[Senate Hearing 115-819]
[From the U.S. Government Publishing Office]
S. Hrg. 115-819
THE HEALTH CARE WORKFORCE:
ADDRESSING SHORTAGES
AND IMPROVING CARE
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
ON
EXAMINING THE HEALTHCARE WORKFORCE, FOCUSING ON ADDRESSING SHORTAGES
AND IMPROVING CARE
__________
MAY 22, 2018
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
30-257 PDF WASHINGTON : 2020
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming PATTY MURRAY, Washington
RICHARD BURR, North Carolina BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky MICHAEL F. BENNET, Colorado
SUSAN M. COLLINS, Maine TAMMY BALDWIN, Wisconsin
BILL CASSIDY, M.D., Louisiana CHRISTOPHER S. MURPHY, Connecticut
TODD YOUNG, Indiana ELIZABETH WARREN, Massachusetts
ORRIN G. HATCH, Utah TIM KAINE, Virginia
PAT ROBERTS, Kansas MAGGIE HASSAN, New Hampshire
LISA MURKOWSKI, Alaska TINA SMITH, Minnesota
TIM SCOTT, South Carolina DOUG JONES, Alabama
David P. Cleary, Republican Staff Director
Lindsey Ward Seidman, Republican Deputy Staff Director
Evan Schatz, Democratic Staff Director
John Righter, Democratic Deputy Staff Director
C O N T E N T S
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STATEMENTS
TUESDAY, MAY 22, 2018
Page
Committee Members
Alexander, Hon. Lamar, Chairman, Committee on Health, Education,
Labor, and Pensions, Opening statement......................... 1
Murray, Hon. Patty, Ranking Member, a U.S. Senator from the State
of Washington, Opening statement............................... 3
Witnesses
Goodell, Kristen, M.D., F.A.A.F.P., Assistant Professor of Family
Medicine, Assistant Dean for Admissions, Boston University
School of Medicine, Boston, MA................................. 6
Prepared statement........................................... 9
Summary statement............................................ 15
Sanford, Julie, D.N.S., R.N., F.A.A.N., Director and Professor,
School of Nursing, James Madison University, Harrisonburg, VA.. 16
Prepared statement........................................... 18
Summary statement............................................ 23
Phelan, Elizabeth, M.D., M.S., Director, Northwest Geriatrics
Workforce Enhancement Center, Associate Professor of Medicine,
Gerontology and Geriatric Medicine, and Adjunct Associate
Professor of Health Services, University of Washington,
Seattle, WA.................................................... 24
Prepared statement........................................... 26
Summary statement............................................ 27
THE HEALTH CARE WORKFORCE:
ADDRESSING SHORTAGES
AND IMPROVING CARE
----------
Tuesday, May 22, 2018
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10:05 a.m. in
room SD-430, Dirksen Senate Office Building, Hon. Lamar
Alexander, Chairman of the Committee, presiding.
Present: Senators Alexander [presiding], Collins, Cassidy,
Young, Murkowski, Murray, Casey, Murphy, Warren, Kaine, Hassan,
and Smith.
OPENING STATEMENT OF SENATOR ALEXANDER
The Chairman. The Senate Committee on Health, Education,
Labor, and Pensions will please come to order.
Senator Murray and I will each have an opening statement,
and then we will introduce the witnesses. After the witnesses'
testimony, Senators will each have 5 minutes of questions.
Today's hearing is an opportunity to:
Learn about the growing shortage of health care
professionals, especially in rural areas;
Examine what the Federal Government is doing to support our
Nation's health care workforce;
Look at how well we are training health care professionals
to meet the needs of patients and;
To better understand where health care professionals are
choosing to work so we can start addressing shortages in rural
and urban areas of the country.
I often hear from doctors and patients in Tennessee about
the shortage of health care professionals, and from Members of
this Committee. We know that the shortage of health care
professionals--which includes doctors, nurses, paramedics, and
X-ray technicians--is a problem that has the potential to keep
getting worse.
First, our country's population is aging and growing, which
is widening the gap between the number of people who need
health care and the number of those who provide it.
According to the Association of American Medical Colleges,
by 2030 our total population is expected to increase by more
than 10 percent and the percentage of people over 65 is
expected to increase 50 percent compared to today.
Second, at a time when we need more health care
professionals, many of the existing health care workforce will
reach retirement age. A third of all doctors will be older than
65 in the next 10 years according to Association of American
Medical Colleges.
Simply put, we may have too many people and too few medical
professionals.
We also know that rural areas, where 60 million Americans
live, suffer the greatest impact of the shortage of health care
professionals. According to the National Rural Health
Association, there are only 39 primary care doctors for every
100,000 people living in rural areas, but 53 primary care
doctors for every 100,000 people in urban areas.
That difference is even more dramatic for
anesthesiologists, neurologists, cardiologists, and other
specialties. Urban areas have 263 specialists for every 100,000
people, but in rural areas there are only 30 for every 100,000
people.
We also know the shortage affects certain populations more
than others. For example in 2014, the American Congress of
Obstetricians and Gynecologists reported that 47 rural
Tennessee counties, out of 95 total, had no OB-GYN. That means
a young couple starting a family may have to travel to Memphis,
Nashville, or Knoxville to see an OB-GYN doctor.
Older Americans could face shortages in the coming years
because there are not enough health care workers trained to
care for geriatric patients. The Bureau of Labor Statistics has
estimated that by 2024, we will need 1.1 million more nursing
aides, home health aides, and other health care workers to
assist older patients.
The Federal Government is doing, currently, three things to
help reduce and prevent shortages of health care workers.
First, about $10 billion goes to Medicare Graduate Medical
Education Programs, which funds resident training for new
doctors. That program is in the jurisdiction of the Finance
Committee.
Second, we spend more than $1 billion on about 70 different
health workforce programs that provide scholarships and loan
repayment for students, faculty, and health care professionals
in exchange for working in rural areas. These programs also
provide grants for children's hospitals that train new doctors
and dentists. All of these programs are within our Committee's
jurisdiction. We need to better understand if they are actually
working and if they need to be changed.
Finally, we spend about $310 million for the National
Health Service Corps, which provides loan repayment for primary
care doctors who go to work in underserved areas. Most of these
doctors choose to work at the 10,000 community health centers
across the country.
We need to know if what the Federal Government currently is
doing is effective or if specific improvements should be made.
Do we need all of these programs or should there be changes to
better meet the needs of patients?
The witnesses here today will also be able to help us
better understand how well we are training health care
professionals, and what we can do to encourage more people to
enter the health care workforce as professionals retire.
I plan to ask our witnesses today what role the Federal
Government can play in encouraging health care professionals to
work in underserved and rural areas of the country where they
are most needed.
I look forward to hearing their recommendations. My hope is
that the Committee will soon begin working on solutions to
address these shortages.
Senator Murray.
STATEMENT OF SENATOR MURRAY
Senator Murray. Well, thank you very much, Mr. Chairman.
Thank you to all of our witnesses for joining us today.
A robust, diverse, collaborative workforce is critical to
the health of our families and our communities. However,
sustaining that workforce is a big challenge, and there are
many smaller interconnected challenges too.
We need a strong pipeline to recruit, retain, and train
more health care professionals, particularly in rural and
underserved areas. We need to make sure the pipeline includes
professionals who have different backgrounds and specialties.
We need a multifaceted approach to build a health care
workforce that is more diverse, better distributed, and trained
through collaborative models to provide as many patients as
possible with care that meets their needs.
No single program could be adequate to meet these nuanced
tasks, which is why the Health Resources and Services
Administration, or HRSA, administers a series of interconnected
programs, programs authorized through Title VII to support
primary care, oral health, mental health, and other providers,
and programs through Title VIII that support nurses.
HRSA provides scholarships and loan repayment programs,
grants to support interprofessional training and residency
programs in community-based settings, and research to help
identify new workforce trends, problems, and solutions. These
programs do not just tackle the workforce shortage at large,
but targets specific challenges.
For example, HRSA administers the Centers of Excellence
program and the Nursing Workforce Diversity program to address
the need for better representation of racial and ethnic
minorities in our health care workforce by supporting
educational opportunities for young, underserved and
underrepresented students.
According to the Association of American Medical Colleges,
only 7 percent of medical school graduates are African-American
and only about 6 percent are Hispanic. Changing that matters
because greater diversity among practitioners, as well as
greater cultural and language competency, can help patients
from all backgrounds get higher health care quality.
It is worth noting that half of the graduates from HRSA's
workforce programs last year were minorities or came from
disadvantaged backgrounds.
But that is not all. HRSA also administers the National
Health Service Corps and the Nurse Corps to target the needs of
underserved communities. About one-fifth of our country's
population is rural, yet only about one-tenth of our physicians
practice in rural areas. In fact, nearly 3 out of 5 areas
facing a shortage of primary care professionals are rural.
Last year, loan repayment and scholarship programs through
HRSA supported more than 12,000 practitioners in underserved
areas nationwide, collectively serving more than 12 million
patients.
At the University of Washington School of Medicine--which
has long been recognized for its work to connect students to
underserved communities, and at the new medical school at
Washington State University--students learn about technologies
and techniques specifically to support care in rural areas
where many institutions are supported by HRSA grants to address
that need.
But that is not all. HRSA also administers the Geriatrics
Workforce Enhancement Program to support the integration of
geriatrics into primary care settings so seniors get care that
reflects their changing needs in their own community.
The number of seniors in our country is expected to nearly
double over the next few decades. As this so-called ``silver
tsunami'' hits, it will put us at risk of a serious workforce
shortage in senior care. U.W.'s Geriatrics Program is among the
HRSA grantees addressing this, and Dr. Phelan, I look forward
to hearing your testimony today about that important work.
But that is not all. HRSA also administers the Behavioral
Health Workforce Education and Training Program to help address
the national shortage of mental and behavioral health experts.
Over half of all counties across the Nation do not have a
single psychiatrist. Over three-fourths have a severe shortage
of psychiatrists.
In fact, according to the Kaiser Family Foundation, our
current mental and behavioral health workforce cannot meet one-
third of our needs in this area. This is an urgent issue,
especially as our communities grapple with the opioid crisis
and the epidemic of substance use disorders.
Last year, our health workforce programs trained over 4,000
new professionals in behavioral and mental health. And even
that is not all. These are just a few of the many programs
authorized by Titles VII and VIII to address our health
workforce needs.
One program supports children's hospitals, another supports
training providers in community-based settings. Another program
supports interprofessional training to help all practitioners
learn to work together, and with community-based organizations,
to provide the most patients with the best care.
Another, the Health Careers Opportunities Program, or HCOP,
improves health workforce diversity by supporting programs that
engage minority and disadvantaged children in health sciences.
Children like Benjamin Danielson, who received mentorship and
guidance that kindled his interest in attending U.W. School of
Medicine.
Today, he now serves as Clinic Chief and Medical Director
of the Odessa Brown Children's Clinic in Seattle, which
provides specialized pediatric care to patients regardless of
their ability to pay. And he also serves as a mentor, through
the same HCOP program that helped him, to support and inspire
future generations of minority medical students.
These are great programs with a positive impact, but we
have got to invest in that impact on a larger scale because,
compared to the scope of the challenge, we are fighting fires
with a squirt gun. We have the right idea, but we need to do a
lot more.
Unfortunately today, President Trump seems interested in
only doing a lot less. His budget proposal would all but end
these efforts, cutting dozens of programs entirely and slashing
funding by over 90 percent.
Now, thankfully, his view is not shared by all Republicans.
Instead of drastic cuts, we worked across the aisle on
substantial increases in our recent bipartisan budget deal. We
increased funding for the National Health Service Corps by over
one-third. We increased funding for behavioral health training
by one-half. We made substance use disorder experts eligible
for workforce loan repayment programs, and I hope we can
continue to build on that bipartisan work.
I also hope we remember that in strengthening our health
care workforce means addressing harassment and sexual assault
in the workplace too. Our health care practitioners need safe
workplaces to do their jobs and I am particularly concerned
about how we provide the safety for home health care aids who
work in very isolated environments.
I have reached out to industry stakeholders about this and
started some good conversations, and I hope we continue that
conversation here in this Committee as well because it is hard
to encourage people to go into a field or to stay in it if they
do not feel safe.
Thank you, Mr. Chairman.
I do ask unanimous consent to submit a letter for the
record from the American Osteopathic Association.
I look forward to hearing from our witnesses today.
The Chairman. So ordered.
The Chairman. Thank you, Senator Murray.
I would note that this is another bipartisan hearing which
means that Senator Murray and I have agreed on the hearing and
on the witnesses. That is often a good way to help us move
toward agreeing on solutions. So I thank her for that.
Each witness will have up to 5 minutes to give testimony. I
welcome you all.
Our first witness today is Dr. Kristen Goodell, Assistant
Professor of Family Medicine and Assistant Dean for Admissions
at Boston University School of Medicine.
She is also the Chair of the Counsel on Graduate Medical
Education, which provides assessments and recommendations to
Congress, the Department of Health and Human Services, and the
private sector on issues related to the physician workforce.
Next, we will hear from Dr. Julie Sanford. Senator Kaine is
here, and I wonder if he would like to introduce her?
Senator Kaine. Thank you, Mr. Chairman. I am glad we are
having this hearing today. I appreciate the Chairman and
Ranking Member for working on it.
I am happy to introduce Dr. Julie Sanford. Julie is the
Director, and also a Professor, at the School of Nursing at
James Madison University in Harrisonburg, Virginia.
Over the course of her career, Dr. Sanford has implemented
nursing programs in rural, diverse, and educationally
disadvantaged areas of Mississippi, Alabama, and Virginia.
She started one of the first doctoral programs in the
country for gerontological acute care nurse practitioners, and
she also built an R.N., B.S.N. program online for students
unable to work in classrooms following Hurricane Katrina.
She plays an integral role at J.M.U. in the Health Policy
Collaborative, which was recently awarded the Innovations in
Professional Nursing Award from the American Association of
Colleges of Nursing. She received her bachelor's degree from
the University of Alabama, Master's from the University of
South Alabama, and Doctor of Science in Nursing from L.S.U.
We are really happy to have you here, Dr. Sanford.
The Chairman. Thanks, Senator Kaine.
Senator Murray will introduce Dr. Phelan.
Senator Murray. Good morning, Dr. Elizabeth Phelan. Thank
you. She joins us from my home State of Washington.
She is an Associate Professor of Medicine, Gerontology, and
Geriatric Medicine at the University if Washington, where she
is teaching and training the next generation of health
professionals to improve care for our seniors.
She is also Director of the Northwest Geriatrics Workforce
Enhancement Center, where she is not only working to develop
the next generation of professionals in geriatrics, but is also
working to pioneer the next generation of innovative care
delivery models for older adults, like Project ECHO, which
allows specialized care providers, like geriatricians, to use
telehealth to help reach patients and providers in our rural
communities.
Dr. Phelan, I know it is a long flight from Washington
State, so I am particularly grateful that you have come out
here to join us today.
Thank you.
The Chairman. Thanks, Senator Murray.
