Remarks to the National Association of Community Health Centers

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by HRSA Administrator Mary K. Wakefield

February 26, 2010
Washington, D.C.

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Thank you, Anita (Anita Monoian, Board Chair, Yakima Neighborhood Health Services) for that kind introduction – and to the Board and everyone else here today for taking the time to come to Washington, DC, which – depending on where each of you hail from – is today either a warm destination or a cold one.

But regardless of whether it feels like the heart of winter or a touch of summer outside, it has been a historic season for the programs we operate and the populations we serve in partnership with all of you.

Let's start off this morning by just considering some recent Recovery Act achievements:

• We've seen the largest increase in new patients – more than 1.6 million – in the 45-year history of the Community Health Center program…closing in fast on an all-time high of 20 million people;
• We've seen the largest recruitment and retention effort ever accomplished in such a short period of time – over 6,700 staff, including more than 1,200 new primary care providers;
• And we've seen as much as $3.2 billion in related economic activity generated, from an original Recovery Act investment in our health centers of $2 billion by the Congress and President Obama;

I could stand up here for quite some time if I had to, reading off this long list of unprecedented accomplishments that Jim Macrae of the Bureau of Primary Health Care has given me, or I can just skate straight to the point, and that point is that:

I have visited close to a dozen Health Centers this year – from Vermont to Virginia; California to Pennsylvania; Hawaii to Washington, D.C. – and I've seen the progress you're making on the ground: in patients served; in improved clinical care; in jobs created…

And to each and every one of you -- from our largest Health Centers to our most remote frontier grantees -- ladies and gentlemen…let me just say from my vantage point as HRSA Administrator:

To each of you, and your colleagues back home, thank you so much for a year's worth of hard but critically important work well done.

When I first spoke to you on March 27, 2009, I had only just arrived in Washington from my home state of North Dakota. You may recall is was a time of tremendous hope… and also of tremendous need.

The economy was in tatters, cutting off more than 4 million people from meaningful work, and leaving many without health insurance or access to the most basic care for their families.

President Obama made a promise to those people: That they would not be forgotten; they would not suffer in silence; they would not be left behind.

And he turned to us to make that promise real – at a time when many of our programs had been underfunded for years, and many of our offices were understaffed.

But the President also gave us the tools we needed: $2.5 billion under the American Recovery and Reinvestment Act for health center and workforce expansion – one of the largest single investments in Primary Health Care in our lifetimes.

President Obama delivered… and he was counting on us to do the same.

Now, I have to tell you, folks, I'm an optimist by nature – aggressively optimistic, you might say, because I learned very early on as an ICU nurse in small rural hospitals that optimism and can-do attitude is essential. But, in all honesty, the sheer size of the undertaking before us then, really was a bit daunting.

No doubt, many of you had the same feeling.

What may be largely invisible from outside the Health Resources and Services Administration, however, is the amount of expertise, willpower and positive energy there is inside this agency of just 1,600 people. And those attributes extended well outside of our doors when it came to implementing the Recovery Act.

It was that “can do” attitude.

Our work affected and involved the families of HRSA staffers, as spouses and parents worked from dawn to midnight, for weeks on end, to put the President's vision into action. It involved people across the agency, who left their desks in other HRSA Bureaus to help their colleagues in Primary Care. It involved the “invention” of new data processes, new review protocols, new guidances.

As one HRSA analyst later described it: “We were flying the plane while we were building it.”

If you heard some of the stories – about the HRSA mom who brought her two young sons to the office to help stuff envelopes; or the project officer who exhausted her private cell phone plan taking calls at home from grantees; or the computer lock-outs when staff e-mail accounts got hit with hundreds of messages in a matter of hours – you'd know why I'm so proud and so appreciative of them…

I know this is a very big room, but I'd like the members of the HRSA Team to stand up for a moment. These are the folks – and their leadership, Jim, Marcia and Becky Spitzgo – that I have the privilege of working with every day, and what a pleasure that is.

And, of course, I'm also proud and appreciative of you, our grantees.

Throughout this entire process, Jim Macrae tells me, your dedication and willingness to do whatever was needed – whenever it was needed -- was superb; and you have continued to do this every day. The level of preparation and attention to detail was exemplary on the part of everyone involved.

