Transcripts For CSPAN2 Tonight From Washington 20130130

The Actual Office to close down gitmo has been closed itself. We gave you all the information we have available on that subject, okay . Currently 30 of u. S. Doctors are primary care physicians. Tuesday, they examined the growing shortage of primary doctors. This is just under two hours. [inaudible conversations] [inaudible] which is going to cover, i believe, an enormously important issue. I want to thank Ranking Member for his work. He and i worked together on a number of issues over the year. I look forward to a productive working relationship. Vermont is a rural state. I know something about rural problems. His state is a lot more rural. We will see how we can go forward together. In our country today, before i begin that, i want to thank all our panelists for being here. We have a great set of panelists from all over the country, and we very much appreciate them being here. We thank them for the work they do every day providing health care, doing research. In our country, today, i think as many people know, weve been almost twice as much as do the people of any other country per capita on health care. Thats about 18 of our gdp, and, yet, our Health Care Outcome in terms of life expectancy, infant mortalitying and disease prevention are not particularly good in terms of international comparison. One of the reasons for that is that we have a major crisis regarding primary Health Care Access that results in lower Quality Health care for our people and greater expenditures. Lower Quality Health care, and, yet, we end up because of the crisis in primary Health Care Spending substantially more than we should. Today, 57 Million People in the United States, one in five americans, cannot see a doctor when they need to. Lack of access to a primary care provider is a National Problem, but those most impacts are people who are low income, minorities, seniors, and people who live in Rural Communities whether its vermont or wyoming. As weve seen time and time again with dental care, Mental Health, and other health care issues, the groups that lead need health care the most are the least likely to receive it. The good news is just 11 months from now well be providing Health Insurance to 30 million more americans through the Affordable Care act. The bad news is we dont know how we are going to be providing primary health care to those americans who now have Health Insurance. Let me rattle off some statistics that i think should be of concern for the congress, and, in fact, for all americans. Not widely known, and maybe youll talk about it, but approximately 45,000 people every single year die in the United States of america because they do not have Health Insurance, and they do not get to a doctor on time, 45 45,000 americanss. According to the Health Resources and health administration, we need 16,000 primary care practitioners to meet the need that exists today with the ratio of one providers for 2,000 patients. Over 52,000 primary care physicians will be needed by 2025. In 2011, 17,000 doctors graduated from american medical schools, despite that half the patient visits are for primary care, only 7 of the nations medical School Graduates now choose a primary care career. 7 . Nearly all of the growth in the number of doctors per capita over the last several decades have been due to arrive in the number of specialists. Between 1965 and 1992, the primary care physician ratio grew by just 14 while the specialists, the population ratio exploded by 120 . The average primary care physician in the United States is 47 years of age, and one quarter on retirement. In 2012, it took about 45 days for new parents to see a Family Doctor up from 29 days in 2010. In other words, even if you request find a family provider, it an takes a lot longer than it should to see him or her. Only 29 of u. S. Primary care practices provide access to care on evenings, weekends, or holidays, compared to 95 of the physicians in the united kingdom. In other words, our culture is dont get sick on saturday, sunday, but nine to five works good. Half of emergency room patients would have gone to a primary care provider if they had been able to get an appointment at the time one was needed. In other words, we are wasting billions of dollars because people end up in the emergency room for nonEmergency Care because they cant find a primary health care physician. In my view, and i think the view of all of the experts who studied the issue, primary care is intended to be and should be the foundation of the u. S. Health care system. In 2008, americans made almost a billion Office Visits to the doctor, 50 of those visits were to primary care, half. According to every study down on the issue, access to primary health care results in Better Health outcomes, reduced health disperties, and lower spending by not only reducing Emergency Rooms, but when you get people to the doctor when they should, they dont get sicker than they otherwise would be and end up in the hospital at great costs. The problem we are discussing is clearly a National Problem existing in 50 states in the country, by its even worse for particular geographic regions. The ratio of primary care doctors in urban areas is 100 for 100,000 people. Double the ratio in Rural Communities where it is 46 for 100,000 so urban communities, clearly, have problems, Rural Communities have even greater problems. 65 of primary Health Care Professional shortage areas are in rural counties. My own state, we do much better than the rest of the country in terms of primary Health Care Providers per hundred thousand, and, yet, i can tell you in the state of vermont, people often have difficulty getting to the primary care provider they need. Although 20 of americans live in rural areas, only 9 of the physicians practice there. One of the significant differences between the u. S. Health care system and the Health Care System of other highly developed countries, which could significantly explain why we spend so much more than other countries around the world, is the ratio of primary care physicians to specialists. In the United States, roughly speaking, 70 of our practitioners are specialists, and 30 are primary Health Care Providers. Around the rest of the world, that number is exactly the opposite, about 70 of their practitioners are primary Health Care Providers, and 30 are specialists. What can congress do to address this very serious issue . Let me just rattle off a few points and then give to mic over. First and foremost, clearly, we must address the issue of primary care reimbursement rates. Specialists earn as much for their lifetime of practice as much as 2. 8 million more than primary carp providers. If you are going spue med sip, if youre a specialist, you can earn throughout your lifetime almost three Million Dollars more than a primary care practitioner. Raid radiologists are twice that. The position for setting reimbursement in this country is largely determined by the 3 31 physicians who sit on the American Medical Association committee called the relative value committee, and the ruc whose payment conditions are accepted by the medicare and medicaid services, over 90 of the time, and adopted by many private insurers is dominated by specialists. Specialists sitting on the committee determine reimburressment rates. We have to look at that issue. Medicare has promoted the growth of residencies in specialty fields rather than primary health care by providing significant subs, 10 billion each year to Teaching Hospitals without requiring any emphasis on training primary care doctors. Its very efficient. Thirdly, unlike other nations that provides significant Financial Support for medical school education, we by and large do not do this in this country, and the result is that the median debt for medical students upon garaguation is more than 160,000 and almost a third of medical School Graduates leave school more than 200,000 in debt. Now, if you leave school 200,000 in debt, what are you going to do . Figure out how to make as much money as possible to deal with that debt, and youre going to gravitate towards fields that pay you higher incomes. So, if were going to attract young people into primary health care, we must make that profession more financially attractive. In other words, we must address the issue of how reimbursement rates affect medicare and impacts reimbursement rates for all physicians. We worked on the issue and greatly expanded Community Health centers around the country. Those provide good quality, Cost Effective health care. We need to do more than that. We made progress. We need to make more progress. In recent years, we significantly increased funding for the National Health service corp. That says to somebody, and if you graduate medical school 200,000 in debt, well help you address that debt, help you pay it off if you practice in under served areas. It is working. It has worked. We made progress. We need to make more progress in that. Teaching Health Centers. Studies shown residents train Community Health centers own Rural Communities are trained in those settings to make a career practicing in underserved or rural areas. The thc pramg was the only new investment in graduation in the Affordable Care act, and the five year funding was just 230 million. We have to expand that. Also got to take a hard look at the role of allied health providers, Nurse Practitioners, and others. How do we better utilize those people in the provision of health care . Weve got a very, very serious problem, lives of thousands of people depend upon what we do, and im very excited about the wonderful panelists we have at this hearing, and i want to hand it over. Thank you, and i look forward to working with you. Id like to thank witnesses for taking time out of the schedules to be with us. I particularly like to welcome tony from chiian of the shes worked with me, and my staff, on Health Care Work force finishes for a number of years, and i appreciate she made the long trip across the country to be here. Its a pleasure to welcome all the witnesses to our hearing. The issue of improving access to primary Care Services alining our Health Care Work force is one thats important to all of us, but particularly significant begin obstacles people face in wyoming. Nearly the entire state is considered a frontier or rural county. 47 of the population lives in a county with fewer than six residents per square mile. Approximately 200,000 residents live in Health Professional shortage areas with inadequate access to primary or dental care. Theres serious challenges in wyoming that require Creative Solutions to resolve. We have one hospital thats served by a physician that every time we lose that physician, the hospital closes. To that end, the state developed programs to meet needs of a frontier state where distance is the biggest barrier to accessing a doctor. We say we have miles and miles of miles and miles, and we recruiting Health Care Providers is a challenge. The Loan Repayment Program and a grant program, these programs work to reduce the high cost of Health Professional graduate and Training Programs, owive often a deterrent to work in primary care or other low income fields. The Network Represents another innovate of approach to improving access and reducing primary care work force shortages. This collaborative arrangement between the Health Professional societies, university of wyoming, and other key partners maintains an extensive data base on wyoming Health Care Facilities and their need for professionals. Sharing information more effectively allows for better allocation of resources and manpower at a time when the fiscal climate limits our ability to spend money on the problem. Theres more that can be done to align federal programs to meet the needs of rural and frop tier states. The cry criteria that meets the eligibility for Rural Health Programs based on factors difficult to prove the needs of underserved in rural and frontier areas. For example, one provider for 3500 people in new york city is entirely different than 3500 People Living in freemont or campbell county. We have to think creatively how to use technology to improve capabilities so that where a person lives has less impact object level of care they receive. The advancement of more powerful Wireless Technology has substantial potential to remotely link individuals across the country to deliver health care in more accessible settings. Weve had quite a bit of success with that with some of the Veterans Outreach clinics where they used this extensively with Nurse Practitioners in charge of handling the equipment, and the doctor on the other hand. I hope the hearing makes it clear we have to think creative ly and think of ways to access primary health Care Services and ensure Health Care Professionals are employed where they are most needed. I look forward to hearing from the witnesses op what needs to be done to solve the problems at the federal, state, and local level. Again, i want to thank witnesses for participation, thank the chairman for his great list of suggestions on things that need to be done, and im sure that we have the capability to come up with some solutions through this committee. Senator enzi, thank you very much. Senator warren was here first. Senator warren . [inaudible] yes. No, i just want to thank you very much for holding this hearing, mr. Chairman. I am very interested in the questions about how we equalize access for all citizen, and particularly interested in the question about how we make the right investments to lower the overall cost of health care. I think the chairman said it best saying what were looking for is Better Outcomes at lowest costs. That is the role that the federal government can make if it makes the right upfront investment. Looking forward to hearing from each the panelists. I also thank the Ranking Member of, i think the comments about access and the reminder that its very different in a large city than it is from a very rural area are comments that are well taken and one for us to remember carefully, and, also, a reminder that has different consequences, even in a state like massachusetts where, obviously, we have very Extensive Health Care Services in some areas, but its still leaves us with the population in massachusetts with difficulties in accessing care. Sometimes distance is less the challenge, but costs can remain the challenge, and transportation even within close areas are a serious challenge so i appreciate the reminder of the diversity of issues that we face in making sure that all of our citizens have good access. Thank you, mr. Chairman. Thank you very much, senator. Thank you, mr. Chairman. Ill not use the allotted time in the entirety and apologize to the panel that i have to sneak out to attend another Committee Meeting and return, i hope, for the q a, but i appreciate, mr. Chairman, your focus on this broad, but very critical issue that has so much relevance seeing through the implementation of the Affordable Care act. I represent a state that has urban concentrations as well as perhaps, not as large spaces of rural areas, but certainly has the array of challenges that are the subject of this hearing, and i appreciate the attention thats going to be focused on it. One of the things that i hope that will hear some elaboration on, aside from issues that compensation pays or plays in this, is the questions of lifestyle for primary care practitioners, things like the differences between the amount of time that somebody might be on call as a specialist versus a primary care physician. As we look at larger payment reforms, how the flexibility in their practice of being able to spend adequate time with a patient, for example, with multiple chronic conditions that is necessary versus seeing folks in 15 minute increments, ect. What impact will those policy changes have on the on the number and number of primary care practitioners in this country. Anyways, mr. Chairman, thank you for focusing attention on this issue, and i hope to return to hear to to here to hear from the witnesses and ask my questions. Thank you very much. Senator franken. Thank you, mr. Chairman, for this incredibly important hearing, and we have 30 million more americans, we hope, if medicaid is adopted by the state, the expansion of medicaid, leaving some people still uninsured. I read the testimonies last night, and it is very clear that when