edberg, as the chairman
has said, and I am the program director for the Northwestern
Family Medicine Residency Program, one of the original 11
Teaching Health Center residency programs, housed at Erie
Family Health, which is a 57-year-old federally qualified
health center serving more than 50,000 patients annually at 12
locations throughout Chicago and the surrounding suburbs.
I am here today to talk about the Teaching Health Center
Graduate Medical Education program and describe the urgent need
to reauthorize this critical program as soon as possible. On
behalf of Erie and the American Association of Teaching Health
Centers, representing the 36 Teaching Health Centers
nationwide, thank you so much for allowing me to speak at this
subcommittee hearing.
The THC program represents a proven and powerful strategy
to address some of the key challenges confronting our health
care system. These include ensuring access to care amidst a
growing shortage of primary care providers and reducing
persistent health disparities that plague our Nation's
communities.
First authorized in 2010, the Teaching Health Center
program is a 5-year program that directly funds primary care
residency positions in community-based and ambulatory care
settings like Erie. It is the only primary care physician and
dentist residency program managed and directed by community
health centers themselves.
Different from traditional GME funding, which funds
hospitals to train physicians in acute care settings, the
THCGME funds go directly to community ambulatory care centers.
This is where we train our residents to address healthcare
issues such as chronic disease management and prevention of
serious illness in an outpatient setting before they become
emergent conditions requiring expensive hospital care. Today,
36 Teaching Health Centers train more than 300 residents who
are providing more than 700,000 primary care visits in
underserved communities nationwide.
Our 24 residents spend the bulk of their time providing
comprehensive primary care to patients at our health center in
Humboldt Park, a low-income, predominately Hispanic community
on Chicago's west side. Last year alone, our Teaching Health
Center residents provided care to 7,200 patients through 13,200
visits. For most of these patients, other options for
affordable high-quality, community-based primary care were
extremely limited or nonexistent.
The THC program has come far in a relatively short period
of time, growing from 11 to 36 sites and expanding the health
system's capacity to care for tens of thousands of people
living in our country's most underserved urban, low-income, and
rural communities. But there is still much to do. Authorization
for the Teaching Health Center program expires in 2015, and the
need for immediate reauthorization has become critical in the
face of extreme provider shortages and a changing healthcare
landscape.
We know that close to 50 million people lack access to
primary care because of physician shortages in their
communities. These shortages are projected to reach 91,500 by
2020, half of which will be in primary care.
In order to improve health outcomes, reduce disparities,
and contain costs, there is an urgent need to ensure and expand
our Nation's capacity to provide high-quality affordable
primary care. That is what FQHCs do, and we do it well.
FQHCs or community health centers are a major sector of
health care, serving 22 million people, or 1 in every 15
Americans, and this number is rapidly growing. Despite the
promise and scope of community health centers and the urgent
need for more primary care providers, we face a significant
challenge in recruiting the number of qualified primary care
physicians necessary to meet demand.
The THC program is the only Graduate Medical Education
program in the country that provides funding directly to the
community health center in order to train primary care
physicians, and we know that many medical students, including
the best and brightest among them, want this opportunity. In
2013, Erie received over 872 applications for eight residency
slots and made a 100 percent match for our top choices of
residents in the incoming class.
Engaging and retaining bright and energetic people like
these into a career in community-based primary care was the
original promise of the Teaching Health Center program, and
it's working. Physicians trained in health centers are three
times more likely to work in a community health center or other
safety net primary care settings. All eight of our last year's
graduates from our residency stayed in primary care settings,
seven remained at community health centers, and five stayed at
Erie.
Today, this innovative program stands at a crossroads. Its
success is in jeopardy without legislation authorizing its
continuation after 2015. Because of the 3-year term of the
primary care residency, Teaching Health Centers are already
feeling the detrimental impact of this potential loss in
support.
This year, THC programs will have to decide whether they
will accept residents who cannot be guaranteed funding for
their full 3-year residency program or leave valuable primary
care residency slots vacant. Students are also approaching THC
residency opportunities with increasing reluctance for fear
that they will not be able to complete their residency in a
stable environment.
To ensure this program continues to thrive, we respectfully
request your support in working to immediately reauthorize the
THCGME program through the Senate HELP Committee. On behalf of
Erie and the American Association of Teaching Health Centers,
we are extremely grateful to Chairman Sanders for introducing
Senate bill 1759, which supports this reauthorization.
We are also thankful to those on this committee who have
been supportive of this bill, including Senator Casey of
Pennsylvania and Senator Kay Hagan of North Carolina. Finally,
I would like to thank our own Senators, Hon. Richard Durbin and
Mark Kirk, who have supported the mission of Erie for years.
Once again, on behalf of Erie and the patients we serve, I
very much appreciate the chance to testify today, and I welcome
your questions.
[The prepared statement of Dr. Edberg follows:]
Prepared Statement of Deborah Edberg, M.D.
Chairman Sanders, Ranking Member Burr, and distinguished members of
the subcommittee: My name is Deborah Edberg. I am a family physician
and program director for one of the original 11 Teaching Health Center
residency programs, housed at Erie Family Health Center in Chicago.
Erie is a 57-year-old federally qualified health center (or FQHC)
serving more than 50,000 patients annually at 12 locations throughout
Chicago and the surrounding suburbs. Like all of our Nation's 1,200
FQHCs, our health centers are located in low-income and medically
underserved communities and provide comprehensive primary care
regardless of patients' insurance status or ability to pay.
I am here today to talk about the Teaching Health Center program
and describe the urgent need to re-authorize this critical program as
soon as possible. On behalf of Erie and the American Association of
Teaching Health Centers, representing the 36 Teaching Health Centers
nationwide, thank you so much for allowing me to speak at this
subcommittee hearing.
The Teaching Health Center Graduate Medical Education Program
represents a proven and powerful strategy to address some of the key
challenges confronting our health care system. These include ensuring
access to care amidst a growing shortage of primary care providers and
reducing persistent health disparities that plague our Nation's
communities. First authorized in 2010, the Teaching Health Center
program is a 5-year program that directly funds primary care residency
positions in community-based and ambulatory care settings like Erie. It
is the only primary care physician and dentist residency program
managed and directed by community health centers themselves. Different
from traditional GME funding which funds hospitals to train physicians
in acute care settings, the THCGME funds go directly to practicing
community ambulatory care centers where their clinicians design and
teach a curriculum that is reflective of the opportunities and
challenges in caring for medically underserved communities in an
outpatient setting. This is where we address health care issues such as
chronic disease management and prevention of serious illness before
they become emergent conditions requiring expensive hospital care.
Today, 36 Teaching Health Centers train more than 300 residents who are
providing more than 700,000 primary care visits in underserved
communities nationwide.
Erie is a partner in the Northwestern McGaw Family Medicine
Residency Program, which brings together Erie, our academic partner
Northwestern University, and Norwegian American Hospital, the
disproportionate share hospital in our community. We accepted our first
class of eight residents in July 2010 and graduated our first class
last summer.
Our 24 residents participate in hospital rotations at Norwegian
American Hospital and specialty rounds at Northwestern Memorial
Hospital and Lurie Children's Hospital. But they spend the bulk of
their time providing comprehensive primary care to patients at our
health center in Humboldt Park, a low-income, predominately Hispanic
community on Chicago's west side. Last year alone, our Teaching Health
Center residents provided care to 7,200 patients through 13,200 visits.
For most of these patients, other options for affordable high quality,
community-based primary care were extremely limited or non-existent.
The THC program has come far in a relatively short period of time--
growing from 11 to 36 sites and expanding the health system's capacity
to care for tens of thousands of people living in our country's most
underserved urban, low-income and rural communities. But there is still
much to do. Authorization for the Teaching Health Center program
expires in 2015 and the need for immediate reauthorization has become
critical in the face of extreme provider shortages and a changing
healthcare landscape.
As was discussed previously in prior hearings, the provider
shortage in this country is acute and growing. Close to 50 million
people lack access to primary care because of physician shortages in
their communities. According to the National Association of American
Medical Colleges' Center for Workforce Studies, physician shortages are
projected to reach 91,500 by 2020, half of which will be in primary
care.
And with tens of millions of people becoming eligible for health
care coverage through the Affordable Care Act, a perfect storm is
brewing. Without enough providers, many of these newly insured
individuals may remain without care or continue to be relegated to
emergency rooms. Meanwhile, overloaded Medicaid providers will be
required to limit the number of patients they see, reduce the services
they provide, and spend less time with their current patients
(Zyzanski, et al, 1998). In order to improve health outcomes, reduce
disparities and contain costs, there is an urgent need to ensure and
expand our Nation's capacity to provide high-quality affordable primary
care.
That is what FQHCs do. And we do it well. FQHCs or community health
centers are a major sector of health care, serving 22 million people,
or 1 in every 15 Americans (NACHC, 2013) and this number is rapidly
growing. Community health centers provide one-quarter of all primary
care visits for the Nation's low-income population. The White House
Office of Management and Budget rated community health centers as one
of the most effective Federal programs (OMB, 2007). And we continue to
grow into communities where we are needed most.
Despite the promise and scope of community health centers and the
urgent need for more primary care providers, we face a significant
challenge in recruiting the number of qualified primary care physicians
necessary to meet demand. The Teaching Health Center program is the
only graduate medical education program in the country that provides
funding directly to the community health center in order to train
primary care physicians and we know that many medical students--
including the best and brightest among them--want this opportunity. For
example, in 2013, Erie received over 872 applications for eight
residency slots and made a 100 percent match for our top choices of
residents in the incoming class. Currently we have 2 residents that are
Pisacano Scholars, meaning that they are among the top medical students
graduate going into family medicine in the country. We have a resident
that has been consulting for the World Health Organization and setting
up community assessments in national and international communities, a
resident that started and was CEO of a small church-based community
health center while getting his MBA in medical school and a resident
that started a sustainable community health center in Bolivia.
Our newly recruited eight Teaching Health Center residents join our
current residents as nationally recognized scholars, as well as
volunteers within domestic and international non-profit organizations,
advocates, authors, researchers and refugees. Their backgrounds are
diverse but they share a passion and commitment to working with
underserved patients in community-based settings.
Engaging and retaining bright and energetic people like these into
a career in community-based primary care was the original promise of
the Teaching Health Center. And it's working. Physicians trained in
health centers are three times more likely to work in community health
centers or other safety-net primary care settings. All eight of last
year's graduates from the Northwestern McGaw Family Medicine Residency
stayed in primary care settings, seven remained at community health
centers and five stayed at Erie.
