Health Professions Education Programs (28-FEB-06, GAO-06-55).	 
                                                                 
For fiscal years 1999 through 2005, the Health Resources and	 
Services Administration (HRSA), an agency within the Department  
of Health and Human Services (HHS), spent about $2.7 billion to  
fund the more than 40 health professions education programs	 
authorized under title VII and title VIII of the Public Health	 
Service Act. These programs include those providing grants to	 
institutions, direct assistance to students, and funding for	 
health workforce analyses. Title VII includes programs related to
the education of providers, such as primary care physicians.	 
Title VIII includes programs related to nursing education. Most  
of these programs were last reauthorized in 1998. GAO reviewed	 
changes in funding and in the number of these programs since	 
1998, HRSA's goals and assessment of the programs, and HRSA's	 
national health professions workforce projections. GAO reviewed  
relevant laws and agency documents and data, and interviewed HRSA
officials and representatives of health professions education	 
associations.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-55						        
    ACCNO:   A47917						        
  TITLE:     Health Professions Education Programs		      
     DATE:   02/28/2006 
  SUBJECT:   Aid for education					 
	     Education or training costs			 
	     Educational grants 				 
	     Grant monitoring					 
	     Health care personnel				 
	     Labor force					 
	     Medical education					 
	     Nurses						 
	     Performance measures				 
	     Personnel recruiting				 
	     Physicians 					 
	     Program evaluation 				 
	     Projections					 
	     Strategic planning 				 

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GAO-06-55

     

     * Results in Brief
     * Background
     * Funding for and Overall Number of Title VII and Title VIII H
     * HRSA's Goals Do Not Apply to All Title VII and Title VIII Pr
          * HRSA's Goals Are Not Comprehensive, and Data to Assess Perfo
          * HRSA Is Developing New Goals and Performance Measures
     * HRSA Has Published Few National Workforce Projections in Rec
          * HRSA Has Not Regularly Published National Health Professions
          * Regular Reassessment of Health Workforce Predictions Is Crit
     * Conclusions
     * Recommendation for Executive Action
     * Agency Comments
     * GAO Contact
     * Acknowledgments
     * GAO's Mission
     * Obtaining Copies of GAO Reports and Testimony
          * Order by Mail or Phone
     * To Report Fraud, Waste, and Abuse in Federal Programs
     * Congressional Relations
     * Public Affairs

Report to Congressional Requesters

United States Government Accountability Office

GAO

February 2006

HEALTH PROFESSIONS EDUCATION PROGRAMS

Action Still Needed to Measure Impact

Health Professions Education Programs 

GAO-06-55

Contents

Letter 1

Results in Brief 4
Background 5
Funding for and Overall Number of Title VII and Title VIII Health
Professions Education Programs Increased 9
HRSA's Goals Do Not Apply to All Title VII and Title VIII Programs, and
Data Are Problematic, but Agency Is Developing Alternatives 15
HRSA Has Published Few National Workforce Projections in Recent Years 20
Conclusions 25
Recommendation for Executive Action 26
Agency Comments 26
Appendix I Examples of Additional Sources of Federal Funding for Health
Professions Education 28
Appendix II Title VII and Title VIII Clusters and Programs, Fiscal Year
2004 30
Appendix III Additional Performance Goals and Targets for Health
Professions and Nursing Education Programs 32
Appendix IV Comments from the Health Resources and Services Administration
34
Appendix V GAO Contact and Staff Acknowledgments 41
Related GAO Products 42

Tables

Table 1: Title VII and Title VIII Programs in Existence Before, and
Organized into Clusters After, 1998 Reauthorization 6
Table 2: Performance Goals and Targets for the Health Professions and
Nursing Education and Training Programs Funded under Title VII and Title
VIII 17
Table 3: HRSA's Most Recent Reports Containing National Workforce Supply
and Demand Projections for Physicians, Dentists, Nurses, and Pharmacists
22
Table 4: Examples of Federal Funding Sources, besides Title VII and Title
VIII Programs, for Postsecondary Education and Training Specifically
Targeted for Health Professions 28
Table 5: Examples of Federal Funding Sources for General Postsecondary
Education and Training Including, but Not Exclusive to, Health Professions
29

