[Senate Hearing 107-626]
[From the U.S. Government Publishing Office]
S. Hrg. 107-626
WHO WILL CARE FOR US?: THE LOOMING
CRISIS OF HEALTH WORKFORCE SHORTAGES
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
ON
EXAMINING THE LOOMING CRISIS OF HEALTH CARE WORKER SHORTAGE
__________
JULY 15, 2002, WARWICK, RI
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
U. S. GOVERNMENT PRINTING OFFICE
81-373 WASHINGTON : 2003
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut JUDD GREGG, New Hampshire
TOM HARKIN, Iowa BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington PAT ROBERTS, Kansas
JACK REED, Rhode Island SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York MIKE DeWINE, Ohio
J. Michael Myers, Staff Director and Chief Counsel
Townsend Lange McNitt, Minority Staff Director
C O N T E N T S
----------
STATEMENTS
Monday, July 15, 2002
Page
Reed, Hon. Jack, a U.S. Senator from the State of Rhode Island... 1
Sepe, Thomas D., President, Community College of Rhode Island.... 1
Fogarty, Hon. Charles J., Lieutenant Governor, State of Rhode
Island......................................................... 2
Prepared statement........................................... 5
Chafee, Hon. Lincoln, a U.S. Senator from the State of Rhode
Island......................................................... 10
Langevin, Hon. James, a Representative in Congress from the State
of Rhode Island................................................ 10
King, Roderick K., Director, Boston Field Office, Region I (New
England), Health Resources and Services Administration......... 13
Prepared statement........................................... 16
Amaral, Joseph, M.D., President and Chief Executive Officer,
Rhode Island Hospital,......................................... 18
Prepared statement........................................... 21
Besdine, Richard W., M.D., FACP, Interim Dean, Brown Medical
School......................................................... 23
Prepared statement........................................... 25
Roberts, Nancy, MSN, RN, President and Chief Executive Officer,
Care New England Home Health................................... 27
Prepared statement........................................... 29
Owens, Norma J., Pharm.D., Professor of Pharmacy, Department of
Pharmacy Practice, University of Rhode Island.................. 32
Prepared statement........................................... 34
McKinney, William Lynn, Dean, College of Human Science and
Services, University of Rhode Island........................... 39
Prepared statement........................................... 41
McGarry, Maureen E., RN, Ph.D., NCC, Dean of Health and
Rehabilitative Services, CCRI-Flanagan Campus.................. 42
Prepared statement........................................... 44
Schepps, Barbara, M.D., Director, Anne C. Pappas Center for
Breast Imaging, Rhode Island Hospital; Professor (Clinical),
Brown University Medical School................................ 48
Prepared statement........................................... 50
McNulty, James, President, National Alliance for the Mentally
Ill,........................................................... 53
Prepared statement........................................... 55
Laprade, Wendy, RN, Staff Nurse, Women and Infants Hospital...... 56
Prepared statement........................................... 63
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:...............
Senator Reed................................................. 72
``Washington Post Highlights Critical Shortage of
Pharmacists''.............................................. 73
The Pharmacist Education Aid Act of 2001..................... 76
Barbara Rayner............................................... 77
Patricia Ryan Recupero, M.D.................................. 78
Jane Williams................................................ 79
WHO WILL CARE FOR US?:
THE LOOMING CRISIS OF HEALTH
WORKFORCE SHORTAGES
----------
MONDAY, JULY 15, 2002
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, D.C.
The committee met, pursuant to notice, at 11 a.m., in the
Presentation Room, fourth floor, Community College of Rhode
Island, Warwick, RI, Senator Reed, presiding.
Present: Senators Reed and Chafee.
Opening Statement of Senator Reed
Senator Reed. Thank you for joining us this morning. We
have a lot to do, and I'll give everyone fair notice that I
have to catch a 2:00 flight to DC. for votes this afternoon, so
about 1:00 we are going to be winding up, and if I run out the
door, it is nothing personal, so forgive me.
I would like now to thank and recognize President Tom Sepe
from the Community College of Rhode Island for his hospitality
and his presence here. Thank you.
[The prepared statement of Senator Reed follows:]
STATEMENT OF THOMAS D. SEPE, PRESIDENT,
COMMUNITY COLLEGE OF RHODE ISLAND
Mr. Sepe. Thank you, Senator, and welcome everyone. My
position back here is, I'll let you know, I will be right
behind you 100 percent.
It is really important to have a meeting like we have
today. We all know this is literally a crisis that we all face,
and CCRI is the largest single provider of healthcare workers,
and certainly feel a special obligation to respond to this
crisis.
We know that it is not the quality of our graduates that we
at higher education are producing, but it is a question of
quantity that we are producing for the field.
It is also very important that we recognize the fact that
we have had increased cooperation and collaboration among the
partners, not only within higher education, but also in the
health care providers and education, as teams.
I would suggest to you that one of the issues that we need
to face in dealing with this issue is, one, looking at the
education-work, education-work, education-work cycle.
Now, there is a terminal process where students come into
an educational system and go to work and that is the end of it.
We know that people in today's life cycle in and out of work,
in and out of education throughout their whole life, but my
suggestion to you today is we also consider this as a cycle, as
a system of higher education and work, more closely integrated
than we thought in the past.
Part of the system I'm talking about, we need to improve
the way we allow entry, reentry, the way we upgrade and promote
people who do have educational credentials.
We also need to improve the number and the motivation and
the educational preparedness of students coming out of our high
schools for our educational systems. We can only introduce
qualified graduates through higher education if the resources
coming to us are sufficient.
Last, certainly resources cannot be avoided. We cannot
throw money at a problem and make it go away, but certainly the
kind of problem we are talking about is going to require
financial and human resources to increase the number of
students going through the pipeline that we have created
between education and the workplace.
As an example, every nursing student that we enroll costs
us $1,000 more than the tuition and State aid that we have
received. So to increase the pipeline for CCRI is to make me
find a profit center somewhere else within my organization, to
supplement that cost or to get outside resources. Costs of
educating individuals into this field are not inexpensive by
its very nature, so we cannot avoid the issue of resources, for
that resource alone is certainly not the issue.
There is no simple answer. It is a complex issue, and the
assemblage we have today I believe is the basis for our dialog
which should address this issue, and, hopefully, we will look
forward to some good outcomes today to start us on the track.
It is important for us to begin to talk as a system, not as
individual components. It is important today, I think, and
Senator Reed, who can appreciate your initiative for bringing
us together for this important topic.
It is now my pleasure to welcome and introduce Charles
Fogarty, Lieutenant Governor, who himself has done a great deal
in this field and to follow-up the program.
Charles.
STATEMENT OF HON. CHARLES J. FOGARTY, LIEUTENANT GOVERNOR,
STATE OF RHODE ISLAND
Mr. Fogarty. Thank you very much. Thank you very much,
President Sepe, Senator Reed, Senator Chafee and Congressman
Langevin and distinguished guests.
Thank you, Senator Reed, for your concerns about this
crucial issue and for hosting today's field hearing in Rhode
Island. I am pleased to share some of my thoughts about how the
issue impacts our State and some of the actions we have taken
to date to address it. It is noteworthy that today's hearing is
here at CCRI, an institution with a long and proud history of
educating and training so many of our health care professionals
and para-professionals.
The health care worker shortage is particularly important
here in Rhode Island for several reasons:
First, as we all know, as we grow older we tend to need and
use more health care services. The Rhode Island population is
older on average than the rest of the country. The 2000 Census
showed that 14.5 percent of the Rhode Island population is age
65 and older as compared to the national average of 12.4
percent. But of even greater importance is the fact that the
older cohort of our senior population--those 85 and older--are
the fastest growing. The number of persons in the State age 85-
plus is projected to increase by 1.2 percent annually between
2001 and 2006. The implications of these demographics for our
health care workforce are enormous. We need to assess our
capacity to meet their health care needs and the adequacy of
our education and training programs to supply the array of
necessary workers, from geriatricians, to nurses, dentists,
pharmacists, therapists and technicians to direct ``hands-on''
long-term care staff.
A second reason that the adequacy of the health care
workforce is so important for our State is the impact that
health care has on our economy. As noted in the 2001 Annual
Report of the Governor's Advisory Council on Health (GACH),
slightly more than 9 percent of Rhode Islanders are working in
the health care industry. This is significantly higher than the
U.S. average of 6.9 percent and higher than our neighboring
States of Massachusetts and Connecticut. There are efforts
underway to position Rhode Island hospitals and other health
service providers as regional leaders in offering expert and
quality health care. It is imperative, therefore, that we take
steps to ensure an adequate number of well-trained health
professionals as well as non-skilled health workers to both
ensure that our residents are able to receive the highest
quality care by in-state providers and to take advantage of
opportunities to market our health care services beyond our
borders.
I know you will be hearing today from many experts who will
be sharing information about supply and educational and
training issues relating to specific health professions and I
look forward to listening to their comments and learning from
them.
I would like to take a few minutes to talk about one
particular area--nursing--that I have been working on and some
of the actions we have taken at the State level to address
critical shortage issues in this area.
Let me tell you briefly about some of the steps we have
taken in our State to address the work shortage.
Last year, hospitals in Rhode Island had over 400 budgeted
vacant nursing positions. Yes, the number of enrollments in
nursing schools dropped 17 percent between 1998 and 2000, and
the number of new persons taking the RN licensing exam dropped
from 523 in 1996 to only 294 in 2000. And all this is happening
at the same time that our nursing population is aging. The
average age of Rhode Island licensed nurses was 47 years, which
in my book is pretty young, 2 years higher than the national
average of 45.
To help deal with this problem have worked with the Rhode
Island Student Loan Authority and the Hospital Association of
Rhode Island and various nursing organizations of our State to
create a nursing program for 2001, which the legislature
passed. This program forgives the interest on student loans for
nurses who practice in Rhode Island licensed health care
facilities. It provides up to 250 of those loans each and every
year.
In talking to Ed Freeland before this meeting I am told
that there's been a significant number of inquiries to the
Rhode Island Student Loan program regarding this program, and
there's been a slight decrease in the number of vacant
positions. So this is the first step. I think the State and
Federal Government must do more to provide financial assistance
as well as incentives to recruit people to this vital field.
In fact, Senator Reed, I want to recognize you for your
assistance on this issue to the Federal Government.
As Chairman of the State Long-Term Care Council, I am
particularly concerned about a long-term care workforce.
Last year our Council issued a fairly comprehensive report
showing the dimensions of this crisis. An increase in the CNA
vacancy rate of 5 percent in 1997 to almost 12 percent in 1999
and in the turnover rate going from 59.2 percent in 1997 to
82.6 percent in 1999. The question that comes out of all of
this is how do we guarantee quality health care for those in
need with figures like that.
Our Council reported ten recommendations to deal with this
issue, including an appropriation of approximately $16 million
to fund a direct care worker pass-through program for long-term
care providers.
Although we were not able to secure the entire amount of
the recommended funding for the compensation pass-through, $4.5
million was provided for nursing homes to increase staff
compensation or staffing and 3 percent increase in
reimbursement for other providers to be used for staff
compensation. We do not have formal data on what effect these
pass-through funds have had, but we do have anecdotal reports
that in some instances wages for CNA's were increased by as
much as $1.50 per hour, that the use of nursing pools to
adequately staff nursing homes has decreased and that worker
retention, but not recruitments, has improved for home care
providers. In the meantime, reports are that the long-term care
sector is experiencing increasing shortages of professional
nursing staff with reported vacancy rates of 18 percent.
In closing, I would like to note two innovative projects
initiated by State government to address the health care
workforce. The first is a Health Care Labor Market Project to
be conducted by the University of Rhode Island with a small
grant from the State Department of Human Services. This project
will help us address data gaps in understanding our health care
labor market. It will analyze factors determining health care
labor demand and supply and make suggestions for improving data
and future research.
The second is the new opportunities for mature workers
project initiated by the Department of Elderly Affairs. Under a
coalition of Federal Title V Senior Community Service
Employment Programs and long-term-care providers, mature
workers will be recruited, trained and placed in a variety of
para-professional and service positions and long-term care
settings. We believe these projects have significant potential.
However, given the severe fiscal constraints faced by the
State, funding to implement innovative State projects that seek
to address the health care workforce shortage is limited. So I
would encourage the Committee to consider providing Federal
grant opportunities to the States to encourage them to design
and implement more programs such as these and to fund
recommendations such as those outlined in our Council's report
on the CNA crisis.
Finally, I want to emphasize the importance in adequate
funding for Medicare and Medicaid to ensure that we can provide
compensation levels that retain persons for the workforce.
Once again, Senator Reed, Senator Chafee, Congressman
Langevin, thank you for conducting this important hearing and
we look forward to working with you in the years ahead to
address this issue.
[The prepared statement of Lt. Gov. Charles J. Fogarty
follows:]
Prepared Statement of Charles J. Fogarty
Thank you, Senator Reed, for your concerns about this crucial issue
and for hosting today's field hearing in Rhode Island. I am pleased to
share some of my thoughts about how the issue impacts our State and
some of the actions we have taken to date to address it. It is
noteworthy that today's hearing is here at CCRI, an institution with a
long and proud history of educating and training so many of our health
care professionals and para-professionals.
The healthcare worker shortage is particularly important here in
Rhode Island for several reasons.
First, as we all know, as we grow older we tend to need and use
more healthcare services. The Rhode Island population is older on
average than the rest of the country. The 2000 census showed that 14.5
percent of the Rhode Island population is age 65 and older as compared
to the national average of 12.4 percent. But of even greater importance
is the fact that the older cohort of our senior population--those age
85 and older--are the fastest growing. The number of persons in the
State age 85-plus is projected to increase by 1.2 percent annually
between 2001 and 2006. The implications of these demographics for our
health care workforce are enormous. We need to assess our capacity to
meet their health care needs and the adequacy of our education and
training programs to supply the array of necessary workers--from
geriatricians, to nurses, dentists, pharmacists, therapists and
technicians to direct ``hands-on'' long-term care staff.
A second reason that the adequacy of the healthcare workforce is so
important for our State is the impact that health care has on our
economy. As noted in the 2001 Annual Report of the Governor's Advisory
Council on Health (GACH), slightly more than 9 percent of Rhode
Islanders are working in the health care industry. This in
significantly higher than the U.S. average of 6.9 percent and higher
than our neighboring States of Massachusetts and Connecticut. There are
efforts underway to position Rhode Island hospitals and other health
service providers as regional leaders in offering expert and quality
health care. It is imperative, therefore, that we take steps to ensure
an adequate number of well-trained health professionals as well as non-
skilled health workers to both ensure that our residents are able to
receive the highest quality care by in-state providers and to take
advantage of opportunities to market our healthcare services beyond our
borders.
I know you will be hearing today from many experts who will be
sharing information about supply and educational and training issues
relating to specific health professions and I look forward to listening
to their comments and learning from them. I would like to take a few
minutes to talk about one particular area--nursing--that I have been
working on and some of the actions we have taken at the State level to
address critical shortage issues in this area.
Last year, the Hospital Association of Rhode Island (HARI),
together with United Nurses and Allied Professionals (UNAP) and Rhode
Island State Nurses Association (RISNA) brought the nursing shortage
issue to my attention. Hospitals in Rhode Island had over 400 budgeted
vacant nurse positions, the number of enrollments in nursing schools
dropped 17 percent between 1998 and 2000, the number of new persons
taking the RN licensing exam dropped from 523 in 1996 to 294 in 2000
and the average age of Rhode Island licensed nurses was 47 years, 2
years higher than the national average of 45 years. Armed with these
facts, we worked with the Rhode Island Student Loan Authority to
develop and enact legislation--The Nurse Reward Program--to forgive the
interest on student loans for nurses who practice in Rhode Island
licensed health care facilities. This new program, which is now in
effect, is a small but good first step to provide incentives for
students to choose nursing careers. We have also joined with HARI and
nursing organizations this year on a media campaign to promote nursing
and to recruit persons to this vital profession. However, both the
State and Federal Governments must do more to provide financial
assistance and incentives to recruit persons into this vital field.
As Chairman of the Long-Term-Care Coordinating Council, I have a
special responsibility to look at the adequacy of our long-term care
workforce. This sector, which serves thousands of frail elders and
persons with disabilities, depends heavily on semi-skilled para-
professionals for direct hands-on care. Last year it faced a crisis in
recruitment and retaining workers. This crisis was documented in
reports issued by the council (Crisis in Care: A Report of the CNA
Study Group) and the Direct Care Task Force, a study group comprised of
the Rhode Island Health Care Association, The Rhode Island Association
of Facilities and Services for the Aged and the Alliance for Better
Long-Term Care. Surveys conducted by the Direct Care Task Force showed
the dimensions of the crisis--an increase in the CNA vacancy rate from
5 percent in 1997 to 11.8 percent in 1999, and in the turnover rate
from 59.2 percent in 1997 to 82.6 percent in 1999. The councils' report
included a ten-step set of recommendations including appropriations of
approximately $16 million to fund a direct-care worker pass-through
program for long-term-care providers. A copy of these recommendations
is attached (See Attachment A).
Although we were not able to secure the entire amount of the
recommended funding for the compensation pass-through, $4.5 million was
provided for nursing homes to increase staff compensation or staffing
and a 3 percent increase in reimbursement for other providers to be
used for staff compensation. While we do not have formal data on what
effect these ``pass-through'' funds have had, we do have anecdotal
reports that in some instances wages for CNA's were increased by as
much as $1.50 per hour, that the use of nursing pools to adequately
staff nursing homes has decreased and that worker retention, but not
recruitment has improved for home care providers. In the meantime,
reports are that the long-term care sector is experiencing increasing
shortages of professional nursing staff with reported vacancy rates of
18 percent.
We need to continue to do much more to ensure an adequate long-term
care workforce for the future. In anticipation of today's hearing, last
week I asked members of the council and long-term-care provider
representatives to share their thoughts and concerns with me and I was
pleased that several took the time to respond. One provider, Cynthia
Conant-Arp, Executive Director of the Feinstein Alzheimer's Center,
stated her concerns poignantly: I am sure they reflect the concerns of
many in the industry and I would like to read them to you.
``Our workers deserve a living wage and the respect due them for
caregiving. Unfortunately, agencies and institutions also need
reasonable revenues to survive, and many would not if they paid living
wages. Certified nursing assistants, in particular, are poorly paid for
backbreaking and physically and emotionally draining work. Even for
truly committed workers it is all too enticing to go where the grass is
greener and the work is less demanding. In yesterday morning's
Providence Journal, a certified nursing assistant was quoted on her
reasons for choosing to leave the long-term care field for the
financial security and benefits of an airport security job. Who can
fault her? CNAs are leaving the field in droves, and many of the
institutionally based nurses are right behind them! With a burgeoning
elderly population, we will soon be facing crisis-level shortages in
qualified personnel.
``I do believe that much of the problem in recruiting healthcare
workers is a matter of economics and respect. Many agencies are unable
to offer full time work and health benefits to their staff. . .another
fact that motivates qualified workers to seek employment in other
sectors. At some, point we have to equate a reasonable employee
compensation package with a measure of our respect for the worker and
the responsibilities he/she performs, but a bit of public education
wouldn't hurt either:
``St. Joseph Hospital recently ran a beautifully done series of
nurse-recruitment ads. Perhaps some validating PR, financial incentives
and career ladders could assist with worker recruitment and retention.
In a time of limited resources, financing will be challenging, but home
and community-based waivers and creative use of existing Federal
programs may offer hope. States cannot continue to absorb as much of
the long-term-care financing burden (mostly reflected in Medicaid
spending) without more Federal assistance. In the long run, though,
long-term care reform and Medicaid reform needs to be integrated with
Medicare and Social Security reform, both in financing and service
delivery. Staffing shortages need to be a major discussion point in any
reform effort:
``The challenges are enormous, but if we don't act soon, the crisis
will be devastating. The labor force and healthcare/long-term care
issues are inextricably linked. Our workers deserve a living wage and
the respect due them for caregiving:''
In closing, I would like to note two innovative projects initiated
by State government to address the healthcare workforce. The first is a
Health Care Labor Market project to be conducted by the University of
Rhode Island with a small grant from the State Department of Human
Services. This project will help us address data gaps in understanding
our health care labor market. It will analyze factors determining
health care labor demand and supply and make suggestions for improving
data and future research. The second is the New Opportunities for
Mature Workers project initiated by the Department of Elderly Affairs.
Under a coalition of Federal Title V Senior Community Service
Employment Programs (SCSEP) and long-term-care providers, mature
workers will be recruited, trained and placed in a variety of para-
professional and service positions in long-term care settings. Each of
these projects has significant potential. However, given the severe
fiscal constraints faced by the State, funding to implement innovative
State projects that seek to address the health care workforce shortage
is limited. I would encourage the Committee to consider providing
Federal grant opportunities to States to encourage them to design and
implement more programs such as these and to fund recommendations such
as those outlined in our council's report on the CNA crisis:
Attachment A
Recommendations of CNA Study Group of the Long-Term-Care Coordinating
Council
1. Improve CNA compensation (wages and benefits) by adopting the
following:
1.1. A nursing home direct care compensation pass-through of at
least $30 million (State and Federal) with accountability measures as
proposed by the Direct Care Task Force with allocation mechanisms to be
determined by the effected parties. The new funding will be used to the
extent permissible by law for direct care staff.
Cost Estimate: $14.1 million (State).
1.2. A home care provider rate increase of $3 per hour with
accountability measures to be determined by the affected parties. The
Study Group suggests that of the $3 per hour rate increase, 87 percent
($2.61) be provided as a compensation pass-through to CNAs (home health
aides) and 13 percent ($.69) be retained by the provider agency to pay
for the increased payroll taxes and workers' compensation insurance
costs associated with the increase.
Cost Estimate: $1,690,000 (State).
1.3. Adequately fund all other providers that employ CNAs through
establishment of COLAs as recommended in legislation requested by the
Long-Term-Care Coordinating Council to institute a mandated 5 percent
COLA for all long-term care providers except nursing homes (which
already have a mandated COLA) for FY2002. Thereafter, the COLA will be
based on an index to be determined by the purchasing departments in
consultation with provider representatives.
1.4. All long-term care providers who participate in State-funded
programs shall collect and report annually on turnover and vacancy
rates for direct care staff in accordance with reporting provisions
developed by the State contracting/purchasing entity.
2. Provide an ongoing source of funding for CNA training and
retraining to ensure an adequate pool of qualified nursing assistants
to care for Rhode Islanders with chronic care needs across the long-
term care service system.
2.1. Implement the CCRI CNA Workforce Development initiative: This
will include four components: training, re-engagement of inactive
nursing assistants, re-training and testing. Training will take place
both at on-campus and off-campus locations such as nursing homes and
home care agencies. This program is not intended to displace those non-
proprietary programs that offer intense specialized support services
and training to students funded by State agencies. (An outline of the
CCRI CNA Workforce Development initiative proposal is found on page
l7.)
Cost estimate: $208,000.
3. Establish pilot or demonstration workforce redesign program/s
specifically targeted to enhancing employee satisfaction and CNA
retention. These demonstration programs could be used as ``best
practices'' for replication by other long-term care providers.
Potential funding sources include Civil Monetary Penalty (CMP) funds,
grant funds from Human Resources Investment Council, and other grant
sources:
4. Develop standards for CNA career ladders and explore college
credit for training.
5. Develop tuition assistance program for CNA training for low-
income persons not eligible under Family Independence program (Note:
this is part of the funding recommended in #4 above).
6. Explore ways to facilitate training and certification for
persons whose primary language is not English:
7. Develop a database on both quantitative and qualitative CNA
employment issues using HEALTHs biennial certification/registration
process.
8. The Long-Term Care Coordinating Council, working in
collaboration with appropriate State agencies, shall provide technical
assistance in disseminating best practices to prividers on CNA
workforce development issues.
9. The Department of Human Services should encourage child care
providers--through the use of incentives and other mechanisms--to
collaborate with long-term care prividers to address gaps in the child
care delivery system that serve as barriers to CNA employment.
10. Support the GACH recommendations calling on the State to
establish a strategy for predicting current and future health care
workforce needs and identifying methods to meet those needs.
Senator Reed. Thank you very much, Lieutenant Governor and
thank you for your statements and also for your work in the
Long-term Care Coordinating Council any many other activities.
I want to welcome everyone here. I will give my opening
statement and then call upon my colleagues, Senator Lincoln
Chafee and my colleague Congressman Jim Langevin.
Again, it is a pleasure to have you all here at the
official field hearing on the Health, Education, Labor and
Pensions Committee.
I want to thank Dr. Tom Sepe, the president, for his
hospitality here today and for his opening remarks.
Also, let me thank the witnesses who are here today and all
of you who have joined us for this very critical topic, the
health care shortage throughout Rhode Island and throughout the
Nation.
Health professionals make up roughly 10.5 percent of the
Nation's total workforce. In Rhode Island, that figure is 11.8
percent, or 53,000 people, who are employed in the health
sector. Amazingly, our small State ranks third in the Nation in
per capita health services employment. Health services
employment in Rhode Island grew 30 percent between 1988 and
1998, compared to 23 percent nationally. So, as the Lt.
Governor pointed out--and others have, this is not just an
issue of health care, this is an issue of our economy, since
health care plays such a critical role in economy. These
figures are only expected to continue to grow robustly, as the
population of our State continues to age and health care
utilization continues to move upward.
Meanwhile, the demand for health professionals exceeds the
number of new workers graduating from training programs each
year. State budget constraints, outdated teaching facilities
and aging faculty strain the ability of community colleges and
State universities around the Nation to produce the volume of
proficient pharmacists, dental and mental health providers,
nurses of all levels, CNA, LPNs, RNs, advanced practice nurses,
therapists and technicians to meet the growing needs of our
health care system.
I have supported legislative initiatives that I hope will
begin to address these various shortages, particularly in the
areas of nursing and pharmacy.
We have all heard about the imminent shortage of nurses.
Many hospital administrators warn that the national nursing
shortage will only grow worse in the coming years because of an
aging population. Nationwide, hospitals have a shortfall of
126,000 nurses. The Journal of the American Medical Association
says that could grow to 400,000 in the next decade.
While the nursing shortage problem is certainly acute in
hospitals in Rhode Island, home health agencies and skilled
nursing facilities are also feeling the painful pinch of these
shortages. Interestingly, 21.8 percent of Rhode Island's health
services workers were employed in nursing care facilities,
while the State ranks ninth in the country in terms of
employment in home health care.
I have co-sponsored legislation intended to enhance our
ability to recruit and retain a new generation of nurses as
well as legislation designed to improve the work environment of
nurses currently on the job.
I have also been interested in the emerging shortage of
pharmacists in this country. There were 6,500 openings for
pharmacists at the 20,500 chain drugstores, and independents
and hospital pharmacies are also recruiting.
The number of pharmacists is expected to only grow by
28,500 over the next 10 years--800 less than the 29,300 over
the last decade. It is also reported that the number of
applicants to pharmacy schools in 1999 was 33 percent lower
than in 1994--the high point of enrollment during the 1990s. In
an effort to address this problem, I have introduced bipartisan
legislation, S. 1806, the Pharmacy Education Aid Act, will
create scholarships for pharmacy students and provide loan
repayment for those students who commit to teaching pharmacy
for at least 2 years or those who practice pharmacy where there
is a dire need--such as remote areas of the country.
Clearly, these are significant issues that have a direct
impact on the ability of Rhode Islanders and all Americans to
access health care services. Health profession shortages also
have the effect of reducing quality of care and patient
outcomes.
A recent New England Journal of Medicine study found that
patient outcomes were directly correlated with nurse staffing
ratios. The report, which examined the discharge records of 6
million patients at 799 hospitals in 11 States, found that in
hospitals with higher numbers of registered nurses, patient
stays were 3 percent to 5 percent shorter and complications
were 2 percent to 9 percent lower than hospitals with fewer
nurses.
The purpose of today's hearing is to explore the nature of
these workforce shortages across the health care spectrum in
Rhode Island, examine what steps are currently being taken at
the State and Federal levels to address these issues, and
ultimately gain a better understanding of the long-term
solutions that will be necessary to tackle this looming crisis.
Before I close, there are a couple of administrative points
I must take.
First, since there is a possibility of Senate votes this
afternoon, Senator Chafee and I will have to leave here quickly
at around 1:00, so we will shoot for a 1:00 p.m. termination of
the hearing, and as such I would ask the witnesses to kindly
respect a 5 minute limit on oral statements, with the
understanding that your full written statement will be included
in the record, we will have cards to assist you with the time.
We will also limit the questions of myself and my
colleagues to 5 minutes each round.
For those interested in submitting written testimony, the
record will be open for 14 days, so we will collect other
reports that are not able to be presented orally today or in
writing here today.
I want to thank you all far being here. One final set of
thanks, to Ed Creole who is our media specialist, and Ed Maxum,
who is our facilities director here, and to the Chief of
Security, Jim Ellis, for their help in arranging this hearing
this morning.
I will now ask for my colleague, Senator Lincoln Chafee,
for opening remarks.
Senator Chafee.
Opening Statement of Senator Chafee
Senator Chafee. It is a pleasure to be here. This is my
first time in this new wing of the Community College of Rhode
Island. Thank you, President Sepe, for hosting us here this
morning. Thank you, Senator Reed, for again being a leader on
an important issue.