These talented doctors increase our Nation's capacity to provide
care in underserved communities. But they are also the leaders of
tomorrow. In addition to direct experience, the McGaw program provides
a rigorous academic curriculum that emphasizes leadership in health
policy, community engagement, and research. The Teaching Health Center
program invests in students, patients, communities and long-term
solutions to some of the most critical challenges facing our health
system and our society.
Today this innovative program stands at a crossroads. Its success
is in jeopardy without legislation authorizing its continuation after
2015. Because of the 3-year term of the primary care residency,
Teaching Health Centers are already feeling the detrimental impact of
this potential loss in support.
This year, for the first time, THC programs will have to decide
whether they will accept residents who cannot be guaranteed funding for
their full 3-year residency program or leave valuable primary care
residency slots vacant. Erie, in particular, relies on support through
the Teaching Health Center program to fund all 24 of our family
medicine residency slots in their entirety. Students are also
approaching THC residency opportunities with increasing reluctance for
fear that they will not be able to complete their residency in a stable
environment.
To ensure this program continues to thrive, we respectfully request
your support in working to immediately reauthorize the THCGME program
through the Senate Health, Education, Labor, and Pensions (HELP)
Committee. On behalf of Erie and the American Association of Teaching
Health Centers, we are extremely grateful to Chairman Sanders for
introducing Senate bill 1759, which supports this reauthorization and
ensures that Teaching Health Centers will continue to guarantee a well-
trained, passionate workforce prepared to meet the needs of underserved
communities nationwide. We are also thankful to those on this committee
who have been supportive of this bill including Senator Casey of
Pennsylvania who is a co-sponsor and a member of this distinguished
subcommittee and Senator Kay Hagen of North Carolina, who has been
supportive of our reauthorization efforts for the past year. Finally, I
would like to thank our own Senators the Honorable(s) Richard Durbin
and Mark Kirk, who have supported the mission of Erie for years and
who, I trust, will continue to make the type of high-quality,
compassionate, and affordable healthcare we provide as an FQHC
possible.
Once again, on behalf of Erie, and the patients we serve--I very
much appreciate the chance to testify today, I welcome your questions,
and I would be happy to be of assistance to you and the committee in
the future.
The author wants to thank Rachel Krause and Dana Kelly for their
assistance in the preparation of this testimony.
Senator Sanders. Thank you very much.
Last, but very much not least, is Dr. James Hotz. Since
1978, Dr. Hotz has been the clinical services director of
Albany Area Primary Healthcare, a community health center he
helped found in south Georgia. He is a graduate of Cornell
University and the Ohio State University School of Medicine.
During medical school, he worked in the office of Congressman
Dr. William Roy who drafted the legislation to create the
National Health Service Corps legislation.
He then joined the National Health Service Corps as a
commissioned officer after completing an internal medicine
residency at Emory University. He is also on the faculty of the
Medical College of Georgia and Mercer University School of
Medicine, served on the Admissions Committee of Mercer, and is
a former president of the Georgia Association for Primary
Healthcare. The film, Doc Hollywood, was based off of Dr.
Hotz's story.
Dr. Hotz, thanks so much for being with us.
STATEMENT OF JAMES HOTZ, M.D., CLINICAL SERVICES DIRECTOR,
ALBANY AREA PRIMARY CARE, ALBANY, GA
Dr. Hotz. Thank you very much for that kind introduction.
Chairman Sanders and Ranking Member Burr, it's a pleasure to be
here and speak before the members of the committee.
Thirty-five years ago, I made this decision to go down to
Albany, GA, and it changed my life. Thirty-six years ago, I
married a Tar Heel and brought her down to Albany with me. So I
have a lot of affection for the State of North Carolina.
My job is to really tell you the view from the trenches and
what it's like. You've heard a lot of the national statistics
about what happened and what things are like. But let me tell
you what happened when I came to work in Congress 40 years ago
with Congressman Roy, who was a physician from Kansas, and
Congressman Paul Rogers. They were drafting very innovative
legislation back then, expanding public funding for residency
programs in family medicine, PA programs, community health
centers. But their crown jewel was the National Health Service
Corps.
Yes, Roy and Rogers worked together, and their legislation
was called by the DC pundits the Happy Trails legislation.
Those of you who are as old as I am remember Roy Rogers, the
singing cowboy, and his theme song was Happy Trails. What has
happened to these happy trails? They brought millions of
physicians to communities where they could take care of and
provide primary access for people throughout the country.
But you wanted a view from the trenches. Let me tell you
what it's like down in Albany, GA. Three million people have
received primary care service visits from our community health
center, two-thirds of them through National Health Service
Corps people. I am here to speak about the National Health
Service Corps.
While I worked for the Congressman, I worked on a piece
that added dentists and scholarship people to the National
Health Service Corps. And I asked for advice from Congressman
Roy, and he said, ``Join the Corps and let us know how it
works.'' I'm telling you, there's never been a program that
works this well.
The National Health Service Corps has been our foot in the
door for recruiting. How do you recruit people from Washington,
DC, or from Atlanta to come down to the swamps of southwest
Georgia? It's through the Corps.
We have 52 clinicians that now help take care of our 34,000
patients we see. Eighty percent fall below poverty. We have the
largest rural HIV program in the country--see 1,000 people.
Twenty-four of these people were recruited through the National
Health Service Corps. We have 286 years of experience with
these folks, or 24.2 years for our average tenure of stay.
Those are metrics, Senator Burr, that I think are very
important from the field.
Unfortunately, the demand for Corps clinicians and loan
forgiveness greatly outstrips our current supply. Last year, we
had six people apply to try to get loan forgiveness. Only three
could get it. We have three spots that are open in our center
right now that we can't fill because we don't have that
available. We just don't have enough slots.
We currently have five slots open. We've never had slots
open in our center. It's the most difficult recruiting we've
faced. Why is it difficult? A lot of people have talked about
the fact that we're not training enough primary care
clinicians. I chair our State's AHEC primary care work group,
and I have extensive written testimony that I've submitted that
tells you that people aren't going into primary care.
But I'm going to give you a view from the trenches. You
wanted to know about debt. I have four kids who have gone
through this, all of whom during medical school have rotated at
our health center, all of whom have decided to go into primary
care, and their debt is not $145,000. These are kids that had
no debt going into medical school. They lived in low-cost
cities in Georgia--Macon and Augusta--and their debts are
$227,000, $224,000, $313,000, and one who's in his third year
of medical school is at $189,000--$1.15 million in debt.
Every one of these kids rotated at our center. All of them
wanted to go into primary care. But my oldest, who's now
starting to do these debt payments--and I've submitted what
that looks like, a screen shot of his loans--he either pays off
at $4,000 a month in 10 years, or he pays off until he's 57
years old. He said, ``Dad, I don't know if I can afford to stay
where I am.'' He works at a community hospital in Rome, GA,
taking care of poor people, and I am very proud of him.
But the future of the National Health Service Corps, this
very important program that's going to put people out there, is
in jeopardy. In fiscal year 2015, it goes away unless you
people do something about it. And time is of the essence. I can
tell you in my 40 years of experience, there's never been a
program that puts primary care clinicians in underserved areas
like the National Health Service Corps. It is the crown jewel.
But don't take my word for it. We have 50 organizations
that have signed a letter that says this is an important thing
to do, and I don't think there's 50 organizations that agree to
anything like this. This is the best program out there, and
everybody agrees with it. But this funding will expire unless
you do something about it. We need a long-term solution to this
problem.
I would like to say it's a pleasure to come before this
committee and talk about this issue. But the solution is not in
academic medicine. The medical schools are not going to solve
the problem. As I learned 40 years ago from Dr. Roy, the
solution is really in your hands. You're the ones who are going
to fix this problem, as you did 40 years ago.
So will that happy trail to primary healthcare continue?
The answer is going to be if you guys do it.
Thank you very much. I'll be glad to answer any questions.
[The prepared statement of Dr. Hotz follows:]
Prepared Statement of James Hotz, M.D.
Hello Chairman Sanders, Ranking Member Burr, and members of the
subcommittee. Thank you for this opportunity to speak to you today
about a program that is near and dear to my heart, the National Health
Service Corps (NHSC). My name is Dr. Jim Hotz, and I am the Clinical
Services Director for Albany Area Primary Health Care (AAPHC) in
Albany, GA, an organization I helped found 35 years ago. Over these
past 35 years, I have helped start and have been on the board of a
variety of different organizations that have been attempting to provide
a high quality medical home for the underserved of the Nation. I have
helped to start a community health center system, a regional AHEC, a
family practice residency program, a regional planning agency, a
regional rural HIV program, and a regional cancer control coalition. I
have been chairman of a regional hospital board, an AHEC, a State
primary care association and a statewide primary care workgroup and
have been on the clinical faculty of two medical schools and a family
practice residency program. All of these organizations are attempting
to cope with the challenge of supporting local health care systems
within the context of a diminishing supply of primary care clinicians.
Unfortunately none of these local programs can solve what is a national
workforce policy crisis. These experiences have made me realize how
crucial it is to have this hearing on ``Addressing Primary Care Access
and Workforce Challenges: Voices from the Field.'' It is my belief that
the NHSC is the single most effective policy innovation this country
has ever developed to address the primary care workforce challenge. I
am here today on behalf of the Association of Clinicians for the
Underserved (ACU), which was founded by NHSC alumni over 15 years ago.
The mission of the ACU is to insure the NHSC will continue to be an
effective solution to the access needs of the medically underserved of
this Nation.
Medical school creates an apprenticeship learning environment where
the student often has a life changing experience while working under
the supervision of the inspirational master clinician. Exactly 40 years
ago I had the direction of my life changed by Dr. William Roy. Health
reform was a major issue in Washington at that time and I wanted to
become involved. I asked my curriculum advisor at Ohio State if he
could help me construct an experience in DC that would satisfy my
community science requirement and allow me to use vacation time to work
as a legislative aid in Congress. I told him I wanted to be where ``the
action was'' in health reform and he told me I needed to ride the
``Happy Trail.'' I didn't know what that meant, except that it was a
song sung by Roy Rogers. However, in Congress at the time were
Congressman Dr. William Roy of Kansas and Congressman Paul Rogers of
Florida--``Roy'' and ``Rogers.'' They had become the architects of the
most dynamic health reform legislation since Medicare and Medicaid.
