Remarks to the American Association of Colleges of Osteopathic Medicine

---

by HRSA Administrator Mary K. Wakefield

April 16, 2009
Rockville, Md.

---

Let me start by commending AACOM and doctors of osteopathic medicine for your support of primary health care and your many contributions to HRSA's community health center and National Health Service Corps (NHSC) programs.

As a nurse, I admire AACOM's commitment to state-of-the-art medical education and osteopathic medicine's devotion to “serving the whole patient.” It's a phrase we hear a lot in provider circles and training programs today. I think it's important to acknowledge that it is strongly rooted in your discipline's philosophy.

HRSA and osteopathic physicians are natural partners. We serve the patients that need us the most, in the communities that depend on us to be there for them. You have a fundamental commitment to primary care, and so do we.

I also want to thank you for the invitation to be here today. I'm just under five weeks in this position and, as you might imagine, it has been a whirlwind of activity for me personally and for all of us at HRSA.

I've been familiar with HRSA's programs for many years as a nurse, as a health researcher and educator, and as a grantee, and I've seen how those programs contribute decisively to the health and well-being of the American people.

So, when the offer came from the White House to serve as HRSA administrator, I was honored to accept.

I also was grateful for the chance to lead HRSA because I knew many of HRSA's programs have the potential to play a key role in the President's health care reform agenda.

Before I discuss that agenda, I want to give you a brief HRSA overview and a sense of the scope and function of this part of the U.S. Department of Health and Human Services.

HRSA operates through a $7 billion budget. We award some 7,200 grants per year to about 3,000 broadly diverse public and private organizations, including 80 different public health programs. These programs and grantees provide direct health care to an overall patient base of 24 million people.

HRSA oversees more than 7,000 community health centers that provide primary and preventive health care regardless of a patients' ability to pay. And that need is growing. Right now, one of out every 18 people living in the United States relies on a HRSA -funded clinic for primary care. But that figure is rising quickly in this recession as more Americans lose their jobs and their health insurance.

Further, HRSA funds many of those community health centers and other providers to deliver medical care and prescription drugs to more than 530,000 Americans living with HIV/AIDS. We also oversee the nation's organ and tissue donation network; and fund state and private agencies to provide maternal health services that reach six out of 10 women who give birth in the U.S.; and provide financial and technical support to keep struggling rural hospitals open. On top of all that, HRSA helps safeguard the public against the consequences of vaccine injuries.

And that's not all. Believe me, I could go on for another 5 minutes...

These are tall and varied orders for just one agency, but I, for one, have always liked a challenge.

Now to return to health care reform and how HRSA will figure in it:

President Obama's campaign and his election in November returned comprehensive health care reform to the political front burner for the first time in 15 years.

To President Obama, health care is not a luxury, it's a necessity. He knows that the nation cannot sustain a continuing, sharp escalation of health care costs for families, businesses and government.

He wants Congress to send him a reform package that he can sign this year, because he knows working families need help with rising health care costs – and those who have lost their jobs and their health insurance need help right away. And reform is crucial to keeping American businesses competitive in the world economy.

President Obama articulated seven principles that he wants reflected in any health reform legislation sent to him to sign. Let me share those with you today. And as I do that, consider – as I'm sure you already are – how you and AACOM can help to ensure these aims are met.

The President believes that health care reform must:

• protect families' financial health;
• assure affordable, quality health coverage for all Americans;
• offer insurance options that are portable and guarantee choice of doctors;
• invest in prevention and wellness;
• improve patient safety and quality of care;
• end barriers to coverage for people with pre-existing medical conditions; and
• reduce the long-term growth of health care costs for businesses and government.

As a nation, we must build a health system that is anchored on two key planks: it is affordable and it provides high-quality care for all Americans.

As I recently told a reporter from a paper in my home state: “Health care reform going forward is going to be about trying to expand access to quality care for more individuals, but it is also about bending the curve on costs.”

As health care providers, you have good ideas, up close and personal, about what type of investments and strategies it will take to serve your patients. And at HRSA, as we work on both health care and health care reform, we welcome your advice.

The President's faith in HRSA's work and our mission was reflected within his first month of taking office. When he signed the American Recovery and Reinvestment Act on February 17, he put HRSA squarely in the middle of his effort to re-imagine, re-invent and re-build the health care system.

