good morning everyone basic care and are responsible for half of all patients miss it but in many parts of the country the a small business practices are becoming an endangered species today we will examine the currently stationed workforce shortage and discuss these potential impacts on health care reform this issue is of particular concern to our committee and not just because most you know our practices are small firms for one  and have the potential to undermine our work towards universal coverage in overhauling health care we're looking to provide coverage that is both affordable and accessible but we cannot do that without the necessary workforce in the last decade we have availability of doctors has dropped off can see that even for those with gold plated policies if care and trends continue the gaap between supply and demand challenges are most are more than an inconvenience some patients may choose to avoid checkups altogether that will be a dangerous consequence one that could blow and the benefits of universal coverage drive up costs over time primary care is preventative care and an effective effective means for reining in costs that is because a person who gets regular checkups is less likely to develop serious conditions down the road and considering that seventy five percent of health care expenditures go towards treating chronic illnesses primary care is critical to the current restrictions she thought it already posing a significant threat to reform reform will bring more on insured americans into default but it will not create more doctors to treat them take the forty six million nearly insured add an aging baby boomer population and you could be very well and that could be services serve communities the region suffering most from the caring shortage this body will soon take steps to transform our broken health care system i think most of all when i've read that it is about time the moving towards reform we need to be sure our foundation foundation is strong it is critical that we have a solid pool of medical professionals to see the process through today i hope we can look for ways to make that happen i would like to thank all of today's witnesses the not bands for the testimony and i am so pleased that they could join us i'm look forward to hearing from all of you and then this hearing was scheduled to start at ten but the small business committee have to be on the floor and they sent a late last night that we needed to be much early with that i will yield the ranking member graves for he saw opening statement thank you madam chair and thank you for calling this hearing on the supply of physicians here in the united states  i want to extend a special thanks to all our witnesses who are here today two thousand a university of missouri study found that the u s could face a shortage of up to forty four thousand family physicians general internists and general pediatricians in the next twenty years many of these professionals operate solo and small group practices small businesses under served urban and rural areas such as parts of my district in missouri with our growing aging population there is an increasing demand for health care services and there is a trend towards a coordinated and continuous care provided by primary care physicians and internists however during the past decade the supply of general generalist physicians has fallen by twenty two percent partly due to the reliance on physician specialists which makes our healthcare more expensive and less efficient the decline in general this continues as fewer medical students are choosing to practice and family care in addition there is evidence that physicians assistants and nurse practitioners may also be choosing to specialize in fields such as cardiology and oncology according to the government accounting accountability office conventional payment systems undervalue primary care compared to specialty care there is a growing income gap between primary care physicians and specialist several physicians organizations have recommended altering compensation structures to encourage medical students to become journalists the kaiser family foundation reported that in two thousand and seven u s health care expenditures exceeded seven thousand twenty six dollars per person surveys on satisfaction with health care mixed some experts believe that there is an over reliance on specialists and the greater use of primary care providers and in terms would lead to better outcomes at lower costs these physicians focus on prevention wellness coordinated care and chronic disease coordination studies show that these services can save money over the long term i want to add a final word about health care reform i strongly oppose employer mandates and a government run health care system these alternatives could cause as many as one hundred twenty million americans to lose their coverage drive companies out of the market and require substantial tax increases on the small businesses we're depending on to create jobs congress will consider these points during a debate and again i don't care thank you for neurosurgical here recently and understandably a great deal of attention has been paid to the shortage of primary care physicians but little attention has been paid to the shortage of surgeons  association of american medical colleges emits a shortage of forty six thousand primary care physicians and forty one thousand surgical specialists by twenty twenty five and while plans are being considered to address the primary care  deficit little is being done to address the shortage of surgical specialists the bureau of health professions projects nineteen percent increase in primary care physicians by two thousand and twenty based on some of the actions that are planned but continued and significant decreases in the number of surgical specialists over the same time at present there are fewer than thirty five hundred practicing board certified neurosurgeons in the united states  serving a population of more than three hundred million people and as the population ages more of our citizens devastating problem such as stroke degenerative spine disease parkinson's disease and brain tumors neurosurgeons treat supply demand mismatch will become