Local DC pundits jokingly called it the ``Happy Trails Legislation.''
Being a physician, Dr. Roy could offer clinical rotations for students
to learn health policy and earn medical school credit and in return he
got cheap source of labor. A group of us worked with Dr. Brian Biles
who was Dr. Roy's chief of staff to craft legislation on a menu of
programs that were to serve as the infrastructure for health reform.
The master blue print was put forth in ``Building a National Health-
Care System'' by the Committee for Economic Development (CED) in April
1973. This 105-page document was created by over 100 men who
represented Fortune 500 companies, academic institutions or major
foundations and felt the urgent need to address ``the health care bill
that increased sharply--between 1965 and 1972 national health
expenditures rose from $39 billion to $83 billion, or from 5.9 to 7.6
per cent of GNP,'' and ``Per capital annual expenditures rose from $78
to $394.''
Dr. Roy, in an amazingly productive 4-year tenure, worked with
Cong. Rogers to put into place an infrastructure to manage an
effective, efficient health system based on the recommendations of
these members of the CED who were in fact successful managers of
effective and efficient business systems. Dr. Roy introduced the HMO
act of 1972 that revolutionized health care financing and made
prepayment legal and placed a premium on keeping people healthy. Yes,
the HMO was delivered by a Kansas Obstetrician! Roy and Rogers
collaborated to preserve and promote the community health centers
program through a major restructuring and reauthorization bill in 1973.
But the program Dr. Roy and Cong. Rogers were most proud of was the
National Health Services Corps. They realized health care could only be
effective and efficient if primary care was available in all
communities. They saw the infant National Health Services Corps as the
solution to the primary care distribution problem in this country.
During a blizzard on December 31, 1970 and minutes before the midnight
deadline, President Richard Nixon signed Public Law 91-623 the
``Emergency Health Personal Act of 1970.'' In his award winning book
``The Dance of Legislation,'' Eric Redman describes how the NHSC was
born through the heroic efforts of Senator Warren Magnuson of
Washington. But what isn't covered in the book is that Dr. Roy with
Cong. Rogers adopted this infant legislation and allowed it to grow
through a series of amendments over the next 4 years. These amendments
helped shape the NHSC into the most effective program ever devised to
distribute primary area clinicians to underserved communities. I helped
work on the National Health Services Manpower Act (H.R. 14357) that
added the scholarship component to the NHSC and greatly expanded the
size and diversity of the field strength of the Corps. The vision of
Dr. Roy was ``any physician who practices--in an area designated to
have a shortage--the Secretary shall pay in full the principle and
interest of any outstanding educational loan.'' Now medical school
could be affordable not only to the wealthy but even the inner city or
poor farm kid could finance his dream of a medical education.
After using up all my vacation and elective time I returned to Ohio
State intending to eventually go back to work in DC. Dr. Roy decided to
run for Senate in the fall of 1974 but got beaten by Bob Dole in a very
bitter campaign by less than 5,000 votes. I called and offered my
condolences and asked for advice on my career. Dr. Roy said ``join the
NHSC and make a difference before you come back here!'' I followed his
advice and convinced Jim Bingle, my brother-in-law, to volunteer with
me into the Commissioned Corps of the NHSC in 1978. I had lived with
Jim during medical school and figured if he was dumb enough to live
with me he probably was dumb enough to join the NHSC and make $32,500
which was the starting salary back then. Through Cong. Roger's
continuing efforts, the ``Happy Trails'' legislation flourished under
President Carter and community health centers and the NHSC grew
rapidly. Unfortunately with this rapid growth was some pain and the
NHSC was having trouble finding a match for the two of us. I was
finishing my Internal Medicine training at Emory in Atlanta and one of
my instructors Dr. Neil Shulman offered to help place me in Georgia. He
arranged a meeting with Dr. Jim Alley, director of Public Health in
Georgia and an appointee while Jimmy Carter was Governor of Georgia.
Dr. Alley arranged for Bingle and me to be assigned to Georgia to help
develop a community health center in areas of greatest need. We were
given several options for communities to serve and preferred Athens
which was near Atlanta but were tricked into visiting several very poor
counties in south Georgia that had no doctors. Dr. Shulman wrote a
humorous account of this adventure that was made into the movie ``Doc
Hollywood.''
We initially worked at a Health System Agency in Albany, GA and
with community groups wrote a grant and to develop a community health
center program that became Albany Area Primary Health Care (AAPHC). Dr.
Bingle and I remained in the Commissioner Corps for 6 years after which
he left to return to Ohio and do a fellowship in cardiology. I stayed
on and for the first 10 years of AAPHC every one of our recruits were
from the NHSC and most were obligated scholars. Our success in those
early years were a byproduct of the legislation of Dr. Roy and Cong.
Rogers--the NHSC, Community Health Centers, and the Health System
Agency--the Happy Trails Legislation indeed created a happy trail of
access for the underserved of south Georgia.
During the past 35 years, AAPHC has had over 3 million patient
visits in one of the poorest and most rural areas in the State. It is
estimated that over 2 million of these primary care encounters were
delivered by a clinician recruited through the NHSC. AAPHC now has
offices at 14 different sites in seven counties and last year had
33,267 users of our health care system. Over 75 percent of our patients
are an ethnic minority, 80 percent live in poverty and 25 percent have
no health insurance. We provide services from ``womb to tomb''--
Obstetrics to Geriatrics; from ``head to toe''--Dentistry to Podiatry;
and everything in between with Pediatrics, Internal Medicine, and
Family Medicine and last year had 136,287 clinical visits.
The NHSC has been an invaluable ``foot in the door'' for our
primary care recruiting. The swamps of southwest Georgia are not a
natural attraction for the medical professional of today. But once
clinicians join our group they receive deep professional satisfaction
from the practice environment we provide. Out of a total of 52 clinical
providers currently employed by AAPHC, 24 have been recruited or
retained using the NHSC. Currently we have 16 physicians, 2 dentists, 5
PAs and 1 Certified Nurse Midwife who were recruited or retained
through the NHSC. Our overall clinical retention rate is 9 years and
for our 24 NHSC awardees this tenure is:
i. 1-10 years = 13 clinicians;
ii. 11-20 years = 7 clinicians; and
iii. 20+ years = 4 clinicians.
The NHSC has led to 286 years of service with an average tenure of
24.2 years.
Although the NHSC field strength has expanded to nearly 8,900 in
2013, the demand has greatly outstripped the supply and last year the
NHSC received twice as many applications as it had resources to fill.
Of those applications six came from AAPHC. Where once our recruiting
was facilitated by the NHSC, we have not been able to secure loan
forgiveness and have lost three recruits in the past year who said they
would have come if the loan forgiveness was available. We have not been
able to recruit a scholar since 2011 and are down to three scholars
fulfilling an obligation and four clinicians who are currently enrolled
in loan forgiveness.
Shelley Spires who has been in charge of recruiting at AAPHC for
the past 13 years says the past couple years have been the most
difficult she has experienced. For over a decade we had no vacant
positions and we currently have five. Several of these positions have
been vacant for over a year. This is now my 36th year of recruiting for
AAPHC and I completely agree with Shelley.
There are a number of reasons recruiting is so challenging. First
and foremost is the overall shortage of primary care physicians being
produced by the GME system of the United States. I chair the Georgia
statewide AHEC Primary Care Work Group and since 2008 we have been
conducting a summit and producing a detailed analysis of the problem
and offering a series of recommendations to our State. The following is
a brief review of the workforce problems we discovered:
An American Journal of Medicine article (2008) predicted
the GME ``funnel'' caused by the Balanced Budget Act of 1997 which
capped Medicare funding for GME. The article forecast a rapid expansion
of our total medical school enrollment from 18,560 in 2005 (2,800 DOs
and 15,760 MDs) to 25,136 in 2012 (5,227 DOs and 19,909 MDs), but there
would be no expansion of PGY1 slots. There were 24,269 such slots in
2005 and projected to be the same in 2012. Where once we imported 5,709
U.S. and foreign International Medical Graduates (IMGs) to fill open
slots, by 2012 there weren't even slots available for 867 U.S. medical
school graduates. This prediction has largely held true and less and
less of these graduates have gone into primary care.
This article also predicted a primary care shortage
of 45,800 by 2025.
A Journal of the American Medical Association article
(2008) showed that even in the three major residency programs producing
primary care, many were not staying in primary care:
Family Medicine: 3,018 and 95 percent Primary Care =
2,867.
Internal Medicine: 8,550 and 45 percent General IM;
Of General IM, 50 percent loss to hospitalist (NEJM 11/27/08) =
1,967.
Pediatric Medicine: 2,645 and 61 percent Primary Care
= 1,967.
Net Yearly Primary care production = 6,447.
The Robert Graham Center in Annals of Family Medicine
(2012) predicted a shortage of 52,000 primary care physicians in 2025
taking into account the ACA and change in residency production.
The Association of American Medical Colleges predicts a
shortage of 91,500 doctors by 2020 and in a report from this
subcommittee last year 1/29/2013 you stated, ``According to the Health
Resources and Services Administration, we need 16,000 primary care
practitioners to meet the need that exists today.''
AAPHC is now recruiting from a pool of primary care physicians that
is shrinking at a time when demand is dramatically increasing. To make
the situation even worse, we are recruiting physicians who are
experiencing a substantial increase in educational debt. Many are
either selling out to the highest bidder like well-funded hospitalist
programs, doing fellowships specializing in higher paying fields like
cardiology or oncology that often pay three to four times what primary
care does or they are signing up with programs that offer significant
loan relief programs. Once the NHSC was the premier program for debt
relief but now it cannot meet even 50 percent of the current demand.
The maximum amount of loan relief was recently cut from $155,000 for 5
years continuous service to now a max of $100,000 for 5 years. For
programs with HPSA scores of less than 14 the amount was reduced to
$30,000 for 2 years. This reduction comes in the face of medical school
debt that now often exceeds $250,000 for recent grads. The vision of
Dr. Roy of the NHSC being a vehicle for relief of all medical school
debt for practice in an underserved area is becoming a greater
challenge given current NHSC resources.
How big is the problem and how big is the fix? In a 2008 NEJM
article, the average debt was $145,000 for public medical schools and
$180,000 for private school. However the total debt for all medical
students was estimated to be $2 billion--the amount we paid in 1 month
for ``cash for clunkers.'' In a 5/28/2011 New York Times article, Bach
and Kocher estimated, ``we could make medical school free for roughly
$2.5 billion.'' They recommended a payback for students choosing to
specialize but none for those going into primary care.
