[Senate Hearing 118-187]
[From the U.S. Government Publishing Office]
S. Hrg. 118-187
EXAMINING HEALTH CARE
WORKFORCE SHORTAGES:
WHERE DO WE GO FROM HERE?
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING HEALTH CARE WORKFORCE SHORTAGES
__________
FEBRUARY 16, 2023
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
54-460 PDF WASHINGTON : 2024
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
BERNIE SANDERS (I), Vermont, Chairman
PATTY MURRAY, Washington
ROBERT P. CASEY, JR., Pennsylvania BILL CASSIDY, M.D., Louisiana,
TAMMY BALDWIN, Wisconsin Ranking Member
CHRISTOPHER S. MURPHY, Connecticut RAND PAUL, Kentucky
TIM KAINE, Virginia SUSAN M. COLLINS, Maine
MAGGIE HASSAN, New Hampshire LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota MIKE BRAUN, Indiana
BEN RAY LUJAN, New Mexico ROGER MARSHALL, M.D., Kansas
JOHN HICKENLOOPER, Colorado MITT ROMNEY, Utah
ED MARKEY, Massachusetts TOMMY TUBERVILLE, Alabama
MARKWAYNE MULLIN, Oklahoma
TED BUDD, North Carolina
Warren Gunnels, Majority Staff Director
Bill Dauster, Majority Deputy Staff Director
Amanda Lincoln, Minority Staff Director
Danielle Janowski, Minority Deputy Staff Director
C O N T E N T S
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STATEMENTS
THURSDAY, FEBRUARY 16, 2023
Page
Committee Members
Sanders, Hon. Bernie, Chairman, Committee on Health, Education,
Labor, and Pensions, Opening statement......................... 1
Cassidy, Hon. Bill, Ranking Member, U.S. Senator from the State
of Louisiana, Opening statement................................ 4
Witnesses
Herbert, James, Ph.D., President, University of New England,
Biddeford, ME.................................................. 6
Prepared statement........................................... 9
Hildreth Sr., James E.K., Ph.D., M.D., President and CEO, Meharry
Medical College, Nashville, TN................................. 20
Prepared statement........................................... 22
Summary statement............................................ 27
Szanton, Sarah, Ph.D., RN, FAAN, Dean, Johns Hopkins School of
Nursing, Baltimore, MD......................................... 28
Prepared statement........................................... 29
Summary statement............................................ 31
Seoane, Leonardo, M.D., FACP, Chief Academic Officer, Ochsner
Health, New Orleans, LA........................................ 32
Prepared statement........................................... 34
Summary statement............................................ 41
Staiger, Douglas, Ph.D., Professor, Dartmouth College, Hanover,
NH............................................................. 42
Prepared statement........................................... 44
Summary statement............................................ 47
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.
Casey, Hon. Robert:
Statement for the Record..................................... 79
19 Stakeholders, Statement for the Record.................... 83
Kaine, Hon. Tim:
Johnson & Johnson, Statement for the Record.................. 81
QUESTIONS AND ANSWERS
Response by James Herbert to questions of:
Sen. Paul.................................................... 258
Sen. Tuberville.............................................. 259
Response by Sarah Szanton to questions of:
Sen. Paul.................................................... 261
Sen. Tuberville.............................................. 262
Response by Leonardo Seoane to questions of:
Sen. Paul.................................................... 263
Sen. Tuberville.............................................. 264
Sen. Budd.................................................... 266
EXAMINING HEALTH CARE
WORKFORCE SHORTAGES:
WHERE DO WE GO FROM HERE?
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Thursday, February 16, 2023
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10 a.m., in room
430, Dirksen Senate Office Building, Hon. Bernard Sanders,
Chairman of the Committee, presiding.
Present: Senators Sanders [presiding], Murray, Baldwin,
Murphy, Kaine, Hassan, Smith, Lujan, Hickenlooper, Markey,
Cassidy, Paul, Collins, Murkowski, Braun, Marshall, Romney,
Tuberville, and Budd.
OPENING STATEMENT OF SENATOR SANDERS
The Chair. The Senate Committee on Health, Education,
Labor, and Pensions will come to order. As I have mentioned
before, and as everybody knows, this Committee covers a huge
gamut of issues that impact the American people. And the
reality is, as everybody knows, that there are going to be some
issues where there are going to be very strong disagreements,
and we will simply agree to disagree and hopefully do that in a
respectful way.
There are going to be other issues, however, that impact
every state in this country where in fact there should be
strong bipartisan support. And the issue we are discussing
today is one of those issues. Let me just start off my remarks,
then I'm going to give the mic over to Senator Cassidy, and we
will have questions, and everybody will have their time.
But let me start off by telling you what the panelists
certainly know, and we thank all of them for being here today,
and every Member here knows, and that is the United States will
face a shortage of up to 124,000 physicians by 2034, including
48,000 primary care physicians. By 2025, the United States will
have a shortage of up to 450,000 nurses.
Right now, and this is an issue we don't discuss much as a
Nation, and I intend to see this Committee discuss it, we need
approximately 100,000 more dentists across the United States.
We have a major crisis in terms of access to dental care in
Vermont, and I expect every state in this country.
The number of people who live in areas without enough
health care providers, I think will use the word health care
deserts since it is the common term used, 99 million primary,
70 million dental, 156 mental health, which everybody in this
Committee knows is a horrendous crisis in America.
Here is my hope, my hope that we can do what the pundits
tell us that we can't do, and that is actually deal with the
issues facing the American people in a serious, nonpartisan way
because these issues impact every state in America. I want to
thank our excellent panelists. I read the testimony and I thank
you all for being here.
Let me begin by saying that it is no secret to anyone that
our Country faces many health care crises. Despite spending
almost twice as much per capita on health care as any other
major country, we spend $13,000 per person, man, woman, and
child on health care, we have massive shortages in health care
providers.
Today, we are going to focus on that crisis. And that is
that we simply do not have in our Nation enough doctors,
nurses, nurse practitioners, dentists, dental hygienists,
pharmacists, mental health providers, among other medical
professions. And what is the impact of those health provider
shortages? What does it mean to ordinary people?
It means that nearly 100 million of our people live in a
primary care desert, where they are unable to gain timely
access to a doctor when they need it. It means that nearly 70
million people live in a dental care desert, unable to get
dental care while teeth in their mouths are rotting.
It means that some 158 million Americans, nearly half our
population, live in a mental health care desert at a time when
this country is facing an unprecedented mental health crisis.
Simply put, it means that a significant percentage of our
population live in places where they cannot access the health
care they desperately need in a timely manner.
Got to tell you, bumped into some people in Vermont, and we
do better than most states, I think. A guy goes in, he wants a,
just a checkup. Four months later, he will get that checkup.
That is in Vermont. In my view, the reality is, this reality is
a contributing factor to the declining life expectancy we are
seeing in many parts of our Country and the fact that our
overall life expectancy is lower than many, many other
countries.
Life expectancy, as I think we all know, is not simply a
factor of access to health care. Deals with economics, a lot of
other things. But access to health care is an important part of
why people are living shorter lives.
Here is a point that you are going to hear me make over and
over again, and that is that not only does the lack of medical
professionals in many parts of this country lead to increased
human suffering and unnecessary death, it is incredibly
wasteful from a financial perspective.
If people cannot access a primary care doctor, they may end
up in an emergency room, which is the most expensive form of
primary health care. Somebody goes to a community health
center, somebody goes to an emergency room. Going to the
community health center is 1/10th the cost to Medicaid than
going to the emergency room.
If their illnesses continue because they don't go to a
doctor when they should, they may end up in a hospital running
up tens of thousands or hundreds of thousands of dollars of
unnecessary expenses if they got the treatment that they needed
when they needed it.
Study after study shows that disease prevention saves
money. If people are able to access care when they need it, if
there are enough medical professionals to provide that care in
every part of this country, our health care costs go down.
A shortage of health care personnel was a problem before
the pandemic, and now it has gotten much worse. Health care
jobs have gotten more challenging and in some cases more
dangerous. Many thousands of our health care workers have died
from COVID, we all know that doctors, nurses, others, taking
care of the American people.
These are genuine heroes and heroines, and we owe them more
than we can ever pay back. According to the best estimates,
over the next decade, our Country faces a shortage of over
120,000 doctors, including a huge shortage of primary care
physicians. And our goal, as long as we get more doctors, is to
get them to the places where they are needed, often in rural
areas, in urban areas.
We don't need more folks on Park Avenue in New York City.
We need them in rural areas where people can't access a doctor,
in urban areas where the waiting lines are too long. Over the
next 2 years, it is estimated we will need up to 450,000 more
nurses. Today it is estimated we need 100,000 more dentists.
In America today, there is a massive shortage and we will
discuss this at length in another occasion, in terms of mental
health providers. and that is psychiatrists, psychologists,
social workers, counselors, addiction specialist, and many
more. In addition to our overall crisis in health care
providers, that problem is especially acute in minority
communities, and we are going to be discussing that today.
We desperately need more African American, Latino, and
Native American health care personnel who are way, way
underrepresented in the health care profession. How we address
these crises is the subject of today's hearing and of a lot
more future discussions that we will all be having.
But talk and hearings, frankly, are not good enough. Our
job is to get the best information we can as quickly as we can,
put that information into good legislation and to pass that
legislation. Let me very briefly talk about some of the
thoughts that I have, others who will have different thoughts.
First, it is a no brainer to understand that when over
100--over 10,000 medical school graduates are unable to fill
residency slots every year, we must significantly expand and
improve the graduate medical education program. That is not
within our jurisdiction. It is in the Finance Committee. But it
is something that we have got to look at.
Further, and in the jurisdiction of this Committee, we must
also greatly expand the teaching health center program, another
really good program that allows residents to work in community
health centers and in primary care. Very important.
Further, at a time when young people are graduating from
medical school, dental school, and nursing school deeply in
debt, everybody here has talked to graduates, doctors leaving
$400,000, $500,000 in debt.
It is pretty obvious that those people graduating with huge
debts are not going to go to rural America, not going to go to
urban America. They are going to go to places where they can
make a lot of money. And that is why we must substantially, in
my view, increase student loan debt forgiveness and
scholarships through the National Health Service Corps Program.
We have expanded that in recent years. We have got to do
more. Further in terms of nursing, boy, that is an issue that I
think impacts everybody. Despite a major nursing shortage, and
I will tell you in my own State of Vermont, and I talked to
Senator Collins about it, I think it is true all over this
country.
We in our hospital in Vermont are spending $125 million on
traveling nurses, an insane amount of money, and yet we have
young people in Vermont who want to become nurses. Our nursing
schools can't accommodate them because we don't have enough
teaching personnel or the kind of equipment that we need.
Totally crazy, and that is an issue I look forward to us
addressing. Well, that is about it for me. And you know, I want
to say also a word about emergency medical services. I know in
Vermont, rural areas, you got great people, often volunteers.
They have to pay for their own training. I hope that that is an
issue we deal with as well.
Bottom line is, look, we have an issue that the American
people want us to resolve. It should be a bipartisan issue. I
intend to work with Republicans and Democrats to make sure that
we get good legislation through. Senator Cassidy.
OPENING STATEMENT OF SENATOR CASSIDY
Senator Cassidy. Thank you, Mr. Chairman. The COVID-19
pandemic has strained our health care system. It has placed a
huge burden on health care workers. So, as we come out of the
pandemic, this hearing is to address workforce issues. Why are
there still shortages post-pandemic? Which are most pressing?
And how do we get the understanding to address it? There is an
old saying in internal medicine, don't just do something,
think.
We must first think about what we should do. Now,
physicians in hospitals in Louisiana tell me they need nurses.
And speaking as a physician who had the great fortune to work
with many incredibly talented nurses, they are essential. Goes
without saying. There are different things we can do.
I am going to use an example of a woman I once worked with
to explain the concept of upskilling. Linda started off in the
clinic as a Medical Assistant. She kept going to school and got
her LPN. Kept going to school and got her BSN. Kept going to
school and got her masters, and at the end was the Nurse
Manager in the clinic in which she had begun as a Medical
Assistant. That is upskilling.
Along the way she improves her family, helps patients, but
demonstrates for her children the power of education and the
power of delayed gratification. There is a lot in that story
that can inform what we should be doing on national policy. And
Linda, you know who you are, wherever you are, I am talking
about you.
Now, something that is--by the way, this is not all
Federal. We know that there is a shortage of nurse educators.
But when you look at the requirements in some states, mine
included, you have to have a master's of nursing to be a nurse
educator. Now, I have worked with certificate nurses who have
been by the bedside for 20 years who knew nursing. The idea
that we cannot use someone such as she in order to educate
others, I think doesn't acknowledge how much she knows.
This is a way to remove a choke point which is preventing
all these applicants from having more slots in which to go to
fill our nursing shortage. Now, I agree with the Chair. We can
and should work in a bipartisan way to address nursing shortage
and other shortages aside from nursing.
My hope for this hearing is to identify those other
providers and those areas, as the Chair mentioned, such as
rural areas that have critical workforce needs. But why don't
we use the workforce we have more efficiently? I say that
because there was a recent study, just before the pandemic, in
the Annals of Internal Medicine that found that physicians
spend as much as 16 minutes per patient filling out the
electronic health record.
Now speaking to my colleagues, many of them retire early
because they are sick of that. It is a major cause of burnout.
So that which has been implemented by the urging of the Federal
Government is creating the problem of physician workforce
shortage.
For the patient, it is a difference between having a
physician type on a screen as he tells you that you have cancer
or looking into your eyes and telling you that you have hope.
We need to give that physician the ability to communicate hope.
This is something this Committee can look into, understand, and
address.
On a larger scale, the Federal Government invests billions
toward health care workforce programs. We need to continue to
support what is working, understand what is not, and fix that
which is broken.
We have to be good stewards of the taxpayers' dollars, not
wasting money. We have to be productive. This year, the
Committee is tasked with extending mandatory funding for
programs like the National Health Service Corps, which offers
loan repayment and scholarships to health care providers in
exchange for working in a health professional shortage area.
And the Teaching Health Centers Graduate Medical Education
Program, which supports the cost of training medical and dental
residents in outpatient settings.
Additionally, we are tasked with reauthorizing the
Children's Hospital Graduate Medical Education Program set to
expire this year. This program, this legislation supports
training of pediatrician and pediatric subspecialists, noting
that nearly half of all pediatric residents train at a
children's hospital.
It is important that the funding for these programs is
extended on time, in a bipartisan fashion, and that it be paid
for. Finally, I know today's witnesses have innovative ideas on
how hospitals and academic institutions can support the
pipeline of health professionals.
One of my witnesses will speak directly to that. The
Federal Government does not play the only role in seeking a
solution to workforce shortage. We need to hear the perspective
of these experts as we bolster America's health care workforce
moving forward, and while doing so, just like Linda, create
more opportunity for the individual. Thank you.
The Chair. Thank you, Senator Cassidy. We have a great
panel of witnesses, and I thank them all for coming.
Our first witness will be Dr. James Herbert, and I first
met Dr. Herbert when Senator Collins brought him to a hearing
that we did. I would like Senator Collins to introduce him.
Senator Collins.
Senator Collins. Thank you so much, Mr. Chairman. I am
delighted to introduce Dr. James Herbert, President of the
University of New England, located in Biddeford and Portland,
Maine.
Dr. Herbert has served as President of UNE since 2017. As
the Chairman has indicated, he offered extraordinarily
insightful testimony before the Primary Health Subcommittee in
2021, and I thank the Chairman and the Ranking Member for
inviting Dr. Herbert back to testify today.
UNE is one of a handful of private universities with a
comprehensive health education mission, including medicine,
pharmacy, dental, nursing, and an array of allied health
professions. UNE ranks in the top 20 of medical schools
nationally for educating primary care physicians, particularly
those trained in rural medicine.
UNE is the largest provider of health professionals to the
State of Maine, the only medical school in our state, and
offers Northern New England's only dental college. Dr. Herbert
holds a doctorate and master's in clinical psychology from the
University of North Carolina at Greensboro, and a B.A. in
Psychology at the University of Texas at Austin.
Dr. Herbert, welcome back. I have appreciated your many
insights that you have shared with me, and I am delighted that
the Chairman and Ranking Member have invited you to return and
share those insights with the Full Committee. Thank you, Mr.
Chairman.
STATEMENT OF JAMES HERBERT PH.D., PRESIDENT, UNIVERSITY OF NEW
ENGLAND, BIDDEFORD, ME
Dr. Herbert. Thank you so much, Senator Collins. Thank you
very much, Chairman Sanders and Ranking Member Cassidy, and
other Members of the Committee for inviting me to speak with
you today.
As the Senator said, my name is James Herbert. I am from
the University of New England in Maine. I won't repeat who we
are because Senator Collins just told you. Thank you very much.
I would stress that we consider ourselves a private university
with a public mission, and we are very proud of that public
mission.
As you probably all know, Maine is the oldest state in the
Nation. We have one of the oldest health care workforces, and
we are tied with Vermont being the most rural state in the
Nation. The challenges that we face today in Maine are
harbingers of what the rest of the country will increasingly
confront as our Nation ages and as urbanization creates pockets
of underserved populations, not only in our cities, but also in
our vast rural areas.
I won't detail the shortage of health care professionals.
Senator Sanders has done that very nicely, and I know you all
appreciate the scope of the problem. What I would like to do
today is to briefly outline six specific strategies that I
believe can go a long way to address this crisis.
At UNE, we are attempting to address each of these
strategies. I don't pretend that we have all the answers, but
we have found that what is critical to moving the needle are
strategic partnerships between higher education, Government,
business, nonprofits, and philanthropy. And it is that
partnership that allows us to move forward.
First and most fundamentally, we must increase the number
of doctors, nurses, and other health care professionals that we
educate. But educating more professionals is not as
straightforward as it might seem. The biggest challenge is the
limited availability of clinical training opportunities.
As financial margins have tightened and clinician workloads
have increased over the past three decades, practicing
clinicians have less time to train students. The single most
important thing we can do to increase the number of health care
providers is to support partnerships between universities, and
community, and health care entities to develop additional
clinical training opportunities.
This includes revision of the Center for Medicare and
Medicaid Services' antiquated policies around funding graduate
medical education, which Senator Sanders touched on. Tuition
for many healthcare professional programs is high and can be an
impediment to many students. I assure you this is not because
greedy universities are trying to get rich on the backs of
students.
Rather, the cost of educating students has skyrocketed.
Just for example, in our case, the costs of training third-and
fourth-year medical students has increased fivefold since I
assumed this position in 2017. Scholarship and loan repayment
programs are critical to make health care education more
accessible to those who would otherwise find it out of reach.
As Senator Sanders mentioned, the National Health Service
Corps is one example of such a program, but it is simply
inadequate in many ways to meet current needs. Another barrier
that has been mentioned is the difficulty in hiring and
retaining qualified faculty members who can typically earn more
in the private sector in direct or indirect clinical settings
than at universities.
Support such as that displayed by Senator Collins and
Sanders and others for a strategic health care faculty loan
repayment programs is critical to ensuring the future of the
health care workforce. So, the second thing we must do is to
intentionally recruit more students who look like the
communities that they serve.
It is well-established that individuals from
underrepresented groups are more likely to seek needed health
care services from practitioners who share their identities and
backgrounds.
Third, it is not enough merely to train more professionals.
As Senator Sanders mentioned, we must address their
maldistribution in society. That is, we must encourage them to
practice in underserved areas following graduation, such as in
tribal and rural and medically underserved communities.
Like Maine, most states have vast rural areas of
distributed population, and these communities have far less
access to health care. Financial support in terms of loan
repayment programs, strategic loan repayment programs to
practice in underserved areas is critical, and I thank
Congressional leadership for their ongoing support.
But these programs are currently insufficient. In the case
of physicians, for example, the loan repayment subsidies don't
compensate for the typical salary gap between rich urban and
suburban communities on the one hand and underserved urban and
rural communities on the other.
Fourth, we must leverage the power of technology to reach
underserved communities. Telehealth and digital medicine have
tremendous potential to help in this regard. Fifth, we need
changes to state level regulations to allow health
professionals to practice at the top of their scope of
practice.
Across the U.S., many states have laws that prevent some
health care professionals from providing services that they are
perfectly trained and able to provide. Many states made
temporary changes to increase the flexibility during the
pandemic, and such flexibility should be continued.
The focus of scope of practice regulation should be on what
level of regulation results in the best outcomes in terms of
health care safety of the population, and not managing guild
driven turf wars between professionals. Sixth, and finally, the
most fundamental change. We must fundamentally change the
prevailing educational model in two ways.
First, accrediting bodies need to allow training programs
to be more creative and innovative and flexible, without
sacrificing educational quality, to adopt new models. This
includes so-called career laddering, opportunities that don't
completely remove professionals from the workplace as they are
training to upskill.
Accrediting bodies should also accept more high-quality
clinical simulation hours in place of hours physically spent in
clinical settings, and that reduces the burden on hospitals
that I touched on earlier. The second educational reform, and I
will conclude, involves breaking down the traditional silos
that characterize health care training and practice.
Anyone who has recently been in a hospital or has cared for
a loved one in a hospital understands how siloed the practice
of health care tends to be. In response, an educational model
has emerged in which students are trained to work together in
multidisciplinary teams, and this is known as interprofessional
education.
This model is shown to improve outcomes, improve patient
satisfaction, decrease medical errors, and decrease provider
burnout. So, in conclusion, successfully addressing America's
health care workforce crisis will require not merely acting on
each of these individual initiatives in isolation, but in
strategically combining them.
I am grateful for your time and consideration. Thank you.
[The prepared statement of Dr. Herbert follows:]
prepared statement of james herbert
Thank you, Chairman Sanders, Ranking Member Cassidy, and other
Members of the Committee for the opportunity to speak with you today.
It's an honor to share some thoughts on strategies for addressing our
Nation's healthcare workforce crisis.
My name is James Herbert, and I am the president of the University
of New England (UNE). UNE is Maine's largest private university, with
campuses in Biddeford and Portland Maine and in Tangier Morocco. We are
a comprehensive university that houses Maine's only medical school and
only physician assistant program, and northern New England's only
dental school. We're the largest provider of healthcare professionals
to the State of Maine, \1\ and we take great pride in being a private
university with a public mission.
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\1\ UNE offers programs in 14 health professions, including
osteopathic medicine, dental medicine, pharmacy, physician assistant,
nursing, nurse anesthesia, dental hygiene, occupational therapy,
physical therapy, social work, nutrition, athletic training, applied
exercise science, and public health.
As you probably know, Maine's population is the oldest in the
nation \2\ and is tied with Vermont as being the most rural \3\ state.
Our healthcare workers are also among the oldest in the country, with
many practitioners approaching, or even practicing beyond, retirement
age. \4\ The challenges we face are in some sense harbingers of what
the rest of the country will increasingly confront as our Nation ages
and as urbanization creates pockets underserved populations in our
cities as well as in our vast remote rural areas.
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\2\ Maine has the highest median age in the U.S.: 44.7 years
relative to the national average of 38.8 (U.S. Census Bureau, 2022). At
21.3 percent Maine also has the highest percentage of citizens over 65
in the U.S. (U.S. Census Bureau, 2019b).
\3\ U.S. Census Bureau, 2019b
\4\ At 39.3 percent, Maine ranks first in the Nation for the
percentage of active physicians who are age 60 or older (AAMC, 2021).
In 9 of16 Maine counties, 50 percent or more of physicians are 55 or
older (Skillman & Stover, 2018). Over 50 percent of Maine's registered
nurses are 50 or older (Maine Nursing Action Coalition, Center for
Health Affairs NEONI, 2017).
I won't detail the growing shortage of healthcare professionals
across our Country, as I'm sure you already appreciate the scope of the
problem. Rather, I will offer six specific strategies that I believe
can go a long way to addressing the crisis (these are summarized
briefly in Appendix A). I will also offer some examples of how we at
UNE are attempting to implement each of these strategies. This is not
to imply that we've figured out all the best solutions, but rather to
provide some specific examples of how higher education can partner
productively with the government, business, and nonprofit sectors to
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move the needle in important ways on this critical problem.
First, and most obviously, we must increase the number of doctors,
nurses, and other healthcare professionals we educate to address our
growing population, aging workforce, and many underserved communities.
But educating more professionals is not as straightforward as it may
seem; we at universities face a number of barriers in doing so. I will
briefly touch on the three most important of these challenges.
By far the most important impediment to training more healthcare
providers is the availability of clinical training experiences in
hospitals and clinics, which has been well documented by the Department
of Health and Human Services Health Resources and Services
Administration (HRSA). \5\ As financial margins have tightened and
clinician workloads have increased over the past three decades,
healthcare facilities and practicing clinicians have fewer resources
and less time to devote to training students. \6\ The single most
important thing we can do to increase the number of healthcare
providers is to support and expand partnerships between universities
and community healthcare settings to develop additional residencies,
clerkships, practica, and other training opportunities. In medicine in
particular, the Center for Medicare and Medicaid Services' (CMS)
payment system for graduate medical education (GME; i.e., physician
residencies) favors academic medical centers, places caps on successful
rural residency programs making expansion difficult, and penalizes
community hospitals that may have previously partnered with other
institutions. In other words, CMS policy is antiquated and makes it
very difficult to grow more residency placements. \7\
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\5\ U.S. Congress: Advisory Committee on Interdisciplinary,
Community-Based Linkages. (2018).
\6\ Benbassat, 2020; Cox & Desai, 2019; Hanna, 2019; Hatfield et
al., 2022; Graziano et al., 2018; Konrad et al., 2010; Krehnbrink et
al, 2020; de Villiers et al., 2018; Rodriguez, 2013
\7\ CMS policies for GME have established caps on most existing
residency programs and although CMS created a somewhat circuitous
pathway for rural hospitals to expand beyond their cap, the criteria of
the review committees of the Accreditation Council on Graduate Medical
Education (ACGME) create significant obstacles to accredited expansion
and the creation of new rural residency programs.
At UNE, one way we have expanded clinical training opportunities is
by working with partners in rural and underserved primary care sites
and federally Qualified Health Centers. One advantage of such
placements is that students learn how to deliver compassionate care to
Maine's most vulnerable residents, many of whom are uninsured and also
navigate chronic physical and mental health conditions. The precepting
clinicians in these settings are dedicated to treating underserved
patients, sometimes with limited access to specialized professional
support. \8\ These settings afford students exposure to a broad range
of conditions and allow them to perform and assist with a wide variety
of procedures.
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\8\ Hempel et al., 2015; Lee et al., 2016.
Clinical training opportunities are not the only infrastructure
limitation to producing more healthcare professionals. Cost, both to
educational institutions and to students themselves, is also a factor.
Standing up new educational facilities, or expanding existing ones,
involves considerable startup costs. One-time governmental support is
often needed to supplement institutional investments and philanthropy.
\9\
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\9\ An example of an effective public-private partnership is UNE's
establishment of our College of Dental Medicine. Recognizing the
region's significant unmet oral healthcare needs and the fact that
there was no dental school in all of northern New England, in 2013 we
partnered with both Federal and state governments, regional industry,
non-profits, and philanthropists to establish a dental school. Senator
Collins was critical in helping to secure Federal support for that
project. And the people of Maine passed a $3.5 million bond to support
not only creation of the school itself, but also community dental
clinics around the state to help them increase their capacity to
provide dental care and to take our students on rotation. The school
was created with an explicit focus on addressing underserved
populations.
Tuition for many programs is high and can be an impediment for many
students, especially those from poor, working class, or even middle-
class backgrounds. Contrary to certain narratives, this is not because
greedy universities are trying to get rich on the backs of students.
\10\ Rather, the costs to educate students have risen considerably. For
example, the cost of training third-and fourth-year medical students
has increased fivefold since 2017. Scholarship and loan repayment
programs can make healthcare education accessible to those who would
otherwise find it out of reach. The National Health Service Corps is
one example of such a program; however, it is inadequate to meet
current needs in many ways. Only a limited number of professions are
covered, the competition is high with many applicants being turned
down, the scholarship or loan reimbursement amounts are inadequate, and
the kinds of eligible sites (FQHCs, tribal clinics, etc.) are too
limited.
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\10\ An exception being certain predatory foreign medical schools,
particularly in the Caribbean, that cater to American students who
cannot gain entry into domestic medical schools and which charge
exorbitant tuition.
A third barrier to training more healthcare professionals is the
difficulty hiring and retaining qualified faculty members, who can
typically earn more in direct care clinical settings and yet require a
higher level of training and credentialing than those working
clinically. \11\ Support such as that displayed by Senators Sanders,
Collins, and others for strategic loan repayment programs targeting
those assuming faculty positions in health professions is critical to
ensuring the future of the healthcare workforce. Loan repayment
programs improve access to graduate/doctoral education by encouraging
qualified individuals to advance their education and subsequently
become employed as faculty. \12\ Title VIII programs, such as the
Nursing Workforce Development Programs, are an example of an important
step in addressing this issue.
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\11\ Christmas et al., 2010; Feldman et al., 2015; Girod et al.,
2017; Nauseen et al., 2018
\12\ The case of dentistry is illustrative of the problem. The
number of dental school graduates entering an academic career
immediately following graduation is quite low. For the Class of 2022
graduates responding to the American Dental Education Association
Senior Survey, 0.7 percent (13 of the 1,757 respondents) indicated they
plan to work as a faculty/staff member at a dental school after
graduation (Istrate et al., 2022). An additional consideration is that
most dental schools provide little exposure to academic careers. At
UNE's College of Dental Medicine (CDM), dental students may participate
as teaching assistants, tutors, peer mentors in the simulation and
patient care clinic, or conduct research with faculty to be exposed to
elements of an academic career. To date, out of six graduating classes,
five alumni have returned to teach as part-time adjunct faculty in the
CDM, one is an adjunct faculty in UNE's dental hygiene program, one
recently joined the CDM as a full-time faculty member, and eight serve
as preceptor faculty at CDM clinical affiliation sites where fourth-
year students complete community-based externship rotations.
In addition, in some cases practicing clinicians can be recruited
to serve as faculty instructors in their existing workplaces. For
example, we have developed a new accelerated nursing program, in which
existing employees of Maine's largest healthcare system are trained
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onsite by a combination of our own faculty and hospital clinicians.
Despite these challenges, at UNE we continuously seek to increase
the number of health profession students we educate. For example, we
have increased the size of our nursing program 300 percent over the
last decade, and we have a grant under review with the U.S. DOL to
further bolster our nursing training. We are currently in the process
of increasing the class size of our medical students from 165 to 200
per year, our dental students from 64 to 72 per year, and our graduate
registered dietician program from 80 to 100 per year. And with these
increases we remain focused on quality training, as evidenced by the
fact that our students routinely score above the state and national
means on clinical board exams, and our medical students have among the
highest residency match rates in the Nation.
