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Remarks to the National Association of Community Health Centersby HRSA Administrator Elizabeth M. Duke September 15, 2008 Listening to Donna Brazile and Dan Bartlett this morning, I was reminded once again that change is inevitable in a democracy like ours. Every four years, we brace for another transition, another “orderly transfer of power” – which truly is the genius of our Constitution. The world over, every school child is taught about the American system of “checks and balances,” embodied in our three branches of government, and the election of a president every four years. What is less well known or understood is that there is a career civil service that takes direction from each new presidential administration picked by the electorate, regardless of how we might have voted ourselves. HRSA is based in law. All of its programs have been blessed with bipartisan support over the years, especially the community health center program. And HRSA will continue to administer the Law of the Land, and support each new administration in the direction it seeks to go. This year, the current administration – working with Congress -- chose to provide an additional $77 million to open the doors on 42 new health centers; expand the capacity of 19 existing centers; bolster our planning grants for new applicants; while providing almost $40 million in base adjustments for all of you. It’s always nice to come bearing gifts, and I want to talk more about those in a moment. But first I want to recognize one of the people from my staff who helps me keep the wheels on the tracks at HRSA every day: Just about everyone here knows Jim Macrae, associate administrator of our Bureau of Primary Health Care, who has the firmest grip on your concerns and needs of anyone in federal government. He has been here all week, and he’s available throughout this conference – just as he is available everyday by phone and e-mail – to give you our perspective and best forecast on what to expect in the next few months and beyond. Jim and his staff are in daily touch with people in Texas to assess the damage from Hurricane Ike and see how we can help. Every election brings a fresh reminder that this thing we do – this safety net we wove together with the help of your state and territorial governments – is under constant scrutiny, along with every other federal program. And every four years brings a new generation of elected leaders with new priorities who may not know all that much about us, or our history, or our sense of mission and purpose…and we’d be naïve to think that simply telling our story is enough anymore. In the new era of data-driven performance measures, qualitative analysis and population geo-mapping, good intentions simply aren’t enough anymore. Today, people want proof, hard facts, verifiable evidence that we are putting the taxpayers’ money right on top of big problems…and solving them. In 1965, when a President from Texas gave us our start, almost 100,000 babies died every year in this country before their first birthdays. African-American infants in the rural South had about as much chance of surviving as children from the developing world. We cut that horrific infant mortality rate by more than 70% -- thanks in large part to the creation of a national safety net to take care of the most vulnerable of our friends and neighbors. Together with our friends in HRSA’s Bureau of Maternal and Child Health, we took on rubella, tuberculosis, mumps and whooping cough. These pediatric scourges could not possibly have been beaten without your help. More recently, under another president from Texas, we added 1,200 new or expanded sites; expanded care by 60% to reach more than 16 million people; and took on a vital role in delivering the anti-retroviral drugs and primary care that have cut the death rate from HIV-AIDS from 100,000 to 15,000 per year in little more than a decade. This is still too many, but we are making progress. YOU did that -- and some of you did it so well over the years that you’re now among the largest health care providers. From a grassroots movement, you’ve grown into big businesses…and not a moment too soon. Let me just stop right here for a moment and acknowledge that we lost one of the true champions of that movement three weeks ago today. Cornell Scott was a caring, committed and gentle man who did everything possible to improve the health of the underserved in his adopted hometown of New Haven, Conn. But “Scotty” was a lion in defense of this program who spent almost as much time working the corridors in Washington in the 1980s as he did with his patients. From one small office, he built the Hill Health Center into one of the largest in the nation – with a staff of 500, 17 outreach clinics and a service-base of 28,000 clients. Cornell Scott would have been the first to tell you – because no one knew more about it than he did -- that the challenges we now face are enormous, and they will require every bit of our business acumen and resolve to manage them, and the realization that we are all in this for the long haul. Change of any scale takes time. The first and biggest challenge, the 800 lb. gorilla in the room today – and it’s not going away anytime soon – are the health care workforce issues that only now have begun to gain the attention of the national media. According to our projections, we are going to be facing shortages within the very near future of one million nurses; 200,000 physicians; almost 30,000 pharmacists…the list goes on and on. In dentistry, we are told by some experts, the overall national supply of graduates is expected to be “adequate” by the year 2020. But, of course, we know better. In our health professions shortage areas, we’re at least 7,000 dentists short already. We have to compete against the big HMOs and medical centers when we’re recruiting, and we often are at a distinct disadvantage in our ability to match the compensation offered by private plan employers – particularly in the field of dentistry, where we are outgunned two bucks to one in the salaries we can afford to pay. Our strength, however, is that we have always tooled our education programs and recruitment efforts to appeal to young professionals for whom medicine is a calling to service – and they are still coming up to work with us. In the past six years alone, the nation’s health centers have added 3,200 physicians – and 2,000 nurse-practitioners. Over that period, you have grown your total full-time clinical compliment to more than 22,000 doctors, dentists and nurses, and a workforce of almost 105,000 employees. At the same time, let me say in all candor that we will have to do a much better job of retaining these hires in the future, because the old conveyor belt model of recruitment and replacement isn’t going to work. Demand for quality care will be driving compensations higher and higher in the healthcare field, at the same time that patient populations are growing and the professional labor pool is shrinking. In psychiatry, as but one example, that labor pool already is down to a puddle. In other words, we’re rapidly reaching the moment – if we haven’t already – when we no longer will be able to recruit our way out of staffing shortfalls.