For those who want a view from the trenches, I asked my four
children to share their debt experience with this committee. All four
were HOPE scholars at the University of Georgia and had zero debt at
the time of graduation. All four were provided with health and auto
insurance by me. They all lived on frugal budgets during medical school
in the low cost cities of Macon and Augusta, GA. They went either to
Mercer, a private school that receives State support, or to the State
school, the Medical College of Georgia (MCG). My oldest, George, is now
an internist working with Floyd Memorial, the community hospital in
Rome, GA. My second son, Jim, is in Internal Medicine Residency at
Indiana University and will be a chief resident next year, planning a
career in primary care. My daughter, Mary, is in her first year of a
primary care Internal Medicine program at the University of South
Carolina--Greenville. My youngest son Steve is in his second year of
medical school at Mercer University in Macon.
Here is the debt they face:
George--Mercer University School of Medicine 2005-9
Current debt: $227,329.55.
Interest: 2.1 to 7.65 percent.
Minimum payment of: $1,536.58.
Loan Payoff Date: 3/7/37!
He is currently trying to make payments of $3,886.09
to pay off in 10 years. He selected Rome to be near his wife's
family and to be able to work in a community like Albany.
Unfortunately his area has no HPSA score above 14 and the
hospital can only afford minimal debt relief. He likes his
practice and does traditional office and hospital internal
medicine, but admits once he starts a family he may need to
reconsider his options. Currently he is my only child who is
paying off his debt but he has communicated many times to his
sister and brothers the reality of the debt crunch when it
becomes payback time!
Jim--Medical College of Georgia 2007-11 (the lowest cost
school in the State)
Current debt: $224,446.
Interest: 6.8 to 7.9 percent.
Mary--Mercer University School of Medicine 2009-13
Current debt: $313,009.
Interest: 6.8 to 7.9 percent.
Steve--Mercer University School of Medicine 2011-present
Current debt: $189,236.
Interest: 6.8 to 7.9 percent.
Total debt of children = $1,154,620.
Our Primary Care Workgroup in Georgia discovered that one way the
medical schools financed their expansion was by increasing tuition.
This had the unfortunate result of dramatically increasing medical
school debt which had the unintended consequence of reducing the
likelihood these students would choose a lower paying career in primary
care. An article in Academic Medicine January 2013 explored the
question, ``Can Medical Students Afford to Choose Primary Care?'' The
conclusion was that ``Graduates pursuing primary care with higher debt
levels ($250,000 to $300,000) need to consider additional strategies to
support repayment--use of Federal loan forgiveness.)
Medical School Tuition in Georgia 2005-2012:
Emory--38,000 to 45,000; increase of 25.0 percent.
MCG--10,850 to 24,726; increase of 108.6 percent.
Mercer--30,220 to 41,457; increase of 37.0 percent.
Morehouse--24,000 to 36,903; increase of 53.8 percent.
PCOM (DO started 2008)--33,587 to 40,812; increase of 21.0 percent.
AAPHC physicians like myself are on the clinical faculty at Mercer
and MCG and each of my children either did 4-year rural continuity
tracts at our practice or took multiple electives here. They each say
these rotations helped convince them to select careers in primary care
internal medicine and they expressed an interest in the NHSC and
working at a community health center but wonder if the NHSC program
will be a viable option for them when they graduate and if they will be
able to afford to stay in primary care
Today the NHSC places roughly 8,900 clinicians across the country.
These placements are for doctors, dentists, dental hygienists, nurse
practitioners, physician assistants, certified nurse midwives and a
variety of mental health provider types. In fact, the largest group of
providers is in mental health today, comprising 28 percent of the total
field strength. These 8,900 providers provide care to nearly 10 million
people across the country.
There are three main parts of the NHSC, including the Scholarship
program, the Loan Repayment program and the recent Students to Service
program that helps fourth year medical students choose primary care by
paying off their debt in exchange for service. However, the largest
part of the NHSC is the Loan Repayment program, and this is what most
people think of when they speak of the Corps. The Loan Repayment
Program pays off a portion of student debt for every year of service in
a Federal shortage area. These are not Federal employees. Each
placement is an employee of the site itself, which uses the NHSC Loan
Repayment program as a recruitment tool--but it is more than that. It
really is a way the Federal Government leverages local resources. While
it isn't a required match of Federal funds, each site pays their
employee much more than the $25,000 or $15,000 they receive in Federal
loan repayment. So in essence, the Federal Government is only picking
up a small slice of their compensation and getting all the benefits to
boot. Being able to place a primary care clinician in an underserved
area for $25,000 or less per year is an incredible deal for the Federal
Government for sure.
current status of nshc funding
Starting in 1974, 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 for the program that was
intended to better address the shortages across our country. However,
recognizing this infusion, in fiscal year 2011 Congress dramatically
decreased the appropriation, and then in fiscal year 2012 eliminated it
altogether. The program now relies completely on this mandatory funding
stream for 100 percent of its operations.
And the ACA funding ends in fiscal year 2016, meaning the program
is completely defunded unless Congress chooses to either extend the
mandatory funding, or once again provides funding through the annual
appropriations process. I understand that neither of these routes will
be easy to navigate. Our country faces record debt levels and there are
nearly continuous negotiations on Federal spending levels.
However, I really 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.
Access to primary care saves lives and saves money, and the NHSC is
designed to increase access where we need it most.
Last month the President proposed one way to address the funding
issues facing the NHSC. His proposal expanded the program in fiscal
year 2015 with a combination of annual appropriations and the creation
of a new mandatory trust fund. Then for the following 5 years, the
program would be funded at $710 million per year through fiscal year
2020.
I would say there are positive and negative things about this
proposal, but we applaud the President for putting it on the table.
Just raising the issue, starting the debate about the future of this
program is important, and we are very appreciative.
But the challenge is now in your hands. Is the NHSC a valuable
program? Based on my 40 years of experience, I would say most
definitely. Is the program threatened? Clearly. How should you fund it,
and what funding level would achieve the goals of the program? That is
up to you to decide. But I would urge you to do it sooner rather than
later. The debt levels are exploding, primary care shortages are
increasing and recruitment and retention in underserved areas is
getting harder and harder.
conclusion
It is amazing how fast these last 40 years have passed. Dr. Roy
returned to practice medicine in Kansas, ran for office twice and lost,
and has been a regular columnist for the Topeka Capital-Journal.
Congressman Rogers went on to decades of distinguished service in
Congress and died just a couple years ago. Their ``Happy Trails''
legislation has made an extraordinary contribution to increase health
care access in this country. It has provided the path for my career and
been a source for primary care over 3 million visits at AAPHC. Will it
provide a trail for my children and other future primary care
clinicians? Without the NHSC, what will be the solution? Neil Shulman
and I along with one of my patients Vic Miller wrote a sequel book and
screenplay to ``Doc Hollywood.'' In this book, ``Where Remedies Lie'',
we describe what happens to ``Doc Hollywood'' as he confronts the
challenges of providing primary care access to a rural region in the
Deep South whose citizens are poor and black. His ``Remedy'' was a
``Happy Trail'' of the NHSC and the community health center program.
In a PBS interview in 1996, Dr. Roy stated how proud he was of his
legislative legacy, but especially of the NHSC. ``I'd worked hard on
the National Health Services Corps to get physicians into rural and
underserved areas,'' he told the reporter. Since its birth in 1970 over
45,000 primary care clinicians have used its help to go to underserved
communities. It is one of the ``crown jewels'' of public health policy
and may face extinction in 2016 if you do not act.
I just want to say thank you to the subcommittee for holding this
hearing, discussing the importance of the Federal programs aimed at
increasing access to primary care, and most of all, raising the profile
of the National Health Service Corps. Dr. Roy 40 years ago inspired me
to follow the ``Happy Trail'' that has led to a fulfilling career at
AAPHC. The National Health Services Corps has been part of my life for
40+ years, and I can assure you it is the most effective program this
country has ever devised to distribute primary care clinicians to the
underserved communities. You are now the ones who must keep the ``Happy
Trail'' open for the citizens you serve. I would be glad to answer any
questions you may have.
______
APPENDIX 1
Current Loan Statement for one of the Hotz children. All loans are medical school-related.
----------------------------------------------------------------------------------------------------------------
Current Current Late
Select Disbursement Type of Loan Principal Interest Outstanding Fees
Date Balance Rate Interest Due
----------------------------------------------------------------------------------------------------------------
................................. 08/22/2005 Direct Subsidized 7,930.28 2.10 12.77 0.00
Stafford Loan.
................................. 08/05/2006 Direct Subsidized 8,393.59 6.55 42.17 0.00
Stafford Loan.
................................. 07/14/2007 Direct Subsidized 8,393.62 6.55 42.17 0.00
Stafford Loan.
................................. 07/08/2008 Direct Subsidized 8,393.53 6.55 42.17 0.00
Stafford Loan.
................................. 08/22/2005 Direct Unsubsidized 36,488.55 2.10 58.78 0.00
Stafford Loan.
................................. 08/05/2006 Direct Unsubsidized 42,880.78 6.55 3,356.31 0.00
Stafford Loan.
................................. 07/14/2007 Direct Unsubsidized 44,372.65 6.55 3,326.07 0.00
Stafford Loan.
................................. 07/08/2008 Direct Unsubsidized 39,435.76 6.55 2,535.03 0.00
Stafford Loan.
................................. 05/10/2007 Direct Student Plus 6,302.78 7.65 1,378.76 0.00
Loan.
................................. 07/25/2007 Direct Student Plus 10,129.83 7.65 2,100.46 0.00
Loan.
................................. 07/25/2008 Direct Student Plus 1,496.53 7.65 216.96 0.00
Loan.
----------------------------------------------------------------------------------------------------------------
Lower Payment
Online Services
Forms
Mortgage Verification
Go Paperless
Account Summary
Principal Balance: 214,217.90
Last Payment: 3,886.09
Received On: 03/07/14
Next Payment: 02/07/15
Total Due: 1,057.77
Final Payment: 03/07/37
Account Status: Repayment
Senator Sanders. Senator Warren has to leave in a few
minutes.
Senator Warren, why don't you begin?
