Remarks to the IOM Committee on Governance and Financing of Graduate Medical Education

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by HRSA Administrator Mary K. Wakefield, PhD, RN

September 4, 2012
Washington, D.C.

I appreciate this opportunity to be here and meet with you, and thank you and committee members for their work on this important topic. Clearly, your findings and recommendations will be important to many different stakeholders, including HRSA.

From our vantage point specifically, we’re interested in ensuring that the populations served by HRSA programs have access to high-quality, appropriate health services. And we’re interested in ensuring that the clinicians HRSA supports through its workforce programs are well suited to deliver those services.

To illustrate how graduate medical education fits in with our work at HRSA, it may help to know that a major part of our mission is to help ensure access to quality care, with a particular emphasis on underserved or vulnerable populations with economic, financial or clinical problems.

To achieve this mission, we need an adequate supply and distribution of clinicians with critical competencies practicing in systems that help them maximize their contributions to the health of patients, families and communities. So HRSA’s focus on workforce is agency-wide – and not just in our programs that support graduate medical education or that support health care workforce training.

This is such a high priority for us that it constitutes one of just three strategic priorities for the entire agency: strengthening the primary care workforce to better meet the health needs of the nation. We focus on primary care because we see access to it as a cornerstone of healthy people and communities, and as an essential component of a high-functioning delivery system.

The characteristics of the health care workforce, and of the physician workforce specifically, impact virtually all of our health care delivery programs. Those characteristics include the supply, distribution and diversity of clinicians, as well as where they are trained. And they include the competencies clinicians acquire and the skills they apply.

Those characteristics influence the care delivered through the nation’s network of Community Health Centers, which are supported by HRSA, and which currently serve more than 20 million people nationwide. They also influence the National Health Service Corps, which places thousands of primary care clinicians in isolated and medically underserved communities.

The characteristics of the physician workforce impact other HRSA programs as well:

• our Maternal and Child Health grants, which help 6 out of every 10 women who give birth and their infants;
• the Ryan White HIV/AIDS program, which provides care to about half the U.S. population that has been diagnosed with HIV; and
• our Office of Rural Health Policy, which works to bolster rural health care infrastructure.

So the adequacy of the workforce is relevant to virtually all our programs and to the millions of people who receive care and services through HRSAs programs.

From that vantage point, we share a common interest: to assess and help, where appropriate, to re-shape the education of the health care workforce in an evolving health care system. And to do that even as health care delivery and the population receiving care look different today than when I was a practicing nurse.

These differences include growing age, racial and ethnic diversity; changes in the health care environment; high expectations to measure care quality; and pressure to limit growth in health care costs.

In this context, it is clear that we need to field a workforce that is aligned with these changes and that relies on our ability to help re-frame the education of health professionals.

We’re focused on reframing a lot of what we support and we’re looking for ideas both within and outside of government to ensure that resources are deployed as effectively as possible. The outside of government is, of course, where your ideas and recommendations ultimately come in.

So, with that as a bit of general context for HRSA’s stake in all of this, let me shift to speak specifically to our training efforts, especially as they’ve been catalyzed by the Affordable Care Act, or ACA.

As you’re likely aware, the ACA provides funds for training in important areas such as Patient-Centered Medical Homes, as well as developing curricula and continuing education specific to its features. Also importantly, the ACA includes language to support primary care education focused in community settings and training in new competencies.

For example, the ACA established the Teaching Health Center program to fund graduate medical education for new residents in primary care and dentistry. This program – administered by HRSA – is unique in several ways.

First, it supports residency training that is focused principally in ambulatory, community-based settings, such as federally qualified health centers and rural health clinics. The health centers participating in this program are located in underserved rural communities and cities with medically underserved populations. And research shows that physicians who train in these types of sites are up to four times more likely to choose to practice in similar environments after they complete their residencies.

Second, the Teaching Health Center program provides direct support to accredited residency programs in these clinical settings. This financing approach provides a much more straightforward link to the residency training programs themselves, compared to Medicare’s teaching hospital model.

Although the Teaching Health Center program is in its infancy – with only one academic year under our belt – we are examining ways for it to support residency training in team-based environments. And we see the potential for MedPAC and other experts see that graduate medical education can help expedite innovative care delivery systems to improve patient outcomes and coordinate services more effectively.

Finally, we are exploring ways to embed accountability for achieving education and practice goals in future years of the Teaching Health Center program. These goals include training primary care residents in skills that promote high-quality and high-value health care delivery consistent with the proposals included in HHS’s 2013 Budget for CMS and MedPAC’s recommendations.

For example, we are considering how the program can further support residency training in patient-centered medical homes, with meaningful health information technology, and with active quality measurement and improvement.

The Affordable Care Act also gives priority to funding projects that support activities that align with many of our own efforts at HRSA. These include:

• Support for collaborative projects among primary care disciplines and for interprofessional education;
• Innovation in teaching in areas such as team-based care and population health;
• Focus on cultural competency and health literacy; and
• Increasing the diversity of students entering professional training.

These activities reflect the recognition that improved health and health care reform cannot be achieved just by increasing the number or distribution of practitioners, but rather that improved health and health care must include a focus in key areas such as ensuring that health professionals work collaboratively in teams and are able to learn from each other.

