Remarks to a Region I Primary Care Workforce Conference

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by HRSA Administrator Mary K. Wakefield, PhD, RN

September 18, 2012
Newport, RI

Thanks, Jeff (Reck, HRSA Regional Administrator), for that introduction, and to all the HRSA staff here, and to Jane Hayward of the Rhode Island Health Center Association for helping to organize this conference. It’s an unexpected pleasure that I could be here with all of you today.

I’m sure I don’t need to enumerate HRSA’s many roles for this audience. As I think you know, HRSA is the safety net agency, charged with ensuring access to high-quality, culturally competent, primary care for all Americans -- and the Community Health Center program is one of our most high-visibility enterprises.

Both in terms of the Affordable Care Act and the Recovery Act, the investments in this one program have really been unprecedented in HRSA’s history.

Also relevant to the conversation today, HRSA is the frontline federal agency for monitoring and leveraging the health care workforce. While the federal government is a key stakeholder in this, it’s not the only one. Many stakeholders have a role in workforce production: state governments, colleges and universities, and private foundations.

There are four main components to HRSA’s role:

• We are charged with helping to ensure an adequate supply of clinicians across the primary care health professions through a variety of grant programs to teaching institutions.
• Beyond the focus on supply, we also work to promote a good distribution of the workforce, principally through loan-repayment programs like the National Health Service Corps that reward clinicians and faculty for serving where they are needed most. I’ll come back to this program in a moment.
• Through the ACA, we also provide long-term planning through a National Center for Health Workforce Analysis to enable federal and state policymakers to better prioritize public workforce investments; and, as part of this…
• We identify and track high-need areas of the country where health care is scarce, difficult to access or in some cases non-existent.

I’m sure that each of you understands the complexity of HRSA’s dual responsibilities for both, one, certifying the nation’s Health Professions Shortage Areas – which we do in partnership with PCOs – and two, devising ways of channeling professional services to those HPSAs. The formulas we use, the criteria we follow, are under current review through negotiated rule-making mandated by the ACA.

At last count, HRSA has identified 5,705 communities nationwide that have primary medical care shortages. Not only are these communities eligible for HRSA funding to host a health center, or Ryan White HIV/AIDS site, their HPSA designations qualify them for many other state and federal programs.

One of those programs, of course, is the National Health Service Corps. The Corps has more than 9,000 primary care professionals practicing in medically underserved areas nationwide. That’s more than double the number in the field when President Obama took office.

That increase results from the Affordable Care Act’s investment of $1.5 billion to build up the Corps through 2015. And it followed a $300 million outlay for the Corps in the Recovery Act.

As you all know, NHSC clinicians represent a range of disciplines – advanced practice nurses, physicians and dentists, among a larger group.

In Rhode Island, there are 35 NHSC clinicians in practice – roughly two-thirds of them in urban areas.

Among many changes in recent years that helped streamline the NHSC and make it more user-friendly, the Affordable Care increased the inducements to service for those clinicians willing to serve in the nation’s neediest communities.

Loan repayments for these practitioners can now reach as high as $60,000 a year, as compared to $40,000 for clinicians who choose to serve in areas with lower HPSA scores. So we give clinicians additional choice now, more than they have had historically.

We refer to this as a “two-tier system” that incents providers to really consider needier communities as established by HPSA scores.

In line with this thinking, health centers and other qualified sites in communities or regions that are surrounded by states with large metropolitan cores, along with needy rural areas with high HPSA scores and historic care shortages, are concerned that they may now be at a disadvantage in recruitment.

But well before these two-tiered tuition repayments were authorized, it was always a guiding policy of Corps – as required by the Public Health Service Act – to make awards to individuals serving in sites with the greatest shortages, as measured by HPSA scores.

And it has always been the case that the NHSC is highly competitive, and we often are not able to fund as many candidates as we have applicants. So, as has always been the case, applicants from lower HPSAs may not be awarded.