you insure people, their Health Care Outcomes are better, and it actually costs us money when people are not ensured. Its so clear. You hear, well, we have health care in the country. Go to the emergency room. Well, thats the most Expensive Health care, and it doesnt mean you get treated after the emergency room. It doesnt mean you get what you need to treed croppic conditions, and it all of your testimonies put the lie to that. I appreciate that. In minnesota, we do health care relative to the rest of the nation, extremely well. Hhss rate is number one in high value care, and outcomes provided by cost, and we, like wisconsin, have kind of a combination of urban centers and not the miles and miles and miles of miles and miles, but we have miles and miles. Ranking member, whom i would like to welcome subcommittee and looking forward to his partnering on this, and i admire his work on rural health which is so important in my state because there are people that are underserved. One of the things that the chairman talked about was the Student Loans that, you know, graduating from medical school was a typical loan debt of 160,000, sometimes more, and then talking about the tennessee for doctors then who just graduated to say how am i going to make this money . We have, you know, med P Organization c, and med pac, and this is an issue you talked about in your testimony. In our country, we pay specialists a ratio more than primary care physicians than they do in other countries that do their health care very successfully and cheaper and less expensively than we do. One of the things about Student Loans, to me, theres nothing good about high costs of college and graduate school, in my mind, except that the only probably good thing is that if creates some tool for us to motivate people to go into the things that we need. The one question id like the panel to think about, an i know you have testimony and well have question, is what is a return on investment if we say to doctors, graduating medical school, will, doing some forgiveness, specialty forgiveness for being a primary physician in a rural area or underserved urban area, but whats the return on investment if we really, really encourage loan forgiveness for doctors to go into primary care . In other words, what is the equation there . If we raise if we say, my goodness, it is such a benefit to society and such a cost benefit to have a higher ratio of primary care physicians that if we said for anybody, those in the primary care physician, medicine, we will its a hundred thousand dollars, right there, boom, whats the cost benefit there . Its good to see you, dr. Reinhardt. Weve talked a number of times. He is a health care economists. Maybe thats something you can mull over. Anyway, i thank you, mr. Chairman, for this up unbelievably important hearing. Thank you. Thank, senator franken. Senator murphy. Thank you very much, mr. Chairman, excited to be a part of the committee and with a fans tas tick panel. Ill get out of the way so you can provide testimony. Ill say this, having chair the Health Committee in the state legislature in virginia for years, we grappled with this problem year after year, and i remember specifically a meeting i had with about, maybe 15 or 20 medical students at the university of connecticut, and at some point in the meeting, we talked about the Affordable Care agent and how it could help medical students, talking about the issue of the high level of indebtedness, and i asked how many are considering, not committed to, but considering going into primary care, and of the 15 students around the table, one raised their hand. One was only even considering it. We started to examine the question as to why they didnt even have it on their mind. Certainly, dollars were the first thing they mentioned. All of them would have extreme levels of indebtedness, even from a state university, and they couldnt figure out how to make it work with the salary they make as a primary care physician. As you started to tease a deeper answer out from each one of them, the second thing that came up was prestige. They didnt feel there was real prestige any longer in being a primary care physician. If you wanted to practice cutting edge medicine, you have to go into the specialties. They had an ego to them that wanted to put them on the front lines of new medicine. I hope thats part of the hearing as well today. How do we put the practice of medicine back into the primary care. How do we allow them to be more than just gate keepers . I think that theres a perfect opportunity as we start to roll out these new Delivery System models as we envision a world where Accountable Care organizations and interconnected, multispecialty practices are the rule rather than the exception while we invest in things like medical home models. Do you allow for primary care physicians to once again control a lot more medicine than they used to control. The prestige comes back, maybe not so much in the medicines they practice, but in the control they have over the Health Care System at large. I think that as we build a new Delivery System, its an opportunity not just to address whats the most critical question, which is how do they just make their familys budget work if they go into primary care, but how do they get to feel really good about the medicine they practice and the value that they are adding to their profession because thats been lost as well over the years as the prestige has moved to the specialists rather than the primary care doctors, and i imagine well examine that topic today as well. Thank you very much, mr. Chairman. Thank you. Senator casey . Mr. Chairman, ill submit a statement for the record. Thank you for calling this hearing. Its a critically important issue, and were grateful you did the work. One quick comment ill make is when we go to the attenning physician as members of congress, we have a doctor available to us here in the capitol, and that doctor, in a sense, if our quarterback. Makes determinations about our health and can refer us to all specialists and others that help us, and we hope that one of the conclusions that results or one of the goals here, i guess, is a better way to say it, of all of this work in the hearing and otherwise, is that everyone has that primary care doctor, quarterback in their life to treat them, but also gets them access to specialists and the best care. Thanks. Thank you. Thank you much, mr. Chairman, and Ranking Member enzi. Thank you for holing the hearing today. It is a critical issue facing the country today. In my state of North Carolina, we have more than a Million People who dont have access to a primary health care because of a shortage of providers, and i know when patients see a primary health care doctor, they frequently end up getting care, obviously, but what happens when they dont have the access . They go to the hospital and thats where Emergency Care and treatment is expensive, and its currently helping to drive up the care of health care, and, also, if you have got a chronic disease and can manage that disease, its much less costly, and, otherwise, they will develop into acute cure episodes. I know there are innovations going on in this area, and one of them is in North Carolina, the blue ridge Community Health services, which is a Community Health center in the western part of the state. It received a grant in november under the teaching help center program. In the blueridge, they served 20,000 patients last year through 70,000 encounters with two primary care sites of four school based help centers and one dental center. They do outreach at a local violence center, and this funding they have been given allowed them to increase the number of residents at this facility in hendersonville, and residents are critical to providing, in helping providing more primary health care physicians. Bluerun is wog of 34 federally qualified Health Centers in North Carolina that provide high quality, Cost Effective care to so many people across our state, and i knowanother provision thats important, and that is the rural physicians pipeline act included in the Affordable Care act giving medical schools the resources to recruit students from Rural Communities. So much the primary care access is lacking in our Rural Communities, and if we train physicians from the Rural Communities, they stay in Rural Communities which i think is certainly a highlight of the provision. Programs like that, i think, have a significant role to play in relieving the primary care shortage. Delighted to have the committee hearing, and i look forward to hearing testimony of all the witnesses today. Thank you. Thank you, senator. Senator whitehouse. Thank you very much, senator sanders, for holding this hearing. Youve drawn a big crowd, i think, because its an important issue. We are all gearing up here in washington for a fiscal cliff, coming in a couple weeks, and with that looming, were beginning to hear the usual refrain how important it is to cut medicare benefits and to limit access to medicare to seniors, and that thats the responsible thing to do so save money, which, of course, is a illinformed idea, particularly, in the context of a Health Care System thats 100 times more expensive than it was in 1960s, and if you look at the graph, its an accelerating curve of upward costs, and when you look at a 2. 7 trillion dollar annual expenditure on health care thats probably 50 higher, theres a 50 infirstefficiency permit paid in the United States compared to all of our industrialized competitors, were at 18 of gdp, its 800 billion a year spent unnecessarily. Look at the scope of this. Look at the accelerating rocketing pace of the increase, and you think youre going to solve that by cutting medicare . Its not right as the ceo said, that is an inept way of thinking about health care. You said its not just wrong, its so wrong its almost criminal so hearings like this that point out a problem with cost and the Delivery System in the United States, and that we really have to address that problem if were not going to misdiagnose what we have, and once, of course, you know, you have a misdiagnosis, you dont get the right cure either. Its really important that we not throw seniors and medicare under the bus because we have failed to address the real problem in health care, which is wild and efficiencies and rocketing costs that are not just in medicare, and, indeed, medicare is probably the most efficient deliverer of health care in our Health Care System. If we get this righting we just dont 40 of the savings come back into the federal budget, but the rest will go to blue cross, to united, to businesses and families all across the country, and so we got a real fight on our hands to make sure we steer this in the right direction, and i hope that steering helps makes sure we make the right choice. Senator whitehouse, thank you very much. I want to remind members of the senate and viewers on cspan, the report of primary care access is available on my welcomes, sanders. Senate. Gov. You panelists are extremely patient. The good news is you have seen an enormous amount of interest in the issue. We are delighted you are here. We thank you, again, for the work you do. Lets begin with dr. Fitzhugh mullan. Hes the head of medicine and Health Policy at the George Washington University School of Public Health and professor of pediatrics at the school of medicine. Thank you so much for being with us. Thank you, chairman sanders, senator enzi, and colleagues, its a great privilege to be here as a primary care physician, a pediatrician, who was in the first class at the National Health service corp. , 1972, subsequently ran the service corp. It is not only a privilege, but an astounding developing history to hear a committee of the u. S. Senate speak with such clarity about the often orphan issues of primary care and Service Delivery in poor rural and underserved communities. I can get over my days, i will try to be cogent, but thank you so much for convening and the thought thats gone into this. As you gave a talk, i was supposed to be the expert, but you were clearly the expert. Ill try to focus on issues of education and system building around primary care. The demand clearly is in front of us. The ages of the population, the add vent of the Affordable Care act, and the terrific entitlements that it provides, but that does present us with a challenge. Just a few demographics. We have about 280 physicians per hundred thousand in the United States which puts us in the middle roughly of the developed world. U. K. And canada have less. Germany and france, for instance, have more. Were roughly in the middle. We have about 800,000 positions, but additionally, we have 190,000 Nurse Practitioners, physician assistants, and certified nurse mid wives. We have almost a 25 add on of providers that didnt exist 3040 years ago, and a point on that, important to remember, when our work force was lean and talking in the 60s and 70s, we were very short, and everybody including the u. S. Congress agreed and began to have a variety of programs that lived on very powerfully today. Among those, excuse me, was the development of the Nurse Practitioner and ftion assistant. It didnt exist before, and the National Services health corp. Excuse me. Lean is not necessarily bad in terms of how we function tab we want to have a more first time system. There are systems used to the payments that they currently get, and they are not going to change until theres a sense and need. Were at that point. While im not for holding where we are now, we have to think about the advantages, perhaps, and the creativity that can come from this period. In terms of the primary Care Challenge i look at it in two ways. One is in the factory, the teaching school, the hospital, and the other is in the market. Clearly, theres elegant testimony as to the pay gap in special terms that they make twice than what a general makes. Thats a pediatrician, general doc, and other disciplines that are generalist in nature and poorly paid. Thats a huge problem, and while education and training is very important, what i do and believe in, you can do the best education and training, and if you put them out in the market with those incentives, you get what we get now. We have to deal with that. Speaking on the educational side, the challenge at the medical school level and residency level, as you know this, residency is very important, and, also, very influential in the nature of the type of physician and location of the physician that come les out of the location popline. There is a culture thats heavily, in this point in time, specially focused. A natural dominance of the more Research Oriented and Specialty Sciences well represented, but the primary care culture is often put to the back of the bus, and theres not a primary care physician that has not been told in their training career by a professor that youre too intelligent to go into primary care. That culture is toxic. Its out there. We have to worry about it. The young doctor today is, as suggested, drawn to lifestyle of specialties. This is a problem too with limited hours clear and rather defined, knowledge requirements, and a predictable life. One can understand those draws, but we need to work on that, and then finally, the sense of social purpose and social mission. Our medical schools have been well treated by the nih, providing 17 billion a year, and by medicare, providing 10 million a year to Teaching Hospitals or residency programs, 10 billion a year, about 100,000 perez per resident. Very, very strong without a work force product at the end. Given those two pay streams, theres dollars in general practitioners, and 3 million in the Health Service core. 27 billion on one side thats specialty oriented and 600 million promoting primary care careers, a huge imbalance. Again, not surprising at the outcome that results from that. The teaching Health Centers, referenced, are very important innovation moving the paradigm out of the hospital into the community, and, importantly, needs to guarantee a pay stream. Cant run a residency without predictability. Thats a very, very important outcome,ing . Outcome, and something that needs attention. The pa is an important asset, as i said, almost 190,000. We need more. They are more nimble. They are easily, more easily trained in larger numbers, and thats a very, very important feature looking at scaling up quickly