Figures

Figure 1: Funding for Title VII and Title VIII Health Professions
Education Programs, Fiscal Years 1999-2005 10
Figure 2: Funding for Title VII Health Professions Education Programs,
Fiscal Years 1999-2005 11
Figure 3: Title VII Funding for New and Competitive Continuation Grants
and for Noncompetitive Continuations, Fiscal Years 1999-2004 14
Figure 4: Title VIII Funding for New and Competitive Continuation Grants
and for Noncompetitive Continuations, Fiscal Years 1999-2004 15

Abbreviations

AMA American Medical Association CMS Centers for Medicare & Medicaid
Services COGME Council on Graduate Medical Education GPRA Government
Performance and Results Act HHS Department of Health and Human Services
HRSA Health Resources and Services Administration NELRP Nursing Education
Loan Repayment Program OMB Office of Management and Budget

This is a work of the U.S. government and is not subject to copyright
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separately.

United States Government Accountability Office

Washington, DC 20548

February 28, 2006

The Honorable Michael B. Enzi Chairman Committee on Health, Education,
Labor, and Pensions United States Senate

The Honorable Judd Gregg United States Senate

An appropriate supply, mix, and distribution of health professionals-today
and in the future-is vital to ensuring that all Americans have adequate
access to health care. For fiscal years 1999 through 2005, the Health
Resources and Services Administration (HRSA), an agency within the
Department of Health and Human Services (HHS), spent about $2.7 billion to
fund health professions education programs authorized under title VII and
title VIII of the Public Health Service Act. Administered by HRSA, the
many title VII and title VIII programs include those providing grants to
institutions training health professionals; direct assistance to students
in the form of scholarships, loans, or repayment of educational loans; and
funding for health workforce analyses. Title VII programs include those
related to the education of providers, such as primary care physicians,
physician assistants, general dentists, pediatric dentists, and allied
health practitioners;1 programs related to education of the public health
workforce; and programs related to the analysis of health workforce
issues, such as estimates of supply and demand. Title VIII programs
include those related to basic and advanced nursing education programs,
which are designed to increase nursing workforce diversity, promote career
advancement, and improve retention. Most of the health professions
education programs were last reauthorized in 1998.2

1Allied health practitioners include, for example, audiologists, dental
hygienists, clinical laboratory technicians, occupational therapists,
physical therapists, medical imaging technologists, and speech
pathologists.

2Most title VII and title VIII programs were last reauthorized by the
Health Professions Education Partnership Act of 1998, Pub. L. No. 105-392,
112 Stat. 3524. Some nursing programs were authorized or reauthorized by
the Nurse Reinvestment Act of 2002, Pub. L. No. 107-205, 116 Stat. 811.

For more than a decade, our reviews of title VII and title VIII programs
have raised questions about HRSA's ability to assess the programs'
effectiveness.3 For example, before the 1998 reauthorization, we noted
that the programs' effectiveness would remain difficult to measure as long
as the health professions education programs were authorized to support a
broad range of health care objectives.4 For fiscal years 2002 through
2005, HRSA's budget justifications have questioned the need for continued
federal support of many of these health professions education programs,
and a review by the Office of Management and Budget (OMB) for the fiscal
year 2004 budget questioned their effectiveness.5

In preparation for congressional consideration of the next reauthorization
of title VII and title VIII programs, you asked us to review the programs,
including changes after the 1998 reauthorization. In this report, we
provide information on (1) changes in funding and in the number of title
VII and title VIII health professions education programs since the 1998
reauthorization; (2) HRSA's stated goals for the programs and the agency's
efforts to measure progress toward meeting them; and (3) national health
professions workforce projections developed by HRSA.

