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WORKFORCE ISSUES IN HEALTH CARE 

REFORM: ASSESSING THE PRESENT AND 

PREPARING FOR THE FUTURE 

HEARING 

BEFORE THE

COMMITTEE ON FINANCE 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

MARCH 12, 2009 

( 

Printed for the use of the Committee on Finance 

COMMITTEE ON FINANCE 

MAX BAUCUS, Montana, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

KENT CONRAD, North Dakota 

JEFF BINGAMAN, New Mexico 

JOHN F. KERRY, Massachusetts 

BLANCHE L. LINCOLN, Arkansas 

RON WYDEN, Oregon 

CHARLES E. SCHUMER, New York 

DEBBIE STABENOW, Michigan 

MARIA CANTWELL, Washington 

BILL NELSON, Florida 

ROBERT MENENDEZ, New Jersey 

THOMAS R. CARPER, Delaware 

CHUCK GRASSLEY, Iowa 

ORRIN G. HATCH, Utah 

OLYMPIA J. SNOWE, Maine 

JON KYL, Arizona 

JIM BUNNING, Kentucky 

MIKE CRAPO, Idaho 

PAT ROBERTS, Kansas 

JOHN ENSIGN, Nevada 

MICHAEL B. ENZI, Wyoming 

JOHN CORNYN, Texas 

RUSSELL SULLIVAN, Staff Director 

KOLAN DAVIS, Republican Staff Director and Chief Counsel 

(II) 

(III) 

C O N T E N T S 

OPENING STATEMENTS 

Page 

Baucus, Hon. Max, a U.S. Senator from Montana, chairman, Committee 

on Finance ............................................................................................................ 1 

Grassley, Hon. Chuck, a U.S. Senator from Iowa ................................................. 2 

WITNESSES 

Mullan, Fitzhugh, M.D., Murdock Head professor of medicine and health 

policy, George Washington University, Washington, DC ................................. 4 

Wartman, Steven A., M.D., Ph.D., MACP, president and CEO, Association 

of Academic Health Centers, Washington, DC .................................................. 6 

Goodman, David C., M.D., M.S., director of the Center for Health Policy 

Research, Dartmouth College, Hanover, NH ..................................................... 8 

Goroll, Allan H., M.D., MACP, professor of medicine, Harvard Medical School, 

Harvard University, Boston, MA ........................................................................ 10 

ALPHABETICAL LISTING AND APPENDIX MATERIAL 

Baucus, Hon. Max: 

Opening statement ........................................................................................... 1 

Enzi, Michael B.: 

Prepared statement .......................................................................................... 31 

Goodman, David C., M.D., M.S.: 

Testimony .......................................................................................................... 8 

Prepared statement .......................................................................................... 32 

Goroll, Allan H., M.D., MACP: 

Testimony .......................................................................................................... 10 

Prepared statement .......................................................................................... 51 

Grassley, Hon. Chuck: 

Opening satement ............................................................................................. 2 

Mullan, Fitzhugh, M.D.: 

Testimony .......................................................................................................... 4 

Prepared statement .......................................................................................... 55 

Wartman, Steven A., M.D., Ph.D., MACP: 

Testimony .......................................................................................................... 6 

Prepared statement .......................................................................................... 67 

Responses to questions from committee members ......................................... 72 

COMMUNICATIONS

AARP ........................................................................................................................ 77

American Academy of Child and Adolescent Psychiatry ...................................... 85 

American Academy of Nursing ............................................................................... 90 

American Academy of Physician Assistants .......................................................... 95 

American Association of Colleges of Nursing ........................................................ 104 

American Association of Occupational Health Nurses, Inc. ................................. 110 

American College of Osteopathic Family Physicians ............................................ 112 

American College of Rheumatology ........................................................................ 117 

American College of Surgeons ................................................................................ 120 

American Dental Education Association (ADEA) ................................................. 128 

American Health Care Association and National Center for Assisted Living .... 143 

American Medical Association ................................................................................ 146 

American Nurses Association ................................................................................. 151 

American Occupational Therapy Association, Inc. ............................................... 154 

Page

IV 

American Organization of Nurse Executives (AONE) .......................................... 157 

American Osteopathic Association ......................................................................... 161 

American Physical Therapy Association (APTA) .................................................. 167 

American Society of Health-System Pharmacists ................................................. 176 

American Society of Pediatric Nephrology ............................................................ 180 

Annapolis Coalition on the Behavioral Health Workforce ................................... 186 

Association of American Medical Colleges (AAMC) .............................................. 201 

Association of periOperative Registered Nurses (AORN) ..................................... 215 

Coalition to Protect Senior Care ............................................................................. 218 

Emergency Nurses Association (ENA) ................................................................... 221 

National League for Nursing (NLN) ...................................................................... 226 

Oncology Nursing Society (ONS) ............................................................................ 233 

Pediatric Work Force Work Group ......................................................................... 238 

Service Employees International Union (SEIU) ................................................... 246 

(1) 

WORKFORCE ISSUES IN HEALTH CARE 

REFORM: ASSESSING THE PRESENT AND 

PREPARING FOR THE FUTURE 

THURSDAY, MARCH 12, 2009 

U.S. SENATE, 

COMMITTEE ON FINANCE, 

Washington, DC. 

The hearing was convened, pursuant to notice, at 10:10 a.m., in 

room SD–215, Dirksen Senate Office Building, Hon. Max Baucus 

(chairman of the committee) presiding. 

Present: Senators Lincoln, Wyden, Cantwell, Nelson, Carper, 

Grassley, Hatch, Snowe, Kyl, Crapo, Enzi, and Cornyn. 

Also present: Democratic Staff: Bill Dauster, Deputy Staff Director and General Counsel; Amber Cottle, International Trade Counsel; Ayesha Khanna, International Trade Counsel; Neleen Eisinger, 

Professional Staff; and Chris Dawe, Professional Staff. Republican 

Staff: Stephen Schaefer, Chief International Trade Counsel; Rodney Whitlock, Health Policy Advisor; Susan Walden, Health Policy 

Advisor; Michael Park, Health Policy Counsel; Nick Wyatt, Tax Assistant; and Terry Postma, Detailee. 

OPENING STATEMENT OF HON. MAX BAUCUS, A U.S. SENATOR 

FROM MONTANA, CHAIRMAN, COMMITTEE ON FINANCE 

The CHAIRMAN. The committee will come to order. 

An old Jewish proverb warns, ‘‘Don’t live in a town where there 

are no doctors.’’ Our question today is: will there be enough doctors, nurses, and other providers for the towns in the future? And 

there is reason for concern. Already, America has too many towns 

without doctors. There are too many under-served areas in too 

many parts of rural America. 

HHS says that in rural America we have roughly 7,000 fewer 

primary care doctors than we need, yet a recent study found that 

only 1 in 50 medical students—only 1 in 50—plans a career in primary care internal medicine. That is down from more than 1 in 5 

in the early 1990s. That is a 10-fold change in the wrong direction. 

That is just as the need for primary care doctors is increasing. 

Between 2005 and 2020, the number of Americans over age 65 will 

grow by 50 percent. As Americans live longer, the burden of illness 

and disease will continue to grow as well. Our aging population 

will require a stronger primary care system to help patients effectively manage and coordinate care. Yet, current payment policies 

place a higher value on specialty care, higher than on primary and 

2 

preventive care. We need to invest in our primary care system to 

help improve quality and lower costs. 

I have also heard from hospitals in my home State of Montana 

and elsewhere about continued problems recruiting nurses. Despite 

this shortage, nursing schools had to turn away more than 40,000 

qualified applicants in 2007 due to shortages in faculty and other 

constraints. 

Today we look at ways to strengthen our Nation’s health care 

workforce. Our Nation’s health care providers—doctors, nurses, and 

other professionals—are on the front line of caring for patients. For 

health reform to succeed, we need a strong health care workforce. 

We must ensure that health care workers have the necessary 

training and the skills to provide that quality care, and new technologies such as telemedicine can help be part of that solution as 

well. I do not want to understate that. There is a huge role for telemedicine to address the shortages in certain parts of the country, 

but that is clearly in no way going to be a complete solution. We 

just need more people in the primary care areas that I mentioned. 

We cannot expect to improve patient health if we are not training 

providers in key areas such as care coordination. 

We need to take a hard look at the way that we pay health care 

providers. As part of that examination, we should ask, first, do today’s payment systems properly reward providers who offer highquality care? Second, do these payment systems encourage medical 

students to choose careers in critical fields like primary care? 

Third, do payment systems encourage medical residents to train in 

settings like community clinics, where many patients are receiving 

care? 

Where the answer is no, we need to make a change. We should 

work to revise our payment systems. We must also step back and 

ask whether we have a solid national strategy to strengthen our 

workforce. Volumes of research have been published on the problems facing our national health workforce, but there is clearly no 

strategy. We must address these challenges head on. We need to 

take steps now to place our Nation’s health care workforce on a 

sound footing. 

Today we are going to hear from four experts in the field. This 

discussion can provide a solid foundation for the work ahead. So let 

us get to work now to ensure that more folks will not have to live 

in towns where there are no doctors, let us do what we can to ensure that doctors get the training and skills necessary to provide 

quality care, and let us do what we can to ensure that there will 

be good health care in towns in America’s future. 

Senator Grassley? 

OPENING STATEMENT OF HON. CHUCK GRASSLEY, 

A U.S. SENATOR FROM IOWA 

Senator GRASSLEY. Thank you, Mr. Chairman. 

Any discussion on health care reform has to include an examination of the health care workforce. One obvious area of focus is what 

impact expanding coverage to all Americans will have on the 

health care workforce of the future. It is easy to see that increased 

health coverage is useless without a workforce to provide the care. 

3 

The experience in Massachusetts provides a useful example of 

how important these issues are in dealing with the workforce. In 

Massachusetts, health care reform efforts have increased the number of people with health insurance, but there are reports that 

many people are now finding it difficult to find and get appointments with primary care providers. The challenge of finding primary care providers has put tremendous pressure on emergency 

rooms and will almost certainly increase health care costs in Massachusetts. Future health care reform efforts ought to proceed with 

the health care workforce in mind in order to avoid unintended 

consequences such as those in Massachusetts. 

