Remarks to the Health Policy Institute of Ohio

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U.S. Department of Health & Human Services
Health Resources and Services Administration
HRSA Press Office: (301) 443-3376


By HRSA Administrator Mary K. Wakefield

December 5, 2012
Columbus, OH

Thank you so much for the invitation to join you today – I am really pleased to be here in Columbus to talk about what we at HRSA consider a very high priority and focus: the health care workforce.  As you heard, I run HRSA, the federal agency responsible for helping assure access to quality health care for all Americans.  Some people know us for our safety net programs and the work we do on the delivery side of health care.

But I understand – and the Secretary and the President do, too – that access to quality health care is tied to insurance coverage – and to an available, highly competent health care workforce.  And that is why we are dedicating so much of our time and attention to ensure that the federal government is doing its part in strengthening the supply of health professionals.

And it is a particular privilege to be talking about workforce here in Ohio.  Your state has been a leader in health professions education and, I think, in many ways is a model for the nation.  This very meeting, dedicated to the “four D’s” of the health care workforce – distribution, diversity, demographics and demand – is another example of your leadership on these issues, your recognition of the multiple dimensions and inherent complexity of the issue – and your commitment to building a strong health workforce that better meets your health care needs.  

Assuring a well-prepared and diverse workforce and assuring that they are well distributed and work consistent with their education and skills clearly requires collaboration among professions, between educational institutions and the service delivery system, between the public and private sector, and between state and federal governments.  Today’s meeting is an important opportunity to continue to build this collaboration for Ohio.

With our time here today, I’m going to cover a few topics that I think may be important to informing your workforce efforts – even as they’re important to informing ours at the federal level.  First, I’d like to talk about the demand for the health care workforce and how we’re addressing that need right here in Ohio, in partnership with you.  Then, three ways that HRSA seeks to influence and shape the health care workforce – by focusing on primary care, by increasing diversity, and by improving the efficiency of the workforce. Finally, I’d like to add a fifth “d” – data.  Historically, workforce decisions have often been made in a data-free zone and so we’re fully engaged in activity at HRSA that’s addressing that gap.  Then I’d be happy to take your questions.

Well, what are we facing?  First of all, the bulk of the demand for health care providers revolves around an expanding U.S. population and an aging demographic.  Those two factors are very significant in terms of driving demand.  Additionally, the ACA brings more people to the health care table for services; it also brings resources both to train more clinicians and deploy them more effectively and efficiently – but more about that later.

So, the first question isn’t: “Do we need providers who deliver primary care services?”  Sure we do.  We’ll have a preliminary HRSA analysis on supply and demand in this area due out by the beginning of next year that quantifies the need.  And, in fact, HRSA has been investing resources to address the need for these services even before the passage of the Affordable Care Act.  But today, we are working on implementing more than 60 provisions of that law – many of them focused on areas and populations of greatest need and many of them directly related to health care workforce production and distribution.

To illustrate some of the ACA’s workforce-related investments, let me take a minute and talk about some that have been or are being made right here in the Buckeye State.

HRSA currently is investing $36 million through more than 100 active workforce training grants in over 25 sites in Ohio, including in colleges, universities and clinical settings.  For example, we are funding primary care programs at Ohio State for the training of primary care medical residents and advanced practice nurses.  We also support training programs in medicine, nursing, public health, faculty development, and geriatric care at many other schools and hospitals, and institutions, including the University of Cincinnati, Northeast Ohio Medical University, Case Western Reserve, the University of Toledo, Marietta College, and Children’s Hospital Medical Center in Cincinnati, just to name a few.

And we’re very excited about an Advanced Nursing Education Traineeship grant we awarded to Ohio University’s School of Nursing, where they are working with regional organizations to help returning military veterans build careers in health care. Specifically, the School is working with the regional VA Medical Center and the state workforce investment board to identify unemployed vets and provide education and career counseling to promote career pathways into nursing.  

Recognizing the importance of frontline health care – often provided by home health aides – I am so pleased that we’ve invested in an effort by the American Red Cross of Greater Cleveland under our Nursing Assistant and Home Health Aide program.  This effort supports the development and implementation of a competency-based curriculum to train nursing assistants. HRSA was able to fund this work through a 2010 grant and then again in 2012, expanding the program to include enhanced skills in restorative care and, really importantly, in care coordination.

In addition, Ohio is one of 23 states that won ACA-funded grants to plan for their future health workforce needs by developing comprehensive health workforce plans.  These plans – that HRSA awarded with ACA funds – had to be developed in partnership with key stakeholders such as health care employers, labor organizations, schools of higher education, state education agencies and philanthropies.  The Ohio Department of Health’s Primary Care Office was awarded this grant.  From it, the Office has been able to determine baseline supply for primary care providers, identify other high-demand occupations, and target federal, state and private resources to assist in recruiting and educating skilled health care providers.

And I’m told that the Ohio Department of Health also has taken the lead on health workforce development by working to establish a Statewide Primary Health Care Workforce Data System to centralize its ability to track health professionals and students moving into practice.  And I’m encouraged to hear that Ohio is working to implement strategies to recruit and retain students and professionals in primary care, including youth programs to prepare them for possible careers in health fields.  