To conduct our work, we analyzed pertinent agency documents and
interviewed HRSA officials. We also analyzed data from HRSA's grants
management system, reviewed relevant laws, and interviewed representatives
of the Health Professions and Nursing Education Coalition and the
Federation of Associations of Schools of the Health Professions. We
examined funding for title VII and title VIII programs for fiscal years
1999 through 2005.6 To analyze the number of title VII and title VIII
programs HRSA administered, we counted (1) programs that awarded funds
competitively through grants or cooperative agreements7 and that announced
funding availability separately or had a separate selection panel8 and (2)
programs providing direct assistance, such as student loans to
individuals, regardless of whether the loan program was using current
appropriations.9

3See "Related GAO Products" at the end of this report.

4GAO, Health Professions Education: Clarifying the Role of Title VII and
VIII Programs Could Improve Accountability, GAO/T-HEHS-97-117 (Washington,
D.C.: Apr. 25, 1997).

5Office of Management and Budget, Program Assessment Rating Tool,
http://www.whitehouse.gov/omb/budget/fy2006/pma/hhs.pdf, downloaded Aug.
9, 2005. The most recent OMB assessment of the health professions programs
took place for the fiscal year 2004 budget.

6We excluding funding for one title VII program-Health Education
Assistance Loans-because the program was not authorized to guarantee new
loans to student borrowers during that period.

7Referred to as "grants" in this report.

For information on HRSA's stated goals and measures of performance in
meeting these goals and on the agency's plans for the future, we reviewed
HRSA's annual performance plans, budget justifications, and strategic
planning documents, and we attended HRSA's Bureau of Health Professions'
first all-grantee conference in June 2005. Regarding the workforce supply
and demand projections HRSA developed, we focused on the most recent
projected estimates of national supply and demand for physicians,
dentists, nurses, and pharmacists.10 We also reviewed physician workforce
reports published by the Council on Graduate Medical Education (COGME),11
which based its physician workforce projections on HRSA-developed
methodologies. We assessed the reliability of grants and other funding
data used in our review by discussing with agency officials validation and
internal controls for HRSA grants data and comparing the aggregate data
with similar aggregate data from other sources. We determined that the
funding data were sufficiently reliable for our purposes. Although we
identified problems with the reliability of other agency data, such as
those used to measure program performance, we included them for
illustrative purposes. We conducted our work in accordance with generally
accepted government auditing standards from June 2004 through January
2006.

8We used the separate selection panel criterion only for programs funded
in fiscal year 2004.

9We excluded advisory groups authorized under title VII or title VIII from
our counts of programs.

10In addition to the national workforce projections discussed in this
report, HRSA and its six regional centers issue reports-such as state
health workforce profiles for each state, the District of Columbia, Puerto
Rico, and the Virgin Islands-containing information about the supply;
demand; distribution; education; and use of physicians, nurses, dentists,
and 20 other health professionals. The scope of our review was limited to
HRSA's estimates of national supply and demand.

11COGME, established under title VII, is required to make recommendations
to the Secretary of HHS and Congress on several issues, including the
supply and distribution of physicians in the United States; current and
future shortages or excesses of physicians in medical and surgical
specialties and subspecialties and appropriate federal policies with
respect to such supply, distribution, shortages, or excesses; and
deficiencies in and needs for improvement in databases concerning the
supply and distribution of physicians in the United States. Public Health
Service Act S: 762 (codified at 42 U.S.C. S: 294o). The views expressed in
COGME's reports are solely those of the council and do not necessarily
represent the views of HRSA or the U.S. government.

                                Results in Brief

After reauthorization in 1998, overall funding for title VII and title
VIII programs increased from about $300 million in fiscal year 1999 to
more than $450 million in fiscal year 2005, and the overall number of
these programs also increased. From fiscal years 1999 through 2005,
funding for title VII programs rose by about one-fourth, while that for
title VIII programs more than doubled. The overall number of title VII and
title VIII programs administered by HRSA increased from 46 in fiscal year
1998 to 50 in fiscal year 2004; this overall increase was due to an
increase in the number of title VIII programs.