Senator Warren. Mr. Chairman, I think I'm not even going to
have time for my questions. But I'm going to do this. I want to
say three things. I have questions around student loans and the
current difficulties that this puts on anyone, but,
particularly, on those who are going into primary care, where
their pay is, on average, going to be about half that of people
going into specialties. So I'm going to submit questions for
the record around student loans.
The second thing I'm going to submit questions for the
record around is why we're not doing better on integrating
nurse practitioners and physician assistants. We know that if
we fully use nurse practitioners and physician assistants, we
could cut the impact of the shortage of primary care physicians
by as much as two-thirds. So I'll have some questions for the
record about that.
But the third thing I want to say is thank you to all of
you for being here. You are committed. You are out there. You
are on the front lines. You are training the next generation.
You are making it happen. You come to us and you remind us that
we know what the problem is. We just all say the same things.
We get what is wrong.
We see innovative solutions. We see effective solutions. We
can see what needs to be done. It is now up to Congress to put
the resources into it so that these programs can be fully
implemented, so they can be fully funded, so we can have the
right regulations in place for you to do your jobs for the
American people.
I appreciate your being here. But I really see this as the
pressure being back on us to do what we ought to be doing here
in Congress to support you and your work. Thank you. Thank you
for being here.
Thank you, Mr. Chairman. I'm sorry that I have to leave.
Senator Sanders. Thank you very much, Senator Warren.
Senator Burr.
Senator Burr. Thank you, Mr. Chairman.
Dr. Hotz, your best quality is your decision as to who you
married and where she was from. Let me say that.
[Laughter.]
But I say to you, as I say to the rest of you, thank you
for the work you do in the trenches. More importantly, thank
you for your willingness to come up here and share with us
information that is vital to the decisions we've got before us.
Dr. Kohn, prior to GAO conducting its review of the
federally supported healthcare workforce programs last year,
was there a comprehensive list of all the federally funded
healthcare workforce training programs in the country?
Ms. Kohn. We didn't find one. We didn't find one, and we
did try. To get our work, we had to check the budget. We had to
check departmental budgets and budget justifications. We had to
look at prior publications, published articles. We went to all
the different agency websites.
We checked a compendium that wasn't complete as a
compendium of Federal programs. That didn't quite get us where
we needed to go. So in the end, we ultimately had to go to
every department, every agency, and do program by program by
program to get the information that we published.
Senator Burr. Mr. Chairman, let me just take a personal
moment, if I could. One, we've got two GAO reports, and we've
got this line of witnesses up here. And this is what really
irks me. Here we had the Assistant Director of HRSA here. But
your testimony wasn't important enough for her to stay. And
this is a person on the front line of it.
I think, we've got to stress with these agencies that this
is not just for us. It's for the folks that are implementing
the programs that we set up, and it's important not that their
staff be here, because they're the ones that drive their staff.
It's important that they be here to hear your stories, to
hear the nuances that exist, because in a lot of cases, we're
trying to thread a needle, trying to determine 30-year-old
programs and their effectiveness and the resounding need to
continue it, trying to look at all the healthcare dollars that
we spend in workforce programs and figure out what doesn't
work. What can we do away with, and can we double down on
something else that everybody agrees does work?
We might hear that from you, but if the people that
implement the programs don't hear it firsthand, we're not going
to be as effective. We may thread half the needle, but not all
of it.
Let me ask you, Dr. Dobson, because the chairman, I know,
is going to be patient with me up to the end of my 5 minutes. I
think you've got some interesting perspectives from the
standpoint of North Carolina. How does the CCNC model address
primary care access, and what could other States learn from
Community Care and the experiences we've gone through?
Dr. Dobson. I think the No. 1 thing is that we bring people
together at the very local level and say this is a shared
responsibility to take care of your citizens in your community.
You have groups of primary care doctors. You have public health
departments. You have these resources. It's really around
coordinating the care. Community Care comes in and provides the
support to knit it together in an effective manner.
I think one of the issues around workforce and getting
people to do primary care is this--it is the money, but it's
also the prestige. I think CCNC has helped people say, ``Well,
primary care is important in North Carolina.''
Senator Burr. You've got a Medicaid beneficiary that walks
in the door and doesn't have a medical home. You're creating a
medical home for them by a primary care doc. Who else is at the
table?
Dr. Dobson. Besides the primary care doc? The hospital, the
community health center, social services, public health,
everybody who works in that community, and understanding that
every community is different. In a rural area, or in my town,
the health delivery system is our clinic and the local
drugstore. That's what we have. It's very different than
Charlotte or urban areas. So you have to work with what you
have.
Senator Burr. But you bring the full consortium of
disciplines, medical disciplines, to the table to assess what's
the best course to follow.
Dr. Dobson. And the flexibility to say it is a function of
what the healthcare system has to provide. So what do we do if
we don't have a community health center in our community? We
work with the rural practices there, and they get extra
support, because we could not do it without them.
Senator Burr. Mr. Chairman, let me just say that--because I
was involved very early on with Allen on this quest that has
turned into what I think is an unbelievable success for our
State--the participants--when I say participants, the medical
professionals--weren't driven by how much money they were
getting out of this. The model was set up where everybody at
the table focused on a patient's healthcare--was focused on
outcome.
And I think this is something we lose when we talk about
policy and we talk about how you structurally put it. If we're
not focused on outcome, then we've made a huge mistake, because
at the end of the day, the metrics ought to carry through all
the way from a standpoint of not only how we do it and is that
successful, but did we change the health outcome of the
individual?
Because I think we all know if we can't take individuals
that are sick and get them well quick and keep them well, if we
can't take those with chronic illness and put them on a
maintenance program that eliminates the hospital visits or the
ER visits, then there's not enough money in healthcare, period,
no matter how much we all collectively might put in, to handle
people that are not making the right decisions based upon good
medical counsel.
So CCNC has done that. I think others realize the successes
in their markets and how similar they are. That just happens to
be our market.
I thank the chair.
Senator Sanders. Thank you very much, Senator Burr.
I'm going to pick up from where Senator Warren left off by
suggesting that as a Nation, we spend a lot of money on
healthcare. We really do. We spend almost twice as much as do
the people of any other country, and yet we heard from Mr.
Brock that all over America, you have people who are desperate,
who are spending their nights in a car to try to get their
teeth pulled and so forth.
Let me ask you this. In terms of money, if we address the
crisis of primary healthcare--we heard that we need some 50,000
new primary care physicians by 2025. That's going to be an
expensive proposition. But here's my question. Do we save
money, or do we waste money by investing in primary care? Is
this, in fact, a good investment, or should we see it as just
another expenditure?
Why don't we just start with you, Dr. Hotz? Is this a good
investment?
Dr. Hotz. There's a number of studies that have been done
on that. The American College of Physicians, the internists,
looked at that, and there's a substantial saving in primary
healthcare. You can actually look at the cost of healthcare
driven by the number of primary care physicians per 100,000
population, and there's a lot of us who really invest in this.
It's interesting--we mentioned a lot about the National
Health Service Corps. I'm here representing the Association of
Clinicians for the Underserved, which is made up of old Corps
docs who believe in what we're doing, because we know we make a
difference. The data is overwhelming. There's white paper that
the ACP put out that goes chapter and verse----
Senator Sanders. Are you making a difference financially?
Dr. Hotz. Do we make a difference financially?
Senator Sanders. Yes. Are we saving money by investing in
primary care?
Dr. Hotz. Yes. Healthcare is less--if you look at the
proportion of the number of primary care docs in health systems
of care--pick a nation. It's always cheaper. The more primary
care docs, the better the ratio. The data is overwhelming. It's
the only way you bend the curve. And look at what people are
investing in. The ACOs and the people who are trying to bend
the cost curve--it's primary care.
Senator Sanders. Dr. Edberg, let's just go right down the
line, please. The question is: Is it cost-effective for America
to invest in primary care?
Dr. Edberg. If I could, I'll share a quick story I heard
from my chairman of family medicine, who told me about a friend
of hers who was a 65-year-old man who had been complaining of
chest pain and went straight to the cardiologist. He had the
EKG, the stress test, and ended up with a cardiac
catheterization--all normal.
He mentioned to her, ``You know, my chest is still
hurting.'' And because she was a family doctor and knew him
well, she said, ``Do you not play the bass at church?'' And he
said he did, and she said, ``I think you need to get a stand
for your bass.'' It was the pain that was just from the bass
resting against his chest.
I think we can obviously see the tens of thousands of
dollars that were wasted in the workup when he could have just
gone to his primary care physician.
Senator Sanders. Thank you.
Dr. Kohn.
Ms. Kohn. GAO's work didn't examine that issue. But we do
know from the listing that we have--didn't focus on primary
care, but we know there's at least 23 or 24 programs that do
explicitly talk about primary care, even though we know there's
more programs than just the ones that explicitly say it. We
know there's more programs doing primary care. So I think by
having the list, there's the potential to be able to start
looking at specific programs and start being able to answer
those questions.
Senator Sanders. Dr. Flinter.
Ms. Flinter. Yes. We absolutely save money by investing in
primary care.
Senator Burr, I thought you might have been alluding to
something a little different in your question about who's there
around the table. So I just want to speak to that element. It's
really a team in primary care these days, and we did not really
get a chance to talk about how important the advancement of the
model of primary care that we have today is, with the full
integration of our behavioral health specialists with our
primary care providers and the nutritionists, the diabetes
educators, sometimes the chiropractors and other people, to
make sure that we're delivering the right care to the right
people at the right level and at the right cost.
And in this we have metrics. I know how important that is
to everyone. I look at the community health centers and the
Uniform Data Set, this UDS report. You can see for all of us,
individually as organizations, collectively as a system of
primary care, how well we are doing at things that we know
directly reduce cost.
Every 1 percent reduction in the hemoglobin A1C of a
diabetic is associated with a reduction in cost, and you can
look and see, individually or collectively, how well we're
doing with that. And that has to be as much our passion as
reducing suffering, because in this case, reducing suffering
and reducing dollars goes hand in hand, and that's really the
path we want to be on.
Senator Sanders. Dr. Nichols.
Dr. Nichols. Senator Sanders, in response to your question,
yes, absolutely. Starting with some very profound research that
was done by the late Barbara Starfield at the Johns Hopkins
School of Public Health and the work that has continued at the
American Academy of Family Physicians, Robert Graham Center,
has consistently shown that primary care is, in fact, an
excellent investment for our Nation's health.