ever more acute in addition the effectiveness of things like deep brain stimulation for treating movement disorders  and compulsive disorder makes it very likely that we're on the verge of a minimally invasive and effective neurosurgical treatment for things like obesity and addiction and because of the prevalence of these disorders many more neurosurgeons will be needed to meet the debate for their neurosurgical treatment we already have an acute neurosurgical workforce problem in the sub specialty areas of pediatric neurosurgery and trauma an emergency surgery there are less than two hundred surgeons certified by the american board of pediatric neurological surgery and within the next ten years more than forty percent of the current pediatric neurosurgeon workforce is centers in pennsylvania tennessee missouri illinois texas and florida were due in part to shortages of neurosurgeons and the national foundation for trauma care reports that after trauma surgeons neurosurgeons or specialists with the highest percentage of trauma care according to the same report physician shortage is caused by a variety of factors including medical liability expense decreasing reimbursement represent one of the major reasons for the closure  and with estimates that ten to twenty percent of the nation's six hundred regional trauma centers may be forced to close within three years it appears that neurosurgeon shortages are affecting the availability of trauma care in the united states despite the fact that more such drama and cerebral hemorrhage from ruptured causes while there are many complex factors that lead medical students to select one specialty over another there are several reasons for the present and impending shortages neurosurgical workforce one of the medical liability neurosurgeons continue to face increased professional liability insurance costs in some areas of the country now approaching three hundred thousand dollars per year according to a survey we conducted a few years ago medical liability issues contributed substantially limiting their availability for emergency trauma care and eliminating treatment of high risk patients and medical liability reform would clearly help address this position work or shortage lifestyle issues must also be considered as a contributing factor in the shortage of surgical specialists project practice patterns are likely to be different in the future because of a greater concern for lifestyle issues among young nurses may be able to address a shortage of physicians but there is no good substitute for a well trained nurse surgeons for patients with spine and nerve injuries brain tumors and other neurosurgical emergencies after graduating from medical school neurosurgeons trained for seven years or more before entering practice and there are less than one hundred euro surgical training programs in the united states with many programs training only one resident per year compound in this problem  put forward any of the details about one of the big problems in health care which already been mentioned by doctor shorty's and i think if we pick just one specialty to try to stimulate it's sort of like putting a finger in  that's got ten holes leaking we've got to do it for everybody and i know we hear a lot about the problems with american medicine and all things and we all agree and we're all committed to help reform but call your attention to the july fourth publication of lancet the respected british medical journal they published a comparison of cancer deaths in the united kingdom eleven countries and the united states using world health organization data bases cancer mortality in the united kingdom which has a federal program as everybody knows were twenty three percent higher than six year p n countries and thirty one percent higher than in the united states so my hope among other things is that whatever we that might be done in the similar void and on the other side of the june second publication the council of economic advisors of the white house embraced the concept of a thirty percent overage that could be money in health care costs by reduction in regional variation by what they call input changes and also by using the false claims act this is of course based on the dartmouth work of a respected investigators but there's four other groups including ours that find different types of data and that would be dr robert burns into the urban institute dr richard cooper of the work  school of business from the university of pennsylvania and our data from dr rick it seems short well there is some regional variation they're only comparing medicare and medicare is only fifty percent of the payers so it's like comparing apples and oranges it's not agreed upon anough to be a promise for health care reform the rest of my comments will deal with shorty just surgeons shortages in every specialty of surgery  today we've done population maps and show that some states are worse off than others but there's not a single state in the union that has more surgeons and they did ten years ago and that's also shown in the dartmouth that was one third of all surgeons are over fifty five years of age and specialization with surgery mentation and other types of technology increase has been monumental but to give some data the general surgeon is sort of the eighty the american board of surgery of which i was chairman at one time in one thousand nine hundred one certified one thousand and forty seven people last year it was one thousand and thirty two and in the meantime population the country has grown by twenty five million each decade we're all america with about twenty percent of the population fifty nine million people require on surgical services to keep their hospitals open that's what allows the hospital to provide the other services it's the backbone of the rural hospital there's thirteen hundred critical access hospitals in the united states and three hundred of them don't even have a surgeon living in the county the surgeon is not available the other service is pretty much  a further example of the shortage is cardiothoracic surgery cardiac disease is a common skill or in the twentieth century and will predictably be for the first part of the twenty first there are only