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Health Overhaul Should Address Workforce Shortages, Hearing Told

By Rebecca Adams, CQ Healthbeat News

March 12, 2009 -- Consumers often complain about the difficulty in getting a doctor's appointment or the frustrations of long waiting room delays before a rushed medical exam, especially in the offices of primary care physicians. Now senators and health care experts are agreeing that the problems are a significant health policy issue that ought to be addressed in health care overhaul legislation.

At a Senate Finance Committee hearing Thursday, senators discussed how to change payment incentives for health care professionals, such as primary care doctors, and better train medical students. Four witnesses testified that unless significant adjustments are made, physician and nursing shortages could be made worse by legislation to expand access to health care because more patients will be seeking care.

"For health reform to succeed, we need a strong health care workforce," said Finance Committee Chairman Max Baucus, D-Mont. "Health care is useless without a workforce to provide that care," said Charles E. Grassley of Iowa, the panel's top Republican.

The decline in access to physicians has grown significantly in the past few decades. In 1965, there were approximately 150 physicians per 100,000 people in the United States. The current ratio is more than 270 per 100,000—less than in countries such as France or Germany but more than in nations such as Canada.

Workforce issues permeate the health care system, affecting providers, patients, insurers, and communities at large.

Students in recent decades have chosen to bypass opportunities to serve as primary care physicians because the job is often harried and pays less than specialty care. Many rural areas have a particularly hard time retaining physicians to do the work of caring for basic illnesses. Fewer than 10 percent of physicians practice in rural areas such as Montana or Iowa, while 20 percent of the national population lives in rural towns.

The issue is gaining more attention as lawmakers focus on the details of writing health care overhaul legislation. The Medicare Payment Advisory Commission (MedPAC) is expected to explore potential changes in a meeting Friday.

Experts testifying before the committee said the current system could be improved by changing payment incentives to improve the efficiency of the current physician workforce. They also urged the creation of a new federal commission to oversee and coordinate health workforce policy.

Allan Gorroll, a professor of medicine at Harvard Medical School, proposed that Medicare payments be changed so that doctors whose patients achieve desired health outcomes would be paid more and physicians would be paid a set amount for a particular illness.

Currently, physicians are often paid for each service that is performed, regardless of whether the patient gets better or whether the care is necessary.

Gorroll also proposed more generous financial incentives to encourage medical students to choose to go into primary care. As a professor who works closely with medical students, Gorroll said that every year students tell him how disappointed they are that the current system discourages them from pursuing primary care because of the lower pay and hectic schedules that lead primary care doctors to "do no more than triage" and send patients to specialists. He argued that Medicare should spend more on medical education.

One expert challenged the notion that there are too few physicians. David C. Goodman, the director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice, said that the problem is that physicians are not distributed in the best way geographically or professionally. There are too few primary care doctors, Goodman said, and too few physicians practicing in particular areas of the country.

But a high concentration of doctors, especially specialists, does not translate into better care. In many areas with a large number of physicians, patients spend more unnecessary time in the hospital and have greater problems with the coordination of their care because they are seeing multiple specialists who do not communicate effectively with each other about patients' treatment. Goodman called for a new commission to evaluate medical training. He suggested that the government should consider providing teaching hospitals more funds to focus on primary care training and higher payments for primary care doctors.

Grassley suggested that senators should find a way to redirect funds so that medical students get more training in clinics rather than in hospitals. The issue of changing the financing of medical education will be a focus of the committee as it writes its health overhaul bill, said Baucus. Changes to graduate medical education are "clearly on the table," he added after the hearing. "It's such a large part of health care. I don't know what the answers are yet, but it's something we will address."

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