HRSA has published performance goals for the title VII and title VIII
health professions education programs, but these goals do not apply to all
the health professions education programs, and the data for tracking
progress are problematic. These performance goals, prepared as part of
HHS's annual reporting under the Government Performance and Results Act
(GPRA) process,12 are spelled out in HRSA's fiscal year 2006 budget
justification. In measuring progress toward meeting these goals, the
agency relies on data we and others have found to be problematic. For
example, although one performance goal is to increase the proportion of
health professionals supported by title VII and title VIII programs who
enter practice in underserved areas, HRSA does not have complete data that
track the practice locations of these health professionals. Recognizing
the need for a better means of measuring the results of title VII and
title VIII programs, HRSA has since 2002 been developing a new strategic
plan for the health professions education programs, which includes program
goals and information on how the agency proposes to measure performance.

Although HRSA is responsible for providing health professions workforce
information to policymakers, HRSA has in the past decade published
national supply and demand projections for the nurse and pharmacist
workforces but no national projections for the physician and dentist
workforces. According to HRSA officials, the agency is preparing a report
to Congress that will provide information about the health workforce for
30 health professions, including national supply and demand projections
for physicians, pharmacists, and nurses. Estimating future health
workforce supply and demand on a regular basis is important because
estimates need to be revised periodically to reflect changes in the health
care environment. In 2005, an HHS advisory council strongly recommended
that the nation develop systems to track physician workforce supply,
demand, and distribution and undertake a comprehensive reassessment within
the following 4 years to guide future decisions on medical education
capacity.

12The Government Performance and Results Act of 1993 requires executive
agencies to develop agencywide performance goals and indicators and to
report progress annually. Pub. L. No. 103-62, S: 4, 107 Stat. 285, 286.

We are recommending that HRSA develop a strategy and time frames to
regularly update and publish national health professions workforce
projections. In commenting on a draft of this report, HRSA agreed with our
conclusion that updated workforce supply and demand projections are vital
for informed decision making about health professions programs.

                                   Background

In response to a shortage of health care providers, Congress amended title
VII of the Public Health Service Act in 196313 and established title VIII
in 1964.14 These titles have been amended over time and now authorize
funding for a variety of programs with diverse objectives. As noted in the
Senate report accompanying the 1998 reauthorization legislation, by the
mid-1970s, two specific areas of need had emerged: overall shortages in
rural and inner-city communities and an imbalance in the supply of primary
care providers as compared with specialists. Subsequent revisions to title
VII focused on encouraging health care workers to practice in underserved
areas, increasing the number of primary care providers, increasing
enrollment of minority and disadvantaged students, and developing faculty.
Revisions to title VIII focused on training advanced practice nurses;
enrolling disadvantaged students; strengthening basic nurse education and
practice; and, most recently, fostering nurse retention by promoting
career development and improving patient care delivery systems.

13Health Professions Educational Assistance Act of 1963, Pub. L. No.
88-128, 77 Stat. 164. See S. Rep. No. 88-485, at 3 (1963).

14Nurse Training Act of 1964, Pub. L. No. 88-581, 78 Stat. 1035. See S.
Rep. No. 88-1378, at 3 (1964).

The 1998 reauthorization resulted in the grouping of the more than 40
programs in existence at the time into seven clusters. The Senate report
accompanying the reauthorization legislation stated that "the bureaucracy
required to administer the existing programs should be simplified and
reduced" and also stated the purpose for each cluster (see table 1).15
According to the Senate report, one purpose of five of the seven clusters
was to provide administrative flexibility and simplification. The report
also stated that one objective of the reauthorization was to allow for
"better targeting of limited resources to address national health
workforce training and distribution deficits."

Table 1: Title VII and Title VIII Programs in Existence Before, and
Organized into Clusters After, 1998 Reauthorization