The second strategy for addressing the Nation's healthcare
workforce involves intentionally recruiting and training more students
who look like the communities we need to serve. It is well established
that individuals from underrepresented groups are more likely to seek
out practitioners who share their identities and backgrounds. \13\
Studies have found that minority patients who are treated by race/
ethnic-concordant clinicians are more likely to use needed health
services and are less likely to delay seeking care. \14\
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\13\ LaVeist et al., 2003; Shen et al., 2018; Takeshita et al.,
2020
\14\ Handtke et al., 2019; LaVeist & Nuru-Jeter, 2002; Saha et
al., 2000;
In Maine, we have a growing immigrant population, especially from
Central and Eastern Africa, and not surprisingly, this community
experiences significant healthcare discrepancies relative to the
broader population. \15\ To address this issue, not only has UNE
increased recruitment efforts targeting students of color across the
entire university, we recently expanded our ``Advanced Standing''
programs in dentistry and pharmacy, which are designed to accelerate
the time it takes for foreign-trained immigrant professionals to
achieve a U.S. degree and become eligible for licensure. We have also
developed partnerships with local community colleges to matriculate
students from our immigrant communities into certain healthcare
programs (e.g., dental hygiene). \16\
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\15\ Drewniak et al., 2017
\16\ National Academies of Sciences, Engineering and Medicine,
2021.
Third, it's not enough merely to train more healthcare
professionals, we must address their maldistribution within our
society. That is, we must encourage healthcare providers to practice in
underserved areas, including rural, tribal, and medically underserved
urban communities. Like Maine, most states have vast rural areas with
highly distributed populations, and these communities have far less
access to healthcare. \17\ The U.S. Government has invested in
programs, administered through the Health Resources and Services
Administration, that provide financial support in the form of loan
repayment to graduates who serve in disadvantaged areas. These programs
are absolutely critical, and we thank Congressional leadership for
their ongoing support. However, they are insufficient. For example, in
the case of physicians, the loan repayment subsidies do not compensate
enough for the typical salary gap between rich urban and suburban
communities and underserved urban and rural areas. \18\
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\17\ The U.S. Department of Health and Human Services has
designated nearly 248 geographic areas in Maine as health professional
shortage areas for primary care, dental health, and mental health, as
of December 31, 2022 (Maine Center for Disease Control & Prevention,
2023). Maine also has 51 medically underserved areas/populations,
defined as areas having too few primary care providers, high infant
mortality, high poverty, and/or a high elderly population. Nearly all
of Maine's medically underserved areas are in Maine's Congressional
District Two, the second most rural congressional district in the
country (U.S. DHHS, 2019).
\18\ In addition to scholarship and loan repayment programs,
revisions to Medicaid reimbursement schedules are needed to meet the
needs of rural populations and to incentivize clinicians to practice in
these areas. Rural populations tend to be more reliant on Medicaid to
pay for healthcare. In the case of dentistry, for example, coverage and
reimbursement rates vary by state. The low reimbursement rates and
cumbersome preauthorization and claims processes deter many
practitioners from accepting Medicaid insurance.
The paucity of physicians and other healthcare providers practicing
in rural areas is particularly acute, fueled in part by the decline of
students from rural backgrounds pursuing healthcare education. \19\ At
UNE, we have successfully used a three-prong strategy to encourage our
graduates to practice in rural areas. We intentionally recruit students
from rural areas, both from Maine and around the country. Students from
small towns and other nonurban areas are more likely to return to such
communities after graduation. \20\ Regardless of where they come from,
we place students in clinical training sites in underserved rural areas
as part of their education to give them a taste of rural practice and
lifestyle. Each year, many graduates exposed to these crucial settings
during rotations return for employment, inspired by the commitment to
quality patient care they witnessed, as well as their love of small-
town life. \21\ For example, between 2013 and 2019 up to 53 percent of
our medical students who completed a rotation in a rural community
hospital in Maine returned to those areas to practice regardless of
where they did their residency or where they were originally from. Our
experience is consistent with research demonstrating a direct
relationship between exposure to rural settings in physician residency
training and subsequent work in rural communities. \22\
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\19\ Shipman, S. (2019)
\20\ American Academy of Family Physicians, 2016; Hu et al., 2022;
Lee et al., 2021; University of Wisconsin, 2020;
\21\ UNE's dental school clinical model is an excellent example of
success in this regard. UNE places students in up to two 12-week
clinical rotations in settings throughout northern New England, working
in collaboration with a network of FQHCs, non-profit clinics, and
private dental offices. Students provide billable services while
receiving supervision from the preceptor and most importantly, learning
about the community they serve. We are grateful for the U.S. Department
of Health and Human Services' on-going funding to Maine's network of
health centers providing access to many of our marginalized residents,
while also offering much-needed clinical placements to students.
\22\ Russell et al., 2022.
Finally, in concert with state and philanthropic partners, we have
developed loan repayment and scholarship programs to incentivize
practice in rural settings. These efforts have paid off; over the past
decade we have made dramatic inroads in addressing the needs of rural
communities. For example, 40 percent of UNE medical school graduates
who practice in Maine do so in health profession shortage areas (HPSAs)
designated by the U.S. Government, positively impacting the HPSA
designation of five counties. \23\ And in our dental school's first six
graduating classes (2017--2022), we educated 377 dentists, 27 percent
of whom are currently practicing in Maine. Of those practicing in
Maine, 57 percent are practicing in a Dental Health Professional
Shortage Area (HPSA), 47 percent are enrolled as MaineCare providers or
are in a practice that accepts MaineCare, and 17 percent practice in a
FQHC or non-profit clinic. \24\ Nearly one in five is employed in a
federally Qualified Health Center, a non-profit community clinic, or
the Veteran's Administration, and four in ten are practicing in Maine's
most disadvantaged areas. \25\
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\23\ NCAHD's Enhanced State Licensure Data, 2016; The Robert
Graham Center, 2012.
\24\ Department of Professional and Financial Regulations, Maine
Board of Dental Practice: Provider directory; Maine Care Services,
Provider directory; Health Resources & Services Administration, Find
shortage areas; National Plan Provider and Provider Enumeration System,
NPPES NPI registry.
\25\ This is particularly noteworthy given that Maine has the
second fewest (just ahead of New Hampshire) dental providers
participating in Medicaid or CHIP in the entire country, according to
the American Dental Association's Health Policy Institute (2019).
The fourth strategy for addressing the healthcare workforce crisis
involves technology. Specifically, we must leverage the power of
technology to reach underserved communities. The COVID-19 pandemic
introduced many Americans for the first time to the value of
telehealth, as we all learned to access healthcare providers via
videoconferencing. \26\ Telehealth and digital medicine have enormous
potential to transform healthcare delivery, particularly in underserved
areas. \27\ In addition to patients accessing their providers through
secure videoconferencing platforms, primary care providers in remote
locations can themselves access specialist colleagues in urban tertiary
care hospitals and university health centers for expert consultation.
And emerging digital medicine and artificial intelligence technologies
will increasingly allow clinicians to monitor patient symptoms and even
deliver certain treatments remotely over the internet. These
technologies can also enhance the education of students in health
profession programs but also the reach and effectiveness of continuing
medical education programs. At UNE, we are integrating robust
telehealth training for all of our health profession students in close
partnership with our various training sites.
---------------------------------------------------------------------------
\26\ Wosik et al., 2020
\27\ Kichloo et al., 2020
Fifth, changes to state level regulations that allow health
professionals to practice at the top of their scope could help address
health care workforce shortages. ``Scope of practice'' defines what
services or procedures a particular type of health professional is
trained for and is legally permitted to provide. Across the U.S., many
states have scope of practice laws that prevent some health
professionals from providing certain services even though they are
trained and prepared to do so. Temporary changes to increase
flexibility of such regulatory practices were made in many states
around the country during the pandemic to help address the pandemic
related workforce crisis. Continuing such flexibility should be
seriously considered. The focus when it comes to developing scope of
practice regulation should be on what level of regulation results in
the best outcomes in terms of health and safety of the population, not
on managing guild-driven turf wars between professions at the ``edges''
of their scope of practice. Overlap and redundancy between professions
---------------------------------------------------------------------------
is a good thing, especially during times of workforce shortages.
Sixth and finally, we must fundamentally change the prevailing
educational model in two ways. First, accrediting bodies need to allow
training programs to be more creative and flexible_without sacrificing
educational quality of course_to develop novel training models. This
would include so-called ``career laddering'' opportunities that do not
completely remove the individual from the workforce while they are
pursuing an advanced degree, such as a physician assistant or nurse
practitioner becoming a physician, a dental hygienist becoming a
dentist, or a certified nursing assistant becoming a registered nurse.
In addition, accrediting bodies should accept more high-quality
clinical simulation hours in place of hours physically spent at
clinical sites, thereby reducing the burden on clinical sites.
The second educational reform involves breaking down the
traditional siloes that characterize healthcare training and practice.
Anyone who has recently been a patient in a hospital, or who has cared
for a hospitalized loved one, understands how siloed the practice of
healthcare tends to be. Far too often, healthcare professionals are all
practicing their respective crafts with scant communication and
coordination among themselves. This siloed practice is a result, at
least in part, of the traditional discipline-centered model of
educating healthcare professionals. In 2001, the Institute of Medicine
issued a groundbreaking report, Crossing the Quality Chasm: A New
Health System for the 21st Century, which laid out the case for
dramatic, systemic changes to health care organization and delivery. In
response, stakeholders from academia, health systems, and government
convened to determine how best to address the Institute's
recommendations. In 2012, these efforts led to the development of a new
educational model in which students from diverse disciplines are
explicitly trained to work together, across traditional boundaries, in
multi-disciplinary teams. Known as ``interprofessional education'' \28\
or ``IPE'' for short, this training model prepares students with team-
based competencies, attitudes, and skills that complement distinctive
disciplinary knowledge. Interprofessional health care teams offer more
than any one discipline can achieve alone, and this is especially
critical as patients' health conditions are becoming increasingly
complex. \29\ Growing evidence suggests that interprofessional
collaborative practice \30\ improves clinical outcomes, \31\ reduces
medical errors, \32\ increases patient satisfaction, \33\ and decreases
provider burnout. \34\
---------------------------------------------------------------------------
\28\ Interprofessional Education occurs when two or more
professions learn about, from, and with each other to improve
collaboration and the quality of patient care.
\29\ Mayo & Williams-Woolley, 2016
\30\ According to the World Health Organization, interprofessional
collaborative practice happens when multiple health workers from
different professional backgrounds work together with patients,
families, care givers, and communities to deliver the highest quality
of care (World Health Organization, 2010)
\31\ Lutfiyya et al., 2019
\32\ Anderson & Lakhan, 2016; Hardisty et al., 2014; Irajpour et
al, 2019; Lygre et al., 2017; Wilson et al., 2016
\33\ Will et al, 2019
\34\ Cain et al., 2017; Dow et al., 2019
The IPE training model, especially when paired with digital health
technologies, can be instrumental in meeting the needs of underserved
communities. \35\ The combination of IPE and telehealth allows doctors,
mid-level clinicians, and other primary care practitioners to
effectively expand their scope of practice, while also extending
specialist care to those for whom it is otherwise out of reach.
---------------------------------------------------------------------------
\35\ One particular area of healthcare that exemplifies the value
of this kind of collaborative approach is geriatrics. Diseases of aging
often encompass a broad scope of conditions and disciplines: heart
disease and diabetes treated by primary care practitioners; mobility
issues by physical and occupational therapists; isolation by social
workers; oral health by dentists and hygienists, and so on. At UNE, we
weave training in geriatrics throughout all of our health profession
programs. Thanks to legislation sponsored by Senator Collins and
supported by Maine's Junior Senator Angus King, and working closely the
University of Maine and multiple statewide partners, UNE is one of 48
organizations nationally to have received funding through HRSA's
Geriatrics Workforce Education Program, which aims to create a more
age-friendly health system by transforming primary care practices and
engaging and empowering older adults.
At UNE, we have been pioneers in IPE over the past decade for all
our healthcare programs. We are currently constructing a new health
sciences training facility on our Portland campus, which will serve as
the new home of our medical school. By co-locating all of our health
profession programs on a single site, we will be able enhance our
---------------------------------------------------------------------------
training of students in this collaborative, team-based model.
In conclusion, successfully addressing America's healthcare
workforce crisis will require not merely acting on each of these six
strategies in isolation, but seamlessly integrating them. Although
strategic investment of resources will be required, much of the work we
confront reflects cultural changes that will require strong leadership,
a willingness to innovate, and coordinated partnership between
academia, government, industry, and the nonprofit sector.
I am grateful for the Committee's time and attention, and
appreciate your efforts to address our Nation's healthcare workforce
crisis. Thank you.
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Appendix A
Table 1
Summary of Recommendations
Increase the number of Increase the number of doctors,
healthcare professionals nurses, dentists, and other healthcare
professionals we educate by: (1)
expanding partnerships between
universities and community healthcare
settings to develop additional
training opportunities; (2) revise
antiquated CMS policies for funding
GME; (3) providing targeted one-time
investments in expanding healthcare
training infrastructure; and (4)
strategic scholarship and loan-
repayment programs, including those
supporting clinical educators to
increase faculty
Representation 1ntentionally recruit and train more
students who look like the communities
they serve
Maldistribution of providers Use a variety of tools to encourage
healthcare providers to practice in
underserved areas, including rural,
tribal, and medically underserved
urban communities
Technology Leverage the power of technology,
including telehealth and digital
medicine, to reach underserved
communities
Scope of practice Modify state level regulations to
allow health professionals to practice
at the top of their scope
Flexibility of educational Encourage accrediting bodies to allow
models training programs to be more creative
and flexible (without sacrificing
educational quality) to develop novel
training models including ``career
laddering'' opportunities that do not
completely remove the individual from
the workforce while they are pursuing
an advanced degree
Interprofessional Education Promote Interprofessional Education
(IPE) training models to break down
traditional healthcare training and
practice siloes
______
Appendix B
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
______
The Chair. Dr. Herbert, thank you very much. Our next
witness is Dr. James Hildreth, who is President and CEO of
Meharry Medical College, the largest private, independent,
historically black academic health sciences center.
Dr. Hildreth was the first African American Rhodes Scholar
from Arkansas, and he holds a Ph.D. in Immunology from Oxford
University. Dr. Hildreth, thanks so much for being with us.
STATEMENT OF JAMES E.K. HILDRETH SR., PH.D., M.D., PRESIDENT
AND CEO, MEHARRY MEDICAL COLLEGE, NASHVILLE, TN
Dr. Hildreth. Thank you, Chairman Sanders, Ranking Member
Cassidy, and Members of the Committee for inviting me to give
testimony today about our Nation's shortage of health care
providers where we need the most, in the field of primary care,
especially in communities without a doctor or nurse or
physician to treat the sick in those communities.
There are many reasons we--our Country is full of medical
specialists but woefully lacking in primary care professionals.
But in the time allotted me today, I would like to talk about
ways to solve the problem and perhaps to solve it very quickly.
I am the proud President of Meharry Medical College, as you
heard.
We are the Nation's four historically black academic health
science centers. We were originally founded to train students
that the white medical system refused to train in order that
those students might treat patients that the white medical
establishment refused to treat.
Our purpose remains essentially the same today. A majority
of the students that we attract come to us to learn primary
care, and they intend to serve in places often ignored by
mainstream medicine.
I am proud to say that 80 percent of our graduates do go on
to serve the underserved. In other words, we already trained
exactly the professionals this country so desperately needs.
The majority of our students do not have to be incentivized to
switch from lucrative subspecialties to practice primary care.
They are fully committed to working in rural communities
and urban health care deserts. In many cases, their
determination is borne out of personal experience. They have
watched a family member die of untreated diabetes or some other
chronic disease.
They have suffered themselves from a lack of access to
wellness checks, common in American communities. I know what
drives them, I am one of them. I was born in rural Arkansas in
the 1950's and watched my father die of cancer because no one
would or could care for him.
I have been trained at the world's most elite institutions,
Harvard, Oxford, Johns Hopkins, yet I choose to lead Meharry
Medical College because Meharry graduates and their
counterparts at Howard, Morehouse, and Drew choose to care for
people like my father, poor blacks, poor whites, poor
Hispanics, poor Native American people who deserve to be
healthy just like the rest of us.
I submit to you that the Consortium of Black Medical
Schools already has the necessary history, structure, deep
relationships for community organizations dedicated to
eradicate health disparities, and we have the credibility
within disenfranchised communities to help alleviate the
shortage.
We have been working for decades to increase the pipeline
of minority health care workers in our Country. We are already
partnering with industries to support the education of minority
physicians, dentists, nurses, researchers, and public health
professionals. We work with neighborhood, middle, and high
school students to introduce them to science and medicine.
At Meharry, we are grateful to Governor Bill Lee and the
leadership of the State of Tennessee for supporting a program
we put in place to fast-track undergraduate students in the
medical school who are committed to serving in rural areas in
the State of Tennessee. But there is no simple solution to the
health care shortage, and it is going to take a variety of
initiatives to solve the problem.
The HBCU Medical School Consortium is well poised to lead
the effort, but we need your help. We have done this work for
generations, even though we have been woefully underfunded.
Because of my 30 plus years at prestigious majority
institutions, I am fully aware of how the Federal Government
sometimes choose to allocate funds to institutions that are
deemed uniquely qualified to solve certain problems facing the
Nation.
Today, I submit to you that HBCU medical schools are
uniquely poised to solve this problem. We ask your help in
doing so. Specifically, we ask for $5 billion over the next 5
years to improve our infrastructure, the labs, the simulation
centers, the study spaces, the classrooms at our institutions
that have been egregiously underfunded for decades.
This would also allow us to dramatically expand our
pipeline programs that are meant to get more minorities in
health care professions. These funds, while they are certainly
significant, are a mere drop in the bucket compared to other
budget items and will pay media dividends to quickly expand the
pipeline and close to health disparity gap.
We also ask that Medicare's GME policy be amended to give
expanded consideration to hospitals that train a large share of
graduates from black medical schools. Finally, we ask for your
support to ease the debt burden of students coming from poor,
working-class families whose hard-earned health care,
especially primary care.
Our students who come from lower income households often
graduate with hundreds of thousands of dollars of debt. This
debt burden can be a deterrent from entering primary care, and
we need those folks in the game and we need them right away.
Our graduates are ready. They are willing. They are
desperately needed. Our nation's HBCU medical schools have
trained them well. We know how to reach others who want to
serve just like they do.
Let's do everything in our power to break down barriers
standing in their way so that America can benefit from the care
they will provide and reduce the barriers to care in the United
States. Thank you, Mr. Chairman.
[The prepared statement of Dr. Hildreth follow:]
prepared statement of james e.k. hildreth
Chairman Sanders, Ranking Member Cassidy, and Members of the
Committee, thank you for the invitation to discuss the implications,
both immediate and long-term, that the health care workforce shortage
has on our Nation and, in particular, to communities of color and
growing segments of the population located in rural and underserved
areas.
Before I begin, I'd like to thank Chairman Sanders for his work to
significantly expand the National Health Service Corps, Community
Health Centers, and Teaching Health Centers to hire more doctors and
nurses of color to underserved areas and boost the Teaching Health
Center Graduate Medical Education program to help train more African
American primary care physicians. We have a number of Meharry students
who are participants in the National Health Service Corps. I'd also
like to thank Senator Cassidy and other Members of the Senate for
passing the John Lewis National Institute on Minority Health and Health
Disparities Research Endowment Revitalization Act. This important
legislation will provide critical funds to Historically Black Colleges
and Universities (HBCUs) to conduct research into and to address
minority health disparities.
This important conversation about the effects that the health care
workforce shortage has on health care, health outcomes, and thus life
opportunities of a growing segment of the U.S. population could not be
coming at a more appropriate time. It is certainly not lost on me that
we are addressing this critical topic both during Black History Month
as well on the 20th anniversary of the National Academy of Medicine's
landmark report, ``Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care'', a report that highlighted the startling
fact that across similar income and education levels, insurance status,
age and even disease type and severity, racial and ethnic minorities,
when compared to their white counterparts, often are diagnosed later,
and consistently have less access to the most advanced care and
treatments, suffer worse health outcomes, and die prematurely. What a
fitting time to draw attention to and call for action on the effects of
our health care workforce shortage on inequities in health care and on
health outcomes.
I have been trained at--and served on the faculty of--some of the
world's most prestigious institutions of higher learning. I chose to
take the helm at Meharry because of the populations it exists to serve.
The reason is because my life--like the lives of so many trained by
Meharry and other HBCU academic health science centers--was shaped by
health care disparities.
Meharry was founded in 1876, made possible by a donation from a
young trader of Scots-Irish descent who was traveling one night through
rough terrain in Tennessee when his wagon became mired in a swamp. A
Black family came to his aid, giving him food and a place to sleep, and
helping him rescue his wagon the next morning. The man said, ``I have
no money, but when I can, I shall do something for your race.'' He was
as good as his word. In 1876, he and his brothers donated $15,000--a
significant sum at that time--to establish a medical school in
Nashville to train Black doctors the white medical establishment would
not train, in order to care for former slaves the white medical
establishment would not care for. The man's name was Samuel Meharry.
The name of the family that helped him remains unknown.
Meharry is the oldest and largest historically Black academic
health science institution in the Nation, dedicated to educating and
training exemplary primary care physicians, dentists, researchers,
public health professionals, and health policy experts. As times began
to change for the better in the mid-20th century and the American
medical establishment began accepting people of color into its ranks,
Meharry expanded and amplified its mission across its schools and
programs to train medical professionals to serve all of the
underserved--those in urban centers where the population is mostly
Black, in rural towns where the population is mostly white, in Latino
and immigrant communities, and on native American reservations. In
fact, four out of every five Meharry physicians and dentists work in
underserved rural and urban communities.
The Present Persistent Problem
Meharry has made major contributions to bolstering the medical,
dental, scientific, and public health workforce in America.
Approximately 14 percent of Black medical doctors, 27 percent of Black
dentists, and 15 percent of Black biomedical scientists in America
graduated from Meharry Medical College. Collectively, with other
historically Black health professions institutions across the United
States, we have educated and trained half of the Black physicians in
the country, half of the Black dentists, and 75 percent of the Nation's
Black pharmacists and veterinarians. No other set of institutions has
such an impressive legacy of accomplishment that is consistent with the
national goal of improving the health status of all population groups.
As we strive to continue to be the leading producer of diverse health
professionals committed to bolstering access to primary care,
eliminating health disparities in rural and urban communities, and
improving health care quality for all, it is not lost on me that we
have a long way to go to close the gaps in our health professions
workforce.
A 2021 article in the Journal of the American Medical Association
highlighted the dearth of underrepresented minorities in many of our
health diagnosing and treating professions. Consider, for example, that
while White Americans account for 68.7 percent of Dentists, Black,
Native American, and Hispanic Americans account for 4.4 percent, 0.1
percent, and 5.7 percent respectively. Comparatively, Black Americans
account for just 5.2 percent of physicians, with Native Americans
accounting, once again, for 0.1 percent and Hispanic Americans
accounting for 6.9 percent. This is in comparison to the 62.4 percent
of physicians that identify as White Americans. The lack of diversity
continues even when considering the other professions at a patient's
bedside. For example, while Black Americans account for 4.5 percent of
Physician Assistants, and Native and Hispanic Americans each account
for 0.5 percent and 7.3 percent respectively, the overwhelming majority
of Physician Assistants are White Americans, as represented by the fact
that they account for 75.9 percent.
The dearth of diverse health providers is associated with
significant disparities in health care access, quality, and treatments,
along with access to critical public health resources. According to the
Association of American Medical Colleges, ``If underserved populations
were to experience the same health care use patterns as populations
with fewer barriers to access, the United States would need an
additional 102,400 to 180,400 physicians.'' In addition, a recent
research brief by the de Beaumont Foundation found that in the wake of
the Covid-19
pandemic, in order to provide a minimum set of public health
services to the Nation, state and local governmental public health
departments need an 80 percent increase in their workforce. What this
percentage equates to in raw numbers, is a minimum of 80,000 more full-
time equivalent positions being required to provide adequate
infrastructure and a minimum package of public health services. This
reality is exacerbated by the fact that in the past decade alone,
state, and local health departments lost 15 percent of their essential
staff. Even further, while approximately 54,000 of the additional
positions that are needed should be deployed to local health
departments, and the remaining 26,000 to state health departments, it
is worth noting that the most acute needs are in local health
departments that specifically serve fewer than 100,000 people (de
Beaumont Foundation, 2021).
The Worsening Future Problem if We Don't Act Now
The United States is in the midst of a moment of heightened
awareness where greater attention is being paid to health inequities.
And so, I look forward to working with the Members of this Committee to
leverage this unique time in history to achieve health equity in a very
real and meaningful way, which requires our serious efforts to address
the health workforce shortage and the lack of diversity in the health
care and public health arena before things get worse. It is important
to remember that most of the recent statistics I just mentioned
happened against the backdrop of the ongoing COVID-19 pandemic and its
stark, disproportionate, and disparate impact on Black, Latino,
American Indian, Asian, Native Hawaiian, and Pacific Islander
individuals and communities. In general, low-income Latino families had
the highest numbers of full families in poor health, followed by Black/
African American low-income families (Braveman & Barclay, 2009).
It is hard for me to overstate the reality that these disparities
were brought to light as racial and ethnic minorities continued to
suffer from less access to affordable, quality health care, and
disproportionately higher rates of incidence and prevalence, as well as
premature death, across every chronic and acute disease and condition.
This includes cancers, diabetes, hypertension, heart disease, asthma,
depression and anxiety, and obesity, just to name a few. During the
pandemic, adults reporting symptoms of mental illness quadrupled, from
one in ten prior to four in ten. COVID exacerbated isolation and stress
for millions during a time when families and communities continued to
grapple with social justice issues and economic stress. This impact
affected Black, Latino, Native Americans, Native Hawaiians, Alaska
Natives, and Asian American adults at a much higher rate than Whites in
the United States owing to structural barriers to health care, public
health, family leave, and economic opportunity.
For example, today, the maternal mortality rate among Black women
is two to three times higher than that among White women. In fact, a
Black woman with an advanced degree is more likely to die from
pregnancy-related complications in the United States than a White woman
with only a high school degree. Unfortunately, their babies do not fare
much better: African American newborns, overall, are three times more
likely than White newborns to die. In some communities, the number is
even higher. Study after study confirms that racial and ethnic health
disparities and inequities are so pervasive that they have--in some
cases--widened over time and become the norm in the United States.
Further adding insult to injury is a report from the Commonwealth Fund
that found that racial and ethnic health inequities not only are
pervasive in this country, but some of the starkest and widest
disparities are actually in states known for having high performing
health care systems. However, according to a ground-breaking study, in
situations where the physician was Black, the infant mortality rates
dropped significantly.
These disparities carry a hefty economic cost. Research shows that
health disparities amount to nearly $93 billion in excess medical care
costs and another $42 billion in lost productivity each year (Laveist,
et al.., 2009). In a study led by one of our researchers at Meharry to
determine the economic burden of mental health inequities, the study
showed that over a 4-year period, $278 billion could have been saved
and reinvested into the economy, and over 116,770 lives could have been
saved had mental health inequities become more equitable--and this is a
conservative estimate (Dawes, et.al., 2022). Han & Ku (2019) reported
that over two-thirds of rural counties had no psychiatrists and almost
half of rural counties had no psychologists. Additionally, Deloitte
also released a major study showing that if we do not address health
disparities in the U.S. by 2040, the top five costly chronic diseases
today will cost us $1 trillion.
Consortium of Black Medical Schools Partnership
The historic halls of Meharry and its fellow HBCU medical schools
are replete with professionals who have experienced the systemic
problem of health disparities, have dedicated their careers to treating
this systemic problem, and are prepared to solve the systemic problems
relative to our national health care workforce shortage.
All four HBCU medical schools, including Meharry Medical College,
Howard University College of Medicine, Morehouse School of Medicine and
Charles R. Drew Medical School established the Consortium of Black
Medical Schools (CBMS) initially to address the COVID-19 crisis, by
providing expanded testing, contact tracing, surveillance, training of
front-line health workers, research & drug development, and policy
recommendations to address the unique needs of vulnerable, low income,
African American, and other underrepresented communities that
experienced disproportionate adverse outcomes due to the pandemic.
Meharry and the other HBCU medical schools are uniquely qualified
to address the shortage of health care professionals for this
population in a way that no others are. The Consortium brings together
the cumulative expertise of the four HBCU academic health science
centers in primary care and subspecialties which treat diseases that
account for the disparities heavily impacting disenfranchised
communities of all races and ethnicities. Together we have worked with
the White House, the Centers for Disease Control and Prevention, the
Department of Health and Human Services, state and local legislatures,
local health departments, faith-based organizations, and other
community stakeholders to reduce areas of disparity in vulnerable and
marginalized communities across the Nation.
The CBMS has the necessary history, organizational structure, deep
relationships with national and international organizations dedicated
to eradicating health care disparities, and credibility within
disenfranchised communities to scale up immediately and rapidly.
Crucially, Black health professionals are trusted in these
communities--trusted because we have always been there when others have
failed them, forgotten them, or, with the best of intentions,
misunderstood them and their needs.
As we have done this work, we also have been woefully underfunded
for generations. Because of my 30+ years of experience at prestigious,
majority institutions, I am aware of how Federal funding is allocated
to those who are deemed ``uniquely qualified'' to address a critical
national need. This is entirely appropriate when it makes the best use
of resources. And especially when and where a crisis is afoot.
We, the four HBCU medical schools, are asking for those same rules
to apply to our work. We are without a doubt ``uniquely qualified'' to
address this growing national health crisis.
We already are our Country's most reliable source for a well-
trained, diverse health care workforce. And the value of a diverse
workforce cannot be underestimated. Trust, cultural competency, and a
strong background in social determinants of health are as crucial
during these times as medical training. We must accept that, in order
to successfully treat at-risk African Americans and other vulnerable
populations, we must hire and deploy a workforce that is trained to
implement a care plan for individuals and communities that addresses
the social forces impacting and undermining their well-being.
Yet currently, HBCU medical schools--the most adept at training
such a workforce--face the challenge of expanding our number of
graduates in light of insufficient funding, an increasingly detrimental
predicament for everyone, especially in a country whose population is
ever-expanding and diversifying. A truly sustainable response to the
shortage of diverse health care workers must include strategies to
support HBCU medical schools.
To do this work, the CBMS requires an immediate infusion of
significant resources in order to scale up quickly, efficiently, and
comprehensively. The CBMS anticipates the cost to develop and implement
our plan will be $5 billion dollars over the next 5 years. We are well-
prepared and well-positioned to offer enormous benefit to the Nation at
comparatively little cost. We plan to use the infrastructure we build
to begin addressing the structural barriers to health in minority
communities. Our plan will therefore have benefits that should reduce
the overall cost of health care for the Nation.
