Testimony Statement by Marcia Brand, Ph.D., Associate Administrator Rural Health Policy Health Resources and Services Administration U.S. Department of Health and Human Services
on Addressing Healthcare Workforce Issues for the Future before Senate Committee on Health, Education, Labor and Pensions
Wednesday, February 13, 2008
Mr. Chairman and Members of the Committee: Thank you for the opportunity to submit this statement for the record on behalf of the Health Resources and Services Administration (HRSA) regarding the Health Professions Education programs carried out under Title VII of the Public Health Service Act. Health Professions Education Programs - Background The Federal government has a long history of involvement in health professions education. For more than 50 years, the Federal government has created and contributed to health professions education through a number of discretionary programs. Title VII health professions programs are intended to address national shortages of health care providers, facilitate the education and training of providers in underserved areas, and enhance the racial and ethnic diversity among healthcare providers. The Health Professions Education programs under Title VII of the Public Health Service Act were last reauthorized under the Health Professions Education Partnerships Act of 1998. To provide administrative flexibility, Congress consolidated more than 40 programs in existence at that time into seven clusters. Six of the clusters are under Title VII: 1) Training of minorities and disadvantaged professionals; 2) Training in primary care medicine and dentistry; 3) Interdisciplinary community-based linkages to establish training centers in remote areas; 4) Health professions workforce information and analysis; 5) Public health workforce development; and 6) Student loans (funding for schools to make student loans). The seventh cluster, Nursing Workforce Development, is administered under Title VIII of the Public Health Service Act. The 1998 reauthorization also made behavioral mental health providers eligible for participation in certain Title VII programs. A key goal of the 1998 reauthorization was to better target resources to address national health workforce training, health professions maldistribution, and program duplication. Today there are over 40 health professions programs that use a wide range of disparate strategies to attempt to address workforce issues. These strategies include awarding funds to schools so that they can make loans and scholarships to students, supporting the development of curricula, fostering linkages between educational institutions and the communities they serve, and targeting high school students to pursue health professions education. Maximizing Federal Investment Federal involvement in the health professions has focused on investment in projects that could be self-sustaining in the long-term. These projects included grants for development of clinical training sites where health professionals learn to serve vulnerable populations, community-oriented primary care curriculum development, and Federal grants to schools to make loans to health professions students. Recent Administration budget requests including the President’s FY 2009 Budget have proposed the reduction or elimination of activities that have demonstrated no impact on the placement of health professionals in underserved areas and invests taxpayer dollars into direct healthcare service delivery. The President’s FY 2009 Budget supports the placement of more doctors, nurses and other health care professionals in the regions of the country that face shortages. We believe the best use of funding is to provide direct care through programs such as the National Health Service Corps (NHSC), and to address the most critical shortages, such as the nursing shortage, through most of the Nursing Workforce Development programs and through the Nursing Loan Repayment and Scholarship programs. In addition, many of the health professions education programs have other sources of Federal funding such as the Department of Education. For example, the Federal Pell Grant Program provides need-based grants to low-income undergraduate students. The Department of Education also operates the Federal Family Education Loan program and the William D. Ford Federal Direct Loan program for individuals in graduate and undergraduate programs. Students can use these grants and loans for nursing baccalaureate programs, and other health professions programs. Indeed, according to the Department of Education, 37 percent of undergraduates majoring in health professions and related sciences receive Pell Grants and a similar percentage receives student loans. Private sector funding is also available for health professions education programs. For example, the Robert Wood Johnson Foundation established a national program, Partnerships for Training: Regional Education Systems for Nurse Practitioners, Certified Nurse-Midwives and Physician Assistants. This program developed eight regional education systems to increase the number of primary care providers in federally designated Medically Underserved Areas of the United States. These regional university-community partnerships used distance education (e.g., Web- and interactive video-based courses) to educate nurse practitioner, certified nurse-midwife and physician assistant students in underserved areas. Many States have also created programs that imitate the success of the NHSC in directing personnel to health professions shortage areas. These State-sponsored loan repayment programs create partnerships with local communities, the NHSC, and other agencies within the Federal government. Some State programs operate alone and offer health professions financial incentives to practice in underserved areas. Rather than continue to direct funds to programs with alternative sources of private sector, Federal and State funding, we feel it best to focus our efforts on those programs where we have demonstrated success and a more immediate and direct impact on improving access to health care. Evaluations of the Title VII programs have also raised questions about the impact of Federal funding for these activities. The Government Accountability Office (GAO) found in 1994 and 1997 that the role of the Title VII Health Professions programs in improving access was unclear. The large number of Title VII program objectives made evaluating the programs’ impacts difficult. In a 2006 report, GAO found that action was still needed to successfully measure the impact of Title VII programs. HRSA agrees with the need for clear, relevant goals and performance measures backed by timely and complete data, and has been working to improve its performance measures. While the Title VII programs have been reporting data on annual measures pursuant to the Government Performance and Results Act and the Program Assessment Rating Tool (PART), the relationship between the annual activities and the long term goals has been unclear, and the data are insufficient to demonstrate progress toward the long term goals. Therefore, HRSA recently secured approval from the Office of Management and Budget for a new data collection instument for grantees. We began collecting data from grantees on more dimensions of the program at the end of 2007. For instance, we are now collecting data on the percentage of students that are