Against this backdrop, let’s consider Rhode Island’s specific circumstances. The state of Rhode Island received more NHSC awards in FYs 2010 and 2011 due, in large part, to the increased funding that the NHSC received from the Recovery Act and the Affordable Care Act. With this additional funding, the NHSC was able to fund further down the HPSA scale.

In FY 2012, however, the program has approximately $90 million less funds. This reduction is compounded by the fact that the increased awards made available in FY 2010 are eligible for continuation, which further reduces the funding available for new awards. Regardless of the differentiated award structure implemented in FY 2012 – take that out of the methodology – the NHSC is unlikely to fund any application with a HPSA score below a 13.

So the “Two-tier” formula is a rather simple descriptor for a more complex set of issues, and I appreciate your interest in discussing them.

I’d like to talk for just a few minutes about a few of those issues and how the Affordable Care Act addresses them.

Now, in terms of the NHSC, as you probably are aware, HRSA has an independent National Advisory Council composed of some of the nation’s leading experts in health professions studies and workforce shortages. Not much escapes their attention, as a brief review of the minutes of their meetings shows.

Here’s just one example: As the NHSC has been going through an unprecedented period of growth under President Obama, state governments have increasingly recognized the urgency of workforce planning within their own borders.

From flat-growth in federal and state loan-repayment programs just a few years ago, we have seen sharp increases in a relatively compressed period of time.

In 2009, for example, Rhode Island joined the growing list of states to fund a primary care loan-repayment program by creating the Fund for a Healthy Rhode Island – the first of its type in the state.

Two years earlier, Massachusetts foundations formed a consortium that included Bank of America, Blue Cross/Blue Shield – and more recently, the Kraft Family – to pay the academic debts of primary care physicians and nurse-practitioners who committed to working in community health centers. By 2010, this program had 113 providers serving 200,000 health center patients, according to a report this year from Massachusetts Partners HealthCare.

These state-only loan repayment programs have more than doubled nationwide in the past six years from 29 to 63 – and the number of clinicians in those programs has more than tripled to 2,057. Even if we account for recent partial funding cuts by some states due to the recession, they’ve been exceeded by funding increases in other states. That’s an important contrast.

Further, state-only programs have tended to disproportionately support physicians – whereas joint state-NHSC programs have more evenly supported mental health, oral health and physician and non-physician primary care providers.

To paraphrase one report from the Rural Health Research and Policy Centers in May, we want to be aware of the various contributing streams and collectively think about how we can calibrate contributions to fill workforce gap.

Remember, all of this has happened in a very brief span of years. And with funding as tight as it is – and the workforce demand as high as it is – I think we all would agree that it’s critical to inventory how these state and federal workforce programs work together, both in terms of overall supply and distribution.

In the meantime, I think it’s safe to say that we certainly don’t lack for recruitment and retention models. When you consider that we were essentially standing still five years ago on workforce development, we’ve come a long way.

The State of Rhode Island was recently awarded a SLRP grant of $125,000 in federal funds. These federal funds will leverage at least an additional $125,000 in non-Federal contributions to support loan repayment awards issued by the state.

The program requirements for the SLRP include broad flexibility for states, and FQHCs are eligible sites. Further, the only requirement in the SLRP is that the clinicians serve in a HPSA. We don’t have a similar requirement, so in this sense the SLRP focus and the NHSC LRP complement each other. So states have the ability to augment the primary care workforce in areas where HPSAs may not be high enough for providers to receive loan repayment from the NHSC program.

In framing the Affordable Care Act, the President and the Congress were mindful of the fact that reliable data on health care scarcity and trends within the health professions were in short supply – especially at the regional and national level.

Looming shortages may have been well understood in the safety net and rural health communities, but in the absence of good data it was difficult for policymakers to make tough budget decisions to prioritize loan-repayment and scholarship programs.