Major Consortium Pipeline Initiatives
The Consortium is now leading the national drive for greater
pipeline diversity and is engaged in multiple initiatives to ensure a
more equitable health care workforce in the future. It has attracted
the interest and investment of $100+ million in public and private
funding to support current students, as well as longer term efforts to
educate, train and employ more Black health care workers. Notable
funders include the National Institutes of Health, Bloomberg
Philanthropies and Mackenzie Scott.
The Consortium convened a gathering of 166
representatives from 54 of the 99 HBCUs with undergraduate
programs to develop a cohesive and aggressive program to
increase the number of Black or African American health science
professionals and improve educational outcomes for both STEM
and humanities students to ensure health science workforce
diversity.
NFL Diversity in Sports Medicine Pipeline Project to
increase diversity in sports medicine by providing HBCU medical
schools the opportunity to complete a clinical rotation with
NFL club medical staff.
Chan Zuckerberg Initiative to advance genomics
research at the four medical schools by contributing $11.5
million per institution over the next 5 years.
Two-year $100 million award to the Consortium from
NIH's Advance Health Equity and Researcher Diversity (AIM-
AHEAD) program.
American Cancer Society's $12 million Diversity in
Cancer Research institutional advancement grants to fund a 4-
year program to increase the pool of minority cancer
researchers at the four HBCU medical schools.
Partnership between the Consortium, the Organ
Donation Advocacy Group and the Association of Organ
Procurement Organizations to initiate programs to increase the
number of U.S. Black organ donation and transplant
professionals across the Nation.
Beacon of Hope Partnership, a 10-year collaboration
of the Consortium, Novartis, Sanofi, and Merck, to create
programs that address the root causes of disparities in health
and education.
As I testify today, I think of Samuel Meharry. His gift in 1875 was
nominal relative to his total wealth. But he had been the beneficiary
of selfless compassion from an African American family. He gave in
order to allow that compassion to exert the maximum influence possible
during that time and in that world, where slavery had been abolished in
name only. I also think of my father, who--generations later--would
succumb to health care disparities as much as he succumbed to cancer. I
think of my mother, who urged me to respond by serving those who are
perennially left out and left behind. I think of Black physicians and
other professionals from the past who because of redlining and
structural racism could not build wealth for their families and
communities. I think of my colleagues across the Nation who could share
similar stories with you of family members and friends locked into
legacies of poor health.
For more than a century, the responsibility for educating Black
doctors, dentists, researchers, and health care professionals in the
U.S. has largely rested on the institutions dedicated to that purpose:
our Nation's four HBCU Medical Schools. Charles R. Drew University of
Medicine and Science in Los Angeles, Howard University College of
Medicine in Washington, DC, Meharry Medical College in Nashville, and
Morehouse School of Medicine in Atlanta have long prioritized the need
for more diversity in medical careers while other colleges and
universities ignored the issue. For years, we have worked individually
in our own communities and together, as a Consortium, on larger
initiatives in the United States and Africa to advance the diversity of
the workforce and the health of the patients they served.
We, the Consortium of Black Medical Schools, are ready. We only
need your endorsement and a modicum of the Nation's resources to make a
profound difference. Let us take our place in this fight. We already
are well-prepared and well-trained. But we must be well-armed. Please
arm us by supporting the policy recommendations outlined below. Thank
you for your time.
Policy Recommendations
$5 billion for infrastructure for Improving Research
and Development Infrastructure for academic health science
centers at Historically Black Graduate Institutions as defined
under Section 326(e) of Title III of the Higher Education Act.
$500 million to maintain and expand programs to
increase research capacity at minority-serving institutions (as
described in sections 371(a) and 326(e)(1) of the Higher
Education Act.
Amend/Expand the Medicare GME policy to add a
priority criterion for hospitals that have a sponsoring
institution for their GME programs that is a Minority-Serving
Institution (to include Historically Black Graduate
Institutions), as well as add ``non-contiguous area'' to the
``rural'' criterion.
______
[summary statement of james e.k. hildreth]
Meharry Background
Meharry is the oldest and largest historically Black academic
health science institution in the Nation, dedicated to educating and
training exemplary primary care physicians, dentists, researchers,
public health professionals, and health policy experts.
Meharry has made major contributions to bolstering the medical,
dental, scientific, and public health workforce in America.
Approximately 14 percent of Black medical doctors, 27 percent of Black
dentists, and 15 percent of Black biomedical scientists in America
graduated from Meharry Medical College.
Focus of Testimony
A 2021 article in the Journal of the American Medical Association
highlighted the dearth of underrepresented minorities in many of our
health diagnosing and treating professions. Consider, for example, that
while White Americans account for 68.7 percent of Dentists, Black,
Native American, and Hispanic Americans account for 4.4 percent, 0.1
percent, and 5.7 percent respectively. Comparatively, Black Americans
account for just 5.2 percent of physicians, with Native Americans
accounting, once again, for 0.1 percent and Hispanic Americans
accounting for 6.9 percent. This is in comparison to the 62.4 percent
of physicians that identify as White Americans.
These disparities carry a hefty economic cost. Research shows that
health disparities amount to nearly $93 billion in excess medical care
costs and another $42 billion in lost productivity each year (Laveist,
et al.., 2009). In a study led by one of our researchers at Meharry to
determine the economic burden of mental health inequities, the study
showed that over a 4-year period, $278 billion could have been saved
and reinvested into the economy, and over 116,770 lives could have been
saved had mental health inequities become more equitable. Han & Ku
(2019) reported that over two-thirds of rural counties had no
psychiatrists and almost half of rural counties had no psychologists.
Additionally, Deloitte also released a major study showing that if we
do not address health disparities in the U.S. by 2040, the top five
costly chronic diseases today will cost us $1 trillion.
Consortium of Black Medical Schools Partnership
For more than a century, the responsibility for educating Black
doctors, dentists, researchers, and health care professionals in the
U.S. has largely rested on the institutions dedicated to that purpose:
our Nation's four HBCU Medical Schools. Charles R. Drew University of
Medicine and Science in Los Angeles, Howard University College of
Medicine in Washington, DC, Meharry Medical College in Nashville, and
Morehouse School of Medicine in Atlanta have long prioritized the need
for more diversity in medical careers.
Meharry and the other HBCU medical schools are uniquely qualified
to address the shortage of healthcare professionals for this population
in a way that no others are. The Consortium brings together the
cumulative expertise of the four HBCU academic health science centers
in primary care and subspecialties which treat diseases that account
for the disparities heavily impacting disenfranchised communities of
all races and ethnicities.
Recommendations to Senate Help Committee
$5 billion for infrastructure for Improving Research and
Development Infrastructure for academic health science centers at
Historically Black Graduate Institutions as defined under Section
326(e) of Title III of the Higher Education Act.
$500 million to maintain and expand programs to increase research
capacity at minority-serving institutions (as described in sections
371(a) and 326(e)(1) of the Higher Education Act.
Amend/Expand the Medicare GME policy to add a priority criterion
for hospitals that have a sponsoring institution for their GME program/
s that is a Minority-Serving Institution (to include Historically Black
Graduate Institutions), as well as add ``non-contiguous area'' to the
``rural'' criterion.
______
The Chair. Well, thank you very much, Dr. Hildreth. Our
next witness is Dr. Sarah Szanton. She is dean of the John
Hopkins School of Nursing and an Advanced Nurse Practitioner
and has published more than 200 papers. Dr. Szanton, thanks so
much for being with us.
STATEMENT OF SARAH SZANTON PH.D., RN, FAAN, DEAN, JOHNS HOPKINS
SCHOOL OF NURSING, BALTIMORE, MD
Dr. Szanton. Chairman Sanders, Ranking Member Cassidy, and
Members of the Committee, thank you for the opportunity to
describe some of the factors contributing to our national
nursing crisis and to offer some solutions for your
consideration.
As you mentioned, I am a Professor, a Nurse, and the Dean
of the Johns Hopkins School of Nursing. I have spent 25 years
at Johns Hopkins teaching nurses, nurse scientists, making
house calls in the community, and conducting research.
I state for the record the opinions expressed here today
are my own and do not necessarily reflect the views of the
Johns Hopkins University or the Johns Hopkins health system. As
we have discussed, our Country is perilously short of nurses,
and those we do have are often not working in the settings that
could provide the most value. This was true before the
pandemic, as you mentioned, and has become more acute.
One thing that has not been mentioned is the average age of
nurses today is 54 years old, and 19 percent of them are 65 or
older. So, you can imagine we are worried about the future as
well. And that, coupled with an aging population that has more
and more chronic conditions as well.
There are 4.5 million nurses and nurses are often
considered the oxygen of any health care setting. So as a
country, we need people to become new nurses and we need to
retain current nurses, and there are many steps to both.
To become a nurse, one needs to first be able to imagine
oneself as a nurse, to apply and be accepted to a nursing
school, and have the resources to pay tuition, food, housing,
and perhaps childcare while in the program.
One needs to have dedicated time and space to learn and
then pass the nursing boards. For the school to be able to
admit that student, it needs enough faculty, adequate
facilities, clinical settings in which to place nursing
students for experience, and scholarships to offer. And then to
stay in nursing, nurses need supportive, safe work
environments, a career ladder, and for some, the ability to
return to school to develop the science behind prevention and
care.
If we take each factor separately, as a field, nursing has
historically been composed of predominantly women, so men have
a hard time seeing themselves in the role. Another
misperception is that nursing is all hospital based, when the
reality is that only 60 percent is.
Turning to nursing schools, 90,000 qualified applications
are turned down from nursing schools each year, as you
mentioned in Vermont, due to lack of space. There is not enough
scholarship and loan repayment money to support nursing
students. And as was mentioned, the nursing shortage is in
large part a nurse faculty shortage.
The country is shy about 2,100 nurse faculty. We need to
increase the number of highly educated nurses who can be
faculty and retain them by paying them as much as their
clinical counterparts would receive.
I mentioned the schools also struggle to find nurses
outside of school willing to precept nurses in training, and
this has been mentioned across the board. Like medical school,
nursing education combines classroom learning with hands on
clinical training, and that clinical training relies on
established nurses willing to precept students. And it has been
mentioned about graduate medical education.
There is nothing similar for graduate nursing education.
There is a small pilot that has ended that was successful. So,
at a time when nurse shortages are glaring, nurses with a full
clinical workload, who are often overtaxed, struggle to take on
students on top of that. Finally, some schools have offices,
classrooms, practice spaces, and simulation areas that are
arcane. So as leaders in nursing, we prepare for both current
and future challenges.
The current we have discussed. But we also need to prepare
people for the health system of the future in which most
encounters will happen at home, online, in clinics, in schools,
and in businesses.
As you consider solutions to the crisis, I want to
acknowledge the vital work Congress has done to strengthen and
grow the Title VIII Nursing Workforce Development Programs and
the CARES Act of 2020. I urge the Committee to support the
Future Advancement of Academic Nursing Act, or FAAN Act, when
it is reintroduced by Senator Merkley, and Congresswoman
Underwood, and co-sponsors.
It would address all of the areas that I have mentioned,
solving barriers for students, preceptors, faculty, and
enhancing infrastructure. And in closing, I would like to
highlight two additional principles to guide this body's
deliberations. First, as a Nation, we must strive to make
nursing more disability inclusive.
27 percent of our Country has a disability, both ethically
and practically. We should tap the strengths and skills of
people with disabilities. Second, robust support for preventive
health care approaches could also save money, reduce poor
health outcomes, and thus require fewer nurses. With a more
deliberate emphasis on a preventive health care system, we
might no longer have a nursing shortage.
Models delivered at home, like the capable program I
spearheaded, for instance, would allow older adults to age in
the community. Today, nurse scientists are developing many
models that may soon provide health care for a nation that is
both better and less expensive. Thank you. I would be pleased
to answer any questions that you have.
[The prepared statement of Dr. Szanton follows:]
prepared statement of sarah szanton
Chairman Sanders, Ranking Member Cassidy and Members of the
Committee.
Thank you for the opportunity to describe some factors contributing
to our national nursing crisis--and to offer some solutions for
consideration.
My name is Sarah Szanton. I am a professor, a nurse and the dean of
the Johns Hopkins School of Nursing. I have spent 25 years at Johns
Hopkins, teaching nurses and nurse scientists, making house calls in
the community, and conducting research. I now lead the Nursing school.
I state for the record that the opinions expressed here today are
my own and do not necessarily reflect the views of The Johns Hopkins
University or the Johns Hopkins Health System.
Our country is perilously short of nurses, and those we do have are
often not working in the settings that could provide the most value.
This was true before the COVID pandemic, and has become more acute
since COVID struck. According to the McKinsey Institute, the Nation
needs at least 200,000 more nurses--and perhaps closer to a half
million.
The average age of U.S. nurses today is 54 years old. Fully one
fifth of working nurses are at least 65 years old! The nurse shortage
will only grow more severe over time, as these nurses approach
retirement at the same time as COVID's long-term disabilities become
clearer, and the aging population encounters more chronic diseases.
Nurses are the largest component of the health care workforce--4.5
million strong. Nurses are often considered the oxygen of any health
care setting.
As a country, we need people to become new nurses and to retain
current nurses. And there are many steps to both.
To become a nurse, one needs to be able to imagine oneself as a
nurse, to apply and be accepted by a nursing school, to have the
resources to pay tuition, food, housing and perhaps childcare while in
the program. One needs to have dedicated time and space to learn. And
then pass the nursing boards. For the school to be able to admit that
student, it needs: enough faculty; adequate facilities; clinical
settings in which to place nursing students for experience; and
scholarships to offer.
To stay in nursing, nurses need: supportive, safe work
environments, a career ladder and, for some, the ability to return to
school to develop the science behind prevention and care.
Let's take each factor separately--As a field, nursing has
historically been composed of predominantly women, so men have a hard
time seeing themselves in the role. Another misperception is that
nursing is all hospital-based, when the reality is that only 60 percent
is.
As for nursing schools, about 90,000 qualified applications are
turned down from nursing schools each year due to lack of space, and
there is not enough scholarship and loan repayment money to support
nursing students. The nursing shortage is, in large part, a nurse
faculty shortage. This country is shy about 2,100 nurse faculty. We
need to increase the number of highly educated nurses who can be
faculty in the U.S. To retain them, we need to pay them on par with
what they can earn clinically.
I mentioned that schools also struggle to find nurses outside of
school willing to precept nursing students-in-training. Like medical
school, nursing education combines classroom learning with hands-on
clinical training in hospitals and clinics. That clinical training
relies on established nurses willing to precept students. In medicine,
there's a paid mechanism through Medicare to support medical education,
but not so in nursing. At a time when nurse shortages are glaring,
nurses with a full clinical workload are often overtaxed and struggle
to take on students, too.
Finally, some schools have offices, classrooms, practice spaces,
and/or simulation areas that are arcane or inadequate.
As leaders in nursing, at Johns Hopkins, we prepare for both
current and future challenges. We prepare nursing students for today's
acute care-focused medical system, and we must prepare them for the
health system of the future, in which most encounters will happen at
home, online, in clinics, at schools, or in businesses.
As you consider solutions to the crisis, I want to acknowledge the
vital work Congress has done to strengthen and grow the Title VIII
nursing workforce development programs through annual appropriations
and the CARES Act of 2020.
I urge the Committee to support the Future Advancement of Academic
Nursing Act (Or FAAN Act) when it is reintroduced by Senator Merkley
and Congresswoman Underwood, and cosponsors. It would address all the
areas I have mentioned, specifically, solving barriers for students,
preceptors, faculty, and enhancing infrastructure.
In closing, I highlight two additional principles to guide this
body's deliberations.
First, as a Nation, we must strive to make nursing more disability-
inclusive. Twenty 7 percent of the country has a disability. Both
ethically and practically, we should tap the strengths and skills of
people with disabilities.
Second robust support for preventive health care approaches could
also save money, reduce poor health outcomes and, thus, require fewer
nurses. With a more deliberate emphasis on a preventive healthcare
system, we might no longer have a nursing shortage. Models delivered at
home, like the CAPABLE program I spearheaded, for instance, would allow
older adults to age in the community. Today, nurse scientists are
developing many models that may soon provide health care for our Nation
that is both better AND less expensive.
Thank you and I would be pleased to answer any questions you may
have.
______
[summary statement of sarah szanton]
Johns Hopkins School of Nursing and Its Dean
Johns Hopkins School of Nursing, in Baltimore, MD, is a
leading school of nursing that educates nurses from all over the
country to become nurses as well as nurse practitioners, nurse
anesthetists, and PhD level nurse scientists.
Sarah Szanton is a professor, nurse and dean of the Johns
Hopkins School of Nursing, where she has spent 25 years teaching nurses
and nurse scientists, making house calls in the community, and
conducting research.
Testimony Focus
The nursing shortage has been exacerbated by COVID with
likely 200,000-400,000 RNs short by 2025.
The average age of the 4.5 million U.S. nurses
is54.Twenty percent of working nurses are at least65 years old.
The nurse shortage will grow more severe as these nurses
approach retirement, and the aging population encounters more chronic
diseases.
There are barriers to becoming a nurse both from the
student perspective and the school perspective.
Schools turn down over 90,000 qualified applications each
year due to shortage of both faculty and clinical preceptors who
provide hands on training, inadequate facilities, and financial aid
shortages.
To stay in nursing, nurses need supportive work
environments, career ladders and for some--opportunity to return for
advanced education.
It's important to simultaneously prepare nursing students
for today's acute care-focused medical system, and the health system of
the future, in which most encounters will happen at home, online, in
clinics, at schools, or in businesses.
We acknowledge the vital work Congress has done to
strengthen and grow the Title VIII nursing workforce development
programs through annual appropriations and the CARES Act of 2020.
Recommendations to Senate Help Committee
Support the Future Advancement of Academic Nursing Act
(FAAN Act) when reintroduced which would address student enrollment and
retention, support modernization of curricula including mental health
of patients and communities, address faculty and precept or shortage
while diversifying the field, enhance outdated infrastructure and train
more nurse scientists.
Improve recruitment and retention of people with
disabilities to be nurses and doctors; this can improve health care and
decrease workforce shortage.
Consider preventive healthcare approaches to improve
health outcomes, save money and possibly require fewer nurses.
______
The Chair. Dr. Szanton, thank you very much. Senator
Cassidy is going to introduce our next witness. Senator
Cassidy.
Senator Cassidy. Dr. Szanton, first let me compliment you.
You finished just at--your time ran out. It was just like a
gymnast getting her feet down perfectly.
[Laughter.]
Senator Cassidy. My pleasure to introduce Dr. Leo Seoane.
And on a note of personal pride, this is, I think, the fifth or
sixth time one of my former students has testified. I think the
first time I have actually invited. So, you have done very
well, Dr. Seoane.
I think you would say your success is despite your
instructor, not because of. But anyway, my pleasure to
introduce Dr. Leo Seoane, the Executive Vice President and
Chief Academic Officer of Ochsner Health System.
He is a graduate of LSU Medical School, and he joined
Ochsner in 2001 and has served in a variety of leadership
roles, overseeing both medical care and medical education. As
Chief Academic Officer, Dr. Seoane leads Ochsner's partnership
with Loyola regarding nursing, Loyola of New Orleans, and
Xavier of New Orleans, which is soon to join Meharry, becoming
the sixth historically black college and university in the
Nation to have a medical school. He is also currently serving
as interim Chief Executive Officer at Ochsner System, North
Louisiana, which has a wide rural catchment area.
For decades, Dr. Seoane has worked to improve the quality
of care for Louisiana families, including partnering with other
academic institutions for workforce development initiatives
within Ochsner, so that future Louisiana health care providers
have access to the best education possible.
As a doctor and educator in Louisiana, Dr. Seoane
understands the challenges that rural and underserved
communities face when it comes to health care shortages. He
also understands the importance of having an educated and
diverse health care workforce to close the health gap and
provide quality care. I look forward to Dr. Seoane's insights
on how to address these issues.
STATEMENT OF LEONARDO SEOANE M.D., FACP, CHIEF ACADEMIC
OFFICER, OCHSNER HEALTH, NEW ORLEANS, LA
Dr. Seoane.
[Technical problems]--Chairman Sanders, and thank you,
Senator Cassidy. I am almost as nervous as I was on rounds with
you when I was----
[Laughter.]
Dr. Seoane [continuing]. and distinguished Members of the
Committee. I am the lead of the medical education programs at
Ochsner in my role as Chief Academic Officer. As Senator
Cassidy said, I lead the partnerships with our universities and
colleges. Headquartered in New Orleans, Ochsner is one of the
Nation's leading nonprofit, clinically integrated academic
health centers.
We deliver care to urban, suburban, and rural communities
throughout the Gulf Coast. Over the last 14 years, in
partnership with the University of Queensland, we have helped
train 800 new physicians for the United States. We also
annually train more than 330 residents and fellows through our
31 ACGME accredited residency programs.
Today's hearing comes at a critical time for us. Like
providers across the Nation, Ochsner faces an alarming shortage
of nurses, doctors, and health professionals. As Senator
Cassidy knows very well, we face a significant challenge in
that Ochsner serves patients who come from low income, rural,
and historically underserved communities.
Ochsner has undertaken dozens of proactive and innovative
initiatives to recruit and develop a pipeline of doctors,
nurses, and allied health professionals. But despite these
efforts, today, we have 1,200 open nursing positions throughout
our system. In addition, we are also experiencing a physician
shortage.
Last year, the American Association of Medical Colleges
projected that over the next decade, as Senator Sanders pointed
out, Louisiana will be the third worst in physician shortages
of all 50 states. And our neighbor Mississippi will be the
worst.
During the past 6 months, these shortages have forced us to
close more than 100 beds across the health system, resulting in
the need to hold more patients in the emergency departments
that are already constrained. There are two main causes for our
nursing shortages in our region.
First, a lack of training and educational capacity that is
preventing us from developing the adequate pipelines needed to
fill our current nursing positions. Second, these shortages are
putting an enormous strain on our current workforce and in turn
leading to loss of our bedside clinical nurses. This has been
exacerbated by the pandemic.
Moreover, these shortages have led to rising costs and
increased competition for qualified health professionals. Since
2019, our non-agency labor costs have grown just under 60
percent. In comparison, over the same period, our contracted
staffing costs for nurses and allied health has increased
nearly 900 percent.
Ochsner is committed to addressing the workforce shortages
today and developing the next generation of health care
providers. We know solutions are multifaceted and require
partnerships with Government, and universities and colleges. We
are trying to do our part. In 2022, we invested more than $5
million to operate dozens of different workforce programs,
impacting more than 1,200 individuals.
We are seeking to grow the pipeline of high school and
college students entering health care careers and provide
career advancement opportunities for existing employees by
offering earn as you learn programs. We in the Gulf Coast
regularly experience and survive hurricanes. This makes us
resilient and innovative. And we have brought these traits to
solving our workforce shortages.
My written testimony provides greater details, but here are
two examples. In 2021, Ochsner invested $20 million to launch a
partnership with the Delgado Community College in New Orleans
to train the next generation of nurses and allied health
professionals. The resources cover a new training facility and
full-time tuition for Ochsner employees pursuing a nursing or
allied health career.
We also provide tuition support for physicians that are
committed to working in primary care and behavioral health, as
well as tuition support for nurses that are committed to
working throughout the Gulf Coast at the Ochsner system post-
graduation. We take--we understand and take real responsibility
that we need to train a more diverse workforce that represent
the diverse communities of Louisiana and Mississippi.
To that end, in January, Ochsner partnered with the Xavier
University, one of our premiere HBCUs, to announce plans to
create the Xavier Ochsner College of Medicine, with the
explicit mission to increase the number of underrepresented
physicians in the U.S. We appreciate that Congress has taken
several steps to address health care workforce gaps. However,
additional efforts are needed to bolster local efforts like the
ones we have undertaken.
My written testimony provides a range of ideas, including
investments to help scale our proven local solutions,
increasing the number of GME slots, and providing more stable
Medicare and Medicaid reimbursement climate for our physicians.
In conclusion, on behalf of Ochsner and all the communities
we have the privilege of serving, thank you again for this
opportunity. We stand ready to work with you and your
colleagues through public, private partnerships to ensure
access to quality care for the patients across the Gulf Coast
and our Nation.
[The prepared statement of Dr. Seoane follows:]
prepared statement of leonardo seoane
Chairman Sanders and Ranking Member Cassidy, I am Dr. Leonardo
(Leo) Seoane of Ochsner Health, where I serve as Executive Vice
President and Chief Academic Officer; Associate Vice-Chancellor of
Academics for LSU Health Shreveport; and Professor of Medicine for
University of Queensland. On behalf of Ochsner Health (Ochsner) and our
nurses, physicians, and other professionals who provide comprehensive,
quality care to families and communities throughout Louisiana and
Mississippi, thank you for the opportunity to present testimony to you
and your colleagues on the Senate Health, Education, Labor, and
Pensions Committee.
Since joining Ochsner in 2001, I have supported Ochsner's continuum
of education, including undergraduate, graduate and continuing medical
education programs, as well as all research initiatives. Additionally,
I oversee Ochsner's partnerships with the University of Queensland
Ochsner Clinical School, Xavier University of Louisiana (Xavier), and
Loyola University of New Orleans. I am particularly proud to serve as
our executive champion for Healthy State by 2030, Ochsner's commitment
to building a healthier Louisiana for all people. As a Cuban American,
this vision and our efforts to create health equity for the diverse
communities we serve are professionally and personally meaningful to
me. I graduated from Loyola University in New Orleans with a Bachelor
of Science in Biological Sciences and earned my Doctor of Medicine
degree at Louisiana State University School of Medicine. I am certified
by the American Board of Internal Medicine in internal medicine,
pulmonary care, critical care, and palliative medicine.
Over the last several years, Congress has taken meaningful steps to
address health care workforce gaps and improve patient access to care.
This includes the support and expansion of various graduate medical
education programs, Health Resources and Services Administration (HRSA)
grants provided to strengthen and expand access to care in rural and
underserved areas, and resources to enhance and facilitate the use of
telehealth. Moreover, substantial resources were provided temporarily
to a wide range of health care providers during the COVID-19 public
health emergency (PHE). However, although the Federal PHE will soon
expire, we know that the pandemic has had a lasting impact on the U.S.
health care system. As I will discuss in greater detail, Ochsner has
undertaken numerous initiatives to retain health care workers and
expand the future pipeline for doctors, nurses, and other allied health
professionals. However, it is clear that additional efforts are needed
in both the public and private sectors. This hearing--the first for the
HELP Committee this Congress--could not be happening at a better time.
We thank the Committee for its leadership and look forward to
contributing to this important examination of policies and programs
that can help improve patient access to care by addressing current and
anticipated workforce challenges.
We are honored to have this opportunity to share with you our
experience with the current health care workforce shortage and discuss
several initiatives to develop and retain existing health professionals
and build a pipeline of the next generation of caregivers. Ochsner
stands ready to be a resource for the Committee and your colleagues in
Congress as you explore ways in which the Federal Government may help
address the current and anticipated shortage of nurses, physicians, and
other health professionals. Working together, we can ensure the
patients of today and tomorrow receive the primary, specialty, urgent,
and emergency care they need and deserve.
About Ochsner
Ochsner, headquartered in New Orleans, is one of the Nation's
leading clinically integrated not-for-profit academic health systems.
Ochsner's mission is to Serve, Heal, Lead, Educate and Innovate. As a
leader in value-based care and delivery system innovation, we provide a
comprehensive range of services across 90 specialties and
subspecialties. This is done through our clinically integrated network
of 4,600 affiliated and employed physicians and 47 owned, managed, and
affiliated hospitals. Of these hospitals, eight are critical access
hospitals located in medically underserved rural areas in Louisiana,
Mississippi, and Alabama. We are proud that our innovative partnership
model through the Ochsner Health Network (OHN) allows many communities
to maintain local ownership and control of their hospitals, while
bringing to bear the benefit of experience and breadth of the Ochsner
clinical and operational teams. Each year we serve more than one
million individual patients who come from every state in the Nation and
more than 70 countries. Ochsner educates thousands of health care
professionals annually. With our partner, LSU Health Shreveport, we are
the leading educator of physicians in Louisiana. For the past 14 years,
Ochsner has been training medical students through a partnership with
University of Queensland, resulting in more than 800 new physicians for
America. In addition, Ochsner is a leader in graduate medical education
(GME) programs with 31 ACGME accredited residency and fellowship
programs, through which we train more than 330 residents and fellows
each year.
Louisiana's Health Care Workforce Shortages
Louisiana and Mississippi historically are the lowest-performing
states for health outcomes in the U.S. Illustrating the myriad
challenges facing the states that we serve, the United Health
Foundation's America's Health Rankings 2022 Annual Report ranked
Louisiana as 50th and Mississippi 49th. \1\ The leading drivers of poor
health for both states are economic hardship, high rates of chronic
disease and premature death, and low high school graduation rates as
compared to other states. Moreover, while Louisiana has expanded
Medicaid and overall numbers of uninsured have decreased, a significant
proportion of the individuals and families we serve are underinsured.
According to the American Community Survey reflecting 2016-2020,
Mississippi and Louisiana are among the top five states and territories
with the highest percentage of the population living in poverty. The
COVID-19 pandemic has had disproportionately large impacts on minority
communities, uninsured populations, and rural communities--all of which
are found in Louisiana and Mississippi. Ochsner was the first to
document the disproportionate impact of COVID-19 on African American
communities in the New England Journal of Medicine in May 2020.
---------------------------------------------------------------------------
\1\ https://assets.americashealthrankings.org/app/uploads/
allstatesummaries-ahr22.pdf
Louisiana has been especially hard hit by the pandemic. The
Louisiana Department of Health's COVID-19 dashboard reports over 1.55
million cases to date in Louisiana and more than 18,600 deaths. This
impact has been further exacerbated by the five named hurricanes that
have made landfall in Louisiana since the pandemic began. Louisiana's
health care workforce has played a critical role in the delivery of
life-saving clinical care throughout the pandemic, but it has placed a
tremendous strain on the entire health care delivery system and our
---------------------------------------------------------------------------
workforce.
Ochsner, like other health care providers throughout Louisiana and
the Nation, continues to face an alarming shortage of nurses practicing
in our communities. Despite multiple efforts to address these
shortages, we currently have nearly 1,200 open registered nurse
positions to fill. Unfortunately, the pipeline of available nurses
being educated in Louisiana is not keeping pace with demand. The 2022
Louisiana State Board of Nursing's Education Capacity Report shows that
more than 1,200 qualified students were denied admission to the pre-RN
licensure schools in 2021 due to insufficient training capacity.
A 2017 study by the U.S. Department of Health and Human Services
(HHS) estimated that the Nation would need 3.6 million nurses by 2030--
or approximately 50,000 new registered nurses each year from 2017
through 2030. \2\ More recently, in September 2022, the U.S. Bureau of
Labor Statistics reported that the Nation will have approximately
203,000 annual openings for new registered nurses through 2026, due to
nurses retiring or otherwise leave the nursing field. \3\ The nursing
shortage was once due to a lack of individuals interested in the field,
but the challenge now is there is lack of nursing school capacity to
support the matriculation of all interested and qualified students.