being trained for a career in primary care and the percentage of students that receive a portion of their clinical training in a non-hospital, primary care setting. Studies have shown that students who receive some training in primary care are more likely to go on to practice in primary care. Future Direction of the Federal Investment in the Healthcare Workforce Past Federal investment in the Health Professions programs has contributed to a foundation that State and local governments, academic institutions and the private sector can build on to address current workforce issues. To maximize the impact of our past support of these programs, the Federal government must leverage cooperation from the private sector and State and local governments. We must address the health workforce issues with an innovative approach -- partnerships between the private sector, academic institutions and the communities they serve will be critical to necessary workforce development. A Federal approach is not the best strategy to address the many diverse workforce needs of the population. Those who live and work in the thousands of communities around the Nation are in a better position to tailor health workforce strategies to their specific needs. HRSA continues to support the Title VII’s sister programs --- the National Health Service Corps, the Nursing Loan Repayment and Scholarship Programs, and the majority of Nursing Workforce Development Programs. As a significant source of highly qualified clinicians for the Health Center Program, as well as other safety net providers, the NHSC is building on its success in increasing health care access to residents of Health Professional Shortage Areas, removing barriers to care, and improving the quality of care to these underserved populations. The Nursing Education Loan Repayment Program is a financial incentive program under which individual registered nurses commit to work full time in a health care facility with a critical shortage of nurses in return for repayment of qualifying nurse educational loans. This program provides nurses who can immediately begin practicing in a health care facility with a critical shortage of nurses. The Nurse Scholarship Program offers scholarships to individuals attending accredited schools of nursing in exchange for a service commitment payback (after graduation) of at least two years in health care facilities with a critical shortage of nurses. This program reduces the financial barrier to nursing education for all levels of professional nursing students, and increases the pipeline supply of nurses. HRSA’s Nursing Workforce Development programs continue to encourage commitments from nurses and nursing students to practice in shortage areas. These programs facilitate flexibility in meeting local and regional nursing needs such as enhancing career ladder programs, and supporting internships and residency programs to facilitate the transition from student to graduate as well as retention initiatives to keep experienced nurses in the workforce. As the largest source of Federal funding for nursing education, the Nursing Workforce Development programs provided loan, scholarship, and programmatic support to more than 61,000 student nurses and nurses in FY 2007. I would like to describe some of the Nursing Workforce Development programs. The Nurse Education, Practice and Retention program awards funding and enters into contracts with eligible entities for projects that focus on three priority areas: education, practice and retention. Some of the specific purposes include: expanding enrollment in baccalaureate nursing programs; creating internships and residency programs; establishing or expanding nursing practice arrangements; providing care for underserved populations and other high risk groups; promoting advancement for nursing personnel through career ladder programs; and improving the retention of nurses and enhancing patient care related to nursing activities. The Nurse Education, Practice and Retention program helps to enhance the educational mix and utilization of the nursing workforce by supporting innovative approaches to shape the nursing workforce. Funding under this program facilitates flexibility in meeting local and regional nursing needs. The Nursing Workforce Diversity program awards grants and enters into contracts with eligible entities to meet the costs of projects designed to increase nursing education opportunities for individuals from disadvantaged backgrounds by providing student scholarships or stipends, pre-entry preparation and retention activities. Historically, this program has played a significant role in enhancing the retention and graduation rates of minority and disadvantaged students through counseling, tutoring and mentoring services designed to assist students in enrolling and completing nursing education programs. Nursing schools that receive funding for Nursing Workforce Diversity programs have enrollments of about 73 percent from minority groups, compared to a national average of 24 percent. The program’s recruitment and retention activities targeting high school students and pre-nursing students have been successful in recruiting disadvantaged and minority young people into nursing. The Nurse Faculty Loan Program works to increase the number of nursing faculty by supporting the development of a student loan fund in schools of nursing to increase the number of qualified nursing faculty. The Department of Health and Human Services enters into an agreement with schools of nursing to establish and operate revolving student loan funds. Students may receive loans up to $30,000 per year for a maximum of 5 years. The program has a cancellation provision for up to 85 percent of loans for recipients working full-time as nursing faculty for a period of four years. Twenty percent of the principal and interest may be canceled for each of the first second and third years. In the fourth year, 25 percent may be canceled with full-time employment as a nursing faculty. This encourages nurses to choose an academic career, an important incentive in an environment with low levels of nurse faculty that too often results in students being turned away from nursing schools. The Comprehensive Geriatric Education program prepares nursing personnel to care for the aging population, the fastest growing demographic group today. The program provides grants to develop and implement initiatives to train and educate individuals providing care for the elderly. Specific uses of the grant funding include: curricula development and dissemination, training for faculty members in geriatrics and continuing education for individuals providing geriatric care. The funding helps prepare nurses aides, licensed practical nurses and registered nurses as well as faculty with expertise in the care of the elderly. Conclusion The Title VII Health Professions programs have a long history of Federal involvement, and past contributions have reached States and communities across the Nation. Private sector, State and local solutions will better address the issues facing the health professions workforce and allow HRSA to focus on providing funding for direct patient care. I’d like to thank the Committee for the opportunity to submit this statement for the record and for your continued interest in addressing the health workforce issues facing the Nation. Last revised: August 29,2008 |