Many of these studies have been cited in your reports on
primary care. However, if there are any members of the Senate
whose memory requires a refresher, I'd be happy to forward
those studies to them.
Senator Sanders. Thank you.
Dr. Dobson.
Dr. Dobson. Yes, absolutely, the return on investment is
large. In the aggregate, it's a long-term investment. But there
are short-term savings that can be had. And I do apologize, but
I probably didn't answer the question that Senator Burr asked,
that we do create teams in the community that deal with need.
It's primary care. It's creating teams around patients.
The biggest short-term investment for the GAO and others is
on the complex patients. How do you take care of them? We've
got some very interesting work around--when you ask the primary
care doctors what they need to take care of the really
complex--I need care management, I need people, I need
psychiatrists, I need a team around this patient.
We've gotten down to saying if we can identify which
patients coming out of the hospital need a home visit within 24
hours, and if three home visits prevent a re-admission--but we
change the trajectory of that patient's care for 365 days,
which means that's your return on investment. And we're getting
more data to be able to say how many people need to get back to
their primary care place of care within 5 days, within 7 days,
to really make a difference.
That's where your money will come to support the long-term
investment, and we need to do more research around it. But
that's--absolutely, there's a return on it.
Senator Sanders. Dr. Wiltz.
Dr. Wiltz. Community health centers serve 15 percent of
Medicaid recipients at 1 percent of the cost. We save the
system $24 billion. We have a model that works. It's proven.
The triple aim of quality, cost, and outcomes--we've had study
after study that shows this.
We exist in a medical neighborhood, so the hospitals, all
of the elements that you talked about--we're a part of that
whole. We're not saying we're the panacea, that we can solve
all the problems. But I do think, and we've proven in our
history, that we are a big part of the solution.
Senator Sanders. Mr. Brock.
Mr. Brock. We're talking about a loss of productivity here
among these people. The age group of the people that we see is
predominantly between the age of 29 and 64. We're only seeing 2
percent or 3 percent children at these events. So we're
talking, really, about the workforce.
All of them, although they may be there primarily for
dental care and vision care, are really there in great need of
basic medical care as well and, particularly, I might, add
mental health problems. We could hold one of these RAM programs
every day of the year and see a thousand people, without a
doubt. So it's an incredible loss of productivity.
Senator Sanders. Thank you. That's a very good point. I
went way over my time.
Senator Burr.
Senator Burr. Mr. Chairman, I'm done except to say thank
you once again to all of our witnesses today. This has been
invaluable from a standpoint of the information you've supplied
to us.
Thank you, Mr. Chairman.
Senator Sanders. Thank you very much.
Let me ask you this. If there was an understanding here in
Congress of what you all just said, that investing in primary
healthcare not only keeps people healthier but saves money, and
if somebody said, ``You know what? We need 50,000 or 60,000 new
primary care physicians by the year 2025'' and looked at it
almost from a military perspective--we've got a mission, and
we've got to accomplish that mission--how do we do it?
Now, I think we've heard a lot of good ideas today, and I
would throw out that maybe someone wants to comment,
``Are we going to do that when kids are graduating
school $250,000 in debt? Are we going to do that if we
don't have a stronger National Health Service Corps?
Are we going to do that if we do not have something the
equivalent of a community health center in every
neighborhood in the United States of America?''
How do we do that?
If you were sitting up there making that decision--let me
start with you, Dr. Wiltz.
Dr. Wiltz. I think I mentioned this before, but you have to
get them when they're stem cells. You have to get a kid when
they are undifferentiated and they're still open to the
possibilities, not a rotation in their third year of medical
school. They have to be exposed in junior high and high school
and be a part of the community and have that experience of
working in a team.
Senator Sanders. So if we say to young people in elementary
school and high school and college,
``You're going to be able to go to medical school
regardless of your income, but we need a commitment
from you of X number of years to serve in underserved
areas.''
Do you think that would be a significant step forward?
Dr. Wiltz. I think all the numbers bear it out. If you're
only able to fund one out of every seven applicants for the
scholarship, that tells you the need is there. I have 10 nurse
practitioners that are on the loan repayment program, and we
still have others that are trying to apply for it.
So the willingness--the American people will serve, if we
make the venue possible and fund it. And the access issue with
community health centers--the new applications point to--that
people are continuously applying. HRSA could tell you that
they're only funding about a third, if not less, of all the
applications that we're getting. So the need is still there.
Senator Sanders. This is despite a huge expansion of the
program.
Dr. Wiltz. That's correct. The need is still there.
Senator Sanders. Other thoughts?
Dr. Hotz.
Dr. Hotz. We describe it as four rights. You've got to get
the right students in. There are plenty of students like Dr.
Nichols that are applying. I was on the medical school
admissions--get them in, make certain we have the medical
schools and the other training programs getting the right
people in.
They have to have the right debt. My belief is that we
ought to forgive all the debt for anybody who want to go to
underserved areas, as long as they stay there. Ms. Spitzgo
talked about the ability to take that debt and get them there--
very important.
You have to have the right training programs at the right
size. Right now, we only train 24,000 people per year, even
though our medical school is going to graduate more. We have to
go up probably 5,000, and it ought to be in primary care, and
it ought to be in Teaching Health Centers.
Those are the things that we have to do. And then we have
to treat them right in medical school. All of my kids have done
continuity tracks out in rural areas and working at health
centers, at the education health centers.
Those are the four rights. Get the right student in, the
right debt, leverage them when they are most vulnerable, when
they're stem cells, get them into the right medical schools,
and you can--and the University of Alabama has a program, and
75 percent of their people go out and do family medicine,
because the State of Alabama pays for people to go into family
medicine in rural areas. And then make certain that you get the
right size--and when you expand GME, make certain that you
expand it in primary care.
Senator Sanders. Dr. Nichols.
Dr. Nichols. Thank you, Senator Sanders. I want to make the
point that those future family physicians of 2025 are this very
year in their freshman year of high school. The clock is
ticking, and the onus is on us within the next 3 years to start
identifying some of these students and offer them an entry way
into this pipeline.
There are many Senators on this committee, Senator Burr
included, who have a lot of experience with pipelines, perhaps
pipelines of a different sort. But the pipeline we're talking
about here today is a pipeline that carries even more valuable
cargo. Instead of oil, we're talking about primary care docs.
But the principle is very much the same and should be
familiar to any of them. The pipeline has to start at the right
place, you've got to plug all the leaks along the way, keep
greedy private interests from siphoning off the cargo along the
way, and get the pipeline to where it needs to go. It needs to
start in high school. It needs to run all the way through to an
eventual primary care practice in the places where we need
them.
We need to keep hospitals from siphoning them off as
subspecialist physicians. And we need to pay them, the point
being that I think we're a lot more valuable than oil. In fact,
I'm worth my--I think I'm easily worth my weight in oil.
Actually, my weight in oil--I did the math this morning.
It's $55. I think if we can all agree that a primary care doc
is worth about $55--all the time and energy we spend talking
about oil pipelines. Maybe we should spend a little bit more
time talking about the primary care pipeline.
Senator Sanders. Dr. Flinter.
Ms. Flinter. No surprise. I'm going to take an opportunity
to speak directly to nurse practitioners as primary care
providers. Ten thousand new nurse practitioners enter the
workforce every year, and, trust me, those specialists and
hospital systems are beginning to go after them, just like
they've gone after the primary care doc. That's why we need to
create opportunities for nurse practitioners who have a passion
to combine everything that is nursing with everything that is
medicine and primary care and practice in our community health
centers and in other underserved settings.
When we sort of did the back of the envelope math on
whether we could authorize these nurse practitioner residency
training programs, 15 health centers could produce 100 nurse
practitioners who have already completed their doctor of
nursing practice or their master's program. Over 5 years,
that's 500 people, each with a minimum panel of 1,000 patients.
That's 5,000 people. It's a math problem as well as an issue of
opportunity and ability.
But we can do it. It's really a matter of committing
ourselves to this course, building the infrastructure, and that
infrastructure stays. It doesn't disappear at the end of a year
or two. Thank you.
Senator Sanders. Dr. Dobson.
Dr. Dobson. I'd add to the comments--let me share a
conversation we had with some students and residents in North
Carolina. When asked, ``What would you like to do when you get
done?'' And they thought, ``Well, my only choice is to either
work at the health system or search out some other
alternative.'' And they said, ``But, gosh, if I could be a
small business and be a primary care doctor in a small town, I
might actually do that.''
The problem is we don't have an infrastructure to support
those choices. So the question is we've got to get the right
people in. We really need to train them where they're going to
practice and in the style they're going to practice. It's
important if you want somebody to practice in a rural area,
they need to understand what it's like. Training them in a big
city is not going to get them in a small practice.
They need to exit without debt or with less debt, and then
we need to even give them a life of significance in their
communities where they're supported and feel part of something,
because it's--trust me, I still live in a town of 1,000, and I
know how healthcare goes, because I go to the grocery store and
it takes me an hour, because I get stopped on every aisle with
people.
Senator Sanders. Try being a Senator going to the grocery
store.
[Laughter.]
Dr. Dobson. Exactly, Senator. I think there are a lot of
opportunities to really make significant strides in health
policy. And, remember, in my testimony, I said a significant
number of the patients are still cared for by small,
independent practices. They're small businesses in the
community.
We've tried to create a virtual community health center,
including our health centers, to support these small rural
practices. They're extremely significant and important in our
rural areas. I think we can crack this nut, and the return on
investment is there. We have to save the money and keep putting
it upstream.
Senator Sanders. Thank you.
Mr. Brock.
Mr. Brock. It's a question of opportunity, and just because
boys and girls maybe come from a minority group or an
underprivileged group, that doesn't mean they're not bright and
that they couldn't meet these academic standards. In my case, I
came from an underprivileged home back there in England. But I
was a fairly bright kid, I think, and I knew--I was told that
there was an opportunity to go to one of Britain's finest
schools if only I could pass the examination to get there.
I worked hard at the books, and I took that examination,
and I went to one of the finest schools in Britain totally
free, with books paid for, everything paid for. I could have
gone all the way to university and all the way to become a
doctor at no cost. I'd like to see some kind of a program for
these underprivileged kids here. I didn't take advantage of
mine because I ran off to Brazil to become a cowboy. But I
could have become a doctor, and it would not have cost me a
nickel.
Senator Sanders. The point that you raise--and I think Dr.