our work force. Finally data and planning, a Work Force Commission voted in through the aca. Its not been funded or met. We need a better brain in our somewhat phallic system. That would be helpful. In conclusion, we have a moral triumph in the aca and entitlements it brings, but, also, a technical challenge. Legislative issues, made permanence of the thcs is important. The full funding and greater funding of the National Health service corp. Is essential, bringing the Work Force Commission to light is important, and, perhaps, most important is medicare gme. We need to get a handle and use that 10 billion in a more constructive primary care fashion. Thank you. Thank you very much. In order for us to have a good rigorous question and answer period, if people keep remarks to five or six minutes, thats appreciated. Next witness is tess kuenning, the executive director of the Care Association with members of the federally qualified Health Care Center in vermont and New Hampshire. Thank you very much for being with us. Chairman sanders, Ranking Member enzi, and distinguished members of the subcommittee, im tess kuenning, the executive director of the Care Association located in vermont and concord, New Hampshire. On behalf of the Health Care Community, including 22 million patients nationwide, and the National Association of Community Health centers, thank you for the opportunity to testify on the role of Community Health centers in addressing our nations primary care access needs. As the committee is aware, two important events significantly altered Health Care Financing and delivery. The Affordable Care act and supreme courts decision about the same. As a result of the events, as many as 30 million americans gain coverage through medicaid and or the Health Insurance exchange. Another 30 mill still remain uninsured. We support the coverage expansions that open the door to a broader Health Care System to our patients; however, we know well that coverage alone does not equate to access. It is access to regular care that makes coverage meaningful. We also believe to achieve a truly reformed health system, our nation needs Sustainable Solutions to increase our primary care capacity, lower and manage our Health Care Costs, and assure quality outcomes. It is for this reason in my view that any effort to increase access to insurance must grow and expand our primary care probing. Community health care have a proven and unique solution to the issues. They are located in medically underserved areas and serve underserved population area and serve regardless of ability to pay. They are directed by patient majority board and care is locally controlled and responsive to each individuals communitys needs. It might surprise you to learn the Community Health center in burlington, vermont provides translations for patients from the sudan, bosnia, somalia, and burma to name only a few. The ability to receive care in ones language removes an access barrier and improves the health of the families. From years in clinical practices, im able to speak that pal with the increaseing immigrant population, and i see the benefits of this relationship. Without access to primary care, many people, including these families, might delay seeking treatment until they are ill and require hospitalization or care in the emergency room at a much higher cost to themselves and the Health Care System. The literature backs up real world experiences. For example, the journal of rural Health Article found counties with a Community Health center had 25 fewer emergency room visits. Other data demonstrates the Community Health center saved the entire system including government and taxpayers approximately 24 billion annually by keeping pairkts patients out of the costlier health care settings. Congress was the leadership fortunately, congress was the leadership of the subcommittees chair and the foresight to include mandatory funding to expand the reach of the nations Community Health centers in fact Affordable Care act to ensure the promise of coverage was met with the reality of care. We believe that things as planned is essential. Unfortunately, the Community Health Center Expansion is not on track. A recent sloisation for grants anticipates spending just 20 million of the 300 million in new fiscal year funding, fiscal 13. The Administration Proposed spreading out growth over a much longer period of time, and we urged that the full Affordable Care act provided increase for fiscal year 13 be immediately extended to care for 2. 5 million new patients as congress intended. The demand for Community Health centers continues to outpace the growth, and more than 60 million Americans Still lack access to primary care. In vermont and New Hampshire in the near term, all 19 Health Centers have identified needs in their areas. Id be remiss if i Department Support another program that has medical homes for underserved americans. The corp. Places Trained Health professions in Health Shortage areas and is a key partners ensuring they lead to demand for primary care thats looming just around the corner with the aca implementation. Community health cementers around the country are ready, willing, and able to be leaders in reforming our health system, community by community from the ground up. We appreciate the leadership and look forward to your and the committees continued support working to provide meaningful Health Care Access to all. Thank you, mr. Chairman. Thank you. Senator enzi, introduce the third witness. Thank you, mr. Chairman. It is my pleasure to introduce toni decklever, a resident in chaiian, biggest city, of 66,000 people. We have 259 townsing but we only have 14 towns where the population exceeds the elevation. [laughter] shes familiar with all of those, and she currently wears several different professional hats, a Government Affairs liaison for the nurses associations and visited washington, d. C. Previously to add vo kate for fellow advocate for fellow nurses. Shes improving the work force by recruiting and preparing individuals for careers in trade, technical, and skilled occupations, including health occupations. She trains individuals in cpr, first aid, medication administration, and how to become a first responder. She has a bachelors of science degree in nurses from the university of northern colorado, and is a certified emt. Shes receivedded a number of awards for Outstanding Service on behalf of the wyomings nurses and Work Force Development groups, and pleased to have her here today. I know in my weekly trips to wyoming, it takes 13 hours in airplanes and airports to get here. Thanks. Thanks for being with us. Thank you, thank you for the opportunity to testify today. I do represent the wyoming nurses association. Ive been a registered nurse for almost 30 years, worked in acute care, long term care, education, and administration. Wyoming is the ninth largest state in the u. S. With only 100,000 square miles of land, but our population is the smallest in the nation with just a little over half a Million People. Wyomings frontier of rural environment impacts our Health Care Systems. Wyoming has 25 hospitals, 16 designated as critical access hospitals, 25 beds or less. Theres two veterans hospitals and 16 rural health clinics. Theres eight Community Health centers, three special population Health Centers, and three are satellites of larger Health Care Centers. Dealing with the extended number of patients and barriers to care for the parties, several components have to be considered. One is the aint for providers to be able to practice to the full scope of the education and license. Another is addressing the shortage of providers due to retirement, and a shortage of qualified faculty to educate new providers. Theres the exception of quality of care and support funding for rural areas. With boomers turning 65 at the rate of 10,000 a day, theres an increase of demand in health care in acute care settings as well as expansion of nonhealth care settings like long term care. Wyomings practice act allows advanced practice, nursing practitioners to practice independently in our state. This ability helps nurses provide patients in rural areas access to primary care. Unfortunately, some federal laws and regulations limit the nurses ability to practice at their full scope. A quirk in medicare law kept aprn from signing home health plannings of care and from certifying medicare patients for home health benefit. In areas where access to physicians is limited, this prohibition led to delays in home Health Services. Moreover, the delays in care inconvenience patients and their families and can lead to increased costs to the head care system. This occurs when partes are unnecessarily left in institutional settings or readmitted after discharge because they did not receive proper home care. A sufficient supply of nurses is critical in providing our nations population with Quality Health now and into the future. Recommendation steered nurses and advanced Practice Nurses are the backbone of hospitals, Community Health clinics, school Health Programs, home health, and long term Health Programs and serve in many settings. According to the 2008 National Sample of surveyed registered nurses, one million of the nations 3. 1 million nurses are over the age of 50 with a quarter of them over the age of 60. In populations like wyoming, the provider population is aging and near retirement age running counter to the older population and regional growth of younger populations. Studies identified the retirement of providers is one of the obstacles to providing comprehensive care. Wyoming responded to the increasing need for nurses creating a funding stream that would assist nurses to continue education and work as faculty at the Community Colleges and at the university allowing the nursing programs to increase enrollment numbers and, thus, educate more registered nurses. Rns are continued to educate into the advanced nursing practice level. Theres a small amount of loan repayment money for students, but the dollar amounts do not meet the demands. To fill this void in funding, some students are able to receive funds from title 8 and title 7. The perception that health care also is delivered in bigger Health Centers equals quality is not easily overcome. Many residents are using Health Services in surrounding states who could have been served in wyoming. To address the issue, one report suggested ways to recharacterize the system by having a stable supply of primary care providers, have appropriately located centers, integrate services at the point of care, medical home concepts, collaborative planning, and policy implementation, effective use of pooled financial resources, shared responsibility for achieving goals for individual health, and organized leadership that keeps the states responses to changing needs. Theres eligibility for federal program like 330 funding and enhanced reimburressments. Shortage areas and medically underserved populations are based on factors that make it difficult to prove the needs of the underserved in rural and frontier areas. As noted by senator enzi, one provider for 3500 people an urban setting is different than 3500 People Living in a county thats almost 10500 miles of land mass. Wyomings economy is based primarily on energy production, coal, natural gas, uranium, and wind making it a boom and bust economy. People working in the Energy Industry make a sufficient salary when working, but in some cases, the salaries are insignificant enough that is skies the arch income for families based on statewide data. Some do well financially, theres a number of people struggling to make ends meet. This income disperty can be another challenge to meeting designation guidelines. Committee members, thank you for your time and attention to the very, very important matter, and i look forward to any questions you may have. Thank you so much for being with us, and thanks for your testimony. Our fourth witness is dr. Andrew wilper. Hes the acting chief of medicine at the Va Medical Center in boise, idaho. Hes a practicing general internist. Hes the associate Program Director for the boise internal Medicine Residency Program and the assistant directer of the boise va center of excellence in primary care education. Thanks very much for being with us. Thank you, chairman sanders, Ranking Member enzi, and members of the committee, a great honor to testify here today. I was asked by senator sanders about my insight, two insights specifically, one about the lack of Health Insurance in the United States and its effect on health and Health Care Outcomes and share thinking on Practical Solutions to the primary physician care shortage we face. To start off, theres literature that is accrued over decades demonstrating a lack of Health Insurance is associated with decreased access to health care, and worse Health Outcomes. Theres a six volume series earlier this century, and the conclusions were clear. Subsequent work built on this evidence including my own that senator sanders mentioned in his opening statement, specifically, a paper published in 2009 in the american journal of Public Health linking lack of insurance to nearly 45,000 deaths among adults in the United States annually. The research is consistent, Health Insurance leads to significant benefits, and its good for your health. Gaping accessing gaining Health Insurance does not guarantee access to medical care, second part of the testimony, nor does it control costs, and, maps. Singular innovation to make at the National Level to reduce costs and improve outcomes in the country with regard to health 1 bolster primary care work force. Now, theres an additional massive body of literature supporting the idea that primary care improves all sorts of Health Outcomes and lower costs. Nevertheless, weve not seen systematic changes to alleviate the shortage in decades. Ill talk a little bit about the three policy levers that i see that this committee could consider to increase the number of physicians entering into the primary care work force, some of which have been referred to by professor mullan. At the medical school level, the period of time after which people graduate from college, in the undergraduate medical training, introduce additional educational debt reduction, change funding streams to emphasize primary care, and increase funding for the service corp. In addition, direct support to Community Health centers to insent vise students to enter into primary care careers. Second point is the area of graduate medical education. First, title vii funding is earmarked to go towards primary care programs and continuously under threat of cuts. Its been cut in the last ten years. Reemphasizing that funding is an important step. Second piece would be direct payment by medicare to Teaching Hospitals for to offset expense of training physicians. As we heard today, nearly 10 billion is spend by the federal government to support these hospitals. Currently, we have no planning in place to actually meet the needs of our population in the United States with regard to a physician work force. Medicare should direct funding to residency programs for education rather than directing it through hospitals. Medicare should require assessments of community and regional physician work for fore for hospitals to qualify for funding. Its run by Teaching Hospitals to meet their own staffing needs or historical staffing needs, and graduates select a field of practice based on personal interest to emphasize a point made moments ago. I was told that the concern is the professional trainees rather than Population Health needs. Perhaps the most important policy reform that we could make to reinvigorate care is to address the paid disperty between primary care physicians and specialists done by raising primary care physicians pay or decreasing that of specialists. I fair its the disperty thats the driving force in this work force problem that were facing today. Indeed, the American Association of medical colleges declared education and training cannot overcome the intense market inacceptabilityives that influence incentives that influence decisions. Despite this, our current acts and includes a network for a decade in medical education as a student, resident, fellow and now faculty member with a Residential Program and its my conviction that publicly sponsored training should be planned to meet the Health Care Needs of our