As the Lieutenant Governor said, Rhode Island has an
enormously high population of elderly, the highest in the
Nation, as well as Florida, Arizona, I think West Virginia is
in there, too, but we are right up there at the top. So this is
an important issue for us, and as Senator Reed said, and, of
course, Rhode Islanders have proved if we can get the leaders
of an issue together, we can solve it, whether it is worker's
comp or anything else, come together, and having management and
representatives of labor here are so important to hammering out
some kind of solution to this shortage which is reaching such
crisis stages.
Senator Reed, once again, I have to thank you for your
legislation. You mentioned your Pharmacist Education Aid Act,
which I look forward to seeing passed, and also the Nurse
Reinvestment Act. They are both good pieces of legislation, and
we on the Federal side and on the State side are working very
hard, Lt. Governor Fogarty, also. It is great to have everybody
here, bringing their substantial brain power to work on this
important issue.
Senator Reed. Thank you, Senator.
Congressman Langevin.
OPENING STATEMENT OF HON. JAMES LANGEVIN
Mr. Langevin. Thank you, Senator Reed, Senator Chafee,
members of the panel, ladies and gentlemen. I, too, am pleased
to be here in joining Senator Reed on this issue of critical
importance, and I commend you, Senator Reed, for having the
vision and foresight to a address this workforce shortage now,
and I hope we can potentially avoid the crisis in the future.
We recognize that increasing longevity of population,
combined with the growing share of elderly persons has been
adding pressure on the health care delivery system. Whether we
are talking about providing better acute care or long-term care
for our loved ones, whether it be grandparents, parents, or
siblings or friends, we are going to have to act now. We are
going to make sure they're getting good quality health care in
the future, and I look forward to working with my colleagues
both in the House and in the Senate to see what we can do to
address this issue, but this hearing is important to take place
when we start. I thank you.
Senator Reed. Thank you very much, Congressman Langevin,
for your statements, and also your great efforts in the House
to help us with this issue.
Now let me introduce our first panel.
Joining us today is Dr. Roderick King of Boston,
Massachusetts. Dr. King is the Director of Boston Field Office
of the Health Resources and Services Administration in the
United States Department of Health and Human Services. He is a
Commander in the Commissioned Corps of the U.S. Public Health
Service. Dr. King recently completed a 1-year appointment to
the Boston field office as a Senior Health Policy Field Intern
as part of a program by HRSA, Harvard University and the
Commonwealth Fund to develop professional public health
leadership. During his appointment, Dr. King examined workforce
issues specific to Massachusetts and New England.
Dr. King was appointed as a senior lecturer in the Health
Science Department of the University of Cape Coast in Ghana,
West Africa. During his tenure, he was involved in a number of
public health projects, including a sickle cell registry and
information center, an AIDS awareness program, and the World
Health Organization Polio Eradication Project.
Dr. King holds a faculty appointment at Harvard Medical
School and continues to practice general pediatrics.
Thank you, Dr. King.
Next to Dr. King is Dr. Joseph Amaral.
Dr. Amaral is currently the President and Chief Executive
Officer of Rhode Island Hospital and the Senior Vice President
of Lifespan. He has been a Diplomat of the American Board of
Surgery and a member of the Association for Patient-Oriented
Research, the American College of Physician Executives. He has
been the Chief of Surgery of Rhode Island Hospital and the
Executive Chief of Surgery for Lifespan Affiliated Hospitals,
as well as the Interim Chairman, Department of Surgery at Brown
University. He has received numerous awards for clinical
practice and scientific achievement. He serves on the Lifespan
Academic Council and the Lifespan Teaching and Administration
subcommittee, and has served on the Committee on Conflict of
Interest.
In addition, he has conducted clinical research and has
participated in the development of surgical devices.
I can say that he is a distinguished clinician here in the
health care community. Thank you for joining us.
Next to Joe is Dr. Richard Besdine, who is currently the
Interim Dean of the Brown Medical School in Providence, RI. He
is also Professor of Medicine and Director of the Center for
Gerontology and Health Care Research at Brown University and
Director of the Division of Geriatrics in the Department of
Medicine. He is the Chief of Geriatrics for Lifespan and the
first Greer Professor of Geriatric Medicine.
The doctor has worked in gerontology and geriatrics for the
last 30 years. He started very young. Before coming to Brown in
2000, he was, among other things, Director of the University of
Connecticut Center on Aging and a principal investigator at the
National Institutes of Health Claude Pepper Older Americans
Independence Center. He served for 15 years on the faculty of
the Harvard Medical School and co-founded its Division on
Aging.
He has a long list of academic and professional
achievements.
He was the Director of the Health Care Financing
Administration's Health Standards and Quality Bureau overseeing
the quality of care for the Nation's 70 million Medicare and
Medicaid recipients. He has been on numerous Federal task
forces on aging and is on the boards of several organizations
devoted to research on issues affecting the health of the
elderly.
Next to Dr. Besdine is Nancy Roberts. Nancy is the
President and Chief Executive Officer of Care New England Home
Health, which represents the Visiting Nurses Association of
Care New England, a Medicare certified, community-based home
health agency, affiliated with Kent Hospital Home Care, the
oldest hospital-based home care program in Rhode Island and
HealthTouch, a private duty nursing agency, all located in
Rhode Island. The organizations' 300 staff members visit over
10,000 patients annually.
Ms. Roberts has served as a consultant to the Rhode Island
Department of Health, Division of Family Health, and has held
several positions at Brigham & Women's Hospital in Boston. She
volunteers her time and expertise to various boards and
committees, including those of the Women & Infants Hospital,
Butler Hospital, Newton Nurses Scholarship Committee, Rhode
Island Public Health Foundation, the Children's Trust Fund
Advisory Group, and the Visiting Nurses Associations of
America, where she is Vice Chair.
Thank you very much, Nancy, for what you bring to the
discussion.
Finally, our last panelist for the first panel is Dr. Norma
J. Owens. Dr. Owens is a Professor of Pharmacy at the College
of Pharmacy at the University of Rhode Island in Kingston. She
is licensed as a registered pharmacist in Arizona, Connecticut
and Rhode Island and is board certified in pharmacotherapy.
She has a clinical appointment as a Geriatric Clinical
Pharmacy Consultant in the Rhode Island Hospital's Division of
Geriatric Medicine and Department of Pharmacy.
She serves on the Pharmacy and Therapeutics Committee, the
AIDS Steering Committee, the Research and Education Committee
and the Antibiotic Use Committee at the Rhode Island Medical
Center, and on the Curriculum Committee, the Admissions
Committee, and the Committee for Prior Learning and as Faculty
Marshall at the University of Rhode Island College of Pharmacy.
She has authored numerous scholarly articles and has
conducted funded clinical research. Much of her writing and
research has focused on pharmaceutical effects on the elderly
in different clinical settings.
Thank you very much, Dr. Owens, for joining us today.
Now, let me turn it over to Dr. King, and with the only one
further admonition, 5 minutes, please.
STATEMENT OF RODERICK K. KING, DIRECTOR, BOSTON FIELD OFFICE,
REGION I (NEW ENGLAND), HEALTH
RESOURCES AND SERVICES ADMINISTRATION
Mr. King. Well, in the spirit of trying to stay on time and
make sure you catch your airplane, I'll jump right into it.
The Health Resources and Services Administration
appreciates this opportunity to testify before the Senate
Health, Education, Labor and Pensions Committee on health
professions workforce shortages.
Legislation authorizes HRSA to work to ensure that an
adequate health care workforce is available to meet the health
care needs of all Americans--regardless of their location and/
or income. HRSA does this through a variety of programs, such
as Titles VII and VIII of the Public Health Service Act, which
created programs that fund the training of health
professionals, including nurses. In addition, the National
Health Service Corps, which provides scholarships and loan
repayment for individuals willing to work in underserved areas,
and this is similar to Nursing Education Loan Repayment Program
under Title VIII.
Additionally, HRSA's National Center for Health Workforce
Analysis, also under Title VII, provides data and analysis on
workforce needs, which is essential for identifying shortages
and to advise planners and policymakers.
I would like to review for the Committee two recent in-
depth studies produced by HRSA's National Center for Health
Workforce analysis which provide detailed information on
workforce needs in two key areas of health professions whose
services are well known to Americans on a daily basis.
The first, ``Project Supply and Demand and Shortages of
Registered Nurses: 2000-2020'' examines data on the most
commonly recognized health care shortage, that is for
registered nurses. Registered nurses make up about a fifth of
all health professionals and serve across the spectrum of
medical specialties and services. Current data indicate that
the demand for the registered nurses is expected to grow by 40
percent between 2000 and 2020. In contrast to this growth in
need, the current projection for growth of this workforce
during this same time period is only 6 percent. Two facts
underlie this deficit: The registered nurse workforce is an
aging population with more and more registered nurses
approaching retirement age, while at the same time the number
of entrants to that workforce is declining. Since 1995, the
number of registered nurse graduates has declined by 31 percent
nationally according to the National Council of State Boards of
Nursing.
The study, ``Projected Supply and Demand Shortages of
Registered Nurses: 2000-2020'' estimates a 6 percent national
shortage of registered nurses in 2000, but by 2010 it projects
the shortage at 12 percent and by 2015, 20 percent. If current
trends continue, there will be a 29 percent shortage by 2020.
In 2000, 30 States and the District of Columbia were
estimated by the National Workforce report to be experiencing
shortages of registered nurses, shortages defined as shortages
greater than 3 percent. By 2020, the number of States with
shortages is projected to grow to 44. The national media
recently widely reported a study which indicated that adequate
ratios of registered nurses are a key to a favorable patient
outcome, as reports from around the Nation increasingly
highlight the inability of medical facilities to adequately
staff registered nurse positions.
Now, Rhode Island substantiates this national trend.
Although the 2000 National Sample Survey from HRSA's Division
of Nursing showed that Rhode Island had a little over 1,000
registered nurses per 100,000 population in 2000--significantly
above the national average of 782 nurses per 100,000, it too is
being affected by national trends. ``Projected Supply and
Demand and Shortages of Registered Nurses 2000-2020'' estimated
a 10 percent shortage in registered nurses in Rhode Island in
2000, a 16 percent shortage in 2005, a 26 percent shortage in
2010, a 38 percent shortage by 2015 and a 48 percent shortage
by 2020.
In a national context, the report indicates that Rhode
Island was one of 14 States in 2000 having a double-digit
shortage in registered nurses, with most shortages in the 10 to
12 percent range. By 2020, report data estimate that Rhode
Island will have the eighth highest shortage among States, with
13 States having shortages of 40 percent or higher.
In response to this critical shortage in nursing and its
effect on our entire health care system, under this
Administration, funding for the Nursing Education Loan
Repayment Program has increased four-fold--from $2.3 million to
$7.3 million for fiscal year 2001 and to $10.3 million in
fiscal year 2002. The President's fiscal year 2003 budget
request is $15 million, another 50 percent increase. This
program is one of the most expeditious means of targeting
nurses to underserved areas, with nurses who already have
degrees, agreeing to serve a minimum of 2 years in a designated
health shortage area in exchange for assistance with their
educational loans.
The second, very briefly, is called, ``The Pharmacist
Workforce: A Study of the Supply and Demand for Pharmacists''
is an in-depth workforce study of pharmacists. The study
details factors beyond population growth that are driving the
demand in this workforce area.
Some of these factors include:
The fact that recent growth in the number of prescriptions
has been four times that of the growth in the number of
pharmacists.
The growing education and prevention role that pharmacists
are now expected to play, especially in the context of an aging
population of patients who have increasingly complex medication
regimens.
The competition among retail pharmacies has resulted in
expanded store hours and new store openings.
The increased insurance coverage for prescription drugs,
resulting in increasing administrative demands on pharmacists'
time.
The increasing role of pharmacists in preventing medication
error.
The increasing entry of women into the pharmacist
workforce, from 13 percent of that workforce in 1970 to 46
percent in 2000, has resulted in workforce participants
desiring part-time and shorter hours, and the increased use of
pharmacists in institutional settings and in research.
Rhode Island is fortunate, according to the HRSA State
Health Workforce Profiles, that it had 95.2 pharmacists and
107.3 pharmacy technicians and aides per 100,000 population in
1998, ranking Rhode Island first and second respectively among
the 50 States in 1998.
However, Rhode Island too is being affected by data
reported by the National Center Report on pharmacists, that
nationally the number of vacancies for pharmacists has doubled
in the last 2 years. In 2000, ``The Pharmacist Workforce''
estimated that the United States needed 14 percent more
pharmacists. By 2005, the estimated need will be 35 percent
more. Report data indicate a decline in the late 1990s in the
number of pharmacy graduates, with a corresponding decline in
the number of applicants to pharmacy schools--the latter were
33 percent lower in 1999 than in 1994, the high point over the
past decade.
The shortage of pharmacists, like that of registered
nurses, crosses the entire spectrum of health care facilities,
including the Federal service. Pharmacist vacancy rates in the
Public Health Service are 11 percent, in the armed forces 15 to
18 percent, and the Department of Veterans Affairs and Native
American health centers have some facilities with less than
half of their pharmacist positions filled, according to ``The
Pharmacist Workforce.'' To ensure and adequate workforce,
however, it is essential to realize that millions of Americans
face barriers to quality health care because of the
maldistribution of the health care workforce. Distribution of
health care personnel is as important as the overall total of
the workforce. In terms of health care, rural areas, inner city
areas, and certain populations of Americans--most notably
certain racial and ethnic populations--are underserved.
Statistics for HRSA's Shortage Designation Branch report
that some 56 million people live in more than 3,100 health
professional shortage areas; 33 million Americans are
underserved, most of them in predominantly rural counties. To
alleviate these gaps in access to basic health care, data
estimate that an additional 15,000 primary care physicians
would be required to fill this need. This is the equivalent of
virtually an entire annual graduating class from U.S. medical
schools according to figures of the Association of American
Medical Colleges.
In 2001, the National Health Service Corps, which has about
2,400 clinicians serving nationwide, received more than 3,800
requests from underserved areas for assistance in recruiting
National Health Service Corps clinicians to provide basic
health care.
The President has made increasing health care services for
the underserved a priority of his Administration. Health
centers are a primary source of health services for the
underserved. The President's Initiative for Health Centers
plans a multi-year expansion to increase the number of Health
Center access points by 1,200 and increase the number of
patients served by 6.1 million.
Recognizing the key role of the HRSA's National Health
Service Corps, the President has requested an increase of over
$44 million for Fiscal Year 2003 for the National Health
Service Corps. As the budget notes, the National Health Service
Corps has been a significant source of staffing support for the
Health Center program, with 46 percent of the National Health
Service Corps clinicians currently serving in Health Centers.
In many cases, the National Health Service Corps is the only
source of clinicians to care for racially and ethnically
diverse communities that lack access to services and experience
increased health disparities.
This increase of $44 million for the National Health
Service Corps program will support an additional 131 scholars
who will be available for future service, an additional 454
National Health Service Corps Loan Repayment recipients who
agree to serve in underserved areas in exchange for assistance
with their educational training loans, and an additional 144
mental and behavioral health National Health Service Corps Loan
Repayment professionals. These will provide needed services in
underserved communities and help staff the growing Health
Centers program.
In the end, the two HRSA reports I discussed on registered
nurses and pharmacists, as well as a major HRSA report issued
last December of State-by-State profiles of the Nation's health
workforce, are available from HRSA, and further information
regarding these and other reports is available at the HRSA
website at www.hrsa.gov. The State-by-State profiles are the
first such comprehensive detailed data on the supply and demand
for physicians, nurses, dentists, and 20 other health care
professionals in all 50 States and the District of Columbia.
Again, I thank you for HRSA's opportunity to testify
regarding this important subject and I will be happy to answer
any questions you might have.
[The prepared statement of Dr. Roderick K. King follows:]
Prepared Statement of Roderick K. King
The Health Resources and Services Administration appreciates this
opportunity to testify before the Senate Health, Education, Labor and
Pensions Committee on health professions workforce shortages.
Legislation authorizes HRSA to work to ensure that an adequate
health care workforce is available to meet the health care needs of all
Americans--regardless of their location or income. HRSA does this
through a variety of programs such as: Titles VII and VIII of the
Public Health Service Act which created programs that fund the training
of health professionals, including nurses; and the National Health
Service Corps (NHSC) which provides scholarships and loan repayment for
individuals willing to work in underserved areas (similar to the
Nursing Education Loan Repayment Program under Title VIII).
Additionally, HRSA's National Center for Health Workforce Analysis,
also under Title VII, provides data and analysis on workforce needs
which is essential for identifying shortages and to advise planners and
policymakers.
I would like to review for the Committee two recent in-depth
studies produced by HRSA's National Center for Health Workforce
Analysis which provide detailed information on workforce needs in two
key areas of health professions whose services are well known to
Americans on a daily basis.
The first, ``Projected Supply and Demand and Shortages of
Registered Nurses: 2000-2020'' examines data on the most commonly
recognized health care shortage, that for registered nurses. Registered
nurses make up about a fifth of all health care professionals and serve
across the spectrum of medical specialities and services. Current data
indicate that the demand for registered nurses is expected to grow by
40 percent between 2000 and 2020. In contrast to this growth in need,
the current projection for growth of this workforce during this same
period is only 6 percent. Two facts underlie this deficit: the
registered nurse workforce is an aging population with more and more
registered nurses approaching retirement age, while at the same time
the number of entrants to that workforce is declining. Since 1995, the
number of registered nurse graduates has declined by 31 percent
nationally according to the National Council of State Boards of
Nursing.
``Projected Supply and Demand and Shortages of Registered Nurses:
2000-2020'' estimates a 6 percent national shortage of registered
nurses in 2000. By 2010, it projects the shortage at 12 percent and by
2015, 20 percent. If current trends continue, there will be a 29
percent shortage by 2020.
In 2000, thirty States and the District of Columbia were estimated
by the National Workforce report to be experiencing shortages of
registered nurses (shortages defined as shortages greater than 3
percent). By 2020, the number of States with shortages is projected to
grow to 44. The national media recently widely reported a study which
indicated that adequate ratios of registered nurses are a key to
favorable patient outcomes, as reports from around the Nation
increasingly highlight the inability of medical facilities to
adequately staff registered nurse positions.
Rhode Island statistics substantiate this national trend. Although
the 2000 National Sample Survey from HRSA's Division of Nursing showed
that Rhode Island had 1,101 registered nurses per 100,000 population in
2000--significantly above the national average of 782 nurses per
100,000, it too is being affected by national trends. ``Projected
Supply and Demand and Shortages of Registered Nurses 2000-2020''
estimated a 10 percent shortage in registered nurses in Rhode Island in
2000, a 16 percent shortage in 2005, a 26 percent shortage in 2010, a
38 percent shortage by 2015, and a 48 percent shortage by 2020.
In a national context, the report indicates that Rhode Island was
one of 14 States in 2000 having a double-digit shortage in registered
nurses, with most shortages in the 10 to 12 percent range. By 2020,
report data estimate that Rhode Island will have the eighth highest
shortage among States, with 13 States having shortages of 40 percent or
higher.
In response to the critical shortage in nursing and its effects on
our entire health care system, under this Administration, funding for
the Nursing Education Loan Repayment Program has increased four-fold--
from $2.3 million to $7.3 million for fiscal year 2001 and to $10.3
million in fiscal year 2002. The President's fiscal year 2003 budget
request is $15 million, another 50 percent increase. This program is
one of the most expeditious means of targeting nurses to underserved
areas, with nurses who already have degrees agreeing to serve a minimum
of 2 years in a designated health shortage area in exchange for
assistance with their educational loans.
The second National Center recently completed report ``The
Pharmacist Workforce: A Study of the Supply and Demand for
Pharmacists'' is an in-depth workforce study of pharmacists. The study
details factors beyond population growth that are driving the demand
this workforce area. Some of these factors include:
The fact that recent growth in the number of prescriptions
has been four times that of the growth in the number of pharmacists;
The growing education and prevention role that pharmacists
are now expected to play, especially in the context of an aging
population of patients who have increasingly complex medication
regimens;
The competition among retail pharmacies has resulted in
expanded store hours and new store openings;
The increased insurance coverage for prescription drugs,
resulting in increasing administrative demands on pharmacists' time;
The increasing role of pharmacists in preventing
medication error; the increasing entry of women into the pharmacist
workforce (from 13 percent of that workforce in 1970 to 46 percent in
2000) has resulted in workforce participants desiring part-time work
and shorter hours; and
The increased use of pharmacists in institutional settings
and in research.
Rhode Island is fortunate, according to HRSA State Health Workforce
Profiles in that it had 95.2 pharmacists and 107.3 pharmacy technicians
and aides per 100,000 population in 1998, ranking Rhode Island first
and second respectively among the 50 States in these areas.
However, Rhode Island too is being affected by data reported by the
National Center Report on pharmacists showing that nationally the
number of vacancies for pharmacists has doubled in the last 2 years. In
2000, ``The Pharmacist Workforce'' estimated that the United States
needed 14 percent more pharmacists; by 2005, the estimated need will be
35 percent more. Report data indicate a decline in the late 1990s in
the number of pharmacy graduates, with a corresponding decline in the
number of applications to pharmacy schools--the latter were 33 percent
lower in 1999 than in 1994, the high point over the past decade.
The shortage of pharmacists, like that of registered nurses,
crosses the entire spectrum of health care facilities including the
Federal service. Pharmacist vacancy rates in the Public Health Service
are 11 percent; in the armed forces, 15 to 18 percent; and the
Department of Veterans Affairs and Native American health centers have
some facilities with less than half of their pharmacist positions
filled. according to ``The Pharmacist Workforce.''
To ensure an adequate workforce, however, it is essential to
realize that millions of Americans face barriers to quality health care
because of the maldistribution of the health care workforce.
Distribution of health care personnel is as important as the overall
total of the workforce. In terms of health care, rural areas, inner
city areas, and certain populations of Americans--most notably certain
racial and ethnic populations--are underserved.
Statistics from HRSA's Shortage Designation Branch report that some
56 million people live in more than 3,100 health professional shortage
areas; 33 million Americans are underserved, most of them in
predominantly rural counties. To alleviate these gaps in access to
basic health care, data estimate that an additional 15,000 primary care
physicians would be required to fill this need. This is the equivalent
of virtually an entire annual graduating class from U.S. medical
schools according to figures of the Association of American Medical
Colleges.
In 2001, the National Health Service Corps, which has about 2,400
clinicians serving nationwide, received more than 3,800 requests from
underserved areas for assistance in recruiting NHSC clinicians to
provide basic health care.
The President has made increasing health care services for the
underserved a priority of his Administration. Health centers are a
primary source of health services for the underserved. The President's
Initiative for Health Centers plans a multi-year expansion to increase
the number of Health Center access points by 1,200 and increase the
number of patients served by 6.1 million.
Recognizing the key role of the HRSA's National Health Service
Corps, the President has requested an increase of over $44 million for
FY2003 for the NHSC. As the budget notes, the NHSC has been a
significant source of staffing support for the Health Center program,
with 46 percent of the NHSC clinicians currently serving in Health
Centers. In many cases, the NHSC is the only source of clinicians to
care for racially and ethnically diverse communities that lack access
to services and experience increased health disparities.
This increase of $44 million for the NHSC program will support an
additional 131 scholars who will be available for future service, an
additional 454 NHSC Loan Repayment recipients who agree to serve in
underserved areas in exchange for assistance with their educational
training loans, and an additional 144 mental and behavioral health NHSC
Loan Repayment professionals. These will provide needed services in
underserved communities and help staff the growing Health Centers
program.
The two HRSA reports I discussed on registered nurses and
pharmacists as well as a major HRSA report issued last December of
State-by-State profiles of the Nation's health workforce are available
from HRSA, and further information regarding these and other reports is
available at the HRSA website at www.hrsa.gov. The State-by-State
profiles are the first such comprehensive detailed data on the supply
and demand for physicians, nurses, dentists, and 20 other health care
professionals in all 50 States and the District of Columbia.
Again, I thank you for HRSA's opportunity to testify regarding this
important subject and will be happy to answer any questions you might
have.
Senator Reed. Thank you, Dr. King, for your very excellent
testimony.
I would like to call now Dr. Amaral, and note that Dr.
Amaral and Dr. King have to leave at noon. So if we are still
going throughout the questioning and we have questions, we'll
submit to them to you in writing.
STATEMENT OF JOSEPH AMARAL, M.D., PRESIDENT AND CHIEF EXECUTIVE
OFFICER, RHODE ISLAND HOSPITAL
Dr. Amaral. Senator Reed, Senator Chafee, Representative
Langevin and Governor Fogarty, it is a pleasure to be here with
you this morning addressing such a vitally important project.
As a professor, and as a practicing surgeon, I have seen up
close the impact of health care workforce shortages on my own
ability to teach, to do research and to provide the highest
quality medical care. As the president of a major teaching
hospital, the third largest in New England, I struggle daily
with the impact of these shortages, on our ability to care for
our patients, on our employee morale, on our labor relations,
on our hospital costs, and ultimately on Rhode Island
Hospital's ability to fulfill its mission.
There is a lot of discussion in the media about the nursing
shortage, and I can tell you that shortage is real. It is a
challenge we face every day. However, I am most grateful that
this hearing is addressing the shortage in all health care
professions, including radiology technicians, respiratory
therapists, pharmacists, and all the other professionals along
the health care continuum including non-direct care providers.
Unless we address these shortages, this looming crisis will
threaten the availability, quality and cost of health care in
the years ahead.
I would like to begin this morning by discussing what I
believe are the broader environmental shifts within health care
that serve as the backdrop for today's health care professional
shortages. I would like to then explain how a lack of available
health care workers plays out at Rhode Island Hospital, and at
hospitals everywhere. Finally, I would like to briefly mention
what we are doing to tackle this challenge. While we need the
help of you and your colleagues in Congress to support pipeline
programs and reimbursement policies that make these professions
attractive again, we in the health care industry need to do our
part as well. I assure you, we are not standing still.
If I could you and your colleagues on a tour of our
hospital to highlight the shortage of health care workers, I
would take you first to our billing and coding department.
Why? Because reimbursement policies, from Medicare to
Medicaid, as well as from private sector insurers, have created
an environment for medical practice that makes providing care
to patients a difficult and thankless job. The documentation-
driven nature of modern health care also gives the perception
to the caregiver that paperwork is more important than
providing care. As any nurse, my wife, for example, she entered
the profession to care for people, not paper.
It is also the case that, quite frankly, hospitals have had
to ask more of nurses and other professionals as part of the
institutions' efforts to control costs.
When hospitals are not paid enough to cover their costs,
which in Rhode Island we are not, when we are also responsible
for caring for the uninsured and the underinsured, which we
are, when we also value teaching and research, which we do,
even though it is costly, then cost cutting becomes an
imperative just to survive.
Any comprehensive effort to reduce costs and manage the
budget requires taking labor and efficiency into account. We
work hard on that every day. Unfortunately, these measures
often require a complete redesign of processes that in
themselves are time consuming, costly and have unanticipated
consequences. But this has in many cases translated to fewer
caregivers caring for more patients. There are right ways and
wrong ways to increase efficiency, however, as I will talk
about it in a minute. Many early attempts at cost control
wrongly focus on nurses and other allied health professionals
as the problem, not the solution. The result is an environment
of declining professional respect for all health members of the
health care team. This must be reversed.
Work environment is not solely to blame. Demographic
trends, increasing opportunities for women throughout the
workforce and the nagging perception of jobs, like nursing as
``woman's professions'' have dwindled the ranks in key health
professions and have slowed the number of new applicants. I am
sure we will hear more about that from other panelists.
What options do these shortages leave in a major teaching
hospital? One is to close beds and services. Doing so affects
how soon patients get the care they need and where they get
that care. If hospitals reduce bed capacity because they simply
don't have the manpower to fully staff the hospital, it means
patients wait longer in the emergency room before being
admitted. Delays in length of stay are associated with
increased costs and oftentimes with no increase in
reimbursement. Moreover, these delays may make patients worse.
And shortages outside the hospital can exacerbate the problem
within it. If physician practices and clinics seeing patients
are available few hours of the day, these patients end up in
the emergency room. It is a game of health care musical chairs,
and when the music stops, it is often the patient without a
seat, or without a bed, or without the quality and continuity
of care that we all aspire to, and the music usually stops in
the emergency room.
Another scenario is to stretch your available workforce as
far as possible through overtime, and to hire expensive
contract labor from for-profit agencies. Neither practice leads
to optimal care, and both are incredibly costly. Let me give
you an example.
In fiscal year 2001, Rhode Island Hospital's net operating
loss was $29 million on contract labor. That is contracting out
to other companies for the shifts and jobs we couldn't cover
with our own employees. That figure does not include what we
spend on overtime, what we spend on recruitment or what we
spent for routine wages and benefits. I certainly would prefer
to spend that money on professionals who are interested in
building a career in our institution and in our State.
Hospital financing has always involved a certain amount of
``robbing peter to pay Paul.'' Well, due to the serve shortages
we are facing, hospitals are paying Peter overtime, and we are
also paying Paul.
OK. Enough hand wringing. What are we doing about it?
For one thing, we are getting smarter about the use of
technology. For example, we have automated our laboratory
services, allowing us to run the lab better and more
efficiently with fewer people, and has benefited patients and
physicians. The same can be said for investments in information
technology, including order entry, nursing documentation and
result tracking.
For another, we are turning our greatest assets, our own
employees, into a recruiting force. On that same tour of Rhode
Island Hospital, one of the first things you would see when you
walked in the door is a sign promoting our recruitment bonus--
we are offering $5,000 to employees who recruit or refer new
hires for key positions.