These workforce issues are driven by a multitude of factors, as 

we are going to hear today, and they have multiple effects on our 

entire system. These issues and how to respond to them affect not 

only the basic access to health care, but they also impact quality 

and cost. 

There are many projections of workforce challenges that we face. 

The Association of American Medical Colleges estimates an overall 

physician shortage of 124,000 by 2025. The Health Resources and 

Services Administration projects that the Nation’s nursing shortage 

will grow to more than 1 million by the year 2020. According to a 

study last year in the Archives of Surgery, the number of general 

surgeons as a proportion of the population fell 26 percent during 

the past 25 years. 

As our population ages, health care workforce shortages are predicted for nursing staff, technicians, general surgeons, and allied 

health professionals. Rural areas—like my home State of Iowa, and 

probably even more rural in Montana—are at greatest risk of 

health care workforce shortages. According to the Health Resources 

and Services Administration, approximately 20 percent of the 

United States’ population lives in rural areas, but only 9 percent 

of the physicians practice there. And, as we have a shortage of primary care providers within our existing workforce, disturbing reports continue to show the dwindling percentage of medical students who plan to become primary care providers. 

It is as low as 2 percent of current medical students, according 

to a study in the Journal of the American Medical Association. Our 

country is becoming increasingly reliant upon foreign medical graduates to fill these gaps, particularly in under-served areas. The increased cost of education and lack of sufficient financial incentives 

for primary care are significant factors in this decline. 

These workforce challenges do not just affect the availability of 

health care, they also have significant impact on how the health 

care delivery system performs. The Dartmouth Atlas Project and 

others have shown that regions with greater primary care presence 

have lower costs, higher quality, and reduced socioeconomic and geographic disparities. 

So we need to change incentives to promote an emphasis on primary care. Patients will then have better access to providers who 

can coordinate their care. We are very interested in delivery system 

reform as part of the larger health reform effort. The fragmented 

incentives in place for education in the medical professions only reinforce the fragmented silos of care that we are trying hard to 

change. We should not expect changes in the delivery system if we 

4 

do not pay more attention to the education of medical professionals. 

The socket has to match the plug. 

So, in addition to reimbursement, we need to look at how Federal 

programs promote workforce development. Over the years, the Federal Government has developed several programs that seek to influence the education, training, and retention of the health care 

workforce. We should consider reforming graduate medical education to more effectively foster broader workforce goals. 

With that, I yield. 

The CHAIRMAN. Thank you, Senator. 

Now I would like to welcome our witnesses. First, we will hear 

from Dr. Fitzhugh Mullan, Murdock Head professor of medicine 

and health policy at George Washington University. Next, Dr. Steven Wartman, who is the president and CEO of the Association of 

Academic Health Centers. The third witness is Dr. David Goodman, director of the Center for Health Policy Research at Dartmouth College. Finally, we will hear from Dr. Allan Goroll. Did I 

pronounce that correctly? 

Dr. GOROLL. Yes. 

The CHAIRMAN. Professor of medicine at Harvard Medical School. 

You all have written statements, I presume, which you will have 

automatically included in the record. We ask you to proceed in any 

way you wish, starting with you, Dr. Mullan. We hold people to 

about 5 minutes. 

STATEMENT OF FITZHUGH MULLAN, M.D., MURDOCK HEAD 

PROFESSOR OF MEDICINE AND HEALTH POLICY, GEORGE 

WASHINGTON UNIVERSITY, WASHINGTON, DC 

Dr. MULLAN. Good morning, Mr. Chairman and members of the 

committee. I am honored to have the opportunity to address you. 

I have been charged with giving an overview of the workforce, and 

I will move rapidly to do that. Five minutes is a challenge; we will 

see how well I do. 

I have served as a primary care provider, as an administrator, 

and a researcher in the field of health workforce research in my 

life, having been the Director of the National Service Corps and Assistant Surgeon General in the Public Health Service, and now a 

professor at GW, so I come at these issues from multiple perspectives. 

Health care reform needs health care workforce reform. Without 

it, reform will not succeed. Massachusetts, as observed already, is 

a living experiment in that: you increase coverage, and the folks 

are not there to provide it. That will be the case around the country as we move forward. 

I want to talk a little bit about the size, shape, and key sufficiency of the current workforce. I ask you to think about it as a 

life cycle in a diagram here that I am afraid is smaller than it 

might be. We suggest three portions of that life cycle. That would 

be, in terms of the physician: medical school, graduate medical education, and practice. Innovation and change need to take place in 

each sector. Without corollary changes in each sector, we will have 

far less than the outcomes we want. 

The CHAIRMAN. You do not have a copy of that slide, do you? 

Dr. MULLAN. It is on the back pages of my testimony. 

5 

The CHAIRMAN. All right. Thank you. 

Dr. MULLAN. The key in many ways, and often overlooked—— 

The CHAIRMAN. Yes, we have it. Thank you. 

Dr. MULLAN. Good. The key element is actually graduate medical 

education, with which this committee has a very important role. 

GME is the keyhole through which everybody has to go, which 

means U.S. allopathic medical school, U.S. osteopathic medical 

school, and foreign medical school graduates. So it is the size and 

shape of graduate medical education that determines the workforce 

of the country, so I ask you to bear that in mind in your deliberations today and in the future. 

The trends in our workforce are that, over the years, it has 

grown for this workforce. We currently are 280 physicians per 

100,000. It puts us about in the middle, a little below the middle, 

of the density in developed countries; a few are higher, a few are 

lower. That has grown steadily, and we will level out at about that 

level with our current inputs. The question that that raises is, is 

it sufficient? Well, certainly we have huge distributional problems, 

both geographically as observed, and in primary care versus specialty care. 

The basic size, I will testify, in my belief, is sufficient. The notion 

of doubling it again, as we did in the past, or even increasing it 

by half again is a very expensive and ill-conceived plan. This, nonetheless, takes into account the fact that we do have an aging population, a growing population. But my judgment is, with several caveats, that the relative level we have is sufficient. 

Those caveats are that we need to organize it better and get better effectiveness out of our physicians in terms of distribution and 

type, and we also should make even more use of two American inventions. We pioneered the physician’s assistant and nurse practitioner, and they are very effective. There are about 70,000 PAs and 

about 100,000 nurse practitioners in practice today. They are more 

quickly trained and more agile in many ways, and they work extremely well as part of the health care team. I think that is where 

we need to look to buffer our future needs, as well as reorganization. 

Additionally, we have instruments already in place for deployment and use of physicians, but there are, in the case of the first, 

the National Service Corps, way under-used, and in the case of the 

latter, community health centers, happily getting some attention. 

But between those two, we have very good instruments in place. 

Funding and support are important for deployment. 

To spend a quick moment on medical schools issues at hand— 

they are expanding. This is good. Title 7, which has been the instrument of the Public Health Service Act to get more primary 

care, more minorities, and better distribution, has been way underfunded and been a target for elimination in the recent past. It 

needs to be reinvigorated, reconceptualized, and refunded. Of 

course, the National Health Service Corps needs support as well. 

At the graduate medical education level, there are modest reforms that call out to be made. I would characterize these as barrier reduction to community and ambulatory practice, and incentivizing that. In the major reforms category, right now Medicare 

GME is without a brain. That is, it does not function as an instruVerDate Nov 24 2008 15:20 Feb 04, 2011 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 R:\DOCS\63483.000 TIMD
6 

ment of directing or shaping the workforce. It is $8.5 billion, which 

is by far the largest Federal investment in health professions education. It needs a new allocation system that aligns Medicare GME 

with the workforce needs of the Nation. Finally, and you will hear 

from others on this, practice reform is key, payment reform, organization, and health information technology. 

Finally, two concepts that have been raised in various settings. 

Happily, some of the new legislation that has been proposed—and 

I think my colleague Dr. Wartman will speak about this—a National Health Workforce Commission is an excellent idea, but a National Center for Health Workforce Studies that would really do 

much better census and analytic work than we have the capability 

of doing now, is necessary as well. 

For health care reform, we need an enhanced primary care workforce that is smart, well supported, flexible, IT-enabled, and accessible throughout the Nation, all of which are achievable goals with 

modifications and redirection of legislation and funding that, by 

and large, exist today. 

Thank you. 

The CHAIRMAN. Thank you, Doctor. That is very interesting, and 

provocative, too. 

[The prepared statement of Dr. Mullan appears in the appendix.] 

The CHAIRMAN. Dr. Wartman? 

STATEMENT OF STEVEN A. WARTMAN, M.D., Ph.D., MACP, 

PRESIDENT AND CEO, ASSOCIATION OF ACADEMIC HEALTH 

CENTERS, WASHINGTON, DC 

Dr. WARTMAN. Thank you. Good morning, everyone. Thank you, 

Mr. Chairman. I wanted to thank the committee for inviting me 

here today. I also wanted to thank my wife, Gina, for coming. 

Thank you, Gina. 

The CHAIRMAN. Yes. We all thank you, Gina. [Laughter.] 

Dr. WARTMAN. I wanted to point out to the committee that the 

Association of Academic Health Centers is the only organization 

that represents all the educational, research, and clinical components of academic health centers. We are not discipline-specific, but 

we represent all these specialties and all the fields of health care. 

Our members are responsible for educating the next generation 

of health professionals, providing comprehensive health care and 

cutting-edge research. The message I want to convey to the committee today is that health system reform cannot be successful 

without simultaneously reforming how we make and implement 

health workforce policy. 

It is critical that a reformed health system have sufficient numbers and types of health professionals who can provide the highquality care needed to best improve the health of patients and the 

public. The AAHC report, ‘‘Out of Order, Out of Time: The State 

of the Nation’s Health Workforce,’’ discusses many aspects of current health workforce policy that are out of order and why we are 

running out of time to change. 

Our report concluded there is a systemic flaw in our century-old 

approach to health workforce policy-making. Responsibility for 

planning and managing the Nation’s health workforce is fragVerDate Nov 24 2008 15:20 Feb 04, 2011 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 R:\DOCS\63483.000 TIMD
7 

mented among literally hundreds of Federal, State, and private 

stakeholders that rarely coordinate their policies or activities. 