Programs in place before                                                   
1998 reauthorizationa     Cluster nameb              Cluster purposec
Title VII                 
Health Education          Student Loans          Continue (1) loan
Assistance Loans Health                          programs that do not
Professions Student Loans                        require federal
Loans for Disadvantaged                          appropriations or
Students Primary Care                            guarantee the
Loans                                            availability of loans for
                                                    health professions
                                                    students and (2) a loan
                                                    program for the
                                                    disadvantagedd
Centers of Excellence     Health Professions     Provide for the training
Exceptional Financial     Training for Diversity of minority and
Need Scholarships Faculty                        disadvantaged health
Loan Repayment Program                           professionals to improve
Financial Assistance for                         health care access in
Disadvantaged Health                             underserved areas and to
Professions Students                             improve representation in
Health Careers                                   the health professionsd
Opportunity Program                              
Minority Faculty                                 
Fellowship Program                               
Cooperative Agreements                           
for Partnerships for                             
Health Professions                               
Education Scholarships                           
for Disadvantaged                                
Students Program                                 
Departments of Family     Training in Family     Provide for the training
Medicine Faculty          Medicine, General      of family physicians,
Development in Family     Internal Medicine,     general internists,
Medicine Faculty          General Pediatrics,    general pediatricians,
Development in General    Physician Assistants,  physician assistants,
Internal Medicine and     General Dentistry, and general dentists, and
General Pediatrics        Pediatric Dentistry    pediatric dentists to
Graduate Training in                             improve access to and
Family Medicine Physician                        quality of health care in
Assistants Training                              underserved areas and to
Pre-doctoral Training in                         assure outside input
Family Medicine                                  regarding primary care
Residencies and Advanced                         training programsd
Education in the Practice                        
of General Dentistry                             
Residency Training in                            
General Internal Medicine                        
and General Pediatrics                           
Allied Health Project     Interdisciplinary,     Provide support for (1)
Grants Basic/Core Area    Community-Based        training centers remote
Health Education Centers  Linkages               from health professions
Chiropractic                                     schools to improve and
Demonstration Project                            maintain the distribution
Grants Geriatric                                 of health providers in
Education Centers                                underserved areas, (2)
Geriatric Fellowships                            geriatric education and
Health Education and                             geriatric faculty
Training Centers                                 fellowships, and (3)
Podiatric Primary Care                           interdisciplinary
Residency Training Grants                        training projectsd
for Interdisciplinary                            
Training for Health Care                         
for Rural Areas                                  
State-Supported Model                            
Area Health Education                            
Centers                                          
Center for Health         Health Professions     Provide for (1) the
Workforce                 Workforce Information  development of
                             and Analysis           information on the health
                                                    professions workforce and
                                                    the analysis of
                                                    workforce-related issues,
                                                    (2) the development of
                                                    necessary information for
                                                    decision making regarding
                                                    future directions in
                                                    health professions and
                                                    nursing programs, and (3)
                                                    continued analysis of
                                                    issues affecting graduate
                                                    medical education
Cooperative Agreement to  Public Health          Provide for an increase
Support Innovative        Workforce              in the number of
Projects Relating to                             individuals in the public
Public Health Education                          health workforce and
and Servicese Dental                             enhance the quality of
Public Health Specialty                          this workforce
Training Grants Health                           
Administration                                   
Traineeships and Special                         
Projects Residency                               
Training in Preventive                           
Medicine Public Health                           
Special Project Grants                           
Public Health                                    
Traineeships to Schools                          
of Public Health and                             
Other Public and                                 
Nonprofit Private                                
Institutions                                     
Title VIII                
Advanced Nurse Education  Nursing Workforce          Provide for the       
Nurse Anesthetist         Development                training of basic and 
Program: Program Grants                              advanced-degree       
Nurse Anesthetist                                    nurses to improve     
Program: Fellowships                                 access to and quality 
Nurse Anesthetist                                    of health care in     
Program: Traineeships                                underserved medical   
Nurse Practitioner/Nurse                             and public health     
Midwifery Nursing                                    areasd                
Education Loan Repayment                             
Program Nursing Education                            
Opportunities for                                    
Individuals from                                     
Disadvantaged Backgrounds                            
Nursing Special Projects                             
Nursing Student Loansf                               
Professional Nurse                                   
Traineeships                                         

15Senate Report No. 105-220 at 13 and 19 (1998) (accompanied legislation
that became Health Professions Education Partnership Act of 1998, Pub. L.
No. 105-392, 112 Stat. 3524). The Senate report is the only congressional
report accompanying Pub. L. No. 105-392.