Inadequate nursing school capacity is due to several factors, including
lack of qualified and available faculty, insufficient funding to
support enough faculty positions, and faculty salaries that are
significantly lower than bedside, management, or administrative nursing
positions. Without numerous interventions to address these issues,
Louisiana will continue to lose interested and qualified nursing
students.
---------------------------------------------------------------------------
\2\ https://www.usnews.com/news/health-news/articles/2022--11--01/
the-state-of-the-nations-nursing-shortage
\3\ https://www.bls.gov/ooh/health care/registered-nurses
In addition to the severe shortage of nurses, we also face a
shortfall in physicians--both in Louisiana and across the Nation. In a
2021 report, the American Association of Medical Colleges projected
that ``physician demand will grow faster than supply, leading to a
projected total physician shortage of between 37,800 and 124,000
physicians by 2034.'' \4\ AAMC estimates that Louisiana will rank third
in the Nation for shortage of physicians by 2030. Louisiana's
population estimate for 2030 is 4.6 million. Therefore, the estimated
shortage of physicians comes to 100 per every 100,000 people.
Neighboring Mississippi is projected to have the worst physician
shortage in the Nation by 2030, with 120 physicians needed for every
100,000 people. Rural and underserved communities throughout Louisiana
and Mississippi are expected to be the hardest hit.
---------------------------------------------------------------------------
\4\ https://www.aamc.org/media/54681/download
---------------------------------------------------------------------------
Impact of the Nursing Shortage on Ochsner and Our Patients
The ongoing nursing workforce challenge has created a nationwide
reliance on agency nurses, which significantly drives the cost of
delivering care. The number of unique job postings in the U.S. for
travel nurses more than doubled from January 2019 to January 2022 and
the average amount staffing agencies charge hospitals and pay their
nurses has increased from 15 percent in January 2019 to 62 percent. \5\
---------------------------------------------------------------------------
\5\ https://www.fiercehealth care.com/providers/aha-Federal-funds-
needed-offset--20-patient-increase-hospital-expenses--2019
The operational and financial impact of staff shortages and nursing
and allied health staff agency costs on the Ochsner system pre-pandemic
to today has been dramatic. Our contract staffing costs alone increased
by 892 percent since 2019. During the same period, non-agency labor
costs grew 59 percent. Ochsner currently contracts with approximately
600 agency registered nurses. In addition to the increased costs,
relying on high numbers of agency nurses can impact the effectiveness
of care delivery teams. Hospital-based health care delivery is centered
on a team-based approach and high functioning teams require consistency
among the team members and iterative practice to assure highly
---------------------------------------------------------------------------
reliable, safe care.
While we have worked hard to reduce this number and convert these
positions to full time roles, the latest report from the Louisiana
Nursing Supply and Demand Council indicates that nursing shortages will
continue to grip the state unless we remove barriers to meet the demand
and undertake more significant interventions.
Of serious concern is that these staffing shortages and the rising
costs, coupled with a growing senior population with multiple chronic
conditions, are impacting our ability to meet current and anticipated
demand for primary, specialty, preventative, urgent, and emergency
care. For example, across our system, we have closed 100 beds,
resulting in the need to hold patients in non-traditional care settings
like emergency departments that are already constrained. While Ochsner
has a very advanced patient flow center that manages transfers across
the state, over the past several months nearly all our 47 locations
have been on inpatient and specialty diversion.
Ochsner's Efforts to Address Workforce Shortages
Ochsner is committed to addressing the workforce shortages of today
and developing the next generation of health care providers and front-
line staff for tomorrow. We know that the solution to this statewide
and national problem is multi-faceted and requires efforts from all
stakeholders, including providers and state and local government. To
that end, we have developed several programs and partnerships dedicated
to workforce development in New Orleans and across Louisiana.
We are proud that last year we invested more than $5 million to
operate more than 29 different workforce programs, serving over 1,200
individuals. We have focused efforts on increasing the supply of
nurses, growing the pipeline of high school and college students
entering health care training programs, and advancing existing
employees by offering ``earn as you learn'' programs to incumbent
employees. The following provides several examples of our current
offerings and strategies.
Delgado Community College Investment. In February
2021, Ochsner launched a partnership with Delgado Community
College (Delgado) to train the next generation of nurses and
allied health professionals, forming the Ochsner Center for
Nursing and Allied Health. Delgado is the largest educator of
nurses and allied health professionals in Louisiana. Together,
Delgado and Ochsner will meet critical workforce demands,
providing more opportunities for local graduates in high-wage
careers, and proactively pursue the career development of
minority and disadvantaged students. Ochsner's $20 million
investment in the center covers full-time tuition for Ochsner
employees pursuing a nursing or allied health certificate or
degree at Delgado and matching funds for a new state-of-the-art
facility on its City Park Campus. In addition to RN and LPN
programs, the facility will host Radiologic Technologist,
Respiratory Therapy, Physical Therapy Assistant, Occupational
Therapy Assistant, Surgical Technologist, Medical Laboratory
Technologist, and Pharmacy Technologist programs.
Ochsner Nurse Scholars offers a tangible solution to
growing a diverse nursing workforce in Louisiana and
Mississippi by providing funding support and professional
development for current LPN, ADN, BSN, MSN nursing students
attending accredited Louisiana and select Mississippi nursing
schools full-time. In exchange for the funding, students are
required to work at Ochsner as a nurse upon graduation for 1-3
years, depending on which degree they are pursuing. There are
currently 364 active nurse scholars and an additional 44 who
have already graduated and joined Ochsner. Over 65 percent of
Ochsner's nurse scholars are demographically diverse with a 90
percent retention rate of program participants. Students are
attending one of 35 academic partners across Louisiana (28) and
Mississippi (7).
Ochsner Nursing Pre-Apprenticeship launched in 2021
in partnership with Delgado Community College and the Louisiana
Department of Education (LDOE). It provides high school
sophomores and community college students an opportunity to
apprentice as nurses. This LDOE-approved Fast Forward Pathway
serves high school students across Jefferson, Orleans, St.
Bernard and the River Parishes and also supports students in
St. Bernard in partnership with Nunez Community College. The
program will soon expand to students in Shreveport, Lafayette,
Monroe and Baton Rouge. With more than 350 students currently,
the program seeks serve more than 600 students over the next 2
years.
Ochsner Facilities Pathway Pre-Apprenticeship
launched in 2022 in partnership with Delgado Community College
and includes a high school pathway for the skilled trades
(plumbing, light electrical, etc.) as well as an incumbent
apprenticeship pathway. While the high school pathway is new in
2023, in partnership with Jefferson Parish Public Schools, the
incumbent pathway has seven apprentices who will graduate in
May 2023 from Delgado. This pathway has been submitted for
recognition as a registered apprenticeship.
The Ochsner Catalyst Summer Internship Program
(Catalyst) build awareness of career opportunities in the
health care industry. In its 3d year, Catalyst draws college
students pursing an undergraduate or graduate degree for an 8-
week paid summer internship. The program provides 1:1
mentorship, hands-on experience, peer networking and
developmental training sessions and assists students in
identifying non-clinical health care career opportunities,
while providing economic security. More than 500 students
applied for the 100 opportunities.
Ochsner's Medical Assistant to Licensed Practical
Nurse (LPN) Apprenticeship recently celebrated the pinning of
31 LPNs. In partnership with LCTCS colleges, North Shore
Technical Community College, and Delgado Community College, the
registered apprenticeship offers tuition-free career growth to
current Ochsner Medical Assistants. Plans are underway to scale
the program into the Shreveport and Lafayette areas.
Ochsner's LPN to Registered Nurse Apprenticeship
celebrated its first cohort in 2022-23. This earn as you learn
registered apprenticeship provides an opportunity for LPN to
advance in the nursing profession to ADN while sustaining their
living. While in an Ochsner apprenticeship, benefits are
subsidized allowing the apprentice to pursue education while
continuing to earn a living wage. Seven students were part of
the inaugural cohort.
IMPACT Essential Skills Builder trained over 200
incumbent environmental services, patient escort, supply chain
dock workers and certified nursing assistants in ethical
decisionmaking, interpersonal communication, and critical
thinking skills. Participants are given opportunity to meet
with a career coach to shape a personal career development plan
that aligns them to opportunities ranging from apprenticeship
pathways to nurse scholars to tuition reimbursement for
college.
MA Now, first launched in 2013, is our signature
community-facing program that links unemployed and
underemployed to a nursing pathway. Students earn several
industry-aligned credentials including the certified clinical
medical assistant, phlebotomy, ED Tech Monitor, and EEG
pathways. More than 250 MA Now graduates have been trained and
employed by Ochsner. Graduates regularly move into leadership,
LPN, and RN positions as they advance their careers.
PAR Now, modeled on the highly successful MA Now, is
Ochsner's community-facing Patient Access Representatives or
PAR Now program. It prepares un-and underemployed for positions
as a clerical medical assistant in the Revenue Cycle job
family. Like MA NOW graduates, PAR NOW graduates earn stackable
credentials that open multiple doors for the graduates.
Community Health Worker (CHW) is helping to build a
diverse workforce to service community clinics and support
health equity initiatives at the neighborhood level. In 2022,
nearly 50 CHWs were trained by Delgado Community College, in
partnership with Clover (previously Kingsley House in New
Orleans) and funded by a grant from Blue Cross Blue Shield.
Patient Care Assistant (PCA) to Certified Nursing
Assistant (CNA) is a 8-week pathway program for those with a
strong desire for bedside caregiving who lack a credential. New
hires enter an ``earn as you learn'' pathway that includes
didactic training at a local community college while students
supplement the ancillary staff in the hospital as they build
their skills. Students graduate as a Certified Nursing
Assistant and enter a pathway to progress to LPN and then on to
RN.
In-Patient Bedside Coding is a 2-year program to
build the knowledge and capacity for an individual to serve as
an in-patient coder. This highly sought-after talent is in
short supply across our Nation. The complexity of in-patient
coding requires advance training. Our apprenticeship allows
students the opportunity to grow their knowledge, skills, and
abilities to successfully compete in this high demand
occupation. Ochsner has successfully trained two cohorts,
including one that progressed during the height of the COVID-19
pandemic.
Ochsner's Efforts to Strengthen and Diversify the Physician Workforce
Ochsner is proud of our long-standing commitment to train the next
generation of primary care and specialty physicians. We are working
diligently to create more resident and fellowship opportunities
throughout the region by building new GME programs in Lafayette and the
Greater New Orleans Area. We are proud to have developed Ochsner's
Program to Introduce Medicine to Underrepresented Students (OPTIMUS),
which provides education about career options in medicine, hands-on
simulations and experiments. Ochsner also sponsors the Ochsner
Academics Summer Internship for Students (OASIS) program. OASIS
provides formative experiences to undergraduate students interested in
pursuing a career as a physician, physician assistant, or researcher in
the biomedical sciences with a focus on supporting African American and
Hispanic students, as well as students of Ochsner employees.
Although Black and African American populations account for 13
percent of U.S. residents, according to the AAMC, representation of
African Americans within medicine lags, as they comprise only 5 percent
of all U.S. doctors. Research shows an urgent need for a Historically
Black College and University (HBCU) medical school. Recognizing this
significant and growing need, in January 2023, Ochsner and Xavier
University announced plans to create the Xavier Ochsner College of
Medicine.
Together, Xavier and Ochsner will create a new curriculum and use
facilities, personnel, and administrative processes of both
institutions to support the new school of medicine. Xavier's College of
Pharmacy, established in 1982, is the oldest in Louisiana and has for
years been among the top in the Nation in producing African American
graduates with Doctor of Pharmacy degrees. The new Xavier Ochsner
School of Medicine will build upon this strong legacy and result in
greater diversity and representation among medical practitioners, which
is critical to improving health outcomes by increasing quality of care,
access, and patient trust in their health care providers.
Other Investments to Build A Diverse and Inclusive Workforce
Ochsner recognizes that an essential component to advancing equity
and reducing health disparities is ensuring that our own workforce and
that of the Nation reflect our diverse communities and society. To that
end, in November 2020, Ochsner announced the creation of the Ochsner-
Xavier Institute for Health Equity and Research (OXIHER) to focus on
five key strategies to address health inequity in Louisiana, including
recruiting, educating, and training a diverse health care workforce.
OXIHER trains health care workers to lead and innovate in health
equity. Ochsner is pursuing this strategy through several initiative
including the following:
In addition to the new medical school and OXIHER,
Xavier and Ochsner also have worked to improve diversity within
the health sciences by establishing a new Physician Assistant
(PA) Program. In May 2022, Ochsner and Xavier celebrated the
first graduating class of 37 students in the full-time graduate
PA Program with a 93 percent completion rate. The program leads
to a master's degree in health sciences and trains the next
generation of providers to make a meaningful impact on health
care. In 2021, Ochsner and Xavier also established a Bachelor
of Arts in Medical Laboratory Science Program. Genetic
counseling and health informatics programs will be available in
the near future and will be offered to students through
classroom instruction at Xavier and clinical rotations at
Ochsner facilities. Xavier will be the first university in
Louisiana to offer a genetic counseling training program. It
will be the only such program based at an HBCU.
NextOp and Ochsner have been awarded a $1.1 million
grant to help transition military and veteran talent in the
Mississippi River Delta area. The Workforce Opportunity for
Rural Communities Initiative Grant from the U.S. Department of
Labor and the Delta Regional Authority will be used to help
qualified applicants find careers in the health care industry.
Over the course of 3 years, the goal is to hire 300 veterans
into clinical and non-clinical careers with Ochsner.
Innovations to Reduce Workforce Strain, Boost Care Delivery, Increase
Teaching Capacity, and Enhance Workplace Safety
Nurses have experienced unprecedented strain, stress, exhaustion,
and anxiety since the start of the PHE and the resulting,
understandable burnout has contributed to the numbers leaving bed-side
nursing. To help reduce the strain on our workforce and address
burnout, we have undertaken a number of steps and launched new efforts,
including the following initiatives:
We are leveraging certified nursing assistants who
can perform functions like taking vital signs, freeing nurses
to engage in the provision of other care and services aligned
with their training and allowing them to practice at the top of
their licenses. Similarly, we are bringing more LPNs to general
medical surgical areas in the inpatient setting so they can
provide care and assistance in a manner consistent with their
state scope of practice and training.
Through innovationOchsner, we have a long history of
successfully leveraging technology to solve access to care
challenges, as seen through our successful digital hypertension
and diabetes health offerings, Connected MOM, telehealth
platform, eICU, and the virtual care program Ochsner Connected
Anywhere. Utilizing our experience with these initiatives, we
currently are piloting a Virtual Nursing Program at our Ochsner
Medical Center Kenner location. There, we have a bunker with a
cadre of nurses who work a 12-hour shift but are not directly
located on an inpatient unit. The Virtual Nurse Program, which
provides 24-hour virtual nursing support to the patient care
team, is an innovative staffing model focused on patient-
centered care and safe distribution of workload across an
integrated team of virtual and bedside nursing personnel. The
bunker contains a bank of computers and a high-tech early
warning system through EPIC, which together allow for the
monitoring of up to 20 patients at a time.
The pilot has already improved risk adjustment mortality
index and turnover rates and we are in the process of expanding
the program to other Ochsner campuses. Further, the bunker
technology allows the remote nurses to virtually enter certain
patient rooms to assist with clinical and administrative
matters, such as discharge paperwork, which often can be
burdensome to the bedside nurse and can cause delays in getting
patients home or to the next care setting. This approach allows
bedside nurses to focus on direct care and leverages the bunker
nurses--via technology hook-ups--to manage non-direct care
matters--resulting in more efficient care delivery, a better
patient discharge experience, and less strain on the bedside
nurse.
------------------------------------------------------------------------
Roles and Responsibilities in Virtual Nurse Care Model
-------------------------------------------------------------------------
Virtual Nurse Mutual/Shared Beside Care Team
------------------------------------------------------------------------
Admission Documentation Educate Conduct
patients physical
assessments
Care Plan Monitor Conduct
patients Bedside Handoff
Discharge Education Hourly
Document Care Purposeful and
Safety Rounds
Transfer Documentation Respond Provide
to patient/ Direct Patient
family Care (med
questions administration,
treatments, care
plan)
Proactive rounds Manage
Collaborate discharge
with process
interprofession
al care team
Conduct real-time quality All
surveillance (nightshift) ``hands-on''
care
Document emergent/urgent
Code Blue/Rapid Response
24-hour chart checks
Review trends (early
intervention for deterioration: AI
alerts
------------------------------------------------------------------------
We are also leveraging technology by providing
patients with MyChart Bedside on personal tablets to help
connect them with their care and their care team. MyChart
Beside puts Ochsner's integrated, electronic health record in
patients' hands, giving them real-time access to lab results,
medications, and treatment plans. Patients also can order
meals, call housekeeping, and have other non-clinical needs
addressed. This reduces the burden and demand on nurses to
handle non-clinical concerns for patients, allowing them to
focus their time, efforts, and expertise on clinical matters.
Recognizing that our nursing schools have limited
capacity due to insufficient numbers of teaching faculty, we
are supporting several of our full-time employed Ochsner nurses
in stepping out of their clinical roles 2 days a week to serve
as clinical adjunct faculty at colleges of nursing. Ochsner
continues to pay their salaries in full, which provides schools
of nursing with faculty at no cost.
There is nothing more important to Ochsner than the
safety and security of our employees and our patients and their
family members. Tragically, workplace violence against health
care workers has been escalating and disruptive or violent
incidents in hospitals--many involving hostile visitors--are on
the rise, including in our own system. As part of our
commitment to the mitigation of workplace violence we have
deployed a multifaceted approach. A key component of this
effort is our multidisciplinary Workplace Violence Committee,
which is focusing on patients, employees, and visitors. Within
our internal communication daily safety escalation huddles
workplace safety is discussed for each campus and as a system,
in addition to patient safety. We are providing education for
our employees on workplace violence and offer support programs
for employees who have been victims. Further, we are
implementing enhanced security solutions and improving our
tracking of incidents and analysis of related data. During the
previous session of Congress, we were proud to lend our support
to Congressman Troy Carter's resolution condemning violence
against health care workers and the bipartisan Safety from
Violence for Healthcare Employees (SAVE) Act, which would
establish legal penalties for assaulting or intimidating
hospital employees.
Recommendations for Federal Policy, Programs, and Funding
We sincerely appreciate you prioritizing the health care workforce
and thank you for your interest in working with Ochsner to advance
solutions for Louisiana and the Nation. We offer the following ideas
for the Committee's consideration. We note that some of these policies
fall squarely within the jurisdiction of this Committee, while other
initiatives will require programmatic changes to Medicare, Medicaid,
and other programs, which may be in the purview of other Senate
Committees:
Health Care Workforce Shortages
Provide funding to non-profit health systems and
academic partners working together to increase the pipeline of
physicians, nurses, and allied health professionals. Prioritize
efforts that demonstrate a commitment to addressing economic
and health disparities in the health care workforce.
Address nursing shortages by investing in nurse
faculty salaries and hospital training time, including
reimbursement for hospitals and health systems that make their
nurses available as faculty to colleges of nursing.
Authorize and fund new programs to support and scale
innovative solutions that reduce the burden on bedside nurses
and other clinicians, like our Virtual Nurse Program.
Boost the Nation's ability to leverage availability
of international physicians and nurses. Increase the visas
available through proposals like the bipartisan Health Care
Workforce Resilience Act which allows for recapture from
previous fiscal years unused immigrant visas for physicians
(15,000) and nurses (25,000), exempts these visas from country
caps, and directs State Department and Department of Homeland
Security to expedite these processing of these recaptured
visas.
Access to Care
Increase the number of physician residency slots and
safeguard GME funding from reductions.
Establish new scholarships for minority health
professional students in return for work in rural or safety net
hospitals, or those in federally designated health professional
shortage areas.
Provide additional Medicare funding to hospitals
experiencing extraordinary inflationary pressures caused by the
pandemic, including a fix to the hospital market basket update
to correct for lag times.
Prevent further reductions to Medicare and Medicaid
physician payments, which may have a negative impact on patient
access to certain services, and support adjustments for
inflation and rising input costs.
Make permanent Medicare coverage of certain
telehealth services made possible during the pandemic,
including lifting geographic and originating site restrictions,
expanding practitioners who can provide telehealth, and
allowing hospital outpatient billing for virtual services.
Redesign current Medicare coverage and payment
policies for remote patient monitoring to remove barriers--such
as cost-sharing--that thwart patient access to innovative care
delivery models shown to improve patient health outcomes and
reduce the overall cost of care for patients.
Conclusion
On behalf of the nurses, physicians, and other professionals who
serve the more than one million individuals we care for each year,
thank you again for this opportunity to present testimony regarding the
current health care workforce challenges we face and for allowing us to
discuss ways in which the shortages can be addressed. We are confident
that through public-private partnerships we can together recruit,
train, educate, and retain a diverse and robust health care workforce
to ensure access to quality primary and specialty care for patients
across the Nation. We are eager to work with you on this national
imperative and welcome the opportunity to discuss our experience
further and answer any questions.
______
[summary statement of leonardo seoane]
About Ochsner Health
Ochsner, headquartered in New Orleans, is a clinically
integrated not-for-profit academic health system with a network of
4,600 affiliated and employed physicians and a combination 47 of owned,
managed, and affiliated hospitals throughout Louisiana, Mississippi,
and Alabama.
Ochsner serves as the top health care educator in
Louisiana, maintaining the state's largest group of GME programs with
31 accredited residency and fellowship programs, through which more
than 330 residents and fellows are trained each year.
Focus of Testimony
Louisiana and Mississippi face unique challenges in
health care delivery, as historically the lowest-performing states in
terms of health outcomes in the U.S.
Staffing shortages have had a tremendous impact on the
Ochsner health care workforce and overall patient care. Despite
multiple efforts to address these shortages, Ochsner currently has
nearly 1,200 open registered nurse positions. By 2030, Louisiana will
rank third in the Nation for shortage of physicians and Mississippi is
projected to have the worst physician shortage in the Nation. Rural and
underserved communities throughout Louisiana and Mississippi are
expected to be the hardest hit.
Main causes of nursing shortages in the states Ochsner
serves include lack of training capacity, impact of shortages on
burnout and premature retirement, and skyrocketing system costs.
Ochsner has led multiple efforts to train and expand a
diverse health care workforce through the Ochsner-Xavier partnership,
specifically the Xavier Ochsner School of Medicine and Institute for
Health Equity and Research (OXIHER), and other workforce development
programs aimed at increasing the participation of persons from
historically underrepresented and underserved backgrounds.
Ochsner has led initiatives to reduce health care
workforce strain, improve patient care, and enhance workplace safety,
including leveraging CNAs and LPNs, making its clinical nurses
available as faculty to colleges of nursing, deploying technology in
innovative ways to enhance delivery of inpatient care, and providing
employee education and support programs related to workplace violence.
Recommendations to Senate Help Committee
Support efforts to address health care workforce
shortages, including investing in nurse faculty salaries, hospital
training time, and non-profit health systems and academic partners
working to increase the health care workforce pipeline, among other
suggested initiatives.
Advance initiatives to expand access to care, including
increasing the number of physician residency slots, safeguarding GME
funding from reductions, establishing new scholarships for minority
health professional students, providing additional Medicare funding to
hospitals experiencing extraordinary COVID-19 related-inflationary
pressures, preventing further reductions in physician payments, and
making permanent Medicare coverage of certain telehealth flexibilities
granted under the PHE, among other suggested policy and programmatic
changes.
______
The Chair. Dr. Seoane, thank you very much for your
testimony. Our final witness will be Dr. Douglas Staiger,
Professor at Dartmouth College. Dr. Staiger received this Ph.D.
in economics from MIT and has served as faculty at Stanford and
Harvard before joining Dartmouth in 1998. Dr. Staiger, thanks
for being with us.
STATEMENT OF DOUGLAS STAIGER PH.D., PROFESSOR, DARTMOUTH
COLLEGE, HANOVER, NH
Dr. Staiger. Thanks, Chairman Sanders, Ranking Member
Cassidy, Members of the Committee. It is an honor to be here
this morning. No group of workers has been touched more
directly and deeply by the COVID-19 pandemic than frontline
health care providers, particularly nurses.
I am going to focus my comments on nurses this morning, and
I am an economist, so I am going to focus on data about
employment and earnings in nurses. The U.S. has enjoyed steady
growth in the registered nurse workforce, doubling the number
of RNs per capita over the last four decades.
However, since the start of the COVID-19 pandemic, RN
workforce has been in flux. So, developing effective policies
to strengthen the current and future RN workforce requires
timely data. Over the last 20 years, I have worked with the
research team to identify emerging trends in the health care
workforce and forecast the future supply of RNs. And based on
our recent and ongoing research, we see three key issues going
forward.
First, after a sharp decline in 2021, our unemployment
recovered in 2022 and now is nearly 5 percent above where it
was in 2019 before the pandemic, so there has been strong
growth. RN earnings have grown slightly faster than inflation
during the pandemic, whereas earnings in other occupations have
grown more slowly than inflation.
Encouragingly, as of 2022, both RN employment and earnings
are at or above their pre-pandemic trends. But the big change
that we have seen during the pandemic has been a shift of RN
employment away from hospitals and into other settings, such as
outpatient clinics, physician offices, schools, etcetera.
All of the growth in RN employment since 2019 occurred
outside of hospitals, and that is very unusual. We haven't seen
that in years before. This helps to explain why hospitals are
reporting shortages of RNs, right. If this trend continues,
actions will be needed to improve the work environment and
attract RNs back to working in hospitals.
Otherwise, hospitals will need to develop strategies and be
supported to better utilize a smaller RN workforce. Second key
issue for the future supply of RN s is the educational
pipeline. Application to nursing schools dipped in 2020 but
rebounded strongly in 2021 and have continued their upward
trend.
Today are as high as they have ever been. However, the
pandemic decreased academic preparedness of high school
students entering nursing programs, which threatens to slow
their educational progression and entry into the workforce.
Similar patterns are seen in nurses taking the licensure
exam, continued steady growth in numbers taking the exam, but a
notable decline in pass rates, from 88 percent pre-pandemic to
about 81, 82 percent in the last couple of years.
These trends paralleled the decline in academic achievement
during the pandemic for students in K-12 education,
particularly those attending high poverty schools who lag
roughly half a grade level behind pre-pandemic achievement
levels.
Nursing schools and employers realize they have to provide
their nursing students and new nursing employees with
additional training, and this may need Federal support. Third
question key issue is the adequacy of the rural RN workforce,
which I know is a concern of Members of the Committee.
The number of RNs per capita in rural areas is actually
comparable to urban areas and projected to steadily grow amidst
declining rural physicians and limited rural nurse
practitioners. So, it is actually quite different from
physicians, where physicians in rural areas are definitely
underrepresented.
However, rural RNs are markedly less diverse than the
population they serve, and only half of rural RNs have a
bachelor's degree or higher, compared to over 70 percent for
urban RNs, a recommendation 10 years ago from the National
Academy of Medicine that 80 percent of RNs have bachelor's
degrees by 2020.
The Department of Health and Human Services has recently
announced large investments in the rural health workforce,
which could be used for programs such as the scholarship and
loan forgiveness, that increase bachelor's degrees among rural
RNs and help achieve greater diversity among RNs in rural
communities.
Putting all this evidence together, we have updated our
forecasts and actually continue to forecast strong growth in
the RN workforce. Forecast that there will be an additional
million RNs over the next decade in the workforce, on top of
the current workforce, employed workforce of about 3.5 million.
The main concerns that need to be addressed in the near
term are the shift of our own workforce away from the hospital,
decreased preparedness of students entering and exiting nursing
schools, and the need to diversify the rural workforce and
increase bachelor's degrees among rural RNs.
Finally, as I stated at the beginning, effective workforce
planning and policymaking requires timely data and analysis. It
would be valuable if there was a Federal effort to coordinate
collection of better data on health care workforce that could
be used to monitor the lingering effects of COVID-19 pandemic.
This was something also that was recommended in the earlier
National Academy of Medicine report. Thank you.
[The prepared statement of Dr. Staiger follows:]
prepared statement of douglas staiger
Introduction
The U.S. has enjoyed steady growth of the registered nurse (RN)
workforce since the 1970's, providing the backbone of the Nation's
growing and evolving health care delivery systems. Now, 3 years into
the COVID-19 pandemic the RN workforce is very much in flux. The acute
needs of the first 2 years of the pandemic placed extraordinary demands
on health care workers and health care institutions, with registered
nurses often at the center of the crises. Reported shortages of key
nursing personnel have been widespread, leading to cancellation of
elective care, bed closures, and severe strain on the provision of both
essential acute and long-term care services. These strains on the
nursing workforce have led to reports of burnout, early retirement, and
workplace dissatisfaction.
Developing effective strategies to strengthen the current and
future RN workforce requires timely data on challenges facing the
current workforce and forecasts of where the workforce is heading over
the next decade. In the next three sections of this testimony, I
summarize recent and ongoing research on the nursing workforce by me
and others that is particularly relevant to understanding the state of
the current RN workforce. In the final section, based on this evidence,
I provide some recommendations on where we go from here.
The analyses that I discuss here focus on economic impacts using
data collected in Federal surveys of the Nation's workforce that
include RNs, including many analyses that are currently under way and
not yet publicly available. This research describes the current nurse
workforce, compares nurse workforce trends before and during the
pandemic, identifies changes in where RNs were working during the
pandemic, and builds on our 20-year record of forecasting the future
growth of the RN workforce. However, these federally collected surveys
do not gather information about the non-economic impacts of the
pandemic on RNs. The COVID-19 pandemic has exerted an enormous toll on
nurses, physicians, and other health care workers, particularly in
hospitals that were impacted initially by the pandemic and by ensuing
strains and waves of the Corona virus. For that broader context, I
defer to others to offer insights on the non-economic impact of the
pandemic on the RN workforce in the U.S.
Employment and Earnings of RNs \1\
---------------------------------------------------------------------------
\1\ This section draws largely from: Auerbach, Buerhaus, Donalan,
and Staiger, ``A worrisome Drop in the Number of Young Nurses,'' Health
Affairs Forefront, April 13, 2022; Buerhaus, Staiger, Auerbach, Yates,
and Donalan, ``Nurse Employment During the First Fifteen Months of the
COVID-19 Pandemic,'' Health Affairs, January 2022; and Auerbach,
Buerhaus, and Staiger, ``Implications of the COVID-19 pandemic for the
future supply of registered nurses,'' unpublished manuscript, 2023.
Over the last four decades the RN workforce grew steadily from just
over one million RNs in 1982 to 3.2 million in 2020. Today, the number
of per capita RNs in the U.S. is either on par with or higher than most
other OECD countries, in contrast with the number of physicians, which
is among the lowest of these nations. In 2000 there were projections of
looming RN shortages as large numbers of RNs were nearing retirement
age and few younger people were entering the profession. \2\ In
response to these projections numerous initiatives and public awareness
campaigns generated increased interest in nursing as a career among
younger people, resulting in continued steady growth of the workforce.