We now will hear from our witnesses, and if you could
summarize your remarks in about 5 minutes, that will leave time
for questions.
Dr. Goodell.
STATEMENT OF KRISTEN GOODELL, M.D., F.A.A.F.P., ASSISTANT
PROFESSOR OF FAMILY MEDICINE, ASSISTANT DEAN FOR ADMISSIONS,
BOSTON UNIVERSITY SCHOOL OF MEDICINE CHAIR, BOSTON,
MASSACHUSETTS
Dr. Goodell. Thank you so much for inviting me to be here
today. I am particularly gratified that this is a bipartisan
hearing because I feel, I am sure we all feel, that taking care
of people is something everyone can agree on.
The aging and growth of our population, as you mentioned,
has led numerous groups to predict a significant workforce
shortage. Now, figuring out exactly how many physicians we are
going to need is a tricky business because there are so many
different factors that go into those models.
But there are certain areas of workforce deficiency that we
all can agree on that are really not in dispute. One of these
important ones is the proportion of rural physicians. As
Senator Alexander outlined, 20 percent of Americans live in
rural areas, but only 9 percent of physicians do. It is
estimated that right now, if we were to fully staff all the
health profession shortage areas, we would need an additional
13,000 physicians today. So rural America has a critical
workforce problem.
In addition, as Senator Murray was talking about, we need
to address issues of physician workforce diversity. Health care
outcomes are not equal for different people in this country,
but we have an opportunity here because we know that physicians
who are themselves from underrepresented minorities are more
likely to take care of poor people. They are more likely to
work in underserved areas. Patients who see those doctors feel
more satisfied with their health care and they also have better
health outcomes.
Another issue that we should think about is the specialty
mix of physicians and most of the physician models that predict
the shortage are predicated on the idea that the specialty mix
would stay constant, the same way it is today is the way it
should be tomorrow.
But if we would like to reduce the cost of health care in
this country, improve the quality of health care in this
country, and reduce disparities, the way to do that is to
increase the proportion of primary care physicians.
The final issue that I want to address is specific
residency training models. Residences were created way back
when we thought what doctors did was intervene in serious and
acute illness and injuries, often at the very end of life, and
spending a lot of time in the hospital. But nowadays, that is
actually not what most doctors spend our time doing.
We are trying to keep people out of the hospital. We are
trying to focus on prevention. As much as we can, we keep care
in peoples' communities and at home. It is less expensive and
it is less risky. But the problem is we still train residents
largely in inpatient settings in the hospital.
If we want our physicians to be able to deliver the kind of
health care that our patients need right now and in the future,
we need to address the specific programs, such as the ones
funded by HRSA, that give residents additional training in
these care models.
There are a lot of different ways that we fund graduate
medical education, as Senator Alexander mentioned. The largest
pool of funding comes through Medicare and that is largely what
determines the number of residents in the country, the
specialty mix, and the geographic distribution.
However, HRSA's many programs--I think there are 80 of
them, actually--do a phenomenal job at identifying and focusing
on these critical issues. The programs are often flexible over
time, and they look at emerging issues, and they really address
the needs of the health care workforce.
There are a couple of specific programs that I will mention
as an example. One of these is from my own institution, Boston
University School of Medicine.
We have a Primary Care Training Enhancement Grant that has
medical students working with physician assistant students, and
social work students, and nutrition students. These students
are put together in interprofessional teams and they see
patients that have complicated health care needs.
They see patients for a whole hour, so that is about four
times more time than their doctor has to spend with them. What
they do is address things that the doctor does not have a
chance to do. They focus on social determinants of health. They
try and work with people to figure out how to get them to eat
better, how to get people to exercise, to take their
medications.
As it turns out those, more than the time spent with the
physician, are things that actually determine peoples' health
care outcomes.
In my program, patients are getting care they otherwise
would not have received. Students are getting trained in
specific interventions that they otherwise would not have been
trained in. They also get the meta message that, ``By the way,
taking care of people is a team effort.''
The coolest thing about this program, actually, is the
outcomes they are tracking. So a lot of the programs that you
mentioned, it can be hard to figure out what sort of an impact
they are having. Some of them are easy.
If you have a pipeline program, you can count the number of
physicians that end up in a rural area or count the number of
physicians from diverse backgrounds. But a lot of the programs
seem to have diffused outcomes of improved health care quality.
This program at B.U. is actually tracking things like
obesity rates, depression indices, and blood sugar rates for
diabetes. So that is the holy grail of health care programs.
They are able to really see that the work they are doing is
making a difference for patients.
I have a lot more stories and I am hoping that people ask
me about some more of these programs, but the big take home
message is that physicians do in practice what they are trained
to do in residency.
If you spend 3 years, the highest yield years of your
training in a big academic medical center with all the expert
consultants you could want and the very best technology, and
then you graduate, and somebody offers you a great job in a
rural area, even with an awesome loan repayment program, there
is no way you are taking it.
That is because the idea of you going out and being ``the
only expert'' in the place where you are working is terrifying
and nobody thinks they are qualified to do that.
We need to create some support programs that train
physicians to practice the way we need them to practice.
Furthermore, if most of your education within your
residency program focused on the newest care models, the most
important interventions, if your seminars dug into the
literature and found out what is the best new emerging
treatment? Well, then you are extremely well qualified to take
care of the patient that is sitting in front of you today.
If you never did a quality improvement project or assessed
the needs of your community, then you do not even know that
that is your job. So we need some of these training
enhancements to help convince residents that that is their job
too.
Thanks very much and I urge everyone to support the HRSA
workforce programs.
[The prepared statement of Dr. Goodell follows:]
prepared statement of kristen goodell
Statement of the Problem
At present and increasingly, our health care workforce is not
adequately meeting the needs of our citizens. Population aging and
growth ensure that our country will require significantly more medical
care. Expanded insurance means that more citizens will be able to
access the care they need. Of particular concern are
Rural areas of the country which have had an
inadequate healthcare workforce for 80 years and counting
The proportion of primary care providers because they
(a) Improve health outcomes, decrease health care
costs, and reduce health disparities
(b) Care for the majority of the health care needs of a
population
(c) Provide care to underserved populations at higher
rates than non-PCPs
Diversity of our physician workforce
Preparedness of physicians to practice in new care
delivery models, to address patient safety concerns, and to
ensure that the quality of their care is improving over time
Introduction and Background
The most recent projections from the Association of American
Medical Colleges describe a shortage of 42,600-121,300 physicians by
2030. Included in this number is a shortage of 14,800-49,300 primary
care physicians. These careful, thorough, and highly sophisticated
prediction ranges account for many scenarios of care provision--
increasing presence of physician assistants and advance practice
nurses, increased efficiencies from team-based care, shorter work
hours/earlier retirement among younger physicians, and different rates
of health insurance.\1\ Despite the uncertainty and the variation
between these predictions and others,\2\-\4\ there are no major models
which suggest that the supply of physicians at current levels will be
adequate.
While the total number of physicians needed is uncertain, it is
abundantly clear that we have a physician workforce distribution
problem in terms of geography, specialty mix, and workforce diversity.
In addition, the very nature of the practice of medicine has shifted
from largely intervening in acute and serious injuries and illness,
often in hospital settings, to emphasizing health maintenance and care
of chronic diseases, and doing as much as possible in the outpatient
setting. Because of the rapid evolution in how medicine is practiced
and health care is delivered, physicians may complete residency
training and find themselves ill-quipped to practice in the settings
where patients most need them.
Geography
Wide swaths of the United States, mostly in rural areas, are
designated as Health Professional Shortage Areas.\5\ Small but
population-dense urban regions are often designated medically
underserved because of the high prevalence of poverty and
elderly patients and high infant mortality rates.\6\ HRSA
estimates that it would require an additional 13,800 primary
care physicians needed today to provide a minimum level of care
that would remove the HPSA designations.\1\ That number
reflects a current shortage of care providers, rather than a
projection for the future. Access to health care in rural areas
has been a problem for more than 80 years. While 20 percent of
Americans live in rural areas, only 9 percent of physicians
do.\7\ The rural maldistribution is expected to worsen without
significant intervention, as growth in urban residencies has
far outpaced growth in rural training programs;\8\ and the
majority of physicians ultimately practice close to where they
trained.\9\
Specialty Mix
Primary care is defined as the provision of integrated,
accessible health care services by clinicians who are
accountable for addressing the large majority of personal
health care needs, developing a sustained partnership with
patients, and practicing in the context of family and
community. It is the foundation of high-quality and cost
effective health care systems. Among OECD countries, those with
stronger primary care systems have better health outcomes than
those with weaker primary care systems.\10\ Comparison of
counties within the US showed the same correlation between
improved quality/lower cost care and a higher proportion of
primary care physicians.\10\ A review of 35 studies showed that
higher ratios of primary care providers led to reduced
mortality from 5 major causes (infant, stroke, heart, cancer,
total). Adults who see a primary care provider have a 19
percent lower risk of premature death. Patients who see a
primary care provider first save 33 percent compared to their
peers who see only specialists, and it's estimated that if
everyone in the US saw a primary care provider first it would
save an estimated $67 billion per year.\11\ Unfortunately,
fewer than 30 percent of physicians in the United States
practice primary care. Generally, predictions of physician
shortages assume maintenance of our current specialty mix, but
if we are to achieve the triple aim of improved quality, lower
costs, and more patient satisfaction, we must increase the
proportion of primary care physicians. Furthermore, primary
care physicians are what is needed in rural America, where low
population density won't support multiple specialists. As the
emphasis in health care shifts from treatment of acute and
serious illness and injuries to prevention and chronic disease
management, the need for primary care providers will only
increase.
Diversity
Racial and ethnic diversity in the healthcare workforce has
been shown to increase access to health care and to improve
outcomes for underserved populations.\12\ African-American,
Hispanic, and Native-American physicians are much more likely
than are white physicians to practice in underserved
communities and to treat larger numbers of minority patients,
regardless of income.\13\ African-American and Hispanic
physicians are more likely to provide care to the poor and
those on Medicaid.\14\ Racial and ethnic minority patients are
generally more satisfied with their care, and are more likely
to report receiving higher-quality care, when treated by a
health professional of their own racial or ethnic
background.\15\-\16\ A 2015 report from the National Center for
Workforce Analysis described diversity in the health workforce
overall, noting that racial and ethnic diversity is greatest
(and increased over the preceding 10 years) among the least
paid, lowest-income, lowest-prestige occupations. In contrast,
graduating physicians are about 6.5 percent black or African-
American (compared to 14.3 percent of Americans) and 8 percent
are Hispanic (compared to 17 percent of the US population).\17\
The AHRQ tracks health care disparities between groups with its
annual National Healthcare Quality and Disparities Report, and
demonstrates the persistence of lower quality care (based on
250 outcome measures) for minorities underrepresented in
medicine.\18\ In order to address deficiencies in health care
access and quality among poor Americans and those from minority
groups, we must improve the diversity of the physician
workforce.
Changing healthcare delivery models
Graduate Medical Education programs are not adequately
preparing new MD graduates to practice in the future. Despite
the fact that fewer than 1 person per thousand in a population
is hospitalized in an Academic Medical Center (AMC) each month,
and despite the fact that 60 percent of procedures are
performed in the outpatient setting, residency training focuses
heavily on inpatients in large AMCs. Residents have inadequate
opportunities to care for patients with chronic diseases
longitudinally, and topics like health systems, quality
improvement, and practice transformation are consigned to the
margins of an intensive curriculum.\19\
Effectiveness of Interventions
The problems described here are neither new nor unknown. For
decades, the Federal Government has funded programs to address these
needs and others as a way to try and encouraged improved health
outcomes for our country. Currently, 80 programs are largely
administered through HRSA's 5 bureaus and 10 offices, and run the gamut
from loan repayment programs, pipeline programs, direct support for
residencies and fellowships, and advanced training initiatives for new
models of care, among others.\20\ The key question is which of these
programs are the most effective and should be supported? What can be
changed, and what should be dropped?
This testimony focuses primarily on programs administered through
the Bureau of Health Workforce funded through Title VII of the Public
Health Service Act, though the goals of some programs align or even
overlap with programs administered through other centers. Because of
the wide variety of program types and their respective goals, it is
difficult to make a comparative assessment about program efficacy. Some
programs have outcomes that are easy to measure. For example, the
Health Careers Opportunity Program establishes pipeline programs which
nurture students from backgrounds underrepresented in health
professions. Success can be determined by counting the ultimate number
of health professionals produced and by monitoring the attrition rate.
Evaluation of other programs is more challenging, for example Centers
of Excellence. Such centers can count the number of people they
``touch'' but because their mission is to collect and provide resources
and enhance training opportunities it can be difficult to produce data
that describes their success. Finally, many of the intended outcomes
are years away from the inception of any program. Initiatives to
increase diversity among physicians may begin in high school; with a
minimum of 8 years before becoming a physician and another 3 before
participants are ready for independent practice. Loan repayment and
other inducements to increase the number of physicians in rural areas
may look effective at 1 year after the commitment is repaid, but the
true need is physicians with an enduring commitment to their
community--and that's not measurable until years later. Our ultimate
goal is improved health for people, however those effects are
sufficiently downstream that collecting information is extremely
challenging, and proving causation even more so given the dozens of
factors in addition to workforce programming that are likely to
influence an individual's health. Despite the difficulty of tracking
and measuring, however, it is essential that Health Workforce and other
programs be monitored so that we can eventually determine which
programs are functioning most effectively. Examples of the kind of
outcomes being currently monitored are below:
Program Metrics for 2016-2017
----------------------------------------------------------------------------------------------------------------
Number of Number of Trainee Program
Program Name Awardees Trainees Characteristics Characteristics
----------------------------------------------------------------------------------------------------------------
Area Health 52 437,267 at all 30.9% URM 62.8% MUC
Education Centers levels 39.7% 62.5% Primary Care
Develop and enhance disadvantaged 42% Rural
training networks that
provide pipeline
programs and advanced
training to expand
diversity, enhance
health care quality,
and improve access in
rural and underserved
areas.
----------------------------------------------------------------------------------------------------------------
Primary Care 68 7,344 residents 23.4% URM 63.5% MUC
Training and 34.2% 61.7% Primary Care
Enhancement disadvantaged 29.7% Rural
Training for primary
care providers in new
models of care
delivery.
----------------------------------------------------------------------------------------------------------------
Teaching Health 57 771 residents 20% URM 99% train in a primary
Centers 23% from rural care setting 600,000
Direct funding for new backgrounds patient-contact hours
residencies designed 20% disadvantaged 83% train in a rural
for improved care 68% of completers are setting or MU
delivery models in MUCs practicing primary
or primary care care (30% national
settings average)
*Funded under Title III. 55% are practicing in
rural settings or MUCs
----------------------------------------------------------------------------------------------------------------
Health Careers 17 1,284 83% URM 36% trained in MUCs
Opportunity 97% disadvantaged 68.2% trained in
Programs primary care settings
Multiple initiatives to
increase diversity and
provide care to
underserved
communities.