population rather than the staffing needs of hospitals or lifestyle preferences of young doctors. Thank you very much, dr. Wilper. My understanding is that they well, thank you, mr. Chairman. I mean, i guess, that would be a yes. Youre talking about the compensation you probably heard my comment earlier about the return on investment in terms of loan forgiveness for primary care physicians. What would that look like . In other words, i know we do some loan forgiveness in aca. We do for people in underserved communities. What would that look like and how could you compete that in terms of the value that you would get back over the course of his positions courier if you said okay, if you are agp 100,000 off of your love. Have studies been done to do that . Has that been like that . Senator franken, thank you for the question. To my knowledge, theres no systematic review of that connection. In my home state of ohio, neighbor to wyoming which is exceptionally rural, we offset related education and those have been somewhat successful. Revert to my palace to my left dr. Reinhardt, a medical economist, may i ask you that . [inaudible] microphone, please. Apis primary care physicians whove accessed in the institute of medicine studies shows that will produce Better Health and life fears and we convert that to quality adjusted life years. Usually the assumption is imputed to die. Normally i know david cutler and others use 100,000 to put a value on it and then say that having more physicians in that field and providing better access, how many qualities have you produced, lives saved or better quality of life and you would get a return i suspect to be fairly high. I would love it if that could be done. In the senior thesis ill ask the students. Ive just got two minutes left in that ill just go. Thats all you have left anyhow. I was making the same point. Id like is three seconds back. To senator murphys question or comment about the status i think your status is partly determined by your salary. I think the relative value portraiture talking about. I cant remember the name right off. Another countries, what is the compensation like in terms of general practitioner to specialists . Is it different . Is it lower . I mean come a ratio higher from gp to nationalist in other countries versus here . Specialist you earn more. For instance in germany, but not as much as they do here. So they generally have lower pay and protest about that, but i dont think the ratio is quite as large. Baylor Health Care Cost and his good outcomes if not better, right clicks a half, yet. Senator murphy brought this set. Accountable care organizations, which we have a lot of in our state and health care homes, medical homes, would they elevate the role of general part kushner in that model in the sense they would be sort of organizing this team that does the care . Does anyone have an opinion on not . Specifically with regard to tco, unless feeforservice mechanisms are changed and theres a proposal to do that in the same medical home models adventure capitalist system, there is some chance i would move the needle in terms of primary care physician reimbursement. I would caution however i know this research fairly well. There is limited evidence that medical home are going to reduce costs. And so, i think that intervention, while worthy and merkin at the state level and within the va is still in my view experimental. Okay, id rather mr. Chairman for the good just one last thing. Ms. Decklever, i thought it was really off base for the Ranking Member to use your willingness to come here to testify to moan about his weekly cameo. [laughter] let me introduce the man who saturday spokane, reintroduce him. Dr. Uwe reinhardt is a professor of political economy and professor of economics and Public Affairs at Princeton University and contributing New York Times economics blog. Dr. Reinhardt, thank you for being with us. [inaudible] i am very honored. I should have added that i was delivered via midwife and of course my mother. I once told that to a member of the American Medical Association and they said well, it shows. Im not sure what he meant. I divided my written statement into three parts good one is their current workforce efficiently used and i think your party hurt from the panel answers. Effectiveness by Public Policy levels does the congress has given that we want more primary care physician to admit them into that field and also to practice. On the third question is to what extent can Financial Services be used, which are pretty talked about. The model of work forecasting have been the focus on population ratios as if all of the other people who work in the primary care team didnt matter. My whole career has spanned to say we should use nonphysician workers far more imaginatively and let them practice independently and full competition with physicians was very controversial many years ago. Many states are allow that. The congress has played a very large role in innovating in this field by funding the training of Nurse Practitioners and physician assistants and also creating Community Health centers in either settings for they can very, very effectively be used. There are issues congress could address. Usually the lacing plaintiffs excuse, professional licensing with appeal to patients being quality. Usually the violins come out when i hear that. I think its mainly over economic terms. It always has been. Her member whether optometrists could dilate pupils. It was subtle, but those are the issues, almost an insurgent war that has to be fought. The congress should simply make sure that licensing is driven by clinical and economic considerations, patient quality and not by economic terms. Theres an issue of the sop is, scopes of practice, which now states dominates and has huge nations do not. I should there be a standard sop for the nation, which in my view essay said, should allow nurses to practice independently. Physicians assistants by their nature are supervised by physicians. On the second question of how can you drive physicians to the extent you definitely need them in these teams into a primary care is the issue of prestige. Senator murphy mention not. Maybe one i is the new models of primary care, medical home, acos, et cetera will quite naturally enhance the professional power. Its not just money. Its also power because they are not gatekeepers, but nevertheless traffic cops. In those settings i told that to her daughter who is an internist yesterday. Id be excited to be a primary care physician. The entrepreneurial opportunities are limitless fair, much less other specialties. On the final point, i had some controversial things. Compensation is clearly an issue. Mr. Chairman, he mentioned over a lifetime a specialist gets two to 3 million more. Its such a small from when you think of a managing dirt if they were the annual bonus, but that probably would do some because its a single value to people. Debt forgiveness, i think should definitely be done. Its really sort of like the National Health service corps. For every year you case or you could say if you go specialized in primary care, well forgive you 80,000 that firm. For every year he specialized in a location that we would like you to go, well forgive you 20,000 come assertive to have that incentive out there. Finally, when i think that we are actually allowing private Equity Managers to take what is really just earned income, a commission and get Capital Gains taxes on the interest, why dont we honor primary care physicians in america as we honor private Equity Managers and give them the same rate if they go to rural areas, et cetera. The president exists. Congress has we want to encourage capital formation. Well, that is capital. Physicians are Human Capital and we want to encourage. Thank you, mr. Chairman. Or reinhardt, thank you very much. Last but not least is dr. Dr. Claudia fegan, chief medical officer for the hospital county and chicago, often referred to as cook county hospital. She was previously the associate chief medical officer for the ambulatory and Community Health network and intra chief officer for the Health Services. Dr. Fegan serves for the Health Program received her undergraduate degree and her medical degree from the university of Illinois College of medicine. Thank you so much for being with us. Thank you, senator sanders, senator enzi another distinguished senators for 40 minutes opportunity to address inadequate assets in the United States. As chief medical officer, known to most people outside of chicago as cook county hospital, to confront on a daily basis the countrys failure to provide universal access to health care as array to which i believe everyone is entitled. Every single day people without insurance sign up to see hundreds of people a week, tens of thousands a year stand out in the wee hours of the morning, hoping to be one of the 120 to 200 people will be seen that day, even better, whether 12 patients assigned a primary care physicians and given an appointment so they wont come back. They hope to be one of the lucky ones will be given a physician of their very own. Our current influenza epidemic highlights vulnerabilities of our patchwork for help or delivery. Too few people in this country of access to a primary care provider. Primary care providers could educate them about influenza and need for influenza vaccines especially vulnerable populations and those in contact with populations. Then their primary care provider could given the vaccine. Instead, tens of thousands of people present to emergency room sick of looking for help. At the peak, or emergency room with the 450 people a day for hospitals around the city and country closed their doors and went on bypass. At cook county, we never go on bypass. We never close our doors. We created the rds system to compensate physicians for cognitive effort in the care of patients. It was hoped that would begin to level the Playing Field between primary care physicians and procedure they specialist. Yet the rvs update test annually was reviewing how medicare compensates physicians for care provided is only allocated for primary care when reimbursement rates. We want to increase the number of primary care physicians, but medicare funds graduate medical hospitals can we disperse a thing about for a Plastic Surgeon as a primary care physician. If we increase hospital reimbursement for primary care physicians in training, over specialist in training will have more primary care physicians. You could do that. I have to say have the privilege of being a primary care physician myself. I love taking care of patients. As one of the most fun things they do. My patients invite me into their lives as they teach them to take care of themselves and get what they need. The daughter of a Labor Union Organizer and social worker he couldve never been able to afford medical school. I was fortunate enough to be a member of the Health Service corps, which beat from a medical education, sorcery to make a decision to follow my passion and become a primary care physician without having to worry about how to pay off loans. Any ctu, if medical students know before they begin middleschool school will have no debt, theyre more likely to make a decision of primary care rather than compensated specialty. The burden is a product of our nations fragmented dysfunctional system of financing hot care with multiple private and public payers including each with its own set of rules. The coffee had workers in primary care physicians is enough to drive major distraction or profession. If we would enact a singlepayer Health Care Program for everyone is entitled to health care is a right, we could focus on delivering care, best care in the world to patients and release positions require to ensure proper Billing Services or providers. The stresses on physicians are tremendous with the implementation of the Electronic Health record that forces them to spend more time looking at the computers and their patients. Most systems today were designed to enhance efficient building, not care. As a result, hideous documentation burden sounds precious time from the physicians they would rather spend engaging with their patients and understand their needs. Theres no question its redesigned bph it too further clinical care, wouldve developed a very different tool. While its true theres elements improve patient safety, theyre far overshadowed by demands of administrative documentation. With this narrative of the individual patients cooper of the pointandclick documentation in the film are efficient. I urge you to return it to difference, not for me or you, but the patients have the privilege of serving who desperately need elected officials to care about what happens to them. Thank you. Dr. Fegan, thank you very much. Let me begin the questioning. I want to ask two brief questions in my five minutes. My understanding is if i have the flu or not emergent and walk into an emergency room, it will cost medicaid Something Like 10 times more than rocking it to committee Health Center to visit my primary health care physician. My understanding is theres millions of americans who hesitate. I know this is true in vermont. People get sick, i think its going to get better. They wait months and months, a year to walk into a doctrine of dr. Says violence years six months ago . Guerrilla element got to get you to the hospital. How much money and human suffering is taking place in this country because people are unable to walk into a Doctors Office when they need to . Who wants to respond to that . Dr. Fegan. I can just tell you about the faces of the patients who line up to be seen at our walkin clinic on a daily basis and i dont know how you measure the cost of human suffering, but we see always people come to county because hell say things shall never see anywhere else in the world. Such advanced stages of disease in people with everything from brain tumors to solutions eroding from the skin. You say why did you stay home . I was taught you, these people are working folks. Is there taxidrivers, college professors, countess, attorneys. The first thing they say to me is i never thought id be here. Id never thought id be a county. I would say it has to be in no exaggeration millions of dollars we lose in the first product tbd as well as in suffering. I see so many patients who get cancer, Breast Cancer and was their jobs and come to instigate further treatment. Theyve lost their homes, many of them by the time they get to us. Were trying to figure out how to get started on chemotherapy and find someplace to live. Comments im not . Yes, thank you. I know from the stories, just in vermont, i cant put a dollar equation to it, but we have a Farm Worker Program that goes out to the farms and works with not only seasonal farmers, the farmers who are coming in for care, we have a 50yearold farmer who has a history with diabetes has never seen the doc are. Dont know they can get care. A lot of it is enrollment into understanding both cultural issues as well as being able to get them into care. Let me switch in touch on port issuing terms of how we determine reimbursement rates for the physician. That is the rock which i think probably is not a household word throughout america and it is an organization which plays an enormously Important Role in determining how much specialist would like, how much primary care physicians would like. We have an organization kind of loaded topheavy with people in the specialties in terms of representing primary care physicians. Is this an important issue . When we talk globally about the area of inequity and how we get a handle. Medicare is the largest single payer and many private payers pay off in a variety of ways, managing the medicare conundrum around the pay gap would be essential to reform and the whole system. The rocket that the center of it. It is well wired msn of its been this way in a long time and theres a variety of approaches to it. I think just in time, daylight, focusing on this you have lurking the question is do you raise the floor or bring the ceiling down . Both will raise all kinds of issues for people involved in philosophically and politically as well. I believe its both. Were not going to pay primary care physicians thousands of dollars a year. When i hear about a physician making 500 or a Million Dollars a year, yes theres people in business from college class, et cetera, et cetera. Its a