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Waxman Wants Universal Coverage But More Doctors Too

By John Reichard, CQ HealthBeat Editor

March 24, 2009 -- House Energy and Commerce Committee Chairman Henry A. Waxman said Tuesday that a congressional overhaul of the health care system must not only provide for universal coverage but also for more primary care doctors and nurses to ensure that an insurance card actually gives the holder access to treatment.

"When our Committee takes up health reform, we will provide coverage for the uninsured," the California Democrat told a hearing by the Energy and Commerce Health Subcommittee. "However, I also want to make sure that our legislation addresses the barriers to access that insurance coverage by itself can't fix," he said.

Witnesses at the hearing suggested various approaches to improving access, ranging from sharply increasing the supply of primary care physicians and nurses, to strengthening Medicaid to addressing racial, ethnic and geographic disparities in access to care. GOP lawmakers stressed the need to increase the supply of doctors by revisions to the medical malpractice system they said have left certain parts of the country without access to specialists.

The need to strengthen the ranks of primary care physicians, viewed as essential to more cost-effective care because they can direct the overall treatment needs of a patient including better preventive care, was one of the biggest themes of the hearing. "Study after study has proven the importance of primary care," Subcommittee Chairman Frank Pallone, Jr., D-N.J., said in his opening statement. "Yet, two-thirds of the physician workforce practice as specialists and the number of young physicians entering primary care fields is declining."

"The United States is experiencing a primary care shortage the likes of which we have not seen," said Jeffrey P. Harris, president of the American College of Physicians. Lower pay is one of the biggest reasons, said Harris, who noted that the average primary care physician earns 55 percent of the average pay for other types of physician care. Harris called for "targeted annual increases" in the Medicare fee schedule payments for primary care physicians over a five-year period to make the field competitive with other physician specialties.

To make salaries competitive, "Medicare and all other payers would need to increase their payments to primary care physicians by 7.5 to 8 percent per year over a five-year period, above the baseline for all other specialties," Harris said in his prepared testimony. That would bring average earnings five years from now to 80 percent of those for other specialties. Annual increases of 12 to 13 percent per year would achieve 100 percent parity, Harris added.

Harris noted that increasing coverage would exacerbate shortages. He said that waiting times for a primary care appointment in Massachusetts, which is now inching closer to universal coverage, are now reportedly as long as 100 days.

George Washington University professor Fitzhugh Mullan testified that "hard work, low pay and 'lifestyle' expectations of medical graduates today have resulted in dramatic reductions in interest in primary care in U.S. medical graduates."

Specialists make up 63 percent of practitioners and primary care doctors 37 percent, he added. "This figure is markedly different than it was 50 years ago when 50 percent of America's physicians were generalists. In Canada today, by contrast, 51 percent of physicians are currently family physicians and general practitioners."

Mullan said the number of doctors overall in the United States is roughly what it should be but that geographic distribution is poor. In the United States some 800,000 doctors practice medicine, or 280 doctors per 100,000 people, more than in Canada, which has 210 per 100,000 and the United Kingdom, with 250 per 100,000. But "metropolitan areas have two to five times as many doctors as non-metropolitan areas" and "economically disadvantaged areas have significant physician access problems."

Title VII programs under the Public Health Service Act should be "reinvented and reinvigorated," he said, to create "incentives and educational pathways that will select and train students for primary care, rural health, diversity and social mission."

Mullan also suggested changes in Medicare's funding of graduate medical education. Modest changes could push Medicare "GME" more toward community-based care rather than hospital-based care, he suggested. Major reform would entail requiring teaching hospitals "to undertake community or regionally oriented analyses of physician workforce needs," he said.

Another witness, neurosurgeon James R. Bean, testifying on behalf of the American Association of Neurological Surgeons, said a health overhaul plan should address barriers in access to care created by flaws in the medical liability system. Bean noted that Democrats including President Obama, Hillary Rodham Clinton when she was a U.S. senator from New York and Senate Finance Committee Chairman Max Baucus of Montana have called for measures to counter the rising cost of malpractice insurance.

"In other words," Bean said in his prepared testimony, "those at the forefront of health reform understand that it will do little good to achieve universal coverage or even the most up-to-date health care IT, if the doctors who actually supply the care are being driven from the business, forced to retire early or shun potentially risky, life-saving procedures because of our broken medical liability system."

GOP lawmakers picked up on the liability issue. Rep. Joe L. Barton of Texas, the top Republican on the Energy and Commerce Committee, urged the subcommittee "to take a serious look at liability reform, as we move into the overall issue of health care reform." Barton asserted that a 2003 Texas law capping pain and suffering awards is bringing doctors back into the state, improving access to care by Texans "living in poor and medically underserved areas."

Michael Kitchell, president-elect of the Iowa Medical Society, described problems with access to care in rural areas. "Rural citizens make up over 20 percent of the nation's population, but only 9 percent of our nation's physicians reside in rural areas," he said. Rural doctors face lower pay and longer hours and vacancies for physicians go unfilled for years, he said. Recruiting won't improve until payment changes. "Physician shortages in rural areas are largely caused by Medicare payment policies that geographically penalize rural physicians," he said, adding that President Obama has urged "geographic equity" in payment. "I hope Congress will agree with President Obama: there should be geographic equity."

Brian D. Smedley of the Joint Center for Political and Economic Studies noted higher cancer death rates among African Americans and a higher prevalence of diabetes among American Indians and Alaska Natives, among many other racial and ethnic disparities in health status and in access to care. Smedley said that "no single policy—such as expanding access to health insurance—will fully address health care inequality. Health care disparities are complex and are rooted in many causal factors" that require changes not only in health care financing but also in health care systems and workforce development, he said.

Diane Rowland, executive vice president of the Kaiser Family Foundation, testified that Medicaid has improved access to health services among the most vulnerable Americans. "Drawing on Medicaid's experience and already substantial coverage of the low-income population offers an appropriate starting point for extending coverage to the low-income uninsured population through health reform," she said in prepared testimony.

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