----------------------------------------------------------------------------------------------------------------
Fortunately, significant effort is being made to clarify and
monitor program outcomes. HRSAs strategic plan for 2016-2018 lists
clear goals, breaks the goals down into measurable objectives, and
describes strategies for reaching the objectives. For each goal,
performance measures are spelled out. This is an excellent strategy
that will allow monitoring for success, and could be replicated at
smaller scale for individual programs. In addition, there is solid data
that in the big picture, Title VII is having the desired effect.
Exposure to a Title VII program during medical school increases the
likelihood of working in a Community Health Center or joining the
National Health Service Corps. 50 percent more students chose family
medicine as a specialty (the specialty most likely to produce primary
care physicians) in schools where there is Title VII funding compared
with schools where there is no such funding. Students from Title VII
schools are also 30 percent more likely to practice in a rural area,
and 30 percent more likely to practice in a physician shortage area. On
the whole, then, and for perhaps our most significant health workforce
problem (the maldistribution problem) Title VII programs are having a
positive effect.\21\
Examples of Successful Title VII Programs
FMR of Western Montana
This program is a perfect example of how traditional GME
funding and HRSA enhancement funding work together to address
workforce needs. The FMR of Western Montana is a new residency
program (started in 2013) sponsored by the University of
Montana, 2 community health centers, 3 primary hospitals, and 9
rural communities. FMRWM serves a population that is so rural
it's actually designated as a frontier. Thus far, 90 percent of
its graduates are practicing in rural areas. Recognizing that
health care delivery is changing and that its graduates needed
to be prepared to practice in the future, the FMRWM received a
HRSA Title VII grant for Primary Care Training and Enhancement.
Project directors leveraged carefully built and nurtured
existing community relationships between schools, hospitals,
and the residency program to identify and disseminate
innovations and best practices from one site to the whole
network. Intensive and longitudinal team training was provided
to all participants, including residents, who came to
understand quality improvement and innovation as part and
parcel of their jobs as rural physicians. Self-reliance and
local expertise were celebrated by having participants
determine the needs of their communities and decide which
projects would be adopted locally. In this example, the PCTE
grant took a residency that was successful in mitigating a
critical personnel shortage and improved it by giving residents
training that they wouldn't have had.
BUSM interprofessional teams
Boston University School of Medicine hosts a Title VII program
that trains teams of interprofessional students to provide care
to underserved (urban poor) patients with complex medical needs
including obesity, diabetes, and eating disorders. Students of
medicine, social work, nutrition, and physician assistant
programs work with a family medicine resident to see complex
patients in a team for an hour at a time to provide care that
keeps patients engaged and that addresses their social
determinants of health (such as nutrition and housing security)
as well as their medical needs. A curriculum for these learners
has been developed and is being refined which, once optimized,
can be easily disseminated to other interprofessional programs.
About half of students' time is spent in direct patient care in
this project, and half is in training for how to provide that
care including very specific skills like SBIRT (screening,
brief intervention, referral, and treatment) and motivational
interviewing that are best practices in behavioral health and
can be applied in any setting. This project is notable for its
emphasis on monitoring patient centered outcomes--in addition
to tracking the number of participants that ultimately practice
in MUAs and primary care, and measures of patient engagement,
this study is tracking patient outcomes such as weight, HbA1c
(glucose monitoring for diabetes), and depression index scores.
Project ECHO: Opioids
Project Echo is a successful national program that provides
advanced specialized care through primary care providers by
connecting specialists at an Academic Medical Center ``Hub''
with their remote primary care colleagues for education and
patient case conferences. In this program, primary care
providers meet with a specialist via videolink for 2 hour
weekly conferences, of which the first 30 minutes is a formal
educational presentation and the last 90 minutes involves case
presentations by PCPs in which the specialists provide
consultations. In this way, patients can receive much-needed
expertise of specialists without traveling, and the specialists
can provide consultations on many more patients in a shorter
time (relying on the expert assessment and reporting of their
PCP colleagues) than if they were seeing them in their offices.
Over time, PCPs develop enhanced expertise in the specific
subject being addressed, and are able to provide the needed
care without consultation. A 2016 paper,\22\ reviewed the 10-
year substance abuse disorder project ECHO based in New Mexico
and found that 950 cases had been discussed and more than 9000
hours of continuing medical education credits had been awarded
to participants. Physicians in that region became licensed to
prescribe buprenorphine (currently the best treatment for
opioid addiction, but requires special licensure) extremely
rapidly, increasing far more than most states, and are now 4th
in the Nation for the number of licensed buprenorphine
prescribers per capita. Currently, a project ECHO focused on
Opioids is running nationally, including a hub at Boston
Medical Center.
Conclusion
Essentially, physicians do in practice what they were trained to do
in school and residency. Hospital vs. Outpatient, urban/superserved vs.
rural/underserved, new care models, etc. If you have spent your three
most intensive years of training taking care of desperately ill people
in a large medical center surrounded by resources and other experts;
the idea of moving out to a location where you are the only expert
around is terrifying and isolating. If your case conferences and
presentation and exams have only dealt with the ins and outs of
treating specific illnesses, or on the newest technological advances
and you never do a quality improvement project or identify the needs of
the community beyond the hospital then you don't have any idea that
it's your job to do those things. One of the reasons physicians are so
bad at tracking health care quality metrics for our patients is that we
didn't see it done, and didn't know we were supposed to. Residents must
be trained in the full array (and in the correct proportion) of
settings where we need them to practice, and they must be trained in
the skills they'll need tomorrow; including team-based care and
practice improvement. In addition to strategies for re-allocation of
GME funding (which is covered elsewhere in statute) HRSA Health
Workforce programs make critical contributions to ensuring an
optimally-prepared physician workforce.
References
1. Association of American Medical Colleges, April 2018. The
Complexities of Physician Supply and Demand: Projections from 2016 to
2030.
2. Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the
Residency Expansion Required to Avoid Projected Primary Care Physician
Shortages by 2035. Ann Fam Med March/April 2015 vol. 13 no. 2 107-114.
3. Robert Graham Center. Trends in physician supply and population
growth. https://www.graham-center.org/rgc/publications-reports/
publications/one-pagers/trends-physician-growth-2013.html. Accessed May
16, 2018.
4. Streeter, R. A., Zangaro, G. A., & Chattopadhyay, A. (2017).
Perspectives: Using Results from HRSA's Health Workforce Simulation
Model to Examine the Geography of Primary Care. Health Services
Research, 52, 481-507. DOI: 10.1111/1475-6773.12663.
5. Johansen ME, Kircher SM, Huerta TR Re-examining the Exology of
Medical Care N Engl J Med 2016; 374:495-496.
6. https://datawarehouse.hrsa.gov/topics/shortageAreas.aspx
accessed 5/16/2018.
7. Howard K. Rabinowitz, MD, James J. Diamond, PhD, Fred W.
Markham, MD, and Jeremy R. Wortman, Medical School Programs to Increase
the Rural Physician Supply: A Systematic Review and Projected Impact of
Widespread Replication. Academic Medicine, Vol. 83, No. 3 / March 2008.
8. Locations and Types of Graduate Training Were Largely Unchanged,
and Federal Efforts May Not Be Sufficient to Meet Needs. GAO-17-411:
Published: May 25, 2017. Publicly Released: Jun 26, 2017.
9. Fagan EB, Gibbons C, Finnegan SC, Petterson S, Peterson KE,
Phillips RL, Bazemore AW. Family Medicine Graduate Proximity to Their
Site of Training: Policy Options for Improving the Distribution of
Primary Care Access. Family Medicine (Fam Med 2015;47(2):124-30.).
10. https://www.graham-center.org/content/dam/rgc/documents/
publications-reports/presentations/bphilps-acadhlth-primary.pdf
accessed 5/16/2018.
11. https://www.primarycareprogress.org/primary-care-case/ accessed
5/16/2018.
12. Council on Graduate Medical Education, Supporting Diversity In
the Health Professions (resource paper) May 2016.
13. Kington R, Tisnado D, Carlisle DM. Increasing racial and ethnic
diversity among physicians: an intervention to address health
disparities? In Smedley BD, Stith AY, Colburn L, Evans CH, (eds.). The
Right Thing to Do, The Smart Thing to Do: Enhancing Diversity in the
Health Professions. Washington, DC: National Academy Press, 2001.
14. Cantor JC, Miles EL, Baker LC, Barker DC. Physician service to
the underserved: implications for affirmative action in medical
education. Inquiry. 1996; 33: 167-180.
15. Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson
C, Ford DE. Race, gender, and partnership in the patient-physician
relationship. JAMA. 1999; 282: 583-589.
16. Cooper LA, Powe NR. Disparities in patient experiences, health
care processes, and outcomes: the role of patient-provider racial,
ethnic, and language concordance. Washington DC: The Commonwealth Fund,
2004.
17. http://aamcdiversityfactsandfigures2016.org/ accessed 5/17/
2018.
18. 2016 National Healthcare Quality and Disparities Report.
Rockville, MD: Agency for Healthcare Research and Quality; July 2017.
AHRQ Pub. No. 17-0001.
19. Goodman D, Robertson R, Accelerating Physician Workforce
Transformation Through Competitive Graduate Medical Education Funding.
HEALTH AFFAIRS 32, NO. 11 (2013): 1887-1892.
20. HRSA Strategic Plan at https://www.hrsa.gov/sites/default/
files/about/strategicplan/strategicplan.pdf. Accessed 5/17/2018.
21. Rittenhouse DR, Fryer GE, Phillips RL, et al. Impact of Title
VII Training Programs on Community Health Center Staffing and National
Health Service Corps Participation. Annals of Family Medicine.
2008;6(5):397-405. doi:10.1370/afm.885.
22. Komaromy M, Duhigg D, Metcalf A, et al. Project ECHO (Extension
for Community Healthcare Outcomes): A new model for educating primary
care providers about treatment of substance use disorders. Substance
Abuse. 2016;37(1):20-24. doi:10.1080/08897077.2015.1129388.
______
[summary statement of kristen goodell]
Population aging and growth have led multiple government and
professional associations to predict significant physician shortages.
While predicting the overall number of physicians needed is tricky due
to the number of variables involved, there are several clear and
persistent physician workforce needs that must be addressed if we are
to meet the healthcare needs of our citizens. Even more certain than a
physician deficit is a physician mix and distribution problem. Needs
include:
Longstanding and worsening shortages of physicians in
enormous rural areas of the country
Primary care/specialty ratio must be improved to
improve health outcomes, reduce cost, and decrease disparities
Diversity of the physician workforce must be increased
in order to improve access to care for poor Americans and those
from minority backgrounds
Training in new models of care delivery, patient
safety, quality improvement, and emerging ``crisis'' topics
The total number of physicians trained in the US, and to some
extent the specialty mix and geographic distribution of them, is
determined by residency programs. We need and don't currently have a
national strategic plan for graduate medical education that would
address these deficiencies, but residencies are almost entirely funded
and regulated elsewhere in statute. That is a behemoth issue that will
take years to figure out. Today's focus is on supplemental programs
which seek to mitigate these problems now, in ways that are nimbly
responsive to current needs and which allow individual programs,
communities or networks to address their most pressing issues in the
way they know will be most effective.
HRSA has been funding these types of programs for decades. One
would think we could identify the ``best'' programs and spread those;
but the challenge is that their goals, timeframe, and structures vary
widely, so measuring success and making comparisons is difficult. For
example
Some program outcomes are specific (number of
physicians in rural areas) and some are diffuse (physicians'
ability to perform quality improvement projects
Some effects take years to measure (for example, if
you have a pipeline program to increase minority high-
schoolers' interest in medicine, it will be 12 years before
they enter practice)
Some outcomes (such as reduced rates of diabetes or
opioid dependency) are impossible to attribute to a single
intervention program.
A centralized data research program, such as the one outlined in
HRSA's'16-'17 strategic plan, will be enormously helpful in monitoring
programs over time. In the meantime, however, we do have evidence that
HRSA-funded workforce programs are successful. Exposure to a Title VII
program during medical school increases the likelihood of working in a
Community Health Center or joining the National Health Service Corps.
50 percent more students chose family medicine as a specialty (the
specialty most likely to produce primary care physicians) in schools
where there is Title VII funding compared with schools where there is
no such funding. Students from Title VII schools are also 30 percent
more likely to practice in a rural area, and 30 percent more likely to
practice in a physician shortage area.
In addition to tracking outcomes, we can learn from some best-
practice examples of HRSA-funded title VII programs:
Family Medicine Residency of Western Montana--a new
residency on the frontier which has 90 percent of its graduates
practicing in rural areas and which used a PCTE grant to set up
a learning network among far-flung partners to learn from each
others' successes and train up its faculty, community hospital
partners, and residents in how to identify needs of the
community and perform quality improvement projects.
Project Echo: Opioids connects an academic medical
center (where there are specialists with advanced training) to
providers of all sorts in local communities to help them care
for opioid-addicted patients. Live videolinks are used for 90-
minute conferences that include a 30-minute education
presentation and then participants describe cases and receive
consultation. This is a way to amplify the impact of
specialists so they can help more people (without anyone
traveling) and to quickly train up PCPs and other health
workers to respond to a crisis.
Boston Medical Center's Interprofessional Teams program--
creates teams of students from different health professions and has
them see patients with complex medical and psychosocial needs for an
hour at a time to try and address key social determinants of health.
Trainees also complete a curriculum in these topic areas and in
teamwork.
In summary, physicians do in practice what they were trained to do
in school and residency. If you have spent 3 years of training taking
care of desperately ill people in a large medical center surrounded by
resources and other experts; the idea of moving out to a location where
you are the only expert around is terrifying. If your curriculum has
primarily dealt with specific illnesses and technological advances, and
you never serve on a patient safety committee or identify the needs of
the community beyond the hospital then you don't have any idea that
it's your job to do those things. Residents must be trained in the full
array (and in the correct proportion) of settings where we need them to
practice, and they must be trained in the skills they'll need tomorrow;
including team-based care and practice improvement. HRSA Health
Workforce programs make critical contributions to ensuring an optimally
prepared physician workforce.
______
The Chairman. Thank you, Dr. Goodell.
Dr. Sanford, welcome.
STATEMENT OF JULIE SANFORD, D.N.S., R.N., F.A.A.N., DIRECTOR
AND PROFESSOR, SCHOOL OF NURSING, JAMES MADISON UNIVERSITY,
HARRISONBURG, VIRGINIA
Dr. Sanford. Thank you, Chairman Alexander, Ranking Member
Murray, and Members of the Committee for the opportunity to
provide testimony on how the nursing profession is helping to
improve health and health care through the support of Federal
investments, such as the Title VIII nursing workforce
development programs.
I am Julie Sanford, Director and Professor of James Madison
University's School of Nursing in Harrisonburg, Virginia.
I am honored to have been selected to provide you with
examples of how these programs address workforce shortages, not
only as a current Academic Nursing Director with Title VIII
funding, but as a recipient myself.
I am a first generation college student from a rural
farming community in Mobile County, Alabama. During my doctoral
program, I received a Title VIII grant that enabled me to
pursue what would become a life in higher education.