moral argument for me to engage this country. Dr. Wilper, you had some strong words on that. Thank you. I do have additional thought and specifically the practice by which the rock evaluates billing codes between the different subspecialties and primary care. This process could be improved by reevaluating the evaluation and management of cpt code. An example of this is as follows. The nontechnologists will build the same code for a 10 minute exam with very little followup needed. A primary care physician who performs rebuilds the same code generally spends 25 to 30 minutes with the patient facetoface come has 25 to 30 minutes to scare documentation and followup in an estimated 20 to 30 minutes another reimbursement for those two services are identical. What we need is a new code and primary care. We need to get our Knowledge Base regarding this issue. This current time estimates for these goods are outdated to the 1980s, 25 years old and small sample sizes. To develop an independent process for code that is transparent, peerreviewed and based on real world data. Dr. Reinhardt, briefly. Yes, the rock determines relative values, not absolute values, it is a zerosum game at this budget neutral. That could put more primary care members would be a good idea. But medpac had also proposed that there be an outside committee, an independent committee of stakeholders who audit and review the recommendations. I dont know if that ever went anywhere, but i would encourage you to look at it and maybe go that way. Thank you very much. Senator enzi. Thank you, mr. Chairman. All began by asking in your testimony you describe some of the challenges that frontier states face and qualifying for federal grants to improve primary care access and the workforce. When is to be done and what can we do to make the process better . Senator enzi, members of the committee. The information from the Community Health centers refers back to the number one advocate death of nation. So it is the number of people per provider rather than the amount of space for those people are located in. The other thing that sometimes are disparity in states like ours, where we have lower minority populations, just by the nature of our state is sometimes those designations were put out of the running as it were because we just dont have a high enough percentage of minority or different types of ethnic background and then the wage disparity, were the average statewide data states that the designated areas are financially in pretty good shape. If you were to look at the overall where we have many people making money and sun making very little, it skews the average and to maybe look at that type of data in those types of figures of size designation goes. Thank you. Ill ask the question of view and ms. Kuenning, what is the collaboration between the federal government and State Government agencies, must effectively deploy the resources, how come he avoids duplicate efforts . Thank you. I know that at least i can speak to vermont and New Hampshire in terms of expecting not just the National Health service loan repayment providers, but also a loan repayment dollar. There are restrictions on how you use those resources. It has to be within shortage areas rather than a new a and n. U. P. If we can get a change in the federal government, states like vermont and New Hampshire who dont take federal funding or loan repayment penn state loan repayment, but no federal loan repayment, and actually would be very favorable. Senator enzi, the federal programs are quite different, ive spoken to the issue of medicare, which i think is you would not issue a contract without a deliverable, without spes thinksty and i think oversight there is lax. I realize thats not the jurisdiction of the committee. Inevitably, speaks to the issue. In regard to the title vii program, these are programs that support educational activity for primary care physicians for physician assistant and the title viii programs for Nurse Practitioners. They are managed fairly tightly. They use a nih grant award system which is federal project officer i think theres good super vision. The schools feel its too tight. The National Service core is a relationship, of course, with the individuals and happy my over the used to be many individuals who bought out, didnt serve. Thats been tighten with the federal legislation. Thats extra indemnity if you dont serve on the citizenship or loan repayment. Thats managed tightly. Theres an area in general a good accountability across the program and no doubt room for improvement. In general its pretty good. Thank you. My time is expired. I have written questions more detailed. Im requesting your answers. Thank you, senator enzi. Senator warren. Thank you. Like senator enzi. I would like to followup with questions about Community Health center as vehicles for delivering primary health care. Its their impact on access on costs and on disparity. And i was very interested. I read through the testimony and very impressed by the work you have done, its terrific work. I was very glad to hear about the work thats done out in wyoming you have Community Health centers there. What i would like to know is what else do we know about them . Any of the dimensions either as i said about cost, access, reducing disparity. Can anyone peek to that . Doctor your head snapped up. Im guessing you. Sorry for that. No. I like it. In addition to my work i work at the Community Health center in boise, idaho. And my cernes provide a critical safety net for the uninsured of our valley. I live in the treasure valley. The uninsurance rate for the population is nearly 50 which is actuallily second highest in the nation. My experience in that clinic despite the access it provides oftentimes there is what we end up providing is care that at least in my other job at the va we wouldnt find acceptable. We wouldnt have other resources to offer. Because they dont have insurance. Even though they have a foot in the door at the Community Health center. Oftentimes they are unable to Access Additional Services that would be standard of care in any other system in the u. S. [inaudible question] is your mike phone on . What we found when we provide access to primary care we uncor specially means. One of the big problems we at the hospital one of the major challenges is the patients have nowhere to go to receive the sufficients and refer them to us. So i think that community hept center Health Center are invaluable. They offer care. Theyre more flexible. People who dont normally have access to care receive access. Then they have nowhere to send them. And we are the safety net and its a continuous tension we have with capacity in meeting the needs. Dr. Mullen . Thank you, senator warren. I have been working for twelve years at the Community Health networking. About two or three miles from here. And what what i saw there daytoday was a population that were not the Health Center would be in the emergency room. There were not private providers in the neighborhood, and to the extent they were, they werent prepared to deal with the needs, the language needs, the support needs of the population. And Health Centers unity here in d. C. And others around the country have tbhilt hard wired in socialwork, Mental Health, and a variety of services that typify the kinds of needs our population had. It represents at best a one stop shop which is the spirit of primary care, particularly in tune to the kind of neighbor and the kind of population youre working with. As i said, without that the emergency room would have been the recourse if care was to be delivered at all. Thank you. I was characterize vermont were working redesign and financial and Delivery System. The cms cms are part of that. Part that have is financing which is do some kind of shared savings or global payment or bundle payment and youre going change with regard to the Delivery System in turn of thats through the relationship with Mental Health and specialists youre not aligning in term of your governance. You are i lining with regard to the total medical expense. You are responsible for the patients expense. Its changing the way were doing business. Were not doing it based on the volume of care. Were doing it and being paid based on value. Its being done at many places. Black stone valley is a great example. Im sorry the senator left. Its a great example how they redesign the visit to have the providers working at the top of the scope, bringing in more assistance to the nurse and Health Centers physicians and they saved over 1 million just in one Community Health center. Looking at total medical experience. But that requires having Electronic Medical records and clean data. So you can see where your patient goes. At the Health Center you have a medical record where they have come to see you. You adopt have any experience in where theyre going in term to the hospital, emergency room, or Mental Health. It aligns the thinking of both phenomenaing and financing and delivery for ourfacients so were thinking about the total medical experience and making interventions that matter. Both in term of the outcome and finances. Thank you. The estimate that weve got a 24 billion savings from the current Community Health centers. And part is coming from keeping people out of Emergency Rooms and part is coming, i assume from integrated care. As dr. Reinhart talks about. Different kind of providers. But its also coming from the innovative approaches. Right. And a lot of the patients that are medical home work in vermont we have a concept called the blueprint. Its think abouting Chronic Care Management and how do you take somebody who has a higher privileges of something and manage their care to keep them out of the emergency room . Keep them out of the hospital and inpatient. As well as returning to the hospital. So its about really focusing in on the patient rather than Delivery System. Right. Thank you. I apologize. Thank you. Senator baldwin. Thank you, mr. Chairman. They are observing mentor and teachers with different level of an ton my. Did different level of flexibility. I think about the difference in experience in a setting where theyre modeling a patient Center Medical home. Versus other settings for service more traditional payment systems, you know, how much is there mentor and teacher on call . Every other night . Is if more recent . Im wondering about the level of knowledge how these noncompensatory factors play to the Decision Making to specialize or go in to primary care. As students have the observations and looking to the future of way we design medicine. I wonder if you would start . Thank you, senator baldwin. Could we spend the afternoon on this . I would love to. I will be quick. [laughter] the culture, as i call it of medical cool and Teaching Hospital over the years has developed a reductionist researchor gent oriented. All have that element. Some do better in term of local accountability and focus. I would like to see every medical school have a work force plan. I travel often to medical school and say what is your geography. State school do better in state. Thats vague. What a school has a fiduciary, a focus, they do better. There a number of schools that do that. Southern illinois be an example. An model in the change of culture is a osteoporosis medical school in phoenix they do one year on campus for the basic science and they take the class for the last three years and distribute them to one of 11 Community Health center and they do the teachings, the clinical medical center. There are other experiments underway. We have ten leading university that dont have Family Practice departments that saying thats somebody elses problem. These issues are core to the economy of the country, the health of the country, and the nature of the physicians that we produce. And i think in general medical school have not taken this as a challenge. Theres a great deal that can be done and spend the afternoon on it. Thats just an example of possibility. I dont know if any other of the within witnesses would like to comment on this. Particularly interested in knowing how much do we know about this . Rather than the antedote sharing we hear . The foundation in 2009, i think, or even later published a comprehensive report on the issue on the whole work force issue, and lifted these financial factor. One is the background of students. People from rural areas are more likely to go there from innercity people who sort of demonstrate they are interested pane through the admissions process you can do probably rearrange the classes. No guarantee, nevertheless, you could go there. You could part is, of course, the culture ive read about that also that one of the senators mentioned youre too smart. You shouldnt go in to primary care. One way perhaps to do this is to graduate medical educate support. Most economists dont actually think its warranted that actually these residences of cheap labor to a hospital. You could differentiate and give the Teaching Hospital more if they develop programs that specifically culturize students in to this. So the residency is in Community Centers and that they have first rate faculty who do mentor them. I think medical schools react much like everyone else to the money. I think through the direct graduate medical education and indirect at them without really asking much in return. Thank you, senator baldwin. Senator murphy . Thank you, mr. Chairman. I worry a little bit about our toobility micromanage this problem. I think a lot talking about is incredibly important. But whether its rate setting or loan forgiveness programs, im sometimes more attracted to ideas that sort of reset the marketplace itself to give the marketplace more reason to invest in primary care. And one of the themes we talked about is what this new Delivery System that is potentially based on bigger systems of care, accountable organizations, more physicians working for salary, rather than for feeforservice that it may lend it may help solve the press teeing issue. If youre in charge of specialists instead of referring tout specialists. You feel a little bit about your work. Theres probably also a theory that says if you have more primary care doctors working for organizations rather than working on their own, and you have an aco getting a big bundle payment to take care of a big group of patients, then aco is going actually be incentivized to pay the primary care physicians more. Its going help them manage their cost and help them keep the delta of whatever they save. And you already see that happening. You see more pry primary care going to work in hospital. I guess i pose that as a question here. Is there a potential that as you shift a Delivery System to have more integrated systems of care. More Accountable Care organizations, that there will be an incentive for the organizations to pay primary care doctors more. Separate aside from decisions that we may make on reimbursement. And maybe ill put it to the economists first as to what dr. Reinhart what you think ultimately the shift in deliver i are system Delivery System may mean in the rate of primary care doctors get paid. The hope is that it will do examplely that. The bundle payment, ideally there should be bundled payment for care that somebody is in charge of managing the money from that bundle, and will realize that having a heavy except of primary care is cost minimizing and therefore profitable in that way. I want to talk i once talked to a group in north texas medical group, and they were an integrated ipa connected with the computer. Who took risks. The hospital piece was done by Pacific Health care and they did the medical piece. I think also the drugs. And they told me they had already tilted the fee schedule internally of primary care substantially and paid the specialists less because they were at risk for a captaination they got. It might be worse to talk to them. They are now actually an aco. They were one of the first pioneer aco. It might be interesting to talk to them or invite them to tell you what they experienced. Doctor, you express the skepticism based on literature. Aco are different. What do we know about the ability of aco with perhaps primary care specialists, primary care doctors elevated to get cost savings we havent seen in the early rollout of medical models . To my knowledge, we know actual very little about how acos will reduce cost or what their effect on cost will be. What we can look to is the mogd of care where i practice in the va which is the ultimated integrated care model. We have people for live after they return from service and do a good job of taking care of them. As i understand i dont know the literature in the entirety. We provide care that is of similar or better quality to most private institutions in the United States at cost that are lower. One final question, you have a provocative statement about the interest of the ama may be serving here. Can you elaborate a little bit on that . Im happy to, thank you. So my personal position on this is that this subcommittee of the ama wheedle power over the physician rate setting. I know, were trying to get away from that. But the federal government is sending out a clear price signal to students about what they want what the federal government would like them to practice in. I think to minimize that, its a little bit dangerous. My personal view is that physician groups treat public payers as if they were own Entitlement Program rather than a source of coverage for the u. S. Population. Thank you, senator murphy. Senator casey. Thank you, mr. Chairman. I have two questions. One would be more specific in the second a is more broad based for the whole panel. We appreciate your testimony. The specific question, ill direct it to dr. Mullan or anyone in between that wants to comment. Health care as it relates to children. Our child advocate remind us that in the context of health care and otherwise children are not small adult. They are different. We have to treat them differently and have strategies that recognize that reality. When we were going through the kind of june july, or may july gay about health care in the bak we worked together and it was the lead on this. To Design Elements in birl to speak to the reality. We had one in particular that spoke to the work force and section 52. 