[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
                                
                                
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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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

                              ----------                              

                               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.
---------------------------------------------------------------------------
               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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