Remarks to the Bureau of Health Professions All Advisory Committees Meeting

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by HRSA Administrator Mary K. Wakefield

April 21, 2009
Bethesda, Md.

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Thanks, Marcia (Brand, HRSA Deputy Administrator), and also many thanks for the years of effort you put into reorganizing the Bureau of Health Professions and keeping workforce issues front and center at HRSA.

As many of you know, I've appointed Dr. Brand to the position of Deputy Administrator, the no. 2 post in the agency. She's now my strong right arm. And that's as loud and clear a signal as I can send about how seriously I take the shortages in the health care workforce.

Obviously, it's an exciting time for me to step into the top leadership post at the agency, and a privilege to be here today with all of you. It's also a privilege to be in our business – with this once-in-a-lifetime chance to re-make one of the most important sectors of American public life: health care.

Make absolutely no mistake about this: President Obama understands that comprehensive health care reform cannot go very far, and won't last very long, without a serious investment of time, energy and money in addressing our workforce shortage issues.

He also is well aware that many of you in this room have devoted years of your lives to studying and substantiating the parameters of the problem. And I want you to know that your work has not gone in vain. Your reports, your studies, are central to this Administration's discussions.

I realize there were times in the past when you may have felt like voices in the wilderness…

when the funds budgeted to address workforce issues did not match the urgency of the moment…

when even the continuing existence of these advisory councils was in question…

Looking forward to reforming our health care system – we're working hard to ensure that those days are over. This President fully understands that you are at the forefront of a national movement spanning many years to do something about workforce shortages before they became a crisis. Now that crisis is upon us, no one could blame you for saying “I told you so!”

HRSA is forecasting an 89,000-physician shortage over the next decade – a third of them in primary care. These are conservative numbers. Some estimates go much higher. When it comes to primary care, in fact, reputable academic forecasts warn of physician shortages far more severe.

Since the Council on Graduate Medical Education first sounded the alarm in their 2005 Report, studies have found nationwide shortages in at least 16 clinical subspecialties – including Emergency, Family and Geriatric Medicine – and at least 200 health care disciplines. Mind you, we had these numbers in hand four years ago, and that was before the economic downturn hit.

The long-term nursing shortage – one million by 2025 – is so thoroughly embedded by now in health care talks that it has long passed the point of academic debate. Less well understood, I think, is the heavy burden of mental health care scarcity in rural counties, which represent 74 percent of the known mental health shortage areas nationwide.

Last year, more than 14,000 students applied to HRSA for financial assistance through the National Health Service Corps, but the agency was only budgeted to grant one of every 7 requests. The shortfall was worst in nursing programs, where the agency received 9,000 applications for 600 available slots. That's a ratio of 15 to 1.

Again, last year, and the year before that, and the year before that, it was proposed that HRSA's Title VII programs be zeroed out, and the agency's Title VIII programs in support of nursing education be cut. Congress restored much of this funding, but as we all know, we've dropped a long way from our historic funding levels.

I could go on, but I'd be telling you facts that you already know.

The reason I'm here today is to thank you, each and every one, for your diligence, your thoughtfulness, your courage, and, yes, your prescience in the face of what I know must have been a confusing time – and to tell you that this President has heard you.

And help is on the way.

The election of President Barack Obama has returned comprehensive health care reform to the front burner for the first time in 15 years. And his signing of the American Recovery and Reinvestment Act put HRSA's workforce programs – and your efforts – squarely in the middle of his plans to fix our broken health care system.

Now, more than ever, we need your eyes, ears and advice. This is the best shot we've had in a very long time, but there's simply no going forward without a healthcare workforce that's up to the monumental task before us.

Let me correct myself… we don't just want your “advice.” We want actionable recommendations. We want you to be more aggressive in your engagement and more urgent in your deliberations.

Because the time for talking about all of this is over.