fifty u s medical school graduates that are provided for primary care and others these things ought to be made available for all specialty not just primary care thank you very much for your attention and certainly available to provide maps of all the states and everything if you'd like to see them  to the small business committee today dr demarco is from my home town of area pennsylvania he is the hundred twelve president of the american osteopathic association he's also a professor and regional dean of clinical medicine and director of ophthalmology residency program at the lake erie college of osteopathic medicine in erie which we call the calm aside from his duties at least calm dr demarco is part of a medical medical  of competent and compassionate whole person care the percentage of our graduates who pursue careers in primary care is sixty seven percent placing in the nation for training primary care physicians but despite this commitment of primary to primary care the challenges facing our profession and our students are increasingly prohibitive central three central factors contribute to our current projected primary care workforce shortage and these factors also apply to general surgery medicare physician payment system graduate medical education reimbursement policies and time consuming administrative burdens that shift attention away from patient care with respect to physician reimbursement studies show that income disparities have a significant negative impact on the choice of primary care careers over specialties among the nation's young physicians this is not surprising given that the average income of a primary care physician is approximately one third of a specialist practice costs are of even higher unless congress takes immediate action to establish a more equitable physician payment system and predicted workforce shortage can only worsen congress to enact financial incentives for primary care physicians to provide a bonus of at least ten percent for primary care services with a mandate annual increases to achieve market competitiveness as you know the instability of the current physician payment system stemming from the flawed sustainable growth rate formula results in the threat of annual costs and cuts we with limited revenues and narrow margins to make difficult decisions about whether to lay off staff reduce their medicare patient population defer investments or retire early medicine is calling but the business of medicine is general in generally is a small business no business can survive with its expenses and revenues diminished rate of burdens create additional strains on primary care physicians resulting in a significant decline in professional satisfaction and hampering recruitment practices is particularly excessive detracting from the time available for patient care primary care physicians role in coordinating here making needed referrals to specialist typically involves frequent interaction with medicare and other third party payers to obtain required approvals services and payments and resulting in paperwork and overhead expenses that almost twice that of other physicians a typical primary care physician must coordinate care for medicare patients with two hundred twenty nine other physicians working in one hundred seventeen different offices no compensation for the care coordination services the away supports the development of a new delivery and payment model such as a patient centered medical home that will allow primary care physician provide comprehensive continuous patient care reforms to the graduate medical education training system are also essential component of work force development first the current graduate medical education system is not capable of meeting increases enroll and in the nation's colleges of us the path medicine college of medicine we support a modification of current limits on the number of funded residency training physicians through a one time increase number of funded positions by fifteen percent residents edition finally researchers show the physicians who are trained in a community health centers for example are twice as likely likely to work in under served settings and four times more likely to work in health centers after completing their residency however opportunities in the real world settings offered exposure to primary care specialties and increases the likelihood that residents will choose to practice in the setting and in small physician practices that make up the backbone of our primary care system and on behalf of considers health care reform as you know the vast majority of family physicians themselves are small businesses delivering care in communities across the nation nearly thirty eight percent of family doctors practice in solo or two physician practices and studies indicate that more americans depend on family physicians than on any other specialty we see up close the hardship of the uninsured and we struggle along with those patients who are insured but then who faced coverage denials we consider an expanded primary care physician workforce essential to the success of health reform unfortunately while the supply of primary care physicians is far from adequate the projections are truly alarming primary care has been described as the base of the health care workforce pyramid but the u s position profile is only thirty one percent primary care and sixty nine percent specialty the a f p supports the steps necessary to build the primary care workforce to at least forty five percent of all practicing physician to restore stability we must adopt workforce policies that ensure an adequate number of primary care physicians who are trained to practice in the conference a patient centered primary care medical home model that model of care provides patients with preventive care as well as coordinates their chronic diseases and appropriate care for acute illness to realize the quality and efficiency benefits of the patient centered medical home we must have an adequate supply a primary care doctors particularly family physician their reasons for the an adequate supply of primary care are many and we must address each one of these the first and most critical has already been mentioned and that is to increase the