And, finally, we are investing in our employees so they
feel better about their jobs and stay in them longer. Through
employee forums, competitive compensation, new professional
development opportunities and commitment to continuing
education, we are making clear to all our employees that we
need them and that we value them. In fact, we have employed a
chief retention officer--and yes, she is a nurse--whose full-
time job is to keep our employees here and happy. I am proud to
say that in the past 2 years we have reduced our turnover rate
at Rhode Island Hospital by 34 percent and our current rate of
9 percent is both low for our State and low for our industry.
We are also working to increase what I call the ``cultural
competency'' of our workforce, with dedicated outreach efforts
to communities under-represented in the health care profession,
as well as language classes for our employees. The face of
America is changing, and at some point the health care
workforce will need to catch up.
What can you in the Congress do? Fund Title VII training
programs that produce more nurses, recruit minorities into the
profession, and increase the ranks of primary caregivers.
Adequately fund and broaden medical education, so that teaching
hospitals can continue to serve as classrooms for tomorrow's
nurses and technicians and pharmacists, as well as doctors, and
continue to hold hearings like this one, raising important
issues and bringing community voices before Congressional
committees.
I am happy to take any questions, but I want to close,
Senator Reed, by thanking you for your leadership on academic
medicine and on health care in general. I have always been
proud to call you my Senator. Thank you.
[The prepared statement of Joseph Amaral, M.D. follows:]
Prepared Statement of Joseph F. Amaral, M.D.
Senator Reed, fellow panelists, my name is Dr. Joseph Amaral, and I
am President and CEO of Rhode Island Hospital and Professor of Surgery
at Brown Medical School. It is a pleasure to be here this morning
addressing such a vitally important topic.
As a professor, and as a practicing surgeon, I have seen up close
the impact of health care workforce shortages on my own ability to
teach, to do research, and to provide the highest quality medical care.
As the president of a major teaching hospital, the third largest in New
England, I struggle daily with the impact of these shortages: on our
ability to care for our patients, on our employee morale, on our labor
relations, on our hospital costs, and ultimately on Rhode Island
Hospital's ability to fulfill its mission.
There is a lot of discussion in the media about the ``nursing
shortage,'' and I can tell you that shortage is real. It is a challenge
we face every day. However, I am most grateful that this hearing is
addressing the shortage in all health professions, including radiology
technologists, respiratory therapists, pharmacists, and other
professionals along the health care continuum including non-direct care
providers. Unless we address these shortages, this looming crisis will
threaten the availability, quality, and cost of health care in the
years ahead.
I would like to begin this morning by discussing what I believe are
the broader environmental shifts within health care that serve as the
backdrop for today's health care professional shortages. I'd like to
then explain how a lack of available health care workers plays out at
Rhode Island Hospital, and at hospitals everywhere. Finally, I'd like
to briefly mention what we're doing to tackle this challenge. While we
need the help of you and your colleagues in Congress to support
pipeline programs and reimbursement policies that make these
professions attractive again, we in the health care industry need to do
our part as well. I assure you, we are not standing still.
If I could take you and your colleagues on a tour of our hospital
to highlight the shortage of health care workers, I'd take you first to
our billing and coding department.
Why? Because reimbursement policies, from Medicare and Medicaid as
well as from private sector insurers, have created an environment for
medical practice that makes providing care to patients a difficult and
thankless job. The documentation-driven nature of modern health care
also gives the perception to the caregiver that paperwork is more
important than providing care. Ask any nurse, my wife for example: she
entered the profession to care for people, not paper.
It is also the case that, quite frankly, hospitals have had to ask
more of nurses and other professionals as part of the institutions'
efforts to control costs.
When hospitals aren't paid enough to cover their costs--which in
Rhode Island we are not--when we are also responsible for caring for
the uninsured and the underinsured--which we are--when we also value
teaching and research--which we do--even though it is costly, then cost
cutting becomes an imperative just to survive.
Any comprehensive effort to reduce costs and manage the budget
requires taking labor and efficiency into account. We work hard on that
every day. Unfortunately, these measures often require a complete
redesign of processes that in themselves are time consuming, costly and
have unanticipated consequences. But this has in many cases translated
to fewer caregivers caring for more patients. There are right ways and
wrong ways to increase efficiency, however, as I'll talk about it a
minute. Many early attempts at cost control wrongly focus on nurses and
other allied health professionals as the problem, not as the solution.
The result is an environment of declining professional respect for all
health care professionals. This must be reversed.
Work environment isn't solely to blame. Demographic trends,
increasing opportunities for women throughout the workforce, and the
nagging perception of jobs like nursing as ``woman's professions'' have
dwindled the ranks in key health professions, and have slowed the
number of new applicants. I'm sure we'll hear more about that from
other panelists.
What options do these shortages leave for in a major teaching
hospital? One is to close beds and services. Doing so affects how soon
patients get the care they need, and where they get that care. If
hospitals reduce bed capacity because they simply don't have the
manpower to fully staff the hospital, it means patients wait longer in
the emergency room before being admitted. Delays in length of stay are
associated with increased costs and often times with no increase in
reimbursement.
Moreover, these delays may make patients worse. And shortages
outside the hospital can exacerbate the problem within it--if physician
practices and clinics seeing patients are available fewer hours of the
day, these patients end up in the emergency room. It is a game of
health care musical chairs, and when the music stops, it is often the
patient without a seat, or without a bed, or without the quality and
continuity of care that we all aspire to, and the music usually stops
in the emergency room.
Another scenario is to stretch your available workforce as far as
possible through overtime, and to hire expensive, contract labor from
for-profit agencies. Neither practice leads to optimal care, and both
are incredibly costly. Let me give you an example.
In fiscal year 2001, Rhode Island Hospital's net operating loss was
$26 million. In that same year, Rhode Island Hospital spent $21 million
on contract labor--that's contracting out to other companies for the
shifts and jobs we couldn't cover with our own employees. That figure
does not include what we spent on overtime, what we spent on
recruitment, or what we spent for routine wages and benefits.
Hospital financing has always involved a certain amount of
``robbing Peter to pay Paul.'' Well, due to the severe shortages we're
facing, we're paying Peter overtime, and we're ALSO paying Paul.
OK, enough hand wringing. What are we doing about it?
For one thing, we are getting smarter about the use of technology.
For example, we have automated our laboratory services, which has
allowed us to run the lab better and more efficiently with fewer
people, and has benefited patients and physicians. The same can be said
for investments in information technology, including order entry,
nursing documentation and result tracking.
For another, we are turning our greatest assets, our own employees,
into a recruiting force. On that same tour of Rhode Island Hospital,
one of the first things you'd see when you walked in the door is a sign
promoting our recruitment bonus--we're offering $5,000 to employees who
recruit or refer new hires for key positions.
And finally, we are investing in our employees so they feel better
about their jobs and stay in them longer. Through employee forums,
competitive compensation, new professional development opportunities
and commitment to continuing education, we are making clear to all our
employees that we need them, and we value them. In fact, we have
employed a chief retention officer--and yes, she's a nurse--whose full-
time job is to keep our employees here and happy.
I am proud to say that in the past 2 years we have reduced our
turnover rate at Rhode Island Hospital by 34 percent and our current
rate of 9 percent is both low for our State and low for our industry.
We are also working to increase what I call the ``cultural competency''
of our workforce, with dedicated outreach efforts to communities under-
represented in the health care profession, as well as language classes
for our employees. The face of America is changing, and at some point
the health care workforce will need to catch up.
What can you in the Congress do? Fund Title VII training programs
that produce more nurses, recruit minorities into the profession, and
increase the ranks of primary caregivers. Adequately fund and broaden
medical education, so that teaching hospitals can continue to serve as
classrooms for tomorrow's nurses and technicians, as well as doctors.
And continue to hold hearings like this one, raising important issues
and bringing community voices before Congressional committees.
I am happy to take any questions, but I want to close, Senator
Reed, by thanking you for your leadership on academic medicine, and on
health care in general. I have always been proud to call you my
Senator. Thank you.
Senator Reed. Thank you very much for your testimony.
Dr. Besdine, please.
STATEMENT OF RICHARD W. BESDINE, M.D., FACP, INTERIM DEAN,
BROWN MEDICAL SCHOOL
Dr. Besdine. Senator Reed, Lieutenant Governor Fogarty, I
want to thank you for the opportunity to testify before the
Committee, and for your leadership in directing Congress's
attention to such an important and pressing issue as the
critical shortages in our Nation's health care workforce.
In addition to serving as Interim Dean of the Medical
School, a post I assumed earlier this month, I also come to
this issue from my additional roles, as president-elect of the
American Geriatrics Society, and as a physician who has worked
in geriatric medicine, as a clinician, educator, scientist and
administrator for more than 30 years. From each of these
vantage points, I see a deeply troubling future for health care
nationally and for future economic harm here in Rhode Island.
In deference to the expertise represented elsewhere on this
panel, I would like to limit my brief remarks this morning to
three topics:
First, a broad overview of the physician workforce trends
and how they influence and are influenced by our health care
system.
Second, the interconnection between physicians and other
health care professionals, whose fields are suffering from
shortages far more severe than we find in medicine, and how
those shortages affect medical education and medical practice.
And, finally, as a geriatrician, I would like to share my
serious concerns abut the coming collision between our rapidly
growing aging population and the paucity of physicians trained
to adequately manage their care.
If there is any good news in physician workforce trends, it
is that there is probably an adequate number of physicians
practicing in the United States overall. The bad news, however,
is that in more than half the country, these practitioners are
working in the geographic area and have skills and training
that are not matched to areas of need.
Imagine if the Red Sox had a lineup total of nine players
in the dugout, but they were three first basemen, six catchers,
and no one to play the outfield.
Here in Rhode Island, some of the most recent data
available suggests that psychiatrists, certain pediatric
specialists, geriatricians and primary care physicians are in
critically short supply. In many of these cases, managed care
policies and Medicare reimbursement biases exacerbate or even
drive these trends, particularly threatening access of our most
disadvantaged, elderly citizens.
Even in practice areas not currently plagued by shortages,
the undersupply of nurses and other health care professionals
impairs the way physicians function, and the care they deliver
at the bedside.
Increasingly, and this is especially true in my field of
geriatrics, delivering quality health care competently and in
high quality is a team effort, and nowhere is it more prudent
than in geriatrics. Many factors, including increasing medical
complexity, the growing role of medications in treating and
managing disease, and the time-compressed nature of a doctor's
practice mean that physicians rely more than ever on nurses,
therapists, pharmacists and other health professionals to do
things that previously have been done solo by doctors.
These non-physician health care professionals have received
highly specialized training and can now perform these tasks
more economically and just as effectively as most physicians.
Nurse clinicians, for example, are far better equipped to
prevent, detect and treat bed sores than most physicians.
Pharmacists are more likely to notice potential drug-disease
and drug-drug interactions and flag them before patient harm
eventually occurs.
You will hear later from my fellow panelists about alarming
workforce trends in nursing, pharmacy, and radiology
technologists. I want to reiterate, as a physician, that every
aspect of medical practice, as well as medical education and
research, relies on a foundation of teaming with nurses and
other professionals. When members of the team vanish, the
foundation weakens, and eventually crumbles.
This is not the time to roll back support for vital Title
VII and Title VIII programs, as has been proposed by President
Bush. This funding supports a wide variety of training and
scholarship programs in the State of Rhode Island. These
programs are designed to increase the number of primary care
providers, particularly in rural and other underserved areas,
through training in multidisciplinary settings. Additionally,
the grants seek to diversity the health professions workforce
by recruiting and training under represented minorities. I
applaud your efforts to restore these important funds, and I
hope you will count on us as your partner in making that
happen.
Finally, I would like to close by doing what all
geriatricians are trained to do: Advocate for optimal care of
elderly patients.
There is an acute and worsening shortage of geriatricians
that threatens the well-being of older Americans, a group that
will double in numbers in the next 30 years. National estimates
project that we will be 25,000 geriatricians short by the year
2030 if current trends continue. In Rhode Island alone, we are
50 geriatricians short, relative to need. That is 5-0. And the
problem is even bigger than that number suggests, since
geriatricians not only care for elderly patients, but also they
train other physicians how to best diagnose and treat the
complex, multi-system diseases and conditions that most often
beset our oldest citizens. In this case, as with nursing, we
are short on practitioners and we are short on teachers.
Ironically, Medicare, the very program created to serve
older Americans' health care needs and to fund graduate medical
education, often does not pay for the training of
geriatricians.
Because of the residency caps imposed as part of the
Balanced Budget Act of 1997, academic medical centers are not
free to respond to the growing need for geriatricians by
expanding their residency programs to include training of
geriatricians. Because geriatrics was a new and emerging field
when the caps were imposed, the training slots around the
country were limited, and despite the increasing demand,
Medicare support has been frozen in time through the BBA--
funding no new residence slots unless teaching hospitals cut
other residencies. Here in Rhode Island, one of the oldest and
fastest aging States in the country, we were only able to
launch our new geriatric fellowship program through the
generosity of the Miriam Hospital Foundation and Brown's other
affiliated hospitals.
I urge you and your Senate colleagues to consider, as part
of this year's health care legislation, giving hospital-based
teaching programs the necessary flexibility to increase their
residency slots to meet the changing health care needs of a
changing America.
Thank you for your time, and I would be happy to answer any
questions.
[The prepared statement of Dr. Richard Besdine follows:]
Prepared Statement of Richard W. Besdine, M.D.
Senator Reed, distinguished guests, my name is Richard Besdine, and
I am Interim Dean for the Brown Medical School.
I want to thank you for the opportunity to testify before this
committee, and for your leadership in directing Congress' attention to
such an important and pressing issue as the critical shortages in our
Nation's health care workforce.
In addition to serving as Interim Dean of the Medical School, a
post I assumed earlier this month, I also come to this issue from my
additional roles: as president-elect of the American Geriatrics
Society, and as a physician who has worked in geriatric medicine, as
clinician, educator, scientist and administrator, for more than 30
years. From each of these vantage points, I see a deeply troubling
future for health care of our citizens.
In deference to the expertise represented elsewhere on this panel,
I'd like to limit my brief remarks this morning to three topics:
First, a broad overview of the physician workforce trends,
and how they influence and are influenced by our health care system;
Second, the interconnection between physicians and other
health care professionals, whose fields are suffering from shortages
far more severe than in medicine, and how those shortages affect
medical education and medical practice; and
Finally, as a geriatrician, I'd like to share my serious
concerns about the coming collision between our rapidly growing aging
population and the paucity of doctors trained to adequately manage
their care.
Physician Supply
If there is any good news in physician workforce trends, it is that
there is probably an adequate number of physicians practicing in the
United States overall. The bad news, however, is that in more than half
the country, these practitioners are working in the wrong places and
have skills and training that are not matched to areas of need.
Imagine if the Red Sox had a total of nine players in the dugout,
but they were three first-basemen, six catchers, and no one to play the
outfield.
Here in Rhode Island, some of the most recent data available
suggests that psychiatrists, certain pediatric specialists,
geriatricians and primary care physicians are in critically short
supply. In many of these cases, managed care policies and Medicare
reimbursement biases exacerbate or drive these trends, particularly
threatening access for our elderly citizens.
Interconnection of Professionals
Even in practice areas not currently plagued by shortages, the
undersupply of nurses and other health care professionals impairs the
way physicians function, and the care they deliver at the bedside.
Increasingly--and this is especially true in my field of
geriatrics--delivering quality health care is a team effort. Many
factors, including increasing medical complexity, the growing role of
medications in treating and managing disease, and the time-compressed
nature of a doctor's practice mean that physicians rely more than ever
on nurses, therapists, pharmacists and other health professionals to do
things that they historically have done alone.
These non-physician health care professionals have received more
specialized training and can now perform these tasks more economically
and just as effectively as most physicians. Nurse clinicians, for
example, are far better equipped to prevent, detect, and treat bed
sores. Pharmacists are more likely to notice potential drug-disease and
drug-drug interactions and flag them before harm occurs.
You'll hear more specifics this morning from my fellow panelists
about the alarming workforce trends in nursing, pharmacy, and radiology
technologists. For my part, I want to reiterate, as a physician and an
educator, that every aspect of medical practice, as well as medical
education and medical research, relies on a foundation of teaming with
nurses and allied health professionals. When members of the team
vanish, the foundation weakens, and eventually crumbles.
This is not the time to roll back support of vital Title VII and
Title VIII programs, as has been proposed by President Bush. This
funding supports a variety of training and scholarship programs in the
State of Rhode Island. These programs are designed to increase the
number of primary care providers, particularly in rural and other
underserved areas, through training in multidisciplinary settings.
Additionally, the grants seek to diversify the health professions
workforce by recruiting and training underrepresented minorities. I
applaud your efforts to restore these important funds, and I hope
you'll count on us as your partner in making that happen.
The Acute Shortage in Geriatrics
Finally, I'd like to close by doing what all geriatricians are
trained to do: advocate for the optimal care of elderly patients.
There is an acute and worsening shortage of geriatricians that
threatens the well-being of older Americans--a group that will double
in numbers in the next 30 years. National estimates project that we'll
be 25,000 geriatricians short by the year 2030 if current trends
continue. In Rhode Island alone, we are 50 geriatricians short,
relative to need. 5-0. And the problem is even bigger than that number
suggests, since geriatricians not only care for elderly patients, but
also they train other physicians how to best diagnose and treat the
complex, multi-system diseases and conditions that most often beset our
oldest citizens. In this case, as with nursing, we're short on doctors
AND we're short on teachers.
Ironically, Medicare, the very program created to serve older
Americans' health needs and to fund graduate medical education, does
not pay for the training of geriatricians.
Because of the residency caps imposed as part of the Balanced
Budget Act of 1997, academic medical centers are not free to respond to
the growing need for geriatricians by expanding their residency
programs to include training of geriatricians. Because geriatrics was a
new and emerging field when the caps were imposed, the training slots
around the country were limited, and despite the increasing demand,
Medicare support has been frozen in time through the BBA--funding no
new residency slots unless teaching hospitals cut other residencies.
Here in Rhode Island, one of the oldest and fastest aging States in the
country, we were only able to launch our new geriatric fellowship
program through the generosity of the Miriam Hospital Foundation and
Brown's other affiliated hospitals.
I urge you and your Senate colleagues to consider, as part of this
year's health care legislation, giving hospital-based teaching programs
the necessary flexibility to increase their residency slots to meet the
changing health care needs of a changing America.
Thank you for your time, and I would be happy to answer any
questions.
Senator Reed. Thank you very much, Doctor, and let me now
call upon the technician.
Nancy Roberts.
STATEMENT OF NANCY ROBERTS, MSN, RN, PRESIDENT AND CHIEF
EXECUTIVE OFFICER, CARE NEW ENGLAND HOME HEALTH
Ms. Roberts. Good morning. It is both an honor and a
privilege to be here and testify and have such distinguished
panelists with me.
Thank you, Senator Reed, for holding this hearing.
We have come together today because nationwide we face a
healthcare worker shortage of an unprecedented nature. Young
men and women are choosing alternative career paths. Practicing
nurses are leaving our profession in droves, due to the intense
job dissatisfaction, the rigors and demands of documentation
and paperwork.
Care New England Home Health staff visit each and every day
600 patients throughout Rhode Island, traveling quietly,
providing care and compassion for patients and families. Plus
in our State we estimate that over 3,000 patients each and
every day receive home health visits. These patients encompass
the entire lifespan, ranging from pre-natal mothers and the
tiniest of infants to those individuals experiencing their
final days.
While this estimate is at 3,000, there are probably another
300 to 400 patients in hospitals and long-term care facilities
awaiting discharge. They struggle with meeting the demand upon
the staffing capacity of home health agencies. Like hospitals,
home health agencies are struggling each and every day. It is
not uncommon to hear from hospital discharge planners that they
have called eight to nine agencies trying to find a home for a
home health patient.
In home health agencies, we employ a variety of
professionals and para-professionals, including nurses,
physical, occupational and speech therapists, social workers,
family workers, childhood and administrative personnel. These
group of individuals work together after the patient has been
discharged from a hospital, from a skilled nursing facility or
referred from the community, provide care in the comfort and
privacy of their home.
While much of our media attention has focused on the
nursing shortage in our acute care settings, as it should,
based on the fact that that is where the majority of patients
receive their care, clearly we are seeing the same struggle,
the point of which is a patient is discharged from a hospital,
return to their home to the community. It is there when a
national crisis bumps up against home health care.
Leslie Jean Neal, respected home health author writes, and
I'll quote: ``Early hospital discharge and understaffing often
preclude thorough teaching from occurring in the hospital. Even
when the patient theoretically has been given sufficient
teaching to understand the care that will be necessary at home,
the patients and caregivers are often overwhelmed and stressed
by the amount of information they received.'' It is lost for
forgotten by the time the nurse arrives. To properly care for
each and every patient, home health care reaches beyond book
learning. To reach beyond book learning means that the nurse,
the home health care nurse uses information and experiences
that are necessarily derived from former schooling. Intuition,
creativity, the ability to be innovative, interpersonal skills
and the knowledge that comes through general life experience,
reaching once again beyond book learning. Clearly the demands
that are on home health nurses go far beyond their traditional
education.
In the interest of time, I will not relate specific stories
in terms of what nurses encounter day in and day out, but
suffice to say, that the challenge that a nurse has in
providing care in the community without the needed resources,
both in terms of family support and community resources,
clearly strain and challenge the most creative and innovative
nurse.
Survey after survey, points to increase job dissatisfaction
by nurses and other health care workers, a recent report
released by Robert Wood Johnson Foundation, written by Bobbi
Kimball, and Edward O'Neill, and again I will quote: ``This
shortage, the shortage of today is unlike any of those in the
past and requires bold new solution. It calls far re-
envisioning the nursing profession itself so that we can emerge
from this crisis and in equal partnership with the profession
of medicine.'' The authors go on to say, ``Work environments
for nurses are more demanding, less fulfilling and more
stressful. These circumstances have impeded many nurses for
providing care that meets their competencies and their
standards of professionals. The resulting dissatisfaction and
disillusionment has led to difficulty in retaining and
recruiting new nurses in many settings.''
We must clearly provide unprecedented levels of education
and to support to our existing staff. While home health is not
an ideal match for many new graduates, and perhaps even some
seasoned practitioners, our experience with recruitment
requires us to be very different from the hospital approach,
focusing on experienced personnel rather than those who are
brand new graduates. Clearly a home health nurse or a home
health professional needs to have a keen interest in caring for
patients at home.
It is essential as an organization that we redefine our
role of health care workers. Our organization needs to come
together to create an image of health care workers through the
use of media and public service announcements.
Specific to home health, we must reposition the practice to
be fully recognized as the specialty it is. We must do a better
job of telling our story, telling the story of the home health
care worker and what that means to our patients in the
community. Education is a key element to that.
To that end, the Senate Bill 1864, the Nurse Reinvestment
Act, which is designed to educate our national and local
communities and other nursing professions. Clearly, the story
of home health must be told as we begin to roll out what it
means to our community to be without the precious resources of
nurses.
Finally, it is essential that we prepare our home health
care workers with the necessary tools to work in the community,
to meet the many demands upon them. The advanced skills, while
they have not been in the area of technical competencies, they
lie in the area of communication, negotiation, conflict
management, innovate practice.
Finally, we must all continue together to work together,
all areas of our health care continuum. This is not a crisis
that effects only one area. We are all affected, and I call on
each and every one of us here today to think about recreating
the image for them to work with quality of work life that they
have within the community, both, as well as the major care
setting.
Thank you, Senator Reed.
[The prepared statement of Nancy Roberts follows:]
Prepared Statement of Nancy Roberts
Good afternoon. My name is Nancy Roberts and I am the President and
Chief Executive Officer of Care New England Home Health. I would like
to thank Senator Jack Reed and the Senate Committee on Health,
Education, Labor and Pensions for holding this special field hearing,
``Who Will Care for Us? The Looming Crisis of the Health Workforce
Shortage.'' It is both an honor and privilege to be here today sharing
the stage with distinguished colleagues who are also stakeholders in
helping to solve this crisis. My comments today will focus on how this
shortage is impacting the delivery of home health to patients and their
families in Rhode Island and provide recommendations for change based
on my experiences as a practicing nurse, educator and healthcare
administrator for the past 25 years.
We have come together today because nationwide we face a healthcare
worker shortage of an unprecedented nature. Young men and women are
choosing alternative career paths, and practicing nurses are leaving
the profession every day due to intense job dissatisfaction, and the
rigors of expansive and extensive paperwork that takes time away from
providing true nursing care.
Care New England Home Health is one of the largest home health
organizations in the State, consisting of the VNA of Care New England,
Kent Hospital Home Care and HealthTouch. On a daily basis, we visit
over 600 patients, quietly traveling throughout Rhode Island, providing
care and compassion for patients and their families within the comfort
of their homes. Collectively, it is estimated that close to 3,000
individuals receive a home health visit each day. These patients
encompass the entire life span, ranging from pre-natal mothers and the
tiniest of infants to those individuals experiencing their final days.
While this estimate is at 3,000, there are probably another 300 to
400 patients held over in hospitals and nursing homes daily, because
much the same way, the hospitals struggle with meeting the demands of
nursing staff to meet patient care needs, home health agencies are also
struggling. It is not uncommon to hear that hospital discharge planners
may have to call nine or ten home health agencies before they can place
a patient. We are also operating at peak capacities and attempting to
meet massive needs with limited workforce resources.
In home health, on a national level, we saw 51,000 fewer nurses
available to work in Medicare-certified home health agencies from 1996
through 1999. This trend has continued and worsened in many areas. Home
health plays a vital role in the overall continuum of care. We employ a
variety of professionals and para-professionals, including nurses,
physical, occupational and speech therapists, home health aides,
nutritionists, family workers, social workers, chaplains and
administrative personnel. This collective group works together after an
individual has been discharged from a hospital, skilled nursing
facility or referred from the community, providing care to ensure that
multiple needs are met and positive health outcomes obtained.
Much of the national attention and media has focused on the nursing
shortage in our acute-care settings, our hospitals. This is logical, as
this is where the majority of Americans receive their health care.
However, there is a point, and it is at discharge from the hospital
back to the patients home, where this national crisis, bumps up against
home health. Patients are discharged following hospitalization with a
myriad of medical and psychosocial needs.
Leslie Jean Neal, respected home health author writes, ``Early
hospital discharge and understaffing often preclude thorough teaching
from occurring in the hospital. Even when the patient theoretically,
has been given sufficient teaching to understand the care that will be
necessary at home, the patient and caregivers are often so overwhelmed
and stressed that the information is lost or forgotten by the time the
home health nurse arrives. To properly care for the patient, the home
health nurse reaches beyond book learning. To reach beyond book
learning means that the home health nurse uses information and
experience that are not necessarily derived from formal schooling.
Intuition, creativity, the ability to be innovative, interpersonal
skills, and the knowledge that comes through general life experience
reach beyond book learning.''
At this point, I would like to share a story that illustrates the
complexity of caring for patients in their homes. Home health workers
must posses a unique set of competencies including flexibility and
persistence in order to meet multiple patient needs and demands. They
must effectively utilize technology, succinctly address multiple
audiences using advanced interpersonal and communication proficiencies,
and utilize advanced problem-solving and management expertise to access
and implement community resources. Now, for my story.
In March, at 13 weeks pregnant, Mary (name has been changed), a
young, very proud, uninsured Hispanic woman who spoke little English
was rushed to the hospital. It was discovered that she had an ectopic
tubular pregnancy that required immediate surgery due to severe
complications. Without the surgery, Mary would die. After the surgery
and following a very brief in-patient stay, she was discharged to home.
It was then that the VNA of Care New England received the referral for
twice a day wound care and dressing change for her surgical incision.
Mary's home consisted of one-room in a multi-family house on the
south side of Providence. It is common knowledge that the crime rate
exceeds the State average in this area and is generally regarded as
unsafe to travel into after dark. Mary had few supports in place to
help her during this difficult time. While her mother agreed to
purchase and deliver the necessary wound care supplies to her home, she
refused to participate in her care. Mary was forced to hide these
supplies for she feared any number of individuals that frequented this
multi-family home might steal them from her room.
After receiving Mary's referral from the hospital Discharge
Planning Department early on a Tuesday morning, the VNA prepared to
send a bi-lingual nurse to Mary's home for the evening wound care and
dressing change. The VNA nurse, Susan, arrived at the home after dark
at 7 pm to be greeted by a large pit bull standing inside the fence of
this multi-family home.
Mary had no phone, so Susan was unable to call and ask that the pit
bull be restrained. Caught between finding a way to care for Mary and
her own safety, she returned to her car and placed a call to the
evening manager. She ignored the unsafe nature of the neighborhood,
locked her car doors and did what needed to be done.
Through thoughtful deliberations, Susan and her manager decided to
contact Mary's mother, the only known support Mary had identified, who
had refused to participate in her actual care. She agreed to reach
someone within the home and ask that the pit bull be restrained so
Susan could safely enter the home. Mary's mother refused to release
this phone number or the name of the individual she had spoken with to
any VNA personnel.
Upon entry, Susan went immediately to Mary's room, to find her with
an elevated temperature and a surgical wound showing early signs of
infection. The physician was called and a new antibiotic ordered. Susan
began the process of caring for the wound and communicating what was
happening to Mary. Susan placed a call to her manager who contacted
Mary's mother asking that she go to the pharmacy to pick-up the
medication. She agreed and ultimately brought it to Mary at 11 p.m.