So I mean it when I say that Ohio is certainly to be complimented on your many programs and initiatives related to the health workforce.  

Well, let me shift focus a bit to describe in greater detail HRSA’s efforts to strengthen access to primary care, improve the distribution of primary care providers, and increase the diversity of the health workforce.  This will help set up a discussion of how we might work together to ensure a health workforce of adequate size, diversity and distribution to assure access for all Ohioans. I’ll share with you some of what we’ve been doing to prepare for the increasing demand for primary care services – even as we near full implementation of the Affordable Care Act.

To help ensure access to primary care, HRSA has markedly broadened efforts to increase the supply of primary care providers and also to support their expanded use.  

Using ACA resources, HRSA has invested in grants to expand overall enrollment in training programs in primary care professions, including physicians, nurse practitioners, physician assistants, and mental/behavioral health professionals.  For example, through one ACA funding stream, we expect to have trained by 2015 an additional 500 primary care physicians; 600 primary care advanced practice nurses; 600 PAs; and 200 more mental/behavioral health providers.  

Also, through ongoing grant programs to health professions schools, we have redirected our focus to boost the training of primary care providers.  These grant programs support, for example, traineeships for advanced nursing students in primary care and scholarships for disadvantaged students, with stronger priority for those in primary care professions.  Two Ohio schools of nursing – at Ohio University and Wright State University – are recipients of advanced nursing traineeship grants.

In addition, the ACA stood up a new Teaching Health Center Program which provides payments to support expanded medical residency training in community-based training sites.  The focus is sharply on strengthening primary care training in community settings, where people frankly tend to get most of their health care.  You see the emphasis shifted a bit to support this focus, rather than just hospital-based care.  And research indicates that teaching health centers produce primary care physicians who are three to four times more likely to provide care for underserved populations in community settings than physicians primarily trained in hospital settings.  So, we’re not just focused on preparing more providers, we’re also focused on harnessing training opportunities that reflect important dimensions.  The Teaching Health Center program currently supports 137 new primary care medical residents, and in FY 2013 we plan to more than double that number.

However, we also know that projections of primary care shortages do not capture very important differences in the distribution of providers across geographic areas.  In Ohio, for example, you have varied distribution.  You have adequate numbers of primary care providers in some communities, while other parts of the state are designated as Health Professional Shortage Areas, or HPSAs.

In HPSAs – defined as communities that are medically underserved with respect to primary care, dental, and/or mental health – recruiting and retaining providers at local, community levels can be a constant challenge.

In our National Health Service Corps program – which pays down the student loans of participating clinicians – we’ve made higher loan repayments available to health care professionals who agree to work in the neediest areas across the nation – both rural and urban.  We wanted to make sure that those valuable human resources are distributed to the communities that need them the most.  Higher payments give clinicians a compelling incentive to practice in those areas.

That policy change has resulted in a 38 percent increase in NHSC professionals choosing to practice in these needy areas.  Additionally, we made Critical Access Hospitals eligible to become NHSC-approved sites; now 29 NHSC clinicians are practicing in these settings.  That’s up from zero before we altered the policy – and it will continue to increase.

Ohio has been a major beneficiary of the ACA’s expansion of the NHSC.  Today there are 178 NHSC clinicians in Ohio, compared with just 69 in 2008.  In Ohio, those NHSC clinicians include 56 physicians; 43 mental and behavioral health providers; 41 nurse practitioners; 30 dental health providers; 7 physician assistants; and one certified nurse midwife.  And of those 178 NHSC clinicians in Ohio, 140 are ACA-funded, as of September 30.  Talk about a big ACA impact!

Across the country, thanks to Obama Administration investments, the number of NHSC clinicians is at an all-time high, rising from 3,600 in 2008 to almost 10,000 in 2012.  So the NHSC is a program that boosts the supply of primary care practitioners and that distributes them more equitably across America.

To continue our efforts to improve distribution, HRSA also is expanding training in rural areas.  Because of the much higher proportion of primary care shortage areas in rural compared to urban areas, HRSA supports grants focused on expanding rural residency training.  Rural Training Tracks are family medicine residency programs in which the resident spends one year in a tertiary care center and two years in a rural practice site.  HRSA supports 23 RTT residency programs and works to increase the number of RTTs nationally.  We think these are important investments, in particular since studies have shown that more than 60 percent of these residents stay to practice in rural areas.  So this program has proven value in retaining health care professionals in rural communities.

Now let me take you from distribution to another “d” – and that’s HRSA’s efforts to promote diversity in the health care workforce.  Many of our health professions programs target assistance to students who are from underrepresented minorities or have disadvantaged backgrounds – typically, economically disadvantaged.

In 2011, 58 percent of graduates from HRSA’s major workforce training programs – which include physicians, physician assistants and nurses – were underrepresented minorities or from low-income disadvantaged backgrounds, or both.

We continue to look for every opportunity to strengthen our programs to support minority students and students from other disadvantaged backgrounds, and we’ve made policy changes over the past couple of years to make sure our grant funds fully support the Obama Administration’s diversity efforts.  This is also important because it helps with culturally competent care and also increases the likelihood of practicing in underserved communities.