payment for primary care this will encourage more student interest in primary care as well as allow for the redesign of existing practices to improve quality and access the next congress should provide targeted incentives such as scholarships loan forgiveness or other forms of debt relief for medical students who choose primary care and family medicine also we are recommending opportunities for programs such as the national health service corps congress should reauthorize and adequately fund title seven health professions training grant programs for primary care medicine  has also called for reforms to graduate medical education payments to ensure that we are training the primary care physician workforce that we need however we would suggest caution with respect to the expansion of residency slots we recommend that unused residency slots be dedicated to primary care before an overall expansion of the number of residency slots considers we are grateful to the house discussion draft that it addresses the primary care physician workforce shortage with the provisions including the bonus payment for primary care services provided in health professions shortage areas  authorization a mandatory funding for title seven section seven four seven the health professions primary care medicine training program and the national health care workforce commission to study and recommend appropriate numbers and distribution of physicians we look forward to continuing to work on work force and other key elements of health care reform now is the time to provide affordable quality health care coverage the status quo is not working neither for the physicians nor for the patients we urge congress to invest in the health care system that we want not the one that we have now thank you very much thank  s doc for coming in from all the way from missouri morning thank you madam chairman ranking member gray's members of the committee i appreciate this opportunity to talk to you i do not represent the society or any other  issues to this issue particularly glad to come to this committee because most physicians traditionally have been small business one of the issues is though that we're seeing there changed dramatically and my community we're down to about a fifty fifty mix of it internal medicine and family practice being self employed most of them have joined some organization again i say i'm a drake traditional internist that means i do everything i go to the hospital i have an office practice i have a nursing home practice recently because of some of the budget issues i've i've added a long term acute care practice  so i know you're all aware that physicians are an evolution and an turners are an evolution particularly we have hospital as we have people who just do office work we have people who do none of that who don't practice active care there are many things that physicians can do now so there are many other opportunities competing for active practice again i think it's important to focus that w traditionally have been businessmen that we imply employ four to five people per practice we pay taxes we pay insurance for those people for a two man practice my health insurance costs for my employees are seventy two thousand a year i bring evidence to you that this george has been going on with since the one nine hundred fifty s when my retired partner got a call after the funeral of one of his patients saying one of your patients cannot now i come can i come to your practice so that brings us to the shortage i think we all agree there is a shortage and happy to hear that in all parts of medicine but particularly primary care why is that happened i think there are a number of factors the evolution the competition other venues the not of hours worked i give you mine but there you wouldn't believe them and the quality life becomes an extremely important issue for all of us we look at comparison the medical peers that's been talked about difference between primary care and such specially reimbursement is three point five million over your working life  you look at comparison of my neighbors they all work a forty hour week i work a sixty hour week and then i'm on call i'm responsible every minute eighty hours that's a great difference in quality and then we wonder why people don't want to go into medicine don't want to go into primary care on top of that we're asking people in primary care to do a great deal of gatekeeping i have to personally find numerous documents allowing other people to be paid this takes approximately thirty minutes every day i have to employ one full time employee to take care medicine issues pre authorization ends with insurance companies as study has been done shit that shows each primary care physician expands sixty thousand dollars to deal with these kind of issues that's one third of my south and it cost me one percent of my salary to come here today on my own dime so how do we fix that what do we do about it we've said that non physician extenders haven't been helpful they go on into such specialties working on equalizing reimbursement but the budget is an issue how do we retain present physicians one of the things is decreasing costs primary care can do that they've been shown to do that maintaining quality again primary care has been shown to do that there are multiple studies documenting that that those communities with more primary care physicians have a longer life span  services secretary some ten to twelve years ago say we're missing the boat we've got to do preventive care we're still missing the boat there's a lot of work to be done there and from my point of view that's the major area where cost savings can be entertaining thank you very much i would like to address my first question the fine made to dr hein you know that more medical training must have greater flexibility if we're going to increase the presence of primary doctors you know he thank you if i understand your question are you asking how do we the number of slots or the types of specialties that people go into man what you're saying that we need more medical training and in order to achieve that we must have greater flexibility if we're going to increase the presence of primary doctor when i when i'm asking these