Susan stayed with Mary during this time as her temperature continued
rising and she wanted to ensure that she understood how to take her new
medication.
When Mary's mother did arrive, Susan thanked her for getting the
medication, administered it and gave specific instructions on what to
do should her condition worsen during the night. Susan asked to speak
with Mary's mother outside of her room and explained the need for
someone to monitor her condition throughout the evening. She refused
and walked to the front door of the home. Looking out the small glass
paned window of the locked door, both Susan and Mary's mother
encountered the pit bull in the fenced in yard. Susan asked that Mary
introduce her to the keeper of the dog, which she did after
considerable protest.
Through expert negotiation skills with Mary's mother, Susan was
able to get the phone number of the pit bull's keeper and left for home
after a visit that should have been 1-hour turned into a 5-hour ordeal.
However, the work was not over, Mary needed to be seen again tomorrow
by 10 a.m., and this was Susan's planned day off. On her way home,
Susan once again contacted her manager who agreed to communicate that
evenings' events to the morning manager.
This story goes on with many twists and turns along the way.
However, the end result was that Mary received the care she needed for
almost 6 weeks and completely recovered. What it took to provide this
care was considerable negotiations with Mary, her mother, all staff
members involved in her care, communication skills that expanded well
beyond the norm and an engagement of multiple community resources.
At this point you are probably thinking to yourself, ``What does
this story have to do with the healthcare worker shortage?'' Before we
can hope to have an impact on solving this huge challenge, we must
recognize a common starting point. What is the common point? Where do
all roads meet? Survey after survey points to increased job
dissatisfaction by nurses and other healthcare workers. A recently
released report commissioned by the Robert Wood Johnson foundation
entitled, ``The American Nursing Shortage'' by Bobbi Kimball, RN, MBA
and Edward O'Neill, Ph.D., MPA states, ``This shortage is unlike any of
those in the past and thus requires bold new solutions. It calls for a
re-envisioning of the nursing profession itself, so that it can emerge
from this crisis stronger and in equal partnership with the profession
of medicine.''
Kimball and O'Neill go on to further state, ``Work environments for
nurses are more demanding, less fulfilling and more stressful. These
circumstances have impeded many nurses from providing care that meets
their standards of competence and professionalism. The resulting
dissatisfaction and disillusionment has led to difficulty in retaining
and recruiting new nurses in many settings.''
The story I just shared with you highlights the need for
development of these advanced competencies. As Kimball and O'Neill
stated, nursing work environments are more demanding, less fulfilling
and more stressful. I propose that a well prepared nurse who has
received adequate training and education to help diffuse situations
akin to one I just related to you, will not only come away from these
situations a winner, but will also develop her skills beyond the role
of traditional nursing care. We must provide unprecedented levels of
education and support to our existing staff. I see this as particularly
important for home health. Today's home health workers are far more
than nurses, therapists and aides, they are masters of skills that
reach far beyond their traditional schooling.
Home health is not an ideal match for many new graduates and even
some experienced practitioners because of the level of autonomy needed
to practice independently in patient homes and fully engage in
competencies that are learned and refined through practice. Therefore,
our recruitment efforts and requirements tend to be much different than
those of our hospital partners, focusing on experienced personnel and
those with a keen interest in caring for patients within their homes.
It is because of these requirements that we face a disadvantage
with nurses and other home health workers joining us later in their
careers, leaving us with fewer productive working years and shortening
our retention cycle by virtue of advanced age. According to the latest
National Sample Survey of Registered Nurses, the average age of the
working registered nurse population was 43.3 in March of 2000, up from
42.3 in 1996. The average age of registered nurses working in Rhode
Island home health agencies is 46-years-old. We find recruitment
extremely challenging as nurses at this age have been jaded by negative
experiences in other institutions, the onerous paperwork associated
with nursing and a general feeling that their efforts are not rewarded
or recognized.
With all of this said, it is essential that we prepare our
organizations to redefine the roles of our healthcare workers. It is
logical to embrace Kimball and O'Neill's recommendation of increasing
the supply and retention of nurses by regarding them as strategic
assets and making positive changes in the work environment. This may be
achieved in a number of different ways including addressing staffing
levels, offering flexible scheduling, mentoring roles, promoting
professional autonomy in clinical decisionmaking, building needed
competencies and expertise in specialty nursing care and leadership;
developing and testing new care delivery models, creating work options
for aging nurses and making use of technology that saves time and money
and speeds clinical decisionmaking.
Our organizations need to come together to create a new image of
healthcare workers through the use of media and public service
announcements and active engagement at both the national and State
levels. We must enhance the image of the profession, promote diversity
in the workforce, encourage people to enter the nursing profession, and
encourage career development for nurses.
Specific to home health, we must reposition the practice to be
fully recognized as the specialty that it is. We must do a better job
of telling the story of the many merits of home health and the
satisfaction that nurses, other healthcare professionals and para-
professionals may ultimately have by joining this unique practice
setting. It is unlike any other setting because each situation from
home to home changes dramatically and oftentimes it is only the
individual practitioner who has the power to make an immediate
difference in the life of a patient.
In closing, I would like to provide recommendations specific to
addressing this shortage as it relates to home health and the need for
the ongoing provision of this vital element in the overall healthcare
continuum.
Education appears to be a key element in all that I have discussed
today. This education needs to span across our communities as suggested
by Neal, Kimball and O'Neill as well as several other noted authors.
Congress seeks to provide public awareness through authorization of $10
million through Senate Bill 1864, the Nurse Reinvestment Act which
would educate our national and local communities on the nursing
profession. It is imperative that we include the home health story as
we face significant recruitment challenges when seeking nurse
specialists. As I mentioned earlier, we care for the tiniest of infants
to those experiencing their final days. There are tremendous
opportunities for pediatric nurses; IV nurses, and those interested in
gerontology or hospice to find fulfillment in the home health setting.
However, we need to educate both our existing pool of potential
candidates as well as novice nurses coming through the ranks that these
opportunities are available to them. The need for home health care will
only continue to grow, as our population ages, especially here in Rhode
Island as we are home to one of the highest per capita percentages of
those over the age of 65. Also, we are faced with patients being
discharged from hospitals both quicker and sicker in desperate need of
home healthcare.
Within the Nurse Reinvestment Act, there is a provision for the
development of grants for nursing internships and residency programs.
If these grants ultimately are awarded to our Rhode Island universities
and colleges, I propose that a home health care specialty program be
developed. I call on the educators here today to consider this and
pledge to work with you to develop appropriate curricula to help train
our healthcare workers of tomorrow.
I challenge my colleagues in home health to look at the hospital
magnet facilities that have so successfully created institutions that
attract and reward nurses. The success of these institutions recognizes
that quality work life is important, ongoing learning and training is
key and staff development must be ongoing.
This sort of certification is needed for home health. We must
recognize that paradigm shifts in institutional and organizational
cultures are necessary to facilitate the type of changes seen at these
magnet institutions and work toward creating these shifts within our
own organizations. It is essentail that we provide our home healthcare
workers with the necessary tools to meet the many demands put upon them
in homes throughout our communities. We must recognize that it is no
longer enough to be clinically advanced, but home healthcare workers
must also possess skills that allow them to be conductors of all
aspects of the care delivered in our patients' homes. They must be
master communicators, organizers and jack-of-all-trades. We must give
them the tools to complete their jobs successfully or we only set them
up to fail and possibly leave the home health or healthcare profession
in its entirety.
Finally, we must all continue to work together. This is not a
crisis that impacts only one area of our healthcare continuum. We are
all affected. I call on each one of us here today to think about
recreating the image of healthcare workers, to think about recreating
our own organizations and to embrace the challenge and know that our
work can make a difference. Susan made a difference in Mary's life as
she worked diligently and tirelessly to ensure that care was provided.
We must attack this shortage with the same diligence and work toward
creating responsive workplaces that create a quality of life for our
employees that is satisfying.
I challenge us to be mindful in our preparations, to not be
shortsighted in our implementation of programs that may seem right at
the moment, but may not present a long-term viable solutions. It is our
ultimate responsibility to work toward making positive changes in our
healthcare work environments if we hope to significantly impact and
change cultures.
We need to focus on preparing the healthcare work force of the
future. It is incumbent upon us as leaders to recognize that we must
prepare now, to ensure that this crisis does not haunt the American
healthcare system for a protracted period of time and continue to limit
the care we are able to provide to those in need.
Once again, I would like to thank Senator Reed and the Senate
Committee on Health, Education, Labor and Pensions for holding this
special field hearing and allowing me the opportunity to share these
recommendations for action with you.
Senator Reed. Thank you very much.
Ms. Norma Owens.
STATEMENT OF NORMA OWENS, PHARM.D., PROFESSOR OF PHARMACY,
DEPARTMENT OF PHARMACY PRACTICE,
UNIVERSITY OF RHODE ISLAND
Ms. Owens. Thank you, Senator Reed, for inviting me and the
College of Pharmacy to speak on this critical topic. Dean
Letendre and Associate Dean Lausier of the College of Pharmacy
send their bests to you and this audience. They're in
attendance at the annual meeting of the American Association of
College of Pharmacy. This is a premier professional group that
deals with issues in pharmacy education, including the present
shortage of pharmacists.
In December 1999, the Secretary of Health and Human
Services conducted a national study to determine the extent of
a pharmacist shortage. This report was provided to Congress 1
year later and provides much useful information.
Pharmacists are the third largest health professional group
in the United States with approximately 196,000 active
pharmacists in 2000. About two-thirds of these pharmacists work
in the community for retail pharmacies; the remainder are
employed by hospitals, long-term care, the pharmaceutical
industry, manufacturing, managed care and insurance groups,
home health and universities. Over the last 10 to 20 years
employment opportunities for pharmacists have greatly expanded,
while the supply of pharmacists has remained essentially even,
roughly about 68 pharmacists per 100,000 citizens in 1991 to 71
pharmacists per 100,000 in 2000.
The increase in demand for pharmacist is related to many
factors including:
A rapid rise in prescription growth, somewhere around 44
percent increase from 1.9 to 2.8 billion from 1992 to 1999.
Also, market growth and competition among retail pharmacies
has lead to longer pharmacy store hours and new store openings.
There is an increase in professional practice
opportunities.
There is an increase in access to health care that has
impacted pharmacists in two ways. First, in the number and
variety of professionals who are authorized to prescribe
medications; and, second, in the insurance coverage for
prescription drugs.
And I will say parenthetically here that I look forward to
prescriptive rights, prescriptive privileges for Medicaid.
Also, there is an increase in the number of female
graduates in pharmacy who work part time. In 1970, female
pharmacists accounted for 13 percent of the pharmacist
workforce. Today they account for greater than 46 percent of
the pharmacist workforce.
Finally, there has been an increase in the number of years
needed to graduate from a College of Pharmacy from 5 years to 6
years, as the profession has changed from requiring a Bachelor
of Science to a Doctor of Pharmacy as the entry-level degree.
At URI, we have phased in the Doctor of Pharmacy degree while
phasing out the BS in Pharmacy over 3 to 4 years. Nonetheless,
all schools in college and pharmacy will have a 1-year gap
where only a few, or no pharmacists graduate.
As a result of these changes, pharmacists' salaries have
greatly increased, vacancy rates are high, and successful
employers offer economic incentives, such as sign-on bonuses,
automobile leases and relocation funds. There is grave concern
that pharmaceutical care services to the patient may be
jeopardized by the pharmacist shortage leading HHS to define
the shortage as both acute and severe.
On a personal note, the University, the College of Pharmacy
and my department have been adversely affected by the change in
the pharmacist workforce. Everyone in my Department of Pharmacy
Practice is a pharmacist. In most academic circles, I would be
regarded as a young-to-middle-aged faculty member, but in my
department I am the oldest, and really ancient, faculty member.
In my 20 years of employment at URI, there has never, never,
never, never been a year when a departmental member has not
resigned. The faculty who have worked with me have been
passionate and excellent practitioners who have changed the
lives of many pharmacists and improved the health care of Rhode
Islanders. They are now working in the pharmaceutical industry,
in advanced practice positions, in a variety of settings, and
for other academic institutions. For the past 2 years, a
pharmacy practice faculty member has received the ``Teacher of
the Year'' award at the College only to leave URI for
employment elsewhere. In the past 2 weeks, another faculty
member tendered her resignation. Our faculty leave URI with
heartfelt regret, and for the same reasons one would expect
given the economic and social issues at work.
I believe the administration at the College and University
would very much like to increase student enrollment in
Pharmacy. Faculty vacancies in my department is only one
variable limiting our ability to graduate more pharmacists. I
can see no quick or easy solution to the problem of the
pharmacist shortage, but I am confident that URI and the
College of Pharmacy are open and willing to try and address
this problem. And thank you for inviting me.
[The prepared statement of Norma Owens follows:]
Prepared Statement of Norma J. Owens
Thank you, Senator Reed, for inviting the College of Pharmacy to
speak on this critical topic. Dean Letendre and Associate Dean Lausier
of the College of Pharmacy send their regrets to you and this audience.
They are in attendance at the Annual Meeting of the American
Association of Colleges of Pharmacy--the premier professional group
that deals with issues in pharmacy education including the present
shortage of pharmacists.
In December 1999, the Secretary of Health and Human Services
conducted a national study to determine the extent of a pharmacist
shortage. This report was provided to Congress 1 year later and
provides much useful information.
Pharmacists are the third largest health professional group in the
U.S. with approximately 196,000 active pharmacists in 2000. About two-
thirds of all pharmacists work in the community for retail pharmacies;
the remainder are employed by hospitals, long-term care, pharmaceutical
manufacturing, managed care and insurance groups, home health, and
universities. Over the last 10 to 20 years, employment opportunities
for pharmacists have greatly expanded while the supply of pharmacists
has remained essentially even--roughly 68 per 100,000 citizens in 1991
to 71 per 100,000 in 2000.
The increase in demand for pharmacists is related to many factors
including:
A rapid rise in prescription growth--a 44 percent increase
from 1.9 to 2.8 billion from 1992 to 1999,
Market growth and competition among retail pharmacies that
has lead to longer pharmacy store hours and new store openings,
An increase in professional practice opportunities,
An increase in access to health care that has impacted
pharmacists in two ways--first in the number and variety of
professionals who are authorized to prescribe medications and second,
in the insurance coverage for prescription drugs,
An increase in the number of female graduates in pharmacy
who work part time. In 1970, female pharmacists accounted for 13
percent of the pharmacist workforce, today they account for greater
than 46 percent,
An increase in the number of years needed to graduate from
a College of Pharmacy from 5 to 6 as the profession has changed from
requiring a Bachelor of Science to a Doctor of Pharmacy as the entry-
level degree. At URI, we have phased in the Doctor of Pharmacy program
while phasing out the BS in Pharmacy over 3-4 years. Nonetheless, all
schools will have a 1 year gap where only a few, or no, pharmacists
graduate.
As a result of these changes, pharmacist's salaries have greatly
increased, vacancy rates are high and successful employers offer
economic incentives such as sign-on bonuses, automobile leases, and
relocation funds. There is grave concern that pharmaceutical care
services to the patient may be jeopardized by the pharmacist shortage
leading HHS to define the shortage as both acute and severe.
On a personal note, the University, the College of Pharmacy, and my
department have been adversely affected by the change in the pharmacist
workforce. Everyone in the Department of Pharmacy Practice is a
pharmacist. In most academic circles I would be regarded as a young- to
middle-aged faculty member, but in my department I am the ``oldest''
faculty member. In my 20 years of employment at URI, there has NEVER
been a year when a departmental member has not resigned. The faculty
who have worked with me have been passionate and excellent
practitioners who have changed the lives of many pharmacists and
improved the health care of Rhode Islanders. They are now working in
pharmaceutical industry, in advanced practice positions in a variety of
settings, and for other academic institutions. For the past 2 years, a
pharmacy practice faculty member has received the ``Teacher of the
Year'' award at the College only to leave URI for employment elsewhere.
In the past 2 weeks, another faculty member tendered her resignation.
Our faculty leave URI with heartfelt regret and for the same reasons
one would expect given the economic and social issues at work.
I believe the administration at the College and University would
very much like to increase student enrollment in Pharmacy. Faculty
vacancies in my department is one variable limiting our ability to
graduate more pharmacists. I can see no quick or easy solution to the
problem of a pharmacist shortage but I am confident that URI and the
College of Pharmacy are open and willing to try and address this
problem.
Senator Reed. Thank you very much, Dr. Owens.
I want to thank all the panelists for their excellent
testimony.
I will take my 5 minutes of questioning and then ask if the
Lieutenant Governor may want to participate. Recognizing that
Dr. Amaral and Dr. Besdine are getting ready to leave, let me
direct questions to them first.
You both referred to in your testimony about the use of
technology, and on two related questions, one, can technology
be used to try to positively change the current paperwork-
dominated environment that seems to be so much effecting the
recruitment of nurses by a professional, and on the other side,
are the schools, the professional schools preparing new
pharmacists, new nurses, new radiologists, et cetera,
technicians to be technologically sophisticated in order to
participate in that workforce? If you can answer both those
questions.
First, Dr. Amaral.
Dr. Amaral. I do believe that technology can make the work
life easier, but right now it carries the complex problem, that
many people are not technologically literate enough and can
actually increase the stress in their job. It is also true that
the technology is scattered into different types that aren't
very good industry standards, so it makes it a difficult
process.
The future is bright, because I think it will, but in the
short term I think there are major problems. And, in addition,
it is the incredible cost associated with implementing this
technology.
As far as training people in this, I really cannot speak
well to that in terms of pharmacy or nursing. I think medical
education, again, if you have it there, you can train people.
If you don't have it, you cannot. I would assume it is going to
be the same in other health care professions.
Dr. Besdine. I don't disagree with anything that Joe said,
which is difficult; however, I think we can only go so far with
technology relieving the burden on clinical providers who are
in short supply as the current regulatory environmental permit,
and the regulatory environment for documentation, as well as
for reimbursement is so burdensome at this time that I see that
as really the major impediment, and technology can really only
alleviate a small portion of that.
Regarding the preparation of health professionals,
ironically what I see is that our graduating physicians and
other health professionals are actually better technologically
prepared than some of their faculty, and they're ready in the
workplace, which is widely variable in its ability to plug them
into utile technologies.
Senator Reed. Nancy and then Norma, Ms. Roberts, the
Professor of the School of Pharmacy.
Ms. Roberts. Sure. I guess as we look ahead we do know that
our nurses today are spending 60 percent of their time
documenting and only 40 percent of their time in actual patient
care. A striking statistic. You look at technology in our home
health environment, our major plan is what you call a point-of-
care system, where there would actually be documentation that
will be done on a laptop computer in the home. That information
will be translated with a directive from a physician's office.
But, just as my colleagues have mentioned, we have some
technologic challenges before us, in terms of our workforce and
their preparation. I believe those will ultimately assist us,
whether they will be time savings or the quality of our care
really being enhanced, I think, is debatable at this point.
Senator Reed. Dr. Owens.
Ms. Owens. I think pharmacists have always embraced
technology and utilize it to an above-average amount in the
profession, including robotics, the vendor machines, like
issues to dispense, or machines to dispense in locations, and
our students are quite comfortable with technology.
I think one area where more effort could be spent would be
in the education trained and pharmacy technician, which we
don't have at the University of Rhode Island. I believe CCRI is
to trying to implement a program, so maybe additional
personnel, and I think we have done a job good, and our
students are not scared of technology and neither are the
pharmacists who practice. It has done a lot to help alleviate
some of the pressures.
Senator Reed. Before you leave, Dr. King, a follow-up on
some of your responses. It seems that technology does offer
some help going forward, but a critical issue of just the lack
of skilled professionals is looming, and it seems to be a
vicious circle. The harder it is to recruit new skilled
professionals, the more difficult it is for existing
professionals to do their job, they get frustrated, they leave,
they go off. Is that a fair description of the process? Just a
yes or no.
Dr. Amaral. Yes.
Senator Reed. The first rule in the Senate is I can make
some rules, so I'm going to ask Dr. King some questions,
because you were so kind to come here today, and your testimony
was outstanding, Doctor. Thank you.
You've looked at this problem of health care professionals
in Rhode Island and throughout New England. We seem in Rhode
Island at this moment to be doing fairly well in terms on
nursing and pharmacists relative to other States, but the
future is bleak. What existing shortages do we have, or work
shortages outside of pharmacy and nursing in the State of Rhode
Island? Do you have that there?
Mr. King. I don't have that on the top of my head. I know,
as was mentioned, radiology technicians is one area, but
actually even the broader area, laboratory technicians is also
another area that has popped up throughout New England. I
haven't specifically looked at Rhode Island, but I know
particularly in Massachusetts there's been an issue that has
popped up at Beth Israel, at a couple of other hospitals.
I see one of my colleagues who is willing to chime in.
Ms. Ross. Hi. I am Maureen Ross from the Department of
Health. I would say that our two most critical shortage areas
are mental, dental, and we see that in our health professional
shortage area designations through the system.
Senator Reed. Thank you.
Now, let me turn to the Lieutenant Governor for a question
or comments he may have. So, thank you, Doctor.
Mr. Fogarty. I know time is short. Are we doing anything to
try to go to such areas, in terms of growth in terms of this
profession and the specific programs that might help us in
dealing with the shortages?
Dr. Amaral. One area that I can speak to, there was a
Robert Foundation Grant, in group health and health centers in
a group of hospitals, allowing us to use those, which is a
means to not only respond better to people in the community who
do not have English as their primary language but also to turn
health care workers in being able to communicate. I think that
is a very important issue. The cultural competence of our work
staff needs to change. It is not culturally competent. In
States like Rhode Island, where it is changing very rapidly, it
becomes more of a problem, so we needed to do more. I think
that is an area to focus on.
Senator Reed. Well, I want to thank the panelists for their
excellent testimony. As I indicated, in the next 14 days if you
have additional material that you would like to give to us or
you prepared in response to our questions. Thank you very, very
much. We would like to wish you well.
I would like to call the next panel forward. We will go
ahead and change the name cards and the stenographer will
change the paper.
[Recess.]
Senator Reed. Let me, once again, call the hearing to order
and introduce our second panel.
Joining us is William Lynn McKinney, Ph.D. Dr. McKinney is
the Dean of the College of Human Science and Services at the
University of Rhode Island. He has served the University in
various roles as teacher or administrator for the last 30
years. He was recently named ``Professor of the Year'' by the
University of Rhode Island Honors Program and was elected
president of AIDS Care Ocean State. He is the former interim
executive director of the Rhode Island Project AIDS, former
volunteer member of Seniors Helping Others and Rhode Island
Furniture Bank. He was the first man named to the Board of
Directors of the Rhode Island Coalition Against Domestic
Violence.
In part because of these activities he is keenly aware of
the need for higher education, and particularly the role of his
college to address the needs of children and also their
families, especially those on the margins of society. Dr.
McKinney is seeking a clearer vision for Children, Families and
Communities Focus Area.
Maureen E. McGarry, Ph.D., R.N., N.C.C. Dr. McGarry is
currently the Dean of the Community College of Rhode Island
Nursing, Allied and Dental Health Programs. She has a doctorate
from the University of Connecticut in Professional Higher
Education Administration and has significant experience in
various aspects of nursing education. She is, as well, a
National Certified Counselor. She serves on the Governor's
Advisory Council on Health and Health Career Programs. She is a
member of the Health Membership Council, Hospital Association
of Rhode Island and of the Warwick Career and Technical Center
Advisory Board.
Her nursing career has included hospice care, drug
evaluation and community mental health. She has served since
1996 as a Member of the Hospital Association of Rhode Island.
She was a member of the Rhode Island Gerontology Exchange
Committee in the Department of Elderly Affairs and a member and
past president of the Rhode Island Board of Nurse Registration
and Nursing Education.
Barbara Schepps, M.D. Dr. Schepps is a radiologist and
Professor of Diagnostic Imaging in the Department of Diagnostic
Imaging at Rhode Island Hospital in Providence. She holds
faculty and hospital appointments at Rhode Island Hospital,
Brown University and Medical School, Women & Infants Hospital
and The Miriam Hospital. She has completed specialty training
in ultrasonography and mammography.
Dr. Schepps has served on numerous hospital committees,
including those in medical education, emergency medicine,
radiation safety, marketing, strategic planning, breast health,
elective admissions and credentials. She is the President of
the Hospital Staff Association at Rhode Island Hospital.
She has been significantly involved in women's health
screening, both in her faculty appointments and in her
participation in the American College of Radiology and the
Radiological Society of America.
In the last several years she has been named ``Rhode Island
Woman Physician of the Year'' and has been awarded the
``Excellence in Ambulatory Teaching Award'' for Clinical
Faculty at Brown University. This past spring she was listed in
America's Top Doctors: The Best in American Medicine.
Thank you, Doctor, very much for joining us.
James P. McNulty. James McNulty of Bristol, Rhode Island is
the President of the Manic Depressive and Depressive
Association of Rhode Island and currently serves as the
President of NAMI, formerly known as the National Alliance for
the Mentally Ill. He serves on the board of the Mental Health
Consumer Advocates of Rhode Island. In 2000, Donna Shalala,
then Secretary of Health and Human Services, invited Mr.
McNulty to serve on the National Advisory Mental Health
Council, a body that advises the Directors of the National
Institute of Mental Health, the Director of the National
Institutes of Health and the Secretary of Health and Human
Services. In addition, he has been facilitating for the last 11
years peer education and support groups focused on recovery.
Mr. McNulty has been active in involving patient and family
advocates in all aspects of treatment for mental illness. He is
currently participating in a NAMI initiative to involve
consumers and family members as members of institutional review
boards. In addition, he is studying the use of discontinuation,
challenge and placebo arms in psychiatric clinical trials and
the use in the United States of the criminal justice and penal
systems in the overall approach to mental illness.
Finally, we are joined by Wendy Laprade. Wendy is a staff
registered nurse at Women & Infants Hospital in Providence. She
served for several years in the women's in-patient surgical
unit and has been for 17 years a nurse in the 21-bed tertiary
care Labor/Delivery/Recovery Unit.
I am glad you are here, our stenographer is due in 2
minutes, Wendy, so it is nice to have a trained professional.
During those years, she also spent a year as a staff nurse
in Rhode Island Hospital's six-bed Cardiovascular Thoracic
Intensive Care Unit. She has had bedside nursing, charge,
preceptor/training and critical care responsibilities. She
served on the Quality Assurance Committee from 1991-1993 and
the Partnership Liaison for Labor/Management Initiative Grant
in 1994 and 1995. In 1995 and 1996 she was a maternal fetal
medicine nurse clinician.
She is licensed in Rhode Island and in Massachusetts as a
registered nurse and is a member of the Association of Women's
Health, Obstetrical and Neonatal Nurses and of the Rhode Island
State Commission chaired by Representative Elizabeth Dennigan
to study Acute Care Facilities Nursing Staffing.
Thank you very, very much.
She is currently an executive board member of the New
England Health Care Employees Union and a board member of the
SEIU Nurse Alliance Board.
Thank you very much.
Thank you for joining us today.
Dr. McKinney, again, if you could abide by our 5-minute
rule, which is violated only by the Chairman.
STATEMENT OF WILLIAM LYNN McKINNEY, DEAN, COLLEGE OF HUMAN
SCIENCE AND SERVICES, UNIVERSITY OF RHODE ISLAND
Mr. McKinney. Thank you, Senator Reed. The College of
Community Science and Services is the second on campus at the
University of Rhode Island. It includes the School of
Education, the Department of Textiles, Fashion Merchandising
and Design and three departments that have health-related
focus, Human Development and Family Studies, Communicative
Disorders and Physical Education and Exercise Science.
Health-elated programs at URI continue to experience
unprecedented high rates of application at both the
undergraduate and graduate levels. In speech pathology, in
physical education and exercise science and in physical
therapy, the demand far exceeds the available places. These
high application rates reflect the real need for highly trained
health care professionals throughout Rhode Island and the
region.
I could provide you seemingly endless statistics, but in
the interest of brevity I will cite only the following:
The U.S. Department of Labor estimates a greater than 36
percent increase in the number of positions available for
physical therapists in the next 8 years.
The American Hospital Association, Commission on Workforce
for Hospital Based Therapists, including physical, occupational
and speech therapists, says there is an 11 percent shortage at
the present time.
Earlier intervention with children is a burgeoning field,
and children in schools are expected to require a greater
physical therapy and speech therapy services as more and more
special education needs are identified.
Rhode Island, as you've heard earlier, has a high density
elderly population that is expected to grow. With current
uncertainty about the economy, we find many of these people
will be in the workforce much longer than they have been in
recent years, and in many cases much longer than they have
anticipated being. This, of course, may result in increased
workplace injury and the resulting need for physical therapy
services.
These statistics are among many that are alarming. Joining
them in raising my concern is increasing knowledge that we need
new types of professionals, particularly individuals whose work
is much more preventive as it is diagnostic and focusing on
treatment. But, our first inclination to focus our attention on
graduate level therapy programs, we must concomitantly enhance
our undergraduate programs in such areas as exercise, science
and nutrition and community health. In short, we need to
consider preventive measures as we also enhance our other
programs.
At the graduate level, accrediting bodies are responding to
changing needs across the Nation by changing expectations of us
at the university.
For example, in audiology, the required professional entry
degree will soon be a clinical doctorate. That will be true of
physical therapy in the near future as well.
