Remarks at the Northwest Regional Primary Care Association's Spring Primary Care Conference

by HRSA Administrator Elizabeth M. Duke

May 21, 2008
Spokane, Washington

I am delighted to be here today. Thank you for the invitation to join you.

I'll start with what I suspect you all want to hear me discuss: HRSA's notice of proposed rulemaking for designating medically underserved populations and health professional shortage areas.

Let me take a moment to explain how the federal rulemaking process works. After we release a proposed rule, we must by law allow for a public comment period. And as you know, we have extended that period by 30 days to May 29.

HRSA staff, by law, must review every comment that comes in, whether there are eight or 800. And I have assembled a cross-cutting team of some of the best people I have throughout the agency to do that review.

Those reviewers must then respond to each specific criticism or suggestion they receive. Their analysis of the comments and their responses will then be considered by HRSA experts and executives to determine whether changes should be made to our initial proposal.

We take this entire process very seriously. It is a process we believe in. We consider it to be an exercise in good government, in open government, in transparent government.

And let me state that while we think this is an important proposal, it is still just that: a proposal. We do not claim full wisdom on this topic. That is why a public comment period is built into the process. We await your comments, we want your comments, we need your comments, and we will take them seriously.

Why are we 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. If we were to update designations under current rules, many underserved communities and providers would lose their status.

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've responded with a proposal that initially uses national data to make most designations and that expands the number of factors that can be used to make designations fairer, more accurate and easier.

Thirdly, we saw ourselves as 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 to get it right.

We've got it started. It's not perfect – nowhere near that, but 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 also 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.

Also, in working with your state PCO you can make a decision about which of the three methods is most advantageous for your communities. You can choose whether to go for an area designation or a population designation. This is important because different communities want to use these designations for different purposes and different programs may require different types of designations, either area or population. For example, some might want to use the population type because it would best serve them to be eligible for National Health Service Corps placements. Others may want to use the geographic area type of designation to qualify for Medicare reform's 10 percent bonus payments for rural providers, known as the Medicare Incentive Payments.

Let me run through the three methods – plus, of course, the fourth, which is a last resort, namely the Governor's requested designation.

Method 1: the current method with some additional factors in the formula – such as percentage of minorities and unemployment rates – and with mid-level providers counted.

Method 2: Same as Method 1 with Federal resources backed out.

Method 3, the safety net designation: serving a low-income or uninsured population.

Under the proposed rule, we'll run the nationally available data to determine which areas or populations we can designate. As I said before, if that result is satisfactory, that's all that's needed. If not, local data can be submitted to get a better result. For the safety net facility designations, we could use UDS data. In fact, as we described in the April 21 notice, our impact analysis using 2005 data showed that all but 16 of the 1,001 health center grantees reporting that year would be designated either under Method 1 or the safety net method using national data. Local data has already proven that 14 of those 16 would remain designated and we may still learn that local data will do the same for those last two.

A deficiency of the current process is that it does not provide for the safety net facility designation. 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. In the April 21 Federal Register notice, we asked for your suggestions on how to score it.

We put into the proposed rule a three-year, phased-in implementation schedule, which should allow HRSA to work with our partners to achieve the twin goals of designating truly needy areas and populations while minimizing disruptions to the safety net.

We certainly don't want to lose our most experienced providers of health care to the poor in the process. We feel the proposed rule minimizes major disruptions to service providers, providers that we know and respect for their skill in reaching those needy areas and groups.

I urge you to look at the map we provided on our HRSA Bureau of Health Professions Web site on the proposed rule. According to our analysis, not a single health center in any of the states in Region X would be potentially affected under the proposed designation guidelines.

Since all of us began working in 2001 to implement the President's vision for health centers, we have created new health center sites or expanded existing ones in more than 1,200 communities. The number of patients served has grown by 50 percent, and now tops 16 million patients annually.

Here in Region X the number of health centers grew by 35 during the expansion and the number of patients served annually rose to almost 1 million. That's an incredible level of growth! On top of that, many existing centers competed for and won grants to expand the range of services offered and the number of satellite sites. I thank all of you for your hard work and dedication to the health center system and I congratulate you for the significant gains you've made.

And you've got to see that we all didn't work this hard for almost eight years to expand and then turn around to destroy it with a punitive regulation! Clearly, that wouldn't be rational – and it is not so!

Let me also offer happy anniversaries to the Northwest Regional PCA and the Idaho PCA: I understand you're both 25 this year! You carry your age well.

We can all be proud of our work in completing the President's Initiative. But reaching that milestone does not mean that growth in the health center system has ended.

In this fiscal year, FY 2008, HRSA will continue to support the development of new sites and the expansion of services.