how can we achieve that goal without impacting or dismantling or affecting or posting new charming juice for our medical education  system slots that we have right now we have asked of those numbers of slots available for training in residency programs those right now are as you noted in your training so that more of those go to primary care that's a redistribution issue the other component is pay for the care that is done in the community part of this regulation change that can occur at c m s having to do with voluntary preceptors the third component is that we believe that that right now funding for training is primarily through government taken off important to note that there's only four specialty more applicants than they do slots and when you talk about unfilled slots most of those are in primary care fields and redistributing back to primary care  that clearly is a shortage of physicians and that includes primary care physicians but certainly is not restricted to primary care physicians there are cute shortages of surgical specialists and we can't simply say we have to shift everything to primary care and that will take care of the problem because it will exacerbate the surgical shortage is there some of the things that i think would be very helpful one would be to revise the cap on medicare support for resident training and that is an important issue where we're creating more medical students right now there are a lot of investment going into new medical schools and largely medical school classes but if we don't enlarge the residency training pool we're simply going to take students that are trained in the united states and they will displace students that are trained in other countries medical schools that now do their residency training here at the end of the pipeline we will have the same number of doctors coming out increasing the number of medical schools without  for the medical profession it seems clear the health reform cannot be achieved without short of placing a cap on medical claims depressed he then has stated he'd be a needs to be addressed as part of  next to caps except for caps unfortunately the caps are a great part because industry knew right away in the early days that workman's comp they knew how to deal with  set their prices the way they needed if there was injuries but without caps in texas for instance when they passed a law the malpractise insurance dropped by twelve and a half percent the next day now it's down by twenty five percent since that passes of caps so i think the caps are an important part of physician liability reform and that is necessary to attract students into specialties that reimbursed less i think the only answer is  cap like the california law three years ago west virginia's liability got so high that all of acute patients with trauma had to be transferred to pennsylvania by helicopter same thing happened in the vat a emergency session of the legislature was called to provide some it won't work unless you cap like california did and we appreciate the house has passed this many times it's a senate that doesn't seem to like it i mean i think determination of compensation where you'd have a health court model that would determine compensation and i think we can also do things like provide medical liability protection for physicians who follow established eviden evidence based practice guidelines if you are practicing to the standard of care even if there is a bad outcome then that shouldn't be a liability issue some minor things would be to protect physicians who volunteer their services in disaster or local emergency situation and i think going back to the cap some reasonable cap on noneconomic damages  on the economic damages to the patient but a cap on noneconomic damages is a very important piece of the puzzle the other piece is that in kansas there's an equalization pool  neighboring state in missouri as president but not funded by pay as much and doing no procedures as a gastroenterologist who is licensed in kansas who does procedures all day long there needs to be more equity in the way the with very extensive your illogical operation in the o r that made no sense so i had to start doing that service for my community because i simply couldn't afford so in some way if i'd like to address it from a local standpoint i mean the private practice model of surgery in the philadelphia area has gone away it's gone away because neurosurgeons are asked to pay three hundred thousand dollars per year for minimal liability coverage that's their insurance so by the time they rent and secretarial help and nurses record keepers and three hundred thousand dollars off the medicine out there to have the numbers i think there are always a lot more people who apply to medical school than get accepted and many of the people who don't get accepted i think would make very fine physicians and are qualified so if we expand the number of medical school training spots we will turn out more medical students who have gotten there and the problem right now is in order to practice independently all of those students they need to go on to do a residency if we don't increase the number of residency positions we simply displace foreign medical graduates with american medical graduates but the number of practicing physicians at the end of the day stays the same  you this when i was chairman of the association of american medical colleges right now sixty four only sixty four percent of the doctors practicing in the united states actually went to medical school here there's thirty two percent more positions in residency than there are graduates of us medical students the most of them come from india the second commonest group come from our offshore caribbean schools those eventually get licensed and if they go to a health services under represented area three years they can get citizenship so if we leave the residency group alone right now we'll not get some of the funding changed that's that's the bottleneck in the system at the moment physicians come out of medical school at least one hundred thousand dollars and the kids these are smart enough to figure that math out and do what works out economically rather than maybe force for their heart in internal medicine