These Ambassadors – like many of you – are working to insure most of all that the 5.3 million children in this country who are the core clients of the health center system get the care they need, and that more sign up.
As part of our continuing efforts to aid in faculty retention in the nation’s nursing schools, we are expanding the Nursing Faculty Loan Program to include part-time students who will become faculty. Of 588 nursing professors who applied, we have been able to fund 156.
As we all know, much of the current workforce crunch is being driven by the aging of the baby boomer generation, and that trend is going to accelerate. When you consider that upwards of a third of caregivers in many medical specialties is now over 50 years of age, you can see that time is not on our side. Among nurses, the average age is the highest it’s been (46.8) since we first began keeping track in 1980. As those people start approaching retirement, we’ll be losing our most experienced clinical managers. Anything we can do to retain them, if only for a few more years, is worth the effort. There’s that word again, retention. Do you sense a theme developing here?
But the vast majority of those 8,000 doctors and nurses I mentioned a second ago are voluntary workers – meaning, they were under no legal duty to work in a shortage area as a condition of their scholarships and loans. They did so of their own accord, probably out of a sense of personal responsibility to serve in the communities where they grew up. These are precisely the students that HRSA recruits most heavily with its scholarship, loan and repayment programs. And we were lucky they answered their consciences or our current shortages might have been much worse.
The biggest class of Corps scholars in recent memory (217) will take the field this year, joining a staff already in service of more than 4,000 physicians, dentists and nurses. History has shown that these are some of the most dedicated, most committed, “soldiers” in our workforce. Well more than half of them serve in rural postings. We all need to make sure they are justly rewarded and understand that their service is valued. If he were here today, one of the things Rick Smith from our Bureau of Clinician Recruitment and Service would tell us is that his staff conducted almost 700 case reviews last year triggered by calls for assistance from NHSC graduates who were unhappy in their clinical placements. The old hands in the room today can guess what those complaints were about, because you’ve heard most of them many times before. The young, idealistic, new doctor or nurse can face quite a reality check upon first arriving in a health center. The caseloads, hours, working conditions and idiosyncrasies of certain patients can come as a shock. And homesickness can set in quickly, particularly for those working in isolated rural settings. I’m here to tell you that we have to do much better at helping these young professionals adjust – just as we have to do better at tending to our entire workforce. No longer can we afford to just leave them to sort out their feelings and their options on their own, because the competition for their services is just too intense. In this respect, we might do well to study the business practices of Horizon HealthCare of Howard, South Dakota. Under John Mengenhausen’s leadership, it has grown from a “classic” grassroots operation over the past 30-plus years into a fully-automated, 10-clinic network serving the entire southern half of the state and two Indian Reservations. Not satisfied to simply rely on the old conveyor belt, Horizon now offers compensation and incentive packages to young doctors well into six figures annually; a month’s vacation annually; 100% medical coverage; guaranteed employment for their spouses; privileges at a critical care hospital. If we want to attract those new hires and keep them, we have to offer them these kind of rewards – and even then, John will tell you, it’s going to be a challenge. We all have to send a clear message, at every opportunity, that we are committed to the long-term growth of our people in their chosen disciplines; we care about them as people and professionals and as families; and we are prepared to be their partners for life. At HRSA, we’re going to prove that in the months ahead as we re-tool the National Health Service Corps and the Bureau of Clinician Recruitment and Service, and hit the road to perform 80 NHSC site visits this year. One of the things we’ll be looking at much more keenly is job satisfaction in your workforce, your clinical working conditions, and ways that HRSA might be able to help retain more of the staff that you and we have gone to so much trouble to train. There’s that word again: retention. Clearly, part of the solution