I am basically here to say, if we do not change how we make and 

implement health workforce policy at the same time we reform the 

health care system, the promise of health reform will be seriously 

undermined. 

Allow me to summarize briefly why I believe this is true. First, 

even without health system reform, the health workforce is already 

under tremendous stress from powerful social and economic forces, 

including the aging of our population and the markedly increased 

need for chronic and long-term care. 

Second, there are serious concerns involving the selection of careers in the health professions, including admissions practices, education debt, workplace conditions, reliance on international health 

care workers, and current payment policies that steer health professionals away from choosing the kinds of careers and communities where they are most needed. 

Third, our current health workforce policy-making and planning 

infrastructure is not adequate to meet these challenges because it 

is hopelessly fragmented among a wide variety of stakeholders that 

responds to immediate needs largely in isolation, and with little coordination. 

Fourth, health system reforms under consideration by this committee add further stress to the already daunting challenges because, for example, expanding coverage will surely increase expectations and demand for services from health professionals, already 

in short supply. Implementing health information technology and 

comparative effectiveness research will require large-scale training 

of health professionals in order to maximize safety, quality, and 

cost-effectiveness. 

Fifth, we are already behind the curve and need to act now. 

All this leads me to conclude that comprehensive health workforce reform is an essential element of effective health system reform and that we need to make workforce reform a national priority in conjunction with system reform. 

I recommend immediate appointment of a National Health Workforce Coordinator to begin mobilizing current resources more effectively as an interim step, followed by creation of a permanent, 

multi-professional, multi-disciplinary national health workforce 

planning body to bring together all stakeholders to address the 

challenges we face in a comprehensive, coordinated, and strategic 

manner. 

A permanent national health workforce planning body allows us 

to assemble all the pieces of the workforce puzzle so we can see the 

whole picture. A national body can harmonize public and private 

standards, requirements, and prevailing practices across jurisdictions. A national body can address access to health professions’ 

education and the ability of educational institutions to respond to 

economic, social, and environmental factors that impact the workforce. And a national planning body can identify unintended consequences among public and private policies, standards, and requirements. 

My concern is that we will press forward with health reform 

without full consideration for the health workforce, all the players 

8 

in the health workforce that will be needed to make these reforms 

successful. I urge you to incorporate a new, integrated and coordinated approach to national health workforce policy as health system reform is considered. 

On behalf of the Nation’s academic health centers, I look forward 

to working with you toward that goal. Thank you. 

The CHAIRMAN. Well, thank you, Doctor. I think your wife is very 

proud of you. [Laughter.] 

[The prepared statement of Dr. Wartman appears in the appendix.] 

The CHAIRMAN. Dr. Goodman? 

STATEMENT OF DAVID C. GOODMAN, M.D., M.S., DIRECTOR OF 

THE CENTER FOR HEALTH POLICY RESEARCH, DARTMOUTH 

COLLEGE, HANOVER, NH 

Dr. GOODMAN. Mr. Chairman and members of the committee, 

thank you for the invitation to talk about the health workforce and 

its relationship to health care reform. 

Policy about the health workforce today has focused nearly exclusively on physician numbers and has assumed that simply adding 

more physicians will improve accessibility and quality. These policies ignore two truths: (1) that current growth rates in health care 

expenditures are unsustainable and will be worsened by indiscriminate growth in physician numbers; and (2) that the workforce we 

train today will shape, for good or bad, tomorrow’s health care system. 

What do we know about the physician workforce? In brief, what 

doctors and nurses do is very important for patient outcomes. Much 

less important is the number of doctors and nurses providing services in a given region or health care system. 

Let me explain this. The notion that there is a single right number of physicians for the U.S. is challenged by the finding that the 

number of clinically active physicians per capita varies dramatically across regions for every specialty, and you can see this on the 

map. These are the Dartmouth Atlas of Health Care regions and 

they show, both for primary care and specialist physicians, very 

dramatic variation. This variation in physician supply is not explained by differences in patient illness levels or in population 

health, but by where doctors prefer to practice and live. 

The last 20 years of growth in physician supply has shown that, 

for every physician that settles in a low-supply region, four settle 

in a region with already high per capita supply. This means that 

lifting the Medicare funding cap on GME will perpetuate today’s 

variation as new doctors settle in places with already high numbers. 

Multiple studies in a variety of settings have shown no benefit 

with a very high—now, this does not speak to very low supply, 

which is a bad thing for patients—supply of physicians. This is true 

both for care of ill newborns, as well as care of Medicare patients. 

Nor is a high supply of physicians associated with better perceived 

access to care, better technical quality, or higher satisfaction with 

the care. 

How can it be that more physicians are not always better? Much 

of what we do as physicians directly improves the health and wellVerDate Nov 24 2008 15:20 Feb 04, 2011 Jkt 000000 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 R:\DOCS\63483.000 TIMD
9 

being of patients, but we know that regions with a higher supply 

of physicians have problems which can make care worse: greater 

unnecessary use of the hospital, greater problems with care coordination because care is fragmented over many different physicians. 

The lesson from places with modest supply is that health care systems are very adaptable to different workforce staffing levels. 

If physician supply is not of paramount importance, then what 

workforce policies will advance health care reform efforts? First, invest in improving what doctors and nurses do. We already have the 

knowledge and means to improve birth outcomes and lessen the 

impact of chronic illness. We also know how to better inform and 

involve patients in treatment decisions through shared decision 

making. We need to invest more in these activities. 

Second, strengthen primary care. We know that medical care 

provided within health systems dominated by primary care has excellent outcomes at lower cost. Training more primary care physicians and fewer specialists will be necessary, but this does not 

mean that simply adding more primary care doctors to a region 

will reform a specialist-based fragmented environment. 

Although the primary care medical home offers promise and 

demonstrations should be pursued, primary care performs best 

when other elements of the health care system support primary 

care providers, as in many integrated delivery systems, such as 

Kaiser Permanente, the Mayo Clinic, the Geisinger Clinic, and the 

Cleveland Clinic. Once we train primary care doctors and nurses, 

we need to keep them from drifting into subspecialties by paying 

them fairly. 

Third, our current GME financing system remains entangled 

with Medicare and favors hospital-based training. All payers 

should participate in medical education funding. 

Fourth, we need to introduce competition and innovation in 

GME. As an example, the NIH is a model of competitive peer review. I believe we can improve physician training and increase the 

number of primary care physicians through gradual introduction of 

competition for Federal GME funds. 

Then, finally, I agree with Dr. Wartman that we need a new 

structure for the development of workforce policy. Currently, the 

most active Federal entity is the Council on Graduate Medical Education, but its charter has greatly impaired formulation of public 

policy. In an editorial published last year in the Journal of the 

American Medical Association, I advanced the idea of a permanent 

health workforce commission to craft evidence-based policies that 

improve access to care, health outcomes, and the quality and affordability of care. 

Three key components. The membership of the commission 

should extend beyond physicians and include experts in public 

health, in patient-centered care, as well as nurses and consumers, 

health care systems, and payers. The commission should consider 

policy not just related to physicians, but to the broader health 

workforce. An effective policy will indeed require a dedicated staff 

that is independent of professional societies and trade associations. 

So here is workforce policy that will help, and not hinder, reform, 

promote the dissemination of medical care in health systems already shown to be effective, and train greater numbers of primary 

10 

care physicians, but also implement financing reform that encourages coordinated care, the coordinated care that patients want and 

need. 

Thank you. 

The CHAIRMAN. Thank you, Doctor, very much. 

[The prepared statement of Dr. Goodman appears in the appendix.] 

The CHAIRMAN. Dr. Goroll? 

STATEMENT OF ALLAN H. GOROLL, M.D., MACP, PROFESSOR 

OF MEDICINE, HARVARD MEDICAL SCHOOL, HARVARD UNIVERSITY, BOSTON, MA 

Dr. GOROLL. Chairman Baucus, Senator Grassley, members of 

the committee, thank you for having me here this morning. I am 

a primary care doctor of 35 years. I have taught generations of 

Harvard medical students. I am an author. I have been a president 

of a medical society and a reformer. I am here today because it has 

broken my heart time and time again to see our fine medical students who came to medical school interested in being physicians— 

primary care physicians who will have an impact on people’s 

lives—tell me, ‘‘Dr. Goroll, I am sorry, I cannot go into the field, 

it is just not doable.’’ 

So I am thrilled that you have taken up a mission to fix this 

problem because, as everybody has said here today, the issue is not 

how many people, it is what they choose to do and the perverse incentives that we currently have, which are not dissimilar from 

what has happened in the banking industry and in finance. I think, 

today, my message is going to be that addressing the workforce 

issue requires dealing with the payment issue. If we are going to 

solve workforce, we are going to have to solve payment. Payment 

is most distorted in the area of primary care, and I will go into that 

in just a minute. 

Another reason for my being here today is that I am from Massachusetts. We have a saying in Massachusetts that it is easier to get 

your son or daughter, grandson or granddaughter into Harvard 

than it is to get a primary care doctor. So, we have a problem. I 

think there are very important lessons, especially as regards health 

insurance: if we are going to solve access to health insurance, we 

have to solve access to primary care. That gets at the issue of how 

we sequence health system reform. 

So let me start with the diagnosis and with a question: why is 

there a serious and growing shortage of U.S. medical school graduates choosing careers in primary care? And by the way, when you 

look at the GAO report on the number of primary care physicians, 

it is somewhat misleading unless you read the fine print. It says 

we have plenty of primary care doctors. The problem is that many 

of them come from overseas, many of them are from third-world 

nations, so we are actually sucking the medical talent of the world 

into our country because we cannot attract our own U.S. medical 

graduates into this role. 

A lot of the issues are very well described. There was a GAO report; there is a recent Graham Center report. The reasons cited included the indebtedness of students, low pay for primary care, lack 

of prestige, heavy time demands. But in speaking with my stuVerDate Nov 24 2008 15:20 Feb 04, 2011 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 R:\DOCS\63483.000 TIMD
11 

dents, what they really say is, I came to medical school, as I mentioned a minute ago, to do something significant, to have an impact. What they find is that the real problem, putting all those 

other issues aside, is that the primary care job today is not doable. 