Source: GAO analysis.

aInclude (1) programs that awarded funds competitively through grants or
cooperative agreements and that announced funding availability separately
and (2) programs providing direct assistance, such as student loans to
individuals, regardless of whether the loan program was using current
appropriations. Table does not include two advisory groups, COGME and the
National Advisory Council on Nurse Education and Practice, operating in
fiscal year 1998. Names for grant and cooperative agreement programs
reflect those used in the Federal Register or other program announcements.

bCluster names reflect headings of parts and subparts of title VII and of
title VIII of the Public Health Service Act, as amended by Pub. L. No.
105-392, and in some cases differ slightly from those in Senate Report No.
105-220.

cCluster purposes as provided in Senate Report No. 105-220.

dAnother purpose for this cluster, cited in Senate Report No. 105-220, was
to provide administrative flexibility and simplification.

eThis program includes a cooperative agreement with the Association of
Schools of Public Health (ASPH) to provide information to, and coordinate
with, the schools of public health that inquire about grant funding
opportunities under this program. HRSA has discretion to determine whether
projects are funded.

fSenate Report No. 105-220 included the Nursing Student Loans program in
the student loans cluster. Because this program is authorized under title
VIII, however, we included it in the nursing workforce development
cluster.

The programs within each cluster are tied to similar purposes. For
example, one cluster-Health Professions Training for Diversity-includes
programs targeting minorities or disadvantaged individuals. Another
cluster-Health Professions Workforce Information and Analysis-includes
work conducted by and for HRSA on health workforce issues, including
HRSA's National Center for Health Workforce Analysis, which received less
than $1 million per year in fiscal years 1999 through 2005.16 Title VII
also authorizes COGME, which provides advice and recommendations to the
Secretary of HHS and Congress on the supply and distribution of physicians
in the United States and other issues.17 According to COGME's charter,
"the Council periodically shall prepare and transmit a report, to the
Secretary and to the Committee on Health, Education, Labor and Pensions
(formerly the Committee on Labor and Human Resources) of the Senate, and
the Committee on Commerce (formerly the Committee on Energy and Commerce)
of the House of Representatives" with respect to supply and distribution
of physicians in the United States and other issues.

16The national center also supports work by six regional centers, which
conduct cross-disciplinary assessments of the health workforce, focusing
on issues at the state and regional levels. In addition, the national
center facilitates research projects contracted and funded by programs
within other clusters; for example, the national center facilitates
nursing workforce research. The congressional conference agreement for the
Department of Health and Human Services' appropriation for fiscal year
2006 did not include funding for the Health Professions Workforce
Information and Analysis cluster. H.R. Conf. Rep. No. 109-337 at 135
(2005).

17Three advisory groups besides COGME have received contract and staff
support from HRSA and have produced a series of reports on workforce
issues. These groups, authorized by title VII or title VIII of the Public
Health Service Act, are the National Advisory Council on Nurse Education
and Practice; the Advisory Committee on Training in Primary Care Medicine
and Dentistry; and the Advisory Committee on Interdisciplinary,
Community-Based Linkages.

For fiscal years 2002 through 2005, HRSA's budget justifications proposed
reducing overall funding for the health professions education
programs-reducing or eliminating funding for most of the title VII
clusters while requesting increased funding for the title VIII nursing
cluster. The agency's budget justification for fiscal year 2005 cited a
number of reasons for reducing or eliminating federal funding for many
title VII programs.18 These reasons included the availability of
alternative sources of funding, such as larger federal programs and state,
local, and private programs. For example, when discussing the reason for
not requesting funds for geriatric education and training under title VII,
HRSA's fiscal year 2005 budget justification stated that recipients of
geriatric education grants can secure support from other sources,
including other federal sources. As part of the Medicare program, HHS's
Centers for Medicare & Medicaid Services (CMS) makes payments for graduate
medical education totaling billions of dollars each year-nearly $8 billion
in fiscal year 2004.19 The Department of Veterans Affairs and the
Department of Labor administer additional programs that support health
professions education. (See app. I for information on other federal
sources of funding for health professions education.)