As we respond at the University to our accrediting bodies
and plan the resulting changes that we must make on the campus,
we confront the realities of 2002. We would close programs only
when all other options were exhausted, but closures are a real
possibility. At the University and within the College we face
budget issues that reduce our flexibility and hiring educators
to supplement our schedule faculty, that prevent us being fully
competitive and offering undergraduate scholarships and
graduate fellowships and that diminish our confidence in having
a steady flow of capital for equipment and supplies.
To respond quickly and vigorously to the looming crisis of
health workforce shortages, we need, at a minimum, a 10-year,
$4-million program that would support the College of Human
Science and Services with flexibility in hiring faculty and
expand a base for undergraduate and graduate student support
and updated equipment and buildings.
As a result of this 10-year plan we can focus training as
market needs shift, we can create 3-year professorships in high
need areas, for example. We can increase the number of graduate
and undergraduate students in our programs, thus increasing the
number of trained professionals. We can attract stronger
applicants and thus stronger graduates. We can enhance our
relationships with community agencies and with schools,
providing more and more services that they require. We can
expand our capacity to work with employers, to enhance worker
safety and comfort and thus reduce workplace stress and injury,
and we can consolidate health-related professional training,
working toward creating a cohesive entity that would foster
multi-discipline clinical training, better patient care and
more efficient operation.
The problem confronting us will require increased
collaboration across all institutions, higher education and
with health care agencies throughout the State. As we in the
College of Human Science and Service at URI, I commit to that
collaboration and to a sustained focus on increasing the supply
of highly trained health care professionals.
As we respond to the impending crisis, I urge us all to
include preventive services.
We know that prevention is considerably less expensive than
commitment and remediation. I thank you.
[The prepared statement of William L. McKinney follows:]
Prepared Statement of William L. McKinney
The College of Human Science and Services is the second largest on
the University of Rhode Island campus and includes the School of
Education and the Departments of Textiles, Fashion Merchandising and
Design, Human Development and Family Studies, Communicative Disorders,
and Physical Education and Exercise Science.
Health-related programs at the URI continue to experience
unprecedented high rates of application, at both the undergraduate and
graduate levels. In Speech Pathology, in Audiology, in Physical
Education and Exercise Science, and in Physical Therapy, the demand for
seats far exceeds the available places. The high application rates
reflect the real need for highly trained health care professionals
throughout Rhode Island and the region.
I could provide you seemingly endless statistics, but, in the
interest of brevity, I will cite only the following:
The U.S. Department of Labor estimates a greater than 36
percent increase in the number of positions available for physical
therapists in the next 8 years.
The American Hospital Association's Commission on
Workforce for hospital-based therapists including physical,
occupational, and speech therapists.
Early intervention with children is a burgeoning field,
and children in schools are expected to require greater physical
therapy and speech therapy services as more special education needs are
identified.
Rhode Island has a high-density elderly population that is
expected to grow. With uncertainty about the economy, many of these
people will be in the workforce longer than they have been in recent
years. This may result increased workplace injury and resulting need
for physical therapy services.
These statistics are among many that are alarming. Joining them in
raising my concern is increasing knowledge that we need new types of
professionals, particularly individuals whose work is as much
preventive as it is diagnostic and treatment. While our first
inclination is to focus our attention on graduate level therapy
programs, we must concomitantly enhance our undergraduate programs in
such areas as exercise science, in nutrition, and in community health.
At the graduate level, accrediting bodies are responding to
changing needs by changing expectations of us at the University. For
example, in Audiology, the required terminal degree is no longer a
Master's, but a clinical doctorate. A clinical doctorate in Physical
Therapy will soon be required as well.
As we respond to our accrediting bodies and plan the resulting
changes that we must make on the campus, we confront the realities of
2002. We would close programs only when all other options were
exhausted, but closures are a real possibility. At the University and
within the College, we face budget issues that
Reduce our flexibility in hiring educators to supplement
our skeletal faculty.
Prevent our being fully competitive in offering
undergraduate scholarships and graduate fellowships.
Diminish confidence in a steady flow of capital.
To respond quickly and vigorously to the looming crisis of health
workforce shortages, I propose a 10-year, $4,000,000 program with
Federal funding that would support the College of Human Science and
Services with flexibility in hiring faculty, an expanded base for
undergraduate and graduate student support, and updated equipment and
buildings.
As a result of this 10-year plan, we could
Focus training as market needs shift; we could create 3-
year professorships in high need areas, for example
Increase the number of graduate and undergraduate students
in our programs, thus increasing the number of trained professionals.
Attract stronger applicant pools and thus stronger
graduates.
Enhance our relationships with community agencies and with
schools, providing more and better services that they require.
Expand our capacity to work with employers to enhance
worker safety and comfort and thus reduce work-place stress and injury.
Consolidate health related professional training, working
toward creating a cohesive entity that would foster multi-discipline
clinical training, better patient care, and more efficient operation.
The problem confronting us will require increased collaboration
across all institutions of higher education and with health care
agencies in Rhode Island. As Dean of the College of Human Science and
Services at the University of Rhode Island, I commit to that
collaboration and to a sustained focus on increasing the supply of
highly trained health care professionals.
Senator Reed. Thank you very much, Dr. McKinney.
Dr. McGarry.
STATEMENT OF MAUREEN E. McGARRY, RN, Ph.D., NCC, DEAN OF HEALTH
AND REHABILITATIVE SCIENCES, CCRI-FLANAGAN CAMPUS
Ms. McGarry. Thank you for this opportunity. One of the
areas that I wanted to mention is that I've been in health care
in one way or another for 36 years, and I certainly have seen
tremendous changes, but none quite like the changes that are
currently underway.
Here at the Community College of Rhode Island we have
always prided ourselves in being able to respond immediately to
the needs of the health care community, and it has only been
recently that we have been unable to do this.
Just taking you back to the 1960s, we had the initial
associate's degree nursing program that was developed, and it
stands today as the only associate degree nursing program
offered in the State, and it has also the distinction of being
the largest in the New England area, with graduates that remain
in Rhode Island and have excelled on the national licensing
examination consistently.
We also know that because of the issues that are occurring
right now, we are not going to be able to continue to respond
the way we have done in the past. I won't bore you with the 16
health career programs that are currently under my
responsibility, but I did want to identify others that are only
one of their kind here in Rhode Island that we offer. We have a
practical nursing program, and there is a renewed need for
practical nurses within the State. We have an associate degree
program in dental hygiene, a physical therapist assistant
associate degree program, as well as a certificate in renal
technology. These all came about because of responses to the
health care community.
Recently, due to the drastically reduced 2000-2003 budget
cut, which our institution, as well as the other higher ed
institutions within Rhode Island suffered, the cost of
equipment and staffing needs and the accommodation of the
continued request will have to be foregone. For instance,
histology technology, pharmacy technology, emergency management
and optician technicians are naming a few of the current
requests that we cannot respond to.
The health career programs in allied health, dental health,
nursing, rehabilitative health, with few exceptions, have
continued to have more applicants than we can accommodate. This
places the student in the unnecessary and unfulfilling position
of being in a holding pattern until a space becomes available.
For the health care provider seeking to hire even more
graduates, this becomes another source of frustration.
It is the college's awareness that we have a number of
first generation college students. Many of these students seek
an education for one of our health careers. The vast majority
of these individuals are adult learners, some whose native
language is other than English. A recent survey of 153 nursing
students, for instance, really reveals some very interesting
findings. We have about 46 percent that indicate that their
primary language is not English and that between 36 to 77
percent identify that they were of minority heritage.
That is increasing, when you compare it the current nursing
population, there were fewer that had that distinction.
I wanted to say a little bit about the aging workforce,
that was mentioned before. We also have an aging workforce
within our faculty. We are anticipating over 50 percent of our
nursing faculty will be anticipating retirement within the next
5 years. Fewer individuals are seeking to take on the career as
a nursing educator, with the advance credentials of a master's
in nursing at a regulatory requirement.
We need to continue to strive to encourage people to
continue to go on and receive their advanced education so that
they will be able to replace those folks who are seeking
retirement.
One of the issues that we have before us is that it is well
known that a new inexperienced graduate is offered a salary
similar to that offered an individual with advanced credentials
for a faculty position. This provides little incentive for an
individual to pursue a faculty position, other than a desire to
facilitate student learning.
Collective resources of health care facilities and colleges
have created innovative strategies to respond to the increased
shortage.
We have Colleagues in Caring-Rhode Island, which has worked
toward tremendous efforts, but we need to continue that vital
role.
Also, the Health Partnership Council of the Hospital
Association of Rhode Island is attempting to respond in a
collective way to these issues.
We also have some of the Black Nurses Association, the
Hispanic Nurses Association that has assisted in terms of
tutoring. These are just to name a few of the innovative
approaches that have recently occurred, as well as the
radiography issues and the dental hygiene issues in terms of
the supply and the demand not being met by our college. We
stand ready to receive whatever additional funding can be
forwarded our way with which to respond to these. Thank you.
[The prepared statement of Maureen E. McGarry follows:]
Prepared Statement of Maureen E. McGarry
I have been a nurse and nursing educator for 37 years. In that
capacity my current role as Dean of Health and Rehabilitative Sciences,
as well as a member of a number of local, regional and national
organizations, I am keenly aware of the looming crisis that is bearing
down on the health care community. This crisis is also impacting
colleges and other institutions that have the responsibility of
educating the health care workforce. The change is unlike earlier
shortfalls experienced by health care is not only the expanding number
of employees needed, but also the broad spectrum of positions where
there are current and anticipated vacancies.
While nursing is not the only profession experiencing a reduction
in the number of individuals seeking or remaining in the health field,
the number of nurses needed to care for the complex needs of our
population in acute care, home care and long term care settings far
surpasses the number required for other health care professions.
In the academic institutions this is also a critical factor as
there are small faculty to student ratios required to provide maximum
monitoring of students caring for patients and provide sufficient
learning opportunities.
Through my role in the National League for Nursing Accrediting
Commission as a program evaluator and panel review member I am aware of
the rigor necessary for nursing programs to achieve and maintain NLNAC
accreditation. One major thrust of the NLNAC has been to examine
program outcomes such as graduate achievement licensure results. These
outcomes are closely monitored, also on the State level, to determine
the ability of programs to supply competent safe practitioners.
In Rhode Island the Board of Nurse Registration and Nursing
Education monitors nursing practice and nursing education through the
regulatory requirements. I have had an opportunity to serve on the
board twice during my career. During both of these appointments, the
serious role of protecting consumers was emphasized as a paramount
function of the board members.
As Dean for over 16-credit bearing health programs, I know students
receive quality education at a reasonable cost, leading them with the
ability to seek employment within a wide range of healthcare
facilities. Unfortunately, the recent critical budget issues within the
State have necessitated that the college raise tuition and fees. This
was deemed necessary as the General Assembly drastically cut the
appropriation for higher education.
Since the inception of the Community College of Rhode Island in the
1960s, there has been a continued effort on the part of the college to
respond to the manpower needs of health care facilities. The College
initially responded by developing an associate degree program in
nursing. The graduates take the licensure examination to become
registered nurses. These graduates have continued to surpass the State
average on the licensure examination. Further, the graduates' success
rate has been over 92 percent. This provides the health care
communities with a steady supply of individuals capable of becoming
credentialed and, therefore, maintain employment. By and large, the
graduates remain in Rhode Island following graduation, further
providing a steady work force for employers.
A review of recent career placement surveys indicate well over 90
percent of our graduates are employed in the career of their choice,
with employers indicating satisfaction with the caliber of their
knowledge and skills. This has been a consistent outcome across all of
the health career program graduate and employer surveys.
At the present time, the College offers a broad array of
certificate and degree programs for a variety of healthcare careers.
These programs were created, without exception, due to the community's
need for this level health care employee.
Degree Programs
Clinical Laboratory Technician
Dental Hygiene
Therapeutic Massage
Associate Degree Nurse (RN)
Occupational Therapy Assistant
Physical Therapist Assistant
Radiologic Technologist
Cardio Respiratory Therapist
Certificate Programs
Dental Assistant
Emergency Medical Technician (EMT)
Practical Nurse (LPN)
Phlebotomist
Renal Dialysis Technician (Hemodialysis Technician)
Magnetic Resonance Imaging Technician
Sonographer
Therapeutic Massage
The College also maintains a Training Center for the American Heart
Association offering Basic Life Support, First Aid and AED
certification. This is one of the ten (10) largest centers in Rhode
Island.
Community Services also offers an opportunity for students to
receive nursing assistant education. The successful candidate can then
take the certification examination and become registered within Rhode
Island as a nursing assistant.
The RI Department of Labor and Training certifies a number of these
programs as options for displaced workers through the Workforce
Investment Act of 1998 (WIA).
Due to the cost of equipment and staffing needs, the College has
been unable to accommodate several recent requests such as: histology
technology (associate degree), pharmacy technology (certificate and
associate degree), and emergency management (certificate and associate
degree). Recently, the College has also been asked to consider an
optician technology associate degree program due to recent changes in
the statutory requirements.
The Allied Health, Dental Health, Nursing and Rehabilitative Health
programs have far more applicants than can be admitted. Many of these
programs have one or two semester waiting lists.
The College serves a number of first-generation college students.
Many of these individuals seek an education in one of the health
careers. The vast majority of these students are adult learners,
individuals whose native language is other than English.
A recent survey of 154 pre-nursing students revealed over 30
percent receive financial aid, up to 46 percent indicated their primary
language is not English and between 36 percent and 77 percent indicated
being of minority heritage.
Three hundred (300) current nursing students were also surveyed.
The first year students indicated that 20 percent classify themselves
as minority and second year students represent 16 percent minorities
within the cohort.
Individuals seek to become healthcare employees for a variety of
reasons: the most common being the desire to care for an individual who
is seeking health care. Many come from varied backgrounds, life
experiences and other careers; banking, fire services, business, etc.
Some come directly from high school and Career and Technical Centers;
some individuals return to college having spent time raising their
families or caring for aging parents.
Each comes with a richness of experiences, which must be
capitalized on as they gain their new knowledge and skills necessary to
become a successful healthcare employee. The diversity of gender,
ethnicity, talents and skills provide excellent opportunities for the
college and healthcare facilities.
The College can no longer respond to health care staff shortages by
expanding student enrollment. There are a number of reasons this is no
longer feasible without significant infusion of resources, mainly
fiscal, capital and credentialed faculty. The State fiscal constraints
has impacted the college budget by significantly reducing the
anticipated 2002-2003 budget by $2.7 million.
Projections
The Rhode Island Employment projections web site indicates through
2006 estimates of 12,000 vacancies in health services. For Registered
Nurses, 366 annual openings exist. The Hospital Association of Rhode
Island has estimated over 600 vacancies currently exist. Annual
estimates of position vacancies are expected through 2020. For Licensed
Practical Nurses, 91 annual openings were identified. The total growth
in Rhode Island for the 50 top occupations lists Registered Nurses as
the second group with the largest expected growth with 2,273 positions
and Licensed Practical Nurses with 421 positions.
Rhode Island projections indicate the demand for registered nurses
will continue beyond 2020. Approximately 12 percent of the workforce in
Rhode Island is employed in health care. The Rhode Island Department of
Labor has projected 10,000 new jobs in health care through 2006. Five
thousand of these are projected to be in nursing.
Projections also are high for Dental Hygienists, Pharmacy
technicians and Radiologic technologists.
Barriers
The aging work force, in particular, that of nursing
faculty, presents a major barrier that must be addressed. Fewer
individuals are seeking a career as a nursing educator, yet within the
next 5 years over 50 percent of the current nursing faculty anticipate
retiring.
The resource acquisition (financial and manpower) has
substantially decreased, yet the demand for increasing enrollment
continues to increase. The college has responded to the continued need
of the community by efficiently delivering education, even offering
courses onsite for health care facilities when requested.
Collective resources for hospitals and colleges must be
infused with additional funds to prepare for the ever-increasing needs
of qualified professional staff. This will ensure meeting the health
care demands.
Even with continued collaboration with health care
facilities and colleges it is imperative that additional funds be
provided, for example, to the Clinical facilities. A consideration
would be to reexamine the Medicare pass-thru option for facilities that
are assisting colleges with faculty and other resources.
Students find it necessary to continue employment
throughout pursuit of their health education. A recent survey revealed
that 90-98 percent work part-time or full-time while a student. It must
be noted each of the health programs are rigorous and accelerated, as
they must be completed within a 2- or 2\1/2\-year time period. This is
stipulated by a number of specialty accreditation requirements.
The public colleges and university have a cap on the
number full-time positions permitted. This places undo limits to
adequately respond to the academic needs of the community.
Increased need for day-care services at each campus has
continued to be expressed by students.
Student stipends could help to decrease the need for
extensive hours of employment and improve success in this rigorous
program. Suggestions students have made regarding this would be to
provide living expense monies as a stipend for students achieving a
solid/high GPA.
Tuition scholarship availability to help decrease the
number of hours that students work has been suggested.
There is an increased need for remediation required by
students applying for admission to the health career programs. This
places an additional strain on the college to provide expanded
resources in developmental education.
State budget constraints have curtailed forward movement
on program expansion particularly with respect to nursing.
Applications have recently increased in nursing (1,700),
radiography (300) and dental hygiene (240). Individuals are placed on
waiting lists, as there is limited ability on the part of the college
to respond to the requests for expansion. As the current time resource
utilization has been maximized.
Most health programs rely upon technology and therefore,
incur additional capital expenses necessary to provide students with
contemporary learning opportunities. Equipment-intensive program
laboratories periodically need to be updated. In addition, high
capacity computers and software is also necessary.
Support courses from a variety of disciplines are required
for each of the health programs. Entering students, at the present
time, need remediation prior to enrolling in the required program
courses. This places additional strain on the colleges lean resources
as courses sections and faculty resources are needed to respond to this
developmental education requirement. This also prolongs the time needed
for the student to complete all program requirements as well as
certification/licensure requirements.
Thirty-six students are currently admitted to the Dental
Hygiene program. There is significant demand within the Dental
Community to increase this enrollment to 45 or more to meet the current
and projected requirements. This is an expensive program, which
requires additional student costs including textbooks and equipment. A
dental kit alone costs approximately $1,200. At the completion of the
program students have additional expenses due to the certification and
license requirements. These students must hire a client for the North
East Regional Board Examination. Expenses for this include: travel cost
to the testing site, hotel costs for student and client as well as
payment to client for loss of wages.
For the college, with very few exceptions, health programs
are expensive. Student tuition and fees do not cover the program costs.
For example, for each nursing student the college admits, there is a
deficit due to program expenses of $1,000. It can be easily identified
that the college would incur the expense of $50,000 per semester if
there is an addition of fifty (50) students admitted in response to the
nursing shortage.
This is also similar to what other programs experience,
but slightly less, as faculty are not in the clinical areas for 15 (15)
hours per week with small faculty to student ratios.
Faculty salaries are low compared to the salaries offered
within the health care community. In addition, Rhode Island Statute
requires advanced academic preparation and yet the new inexperienced
graduate may receive an initial salary offers very similar to the
salary offered for an initial faculty position. This makes it very
difficult to recruit faculty for the health programs.
There is a recent practice of sign-on bonuses in the
community to attract individuals. The experienced staff nurse has few
opportunities for salary incentives, however, unless they receive
compensation for mentoring or precepting new graduates.
Salary compression has recently been identified as a
discouraging factor for faculty in the health programs when compared to
new hires in other academic departments. Salary compression has also
been identified as an issue within the health care facilities.
This frustration, as well as additional employment
demands, can serve as negative factors if individuals are about to
pursue a health care career and have discussions with frustrated and
discouraged employees.
Colleges must continue to be proactive in increasing
faculty salary opportunities through the State fiscal offices to
provide a consistent supply of qualified faculty.
Strategies to Help Resolve the Critical Shortage
Continue to collaborate with the dental community to
reduce program and student costs.
Continue the activities of Colleagues in Caring-Rhode
Island. This group consists of representatives from the Hospital
Association of Rhode Island, nursing practice, nursing administration
representing a variety of settings, such as: nursing homes, home care,
nursing educators as well as Rhode Island State Nurses Association,
Rhode Island Department of Health and the Rhode Island General
Assembly, organized labor and other interested parties. A number of
vital areas have been examined through the task force committees and
CIC-RI mission: recruitment and retention of students and staff,
creation of the Nursing Career Information Center of Rhode Island
through Ambassadors for Nursing, workforce data collection, short-term
staffing strategies and sustainability. The vital role of the project
director needs to be financially sustained.
Continue active participation in the Health Partnership
Council of the Hospital Association of Rhode Island. I am currently
serving a 2-year term as co-chair of this council. This provides an
opportunity for the council to focus on the vital needs of the health
care work force and the role of the academic institutions.
Continue to strengthen partnerships within the health care
community and colleges to develop innovative approaches to deal with
the health care staff shortage including recruitment activities.
Examine potential of ``joint appointments'' of Masters in
Nursing prepared staff interested in retaining their clinical
connection, yet, also facilitate learning for nursing students.
Encourage assistance from the State professional
association members to mentor and tutor students. Members of the Black
Nurses Association and the Hispanic Nurses Association have been
serving as volunteers.
Continue to develop articulations with High Schools and
Career and Technical Centers to attract individuals to pursue a career
in the health field.
A partnership with a community hospital has recently been
developed to respond to a new effort by the hospital to provide RN-
Refresher programs.
Provide a wide array of non-credit remediation courses to
avoid students maximizing the use of financial aid and then be unable
to continue due to financial constraints.
Nursing faculty be more directly involved with counseling/
advising regarding career choices and course selection. Reducing
faculty load to provide collaboration opportunities with student
support services would be one approach.
Through collaborative effort by State representatives,
seek bank leniency for loans for nursing students, particularly
minority students. If the College has evidence students are
participating in reinforcement sessions etc., have excellent class
attendance; prior poor academic performance may be viewed in a
different light.
Students need remediation in a number of basic skill
areas: Math, English, written and verbal communication. Develop a
``Caring Group Network'' prior to nursing program admission. The small
group of 8 or 9 students with a nursing faculty facilitator could begin
weekly sessions, for 1 hour a week, about a month before classes are in
session and then continue to meet as a team throughout the program.
Anecdotal Information
One of the largest Rhode Island health care facilities has
indicated that the Community College of Rhode Island has educated 65
percent of the hospital staff.
Recently, a student spoke of a strong desire to enter the
nursing program, however, having incurred over $10,000,000 in loans
from a previous educational pursuit, she is reluctant to have
additional financial responsibilities. While there are a number of
recent legislative initiatives, such as, interest free loan assistance
and nursing education scholarships, students would need to still need
to make an initial investment.
The Health Resources and Services Administration
Scholarships for Disadvantaged Students (SDS) have continued to award
CCRI with monies. The stipulations have prevented the college from
awarding the scholarships for the following reasons: requirement that
students be full-time (12 or more credits) and the need for parent
income tax information. The student population we have served, by in
large, are well over 30 years of age. This becomes an unnecessary
hardship for these students to comply with these requirements.
Senator Reed. Thank you very much, Dr. McGarry.
Dr. Schepps.
STATEMENT OF BARBARA SCHEPPS, M.D., DIRECTOR, ANNE C. PAPPAS
CENTER FOR BREAST IMAGING, RHODE ISLAND HOSPITAL, PROFESSOR
(CLINICAL) BROWN UNIVERSITY MEDICAL SCHOOL
Dr. Schepps. Thank you for the opportunity to address this
committee. I appreciate being able to testify on behalf of the
228,000 radiologic technologists in the United States and the
1,100 who are registered here and licensed here in Rhode
Island. They're an integral part of the health care team who
are often forgotten.
As already noted, there is a severe shortage of these
individuals. The cause is multifactorial. Over the past 30
years, new imaging modalities have become not only part of the
physician's vocabulary, but they are daily words in the
public's honormantarium.
CT is now discussed to diagnose appendicitis. Before going
to the operating room instead of just physical examination
alone. With MRI, an interventional radiology, we can diagnose
abnormalities, such as blood vessel aneurysms, and treat them
without taking the patient to the operating room, but merely to
the radiology suite.
The number of imaging procedures for 100 people in 1960 was
36. In 2000, 130 procedures for 100 people were performed.
Screening tests, such as mammography, have allowed the
diagnosis with merely a needle and an x-ray and mortality of
breast cancer has directly been improved, and we have allowed
the patients to have more conservative therapy based on early
diagnosis by screening.
In addition to these improvements, increasing numbers have
been based also because of defensive medicines being practiced.
Doctors are ordering more and more imaging tests to cover
themselves against the threat of malpractice.
Another problem that is causing an increase in the number
of imaging tests performed is the number of Baby Boomers and
older people. We have talked about this earlier, and by the
year 2030 it is projected that the number of people who are 65
and older will double and those 85 and older will triple.
The workforce technology is also aging. It is interesting
to note that 70 percent of the radiological technologist
workforce is over the age of 35.
There is also a decrease in the number of people entering
the field. Women have other options. They don't all choose to
go into the hospital-based professions. There are decreasing
number of schools of radiological technology. In Rhode Island
there are two, in CCRI there's one and Rhode Island Hospital
has one, but it is interesting the applications are limited and
the number of graduates that actually matriculate is probably
about half of those that matriculate, and this has been a
trend.
In 1994 there were 10,629 graduates of technology programs
in the United States. In the year 2000 there were merely 749
graduates. There are many other schools for radiation therapy
technologists in Rhode Island, the nearest being in Worcester,
being in Boston. Now technologists are also leaving the field.
They are leaving it because of burnout, they work nights, they
work weekends. It is a 24-hour-a-day, 7-day-a-week job, they
have holidays, and a new graduate can be assured that he or she
will be working Christmas and New Year's for the next 5 years.
There are better jobs. Technologists are leaving Rhode
Island in particular for other jobs. There are better paying
jobs just across the border at some of the hospitals previously
mentioned, and people are leaving to take these jobs. They're
being offered three times the salary they can make here. They
also are going in other fields. Many of them are choosing to
teach, they're doing academics and they're also working in
research positions.
The workforce is also a part-time workforce. Say we have
1,100 registered technologists--licensed technologists in Rhode
Island, but most of those people are either part time, and many
of them don't work at all. In radiologic technology in the
United States there was a 15.3 percent vacancy rate, and one
out of seven can be filled.
What are the consequences? The consequences include closing
shifts, decreasing accessibility, increasing length of stay,
decreasing emergency room throughput and increased waits for
screening tests.
What are the strategies that might help improve the
shortage. One might be so we can decrease the number of having
less defensive medicine. Others might be soliciting students at
younger ages, in junior high school and high school and
creating interest in these jobs. Subsidizing their education
would be helpful. Most currently these schools cost between $4-
and $5,000 for a 2-year program, and that is prohibitive for
some of these young people.
Looking at minorities and people returning to the workforce
in other areas. The technologists with whom I speak say that
they would like to have respect and a career ladder, a way to
go from just being a staff technologist and improve. They would
also like to get a degree, an associate's degree for their 2
years of training. They do that at CCRI, but in many other
programs they don't get them. And, of course, they all like
increased remuneration.
[The prepared statement of Dr. Barbara Schepps follows:]
Prepared Statement of Barbara Schepps, M.D.
My name is Barbara Schepps and I am a practicing board certified
radiologist. I am on the active staff of Rhode Island Hospital, Women
and Infants Hospital and the Miriam Hospital. I am employed by Rhode
Island Medical Imaging, am an owner of this radiology practice and have
served as its president for the past 12 years. I am a past president of
the Rhode Island Medical Society. Currently I am chairperson of the
American College of Radiology's (ACR) Radiologist Resources (Manpower)
Committee and the ACR's Commission on Human Resources. I have
coauthored a number of papers on the national shortage of radiologists.
From each of these perspectives, as a practicing radiologist in a
hospital setting, part owner of a large diagnostic imaging practice,
and chairperson of the ACR's manpower committee and past president of
the State's medical society, I have a unique perspective on the current
crisis caused by the shortage or radiologic technologists and the
potential for even far more dramatic consequences if this local and
national crisis is not addressed.
Background
Over the last 30 years, radiology has changed how medicine is
practiced. When I began my career in radiology there was x-ray and the
beginnings of modern day radiation therapy and nuclear medicine. Today,
part of most laypersons vocabulary are words like CT scan, MRI, and PET
scans. Doctors are referring their patients for such things as non-
invasive cardiac nuclear scans, ultrasound studies of unborn babies and
granny's carotid arteries, and for some patients, radiation therapy to
treat prostate cancer, all unheard of when my career began.
Radiology can now reduce unnecessary surgery by looking inside the
body without a scalpel, but with a CT scan. In the hospital of the 21st
century, prior to a patient being rushed to the operating room for an
appendectomy, a CT scan is obtained to be certain if the diagnosis is
indeed appendicitis. In the radiology suite of this century
radiologists are diagnosing tumors with needles guided by CT,
ultrasound, MRI or x-ray without the need for exploratory surgery.
Vascular radiologists are opening clogged blood vessels with catheters
and stents (tubes) inserted with only a nick in the skin.
Radiology is truly a burgeoning field and is the lynchpin in most
of the recent advances in the diagnosis and treatment of disease.