The Recovery Act has directed $2 billion to HRSA to expand our health center programs, and another $500 million to support the National Health Service Corps and our Title VII and VIII health professions programs. That additional two-year infusion of money is more than a third of HRSA's total annual budget.

As the days pass, the President and Vice President Biden have made sure that health centers stay front and center as the nation watches.

On March 2, President Obama led off his news conference to introduce Kansas Governor Kathleen Sebelius as his selection for HHS Secretary by announcing the award of grants worth $155 million to establish 126 new health centers across the nation. Those grants mean another 750,000 people in 39 states and two territories will have access to quality health care.

And on April 1, I had the honor of traveling to North Carolina with the Vice President as he awarded a grant to a health center in rural Faison, N.C., to expand the services they offer local residents. I should add that I met a DO working at the clinic. Agriculture Secretary Tom Vilsack also made the trip, and we were fortunate to be able to discuss a few programs at USDA with particular relevance to HRSA and to health care.

Nationally, HRSA has just recently shared a total of $338 million of Recovery Act funds with 1,128 health center grantees to help them expand care to families hit hard by the economic downturn. With those new funds, health centers will serve an additional 2 million people.

And these are but the first of many Recovery Act-related announcements to come.

Later this year, we will award $1.5 billion – that's billion with a “b” – to health centers to fund capital improvements and support health information technology investments.

And this is a booster shot, if you will, to the $125 million increase in the FY 2009 appropriation for health centers, raising its total budget to $2.2 billion.

This explosive growth in the health center network sparked by the Recovery Act investments raises a crucial question: how will we find the staff needed to support it?

Part of the answer is in the $300 million investment HRSA received for the National Health Service Corps. We plan to use those funds to add 4,100 doctors, dentists, advanced-practice nurses and other professionals to effectively double the number of NHSC clinicians in the field today. This represents a great opportunity for DOs – while you comprise 7 percent of all U.S. physicians, you contribute 20 percent of all physicians in the NHSC.

Those numbers tell a pretty compelling story. We know you are heavily committed to this cause. Now, we need your help in recruiting this next generation of NHSC physicians. The Corps provides a great opportunity and we really need your partnership in getting the word out.

Another part of the answer will come from the remaining $200 million in the Recovery Act for the Title VII and VIII health professions programs. We're working on the details of all that now.

But even these historic investments will only get us so far. They will not, in and of themselves, solve the dilemmas we face:

• We recognize that doctors and dentists are coming out of school with crushing debt – well in excess of $100,000 on average. How do we persuade them to work in primary health care?
• We know there's a serious long-term shortage of nurses. How will we recruit those available to work with us when competing opportunities exist?
• More than a third of doctors and dentists currently in practice are 55 or older and likely to retire in the next 10 to 15 years. And the average age of a nurse in practice today is the highest it has been since HRSA first started tracking the profession in 1980. We need new blood – new workforce and delivery system strategies – and we need them fast.
• And it's hardly a secret that shortages of nurses, doctors, dentists and other care providers land hardest in rural communities. We have 20 mostly rural states reporting workforce shortages.
• Also hitting home for us at HRSA is the fact that while health centers have 8,000 physicians on staff, they have thousands of clinical vacancies that are proving very hard to fill.

So no matter which part of the health care problem we are looking at, the healthcare workforce crisis looms larger and larger before us as a limiting factor – and not just in the growth of health centers but in health care reform writ large. We have deferred these challenges for too long. And we simply can't wait any longer. When it comes to the health care workforce, we're out of time.

The $500 million investment Congress and the President have made gives us some time to figure out a broader, more inclusive strategy to develop a sufficient, sustainable health care workforce. But no one should be under the false impression that it solves our long-term workforce issues.

The Recovery Act alone won't cure the recruitment conundrum. We must do a better job of deploying, organizing and retaining the workforce we have, and we must consider innovative ways to bring in community-based providers.

The AACOM Web site tells us that colleges of osteopathic medicine are graduating more and more students each year. By 2010, you're saying some 4,000 new osteopathic physicians will enter the workforce yearly.

I see that as a great opportunity for us to put our heads together to fill physician slots at community health centers, critical access hospitals and other high-need areas with DOs. And what better time than now, when they can take advantage of the ballooning opportunities in the NHSC loan repayor program.