I have spent my career using innovation as a key element to
ensure nursing care reaches vulnerable populations. A
cornerstone to this success has been the Title VIII Nursing
Workforce Development programs.
Access to quality health care in underserved, rural
communities is challenging, and a principle barrier to meeting
health care needs is the shortage of clinicians.
Recruiting providers to the most rural and remote areas of
the country is paramount, but it is not an easy task. My own
experience has shown a different approach.
I know that the secret lies in not necessarily recruiting
more nurses to underserved communities, but bringing
opportunities to educationally disadvantaged students in those
areas.
In the late 1990's and early 2000's, I worked on Title VIII
grants in Alabama and Mississippi that helped Associate Degree-
prepared nurses obtain their Baccalaureate Degree. We
transitioned our programs from being offered in-person to
online platforms.
At the time, the use of the Internet as a method of
educational delivery was new and very different. By moving
these programs online, we reached rural Alabama and Mississippi
nurses by removing barriers they faced while completing their
baccalaureate degree.
The majority of these newly graduated nurses, who were from
underrepresented backgrounds, lived in rural communities that
were medically underserved. All were educationally
disadvantaged. Most stayed in their communities to work and
improve patient outcomes.
The Title VIII programs help nurses pursue their education,
but it is the outcomes of those educated nurses that make a
difference: improved patient care.
In 2014, James Madison University obtained Title VIII
funding to begin an online Doctor of Nursing Practice program
with a focus on interprofessional education. At the time of
grant completion, 10 doctoral students had graduated and an
additional 35 students were enrolled.
One of our graduates, Dr. Patra Reed, worked at our local
community hospital that serves the rural Shenandoah Valley. As
a part of her doctoral study, she developed a community health
worker program to assess patients with chronic heart
conditions. This program decreased readmissions and saved her
hospital $300,000 in the first 6 months of the program's
existence.
Recently, James Madison University was awarded funding for
a proposal where we will partner with Valley Health Page
Memorial Rural Health Centers in counseling and psychological
services in rural Page County, Virginia to address shortages in
primary, mental health, and substance opioid abuse treatment.
The Title VIII programs allow for innovation and can be
tailored year to year to meet pressing health care priorities
like the opioid epidemic.
The reality of the nursing profession is clear. The demand
for nurses is projected to increase by 28 percent by 2030. We
know that the nursing workforce is aging and retiring, which is
a central contributor to the impending shortage. This is of
particular concern as it relates to the profession's ability to
educate a new generation of nurses.
According to the American Association of Colleges of
Nursing, U.S. nursing schools turned away 68,000 qualified
applicants in 2017 citing faculty shortages as a top reason for
not accepting those who were qualified.
These are challenging times as health care demands are
increasing exponentially. Today, I am here to reinforce the
message the Title VIII nursing workforce development programs
work and they are key in our profession's ability to improve
America's health. They must be reauthorized and the Title VIII
Nursing Workforce Development Reauthorization Act will help us
achieve this goal.
Thank you for allowing me to share my perspectives on the
critical importance of these programs.
[The prepared statement of Dr. Sanford follows:]
prepared statement of julie tanner sanford
Thank you Chairman Alexander, Ranking Member Murray, and Members of
the Committee for the opportunity to provide testimony on the nursing
workforce and its ability to meet the Nation's healthcare demands as
well as the importance of the Nursing Workforce Development Programs
(Title VIII of the Public Health Service Act [42 U.S.C. 296 et seq.]).
I am Julie Sanford, Director and Professor of James Madison
University's School of Nursing. As an awardee of Title VIII grants, I
am honored to have been selected to provide you with the impact and
success of these programs on increasing not only the number but also
the geographic distribution of nurses able to care for patients,
families, and communities in our most underserved areas. As a first
generation college student from a rural farming community in Mobile,
Alabama, I know first-hand how receiving a Federal grant can change
your life. During my doctoral program, I received a Title VIII grant
that enabled me to pursue what would become a life in higher education,
helping to educate the next generation of nurses.
The demand for nurses inevitably varies by state, but the national
need is projected to increase by 28 percent by the year 2030. \1\ This
projected nursing shortage is intensified in certain areas due to the
inequitable distribution of the workforce. According to the Health
Resources and Services Administration's Supply and Demand Projections
of the Nursing Workforce: 2014-2030, four states, including California,
Texas, New Jersey, and South Carolina, are expected to have a nursing
deficit of over 10,000 nurses. \2\ In addition to those states, there
are 7,243 designated Primary Care Health Professional Shortage Areas
(HPSAs) throughout the country that impacts over 84 million Americans.
There are also 4,243 designated Medically Underserved Areas (MUAs) in
the country. \3\
---------------------------------------------------------------------------
\1\ Health Resources and Services Administration. Supply and Demand
Projections of the Nursing Workforce: 2014-2030. Retrieved from:
https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/
NCHWA_HRSA_Nursing_Report.pdf.
\2\ Ibid.
\3\ Health Resources and Services Administration. Designated Health
Professional Shortage Areas Statistics. Retrieved from: https://
datawarehouse.hrsa.gov/topics/shortageAreas.aspx.
---------------------------------------------------------------------------
Further exacerbating this shortage is the increasing age of nurses
currently practicing. Since 2000, the number of active Registered
Nurses (RNs) older than 50 has accounted for 30 percent of RNs working
in hospital settings and for 40 percent of RNs working in nonhospital
settings. \4\ By 2022, it is projected that 70,000 baby boomer RNs will
retire each year, with them approximately 1.7 million experience years
will be lost annually. \5\ This is expected to cause a 1.3 percent
reduction in the growth of the workforce annually from 2015-2030. \6\
---------------------------------------------------------------------------
\4\ Peter Buerhaus, Lucy Skinner, David Auerbach, Douglas Staiger,
et al. 2017. ``Four Challenges Facing the Nursing Workforce in the
United States.'' Journal of Nursing Regulation, Volume 8, Issue 2.
\5\ Ibid.
\6\ David Auerbach, Peter Buerhaus, and Douglas Staiger.
``Millennials Almost Twice as Likely to be Registered Nurses as Baby
Boomers Were.'' Health Affairs, Volume 36, Issue 10.
---------------------------------------------------------------------------
This is of particular concern as it relates to the profession's
ability to educate a new generation of nurses. According to the
American Association of Colleges of Nursing (AACN), U.S. nursing
schools turned away 68,922 qualified applicants from baccalaureate and
graduate nursing programs in 2017, citing faculty shortages as a top
reason for not accepting those who were qualified. \7\ This past
academic year, there were 1,565 faculty vacancies in schools of
nursing. These vacancies are due to aging faculty, a spike in faculty
retirements (which is expected to continue over the next 10 years),
competition with clinical and private-sector settings, and a
diminishing pool of potential nurse educators. \8\ This past year, 31
percent of nursing faculty were aged 60 or older and that same cohort
of faculty are expected to retire over the next 10 years. The faculty
currently slated to replace them are largely in the 50-59 years old age
range as younger faculty are more likely to lack doctoral degrees and
experience needed to teach graduate students. \9\ Worsening this
faculty shortage, AACN found 11,959 qualified applicants were turned
away from master's and doctoral programs, further constraining the
pipeline for future faculty.
---------------------------------------------------------------------------
\7\ American Association of Colleges of Nursing. (2017). 2016-2017
Enrollment and Graduations in Baccalaureate and Graduate Programs in
Nursing. Washington, DC.
\8\ American Association of Colleges of Nursing. Nursing Faculty
Shortage as of April 26, 2017. Retrieved from: http://
www.aacnnursing.org/News-Information/Fact-Sheets/NursingFaculty-
Shortage.
\9\ Ibid.
---------------------------------------------------------------------------
In the State of Virginia, 54.6 percent of nursing schools
responding to AACN's survey reported a need for additional faculty. One
of the most critical issues noted by Virginia nursing schools
struggling to recruit faculty was a willingness to move to a rural,
underserved area, such as the Shenandoah Valley where James Madison
University is located.
Source: American Association of Colleges of Nursing. ``Special
Survey on Vacant Faculty Positions.'' http://www.aacnnursing.org/News-
Information/Research-Data-Center/Annual-Surveys.
The Title VIII programs have been successful in both the short-and
long-term as a way to not only increase the supply of nurses able to
care for patients, but also increase the number of nurse educators and
reduce the nursing workforce bottleneck. For the past decade, these
programs have remained steadfast in their ability to be flexible and
alleviate the stressors patients and communities feel by having nursing
shortages. These programs are structured to address education,
recruitment, retention, and faculty preparation, while being nimble
enough to focus on the most pressing concerns nationally, and equally
as critical, locally. It is imperative each of these six programs
remain authorized and funded.
The Title VIII Nursing Workforce Reauthorization Act (S. 1109/H.R.
959) is critical to making sure these programs continue to meet the
care demands of rural and underserved communities by the largest
healthcare workforce, nurses. Supported by 51 national nursing
organizations, this legislation has resounding support by the
profession. In a recent letter to this critical Committee of
jurisdiction, the Nursing Community Coalition reinforced that passing
the Title VIII Nursing Workforce Development Act is their main priority
in the 115th Congress. \10\ The Nursing Community Coalition and the
legislation's congressional champions, Senators Jeff Merkley (D-OR),
Richard Burr (R-NC), Tammy Baldwin (D-WI), and Susan Collins (R-ME)
agreed that these programs work. The American Association of Colleges
of Nursing, of which my school is a member, sought feedback from us as
constituents and I am here today to attest to that feedback, which is
that the Title VIII programs are essential and work.
---------------------------------------------------------------------------
\10\ Nursing Community Coalition letter to Senate HELP Committee,
May 14, 2018. https://docs.wixstatic.com/ugd/
148923_c39d891d5adf4f1c80554b97d304a0af.pdf.
---------------------------------------------------------------------------
The Title VIII Nursing Workforce Reauthorization Act includes three
areas of modernization and authorizes the funding for these programs
through 2020. The first modernization recognizes all four Advanced
Practice Registered Nurse (APRNs) roles in statue by adding Clinical
Nurses Specialists under the Advanced Nursing Education section and
under the National Advisory Council on Nursing Education and Practice
section. Historically, only three (Nurse Practitioners, Certified
Registered Nurse Anesthetists, and Certified Nurse-Midwives) of the
four APRN roles were included in statute. This change came out of the
work by national nursing organizations to standardize APRN licensure,
accreditation, certification, and education through the APRN Consensus
Model in 2010. \11\ Second, the legislation adds a definition of nurse-
managed health clinics to ensure these vital health centers are an
eligible entity to receive grants under Title VIII. Finally, the
Clinical Nurse Leader role, which evaluates patient outcomes, and
assesses cohort risk, was added to the statute to allow for parity with
the other master's degree programs that can apply for the Advanced
Nursing Education program. These modernizations are slight. However, as
noted, the core Title VIII programs work.
---------------------------------------------------------------------------
\11\ American Association of Colleges of Nursing. APRN Consensus
Model. Retrieved from: http://www.aacnnursing.org/Education-Resources/
APRN-Education/APRN-Consensus-Model.
---------------------------------------------------------------------------
Advanced Nursing Education Programs
The demand for care provided by clinicians with advanced education
is mounting, particularly as the population ages and public health
crises need immediate attention. From January 1, 2011 to December 31,
2029, it is projected that 10,000 baby boomers will turn 65 each day.
\12\ As rates of chronic illnesses associated with aging, such as heart
disease, stroke, cancer, diabetes, and arthritis, rise, the gravity of
increasing the healthcare workforce comes into view. The Centers for
Disease Control and Prevention (CDC) states that about half of all
adults across the Nation (117 million individuals) have one or more
chronic health conditions. \13\ Access to quality care is paramount and
more providers, including advanced practice registered nurses, are
needed, particularly in our Nation's most rural and underserved
populations. The healthcare workforce needs in these areas of the
country can be acutely seen as we work to address the opioid epidemic.
The CDC states that the rate of drug overdose deaths in rural areas is
higher than in urban areas. From 1999 to 2015, death rates due to
opioid overdose in rural populations quadrupled among those 18-25 years
old and tripled for females. \14\
---------------------------------------------------------------------------
\12\ Pew Research Center. (2010). Baby Boomers Retire. http://
www.pewresearch.org/fact-tank/2010/12/29/baby-boomers-retire.
\13\ U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention. (2016). Chronic Diseases: The Leading
Causes of Death and Disability in the United States. Retrieved from
https://www.cdc.gov/chronicdisease/overview/.
\14\ U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention. (2017). Rural America in Crisis: The
Changing Opioid Overdose Epidemic. Retrieved from https://
blogs.cdc.gov/publichealthmatters/2017/11/opioids/.
---------------------------------------------------------------------------
The Advanced Nursing Education Workforce (ANEW) Program, Advanced
Nursing Education (ANE) Program, Nurse Anesthetist Traineeship (NAT)
Program, and Advanced Education Nursing Traineeship (AENT) Program,
support those studying to become nurse practitioners, clinical nurse
specialists, certified nurse-midwives, certified registered nurse
anesthetists, nurse educators, administrators, public health nurses,
and other nurses requiring a master's or doctoral degree through
traineeships, as well as, curriculum and faculty development. These
programs help prepare a workforce ready to meet the challenges of today
and tomorrow. Collectively, these four programs supported 10,537
students in the 2016-2017 academic years, over 3,700 of whom graduated
this year. \15\ Just as critical to the students supported, these
programs offer schools of nursing, particularly one like mine, the
opportunity to innovate so that our educational programs can meet the
needs of the community in real time.
---------------------------------------------------------------------------
\15\ Health Resources and Services Administration. Fiscal Year 2019
Budget Justification. Retrieved from: https://www.hrsa.gov/sites/
default/files/hrsa/about/budget/budget-justification-fy2019.pdf.
---------------------------------------------------------------------------
The programs give preference for supporting those in rural and
underserved communities. This past year, 40 percent of ANE, 75 percent
of NAT, and 61 percent of AENT grantees received their training in an
MUA. Additionally, of the graduating students receiving NAT and AENT
funding, over 50 percent reported they planned to pursue employment in
MUAs. \16\
---------------------------------------------------------------------------
\16\ Ibid.
---------------------------------------------------------------------------
In 2014, James Madison University obtained funding through the ANE
program to begin an online Doctor of Nursing Practice (DNP) program,
with a focus on interprofessional education. At the time of completion,
one class of 10 doctoral students had graduated and an additional 35
students were enrolled in the DNP program. One of our graduates, Dr.
Patra Reed, works at our local community hospital that serves the rural
Shenandoah Valley. As a part of her doctoral study, Dr. Reed developed
a community health worker program to assist patients in the community
with chronic heart conditions. This program decreased readmissions and
saved her hospital $300,000 in the first 6 months of the program's
existence. Other graduates have done similar projects that have
improved patient care and health outcomes, while reducing costs.
