Remarks to the National Hispanic Medical Association

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by HRSA Administrator Mary K. Wakefield

March 26, 2010
Washington, D.C.

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Your chairman, Dr. Ciro Sumaya, is, of course, one of my predecessors as HRSA Administrator under President Clinton. Dr. Sumaya, it is a pleasure to see you.

Dr. (Elena) Rios, thank you for the invitation to visit with you and your members.

I see last night you honored NHMA's National Leadership Fellows, an effort HRSA was proud to have helped launch. Dr. Kathy Flores, secretary of the NHMA's board of directors, was a fellow, as was our own Dr. Ahmed Calvo, who is senior medical officer in HRSA's Office of Health Information Technology and Quality.

Besides Dr. Calvo, HRSA has a number of Hispanic health care professionals in senior positions.

Your Women-in-Medicine awardee, Dr. Tanya Pagán Raggio-Ashley, is medical officer for our Division of Healthy Start and Perinatal Services in the Maternal and Child Health Bureau.

At our HIV/AIDS Bureau, Dr. Margarita Figueroa-González is director of the Division of Community Based Programs, and Dr. José Rafael Morales, known to us as “Rafi,” is chief medical officer of the Global HIV/AIDS Program.

In addition, Henry Lopez runs the Office of Minority and Special Populations in our Bureau of Primary Health Care – Henry's office oversees the migrant health centers -- and Diana Espinoza is deputy administrator of our Bureau of Health Professions.

They are people whose expertise and advice I count on, and they are a real asset to HRSA. I want to add, however, that we need to markedly increase our numbers of Hispanic health care professionals at HRSA. This is a great time for faculty to think about a two-year stint at HRSA, for practicing clinicians, for former NHSC providers to think about public service through a new lens. If you are interested, or you know someone who might be, we'd welcome the opportunity to talk.

Today I'd like to talk about HRSA's future and the vital role President Obama has planned for us as health reform rolls out. HRSA is a $7.2 billion agency with varied responsibilities. Included among them are:

• The Ryan White HIV/AIDS program, whose grantees provide deliver life-saving pharmaceuticals, medical care and support services to some 500,000 low-income and uninsured people living with HIV/AIDS. It's a $2 billion program that delivers some of the best HIV/AIDS care that can be found anywhere.
• Our Maternal and Child Health Bureau leads federal efforts to improve the health of mothers and their children. Every year, its state block grant funds provide health services that reach six out of 10 women who give birth in the U.S. The Bureau also runs the Healthy Start program, whose 102 grantees pull together community resources, education and outreach to reduce infant mortality in communities where the rate is simply unacceptable for a developed nation. Healthy Start grantees are located in cities like San Juan (Puerto Rico), San Antonio, and South Phoenix (Arizona), and along the U.S.-Mexico border in smaller communities like Brownsville-Harlingen in Texas and Las Cruces and Luna County in New Mexico.
• We also administer programs that encourage organ donation and procurement, improve health delivery in rural areas, operate poison control centers, and provide discounted pharmaceuticals to safety-net providers, among others.

Even as he was working toward health reform, President Obama in the past year has focused resources, time, and attention on two key HRSA responsibilities:

• First, delivering quality primary health care through our health center network; and
• Second, supporting health care professionals through programs we administer in our Bureau of Health Professions. In the area of health professions, the President's intent can be summed pretty succinctly: to expand training and educational opportunities for health care professionals, and to provide additional incentives for them to practice in our most underserved neighborhoods.

Let me say a word about each of these priorities, which are targeted toward access to quality primary health care. They are rooted in the American Reinvestment and Recovery Act he signed early last year – an act that directed $2.5 billion in new funds to HRSA. These priorities are also reflected in his proposed budget for HRSA for 2011, and in the just-passed health reform legislation.

The President knows, as we all do, that regular access to primary care holds the promise of a healthier nation, with fewer people progressing to chronic illnesses, and fewer of them using expensive emergency room care. If we expand access to health homes and to health promotion and disease prevention activities, we can, as you well know, reduce the number of Americans with chronic disease and better manage the care needs of people who do present with these conditions.