In terms of distribution, for example, we can do a better job of identifying communities and populations with the greatest health workforce needs. Last year, as a result of the ACA, a Negotiated Rulemaking Committee developed comprehensive recommendations to improve our methodologies for designating health professional shortage areas and medically underserved areas. These recommendations are under review, and they will contribute to an improved methodology in the future.

In addition, the ACA recognizes the importance not just of the distribution of the workforce but also of the infrastructure that supports both education and practice.

To illustrate this point, the law recognizes that team-based health care represents an important model for improving quality and efficiency by capitalizing on the knowledge and skills of everyone engaged in delivering patient-centered care.

And we have taken several routes to foster continued development of interprofessional health care training and education – not just for physicians, but also for advanced practice nurses, physician assistants, dentists, psychologists and others.

For example, in response to the HRSA-supported IOM reports on oral health released last year, we launched the Interprofessional Oral Health Clinical Competencies project to explore how to close the chasm between medical and dental care, with the goal of aligning oral health and overall health.

The project brings together oral health and primary care providers, health systems leaders and funders with the aim of enhancing physicians’ ability to do oral health assessments in collaboration with dentists and other oral health providers.

The new emphasis on team-based care and interprofessional competencies is sparking a dialogue about how we educate the current and next generation of providers to work in team-based environments.

While many of our programs, by statute, traditionally focus on a specific discipline, we recognize that there is great value in having this conversation across professions and across sectors, so that it impacts both academe and practice.

We must make the boundaries between professions and between academia and practice as porous as possible, and health professions educators and clinical leaders need to work together across disciplines to create the training models and the care models that achieve this vision.

Let me give you a couple of examples of how we’re moving toward this vision.

One is HRSA’s new Coordinating Center for Interprofessional Education and Collaborative Practice, which also was created thanks to the ACA. Competition for the $4 million, five-year initiative ended in July, and we are now reviewing applications. An award announcement is expected soon.

The focus of the Center is to advance the evolution of the health care delivery system to one that encourages collaborative, team-based practice informed by interprofessional education. Four private foundations have committed over $8 million in additional funds to support the Center’s projects and activities.

Another example of our work in this area, as I believe you know, is the announcement we made last year – with some private foundation partners and representatives from the Interprofessional Education Consortium – of a new set of interprofessional competencies. We’ve disseminated those competencies for use in health professions education and practice, and we’ll soon announce more activity to drive this agenda forward.

At the same time, we are working closely with the three primary care certifying boards – the American Board of Family Medicine, the American Board of Internal Medicine, and the American Board of Pediatrics – to equip primary care faculty with the skills necessary to train residents in these new models and systems of care.

The initiative involves support for curriculum development, implementation of one or more regional pilot projects, and an evaluation component. We’d like to see this effort reach virtually all primary care residency training programs over the next five years.

We are also improving primary care and public health collaboration through HRSA’s Interdisciplinary and Interprofessional Joint Graduate Degree Program that supports the integration of medical education and public health training. This year, we increased the number of grantees from 3 to 13.

Beyond responsibilities to boost the quantity, quality, knowledge and skill sets of the health care workforce, the ACA also gave HRSA a crucial role in providing a hub for data collection and analysis on health professions, including tracking trends in the supply and demand of our healthcare workforce.

HRSA’s almost two-year-old National Center for Health Workforce Analysis is rapidly strengthening its capabilities to identify future health workforce needs. Although we are examining trends across many specialties, some of our early efforts have focused on the primary care workforce.

Currently, we are examining ways to project workforce needs that consider multiple professions within primary care, including physicians, physician assistants and nurse practitioners. It is challenging but we think it’s critical that we focus on needed health care services, not just by provider, discipline by discipline.

Additionally, the Center just completed its national sample survey of more than 13,000 nurse practitioners who are playing an increasingly important role in the delivery system. Reports on diversity in the health professions workforce are also under development, and the Area Resource File – a widely used health professions database – is being expanded to include state and national level data.

Because health workforce planning is a shared federal-state responsibility, we are working with states through such entities as Primary Care Offices, State Offices of Rural Health, and Health Workforce Development grantees to strengthen state-level capacity to assess workforce needs – and ultimately target their training and education resources.

HRSA is also working closely with the Department of Labor to ensure coordination of our workforce initiatives. And we have been working closely with the CMS Innovation Center as it awards projects that look at how to deliver care in ways that might serve as models nationally. I’m pleased to tell you that each of the 107 Health Care Innovation awards that CMS made this year included a requirement that applicants include plans for workforce development.

Before I close, let me address another major area of responsibility for HRSA: our maternal and child health portfolio.

One of HRSA’s largest graduate medical education programs is the Children’s Hospital Graduate Medical Education Program. This program provides funds to more than 50 children’s hospitals across the nation for residency and fellowship training in pediatrics and other related medical and surgical specialties.

As this Committee is looking closely at GME financing issues, it is important to note that, unlike Medicare’s GME funding, HRSA’s funding for the Children’s Hospital program is determined by annual appropriations. Accordingly, the size of the program’s appropriation affects the amount we can pay per resident each year.

Outside of the Children’s hospital GME program, HRSA funding also supports pediatric residency training through other programs, such as the Teaching Health Center program I mentioned earlier and other primary care residency expansion programs. We also provide funding for preventive medicine residency programs.

Let me close by reiterating that I – and the Department – hold your opinions and perspectives in high esteem. As we administer the laws and programs that we have the authority to oversee, we look to you for advice.

Thank you.