Hotz also raised it and others--it's not a radical idea that
we're talking about. I mean, in many countries around the
world, people graduate medical school with, amazingly enough,
no debt whatsoever, because those nations feel that it is in
the country's best interest to have doctors.
Maybe people can comment on this--my understanding is that
if the U.S. military wants a doctor, what they will say to you
is, ``Young man, young woman, congratulations. We're going to
send you to medical school, and in payment, you're going to
give us 5, 7 years of your life.''
Dr. Hotz, is that true?
Dr. Hotz. Yes. We had an expression back when we were
working on this. We called it ``Give me five.'' Give us 5
years, and you're debt free, and that's what the military does.
Senator Sanders. And it works.
Dr. Hotz. It works.
Senator Sanders. Yes, Dr. Nichols.
Dr. Nichols. I'm actually an example of the sort of program
that Mr. Brock is describing. The program I alluded to, the
Premedical Honors College, since 1994, has been a really
innovative partnership between Baylor College of Medicine and
the University of Texas Pan American, which is soon to be
renamed the University of Texas Rio Grande Valley, being
reorganized to better serve Hispanic students from the poorest
areas of Texas and Hispanic students all over the country, in
fact, now coming to this school.
But the need was for primary care physicians, particularly,
that could provide culturally sensitive care to patients on the
border with the United States and Mexico. Since 1994, 297
students have matriculated into the Premedical Honors College.
As of June 2013, 206 have successfully completed their
undergraduate components, getting bachelor of science degrees
from UTPA; 181 graduates have entered a Texas medical school,
145 at Baylor College of Medicine, but some at other schools as
well; 124 students have earned their M.D. degrees, including
myself; and 51 of us have completed our advanced training and
are now in practice, 24 of those 51 in south Texas, and that's
without any particular requirements, just feeling an obligation
to come back and practice.
The majority of the rest of them that are not practicing in
south Texas are practicing in underserved areas in San Antonio
and other Hispanic enclaves of underserved and the urban areas
of Texas. Thirty-seven students are currently enrolled at
Baylor, and 42 are currently enrolled at UTPA, so the pipeline
continues. Despite the loss of Federal funding years ago, the
pipeline continues.
Senator Sanders. Let me just conclude, first of all,
thanking all of you, personally, for the work you are doing. As
we have heard many times this morning, you're in the trenches.
You are saving people's lives. You are working in an area that
gives hope to people in your community who, I suspect, if you
were not there, would not know what to do. You have also given
us this morning a whole lot of good ideas about where we have
got to go.
But let me conclude in a hopeful way. I think we know where
we have got to go, and I think virtually all of you have raised
those issues about where we need to go. So our job now is to
pick up that ball and run with it, and let's see if we can
transform our healthcare system and put a much greater focus on
primary care.
Thank you all very much for being here this morning. The
meeting is adjourned.
[Additional material follows.]
ADDITIONAL MATERIAL
Community Health Center, Inc.,
Middletown, CT 06457
May 18, 2014.
Hon. Elizabeth Warren,
SH-317 Hart Senate Office,
U.S. Senate,
Washington, DC. 20510.
Dear Senator Warren: Thank you for the honor of testifying before
you and the Senate HELP Committee's Primary Care and Aging Subcommittee
on April 9, 2014. It is my pleasure to respond here to the question you
posed to us at the end of the hearing.
In your remarks, you said,
``Not every medical incident requires a doctor to get the job
done. Last November, the Health Resources and Services
Administration released a report estimating that the projected
primary care shortage could be cut by more than two thirds if
nurse practitioners and physician assistants were fully
integrated into the primary care delivery system. It's
important to think creatively about ways to fully mobilize this
workforce. For example, the VA defines its own scope of
practice for nurse practitioners and physician assistants,
without regard to which State the facility is located in. And
the government authorized support for nurse practitioner
residency programs--including those in Massachusetts--but
Congress never funded the initiative. All medical professionals
have a role to play in meeting the increasing demand for health
care in this country, and all of them should have the chance to
practice up to the level of their training.''
Your question was then:
``What steps can Congress take to help ensure that our health
care system uses the full range of providers to reach the
highest number of patients, in the most efficient way
possible?''
Let me answer your question by addressing three different areas:
(1) the importance of nurse practitioners and physician assistants as
full primary care providers in the U.S. health care system, and the
steps we can take to support and ensure their choice of primary care as
the focus of their primary care careers; (2) the critical importance of
the primary care team in ensuring outstanding clinical care and
increasing the capacity of each and every primary care provider to
manage far more patients in a way that is both clinically effective and
satisfying to patients and providers alike; and (3) the steps that
Congress can take to help ensure use of the full range of providers to
reach the highest number of patients in the most efficient way
possible.
First, let me address the importance of NPs and PAs as primary care
providers. You are correct when you say that, ``not every medical
incident requires a doctor to get the job done.'' We have nearly a half
century of experience and research since Dr. Loretta Ford first
developed the expanded role of nursing and created a new role, that of
nurse practitioner, established for nurses prepared at the graduate
level, who can provide a full range of preventive, acute, and chronic
care to individuals and families. The scope of this new nursing role
was broadened to include diagnoses, treatment, and management of health
problems. Over the decades, as the education, training, and
certification of NPs has advanced, NPs have become central and critical
to the U.S. primary health care system. The American Academy of Nurse
Practitioners (AANPs) estimates that one-fifth of all primary care
services in the United States are delivered by an NP in settings that
range from private practice to community health centers; from nurse-
managed health centers to retail clinics; from schools to correctional
facilities; and beyond. Unlike physician residents in medicine, the
majority of NPs still choose a primary care focus for their practice
careers, although they are also well-represented in non-primary care
specialties, such as acute care. I am very appreciative of the efforts
of the Federal Government over many years to support and increase the
capacity of our Nation's universities to develop our fine system for
educating nurse practitioners and preparing them for practice in all
areas.
We have ample evidence to document the quality, safety and
acceptability of care provided by NPs in primary care. In my decades of
practice and leadership as an NP, I have seen the slow but steady
progress over time in our State scope of practice laws that have
gradually, but far too slowly, moved in the direction of independent
practice by NPs. Today, 19 States allow fully independent NP practice
while the remainder have some combination of requirements for
collaboration or supervision in certain domains of practice.
As you are so well aware, though, we must focus not just on the
provision of medical ``incident care'' such as one might find in the
NP-run retail clinics--with their excellent track records of providing
a well-defined list of services and treatments for episodic/acute
ailments in convenient, accessible locations. In addition, we must also
attend to the far more complex role of NPs as primary care providers
who take responsibility and are accountable for the ongoing care and
treatment of an entire panel of patients. This is particularly true in
our Nation's safety net of community health centers, where nearly 20
million individuals are enrolled to receive comprehensive primary
health care.
As the primary care provider shortage looms, we have to ensure that
we can attract the best, brightest, and most committed potential
primary care providers--physicians, NPs, and PAs--into this role. As I
stated during my testimony, we are doing this at a time when primary
care has never been more exciting--or more challenging. The complexity
of patient clinical co-morbidities, the need to provide what was
formerly considered specialty level care in primary care in
collaboration with specialists, the range of treatment options, the
advances in research and technology, and the redesign of primary care
practice--combined with the need for every PCP to manage larger panels
of patients than ever before--can be overwhelming to those who are new
to practice. These factors combine to demand that we create
postgraduate residency training opportunities for those new NPs who
aspire to this role. We simply have to ask, ``who wants to be a primary
care provider?'' and ensure that we have done everything in our power
structurally, and in terms of the transition from their excellent
education to practice, to support them. That's why we at CHC, Inc. in
Connecticut created the country's first formal postgraduate NP
residency training program, and why so many other FQHCs around the
country are following suit. We are very happy to see that several
institutions are developing similar programs for PAs, and some are
combining their postgraduate residency training programs in what are
called ``Advanced Practice Clinician'' residencies, which are inclusive
of both NPs and PAs. It is clear, based on our 7 years of experience in
designing and hosting NP residency training programs, that new NPs who
aspire to practice careers as primary care providers, in the
challenging setting of FQHCs, want, need, and deserve this opportunity
for further training and the mastery, confidence, competence, and
potential for leadership in practice that come with such additional
training.
The second area I would like to address is the potential for
primary care teams to significantly increase their capacity to manage
larger panels of patients and thus reduce the ``shortage'' of primary
care providers in a different way. I am the national co-director of a
Robert Wood Johnson-funded project called, ``PCT-LEAP'' for ``Primary
Care Teams: Learning from Effective Ambulatory Practices''. I am a co-
director of this RWJF project, along with Dr. Ed Wagner of the McColl
Institute at Group Health in Seattle, and Dr. Tom Bodenheimer of the
Center for Excellence in Primary Care at the University of California
at San Francisco. On May 15, 2014, I had the pleasure of hosting Dr.
Wagner and Dr. Bodenheimer at the Community Health Center, Inc.'s Ninth
Annual Weitzman Symposium on Innovation in Community Health and Primary
Care. We reviewed the evidence from the PCT-LEAP project and other
projects studying ``exemplary'' primary care practices around the
country. It is exceedingly important when we think about the primary
care team as well as the primary care provider--when we think about
expanding the role of medical assistants, redefining the role of the
primary care nurse, integrating behavioral health clinicians into the
team, adding pharmacists whether directly or by electronic
consultation, adding health coaching as a skill for all members of the
team, and supporting the entire team with timely, actionable data on
care and gaps in care--that we are creating a new day in primary care,
where patients maintain their satisfying and healing relationship with
their own MD, NP, or PA as their primary care provider, but also know
and are well-cared for by a high performance team of individuals
committed to their best healthcare and health. As Dr. Wagner said,
``the future of primary care is already here; it's just not evenly
distributed.'' His comment illustrates the point that while we have
identified many practices that have now achieved the goal of
constituting a high performance primary care team, our next challenge
is to disseminate the knowledge and tools to expand these teams across
the country.
Finally, I would like to answer your question about how Congress
can support these efforts. You noted that Congress in 2010 authorized
Section 5316 of the Affordable Care Act, a provision that would provide
residency training for new nurse practitioners in community health
centers and nurse-managed health clinics across the Nation. However,
Congress never funded this initiative. I would therefore ask you to
support the reauthorization and funding of section 5316 in the amount
of $75 million through fiscal year 2019, as currently included in S.