What they see are doctors who are struggling. There is high visit 

volume, rushed care, and inadequate time to do the job properly. 

As I have alluded to, this sorry state of affairs derives from a ‘‘dysfunctional’’ payment system—a term used over and over again— 

dominated by Medicare’s fee-for-service system, Resource-Based 

Relative Value Scale (RBRVS). 

Being a Harvard faculty member, I do have to take responsibility 

because RBRVS was designed by my colleagues, Bill Hsiao and 

Peter Braun at the Harvard School of Public Health, to actually fix 

the problem that we have right now, which is to rationalize payment and to rebalance the imbalance between procedural care and 

evaluation and management services. But RBRVS got distorted in 

its implementation. You folks are expert in knowing that we pay 

disproportionately for procedures, and we greatly ‘‘undervalue’’— 

the term used in the GAO report—the basic doctoring, the evaluation and management services that are the heart and soul of primary care. 

Medicare’s physician fee schedule basically sets the standard for 

all health insurance in the United States, so fixing Medicare is essential for fixing health insurance in general, and for fixing the 

payment system in particular. As we all know, we get exactly what 

we pay for. We are number one in the world in cost, and we are 

number 25 to 35 in health outcomes because we have high volumes 

of expensive procedures and we have too little doctoring. It is totally predictable. 

Now, compounding the problem is that, as you know, all physicians get paid out of a single pool. What has been happening is 

that the ever-increasing proportion of Medicare dollars that goes 

for expensive procedures decreased the proportion of dollars available to primary care for evaluation and management services. 

By the way, there are other physicians who are specialists who 

are non-proceduralists who also have the same problem. Neurologists, rheumatologists and others have this. This is not unique to 

primary care, but it is central to primary care. 

Consequently, we get exactly what we pay for, as I have mentioned. How do primary care practices respond? Well, the only way 

they can respond. They respond by increasing volume. Now we are 

in a death spiral, because as the volume goes up, the time for talking with patients goes down, the time for diagnosis disappears. 

What do we end up doing? Harried physicians find that they basically do nothing more than triage. They both over-order elaborate 

diagnostic tests to meet patients’ concerns (because patients do not 

have time with their doctors), and, finally, they end up making referrals at a very low threshold for things that they have been 

trained to do themselves. 

Finally, also, they cannot afford the multi-disciplinary teams, the 

health information technology, the infrastructure that is always 

talked about as essential for high-performing health care. The net 

result? We have taken our quarterbacks, if you will, and we have 

12 

turned them into gatekeepers, that old term. But that is exactly 

what they are doing right now. 

So now, put yourself in the position of our very talented, very excellent medical students and ask the question, if you were a smart, 

perceptive person, would you choose this field as a career? The answer is obvious. But would you choose this as a career if we fix it? 

The answer is, absolutely, yes. So I think that we have an opportunity here. 

I am going to stop right here and talk about the treatment plan 

later in the context of our conversation, but I think we have a wonderful opportunity right now to fix and ensure health system reform by fixing the primary care base. And since it is the base of 

our health care delivery system, we need to start with fixing primary care. It is very doable, and I think it is bipartisan and something that we can all agree upon. 

Thank you. 

[The prepared statement of Dr. Goroll appears in the appendix.] 

The CHAIRMAN. Thank you, Dr. Goroll. I do not know whether 

you intended this or not. If you did, that is very clever. My first 

question will be for you to now give a solution. [Laughter.] What 

do we do? You have all described the problem very, very well. 

When I talk to primary care doctors, I hear the same thing. I have 

wondered myself, when I see their appointment schedule, how in 

the world can they do it? There are so many patients coming in 

and out, it is like churning. I do not know how they do it. A lot 

of them do not. But what do you think some of the solutions are 

here? 

Dr. GOROLL. Well, we have to reorient the payment system. 

Right now, it pays for volume. It pays piecemeal. 

The CHAIRMAN. Right. 

Dr. GOROLL. Primary care is comprehensive work. Can you imagine if you only got paid for seeing constituents? 

The CHAIRMAN. Right. 

Dr. GOROLL. That is our life. Yet, your job description is a very 

comprehensive one. 

The CHAIRMAN. We know that part of the problem. 

Dr. GOROLL. All right. That is number one. So essentially what 

I would do—and let me talk very technically for a moment—is I 

would tease out from Medicare, and Medicaid, the proverbial 800- 

pound gorilla. 

The CHAIRMAN. Right. Right. 

Dr. GOROLL. I would tease out RBRVS for payment for primary 

care. I would do it in a transitional way, starting with practices 

that are prepared to transform. Those of us who are thinking about 

this understand there has to be a new social contract; primary care 

practices have to beef up. They have to be able to be more capable 

than they are right now. They have to organize differently if they 

are going to meet the demands without a greatly increased number 

of physicians. 

They are going to have to learn to work in modern systems, with 

modern teams. If they undergo so-called ‘‘practice transformation’’ 

and implement reforms such as the medical home model, I would 

make those practices eligible for a different payment model, one 

that I think will enhance their practice. There are many different 

13 

models that can be tested. Ours would be a risk-adjusted, comprehensive payment with a major bonus for desired outcomes. We 

align the payment system with the desired outcomes of improved 

access, cost containment, and higher quality. 

I think if we combine payment reform with insurance reform, 

then we will not have the situation we have in Massachusetts, 

which is as you folks have pointed out. So we would now empower 

the practices; we would give them the money that they can now use 

for investment to become high-performing practices, as Karen 

Davis and her folks at the Commonwealth Fund have pointed out. 

I think we then begin to build a strong foundation in the country. 

And by the way, if we re-empower the primary care folks, we will 

get the best and brightest of our medical students to go into this 

field, not the people who do not have any other choices. That solid 

foundation, I think, will start to build the base from which to do 

the other parts of health system reform that we have to do. I would 

not start a food fight with the specialists on, ‘‘You are over-paid.’’ 

I think what we do is we cut down on the unnecessary procedural 

work we are doing by enabling primary care physicians to do their 

job. The savings can be achieved by having time to talk with patients, examine them properly, and make intelligent decisions. 

That is what I am trained to do. 

The CHAIRMAN. What would you do about GME? 

Dr. GOROLL. I think GME would—I would not set quotas. I would 

let the market take care of itself. If we fix primary care, they will 

come, and they will put demands on primary care training programs. But I think we need to support the faculty. I think we also 

need to support undergraduate medical education. Title 7 dollars 

are not even a decimal point in the Federal budget, and yet they 

have had tremendous impact. So I think we need to look at—and 

I like the idea of bringing a commission together—what kinds of 

resources need to be targeted. There is a lot of data on the impact 

of these programs over the years. 

The CHAIRMAN. Let me ask anybody else who wants to pipe up 

here. Dr. Wartman? 

Dr. WARTMAN. Yes. Thank you. I certainly agree that primary 

care is a centrally important issue in health system reform, but I 

think we need to remember that we are dealing with a lot of other 

health professionals who are very, very important and critical to 

any future health care that we have, whether it is nursing, whether it is allied health, pharmacy, psychology, dentistry, public 

health; you just name it. It is a very, very long list of dedicated and 

important individuals. 

One of my colleagues gave me an analogy last week. He said, you 

know, it is like a big jigsaw puzzle. If we keep putting pieces in 

the box called health care providers, we shake up the box and then 

we take it out and see what we have, we generally do not have a 

complete picture. 

The CHAIRMAN. That is what happens in Congress every day. 

[Laughter.] You shake it all up and it is different every day. 

Dr. WARTMAN. So you can relate to it. I guess what I am suggesting is that we really need to take an over-arching look at all 

the different kinds of health providers and ask the question, if we 

do indeed need more, what is it that we need them to do, and try 

14 

to take those pieces out of the box and make it into a coherent picture. 

The CHAIRMAN. Why is there such a nursing shortage? 

Dr. WARTMAN. Well, I think that nursing shortages occur for a 

variety of reasons. They are real. 

The CHAIRMAN. Why? 

Dr. WARTMAN. Two things. One is the ability of nursing schools 

to, I think, educate and train the number of nurses who are needed 

is not there. There are faculty shortages, there are other problems. 

The CHAIRMAN. Why? Why are there faculty shortages? 

Dr. WARTMAN. I would say that probably the incentives for 

nurses to come and stay on faculty are the salaries and other 

things. 

The CHAIRMAN. How do we change that? 

Dr. WARTMAN. Well, I think you need to look at nursing not in 

isolation from the other professions and say, what can we do to 

make salary and other lifestyle issues more appropriate for those 

who would like to train the next generation of health professionals? 

But I am arguing very strongly here this morning, Mr. Chairman, 

that an over-arching, concrete look at the entire panoply of health 

professions and how they might best fit together is what we need 

to do. 

The CHAIRMAN. We understand that. We understand that. My 

time has expired. 

Senator Grassley? 

Senator GRASSLEY. Dr. Goodman, you suggested that the number 

of physicians is adequate, just poorly distributed. Dr. Goroll, your 

experience in Massachusetts, however, is that there is a severe 

shortage of primary care physicians in the wake of increased coverage, even though Massachusetts has the highest number of physicians per capita of any of the States. 

So could you help clarify whether or not there is truly a workforce shortage? 

Dr. GOODMAN. I think that Massachusetts is very instructive. 

What we have not talked about very much today, just a reminder, 

that not only does the supply of physicians per capita vary tremendously, but the cost of health care per Medicare beneficiary. I think 

there has been wide recognition that there is substantial waste and 

disorganization in health care. If you look at costs and you think 

of what money buys, the reality is, it buys bricks and mortar and 

it buys people’s time, it buys salaries, it buys physicians. 

Massachusetts is emblematic of a health care system that in 

some parts is extraordinarily good, has the best academic medical 

centers in the country. At the same time, it is very subspecialty oriented, it is very high-cost, very high-volume, and quite fragmented. 

In fragmented delivery systems, you can add doctors ever more— 

and Massachusetts is an example of that—and not result in care 

that is the care that patients want, not result in care with good 

outcomes, not result in care that feels accessible to patients. 

I share Dr. Goroll’s interest in terms of reforming primary care, 

but we need to recognize that it is within a context of a greater delivery system and of subspecialty supply. Primary care physicians 

can create their own islands of rationality, but as long as they are 

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15 

ume of subspecialty services, we will always lose the battle of quality of care outcomes and costs. 