But you know we all do this – the extra hours and the extra effort – because it's our mission to serve the needs of the country; and opportunities to do that on this scale don't come around very often.

Which is how we got to where we are today, and not a moment too soon for the thousands of patients whose lives were directly affected by this collective push.

Here's one example, from a 50-year-old woman in Miami who had lost her job and all but given up on finding help for her diabetes when she was contacted by outreach workers from Community Health of South Florida. She wrote a short note that spoke volumes: “I have been so down and depressed...Thank you so much!”

Or this, from an elderly patient who did not know she had serious heart disease until she found help at the Metro Community Provider Network in Englewood, Colo. She wrote: “ I am currently on Social Se­curity, but have been unable to qualify for Medicaid. I am disabled and divorced and on my own. I appreciate that (MCPN) caught my condition in time!”

We have received, literally, scores of these testimonials from people whose lives were changed by the Recovery Act. I wish I could say that these were just “exceptional” cases, but we all know they're not.

Rather, they're representative of the continuing need in our communities. And there are many more people out there whom we have yet to reach; and the ongoing economic recovery means we'll be seeing these patients for quite some time to come.

So, while I am pleased almost beyond words – and I'm rarely almost beyond words -- with what we have achieved together in the past year, I did not come here today to declare: mission accomplished!

Rather, I came again to ask you for your help.

For as far as we have come in the past year, I believe our work has just begun: in continuing to meet the increased demand for services; in building new sites and improving existing ones; in purchasing new equipment and installing electronic health record systems to carry us into the 21st Century. And let's not forget our intensive provider recruitment and retention drive – all while continuing to serve a vastly expanded patient base.

All, as that HRSA staffer said, as we are flying the plane, even while we're re-engineering it.

I know we all would have liked a larger pool of facilities investment funding than the $500 million we received; and I know that because we got $3.2 billion in funding requests from all of you for 620 projects. Still, the 85 we were able to fund set yet another record, and those projects give us another opportunity to prove the benefits of such investments so support for the program continues.

We have seen steady increases in the baseline budget for the Health Center program since this Administration took office, and the President's 2011 budget includes an additional $250 million to keep up the increased pitch of activity initiated by the Recovery Act.

In addition, there is funding available to open 25 new access points – as well as resources to leverage the expansion of more sites to provide integrated behavioral health – which, as everyone here knows, is a critical shortage area within the Health Center system.

At the same time, both the President and Congress have made it emphatically clear that they believe in the National Health Service Corps.

HRSA received $300 million under the Recovery Act to double the field strength of the Corps by 2011 – as well as an overall 15 percent increase across the Corps' baseline budget over the 2008 levels in the past two years.

Further, the President's 2011 budget contemplates yet another increase that would push the overall baseline by 37 percent in three years to $168 million. It also should be noted that expansion of the NHSC is explicit in both Health Care Reform legislation currently under consideration by Congress.

So what does all of this mean?

It means that:

• The Recovery Act already has brought the largest-ever investment in the NHSC in its 40-year history;
• It will fund unprecedented growth in the Corps ranks in the coming months – on top of a 32 percent increase in staffing commitments achieved already since 2008;
• And it will support the renewal this year of a marketing and recruitment effort that had been underfunded and largely abandoned in prior years.

All of this translates into:

• Our field strength rapidly closing in on 5,000 practitioners – which is a count I'm sure many of us never expected to hear – including more than 1,400 PAs and advanced-practice nurses; almost 1,700 physicians and over 1,000 mental and behavioral health professionals;
• By last June alone, we had received 6,000 applications to the Corps – so we know the word is getting out;
• And we've already awarded 2,000 loan repayment contracts, and we're aiming to execute almost a thousand more by April. On top of this, we will be launching a pilot demonstration project to bring another 400 part-time practitioners into the Corps for the first time.

These are the kind of increases that will be felt on the ground – in rural communities, small towns and large, and public health agencies nationwide.

I extend special thanks to Becky Spitzgo, who is our relatively new Associate Administrator of the Bureau of Clinician Recruitment and Services, the Bureau that houses the NHSC. Like Jim Macrae in his job, she has been stellar in leading these new efforts.