If you look at the NHSC, it was stalled, as were other workforce programs. Last decade, for example, there was very little relative growth.

These data-free zones are what prompted the Affordable Care Act to create the National Center for Health Workforce Analysis, housed at HRSA.

Later this year or early in 2013, the National Center plans to release three studies that will help orient and coordinate our work.

• First, the National Center will produce a series of reports that project workforce needs by occupation. First up is a report on physicians, nurse practitioners and physician assistants by clinical area. That will be followed by biennial projections for a wide range of professions beginning in late 2013.
• The second report is a state-by-state health workforce data base, something we’ve been working with the states on for some time. In many places, this will be the first comprehensive inventory we’ve ever had.
• The third report, tentatively titled “Diversity in the Health Professions 2012,” will include data on more than 30 health professions by race, ethnicity and gender for practitioners and new graduates.

In addition to distribution and supply, for HRSA and this Administration a very high priority is to build a health workforce that is trained to provide high-quality, culturally and linguistically appropriate care, using a more efficient interprofessional, team approach.

We want that workforce to be diverse and more representative of the U.S. population, and we want to reduce disparities in care quality across populations and communities.

With this focus, we’re also aiming to increase efficiency and quality of care; and we want to improve retention – as studies strongly suggest that health professionals from disadvantaged and minority backgrounds are more likely to continue to practice in underserved areas.

Again, the NHSC makes some interesting and significant contributions to our future workforce development efforts and to meeting health care needs.

For example, African Americans and Hispanics are only about 11 percent of the physician workforce, even though African Americans and Hispanics are 26 percent of the U.S. population.

In the NHSC, however, African Americans and Hispanics total more than 27 percent of the Corps’ 2,150 physicians. So for physicians in the NHSC, African Americans and Hispanics mirror the U.S. population – and more than double their representation in the national physician workforce.

Further, among rural NHSC providers, studies have repeatedly found that half or more continue to live and work in non-metropolitan counties several years after they leave the Corps.

In fact, a study funded by HRSA’s Office of Rural Health Policy and released this summer found that NHSC clinicians tended to serve for an average of 8.37 years in the same clinical facilities – despite a relative lack of formal retention programs by their employers.

Now I just want to say a word specifically about nurses and workforce programs other than the NHSC.

Right now there are more than 16,500 nurses – including 4,700 advanced practice nurses – working at health centers across the U.S. Since the expansion began, health centers have added about 3,300 nursing positions, including 1,300 in advanced practice.

Health centers also are great places to educate students in the nursing, medical and behavioral health fields – and we know that health care professionals trained in health centers are more likely to work in underserved areas than those not trained at health centers.

Once again, the Affordable Care Act incorporates these retention concepts. Beyond health centers and the NHSC, the ACA affirms nurses’ vital role in delivering primary health care by investing in several nurse training and education programs that HRSA administers.

In fact, HRSA has committed nearly $1.1 billion over the past almost four years to educate new nurses, improve the education of today’s nurses, and place nurses in areas of the country where they are needed most. This is unprecedented.

HRSA’s Nursing Education Loan Repayment Program, for example, has seen its budget more than double since 2009 to almost $83.1 million today. Under this program, RNs who work for two years in a facility with a critical nursing shortage can get 60 percent of their school debt paid off.

We currently have more than 2,500 nurse scholars and loan repayors working through this program nationwide.

And in response to Secretary Sebelius’ interest in strengthening our primary care workforce, HRSA has taken steps to ensure that more nurse practitioners take advantage of this loan repayment program.

In December of 2011, we released guidance that reserved half of available 2012 funds to repay the loans of nurse practitioners. We want nurse practitioners in the workforce as quickly as possible, and this will help them go to school full-time.

Similarly, at the Center for Medicare and Medicaid Services – our sister agency at HHS – a new Graduate Nurse Education Demonstration grants program announced a couple of weeks ago will reimburse hospitals that train Advanced Practice Registered Nurses using $200 million authorized by the ACA over four years.

