[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










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81-373                          WASHINGTON : 2003
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          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.]

                                    

      
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