ten years ago the number of people going into primary care was fifty four percent now it's down to twenty six percent of that's a dramatic change in the last ten years  how can we change the reimbursement the quality of life the hassle factors you know at my hospital now i have to talk to two people before i can decide whether they can be admitted or an observation that has nothing to do with what i do it has to do with medicare reimbursement so it takes me about twice as long to make hospital  i think there are two other components when you're talking about student and medical school one of it is we know from prior studies that there are certain types of medical students who are more likely to go into primary care and there is actually ways that states have incentivized more students going into primary care there are demographics or no medical school admissions committees who are aware of this can increase the number of students who are interested in primary care and secondly going to the mismatch the currently under filled slot and family medicine and primary care is true we have not been feeling which i think just highlights the fact that we we need to turn around those incentives for students to go into primary care but i would say that the current proposals are such to primary care you created the incentive for them to want to be there so don't then pull away the slot just at the time when you're telling them they have a right to be interested in stick about primary care please keep those slots available for them to go into but i appreciate the shortage of primary care but we have acute shortage is surgical care as well which will only get worse if we say that new residency spots must be restricted to primary care we may make primary care better i believe that would happen but we will exacerbate what's already a shortage of surgical specialists and if you look at the projections the projected shortage of surgical specialists by twenty twenty five is almost identical to the projected shortage of primary care physicians and weak he and make one problem dramatically worse at the neurosurgery i must say that you're pointing out a real a real sensitive area for me and where we as physicians have been asleep at the switch we show up only in congress to be sure our reimbursements are ok but for the last three decades we have said nothing about the fact that we were in charge of not you but we generically have been in charge of recognizing that the baby boomers were going to come through the system we were delivering them but we didn't we did it made no difference to us in our medical schools we did increase our numbers but increase the number of medical schools a number of kids coming out and now we're faced with an acute shortage we've got an acute shortage of general surgeons we've got an acute shortage of neurosurgeons orthopedic surgeons because as they practice they begin to cut back on their trauma their quality of life they're ready in their fifty's to slow down a little bit  residency programs of full of non u s graduates and so we as a as a as a group as a group have let us all down by not making enough noise not participating in the political  system through bridgend what i will say this i don't think we can pass any sort of health care reform without malpractise reform there's always for people in your room when you're examining a patient i the patient the nurse and the plaintiff's attorney unseen is dire and if we do not fix that all of this reform all of this reform will be for naught because we will not control cost because as madam chair said if everyone has an insurance card they still can't see a doctor because if we don't reform the number of providers and we continue to try to reform a system around a scarcity we create the black market we create we create the concierge medicine and everybody else is over here fighting to see someone so we've got a real problem on our hands and i'm afraid that this rush to meet an artificial deadline on health care reform may have some severe unintended consequences so my my my question to you or my plea to you is when you go back to see your people that you represent they have got to get interested in the political process you've got to tell them to get interested because you're going to your site is going to be sealed those of us on a panel like this who know very little about what you do so but thank you each for comment we really appreciate it medical liability the cost of that out of pocket for physicians but the cost of the system with frankly having a medical record to be able to defend yourself with the plaintiff attorney that's not seen what but always present  and the workforce issue which is significant pressure to panel being here it sounded a little bit like a family feud here the past couple questions and and there's a lot of competition specialties and i think nobody here is questioning the need to support primary care physicians concern from the surgical specialties is that if that is done at the expense so the surgical focus has to be then i think you really run the risk of fixing that problem but exacerbating another problem and i think the surgical specialists are as important as primary care for the overall health of the nation particularly in areas like trauma where it's not going to go away and you need surgical specialists to be there right away you know a life threatening situation  that to exacerbate the one problem to fix the other doesn't make sense we have publications in health affairs about two years ago and the numbers go between twenty and forty thousand doctors across the board now that number these numbers are going to be right looking back because medical schools are a target of thirteen percent increase with now one hundred thirty medical schools has just the last few years the problem though is it's a residency level because if we don't get something fixed they're changing the balanced budget act and that we're going to just be robbing countries that can't afford to give us their people i worked all my life in public hospitals and that's what we're going to be doing and we we ought to be able to have our workforce funding be self sufficient well that's a good segue kind of part to my question is