Additionally, grant faculty began a ``Suitcase Clinic'' that
provides healthcare to the homeless population via a nurse practitioner
rolling a suitcase full of medical supplies to the area's homeless
shelters to see patients. Nursing and psychology faculty are
collaborating to address patients' mental health needs and chronic
illnesses, such as diabetes. Emergency room visits by the homeless
population have decreased dramatically in our local hospital as a
result of this program. This is what the ANE programs are helping to
achieve: educate students to build an evidence-based practice that
creates positive health outcomes in the community.
Nursing Workforce Diversity Grants
There is a strong connection between the diversity of the nursing
workforce and the ability to provide quality, culturally sensitive
patient care. Significant movement has occurred in diversifying the
nursing profession, yet current national demographics and projected
trends clearly indicate that more efforts must be placed on attracting
individuals from all backgrounds to pursue nursing. Research shows that
health professionals from underrepresented populations are more likely
to serve in underrepresented and medically underserved areas, which
would help close these ethnic and racial gaps in treatment. \17\ The
profession must consider how individuals' career paths are supported at
an early age and how candidates are reviewed as they apply to nursing
school to enhance diversity and inclusion in the student body.
---------------------------------------------------------------------------
\17\ The Sullivan Commission. (2004). Missing persons: Minorities
in the health professions. A report of the Sullivan Committee on
diversity in the healthcare workforce. Retrieved from http://
www.aacnnursing.org/Portals/42/Diversity/SullivanReport.pdf.
---------------------------------------------------------------------------
The Nursing Workforce Diversity Grants help schools recruit and
retain students from diverse and disadvantaged backgrounds to work in
the nursing profession. Through stipends, scholarships, a variety of
pre-entry preparation, advanced education preparation, and retention
activities, these programs increase access to quality, culturally
sensitive patient care. In the 2016-2017 academic year, a total of 57
collegiate programs were supported and 38 training programs were
conducted. This helped to support 4,416 nursing students at 571
training sites, 49 percent of which were located in MUAs, through 7,800
clinical training experiences. \18\
---------------------------------------------------------------------------
\18\ Health Resources and Services Administration. Fiscal Year 2019
Budget Justification. Retrieved from: https://www.hrsa.gov/sites/
default/files/hrsa/about/budget/budget-justification-fy2019.pdf.
---------------------------------------------------------------------------
Nurse Education, Practice, Quality, and Retention Programs
As evidenced by the current and impending demand for nurses as
highlighted above, recruitment and retention are chiefly important to
meet the economic and societal trends that impact workforce
development. The Nurse Education, Practice, Quality, and Retention
(NEPQR) Program has helped address these trends through innovation and
excellence by testing new strategies and calling on academic
institutions, healthcare settings, and the community to be nimble in
their approach to preparing a highly educated workforce ready to
practice now and in the future.
NEPQR includes the Interprofessional Collaborative Practice (IPCP)
program and the Bachelor of Science in Nursing Practicums in Community-
based Settings (BPCS) program, both of which help schools of nursing,
academic health centers, nurse-managed health clinics, state and local
governments, and healthcare facilities meet shifting demands in health
care through pioneering programs. In the past academic year, the IPCP
program partnered with 148 clinical sites to train 6,430 individuals
from a variety of professional backgrounds. Of the clinical sites where
this training occurred, 71 percent were in MUAs. Meanwhile, the 11 BPCS
awardees trained 681 students, 26 percent of whom reported coming from
rural backgrounds. Awardees partnered with 57 clinical sites, 75
percent of which were located in MUAs. \19\
---------------------------------------------------------------------------
\19\ Ibid.
---------------------------------------------------------------------------
In the late 1990's, I worked as part of a grant team to transition
a program that helped associate degree prepared nurses obtain their
baccalaureate degree from one that was in-person to one that was online
at the University of South Alabama. At the time, the use of the
internet as a method of educational delivery was a newly charted
territory. Transitioning the program to an online platform helped to
reach rural Alabama nurses by removing access issues, time constraints,
and other barriers they faced while completing their baccalaureate
degree. The program was very popular, the college of nursing became a
leader in online nursing programs, and many rural nurses were able to
complete their degree. Evidence supports that patients receiving care
from higher educated nurses experience better outcomes. \20\ Most
importantly, the vast majority of these newly graduated, rural,
baccalaureate-prepared nurses stayed in their communities to work and
improve patient outcomes.
---------------------------------------------------------------------------
\20\ American Association of Colleges of Nursing. Creating a More
Highly Qualified Nursing Workforce. Retrieved from: http://
www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-Workforce-Fact-
Sheet.pdf.
---------------------------------------------------------------------------
In 2006, I was project director of a similar NEPQR grant that
transitioned a face-to-face program designed to help practicing RNs
obtain their baccalaureate degree to an online program at the
University of Southern Mississippi in Hattiesburg, MS. The focus and
outcome mirrored that of the program at the University of South
Alabama. Our goal was to remove barriers for adult students, many of
whom were from underrepresented backgrounds, lived in rural communities
that were medically underserved, and met the criteria for being
educationally disadvantaged. The program was highly successful in
reaching and educating the nursing students who participated.
Recently, James Madison University was awarded funding for a
proposal that was submitted to educate baccalaureate prepared nurses to
work in community settings. For this proposal, we partnered with Valley
Health Page Memorial Rural Health Centers, and Counseling and
Psychological Services to address shortages in primary, mental health,
and substance/opioid abuse treatment in Page County, Virginia. Through
this grant, our goal is to partner with the clinics to help educate
baccalaureate nurses in the community setting and place a much needed
focus on the opioid epidemic. As you can see by these examples,
workforce development remains constant, but the programs allow for
innovation and can be tailored year-to-year to meet pressing healthcare
priorities.
Nurse Faculty Loan Program
As noted, the national nursing faculty shortage is causing
significant barriers to schools of nursing accepting all qualified
applications. In the State of Virginia, our vacancy rate is 5.5
percent, but some states, like Alaska (16.7 percent), California (13.6
percent), and Washington (12.6 percent) have some of the highest in our
country. \21\ Academic and practice employers are competing for the
same pool of nurses with master's and doctoral degrees who have
clinical and research expertise. This past year, 84 schools received
new Nurse Faculty Loan Program grants. \22\ These awards are granted to
schools of nursing that, in turn, provide loans to graduate students
committed to serving as faculty members to educate the next generation
of nurses, by repaying up to 85 percent of their loans. Close to 2,000
nursing students were supported in 2017. In my own faculty, I have a
large number of individuals who received this grant during their career
and said it was the linchpin for allowing them to pursue a career in
academia, and most importantly for us, help educate nurses who will go
on to serve in rural and underserved areas.
---------------------------------------------------------------------------
\21\ Health Resources and Services Administration. Fiscal Year 2019
Budget Justification. Retrieved from: https://www.hrsa.gov/sites/
default/files/hrsa/about/budget/budget-justification-fy2019.pdf.
\22\ Ibid.
---------------------------------------------------------------------------
NURSE Corps Programs
The NURSE Corps Loan Repayment (LRP) and Scholarship (SP) Programs
ensure nursing students and nurses entering the workforce are placed in
areas that need them most, HPSAs and MUAs. In exchange for scholarship
or loan repayment, these nurses fulfill their service obligation in
underserved areas. In 2016, 55 percent of participants voluntarily
extended their service requirement by a year and 86 percent of
participants remained at their Critical Shortage Facility for over 2
years beyond their commitment. \23\
---------------------------------------------------------------------------
\23\ Ibid.
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Comprehensive Geriatric Education Program
The aging population needs nursing care, plain and simple. The
Comprehensive Geriatric Program supports nurses who are interested in
focusing their career on the care of the elderly. Now under the
Comprehensive Workforce Enhancement Program (GWEP) in the Title VII
Health Professions Programs, the language in the Title VIII statute is
still supported and provides training across the provider continuum
focusing on education in interprofessional and team-based care.
As demonstrated by my own background and experience with the
programs, support from Title VIII is essential to the sustainability of
the nursing workforce. Each of these programs help to provide students,
faculty, schools, clinical training sites, and community partners the
resources necessary to ensure the supply of nurses remains strong to
provide care to millions of patients in every corner of the country. I
am honored to provide testimony on the programs that have been
foundational to my own success and that of countless nurses before and
after me. I urge you to pass S. 1109, The Title VIII Nursing Workforce
Development Reauthorization Act. Thank you for your continued
sponsorship of America's health and wellness through nursing care.
______
[summary statement of julie tanner sanford]
The Nation's Demand for Nurses
The demand for nurses inevitably varies by state, but the national
need is projected to increase by 28 percent by the year 2030 with four
states expected to have a nursing deficit of over 10,000 nurses. This
projected nursing shortage is intensified in certain areas due to the
inequitable distribution of the workforce. There are 4,243 designated
Medically Underserved Areas (MUAs) as well as 7,243 designated Primary
Care Health Professional Shortage Areas (HPSA) in America that impacts
over 84 million Americans.
Further exacerbating this shortage is the increasing rate of nurses
retiring. By 2022, it is projected that 70,000 baby boomer registered
nurses will retire annually. This is expected to cause a 1.3 percent
reduction in the growth of the workforce each year from 2015-2030. This
is of particular concern as it relates to the profession's ability to
educate a new generation of nurses. According to the American
Association of Colleges of Nursing (AACN), U.S. nursing schools turned
away 68,922 qualified applicants from baccalaureate and graduate
nursing programs in 2017, citing the 1,565 faculty vacancies as a top
reason for not accepting qualified applicants. Worsening this faculty
shortage, AACN's data shows 11,959 qualified applicants were turned
away from master's and doctoral programs, further constraining the
pipeline for future faculty.
Summary of Title VIII Programs and Changes to Legislation
The Nursing Workforce Development programs (Title VIII of the
Public Health Service Act [42 U.S.C. 296 et seq.]) have been successful
in increasing the supply of nurses and the number of nurse educators.
These programs are structured to address education, recruitment,
retention, and faculty preparation while being nimble enough to focus
on the most pressing concerns nationally and locally in communities
that need broader access to care. In the past academic year, thousands
of students have been supported through one of these programs, with a
majority of those students receiving clinical training in MUAs. It is
important each of these six programs remain authorized and funded.
The Title VIII Nursing Workforce Reauthorization Act (S. 1109/H.R.
959) is critical to making sure these programs continue to meet the
care demands in every corner of the country. This legislation makes
essentially three modernizations to the programs and authorizes the
funding through 2020. The first modernization recognizes all four
Advanced Practice Registered Nurse (APRNs) roles in statue by adding
Clinical Nurses Specialists under the Advanced Nursing Education
section and under the National Advisory Council on Nursing Education
and Practice. Historically, only three (Nurse Practitioners, Certified
Registered Nurse Anesthetists, and Certified Nurse-Midwives) of the
four APRN roles were included in statute. Second, the legislation adds
a definition of nurse-managed health clinics to ensure these vital
health centers are an eligible entity to receive grants under Title
VIII. Finally, the Clinical Nurse Leader role, which evaluates patient
outcomes and assesses cohort risk, was added to the statute to allow
for parity with the other master's degree programs that can apply for
the Title VIII Advanced Nursing Education program.
These programs allow awardees to be innovative in their approaches
to educate nurses and offer them critical exposure to providing high
quality, cost-effective care in our Nation's most rural and underserved
communities.
______
The Chairman. Thank you, Dr. Sanford.
Dr. Phelan, welcome.
STATEMENT OF ELIZABETH PHELAN, M.D., M.S., NORTHWEST GERIATRICS
WORKFORCE ENHANCEMENT CENTER, ASSOCIATE PROFESSOR OF MEDICINE,
GERONTOLOGY AND GERIATRIC MEDICINE, AND ADJUNCT ASSOCIATE
PROFESSOR OF HEALTH SERVICES, UNIVERSITY OF WASHINGTON,
SEATTLE, WASHINGTON
Dr. Phelan. Good morning, Chairman Alexander, and Ranking
Senator Murray who, I am proud to say, is my Senator, and
distinguished Members of the Committee.
It is my pleasure to be here and to speak with you today
about the value of the Geriatrics Workforce Enhancement
Program. The Geriatric Workforce Enhancement Program is the
only U.S. Government program dedicated to preparing primary
care providers to care for older adults.
My name is Elizabeth Phelan and I am a clinically active,
fellowship-trained geriatrician. I direct one of the only fall
prevention clinics in the country, and I am also the Director
of the Northwest Geriatrics Workforce Enhancement Center, one
of 44 so called GWEP's nationally.
I have devoted my career to improving primary care of older
adults through research and teaching, and particularly the care
of conditions that disproportionately afflict adults in later
life, conditions like falls, osteoporotic fractures, and
dementia.
May is Older Americans Month, a time to recognize and
celebrate the value and contributions of older adults in all of
our lives. But unfortunately, many older adults are suffering
from conditions that, if not properly managed, will rob them of
their well-being and independence.
I am going to give you just two examples, from a myriad
that I could cite from around the country, to illustrate this
nationwide challenge that we are facing.
First, there is Mr. H., a 68-year-old gentleman from
Montana. He lives in his own home. He was taking Ambien, a
sleeping aid. He got up one night. He fell. He broke his
pelvis, and he was transported to the University of Washington
Medical Center for surgical management of that fracture.
At the hospital, we discovered that he was likely suffering
from undiagnosed obstructive sleep apnea. Obstructive sleep
apnea in people who are at high risk, in those people, only
about 8 percent of those people receive actual testing to make
the diagnosis.
If he had been properly diagnosed and treated, Mr. H. might
have avoided using Ambien and the injurious fall that he
sustained.
Another example is Mrs. W., an 80-year-old female, also
living in her own home in rural Florida. She is absolutely
paralyzed by anxiety and panic attacks. Because of the anxiety
and panic, she no longer drives. She does not see friends. She
has become very socially isolated.
Her doctor is treating her anxiety with a pill called
Xanax. This is a very risky medication for adults in later
life, and it is ineffective for treatment if anxiety and panic
are chronic. In essence, it is just putting a band-aid on this
condition.
In Washington State, in our Geriatric Workforce Enhancement
Center, we are partnering with two area agencies on aging, and
we are using about one-third of our GWEP dollars to fund a
position within those agencies that we call the Primary Care
Liaison.
The Primary Care Liaison's role is actively outreach to
primary care practices with education about how area agencies
on aging can support the work of primary care to deliver high
quality care to older adults. Area agencies on aging do this by
providing access to critical community programs and resources
that primary care has little awareness of at this point, but
which are critical to keeping older adults staying in their own
homes, living in the community, and to avoid unnecessary costs
of hospitalization and long term care that oftentimes otherwise
will result.
We are trying to break down the silos of care between
clinic and community, because care that bridges between
community and clinic can optimize the health of an older adult
and his or her caregiver to keep them living in the community,
and active, and connected.
We are finding that even minimal exposure to geriatrics
principles of care is making a big difference. Our trainees are
citing increased knowledge and confidence to bring these
agencies on aging, community resources, and services to bear on
the care of their older patients.
We all know we have a shortage of primary care workforce
and that there are a number of ways to address this, but all
need training in geriatrics.
Because older adults will continue to receive primary care
from frontline providers in the fields of family medicine,
general medicine, and from nurse practitioners--and not
geriatricians--we must support the training of providers in
those disciplines to have this care, high quality care become a
reality.
