(March 5, 2008) On February 12, the Senate Health, Education, Labor and Pensions (HELP) Committee convened a roundtable discussion on physician workforce issues. The following individuals participated: Bruce Auerbach, President Elect, Massachusetts Medical Society; Kevin Grumbach, Director, UCSF Center for California Health; Roderick Hooker, Director of Research, Rheumatology Section, Medical Service Department of Veterans Affairs, Dallas VA Medical Center; Beth Landon, Director, Alaska Center for Rural Health; Jennifer Laurent, President, Vermont Nurse Practitioner Association; John Maupin Jr., President, Morehouse School of Medicine; Edward Salsberg, Director, AAMC Center for Workforce Studies; A. Bruce Steinwald, Director, Healthcare Government Accountability Office; and James Swift, Board President, American Dental Education Association. Although AACOM did not participate in the discussion, AACOM and AOA submitted
joint testimony for the record.
The following members of the HELP Committee were present: Senator Bernie Sanders (I-VT), chairman; Senator Ted Kennedy (D-MA); Senator Patty Murray (D-WA); Senator Sherrod Brown (D-OH); Senator Lisa Murkowski (R-AK); and Senator Wayne Allard (R-CO).
The roundtable opened with a statement from Senator Sanders, who chaired the discussion. He noted that even if there were universal health care in this country, there still would be an access crisis. He also noted that fewer students are entering the field of primary care. He cited the need to reauthorize Title VII with increased funding, to double the funding and size of the National Health Service Corps, to increase funding for community health centers, to reform Graduate Medical Education Spending to allow for increased flexibility and to alter the Medicare reimbursement system so it no longer provides disincentives for primary care.
In his opening remarks, Senator Kennedy stated that plans for universal coverage must start with having the personnel to provide care. He recognized that indebtedness is moving students from primary care. He also noted that Titles VII and VIII, programs that help steer students into primary care, were eliminated by the President in his proposed budget.
Like Senator Sanders, Senator Murkowski focused on the access crisis, especially the problems that people face in rural and medically underserved areas. She mentioned the Physician Shortage Elimination Act, which funds community health centers and provides for training in alternative sites for graduate medical education (GME), as a method of addressing this issue. She noted that while 62 percent of Americans live in medically underserved areas, only 9 percent of physicians practice in those areas.
Bruce Steinwald of the Government Accountability Office focused his comments on three areas related to the supply of primary care professionals: (1) recent supply trends, including information on training and demographic characteristics; (2) projections of future supply for primary care professionals; and (3) the influence of the health care system’s financing mechanisms on the valuation of primary care services. In recent years, the supply of primary care professionals increased, with the supply of non-physicians increasing faster than the supply of physicians. At the same time, the numbers of primary care professionals in training programs has also increased. Between 1995 and 2006, the number of primary care residents increased by 6 percent, while the number of specialist residents increased by 8 percent. The HRSA Bureau of Health Professions has projected that there will be a primary care physician shortage by 2020. An important trend noted by GAO is that there has been a decline in the proportion of U.S.-trained primary care residents, and this may be the direct result of the undervaluing of primary care services. Steinwald illustrated this by sharing that in Boston, the Medicare fee for a 25- to 30-minute office visit for an established patient with a complex medical condition is $103.42; in contrast, Medicare’s fee for a diagnostic colonoscopy, a procedure of similar duration, is $449.44. However, he noted that increased reimbursement alone will not solve this problem.
Dr. Kevin Grumbach opened by stating that the primary care infrastructure in this country is crumbling and patient access to primary care is suffering. In his view, the federal government can address the crisis in primary care through targeted programs such as Title VII and the National Health Service Corps, both of which have strong evidence bases. He also noted that the reform of Medicare GME is necessary. However, these programs alone will not address the deficit without Medicare physician payment reform.
Dr. Roderick Hooker addressed the role that physician assistants (PAs) and nurse practitioners (NPs) have in providing primary care. The research shows that absent a PA or NP, some populations would have no access to health care. He noted that PAs and NPs go into primary care in greater percentages than physicians, and that the professions have grown because of the benefit of Titles VII and VIII.
According to Edward Salsberg, the nation is likely to face a major shortage of physicians in the future because of a growing and aging population, advances in medicine leading to longer life, an aging physician workforce and shorter work hours for younger physicians in practice. To address this future shortage, the AAMC recommends a 30 percent increase in medical school enrollment by 2015 and funding for additional GME positions. However, he added that increasing physician supply alone will not address the geographic and specialty maldistribution of physicians. To address these issues, he suggested that the National Health Service Corps awards be doubled and funding for Title VII be increased.
Dr. James Swift addressed the issue of access to oral health care. He shared that the American Dental Education Association has a diversity mission because more minorities are needed to serve other minorities with poor access to dental care. He also noted that the large debt load dentists face prevents them from working in underserved areas.
Echoing the statements of the Committee members, Dr. Bruce Auerbach stated that the primary care physician shortage will be exacerbated by universal health coverage. He stressed the importance of Title VII programs in increasing the number of primary care providers. But, he also highlighted the need for a more accurate count of full-time practicing physicians and physician debt relief to fully address this problem.
Beth Landon addressed this problem from the perspective of rural America. She stressed that a multifaceted approach will be needed to address the access problem. Her experience shows that the Area Health Education Centers (AHECs) and other Title VII and VIII programs are essential in providing rural students with the skills they need to succeed in medical school. John Maupin echoed some of Landon’s comments by sharing how Title VII has connected minorities to AHECs and community health centers.
Senator Sanders asked why the United States is not educating the number of primary care professionals that it should. The panel’s response was that the incentives are to practice in highly specialized fields; until that is addressed, this problem will continue. While primary care has been shown to provide better outcomes at lower costs, students see the difference in earning potential and gravitate to specialties. It was also noted that in other countries medical students attend school almost for free, but in the United States, medical students graduate with a significant amount of debt. It was also noted that there is an underutilization of NPs as primary care providers since Medicaid does not reimburse NPs as primary care providers.
Senator Allard asked the panel if there is a problem recruiting medical students. According to Salsberg, applications have been increasing and there are two applicants for every slot. It was also noted by Hooker that primary care professionals tend to remain in the communities where they train, so that is a factor in the distribution of these professionals.
Moving away from the issue of primary care professionals, Senator Murray asked if support professions were faced with the same problem. Hooker responded that all allied health professionals are affected to some extent. Salsberg noted that one of Title VII programs’ successes is their ability to span professions. However, Maupin cautioned that the erosion of Title VII funding is affecting outreach to minority students in all of the health professions.
Senator Murkowski asked the panel if is it is more beneficial to invest in PA and NP programs. The consensus of the panel was that having more PAs and NPs is beneficial, but a team-based approach to care that includes primary care physicians is optimal. The Senator followed up her earlier question by asking about the role of mid-level practitioners. Again, the panel responded by discussing the team approach to health care and the current work being done on the primary care medical home.
When Senator Murray asked if physicians who train in community health centers remain there, Auerbach responded that about 80 percent of these physicians stay in rural and underserved areas, even if they do not remain in the particular area in which they trained. Maupin echoed this sentiment by saying that these programs work as intended but that appropriations are a problem.
Senator Murkowski recognizes that Title VII and VIII programs and GME are essential, but asked how to get practitioners to stay in rural and underserved areas. Steinwald replied that there is enough money in the system, but the rewards for volume must be replaced with incentives for team based health care.
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