In terms of primary care, HRSA delivers it to underserved populations through our network of health center grantees. These 1,100 community-based health center grantees operate 7,500 service delivery sites in urban and rural areas across the nation. Together with the nation's public hospitals, they form the foundation a large part of the nation's health care safety net.

Every person who enters a health center receives care, regardless of their life circumstances. Payment is determined by sliding fee scales; the poorest pay nothing. About 40 percent of health center patients have no health insurance.

Health centers provide a broad range of care, emphasizing the treatment and control of chronic illness such as diabetes, asthma, cardiovascular disease and HIV. They also provide prenatal care for expectant mothers and care for their infants after birth. Increasingly, health centers provide comprehensive dental care, mental health care, and substance abuse treatment.

Of the $2.5 billion in Recovery Act funds directed to HRSA, $2 billion of that was targeted to health centers to expand the number of sites, the range of services they provide, and their hours of operation. The additional funds also helped build new facilities, renovate old ones, and invest in health information technology. In addition, the Recovery investment helped health centers add or retain more than 6,700 staff, including more than 1,200 new primary care providers, and generated as much as $3.2 billion in related economic activity.

The $2 billion in Recovery funds was a remarkable infusion for a program accustomed to an annual budget of essentially the same amount. With it, our grantees now care for close to about 20 million people, an all-time high. That makes the HRSA health center network the largest deliverer of primary health care in the United States, public or private. In 2008, a third of health center patients identified themselves as Hispanic or Latino, making them the largest ethnic or minority population served through the health center network.

Many of you know that the health center program includes a targeted effort to improve the health of migrant and seasonal farmworkers. The migrant health centers we support served 834,000 patients in 2008, the latest data compilation available to us.

With such a diverse patient base, health centers are keen to deliver culturally competent care, and they work diligently to furnish medical translations, when needed, in the language of the patient.

Health centers are operated by local, community-based organizations, so none of their names starts with “HRSA,” and their affiliation as a federal grantee is often unclear even to patients and community residents. But I imagine you're familiar with many of them:

• In the Bronx, for example, Urban Health Plan is a health center grantee. The CEO and Chief Medical Officer both are Hispanic.
• In Chicago, Alivio Medical Center – founded, staffed and directed by Hispanics -- serves a mostly Mexican-American patient base.
• Near the U.S.-Mexico border the health center presence is strong, and so is the commitment of Hispanic Americans to their communities. At the San Ysidro, California, health center – where Ahmed Calvo was once chief medical officer – Ed Martinez is the CEO. And at the El Rio Health Center in Tucson, the chief medical officer is Dr. Art Martinez.

When they were created more than four decades ago, health centers existed simply to provide access to care to those who had no other opportunities. But for many years now, HRSA has developed strategies to improve patient outcomes, to the point where multiple independent studies have concluded that health center care is equal to or better than care that can be obtained most anywhere.

For example, 90 percent of our health centers have participated in what we call “health disparities collaboratives,” which bring together teams of health center staff – doctors, dentists, nurses, and social workers – to improve care systems by learning about and then implementing better ways to work together and better ways to care for their patients.

Data collection and analysis of patient outcomes are at the core of this work. Health centers track patient outcomes and that information informs their thinking about the value of the changes they implement. Each year all of our health center grantees input information on patient demographics, services provided, staffing, clinical indicators, utilization rates, costs and revenues.

HRSA staff first review data to ensure compliance with legislative and regulatory requirements. Then they use the data to identify interventions capable of improving care for patients with chronic diseases.

In 2008, health centers established a core set of clinical performance measures for several key health conditions and age groups served by health centers. These measures – which include childhood immunization rates, entry into prenatal care, and control of hypertension -- are aligned with those of national quality measurement organizations, such as the Ambulatory Care Quality Alliance and the National Quality Forum.