to the workforce crunch is to continue pressing ahead with innovative, labor-saving digital technologies and data systems. Looking back just a few years, these were considered “nice to have” items – and I can remember being told more than once that community-based organizations are often “late-adapters” of technology. In your case, that hasn’t been true. Indeed, you’ve been “adapting” as fast as HRSA has been able to provide the funding. When I visited Arizona in July, I stopped by to visit our grantees at Clinica Adelante on the outskirts of Phoenix and was tickled at how quickly the results of routine mammograms and other screening tests were zipped by computers from off-site labs, straight into electronic patient files and onto video monitors in the clinic. Functions that might have taken hours to complete can now be performed in minutes in a fully digitized and inter-connected clinic like Adelante. It also helps to improve patient safety, quality of care and portability. Based on reports from our grantees, we are just about at the point that 1 out of 4 patients receiving care today is being served in health centers equipped with electronic records systems. We also are putting increasing emphasis on technical assistance to ease the transition for all of our grantees. In Arizona, one out of every three children has never had a dental checkup, and 400,000 of them have serious tooth decay. In a state with one of the fastest growing populations in the nation, 6,000 dentists retire every year for every 4,000 who graduate. If this doesn’t sound like a recipe for disaster, I don’t know what does. But in July, I visited a new community-focused dental school in Arizona – the A.T. Still University School of Dentistry and Oral Health in Mesa. They had just graduated their first class of 54 dentists. That might not sound like a big number, but there’s more to the story. A.T. Still is funded and supported by a partnership of the University, NACHC, and HRSA – the first school of dentistry in Arizona, operating an on-campus clinic dedicated to serving patients in need. That clinic is staffed by 2nd-, 3rd-, and 4th-year students. These young clinicians are gaining invaluable experience while at the same time caring for 2,500 patients a year who have never seen a dentist before in their lives. The gains you made in the provision of mental health services were even more striking: tripling the number of clients to 613,000 in a matter of a few years. To increase this “first,” HRSA and two of its sister agencies in Health and Human Services developed a report that was released in July, addressing seven major barriers to reimbursement for mental health services. Please get a copy, read it, and use it. Among the problems we have discussed in this report are the need for increased payments to non-physician practitioners in underserved areas; reimbursements for services rendered in a primary care setting; and, especially important, proper billing and payment for telemedicine counseling – which often is the only counseling our clients can get. One more time, from the bottom of my heart, thank you. I realize it seems like this discussion of the HRSA designation regulations has been going on forever, and it’s a raw nerve for a lot of you – and certainly for me. But as you well know, we are trying to achieve a delicate balance between competing objectives. The law under which HRSA operates is unambiguous: we must serve the neediest areas of the nation – from the rural frontier lands to forgotten inner-city neighborhoods. At the same time, there isn’t a person inside HRSA who doesn’t understand the importance of the “fixed assets” on the ground, the already-existing health clinics themselves. We are wrestling with the demographics of poverty and geography; economics and aging. And none of us sitting here today – in this time and place – dares discount acts of God. Hurricane Katrina displaced more than a million people from this city and region, including some 4,500 doctors, initially. Hospitals and clinics closed. Many residents left and never came back. There are whole neighborhoods in New Orleans today that still are virtually abandoned three years later. That, in a nutshell, is the challenge we are facing with the HPSA designation rules – which, frankly, drive most of our programs. People move. Buildings don’t. And the law says we have to follow the people, who sometimes are forced to move overnight. As we published in the Federal Register, we received many substantive comments on the proposed rule and are considering these comments carefully. We’re working on a new NPRM that you will all have the chance to comment on. We will welcome your comments and feedback when it comes out. Thank you. |
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