The Actual Office to close down gitmo has been closed itself. We gave you all the information we have available on that subject, okay . Currently 30 of u. S. Doctors are primary care physicians. Tuesday, they examined the growing shortage of primary doctors. This is just under two hours. [inaudible conversations] [inaudible] which is going to cover, i believe, an enormously important issue. I want to thank Ranking Member for his work. He and i worked together on a number of issues over the year. I look forward to a productive working relationship. Vermont is a rural state. I know something about rural problems. His state is a lot more rural. We will see how we can go forward together. In our country today, before i begin that, i want to thank all our panelists for being here. We have a great set of panelists from all over the country, and we very much appreciate them being here. We thank them for the work they do every day providing health care, doing research. In our country, today, i think as many people know, weve been almost twice as much as do the people of any other country per capita on health care. Thats about 18 of our gdp, and, yet, our Health Care Outcome in terms of life expectancy, infant mortalitying and disease prevention are not particularly good in terms of international comparison. One of the reasons for that is that we have a major crisis regarding primary Health Care Access that results in lower Quality Health care for our people and greater expenditures. Lower Quality Health care, and, yet, we end up because of the crisis in primary Health Care Spending substantially more than we should. Today, 57 Million People in the United States, one in five americans, cannot see a doctor when they need to. Lack of access to a primary care provider is a National Problem, but those most impacts are people who are low income, minorities, seniors, and people who live in Rural Communities whether its vermont or wyoming. As weve seen time and time again with dental care, Mental Health, and other health care issues, the groups that lead need health care the most are the least likely to receive it. The good news is just 11 months from now well be providing Health Insurance to 30 million more americans through the Affordable Care act. The bad news is we dont know how we are going to be providing primary health care to those americans who now have Health Insurance. Let me rattle off some statistics that i think should be of concern for the congress, and, in fact, for all americans. Not widely known, and maybe youll talk about it, but approximately 45,000 people every single year die in the United States of america because they do not have Health Insurance, and they do not get to a doctor on time, 45 45,000 americanss. According to the Health Resources and health administration, we need 16,000 primary care practitioners to meet the need that exists today with the ratio of one providers for 2,000 patients. Over 52,000 primary care physicians will be needed by 2025. In 2011, 17,000 doctors graduated from american medical schools, despite that half the patient visits are for primary care, only 7 of the nations medical School Graduates now choose a primary care career. 7 . Nearly all of the growth in the number of doctors per capita over the last several decades have been due to arrive in the number of specialists. Between 1965 and 1992, the primary care physician ratio grew by just 14 while the specialists, the population ratio exploded by 120 . The average primary care physician in the United States is 47 years of age, and one quarter on retirement. In 2012, it took about 45 days for new parents to see a Family Doctor up from 29 days in 2010. In other words, even if you request find a family provider, it an takes a lot longer than it should to see him or her. Only 29 of u. S. Primary care practices provide access to care on evenings, weekends, or holidays, compared to 95 of the physicians in the united kingdom. In other words, our culture is dont get sick on saturday, sunday, but nine to five works good. Half of emergency room patients would have gone to a primary care provider if they had been able to get an appointment at the time one was needed. In other words, we are wasting billions of dollars because people end up in the emergency room for nonEmergency Care because they cant find a primary health care physician. In my view, and i think the view of all of the experts who studied the issue, primary care is intended to be and should be the foundation of the u. S. Health care system. In 2008, americans made almost a billion Office Visits to the doctor, 50 of those visits were to primary care, half. According to every study down on the issue, access to primary health care results in Better Health outcomes, reduced health disperties, and lower spending by not only reducing Emergency Rooms, but when you get people to the doctor when they should, they dont get sicker than they otherwise would be and end up in the hospital at great costs. The problem we are discussing is clearly a National Problem existing in 50 states in the country, by its even worse for particular geographic regions. The ratio of primary care doctors in urban areas is 100 for 100,000 people. Double the ratio in Rural Communities where it is 46 for 100,000 so urban communities, clearly, have problems, Rural Communities have even greater problems. 