This President is moving, so fast that we all need to do more to keep up. Here are just a few things that have happened in the last 30 days:

First, creation of an Executive Office for Health Care Reform: On April 8, President Obama set up this internal policy group as a kind of clearinghouse for new ideas and approaches to fixing the health care system. It will be headed by Nancy-Ann DeParle, who previously ran the Health Care Financing Administration in the Clinton Administration.

In the Department of Health and Human Services, Nancy's office will have a counterpart group at HHS, which is expected to be headed by Jeanne Lambrew. Jeanne previously worked in the Office of Management and Budget and as senior health analyst during the Clinton Administration.

In workforce monitoring: Among HRSA's many functions, we are responsible for monitoring health care workforce trends on behalf of HHS. And while I wish we had a more optimistic forecast to give to the Administration, we have transmitted our concerns through Jeanne and Nancy to the highest levels. Some of our concerns focus on:

• Admissions: With more than a third of physicians and dentists approaching retirement, and the average age of practicing nurse near 50, we have to break admissions logjams in our schools.
• Care Reform: There is almost universal agreement that the Medical Home model of health care is an attainable ideal, but we need to ensure the health care workforce is oriented toward coordination and care quality.
• We need porous borders across health care settings and clinicians working together. President Obama has said that there must be no “sacred cows” in our quest to reform American health care. But everyone here today knows that we are standing in the middle of a stampede – a herd of sacred cows – running in different directions. More than anything else, this is what has trampled the reform efforts of the past.
• Within agencies, between agencies, and throughout the health professions, we see silos of interests. The United States now has the most expensive health care system on earth, due in no small part to our willingness in the past to accommodate ancient codes of hierarchy and status quo.

Let me share three examples:

• First, changing relationships: Because of the workforce shortages we are facing, and the need to efficiently harness technology and improve care quality, there is a need for new practice models and interdisciplinary team approaches to patient care. And I don't mind being the one who says: “We no longer have the luxury of maintaining rigid lines between health care sectors and health care providers, between physicians, dentists, nurses, hygienists, P.A.s, pharmacists, psychologists and others who hold the health care system together.” Efficiently capturing and capitalizing on strengths across all members of the care team is what we need to teach and how we need to practice. Rather than lobbying against change, your work is an opportunity to test redeployment of clinicians to shape change, and to lead it.
• The second example of needed change is in the harnessing of Health Information Technology. As information is power, there's going to be a lot more of it available in coming years; and it's going to be moving at lightning speed – and just in time for the delivery of safe care. A quarter of our patients in the HRSA-funded health center system are now being treated in HIT-wired clinics. That's good, but not good enough. This Administration is about to spend more than $1 billion in stimulus funds on this technology – and that investment is going to drive innovation in collaborative practice for years to come. Once again, we are at the forefront of transformation to a more dynamic, efficient, high-quality health care system.
• The third example I want to share has to do with intra-agency and inter-agency cooperation. It would be disingenuous of me to stand up here and talk about sacred cows without acknowledging we have a few of our own. Taken together, as one example, HRSA and the Veterans Administration underwrite the treatment of more than 24 million patients. Medicare and Medicaid account for 67 million. The Indian Health Service reaches more than 1.5 million.
  
  HRSA's programs alone touch 17 million health center patients; more than a half-million Ryan White clients living with HIV-AIDS; 60 percent of all pregnant women in the U.S. through our Maternal and Child Health Bureau; and 12,000 qualifying dispensaries that fill hundreds of thousands of discounted 340B prescriptions annually.
  
  In these numbers there is tremendous leverage to shape health care. In these numbers, there is an enormous constituency-in-waiting. In these numbers, we should be able to see some of the future of health care in America.
  
  And, of course, these are not merely numbers. They are patients.

As HRSA Administrator, I guarantee you, I will be reaching out in every conceivable direction to build partnerships with HRSA's sister agencies – CMS, SAMHSA, CDC and others.

And, going forward, the President's 2010 budget, which is expected to be released in greater detail sometime next month, targets $330 million to address the shortage of clinicians, particularly in rural America.