Effective treatments rely on accurate diagnosis. For instance,
radiology has directly contributed to the reduction in the mortality
from certain diseases, such as breast cancer, by screening women with
mammography who have no symptoms to find unsuspected disease. When a
mammogram shows a suspicious area, the radiologist can diagnose breast
cancer with a needle without a trip to the operating room. Not only has
the mortality reduced, but also women who are diagnosed with breast
cancer may be candidates for a more minimal surgical procedure because
tumors are found at an earlier stage. Over the span of my practice the
radiologist had gone from only interpreting simple x-rays to being a
diagnostician performing minimally invasive procedures to treat many
with minimally invasive techniques.
The field of radiation oncology has grown by leaps and bounds. Over
the years, the radiation oncologist (a physician) and the radiation
therapist (a technologist), have worked hand-in-hand to both cure many
cancer victims and reduce the suffering of others. For some, radiation
therapy may replace more invasive surgery entirely. An integral part of
the practice of radiology is the radiologic technologist. Radiolgic
technologists are part of a team. The radiologic technologist actually
takes the x-rays and the images for CT, MR, PET and ultrasound. In the
radiology suite of today, much of the work of a technologist involves
the use of computers, The radiation therapist delivers the radiation
for therapy treatments. The nuclear technologist measures and delivers
doses of radioisotopes and takes the images for the radiologist to
interpret. All technologists are versed in radiation protection
practices.
To become a radiologic technologist most individuals attend a full
2-year accredited school. There are two such schools in Rhode Island,
one at Rhode Island Hospital (RIH) and the other at the Community
College of Rhode Island (CCRI). The requirements for admission to the
RIH program are a high school diploma or GED, necessary health
requirements, a C or better average in algebra or higher, a course in
human anatomy, and a basic computer course. Throughout the program the
student is given written examinations, clinical evaluations, and
competency evaluations. Upon completing training at the program at RIH,
a graduate earns a Certificate in Radiologic Technology that entitles
them to take the American Registry for Radiologic Technologist (AART)
exam to become a Registered Radiologic Technologist (RRT). Students
graduating from CCRI also receive an Associates Degree. The cost for
the entire 2 year program at Rhode Island Hospital is $4,000 and at
CCRI, $5,000. RIH is licensed for a class of 15 students per year;
CCRI, 46.
There is a new 4-year program at Quinnipiac University in
Connecticut. In this program a student qualifies to sit for the ARRT
examination after the first 2 years. In the subsequent time they may go
on for advanced certification such as in ultrasound and are then able
to take that advanced registry. They receive a BS degree at the end of
4 years.
The Problem
The need for diagnostic imaging services is burgeoning. Utilization
is driven by an aging population, new and better equipment, patients
demands for tests they have read about on the internet or seen
advertised, and physicians seeking quicker, more accurate and less
invasive means of obtaining diagnoses. While the number of radiologic
technologist remains stagnant or is decreasing, the demand for
diagnostic imaging services has grown by 3 to 4 percent annually. Since
the 1960s, the use of imaging resources has increased from about 36
procedures per 100 people to 130 procedures per person in the 1990s. It
is projected that there will be a 140 percent increase in imaging
procedures by 2020. More than 30 million radiographic procedures are
performed in the United States each year. For the radiologic
technologist this translates into longer working hours and increased
number of studies performed per hour. An American Healthcare
Radiologist survey showed that the average hospital-based radiographer
performed 3,308 examinations in 2000, an increase of almost 550 over
1995 numbers. The average interventional technologist workload
increased 95 percent over the same 5-year period.
As the population ages, there is and will be an increasing need for
imaging services. The oldest of the Baby Boom Generation, approximately
78 million Americans, are now in their mid-50s. It is estimated that by
2030 the population over age 65 will double and the population over 85
will triple. Clearly the demand for imaging will skyrocket. Seniors
utilize 3 to 4 times more health care resources than younger adults.
Another compounding factor is the aging technologist workforce. The
average age of a radiologic technologist is 41, one of the oldest
averages in the allied health care field. Unfortunately, many of these
very necessary workers are part of the Baby Boom Generation and will be
retiring just as the need for radiologic technologists is soaring. In a
study by the ASRT, only 14.5 percent of radiologic technologists were
younger than 30 and only 30 percent were under 35 years of age.
Further contributing to the workforce shortage is the fact that
fewer people are entering the field. Nationally, the number of people
taking the ARRT radiolorgic technology registry declined between 1994
and 2000 from 10,629 to 7,149. For radiation oncology, the drop was
even more dramatic, from 1,046 in 1994 to 399 in 2000. A slight upturn
was noted in 2001 with 7,434 and 579 in diagnostic radiology and
radiation oncology respectively.
Additionally, there are fewer places to study radiologic
technology. Because of cutback in reimbursement and decreasing
applications, many hospitals have been forced to abandon their
programs. In 1994 there were 692 JRCERT-accredited educational programs
for radiography, in 2001, only 583. For radiation therapy the numbers
are even more dismal: 125 programs in 1994 and 69 in 2001. The schools
nearest Rhode Island are in Worcester, Boston and Hartford. Fourteen
States have no radiation therapy programs at all.
Many of those applying to programs do not meet the qualifications.
Of those accepted, some pay the initial deposit and never matriculate.
Many do not complete the program. For the class of 2001 at RIH, there
were 26 individuals applied, 12 accepted, 8 matriculated and 5
graduated. In 2002, 32 applied, 13 accepted, 11 matriculated and 7
completed the program. At CCRI in 2001, the class began with 32
individuals and graduated 16; in 2002, 40 matriculated and 24
graduated.
Why are people not choosing to enter this field? One reason is that
traditionally women comprised much of the workforce and today women
have many other career opportunities open to them. Another reason is
that careers in health care have lost their appeal. Relatively low
wages combined with high stress, the 24/7 nature of the job, and the
increasing healthcare bureaucracy contribute to the lack of interest in
the field. High school students are not encouraged to attend 2-year
programs, but are enjoined to strive for a traditional 4-year college
degree. Today's youth who do attend 2-year and some 4-year programs,
choose jobs in the computer industry that are higher paying and more
``fun.'' Ads for airport screeners this week were advertised at $20,000
to $40,000 without the 2- to 4 years of additional education.
Why do people leave the field? Many burn out from job-related
stress. Others see better paying opportunities. In speaking with
technologists, the single greatest reason for seeking other work is
salary. As rewarding as the technologist's life may be, it may also be
quite demanding. Working with the sick, the well and the worried can be
a strain.
Others seek jobs with no call, nights or obligatory weekends and
shift work. Hospitals are particularly vulnerable because of the 24/7
nature of their service needs. A few cite the lack of a career ladder
for radiographers. Some seek less demanding and more financially
rewarding careers with or without the need for additional education.
Why do technologists leave Rhode Island? Some leave for better paying
jobs, frequently just across the border in neighboring Massachusetts or
Connecticut. Certain hospitals in Boston, so desperate for
technologists, pay salaries that can be 3 to 5 times those in Rhode
Island. Others will relocate further for even higher salaries.
In the United States there are currently 227,863 ARRT certified
technologists. Many of these individuals are certified in more than a
single area. Areas of certification include: nuclear medicine,
cardiovascular, mammography, CT, MRI, sonography, vascular, and quality
assurance. Rhode Island has 1,078 registered technologists. Since 1995,
State licensure is required in Rhode Island. There are 1,232 licensed
radiologic technologists in Rhode Island (may not live or work in the
State or may be contract employees to brought to the State for unfilled
vacancies). While these numbers may seem reasonable they do not tell
the whole story. Many technologists keep up their registry and
licensure but do not work in the field. Many, many others work less
than the 40-hour week. Of those who work, some hold administrative,
supervisory, or research positions and do no clinical work. While a
vast majority of technologists are radiographers (x-ray technologists),
many hold additional certification(s) and only work in a sub-specialty.
In November 2001, the U.S. Bureau of Labor Statistics projected the
need for 75,000 more radiologic technologists in 2010 than it did for
2000 along with the need for 22,000 more cardiovascular technologists,
16,000 more sonographers, 8,000 more nuclear medicine technologists,
and 7,000 more radiation therapists. These numbers reflect both growth
within the specialty and vacancies left by those retiring or changing
careers. It is interesting to note that a January 2002 survey of the
American Hospital Association and three other hospital organizations
reported a 15.3 percent vacancy rate for radiologic technologists,
meaning that 1 of every 7 jobs for radiologic technologists cannot be
filled. This vacancy rate is higher than the reported 13 percent
vacancy rate for nurses and 12.7 percent vacancy rate for pharmacists.
It is interesting to note that starting salaries for both pharmacy
technicians are double to triple that of an entry-level technologist.
Consequences of the Shortage
The shortage of radiology technologists affects everyone. As an
employer of more than 100 technologists, a vast amount of resources are
expended recruiting and retaining our technologist workforce. Our
practice offers flexible hours, generous benefits and a comfortable
work environment. There is no mandatory overtime or night work. The
office practice of radiology is frequently less demanding than the
hospital setting. Patients walk and talk. All of these factors
contribute to the increased cost of running a radiology practice in a
day of decreasing reimbursement. Over the past 2 years, however,
despite our favorable salaries and working conditions, we have had
increasing difficulty filling our positions. We vie with other
practices and hospitals for the same limited workforce. This translates
into curtailing some non-emergent services and sharply reducing others.
One that has been a trigger point with both patients and referring
physicians has been our need to decrease our mammography services. We
no longer offer evening and Saturday appointments. Patients have to
wait as long as 5 months to obtain routine mammographic screening. This
translates into decreased patient and physician satisfaction. This
problem is nationwide. Due in part to the technologist shortage,
practices are choosing to stop performing mammography altogether. The
FDA website shows that in March of 2001 there were 9,873 MQSA
mammography practices, in July of 2002, only 9,349. While some of this
might be due to consolidation, with reported waits for screening
mammography as high as 6 months, at least part of the facility closings
can be directly attributed to the shortage of mammography
technologists. Furthermore, if, as it has been shown, early detection
of breast cancer is dependant upon finding tumors early, the decrease
in access will have a direct impact on the lives of American women.
Other services are being limited. At Rhode Island Hospital we have
been forced to close some of our CT scanners from time to time because
there are no technologists to work. Around the country, practices are
being forced to limit or eliminate critical services.
Another consequence that must never occur is the use of unqualified
personnel to fill the need. The use of ionizing radiation is a serious
matter. A significant portion of the radiologic technologist's
education centers around the safe use of x-rays. Conjure the image of
untrained personnel misusing this precious resource!
In the hospital setting this can impact directly on length of stay,
emergency department throughput and operating room schedules and all of
these have a direct effect on the cost of healthcare. Morale of the
working technologist is affected. This coupled with similar shortages
in other allied health fields affect the workplace and make recruiting
and retention of healthcare workers more difficult.
Possible Solutions
While it is not possible to change some of the factors leading to
the impending crisis such as the aging population or the increasing
indications for the use of imaging and image-guided interventions and
therapies, attention must be focused to recruiting and retaining young
people. We must pique their interest. An interesting anecdote relayed
to me is that no student entering the CCRI program this year is under
20. High school counselors do not encourage students to enter these
fields. This may stem from their personal lack of knowledge of the
rewards and benefits of the technical areas of imaging. One strategy is
try to attract students is to talk to students as early as middle
school and educate them about this career opportunity. Another might be
offering the free education with a concomitant means of earning income.
The granting of an associate degree from all 2-year programs would also
be attractive.
Other individuals to target might be minorities who traditionally
have been locked in dead-end low-paying jobs. This can be accomplished
with outreach programs and career days. Single parent families are
another excellent target audience; the parent could benefit from a job
with flexible hours.
Perhaps another source to be tapped are those seeking a career
changes. Schools of technology should attend job fairs to create
awareness.
Finally, perhaps the development of a career ladder with increasing
rewards with such advancement might help to retain those in the field.
The development of a program such as an R.T. Clinical Specialist could
help the beleaguered radiologists and serve as a means of both
attracting new technologists and facilitating upward mobility among the
current technologists.
Thank you for allowing me to speak to you today on this very
important topic.
Senator Reed. Thank you.
Jim McNulty.
STATEMENT OF JAMES McNULTY, PRESIDENT, NATIONAL ALLIANCE FOR
THE MENTALLY ILL
Mr. McNulty. Thank you, Senator Reed, Governor Fogarty for
being here, for the opportunity to speak today.
It has been an interesting hour and a bit listening to all
of the testimony. You have my written testimony. I am going to
try and give you some insight into some of the things that
helped form some of that testimony.
I spent the last year traveling in the United States. I was
elected President of the NAMI a year ago and I have since put
on 130,000 miles, visited 20 States and about 13 major
metropolitan areas, and things aren't very good anywhere. Some
are a little better than others, but most are in pretty dismal
straits. The system delivering our health care services is on
the edge of total breakdown. I am not an alarmist. You have
known me for several years. I don't say things like that
lightly, but it is true. It is not far different than that in
other areas of medicine, but I think mental health has been
sort of the leading edge, and it is one of the major brunts and
the cost containment efforts have been represented most by the
managed care organizations in this country.
I am not here to beat on the managed care organizations,
because that is futile. They have to run what they are doing
simply because we as a Nation have refused to make the right
decisions on health care. We have made no policy. We have
chosen to sit by and let things evolve into chaos. Those of you
in leadership that have shown us so many different things,
Senator, I am asking you, and, Governor Fogarty, asking you as
well, to continue showing me leadership. You are in a unique
position to implement policy.
One of the things that occurred to me while I was listening
to everybody, there are many problems here. There is a mind
numbing level of detail to the problems that you heard today.
What we need to do is put the patient in the proper place,
which is first. It is my belief that if you put a patient at
the center of the health care system and work from there, you
will have a health care system that not only takes care of the
patient, the caregiver, but the professionals that work in the
system and the institutions that care for patients. What I have
seen for years is the fact that we have sort of robbed Peter to
pay Paul, put fingers on various dikes, we have used duct tape
to an extraordinary degree to try and keep the system together,
and I think one of the ironies to me is that we have such
extraordinarily good and dedicated health care professionals,
that these people have done a superb job of just keeping things
together, but it is reaching the state where they are not going
to be able to keep things together, and I think we need to
recognize that, and we need our Government at this time, as in
no time without calling the past to take the lead back on
health care. This is not something that one group, one guild
can lead on. It has to be everybody involved in it, and,
frankly, based on what my observation of the last several
administrations in Washington has been, I don't hold great
hopes that the administrations are going to be able to solve
that. I think it is going to take the legislative
representatives of people to address some of these issues.
Obviously, we stand ready to help you in any way and to
advise you. It is a big job, I am not going to minimize the
fact that it is, but what I would like to tell you about is a
couple of stories of how patients are impacted.
One of my very best friends and colleagues in Rhode Island,
Mickey Siline, who is the Executive Director of NAMI in Rhode
Island, has a son with major mental illness, and he has
suffered from this since he was a teenager and he is now in his
mid-30s, and one of the things that works well for people with
mental illness is to have case managers. People who help them
with the activities of daily living, it is helping them deal
with the things that caregivers cannot do all the time because
of the caregiver burnout, and we have a very good, very good
public mental health system here in Rhode Island, which is in
danger of falling to pieces, as are all other health care
systems. The tragic thing was that Jimmy had a wonderful care
manager, an individual left working for the public mental
health system to take a job as a commercial office cleaner
because it was more pay, and I think that that, that is just
horrible to think that that is how we reimburse our health care
professional. I have to tell you that the consequence of not
treating people's health problems is not just a--it is sick,
stay sick, but it is often death.
One of my very best friends, someone whom I knew years from
the days that I started, is an advocate in running support
groups, committed suicide 2 years ago because of the lack of
health care, people that could help him and reach out to him.
There is a real consequence, a very real consequence to the
fact that we as a Nation have not addressed our health care
needs. Thank you.
[The prepared statement of James McNulty follows:]
Prepared Statement of James McNulty
Senator Reed, I want to thank you for the opportunity to present
oral and written testimony at this Senate field hearing, which you are
so graciously and capably chairing.
My name is Jim McNulty, of Bristol, RI. I am the President of the
National Alliance for the Mentally Ill. Today, NAMI has more than
220,000 consumer and family members nationwide dedicated to improving
the lives of persons with severe mental illnesses. As a person
diagnosed with bipolar disorder (manic-depressive illness), I am proud
to serve as NAMI's President and proud that NAMI is the Nation's
``voice on mental illness'' representing both consumers and family
members.
I am also president of the Manic Depressive and Depressive
Association of Rhode Island, a support and advocacy organization. I
serve as a member of the board of directors of the National Alliance
for the Mentally Ill of Rhode Island, and Mental Health Consumers of
Rhode Island.
I am a member of the Governor's Council on Behavioral Health, and
was appointed to a 4-year term, in January 2001, on the National
Advisory Mental Health Council, which advises the administration,
specifically NIH Director Dr. Elias Zerhouni and Secretary of HHS Tommy
Thompson on issues of policy on mental health research and service
delivery.
I am an advisor on numerous research studies, and grants at
academic medical centers around the United States--I will forebear
citing the entire list here. I serve on an Institute of Medicine panel
studying protection of human subjects in research.
Of more immediate significance, I have traveled over 130,000 miles
since being elected president of NAMI in July, 2001. In this capacity I
have visited 20 States, and numerous large metropolitan centers in the
U.S.--New Orleans; Washington, DC; New York; Los Angeles; Minneapolis;
Seattle; Dallas; Houston; Chicago--and I must tell you that what I have
observed is very alarming.
The system of delivering mental health care services in this
country is teetering on the edge of irreversible breakdown. There are
still bright spots, but not many. And all of the bright spots are in
danger of dissolution, too. This is as true in Rhode Island, an area of
major concern for most of us here today, as in all other areas of the
country.
In my career as an advocate for mental health services, I have
eschewed being an alarmist and shouting continually that the mental
health system is broken, since it wasn't until very recently. I have
spoken about this with Paul Appelbaum, M.D., president of the American
Psychiatric Association, staff of the American Psychiatric Nursing
Association, members of the American Psychological Association--and
many, many others. Looking back 2 years, Felice Freyer of the
Providence Journal asked me for my assessment of the state of mental
health care in our State. I told her then that we were watching a train
wreck in slow motion. That was true then, and it is truer today.
I keep my fingers on the pulse of what happens in our community by
spending time conducting support groups for family members and
consumers, and answering calls for help by people seeking emergency
mental health care.
In fact, the system for providing outpatient mental health care
here in Rhode Island is so bad in the adult system that those without
an attending psychiatrist when admitted to a hospital must wait weeks--
8 to 12 weeks is not an uncommon wait--for outpatient follow-up care
with a psychiatrist. Accordingly, internists, primary care physicians,
family practitioners, pediatricians, nurse practitioners,
gastroenterologists and other non-psychiatrically trained specialists
are forced to provide mental health services. These specialists, well-
intentioned and devoted to caring for their patients, are performing
services that they have insufficient training for, and are not equipped
to provide in any reasonable way.
Managed care has decimated the ranks of all mental health
clinicians, not psychiatrists alone. The claim is made that we have the
same number of mental health providers as we have had for the last 12
years. Real-life patients and advocates will tell you that there is a
phenomenon called the ``phantom network'': all of these providers may
exist on paper, at the offices of managed care organizations and at the
RI Department of Health, but God help you in trying to obtain an
appointment.
This dire situation is worse still in the areas of treating
children's mental health. The Center for Mental Health Services, an
agency of DHHS, estimates that 20 percent or 13,700,000 of the Nation's
children and adolescents have a diagnosable mental disorder, and about
two-thirds of these children and adolescents do not receive mental
health care. We have about 8,000 boarded child and adolescent
psychiatrists--and we need more like 30,000. We cannot even begin to
assess the need for counselors--school and family, alike, or
residential treatment facilities nationally. And we a faithful image of
the national picture here in RI.
We have appallingly few resources for the elderly mental ill, many
of whom would benefit from appropriate and timely services, which would
decrease the costs associated with putting many seniors in nursing
homes and hospitals.
Our Veterans Administration mental health care networks are
staggering under the burden of an unanticipated influx of new patients,
refugees from the private sector, many of whom lost their retirement
healthcare coverage.
The public mental health system, in most States also a phantom
network, is struggling after years of funding neglect and insufficient
attention from State administrators. It is no different here in Rhode
Island, despite heroic efforts from the Community Mental Health Centers
and the department of MHRH.
I could enumerate problems for several more pages, but I want to
ask you as my Senator, and the Committee, to focus on several things:
Rep. Patrick Kennedy, D-RI, has introduced H.R. 5078, the Child
Mental Health Service Expansion Act; I ask you to consider sponsoring a
companion bill in the Senate.
Introduce legislation to end the blatantly discriminatory treatment
of mental illness under Medicare (and keep up the pressure for
insurance parity in the private sector).
Keeping this Administration honest on mental health issues--to the
extent feasible, participating in the President's Commission on Mental
Health
Continue providing national leadership on healthcare--many of the
problems we have in healthcare today exist because Presidents have not
had a vision of what a national health policy should be. As a Nation,
we made a decision by agreeing not to make a decision, and we have
chaos instead.
Last, we need our leaders to communicate to the professional
societies--guilds, if you will, and health care providers and insurers
that they must focus on taking care of their patients. If our goal is
to provide appropriate, effective care to those who need it, we will
build a good system. If we continue to allow various constituencies to
use their narrow concerns as a proxy for good health care any system we
try to build will fail.
NAMI, nationally and locally, stands ready to assist and advise in
any way you ask, to avert tragedy in our health care system, and
especially in our mental health care delivery. We are conducting a
survey of all the States to help understand the problems, and work
toward solutions.
Senator Reed, thank you for this opportunity to testify before the
Committee.
Senator Reed. Thank you very much, Jim.
Wendy Laprade.
STATEMENT OF WENDY LAPRADE, RNC, STAFF NURSE, WOMEN AND INFANTS
HOSPITAL
Ms. Laprade. Thank you, Senator Reed, for inviting me
today.
Nineteen years ago, when I started my nursing career as a
staff nurse I knew that certain inconveniences came with the
profession.
Providing care for patients in the acute care required me
working evenings, nights, weekends and holidays. I did not,
however, anticipate unsafe staffing problems, mandatory
overtime, floating to unfamiliar areas of the facility, the
ergonomic strain, safety and health issues. I never imagined
that my nursing time would be occupied with non-nursing duties,
counting drugs and supplies, checking equipment, transporting,
as well as typing, ordering, cleaning and justifying. We must
fix the underlying problems, not just whitewash the nursing
picture, for as fast as the educators can help to produce new
nurses, they will be leaving the bedside for more acceptable
opportunities.
But there is a step we can take today, immediately, to stop
the hemorrhaging, and that is to put a ban on mandatory
overtime. Senate Bill 1686, ``Safe Nursing and Patient Care
Act'' introduced by Senators Kennedy and Kerry would do this.
Limiting forced overtime will ease the impact of the shrinking
supply of nurses by encouraging more nurses to say in the
profession. It will protect countless patients in the same way
that limits on mandatory overtime for trained engineers, air
traffic controllers, truck drivers and other occupations where
public safety is at risk.
With the rise of managed care in the 1980s, long before a
nursing shortage began to emerge, hospital administrators moved
to cut costs by cutting expenses, particularly by laying off
and decreasing hours for huge numbers of registered nurses
across the country, the industry reduced staffing levels to the
point where nurses, increasingly unable to provide our patients
with the care we were trained to give, began to leave hospitals
for more rewarding and less physically and emotionally taxing
jobs.
Nurses in hospitals and related facilities are caring for
more patients today than we did a decade ago. Because of
restrictions on hospital admissions and lengths of stay imposed
by managed care, the patients in hospitals are more acutely ill
and in need of greater care.
The result is that hospitals are having increasing
difficulties filling vacancies for RNs. This is confirmed by
our SEIU Nurse Alliance Survey, where:
Nurses reported that on average it took nearly 11 weeks
(10.77) to fill a nursing vacancy in their unit, and 52 percent
of the nurses believed that it takes longer to fill vacancies
today than 3 years ago.
This doesn't show nurses' job dissatisfaction; it signals a
real problem for patients. When staff is less experienced and
unstable, it is more likely that patient care will suffer.
The hospital industry cites many of these statistics to
point to a nationwide ``nursing shortage.'' But a closer look
at the data suggests that the real problem is a shortage of
nurses willing to work in hospitals under current working
conditions. This opinion was also shared by the General
Accounting Office in their recent report. ``Nursing Workforce:
Emerging Nurse Shortages Due to Multiple Factors.'' Many view
the situation as a staffing crisis rather than a nursing
shortage; system understaffing brought on by the restructuring
of the industry under managed care has led to dramatically
deteriorating working conditions and increasing concern about
the quality of patient care which is causing nurses to leave
hospitals. This is confirmed in a survey of health care human
resource managers conducted by the William M. Mercer Consulting
Company who found two important factors affecting turnover:
``Dissatisfaction with the job itself, working conditions,
the relationship with the supervisor, or career
opportunities;'' ``Workload and staffing,'' noting that ``a
reduction in RN resources has increased the job demands of
those remaining in the workforce.'' In the report, the
consulting company suggests that the employers concerned about
turnover ``should examine their own practices and work
environment.'' It cannot be stressed enough that when our
nursing profession is in crisis, our Nation's health care
system is in crisis.
Inadequate staffing has given rise to increased numbers of
medical errors. In 1999, the Institute of Medicine found that
between 44,000 and 98,000 Americans die every year in hospitals
due to medical errors; more people die of medical errors than
from motor vehicle accidents, breast cancer or AIDS. While the
IOM report exposed a national crisis, it did not explore one of
the primary causes of it: Understaffing. However, this issue
was comprehensively assessed by a research team from the
Harvard School of Public Health led by Professor Jack
Needleman, which found that higher RN staffing was nursing, in
particular urinary tract infections, pneumonia, length of stay,
upper gastrointestinal bleeding and shock.
A majority of nurses in our SEIU Nurse Alliance Survey
identified understaffing as a cause of medical errors. The
situation, they say, is not improving.
Fifty-four percent of nurses say that half or more of the
errors they report are the direct result of inadequate
staffing.
Despite the growing attention focused on medical errors,
most nurses say the rate of incidents has remained unchanged
over the last year--while fully 30 percent of nurses say the
errors have actually increased.
We also should keep in mind that there are many more
medical errors that go unreported for fear of retaliation. Most
health care workers who blow the whistle on short staffing and
poor patient care have no legal projections against
retaliation. Federal whistleblower laws are narrow in coverage
and do not apply specifically to the health care industry.
The staffing crisis and the deteriorating conditions it has
created has compromised quality care for people in our
communities. According to the Maryland Hospital Association,
``over half the hospitals throughout Maryland report they have
had to close beds, delay and cancel surgeries, disrupt
scheduled procedures, and `reroute' ambulances to other
facilities for emergency patient care.'' The MHA says that is
increasingly common for patients arriving in an emergency
department ``to be held there until adequate staffing becomes
available on a patient unit.'' These situations are not unique
to the State of Maryland.
A particularly devastating side effect of the understaffing
crisis is the abuse of mandatory overtime by many health care
employers. Nurses are often mandated to work back-to-back 8-
hour shifts or 4 extra hours on top of a 12-hour shift to fill
gaps in staffing. Of course this threatens patient safety.
There is no way an exhausted, overworked nurse is as alert and
accurate as a well-rested nurse working a regular shift.
Mandatory overtime also places an incredible stress on family
life, particularly when last minute changes have to be made to
find childcare or care for elderly parents.
According to our survey, nurses in acute care hospitals
work an additional 340 hours of overtime on average every year.
Nurses are not only being increasingly required to work
excessive amounts of mandatory overtime, but also routinely are
required to ``float'' or be reassigned to units where they lack
the experience and training. Nurses are being stretched to the
limit, experiencing high levels of stress, chronic fatigue and
work-related injuries. These intolerable work practices lead to
further burnout, undermine nurses' sense of professionalism and
drive nurses from hospitals.
Nineteen years ago when I started my practice most
hospitals provided new employees with a fairly extensive
initial training and continuing education program. In 1995, an
average initial training lasted 3 months. In 2000, that was
decreased to 30 days.
Nurses want to provide safe and efficient care for our
patients. We need appropriate nursing education to keep up the
ever-expanding technology.
Correcting these issues, I believe, will help restore a
sense of value back in the nursing profession. Workers stay
when they feel a sense of value and pride in their work.
According to the SEIU Nurse Alliance Survey:
Only 55 percent of acute nurses plan to stay in hospitals
until they retire.
And only 43 percent of nurses under 35 plan to stay in
hospitals until retirement.
But 68 percent of nurses say they would be more likely to
stay in acute care if staffing levels in their facilities were
adequate.
These statistics show a little discussed fact about today's
shortage. In reality, the current supply of nurses far exceeds
demand. The proportion of RNs employed in hospitals has
decreased substantially and consistently from 698 percent in
1988 to 59 percent in 2000. Our current crisis is not a
shortage of nurses, it is a shortage of nurses working at the
bedside. Nationwide there are approximately 2.7 million
registered nurses, however, 500,000 of those RNs are not
working in nursing. According to The American Hospital
Association statistics, nationwide there is a 12 percent
vacancy rate in nursing. This translates to 126,000 nursing
vacancies. It is easy to see that we have the nurses, but they
are not working in nursing positions.