Right now we're deeply engaged in efforts to see that health centers make full use of electronic health records and other health information technology. Because we, of course, view EHRs and HIT are central elements in our multi-layered strategy to improve health outcomes for our patients. As part of this we're using new technologies to expand data collection and analysis because we know it can point the entire network toward improvements in individual care, in management of resources, and in strategies to improve health at the community level.

Dr. Calvo has been deeply involved in developing and directing our quality efforts, and he can explain in detail about our health center controlled networks, our HIT technical assistance to grantees, and our efforts to improve patient safety by improving pharmacy services.

So that's where we're headed with health centers and their delivery of federally supported primary health care.

As I mentioned earlier, the second key element of President Obama's support for HRSA's programs involves health professions, an area where federal support had seriously eroded over the last decade. The President wants to make sure we have more trained health professionals, especially nurses and primary care physicians and others in high demand. Clearly, increasing access to appropriate care has implications for the numbers of nurses, dentists, doctors and others to provide it.

Under the Recovery Act, HRSA received $500 million to bolster the health professions, an effort to build a platform anticipating the passage of health care reform:

• $200 million of that amount aimed to counter health workforce shortages by expanding training and educational opportunities. Colleges and universities competing for these funds are using them to pay for scholarships, loans and loan repayments that will train 14,000 clinicians over the next few years. Of the $80 million awarded to date, about half has gone to students, health professionals and faculty 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 are 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.
• The remaining $300 million of HRSA's Recovery money will add thousands of new clinicians to the ranks of the National Health Service Corps.
  
  The Recovery Act is generating unprecedented growth in the NHSC, and our field strength is rapidly closing in on 5,000 practitioners, hundreds more than we had just two years ago. That total includes about 1,700 physicians, 1,400 physician assistants and advanced-practice nurses, 1,000 mental and behavioral health professionals, and 700 dentists and dental hygienists.
  
  Let me pause here for a commercial: The NHSC is a great option for these health care professionals. Here's the deal: if they sign up for two-year terms to work in underserved areas, they can get up to $50,000 in student loans paid for by the federal government. Those who opt for a five-year commitment to the Corps can get up to $150,000 in loans paid off. In addition, we'll soon be piloting a large part-time NHSC opportunity that would allow clinicians to work half-time in an underserved area for four years instead of two, for example.
  
  We've worked hard to streamline the process of joining the Corps and we're accepting applications for Recovery Act funds through July 29 of this year, or until those funds are exhausted. If you know nurses, dentists and doctors who are dedicated to delivering primary care for the underserved – and who want the government to pay off their loans while making a palpable difference – please tell them about the NHSC and urge them to go to www.hrsa.gov to learn more.

Looking forward, the President's drive to improve and expand primary care and health professions continues in the FY 2011 budget proposal that he announced in February.

The President's budget proposal includes an additional $290 million for health centers (to a total of more than $2.45 billion) over the 2009 level to keep up the increased pitch of activity initiated by the Recovery Act. If agreed to by Congress, the additional funds will create 25 new health centers across the country and further expand health centers' ability to provide behavioral health care.

That's the first step in a series of funding increases for health centers included in the health care reform bill the President signed on Tuesday. The health care reform legislation contains provisions that will allow us to nearly the double the number of patients that health centers over the coming five years.

The 2011 proposal continues the increase over the past year for the Nurse Loan Repayment and Scholarship program. The President again asks for $94 million, an increase of more than 150 percent over the FY 2009 total of $37 million. This infusion of funds supports hundreds of additional contracts for nurses in critical-shortage facilities.

And the President's request sustains his expansion of the NHSC. He asks for $169 million in 2011, an increase of $34 million over the 2009 appropriation. That's in addition to a very significant boost for the NHSC in the health care reform legislation.

In addition, other continuing investments to increase the number of primary care doctors, nurses and others are included in the health care reform legislation.

That's a summary of where HRSA is headed under President Obama's leadership and of the investments he's supported to build a brighter future for primary health care, for the health professions and, as a result, for the American people.

Now I'll be happy to take any questions you may have for me.