Remarks to The Healthcare Workforce Crisis: A Summit on the Future of Primary Care in Rural and Urban America

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by HRSA Administrator Mary K. Wakefield

August 10, 2009
Washington, D.C.

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I want to start out this afternoon by thanking all of you for braving the heat of August in Washington to be with us. This is usually the time of year when everyone leaves the District for the beach or the mountains -- or some more pleasant place like North Dakota. So, given those other great choices, we know how much fortitude it takes to be here.

I also want to say what a pleasure it is to see so many friends and colleagues in the audience today. It feels like Old Home Week!

As you can see from the agenda, we'll be tackling some of the same issues we've been dealing with for years now – except this time, we're in a position to begin to do something about it.

And who better than you? If this isn't an All-Star line-up, then I don't know what one looks like – not just the speakers on the agenda but those of you in this room today from academe and service.

We're very appreciative that you're here.

As you've no doubt heard by now, President Obama has placed $2.5 billion in Recovery Act funds in the Health Resources and Services Administration in the past few months -- in what amounts to the single largest investment in primary health care in recent memory.

About 20 percent of those funds are dedicated to expanding the health professions workforce in primary care. I'm talking here, of course, about the National Health Service Corps and Title VII and VIII of the Public Health Services Act. And I'll say more about the Recovery Act and other efforts in a few moments.

These workforce programs grew out of the last major workforce crisis in the health care industry dating back to the mid-1960s, and they've been with us ever since. Although frequently underfunded, and sometimes misunderstood by a later generation of policymakers, these programs have played a vital role in ensuring that millions of underserved communities were not completely cut-off from care.

On this note, I just want to make a quick point of saying that the workforce issues we now are facing were barely on the public agenda a couple of years ago. But thanks to the foresight and leadership of so many of you in this room today, that has changed.

That's because you kept making the case, and advancing the data, and perfecting the record until the debate among and between health professions began to seep much more broadly into the consciousness of the public and policymakers.

It's now fairly well recognized that health care in this nation is in desperate need of repair. We are saddled with the most expensive health care system on earth, which is far too inaccessible to an ever-increasing population of uninsured and underinsured people; characterized too frequently by outmoded and inefficient organization of care; broken reimbursement models; and a workforce that is being overwhelmed on all sides.

As evident from his Recovery Act investments, this President well understands the challenges to health care as it is currently delivered and the opportunities that can come through recalibrating not just the workforce, but other key dimensions, as well.

Thanks in large part to your work, a lot of other people are beginning to see the light, too.

When I look back over the past decade – to the early studies by the Graham Center on the closure of family medicine residency programs; to the Commonwealth Fund's first reports on the nursing workforce shortage; to the millions of dollars in research and program grants awarded by the Robert Wood Johnson and Macy Foundations; to the concerted efforts of the Kaiser Family Foundation, Johnson and Johnson, the Council on Graduate Medical Education, the Institute of Medicine…not to mention the important work done by our six Rural Health Research Centers and the list goes on – the evidence you have assembled is increasingly the common currency among leaders in health care and public policy.

And with your data and ideas in hand, they are speaking a different language: broader and more engaging conversations that speak to issues beyond workforce supply and demand, to competencies and technologies like HIT that can extend the reach and quality of a clinician's contributions and more fully engage patients and populations.

In the same spirit in which you pursued that cause, I hope, too, that you will support the current call for health care reform – engaging a full and, I might add, an accurate accounting of what is and isn't being proposed.

In terms of workforce, even with your foundation of work, there is nevertheless much more to be done in ensuring an adequate workforce and reforming health care more broadly.

That's why we're all here…to shape the answers.

As we look forward, we need more than wishful recommendations; we need your ideas -- your actionable proposals – which is the main thing I came here today to talk about.

This conference was designed from the ground up to yield those proposals. It is my hope that this summit helps to shed light on how to build and sustain a primary care workforce. If prevention and health promotion are key to containing costs and keeping people healthy over the long run, primary care becomes the essential bedrock of a health care reform. And it has to become commonplace care for all those Americans who, instead, depend so heavily on emergency rooms for care today.

So it's my hope that we can move deliberately from this opening session into serious working meetings and discussions. Re-engaging on primary care, and reforming health care more broadly, are pivotal if we are going to effect real and needed change.

So, while this is about sharing ideas, and engaging the issues on an intellectual plane, it's also about leaning out of the comfort zone of our discipline, our faculty home, our health care setting.

It's about forging new partnerships across multiple disciplines and health care sectors.

It's about further bridging the gap between the academic and practice environments.