65 of primary Health Care Professional shortage areas are in rural counties. My own state, we do much better than the rest of the country in terms of primary Health Care Providers per hundred thousand, and, yet, i can tell you in the state of vermont, people often have difficulty getting to the primary care provider they need. Although 20 of americans live in rural areas, only 9 of the physicians practice there. One of the significant differences between the u. S. Health care system and the Health Care System of other highly developed countries, which could significantly explain why we spend so much more than other countries around the world, is the ratio of primary care physicians to specialists. In the United States, roughly speaking, 70 of our practitioners are specialists, and 30 are primary Health Care Providers. Around the rest of the world, that number is exactly the opposite, about 70 of their practitioners are primary Health Care Providers, and 30 are specialists. What can congress do to address this very serious issue . Let me just rattle off a few points and then give to mic over. First and foremost, clearly, we must address the issue of primary care reimbursement rates. Specialists earn as much for their lifetime of practice as much as 2. 8 million more than primary carp providers. If you are going spue med sip, if youre a specialist, you can earn throughout your lifetime almost three Million Dollars more than a primary care practitioner. Raid radiologists are twice that. The position for setting reimbursement in this country is largely determined by the 3 31 physicians who sit on the American Medical Association committee called the relative value committee, and the ruc whose payment conditions are accepted by the medicare and medicaid services, over 90 of the time, and adopted by many private insurers is dominated by specialists. Specialists sitting on the committee determine reimburressment rates. We have to look at that issue. Medicare has promoted the growth of residencies in specialty fields rather than primary health care by providing significant subs, 10 billion each year to Teaching Hospitals without requiring any emphasis on training primary care doctors. Its very efficient. Thirdly, unlike other nations that provides significant Financial Support for medical school education, we by and large do not do this in this country, and the result is that the median debt for medical students upon garaguation is more than 160,000 and almost a third of medical School Graduates leave school more than 200,000 in debt. Now, if you leave school 200,000 in debt, what are you going to do . Figure out how to make as much money as possible to deal with that debt, and youre going to gravitate towards fields that pay you higher incomes. So, if were going to attract young people into primary health care, we must make that profession more financially attractive. In other words, we must address the issue of how reimbursement rates affect medicare and impacts reimbursement rates for all physicians. We worked on the issue and greatly expanded Community Health centers around the country. Those provide good quality, Cost Effective health care. We need to do more than that. We made progress. We need to make more progress. In recent years, we significantly increased funding for the National Health service corp. That says to somebody, and if you graduate medical school 200,000 in debt, well help you address that debt, help you pay it off if you practice in under served areas. It is working. It has worked. We made progress. We need to make more progress in that. Teaching Health Centers. Studies shown residents train Community Health centers own Rural Communities are trained in those settings to make a career practicing in underserved or rural areas. The thc pramg was the only new investment in graduation in the Affordable Care act, and the five year funding was just 230 million. We have to expand that. Also got to take a hard look at the role of allied health providers, Nurse Practitioners, and others. How do we better utilize those people in the provision of health care . Weve got a very, very serious problem, lives of thousands of people depend upon what we do, and im very excited about the wonderful panelists we have at this hearing, and i want to hand it over. Thank you, and i look forward to working with you. Id like to thank witnesses for taking time out of the schedules to be with us. I particularly like to welcome tony from chiian of the shes worked with me, and my staff, on Health Care Work force finishes for a number of years, and i appreciate she made the long trip across the country to be here. Its a pleasure to welcome all the witnesses to our hearing. The issue of improving access to primary Care Services alining our Health Care Work force is one thats important to all of us, but particularly significant begin obstacles people face in wyoming. Nearly the entire state is considered a frontier or rural county. 