03 Health Care Work force Loan Repayment Program establishing a Loan Repayment Program for pediatric sub specialists and providers of the mental and behavior Health Services to children and adults who will be working in Health Professional shortage areas. It goes on from that. There was our intent, we were successful in that, but im wondering in the now were beyond just the stake and we have a piece of legislature which is in place and continuing to be implemented in the broader topic of primary care, are there steps we need take to make sure that that primary care physician and the services and treatment that come with it are available for children . And are doctor, i dont know if you have a thought about that . Thank you, senator casey. Your observation about children are, of course, one point. Children are more vulnerable, they are poor, and more underserved than the rest of the population as a matter of analysis of the benefits that come to children. We are definitely weighted toward the elderly in term of benefit public benefits. And that creates a challenge particularly with the aca principles in trying to be inclusive and bring kids in. I think were optimistic particularly with the Medicaid Expansion where it occurs kids will get good benefits or better than in the past. The specific issue in pediatric generally the notion of primary care does not include subspecialty. I think probably a more correct notion is underserved more underpopulated discipline which primary care is the heart of it. There are some general surgery. We have a growing trend of shortage. Pediatric subspecialty. The argument is made. I dont know them well. They have stan substantiated there theres not the tend there arent as many Training Programs a when probably need more. The spirit of the legislation that was encouraging that i think makes sense in term of Work Force Development. I wouldnt want to seat profile well over twothirds of adult internallists or specializes and going hospital medicine. Hospitallist which is a good development, it takes them out of the primary care field. Its that challenge. Pediatric had a good market. The medical students like it. They tend to go in to it in large numbers. Its not short. The advantage point of chicago in the pediatric work force. [inaudible] the issue of peed yak pediatric specialist the number are specialists that are pediatric that are available at general hospitals is very low. In dhij we actually have i would say a glut of pediatric hospitals the special are generally available. I know, that in a more rural community, this is a tremendous challenge in term of providing access for those children. Complicated children who need multidiscipline support and so providing those services for them is increasingly difficult today. So encouraging people not only to specialty is not that they are underrepresented they are poorly distributed in term where the area of need are. Ill hold any second question. Anyone in the middle fifteen second we have . Want to comment on the question or not . Ill put a question on the record because were out of time. Thank you. Thank you, senator casey. Let me conclude by thanking the senators who participated in the hearing. I think the large turnout tells you howe seriously many feel about the issue. Most importantly i want to thank all of our panelists for their wonderful testimony and to tell you we are going to listen very seriously to what you have to tell us and i esspecially want to thank those who came from far distances. Thank you for your help. Okay. This hearings is adjourned. [inaudible conversations] glmpleght coming up next a National Journal forum looked at medicare costs. Then senator speak on the conformation of senator john kerry to be the next secretary of state. Later well reair the Health Subcommittee hearing on the shortage of primary care physicians. Coming up onment next washington journal, a look at the newest push for Immigration Reform, secretary carlos, a member of the super pac republicans for Immigration Reform will be our guest. Wednesday a hearing on reducing gun violence, retired astronaut marc kelly husband of Gabby Giffords will testify before the Senate Judiciary committee along with the National Rifle association. Live coverage starting at 10 00 a. M. Eastern on cspan. One cant count the times that americans say were the best country in the world. What a stupid thing to say. Of all the countries in the world, everybody thinks that the country is pretty good. Why do we have to believe that were the best . What does that what does that mean . And why do we have to assert it all of the time . And what does it mean to other people who consume it . American. They go around the world so they are observed by people in every corner of the world. And we teach them not like us. Author, activist, and transafrica founder Randall Robinson taking your call, email, comments and tweets. Three hours live at sunday noon eastern on booktv on cspan2. Next a look at efforts to decrees medicare cost without cutting benefits. This event hosted by National Journal is just over two hours. [inaudible conversations] good morning. Im i want to welcome you to the morning policy summit building a higher performing medicare system. The folks in the room i want to welcome the live stream video viewers. So we can have your full attention. I would ask you take a moment to silence your cell phone. We do want this to be a lively discussion. We want you to tell us what youre doing this comment. We welcome your comment and discussion. We will be coming around during the q a portion of the event with the microphone. We ask you state your name and organization before asking the question. The policy summit would not be possibility without the support of the American Medical Association. Here this morning we have dr. James who serves a executive Vice President and ceo. Prior to joining the ama an accomplished physician, medical scientist, served as the professor and chair of pathologist and Laboratory Medicine at the emery University School of medicine before assuming the professorship and deanship at university of Chicago School of medicine. [applause] thank you, good morning, welcome. In the news gallery here at the museum, youll find an archive newspaper from july 31st, 1965 in it will be a banner headline with a photograph of president Lyndon Johnson signing medicare in to law. We are almost a half century later in that same structure, and there are concerns about the program as needing renovation. So today we come together to ask how congress and the Health Care Community can Work Together to reimagine the Medicare Program to ensure that patients get both high quality care but also in a Cost Effective way. Well hear about new payment models, the need for timely and accurate performance information, and also the need to include physicians that are at the front lines in delivering care to medicare population. Physicians and others in the Health Care Community understand the urgent need for reform and the urgent need to Work Together toward the end. The ama, along with several physician organizations and specially organizations, 110os in all have drafted a framework for what is needed and how we can come together to resolve the lingering issues. This framework outlines core elements essential in transitioning to a new care and payment delivery knowledges. Models and principle of the framework include the dwo. Model that reflect physician diversity in practice, geography specialty, one size will not fit all. Secondly, model that reward physicians for innovation that improve the quality of care and lowers the rate by which cost grows. And thirdly, concrete ways to measure progress. And the show policy makers that the physicianers are accepting accountability both for quality and for costs. This approach, we believe, is sensible and represents diversity of physician practices, patient population, and Community Needs around our nation. And as you leave today, this framework will be available to you. And while new efforts to shape the medicare system must move forward, we also know that Real Progress cant be made until the fatally familiared sgr formula is repealed once and for all. This long standing and lingering problem perpetuates the annual threat of cuts that this stablize physician practice, erodes confidence in medicare within and limits access for our patients. These reality post obstacles to Widespread Adoption of the kind of Innovative Care and delivery models needed to reinvigorate our Medicare Program in the service of 47 million americans. Our work to build a strong and sustainable medicare system is just one effort by the American Medical Association, and making and shaping a Better Future for the physicians, patients, and our nation. We have embarrassed embarked on fiveyear strategy focused on three critical area to the future of health care. First, to improve patients Health Outcomes and reduce health costs. Second, to accelerate innovation in medical education to align physician training and education with the combined of environment kind of environment that will actually experience once the education is through. And three, to enhance practice sustainability. By helping physicians adopt delivery and payment model that makes sense for the practice, the patient, and the communities that they serve. These are big and ambition goals. We believe theyre the Foundation Upon which we will contribute and fulfill the mission of the ama, which simply is to promote the art and science of medicine and the betterment of Public Health. We know to meet the challenges of Todays Health Care environment, it has to be done as a group. We must all participate to make a difference. And this morning the National Journal is gathered experts to share their ideas on what is right and what is wrong with medicare. Why we must adapt and adopt now so question dont accomplish that which cant be accomplished by any one sector of the Health Care Industry alone. So i want to thank you for being here this morning. And i look forward to the discussion give the nature of the participates. Thank you very much. [applause] thank you, doctor. While we are starting to set up here for the first panel. I quickly want to give you a run down of the program. We are going have three distinct panel. The first is leader in health care followed by a second panel focusing on positions and finally a panel of experts who respond what has been discussed. Moderating all three panels is maggie fox. Maggie ask a Senior Writer on health on nbc news. Com. And today. Com. Before joining National Journal, she was Global Health and science editor for riters she established an Agenda Setting file. Joining maggie we have dr. Paul. Dr. George maison university and the honorable gail senior fellow at project hope. Maggie . [inaudible] [inaudible conversations] good morning, thanks everybody for being here. I would like to thank the panel for being here. As the Program Points out these are three of the deepest thinkers on Health Policy issues in the country. Im representing the shaling low end of the scale here. The to balance it out so you can see the stage is tipping. [laughter] pretty hard. Its a metaphoric. [laughter] i think doctor said a good tone in the opening comment and i think thats probably a good way to get to our discussion is to ask about these points he raised especially will the f and perhaps transition to ways we can get physicians, patients, and insurers more on board with improving medicare. And how medicare can lead the way. I know, you have very specific thought on this subject, but dr. Ginsburg, i love my job. I can call people doctor. I know, it will be safe. Doctor ginsburg whats is the best way to get physicians better involved in improving care via medicare . Actually i think the main strategy longterm is not so much to have individual physicians interact with medicare in new ways, but to have physicians join organizations physician organizations working for hospitals, where the organizations will interact with medicare. Contracting with it as an Accountable Care organization for payments rather than somehow twisting medicare feeforservice to a prism to be evaluating individual physicians for the quality and efficiency of the care theyre giving medicare patients. So in a sense, i think that we need an organizational interface intermediary between the practicing physician and the Medicare Program. By organization, what do you mean . , i mean, it could be a medical group a multiSpecialty Group, it could be, as i mentioned an Accountable Care organization where at least physicians and, you know, according to the law has to be primary care physicians at the core of it. Whether its a physician organization, independent practice association, a group practice, or could be a hospital. With either employment relationships with physicians, or contract yule relationship with physicians. We are an individual by agree im going to be part of the Accountable Care organization. Im going accept some of the risk. Ill be accountable. I really see the future of physicians with medicare as developing organizations to they would their allegiance to and their accountability toward and the organization interact with medicare. Dr. Im sure you have contrasting thoughts on this area. Actually this is an area where dictionally there is a lot of agreement both among policy people and with the practicing Physician Community and other participates in the health care Delivery System. That is for way too Long Health Care in the United States has been volumedriven and not enough attention has been paid to how to improve quality, how to improve e fresh sei, and the issue is how to try to get from where we are to where we need to be. There is a larger payment that covers a evaluatorty of services it would allow them to focus on the general purpose of the visit, the hospital stay, or the home care visit and not be too focused on each individual item tied by the billing system. Physicians have long been in a very different world. They bill for some 10,000 different item, the ctp codes. They have stayed with very disaggregated fee schedule that was attempting to keep spending in the aggregate at the specified limit by the infamous Sustainable Growth rate that the doctor referenced. And everybody ended up being frustrated. Physicians because they felt con constrainted in term what they could do by what they could bill for even if that was the best combination of Services Taking care of somebody with complex diabetes. You want to be able