Senator GRASSLEY. If he spoke for you, and I quoted you accurately, then we will just go on. If you want to say something, please 

go ahead. 

Dr. GOROLL. Yes. I think it represents the distortion of the 

decision-making of our graduates. Yes, a lot of Massachusetts’ data 

is because we have a huge research commitment, and a lot of our 

physicians, even though they may be listed as internists, and 

therefore as primary care doctors in category, are hardly that at 

all. So the numbers are very deceptive. 

The real way to measure this is, how long does it take to get an 

appointment with a primary care doctor? The Mass Medical Society 

commissioned a superb study that indicated that it is now about 

2 months, and that is if you can get one. In eastern Massachusetts, 

as I mentioned, it is almost impossible to find a primary care physician. Our local television station had a doctor who could not get 

a primary care doctor. So, this was a doctor, a lovely, wonderful 

young physician who could not find a doctor. 

So I think what we have is, I would say, a 2-decade distortion 

of the career choices of our young men and women. And by the 

way, again, this is not a generational thing. These people are as 

committed as our generation was, and they are ready to go. But we 

have to build it, and they will come. I think that that is the mission. 

Senator GRASSLEY. Could I also ask Dr. Goodman and Dr. 

Mullan—this will have to be my last question for this round—the 

geographic adjustment in Medicare payment is a major factor in 

difficulties that rural States like my State of Iowa experience in recruiting and retaining physicians. Physicians in rural areas receive 

significantly lower Medicare payments than those practicing in 

urban areas. This is especially ironic, since Iowa is recognized as 

providing some of the highest quality care. I could quote a Dartmouth study, but I will not go into that. 

Question: in your view, what has been the impact of the current 

Medicare geographic adjuster on the shortage of physicians and 

other health care providers? And a follow-up question: what 

changes in Medicare reimbursement would you suggest that might 

help increase the percentage of physicians and other health care 

professions practicing in rural America? 

Dr. GOODMAN. Right. I certainly would agree that hospitals in 

Iowa, hospitals in Montana as well, hospitals in Utah, have some 

of the most efficient and high-quality delivery systems, and they do 

it with a very modest physician full-time equivalent input into patient cohorts. They do it very well for a very modest amount of, if 

you will, physician labor. So the current geographic adjustment 

really unfortunately penalizes efficient systems and perpetuates inefficient systems based upon volume. 

Now, I am going to make a distinction, because I have mostly 

talked about physician supply in the context of supply that is at 

least by, say, HRSA standards, considered adequate, if not ample. 

The issue of under-service, of health profession shortage areas or 

medically under-served areas is very real. It is real in my State. 

I am a former National Health Service Corps physician. It is a perVerDate Nov 24 2008 15:20 Feb 04, 2011 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6633 R:\DOCS\63483.000 TIMD
16 

sistent problem, but it is also one of all of our problems in our delivery system, one that we really have the best means to take care 

of. 

We do have programs that have been shown to be very effective: 

the National Health Service Corps, community health centers. We 

have, unfortunately, persistently under-invested in them. It involves a relatively small number of physicians to rectify these problems. Because of that, most of our work at Dartmouth has really 

focused on physician supply distribution beyond under-service, because that is where some of our greatest opportunities are in terms 

of physician labor that is now really quite inefficiently deployed 

and could help to solve the problems, the needs of other patient 

populations, without raising costs further. 

Senator GRASSLEY. Dr. Mullan, do you have something to add or 

any disagreement? 

Dr. MULLAN. No disagreement. A quick add-on. The Medicare incentives have been less effective than one might want, which 

speaks to two issues. One is, they could be stronger. They are not 

very well publicized, not very well used in certain areas. 

But the second item is the organization of the system. When we 

talk about practice reform, I think we need to talk about other 

ways, not simply cash incentives within the current arrangements, 

to incentivize other care provision arrangements, which in primary 

care will certainly help, and probably in the system as a whole will 

help as well. 

Senator GRASSLEY. Thank you, Mr. Chairman. 

The CHAIRMAN. Senator Wyden? 

Senator WYDEN. Thank you, Mr. Chairman. This has been an excellent hearing and a great panel. 

It seems to me that thousands of Americans are losing their jobs 

at the precise time when thousands of new health care providers 

are needed, and sensible health workforce policies then provide 

multiple benefits. You have Americans getting good-paying jobs in 

their communities, jobs that cannot be out-sourced, while at the 

same time patients in the health care system benefit from having 

fresh health care provider talent and advocates. 

So I want to start with some issues relating to the workforce 

question. I was interested in your comments, Dr. Wartman, because it really goes to something that has really concerned me 

greatly as I have gotten into this issue. 

For example, under the Workforce Investment Act, the government spends close to $4 billion, and it is not possible to see what 

is going in, clearly, to the health professions. For example, we 

would like to know what is going in to training nurses, nurses’ 

aides, and areas where there is a consensus that more talent is 

needed. I gather that you are very troubled about the fact that 

some of this money is not spent very efficiently, and that is why 

you would like someone to serve as a coordinator to try to gather 

exactly what is being done with the Federal dollars today. 

Dr. WARTMAN. Well, I am a big vision person, and I think that 

we need to have a much better overall vision and perspective on 

the whole picture and what is going on, what are the inputs, what 

are the outputs, in terms that everyone can understand in a very 

transparent sort of way. So, yes, I would agree. 

17 

Senator WYDEN. Now, Dr. Goodman, you all at Dartmouth have 

been doing very good work. I was interested in your idea of competition for GME funding. Now, before a big brawl breaks out over 

that one, let me ask you, if I might, would there be a way to ensure 

that that could be structured so that everybody would have a fair 

chance to be part of it? Because I think, for example, what you all 

have done at Dartmouth is to show the tremendous value of shared 

patient decision-making, and that ought to be one of the things 

that is taught and emphasized, and is clear. Jack Wennberg, for example, has drilled that point home. We ought to be promoting it. 

How would you structure the competition so as to have schools promoting that sort of approach in their applications for GME funding, 

so it was done fairly? 

Dr. GOODMAN. Thank you. I will try to be brief. I used the example of the NIH because I really feel that that is a model, and that 

one can set programmatic aims and then—NIH funding is free and 

fair funding. I mean, there is no favor, really. It is a great model. 

Right now, GME is fossilized. Those who have had great training 

programs in the past, or at least large training programs, forevermore will receive funding for those programs. There is very little 

incentive for innovation, there is very little ability in terms of the 

government to be able to influence the specifics of training, like incorporating shared decision-making or a notion of population 

health, or any other curriculum innovation. 

This would also allow, for places that traditionally have not had 

large GME training programs, places like Utah or Montana, to 

begin to expand their training programs without the assumption 

that places that have always done it should always do it just because they have done it. 

Senator WYDEN. We would like to follow up with you on that. 

Let me see if I can get you, Dr. Mullan, on one last point. I think 

it is well understood that there is tremendous promise with what 

a lot of people call the medical home. I like to call it the health 

care home, because I think we ought to be saying that in a lot of 

instances, individuals other than physicians ought to be the medical team leader. 

So, if you take the proposition—Chairman Baucus has focused on 

it in the white paper, a lot of Senators are interested in this— 

where do you think would be the best place at the Federal level to 

say, this is where we ought to lead the effort to train people to 

have a health care home or be the medical team leader? Would 

Medicare be the best place to do this? What would be the appropriate place at the Federal level to lead that effort to get the medical team leaders? 

Dr. MULLAN. A good question, Senator Wyden. Medicare has had 

the leading role, de facto role, in health workforce policy because 

of the enormous impact of Medicare GME, but it has been a role 

that has not been an active one in the sense of having either the 

mandate or the capacity to do analytic work, or projections, or then 

to move the money around, as Dr. Goodman has suggested. The 

Bureau of Health Professions in HRSA has had a more cerebral 

role, but no money or mandate to move out in an aggressive way 

in this regard. 

18 

So I think you would need a reorganization or a separate unit 

set up within the government. I think funding traditionally for 

workforce programs has come through title 7 to HRSA, which is a 

different authority, different jurisdiction, which, while we are on 

the topic, I am delighted this hearing is as broad as it is. For those 

of us working in the field, the jurisdictional issues between finance 

and health, for instance, have prevented a big-picture look at 

issues like—— 

The CHAIRMAN. Not this year. Not this year. 

Dr. MULLAN. This is wonderful for those of us who have been 

here. So, in answer to the question, I think you put your finger on 

a real problem in an area for growth in public policy. Right now, 

the agencies and HHS, neither one has all of the abilities to do it. 

Between them—that is, HRSA and CMS—there needs to be responsibility for this, and that could be a joint effort or lodged at either 

one with correct authority. 

Senator WYDEN. Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you. 

I am going to interrupt our proceedings right here—we have a 

quorum present—to report out the nomination of Mr. Kirk to be 

USTR. A quorum is now present, and I thank my colleagues for adjusting their schedules and allowing us to have a quorum. 

[Whereupon, at 11:05 a.m., the hearing was recessed, reconvening at 11:12 a.m.] 

The CHAIRMAN. We will now return to our regularly scheduled 

programming. [Laughter.] 

Senator Nelson, you are next. 

Senator NELSON. Thank you, Mr. Chairman. 

You all have testified that we need more primary care physicians. I agree with you, and I understand that. But that does not 

answer the basic geographic dislocation of a high-gross State that 

was suddenly frozen in its number of residents back in the 1990s 

and rewards to those States that have not grown, with the result 

that a State like mine, Florida—Nevada is also in this category— 

we educate the doctors, but then we do not have the residency 

slots. And we can address the over-utilization of specialties that 

you are talking about, but then, once we educate them, they have 

to go find a residency outside of the State of Florida. Of course, you 

know that a doctor will usually practice where they have done their 

residency. 

Now, that is what we are trying to get at with lifting the cap. 

What do you all think about that? 

Dr. GOODMAN. Well, since I have taken a very strong stance on 

this, I would just point to the fact—let me agree that this is a problem, which is one of the reasons why I have suggested that we 

have competition for GME funds. If we look at the last 20 years, 

in the last 20 years we have grown physician supply dramatically 

in this country, but physicians continue to settle—I will say it 

again: for every physician that settled in a low-supply region, four 

physicians settled in a region with already very high supply. 