---------------------------------------------------------------------------
\2\ Buerhaus, Staiger, and Auerbach, ``Implications of an Aging
Registered Nurse Workforce,'' JAMA, June 14, 2000.
Since the start of the COVID-19 pandemic the RN workforce has been
in flux. Recently published data found that the total employment of RNs
declined by more than 100,000 between 2020 and 2021, the largest such
decline since at least 1980. However, RN employment recovered
dramatically in 2022 and is now nearly 5 percent above where it was in
2019. Hourly earnings of RNs (adjusted for inflation) were relatively
unchanged in the decade before the pandemic, but have grown slightly
faster than inflation since 2019, while earnings across all occupations
have grown more slowly than inflation. \3\ Thus, as of 2022, both RN
employment and erning have grown at or above their pre-pandemic trends.
---------------------------------------------------------------------------
\3\ The number of nurses working for employment agencies--
including travel nurses--has nearly doubled during the pandemic. While
these nurses are paid more than other nurses, they remain a small
fraction of the workforce, accounting for less than 3 percent of the RN
workforce in 2022.
The most notable development during the pandemic has been a shift
of RN employment away from hospitals and into other settings such as
outpatient clinics, MD offices, schools, etc.: All of the growth in RN
employment between 2019 and 2022 occurred outside of hospitals. This
helps to explain why hospitals continue reporting shortages of RNs
despite robust growth of the overall RN workforce. Why this has
occurred, and whether this trend will continue, is less clear. The
shift away from hospital employment was particularly dramatic for older
RNs, consistent with reports of increased stress and difficult working
conditions exacerbated by the pandemic: A recent Medscape survey found
that 40 percent of RNs said that COVID-19 had negatively impacted their
career satisfaction. Actions will be needed to improve the workplace
environment and attract RNs back to working in hospitals. Otherwise,
hospitals will need to develop strategies to better utilize a smaller
RN workforce.
The Nursing Pipeline \4\
---------------------------------------------------------------------------
\4\ Data on applications to BSN programs and NCLEX discussed in
this section come from the National Council of State Boards of Nursing
and the American Association of Colleges of Nursing.
A key factor in understanding the future supply of RNs is the
educational pipeline. The number of applications to baccalaureate
nursing programs has risen rapidly over the past 20 years (more than
doubling). While application growth slowed in 2020, it accelerated
again in 2021, allaying concerns of declining interest in a nursing
career. However, the pandemic decreased the academic preparedness of
high school students entering nursing programs, which threatens to slow
their educational progression and entry into the workforce. \5\
---------------------------------------------------------------------------
\5\ https://www.prnewswire.com/news-releases/amid-a-national-
nursing-shortage-prospective-nursing-students-say-lack-of-academic-
preparedness-is-the-driving-decision-to-delay-or-forego-nursing-
school--301621715.html
Similar patterns have occurred in annual graduations from nursing
education programs and the number of NCLEX test-takers (the RN
licensure exam), which have grown steadily through the pandemic and
have never been higher. However, pass rates on the NCLEX declined
sharply during the pandemic, from 88 percent in 2018 and 2019 to 81-82
percent in 2021 and 2022, again suggesting decreased preparedness of
graduates to enter the workforce. Pass rates are likely to fall further
with the introduction of the more difficult NextGen NCLEX coming later
this year. Developing strategies to reverse these trends is essential.
Rural Nurses \6\
---------------------------------------------------------------------------
\6\ This section draws from Yates, Auerbach, Staiger & Buerhaus,
``Characteristics of rural registered nurses and the implications for
workforce policy,'' The Journal of Rural Health, 2023.
Rural RNs play an integral role in providing care for an
underserved population with worse health outcomes than urban
counterparts. In contrast to physicians, the number of RNs per capita
in rural areas is comparable to urban areas. While the number of
physicians serving rural populations has decreased in recent years, and
rural nurse practitioners (NPs) remain in short supply, rural RNs have
steadily grown in numbers at a rate comparable to urban RNs. Moreover,
young rural nurses appear on pace with urban nurses to adequately
---------------------------------------------------------------------------
replace older nurses and continue to grow the workforce.
While the numbers of rural RNs appear to be sufficient, the
characteristics of the workforce do not align with the needs of the
rural population. Rural RNs in 2019 were markedly more likely to be
white, non-Hispanic (89.1 percent) than either urban RNs (68.4 percent)
or the rural population they serve (77.3 percent). In 2011, the
Institute of Medicine recommended that 80 percent of RNs have a
bachelor's degree by 2020, yet only half of rural RNs had a bachelor's
degree or higher in 2019 compared to over 70 percent of urban RNs. The
Department of Health and Human Services has recently announced
``record-setting investments'' to bolster the rural health workforce,
including RNs, and to advance equity and ensure access to care. These
burgeoning investments in the rural health workforce present
opportunities to help diversify, increase educational access, and
further rural readiness for RNs moving forward.
Where Do We Go from Here?
While 100,000 RNs left the workforce in 2021, the RN workforce
rebounded in 2022 and is back on track with pre-pandemic projections.
In ongoing work with David Auerbach and Peter Buerhaus building on our
20-year record of forecasting the future growth of the RN workforce, we
have estimated updated forecasts of growth in the RN workforce that
incorporate these trends through 2022. Over the next decade we project
the national RN workforce to not only replace the expected retirement
of an estimated 500,000 RNs but further expand by nearly 1 million RNs,
with growth in RNs serving both rural and urban populations.
Nevertheless, there are three main concerns looking ahead:
1. Addressing the shift of the RN workforce away from the
hospital. While the exact reasons for this shift are not yet
clear, the trend is consistent with reports of increased stress
and difficult working conditions in hospitals exacerbated by
the pandemic. Improving the workplace environment will require
constructive engagement with nurses to identify supportive
characteristics of an organization's culture and reset trusting
relationships with administrative and executive leaders. Much
work has been done that hospitals and other organizations can
draw from to frame and guide these conversations, particularly
the National Academy of Medicine's National Plan for Health
Workforce Well-Being (2022). Maximizing the services provided
by the remaining RNs in the hospital will require redesigning
of care delivery models and removal of unnecessary restrictions
on nurses' scope of practice.
2. Addressing the decreased academic preparedness of students
entering and exiting nursing schools. The decline in academic
preparedness of students exiting nursing school may be short-
lived if it is driven by remote instruction during the
pandemic. However, it may continue for many years as students
graduating from high school suffer the lingering effects of the
pandemic. Recent estimates suggest that students in all grades,
particularly those attending high poverty schools, lag roughly
half a grade level behind pre-pandemic achievement levels. \7\
In either case, at least in the short term, nursing schools and
employers will need to develop "booster" programs to provide
their nursing students and new nurse employees with needed
training. Otherwise, the pipeline of incoming nurses will be
both fewer in number and less well prepared. It would be
appropriate for the federal government to provide some support
for this training through pandemic relief funds.
---------------------------------------------------------------------------
\7\ https://projects.iq.harvard.edu/cepr/education-recovery-
scorecard
---------------------------------------------------------------------------
3. Addressing the need to diversify the rural workforce and
increase bachelor's degrees among rural RNs. The American
Rescue Plan and CARES acts directed a new Health Workforce
Strategic Plan from the Department of Health and Human
Services, in which increased rural access to care and workforce
diversity are critical goals. Because RNs represent a large and
growing proportion of health care providers serving rural
communities, policymakers should consider directing some of
these resources toward the RN workforce to increase bachelor's
degrees among rural RNs and help achieve greater diversity
among the RN providers in rural communities. For example,
scholarships that require subsequent service in rural hospitals
(like loan forgiveness but without the negative connotations
associated with debt) could be used to encourage under-
represented groups to become rural RNs or to encourage rural
RNs with an associates degree to obtain a baccalaureate degree.
Finally, as I stated at the beginning, developing effective
strategies to strengthen the current and future RN workforce requires
timely data. One of the 4 key messages in the Institute of Medicine's
2011 report The Future of Nursing: Leading Change, Advancing Health was
that ``Effective workforce planning and policymaking requires better
data collection and an improved information infrastructure.'' The ACA
created the National Health Care Workforce Commission and the National
Center for Workforce Analysis to, among other things, coordinate the
collection of data and analysis of the health care workforce. This
would be an opportune time to use those existing structures to support
better data collection and continued analysis for monitoring the
lingering effects of the COVID-19 pandemic on the health care
workforce.
______
[summary statement of douglas staiger]
In my written testimony, I summarize recent and ongoing research on
the nursing workforce by me and others that is particularly relevant to
understanding the state of the current RN workforce, and then provide
some recommendations on where we go from here. Recent evidence suggests
the following:
1. After a worrisome decline in 2021, registered nurse (RN)
employment has recovered in 2022 and is nearly 5 percent above
where it was in 2019. RN earnings have grown slightly faster
than inflation, whereas earnings across all occupations have
grown more slowly than inflation. But the big change during the
pandemic has been a shift of RN employment away from hospitals
and into other settings such as outpatient clinics, MD offices,
schools, etc.: All of the growth in RN employment between 2019
and 2022 occurred outside of hospitals. This helps to explain
why hospitals are reporting shortages of RNs.
2. Applications to nursing schools dipped in 2020 but
rebounded strongly in 2021 and continue their steady upward
trend. However, there are concerns about decreased academic
preparedness of entering students. Similar patterns are seen in
nurses taking the licensure exam--continued steady growth, but
a notable decline in the pass rates in 2021.
3. The number of RNs per capita in rural areas is comparable
to urban areas and is projected to steadily grow amidst
declining rural physicians and limited rural Nurse
Practitioners (NPs). However, rural RNs are markedly less
diverse than the populations they serve and only half of rural
RNs have a bachelor's degree or higher compared to over 70
percent for urban RNs.
Putting this evidence together, we continue to forecast strong
growth in the RN workforce over the next decade. The main concerns
looking ahead are (1) a shift of the RN workforce away from the
hospital, (2) decreased preparedness of students entering & exiting
nursing schools, and (3) a need to diversify the rural workforce and
increase bachelor's degrees among rural RNs.
______
The Chair. Thank you very much. Let me begin the
questioning, and I will give the mic over to Senator Cassidy,
and we will go around the table.
As I mentioned earlier, in my state, in our largest
hospital, we have seen a huge expenditure of $125 million for
traveling nurses at a time when we have more young people who
want to become nurses but can't accommodate them in our nursing
schools.
Dr. Herbert, is that in fact just a Vermont problem or is
that a main problem? Is that a national problem?
Dr. Herbert. Senator Sanders, it is very much a national
problem. The traveling nurse situation that you described, you
are exactly right. We are seeing the exact same thing in Maine.
There's a number of reasons for it.
But I think what you are hearing from the panel today,
there is consistency in terms of the nurse educator problem.
But there's also hospitals are really strapped with the
workload issues that I that I described earlier in terms of
reimbursements.
It is complicated, but the clinical training sites like
hospitals need support to be able to accommodate more trainees,
which will help with the problem.
The Chair. Okay. Dr. Szanton, how are we going to--give me
some specific ideas as to how we get more nurse educators out
there so we can accommodate the number of young people who want
to become nurses?
Dr. Szanton. If we can increase all the programs through
HRSA, like the nurse corps, that would be a really concrete
suggestion. Currently, almost none of our students are able to
get the nurse corps because we are a master's program.
I think solving all the problems that we talked about and
having more simulation passing the FAAN Act would be ways of
quickly trying to increase the nurse faculty abilities of this
country.
The Chair. Okay. Dr. Hildreth, it is widely recognized, not
debated, that African Americans, Latinos, and Native Americans
are underrepresented in the health care profession and debates
that what is the impact of that. You know, people say, so what
is the difference? You know, so you have a white doctor, a
black doctor who cares? Is there a difference? What is the
difference?
Dr. Seoane. Thank you, Senator Sanders. The data is very
clear, as my colleague referenced earlier, that when the health
care workforce reflects the population, they care for, outcomes
are better. That is not to say that a white doctor can't
provide great care to a black patient.
That happens every single day in our Country and vice
versa. But when the provider team looks like the population
they are caring for, the outcomes are better. That has been
demonstrated over and over again. That is what we lose by not
having a diverse workforce, the best outcomes for communities.
The Chair. Thanks very much. Dr. Seoane, you talked about
large areas of Louisiana, in fact, all over this country, not
having enough physicians, nurses, etcetera.
It is a little bit outside of the scope of this hearing,
although I am going to get back to it because we have
jurisdiction over the community health center program. Do you
think that expanding community health centers in rural areas in
America would make a lot of sense?
Dr. Seoane. Thank you for that question, Senator Sanders. I
do. I think they are important. Ochsner is starting 13
community health centers throughout Louisiana. They serve an
important need.
The Chair. Are these federally qualified community health
centers?
Dr. Seoane. These are our own. We have gone outside the
federally qualified centers. So, we partnered with federally
qualified health centers, and we are starting our own community
health centers, too. We are meeting all the Federal health
qualified center guidelines, but it was quicker to get there
into our communities to serve.
The Chair. Would it be advantageous if they were FQHCs?
Would it work well for you or not?
Dr. Seoane. It would be advantageous if we could work with
the Government to make health centers like Ochsner be able to
start these federally health qualified centers and spread them
more quickly.
The Chair. Good. Let me ask, go back to Dr. Herbert. One of
the areas that we do have jurisdiction over, and I am very
strongly in support of, teaching health centers, GME. And that
is an opportunity to get residents out of teaching hospitals
and into primary health care facilities. Perhaps you and Dr.
Hildreth can say a word about that. Is that a good idea to
expand those programs?
Dr. Herbert. That is a very good idea. And because of the
caps on GME funding from the Federal Government, states have
actually stepped in and done some creative things. I mean, for
example, the State of Georgia has done that.
We are now working with colleagues in Maine to establish,
trying to get some legislation through the State of Maine to
actually directly fund GME through partnerships based in
community hospitals, but in partnerships with the teaching
hospitals.
There are some creative things that can be done. Could be
done much more fast, much more quickly if the CMS rules were
changed in the way they fund GME. But there is innovative,
other innovative ways of doing it.
But we absolutely need more GME. This is critical not only
for primary care but for some specialty care as well. Senator
Sanders and I worked--Senator Collins, and I apologize. We are
talking this morning about obstetrics and the closure of
obstetric units in rural hospitals and community hospitals.
Again, GME is really the key to addressing these various
issues.
The Chair. Dr. Hildreth, do you agree or--?
Dr. Hildreth. I definitely agree. And as you referenced
earlier, Senator Sanders, we want to make health care happen in
the lowest cost setting possible, and that is certainly
outpatient setting for primary care. I definitely agree that
more GME in those settings would be great.
The Chair. Great, good.
Dr. Hildreth. Thank you.
The Chair. Thank you very much.
Senator Cassidy.
Senator Cassidy. I am going to defer to Senator Paul.
The Chair. Senator Paul.
Senator Paul. Thank you. Dr. Szanton, are you pro-choice
with regard to patients making individualized medical choices?
Dr. Szanton. Broadly, thank you, yes.
Senator Paul. Are you aware that your university doesn't
allow choice with regard to vaccination, that you require all
of your students to have three vaccines in order to be
students?
Dr. Szanton. Yes.
Senator Paul. It is sort of choice, but not so much when
regarding vaccination. Are you aware of the increased risk of
myocarditis with the COVID vaccine, particularly with
successive COVID vaccinations in males between the ages of 16
and 24?
Dr. Szanton. Senator, thank you for the question. I am
prepared to talk about the nursing crisis, and that we have
vaccine requirements across the board for----
Senator Paul. Here is the problem, if you exclude everybody
from being a nurse who believes in basic immunology, you are
going to include a lot of smart people, people who believe that
you can get immunity from both vaccination as well as
infection.
If you say, well, we are just not going to take the people
who believe in that old fashioned infection thing, providing
immunity, we are only going to take the people who will do as
they are told. I mean, do you think individuals should be
treated the same when they come to the emergency room?
If you have got an 18-year-old with chest pain and a 68-
year-old obese diabetic with chest pain, you think they get
treated the same in the emergency room? There are differences
based on age. We used to always make differences even on the
flu vaccine. We advise it for people at risk. We have done this
forever.
This is the first time we have done it. We are now doing it
with an experimental vaccine, one that has not been approved.
Do you think that prior infection affects your immunity?
Dr. Szanton. Senator, I am not--I don't make the choices
about the vaccinations. That is a Johns Hopkins University----
Senator Paul. Right, but you are a leader at Johns Hopkins
University and you could well have your opinion stated. Dr.
Marty Makary is there, and Dr. Marty Makary has been very
active in this. He has looked at the incidence of myocarditis
and he says it is 28 times more likely to get myocarditis from
the vaccine than from COVID for a particular cohort of young
men. Women, this also applies to, but more men and women.
I assume you have men and women in your nursing program.
This is a big deal and it might affect them. It affects the
Marines. It affects everybody else. We finally fixed it with
the Marines. We are not making them do it anymore. But the
thing is, is you are at an institution of higher learning. We
should have questions.
I know sometimes we have to do as we are told, but you are
also dean of the school. You have a voice. And we should be
curious about things. In Britain, France, Germany, Norway,
Sweden, Denmark, they don't have university mandates on this.
Some countries don't recommend it for children at all.
There really is a debate and discussion. You can have an
opposite debate, but if you believe in choice, when something
has a debate and there are arguments on both sides, you would
give people the choice. So, the CDC did a study of a million
patients. That is a pretty big study. It is an observational
study, but it is a large study. And they asked, what are the
chances that you will go to the hospital? And they divided into
different groups.
One group was vaccination, and it showed a 20 times, and
this has been repeated a lot, 20 times lowering of your rate of
going to the hospital if you have been vaccinated. I think most
people accept that.
Now, it doesn't stop transmission. So, when you mandate
this, you can't make any arguments about protecting other
people. It is only about you at this point. But what they also
found in this study of a million people was that people who had
not been vaccinated but had been infected on a prior occasion
by COVID were 57 times less likely to go to the hospital. So
really it isn't an argument against vaccination.
I mean, if you haven't been infected, you ought to be
vaccinated, but you got to have a choice. You are not giving
people any choice. And actually, this applies to all your
universities. None of your universities--I think we all mandate
three vaccines. And frankly, I think the literature actually
shows it to be malpractice.
That is why you should all have a voice in this. A large
study in Israel shows that the rate of myocarditis among
vaccinated is about 1 in 3,000 to 1 in 6,000. There is another
study that shows it is 40 times greater. So, between 28 and 40
times. And this isn't an argument against vaccination, it is an
argument for thinking and understanding the people of different
ages could respond differently.
My hope, and what I would offer to all of you is that
people should speak up. We are living in a world where
everybody sticks your head in the sand and says, do as you are
told, take three vaccines. And there are people with
myocarditis that are seriously ill currently. I mean, think
about this.
Here is a question, your 15-year-old kid has had COVID,
takes the vaccine, and has myocarditis enough to be
hospitalized. What would you do? Would you give him another
vaccine?
Dr. Szanton. Thank you. I am not--I will take into
consideration what you have said and I will bring it back----
Senator Paul. Well, it is an individual decision, and you
ought to be able to answer. At least be honest and look
backward. The thing is, the CDC says if your kids had
myocarditis, got sick and went to the hospital, as soon as he
gets better, give him another one. I think most parents in the
country would say that is a stupid idea and defies all common
sense and they would resist this.
But when the Government tells you to do it and it is a
really stupid idea that defies common sense, guess what, people
lose trust in Government. People--we want to have trust in the
people running our medical schools and our nursing schools. But
somebody needs to ask these questions.
Dr. Marty Makary is doing it. Dr. Vinod Prasad is doing it
out at UC San Francisco. And it is a growing movement, but I
would hope that you all will open your minds to at least
thinking about the choice of the individual in medicine.
The Chair. Okay. Thank you, Senator Paul.
Senator Hassan.
Senator Hassan. Well, thank you very much, Mr. Chair and
Ranking Member Cassidy, for this hearing. And thank you to all
of our witnesses. I greatly appreciate what all of you do. Dr.
Staiger, I wanted to start with a question to you.
Thank you again for being here and for sharing your
expertise on the workforce shortages facing health systems in
New Hampshire and all around the country. As we work to address
this shortage, we don't want nurses or other health care
workers to have to leave their jobs to get a degree or
credential that they need to advance their career.
Last Congress, I worked with Senator Young to introduce the
Upskilling and Retraining Assistance Act, which would double
the amount of tax-free educational assistance that workers can
receive as a benefit from their employers.
Dr. Staiger, would offering tax free education benefits
help keep health care workers in the field and ease the labor
shortages facing hospitals and other providers?
Dr. Staiger. I actually think that is quite a good idea. It
is--I think of it as scholarships from your employer, right.
These are often offered with the agreement that you have a
commitment to the employer afterwards, which is a good way,
rather than doing a loan, to support this.
You keep them in, they tend to take a day off here or
there, and they stay connected. I especially think these are if
you had to target this, it should be targeted in places that
are--where we have particular need, sure.
Senator Hassan. That makes sense. Let me turn to Dr.
Herbert. When I visited with health care leaders at Memorial
Hospital in North Conway last month, they told me about the
challenges that they face every day as a result of the nursing
shortage.
While it is essential that we train more registered nurses,
we also need these nurses to continue to practice in rural
areas of states like New Hampshire and Maine and Vermont after
they get their license. So how can we encourage nurses trained
in rural states to stay and practice there after graduating?
Dr. Herbert. Thank you very much for the question. We use a
three-pronged approach that we found helpful. The first is we
try to attract students from rural areas. And what we found is
students from rural areas are more likely to go and practice in
a rural area, even if it is not their same hometown.
That is the first key. Second, and this is very important,
regardless of where they come from, during training, placing
them in clinical sites in rural areas, very, very important.
They get a taste of rural life and many of them actually really
like small town and rural life and prefer to work in those
settings.
Third and most importantly is something I mentioned before,
which is either scholarship or loan repayment programs with
strings attached, with a commitment to practice in those areas.
You can do it on the front end of scholarships, on the back
end as loan repayment, but there needs to be an incentive
because, as Chairman Sanders said, if you are looking at a big
debt that you need to pay off and there is a major hospital in
Boston that will give you x additional salary, we need to at
least--even if we don't even if we don't make up the entire
amount, we need to offset that enough to incentivize people to
practice in rural areas. That three-pronged approaches, we
found it helpful for not only nurses but dentists and other
professionals.
Senator Hassan. Well, I thank you for that response. I will
add that the other piece of the conversation that came up in
North Conway and has come up all around my state, is just the
need for housing for employees, especially in rural New England
right now, Northern New England.
Dr. Herbert. Couldn't agree more.
Senator Hassan. Dr. Szanton, I wanted to ask you a
question. In response to the growing shortage of licensed
nursing assistants, New England College has created a joint
nursing education program with Eliot Hospital in Manchester.
The college's students earned 25 percent of their college
credits working as licensed nursing assistants at Eliot
Hospital. They graduate with a Bachelor of Science in Nursing.
How can we encourage these kinds of innovative partnerships and
other efforts to train and develop more licensed nursing
assistants?
Because what we are finding is these nursing assistants are
doing the work they need at the bedside, but they are also
getting critical clinical experience with oversight from nurses
in a clinical setting.
Dr. Szanton. Absolutely. I think that is a wonderful idea.
And we have such a shortage, especially in the hospitals, that
it is going to take it all of the above kind of strategy, and
some training in the clinical places, and some in the
universities. And that sounds like a wonderful idea.
Senator Hassan. Thank you. Dr. Seoane, in December,
Congress funded the training of 200 new physicians, including
at least 100 psychiatrists or addiction medicine specialists,
building off a bill that Senator Collins and I did, called the
Opioid Workforce Act.
Dr. Seoane, how will additional psychiatrists help meet the
existing behavioral health crisis, and what more can we do to
continue developing the behavioral health workforce?
Dr. Seoane. Thank you for that question. There is a
critical shortage of psychiatrists in the U.S., and in
particular in my state. That is why at Ochsner we have our
scholarships around primary care and psychiatrists. And
psychiatrists are part of a team.
They are psychologists, nurse practitioners, and others
that can participate in that. But that program is essential to
growing the workforce. And psychiatrists are they are the
spearhead to help be part of the solution for this mental
health crisis that we are facing in the United States.
Senator Hassan. Thank you very much, thank you, Mr. Chair.
The Chair. Thank you, Senator Hassan.
Senator Cassidy.
Senator Cassidy. I will once again defer this time to
Senator Collins.
Senator Collins. Thank you very much, Senator Cassidy. Dr.
Herbert, I do want to follow-up with you on the issue of the
shortage of nursing faculty. It just is astonishing to me that
at last, I guess it was in 2021, almost 92,000 applications for
baccalaureate and graduate nursing programs were turned away,
with faculty shortages cited as the top reason. And the
University of Maine this year had 1,239 applications for only
80 slots.
I think there is this misperception that people don't want
to become nurses when in fact we have a ton of applicants from
people who do want to enter the field of nursing, but we don't
have the professors to teach them. And that is why the Chairman
and I and the Ranking Member have been working hard to come up
with a solution.
I want to--more with you on how we bridge the faculty gap.
You mentioned in your testimony, Dr. Herbert, that in some
cases, practicing clinicians can be recruited to serve as
faculty instructors in their existing workplaces. Could you
give the Committee an example of how UNE is working with an
academic institution or a hospital to expand training capacity?
Dr. Herbert. Thank you very much, Senator Collins. We are
doing exactly that. First of all, I agree with everything you
said. It is a real problem. And you are also right that there
is a lot of demand out there for people who want to become
nurses and other health care professionals, and, but with
limitations on what we can do. At UNE, we have increased the
number of nurses.
We trained 300 percent in the past 10 years, so we are
continuously looking how we can expand that. A program along
the lines that you are describing is something we are doing in
partnership with MaineHealth. MaineHealth is Maine's largest
health care network of providers, and also has branches in New
Hampshire as well, Southern New Hampshire.
We, what we are doing is we are actually using the faculty
onsite, using nurses onsite. We provide professional
development and support from the university to have them train
people onsite, in the MaineHealth hospitals, hospitals system.
So, using clinicians, this is part of that laddering approach.
We are also training the nurses, upskilling the nurses,
going from LPNs to RNs, RNs to BSNs, BSNs to nurse
practitioners onsite, in partnership with MaineHealth. And we
are looking to expand that program with other health care
programs as well. So, trying to find creative ways of
addressing the faculty shortage.
Senator Collins. Thank you. Dr. Staiger, I saw you nodding.
Did you have something to add?
Dr. Staiger. I was just going to say I--there has been such
strong growth in the number of people going through nursing
schools. Applicants have outpaced that, so that is why there--
the thing and so we shouldn't be surprised there are faculty
shortages.
It has been chronic because we have tripled the number of
students going through nursing programs in the last 25 years.
That, nobody thought that could happen 25 years ago. It has
been heroic what the nursing schools have done.
It is, it is a chronic problem. I also think it is a
problem that the nursing schools have been able to solve with
help, and I am optimistic going ahead.
Senator Collins. But we have still got this huge gap. Dr.
Hildreth, I was very moved by your testimony, and I was
reminded of the fact that one reason UNE has been so successful
in getting its graduates to practice in rural areas is they do
that third-year program in rural areas. So, do you do something
similar to that in order to encourage people to return to
underserved areas?
Dr. Hildreth. Thank you, Senator Collins. I mentioned
earlier that we are really happy that the Governor of
Tennessee, Governor Lee, and his leadership helped us create a
program where we recruit students from rural areas to come to
university there, and they are admitted into medical school at
the same time.
It is an accelerated program in which their tuition is
paid, both undergraduate and medical school, and they have
committed to go back and work in the communities they come
from. I think that is a model that should be repeated all over
the country. Thank you.
Senator Collins. Thank you.
The Chair. Thank you very much, Senator Collins.
Senator Hickenlooper.
Senator Hickenlooper. Thank you, Mr. Chair. And thank all
of you for your work and your commitment to this at a time
when, as both the Chair and the Ranking Member made so clear in
their opening statements, this is an emergency and you all
share that sense of urgency. Dr. Seoane, while I was Governor
in Colorado, we worked hard to expand youth apprenticeship
opportunities.
I was moved to read the testimony about the different ways
Ochsner is using apprenticeships to foster interest in medicine
and as a workforce solution. Especially enthusiastic to learn
about the Ochsner Nursing Pre-Apprenticeship Program, which is
open to high school sophomores hoping to serve more than 600
students over the next 2 years.
That really is incredible. Have any of your pre-
apprenticeship program graduates remained with Ochsner or
stayed in the field, and has opened these programs to high
school students helped--you know, do you see an impact in terms
of addressing your challenges?
Dr. Seoane. Thank you very much for that question, Senator.
It is early in the program. We started in 2021. We have
currently about 350 apprenticeships in the program. By this
fall, we will have 600 students in the program.
It is early in the program. But we--but this grew out of
another program, the MA Now Program, which is a program where
we went into our communities, underserved communities, where
they had high unemployment rates, partnered with our local
community partners there to identify applicants for MA Now
Program. And then we certified those programs.
There is 6 months training. We trained them, they got a
certificate program to be an MA. Now we have over 600 of those
MA we hired through that program. The apprenticeship program
for us is very important as we launched our Healthy State
Initiative, which is Ochsner's initiative to do a collective
impact in Louisiana to improve our health rankings from 50th,
which unfortunately is where we have been, 50th or 49th for the
last 30 years, to 40th over the next 10 years.
High school graduation rate is one of the key factors for
our poor health rankings. So, this apprenticeship program
really gets at two components. One, can we get to our
sophomores in high school, keep them in high school by allowing
them to work as apprentices to nurses, and therefore pay them
some during high school, and then they get a free year of
community college when they finish high school, and then they
are an LPN.
We are early on in the program, Senator, but we are very
enthusiastic about it.
Senator Hickenlooper. Great. I am very excited about it as
well. I have talked to both Cassidy and Senator Sanders about
the value of apprenticeships, looking at that on a broader
scale in health care. The pandemic showed us how important it
is to address the shortage of public health workers.
Colorado offers a first of its kind state program called
Colorado Public Health Works that connects AmeriCorps
volunteers with a registered apprenticeship program run by the
Trailhead Institute.
This allows AmeriCorps members to gain valuable, on the job
apprenticeship experience while helping meet our public health
needs at the same time. Dr. Staiger, how can we build out
programs like this to help address our larger public health
workforce needs?
Dr. Staiger. Not sure I have great concrete advice on that.
I think these kind of programs are critical. Everyone has
talked about the step step programs and people going there
wasn't--didn't used to be a career ladder here for people to
get trained and gradually move up from medical assistant to RN
to NP, etcetera.
I think the more we can encourage that, the better. I still
think this is best done by providers, right. They are the most
close to the ground. They can figure this out. So, providing
them with the resources and incentives to develop these
programs.