The demonstration is operated by the CMS Innovation Center, which the ACA set up to test innovative payment and service delivery models that are structured to cut costs while enhancing care quality. Their work is definitely worth keeping a close eye on.

The Affordable Care Act also funds 28 different training programs to produce an estimated 600 physician assistants by 2015.

To keep up with all the many developments regarding the Affordable Care Act, I suggest you bookmark the site: www.healthcare.gov. It’s updated regularly and has all the facts about the law.

Before I close, I’d like to discuss the growing recognition – codified in the ACA – that team-based health care represents an essential strategy for improving quality care, delivering patient-centered care, and keeping costs in check.

This recognition – while not always easy to execute – is, I think, an essential underpinning to move health and health care from where we are to where we need to go. I can’t stress enough that the fundamental system changes already in place make it increasingly important that we all change the way we do business.

To show you how this orientation is resonating at high levels, including HHS, Secretary Sebelius has commented on the need for “entirely new levels of seamlessness, coordination, and cooperative care … over time and in different places,” as she told the Senate Finance Committee last year.

To achieve the shift that the Secretary and many other public and private sector representatives talk about requires both health professional educators and clinical leaders working together across disciplines to create appropriate training and care models.

And we need health care systems to embrace the changes needed to incorporate this orientation. This includes our partner health centers, state PCAs and PCOs.

This change really begins “upstream,” with new ways to educate the health workforce to deliver care that has quality and safety – and their requisite attributes of care coordination and team engagement – at its core.

We need more of these cross-sector conversations. We need to make the boundaries between professions and between sectors more porous – just as you all are doing here today in Rhode Island.

In an effort to do our part to reorient care delivery, HRSA has become deeply involved in efforts across the health care spectrum to push forward the concept of interprofessional education and team practice.

For example, just last week, the Secretary announced a $4 million award through HRSA to the University of Minnesota Academic Health Center to create a new Coordinating Center for Interprofessional Education and Collaborative Practice over the next 5 years. The new Center is designed to “promote expertise in interprofessional education and collaborative practice, particularly in medically underserved areas,” and encourage collaborative, team-based practice system-wide.

And, illustrative of our work and with other partners on this agency, HRSA and representatives of the Interprofessional Education Consortium in May of last year announced the creation of a set of interprofessional competencies that have been disseminated for use in health professions education and practice.

We’ll soon be announcing more activity to drive this agenda forward.

So we come at workforce issues from a multidimensional perspective – only some of which I’ve had the time to comment on here.

To get this agenda right, we really need the best thinking from everyone and, to that end, I’m asking for active participation.

We need your best ideas. So does the NHSC Advisory Council, and the National Center for Health Workforce Analysis.

One of the things that makes the Affordable Care Act so innovative is that it doesn’t address any one program or initiative in isolation, but rather in the context of a web of policy imperatives involving hospitals, clinics, individual practitioners, health centers, colleges and universities, state PCAs and PCOs, foundations and insurers -- both public and private.

And for Americans across the country, coming together, it’s working…

Just this month, for example, we learned that the Affordable Care Act has already saved consumers an estimated $2.1 billion on health insurance premiums.

For the first time ever, new rate review rules in the health care law prevent insurance companies in all states from raising rates with no accountability or transparency.

To date, rate review has helped save an estimated $1 billion for Americans. And the law’s Medical Loss Ratio (or 80/20) rule is helping deliver rebates worth $1.1 billion to nearly 13 million consumers.

So, through this and a host of provisions already implemented – and those yet to come – we’re seeing major gains for the American public, and through 2014 with implementation of the remaining provisions we’ll be seeing more.

Change often isn’t easy, but I think the opportunities have never been as robust or exciting to strengthen health care – with the ultimate aim of strengthening and improving the health of the people of your great state, Rhode Island, and all the states.

Thank you for inviting me here today.