Subcommittee Hearing, Committee on Health, Education, Labor and Pensions
United States Senate, January 29, 2013
Primary Care Access
A Report from Chairman Bernard Sanders
The primary health care system in America and its workforce is in significant need of a checkup. As the population grows and ages, as more doctors retire, and as the primary care pipeline dries up, we face a severe shortage of providers. The result is that millions of Americans are not getting the care that they need now and the situation may only get worse. Although the ACA took important steps towards expanding access points by increasing funding for community health centers and the National Health Service Corps, for example, the tremendous scope of the problem requires further attention and action. Just like an illness from which it will be more difficult and costly to recover from the longer we wait, we must take steps now to address the primary care access crisis in America.
Video of the hearing (2 hours):
Written testimonies of the witnesses:
Fitzhugh Mullan, MD , Murdock Head Professor of Medicine and Health Policy at the George Washington University School of Public Health and Professor of Pediatrics at the George Washington University School of Medicine, Washington, DC:
Tess Stack Kuenning, CNS, MS, RN , Executive Director, Bi-State Primary Care Association, Montpelier, VT:
Toni Decklever, MA, RN , Government Affairs, Wyoming Nurses Association, Cheyenne, WY:
Andrew Wilper, MD, MPH , Acting Chief of Medicine, VA Medical Center, Boise, ID:
Uwe Reinhardt, PhD , James Madison Professor of Political Economy and Professor of Economics and Public Affairs, Princeton University, Princeton, NJ:
Claudia Fegan, MD , Chief Medical Officer, John H. Stroger Jr. Hospital of Cook County, Chicago, IL:
By Don McCanne, M.D.
We have a crisis in primary care. Unless we improve and expand our primary care infrastructure, we will become more dependent on the alternatives: overuse of emergency departments, fragmented care in walk-in clinics, traveling large distances from rural communities devoid of primary care, excessive use of direct access to specialized services limited to those who can afford it, and, worst of all, limited or no health care access for those who are uninsured and cannot afford it.
Today’s hearing of the Senate HELP Committee is important because it brings attention to the seriousness of this problem, demonstrating that action is an imperative. Although, as you read this, you do not have time to watch a 2 hour video nor read a half dozen testimonies, links are provided so that you can access these resources later – perhaps during the weekend when many of you have more time. If not, these links can be saved for later reference.
Although this session was focused on primary care, a couple of comments from the testimony of Claudia Fegan are apropos because of the larger needs in health care. Claudia is not only Chief Medical Officer of Cook County Hospital, she is also a former President of Physicians for a National Health Program. She understands that primary care would function much better if we had comprehensive health care reform.
As she states, “If we would enact a single-payer national health program, where everyone was entitled to health care as a right, we could focus on delivering to our patients the best care in the world and relieve our physicians of the administrative hassles…”
And her plea to the members of the Senate HELP Committee, “I urge you to work to make a difference, not for me or you, but for the patients I have the privilege of serving, who desperately need their elected officials to care about what happens to them.”
And isn’t her advocacy truly representative of the essence of primary care?
PNHP note: One of our members, Dr. Deborah Schumann of Washington, D.C., attended the hearing. Here are her notes and observations from the hearing room.
Notes from the Senate hearing room
By Deborah Schumann, M.D.
Senator Bernie Sanders (I-Vt) chaired the standing-room-only subcommittee hearing, which drew an audience of around 100 people. Sen. Mike Enzi (R-Wy.) co-chaired the meeting, which was attended by seven more senators: Elizabeth Warren (D-Mass.), Tammy Baldwin (D-Wis.), Al Franken (D-Minn.), Chris Murphy (D-Conn.), Bob Casey (D-Pa.), Kay Hagan (D-N.C.) and Sheldon Whitehouse (D-R.I.).
Sen. Sanders summarized some of the problems with the U.S. health care system, particularly with regard to inadequate access to primary care. He pointed out that the U.S. spends 18 percent of GDP on health care but doesn’t measure up to other developed countries on outcomes. With 1 in 5 patients unable to see a primary care doctor when they need to, not only do medical conditions get worse, but also some of these patients resort to expensive treatment in a hospital E.R. The problem of inadequate access to primary care is worst in rural areas such as Wyoming and Idaho, but even small states like Vermont and Connecticut have areas that are affected, particularly for low-income or minority populations.