We have a very long way to go to realize this imperative
because current training for most health professionals does not
include dedicated training in geriatrics care.
We need programs like the Geriatrics Workforce Enhancement
Program to fill that gap. It is a critical gap and doing this
will have a large impact on how well the older adult lives if
he or she encounters a primary care provider who is prepared,
and equipped, and competent to address the specific needs of
that aging individual.
Just to sum up, I urge the entire Committee to support the
Geriatrics Workforce Enhancements continuation.
Thank you for this opportunity to testify. I look forward
to answering your questions.
[The prepared statement of Dr. Phelan follows:]
prepared statement of elizabeth a. phelan
Good morning, Chairman Alexander and Ranking Member Murray, whom I
am proud to say is my Senator, and distinguished Members of the
Committee. Thank you for this opportunity to speak with you today about
the value of the Geriatrics Workforce Enhancement Program (or
``GWEP''), administered by the Health Resources and Services
Administration (HRSA). The GWEP is the only U.S. Government program
dedicated to preparing primary care providers to care for older adults.
My name is Elizabeth Phelan, and I am a clinically active internist and
fellowship-trained geriatrician. I direct one of the only fall
prevention clinics in the country, and I am also the director of the
Northwest Geriatrics Workforce Enhancement Center, one of 44 GWEPs
nationally. Our GWEP is a member of the National Association for
Geriatric Education (NAGE), and our GWEP leaders are members of The
Gerontological Society of America (GSA). I have devoted my career to
improving primary care of older adults, particularly care of conditions
that disproportionately afflict adults in later life, such as falls,
osteoporotic fractures, and dementia.
May is Older Americans Month,--a time to recognize and celebrate
the value and contributions of older adults in our lives.
Unfortunately, many older adults are suffering from conditions that, if
not properly managed, will rob them of their well-being and
independence. Conditions like falls, depression, and heart failure. I
will give you just two examples, from a myriad of examples that I could
cite, to illustrate the nationwide challenge that we face. First, there
is Mr. H, a 68 year old from Montana who lives in his own home, was
taking Ambien, a sleeping pill for insomnia, who got up one night and
fell, breaking his pelvis. At the hospital, it was discovered that he
was likely suffering from undiagnosed sleep apnea. If sleep apnea had
been diagnosed and treated, Mr. H may have avoided Ambien and the
injurious fall he sustained. Recent data has found that obstructive
sleep apnea is diagnosed in just 8 percent of older adults. As another
example, Mrs. W, an 80 year old female, widowed for the past 10 years,
who lives in a rural part of Florida and also in her own home, who is
absolutely paralyzed by anxiety and panic attacks. Because of the
anxiety, she no longer drives and has become very socially isolated.
Her doctor is treating her with Xanax. Xanax and other medications in
this same class are very risky for people in later life, and Xanax is
ineffective for anxiety and panic. In essence, it is just putting a
band-aid on the condition.
Why does medical mismanagement of older adults like this occur? Is
it that there are bad apples in medical practice? No. Most health care
providers want to do the right thing for their patients. But when it
comes to care of older adults, most don't know what the right thing is.
That is because geriatrics, or the clinical care of the elderly, has
not been a part of the training of most health professionals in
practice today. And even those in current training for health
professions careers usually still get to the end of their training and
never receive any formal exposure to geriatrics. With GWEP funding, we
have the opportunity to change that.
GWEPs focus on enhancing the ability of America's primary care
workforce to provide high-quality care for older adults. Our Northwest
Geriatrics Workforce Enhancement Center is working to achieve the
vision that wherever an older adult goes for primary care, he/she will
encounter a provider who is prepared to meet his/her needs and to
provide the right care at the right time--that is, care that is
tailored to the older adult's health and functional status, and his/her
personal goals and preferences. Our Center has chosen to focus training
on the next generation of primary care providers, and we are taking a
comprehensive, inclusive view of primary care. A key target for our
educational activities are the resident physicians in the Family
Medicine Residency Network, a network of 25 independent residency
training programs in a five-state region known as ``WWAMI''
(Washington, Wyoming, Alaska, Montana, and Idaho). We are also training
nurse practitioner and physician assistant students and those on the
front lines of hands-on, daily care, including family caregivers and
home care workers.
How exactly is our Center preparing the next generation of primary
care providers to provide high-quality, evidence-based care for older
adults? We are doing this in a number of ways. For example, we have
adopted the ECHO model to teach general principles of geriatrics and
reach family medicine resident physicians and nurse practitioner and
physician assistant trainees across the Pacific Northwest. We have
partnered with two Area Agencies on Aging and are using about a third
of our GWEP dollars to fund a position within those agencies that we
call a Primary Care Liaison, whose role is to actively outreach to
primary care practices with education about how Area Agencies on Aging
can support the work of primary care by bringing community resources to
bear. We are trying to break down silos of care between clinic and
community, because care that is tuned into the resources that the
community can bring to bear can optimize the health of an older adult
and keep him/her living in the community--AND avoid the unnecessary
costs of hospitalizations and long-term care that so often otherwise
results. And we are finding that even minimal exposure to geriatrics
principles of care makes a difference in trainee knowledge and
confidence to bring AAA resources to bear on the care of their older
patients. For example, with our AAA Practicum, family medicine
residents who spent just 1 day with an AAA staff member, after exposure
to a standard curriculum developed by our AAA partners about the role
of AAAs, significantly increased their likelihood to access family
caregiver resources, elder abuse resources, and mental health resources
on behalf of their patients.
We know we have a shortage of primary care workforce, and there are
a number of ways that we can address this, but ALL need training in
geriatrics. Because most older adults will continue to receive primary
care from frontline providers from the fields of family medicine,
general internal medicine, and nurse practitioners,--not
geriatricians,--we must support the training of providers in those
disciplines to make good care a reality. We have a long way to go to
realize this imperative. Doing the right thing does have a large impact
on how well an older adult lives and how long he/she stays living in
the community. For this reason, I urge the entire Committee to continue
to support the Geriatrics Workforce Enhancement Program. Thank you
again for this opportunity to testify, and I look forward to answering
your questions.
______
[summary statement of elizabeth a. phelan]
Good morning, Chairman Alexander and Ranking Member Murray, whom I
am proud to say is my Senator, and distinguished Members of the
Committee. Thank you for this opportunity to speak with you today about
the value of the Geriatrics Workforce Enhancement Program (or
``GWEP''), administered by the Health Resources and Services
Administration (HRSA). The GWEP is the only U.S. Government program
dedicated to preparing primary care providers to care for older adults.
My name is Elizabeth Phelan, and I am a clinically active internist and
fellowship-trained geriatrician. I direct one of the only fall
prevention clinics in the country, and I am also the director of the
Northwest Geriatrics Workforce Enhancement Center, one of 44 GWEPs
nationally. Our GWEP is a member of the National Association for
Geriatric Education (NAGE), and our GWEP leaders are members of The
Gerontological Society of America (GSA). I have devoted my career to
improving primary care of older adults, particularly care of conditions
that disproportionately afflict adults in later life, such as falls,
osteoporotic fractures, and dementia.
May is Older Americans Month,--a time to recognize and celebrate
the value and contributions of older adults in our lives.
Unfortunately, many older adults are suffering from conditions that, if
not properly managed, will rob them of their well-being and
independence. Conditions like falls, depression, and heart failure. I
will give you just two examples, from a myriad of examples that I could
cite, to illustrate the nationwide challenge that we face. First, there
is Mr. H, a 68 year old from Montana who lives in his own home, was
taking Ambien, a sleeping pill for insomnia, who got up one night and
fell, breaking his pelvis. At the hospital, it was discovered that he
was likely suffering from undiagnosed sleep apnea. If sleep apnea had
been diagnosed and treated, Mr. H may have avoided Ambien and the
injurious fall he sustained. Recent data has found that obstructive
sleep apnea is diagnosed in just 8 percent of older adults. As another
example, Mrs. W, an 80 year old female, widowed for the past 10 years,
who lives in a rural part of Florida and also in her own home, who is
absolutely paralyzed by anxiety and panic attacks. Because of the
anxiety, she no longer drives and has become very socially isolated.
Her doctor is treating her with Xanax. Xanax and other medications in
this same class are very risky for people in later life, and Xanax is
ineffective for anxiety and panic. In essence, it is just putting a
band-aid on the condition.
We know we have a shortage of primary care workforce, and there are
a number of ways that we can address this, but ALL need training in
geriatrics. Because most older adults will continue to receive primary
care from frontline providers from the fields of family medicine,
general internal medicine, and nurse practitioners,--not
geriatricians,--we must support the training of providers in those
disciplines to make good care a reality. We have a long way to go to
realize this imperative. Doing the right thing does have a large impact
on how well an older adult lives and how long he/she stays living in
the community. For this reason, I urge the entire Committee to continue
to support the Geriatrics Workforce Enhancement Program. Thank you
again for this opportunity to testify, and I look forward to answering
your questions.
______
The Chairman. Thank you, Dr. Phelan, and thanks to all
three of you.
We will now move to 5 minute rounds of questions from the
Senators. We will begin with Senator Murkowski.
Senator Murkowski. Mr. Chairman, Ranking Member Murray,
thank you for this very, very, very important hearing.
We, again, are a place of extremes. We are a long ways
away. We do not have a medical school. We have the most rapidly
aging population per capita in the state right now. We are not
ready for it. We do not have geriatrics training. We do not
have providers that are willing to take new Medicare eligible
individuals.
The way it is referenced around the state is, ``When you
hit 65, you are given a bus ticket,'' but there is never a bus
that will show up because we do not have sufficient providers.
So what we are talking about today is of extreme interest to
me.
Dr. Goodell, I want to begin with you. And again, thank you
each for your comments this morning and your contributions.
One of the complaints that I am hearing from providers in
the state, and other rural areas, is that all the GME money
gets sucked up by the big teaching hospitals in urban areas.
And so, it is very hard for us to be able to support residency
programs, not only in the one urban center in Anchorage, but in
the smaller towns outside of Anchorage and very, very difficult
in hub cities in rural areas like Nome or Bethel.
Our state legislature helps pay for 20 residency slots
through the University of Washington Medical School. But there
is no guarantee that those 20 come back to the State of Alaska.
The resident training issue for us is, in terms of the
impact to the cost of care, it can cost one hospital in
Fairbanks between $750,000 to $1 million to recruit a midcareer
physician, and these jobs can take years to fill.
The point that you have made, all of you, about doctors
tending to practice where they do residency really prompts my
question. You left the door open to be able to speak to more of
these programs that can help allow for residencies in these
areas where we need the doctors.
I would be curious to hear about more of the programs, but
also whether or not you think we need to move more of these GME
dollars out of the hospitals to perhaps clinics, or outpatient
facilities, or small group practices in our rural areas.
How do we avoid this concentration? Because we see
firsthand that you have people who come to the state. They are
excited about the adventure. They are there for a year, and
then they leave, and the investment that we have made, and then
we have to start all over.
Dr. Goodell. Right. I completely agree with you. And taking
care of the people of Alaska, no doubt, is going to require a
multilevel approach.
To address your first point, I think that the State of
Alaska is a perfect example of where the Teaching Health Center
Program can make a major impact. You have one big university
hospital and it is in the big city. The problem is most of the
people that live or many of the people that live in Alaska are
much more widely spread.
The Teaching Health Center Program is a separately funded
program that locates residencies, not in the big university
setting, but has them spend, primarily spending their time in
community health centers.
When residents go there for training, they spend at least 3
years there. They really get a feel for the community. They
become connected with their patients and especially in primary
care. That is actually why we do it so that we can get
connected with our patients.
Having residents have the potential to make the connection
with the community and their patients over time vastly
increases the likelihood that they will actually stay
practicing there.
I also would give a shout out to some additional programs
that can help provide care in slightly different ways.
Dr. Phelan, I think, mentioned briefly Project ECHO, or
somebody mentioned Project ECHO, which is a terrific way to
leverage the expertise that is based in big academic medical
centers and use that expertise to train up primary care
providers, not just physicians, but other sorts of providers
that are more widely spread. So you can train people in how to
take care of opioid addiction and how to manage complicated
psychiatric illness, how to manage hepatitis C, everything.
Focusing on Teaching Health Centers is probably the single
most impactful thing.
Senator Murkowski. Think about raising the cap on residency
slots. Does that help? Or are you still stuck with the fact
that these people are not going to be comfortable because they
have not really experienced life in that rural and remote
setting?
Dr. Goodell. Simply raising the cap at one hospital may
increase the number of people that you have that stay in the
state. But generally, the data shows that people tend to
practice, the majority of people stay within 100 miles of where
they were trained after residency. So it depends on how widely
spread you need people.
Senator Murkowski. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Murkowski.
Senator Murray.
Senator Murray. Thank you all very much for your excellent
testimony.
As Baby Boomers age and health providers retire, there is a
serious crisis in our geriatric workforce, which is brewing.
Our senior population is expected to nearly double from 48
million to 88 million by 2050 and more than 40 percent of
practicing physicians are 55 years or older. As a result, HRSA
is now projecting a national shortage of more than 27,000
geriatricians by 2025.
Recognizing this problem back in 2015, HRSA created the
Geriatric Workforce Enhancement Program, GWEP, which called on
geriatricians to collaborate with primary care providers and
community-based organizations to deliver the care and the
support seniors need to age in their own communities.
I am really pleased that Washington State is leading the
way in utilizing programs like GWEP to develop best practices
to help communities care for seniors, particularly in our
underserved areas and to further implement innovative models,
like we just talked about, Project ECHO.
Dr. Phelan, maybe you can share with the Committee how you
have been able to leverage the GWEP program to expand the reach
of geriatric care into our underserved areas.
Dr. Phelan. I would be glad to speak to that, and thank you
for the question.
To build peoples' understanding of Project ECHO, our model
is modeled after other ECHO programs in the country. But we are
unique in that we focus on training around general geriatrics
issues for the primary care population. So not long term care,
not hospital inpatient relevant conditions, but general
geriatric issues that our primary care providers would face in
his or her clinic on a daily basis and practice.
Actually, our strategy has been to target the next
generation of primary care providers. We are reaching across a
network that is known as the WWAMI network, which is a network
of between 20 and 30 family medicine residencies, independent
residencies, in the five state regions: Washington, Wyoming,
Alaska, Montana, and Idaho.
We, once a month, have what is essentially a case
conference where people join in, sign on using zoom technology.
So they are in the room with us and we are speaking directly to
them. It gives the person presenting a case an opportunity to
bring a challenging patient case, or just a question about
management or diagnosis, before a panel of geriatrics experts.
We have on our panel, in addition to some of our faculty,
who are funded. Part of their salary is paid through the GWEP
dollars to work as part of our Center. These are faculty that I
work closely with who are excellent educators in geriatrics.
Geriatricians are typically educators of other providers around
older adults.
But in addition to a couple of geriatricians, we have a
geriatric psychiatrist, a social worker, nursing, and we also
have representatives from each of our agencies on aging who
always discuss relevant community programs that are offered,
hopefully, in the settings where those providers presenting
their cases are practicing.
