Dr. ESHLEMAN. Yes, but I am employed by the Alameda County Health Department, so my own salary comes from them. Senator PERCY. Would you mind saying what your gross income is per year now? What was it in your income tax return filed last year? What was your gross income? Dr. ESHLEMAN. My wife and I have a combined income of $47,000 of which $41,000 is my own contribution. Senator PERCY. Let me go back to the So I approached the region 9 office, asking them for permission to switch my private practice assignment from the West Berkeley Health Clinic shortage area to the Newark-Union City shortage area. This request was duly forwarded to Washington, and before Washington actually commented on the merits of my case, I received, by registered mail, exactly 212 weeks ago, a default bill for $138,000 which represents, under triple payback, the $28,000 that the Government used to pay for my education. Now, I want to say that I feel a very, very I strong obligation. My feelings have not changed one whit from the time that I filled out that application. I believe this is a serviceoriented organization. I believe it is my duty to serve. Senator PERCY. To pay it back. Dr. EsHLEMAN. And I also believe that I am serving. This, I think, is the frustration that so many of the obligated Corps physicians are feeling right now. I think that the stereotype of the physician who walks away from a Federal loan into a lucrative private practice is exactly that, a stereotype. Senator PERCY. All right. Let me just ask you, then, one last question. Dr. ESHLEMAN. Certainly. Senator PERCY. Not in your personal category, but in your category as representing an organization. Dr. ESHLEMAN. Yes. Could I state the name of the organization, by the way! Senator PERCY. The common complaint from contract-breaching doctors is that they cannot always serve in the urban area where they and their families would like to settle. Let me just quote again from the first doctor whose application I showed you was signed in 1977. He said: Should I have to serve in what will likely be a rural area separated from my spouse, family, and friends Now, this is afterward: I worry that the quality of service I could offer my patients would suffer substantially. In addition, there would be no likelihood that I would remain in the area to which I was assigned. Totally contrary to the application that he filed. The purpose of this scholarship program was not to give doctors a free education and then set them up in a profitable practice. Anyone who would introduce such legislation or voted for it would have been thrown out of office by angry taxpayers for being totally unrepresentative of what should be done with taxpayer's money. The purpose was to provide medical services in areas under-served by doctors, and anyone would recognize that serves a social purpose, and therefore, let's see that this doctor is given this grant, and it is a a a very generous program but conditioned upon, always, he is going to fulfill a social service for a given number of years. I am troubled with the notion that the scholarship recipients might not perform quality services if they aren't assigned to their first choice of location or to a fashionable urban area. Do you think, having seen a number of cases and putting yourself in the shoes of the taxpayers, now, and the Congress and the Justice Department, do you think this is a problem if doctors say that they can't accept service in a needed area, they will have to go to another area where there isn't a demonstrated need but it serves their present family purpose, now? Is that a problem? Could you give me a very concise answer? Dr. ESHLEMAN. I cannot say it is not, but I would like to say that there seems to be an emphasis here in this hearing on asking Corpsobligated physicians to go exclusively into rural areas, and we know for a fact that the Nation's cities are also medically under-served areas. Senator Percy. We are not all asking them to do that. We have got all of Cook County up there. That is an area that is not devoid of cities. It is the third now, I have to say, the third largest city in the United States embraced in that area, and we do have sections of Chicago that we have a great deal of difficulty getting doctors to live in. Dr. ESHLEMAN. This is perhaps true, but in the last 6 months, the National Health Service Corps has dedesignated some 40 percent of all health shortage manpower areas in the United States, and these dedesignation have cut rather heavily into urban inner city areas, specifically, Atlanta, the South Bronx, Los Angeles, and Detroit have all had vast areas which, by all medical indices of infant mortality and chronic disease, still remain severely under-served areas, and yet these areas are no longer designated to receive Corps physicians. Not only that, the matching process for this year began last summer when these places were still on the lists that the obligants were sent, and many obligants attempted in good faith to establish practices in those areas only to be told, over the last 6 months, that their tentative match had been disapproved because the site had been dedesignated. What I am trying to stress here is that I don't want you to go away from this hearing with the stereotype of this woman in Los Angeles making $153,000 a year and not wanting to make a reasonable payment on her loan. I think by far, the majority of the defaulters are people that have been frustrated by Corps policy, administrative policy that makes it very, very, very difficult to actually find a position, especially since, in the last few years, the Corps has changed its emphasis from federally funded positions at community health centers and regional health centers to what is now called the private practice option." Guidelines for this year call for a minimum 40 percent of all obligated practitioners to repay their debt through private practice, and in many cases, these physicians are given very little in the way of assistance in this practice. Some have been assigned to States where every one of the practice opportunities was listed as a private practice, and in many of the cases, they have come into a town so designated to find no medical facilities, nobody in the community knowing that they were coming, and really, no help from the Corps. They are essentially sent out without a map and a compass and told, "build thee a clinic on this a a spot, and if it is in conformation with our rules, we will forgive your debt to the Government." I think that rural placements are fine, and I think that urban placements are fine, but I think that a rural placement that includes no site development and we have ample, ample documentation of this in our file; of people being literally sent to