• We expect to award 42 new access point awards, worth about $25 million, on August 1.
  
  
• And on September 1, we hope to announce grant recipients in three competitions. There will be $30 million for 160 service expansion grants, $10 million for 20 expanded medical capacity grants, and $2 million for 25 planning grants.

Jim (Macrae) tells me that the competition for these awards is fierce. HRSA has received:

• 600 applications for the service expansion awards – that's a ratio of almost four applications to every award;
  
  
• 250 applications for the new access point awards – a six-to-one ratio;
  
  
• 220 applications for the expanded medical capacity grants – an 11-to-one ratio; and
  
  
• 55 applications for the planning grants, about two to one.

To all of you who have sent in applications, I wish you good luck and good fortune. Jim is right: that's a fierce competition!

For FY 2009, which begins October 1, President Bush has proposed a $26 million increase for health centers, which would raise funding to just over $2 billion. The increase would fund up to 40 new health centers in high-poverty areas that currently have no health center sites and up to 25 planning grants to help community-based organizations in high-poverty areas win grants in future competitions.

Regarding what we are now calling “high-poverty area grants,” we heard the concerns that many groups had about the limitation of counties as a geographic area to target funds. We are as committed as ever to make sure that these new dollars go to the poorest and neediest areas. But in the future, we will be looking to target funds to the truly neediest communities, and we will not restrict that search to counties.

Staffing these new sites with sufficient numbers of health professionals remains a challenge. With that in mind, the President asked for $11 million in for the National Health Service Corps in FY 09 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 our determination at HRSA to expand Americans' access to oral health care. I won't relent until 100 percent of health center facilities provide preventive dental care!

Let me now turn to HRSA 's activities to improve quality, which are focused squarely on improving patient outcomes . We want our grantees to provide care that is equal to or better than in the health care system in general.

I'm sure you know that HRSA has selected its first set of Core Clinical Quality Performance and Improvement Measures. They are at the heart of aligning, tracking and improving the quality of direct health care for patients served by HRSA grantees.

The six new Core measures are:

• Childhood immunization rates;
• Entry into prenatal care;
• Low birth-weight babies;
• Percent of females with Pap tests;
• Diabetes control; and
• Control of high blood pressure.

These measures have already 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. As I said at the NACHC Policy and Issues meeting in Washington in March, 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 determine 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 all of 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.

Another HRSA-wide effort to improve performance, also led by our Center for Quality in partnership with our Office for Pharmacy Affairs, has brought together HRSA and dozens of partner organizations on a bold, new national Patient Safety and Pharmacy Collaborative. The new collaborative has three aims:

• Improve health outcomes;
• Improve patient safety; and
• Increase clinical pharmacy services.

This effort has been in the planning phase for the last year or two. The impetus for the collaborative grew out of a 1999 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 medications.

The collaborative also responded 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 asking representatives of all health care disciplines, at all levels, to work together in teams to spread our “best practices” around the country. You can learn more about the collaborative and how to get involved at the HRSA Patient Safety & Clinical Pharmacy Services Collaborative Web site.

At the same time HRSA is pushing to make sure our patients get the best available care, we're acting to help patients avoid the chronic illnesses that are so costly to individuals and to families. Specifically, we're launching a new push to stop smoking.

Five hundred and fifty health center grantees are involved in tobacco cessation programs to date. That's less than half, so obviously we can do much better.

The goals of Healthy People 2010 on tobacco use have not been met and almost half a million people die needlessly each year because they smoke tobacco, something scientists have known causes lung cancer for two generations! And we've all known in our guts that it's a killer for a lot longer than that. So we have to act.

HRSA is determined to do a better job of organizing our efforts and sending out a single message against tobacco use. So we've organized a Tobacco Cessation Committee, headed by our chief medical officer and director of our Office of Minority Health and Health Disparities.

The committee met for the first time earlier this year. They've already compiled information throughout HRSA on what our bureaus and offices are doing in tobacco cessation.  They're also collecting valuable resources from our sister HHS agencies.  We will make all of this information available on a new Web page on tobacco cessation that our grantees can use to create effective prevention programs, so look for that coming up.

Additionally, our Center for Quality is looking into the possibility of adding smoking cessation to the core clinical performance measures.

Let me conclude by thanking all of you for your energy and commitment to the underserved. I ask you to continue – and even accelerate – that dedication and resolve in the future.

I hope to see many of you again in late June for the Primary Health Care all-grantee meeting. It will be one of the first big meetings at the brand-new National Harbor complex across the Woodrow Wilson Bridge from Alexandria and a comprehensive agenda is being planned by Jim and his staff.

Thank you.

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