You'll be hearing more from her over the next few days. So I'll leave it to her to fill you in on the details.

Coming right behind these NHSC providers, we expect 14,000 clinicians to emerge over the next few years from colleges and universities supported by HRSA's Title VII and VIII programs, which received an infusion of $200 million under the Recovery Act.

Of those funds, $80 million have been targeted for scholarships, loans and loan-repayment awards to students, health professionals and faculty – half of them from minority and disadvantaged backgrounds.

This, I think, is an enormous step in the right direction, as workforce diversity is one of the biggest challenges we will be facing over the next decade; and we know from long experience that students from disadvantaged backgrounds are precisely the ones most likely to pursue practice in underserved communities.

On this note, I don't want to leave here today without making a comment on what I consider to be our larger mission, and it requires communication on all parts to see it through.

The President could not have put it more plainly when he said – more than once or twice – that he has little patience for “business as usual.” And when it comes to the deployment of resources through the Recovery Act, President Obama has appointed the Vice-President as his equivalent of a Sergeant-at-Arms.

If anyone here today imagined that overseeing the Recovery Act across the federal government would be a purely ceremonial post, trust me, Vice-President Biden never got that memo.

So how are we doing – you and HRSA together -- on compliance with the reporting requirements, while putting the money to work as fast as possible? Let me tell you, when it hits the Vice-President's desk, along with other Recovery Act Initiatives, he is hands on, monitoring programs and asking questions.

And so, against this complex and intense backdrop of activity, we also have other efforts underway worth noting that will change our way of doing business, old and new:

At HRSA, we are focused like a laser on improving:

• Collaboration;
• Integrating our programs with a renewed focus on Public Health;
• and improving the Quality of Care for the populations HRSA is charged to serve.

By Collaboration, this Administration means “cooperation on all fronts” -- within our own agency; between agencies (federal, state and local); among our grantees; and throughout our stakeholder network.

In terms of between agencies, for example, we've strengthened our relationships between HRSA and CMS – working collaboratively on CHIP outreach, on rural health issues – and understand that it wasn't always this way. But it's our stakeholders who lose when we don't.

Within HRSA, as just one example among many I could give you to illustrate our orientation to breaking through our own silos, while we all are meeting here today, HRSA has a team in Atlanta conducting their fourth fact-finding forum on the National Health Service Corps to find out how we can improve recruitment, satisfaction and retention of our providers in the face of projected shortages across the professions.

And we're doing it with representatives not just of the NHSC, but of other programs like AHECs, Health Centers, PCAs – and we're not telling them how we're running the program; we're asking them for their best advice about how we can improve the NHSC program.

Another example is how we have totally revamped the role of our Regional Offices to act as HRSA's key linkages between our programs, and grantees and others on the ground. You'll be hearing more about this later from Regan Crump – our new Associate Administrator for Regional Operations, who also happens to be an alumnus of the NHSC.

In a nutshell, the Regional Offices will work to strengthen connections between such entities as our major Academic Health Centers, State and local Health Departments, and HRSA's various grantees, as we seek to better mesh our efforts to promote our Public Health Mission.

And what I am asking of all of you is to start thinking about your role in this collaborative environment, and how we can support cooperative efforts – not just among Health Centers, but across all health care entities in your communities in order to maximize efficiency and improve access to quality care.

It's critical…because we will be hard-pressed to sustain the progress we've made without it, particularly in fiscally challenging times.

Here's just two examples:

1. In terms of provider retention: The expansion of the NHSC should not be misunderstood as a return to the “conveyor belt” model of staffing, in which we simply replace a transient workforce every 3 years. The provider shortage is real, and it's going to get worse. So it is of the utmost importance that we retain as many of our Service Corps clinicians as possible, as long as possible. And that is going to require much greater collaboration on both our parts.
   
   Young clinicians these days have in their futures greater job prospects and mobility than ever before. Currently, of the 8,500 posted NHSC vacancies, half are in your health centers. The rest are in other qualified facilities and agencies.
   