how do we fix this so we're not competing back and forth that we that we're growing enough future professionals to meet all the needs and needs significant with the aging baby boomer population the attrition of retirements that are has been happening for some time now it's going to intensify plus the amount of need that will be out there as a population ages i make one more be ok right now but we froze everything at that period of time with a balanced budget act and with the voluntary cap by the medical schools graduate medical education no one's i mentioned about the fact that medicare right now the residents are reimbursed through the hospital and that's convoluted formula of direct and indirect payments and meanwhile the last two decades medicare funds been going to independent insurance companies who don't contribute back to the graduate medical education system it's only on the on the back of medicare medicaid and i think that would increase tremendously because at the medical school level we're all doing our job trying to increase the class sizes dedicated to certain specialties or not they belong to the hospital and they can divvy them out any way they want and if you don't use them in three years you lose  counseling graduate medical edge cations predicted a ten percent shortfall of physicians by two thousand and twenty and as we've seen in massachusetts health care reform only exacerbate this impending decline in health care reform must strive to not only expand health insurance coverage but also to provide everyone access to visitation these physicians sort of shortage is a particularly troublesome in rural areas such as my district in western pennsylvania so it's less doctors tend to be attracted to fill those positions in the rural areas and this day and i was pleased to see that you know the additional funding for the national health service corps which was already mentioned today and we also need to discuss the we also need to address the debt that the students carry which was just talked about but i want to ask you dr demarco that there are twenty five hundred hospitals united states that do not have teaching programs and many of these are located in those rural and suburban communities as a solution to our workforce shortage problem the american osteopathic association recommends expanding the number of teaching programs what steps should be taken to achieve this goal and what kind of support would hospitals need to build these build these programs well of course you know it's brain drain issue but the thing is is that in the  there's a loophole in the balanced budget act that says if it's a hospital it's never had an intern or resident you can cap that hospital the new number of first time and that's were true or achieving at this time we have hospitals in colorado in colorado second year called me that not only talked about the primary care shortage but about six stress specialties which included to ensure jury and called me is late coming around to recognizing the projected needs for the need to have more attention paid to the world when i discharge a patient from the hospital i often cannot find anyone to take care of that patient so simply having insurance even if the paid there's nobody there for me to refer to we are also part of the patient centered medical home demonstration project where we're looking with residents in a desperation project to see new ways of doing trainee likewise have been moving residents from the traditional tertiary big hospital out to small community hospitals as an innovative way of improving their training providing some workforce to the  and also decreasing costs we also think that you have to change the payment system and make sure that health care insurance is available for all because otherwise it is the small rural hospitals that are really you were talking about the foreign medical graduates are thinking dr shelton with the question as to what percentage of those who take those residency spot top what percentage of those are staying here what percentage are actually leaving to my knowledge the vast majority  stay in the united states dr sheldon may have more well over sixty percent of india's now india has more medical schools and we do and they'll often send people here with a plan to go back and has a real problem with had i believe twelve undergraduates half of practice in the united states today and there are ratios if you look at the world health organization chart is just dismal we should be taking we shouldn't be robbing the other when you go ahead that's fine i work in internal medicine and geriatrics deal with patients all the time i've had multiple patients tell me that this is not the american way we do not limit care we d five percent of my patients are on medicare so and they are very concerned about this issue that patients are physicians are as well the impact upon myself and other payers had a top topic here thank you just like to point out that i think under our current system we do ration care if you if you do not have health insurance right now you oftentimes delay or do not get care that is rational i also think though that even even those people who have insurance currently i see a disparity and we all know that there are just here in this  country so i think that when we develop health care reform we have to look at the spirit is right now what's the rationing that's currently going on as we move forward to a different program but it exists out there right now and i face it every day in my active practice we have a safety net hospital eighteen percent of our work is uncompensated coming to close to three hundred million dollars a year rationing rationing is  common in the public programs in england in the on the continent and it is often pig headed prescience age and unfortunately with all the patients everybody getting older in this country especially that's when most of the diseases come longer need care in this to cancer statistics that i quoted earlier in my comments may well in part me do the fact that they have limitations on what care you can get at certain ages and it's it's hard to get it right i think if we follow the council the advisory council of economic advisors so that was the in the june