Senator Hickenlooper. All right. But facilitating also, I
think using resources like AmeriCorps and making sure that you
can facilitate that connection.
Dr. Staiger. Yes, that is exactly----
Senator Hickenlooper. Dr. Hildreth, as I do--well, I will
leave that. I will go on to the next one. I can get carried
away. Dr. Herbert, I was going to ask you about the IPE and
that effort. Well, let's just--I will give that a written
question. Just know that I am very attracted to and, appreciate
the IPE model, and I think the collaboration and what it allows
providers is a big thing.
I will go to Dr. Hildreth, and you have spoken about the
critical needs in terms of how important it is to increase
diversity. I have been on a number of roundtables where the
small numbers of not just doctors but midwives, in terms of how
expectant mothers are taken care of, really, the women of color
don't get offered the same choices, right.
The only way we are going to change that is really to
change the makeup of who are tending to them. How can we foster
programs that encourage early exposure, this kind of early
exposure at the Federal level that make sure that younger kids
see a role for them in health care?
Thank you, Senator, for the question. What we have done at
Meharry is we have adopted two middle schools. And what we do
is we make sure that our student in medical school, dental
school, and our graduate programs are present with those kids
to show them that it is possible for them because they see
students in professional programs that look like them, and we
think this is a very powerful way to get students engaged early
on and keep them engaged by having our students interact with
them. Thank you for the question.
Senator Hickenlooper. Thank you. I yield back.
The Chair. Senator Cassidy.
Senator Cassidy. I will defer to Senator Romney.
Senator Romney. Thank you, Senator Cassidy. I was struck by
the Chairman's opening comments that we spend so much per
person in this country and health results are not that much
different. We spend almost double as much as the people in the
average developed nation in health care.
Sometimes we in Washington think, well, the answer is to
spend more. But I would suggest that there must be a different
approach. If we are already spending almost twice as much as
everybody else, then there has got to be some other reason that
we are not able to provide the quality at a reasonable cost
that we would like to do.
I note that my prior experience in the private sector
showed that almost everything that we buy gets better and
better, better quality and lower cost in real terms over time,
and that productivity increases over time.
The exception to that are really three major areas, health
care, education, and the military. Those happen to be three
areas that are dominated by Government. I think I have an idea
as to where the problem lies and would suggest the right answer
is, is not more Government.
In this case, I think we can look at health care and say,
we have--what is the old Pogo cartoon? I have met the enemy and
the enemy is us. And one aspect of that enemy relates to
immigration. My understanding is that typically almost 20
percent of the nurses and medical professionals this country
come from foreign countries. But the backlog of medical
professionals that want to come into this country has become
enormous.
We required them to be interviewed, and given our security
needs, it is appropriate that they be interviewed about the
State Department. But apparently, the State Department is still
so concerned about COVID that they are not interviewing these
people.
Places like the Philippines, where there are some 30,000
people who want to come here and serve as nurses, we can't get
those nurses in. Are you aware of this feature, given by the
President of college at the University of New England, are you
aware of the fact that our Government is just not doing the
interviews necessary to bring people in that would help
dramatically reduce our nursing shortage?
Dr. Herbert. Senator Romney, I'm going to be honest with
you, I am not aware of that. I am not up on that particular
issue with the interviews. But if I--I am going to be happy to
speak to because I agree with you about the importance of
immigrants in our health care workforce.
More broadly, if I can just very quickly say, one of the
things we need is programs like we are doing at UNE in our
pharmacy school and our dental school, which are programs that
are accelerated programs that take foreign trained dentists or
pharmacist or doctors for that matter, and then help them
become eligible for American licensure.
To meet the requirements so they can sit for their exams
and become eligible. So, these accelerated programs are very
valuable. And because we have professionals who are legal, they
have green cards, they are in some cases citizens, and who
could work but can't work in their field that they were
trained.
They may have been a surgeon for 20 years in a foreign
country, but and these are often people of color from the
developing world. So, we have developed programs in that
regard. But then you also have, and just in the case of Maine,
to give you an example, we have a lot of asylum seekers from
Africa and they are sitting in hotel rooms and can't work and
they want to work.
Senator Romney. Yes. Let's interview these people. Let's
stop allowing our Government workers to work from home saying,
because they have COVID, we can't allow you to come back to the
workplace. You can't do the interviews of these people who want
to come to our Country and fill the desperate needs we have in
health care.
If we have a nursing shortage and a doctor shortage, let's
let those who are in line that are qualified come here. I agree
with you with regards to the education programs. I note with
regards to educating our own citizens here, the work that you
are doing in your respective institutions is critical.
There is one in the Western part of our Country called
Western Governors University. You are probably familiar with
it. It graduates more nurses than any other institution of
higher learning in the country. Its tuition, Mr. Chairman, is
$6,700 every 6 months, very reasonable tuition compared to the
cost in most places. 126,000 students at Western Governors
University.
It is a not for profit. It was established by former
Governor Mike Leavitt and the Governors of five other western
states. We have a capacity to educate. They can take on more
students at reasonable cost. So, the approach is that we can
learn from one another and expand the best practices that we
are seeing in some places.
But legal immigrants, following the legal process, where
the State Department does the job, they need to do and doesn't
stay home because of COVID, will allow us to dramatically
reduce the shortage that we are seeing in this country. Thank
you, Mr. Chairman.
The Chair. Senator Kaine.
Senator Kaine. Thank you, Mr. Chairman. Chair Sanders and
Ranking Member Cassidy, thank you for making this the first
hearing of this Committee in the 118th Congress. I think this
issue is huge and challenging, but one that is very amenable to
some bipartisan work that can be done.
Senator Romney beat me to the punch, not the first time,
because I wanted to talk about immigration. I was interested in
none of the opening testimony was this put on the table as a
potential solution, although I think in some of your written
testimony, a couple of you mentioned it. Just to give you a
numbers on this.
According to the Migration Policy Institute, as of 2018,
the foreign born comprise almost 18 percent of the 14.7 million
people in the U.S. who work in health care, nearly 1 in 5. The
foreign born make up a disproportionate share of certain both
high and low skilled health care workforces.
28 percent of our physicians and surgeons are foreign born,
and 38 percent of our home health aides were born outside the
United States. And this isn't just about employment-based
immigration, it is also focused on family and humanitarian
immigration systems.
Another statistic, more than 310,000 health care workers,
12 percent of the immigrants who are employed in health care
occupations are not here on work related visas, they are here
for humanitarian reasons, resettled refugees, asylees, special
immigrant visa holders, TPS recipients, and Cuban and Haitian
entrants.
President Herbert, you have already addressed this with
Senator Romney, but what could we do with an immigration reform
that is focused on health care or other critical workforce
areas that would make all of your jobs easier in educating a
diverse and sufficiently sized health care workforce?
Dr. Herbert. Senator Kaine, thank you very much. First of
all, I should say I am not an immigration expert. I make no
pretends to be, but I echo your concerns. I think that there is
no question that immigrants disproportionately go into health
care at various levels. They are very hard workers. They want
to work.
I can tell you from personal experience, at least locally,
what I see is a lot of folks who want to work, they are here
legally, but they are not able to work because of arcane
regulations that really should be changed. And so, yes, we
need--and we think we need to encourage immigration.
In a state like Maine, where we are losing native
population and the only way our population is staying stable
and even growing is through immigration. And there are many new
Mainers who want to work and are not able to.
Senator Kaine. My perception, and I don't have the data on
this, but my perception in Virginia is that the foreign-born
health care workforce is also more likely to work in rural
Virginia.
If I talk to the physicians in Appalachia, they are more
likely to be foreign born than if I am doing it where I live in
Richmond or metropolitan--other metropolitan areas of the
state. I have other topics I want to get to, but is anyone else
want to weigh in on immigration? Yes, Dr. Hildreth.
Dr. Hildreth. Senator Kaine, thank you for the question. I
have nothing against bringing in foreign born folks to work in
our health care enterprise. We have lots of talent we have not
tapped into in our own country here.
For example, it used to be that 26 percent of all the black
students who went to medical school came from HBCUs. It is now
less than 10 percent. Why is that? Because we have
underinvested, under-resourced those schools.
I would submit to you, but that by properly resourcing the
schools we have, we can fill a lot of that gap with native born
talent right here in the United States.
Senator Kaine. I have a piece of legislation that is called
the Expanding Medical Education Act, which I am going to
reintroduce this Congress, I introduced that in the last, that
is very focused on HBCUs and other minority serving
institutions. In your testimony and in doctor--is at Seoane.
Dr. Seoane's testimony, you both laid out some innovative
programs you are doing and the need for additional investment.
I completely agree with that. Let me ask a question about the
direct care workforce shortage or just bring it to the
attention of the Committee. Our direct care workforce shortage
is often left out of the conversation about health care
workforce shortages.
Direct care professionals make an average of $11.75 an
hour. They are some of the lowest paid workers in the economy,
but they provide difficult hands-on care to seniors and people
with disabilities. And this workforce shortage kind of
compounds other shortages.
I go to hospital emergency rooms and they say we have to
keep people in hospitals longer because the direct care
workforce shortage means that there are no placements where we
can discharge someone from a hospital to a long-term care
setting or to appropriate home health care.
I hope as we look at this problem, we will focus on the
direct care workforce. Finally, Mr. Chairman, I would like to
introduce a letter for the record. Johnson and Johnson wrote a
letter to thank Senator Cassidy and the whole Committee for a
bill we passed, the Lorna Breen Health Care Provider Protection
Act, which is to provide mental health resources to frontline
health care workers.
One of the ways we will keep a robust health care workforce
is making sure that they have the resources they need to be
resilient. I would like to introduce that letter for the
record, if I could.
The Chair. Without objection.
[The following information can be found on page 81 in
Additional Material:]
Senator Kaine. Thank you. I yield back.
The Chair. Thank you very much, Senator Kaine.
Senator Cassidy.
Senator Cassidy. I will defer to Dr. Marshall, who for the
first time in 2 weeks, is not wearing Kansas City Chiefs
colors.
[Laughter.]
Senator Marshall. Well, thank you, Ranking Member and
Chairman. I want to just remind folks that Kansas has two
nationally ranked basketball teams in the top 10 and it is time
to move on to basketball season. But I am honored to be here
today to talk about an issue near and dear to my heart.
This is the dream, the nightmare that I have lived the last
40 years of my life. There has been a physician shortage in
rural America for at least 40 years. There has been a nursing
shortage in rural America for at least 20 years. So, the
challenge before me as a person operating a private practice in
rural America has been to recruit doctors, and then as running
a hospital, is recruiting nurses.
Myself, I went back to rural America. One of the reasons
is, was I had a scholarship, a state sponsored tuition
scholarship if I would go back to an underserved area. My
partner was a recipient of a National Health Service Corps loan
as well and was able to repay it. So those are certainly some
of the things that are working.
I want to talk about nursing shortage for just a second. 80
percent of the nurses could come from community colleges. Let
me say that a different way. 80 percent of the jobs in health
care can be done with community college nurses.
Community colleges are the answer to the nursing shortage.
Those folks are typically from a small town. They are going to
go to that small town community college, are more likely to
stay in that small town.
Of all the students from my hometown that went off to the
university medical school, I could maybe count on my hand the
ones that came back. There was a 4-year program in Fort Hays,
more of a rural community program. Those folks were more likely
to stay back. But once those young nurses tasted life in the
big city, they like it and they stay there.
As we think about going forward, I hope we can come back
and talk to the community colleges nursing programs a little
bit more. What can we do to accentuate them and the small
colleges as well? There are quite a few small colleges with
good 4-year programs as well.
By the way, their student debt is maybe a fourth or a fifth
of what a person who went to a university would be. Talk about
physician shortages for a second. We will go on the other end
of the spectrum. A lot of our physicians are leaving the market
right now because of burnout. Issues like prior authorization,
surprise billing.
Our ER doctors have just been overworked and underpaid, if
you will, but mostly they are burned out. They are getting
burned out on that with the surprise billing issues and just
frankly, just the COVID epidemic just overwhelmed the system.
Those folks are leaving, leaving like we have never seen
them before. Nurses again we forced them to take a vaccine.
Some of them didn't like that. And certainly, they were burned
out as well. Anyone want to speak to burnout in the profession?
Just one of you go ahead.
Dr. Seoane. I will speak to it. Thank you for that
question, Senator Marshall. Look, I think what sometimes we
forget when we are not on the front lines of health care every
day is that the pandemic for us, for many of us, we can go and
turn off our TV and go back home or work from home or work from
our offices, and we can get away from the pandemic.
We can get away from those stressors. For those frontline
nurses and those frontline physicians, they can never get away
from the pandemic. It is day in, day out, and it takes a toll.
It is an impact on ill people, death and dying, and it has been
a marathon for them, not a sprint.
That marathon continues. I think we have got to work on
ways that we can improve the working environment. And it has
been a more violent working environment as there has been more
verbal and physical assaults on health care providers.
To that end, I think at Ochsner, we have really taken the
approach of we have a wellness office. We have provided a lot
of wellness programs for our nurses and physicians. We also
worked with our State Legislators and State of Louisiana to
make violence in the health care workplace a felony.
Also training our workforce on de-escalation techniques.
But we have to be proactive in this area. And then I think the
other thing, and speaking with the nursing programs, is we got
to develop innovative new ways to think of respite for our
frontline nurses. So, one of the things----
Senator Marshall. I am sorry, I am running out of time. I
am. Sorry. So those are--I mean would you quickly talk, though
about residency programs. Where Kansas loses our doctors and
our medical students is residency programs. We don't have,
specifically our primary care doctor slots.
One of the challenges I see is that the orthopedic
residencies are a moneymaker for hospitals, so the hospitals
are willing to fund them, but primary care is not a moneymaker
for hospitals, and consequently they don't want to fund them.
They want more Government funding.
Just--I am sorry, I am over time, quickly address just how
big medical center hospitals look at primary care residencies
as opposed to, say, a specialty residency that makes money?
Dr. Seoane. Well, primary care doctors are essential for
any large health system. And especially a group practice
integrated health system like ours, primary care doctors are
key. So, we value them as much as we value our orthopedists.
As Senator Sanders already mentioned, I think being able to
fund community-based clinic, primary care to expand our funding
for primary care residencies, we would be very excited about
that.
Senator Marshall. Thank you. I yield back.
The Chair. Thank you, Senator Marshall.
Senator Markey.
Senator Markey. Thank you, Mr. Chairman, very much. And
thanks to our witnesses, and thanks for focusing upon the
critical health care issues that are facing our Country today.
Massachusetts is renowned for its top research institutions and
its second to none health care system.
It creates an ecosystem for innovation and for care. But at
the same time, even in Massachusetts, there are 19,000
positions sitting empty in acute care at hospitals. Half of all
licensed practical nurse positions at acute care hospitals sit
empty.
But home care aides, mental health workers, social workers,
paramedics, 1 in 3 of those jobs is empty in Massachusetts. I
appreciate the concerns I am hearing from more rural states,
but we have the exact same set of issues.
It is an urgent crisis. Patients are facing long wait times
for an annual well visit. Kids are sitting in adult emergency
rooms for hours, days, weeks, waiting for mental health
treatment in Massachusetts.
People trying to get help meet deadly delays in access to
opioid use disorder treatment like methadone medication, and
the health care system strained under the weight of surges like
the COVID pandemic and natural disasters.
Meanwhile, our health care heroes who get into their
careers to help people, in their greatest hour of need are
facing their own hour of need. The current system is forcing
them to make impossible choices when faced with huge caseloads,
immense pressure, intense burnout.
Advocates in health care unions across the country are
fighting to make sure we can keep our workers on the job
through better pay and safer working conditions. But without
enough of these critical workers, health care centers are
closing their doors, turning people away, happening in
Massachusetts, are forcing patients to wait in line for care.
We have to make sure that we care for our health care
workers. So let me ask you, Dr. Herbert. I am hearing over and
over again that children are waiting for behavioral health
services or people are having trouble getting treatment for a
substance use disorder.
For people in rural communities, in Western Massachusetts
or in Northern New England, obviously these problems are very
real. Can you talk about that and what you would recommend as a
solution?
Dr. Herbert. Absolutely. And let me begin by saying that I
completely agree with you. My comments are largely focusing on
rural, the underserved areas and rural areas. They are
absolutely, and as the Chairman entered it in his introductory
comments mentioned, there are underserved areas in urban areas
as well that are just as acute and problematic.
In terms of behavioral health, we need--there is a number
of things that we need. The first thing I would say is there is
a critical shortage of psychiatrists, but we are not--we are
never going to train enough psychiatrists to meet the
psychiatric needs of underserved areas. It is just, I just
don't see it happening in the next decade. There are answers,
though, for example, nurse practitioners.
We can train more nurse practitioners in psychiatric--to be
psychiatric nurse practitioners, and we are developing
precisely one of those programs right now. So, there is--we
need the full range of behavioral, investments in the full
range of behavioral health services, all the way from
psychiatry, nurse practitioners, down to in some states like
Maine, there are opportunities for a credential for
undergraduates with an undergraduate degree to work in
behavioral health.
Most states don't have that. We do. I think more states
should so that you can actually at entry level mental health
position, behavioral health in nursing homes, and in various
kinds of community settings, schools with just a bachelor's
degree, and so we need investments across the board.
Senator Markey. Yes, no question. My wife is a
psychiatrist, so I appreciate this mental health crisis that we
have in our Country right now. We have a climate crisis as
well. And climate can impact upon a community's health care
resources. Dr. Seoane, could you talk about that in Louisiana.
Dr. Seoane. You know, unfortunately, because of our
geographic location, we are no strangers to hurricanes. And we
have dealt them--I grew up in New Orleans, so I have dealt with
them for a long time, and we continue to deal with them. It is
unfortunately part of our way of life down on the Gulf Coast,
and we just look at ways to be resilient and adaptive.
Senator Markey. How difficult is it, given the sometimes
catastrophic events that you have to deal with?
Dr. Seoane. I think it is quite obvious that we deal with
this. I will say it brings the community together, and of
course, it is difficult, yes.
Senator Markey. Okay. Thank you, thank you, Mr. Chairman.
The Chair. Thank you, Senator Markey.
Senator Cassidy.
Senator Cassidy. I will defer to Senator Budd.
Senator Budd. I thank the Chair. Thank the Ranking Member.
I have heard firsthand from patients, doctors, nurses, and
hospitals all around North Carolina about ongoing workforce
challenges.
I think we need to focus on preparing future health care
workforce. For example, Wake Forest, Early College of Health
and Sciences, partners with Wake Tech, Community College, and
WakeMed to provide students with hands on experience,
certifications, and even college credit. So, in the House of
Representatives, I led the Critical Health Care Careers Act.
The bill would help community colleges prepare the next
generation of health care workers. Students should have the
opportunity to gain on the job experience to prepare them for
careers in health care.
Dr. Seoane, what steps is your health system in Louisiana
taking to offer new credentials and educational opportunities
for workers to join the health care workforce?
Dr. Seoane. Thank you for that question. I mentioned the MA
Now Program, which is one where we partner with our
communities, where there is high unemployment or
underemployment to introduce workers into the health system
through the medical assistant job.
Then it is about upskilling, as Senator Cassidy has
mentioned. We like to call it earn as you learn or the ladders,
and then taking those MAs and then working with our community
colleges to be able to, as their work, support them, give them
free tuition, to be able then to become LPNs, associate
degrees.
Then now we are working with our university partners for
them to be able to have bachelor's degree. That story that
Senator Cassidy shared with us is exactly what we are trying to
do by getting more entry level into health care and then being
able to meet our health care needs. And it is a win, win across
the board, right.
We are leveraging the human capital of the State of
Louisiana and Mississippi, but we are also giving people a
living wage for them to raise their family.
Senator Budd. Thank you. So earlier in your testimony, I
understand that you mentioned using non-physician providers
like CNAs, licensed practical nurses. Do you agree that
maintaining access to services delivered by non-physician, such
as testing, treatment, vaccinations at local pharmacies, do you
think that is an important part of addressing the health care
workforce shortage?
Dr. Seoane. You know, medicine is a team. It is a team
effort. Physicians are a very important part of that team, but
many other providers are also extremely important part of that
team, so I agree.
Senator Budd. Yes. So, what steps do you think institutions
should take? I know you are from the Louisiana perspective, but
as you think about all the way to North Carolina, what can
institutions do to better prepare health care workers to serve
patients outside of a traditional hospital setting? I am
thinking in-home telehealth, community health centers, or
anything else.
Dr. Seoane. You know, health care is shifting to
outpatient. And one of the things we need to do is to be able
to be innovative about how we care for more patients. And it
has already been mentioned at this Committee at lower cost
settings.
As we can transition an inpatient stay to a home stay, as
we can leverage a medical home model where we can have digital
tools, telehealth tools to--for patient who may have stayed in
the hospital 3 days now could stay 2 days.
That obviously opens up more hospital beds to care for more
acute patients, but it is also a more family, patient friendly
model as we transition toward this medical home model. So, we
would agree with that, and we currently are pursuing innovative
models that we can do that.
Senator Budd. Thank you very much. I would like to yield
back to the Ranking Member.
The Chair. Thank you very much.
Senator Baldwin.
Senator Baldwin. Thank you, Mr. Chairman. Thank you to our
panel of witnesses. Really appreciate the conversation that we
are having today. I wanted to start and raise once again an
issue that came up in previous questioning relating to violence
and harassment faced by health care providers, and how that
impacts the question that we are tackling today.
A recent study found that more than two-thirds of nurses
reported experiencing verbal abuse, and 44 percent reported
being subject to physical violence. Last year, I was proud to
reintroduce the Workplace Violence Prevention for Health Care
and Social Service Workers Act.
This Act would require health care and social service
employers to write and implement workplace violence prevention
plans to prevent and protect their employees from violent
incidents Violence against health care workers is totally
unacceptable, and we need, I think, to do more to provide
protection.
Dr. Szanton, I would like to ask you to reflect on how
violence against health care workers contributes to reduction
of staffing levels, burnout, and the consequences of reduced
staffing for patient safety. But since Dr. Seoane also raised
this, I would like to call on you additionally to comment.
Dr. Szanton. Thank you for the question, Senator.
Absolutely, it is an issue. I think we are in the middle of the
mental health crisis and a substance use crisis, and the way
that the country feels more and more fractured.
I think all of those together add to--you know, I talk to
nurses who say I used to be the hero walking into their room
and I used to have this respect based on being a nurse, and now
I don't always get that.
Suffer verbal abuse and sometimes physical abuse. I do
think that it has been mentioned that hospitals are going to
shrink and become more and more operating rooms and intensive
care units and that almost everything else will happen out in
the community.
I do think that when people are at home and in their
community, and in lower cost settings, and more family centered
settings, that some of that will dissipate.
Senator Baldwin. Thank you.
Dr. Seoane.
Dr. Seoane. Yes. I will say it is 28 years of practicing
medicine, including my training, and I have never seen such a
charged environment as every day throughout our health system,
at our safety huddle, our daily safety huddle, there is an
issue around either verbal and physical abuse to our health
care provider. So, it is a true crisis.
We have like I said, we have been working with our State
Legislators to make sure that it is a felony. We have put up
signage. And also, it is not just the, as you have pointed out,
the physical abuse, but the verbal abuse.
Part of that state bill was that if you interrupt the
ability to deliver health care by being verbally abusive, that
that also is now a crime, so.
Senator Baldwin. Well, and it also sounds like you said
your health care system is taking proactive steps. We want to
see that more uniform around the country. I also, turning to a
different topic, I have been proud to lead the bipartisan
Palliative Care and Hospice Education and Training Act with my
colleague, Senator Capito.
The bill would grow, improve, and sustain the palliative
and hospice care workforce. It addresses each aspect of the
health care workforce pipeline. Importantly, the bill provides
grants to schools of medicine and teaching hospitals to train
physicians who plan to teach and establishes fellowship
programs to give providers the opportunity to learn more about
providing palliative and hospice care.
Dr. Seoane, could you briefly describe why it is important
for academic health systems to provide physicians with both
training, to teach, and opportunities to build their skills,
upskill. And as a follow-up, how does additional training
support or alleviate burnout?
Dr. Seoane. Senator Baldwin, thank you very much for that
question, because 15 years ago, I created a course to train
residents in the intensive care unit around death and dying and
palliative care.
In that course, we taught residents with real cases, cases
that they experienced during their month in the intensive care
unit. And we had a debrief at the end where we went through
what they learned, but really kind of an emotional reset for
them.
There were some real critical learnings from that. One of
them was, while we were teaching them skills about having--how
to have difficult conversations and how to manage patients that
are critically ill, we quickly learned that one of the most
important parts of the course was actually the benefit to the
residents would be able to debrief, the mental health and
wellness for the residents to be able to be able to speak about
what they had experienced in that month.
Because remember, for many of these young medical students
are residents. That is their first experience with death and
dying. So, it has an incredible benefit to the wellness of our
health care workers. I have experienced that firsthand through
that course.
I want to thank you for putting that legislation forward.
We are trying to start our own fellowship in palliative care.
That is the next program that we actually are going to start.
And it is critically important for the way we practice
medicine.
As our population ages, it is critically important, not
just for health care providers, that we be able to provide the
appropriate care for patients in their time of need.
The Chair. Thank you, Senator Baldwin.
Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman. Thank you for
this hearing today. As you and I have discussed, workforce
within health care is something that is critically important.
We both come from rural states, and when I think about the
challenges that we face in providing health care in a big state
geographically with a small population and the many challenges
that we face, we can overcome a lot of that, but if we don't
have the trained workforce, it just doesn't come together.
Don't take my lack of Chair time here as an indicator that
I am not interested in addressing the challenges that we face
in this. We have got competing hearings this morning, and so I
have been jumping in between.
But one of the ways that we have been trying to facilitate
better access to care in a remote place like Alaska, where 80
percent of our communities are not connected by a road, is
telehealth. We are working on the broadband to connect
everybody so that that telehealth actually is more than just
the device, but it actually works.
I know that this subject has been raised, but I would ask
you, Dr. Seoane, apparently you had mentioned a pilot program
for virtual nursing education. So, in other words, this is a
big challenge for us in Alaska.
We got a nursing program, but how you get the teachers to
teach it. Can more be done with the nursing education programs
for telehealth as opposed to just how we are thinking about
telehealth generally?
Dr. Seoane. Yes. Thank you for that question, Senator
Murkowski. Look, telehealth is a critical component for how we
reach our rural communities and address some of this, including
on mental health, where there are many good models.
With the pandemic, we saw about a 400, 500 percent increase
in telehealth used in a pandemic. And we are able to
demonstrate effective care for many patients using telehealth.
I think we have learned a lot from the pandemic.
On the nursing side, our virtual nursing program really is
a, not an education program, although there are some learnings
for the bedside nurse, as it is a patient facing program. And
so, there is a bunker where we 24 hour monitor the patients and
that allows the nurse then to be at the clinics--at the
bedside, caring for the patient, and all of that electronic
health, medical records, and all of that administrative work
can be done by the nurses in the bunker.
For instance, a good example would be upon discharge, which
could be an arduous process of all the paperwork to discharge,
the bunker can do a lot of the administrative and all the
discharge work while the bedside nurse can just do the clinical
work and we can quickly facilitate transitions from a patient
from the hospital to their home.
We haven't done a lot of on the telehealth education on the
nursing side other than that program. And like I said, the
good--the education component is that bunker also can work with
the bedside nurse as an education part.
Senator Murkowski. Let me ask a little bit different
question. And again, it speaks to some of the ways that we are
addressing health care challenges in Alaska. We rely a lot on
EMS, EMTs. I was just visiting with a woman from Chicken,
Alaska. Chicken has probably never been a population of more
than a 100 people.
Probably--but her son is an EMT there, and basically what
they do is they work to make sure that anybody, anybody out
there can be trained in emergency services. But I understand
that right now we have a significant shortage of EMS
professionals.
Studies have found that less than 20 percent of EMS
organizations, at least in Alaska, have an adequate level of
staff across the Nation. Turnover of EMS professionals hovers
near 30 percent.
Very few stay in their role long enough to establish the
stability that they need. What more do we need to do in this
area? We have been talking about everything else, but what
about emergency medical services? Dr. Herbert, you are nodding.
I don't know who to direct this to, so I will just throw it out
there.
Dr. Herbert. Thank you. I was just agreeing with you. I
tend to nod. I am not a good poker player, so.
Senator Murkowski. I am a nodder too. That is okay.
Dr. Herbert. But I will--first of all, I completely agree
with you about EMS. And so, there are many of us, I am sure my
colleagues on the panel are responding by strengthening our
programs in that regard. And we have a robust program at my
university. But if I could speak briefly about the telehealth
piece, because I completely agree with you. We face the same
challenges in Maine.
The last time you and I talked was in Reykjavik, and there
are people in Iceland and in Scandinavia that are really
leading the world in terms of telehealth developments. And so,
we have a lot to learn from those folks.
Telehealth is exploding in terms of beyond just telehealth,
digital medicine, being able to monitor chronic conditions
remotely and feed that information back in real time to
providers. And then in terms of rural settings, people think of
telehealth being from the provider to the patient, but it is
also the provider back to the tertiary care medical center to
get the consultation that they need.
Tremendous work going on in this. What I would simply add
is that we need to make sure that our regulations, the state
level regulations, licensing boards, accrediting bodies,
Government reimbursement, that it keeps up.
We saw some positive changes during the pandemic. We need
to make sure that those are sustained. But there is--my concern
is that with the incredible innovation that is going on, and
this really is going to be transformative over the next 10
years, that these entities are going to fall behind, and this
creates tension and delays the full utilization of telehealth
and digital medicine.
Senator Murkowski. Thank you. I am well over my time, so
thank you all. And we will probably be following up on some of
the telehealth conversations. Thank you so much.
Senator Lujan. Thank you, Senator.
Senator Smith, you are recognized for questions.
Senator Smith. Thank you, Chair Lujan. And thank you to all
of you for being here. I want to just note my good friend,
Senator Murkowski, and I have worked a lot on rural health care
issues together, so I appreciate your questions about that.
Both of us have large areas of rural communities in our
state. Though I think Alaska trumps Minnesota in some ways on
that. I just want to thank you for your questions there. I am
grateful for this hearing and the bipartisan spirit of this
hearing. I would like to start by focusing on the mental health
care workforce.
You know, even before the pandemic, we knew that there was
a growing need for mental health services. And the pandemic
has, I think, shone a light on the deep need and made the need
bigger.
HRSA estimates that by 2025, we will need an additional
250,000 mental health professionals, from psychiatrist and
mental health and substance abuse, substance use disorder
specialists, school psychologists, school counselors.
Of course, as Senator Murkowski is pointing out, rural
communities are much more likely to have a shortage of mental
health professionals, and people of color are much, much more
likely to live in places where there is a shortage of mental
health care. So today we are talking about the barriers that
are facing people who want to get into this field, and one of
them is money.