towns where there weren't any buildings to put their practice into—is bad policy. If the Corps finds a need in rural areas and wants to assign us to rural areas, that's fine, and it is necessary. But let them provide us with a place to practice. Let not the obligant take on both the medical and the financial responsibility for caring for the medically under-served. Senator PERCY. Dr. Eshleman, one last question. Senator PERCY. Mr. Nelson told this subcommittee that an organization in the San Francisco Bay area may be counseling doctors not to serve where the National Health Service organization sends them and not to pay back their debts. You are from the bay area. Do you know anything about this organization? Have you ever heard of such an organization ? Dr. ESHLEMAN. No. My own organization, the Association of National Health Service Corps Scholarship Recipients [ANSR] does not counsel any scholarship applicants not to repay their obligations. Senator PERCY. No; but does any organization that you know of? Dr. ESHLEMAN. I don't know of any organization. In fact, on joining ANSR, one principle we all subscribe to is that we do have an obligation, that we feel that the Corps' own policies have made it increasingly more and more difficult to perform our obligation. We essentially have personal services agreements with the Corps, and in such an agreement, rights and obligations flow both ways. Senator PERCY. Yes. Dr. EsHLEMAN. The medical education pipeline, if you will, is a long one, 7 to 8 years from the time one enters medical school until you finish a primary care residency, and, of course, we are all obligated to do primary care residencies. In those 7 to 8 years, conditions of the Corps have changed very dramatically, and the promises that were made to us when we were recruited, and I must stress that we were actively recruited, that we had other options. We could have borrowed money from bankers. From friends Senator Percy. But you voluntarily signed up for this program; you chose this program above all other programs. Dr. EsHLEMAN. Because we believe and still believe in the mission of the Corps. Senator PERCY. Of course, they went out and recruited. They have a need. They are trying to fill that need. Dr. ESHLEMAN. Remedying the problems of physicians' distribution is what I am trying to remedy. What I am saying here, and again harkening back to my own case, the place I was assigned to was clearly, in the opinion of all the medical professionals in the area, not a suitable site. I went to a second health manpower shortage area which was a suitable site, and for this, I am now awarded a default bill of $138,000, interest on which probably exceeds my annual income. I think that the policies of the Corps have become very, very inflexible, and I think it is absolutely essential that the Corps loosen up their placement policies, that the Corps spend more time on site development and technical assistance. If they do this, I think very few problems are going to remain, and those problems that do remain should be handled by some new procedure of due process. Because again, I feel that I was not granted due process by the Corps. I protested a decision, and the reply to my protest was not a reasoned discourse. It was a bill for $138,000. Senator PERCY. Our next witness, we requested them on site selection. I want to thank both of you very much indeed. That completes this portion of the hearing. Thank you very much indeed. Any further comments you would like to have, you would like to make to us in addition to your full testimony, any further comments you would like to submit will be incorporated in the record immediately following your comments in the event that you can get word to us within a week. Dr. ESHLEMAN. OK. I would like to pledge the support of ANSR to your committee and to your staff in ironing out what we think are very serious problems with the National Health Service Corps. Senator Percy. Thank you very much. [The prepared statement of Dr. Eshleman, with attachments follow:] ANSR Association of NHSC Scholarship Recipients Testimony of Alan Eshleman, MD, MPH Mr. Chairman and Members of the Committee: Thank you for providing me with the opportunity to testify today. My name is Alan Eshleman, I am a National Health Service Corps (NHSC) Scholarship Recipient and completed residency training in Internal Medicine last July. I am here today representing the Association of National Health Service Corps Scholarship Recipients (ANSR), an organization formed last fall by obligated physicians, dentists, and other health professionals who were distressed by recent changes in the philosophy of the NHSC. ANSR supports the original goals of the NHSC: to match obligated health professionals with underserved communities in an attempt to provide a long-term solution to the problem of physician maldistribution. Many of us in selecting the NHSC scholarship rather than a military scholarship, believed we were choosing a career working in federally supported sites providing needed medical care for those Americans who for reasons of geography, language or poverty were denied access to health care services. Many of us due to begin our service obligations during the past several years have discovered that the NHSC has undergone significant changes; changes which my colleagues and I believe violate the spirit and intent of Congress and deny thousands access to health care. These changes are a consequence of several factors: 1) changes in the national need for health professionals; 2) changes in Congressional budget priorities; 3) changes in the way that the program is administered. It is primarily these administrative changes which we believe are forcing obligees into default. For example, the Corps assigns obligees to develop a private practice in underserved communities which cannot financially support a private practice. I am a victim of this policy. Federal budget constraints are forcing more and more obligees into the Private Practice Option (PPO). This year no less than 40% were to be assigned to the PPO. Yet, the NHSC has so severly restricted the Health Manpower Shortage Areas allowable under the PPO that only those most needy qualify.. These same communities are often least able to support a 'private practice. In authoring the NHSC legislation, Congress astutely recognized the importance of a good match betweeen, obligees, their spouses and underserved communities in promoting retention of NHSC personnel. Unfortunately, this is not a priority for present NHSC administrators. Rigid Corps policy: Often forces families to spilt up or face de fault; Refuses to recognize special medical needs of obligees 2124 Kittredge Street Suite S Berkeley CA 94704 (415) 841-6500 ext. 512 |