We try to tailor our recommendations so that we can give
very useful, practical suggestions in addition to increasing
the general competence of a particular condition. We talk about
everything from safe prescribing, to prevention of falls,
screening for falls, management of behavioral problems for
people who are suffering from dementia, caregiver issues,
caregiver burnout, caregiver stress.
To build on the question that Senator Murkowski asked a bit
ago as well, for people to stay in rural areas and practice
where they are. The person on the frontlines of care on a year
to year basis to have access to that community of learning and
shared knowledge is really critical.
Senator Murray. Thank you very much.
The Chairman. Thank you, Senator Murray.
Dr. Cassidy.
Senator Cassidy. I am also a physician. And it is
interesting, I still am getting emails from the hospital where
I have practiced, and they did a survey on burnout. It is
amazing the burnout rate.
It is not burned out when you are 75 years old and one foot
in the grave, although I hope I am not that way at 75, but it
is somebody who is 50 to 55, or it is the mom who is 45 and she
just wants to quit. In fact, I think I know that women leave
practice at an earlier age on average than do men; competing
pressures of family and work just make it difficult.
Now, I am concerned that a lot of what we have done here,
although well-meaning, has contributed to that. When I look at,
again, the survey at the hospital where I have practiced, the
electronic medical record, meaningful use, other administrative
burdens, and if they can afford it, they walk. Or, if they are
an OB-GYN, they start doing Botox for cash as opposed to
delivering babies.
Dr. Goodell, any thoughts about that, and agree or
disagree, and if so, any thoughts? Is that a contribution to
our looming shortage, our worsening shortage?
Dr. Goodell. Yes, burnout is an enormous problem among
physicians. It is a big problem, certainly, among family
physicians, which is my specialty. There are a number of causes
for this and no doubt, the administrative burden that you are
talking about is a big one of them. This is on everyone's
radar.
One thing that we need to think about, and you asked if it
was contributing to physician workforce problems. And yet, it
is because one thing that we know for sure is that people are
choosing to practice fewer hours a week. So back in the day, a
physician would practice 60, 70 hours a week and today, people
are not able to do that. It is simply too exhausting.
One of the things that we need to do is think about how we
can increase physician flexibility. One way to do that is by
changing the way we pay physicians to do their work so that
instead of paying them by volume, instead of collecting money
based on every patient they see in a day, we collect money for
the quality of care they are delivering overall.
Senator Cassidy. Let me stop you for a second though,
because there is something about if you see somebody, you get
more money. If you earn a salary, it does not matter how many
you see. There is a very profound incentive there.
A friend of mine is an obstetrician and he wanted the folks
in his practice to start counseling regarding the human
papillomavirus vaccine. But really, in everything they had to
cover, the only way he made it happen is he said, ``Okay. If
you do the HPV counseling and administer first dose, I will
give you a little extra.''
You are nodding your head. It sounds like you agree that
positive incentive is a positive thing in terms of getting more
productivity.
Dr. Goodell. As long as you do not mind burning people out
in 5 years, then yes. You can incentivize people to work as
fast as possible.
What I was nodding to is the idea that the enormous number
of tasks we are requiring people to do is crowding out things
that are really important.
For example, we were talking about taking care of older
patients. Older patients typically have many medical needs. A
lot of them are really complicated. Patients from medically
underserved areas have a lot of psychosocial determinants of
health. Those are not problems that can be addressed in a
really short timeframe.
The issue with paying people for volume is that you cut
down the number of minutes you have per person and a lot of
really necessary health care falls right off the agenda.
Senator Cassidy. To my colleagues, there will be folks here
from the Direct Primary Care today, you may run into them, DPC
is blue collar concierge, and so they kind of take that model,
and run with it, and improve access.
Let me ask one more thing. I forget if it is in your
testimony or your testimony, by the way, great admirers of the
people at Project ECHO. My wife has worked with them on the
issue of dyslexia in transmitted, et cetera. I once spoke to
their conference and got roundly booed, but that is another
story.
Your testimony or another is about the geographic
maldistribution of training slots. You pointed out that most
folks practice within 100 miles of where they wish to be.
Now the northeast, of course, is a high concentration of
training slots. New York City, I think, the highest of all,
maybe Boston is a little bit higher per capita. And a lot of
those in New York City go unfilled. In fact, it takes someone
graduating from a foreign medical school in order to fill,
whereas if you are in Anchorage, I suspect that there is a
shortage. There is a shortage in some of my towns in Louisiana.
Any thoughts about maldistribution? Because frankly it is
the perception of the rest of the country that the northeast
jealously guards that maldistribution, and no offense, whereas
Virginia would not get, Tennessee would not get, et cetera.
Any thoughts on that?
Dr. Goodell. I believe that we need to think about Graduate
Medical Education as a priority in the Nation overall.
Right now, we do not really have a GME system. We have a
payment structure which gives funding to hospitals.
Senator Cassidy. I accept that, but speaking specifically,
and I am over, so I have to hustle you a little bit, speaking
specifically about the maldistribution where per capita, states
like New York and Massachusetts have far more per capita than a
state like Virginia or Louisiana.
Dr. Goodell. We need to change the way we allocate slots so
that we allocate more residency training slots in places where
we need them.
Senator Cassidy. Good, thank you. I yield back.
The Chairman. Thanks, Senator Cassidy.
Senator Kaine.
Senator Kaine. Thank you.
Excellent testimony. I have about an hour's worth of
questions, but I have a hearing to co-chair at 11, so I am
going to get right to it.
Dr. Sanford, I want to ask you about your testimony. In
your written and delivered testimony, you talked about the
faculty vacancies in nursing faculties now. I dealt with a
similar issue when I was Governor of Virginia. What we found in
the state was that the salaries of faculty members were,
frankly, very disadvantageous to what they could earn if they
were practitioners, and that led to big faculty vacancies. I
don't know if that is the reason for the current faculty
vacancy issue nationally, but tell me a little bit about that
and how we solve it.
Dr. Sanford. Well, that is a problem, Senator Kaine. Thank
you for the question.
Our nursing faculty at James Madison University, I polled a
question before I came, and I asked, ``How many of you have
received nurse faculty payment, or repayment support, or
training support?'' Roughly 40 percent of our faculty had.
I see those programs to support the loans that are required
to help repay those as being really critical to us to be able
to maintain the faculty that we have.
I do think there are some problems between the service side
and the academia side. There is a disparity there with the
salaries.
Having the ability to know that your loans--about 70
percent of our graduate students take out loans--having the
ability to know that your loan is going to be repaid sometimes
is the tipping point or the tipping factor for faculty for
nurses to choose to go into academia.
I see those programs as critical to helping us address
faculty shortage.
Senator Kaine. Let me ask all of you one last question,
which is some of the ways we deal with shortages.
We have a misallocation, more people here than we need and
less people there, is sort of extending the work ability of
people. Not necessarily moving them into a location, but
extending their ability to work and I am thinking of
telemedicine.
In Virginia, we have very active telemedicine programs that
do reach into some of the underserved parts of our state,
Appalachia in particular. And we see it maybe having some
specific benefit in areas that already have too few
practitioners like behavioral health as we are trying to tackle
the opioid related challenge. To try to have behavioral health
practitioners at the University of Virginia, for example, be
able to interact with nurses and other allied health
professionals in southwest Virginia to deal with folks.
Talk a little bit about telemedicine as part of an extender
of the health care workforce. Do we need to think differently
about even reimbursement models, et cetera, to allow
reimbursement models that would incentivize appropriate use of
telemedicine?
Dr. Sanford, I will start with you since you started an
online curriculum for training of nurses.
Dr. Sanford. Yes, that is true and one of the things that
we have found is that whenever we offer programs where the
students can live in their communities and do their clinical in
their communities, they stay in those communities.
We are taking the programs to those who are educationally
disadvantaged, which would help with the issue that you are
citing, Senator. It would help us educate those individuals to
stay in their communities, which is highly, highly impactful.
We have had success with that model here at James Madison
University as well as other universities across the country.
Within the Nursing Workforce Development Programs, I can
say that there is distribution of those funds across the
country. They are not centrally located in one geographical
area versus another.
We have an equal opportunity to submit for funding and we
are giving funding preference if those areas are rural and they
are underserved. So I would say that these programs are
reaching underserved areas.
Dr. Goodell. Yes, there are a number of excellent models of
how you can extend expertise over a wide geographic area.
A really interesting one in the realm of mental health and
primary care integration actually happened in Arizona. Now,
this was a program that was established to train psychiatric
nurse practitioners to deliver care in some of the rural and
remote areas.
They developed field placements for these folks so they can
go out and be part of their communities. And then also, while
they were there, they utilized video link technology to do case
conferences and ongoing training. A really powerful model,
again, that is getting people in the communities where they
need to be doing the work they need to do.
The Project ECHO for opioids that was in New Mexico was the
first one studied. A 10-year study of that program showed that
New Mexico, after that program was running, had the fastest
growing rate of physicians that were able to provide medication
associated treatment for opioid use disorders.
A really powerful model and a great way to leverage
technology to get more people the care they need.
Senator Kaine. Thank you.
Thanks, Mr. Chairman.
The Chairman. Thank you, Senator Kaine.
Senator Collins.
Senator Collins. Thank you, Mr. Chairman.
First, let me apologize to the witnesses. I have been in
and out because we have an Appropriations subcommittee meeting
going on at the same time.
The Chairman. One of these witnesses has a Maine
background.
Senator Collins. Really? I did not know that.
The Chairman. I think Dr. Phelan.
Senator Collins. Dr. Phelan does? Well, as luck would have
it, all of my questions are directed to you. So there must have
been this sort of a mind merge here.
[Laughter.]
Senator Collins. First, let me thank the Chairman and
Ranking Member for holding this very important hearing on
developing the workforce to care for both an aging America and
a rural America.
In Maine, we are reaching that aging milestone faster than
most states. Within the next 2 years, our seniors will
outnumber our children, 15 years ahead of the national
projections. Much of Maine is also rural, so this hearing
really hits home on both of these fronts.
Yesterday, I introduced a bill with Senator Casey, the
Geriatrics Workforce Improvement Act, which would reauthorize
the GWEP programs and reinstate the Geriatric Academic Career
Awards program.
Obviously, we want to build a workforce to provide
geriatric care and ensure that older adults, and their families
in rural America, are provided with the resources that they
need to care for aging loved ones.
I would ask unanimous consent that there be two letters of
support entered into the record. It is from the National
Association for Geriatric Education and the National
Association of Geriatric Education Centers.
The Chairman. So ordered.
Senator Collins. Thank you, Mr. Chairman.
My question for you, Dr. Phelan, could you expand on why it
is critical to infuse geriatrics training across health
professions and in settings of care?
Dr. Phelan. I would be glad to. Thanks for that question.
For pretty much every health care provider in practice,
unless he or she is a pediatrician, he or she will encounter an
older adult as part of their day to day practice. And having
the basic understanding of how caring for older adults differs
from care of people who are younger is very critical to making
safe choices about treatment, and also understanding with
aging, changing functional and health status, the role of
patient preferences in care decisions.
Senator Collins. One of the main metrics for gauging our
progress in developing a health care workforce to care for
older adults is a certification in geriatrics. But when you
look across the health care professionals, I believe it is
fewer than 1 percent of physicians and registered nurses are
certified in geriatrics. So the vast majority of practitioners
do not obtain that broad certification.
Should we look at other metrics to show progress in
improving our readiness to care for an aging population?
Dr. Phelan. I think patient level outcomes, like what we
are in the process of measuring through the Geriatrics
Workforce Enhancement Centers, would be one way to go with
that. So actually looking at the level of, for example,
prescribing practices, safe prescribing practices, numbers,
rates of hospitalizations related to falls. Those are all
important outcomes that should be measurable.
Our Geriatric Workforce Enhancement Centers could partner
to collect data to measure common outcomes that really do make
a difference in terms of older adults' health and well-being.
Senator Collins. Thank you. And let me just remind you that
it rains far less often in Maine than it does in Washington
State.
[Laughter.]
Senator Collins. It is much sunnier, brighter, and we would
welcome you back.
Dr. Phelan. Thank you.
The Chairman. Thank you, Senator Collins.
Senator Smith.
Senator Smith. Thank you, Senator Alexander. And thank you,
also, Ranking Member Murray.
I have been so excited about this hearing because these
issues are just uppermost in the minds of so many Minnesotans.
Just a week or so ago, Senator Heitkamp and I did a
roundtable on the challenges around rural health right in
Breckinridge, Minnesota, which is right on the border between
North Dakota and Minnesota. We were talking about these exact
same issues.
What we heard there is many of the same issues we are
talking about, challenges in rural areas, treating older,
sicker people, also challenges around the opioid issues, and
drug issues, and mental and behavioral health generally. Also,
we heard a lot about the challenges of hospitals trying to keep
it all together, and then, of course, this workforce issue. So
I am just so appreciative of this.
One of the things that was a point that was made in
Breckenridge is how hard it is to recruit people, as you have
been talking about, all of you. And that there are auxiliary
factors related to recruiting that make it even more difficult.
If you are in a rural area and there is no childcare, how
are you going to be able to recruit people to come when you
have that challenge?
There is no broadband. Then the people are trying to figure
out, especially if you have couples, spouses that want to move
together, how to make that work in a family when that is not
what you are used to. And then, of course, just the challenges
that hospitals have recruiting people who need to work
different hours.
I would just really appreciate if you could, in your
experience, talk a little bit, Dr. Sanford or any of you,
really talk about how you see that and what you have seen that
helps us address those issues when it comes to recruiting.
Dr. Sanford. Well, thank you, Senator Smith, for the
question. I do see that as a problem, and it is a challenge
that we all work very hard to address.
One of the things that we are doing at J.M.U. is we just
recently were awarded a Title VIII Nursing Workforce
Development Grant. We are going to be partnering with our rural
health clinics in Page County. So we are going to
longitudinally put pre-licensure B.S.N. nurses in every health
care facility in that county.
We are very excited about the program because we think that
having that partnership over a period of time will encourage
our nurses to want to go into the community in the rural
settings to make a difference.
I think that, as we have said before, taking the programs
to the residents in those areas is really important and
impactful as well.
Senator Smith. Yes, thank you.
Does anyone else want to comment on that? Dr. Goodell, you
look like you have something to say. I was curious.
Dr. Goodell. One of my favorite programs that I found out
about, as I was preparing for this hearing, is the Family
Medicine Residency of Western Montana, so a different state, I
know.
That is a prefect example of how Federal funding through
typical Medicare pathways and then the types of programs that
we are talking about that are HRSA-supported work together to
produce really good outcomes.
The Family Medicine Residency of Western Montana is a new
program. It was started in 2013 and it has the goal of
producing rural physicians. And, in fact, the residency is
located in an area that is so rural, it is not even designated
as rural. It is designated as frontier. So far, 90 percent of
their graduates continue to work in these rural areas. So that
is a huge success.
