Remarks to the 2008 Primary Health Care All-Grantee Meeting
by HRSA Administrator Elizabeth M. Duke
June 23, 2008
It's wonderful to see you all again. Three years have passed since we last met for an all-grantee conference. Those three years have been a period of enormous growth and achievement in the health center system.
Together, we have completed the health center initiative President Bush announced in 2001 and continued the expansion efforts to bring the advantages of health center care to more Americans than ever before.
When we last met, three years into the President's initiative, we had added 770 new or expanded health center sites. Last November, President Bush visited the One World health center in Omaha. There he celebrated our reaching his goal of 1,200 new or expanded sites. We're now at 1,236 new sites and still moving forward.
The pace of growth in these three years has really been remarkable:
Those are some of the cumulative totals, and they are impressive. But the impact of our work over the past three years is far stronger when we consider how our work together is changing lives in your communities.
Immediately after the disasters, HRSA worked closely with state officials to accelerate New Access Point awards, Look-Alike designations, and HPSA and MUA/MUP designations.
And we helped rebuild the devastated health care system in the affected region by awarding 21 New Access Point grants and 5 Expanded Medical Capacity grants worth a total of $15 million. Those grants are helping expand or restore health center services to more than 125,000 people.
As these few examples illustrate, we all have reason to be proud of what we've done together over the past three years to complete the President's Initiative. But reaching that milestone does not mean that growth in the health center system has ended. In late summer, we expect to award 42 new access point awards, worth about $25 million.
At the same time, we also will announce recipients in three competitions: $30 million for 160 service expansion grants, $10 million for 20 expanded medical capacity grants, and $2 million for 25 planning grants.
For FY 2009, President Bush has proposed a $26 million increase for health centers. Those funds would support up to 40 health centers in high-poverty areas that currently have no health center sites and up to 25 planning grants to help community organizations in high-poverty areas compete for grants in the future.
Staffing new and expanded sites with enough health professionals remains a challenge, even though the total number of full-time staff at health centers just passed the 100,000 mark for the first time.
With that in mind, the President asked for $11 million for the National Health Service Corps to support four dental student scholars and new loan repayment contracts for 210 dentists and dental hygienists. That's over and above the 716 new loan repayment contracts that are projected to be made for the Corps.
Those funds would help some of you add dentists and hygienists to your operations, and their existence in the '09 budget reflects HRSA's determination to expand access to oral health care. I won't relent until 100 percent of health center facilities provide preventive dental care!
Now let me address the notice of proposed rulemaking for designating medically underserved populations and health professional shortage areas. We published it on February 29.
We have been asked, “Why are you doing this? What is `behind' the proposal?”
First, our current system hasn't been updated in over 25 years – and the Government Accountability Office has criticized us severely for that. We need to update the way we designate areas, and the proposed rule is geared to identify and designate areas that most need our help.
Second, we heard your concerns over the years about the current designation process – that it was burdensome, that factors didn't accurately reflect your community's needs. And we feel our proposal does a better job of making designations easier and more reflective of the need that exists.
Third, we feel very strongly that this process is an exercise in good government, in transparent government. We want to work with you to improve the current system. We hope you see HRSA doing this for you and with you – not to you.
The proposed rule process is a collaborative process. It takes a “proposal” to get it started. We've done that. Then it takes good partners to show what's right and wrong with the proposal and offer suggestions for us to get it right. That's your role. And let me assure you that I have assembled a team of some of the best people in HRSA to review and respond to every single comment that comes in.
Our proposal got the process started. It's not perfect – nowhere near that – but it's a start, with many advantages over the existing method. When we published the proposed rule, we discovered right away that we needed to clarify some portions of it to save people work and worry. So on April 21 we published a Federal Register notice to clarify a few points. The first is that the Federally Qualified Health Center designation is at the grantee level, not the site level.
We explained in the April notice that we were trying very hard to assure that needy areas are identified and designated. From our own impact analysis for the 1,001 health center grantees that existed in 2005 and from the analysis done by Primary Care Offices, we see that many new areas can be designated under the proposed rule. And some areas de-designated under the existing process could be re-designated under the proposed rule.
The proposed rule recognizes that some existing health centers are located in counties or sub-county areas that are becoming more affluent, but these centers continue to serve underserved populations. The new safety net facility designation allows such health centers to be designated based on their service to underserved populations, namely low-income and uninsured patients.
So the proposed rule offers three equal ways to get designated. For FQHCs, we can take a first pass at each of these methods using nationally available data and thereby save some work for you and your PCOs. If we designate using national data and you are satisfied with the result, the work stops there. If you want a better result, local data can always be substituted for national data.
The safety net option is one of the more creative ideas in the proposed rule. It was included as a result of listening to the PCOs and Primary Care Associations that helped us develop the draft rule some years ago. A deficiency in the proposed rule is that it doesn't have a scoring mechanism for the safety net process. In the April 21 Federal Register notice, we asked for your suggestions on how to score it.
Additionally, we put into the proposed rule a three-year, phased-in implementation schedule, which should allow HRSA to work with you, our partners, to achieve the twin goals of designating truly needy areas and populations while minimizing disruptions to the safety net.
We would consider our efforts to be a failure if, as a result, we lost our most experienced providers of health care to the poor. That could never be our intent, because we honor your commitment and respect your skill in reaching needy areas and groups.
Let me return now to the progress we've made since we last convened. It's not enough just to have more health centers. We want better, too. We want to make sure that our health center grantees provide care that is equal to or better than in the health care system in general.