47 of the population lives in a county with fewer than six residents per square mile. Approximately 200,000 residents live in Health Professional shortage areas with inadequate access to primary or dental care. Theres serious challenges in wyoming that require Creative Solutions to resolve. We have one hospital thats served by a physician that every time we lose that physician, the hospital closes. To that end, the state developed programs to meet needs of a frontier state where distance is the biggest barrier to accessing a doctor. We say we have miles and miles of miles and miles, and we recruiting Health Care Providers is a challenge. The Loan Repayment Program and a grant program, these programs work to reduce the high cost of Health Professional graduate and Training Programs, owive often a deterrent to work in primary care or other low income fields. The Network Represents another innovate of approach to improving access and reducing primary care work force shortages. This collaborative arrangement between the Health Professional societies, university of wyoming, and other key partners maintains an extensive data base on wyoming Health Care Facilities and their need for professionals. Sharing information more effectively allows for better allocation of resources and manpower at a time when the fiscal climate limits our ability to spend money on the problem. Theres more that can be done to align federal programs to meet the needs of rural and frop tier states. The cry criteria that meets the eligibility for Rural Health Programs based on factors difficult to prove the needs of underserved in rural and frontier areas. For example, one provider for 3500 people in new york city is entirely different than 3500 People Living in freemont or campbell county. We have to think creatively how to use technology to improve capabilities so that where a person lives has less impact object level of care they receive. The advancement of more powerful Wireless Technology has substantial potential to remotely link individuals across the country to deliver health care in more accessible settings. Weve had quite a bit of success with that with some of the Veterans Outreach clinics where they used this extensively with Nurse Practitioners in charge of handling the equipment, and the doctor on the other hand. I hope the hearing makes it clear we have to think creative ly and think of ways to access primary health Care Services and ensure Health Care Professionals are employed where they are most needed. I look forward to hearing from the witnesses op what needs to be done to solve the problems at the federal, state, and local level. Again, i want to thank witnesses for participation, thank the chairman for his great list of suggestions on things that need to be done, and im sure that we have the capability to come up with some solutions through this committee. Senator enzi, thank you very much. Senator warren was here first. Senator warren . [inaudible] yes. No, i just want to thank you very much for holding this hearing, mr. Chairman. I am very interested in the questions about how we equalize access for all citizen, and particularly interested in the question about how we make the right investments to lower the overall cost of health care. I think the chairman said it best saying what were looking for is Better Outcomes at lowest costs. That is the role that the federal government can make if it makes the right upfront investment. Looking forward to hearing from each the panelists. I also thank the Ranking Member of, i think the comments about access and the reminder that its very different in a large city than it is from a very rural area are comments that are well taken and one for us to remember carefully, and, also, a reminder that has different consequences, even in a state like massachusetts where, obviously, we have very Extensive HealthCare Services in some areas, but its still leaves us with the population in massachusetts with difficulties in accessing care. Sometimes distance is less the challenge, but costs can remain the challenge, and transportation even within close areas are a serious challenge so i appreciate the reminder of the diversity of issues that we face in making sure that all of our citizens have good access. Thank you, mr. Chairman. Thank you very much, senator. Thank you, mr. Chairman. Ill not use the allotted time in the entirety and apologize to the panel that i have to sneak out to attend another Committee Meeting and return, i hope, for the q a, but i appreciate, mr. Chairman, your focus on this broad, but very critical issue that has so much relevance seeing through the implementation of the Affordable Care act. I represent a state that has urban concentrations as well as perhaps, not as large spaces of rural areas, but certainly has the array of challenges that are the subject of this hearing, and i appreciate the attention thats going to be focused on it. One of the things that i hope that will hear some elaboration on, aside from issues that compensation pays or plays in this, is the questions of lifestyle for primary care practitioners, things like the differences between the amount of time that somebody might be on call as a specialist versus a primary care physician. As we look at larger payment reforms, how the flexibility in their prac