Deteriorating staffing and working conditions have led many
nurses to leave the profession all together and fewer young
people are entering it: Nursing school enrollment has declined
in each of the last 6 years. According to Dr. Dennis O'Leary,
President of the Joint Commission on the Accreditation of
Healthcare Organizations, (JCAHO) in the May 2000 report
``Framing the Issues: In pursuit of solutions to the National
Nurses Workforce Dilemma,'' there are 21,000 fewer nursing
students in 2000 than in 1995. As a result, the average age of
working RNs has increased 7.8 years since 1983 to 45.2 years.
As these trends continue, there is likely to be a severe
nursing shortage in the future. By 2020, we expect that will be
a shortage of 400,000 nurses, when the majority of the Baby
Boomers will be seeking care.
Many nurses wish to remain in hospital work, and would do
so if staffing and working conditions improve. If these
conditions are not improved, nurses' flight from hospital care
will intensify and in the near future we will face a true
shortage. The fact that younger nurses are even less likely to
stay in acute care than their older colleagues is a warning
sign.
The American Hospital Association reported in its report
``Commission on Workforce for Hospitals and Health Systems,''
many hospital workers do not feel valued and discourage others
from entering health care.
I have focused my remarks principally on hospitals, since
that is where my practice is and where I believe the nursing
crisis is most severe. There is however, a related and equally
serious problem in nursing homes. While RNs make up a small
proportion of the nursing home workforce, and are largely in
managerial positions, most of the staff in nursing homes are
certified nurse assistants, and to a lesser extent, licensed
practical nurses or licensed vocational nurses.
SEIU members include more than 120,000 nursing home
employees, the vast majority of whom are CNAs and a large
number of whom are LPNs/LVNs. Similar to administrators in the
hospital industry, nursing home owners have argued that they
are facing a shortage of nurses and nurse aides. For this
reason they have asked for increased Medicare and Medicaid
reimbursement and have resisted the setting of minimum staffing
standards.
But just like in hospitals, the real problem isn't finding
people to work in nursing homes, it is keeping them there.
Turnover rates for direct care workers in nursing homes are
nearly 100 percent, creating a revolving door of caregivers
that renders continuity of care impossible. Workers are leaving
due to heavy workloads. They simply do not have enough time to
care for the number of residents they are assigned to, which
leads to stress, guilt and burnout.
Moreover, low wages, lack of health insurance coverage,
pensions and high injury rates also make nursing home work
unsustainable for many workers.
Nurses across America are sounding the alarm: Staffing
levels are too low to provide the quality of care their
patients need. In many States, nurses who are in unions have
turned to the bargaining table to change their working
conditions in order to ensure safer staffing and better patient
care. Eliminating mandatory overtime, establishing safe
staffing standards and improving recruitment and retention by
increasing pay have been the primary issues in nurse contract
negotiations from coast to coast.
Many members of SEIU's Nurse Alliance have been able to
negotiate limits, if not outright prohibitions, on mandatory
overtime. At the Dimensions Health Care, in Maryland, the
nurses, through their union contract, have ensured that their
hospital's past practice of not requiring mandatory overtime is
followed, a practice that is an incentive for many nurses to
stay on at that hospital. Earlier this year, SEIU nurses at
Aliquippa Community Hospital in Philadelphia became the first
in their State to win an agreement in their contract
eliminating mandatory overtime. Their hospital CEO, Fred Hyde,
recently joined nurses in pressing for State law in
Pennsylvania to protect patients and nurses from mandatory
overtime, calling it ``involuntary servitude.'' SEIU nurses at
Kaiser Permanente, the League of Voluntary Hospitals in New
York, Swedish Medical Center in Washington State, and many
other hospitals have negotiated contracts with breakthrough
agreements that give bedside nurses a voice in getting safer
staffing levels through labor-management committees. But, while
we have made some progress, this issue is too big and too
important to the health of our profession, our hospitals and
our communities to address hospital-by-hospital and contract-
by-contract nurses working together with SEIU, unions and the
American Nurses Association have introduced legislation on the
State level to establish safe staffing standards, ban mandatory
overtime, provide whistleblower protection for nurses when they
speak out on understaffing that jeopardizes good patient care,
and provide for involvement of direct care nurses in the
development of staffing policies.
California was the first State, in 1999, to pass
legislation to require fixed minimum staff-to-patient ratios in
hospitals. Proposed ratios were issued earlier this year, with
hearings planned. Legislation has now been passed and signed
into law in a total of 7 States while legislators in 16
additional States have considered elements of safer staffing,
primarily banning mandatory overtime.
The State-based impetus to ban or to limit mandatory
overtime has given rise to Federal legislation, The Safe
Nursing and Patient Care Act, now with 93 co-sponsors in the
House and 12 in the Senate. Addressing the problem of mandatory
overtime creates a significant improvement in the nurses'
working conditions. A significant majority of nurses surveyed
by SEIU in February and March of 2002 state that they would be
more likely to stay in hospital nursing if mandatory overtime
were eliminated.
Comprehensive safe staffing legislation should contain all
the elements of the SEIU model-legislation, including:
Minimum staffing requirements set by the legislation.
Submission of annual staffing plans that includes a system
for determining staffing levels based on acuity.
Maintenance of daily staffing records.
Prohibition of mandatory overtime.
Maximum number of working hours for nurses.
Protection for whistleblowers.
Public disclosure of mandated and actual staffing levels.
Unannounced inspections.
On the Federal level, legislation has been introduced
designed to attract new people into the nursing profession by
making it easier to access educational and training resources.
Continued support for education is essential. Your continued
support for education through The Nursing Reinvestment Act and
entry-level nursing programs is essential.
Additionally, on the education front, I would encourage
this Committee to explore support for the establishment of
public-private partnerships that would provide educational
programs that establish career ladders for nursing assistants
to become licensed practical nurses and for licensed practical
nurses to become registered nurses. These workers who are
currently working in related fields, have a more realistic idea
of the work. Providing these workers, as well as clerical
workers, dietary and housekeeping workers with educational
opportunities through progressive steps toward employment in
professions that demonstrate the greatest need. There are tens
of thousands of dedicated health care workers in our country's
hospitals, nursing homes and in-home care, who leave health
care employment because of intolerable working conditions, poor
pay and benefits. They could be a valuable resource to address
our future shortage needs. These programs should be worker
friendly, crediting the student for prior learning and
experience, perhaps through the use of online distance learning
with a clinical component based in the workplace. This would
enable them to complete the course work in as expeditious a
manner as possible and move them into the workplace where their
services are so desperately needed. Obviously, these programs
would have to be fully credentialed, and the providers must be
reputable institutions of higher education.
While these efforts are to be applauded, this will not
address the fundamental problems facing our profession and our
patients. America's hospitals are in a state of emergency. And
it is one that will only grow worse as the nursing shortage
grows more severe. Forcing more mandatory overtime or simply
relying on new nurse recruitment programs won't solve the
problem either. Likewise, easing immigration rules to attract
more foreign workers or expanding the number of visas allowed
for nurses and nursing home workers will only push more
caregivers through the revolving doors of our Nation's
hospitals and nursing homes. All of these measures will only
treat the symptoms, not cure the disease. Unless and until we
address the understaffing and poor working and patient care
conditions that plague nurses, we will never solve the
shortage.
In order to address the crisis that exists in our hospitals
and nursing homes, we must discuss what is being done to change
these conditions and what can Congress do to stop the nursing
profession from bleeding to death.
Fundamentally, the solution to the nursing crisis lies in
the establishment of safe staffing standards in our hospitals
and extended care facilities.
We also need staffing standards that will change the
culture of care in nursing homes to one which ends the assembly
line and instead truly values residents and their lives. And we
need adequate reimbursement with built-in accountability to
ensure that taxpayer dollars are spent on resident care instead
of profits.
In hospitals, we must set enforceable minimum staffing
standards linked to the acuity of patients, skill of the staff,
and skill mix to ensure good quality care in hospitals,
emergency rooms and outpatient facilities. But we must make
sure that such minimums do not become the maximums.
We must make safe staffing a requirement for all hospitals
receiving Federal money taxpayer dollars.
We must make sure the Federal Government provides adequate
oversight of our hospitals, and that the industry's self-
monitoring system under the Joint Commission of the
Accreditation of Healthcare Organizations be reformed.
And we must protect the rights of patients and the rights
of health care workers who blow the whistle on staffing
problems that jeopardize the quality of care.
To be sure, it will take time to enact and implement
staffing standards. The understaffing problem did not develop
overnight, and neither will the solution. Again, I wold request
the immediate support of Congress for The Safe Nursing and
Patient Care Act. While this certainly will not end the crisis,
it will hopefully begin the healing process.
At the same time, we cannot lose sight of the fact that the
system needs a fix. We must find ways to set meaningful
standards for staffing in the health care industry.
Understaffing in our Nation's hospitals is a serious health
problem. It is a problem that will only be solved through the
joint efforts of public officials, nurses and hospital
administrators. And it is a problem that must be solved if we
are to guarantee quality care for patients--and keep skilled
nurses in our hospitals and at the bedside.
I would like to thank you, Senator Reed, for your co-
sponsoring of the Safe Nursing and Patient Care Act. My thanks
to the entire Committee for allowing us to speak about these
issues that are so close to my heart.
[The prepared statement of Wendy Laprade follows:]
Prepared Statement of Wendy Laprade
Thank you, Senator Reed for inviting me to testify at this hearing
on the current nursing crisis in this country.
My name is Wendy Laprade. I am a registered nurse. I am a staff
nurse. I work at the bedside giving patient care. I have worked at
Women and Infants Hospital for the last 18 years. I am a member of
District 1199, New England Health Care Employees Union and a member of
the Service Employees International Union Nurse Alliance. While I have
contact with representatives of over 110,000 nurses through the SEIU
Nurse Alliance, my comments today will be primarily from a more
personal prospective.
Nineteen years ago when I started my nursing career, I knew that
certain inconveniences came with the profession. Providing care for
patients in the acute care setting requires working evenings, nights,
weekends and holidays. I did not anticipate unsafe staffing levels,
mandatory overtime, floating to other unfamiliar areas of the facility,
ergonomic strains, safety and health issues. I never imagined my
nursing time would be occupied with non-nursing duties--counting drugs
and supplies, checking equipment, transporting, having to speak on the
telephone constantly and being put on hold for long periods of time
with doctors and other departments, typing, ordering, cleaning and
justifying. We must fix the underlying problems, not just whitewash the
nursing picture, for as fast as educators can help to produce new
nurses, they will be leaving the bedside for more acceptable
opportunities.
But there is a step we can take today, immediately, to stop the
hemorrhaging--and that's to put a ban on mandatory overtime. Senate
Bill 1686, Safe Nursing and Patient Care Act, introduced by Senators
Kennedy and Kerry would do this. Limiting forced overtime will ease the
impact of the shrinking supply of nurses by encouraging more nurses to
stay in the profession. It will protect countless patients in the same
way that limits on mandatory overtime for train engineers, air traffic
controllers, truck drivers and other occupations where public safety is
at risk.
With the rise of managed care in the 1980s, long before a nursing
shortage began to emerge, hospital administrators moved to cut costs by
cutting expenses, particularly by laying off and decreasing hours for
huge numbers of registered nurses. Across the country, the industry
reduced staffing levels to the point where nurses--increasingly unable
to provide our patients with the care we were trained to give--began to
leave hospitals for more rewarding and less physically and emotionally
taxing jobs.
Nurses in hospitals and related facilities are caring for more
patients today than we did a decade ago. Because of restrictions on
hospital admissions and lengths of stay imposed by managed care, the
patients in hospitals are more acutely ill and in need of greater care.
The result is that hospitals are having increasing difficulties
filling vacancies for RNs. This is confirmed by our SERJ Nurse Alliance
Survey, where:
Nurses reported that on average it took nearly 11 weeks (10.77) to
fill a nursing vacancy in their unit, and 52 percent of the nurses
believed that it takes longer to fill vacancies today than 3 years ago.
This doesn't just show nurses' job dissatisfaction; it signals a
real problem for patients. When staff is less experienced and unstable,
it is more likely that patient care will suffer.
The hospital industry cites many of these statistics to point to a
nationwide ``nursing shortage.'' But a closer look at the data suggests
that the real problem is a shortage of nurses willing to work in
hospitals under current working conditions. This opinion was also
shared by the General Accounting Office in their recent report,
``Nursing Workforce: Emerging Nurse Shortages Due To Multiple
Factors.'' Many view the situation as a staffing crisis rather than a
nursing shortage; systemic understaffmg brought on by the restructuring
of the industry under managed care has led to dramatically
deteriorating working conditions and increasing concern about the
quality of patient care which is causing nurses to leave hospitals.
This is confirmed in a survey of health care human resource managers
conducted by the William M. Mercer Consulting Company, who found two
important factors affecting turnover:
``Dissatisfaction with the job itself, working conditions, the
relationship with the supervisor, or career opportunities;''
``Workload and staffing,'' noting that ``a reduction in RN
resources has increased the job demands of those remaining in the
workforce.''
In the report, the consulting company suggests that the employers
concerned about turnover ``should examine their own practices and work
environment.'' It cannot be stressed enough that when our nursing
profession is in crisis, our Nation's health care system is in crisis.
Inadequate staffing has given rise to increased numbers of medical
errors. In 1999, the Institute of Medicine found that between 44,000
and 98,000 Americans die every year in hospitals due to medical errors;
more people die of medical errors than from motor vehicle accidents,
breast cancer, or AIDS. While the IOM report exposed a national crisis,
it did not explore one of the primary causes of it: understafling.
However this issue was comprehensively assessed by a research team from
the Harvard School of Public Health led by Professor Jack Needleman,
which found that higher RN staffing was associated with a 3 to 12
percent reduction in the rates of patient outcomes sensitive to
nursing--in particular urinary tract infections, pneumonia, length of
stay, upper gastrointestinal bleeding, and shock.
A majority of nurses in our SEW Nurse Alliance survey identified
understaffmg as a cause of medical errors. The situation, they say, is
not improving.
Fifty-four percent of nurses say that half or more of the errors
they report are the direct result of inadequate staffing.
Despite the growing attention focused on medical errors, most
nurses say the rate of incidents has remained unchanged over the last
year--while fully 30 percent of nurses say the errors have actually
increased.
We also should keep in mind that there are many more medical errors
that go unreported for fear of retaliation. Most health care workers
who blow the whistle on short staffing and poor patient care have no
legal protections against retaliation. Federal whistleblower laws are
narrow in coverage and do not apply specifically to the health care
industry.
The staffing crisis and the deteriorating conditions it has created
has compromised quality care for people in our communities. According
to the Maryland Hospital Association, ``over half the hospitals
throughout Maryland report they have had to close beds, delay and
cancel surgeries, disrupt scheduled procedures, and `reroute'
ambulances to other facilities for emergency patient care.'' The MHA
says that it is increasingly common for patients arriving in an
emergency department ``to be held there until adequate staffing becomes
available on a patient unit.'' These situations are not unique to the
State of Maryland.
A particularly devastating side effect of the understaffing crisis
is the abuse of mandatory overtime by many health care employers.
Nurses are often mandated to work back-to-back 8-hour shifts, or 4
extra hours on top of a 12-hour shift to fill gaps in staffing. Of
course, this threatens patient safety. There is no way an exhausted,
overworked nurse is as alert and accurate as a well-rested nurse
working a regular shift. Mandatory overtime also places an incredible
stress on family life, particularly when last-minute changes have to be
made to find childcare or care for elderly parents.
According to our survey, nurses in acute care hospitals work an
additional 340 hours of overtime on average every year. Nurses are not
only being increasingly required to work excessive amounts of mandatory
overtime, but also routinely are required to ``float'' or be reassigned
to units where they lack the experience and training. Nurses are being
stretched to the limit, experiencing high levels of stress, chronic
fatigue, and work-related injuries. These intolerable work practices:
lead to further ``burnout,'' undermine nurses' sense of
professionalism, drive nurses from hospitals.
Nineteen years ago when I started my practice, most hospitals
provided new employees with a fairly extensive initial training and
continuing education program. In 1995, an average initial training
lasted 3 months. In 2000, that was decreased to 30 days.
Nurses want to provide safe and effective care for our patients. We
need appropriate nursing education to keep up with the ever-expanding
technology.
Correcting these issues, I believe, will help restore a sense of
value back in the nursing profession. Workers stay when they feel a
sense of value and pride in their work.
According to the SEIU Nurse Alliance survey: Only 55 percent of
acute care nurses plan to stay in hospitals until they retire. And only
43 percent of nurses under 35 plan to stay in hospitals until
retirement. But 68 percent of nurses say they would be more likely to
stay in acute care if staffing levels in their facilities were
adequate.
These statistics show a little-discussed fact about today's
``shortage.'' In reality, the current supply of nurses far exceeds
demand. The proportion of RNs employed in hospitals has decreased
substantially and consistently from 68 percent in 1988 to 59 percent in
2000. Our current crisis is not a shortage of nurses--it is a shortage
of nurses working at the bedside. Nationwide there are approximately
2.7 million Registered Nurses, however, 500,000 of those RNs are not
working in nursing. According to The American Hospital Association
statistics, nationwide there is a 12 percent vacancy rate in nursing.
This translates to 126,000 nursing vacancies. It is easy to see that we
have the nurses, but they are not working in nursing positions.
Deteriorating staffmg and working conditions have led many nurses
to leave the profession altogether and fewer young people are entering
it: nursing school enrollment has declined in each of the last 6 years.
According to Dr. Dennis O'Leary, President of Joint Commission on the
Accreditation Healthcare Organizations (JCAHO) in the May 2000 report
Framing the Issues: In pursuit of solutions to the National Nurses
Workforce Dilemma, there are 21,000 fewer nursing students in 2000 than
in 1995. As a result, the average age of working RNs has increased 7.8
years since 1983 to 45.2 years. As these trends continue, there is
likely to be a severe nursing shortage in the future. By 2020, we
expect that will be a shortage of 400,000 nurses, when the majority of
the baby boomers will be seeking care.
Many nurses wish to remain in hospital work, and would do so if
staffing and working conditions improve. If these conditions are not
improved, nurses' flight from hospital care will intensify and in the
near future we will face a true shortage. The fact that younger nurses
are even less likely to stay in acute care than their older colleagues
is a warning sign.
The American Hospital Association reported in its report
``Commission on Workforce for Hospitals and Health Systems,'' many
hospital workers do not feel valued and discourage others from entering
health care.
I have focused my remarks principally on hospitals, since that is
where my practice is and where I believe the nursing crisis is most
severe. There is, however, a related and equally serious problem in
nursing homes. While RNs make up a small proportion of the nursing home
workforce, and are largely in managerial positions, most of the staff
in nursing homes are certified nurse assistants (CNAs) and, to a lesser
extent, licensed practical nurses (LPNs) or licensed vocational nurses
(LVNs).
SEW members include more than 120,000 nursing home employees, the
vast majority of whom are CNAs and a large number of whom are LPNs/
LVNs. Similar to administrators in the hospital industry, nursing home
owners have argued that they are facing a shortage of nurses and nurse
aides. For this reason they have asked for increased Medicare and
Medicaid reimbursement and have resisted the setting of minimum
staffing standards.
But just like in hospitals, the real problem isn't finding people
to work in nursing homes, it is keeping them there. Turnover rates for
direct care workers in nursing homes are nearly 100 percent, creating a
revolving door of caregivers that renders continuity of care
impossible. Workers are leaving due to heavy workloads. They simply do
not have enough time to care for the number of residents they are
assigned to, which leads to stress, guilt and burnout.
Moreover, low wages, lack of health insurance coverage, pensions
and high injury rates also make nursing home work unsustainable for
many workers.
Nurses across America are sounding the alarm: staffing levels are
too low to provide the quality of care their patients need. In many
States, nurses who are in unions have turned to the bargaining table to
change their working conditions in order to ensure safer staffing and
better patient care. Eliminating mandatory overtime, establishing safe
staffing standards and improving recruitment and retention by
increasing pay have been the primary issues in nurse contract
negotiations from coast to coast.
Many members of SEIU's Nurse Alliance have been able to negotiate
limits--if not outright prohibitions--on mandatory overtime. At the
Dimensions Health Care, in Maryland, the nurses through their union
contract have ensured that their hospital's past practice of not
requiring mandatory overtime is followed, a practice that is an
incentive for many nurses to stay on at that hospital. Earlier this
year, SEIU nurses at Aliquippa Community Hospital in Pennsylvania
became the first in their State to win an agreement in their contract
eliminating mandatory overtime. Their hospital CEO, Fred Hyde, recently
joined nurses in pressing for State law in Pennsylvania to protect
patients and nurses from mandatory overtime, calling it ``involuntary
servitude.''
SElU nurses at Kaiser Permanente, the League of Voluntary Hospitals
in New York, Swedish Medical Center in Washington State, and many other
hospitals have negotiated contracts with breakthrough agreements that
give bedside nurses a voice in getting safer staffing levels through
labor-management committees. But, while we have made some progress,
this issue is too big and too important to the health of our
profession, our hospitals and our communities to address hospital-by-
hospital and contract-by-contract.
Nurses working together with SEW, unions and the American Nurses
Association have introduced legislation on the State level to establish
safe staffing standards, ban mandatory overtime, provide whistleblower
protection for nurses when they speak out on understaffing that
jeopardizes good patient care, and provide for involvement of direct
care nurses in the development of staffing policies.
California was the first State, in 1999, to pass legislation to
require fixed minimum staff-to-patient ratios in hospitals. Proposed
ratios were issued earlier this year, with hearings planned.
Legislation has now been passed and signed into law in a total of 7
States while legislators in 16 additional States have considered
elements of safer staffing, primarily banning mandatory overtime.
The State-based impetus to ban or to limit mandatory overtime has
given rise to Federal legislation, The Safe Nursing and Patient Care
Act (HR 3238/S 1686), now with 93 co-sponsors in the House and 12 in
the Senate. Addressing the problem of mandatory overtime creates a
significant improvement in the nurses' working conditions. A
significant majority of nurses surveyed by SEIU in February and March
of 2002 state that they would be more likely to stay in hospital
nursing if mandatory overtime were eliminated.
Comprehensive safe staffing legislation should contain all the
elements of the SEIU model-legislation, including:
Minimum staffing requirements set by the legislation; Submission of
annual staffing plans that includes a system for determining staffing
levels based on acuity (severity of illness or injury); Maintenance of
daily staffing records; Prohibition on mandatory overtime; Maximum
number of working hours for nurses; Protection for whistleblowers;
Public disclosure of mandated and actual staffing levels; Unannounced
inspections.
On the Federal level, legislation has been introduced designed to
attract new people into the nursing profession by making it easier to
access educational and training resources. Continued support for
education is essential. Your continued support for education through
the Nursing Reinvestment Act and entry-level nursing programs is
essential.
Additionally, on the education front, I would encourage this
Committee to explore support for the establishment of public-private
partnerships that would provide educational programs that establish
career ladders for nursing assistants to become licensed practical
nurses and for licensed practical nurses to become registered nurses.
These workers who are currently working in related fields, have a more
realistic idea of the work. Providing these workers as well as,
clerical workers, dietary and housekeeping workers with educational
opportunities through progressive steps toward employment in
professions that demonstrate the greatest need. There are tens of
thousands of dedicated health care workers in our country's hospitals,
nursing homes and in home care, who leave healthcare employment because
of intolerable working conditions, poor pay and benefits. They could be
a valuable resource to address our future shortage needs. These
programs should be worker-friendly, crediting the student for prior
learning and experience, perhaps through the use of online distance
learning with a clinical component based in the workplace. This would
enable them to complete the course work in as expeditious a manner as
possible and move them into the workplace where their services are so
desperately needed. Obviously, these programs would have to be fully
credentialed, and the providers must be reputable institutions of
higher education.
While these efforts are to be applauded, this will not address the
fundamental problems facing our profession and our patients. America's
hospitals are in a state of emergency. And it's one that will only grow
worse as the nursing shortage grows more severe. Forcing more mandatory
overtime or simply relying on new nurse recruitment programs won't
solve the problem either. Likewise, easing immigration rules to attract
more foreign workers or expanding the number of visas allowed for
nurses and nursing home workers will only push more caregivers through
the revolving doors of our Nation's hospitals and nursing homes. All of
these measures will only treat the symptoms, not cure the disease.
Unless and until we address the understaffmg and poor working and
patient care conditions that plague nurses, we will never solve the
shortage.
In order to address the crisis that exists in our hospitals and
nursing homes, we must discuss what is being done to change these
conditions and what can Congress do to stop the nursing profession from
bleeding to death.
Fundamentally, the solution to the nursing crisis lies in the
establishment of safe staffing standards in our hospitals and extended
care facilities.
We also need staffmg standards that will change the culture of care
in nursing homes to one which ends the assembly line and instead truly
values residents and their lives. And we need adequate reimbursement
with built-in accountability to ensure that taxpayer dollars are spent
on resident care instead of profits.
In hospitals, we must set enforceable minimum staffing standards
linked to the acuity of patients, skill of the staff, and skill mix to
ensure good quality care in hospitals, emergency rooms and outpatient
facilities. But we must make sure that such minimums do not become the
maximums.
We must make safe staffing a requirement for all hospitals
receiving Federal taxpayer dollars.
We must make sure the Federal Government provides adequate
oversight of our hospitals, and that the industry's self-monitoring
system under the Joint Commission on the Accreditation of Healthcare
Organizations be reformed.
And we must protect the rights of patients and the rights of health
care workers who blow the whistle on staffing problems that jeopardize
the quality of care.
To be sure, it will take time to enact and implement staffing
standards. The understaffing problem didn't develop overnight, and
neither will the solution. Again I would request the immediate support
of Congress for the Safe Nursing and Patient Care Act. While this will
certainly not end the crisis, it will, hopefully, begin the healing
process.
At the same time, we cannot lose sight of the fact that the system
needs a fix. We must find ways to set meaningful standards for staffing
in the health care industry. Understaffmg in our Nation's hospitals is
a serious health problem. It's a problem that will only be solved
through the joint efforts of public officials, nurses and hospital
administrators. And it's a problem that must be solved if we are to
guarantee quality care for patients--and keep skilled nurses in our
hospitals and at the bedside.
I would like to thank you again, Senator Reed, and the Committee
for allowing me to speak about these issues that are close to my heart.
I look forward to working with you in the future.
Senator Reed. Well, thank you very much.
My thanks to all the panel for their excellent testimony.
Let me take my round and then turn to the Lieutenant Governor.
One of the things that is just persistent in all the
comments this morning is the frustration of the workplace as a
major source or cause which drives the nurses away, the
radiologists away, acts as an inhibition for students to go
into nursing.
Again, Wendy, you seem to be suggesting this is really the
principal issue in terms of the frustration of the workplace.
What more can we do, besides the measures you have pointed out,
and I'm going to ask all the panel to just think about the
Federal and State level, because without dealing with this
issue, even increased remuneration, as Dr. Schepps suggested,
is not going to really cure the problem.
Ms. Laprade. Boy, am I sorry you're asking me first.
Senator Reed. Well, I will ask Dr. McKinney first his
theory.
Mr. McKinney. I think the distance between the practitioner
and where important decisions are being made is the biggest
factor, and those decisions, it seems to me, have to be the
prerogative of those people who are actually providing the
care, and that is not the case these days.
Senator Reed. So that would suggest a new way to operate,
not so much that there's technology, just decisionmaking as
having smaller feedback.
Dr. McGarry.
Ms. McGarry. It also strikes me from some of the reports
that I've seen, even in terms of all of the surveys, that
certainly increasing salary is one aspect, but the more
important is respect, is the recognition of the critical
thinking and decisionmaking that goes on on a day-in/day-out
basis, and also one the anecdotes that I had supplied for you
in my testimony had to do with a person who left after about 18
years being in the health care community because she did not
feel that there was any recognition for the increased
responsibility of even tutoring or mentoring or being a
preceptor for some of the newer or even more inexperienced
staff. I think those are the other types of things that need to
have that recognition, in addition to the Nurses' Week, that
fully recognizes nurses, et cetera, but have something that is
more pervasive, 365 days, all through the hours of the shift,
et cetera.
Senator Reed. As far as you responded and others, is this
perception of the need to show appreciation for these medical
professionals, is this increasing? Are we getting the message?
Dr. Schepps. No, I really don't think that, particularly
radiologic technologists who are basically, for the most part,
a non-degree program graduate, they feel that they're kind of
second class citizens in health care, and they really would
like to have, not just respect 1 week a year, but all the year,
and I think that what they do, what they do is quite different
from what they did 30 years ago, and perhaps their education of
2 years is not long enough, and perhaps it should be a 4-year
program, and we need to look to change those kinds of things,
but who is going to support them. The people who go into this
field generally cannot afford a 4-year college or cannot even
afford a 2-year college, and this is a way for them--many of
them are immigrants, they're minority, they are people that
have no other way to become upwardly mobile and they need to
have some infrastructure there for them to gain this respect,
this daily respect, not just recognition once a year.
Senator Reed. Jim, your perception on the mental health
care.
Mr. McNulty. Well, again, I agree with everything that my
fellow panelists have said. A quick anecdote to sort of
illustrate. I mean, we have very highly trained people in
mental health that give front line care, not just psychiatrists
or psychologists, social workers, mental health workers. I have
a friend who is a nurse, a mental health clinician, and she
told me that she had an interaction with a managed care
organization. She had interviewed a patient who was very
suicidal, who had attempted to jump up out of a car while she
was being transported to this facility for an interview, and
the managed care staffer said, ``Well, gee, how fast was the
car traveling?'' And she said, ``Gee, I don't know.'' Turned
around and asked the patient's husband, and the husband said,
``Well, about 25 miles an hour.'' ``25 miles an hour? Oh, well
you cannot get killed jumping out of a car going that speed.''