So just lifting the cap is not going to rectify the geographic disparities or the specialty disparities. It needs to be more nuanced 

than that. Because we all, I think, bridle against the idea of a commission or an individual who would decide where these physicians 

19 

go, I think the fairest way—and we know the most effective way— 

is a peer review competitive system. There is no reason why Florida should be disadvantaged because New York got there ahead of 

them. Florida needs to grow. New York needs to make its case, 

would be my point. 

Senator NELSON. Well, the fact is that Florida is going to surpass 

New York in total population in the year 2012. From 2012 back to 

the date that there was the freezing, which is going to be some 14, 

15 years, New York has shrunk in population and Florida has exploded in population. We are meeting that population. I want to 

hear from some of the rest of you. Some of you were nodding your 

heads, agreeing with me. I want to hear from you. [Laughter.] 

Dr. MULLAN. I think the problem you point out is a real one and 

it will get worse, for exactly the reasons you suggest. Freezing or 

capping GME funding by Medicare was, as I understand it, an effort to prevent continued cost escalation by more residents with no 

particular plan, and it served at the moment. You raised a question 

of the future. 

I think it brings up the key question about graduate medical 

education, which, as you will recall, I suggested was the governor, 

was the regulator of what we got in the way of workforce eventually. It does need a more nuanced, as Dr. Goodman suggests, approach. It needs to be not simply formulaic with a cap that rises 

or falls, but it needs a more specific plan. Whether that plan is national, regional, or local, we need to insert accountability planning 

and accountability into that system. Simply raising the cap under 

the current circumstances would certainly help in areas of fast 

growth, but as a national policy would, for the reasons we have described, in my judgment, not make sense. 

Senator NELSON. Dr. Goroll, I want to hear from you before my 

time is up. I want you to tell the chairman how we do this nuanced 

approach so that we are not constantly behind the 8-ball in high 

growth States. 

Dr. GOROLL. Well, I can only speak for primary care, but I would 

tell you that I think the standard should be not a political one, but 

it should be access to, in my field, to primary care. There are validated measures of that. If a State is found to have inadequate access, and I think, since primary care is the foundation, one might 

say that is a first target that you would want to work on, then that 

could be the basis to then go to Medicare as an application or a 

criterion for application for additional slots. One could also apply 

that to other specialties. There are some standards as to what is 

an appropriate referral rate. For example, in your State you may 

have an over-supply in certain specialties, but not enough in primary care. So I think there is a rational way to do this and getting 

around just an outright cap. 

Senator NELSON. Can we work on that, Mr. Chairman? 

The CHAIRMAN. We have to, Senator. This is a hugely important 

problem. 

Senator Hatch? 

Senator HATCH. Thank you, Mr. Chairman. 

I want to congratulate the panel for being a great panel and 

helping us to understand these matters a little bit better. 

20 

Dr. Mullan, you have mentioned the need for a national health 

commission on workforce. You feel that we need this. Could you 

just elaborate a little bit more on what having such a commission 

might yield for us? 

Dr. MULLAN. Well, there are two levels of commissions. One 

would be a Federal commission, which would, with better information, develop long-term recommendations for workforce development in medicine and other health disciplines. 

There have been many experiments, or growing numbers of experiments, in State-based activities. I think Utah has really shown 

the way with the Utah Medical Education Council, which, I am 

sure you are aware, is under a demonstration authority with Medicare, and has essentially taken responsibility for graduate medical 

education planning and funding in a local area, a State, in this 

case. 

I think that begins to talk about the nuances that we need for 

planning and how Medicare could begin to move in a way that was 

more specified and would have flexibility as the demographics of 

the country move. They move west, in particular, or south, to move 

our residency support in concert with that. So, I think that is a 

very instructive example on a regional level, and it would be good 

if we had a kind of brain trust on the Federal level that could work 

with it. 

Senator HATCH. Great. 

Dr. Goodman, we have been told that there are geographic differences in utilization. How does the physician mix or the availability of certain specialties influence the high use of services in 

some areas? 

Dr. GOODMAN. Well, we have a great deal of information about 

this now. It is not what we would expect. Let me say that we know 

that, in general, high physician supply is associated with high utilization of services, but with a particular characteristic: it is services 

that tend to be, one, much more hospital-based, a lot of intensive 

care unit days, and fragmented over many, many different types of 

physicians. 

The irony of the geographic variation is that there is a strong 

correlation in the per capita supply of primary care physicians at 

this regional level, broad regional level, as there is of special physicians: where you find more of one, you find more of others. 

But, if you look within health care systems where the care tends 

to be dominated by primary care, so the ratio, if you will, favors 

primary care, this is where care becomes much more efficient, Senator Hatch. 

Senator HATCH. Well, thank you. I think this panel has been 

very helpful to the committee. We have some very tough issues 

ahead of us and a very short period of time to resolve major health 

care reform issues, but with your help, we may be able to do some 

good in this area. I have appreciated every one of your testimonies 

here today. 

Thanks, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator. 

Senator Carper, you are next. 

Senator CARPER. Thank you, Mr. Chairman. 

21 

I just want to say, I fully concur with what Senator Hatch has 

just said. We have a lot of witnesses who come before this panel 

and, almost without exception, the panels are of value. This is especially so, so thank you for being here. 

In my last job, I was privileged to serve as Governor of the State 

of Delaware, and we, in our education reform efforts, sought to harness information technology and bring it into not just every school, 

but every school classroom. I think we were the first State to offer 

Internet access to every public school classroom in our State. We 

worked hard to fund and to bring computers into our State, and I 

think we had the best ratio of students-to-computers of any State 

in America at one time, and we may still have that. 

We found, having done all of that, that a lot of our teachers use 

the computers for sending e-mail, but not much else, because they 

had never been trained to use the technology. They were not familiar with how to bring it into the classroom, how to use it to bring 

the real world into the classroom and to enrich the learning for 

their students. 

We entered into a partnership statewide with Delaware Technical Community College to offer training for our veteran teachers, 

and that training was augmented by new graduates from colleges 

and universities who were becoming teachers and were familiar 

with the technology. Interestingly enough, they trained the veterans. It usually works the other way when people join a school. 

Dr. Mullan, I think you mentioned the need for health IT training. Given the experience that we had with respect to our education, our schools, I could not agree more. 

Congress provided, in the recently adopted stimulus package, some $19 billion of funding to advance health IT in our hospitals 

and our doctors’ offices. But implementing a health IT program is 

not enough. For us to see the maximum benefit from our health IT 

system, doctors, nurses, other health care providers are going to 

need to learn how to use it effectively, much as we did in that 

school classroom. 

My question to you is: what do medical schools do now? And 

maybe not just medical schools, but schools that train nurses, too. 

But what do they do for health IT training? Do you believe that 

medical schools or residency programs need to do more, can do 

more? 

Dr. MULLAN. That is a good question. I think I cannot speak definitively about it, but I will say we have two things going for us. 

One is that many academic health centers and teaching settings 

now have adopted a much more electronic format for information 

management, so those of us who grew up with the electronic medical record will be much more effective at using it and critiquing 

it towards the future. The second is, we are blessed with a generation of young people coming on who are much more computer literate themselves, who participate in the changing, growth, and development of the application of the technology. 

Senator CARPER. Sort of like my sons do with me. [Laughter.] 

Does anyone else want to comment? 

Dr. WARTMAN. Yes. I just want to mention that we are involved 

with a project with the American Medical Informatics Association 

in which we have put together a grant proposal to develop a teachVerDate Nov 24 2008 15:20 Feb 04, 2011 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6633 R:\DOCS\63483.000 TIMD
22 

ing course in informatics for all clinical students in every health 

profession as an integrated phenomenon, and it is really a groundbreaking kind of proposal. 

I think one of the central problems in IT is that there is no single 

consistent platform that everybody uses from office to office, from 

State to State, and around the country. I would like to think of IT 

more like the interstate highway system. You can get on the highway in Delaware, or you can get on it in Montana, and you pretty 

much know the rules of the road. The speed limit may change a 

little bit, but you know how to get there. 

Senator CARPER. I do not know if they have speed limits in Montana. [Laughter.] 

Dr. WARTMAN. Yes. I am just saying I think it would be great 

to have some kind of uniform national standards for IT so that everybody can talk to each other and work the system. 

Senator CARPER. All right. Thank you. 

Another one for Dr. Mullan. If others want to comment, please 

feel free. But I think you mentioned a proposal, I believe it was in 

title 7, to use those funds there to create Teaching Community 

Health Centers. I think that is what you called them, essentially 

partnerships for training purposes between medical schools and 

title-supported community health centers, which enjoy a lot of support around here. Could you just drive this initiative in more detail 

for us, and tell us how it would work effectively with the National 

Health Service Corps to help improve training and recruit new primary care doctors, especially to under-served areas? 

Dr. MULLAN. Teaching in community health centers has always 

been a challenge because they, of course, are not basically teaching 

institutions, they are service institutions and usually hard-pressed. 

So to have the supervision in the way of clinicians to teach, the 

space in order to have extra rooms to have students, and the communications capability to work with the students and their sending 

institution, are all add-ons that, in many community health settings, are simply not possible, or if they are they are really ragged. 

This is not to say that a lot of teaching has not gone on and does 

not go on, but this could be much more industrialized. It could be 

part of what we do invest in on both the health center side and the 

medical school or teaching hospital side. We have never had an initiative like this that made the Teaching Community Health Center 

a primary concept supported by financial incentives. This would be 

a great asset on both the teaching side and on the health center 

side. 

Finally, the National Service Corps, which should be much more 

prominent in all of this if there were more corps members, would 

play a role, as many of them do work in health centers. A minor 

issue to that is, they are required to do 80 percent time clinical 

work. Now, if they can teach in that, that is good, but certainly giving them recognition for teaching as part of their clinical work 

would be an important asset to harmonizing the whole system. 

Senator CARPER. Thank you very, very much. Thanks to all of 

you. 

The CHAIRMAN. Senator Lincoln? 