Either way, let's work together – HRSA and AACOM – to help these newly credentialed DOs serve in the communities that really need their expertise.

It's important because as we look across the nation, we have about 36 million people living in some 1,700 discrete geographic regions of the U.S., its territories and possessions which are experiencing ongoing shortages of about 8,000 physicians, 7,000 dentists and 1,800 mental health caseworkers and addiction counselors. So, even as statistics come in on layoffs in certain health professions, shortages throughout the nation will persist as we recover.

Please tell us how you think we can improve HRSA's programs and tell us what we can do to market these opportunities to your new graduates. Potentially, you've got the perfect docs for the places HRSA cares about most. Help us find them not just a job, but a career serving people who need their skills and knowledge.

One source of innovation to expand the ranks of primary care providers to meet underserved areas is coming from a revamp of features of the NHSC. Let me share a couple of the innovations we're undertaking.

First, we're working on a demonstration project that would allow clinicians to work part-time for the NHSC. Up to now, our loan repayment programs have locked out mid-career professionals who might be willing to split time between private practice and a health center position. We think that a part-time option will bring in seasoned practitioners with much to offer patients and young clinicians alike.

Some of those providers might be you yourselves, or your students.

In addition, we're about to move to an open and continuous application process. Currently, the application window for an NHSC scholarship or loan repayment contract is a fixed, 30-day, one-time annual period. Beginning in June, HRSA will suspend this requirement for the duration of the Recovery Act, and switch to a “rolling application” model. I hope we can continue this even after the Recovery Act efforts end.

Clearly, this is more responsive and will allow us to get clinicians in the field much faster.

Applicants also will be able to start the process of joining the NHSC much earlier through a process we call “provisional qualification.”

Historically, students seeking loan repayments couldn't apply until they graduated, secured the licenses they needed to practice and had an employment contract in hand. For many, this added a year or more before they were eligible to apply – and in the meantime, some of them found other jobs. To eliminate this lag period, HRSA is developing a protocol to accept applications any time during a student's final year in training.

And as these “provisional qualifiers” get closer to graduation, we'll send their names to clinics looking for practitioners. We'll also give the provisional qualifiers access to HRSA's online job placement directory so that they can market themselves directly for one of the 7,000 vacancies nationwide in the NHSC's Job Opportunities list.

Additionally, we're going to give community health center sites the ability to compete for many more providers than they were able to in the past. Formerly, health centers were restricted in the number of vacant positions they could post online in the HRSA job placement directory to two positions for any clinical specialty.

But now, with the incredible expansion of the Corps under the Recovery Act, HRSA will allow eligible sites to advertise for more positions.

To keep up with the changes we're planning, we'll post on the NHSC Web site when these initiatives will start.

With NHSC upgrades in mind, I would appreciate it if you would continue to consider what you can do through AACOM and other organizations to which you belong to:

• educate colleagues and students on the mission of the NHSC;
• mentor primary health care students and new primary health care clinicians; and
• establish awards programs as incentives for choosing primary health care careers;

You can partner with us, too, by:

• encouraging students to take practicums in community-based settings;
• encouraging them to assume careers in primary care and in medically underserved communities;
• urging them to get involved in community-based health care delivery; and pointing them toward volunteering at local non-profit health clinics.

Well, as you can tell, HRSA has a load of work before us. In addition to our day-to-day tasks, we must implement the President's Recovery Act. And we will have a strong voice in health care reform.

We look forward to hearing AACOM weigh in on reform and on issues regarding the health workforce.

When President Obama addressed his health care reform summit March 5, he said: “Every voice has to be heard. Every idea must be considered... there should be no sacred cows. Each of us must accept that none of us will get everything that we want, and that no proposal for reform will be perfect.”

He said only one option is not on the table: the status quo. And as HRSA administrator, I'm not about the status quo.

I've always operated as someone who brings everyone to the table. I want to join you in real partnerships. I've found that when that happens, key leaders emerge who push forward viable solutions.

I want to learn from and work with organizations like AACOM as health care reform continues and our choices and options become clearer.

We are on the precipice of historic, critically needed reform. HRSA – and our portfolio of programs – and organizations like AACOM are key contributors.

It is time to use our responsibility and experience wisely on behalf of our patients and the American people.

I thank you for your contributions to the health and well-being of the American people and I look forward to pushing the refresh button and implementing health care reform alongside you.

Thank you.