It's about strengthening partnerships between you and us at HRSA to create new and more direct alliances.

And it's about moving the needle on workforce in the context of reforming health care.

So, how do we forge new directions here and now in order to begin our work? Well, we are leveraging the usual conference evaluation forms with real-time data collection. We have set up an email address that you can use from your Blackberries, I-Phones or laptops during and after each and every session. That email is: Workforcesummit@hrsa.gov. This address will be active until September 30, 2009, and we will be sifting through it every day between now and then.

HRSA staff will be collecting these comments and questions, both from the flyers and emails, throughout this Summit, and we will begin to address what we've heard at the closing session on Wednesday.

We greatly value your insights and ideas, and we want to receive them as they occur to you. We want it this minute – before, during and after every session. At breakfast and a week from now.

And to be sure we get it, we are staffing this conference with HRSA senior managers. You know most of them already, but I'd like them to stand up now so you can see the folks I'd like you to meet and talk with at some point as we go along…

(Introduce HRSA staff)

To illustrate how important this meeting is to us:

• This is the first time the agency has ever had so many of its Bureau chiefs and Office directors in one place at the same time;
• It's the first joint conference of its kind that we've ever held;
• It's the first gathering with such a broad cross-section of HRSA's partners and health professions in attendance.

That's how determined we are to come out with actionable information for HRSA and for this Administration.

Because moving on health care reform and moving on health workforce go hand in hand.

So this is not about continuing the status quo and producing more of the same. It's about breaking the mold and going beyond our existing programs. Important as they are, we need to evaluate and expand our thinking about and beyond Title VII and VIII; beyond the NHSC; beyond the here and now – because the workforce we build today in the classes entering training programs across the country even this fall is the workforce we will have for the next 30-40 years.

We need to be thinking about:

• emerging technology: telehealth, electronic records, systems automation, next-generation simulation; and
• the changing role of physicians, physicians assistants, pharmacists and others within dramatically altered care settings – coordinated, patient-centered, not provider-centered.

We need to be thinking about expanding training opportunities to accommodate continual, contextual and just-in-time learning across the professions.

We need hard and objective looks at license portability, scope of practice, diversity in health professions education (both among students, and within our faculties) -- and a range of other strategies and innovations that are heavily dependent upon cooperation between state, federal and professional organizations. This shared responsibility for ensuring the adequacy of the primary care workforce cannot be stressed enough.

We also need integrated, interdisciplinary care for a population that will include far greater numbers of chronically ill and elderly.

Last, but by no means least, I think most people here today would agree that we need to realign our current reimbursement models. So we have panels scheduled to discuss that, as well.

Many of these models have been “imagined” already. Now we need to innovate our way to it.

Basically, we're talking about game-changers – how to implement them, how best to evaluate them. So, this conference is more than a conference, more than a quest for more good ideas.

It's not about putting new tires on the old truck. Or a fresh coat of paint. What we need is a new vehicle. Maybe we need an equivalent to cash for clunkers. Not the money -- the idea of sweeping inefficiency and outmoded efforts to the sidelines. It would be nice to know what you think those new efforts and partnerships should look like by Wednesday afternoon.

That is, what our role could and should be, what your role is going forward, and what our role together should be. We're inviting your best thinking.

Now, for those of you who may not be as familiar with the work of HRSA and how to engage with us, here's a very brief abstract of this small, but mighty powerhouse agency and its 1,400 employees.

In addition to being the lead federal office for the development of the Health Professions, HRSA is a $7.2 billion operating division of HHS -- responsible for 80 different programs that lend technical and financial support to every state and U.S. territory, as well as 3,000 discrete provider organizations.

It's almost easier to describe what HRSA doesn't do, than it is to enumerate all of the critical functions it performs and the populations and dimensions of health care delivery it serves.

Suffice it to say that if it involves at-risk people – migrant workers, the homeless, public housing residents, poor pregnant women and infants, the uninsured – HRSA very likely has a hand in it.

The agency connects annually with about 24 million patients nationwide, most immediately through the 7,500 Community Health Center sites that we fund and oversee.

I tell you this to illustrate that when it comes to shortfalls in the primary care workforce, HRSA has a lot at stake in this discussion – on both the education and clinical services sides.

For the first time in the 43-year history of the Community Health Center program, for example, our patient base has topped 17 million people – which constitutes the largest client population in any sector of the U.S. health care system today, public or private. 17 million people seeking primary care.