Senator LINCOLN. Thanks, Mr. Chairman. Thanks to our distinguished panel. We appreciate your willingness to be here and help 

23 

us solve these problems. Being married to a physician who has 

been in academics, in research, and now in private practice, I hear 

an awful lot of your side of the story. But we are glad you are here, 

and I am glad that you are here on behalf of my other colleagues. 

Many of you have made the point that there are down sides to 

simply growing our physician supply without making the muchneeded changes to the way that we deliver care and pay for care. 

And while we may not need a gross increase in the number of physicians nationwide, you also have to recognize, I hope, that we have 

some serious workforce struggles in rural America. 

I represent a State that is predominantly rural. We are also a 

snapshot of where the rest of the country is going to be in the next 

10 to 15 years. We are disproportionately elderly. Our elderly are 

disproportionately low-income, and they disproportionately live in 

rural areas where they are more difficult to serve. 

So it is critically important for us to get it right now because, 

again, we are already where the rest of the country has not gotten 

to yet, and it is important. In realigning payment incentives towards primary care, high quality and coordination of care, is that 

really enough in terms of getting practitioners out into rural areas? 

We have had difficulties. 

We still have problems getting providers to stay in the communities that have made matches. Once they meet their match requirement, they are ready to go somewhere where a spouse can get 

a better job, or there are better schools, or there is better cultural 

life, a whole host of different things. Are those three things enough 

to really see an increase of primary care physicians out there in 

rural areas? 

Dr. GOROLL. There is some very interesting data from the 

Graham Center that has just been collated on the effectiveness of 

various interventions for having people stay in rural areas. One of 

the most powerful is the National Health Services Corps because 

these folks become part of communities in their service and many 

of them go on to stay. So I think forming bonds and ties is very, 

very important, and becoming part of a community which might 

overcome some of the other cultural problems and barriers for people who would come out there. 

By the way, that is why I am not in favor of just a loan forgiveness program for a certain number of years of service, because 

nothing is more disruptive than somebody who becomes a primary 

care doctor for 4 years and then says, I have done my duty and I 

am out of there. 

I think if we are going to fix this problem, we are really going 

to need smarter strategies and longer-term financial inducements. 

For example, maybe we will give somebody a pension if they stay 

their career, just like we do in the military; if you serve 30 years, 

you will be financially secure thereafter. But I think the simpleminded things of, well, these students have a lot of debt, let us just 

give them debt relief, actually, the data shows that there is no correlation between debt and going into, or not going into, primary 

care. It has to do with—— 

Senator LINCOLN. In a rural area, it does. 

Dr. GOROLL. No. I am talking about—— 

Senator LINCOLN. Not just primary care. 

24 

Dr. GOROLL. Right. 

Senator LINCOLN. But service in a rural area. There is definitely 

a disparity. 

Dr. GOROLL. A separate issue. 

Senator LINCOLN. Right. Well, that is my issue, is rural areas. 

Dr. GOROLL. I understand. But I think what the data does support is the National Health Services Corps being—and I think 

Dr. Mullan alluded, to this—reenergized. Remember that show, 

‘‘Northern Exposure,’’ that was on television? That was an example 

of somebody becoming part of the community. 

Senator LINCOLN. Right. 

Dr. GOROLL. And we have to—— 

Senator LINCOLN. We fought really hard, whether it was in the 

matches, the loan program, or whatever. Those communities desperately need those physicians and they make every effort to make 

them a part of the community. But when the incentives become 

greater in other areas, there is a whole host of different things. I 

just think it is an important issue that we have to address because 

that is critical. 

I would just like to throw out my second question before I lose 

my time. Inadequate Medicare reimbursement for geriatic-based 

services such as care coordination, geriatric assessment, I think is 

one of the leading disincentives to beginning and continuing a career in geriatrics. 

We have seen in a recent report from the Institute of Medicine, 

in Arkansas alone, there are currently only 56 geriatricians available to care for more than 385,000 adults 65 and older, an estimated shortfall of 142 geriatricians. It is also estimated, in addition, that we will need 337 geriatricians in the year 2030, when the 

projected population doubles in terms of that age over 65. 

So what type of training do we need to think about to support 

primary care providers so that they are adequately prepared to provide the kind of geriatric assessment and care coordination to service these types of populations, because it is going to be huge? 

Dr. WARTMAN. I would like to respond to both questions, if I can, 

by emphasizing that I think it is really important for the committee to look beyond physicians to solve these problems. 

Senator LINCOLN. Absolutely. 

Dr. WARTMAN. We have heard, mostly, talk about physicians 

today. There are a host of other professions that are out there that 

could be very, very helpful—in fact, in some models that I have 

seen, instrumental—in bringing care to needed populations, whether they be in the nursing profession at a variety of levels or whether it be in the physician assistant programs, pharmacy in the community, psychology, things of that sort. It is all out there. 

Moving beyond just looking at the physicians, we need to consider all health professionals as we put this together, and then you 

bump right into the problem that I alluded to earlier in my remarks, which is that there are a lot of barriers to making that 

work well. 

Those barriers could be everything from health workforce laws, 

standards, scope of practice, licensing, credentialing, things of that 

sort. How do you reimburse team care? What does that mean? How 

can we improve that? So I think there is a real good opportunity 

25 

here to begin to look at the big picture of all the providers that are 

out there and figure out ways to overcome the barriers that keep 

them from working very effectively together. My opinion is that, if 

we rely solely on physicians, we will not have a solution that 

works. 

Senator LINCOLN. Absolutely. 

Mr. Chairman, if I could just comment quickly, you are so right. 

We are working hard on bills now that will provide additional 

training for nurses, nurse practitioners, and others for specific 

areas of geriatric training that could be something that would really be night and day in terms of their ability just to really focus on 

the geriatric population. There are other great institutional settings, like the Geriatric Education Centers, the Area Health Education Centers. I do not know how familiar you all are with AHEC, 

but it is a wonderful system with our medical school in Arkansas 

where we can actually get people out into those areas. 

But I would also say that it is going to be critical if we are going 

to use these other medical professionals that the insurance or the 

delivery has to be able to accept them, because you have communities where you have a whole population of people who may have 

worked for the same company and the same insurance, and if the 

coverage does not cover a PA, or whatever, they are going to still 

have to travel the 2 hours to get the health care somewhere else. 

So, it all has to fit together. 

So we appreciate your help and look forward to working with you 

on that. 

Dr. WARTMAN. Thank you. 

Senator LINCOLN. Thank you, Mr. Chairman. 

The CHAIRMAN. A point I would like to ask Dr. Mullan is with 

respect to GME programs. It would make better use of GME by encouraging programs to help teach providers to learn new skills, like 

health IT, care coordination. I mean, you said GME does not have 

a brain. So, if we were to give it a brain, assuming it is an intelligent brain, how could an intelligent GME brain operate to help 

solve some of the questions we are talking about here? 

Dr. MULLAN. A very good question, Mr. Chairman, and a tough 

one. There are two levels on which the brain could be activated: 

one is the distributional level in terms of allocations, the second 

would be a content level in terms of influence on what is taught. 

On the latter level, one would have more difficulty with the institutions, or the professions, or the specialties not wanting intrusion 

by the Feds or outside forces as to what we ought to teach. The 

issue, nonetheless, is an important one because there is a group, 

the ACGME, the Accreditation Council for Graduate Medical Education, that accredits programs, and they have attempted some degree of course correction with a set of competencies that are now 

required of all residency programs. I think in the judgment of most, 

those have had some impact. They certainly have had an impact 

in terms of what gets done. The outcomes are a little harder to 

judge. Now, is there a Federal role in that? I think that would deserve debate. 

The CHAIRMAN. What do you think? 

Dr. MULLAN. I think it would be, beyond some large indicators 

of what we are concerned with—the absence of instruction in 

26 

patient-centered care, or care coordination; that would be good. To 

get into managing which program does or does not do it would become, I suspect, very entangling very quickly. 

But as part of the allocation process, which I think is unavoidable, somehow we are going to have to work out a system in which 

somebody, some brain, is saying we need more residency training 

in Utah and less somewhere else. As part of that, there could be 

content as well. 

I am increasingly persuaded that that should not be done from 

Washington, that it should be done with intermediate organizations, whether they are State-based, regional-based, or a consortium of some sort, which require medical educators—in this case, 

graduate medical education, folks responsible for graduate medical 

education—to both look to the needs of their region or their State 

and talk to Washington about what is warranted in terms of support. So you would need the ability for Medicare to work through 

intermediaries. 

The CHAIRMAN. I want to explore this a little bit. I remember Dr. 

Goroll earlier saying something to the effect, do not reform GME, 

just build it and they will come, or something along those lines. 

That is, change the incentives so that the medical school students 

want to go into primary care, and then the GME allocation would 

follow. I will give you a chance to say what you think. Dr. Goroll, 

what do you think about what Dr. Mullan said? 

Dr. GOROLL. There is also another way to drive the GME agenda. 

I sat on the ACGME for 6 years, and it is very focused on training 

physicians. (By the way, it is the only educational accrediting body 

in the country that is not public; that is, it is run by the profession, 

not by a government body.) It is very interesting in terms of where 

it stands educationally. They are very thoughtful people there. Its 

accreditation criteria have become increasingly outcomes-based instead of processed-based for the applicants. So, I think they are a 

potentially very constructive force. 

But I would not have the Federal Government saying there 

should be training in X, Y, or Z. What I would do is have payment 

based on outcomes for a substantial amount of physician payment, 

and now those outcomes are the patient—— 

The CHAIRMAN. Are you talking about GME payments? We are 

talking about reimbursement, physician reimbursement. 

Dr. GOROLL. Right. But the way you affect GME is, you change 

the rules of the road for your professional life. If you are now going 

to get paid according to patient satisfaction, and access, and efficiency, and cost effectiveness, and quality of care, then you as a 

trainee want from your training program the skill set that is going 

to allow you to be successful in that. Right now, all it is is, we are 

going to emphasize training in procedures (e.g., catheterization), 

and we are going to train you to do as many as you can possibly 

do. What I am suggesting is, if you change the rules for payment, 

you will change the agenda in these other areas. 

The CHAIRMAN. Dr. Goodman, do you want to say something? 