to spend time counseling them or have somebody in the practice with them. You dont want to necessarily have to focus on is it something i can bill for or find something i can bill for . And so trying to figure out the best way to be in a position where they can take good care of their patients and not fight the billing system is really the issue that we are dealing with. As i said directionally theres a lot of agreement about what that would look like. The specifics about how to help move physicians who have tend to be in small single specialty practice units to a larger group like paul was describing, either where there are groups of physicians or the physicians are tied to hospitals or they are part of larger integrated Delivery Systems so that they can focus on taking care of the parents and patients and have the measurement and performance be more fairly measured in terms of whether or not their parents have good clinical outcome and its done in a reasonable costly way. How to make that transformation is where were stuck now. And lot of different ideas figuring out what actually works is going to be the number one job for the next few years. And not a very easy one. It will be actual getting our hands on d. A. , deciding how we have to adjust for the different populations that were under consideration or the different mixes of physician and understanding what we have learned is not going to be easy. The positive way to look at this, is it is a lot of agreement among people like threat of us, but also but the broader Physician Community and in the leadership, that where we intend not a good place to look to the future. We really do have to find a smarter way to provide better, more Efficient Health care to the american public. Doctor, i think it is true theres almost perfect harmony when it comes pointing out the problem. The hard part is figuring out what we can do in reality. Given our current political climate. What are some of the realistic goals you think can be achieved . First of all, you should buy good bourbon. [laughter] , i mean, talk about political goal. I would pick on where gail left. What gail was describing was fundamentally how to get physicians engaged in world we know Everybody Knows we have to move. We know which to go. We dont know how to get there. I would say its simply no one showing physicians the math. We havent written down the math. We havent worked it out. Its going to be different in South Carolina than rural arkansas or seattle or boston. Its a diverse country. You want to listen to physicians. The doctor said it well, the sgr is is hanging over their head. We need to get that away. Because they cant focus with that sword. The second thing, listen to what they complain about. Whey hear complaints about is how much spend they doing documentation that improve care. Thats called bull shit. You think of multipayer solutions. We spend too much time and lord knows we had to in many cases. Spent too much time trying to drive the Health Care System through the medicare fee schedule. Its the single most important piece. It turns out they get paid by other people there are 1300 members of how many can you name . Thats the point. So they have to get paid by all. What i have to figure out how can you have multipayer arrangement so they can spend less time on documentation and more time on patient care . I think we need focus more on responding to and joining local initiatives. To me, one of the most exciting pieces of the Affordable Care act full experiment is innovation challenge grants. They basically said to the country. You tell us how you want to be paid how youre going to document what youre doing to improve patient care. Three thousand applications, three thousand applications, that means three thousand different groups of physicians, hospitals, came up with ideas about how it make our system better. Where say that live and work. My favorite is one is new york. Why . In rod chester they have everybody at the table. The hospital, the health plan, the medical society, the doctor who run the community voices. Employers. What a concept. Private employers. Every commission i have ever met, and im old enough to admit quite a few. All of them want to be paid for what they do and n one way. They want to have one set of incentive, quality reporting one set of Feedback Group so they can focus on patient care. How do you do that if you cant get the payer to agree. Not so much on the level but structure of the payment. I want medicare to figure out how. I know, they are smart enough. To join local initiatives. Where they are worked out already. Among the multiple private payers and have medicare join the party. Bring their d. A. , and bring their flexibility to adjust and adapt the incentive structure that the locals have figured out. And you look at new york and you have a great example. I think you thoughts. I want to add something to what they said. I think we are at the very exciting time for anybody who has been in the field for a long time. Im optimistic for the change that the fact that the leadership of medicine and hospital and insures are all saying the same thing about what we want to get away from. We want to get away from fragmented volumedriven care. And were a little vague what we want to go to and its going take awhile to figure it out. My sense is that this is going to be a journey where its not that we decide something is not working. Well get rid of it and go back to where we are. If its not working were going come up with ways of modifying it and fixing it. I think we are well established on journey map. Its not going easy. But the fact that theres such a consensus envision among the different stakeholders which is encouraging to me. To what degree can the Affordable Care act get us there. What is in it that is ghood what is missing . The part that is good and important if the u. S. Is that most people starting in 2014 will have Insurance Coverage. This has been a serious problem at all levels for the country its been embarrassing for for a wealthy country like ours to have so much of the population without Insurance Coverage. Its been difficult for the people in the institutions who provide care to people when nay get sick, and this has been a country where you get sick enough by law the hospitals at least have to take care of you. And many of the physicians and the Community Also have been providing services. So it will be important that we will substantially reduce, not completely eliminate. Substantially reduce the number of people without Insurance Coverage. What the Affordable Care a act has done is to set up an environment in which there is support and encouragement for new innovations. The center for Medicare Medicaid innovation is sponsoring some of these. She mentioned one, the change grant. The carriage danger that i see and worry about is that in law medicare payment stays exactly as it was the same fractured siloed paying for volume not for performance system that weve had. There are some very small movements in the law so that there is a little bit of reward that will go hospitals starting in 2013 and starting in 2015. Theres something called a value modifier that will tweak physician payments for large groups and everybody. But basically these are not large changes. These are tweak at the end of the tail of the payment scheme. What we need to be vigilant about is that we drive the changes that bubbling up to become part of medicare and medicaid reimbursement. Thats going take some doing. Weve had some experiences in the past where we be get promises idea and innovation that start and tend petter out. And it is going to be bringing the dynamic change that is being tried and various part of the country either as part of medicare or part of larger communities, little hard to imagine what new york is pulling off say in miami or new york city, for example. And who has the responsibility drive . Em is it the local organization . Cmf . That really is going to be one of the hardest questions. Cmf within the advantage the medicare and medicate is when if moves forward, it moves forward in a major way. I used to love when i was running medicare being called the 800pound gorilla. The fact is there are huge constraints with how and how fast medicare can move. The wonderful part about the private sector is it doesnt have to play mother may i . In order do a Accountable Care organization, congress had to pelter physicians in hospitals to come together and share savings. This they didnt they would be violating the aint kick back provision. The privateer sector has been doing Accountable Care organizationtype activities for the last four or five years because it didnt have to play the mother, may i routine. The point is, that the public and private sector are going to have to figure out how to do this jointly to allow the innovation of the private sector to feed to the Decision Making of the public sector. Now theres nqf or n cq a that the Quality Assurance group in many ways provides an interesting model because by being fundamentally private, but with the cmf or hhs, one of the members they had the government at the table but without all of the constraints of having to do it as a government activity, which means every single change has to go through the administrator procedures act. Regulations have to be written. They have to go through a very complicated procedure. Finding a way for the public and private sector to come together, Work Together, and then when the results seem clear either for an area or for the country as whole, at that point make it national policy. But it really is going be this figuring out how to move together. There are things that each sector can do best. I want to go back to who is responsible. I think that is, in many ways. The question. The answer is all of us are responsible. Thats why i love the rochester model. Everybody is at the table. We have to figure out how to get everybody at the table. In any other opinion. Physicians have to lead this because at the end of the day, people dont trust health plans. People dont trust government. You can argue there good reasons. No situation can enable every dock to be at the table. Ly say there have been occasions when physician leadershiP Organizations were not helpful every moment of every day. Ly also say that physicians have to take ownership of the stewardship we have to provide. How are we going make our societies afford the Health Care Question produce . Only if we make our system far more efficient. The only person playing the blapsing ang with the trust was benefit of the welfare. We have to have the doc at the stable. They to learn economics. Im said to say what they know now is more is better. Its not always. More was better when you pay economically. The problem with that having all of us being responsible is you frequently that means none of us are responsible. Making sure we can hold accountable the major payers of which frequently are medicare and medicaid and also the private system the big employers is going important. Making sure that the public gets involved which is frequently not been the case and they also feel like they are part in partial to the activity not something we have been known for. Thats another point bring is patient involvement. I think everybody agrees patients cant sit back and. One of the limiting factors of the Accountable Care organizations as theyve been officially construct forked medicare is they fundamentally do not include the patients in any direct way. I think that is a fail flaw. But i dont think it is necessarily a permanent issue because Accountable Care organizations medicare may be a transitory phenomena. They may be a way to get physicians to Work Together. It may be a way to get physicians in hospital who havent worked together in the past to come form units and then become more stable organizations that actively involve and enroll patients. We cant get the patients involved. Its going hard to solve the problem. I completely agree with you. We need to have physicians much more involved than have in sometimes. But maltly if we dont get the patient in there actively at all levels in terms of the Health Care Responsibility and financial involvement, its hard to get the problem solvedded. I agree more. We missed a huge at any opportunity by not building in patient incentive in the Accountable Care organization structure. We cant give a physician, the patient a positive incent toif stay with a group they pick. Cant be thats crazy. We should have that sort of thing. Thing is a disease that congress has had far long time. That despite everything that is happened in health care in private insurance, they still want to completely medicare beb fish beneficiary from all type of responsibility whether its financial or others. I think it has to change. Perhaps from strong, successful model in private insurance showing very constructive ways of engaging patients. Two patients part of this group are recognizing compliance is a major issue in the treatment of diabetes. And so, it wasnt just encouraging physicians to do everything they could do to keep these patients in good health. But encouraging the patients to be compliant with other medical advice that they were receiving. For some of the groups that are offering a financial or nonfinancial and sent to membership two different groups if they comply with various bonus strategies. If they engage in exercise, if they are engaging in nutrition classes. There have been at dvds to try to encourage the cessation of smoking and to keep it in an ongoing race and its not only stopping in this case a negative act to video smoking, by making sure people continue has been a real problem in the past. So it is the use of financial or not financially todays to try to provide people with information they need, with rewards, recognition to try to make them feel that they are part and parcel of having Better Health outcomes. Not this passive participant but even good health and outcomes that you the patient can participate in. Getting to focus on the Health Outcome and not the health care input is really just a different way to think about it. And it means starting early in the schools, getting kids in schools to think about it. We see little glimmers of hope with the emphasis on undernutrition in the School Lunch Programs and not using it just is the way to dump some surplus Agricultural Products into the schools, but focusing on proper nutrition and starting very young with the importance of nutrition and exercise. I grew up on that, but i also want to add, we need consumer patient and put him in the signup process and structures. I know the hot but on seattle, virginia mason, that was going to have a major expansion in the surgery wing and they basically brought in patients with recent patients to talk about what was bad and that design is far more patient friendly and popular far more effect is and generates Patient Satisfaction as well as outcomes. The second thing is listened to patients and offices. I was at a conference of people in medical homes all over the country. They had a patient in the room. Hey, what a concept. Im afraid to ask a question. You need to make sure a know how to use this inhaler. Im afraid to ask you. And eventually its about learning to listen and bring the listening and to the design of your processes so you can generate your care and get a more engaged and i had surgery a mullet primary care. I want you to continue with your thoughts, but were going up into questions from the audience as well. If you at least say who you are and stand up to it or question, theres a couple questions over here. Qaeda, the caroline, a practicing primary care physician. Weve talked about lowering costs and improving results. Every other country in the oecd has health care for everyone. They get Better Outcomes and at least 30 lower cost. There somebody here from the embassy of the netherlands. Why dont we ever talk about that . I mean, thats a model up and running and its decentralized. Well, we do talk about it and we spent a very long 2008, 2009 and half of 2010 trying to decide what would work for this country, which is much bigger and more diverse than the netherlands or street or norway or countries who talk about. I dont know whether what was passed in 2010 is going to work very well or not. I have doubts about some aspects. The positive as i said earlier is that it goes a long way to ask an Insurance Coverage to almost all legal citizen in the u. S. Immigration reform does occur, that will open up another group of people who were left out of the Affordable Care act. Doing it in a way that works for this big diverse country is tricky but something referenced earlier. It works in one part of the u. S. May not work in another part. Its not that other countries dont have this issue, but think about the Health Care System that would work for the e. U. But the closer model in the Health Care System that works for the netherlands. Thats a thinking one of our larger state, adopting it. So it is recognizing weve taken one step in terms of expanding coverage. We are still struggling with how to get a more efficient outcome orient to Health Care System and its going to take a lot of changes over the next decade or two decades. Weve been having these discussions in medicare since its inception, which is now roughly 50 years. This is not going to get salt because one piece of legislation was passed. Health care reform 1. 