This allocation – which will seem more like a down payment compared to a few things I'm going to tell you about in a moment – will expand student loan relief programs in the health professions, and bolster the capacity of nursing schools to increase admissions. It also will allow States to increase access to oral health, and sustain the expansion of the health care workforce funded in the American Recovery and Reinvestment Act.

Further, the Administration has put $338 million into Increased Demand for Services grants to extend the hours and current services of our 7,000 HRSA-supported health center clinics; to add staff – and to prevent the lay-offs of existing staff as the centers struggle with the economic downturn and a crush of more than a million new patients. These grants – and the beneficial impact they're already having – were front-page news this past weekend in the Washington Post.

Besides aiding patients in need, a third of whom are children, this is yet another investment in the primary care workforce. At a time when private-payer plans and medical centers are being forced to lay-off clinicians – or at least delay hiring – HRSA's health centers are actually adding and filling positions.

Beyond this funding, the President is attacking the workforce shortage crisis on multiple fronts, as a precursor to wider reform efforts. For starters, HRSA has received $500 million in Recovery Act funds for immediate investment in workforce development:

• $300 million will go to the NHSC to effectively double its field compliment. That's 4,100 doctors, dentists, advanced-practice nurses and other professionals who will receive full or partial relief from their student debts beginning this year in exchange for their service in some of the hardest hit shortage areas in the country. We also are dramatically streamlining our application and placement practices to get more candidates into the Corps as quickly as possible.
• The remaining $200 million will be invested in Title VII and VIII health professions programs, with an emphasis on nursing. We expect these funds to flow quickly to colleges and universities to help them build institutional capacity and underwrite the educations of qualified students.

Taken together, the “pass-through” impact of this half-billion-dollar infusion into higher education for the health professions will help to slow, if not reverse, more than a decade of shrinking primary care programs and sagging interest in the field. It won't solve all of our problems, but it will buy us some time.

A long-time concern with these programs has been their reliability. Our funding levels over the years – certainly over the past decade – have been inconsistent. So we have turned away literally thousands of qualified scholarship and loan applicants.

We are well aware from looking at graduate student bulletin boards, health professions blogs and correspondence from career development counselors that this often has left applicants frustrated.

At the same time, we recognize the need for better data on specific efforts. We've done some work recently on physicians and pharmacists, but we want to improve our capacity to better target program investments. To that end, we're proceeding full-bore with the following initiatives:

• A Web-based Health Workforce Information Center: a one-stop shop for health professions information. 4,500 people visited this HRSA-funded Web site on the first week it opened in January; now, on average, 1,860 users are visiting each week. As the economy continues to struggle, we fully expect that more and more users will be checking in.
• We're also sponsoring a meeting August 8-10 called “The Healthcare Workforce Crisis: A Summit on the Future of Primary Care in Rural and Urban America.” We are planning on 600 national experts for this conference – ranging from HRSA grantees to academicians and policymakers – and I would fully expect and hope that some of you will be among them. We're going to discuss factors of supply and demand on the primary care workforce; current research and evidence-based models that work; and potential reform of payment models, among many topics.
• This also could be the year that Congress reauthorizes Title VII and VIII. Let's not flinch on this important fact: these programs are 40 years old now, and merit a good review.

Finally, you couldn't have picked a better time to issue a Joint Report. Speaking with one voice, across so many professions, you will be heard…and now is the time when it can do the most good. When I spoke earlier about the President's desire for recommendations that are immediately actionable, this report you've been working on fits the bill.

In many ways, this document represents a template for the kind of collaboration and cooperation we need to see everywhere as we move forward with health care reform.

We must all look beyond our parochial interests and specialties, not only because it's the right thing to do, and a clear path to meaningful change, but also because the current system simply cannot be sustained.

We are looking to you now for leadership, as we endeavor to field a solid health care workforce and put our patients first.

Thank you.