Dr. GOODMAN. Yes. I do not disagree with you, but I think that for the nearly $10 billion in Federal funds that go into GME, that 

some accountability is in order. So, when programs go back to the 

Federal Government and seek more funds, there ought to be measVerDate Nov 24 2008 15:20 Feb 04, 2011 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6633 R:\DOCS\63483.000 TIMD
27 

urement and there ought to be reporting, and it ought to be against 

explicit goals and whether they have been achieved or not. They 

could be curriculum goals or they could be distributional goals. It 

does not have to involve micromanaging. I think that the worry 

about micromanaging is really sort of a cover for our old profession’s fear of any sort of involvement or at times, quite frankly, accountability in this realm. 

GME decisions now, our brain, are the individual decisions of all 

the teaching hospitals in the U.S., their individual decisions collectively in an uncoordinated way. These are tomorrow’s physicians, 

so introducing some measurement and accountability, I think, 

would augment and certainly compliment exactly what you are saying. 

The CHAIRMAN. Dr. Goroll, what do you think of what Dr. Goodman said? 

Dr. GOROLL. I think it makes excellent sense. 

The CHAIRMAN. Some measurement. 

Dr. GOROLL. I think that makes sense, as long as it is tied into 

where we are going as a society altogether so this is part of a consistent message. We have, often, in medical school had such mandates or actually such programs. We could name a hundred of 

them: HIV testing, women’s health, on and on. There is a whole 

agenda, social agenda. But they are not durable because, when people get out in the real world, the rules are different. What I am 

suggesting is that we make the rules, and that includes payment 

but that also includes accountability, to be consistent and thoughtful, and again, aiming at what are we really trying to accomplish. 

The CHAIRMAN. Thank you. 

Senator Grassley? 

Senator GRASSLEY. Yes. I just have two questions. The first one 

will go to Dr. Mullan and Dr. Goodman, and then the last one to 

Dr. Mullan. 

On the first case, one of the concerns I have heard over the years 

is the challenge of providing off-site training to residents. It makes 

sense for residents who plan on practicing in settings like community health centers or doctors’ offices, to train there. This seems 

more appropriate than spending the entire time at a hospital. 

Based on testimony we have heard this morning, it seems like 

GME funding rules play a part in this challenge. Can you provide 

more detail about how GME funding rules are an impediment to 

off-site training, and what reforms Congress can make to promote 

off-site training? 

Dr. MULLAN. The current rules for Medicare GME provide a 

number of barriers to off-site training in both the indirect and direct portions, and they get complicated quickly. But essentially, the 

system in place, the default system, is one that funds hospitals for 

residents that are in hospitals. When they move off-site, the hospitals will lose funding for those individuals. 

Now, it is a little different for direct and indirect, but that is the 

essential problem on the hospital side. On the community side, the 

community health center, the private office, the public health office, they, by current law, do not get the benefit of the training dollars, which stay with the hospital or do not get funded at all. So 

we need to both reduce the barriers for moving out of the hospital 

28 

and provide incentive or assistance to the community-based site 

that would be doing the training for that period of time as well. So, 

there are many fine points to that, but those are the essence of it. 

Senator GRASSLEY. Anything to add, Dr. Goodman? 

Dr. GOODMAN. No. 

Senator GRASSLEY. All right. 

Then to Dr. Mullan, you testified that the U.S. primary care 

workforce has become reliant upon international medical graduates. Would changes in the structure of education, training, and 

reimbursement of health care professionals have an impact on our 

reliance on international medical graduates? 

Dr. MULLAN. The major way in which we could move to become 

more self-sufficient in the United States is by increasing the number of medical students we train, but not increasing the number of 

residencies. 

Right now, a quarter of our residencies are occupied by international graduates, and about the same number of our physicians 

in practice are international medical graduates. So, very briefly, we 

graduate about 18,000 medical students each year from U.S. 

allopathic and osteopathic schools, and we have about 24,000 physicians who are interns, first-year residents. 

The difference, that 6,000, is made up by very able, very eager 

international, very bright international medical graduates, and 

there are probably 2 or 3 times that many ready to take the jobs. 

There is an infinite supply of people who want to come. 

If we increase our medical school output, which is happening as 

we speak—happily, in my judgment—but we do not raise the roof, 

the ceiling, as it were, the GME dollars for the GME physicians, 

at least we do not raise it radically, gradually the U.S. graduates 

will fill in more of those spaces and we will be more self-sufficient. 

That is good domestic policy and that is good foreign policy, because around the world there is considerable concern now, as the 

world tries to get its medical house in order, that the United States 

and other northern nations are poaching the south relentlessly, and 

we should, after all, be able to train enough of our own. So this is 

very good in terms of U.S. global positioning. This also increases 

opportunities for domestic students. I think we are on a good trajectory. 

Senator GRASSLEY. All right. Thanks to all of you for your fine 

testimony. We will probably be getting back to you sometime. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator. 

Dr. Wartman, I want you to know, we have not forgotten your 

main issue, which is that we need a lot more health providers in 

addition to doctors, nurses. We very much appreciate that. You 

gave some clues as to what some of the barriers were. I assume 

that, therefore, that is a clue to what some solutions are to address 

those same barriers. 

Just a couple more general questions. If we provide universal 

coverage, if everyone in America has health insurance, as one of 

you said, that is going to add more stress to access, I guess. We 

will not have enough primary care doctors with all this new universal coverage. That is part of the problem in Massachusetts. I assume that is right, that you are saying it is going to further exacerVerDate Nov 24 2008 15:20 Feb 04, 2011 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 R:\DOCS\63483.000 TIMD
29 

bate the problem the more this country moves toward universal 

coverage where everyone has health insurance. Is that true? Is my 

conclusion accurate or inaccurate? 

Dr. MULLAN. It is accurate, in my judgment. I think that just 

adding more, which we need—certainly universal coverage, but 

again, without reforming the parts—if we are also interested in addressing costs and outcomes, we are going to have huge problems. 

The CHAIRMAN. But is this not going to be more costly? 

Dr. MULLAN. It does not have to be more costly. 

The CHAIRMAN. I am sorry? 

Dr. MULLAN. It does not have to be more costly. 

The CHAIRMAN. Some people looking at this and listening to this 

hearing might say, my gosh, that is going to add that much more 

cost to an already costly health care system in this country. So 

what do we do to solve that one? Dr. Goroll? 

Dr. GOROLL. Well, if we have 30 percent waste, or even a fraction 

of that—— 

The CHAIRMAN. And you think that is what we have? 

Dr. GOROLL. Well, I always depend on the Dartmouth data. 

The CHAIRMAN. Everybody looks at Dartmouth. Everybody looks 

at Dartmouth. 

Dr. GOROLL. But let us assume Jack Wennberg and his colleagues are off by 50 percent. Let us say it is 15 percent. If we can 

bring that down by 5 percent, we can cover a whole lot more folks. 

If we can strengthen primary care—Barbara Starfield’s data from 

Hopkins shows that costs go down when there is strong primary 

care. So I think that, if we convert that waste into useful dollars 

well spent and we do that through strengthening the primary care 

base, we can almost go on a pay-as-you-go basis. I do not think it 

is hopeless, but I think that, if we do insurance without doing primary care, I think we will have a Massachusetts experience. 

The CHAIRMAN. All right. Other comments? 

Dr. WARTMAN. I just think that, if you consider the cost of people 

without insurance, when they do encounter the health system, 

those costs seem to be very high because they have not had any 

preventive care, et cetera, et cetera, et cetera. Bringing them in, I 

think, is a very smart move. I think the real question is, who will 

take care of them, and what will be their distribution of specialty 

types? How will they work together and achieve the best health 

outcomes? I think that is the real question. That could be very affordable. 

The CHAIRMAN. That is what everyone is saying. 

Dr. WARTMAN. From a workforce perspective—— 

The CHAIRMAN. I was wondering whether you all four basically 

agree with that concept. Yes? 

Dr. MULLAN. The basic arithmetic of your concern is absolutely 

unimpeachable. That is, more people, then more problems, more 

services required. 

The CHAIRMAN. Yes. 

Dr. MULLAN. But my suggestion, given the circumstances, to be 

lean is better. That is, a lean workforce will force creativity, force 

economies. The workforce we have today has been characterized by 

one of our colleagues as an SUV, in the sense that it is big, comfortable, and very expensive. An SUV is not an answer that we can 

30 

afford and not an answer that we should look to. So strategies that 

will cause us to invest in those parts of the workforce that need 

gearing up, it will force creativity from the academics and the service sector both in rearranging our system. I think that is where the 

real savings and the real good policy of the future and good patient 

care in the future will lie. 

The CHAIRMAN. One of you said something that caught my attention. I think I know what you were driving at. It is analogous to 

the problems in our financial sector in our economy. I think the 

conclusion is going to be that our incentives are driving people to 

go to the wrong places. Maybe it was you, Dr. Goroll, who made 

that comment, or maybe Dr. Goodman. One of you said something 

along those lines. 

Dr. GOROLL. No, I take responsibility for that. 

The CHAIRMAN. What did you say? 

Dr. GOROLL. Well, it distorts. There are many parallels. Very 

briefly, it distorts the decisions of our best and brightest people, 

and they are going to the wrong places. As I started out by saying, 

they come to me, almost ashamed, because they know what they 

would like to do and what they want to do, and we have set up 

a perverse set of incentives. I think it is very fixable. It is very fixable. 

One comment about the cost. We have universal health care in 

the United States: it is called emergency rooms. Emergency room 

costs—just look at our emergency rooms. If you went in any emergency room in any major city in the United States today, it would 

look like World War III. That is where universal care is being carried out right now, and it is extraordinarily expensive. So I think 

there are ways of doing this smartly and not saying that the net 

investment is not worth it. 

The CHAIRMAN. I have to conclude this hearing, but thank you 

very, very much, all four of you. This has been most helpful. I urge 

you, frankly, just to keep following up. Senators will have questions. But if you get some bright idea, do not hesitate to let us 

know. Give us a call. All right. 

The hearing is adjourned. 

[Whereupon, at 11:53 a.m., the hearing was concluded.] 

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(77) 

COMMUNICATIONS


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Æ 


63483219.eps