This morning, I reintroduced my bipartisan bill, the Mental
Health Professionals Workforce Shortage Loan Repayment Act. You
do not need to remember the name, just remember the idea. With
Senators Murkowski and Hassan.
What our bill would do is to provide student loan repayment
for mental health professionals who want to practice in places
where there are shortages. Dr. Herbert, if I could start with
you.
Could you talk about the importance of loan repayment
programs? You said how important it was that they were
strategic in your opening remarks. I would like you--I would
like to hear more about that and tell us what you think we
should have in our minds as we design and move these student
loan repayment programs.
Dr. Herbert. Well, thank you, Senator, for the question. I
completely agree with you about the mental health crisis. And
it is important that--there is a number of things to say about
this.
First of all, we need to make sure that we train people in
primary care who are not mental health specialists to do mental
health first aid, to be able to--people in our schools, for
example, teachers, to be able to recognize and be able to make
appropriate referrals. So that is one piece that is there.
In terms of loan repayment programs, these can work very,
very well if they are done strategically. So just to give you
one example, the Chairman mentioned dentistry before, and we
haven't talked a lot about that today.
We have an incredible partnership with Delta Dental,
Northeast Delta Dental for loan repayment programs for dental
graduates who decide to set up shop in underserved rural areas.
And we have been able to place in the 5-years, five graduating
classes of our new dental school, we have been able to place
about 20 dentists in very, very remote rural communities that
didn't have dentists before.
With regard to mental health, it is the exact same thing.
We just need to make sure that we are targeting--that there is
a strong contingency where they need to practice in underserved
areas, either rural or urban areas, and it is not just--I mean,
I am great about loan repayment programs in general, but to be
maximally effective, they have to target underserved areas.
Senator Smith. Yes, exactly. I appreciate your comment
about training in primary care, because our brains and our
bodies are connected. It is one person, one body, and we too
often segment out our mental health care from our physical
health care in ways that are not good for our overall health
care.
Thank you for that. Dr. Hildreth, I so appreciated your
testimony, which I was able to hear before I went off to other
committees, about the crucial role that historically black
medical schools play, and the assets that you have when it
comes to relationships, and expertise, and trust.
I wonder if you could just--and also, I mean, you very well
pointed out the disparities that you experienced in terms of
the resources that you have available to build on your mission.
I wonder if you could talk a bit more about that.
Maybe I care a lot and have focused a lot on the great
disparities in maternal health care, maternal morbidity, the
disparities between black women and white women, and how that
kind of pans out as you think about the practices and the
people that you work with.
Dr. Hildreth. Senator Smith, thank you for the question.
And clearly, as we have alluded to earlier, when the provider
can relate to the patient in terms of culture, race, and all of
that, the outcomes are better.
There are studies to show that black women who are cared
for by black OBs have better outcomes, and our babies do as
well. But it all comes back to what I said earlier. We are--
have been training health care professionals who are really
competent and skilled, connected to their communities for
decades, but our challenge is the infrastructure we have to do
that. What we teach and how we teach it has changed
dramatically.
Majority institutions have been able to keep up with that
change, but we don't have the resources, for example, to do
small group teaching as opposed to on a stage. Standing in
front of 100 students in a lecture hall is a great way to
teach, but it is a terrible way to learn.
We need to change how we teach this. We like to do that at
our institutions, but we don't have the resources to do it. I
would just submit again that if you gave us those resources,
the payoff would be tremendous for the country. But thank you
for the question.
Senator Smith. Thank you very much, thank you.
Senator Cassidy. I will defer to Senator Braun.
Senator Braun. Thank you, Mr. Chair. I come from the world
of fixing issues. I ran a company for 37 years that was so
little, many of the issues didn't even come to the forefront
because you were worried about turning the lights on in the
morning, off in the evening, and all the stuff that happened in
between.
Lucky enough to take a little hard scrabble company and
turn it into a national distribution logistics company. Biggest
thing I wrestled with once we got larger was the high cost of
health care. And now, we have not only got that to contend
with, we have got the issue of how are you going to get people
into the business of it when it is the largest sector of our
economy. Travel, 92 counties in Indiana, workforce, workforce,
workforce.
It was a bigger issue now than it was pre-COVID, and that
is what I heard mostly pre-COVID. I can say one thing, if you
give good benefits, you pay your people well, folks come to
your door to work there. I weigh in on those issues a lot, and
every company is going to find its own way to do that. But
let's look at this issue.
I don't think that we would want to look to the Federal
Government to take on something so granular when currently we
borrow 30 percent of every dollar we spend here. I don't know
if you know that. It was about 20 percent when I got here just
4 years ago. Terrible long term business plan.
We are not going to be able to solve anything by borrowing
money from our kids and grandkids, and that is what this place
does. Let me turn my attention to what I think would work. I
think companies, I think the health care industry, let's focus
in on what we are talking about, has now become so top heavy
where doctors, the practitioners are wondering if it was even
worth it to get their degree.
Nurses as well, analogous to farmers in big Ag. Had a
startup recently in Indiana where a bunch of anesthesiologists
and surgeons wanted to start their own practice. It was almost
impossible to do. Most of them got fired from their hospital
they were working for. Let me tell you what they were able to
do. They were able to take a gallbladder removal that cost
$21,000 in Indiana if you were covered with insurance, $32,000,
that is bizarre, if you didn't have insurance but could afford
to pay for it. They are doing it for $8,000.
They are going to pay themselves twice as much in terms of
fees. That is what is got to change, basically, or else you are
not going to have anybody wanting to get into the industry. And
until you fix the industry itself with competition,
transparency, removing the barriers to entry, making it
entrepreneurial, the whole idea of getting people to work
within it is almost going to be a secondary consideration.
Now let's get to the matter of what we are talking about
here, workforce in a broken industry, how do you improve upon
it? Well, No. 1, I wouldn't look to this place. That ought to
be something that would be easy among the people in the
business.
If you are occupying 18 to 20 percent of our GDP, you ought
to be making some effort to do workforce through your own
businesses, which now is mostly hospitals, over 40 percent,
pharma is 15 percent, practitioners are shrinking because they
are going on the payroll of hospitals, and then you have got
insurance, which is kind of the Darth Vader of the whole
industry in terms of getting to any of this getting fixed.
I would say, because I wrestled and I was on our school
board locally for 10 years, this ought to be something we are
doing better in K-12. Look at the parents that regret that they
didn't have some guidance somewhere along the way in high
school or back in middle school that, don't pursue a 4-year
degree when only 35 percent of the jobs need it.
I get 10 people show up for that one. I got one open. I am
lucky on a Friday if three people come in for a job that would
pay as much as most 4-year degrees. But they show up on Monday,
and we got to get that figured out.
Better guidance in high school. Starting to take high
demand, high wage jobs, which nurses would be one of them.
Doctors, if you can put up with how long it takes to be
educated and not to be frustrated once you become one, we need
to do that back there, where you live within your means and you
get results.
Dr. Seoane, I would like you to comment and anybody else
fairly briefly, should we be doing more here, or is a solution
getting better value when they are in K-12, essentially middle
school through high school, for the problems we are dealing
with and talking about here?
Dr. Seoane. I think partnerships are important. I think we
need to work together. And we have done some of the programs
you have described. That is exactly what we have kind of done
with.
We have got the high school apprenticeship, going to our
high schools, partnering with our high schools, creating that
nurse apprenticeship program to keep them to graduate high
school and then become LPNs, and then move up.
Those programs that I describe in my statement have all
been supported through the Ochsner health system. But to scale
them, we need support from our universities, we need support
from our community colleges, we need support from our
Government. I do think it is a partnership.
Senator Braun. Good news. I see that happening back in my
own home state. And anybody else want to weigh in on that? Yes,
sir.
Dr. Hildreth. Thank you. I want to make a point that is
often missed, which is our health care is actually sick care.
And if we focused on keeping people without the need to see a
doctor, to be hospitalized, that is the solution. And some of
that $4.3 trillion we spend on sick care, if we reduce that by
10 percent, we would have $400 billion to invest in public
health, and that is exactly what we should be doing, in my
humble opinion.
Senator Braun. Amen to that, because I will part with this,
back 15 years ago, when I was sick and tired of hearing how
lucky I was that it is only going up 5 to 10 percent each year,
I was large enough to self-insure, I found out they were making
25 percent profit margins on the plan I had in place, and the
insurance companies told me just what you said.
An ounce of prevention worth a pound of cure, avoid the
business we are in. I took it to heart. Paid for 100 percent of
wellness. Skin in the game from dollar one. We have not had a
premium increase in 15 years and I got a healthier profile of
employees. Thank you.
The Chair. Okay. Thank you very much, Senator Braun. If you
see people running in and out, it is not lack of interest, it
is a vote on the floor.
Senator Lujan.
Senator Lujan. Thank you, Mr. Chairman. I want to thank
everyone for being here today as well. In rural areas like New
Mexico, primary care providers serve as vital lifelines for all
health care needs.
That is why the Project Echo Model, which was developed at
the University of New Mexico by Dr. Sanjeev Arora, is so
critical. Dr. Herbert, Project Echo, as you know from the
University of New England, Maine's own effort is a
telementoring model that gives health care providers access to
the tools and mentoring they need to treat complex medical
cases.
Project Echo was found to be effective at equipping primary
rural providers to screen for skin cancer when patients don't
have access to dermatologists, as just one example. Dr.
Herbert, as we work to address the shortage of health care
providers in rural areas, how can we better utilize and
innovate models like Project Echo to expand access to
lifesaving medical care?
Dr. Herbert. Excellent question. Thank you very much. And
we do have a Project Echo project at our university as well, so
I appreciate the question. I think it touches on a number of
issues.
First of all, the importance of prevention that we were
just talking about. Early assessment and intervention of
problems. Training primary care professionals to stretch their
scope of practice. So earlier today we were talking about scope
of practice laws that are overly limiting in terms of what
primary care can do.
Universities have a role in making sure not just in
training new students, but in providing continuing education
and professional development for existing providers using tools
like Project Echo.
But also, other kinds of continuing education tools to make
sure that our primary care workers, physicians and others, are
equipped to address a broader range of concerns. Because there
is no way in a rural state, we are going to be able to place
highly trained specialists of every kind in every community.
Senator Lujan. I appreciate that very much. Mr. Chairman,
we have already seen and witnessed the benefits of Echo models
for health delivery. We are starting to see more and more
benefit for educational opportunities as well with the Echo
model, so I am hoping that we will see expansion.
Dr. Hildreth, this will be for you, sir. Despite the
growing need for behavioral health services, the behavioral
health workforce has unfortunately been hemorrhaging workers.
More than 122 million Americans and 65 percent of New
Mexicans live in areas with mental health professional
shortages. While training and education are critical to build
on behavioral health workforce, I want to focus on keeping the
providers we have. Dr. Hildreth, how would dedicated retention
efforts for behavioral health workers impact this vital
workforce?
Dr. Hildreth. I think the retention is a really important
part of our strategy. But I would also say that getting more
training in behavioral health to primary care physicians who
are at the front lines of this.
We are not going to be able to train enough psychiatrists
to solve this problem, but by bolstering the training of
primary care doctors in behavioral health, that is going to be
a big part of the solution.
Again, one of the things I worry about is, they play such
an important role in our health care system, but they are, to
me, underpaid for what they do because they are the frontline
in bringing down the costs.
Because if you can catch someone early with a chronic
disease and get them into care, that is going to reduce the
long-term cost for the country. I would just suggest that
training primary care doctors in behavioral health has to be a
part of the solution. Thank you.
Senator Lujan. I very much appreciate that. Doctor, thank
you. Dr. Szanton, how can we explore promoting utilization of
services to include midwife expansion and benefits?
I have been a big proponent and having to explain to so
many that the services that midwives provide is not just
delivering babies to many communities.
This is the only care that they have and they are the
primary care providers in the area. So, in that respect, how
can we explore promoting utilization of these services to not
only support these families, but strengthen the health care
workforce as well?
Dr. Szanton. Thank you. Yes. Nurse midwives provide vital
care throughout the postpartum period, pre-partum, and during.
And they work often with doulas. And I think there has been a
lot of emphasis today about rural areas.
I think that focusing also on the infrastructure we do have
in rural areas like postal workers like daycare centers, like
Meals on Wheels, that we have got a lot of infrastructure we
can take advantage of for the health of the Nation.
But back to the midwives, they are just really essential
components, often under looked, and can provide really
comprehensive tailored care.
Senator Lujan. I appreciate that response. Mr. Chairman, in
my closing time, Senator Murkowski was asking some questions
around EMS providers as well, which I very much appreciate the
attention there.
As some of you may know, I survived a stroke a year ago. My
sister, who took me to the hospital from a rural community 30
minutes or so away from Santa Fe to where I live, had the
foresight to stop at a local fire department because they were
washing vehicles as she was passing by.
That was 5 minutes from my home. Those EMS providers
provided incredible care to me, immediately being able to
provide stabilization, and I know communicating with that
emergency room before I arrived. Had it not been for them, I
don't know that I would be here today.
I hope that we will see more support and attention with
this kind of service, and especially acknowledging some local
governments and communities across the country, their budgets
don't allow for that kind of investment. I thank you for that
as well.
The Chair. Well, thank you, Senator. I did mention that in
my opening remarks, and we are going to get back to that.
Senator Cassidy has been a true gentleman, scholar, gentleman
allowing his colleagues to go before him. Senator Cassidy.
Senator Cassidy. Yes. I have lots of questions, but even
though I am last, limited time, so I will go a little rapid
fire.
It has been a fantastic panel, by the way. I don't know if
we have ever seen this much kind of participation from Members,
and congrats to the Chair. I think it has just gone very well
and you have all been really good.
Dr. Seoane, happy Mardi Gras to all of those who are not as
blessed as you and I to live in New Orleans and for this
upcoming weekend. We have got to do something relatively
quickly. Facilities for HBCUs, nursing, the pipeline, it is
actually kind of okay.
It finally gets there. One of the things that I have been
thinking about how we could initially, boom have an impact,
aside from immigration change, which would be huge, Dr. Seoane,
you mentioned the press of people coming to ERs and even the
violence associated with.
I have read that we have an absence of medication assisted
therapy clinics. I am assuming there are a fair number of
people come to ERs. Dr. Hildreth, you are in an urban area as
well. Oh, my gosh.
Dr. Szanton, oh my gosh, that if we had effective MAT, in
which we were keeping people from coming to the ER because they
were less likely to be an overdose or withdrawal, that that
could be something that could be relatively quickly implemented
to have a relatively rapid response. Dr. Seoane.
Dr. Seoane. Senator Cassidy, thank you for that question.
Look, I couldn't agree more. I think those are critical and
important. I think it goes beyond just the medication
assistance therapies programs.
There is other interventions like it was mentioned digital
medicine, digital monitoring, but there is actually digital
management programs, digital hypertension, digital diabetes.
We did a pilot in 3,000 Medicaid patients in rural areas
where we manage their diabetes or their hypertension through
the digital program.
We showed in 1 year, in a Medicaid population, decreased
hospitalizations and decreased ER visits. So I think you are
right, Senator Cassidy, we need to move care into the community
to prevent the ER visits.
Senator Cassidy. That has been a theme from all of you. Dr.
Staiger, I have been just chomping at the bit to ask you this
question. Are you ready? The sophistication of your research,
you say that the pass rate of licensing exam is down. Now, you
have done some sort of multivariate analysis.
Is it--who is less likely to pass? Is it the online school?
Is it the for profit school? Is it the person who graduated
during the pandemic? Is it poor preparation prior to coming to
school? What are the variables that can be affected?
Dr. Staiger. We are working on that. I don't have--Oh, come
on.
[Laughter.]
Dr. Staiger. But I can--I have some answers. The people who
are not passing the licensure exam are people who were in
nursing school during the pandemic. And all belief is that it
was the, you know----
Senator Cassidy. So that cuts across the institution. Johns
Hopkins, all the way to your community college?
Dr. Staiger. Well, I can't say Johns Hopkins specifically,
but they are seeing it across the board in terms of the
declining pattern.
Senator Cassidy. Let me ask you then, online nursing
instruction, which I will come back to you, ma'am. Online
nursing instruction, I am out by the bedside person and your
quote, I will steal it, Dr. Hildreth.
In fact, I will attribute it the first time, but then after
that, I will just forget you. Speaking to 100 people is a great
way to teach, but a bad way to learn. So online seems like a
great way to teach, but a bad way to learn for nursing skills.
Am I right or am I wrong?
Dr. Staiger. Well, I think the challenge has been
particularly for clinical skills, right, that bedside skills.
And the exam, and it is changing in April is--focuses
increasingly on clinical skills and clinical experience for the
nurse licensure exam.
That is becoming--you know, the belief is that the pass
rates are going to get much worse this year this next year
because of that.
Senator Cassidy. Because there has been a lack of
preparation for clinical.
Dr. Staiger. Lack of the clinical experience----
Senator Cassidy. So let me move on. Dr. Szanton, I suspect
you are chomping at the bit. Now, I endorse what Marshall said,
the woman or the man that goes to the community college, I
think is probably more likely to stay in her community.
I will just say from my personal experience as a physician,
certificate nurses, the one that I worked with for 30 years,
she was just fantastic. There is a clear bias toward BSNs, but
it seems more expensive, it seems a longer pipeline to get them
out, and again, as he says, there may be a predisposition for
those folks to stay where they were trained at the university
town as opposed to their community.
We got a couple of things to throw before you. One, what
about that, the Marshall issue? Dr. Staiger, what about this
kind of clinical skills gap? And what should we be thinking
about in terms of online training and what I would intuitively
think would make them less prepared?
Dr. Szanton. Thank you very much for those questions. About
the online training, so at Johns Hopkins, I can't speak for all
nursing schools, but at Johns Hopkins, when we talk about an
online program, what they mean is that the some of the didactic
portion when you are learning about pathophysiology and you are
learning about how the heart works, and that that can be online
modules.
But they come to campus multiple times a year and they have
clinical experiences wherever they are. There is--at least at
Johns Hopkins, there is no such thing as online only nursing
program. To your point, that wouldn't make sense.
Senator Cassidy. I know that there is some online only
classes? Do I know that? Some universities all do 100 percent
online. Dr. Staiger, did you know that.
Dr. Szanton. Classes----
Dr. Staiger. During the pandemic, and there was--typically,
no, right. They all----
Dr. Szanton. For example, at Johns Hopkins March 2020,
everything shut down briefly, but we pivoted quickly and people
were back doing clinical hours. Sometimes they were more out in
the community than in the hospital, for example. But people got
really hands on clinical experiences during the pandemic. I
want to just mention about RN, I wouldn't call it a bias
respectfully, toward BSN education.
There are decades of evidence, and I am sure you can back
me up, showing that health systems that have a higher
proportion of BSNs have better health outcomes for the
patients.
Of course, you need a team of all different kinds of
people, but there is a lot and a lot of evidence that we would
be happy to share over time about the need for the BSNs.
Senator Cassidy. Now, the choice is between the marginal
increase in outcome, which again, you want a multivariate
analysis to look at that, as opposed to having a shortage of
nurses. Which would be more impactful, more nurses or more of
them being BSNs?
Dr. Staiger. You know, nurses first, right, then skills,
then upskilling. And you know the evidence--the National
Academy of Medicine came out and this was their recommendation,
so I won't argue with that. It is not perfect evidence, but it
is good evidence. I think the key to the associate degree
nurses is the entry in the career steps.
You know, it is a way for people to get in with 2 years,
but then have a career ahead of them where they can get trained
up to be a bachelor's nurse. And the key is facilitating that.
That is how you get people to enter at these lower wage jobs,
is they see the career ahead.
Senator Cassidy. With upskill, can I have one more
question? Dr. Hildreth, you alluded to, Dr. Szanton spoke
specifically, that if we address the burden of chronic disease,
we can decrease our utilization.
Dr. Seoane mentioned an innovative program in terms of
digital health. We are going to have some hearings on
pharmaceuticals, but whatever we say about pharmaceuticals,
they have been incredibly innovative.
We know the burden of metabolic disease disproportionately
falls upon the poor, and that if we do something about the
metabolic syndrome, then we are going to decrease renal
failure, hypertension, diabetes, heart disease, stroke.
I say that, I am not sure there is a question there, but
just an observation, that there has been a consistent refrain
that if we do something about the burden of chronic disease,
that we can decrease the demand upon our health care
facilities, if you will, a more fundamental way to address the
shortfall as opposed to just more nursing schools, which we
also need. Any comment on that, sir?
Dr. Hildreth. Thank you, Senator Cassidy. I will just
repeat what I said earlier. Our health care system is actually
a sick care system.
We need to be focused on the social determinants of health,
where you live, where you work, how much money you make, your
educational attainment, all of those things contribute much
more to your health than going to see a doctor.
Now, in my job, I am in the business of training doctors,
dentists, researchers, but the reality is that what we need
more of this investment in public health.
I would argue that re-integrating public health in primary
care is the best way forward, so we can actually get better
outcomes for communities, not one person at a time. Thank you.
The Chair. Thank you, Senator Cassidy. Look, I agree with
Senator Cassidy. I thought this, Senator Cassidy, was an
extraordinary hearing.
I think we had the attendance of virtually every Member
here on both sides, which tells--should tell us and tell all of
us, rural, urban, no matter where you are from, we have got a
major crisis in health care workforce.
This has been a great panel and I want to thank each and
every one of you for being here. We are going to get back to
you. We are going to produce legislation. I don't do hearings
for the sake of hearings.
All of you have been invaluable in your contributions. So,
let's work together. Let's do something for the American people
and thank you very much.
For any Senators who wish to ask additional questions,
questions for the record will be due in 10 business days, March
3rd at 5.00 p.m.
Finally, I ask unanimous consent to enter at the record a
statement from Senator Casey and 19 statements from stakeholder
groups sharing their health care workforce priorities. So,
ordered.
[The following information can be found on page 79 and 83
in Additional Material:]
The Chair. The Committee stands adjourned.
ADDITIONAL MATERIAL
senator robert p. casey, jr., statement for the record
I regret that I was unable to attend the Committee on Health,
Education, Labor, and Pensions (HELP) hearing on Thursday, February 16,
2023 due to medical leave. This hearing covered a critical and timely
matter: health professional shortages and their impact on the health
care system.
The COVID-19 pandemic placed an immense strain on the health care
workforce across the field, from outpatient to intensive care. While
the world went into lockdown, health care facilities and the personnel
that staff them remained open, fielding the swell of patients
exhibiting the symptoms of a virus the medical community was only
beginning to understand. The data suggest that one in five health care
workers quit their jobs during the pandemic. Working long hours, often
without adequate personal protective equipment, health care providers
were steadfast in their commitment to serving their communities.
We must apply lessons learned during the acute phases of the COVID-
19 pandemic to future policy. I look forward to working with my
colleagues on both sides of the aisle this Congress to reauthorize the
Pandemics and All Hazards Preparedness Act to fortify our health care
system against future public health threats. It will be vitally
important to prioritize building supports for our frontline health care
personnel, so they are able to provide the best care possible when it
is needed most.
There are a number of Federal programs aimed at building the health
workforce pipeline, including the National Health Service Corps (NHSC)
and Medicare Graduate Medical Education (GME) payments to support
residency slots to train new doctors. In Pennsylvania, loan repayment
programs like the NHSC are especially important for our rural health
care facilities who may otherwise struggle to attract new providers
without incentives like loan repayment. I was pleased to see that the
Consolidated Appropriations Act, 2023 included an expansion of GME
slots, but systemic underinvestment in these--and similar--programs can
limit their impact.
There are further considerations for specialty providers, who
receive extra training. I have led efforts to reauthorize the
Children's Hospital Graduate Medical Education program for many years.
This program supports the pediatric health care workforce and addresses
shortages in pediatric specialty care by supporting residency slots at
freestanding children's hospitals. I look forward to working on the
reauthorization of this important program this Congress.
As it stands, our health care workforce does not reflect the
diversity of the communities they serve. My bill, the Allied Health
Workforce Diversity Act, recently passed with the Consolidated
Appropriations Act, 2023. This legislation authorizes $8 million per
year over the next 5 years for a new grant program aimed at recruiting
a diverse body of professionals in the allied health fields, including
occupational therapists, physical therapists, speech-language
pathologists, and audiologists.
Our work is not done once a health care worker is hired, though.
Health care workers consistently face elevated rates of workplace
violence, and I am proud to support Senator Baldwin's work in
addressing this serious issue. There was an outpouring of support for
our health care professionals during the acute phases of the COVID-19
pandemic, in recognition of their truly heroic work. We must continue
to show up for our providers, and I look forward to working with my
colleagues on the HELP Committee this Congress to develop new,
innovative ways to build this critical workforce.
Pennsylvania's world-class medical community will be part of these
developments, and I will continue to work on behalf of our health care
providers to make sure we have the proper resources to keep up with the
changing health care landscape without sacrificing care quality.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
QUESTIONS FOR THE RECORD
Response by James Herbert to questions of Senator Paul and Senator
Tuberville
senator paul
Question 1. The American Nurses Association reports that the
average age of a nurse is 52 years old and that at least a fifth of all
U.S. nurses will be retiring in the next 5 years. The U.S. Department
of Labor says that there are in excess of 200,000 open RN positions
right now and that number is expected grow. Nurses are reporting
record-high levels of stress because of severe workforce shortages.
This data implies that the nursing shortage is about to get much worse.
What is being done to combat these workforce shortages and alleviate
the immense stress being suffered by nurses?
Answer 1. Nurse stress, burnout, and compassion fatigue are
collectively contributing to the departure of nurses in the workforce.
In order to combat this reality, healthcare systems need to analyze and
address the root causes of nurse stress. At an organizational or micro
level, these issues are varied and often co-occurring. It is vital for
institutions to establish appropriate staffing levels reflective of
patient complexity and acuity, the number of admissions or discharges
within a given assignment, and the availability of support personnel.
The work environment itself needs to be assessed and determined to be
safe and free from harm. Nurses are encountering increasing acts of
aggression, both verbal and/or physical, and health systems need to
promote a 24-hour safe setting for nurses to execute their work.
Compensation structures for nurses need to be reevaluated, along with
ensuring that nurses are able to practice to the full extent of their
academic preparation, experience, and professional licensure/
credentialing.
At a macro-disciplinary level, a number of professional
organizations are working to combat nurse stress and fatigue. For
example, the American Nurses Association (ANA) launched the Healthy
Nurse/ Healthy Nation initiative. This social action endeavor aims to
enhance the health and well-being of the 4 Million registered nurses in
the U.S., and in so doing, favorably impact the health of the Nation.
The program offers ANA members health and wellness assessments, tool
kits to improve focus areas such as sleep, activity, nutrition, stress
management, and vehicles for establishing support/connections with
others.
Finally, as I discussed in my testimony with respect to healthcare
professionals more generally, we need to facilitate the training of
more nurses, including both new, entry-level nurses as well as programs
to upskill lower-level providers to become nurses. The primary
bottlenecks in this regard are insufficient clinical training sites and
the paucity of nurse educators. Many institutions (including my home
university, the University of New England) are doing creative things to
address both of these issues, but these could be facilitated with
additional state and/or Federal support.
Question 2. For the last 15 years, nursing school enrollment has
not kept up with hospital demand for nurses. The primary barriers to
accepting all qualified students at nursing schools continue to be
insufficient clinical placement sites, faculty, preceptors, and
classroom space. How are we increasing nursing opportunities for U.S.
students?
Answer 2. Increasing nursing school enrollment is a complex and
multifaceted issue. The lack of appropriately prepared nurse faculty,
limitations in expanding clinical placement sites, and modernizing
nursing education infrastructure illustrate these vexing challenges.
This can be best addressed by investing in nursing education. The re-
authorization of the Title VIII Nursing Workforce Development Program
as part of the CARES Act was an essential first step. Ongoing
congressional funding is essential to continue to support opportunities
to grow nursing education faculty, imagine innovative models for
clinical education, and modernize nursing education facilities. The
interest of the U.S. Department of Labor is also essential in solving
this issue. Individual states play a role as well, providing funding
opportunities to support the expansion of graduate medical education
and creation of novel clinical rotational opportunities.
Embarking on new, innovative partnerships is also essential for
addressing these challenges. This may involve creation of unique health
system/academic institution alliances, or public/private educational
institutions working in concert to co-create nursing education programs
responsive to local or regional needs.
Question 3. Fifteen percent of U.S. nurses are foreign-trained,
meaning that thousands of new U.S. nurses per year are foreign workers.
Retrogression of visas is expected in 2024. If this pool of nurses were
to run out, stress on nursing staff would be unsustainable, likely
leading to even earlier retirements. Since visa retrogression will
happen in 2024 and no foreign nurses will be able to enter the U.S.,
what steps are being taken to maintain foreign nurses' entry into the
U.S.?
Answer 3. Entry into the United States and visa issuance is a
legislative issue. Credentialing of foreign trained nurses and
conferment of licensure is a nursing regulatory matter. The National
Council of State Board of Nursing (NCSBN) is a not-for-profit
organization through which nursing regulatory bodies (i.e., each of the
50 state boards of nursing) confer and act and together on issues
impacting public health, safety, and welfare, including the licensure
of nurses. The NCSBN is a member organization of the international
center for regulatory scholarship, uniting nine member nursing
organizations around the world to promoting research and data sharing
to influence policy impacting the health, safety, and welfare of the
public.
Foreign trained nurses applying for licensure in the United States
need to be credentialed through the Commission on Graduates of Foreign
Nursing Schools (CGFNS). This process verifies and authenticates the
credentials for an internationally educated applicant. Foreign trained
nurses may need to initially complete a qualifying examination and/or
demonstrate English language proficiency. Foreign trained nurses may or
may not be required to successfully pass the National Council Licensing
Examination (NCLEX-RN). This is dependent upon their prior preparation.
Each state board of nursing has its own requirements in determining
educational and experiential comparability for individuals trained
outside of the United States.
senator tuberville
Question 1. In addition to doctors and nurses, the current health
worker shortage includes technicians, assistants, pharmacy personnel,
home health aides, nursing home staff, and more. America is
experiencing shortages across every aspect of America's health care
systems--not just the jobs requiring high-level and post-grad degrees.
We need to train people throughout the care team, all across the
industry. Not everyone desiring to pursue a career in health care wants
to go to a full 4-year college or nursing or medical school.
Question 1(a). Please highlight what other opportunities outside
traditional 4-year college settings are available to interested
students?
Question 1(b). What training and incentive programs are out there?
Answer 1. There are an abundant number of essential health care
roles that do not require 4-year baccalaureate education or graduate
study. Certified nursing assistants (CNA's), home health aides (HHA's),
medical assistants (MA's), licensed practical nurses (LPN's), X-ray
technicians, and phlebotomists are examples of vital paraprofessional
roles. Educational requirements differ depending upon the role, ranging
from a few weeks to a year to complete training. Credentialing also
varies, ranging from certification to licensure. Each state determines
rules and regulations for these positions. Licensed practical nurses
(LPN's) are governed by NSCBN (described above) and must successfully
pass the NCLEX-PN to practice.