In our travels, we've visited health centers that offer a full range of patient-centered, culturally competent services, including oral health and mental health care and pharmacies on site – all of it supported by up-to-date health information technology and managed by leaders in the community. That's the vision we have for all health centers.
That vision is why we revised and improved the Uniform Data System reporting, so that we have a better idea of how the whole system is performing – and, indeed, how many sites we have and where they are! Thanks to your work in helping us revise UDS reports, our baseline scope verification reveals that we have 7,000 separate health center sites across the country, far more than you had previously documented. And that new information allowed us to dramatically improve the “Find a Health Center ” tool on the HRSA Web site: now people will be able to see all funded sites. They'll get a much better picture of where the sites nearest to them are.
Thanks to your improved reporting, we also know that health centers serve 1 in 7 people living in poverty, and 1 in 9 Latinos and 1 in 12 African Americans nationwide. That's a remarkable story of service and we thank you for helping us tell it.
Our push to improve quality is why in December 2005 we created an Office of Health Information Technology. We wanted to help you through the challenge of integrating these 21 st century tools into your clinical practice and management operations.
And it's why our Center for Quality developed the first set of Core Clinical Quality Performance and Improvement Measures. The six core measures are designed to track and improve the quality of direct health care for patients served by HRSA grantees.
As you know, the core measures have been incorporated into the 2008 UDS reporting, which will be due in mid-2009. So we'll be able to gauge their impact about this time next year.
I urge all of you to align your internal systems, quality improvement efforts, and reporting systems with the core measures. We want you to use the data you collect on the core measures to document the level of care you provide and take steps to improve it, if needed.
The core measures give us a way to prove the worth of the clinical care that our grantees provide. And that's of vital importance in today's very tight budget environment on Capitol Hill, an environment that only promises to get tighter in years to come.
Our latest HRSA-wide effort to improve performance has also been led by our Center for Quality, in partnership with our Office for Pharmacy Affairs. They have brought together HRSA and dozens of partner organizations on a new national Patient Safety and Pharmacy Collaborative. It has three aims:
The impetus for the collaborative grew out of an Institute of Medicine study (To Err is Human) which found that medication errors injure 1.5 million people every year. For every dollar spent on ambulatory medications, the report said, another dollar is spent to treat new health problems caused by the medications.
Additionally, the collaborative responds to the rapid growth of pharmacy services in HRSA programs and among our safety-net partners. More and more, we're finding that patient safety is closely intertwined with and affected by the level and quality of pharmacy services.
We're also keeping our eye on a critical prevention goal: stopping smoking among the patients you treat. Smoking is the single most preventable cause of death. Getting your patients to quit means their health outcomes will improve – and so will the quality of their lives. So also will their wallets! It's really just about that simple.
A little more than half of all health center grantees have formal tobacco cessation programs, so obviously we can do much better. And we must. Those of you who don't have formal programs may want to begin by checking out your state's tobacco and cancer control coalitions and getting involved in their activities.
Earlier this year, HRSA organized a Tobacco Cessation Committee, headed by our Chief Medical Officer. The committee is working to put together a Web page on quitting that will link you to a lot of effective prevention information, so look for that coming up.
We're not going to duplicate what's already out there, and there's already quite a lot, much of it within the Department of Health and Human Services. For example, the Department has a 1-800-Quit-Now hotline and Web site with a list of counseling services and other resources.
Furthermore, tobacco cessation medications can be purchased by health centers enrolled in the 340B Drug Pricing program as long as the medication is a prescription drug used in an outpatient setting. So that's an additional tool you can use to get your patients to stop.
And Jimmy Mitchell's office told me about a wonderful partnership that has developed in Iowa among the Iowa/Nebraska Primary Care Association, the state health department and state health centers. The PCA entered into a contract with the health department to provide free tobacco cessation medication and counseling for health center patients who need it.
Since the low-income people health centers serve often smoke at higher rates than the general public, Iowa sees the partnership as prevention dollars well-spent. The health centers are happy the state reimburses them for the cost of the medication and counseling. And the fact that they get 340B pricing for the drugs stretches the state's dollars even further. Best of all: people are getting healthier! So that's a great arrangement and I congratulate all of you who were involved in putting it together.
Finally, our Center for Quality is looking into the possibility of adding smoking cessation to the core clinical performance measures, so you may be seeing that in the future.
Let me conclude by telling you about some news I got last week that brightened my day. It happened when Jim Macrae shared with me the results of the “2008 BPHC grantee satisfaction survey.” Among the results were these:
In the last three years, we have made your satisfaction with our work a big focus of what we do. We have done that because our work together is part of the same commitment to serve those who need us most.
Together, we receive, distribute, and invest public funds and oversee and implement programs that reflect the will of the American people, as expressed through their elected representatives, to use tax dollars to help our neighbors.
We share a “trust relationship” to implement public policy and spend those tax dollars wisely. You are our partners in this noble cause.
Some may laugh at hearing the word “noble” applied to government work, but is there any doubt, to paraphrase Abraham Lincoln, that government of the people, by the people, and for the people remains the last best hope of earth?
So we are here today and for the next few days in a never-ending quest to perfect the work we do for the American people. And that's what makes this all-grantee meeting different from any other convention you may attend. Here our only interest is that which advances the health and welfare of the people we serve.
To fulfill that highest of aspirations, we have made arrangements for you to meet with your project officers. We have provided technical assistance opportunities and a broad array of breakout sessions to help you. We have assembled staff from across HRSA – from the offices of HIT, 340B, the National Health Service Corps and more. All of them are here to improve our understanding of one another and the way we work together.
I urge you to take full advantage of the people and resources we've gathered, and I thank you for your dedication and your service.