   So, from the start, you face the challenge of positioning yourselves as the employers-of-choice among many competitors; and then retaining these providers that you've helped to develop once their contracts expire. So I'd be asking myself:
   
   Do I have a good collaborative relationship with my clinicians?
   Do they feel valued?
   Am I doing enough to help them develop professionally and see the health centers as a long-term career option?
   
   Given the shortage projections, I think we'd all agree that we need to take a fresh look at fostering stronger collaborative relationship with all of our providers.
   
   At the national level, I have charged Becky Spitzgo with building stronger connections among our NHSC clinicians – to reinvigorate and instill a true sense of Corps identity – to help our awardees see that they are part of a bigger mission and calling for this country.
    
2. Rural Access: A second crucial area where we need better collaboration and cooperation is in the relationship between Health Centers, small Critical Access Hospitals, and solo practitioners.
   
   More than a third of our Health Center sites are now located in rural communities. At the same time, we have made great strides in helping the nation's 1,300 Critical Access Hospitals stabilize their financial standing through improved management of their Medicare-eligible patients; better participation in the 340b drug discounting program; and the adoption of Health IT and Telehealth.
   
   And we've got models of communities where the CAHs and the CHCs are working together in creative ways. I've seen this first hand in Northwood, North Dakota near Grand Forks, where the CAH and the CHC are co-located and routinely share clinical resources.
   
   But, we've also got situations where these two important safety net providers are not working together, and in some cases maybe working at cross purposes.
   
   In many of our rural communities, we lack the economies of scale to have duplicate rural delivery systems. We all know well the challenges of recruiting physicians and other health care providers to rural communities.
   
   We also know that when local health care providers don't work together it's the community that loses, and we just can't afford that, given the scarcity of health care in rural America.
   
   We all need to do our part in supporting all local rural providers.
   
   HRSA is getting ready to release a new manual that examines how CAHs and FQHCs can collaborate. The object of the manual is to illustrate the potential benefits that can accrue through strong partnerships.
   
   The manual is, itself, a collaborative effort between HRSA's Bureau of Primary Health Care and the Office of Rural Health Policy.
   
   It covers all the basics; detailed information about each provider type to be clear about their roles and responsibilities; potential areas of overlap and cooperation; and examples in which collaboration is working to strengthen both.
   
   This is so fundamental to what we do that it should come easily – because it just makes sense.

In terms of that second area of focus – Public Health -- I had a chance a couple of months ago to meet with some of the highest-ranking State and Territorial Health Officials in the nation – and here's what I told them about all of you:

“For the 24 million Americans who depend on HRSA programs, we are a lifeline. The community health centers now serve the largest patient population in the Nation -- more than any other sector, public or private. And they provide much more than clinical care.

The health centers counsel patients on the steps they and other members of their communities should take to promote better health and prevent disease. They monitor local workforces for occupational injuries. They are acutely attuned to environmental conditions impacting the health of local populations.

In essence, our health centers are public health guard posts – the largest such network in the nation, with 7,500 discrete clinical locations that reach deep into communities to serve some of our most vulnerable citizens.”

That is a historic position for Health Centers, which I think is now more important than ever.

One recent survey found that we have lost 11,000 state and local public health staff positions in the recent economic downturn – and there is evidence that the trend has worsened since that survey was conducted. Attrition, coupled with layoffs and furloughs, have severely diminished our state and local public health agencies.

So we need to look for gaps and extend our reach when we can to help continue the broader effort in support of public health.

Finally, before I open this up for your questions, I want to give you all my personal thanks for helping to lead the way on the President's Quality initiative.

Not only did you respond brilliantly to the addition of new clinical reporting requirements in the past year, you honored the President's call for “transparency” in the administration of the Recovery Act with the quick adoption of a whole new set of guidances and reporting protocols.

We now know more about the health of our communities than ever before; the success of your efforts to improve health outcomes; and the overall Public Health of the Nation.

And I have to tell you, it's one big reason that the Health Centers enjoy such broad support on both sides of the aisle in Congress in what has been an often contentious and fractious debate over Health Care Reform.

The bottomline, friends: The Nation's Community Health Centers… work.

They're tried, true and time-tested.

And, simply put, the health of the Nation has never needed you more.

Thank you all.