second document from the white house the inevitable result will be losing public money  and probably will make things worse i think the specter of rationing is that someone who doesn't know an individual patient will make a determination that this particular patient cannot receive care that may in that case be life sustaining and that scares people to death i don't think we need to go there if we had better research on what care is truly effective and what care was futile or ineffective we would take care of a lot of the expense problems that we we have now if you look at the dartmouth health care maps and i spent one time at dartmouth and was part of their surgical outcomes group if you look at the variability and number of surgical procedures done from region to region what you find is that where the indications for surgery are big us you have a great deal of variability and it tends to follow the number of surgeons on the other hand when you have very clear cut indications for surgery you find that the rate of those operations is the same all over the country so we can do a much better job of finding out clearcut indications for surgical care and i'm sure the same is true for other types of care and the comparative effectiveness approach i think if done right has a lot of thank you very much sorry that i was light i think in moving forward need we need to recognize that we really do not have much of a health care system in this country we have a really really good sick care system the best in the world probably and i hope that in moving forward that we are focused a bit more on a whole lot more on health care maybe if we had a better health care system we wouldn't need to have such a big sick care  system one of the problems that we have in rural areas and i guess in some of our inner cities too is that the government now controls the health care for almost fifty percent of our population all of our military all of our veterans s chip children  medicare and medicaid and by design the government intends to pay less than the cost of health care obviously you can't do this so you can stay in business so there's a lot of cost shifting going on how are you dealing with this problem in rural areas where frequently large percentages of your patients i have some rural areas in my district and i know that some of their nursing homes are ninety odd percent of all medicaid tough to run an institution when when the person who is paying the bill intends to pay less than the full cost of health care how you're dealing with this well it's a large academic medical center this is an acute problem because live in a part of pennsylvania that also has a pretty good payer mix and other parts of the population and it's clearly cost shifting that people who have insurance are paying enough to care for the people who don't cover their expenses with medicaid you have to do this or you're out of business yes i think it is really becoming an issue i deal with sixty five percent medicare patients and realistically it's coming to a point where i cannot any longer be a private physician running my own business after thirty years of doing this thirty years of being a very good efficient busy physician i have not been able to give my employees a raise for five years and not funded my pension profit sharing plan i'm looking at other options for my practice at this point i will probably become an employed physician we will probably lose another small business and this is a time where i should be doing well not suffering and that's a personal story but that's a way i think most people are struggling with it not very well hoping they get enough of the private insurance people who pay a little better so that they can keep going or looking for other people to pay those bills studies are shown the average primary care physician loses eighty seven thousand dollars a year there are a few things that i think we can look to for models one is in north carolina we have the north carolina community care which actually is built around medicaid patients right now and as you said you lose money on on your medicaid patients and so simply filling up your practice usually with medicaid like any small business knows that volume doesn't work when you lose more money so but in the north carolina the order to coordinate the care across a certain disease state what that has done is increase the payment for the primary care physician to a point that they can afford to not the other thing that that i agree i think what we're seeing is a change in primary care practices they're starting to do more procedures which is not what we want because the system has driven people to simply do more things rather than looking at health outcomes and we've also seen that there are a lot of our members who are now selling out their practice and starting to work for a hospital system do is preventive here the patient with the symptomatic carotids to notice is who is at risk of stroke very effective surgical intervention to prevent a stroke and all of the costs to go with that the patient with the on ruptured aneurysm who is at risk of a devastating hemorrhage before the hemorrhage occurs that saves an immense amount of cost in the system and as mentioned briefly my testimony i think there are neurosurgical procedures just around the corner that would minimally invasive and effective treatment for things like addiction means addiction to tobacco and alcohol and cetera and obesity and that would be neurosurgical example a very effective preventive care that could save a mensa amounts of money so when we talk about prevention let's be which is already seen progress since that's become more common similarly one of the differences that the united states has led the world in is frequency of mammograms instead of diagnosing a breast cancer at stage three where you're getting stage one as far as programs that have been authorized by congress program in our state has also been very effective been helping with some of these things and making access  week i'll be meeting with some of the leaders dealing with the committee of jurisdiction and discussing some of the important issues related to health care reform with small businesses this shortage of the station is a