2229, the ``Expanding Primary Care and Workforce Act,'' introduced by
Senator Sanders on April 9, 2014. Properly funding section 5316 would
establish a demonstration project with 20 to 25 sites nationwide, where
a minimum of three nurse practitioners would be trained as residents at
each site, each year, for 3 years. Each site would be funded up to
$600,000 per year. The Sanders bill would also reauthorize and create a
mandatory appropriation for the National Health Service Corps (NHSC) of
$4.9 billion through fiscal year 2020; appropriate $10 million for the
National Health Care Workforce Commission; reauthorize the Nurse
Faculty Loan Program through fiscal year 2019; reauthorize the Primary
Care Residency Expansion Program through fiscal year 2019; and
reauthorize the Area Health Education Centers (AHECs) through fiscal
year 2019.
Second, I would ask your support for reauthorization and funding of
the Teaching Health Center Graduate Medical Education (THCGME) program,
along with the expansion of that program to include residency training
for new NPs and other health care professionals, so that FQHCs can
innovate and develop residency training programs not only for
physicians but also for other professionals such as NPs and PAs.
Reauthorization of the THCGME program is funded at $800 million in S.
2229, though use of the funds is not expanded to include NPs or PAs;
unfortunately, the bill as drafted supports only training of physician
residents. That should be changed.
Third, I would ask your continued support for the community health
center program in general. The Sanders bill, S. 2229, also creates a
mandatory appropriation for FQHCs of $25 billion through fiscal year
2020.
Fourth, I would suggest that Congress focus on those primary care
settings that have already developed highly innovative models of high
performance primary care and have systematically developed the
infrastructure, training, and tools to help other practices achieve the
same goals. In my organization, we have developed a rigorous approach
to dissemination, training, and on-going support for other highly
motivated practices, whether they seek to implement NP residency
training; to transform from provider-centric to team-based primary
care; to develop new data systems to support care; or to tackle the
highest complexity issues we see in primary care, such as managing
chronic pain and addiction.
We at CHC, Inc. in Connecticut are ready and able to work with
others, and we have the structure in place through the adoption of the
Project ECHO (Extension for Community Health Outcomes) telemedicine
model first developed in New Mexico to help primary care providers
manage Hepatitis C in primary care with the support of specialists. At
CHC, Inc., we have adopted, refined, and grown the Project ECHO model
and now help organizations across the country and the world improve
their primary care practices through this case-based, distance learning
opportunity that provides support over time to primary care practices
tackling ambitious goals of transformation and improvement. I would
urge Congress to consider the establishment of one or more national
training centers to fulfill exactly this urgently needed role using our
model.
Thank you for this opportunity to respond to your question, and for
your commitment to good health and health care for everyone.
Sincerely,
Margaret Flinter, APRN, Ph.D., c-FNP, FAAN, FAANP,
Senior Vice President and Clinical Director,
Community Health Center, Inc.
Response by Joseph S. Nichols, M.D., MPH to Questions of Senator Warren
The research is mixed on how student debt factors into the decision
to pursue a medical career in primary care. Primary care doctors make,
on average, a little more than 50 percent of what a specialist makes,
so the burden of debt certainly weighs heavily on them. Medical
students graduate with an average of about $170,000 in student loan
debt. That's a lot, but debt at graduation tells only half the story.
According to the American Association of Medical Colleges, a doctor who
started off with $175,000 in debt can end up repaying more than
$300,000 once interest is factored in. The interest rate is not set at
the cost to the government. Instead, it is set at a level that is
projected to produce billions of dollars in profits. A recent GAO
report estimated that the Federal Government will bring in $66 billion
off the loans it made between 2007 and 2012.
Question. Recognizing that these are estimates, and of course
estimates can change, what are your thoughts about the U.S. government
turning a profit on student loan interest rates at a time when Federal
policy should be making it as easy as possible for medical students to
choose careers in primary care?
Answer. Thank you, Senator Warren, for the question and for your
leadership on this issue.
Almost no one can afford the cost of a medical school education.
This is because, in addition to the high sticker price, there are
numerous intangible costs to medical education that are subsidized by
Federal and State Governments. Therefore, every medical student
graduates with a significant amount of debt, whether or not this debt
can be added up in the form of student loans. However, the message
medical students receive from the Federal Government upon graduation is
that our educational loan debt is the debt that is of most interest to
our society.
The contract between medical school graduates and society must be
rewritten in a way that challenges our doctors to begin their careers
with service in the places where they are most needed. If broader
opportunities existed, many medical school graduates would gladly
exchange their financial debt for a social debt, repaid not with
monthly payment amounts that only inflated sub-specialist wages can
support, but with service to the sickest patients in the areas of the
country experiencing the most need.
The Federal Government currently profits tremendously off of the
interest charged to our student loan debt. However this profit is
shortsighted when measured in dollars and cents, considering the huge
opportunity cost of the health needs that could be met if this monetary
debt was effectively transformed into a social debt repaid through
service.
Clearly, this situation calls for expansion of current, time tested
and effective loan repayment programs incentivizing service as a
primary care provider to medically underserved areas. Future expansions
of these programs should aim to entirely eliminate the debt faced by
physicians who commit their careers in service of the greatest needs of
our society.
Response by James Hotz, M.D. to Questions of Senator Warren
The research is mixed on how student debt factors into the decision
to pursue a medical career in primary care. Primary care doctors make,
on average, a little more than 50 percent of what a specialist makes,
so the burden of debt certainly weighs heavily on them. Medical
students graduate with an average of about $170,000 in student loan
debt. That's a lot, but debt at graduation tells only half the story.
According to the American Association of Medical Colleges, a doctor who
started off with $175,000 in debt can end up repaying more than
$300,000 once interest is factored in. The interest rate is not set at
the cost to the government. Instead, it is set at a level that is
projected to produce billions of dollars in profits. A recent GAO
report estimated that the Federal Government will bring in $66 billion
off the loans it made between 2007 and 2012.
Question. Recognizing that these are estimates, and of course
estimates can change, what are your thoughts about the U.S. government
turning a profit on student loan interest rates at a time when Federal
policy should be making it as easy as possible for medical students to
choose careers in primary care?
Answer. Senator Warren, I appreciate your recognition of the
negative impact that student loan interest rates have on medical
students selecting careers in primary care. At a time when our Nation
needs an additional 52,000 primary care physicians to satisfy the
demands of 2025, it makes no sense to have a Federal loan program that
increased the cost of student loans by $66 billion from 2007 to 2012!
Instead of recruiting the additional 5,000 primary care physicians we
need each year; the current loan structure is creating a marketplace
that drives physicians out of primary care practice. In a thought
provoking New York Times letter on May 28, 2011 Peter Bach and Robert
Kocher propose, ``Why Medical School Should Be Free.'' They point out
that ``for roughly $2.5 billion per year--we can make medical school
free.'' Their suggestion is to keep medical school free for those
electing primary care and to have those going in higher paying
specialties pay back the cost of their education. This would be one
option.
A more moderate proposal would be to expand the National Health
Service Corps loan forgiveness program to forgive the loans of all
primary care practitioners going to areas of greatest need in this
country. Another option would be to restructure the current student
loan interest and repayment mechanisms to incentivize primary care. A
menu of options could run from lower interest for those selecting
primary care to no interest and some principal reduction for those
selecting primary care in the most underserved areas. With a $66
billion profit generated in the 5 years up to 2012 there seems to be
room in the Federal student loan program for revisions that would
create economic incentives to distribute the primary care workforce to
areas of greatest need in this country. I am optimistic that Congress
can find ways to restructure the current Federal loan program to better
meet not only the primary care needs but also the larger workforce
needs of the people you serve.
In keeping with the ``Voices from the Field'' theme of the hearing
I would like to show the pressure the current Federal loan program
places on someone I know well who is trying to start a career in
primary care. My oldest son, George, resisted the temptation of higher
paying specialty opportunities after completing an internal medicine
residency. He took a job with a regional hospital in Rome, GA and
joined a primary care practice that has its doors open to all in the
community. His income is less than half what a specialist would make
but this was his calling and his wife supported the decision and all
started out smoothly. He was making four times his salary as a
resident, Rome was near his wife's home, they bought a small house,
they were used to living on a tight budget, and then they started
paying his medical school loans! They elected an amount slightly under
their monthly mortgage payment and after paying $1,650.49 a month from
10/2012 to 4/2013 they were shocked to see they had made 7 payments
totaling $11,553.43 and ALL went to interest! The principal had not
been reduced at all, and unlike the home mortgage none of this was
deductible. George and his wife took a hard look at their financial
situation. Until then the loan was just an abstract threat, but now
reality has set in. They had to make some hard decisions--to tighten
the budget more and pay off a larger amount each month or else this
debt monkey would be on their back for 25 more years--or George could
decide to go back into a higher paying specialty. Fortunately for the
people of Rome, they decided to stay, cut down more on spending and
increased their payments to $3,886.09 a month so they would be out of
debt in 10 years. That first payment was made on 3/7/14 and $893.04
went to principal and $2,993.05 to interest.
Before 2006, George was able to get part of his Stafford Loan at
2.1 percent. After 2007 until his graduation in 2008, the interest
rates skyrocketed to 6.55 and 7.65 percent. My youngest son, Steve, is
in medical school now and his rates are also in the same range--from
6.8 to 7.9 percent. For Steve and most of his classmates these loans
are significant only when a family member, friend or a physician
faculty member tells them of the grim reality of debt, high interest
and the pain of repayment. That is when this debt storm starts raining
down on the dreams of a career in primary care. Unfortunately there has
also been a relentless increase in medical school tuition to pay for
expanding class sizes resulting in substantially larger medical school
debt at a time in which the interest rates have risen to painfully high
levels. It is clear what the future primary care ``Voices from the
Field'' are saying, ``Help!''
Senator Warren and subcommittee members the time for action is now.
The first step in ``Addressing Primary Access and Workforce
Challenges'' is in addressing the excessive burden of medical school
debt and interest. This can happen in a number of ways, including a
reduction of interest rates, a reduction in tuition costs or full loan
repayment. Each of these can be achieved by strategic use of the
National Health Service Corps program, and I'd be happy to work with
you to make that a reality.
Thank you Senator Warren for this opportunity to answer your timely
and insightful question and I hope my comments will be of help. I am
here on behalf of the Association of Clinicians for the Underserved and
you can feel free to contact me or the Association if there are any
further questions or if we can be of any service in the future.
[Whereupon, at 12:20 p.m., the hearing was adjourned.]
[all]