It is estimated that about half of doctor visits need a primary care provider, but in the U.S. only about 30 percent of physicians practice primary care. Furthermore, it is estimated that one quarter of them are nearing retirement and only 7 percent of medical students are currently choosing primary care.
The reasons why the U.S. is deficient in primary care and over-supplied with specialists were discussed:
* The number one reason was felt to be financial disparities between specialist reimbursement and primary care reimbursement. On average a specialist can expect to earn double that of a primary care doctor.
* Since students come out of medical school with a median debt of $160,000 there is an increased incentive to choose a highly-reimbursed specialty such as radiology or gastroenterology.
* Dr. Fitzhugh Mullan stated that medical schools are “specialty focused,” and that they create a “toxic culture” for primary care.
* Senator Murphy commented that there is a prestige factor involved in choice of practice.
* Senator Baldwin pointed out the lifestyle implications of the choice. For example a rural primary care doctor taking care of 3500 patients in Wyoming is looking at a much more difficult work life than a radiologist who practices in a suburb of Boston.
The consequences of lack of primary care were discussed:
* Senator Hagan stated that in her state of North Carolina a million patients can’t access management of chronic disease because of a shortage of providers.
* Dr. Andrew Wilper reminded the committee that 45,000 patients per year die for lack of health care coverage and that good primary care costs less and improves outcomes.
* Dr. Claudia Fegan described the scene outside of her clinic in Chicago where hundreds of patients line up every day hoping that they will find a doctor.
* Toni Decklever, R.N., described how lack of primary care follow-up can lead to long
er institutional stays and higher readmission rates after hospitalization.
Senator Casey stated that the “goal is for everyone to have a primary care provider” just like members of Congress do.
Possible policy changes that could improve the situation were presented:
* Increase the number of community health centers similar to Blue Ridge Community Health Center, a federally qualified health center, as described by Senator Hagan. Also have community health centers open evenings and weekends.
* Increase the number of non-physician providers. Uwe Reinhardt suggested that a federal licensing system could be set up to increase this workforce.
* Senator Enzi suggested increased use of telemedicine to help reach underserved rural areas.
* Encourage more medical students to choose primary care through programs such as the National Health Service Corps, loan forgiveness and greater parity of compensation between primary care and specialties.
* Dr. Andrew Wilper suggested that the Medicare funding stream that goes to hospitals for residency programs be made contingent on developing more robust training programs in primary care. Some of these residents could work in the expanded community health center sector, for example.
* Reform the Relative Value Scale Update Committee (RUC). This AMA committee is overwhelmingly controlled by specialty groups who keep their own reimbursement high at the expense of primary care doctors. Uwe Reinhardt recommended outside auditors to deal with this issue.
* Recruit more medical students from underserved areas such as rural parts of the country and low-income urban areas. Senator Franken commented, “there is nothing good about the high cost of education.” The astronomical cost of medical education bars many from entry.
Everyone on the committee seemed motivated to do something about the problem of inadequate access to primary care, but there are huge challenges ahead. While the Affordable Care Act (ACA) expands coverage to an estimated 30 million patients, “coverage does not equal access,” said Tess Kuenning, R.N. Health care costs are on an accelerating curve, Senator Whitehouse said. “We need better outcomes at lower costs,” Senator Warren emphasized. There was consensus that primary care providers are indispensable.
Not only are patients suffering from lack of access to health care, but providers are “being driven to distraction or exiting the profession” because of onerous billing and administrative responsibilities, said Dr. Fegan. She pointed to the hundreds of insurance companies that her clinic has to deal with in addition to the fact that current electronic health records are aimed more at billing and coding than at continuity of patient care.
Dr. Mullan commented that the ACA is a moral victory but presents a technical challenge. Dr. Fegan stated that “health care is a right,” and that a single-payer, improved-Medicare-for-all approach would bring everyone in, leave nobody out, be affordable to the country and lead to better outcomes.