Not surprisingly, these health centers were some of the first primary care access points in the nation to detect and report the H1N1 flu virus. With 8,000 physicians, 4,700 nurse-practitioners and PAs, and more than 9,000 nurses on staff, the health centers act as sentries against infectious disease in some of the most remote, socially isolated and vulnerable populations in the country.

So you can see the obvious implications and numerous linkages between HRSA's principal functions and some of the more crucial issues in the health care reform and workforce discussions now taking place.

For HRSA's programs and for all of health care, we cannot sustain a functional health care system without an adequate workforce – and that workforce is going to need to be digitally literate, culturally adept and fast on its feet to deal with the changes that are unfolding in health care.

The scarcity of health professionals is particularly acute, and getting worse, in rural America -- where seven out of 10 of our primary care shortage areas are located and a predominance of dental and mental health shortages as well.

This, at a time when we are facing a rapidly growing aging population, both urban and rural. And much of the demand will involve patients who are chronically ill.

“So what are we doing about it?” Well, the good news is that the Administration recognizes the challenge, and so the short answer is: “A lot.”

Consider that in February, the President committed $2 billion under the Recovery Act to the HRSA health center system. Those funds will increase the number of service sites, repair and renovate existing centers, and introduce long-overdue health information technology to help improve the efficiency of the workforce.

On June 5, the Administration invested almost $200 million under the Act to nearly double the size of the National Health Service Corps. In exchange for academic debt relief, more than 3,000 clinicians will go to work in the hardest hit shortage areas in the country.

Within six weeks, 3,800 practitioners had registered into our job bank and 2,300 had applied for admission into the Corps – so we know that altruism coupled with the relief that comes with debt reduction is alive and well in the health professions.

We know that today's graduates carry significant debts, including but certainly not limited to new physicians. The average dentist, $137,000. Psychologist, $74,000. Nurse-practitioner, $68,000. The de-funding of student grants-in-aid programs in recent decades, coupled with rising tuition, has made cost a major barrier to solving the current workforce shortage problem.

Finally, Secretary Sebelius recently announced another $200 million under the Recovery Act for Title VII and VIII expansion grants to colleges and universities – which will support the education of 8,000 students in the primary care field, including dentistry and nursing scholarships and loan repayments. And, I'm pleased to say that on Wednesday we'll have a special announcement related to this from HHS Deputy Secretary Bill Corr.

To give you a concrete example of just one program's efforts, just this past week – in one week – we processed 28 physicians for the National Health Service Corps. That might not sound like much, but it means that 29,400 more patients will be seen in underserved areas – from just the physicians' part of the NHSC Recovery Act. That's last week in HRSA, in just the Bureau of Clinician and Recruitment Services. This week, next week, next month…through next year we'll process more NHSC providers to serve in underserved areas.

In addition, the President has proposed increasing HRSA's budget for all of these programs over their 2008 levels: 48 percent for Clinician Recruitment; 13 percent for Health Professions; six percent for Primary Care…

In less than five months, the Administration is engaging in concerted, measurable efforts to address supply and distribution issues – which give Congress and our cash-strapped state governments a head start on fixing it permanently.

Of course, the impact of these dollars is heavily contingent on states, universities, professional associations and others. For example, in nursing the admissions backlog is a major brake on workforce expansion.

With all of this, as necessity is the mother of invention when it comes to fielding our health care workforce, we should be seeing boatloads of innovation that involve efforts from all stakeholders.

In fact, responding to necessity isn't just owned by the federal or state governments or national organizations.

That impulse, we recently learned in a national survey, has led 384 of our HRSA-supported Community Health Centers to enter into cooperative agreements with hundreds of colleges, universities and state agencies to provide clinical internship slots at their sites – many for the first time. And a majority recently expanded their programs.

So, we see, there has never been a more opportune time for these kinds of federal-state-private provider collaborations; for creative thinking; for rebuilding, and reaffirming our commitment to basic, quality primary care for all Americans.

And it all starts with the quality and sufficiency of the workforce.

For example, at a time when African-Americans and Latinos represent more than a quarter of the U.S. population, for example, the fact that they comprise less than 10 percent of the physician workforce nationwide stands out as a crisis within a crisis.

Nationally, Latinos are only 3 percent of the active dental workforce. But they provide 40 percent of the care in Spanish-speaking communities.

My point is that diversity in the health professions is no longer simply a dream deferred. It's an unmet public health imperative. As we look to reform our health care system and our workforce, we have a golden opportunity at long last to do something about this, too.

At HRSA, we believe the time to do it is now.

And the people most able to help show us the way are…YOU – the best in the business.

Thanks again to each and every one of you for coming.