This illustrates exactly what it is. That is the respect issue.
You have highly trained clinicians who know what the hell
they're doing and they're not allowed to do their jobs at any
level. It is your secondguess by people who have a pressure on
them to keep costs down, and that is what I said in my
testimony, I don't know how we are going to address that
balance, but we have to. If we don't do that, then the system
is not going to get better.
Senator Reed. Wendy, any further comments? If you want to
supplement your testimony.
Ms. Laprade. Well, as Dr. McGarry said, the issue of
respect is huge in nursing. The majority of my peers are all
saying the same thing, whether they are nursing peers,
radiology peers, med techs, they are all saying the same thing,
it comes down to a system where our education within the
hospitals has been decimated. With managed care coming in,
costs had to be cut, and the education department, at least for
nursing, was a huge hit. Initial training for nurses coming in
has decreased. You're sending brand new grads in that don't
have the bases. They're trying to be trained and they're being
overwhelmed and then put right onto the floors, and they're
leaving. Continuing education for the nurses that are currently
there has decreased, which shows us less value, and that is a
huge issue for us. The non-nursing issues, as I had spoken
about before, is also something. When we are spending our time
with different regulations that come out, a lot of times
related to JCAHO, which says that I cannot dipstick a urine
because I might be color blind, when I have been dip sticking
urines for 19 years. You know, it is just some of the basic--
pardon me--foolishness that goes on.
Senator Reed. I am just glad that I have never heard those
terms in the same sentence.
[Laughter.]
Mr. Fogarty. Just maybe a question or comment to Jim
McNulty.
Based on the work of the our task force last year, the
thing that most concerned me about crisis in the children's
mental health services in our State where, I mean, families
have to be beyond crisis asks to get help. Do you see any
change in the foreseeable future on that? Because I just don't
know what parents do when their kids are in a situation, and if
we cannot take care of their problems early on, but it is,
obviously, much more costly to them as a whole, the whole
health care system?
Mr. McNulty. Yes. Representative Kennedy has, in fact,
introduced a bill in the House, H.R. 5078. One of the things I
asked Senator Reed to do was to consider passing a similar bill
in the Senate, of the Childhood Mental Health Services
Management Act, and it has many of the elements in it that
help, and I think it is a good start. It is a good place to
start. To illustrate the problem, we have 8,000 child and
adolescent psychologists in the United States. The need right
now is for 30,000, and it is going to get worse, and the same
thing prevails at the geriatric end of the scale, as one of the
earlier panelists mentioned. Government is so frightening that
I can almost barely bring myself to think about it, because we
are so short of resources. Our two psychiatric hospitals in the
State have done a great job. We cannot get paid. Psychologists
don't get paid enough anyway, psychiatrists don't get paid
enough anyway, but what happens is the children in particular
have collateral times. Collateral times means time you spend
working on a patient, but you cannot bill for that. With
children and adolescents, that ends up being sometimes two or
three times the hour that you might spend face to face with the
child or adolescent. So you are essentially working for half or
one-third of your pay. No one can do that for very long. You
cannot ask the mental health professional to think about
poverty in addition to all the other things that they have to
put up with.
Senator Reed. Let me ask one final question. That is, we
focused in on practitioners. Turning to the students, are you
saying, and it might refresh your testimony, both Mr. McKinney
and Dr. McGarry, by your physical facilities or your staff in
terms of training all the young people who come to the
University of Rhode Island or the Community College of Rhode
Island who say, I want to be a health care professional, is
that a real concern to you? We are talking now about a problem
of years of shortage and facing the daunting challenge, that
all the panelists expressed so well, the many different factors
that are contributing to it, but if we have a show point at the
very beginning of the system where young people walk up and
say, I would like to be a nurse, I would like to be a physical
therapist, I would like to be a mental health professional and
our schools say, that is nice, but come back in years from now
when the waiting list has gone down.
Mr. McKinney. Yes. It is a serious difficulty. Until very
recently in our physical therapy master's program, we had 24
seats and in excess of 500 applications. Now that has dwindled
a bit, but it is starting to build again. The competition in
the speech pathology and audiology is as about as high as it is
for any graduate program at the university.
Senator Reed. Dr. McGarry.
Ms. McGarry. Actually, we have had significant increases in
particularly our nursing application pool, and we think that
this is being in response to the media, as have been going on
both nationally as well as locally. Seventeen-hundred
applications for 250 spots. We have enriched the flexibility
opportunities. We have day programs, we have evening and
weekend programs. However, the most striking problem that has
just occurred is the closing of all of our satellites. One of
our satellites houses four programs. Four health programs, I
might add. These folks are all going to be displaced into the
some, or one or three of the main campuses, depending upon
where these can be housed. These all have critical
accreditation requirements, one of which is being written as we
are sitting before us today, and those things have to be
addressed, because there are some vital issues that will not be
answered and we are not going to continue to respond to the
needs, the health care force needs. So, those are the kinds of
things that we are struggling with. We know those decisions, in
terms of the satellites, did not come easy. There seems to be
no other way, short of reducing our intake of students, and
that was not a viable or pallial decision. So, it is coupled by
many things, but that to me is the most striking concern that
is before us.
Senator Reed. Thank you very much. I want to thank all of
the witnesses this morning. It was an excellent series of
panels. We face an extraordinarily daunting challenge. There
are shortages today that they can grow to be critical in the
not-too-distant future, that will be parallel with quality and
the affordability of the health care system, and so we have to
act today.
One of the comforting aspects, though, that has been
demonstrated this morning, we have so many very talented, very
skilled professionals here in Rhode Island who are committed to
working with the problem. That is the problem before us, and we
have to act now so we don't end up one day wondering what
happened to our health care system.
Let me thank all the witnesses. Let me thank the Lieutenant
Governor particularly. He has to respond this morning to his
outstanding leadership on all these issues in the State of
Rhode Island, and my colleagues, Senator Chafee and Congressman
Langevin. The hearing is adjourned.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Senator Reed
Good morning. Thank you all for taking time out of your schedules
to be here today to attend this official field hearing of the Senate
Health, Education, Labor and Pensions Committee. I would like to thank
Dr. Tom Sepe for his warm welcome and our Lieutenant Governor for his
opening remarks and for his strong leadership on the health workforce
shortage issue here in Rhode Island. I would also like to take a moment
to give a special thank you to all of our witnesses here today. I
appreciate your willingness to come here on relatively short notice and
share your thoughts and perspectives on this critical issue.
The Health Care Workforce in Rhode Island
Over the past decade, health care has become an increasing portion
of our overall Gross Domestic Product (GDP), as well as a growing
percentage of our Nation's expenditures. It is estimated that the
United States spends more on health care than any other Nation in the
world and we as Americans expect to have access to the best and latest
treatments and we expect high quality of care.
Health professionals make up roughly 10.5 percent of the Nation's
total workforce. In Rhode Island, that figure is 11.8 percent--or
53,000 people--who are employed in the health sector. Amazingly, our
small State ranks third in the Nation in per capita health services
employment. Health services employment in Rhode Island grew 30 percent
between 1988 and 1998, compared to 23 percent nationally. These figures
are only expected to continue to grow robustly, as the population of
our State continues to age and health care utilization continues to
move upward.
Our Educational System Struggles to Keep Up with the Need
Meanwhile, the demand for health professionals exceeds the number
of new workers graduating from training programs each year. Budget
constraints, outdated teaching facilities and aging faculty strain the
ability of community colleges and State universities around the Nation
to produce the volume of proficient pharmacists, dental and mental
health providers, nurses of all levels (CNA, LPNs, RNs, Advanced
Practice Nurses), therapists and technicians to meet the growing needs
of our health care system.
In the U.S. Senate, I have supported legislative initiatives that I
hope will begin to address these various shortages, particularly in the
areas of nursing and pharmacy. We have all heard about the imminent
shortage of nurses, not only in Rhode Island, but around the Nation.
Many hospital administrators warn that the national nursing shortage
will only grow worse in the coming years because of an aging
population. Nationwide, hospitals have a shortfall of 126,000 nurses.
The Journal of the American Medical Association says that could grow to
400,000 in the next decade.
While the nursing shortage problem is certainly acute in hospitals
in Rhode Island, home health agencies and skilled nursing facilities
are also feeling the painful pinch of these shortages. Interestingly,
21.8 percent of Rhode Island's heath services workers were employed in
nursing care facilities, while the State ranks ninth in the country in
terms of employment in home health care.
I have co-sponsored legislation intended to enhance our ability to
recruit and retain a new generation of nurses as well as legislation
designed to improve the work environment for nurses currently on the
job.
I have also been interested in the emerging shortage of pharmacists
in this country. There were 6,500 openings for pharmacists at the
20,500 chain drugstores, and independents and hospital pharmacies are
also recruiting. The number of pharmacists is expected to only grow by
28,500 over the next 10 years--800 less than the 29,300 over the last
decade. It is also reported that the number of applicants to pharmacy
schools in 1999 was 33 percent lower than in 1994--the high point of
enrollment during the 1990s. In an effort to address this problem, I
have introduced bipartisan legislation to increase financial assistance
to students, faculty and schools of pharmacy in order to encourage more
students to pursue careers in pharmacy and provide pharmacists to
underserved areas of the country.
S. 1806, the Pharmacy Education Aid Act, will create scholarships
for pharmacy students and provide loan repayment for those students who
commit to teaching pharmacy for at least 2 years or those who practice
pharmacy where there is a dire need--such as remote areas of the
country.
The Impact of Workforce Shortages on Care
Clearly, these are significant issues that have a direct impact on
the ability of Rhode Islanders and all Americans to access health care
services. Health professions shortages also have the effect of reducing
quality of care and patient outcomes.
Specifically, a recent New England Journal of Medicine study found
that patient outcomes were directly correlated with nurse staffing
ratios. The report, which examined the discharge records of six million
patients at 799 hospitals in 11 States, found that in hospitals with
higher numbers of registered nurses, patient stays were 3 percent to 5
percent shorter and complications were 2 percent to 9 percent lower
than hospitals with fewer nurses.
The purpose of today's hearing is to explore the nature of these
workforce shortages across the health care spectrum in Rhode Island,
examine what steps are currently being taken at the State and Federal
levels to address these issues, and ultimately, gain a better
understanding of the long-term solutions that will be necessary to
tackling this looming crisis.
Thank you all for being here and I look forward to the testimony of
the distinguished panelists who have graciously agreed to take time out
of their busy schedules to be here with us today.
______
Washington Post Highlights Critical Shortage of Pharmacists
Reed Legislation Would Provide Financial Assistance to Encourage
Students
to Become Pharmacists
A June 21, 2002 Washington Post story highlighted the critical
shortage of qualified pharmacists currently facing the health care
system.
U.S. Senator Jack Reed has introduced legislation to increase
financial assistance to students, faculty and schools of pharmacy in
order to encourage more students to pursue careers in pharmacy and
provide pharmacists to under served areas of the country.
In the Washington Post story, David A. Knapp, dean of the
University of Maryland's pharmacy school describes the shortage as
``[t]he ticking time bomb.''
According to the story, he warns of ``stressed out'' pharmacy
staffers--many working 12-hour shifts--miscounting pills and ``grabbing
the wrong bottle off the shelf.'' He added: ``With the elderly
population increasing, the extent of those problems is going to
increase as well.''
According to the Health Resources and Services Administration
(HRSA), the number of pharmacists is expected to only grow by 28,500
over the next 10 years--800 less than the 29,300 over the last decade.
HRSA also reported that the number of applicants to pharmacy schools in
1999 was 33 percent lower than 1994--the high point of enrollment
during the 1990s.
The Washington Post story stated, ``The 56,000 retail and mail-
order pharmacies in the United States filled 3 billion prescriptions
last year, up from 1.9 billion in 1992. The number will soar to 4
billion by 2005, according to industry estimates. At last count, there
were 6,500 openings for pharmacists at the 20,500 chain drugstores, and
independents and hospital pharmacies are also recruiting.''
Reed's legislation, S. 1806, the Pharmacy Education Aid Act, will
create scholarships for pharmacy students and provide loan repayment
for those students who commit to teaching pharmacy for at least 2 years
or those who practice pharmacy where there is a dire need--such as
remote areas of the country.
The bill modifies a law that created the highly successful National
Health Service Corps (NHSC), a Federal program that has helped fund the
education of 20,000 primary care professionals, in exchange for their
commitment to serve in traditionally under served rural and urban
areas.
The Reed bill will allow students entering pharmacy school and
students who have graduated with a pharmacy degree to apply for NHSC
Scholarship and Loan Repayment funds. In return, the students would
commit to practicing in an area of the country in need of pharmacists
for a least 2 years. It would also allow students or practicing
pharmacists who teach full-time for 2 years at a school of pharmacy to
apply for loan repayment assistance. This loan repayment assistance
will be funded by both the school of pharmacy and the Federal
Government. In addition, the bill provides schools of pharmacy access
to grants to help defray the cost of classroom and facilities
construction and expansion.
Last year, an amendment authored by Reed created a 4-year pilot
program to make pharmacy students eligible for loan repayments in
exchange for a 2-year commitment to serve in areas of the country where
significant shortages of medical professionals persist, was included in
the Safety Net Amendment Act of 2001.
Congressmen Jim McGovern and (D-MA) and Mike Simpson (R-ID) have
sponsored similar legislation in the House of Representatives.
[GRAPHIC] [TIFF OMITTED] 8373.001
[GRAPHIC] [TIFF OMITTED] 81373.002
The Pharmacist Education Aid Act of 2001
I. Overview
Pharmacists are the third largest health professional group in the
U.S. and play a key role in the healthcare delivery system. Today's
pharmacist receives an education that broadens the traditional
dispensing activities to focus on improved compliance and health status
of individuals. However, a December 2000 report released by the
Secretary of Health and Human Services (HHS) concluded that ``there has
been an unprecedented demand for pharmacists and for pharmaceutical
care services, which has not been met by the currently available
supply.'' Specifically, ``The Pharmacist Workforce: A Study of the
Supply and Demand for Pharmacists'' documented the critical role that
pharmacists play in our health delivery system and concluded that there
is a shortage of these critical health providers that will continue to
grow increasingly worse unless significant changes are made.
Factors influencing the demand for pharmacists include the growth
in the elderly population, increased use of complex prescription
medications and improved insurance coverage of prescription drugs. The
growing pharmacist shortage has been well documented:
The HHS study found that the number of unfilled full-time
and part-time pharmacist positions increased from 2,700 to 7,000
between 1998 and 2000;
A survey by the National Association of Chain Drug stores
found that the number of vacancies among member companies had increased
by 1,000 positions in the last 6 months;
A November 2001 GAO report found that, on average,
hospitals report 21 percent of their pharmacist positions are currently
unfilled. Vacancy rates are even higher in Federal systems, such as the
Department of Veterans Affairs, the Department of Defense and the
Indian Health Service.
1. Legislation Summary
The Pharmacist Education Aid Act, or PharmEd, addresses the current
shortage of pharmacists in the U.S. by increasing the chance an
individual will pursue an education as a pharmacist and the schools
will have the capacity to provide them with a high quality education.
Aid to Students
PharmEd allows students entering pharmacy school and students who
have graduated with a PharmD degree to apply for National Health
Service Corps (NHSC) Scholarship and Loan Repayment funds. It also
provides new funds for students who demonstrate financial need to apply
for scholarships to qualifying schools of pharmacy.
To attract more pharmacists to become faculty, students or
practicing pharmacists who contract to teach full time at qualifying
schools of pharmacy for at least 2 years will also be eligible for
educational loan repayment.
Aid to Schools
The practice environment for which schools of pharmacy must prepare
their students is changing rapidly. Schools of pharmacy need to install
and upgrade their information technology systems so that their students
get the best possible training for a career practicing in today's
pharmacies. Information technology improvements also allow schools to
increase their educational capacity through the creation or expansion
of distance learning programs. PharmEd authorizes competitive grants
for information technology systems improvements to qualifying schools.
Many schools of pharmacy currently educate the pharmacist of
tomorrow in the buildings of yesterday. Many schools lack building
capacity and need help to renovate, and in some cases expand, their
buildings and teaching facilities. PharmEd provides competitive grants
for construction to qualifying schools of pharmacy in particular need.
An important feature of PharmEd is its commitment to improving the
health status of populations served by many Federal supported health
programs, including those programs and institutions that are currently
operating with high vacancy rates for pharmacists. Schools of pharmacy
are considered ``qualifying'' if they require their students to perform
at least one of their clinical rotations in one of the types of
facilities having the hardest time recruiting pharmacists into
permanent positions. These facilities include, but are not limited to,
disproportionate share hospitals, facilities in rural and inner city
areas with medically underserved client populations, facilities run by
the Armed Forces of the United States, the Veteran's Administration,
the Bureau of Prisons and the Indian Health Service.
Groups that endorse the bill include the American Association of
Colleges of Pharmacy, American Pharmaceutical Association (APHA),
National Association of Chain Drug Stores, National Community
Pharmacists Association, American College of Clinical Pharmacy and
American Society of Health-System Pharmacists.
III. Other Resources
(1) HHS study--http://www.bhpr.hrsa.gov/healthworkforce/
pharmacist.html
(2) GAO report--http://www.gao.-gov/ (GAO-02-137R--November 13,
2001)
__________
Prepared Statement of Barbara A. Rayner
It is with pleasure that I convey to you some thoughts and
observations relative to the health care workforce shortage issues
being examined in this Senate Field Hearing.
The State Department of Elderly Affairs is responsible for the
management of a host of direct service programs which benefit frail,
at-risk elders in their quest to remain living independently and in
their home environment.
These include: the Homemaker/Home Health Aide Program; Adult Day
Services Programs; Respite Services; Alzheimer Support Programs;
Caregiver Support Programs; Protective Services including abuse,
neglect and self-neglect; and, Case Management Services.
While these services, in combination with our community-based
system of care are available and accessible through Senior Centers, the
reality is that because of the workforce shortages, economic
constraints of retirement incomes and their inability to navigate and
access services, care plans are not adequately activated by elders and
their families.
I believe these points have been adequately addressed at the
hearing, and provide this brief statement only as a reinforcement of
testimony.
I believe Rhode Island, and the country as a whole, needs to
approach the provision of health care and the related staffing, goods,
and services as an economic development opportunity, rather than the
current prevailing view of a financial burden to taxpayers. This
philosophical difference has long been evidenced in the efforts of such
countries as Japan. Because of the elevated status of the aged of
Japan, and the corresponding cultural attitudes, Japan has been working
since the early 1980s in developing products, which preserve dignity,
yet compensate for physiological losses. I clearly recall learning of
these projects through my work with the National Council on Aging's
International Affairs Committee, and my exposure to actual products
being developed and shared with other scientists interested in this
work. The simplest example I recall was a beautiful tapestry bib, which
could be worn by a frail elder experiencing drooling, and inability to
control food in their mouths. A more elaborate example was wheelchairs,
which could fold down into an economy size car. In summary, elders and
family caregivers need to be thought of as consumers of services and
purchasers of goods and equipment, which promotes the independence of
elders and their families.
We have come to depend on volunteerism as a resource to support the
care of frail elders: I feel we need to be cautious in recognizing the
limitations and appropriate placement of this workforce.
The population we are focusing on in this discussion is typically
very compromised and complex: therefore, the role of the volunteer as a
friendly visitor is certainly appropriate with the understanding that
this function is the limit. Volunteerism, while critically important to
the services we provide, should be designed to support, not supplant,
the provision of direct care.
Cash and counseling programs have a long and successful history in
a number of European countries as well as the United States. These
programs epitomize the strength of families in managing the care of
their frail loved one and, further, they can provide financial support
to primary caregivers who must also be earning a living. This approach
to providing services has been demonstrated within the disability
community here in Rhode Island with great success.
Demonstrated outcomes not only illustrate expanded and
individualized services, but also experience one of the lowest
incidences of fraud and abuse. Overarching the outcomes of this
approach is the reality that the family caregivers have been, and
remain, the most preferred level of advocate by the elders themselves.
Closely connected to issues related to successful independent
aging-in-place is the matter of medication management for and by the
frail elder. DEA instituted a pharmacy counseling program that matches
high-risk elders with pharmacy counseling provided at a local pharmacy.
Through our RIPAE program this intervention identifies diabetics and
high-end consumers of medications who are offered this service. This
approach represents optimal utilization of our pharmacists, offers
targeted education, reduces unnecessary emergency room visits, and,
most importantly, supports the elder and the family through direct
training and family support.
While this does not directly address the shortage of pharmacists in
our country, programs of this sort ensure optimal and appropriate
utilization of this limited resource.
A declining economy and increased unemployment rate typically
generates more citizens interested in training, education,
certification and licensing in the health care field. On the other
hand, a strengthening and strong economy moves these same workers out
of the health care field. I fully support any and all measures, which
can be taken to strengthen this workforce through incentives, higher
wages, and overall image enhancing of these valuable and honorable
professions, which provide the link to independence for our elders. I
encourage expansion of workforce training of older persons age 55 and
older to enter this field and any other innovative approaches, which
encourage retention, recruitment, expansion, and legitimization of this
para-professional workforce. Further, we must review our training or
re-training requirements to customize and better meet the interest and
needs of older workers.
__________
Prepared Statement of Patricia Ryan Recupero, JD, M.D.
I applaud Senator Jack Reed for directing the public's attention to
the important issue of the growing shortage of trained health care
professionals. Certainly, the shortage in pharmacists, nurses and
others that he highlighted is one that deserves quick and decisive
action to correct.
I would like to take this opportunity to call attention to another
shortage that is already having a severe and devastating impact on
families and communities throughout Rhode Island and around the
country. The mental health field at all levels--patients, providers,
educators, and researchers--suffers from a major lack of financial
support from the insurance industry, Federal amd State governments, and
businesses that continue to ignore the needs of the mentally ill
because of stigma or a lack of information.
I do not wish to blame or condemn any group or individuals for this
situation. In fact, there are signs that we may see ``a light at the
end of the tunnel.'' Senator Reed and a number of his colleagues in
Washington, including Rep. Patrick Kennedy, D-RI, as well as Lt.
Governor Fogarty in Rhode Island, and President Bush have been
instrumental in spotlighting the need for parity of benefits covered by
insurance companies. Great progress has been made on this front.
Organizations such as the National Alliance for the Mentally Ill and
the Mental Health Association are beginning to bear fruit.
Equally important, and so badly needed, is parity in reimbursement.
I know the Senator is familiar with recent national and international
studies documenting the effects mental disorders have on individuals,
families, businesses and communities around the world. Suffice to say
that study after study points to the undeniable fact that serious,
chronic diseases of the brain are no less debilitating--no less fatal--
than diseases of the kidney, heart and other organs. A report in the
July issue of the American Journal of Preventive Medicine indicated
that people with depression are 1.5 to 4 times more at risk of heart
disease. There can be no doubt of the existence of a ``mind/body
connection'' that can be studied and measured.
Those of us in the field are hopeful that this trend of recognizing
mental illness as a treatable disorder of the brain will begin to bring
relief for patients and health care professionals who for many years
have faced difficult and unfair restrictions. However, it needs to be
stated that the process of making improvements has been all too slow.
There are a number of factors contributing to the problem of access
to appropriate and timely psychiatric care, but there is one crucial
and overriding cause--reimbursement for behavioral medicine (mental
health and substance abuse) has been consistently set at a lower level
than reimbursement for other types of medical care. For Butler
Hospital, and others like us, that means we cannot maintain any reserve
capacity and our beds are almost always full. The situation is even
worse on the outpatient side, where more providers are opting-out of
insurance panels, resulting in drastically reduced access to care. This
was dramatically brought to the public's attention last year in Rhode
Island, when the State's Eleanor Slater Hospital was overwhelmed on
several occasions with emergency weekend admissions because of a lack
of available services at local community mental health centers.
Nowhere do we see more graphic evidence of these problems than in
child psychiatry. The pool of child psychiatrists in Rhode Island has
been seriously depleted over the past 10 years. The primary reason for
this is, once again, a reimbursement structure not based in reality.
The result is that facilities like Butler Hospital, which trains many
of the residents in Brown Medical School, cannot retain these
professionals upon graduation.
Another problem area exists in psychiatric nursing. In simple
terms, mental health care providers are discriminated against. We must
pay our nurses less than at general hospitals because we are reimbursed
less. Forced to operate on this ``uneven playing field,'' our ability
to find and retain psychiatric nurses has been eroded over the past
decade.
These are but two critical areas in need of immediate attention.
This mental health crisis exists against a backdrop of a growing body
of scientific evidence pointing to the direct impact that a person's
mental health can have on other major organs in the body. Studies in
this country and around the world confirm that the brain, the most
complex organ in the body, can cause incalculable human tragedy and
cost business and society billions in lost productivity and accidents.
For example, a 1999 study of an employer with over 20,000 employees
found that when mental health spending was cut, general health costs
and sick days went up.\1\
---------------------------------------------------------------------------
\1\ Rosenbeck, Robert A., et. al. (1999). Effect Of Declining
Mental Health Service Use On Employees Of A Large Corporation. Health
Affairs; 1999 Sept.-Oct.; 18(5): 192-203.
---------------------------------------------------------------------------
In closing, I again want to commend Senator Reed for his efforts on
behalf of the people and families struggling with mental disorders or
substance abuse. Also, let the record show that Butler Hospital
endorses and supports the five points that were presented by Mr. James
McNulty, president of the National Alliance for the Mentally Ill
(NAMI). In particular, we support his request to Senator Reed to
sponsor a companion bill in the Senate similar to the one introduced by
Rep. Patrick Kennedy, D-RI, H.R. 5078. I am optimistic that working
with Senator Reed, NAMI, and others, we can look forward to a new era
when mental illness will no longer be looked on as just a minor problem
that only affects a small percent of the population.
__________
Prepared Statement of Jane Williams
Thank you for conducting the Senate Health, Education, Labor, and
Pensions Committee field hearing, ``Who will care for us?'' on health
workforce shortages earlier this month. At the hearing you invited
written testimony and I respectfully submit the following comments.
As Chair of the Department of Nursing at Rhode Island College, I
have over 300 enrolled nursing majors with 100 students graduating each
year, making us the largest baccalaureate program in Rhode Island. I
represent a perspective that was not specifically presented at the
hearing.
In answer to your question, ``What can the Federal Government do?''
increased Federal support is needed. Specific strategies I would
suggest include:
Increase financial support for baccalaureate nursing
students. Provide scholarships and stipends for basic students and for
registered nurses with associate degrees and hospital diplomas who want
to earn bachelor's degrees. There is a need to increase the number of
bachelor's degree nurses educated each year. With patient care growing
more complex, ensuring a sufficient RN workforce is truly an issue of
preparing an adequate number of nurses with the right educational mix
to meet health care demands. The National Advisory Council on Nurse
Education and Practice (NACNEP), an advisory body to Congress and the
U.S. Secretary for Health and Human Services on policy issues related
to nursing, has urged that at least two-thirds of the nurse workforce
hold baccalaureate or higher degrees in nursing by 2010. Currently,
only 40 percent of nurses hold degrees at the baccalaureate level and
above. Baccalaureate education provides a base from which nurses move
into graduate education to fulfill the expanding needs for nurses in
advanced practice and management of complex health care systems. Nurse
executives, Federal agencies, the military, national nursing
organizations, health care foundations, magnet hospitals, and minority
nurse advocacy groups concur with NACNEP and recognize the need for
more baccalaureate and graduate-prepared nurses in the workforce.
Increase funding for graduate nurse education. There is a
shortage, not only of registered nurses, but also of future teachers
and researchers. In fact, thousands of qualified students are turned
away from nursing schools each year due to an insufficient number of
faculty members available to teach in nursing programs. With a wave of
faculty retirements projected over the next 5 years, funding should be
allocated for fast-track faculty development programs and scholarships
to encourage full-time doctoral students to pursue teaching careers.
Fully fund the Nurse Reinvestment Act that was passed by
unanimous consent by the Senate on July 22. These programs will provide
scholarships for nursing students, incentives for nursing faculty,
grants for career ladder partnerships, and best practices grants.
Provide incentives to colleges and universities that house
nursing education programs. For example,
(1) Provide support for educational initiatives, such as creative
programs designed to meet the diverse academic needs of students
entering nursing. In our nursing program, 30 percent of the students
accepted into the nursing program last year reported having English as
a second language, 91 percent are employed (20 percent full time), and
many have significant family responsibilities. In Rhode Island, reduced
State funding is likely to decrease student services at a time of
increased need.
(2) Fund faculty development. Restricted budgets will impair our
ability to support faculty development activities and attract new
faculty.
(3) Contribute to improvements of physical facilities. The learning
environment of the Department of Nursing at Rhode Island College needs
improvement. A critical need, is for computers in the Nursing Resource
Laboratory. Classrooms need to be renovated and outfitted with current
teaching technology.
The expert panelists attested that the health care delivery system
needs improvement. There are many problems, but the nursing shortage is
a critical one. As the American Nurses Association has put it,
supporting nursing means ``keeping the care in healthcare.'' The
nursing shortage must be addressed. The nursing profession must be
strengthened.
Thank you for notifying me of the hearing and offering the
opportunity to contribute to the discussion of these important issues.
If I can be of any assistance please contact me.
[Whereupon, at 1 p.m. the hearing was adjourned.]