Public K-12 education is often also engaged in paraprofessional
training, providing secondary students with health care ``tracks'' or
``concentrations'' leading to nursing assistant credentialing. Many
community, technical, or vocational colleges offer this training in a
post-secondary manner. Municipalities have become increasingly involved
in this arena through adult education, offering nursing assistant
training to community residents to enhance the regional workforce.
Health care systems have also assumed an educational role, creating
paid training programs in an effort to ``grow their own'' workforce.
These models commonly pay an individual to complete the specified
training, and once successfully completed, require future employment
for a specified number of years. There are abundant opportunities for
innovative higher education/health system partnerships to expand this
essential workforce. Federal and state funding initiatives are critical
to support the workforce growth needed in this arena.
Question 2. I have been contacted in particular by EMS
professionals in Alabama who are sounding the alarm about their own
individual shortages. Specifically, I recently heard from an EMS
company in the state, NorthStar EMS. They are providing vital 911
emergency and interfacility ground ambulance services in both rural and
urban counties in Alabama. Their organization, and every other
ambulance service provider in Alabama, is facing an unprecedented
workforce shortage. NorthStar noticed this issue several years prior to
the pandemic and started their own training academy in order to make
EMT education more accessible to people desiring to enter the field.
When the pandemic started, interest in attending EMT school dropped.
Not many people wanted to put themselves into a front-line position,
which made the problem worse. However, the ones who wanted to get into
the profession at that time turned out to be some of the best students
and workers they have had in years. They have finally started to see an
uptick in interest from prospective students, but nowhere near where
they need to be in order to get back to pre-pandemic levels, which
leaves them far short of where they need to be.
According to NorthStar, a recent survey on the EMS workforce
shortage--involving nearly 20,000 employees working at 258 EMS
organizations--found that overall turnover among paramedics and EMTs
ranges from 20 to 30 percent annually. With percentages that high,
ambulance service providers face 100 percent turnover within a 4-year
period. Staffing shortages compromise their ability to respond to
health emergencies, especially in rural and underserved parts of the
country. In several rural counties in Alabama, only one ambulance is
staffed most days of the week--not because that is what the service
wants to do, but because there are no staff to cover the open shifts.
The EMS workforce shortage has continually worsened over a period
of several years with the pandemic exacerbating the current shortage
and highlighting the need to better understand the drivers of workforce
turnover.
Question 2(a). From your perspective, what can be done to correct
the training and staffing pipeline of EMS workers, especially in rural
areas?
Answer 2. Emergency management services (EMS) are part of the
healthcare ecosystem and involve public safety (police and fire),
public health, and regional healthcare delivery systems. EMS is
generally organized around four (4) levels of care or responders to
include: Emergency Medical Responder (EMR); Emergency Medicine
Technician (EMT-B); Advanced Emergency Medical Technician (EMT-A); and
paramedic (EMT-P). Each of these require different levels of education
and preparation. The delivery of acute, complex, and life-threatening
care optimally requires intervention at the EMT-A and paramedic level.
There are many drivers that threaten the current and future EMS
workforce and pipeline. The impact of the pandemic on personal health
and well-being has influenced the entire health care workforce, to
include EMS. EMS compensation structures remain persistently low,
rendering the role unattractive. According to the Bureau of Labor
statistics, the 2021 median annual wage for emergency medical
technicians was $35,470; and the 2021 median annual wage for paramedics
was $46,770. The provision of EMS services requires 24-hour coverage,
and staffing shortages commonly necessitate mandatory overtime to
ensure appropriate community coverage. Career mobility is limited with
few opportunities for professional growth and advancement.
The delivery of EMS services is complex and differs from region to
region. A variety of entities including municipal fire departments,
rescue squads, hospitals, and private companies all represent the
numerous ways that EMS care is delivered. Rurality presents unique
challenges to the EMS industry. The workforce itself, particularly at
the higher levels of practice, is in scare supply. Response times in
rural regions are significantly longer, and the public is more likely
to survive a life-threatening event if care is rendered by an EMT-A or
paramedic. In addition to longer response times, transport times are
also lengthy, thus taking an ambulance out of service for another
possible call. Ground ambulance costs have increased steadily over the
past 5 years, and CMS reimbursement rates commonly do not cover the
cost of services and transport. This results in a financial deficit for
the EMS system, be it administered by a municipality, private company,
and/or hospital.
Innovative educational programs to increase student interest and
enrollment are needed to expand the pipeline of EMS provider. Federal
and state funding should be allocated to support student scholarships
and/or loan repayment once credentialed. CMS reimbursement rates must
be re-examined to ensure the sustainability of the EMS system.
Question 3. In your testimony, you mention how critical is that we
leverage the power of technology to reach underserved communities. In
Alabama, we used Federal authority to make telehealth much more
effective and feasible for patients and doctors during COVID. Providers
in rural states were able to reach more patients with fewer health care
workers using virtual visits and follow-ups. It was a lifeline in many
rural areas and helped lift the burden placed on brick-and-mortar
health care centers.
Question 3(a). What can we do to encourage further use and
innovation in telehealth, especially in rural states and communities?
Question 3(b). How can it be best utilized to help address the
current workforce shortage?
Answer 3. Telehealth is dependent upon the availability of
appropriate tools and resources to achieve successful and sustainable
telehealth practices. Reliable Internet, inclusive of broadband, is
essential to support video chat capability, visual imaging, and two-way
exchange. Federal and state funding is critical to ensure such
infrastructure is regionally in place.
As noted, telehealth can provide vital patient care services,
thereby improving access to care and health outcomes. Telehealth can
also include telemonitoring, as with home care services which monitor
and collect patient status data (e.g., self-care for heart failure
programs). Telemonitoring can also be employed with respect to hospital
inpatient unit oversight, such as an offsite clinician observing real
time patient data and alerting facility-based staff regarding changes
(e.g., virtual telemetry monitoring). Telehealth has additionally been
impactful in creating virtual learning communities of health
professionals and subject matter experts to inform best practices in
care delivery (e.g., Project ECHO). Telehealth can also be employed
with tele-precepting, uniting expert faculty with rural-based learners
in supervising specialized patient care.
Academic preparation of today's health profession student needs to
include didactic exposure and clinical experience with telehealth.
Students need to be oriented to telehealth practices, examination
strategies, approaches for building positive relationships with
patients, appropriate documentation, and legal and policy implications.
Faculty development is often needed, as telehealth is a new and
evolving field. The integration of telehealth into health care
curricula promotes graduate workforce readiness in this growing arena.
Question 4. Dental practices across the country are experiencing a
significant shortage of hygienists and dental assistants.
Question 4(a). Are dental schools working with community colleges
and career and technical training programs to come up with ways they
can collectively encourage increased interest in those careers?
Question 4(b). What can we do at the Federal level to support those
efforts?
Answer 4. Dental medicine and dental hygiene programs are actively
partnering with community colleges to create educational pathways and
promote student interest in the field of oral health. Community college
graduates who earn an Associate Degree in health science are well
qualified for entry into baccalaureate level dental hygiene education.
For example, the University of New England has robust articulation
agreements with regional community colleges for this very purpose. Each
year, the dental hygiene program admits approximately 12 new community
college graduates who will then study four additional semesters to earn
the Bachelor of Science Dental Hygiene and eligibility for licensure.
Innovative, accelerated pathways also exist for students seeking to
attain dental medicine degrees (DDS, DMD).
Federal and state funding level can support these initiatives by
enhancing scholarship opportunities to incentivize students into these
careers. Additionally, loan repayment programs are another effective
approach, especially for retaining graduates in documented regions with
few oral health providers.
______
Response by Sarah Szanton to questions of Senator Paul and Senator
Tuberville
senator paul
Question 1. The American Nurses Association reports that the
average age of a nurse is 52 years old and that at least a fifth of all
U.S. nurses will be retiring in the next 5 years. The U.S. Department
of Labor says that there are in excess of 200,000 open RN positions
right now and that number is expected grow. Nurses are reporting
record-high levels of stress because of severe workforce shortages.
This data implies that the nursing shortage is about to get much worse.
What is being done to combat these workforce shortages and alleviate
the immense stress being suffered by nurses?
Answer 1. Thank you for the question. We are agree that the stress
and shortages are a major problem. The FAAN act (Senate bill 246 from
117th Congress) which has not yet been re-introduced in this Congress
would go a long way to solving many of the shortages, including
addressing shortage of preceptors, financial aid for students and
increasing the number of faculty members in nursing schools.
Question 2. For the last 15 years, nursing school enrollment has
not kept up with hospital demand for nurses. The primary barriers to
accepting all qualified students at nursing schools continue to be
insufficient clinical placement sites, faculty, preceptors, and
classroom space. How are we increasing nursing opportunities for U.S.
students?
Answer 2. Thank you. The FAAN act described above would address
each of these issues.
Question 3. Fifteen percent of U.S. nurses are foreign-trained,
meaning that thousands of new U.S. nurses per year are foreign workers.
Retrogression of visas is expected in 2024. If this pool of nurses were
to run out, stress on nursing staff would be unsustainable, likely
leading to even earlier retirements. Since visa retrogression will
happen in 2024 and no foreign nurses will be able to enter the U.S.,
what steps are being taken to maintain foreign nurses' entry into the
U.S.?
Answer 3. That's a great question. It is outside of my area of
expertise as a Nursing School Dean so I do not have the technical
expertise to provide the Senator the answer his important question
deserves.
senator tuberville
Question 1. In addition to doctors and nurses, the current health
worker shortage includes technicians, assistants, pharmacy personnel,
home health aides, nursing home staff, and more. America is
experiencing shortages across every aspect of America's health care
systems--not just the jobs requiring high-level and post-grad degrees.
We need to train people throughout the care team, all across the
industry. Not everyone desiring to pursue a career in health care wants
to go to a full 4-year college or nursing or medical school.
Question 1(a). Please highlight what other opportunities outside
traditional 4-year college settings are available to interested
students?
Question 1(b). What training and incentive programs are out there?
Answer 1. Thank you for the question. I completely agree that not
everyone wants to go to a full 4-year collage or nursing or medical
school. One of the wonderful things about the health professions is
that there are many rungs to jump onto to be able to serve patients,
their families and communities. These include many community college
programs for 2 year degrees and shorter than that for some fields. I am
less aware of what incentive programs there are for other professions
because I am a nursing school Dean and don't have technical expertise
in the other professions.
Question 2. I have been contacted in particular by EMS
professionals in Alabama who are sounding the alarm about their own
individual shortages. Specifically, I recently heard from an EMS
company in the state, NorthStar EMS. They are providing vital 911
emergency and interfacility ground ambulance services in both rural and
urban counties in Alabama. Their organization, and every other
ambulance service provider in Alabama, is facing an unprecedented
workforce shortage. NorthStar noticed this issue several years prior to
the pandemic and started their own training academy in order to make
EMT education more accessible to people desiring to enter the field.
When the pandemic started, interest in attending EMT school dropped.
Not many people wanted to put themselves into a front-line position,
which made the problem worse. However, the ones who wanted to get into
the profession at that time turned out to be some of the best students
and workers they have had in years. They have finally started to see an
uptick in interest from prospective students, but nowhere near where
they need to be in order to get back to pre-pandemic levels, which
leaves them far short of where they need to be.
According to NorthStar, a recent survey on the EMS workforce
shortage--involving nearly 20,000 employees working at 258 EMS
organizations--found that overall turnover among paramedics and EMTs
ranges from 20 to 30 percent annually. With percentages that high,
ambulance service providers face 100 percent turnover within a 4-year
period. Staffing shortages compromise their ability to respond to
health emergencies, especially in rural and underserved parts of the
country. In several rural counties in Alabama, only one ambulance is
staffed most days of the week--not because that is what the service
wants to do, but because there are no staff to cover the open shifts.
The EMS workforce shortage has continually worsened over a period
of several years with the pandemic exacerbating the current shortage
and highlighting the need to better understand the drivers of workforce
turnover.
Question 2(a). From your perspective, what can be done to correct
the training and staffing pipeline of EMS workers, especially in rural
areas?
Answer 2. Thank you for the question. EMS workers are essential to
providing Americans with emergency care. With new models, some are also
providing important community based care such as check-ins for
loneliness and whether people have enough food. As a nursing school
dean, however, I do not have the technical expertise to provide the
Senator the answer his important question deserves.
______
Response by Leonardo Seoane to questions of Senator Paul, Senator
Tuberville, and Senator Budd
senator paul
Question 1. The American Nurses Association reports that the
average age of a nurse is 52 years old and that at least a fifth of all
U.S. nurses will be retiring in the next 5 years. The U.S. Department
of Labor says that there are in excess of 200,000 open RN positions
right now and that number is expected grow. Nurses are reporting
record-high levels of stress because of severe workforce shortages.
This data implies that the nursing shortage is about to get much worse.
What is being done to combat these workforce shortages and alleviate
the immense stress being suffered by nurses?
Answer 1. The nursing shortage--and its strain on our existing
workforce--is a significant concern to Ochsner Health. With over 1,200
open nursing positions across our system, and the cost of contract
nursing having increased more than 800 percent since 2019, steps must
be taken to grow the number of nurses in the health care workforce. At
Ochsner, we have committed significant resources to the training and
retention of nurses and implemented numerous programs to alleviate
provider stress and prevent burnout.
Ochsner and our partners have developed nursing workforce programs
that are accessible to individuals at all stages of their nursing
career. We offer nursing pre-apprenticeship programs to high school and
community college students, tuition reimbursement programs to full time
community college and university nursing students, as well as ``earn as
you learn'' apprenticeship programs for individuals already working as
a Medical Assistant who want to become and LPN. We also offer
scholarships and other financial assistance to employees who want to
advance their careers by way of our career pathway programs. Finally,
we have provided significant capital funds to build a new nursing
program at a local community college, as well as providing Ochsner
clinical nurses to serve in faculty positions at various nursing
schools at no cost to the school.
At Ochsner, the mental health and well-being of our employees is of
utmost importance, and we understand the strain and pressure the PHE
put on our employees, but particularly bedside providers. We are
particularly concerned that our clinicians are facing a more violent
working environment; there has been more verbal and physical assaults
on health care providers, including in our system. To help reduce the
strain on our workforce and address burnout, we have undertaken a
number of steps and launched new efforts in the clinical setting. We
have a wellness office for our nurses and physicians. Other efforts
include expanding the bedside care team to include more nursing
assistants and LPNs in addition to RNs, all practicing within the scope
of their licensure, to spread the workload and reduce pressure on the
care team more evenly. Ochsner is also leveraging its long history of
digital innovation to address provider stress through the
implementation of the Virtual Nurse Program. This program, which
provides 24-hour virtual nursing support to the patient care team, is
an innovative staffing model focused on patient-centered care and safe
distribution of workload across an integrated team of virtual and
bedside nursing personnel. This approach allows bedside nurses to focus
on direct care and leverages the bunker nurses--via technology hook-
ups--to manage non-direct care matters--resulting in more efficient
care delivery, a better patient discharge experience, and less strain
on the bedside nurse. We worked with the Louisiana state legislature to
make violence against health care workers a crime and we urge Congress
to take similar action to provide the same safeguards to health care
workers as are afforded airline employees.
Question 2. For the last 15 years, nursing school enrollment has
not kept up with hospital demand for nurses. The primary barriers to
accepting all qualified students at nursing schools continue to be
insufficient clinical placement sites, faculty, preceptors, and
classroom space. How are we increasing nursing opportunities for U.S.
students?
Answer 2. Ochsner has made significant investments in educational
opportunities for health care students. As the largest health care
provider in Louisiana, Ochsner is proud to serve as a clinical training
site for numerous programs in the region. Additionally, Ochsner's $20
million investment in the Ochsner Center for Nursing and Allied Health
at Delgado Community College provides matching funds for a new state-
of-the-art facility on its campus in New Orleans, and covers full-time
tuition for Ochsner employees pursuing a nursing or allied health
certificate or degree at Delgado. Finally, we recognize that our
nursing schools have limited capacity due to insufficient numbers of
teaching faculty, and we are supporting several of our full-time
employed Ochsner nurses in stepping out of their clinical roles 2 days
a week to serve as clinical adjunct faculty at colleges of nursing.
Ochsner continues to pay their salaries in full, which provides schools
of nursing with faculty at no cost.
Question 3. Fifteen percent of U.S. nurses are foreign-trained,
meaning that thousands of new U.S. nurses per year are foreign workers.
Retrogression of visas is expected in 2024. If this pool of nurses were
to run out, stress on nursing staff would be unsustainable, likely
leading to even earlier retirements. Since visa retrogression will
happen in 2024 and no foreign nurses will be able to enter the U.S.,
what steps are being taken to maintain foreign nurses' entry into the
U.S.?
Answer 3. Ochsner agrees that maintaining a supply of well trained
nurses who have a legal pathway to work in the U.S. is essential to
helping us address workplace shortages and critical to closing the gap
between patient demand and nursing need. We would support efforts to
increase the visas available through proposals like the bipartisan
Health Care Workforce Resilience Act which allows for recapture from
previous fiscal years unused immigrant visas for physicians (15,000)
and nurses (25,000), exempts these visas from country caps, and directs
State Department and Department of Homeland Security to expedite these
processing of these recaptured visas.
senator tuberville
Question 1. In addition to doctors and nurses, the current health
worker shortage includes technicians, assistants, pharmacy personnel,
home health aides, nursing home staff, and more. America is
experiencing shortages across every aspect of America's health care
systems--not just the jobs requiring high-level and post-grad degrees.
We need to train people throughout the care team, all across the
industry. Not everyone desiring to pursue a career in health care wants
to go to a full 4-year college or nursing or medical school.
Question 1(a). Please highlight what other opportunities outside
traditional 4-year college settings are available to interested
students?
Question 1(b). What training and incentive programs are out there?
Answer 1. Ochsner is proud that last year we invested more than $5
million to operate more than 29 different workforce programs, serving
over 1,200 individuals. We have worked hard to ensure that these
programs are accessible to individuals in both traditional educational
pathways and those who choose alternate routes. Most of these programs
are provided free of charge or include tuition assistance. Employment
opportunities also await individuals finishing these programs. Ochsner
offers nursing pre-apprenticeship programs to high school and community
college students, as well as ``earn as you learn'' apprenticeship
programs for individuals already working as a Medical Assistant who
want to become and LPN. We also offer scholarships and other financial
assistance to employees who want to advance their careers by way of our
career pathway programs. We also have programs focused on individuals
who are either un-or underemployed or lack proper credentials but wish
to pursue opportunities within the health care system. MA Now is our
signature community-facing program that links unemployed and
underemployed to a nursing pathway. Students earn several industry-
aligned credentials including the certified clinical medical assistant,
phlebotomy, ED Tech Monitor, and EEG pathways. More than 250 MA Now
graduates have been trained and employed by Ochsner. Graduates
regularly move into leadership, LPN, and RN positions as they advance
their careers. We also offer non-clinical opportunities including In-
Patient Bedside Coding. This program is a 2-year program to build the
knowledge and capacity for an individual to serve as an in-patient
coder. This highly sought-after talent is in short supply across our
Nation. The complexity of in-patient coding requires advance training.
Our apprenticeship allows students the opportunity to grow their
knowledge, skills, and abilities to successfully compete in this high
demand occupation.
Specifically, with respect to students attending 2-year community
college we have a number of programs.
In February 2021, Ochsner launched a partnership with
Delgado Community College (Delgado) to train the next
generation of nurses and allied health professionals, forming
the Ochsner Center for Nursing and Allied Health. Delgado is
the largest educator of nurses and allied health professionals
in Louisiana. Together, Delgado and Ochsner will meet critical
workforce demands, providing more opportunities for local
graduates in high-wage careers, and proactively pursue the
career development of minority and disadvantaged students.
Ochsner's $20 million investment in the center covers full-time
tuition for Ochsner employees pursuing a nursing or allied
health certificate or degree at Delgado and matching funds for
a new state-of-the-art facility on its City Park Campus. In
addition to RN and LPN programs, the facility will host
Radiologic Technologist, Respiratory Therapy, Physical Therapy
Assistant, Occupational Therapy Assistant, Surgical
Technologist, Medical Laboratory Technologist, and Pharmacy
Technologist programs.
Ochsner Nursing Pre-Apprenticeship launched in 2021
in partnership with Delgado Community College and the Louisiana
Department of Education (LDOE). It provides high school
sophomores and community college students an opportunity to
apprentice as nurses. This LDOE-approved Fast Forward Pathway
serves high school students across Jefferson, Orleans, St.
Bernard and the River Parishes and also supports students in
St. Bernard in partnership with Nunez Community College. The
program will soon expand to students in Shreveport, Lafayette,
Monroe and Baton Rouge. With more than 350 students currently,
the program seeks serve more than 600 students over the next 2
years.
Ochsner Facilities Pathway Pre-Apprenticeship
launched in 2022 in partnership with Delgado Community College
and includes a high school pathway for the skilled trades
(plumbing, light electrical, etc.) as well as an incumbent
apprenticeship pathway. While the high school pathway is new in
2023, in partnership with Jefferson Parish Public Schools, the
incumbent pathway has seven apprentices who will graduate in
May 2023 from Delgado. This pathway has been submitted for
recognition as a registered apprenticeship.
Ochsner's Medical Assistant to Licensed Practical
Nurse (LPN) Apprenticeship recently celebrated the pinning of
31 LPNs. In partnership with LCTCS colleges, North Shore
Technical Community College, and Delgado Community College, the
registered apprenticeship offers tuition-free career growth to
current Ochsner Medical Assistants. Plans are underway to scale
the program into the Shreveport and Lafayette areas.
Patient Care Assistant (PCA) to Certified Nursing
Assistant (CNA) is a 8-week pathway program for those with a
strong desire for bedside caregiving who lack a credential. New
hires enter an ``earn as you learn'' pathway that includes
didactic training at a local community college while students
supplement the ancillary staff in the hospital as they build
their skills. Students graduate as a Certified Nursing
Assistant and enter a pathway to progress to LPN and then on to
RN.
Question 2. I have been contacted in particular by EMS
professionals in Alabama who are sounding the alarm about their own
individual shortages. Specifically, I recently heard from an EMS
company in the state, NorthStar EMS. They are providing vital 911
emergency and interfacility ground ambulance services in both rural and
urban counties in Alabama. Their organization, and every other
ambulance service provider in Alabama, is facing an unprecedented
workforce shortage. NorthStar noticed this issue several years prior to
the pandemic and started their own training academy in order to make
EMT education more accessible to people desiring to enter the field.
When the pandemic started, interest in attending EMT school dropped.
Not many people wanted to put themselves into a front-line position,
which made the problem worse. However, the ones who wanted to get into
the profession at that time turned out to be some of the best students
and workers they have had in years. They have finally started to see an
uptick in interest from prospective students, but nowhere near where
they need to be in order to get back to pre-pandemic levels, which
leaves them far short of where they need to be.
According to NorthStar, a recent survey on the EMS workforce
shortage--involving nearly 20,000 employees working at 258 EMS
organizations--found that overall turnover among paramedics and EMTs
ranges from 20 to 30 percent annually. With percentages that high,
ambulance service providers face 100 percent turnover within a 4-year
period. Staffing shortages compromise their ability to respond to
health emergencies, especially in rural and underserved parts of the
country. In several rural counties in Alabama, only one ambulance is
staffed most days of the week--not because that is what the service
wants to do, but because there are no staff to cover the open shifts.
The EMS workforce shortage has continually worsened over a period
of several years with the pandemic exacerbating the current shortage
and highlighting the need to better understand the drivers of workforce
turnover.
Question 2(a). From your perspective, what can be done to correct
the training and staffing pipeline of EMS workers, especially in rural
areas?
Answer 2. Ochsner Health cannot fulfill our vision and mission
without our EMS partners. Whether they are delivering a 911 emergency
patient to our emergency departments (ED) or emergently transporting
our patients between facilities in order to provide them the level of
care needed, EMS is an essential component of our health care system.
We have definitely felt the significant impact of the shortage of EMS
staffing. Because of delays in EMS response to 911 calls due to
shortages, our patients are arriving to us sicker. Our patients are
facing delays in care due to a lack of available resources to transport
critically ill or injured patients from a smaller facility to one that
has the available resources and expertise to manage their conditions.
We value and appreciate what our EMS colleagues bring to patient
care. We recently implemented an ``EMS Timeout'' initiative where we
provide EMS professionals with an opportunity to present their patients
to us upon arrival in the ED in a respectful, attentive environment.
When these health care professionals are seen as peers and
counterparts, it leads to improved patient care.
We also recognize that being a field EMT is physically demanding,
and many are forced to seek alternative jobs due to the physicality of
the profession. Ochsner Health has provided an additional avenue for
paramedics who might have otherwise left the profession completely,
leading to retention of experienced paramedics to continue practicing
in their chosen field, albeit in the hospital setting, where they have
become an integral part of our on campus care team. We work closely
with our EMS partners and state entities to ensure EMS interests are
supported and maintained at the highest level of excellence to arrive
at the best possible patient outcomes. We also have an elite helicopter
EMS program, Ochsner Flight Care, with intense, ongoing advanced skills
training as another avenue for paramedics to pursue. We have a parish-
based 911 EMS Service, St. Charles Parish EMS, that operates from one
of our facilities.
We believe that providing our EMS colleagues with additional
opportunities for employment will help to bring more interest to the
profession. We strive to promote EMS as a lifelong career, rather than
simply as a stepping stone, while also supporting paramedics who wish
to continue their education to become nurses, advanced practice
providers, or physicians.
senator ted budd
Question 1. Dr. Seoane, how can health systems better partner with
high schools and community colleges to develop and credential students
for in-demand health careers?
Answer 1. Community colleges play a critical role in Ochsner's
efforts to grow the health care workforce in our region. We are
fortunate to have developed partnerships with excellent community
colleges across Louisiana who educate and train Ochsner's current and
future employees and providers in high quality programs in high demand
fields. In return, Ochsner is proud to support our partners through
capital investments, assistance with curriculum development, financial
support for clinical faculty, and tuition assistance for students.
Specifically, with respect to students attending 2-year community
college we offer the following programs:
Answer 1(a). In February 2021, Ochsner launched a partnership with
Delgado Community College (Delgado) to train the next generation of
nurses and allied health professionals, forming the Ochsner Center for
Nursing and Allied Health. Delgado is the largest educator of nurses
and allied health professionals in Louisiana. Together, Delgado and
Ochsner will meet critical workforce demands, providing more
opportunities for local graduates in high-wage careers, and proactively
pursue the career development of minority and disadvantaged students.
Ochsner's $20 million investment in the center covers full-time tuition
for Ochsner employees pursuing a nursing or allied health certificate
or degree at Delgado and matching funds for a new state-of-the-art
facility on its City Park Campus. In addition to RN and LPN programs,
the facility will host Radiologic Technologist, Respiratory Therapy,
Physical Therapy Assistant, Occupational Therapy Assistant, Surgical
Technologist, Medical Laboratory Technologist, and Pharmacy
Technologist programs.
Ochsner Nursing Pre-Apprenticeship launched in 2021 in partnership
with Delgado Community College and the Louisiana Department of
Education (LDOE). It provides high school sophomores and community
college students an opportunity to apprentice as nurses. This LDOE-
approved Fast Forward Pathway serves high school students across
Jefferson, Orleans, St. Bernard and the River Parishes and also
supports students in St. Bernard in partnership with Nunez Community
College. The program will soon expand to students in Shreveport,
Lafayette, Monroe and Baton Rouge. With more than 350 students
currently, the program seeks serve more than 600 students over the next
2 years.
Ochsner Facilities Pathway Pre-Apprenticeship launched in 2022 in
partnership with Delgado Community College and includes a high school
pathway for the skilled trades (plumbing, light electrical, etc.) as
well as an incumbent apprenticeship pathway. While the high school
pathway is new in 2023, in partnership with Jefferson Parish Public
Schools, the incumbent pathway has seven apprentices who will graduate
in May 2023 from Delgado. This pathway has been submitted for
recognition as a registered apprenticeship.
Ochsner's Medical Assistant to Licensed Practical Nurse (LPN)
Apprenticeship recently celebrated the pinning of 31 LPNs. In
partnership with LCTCS colleges, North Shore Technical Community
College, and Delgado Community College, the registered apprenticeship
offers tuition-free career growth to current Ochsner Medical
Assistants. Plans are underway to scale the program into the Shreveport
and Lafayette areas.
Patient Care Assistant (PCA) to Certified Nursing Assistant (CNA)
is a 8-week pathway program for those with a strong desire for bedside
caregiving who lack a credential. New hires enter an ``earn as you
learn'' pathway that includes didactic training at a local community
college while students supplement the ancillary staff in the hospital
as they build their skills. Students graduate as a Certified Nursing
Assistant and enter a pathway to progress to LPN and then on to RN.
A newer addition to our workforce offerings, is Ochsner's
partnership with school districts and high schools around the state to
offer their students an opportunity to experience working in the health
care system during a particularly important time in their educational
career. These unique programs offer high school students the
opportunity to start a paid job in a high demand career field while
still in high school, with the promise of free college tuition and a
job upon completion of the program.
Specifically, with regards to high school students, we offer the
following programs:
Ochsner Nursing Pre-Apprenticeship launched in 2021 in partnership
with Delgado Community College and the Louisiana Department of
Education (LDOE). It provides high school sophomores and community
college students an opportunity to apprentice as nurses. This LDOE-
approved Fast Forward Pathway serves high school students across
Jefferson, Orleans, St. Bernard and the River Parishes and also
supports students in St. Bernard in partnership with Nunez Community
College. The program will soon expand to students in Shreveport,
Lafayette, Monroe and Baton Rouge. With more than 350 students
currently, the program seeks serve more than 600 students over the next
2 years.
Ochsner Facilities Pathway Pre-Apprenticeship launched in 2022 in
partnership with Delgado Community College and includes a high school
pathway for the skilled trades (plumbing, light electrical, etc.) as
well as an incumbent apprenticeship pathway. While the high school
pathway is new in 2023, in partnership with Jefferson Parish Public
Schools, the incumbent pathway has seven apprentices who will graduate
in May 2023 from Delgado. This pathway has been submitted for
recognition as a registered apprenticeship.
A key aspect of scaling these types of programs is the availability
of funding. Ochsner spends significant resources on developing and
operating these programs, which limits the size and scope of any self-
funded program. To encourage the growth in coordination between the
Nation's academic institutions and health-systems, we would urge
Congress to provide funding to support entities working together to
increase the pipeline of physicians, nurses, and allied health
professionals. We would also encourage funding to be prioritized for
efforts that demonstrate a commitment to addressing economic and health
disparities in the health care workforce.
------
[Whereupon, at 12:30 p.m., the hearing was adjourned.]
[all]