0. Hang on, the rest is coming the next decade or two. Dr. Ginsberg. In our history weve had in this country that cannot Health Systems abroad because of ideology. Msp terrible if its not ours. I think what is happening is weve identified a whole range of more technical issues come you know, how to pay organizations, individual providers, how to engage patients that can cross boards. I think that theres an opening to learn more from what is working in other developed countries now than there was before. I think they are learning from us as well, even though our statistics are very good compared to other questions. I think theres opportunities here that didnt exist before. Another question right here. Thank you. Mike miller, Health Policy communications consultant. I was involved in a somewhat similar involvement in a project in cincinnati with the brought together stakeholders for the last two years to make good progress, but its only happening in a few places around the country had with five dozen hospitals or five or 600,000 physicians getting spread with these innovations in the innovation tenor is really going to be a challenge. Youve been doing this for a few years. Inevitably have more provisions coming to be ineffective, there could be backlash. This is a work of a slowdown, delay. Can you talk about how to get through the inevitable months well hear from different provider payer group that we cant do this, and this is hard. Which another sixmonth coming year, two years, five years. Dont do that reporting. Thats their job. At some level thats what we need because galas rate. We wrote 1. 0. We need 3. 0. Thats what you need to make it better. I take your point about cincinnati, rochester, grand junction, colorado, but the shirts is we dont need the whole country to do it on their own. We do need are good examples we can show everywhere. Figure out what works and i was sick and her point. Its going to be hard, but figure out what works and then spread that. Or maybe, what a concept, hold two, three different models that we know work. Pick which one works for you and its going to be different in different parts of the country. I think this is going to be a fun. [laughter] because a lot of this is voluntary in the sense that a lot of organizations are coming forward, seeking to contract with medicare or private insurers, but its pretty much all voluntary now for now. But i think it can save voluntary longterm because just the fact that its voluntary, working only with volunteers constrains the way these things can be done. You know, the fact that eventually were going to have to assess what is working, make sure theres different ways and areas of the country to meet those goals and transition to something that is more mandatory so that this is the way to do it. And this is where i think sgr is going to come in. I think sgr has been a major policy error when it was developed to basically creating an incentive structure, where the people at risk had no way of succeeding and then loading it on with better performance and thats where it got to where we are the sgr underscore in the just hasnt enabled to figure out how to get out of it. But i actually tank the transition keeps feet to the fire. Brings more physicians into new ways of delivering care is we think we know that week ago. If you will work this way, participate in new organizations, then youre excused from sgr. At least members of congress can say we finally figured out how to deliver care under medicare more efficiently, so we are ready now to try and titian. You raise an important point that the losers in the system will start screaming that a murderer and i can tell you now what theyre going to say. Its the evil government or evil private payers are keeping me from providing you, my paycheck come with everything you want and id be only too happy to provide you even if there is an empirical evidence that will improve your Health Outcomes. That is going to be a struggle because you can expect in the show if theres going to be real winners and real losers and theyre going to be lobbing grenades and its always going to be patient quality is suffering. Maybe if we have better information and statistics we can at least try to push back. It just isnt so that Patient Health is suffering because of the change systems. This got to expect its going to happen because there are going to be winners and losers in this new way of delivering health care. Speaking of winners and losers, weve run out of time for any more questions and for this panel of thinkers who are clearly deep talkers as well. [laughter] you all have presented their interest being and compelling ideas. Thank you so much. Our next panel will be physicians to take the heat youve handed out. He put the feet to the fire. Lets see if they kick you back. Thank you so much. [applause] id like to thank our distinguished panel and if not if not he said, welcome our second panel which is focused on sessions. While we set the stage, im going to announce who will be joining maggie for piano number two. We have dr. Edward g murphy, president of medicine, Virginia Tech school of medicine and dr. Grace terrell of Cornerstone Health care. Maggie, back to you. Thank you so much. You guys have a lot to work from, a lot of things thrown out there. Probably the first and most obvious is well fixing the sgr fix a lot of this struggle or have we been focusing on such an intransigent problem and maybe it wont be so magical if congress does all this. Dark or train to come youre sitting next to me. I think is clearly an issue for patients who have medicare coverage. I dont think fixing the sgr fixes the problem. Id like to take off on what type are in a cool site to get physicians involved is the key to this, the key part. From our perspective, the way you do that is provided with this sounds. You dont loathe the burden on individual providers. You dont have someone on the own to figure out how to do with chronic disease management and how you figure out how to save money in the system. You provide them assistance to do quality measurement can measure quality and report to doctors on quality. You support them in their absurd to achieve those qualities and many provide them assistance to do the management, to do the management that we all know has to be done. We have to get away from the individual encounter. It has to be a team of people who are taking care of a panel of haitians and it means nurses, physicians assistant, part dictionaries, administrative staff are working together to care for the patient not only when the patient is in the. His office, but also when the patient is at home, other areas of the medical care system. We have to develop systems to do that. In our world, weve done some of that, generated some systems they seem to have save some money and in truth quality. Part of the way weve done not a family weve and innovative relationships with Medicare Advantage providers and insurers who have been willing to fund upfront those systems because theyve seen in some of the pilot areas weve done it on the backhand, hospital utilization, office kinds of things decrease in this net savings to the system. Ill take a little issue with dr. Nichols when he referred to the one primary care. I think the primary care doctor is the key to all of this. The relationship of the primary care doctor, the ability of the staff of the doctorpatient to relate hopes to get the patients involved in it a system that works better than a fragmented system in which the patient has a relationship with 12 different stations, none of which he or she is particularly close to. An access for this engagement going forward. Dr. Terrell, youre at the ground level doing this. I am a primary care physician, a general internist. An 89yearold haitians have been seen for 20 years back in november was someone medicine. She lived alone. She drove, she was sharp as a tack. She got probably the word virus over christmas or before then and rather than coming to my office or she couldve gotten iv fluids and had inexpensive care, she called her friend who took her to an emergency room with a pertinent to pulmonary edema and then she had a stroke and ended up in the nursing home and then she fell, so when she showed up my office last week, she was in a wheelchair and her sons were trying to figure out what to do about her care. She wasnt talking straight and she was on 20 medicines, 19 of which i stopped. But you know what, we all make money off of that. Ill bet you that was 30,000, 40 minimum of profit in our current Health Care Providers pockets. What to make sure we talk about things like sgr and valuebased care to rethink about her patient because she did not take it care in my opinion. Everyone is doing what they thought was the right thing and everybody made a lot of money. So the primary care physicians may be one solution to it. Its going to be crucial, but it will require far more than that. Im a physician. Im also chief executive of zurich of an organization thats a Specialty Group and we decided to go for it. A year and a half ago we said were going to go ahead, change all of our contracts, invest at least 25 million into putting the care transformation models and figure out how to contract with everybody, medicare and everybody else in the new system to see if we can do a better job with this. The interesting thing about that is how very hard that is. Its hard to get capital if youre an independent group as opposed to a hospital, the original acquisition machines and they should be back in the 20 century when it was about large ics and technology. Its hard to bring the payers a lot because theres much as everybody is talking about what we are to be doing, we are still enough profit novel in the daytoday world by returning to innovate. My organization has not been not hard to bring physicians believe it or not someone has to keep telling stories about the patient like the one i just did. Patients will have delete this. Well have to go to the relationship between physician and patient and what we went to medical school to be about to become a endured in a system where everybody is about the patient again. Part of that in terms of getting skin in the game with a consumer model is to get them into the picture, too. The other thing in 1965 israel televisions with rabbit ears on them. Now weve got telephones and tvs and smartphones that we dont really talk about what we need to do to get our phones better 50 years later. We talk about what we have to do to get her help care system better. Its because the way we pay. Its going to be hard to get there. The mullahs are trying to get there. The only way were going to get there is to get everybody looking at the capital infrastructure, not just a sgr, but across the board and make a model that the Value Proposition , and the value migration happens if i can be a little economic out of the system we have for the profit value is captured and doing lots and lots of things that are quite bad for patients more often than not. Dr. Murphy, youre nodding your head. Yes, thats very observant. Ill deviate a little bit. Ill ask a question and answer to this i guess its a rhetorical question. At least in my ear ill throw my hat about which you have to do, what the solution is. A fair question to me is if there is that level of unanimity about a direction we should take, while a further down the road quiets the reason as, in my opinion, that the body of work we are describing we need to do is fundamentally different than the last 100 years of medicines has led us to. Safran as has been described well i think, driven by the reimbursement system, where transactionbased service system. We Practice Medicine in an individual, discrete billable transactions. There is thanks a cataract surgery which are appropriate. If you look at the Health Problems of complex chronic disease, which management of those patients does not lend itself to transactions. Its a longitudinal management problem, which means different work, Different Number structure, investment, different incentives, different employees, just a different model and approach. The problem getting there as we are blessed in what we had today. Everybody thought didnt. My friend len gave you his economic principle cannot it be mine which is everybody wants to go to heaven, but nobody wants to die. Youve got a lot of deeply rooted, wellfinanced, strongly held in pediment to getting there. Insurance companies with their motto, hospitals,. Areas, a very large cultural bias. Doctors who have been trained and ive gotten comfortable crack is seen in a certain way for two thirds of the courier, to start doing things fundamentally differently, spontaneously, voluntarily, to get doctors to do great work, but a Broad Movement of change across the country. It seems to me theres another thing, in my opinion, youre really only going to get there any Massive Movement over some short period of time if people become convinced the status quo is not a practical alternative and that gets to gales point that as long as its voluntary and we have disincentives, i mean, early doctors overcome tremendous hurdles, not just financial, but political and business infrastructure trying to negotiate payers. Even for people who are early curzon leaders and early movers, i think we need a cultural shift to say its important for us any real way became to do Something Different and thats going to create winners and losers in train stations and its going to be very hard. A lot of us in the news media have been writing stories about concierge. There is, concierge practices. People who can afford them flocked to the gun. Is there something they can do in the medicare model . And how does one do that . Go for it. If you talk about an economic model where people can have their own concierge person and a separate Economic System is one thing. But if you talk about meeting a patients name and do it in a way more comprehensive, it doesnt require that payment model. For example, some of the things we are doing right now in oncology is in cardiology is embedding psychology, behavioral medicine, social work, pharmacy, elitist care into his teammates cracked this. It is around what a particular patient will need. Our Medicare Savings Program right now can keep somebody out of the hospital and one of these teammates care systems and our heart function clinic here that the patients have to pay a copay every time. For some patients its cheaper just to get really sick and go to the hospital and spent 30 grandma to come in on a frequent basis and certainly we dont have an economic model yet that would allow us to go to the patients. I actually dont think the concierge model with the workers. A lot of whats going to drive the cost of care down as the smartphones and other ways that were completely bypass the Health Care System as its now construct it. Its going to be no different than the way the iphone basically distracted the odyssey Music Industry before. You had one model and someone came in with something far different. When you get to the application state of things coming up in the system that will have to be very different. The piece important and not as you can have other services. Its actually cheaper to the system, but you have to tweet the payment model and the waste of Global Payments and start paying for value as opposed to volume. The somebody mentionedli