The distribution program I was talking about a minute ago – the NHSC – also impacts diversity.  For example, diversity among NHSC clinicians is greater than that in the overall health professions workforce.  In FY 2012, for example, African American physicians totaled 17 percent of NHSC physicians, far exceeding their 6.3 percent share in the national physician workforce.  And for Hispanics, nationally they represent only about 5 percent of the national physician workforce, but they’re 13 percent of the Corps’ 2,150 physicians.

I’ve talked so far mostly about numbers in terms of demand and supply, but we’ll never meet demand and improve care quality simply by training more health care workers and enhancing their diversity.  We need them to work more effectively and – where possible – more efficiently.

A recent IOM report noted that over half of the $750 billion cited as unnecessary costs spent on health care could be reduced and potentially eliminated through more effectively delivered care, including through collaboration across teams of clinicians and patients.

So HRSA has several initiatives that focus on educating health professionals to work as part of a team.  Many of HRSA’s grant programs now require interprofessional training and collaborative practice to promote high-functioning, team-based models of care.  In addition, several of our primary care training programs also call for joint learning and experience with public health. That alignment is important to designing delivery systems that are accountable both to meeting the needs of individual patients and to meeting the needs of populations and communities.  

And we are providing technical assistance to promote interprofessional education and practice.  We recently funded a Coordinating Center for Interprofessional Education and Collaborative Practice that provides an infrastructure for expertise and support to enhance interprofessional education among health professions and provider organizations across the U.S. – particularly in medically underserved areas.  The coordinating center will work to strengthen high-quality, coordinated, team-based care that is informed by interprofessional education and best-practice models.  Stemming from collaborative efforts between HRSA and four private foundations, an additional $8 million from foundations will support the federal investment in the Center.

What do we want to see from these efforts?  We want to build an environment in which each member of a health care team practices in a way that maximizes the use of his or her knowledge and skill set.  This will enhance the efficient use of health care providers and also improve the seamless coordination of care.

Across the nation, given limited resources, the need to assure access to care is leading efforts to make more effective use of our existing health workforce – including assistive personnel as well as licensed health professionals.

These efforts are exciting, because they offer a path forward toward cost-effective, quality care and of more satisfying health careers.  This is an area in which we all need to be open and to learn from each other.

Finally, the ACA also is working for Ohio and with states across the nation through its creation of the National Center for Healthcare Workforce Analysis, an important source of health professions data.

The National Center is housed in HRSA and it has been given the task of improving our ability to identify current and future priority health workforce needs.  In addition to improving data collection and analysis, the National Center is charged with projecting national health workforce supply and demand, and disseminating data and information to help inform decision-making at all levels of government.

We hope to be able to release in the near future several reports from the National Center that will be of great interest and relevance to you and your work:

  • One is a report on the primary care workforce that projects future supply and demand for primary care physicians, nurse practitioners and physician assistants through 2020.
  • Another report will track trends in the nursing supply and include descriptive data on the nursing workforce, such as demographic characteristics, education and practice, and distribution by state.
  • A third study on diversity in the health professions will include data on more than 30 health professions by race, ethnicity and sex of practitioners and new graduates.  It also examines data on faculty diversity for some of the professions.
  • A fourth project will provide a comprehensive resource on the supply, distribution, education and practice characteristics for 60 health professions.  Of special interest to all of you, an accompanying database will include data on these occupations by state.

Another product of the National Center that some of you likely already know about is its work to build a Minimum Data Set on the health care workforce that will be comparable across time periods, professions, and states.  We don’t have an MDS now, due to the variability across states and professions regarding data collection.  But it’s something we badly need, since accurate, comparable data are critical to inform state and federal policymakers.  So the Center is working with existing efforts, especially those of state licensure boards, to build the MDS.

The MDS will give us information over a wide range of professions on what practitioners do  – such as patient care, research or specialty – how many hours of week they work, where they practice, and in what type of setting.

I understand that Ohio has already begun MDS efforts with your physicians, and that these efforts serve as a model for other states considering developing or adopting a minimum data set for their health professions.  I just want to say that HRSA strongly supports states collecting workforce data as part of the licensure process – as permitted by Ohio statute – and that states collect data consistent with the recommendations of their national association of licensure boards.

For our part, at the federal level, the MDS will give us better ability to target federal programs and resources; a clearer understanding of national supply and demand across the health workforce; greater knowledge of the relative supply across regions, states and localities; and an increased ability to provide technical assistance to states.

And in states, policymakers will be able to compare their states to others regarding the supply and distribution of health care workers.  And it will provide information to guide state policy development and help state educational institutions guide program investments and enrollment.

Well, that wraps up my overview of HRSA’s work to strengthen the supply, distribution, competencies and diversity of health care workers capable of meeting the demands of a growing, aging and more diverse America.

All of us at HRSA look forward to working with you to capitalize on opportunities and to address the challenges we face in building a healthier nation through a strong health care workforce.

Date Last Reviewed:  April 2017