Now, another thing that they have done is they have pulled
together these community hospitals that are hundreds of miles
apart and they have created a network between the community
hospitals. Turns out, each of these hospitals was doing
specific things really well, but they did not really have any
way to communicate.
They put their residents in the middle as the communicators
and assigned their residents to do improvement projects at
these different hospitals.
With the residents as the glue and a couple of meetings a
year, and lots of video links, they were able to learn from
each other. The residents were able to learn how to do
improvement projects, and they got that meta message that, ``By
the way, taking care of your system and making sure that it is
progressing and getting better and better is part of your
job.''
That is an example of the multipronged approach that we
need to adopt if we are going to make these sorts of
improvements, especially in rural areas.
Senator Smith. Right. It is not just one thing that you do.
You have to do a multitude of things.
In Minnesota, the University of Minnesota Duluth has a
really excellent medical school that focuses on training
physicians who are prepared to serve in rural areas. It is only
60 people in a class. I do not know how that compares to the
big medical schools, but I am suspecting it is a lot smaller.
It works because the students who go there connect to the
community. They connect to the fieldwork that they do, and then
more than half of them stay, which is, I think, what we are
trying to achieve.
Thank you very much.
The Chairman. Thank you, Senator Smith.
Senator Hassan.
Senator Hassan. Well, thank you, Senator Alexander and
Ranking Member Murray for having this hearing.
Thank you to our panelists for just excellent testimony and
for the work you do.
I am the mom of a young man who is approaching his 30th
birthday, who happens to experience very severe cerebral palsy
and a whole bunch of related conditions that come with that.
I have observed over the course of his lifetime, he lives
at home supported with an awful lot of direct care, but also at
home because of medical technology and pharmaceuticals that we
did not have a generation or two ago.
I am always reflecting on the fact that the model of
training and workforce deployment that we have--and the kind of
conditions that patients now have and the settings in which
they are living their lives--are somewhat misaligned. We have
more people with severe disabilities, more people who are
aging, and we also have some different kinds, now, of diseases
like opioid use disorders that we are trying to treat.
What this hearing, to me seems more than anything to be
about is really how we let our deployment models catch up to
the population we are really trying to treat and the settings
that they all live in.
I have three questions about that, that I probably will not
get through all three, but let me start, Dr. Sanford, with you.
In your testimony, you describe a new grant that James
Madison University was just awarded relating to the nursing
workforce. It is a partnership to educate baccalaureate
prepared nurses to work in community settings to address the
opioid crisis.
Rivier University, a school in Nashua, New Hampshire, just
received a Title VIII Nurse Education, Practice, Quality, and
Retention grant for the upcoming fiscal year. The goal of
Rivier's grant is similar to a grant you described in your
testimony, to prepare nurses to go into careers in community-
based primary care settings to help them address the opioid
epidemic.
One aspect of Rivier's grant is to increase nursing
students' clinical rotations in primary care settings.
In your experience, how has exposure to community settings
changed the ability of nurses to be ready to care for patients
and families impacted by public health crises like opioid
addiction?
Dr. Sanford. Thank you, Senator Hassan, for the question.
In my experience, whenever we have clinical rotations in
community settings, it exposes our nursing students to the
opportunities that, sometimes, they do not consider. A lot of
times when we are going through acute care facilities for our
clinical, they think of nursing as being in the hospital, but
we all know that health care is shifting out into the
community, and more and more needs are in the community.
Partnering with rural health clinics, partnering with
critical access hospitals is very important as we look at
training the next generation of nurses. Anecdotally, students
tell us that if they have strong preceptors, preceptor training
is important as well.
Senator Hassan. Right.
Dr. Sanford. If they have strong preceptors, that will
impact the choice of where they choose to practice.
Senator Hassan. Excellent. Well, thank you for that answer
and thank you for your work.
Dr. Phelan, in your testimony, you discussed the work of
the Northwest Geriatrics Workforce Enhancement Center. While
your main focus is on training for primary care providers in
geriatrics, you also mentioned that workers on the, quote,
``Frontlines of hands-on daily care include family caregivers
and home care workers.''
In New Hampshire, it is estimated that 70 to 80 percent of
paid hands-on care for older adults and individuals who
experience disabilities is provided by direct care workers,
including personal care aides, home health aides, and nursing
assistants.
The demand for direct care workers is expected to increase
49 percent between now and 2022, further exacerbating a
workforce shortage that already exists in many communities
across the country.
Beyond high quality primary care, we know many individuals'
long term success in the community hinges on the direct support
that they get at home.
Dr. Phelan, drawing from your experience with geriatric
workforce initiatives, what can Congress do to support the
recruitment, training, and retention of high quality, direct
care workforce now and in the future?
Dr. Phelan. Part of the issue is, again, fundamentals,
making sure that those individuals are well-prepared for the
position that they are seeking to fill.
Senator Hassan. Yes.
Dr. Phelan. Direct care workers, as you say, are at the
frontlines doing hands-on daily care for people who are at
home, living with chronic illnesses, if they are elderly, often
with dementia.
There are competencies around care, for example, of a
person with dementia and understanding of their particular
health risks and safety concerns that are necessary and
integral to preparing a homecare worker to be there and be that
person, that one-on-one person on a daily basis.
One of the ways that we are currently doing this through
the Geriatrics Workforce Enhancement Programs, at least
speaking of our GWEP in Washington, is we are taking the
broadest view of who is primary care. We are including home
care workers as part of our audience for training.
Just recently, we have a program called Full Life, which is
an adult day health program in western Washington. Adult day
health is an entity similar to daycare for children, except it
has more of a health orientation and its audience is older
adults or people living at younger ages with disabilities in
the community.
The staff of Full Life is now participating in a number of
our training activities that we offer so that they are getting
the same exposure to the geriatrics competencies that, say, the
family medicine residents that we are reaching across the
family medicine residency network are getting.
Senator Hassan. Thank you very much.
Thank you, Mr. Chairman, for allowing me to go over.
The Chairman. No, thank you, Senator Hassan.
I am struck by the obvious here, which you seem to agree,
that maybe the best way to locate medical professionals in
underserved areas is to train them where they live.
I think of a visit I made recently to the Lewis County
Community Health Center, a county of 12,000 in Tennessee. They
had a big fight. They decided they could not support a
hospital, but they have a terrific, clean, open community
health center that everybody can go to; one doctor, two nurse
practitioners. It is open, from my guess, like 7 in the morning
until 8 or 9 at night.
They estimate they can deal with about 90 percent of what
comes in the door, and the rest goes 45 miles away, and the
open heart surgery goes to Vanderbilt, which is 60 miles away.
Now, in that county, that is one doctor, two nurse
practitioners, 12,000 people. The estimate, according to
National Rural Health Association is 39 primary care doctors
for every 100,000 people. There might be two or three other
doctors in Lewis County, but there are probably not many. There
are 10,000 community health centers.
I guess, first, in terms of nurses, then in terms of
doctors, how can we be more aggressive here appropriately
without interfering too much in the practice of medicine to
encourage more clinical training where you live and where you
might practice?
I think of a restaurant, a large restaurant company where
the CEO said that he wanted the headquarters to be thought of
as a service center, and the headquarters were really the
restaurants. I would think that maybe the community health
centers, of which there are 10,000 in the country, could be the
headquarters and the training hospitals could be the service
centers.
What can we do to aggressively do that? I would think it
might be easier with nurses and nurse practitioners than it
would be with physicians because there would be a resistance, I
would think, from the medical centers to losing too much
control over the training.
What works best? Dr. Sanford, let us start with you.
Dr. Sanford. Well, I will share, Senator Alexander, and
thank you for the question, I will share that we have a
community health center, a federally qualified community health
center in Harrisonburg, Virginia and they are gracious, and
they have our nurse practitioner students, and we do training
in that area.
What is so wonderful for our nurse practitioner students is
most of them choose to work in rural and primary care.
The Chairman. But that is just one center. But could they
work in all the centers in Virginia and still be affiliated
with you?
Dr. Sanford. Absolutely, because we have some distance
components. We have students all over Virginia. They are not
just in Harrisonburg.
The Chairman. How long is your training? Two years?
Dr. Sanford. Two years, right, full time.
The Chairman. Two years.
Well, how much of the time could they spend in a clinical
setting out of your hospital? I guess that is where you train
people?
Dr. Sanford. Well, there are different kinds of nurse
practitioners and we have a family nurse practitioner program
that is primary care focused, so all of their clinical is in
primary care. So the federally qualified health centers or
community health centers, they could spend almost 100 percent
of their clinical in those settings.
The Chairman. What percent of their total time with you is
clinical? What percent of the 2-years could they be out in the
rural area?
Dr. Sanford. Sure. It is roughly about 16 months of the 2-
years.
The Chairman. That much?
Dr. Sanford. Yes, so nurse practitioners, the wonderful
thing about nurse practitioners is that they often choose to go
into primary care in underserved areas.
The Chairman. You would agree that that turns out to be,
just in terms of human nature, a very strong way to populate
underserved areas?
Dr. Sanford. Yes, sir.
The Chairman. Dr. Goodell, what about doctors? How do you
get them out of the university center? How much of their time
can be spent in underserved areas and still get the proper
training at the hospital?
Dr. Goodell. Yes, so there are actually a number of models
looking at this and several of them actually come from the
Midwest, Upper Midwest where the big medical schools--and this
is at the student level rather than residents--but big medical
schools now have specific programs that focus on rural primary
care training.
The students will do their classroom work, which is the
first year and a half, sometimes two yeas, in the big medical
school with all their classmates. And then a select few
students, who apply to this program, do most of their clinical
work out in much more rural settings.
Just as we see happening in other kinds of training
programs later on, they build relationships with those folks.
They come to feel comfortable and they like it there.
The Chairman. That would be the third and the fourth year
of medical school, basically?
Dr. Goodell. Yes. Usually there is clinical basics, like a
clinical skills training course that happens in the first year
or two of medical school, and so some of these programs have
their students doing that initial clinical training. It is like
1 day a week, often, and they will do that in a rural area, but
then a lot of their time is in the classroom.
Then for their third year, which is really the core
clinical training, they will spend all or part of that, again,
out in a community health center or several of their rotations
are made to be longitudinal and so they go there for months at
a time.
The Chairman. But it seems like it would be important not
just to have a single clinical health center, because the idea
would be to get them to a place where they might stay.
Dr. Goodell. That is right. And actually, most of the
programs that I am aware of have several different options. So
students will elect to do the rural track, and then there are a
number of different site placements in addition to Wisconsin
and Minnesota, I know they have the same thing in Maine that is
affiliated with Tufts Medical School.
The Chairman. How much of their 4 years in medical school
might they spend in that sort of clinical setting outside of
the university hospital, say?
Dr. Goodell. Let us see, I would say maybe it is 10 percent
in the first 2 years, average, and then maybe a third of the
time of their second 2 years.
The Chairman. Then during the residency, how much time
could they spend?
Dr. Goodell. Residency totally depends on where they match.
And so, that is a whole separate endeavor.
The Chairman. Yes.
Dr. Goodell. You apply to all these programs. And then
residency programs, you can either work in a teaching health
center, which is, by definition, outside of a hospital. Or,
much more commonly, you are affiliated with a big university
hospital and then sometimes, but much, much less frequently,
you have the option to do some rural training.
Looking at models, and these are the innovative models
where you have your longitudinal continuity clinic in a more
rural setting, is an innovative idea to do that. But I do not
know of specific programs where they have done that yet to
produce rural physicians.
The Chairman. Thank you.
Senator Murray.
Senator Murray. Thank you, very much, Mr. Chairman.
We spend a lot of time talking about rural underserved
areas. It is critically important. Good testimony. But I wanted
to focus on something else and that is workplace diversity.
We know that while people of color represent more than 25
percent of our population, they represent only 10 percent of
health professionals. That lack of diversity is really
important to address because we know having a diverse workforce
improves patient satisfaction, patient-clinician communication,
and access for people who are minorities. There are some really
devastating health disparities in our country today.
For example, black women are three to four times more
likely to die in childbirth than white women.
I think it is really imperative that Congress prioritize
efforts to improve workforce diversity. Our 2018 spending bill
increased funding for programs that provide scholarships and
supports recruitment and training of minority students to join
the health care workforce. But I really believe Congress has to
do more.
Dr. Goodell, let me start with you.
How can we leverage our workforce programs to better
address the health disparities that I talked about?
Dr. Goodell. You are absolutely right. If we are going to
reduce health disparities in this country, it is essential that
we diversify the physician workforce.
Probably the biggest way to do that is by focusing on
pipeline programs like the Health Careers Opportunities
program.
I recently was at a medical conference, and I met some
students and their mentor from a program in the Bronx. This was
a program that was located in a community health center. It was
started by a family physician for students in that community.
And these are students who are in college or college graduates
who are potentially interested in health professions.
The students in this program sign up. They commit to a
certain number of volunteer hours. I want to say it is 100
volunteer hours over either a semester or a year. They also get
one-on-one mentoring to figure out how to apply to go to
graduate school. They get help with their entrance exams.
Moreover, they get a really good community that supports them
through that process.
Applying to graduate school and the health profession is a
relatively grueling enterprise. If you come from a community
where you are the first person that ever went to college, you
do not have anybody around telling you how to do it and kind of
commiserating with you over your long nights.
This program has done that for these students. They have,
so far, a 93 percent success rate in getting their students
into medical school. I am the Dean of Admissions. It is 40
percent nationwide.
I met five of these students. Three of them had gotten into
medical school already. Two of them are applying this year. I
gave both of them my card. These are students that are people
of color. They have been living in the Bronx. They are
socioeconomically disadvantaged. They did not go to Ivy League
colleges, Bronx Community College, other places like that.
These are exactly the students that we need to be focusing on.
We need a lot more programs like that that help train up
students and support them so we can get them into the school
where they need to be so they can provide care.
Senator Murray. Dr. Sanford, do you want to comment?
Dr. Sanford. I would like to add some information from a
nursing perspective. One-third of graduate students are from
diverse backgrounds who are nursing students. So we are really
excited about the progress we have made in nursing. We have a
ways to go.
But we have also, in nursing, been focused on holistic
mission processes. This has helped us increase our diversity.
And also, we have pipeline development programs in nursing that
are similar that my colleague is speaking to, and those
pipeline programs are supported by Title VIII Nursing Workforce
Development program.
I would say that the impact of the Title VIII Nursing
Workforce Development program is very important for diverse
clinicians in helping us with increasing patient outcomes.
Senator Murray. Thank you.
Thank you to all of our witnesses. A really good hearing
today.
Mr. Chairman, I look forward to working with you on this
Committee on addressing this. Thank you.
The Chairman. Thank you, Senator Murray.
Thanks to all three of you for your time, and your good
advice, and for being here today.
Our hearing record will remain open for 10 days. Members
may submit additional information within that time, if they
would like.
Our Committee will meet again tomorrow, Wednesday, May 23
at 10 a.m., for an executive session to vote on the Pandemic
and All-Hazards Preparedness and Advancing Innovation Act.
Thank you for being here.
The Committee will stand adjourned.
[Whereupon, at 11:30 a.m., the hearing was adjourned.]
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