 Funding for and Overall Number of Title VII and Title VIII Health Professions
                          Education Programs Increased

After the 1998 reauthorization, overall funding for title VII and title
VIII programs generally increased, as did the total number of programs.
From fiscal years 1999 through 2005, overall funding for these programs
rose by 48 percent, from about $304 million to slightly more than $450
million. The overall number of title VII and title VIII programs
administered by HRSA also increased, from 46 programs before
reauthorization to 50 programs in fiscal year 2004, because of an increase
in the number of title VIII programs. The allocation of funding for these
programs is affected by factors such as statutory formulas and commitments
of future funding to grant recipients.

18Department of Health and Human Services, Health Resources and Services
Administration, Fiscal Year 2005 Justification of Estimates for
Appropriations Committees, vol. I, Budget (Washington, D.C.: n.d.).

19Medicare's graduate medical education payments are made to teaching
hospitals for both direct and indirect graduate medical education costs on
the basis of factors such as the number of physicians being trained,
Medicare's share of patient days in the hospital, and the hospital's ratio
of residents to beds.

Over the period from fiscal years 1999 through 2005, funding for both
title VII and title VIII programs increased (see fig. 1). Title VII
funding increased from about $236 million to about $300 million, or 27
percent, and title VIII funding increased from about $68 million to about
$151 million, or 122 percent.

Figure 1: Funding for Title VII and Title VIII Health Professions
Education Programs, Fiscal Years 1999-2005

Note: Graph excludes student loan programs. The Health Education
Assistance Loans program was not authorized to guarantee new loans to
student borrowers during this period. The remaining loan programs have
received no new federal funds since fiscal year 1998.

Among title VII's five program clusters-those other than the cluster for
student loans20-the proportion of funding allocated to each cluster
changed little from fiscal year 1999 through 2005. Throughout this period,
one of the clusters-Health Professions Training for Diversity-received the
largest share (around 39 percent annually) of title VII funding (see fig.
2).

Figure 2: Funding for Title VII Health Professions Education Programs,
Fiscal Years 1999-2005

Note: Graph excludes student loan programs. The Health Education
Assistance Loans program was not authorized to guarantee new loans to
student borrowers during this period. The remaining loan programs have
received no new federal funds since fiscal year 1998.

20We excluded the student loan cluster from this analysis. The Health
Education Assistance Loans program was not authorized to guarantee new
loans to student borrowers during this period. The remaining loan programs
have received no new federal funds since fiscal year 1998, although HRSA
continues to administer them.

Although the Senate report accompanying the 1998 reauthorization
legislation indicated that one of the purposes of five of the seven
clusters was to provide administrative flexibility and simplification, the
1998 reauthorization may not have had this effect. The overall number of
title VII and title VIII programs administered by HRSA increased. The
number of title VII programs HRSA administered (36) was the same in fiscal
year 1998 before reauthorization as in fiscal year 2004. Over the same
period, the number of title VIII programs HRSA administered increased from
10 to 14.21 (App. II lists programs that HRSA administered in 2004.22)
Regarding flexibility, several factors-including provisions of the Public
Health Service Act that specify how some program funds must be allocated
and commitments of future funding to grant recipients-affect how HRSA
allocates available funds among and within the health professions
programs.

           o  Statutory formulas for allocating funding: The Public Health
           Service Act, as amended by the 1998 reauthorization, specifies how
           funds are to be allocated among the institutions and individuals
           that apply for and receive certain health professions education
           program grant awards. For example, the act authorizes funding for
           grants within the cluster for training in family medicine, general
           internal medicine, general pediatrics, physician assistants,
           general dentistry, and pediatric dentistry by allocating it among
           programs within various disciplines according to a specified
           formula.23 Another example is the formula for allocating grant
           funding among recipients of one of the programs-Centers of
           Excellence-within the Health Professions Training for Diversity
           cluster. This program assists schools in supporting health
           professions education for underrepresented minorities. The Public
           Health Service Act specifies formulas for allocating funding among
           (1) centers of excellence at certain historically black colleges
           and universities, (2) Hispanic centers of excellence, (3) Native
           American centers of excellence, and (4) centers of excellence at
           other institutions.24 
           o  Commitments of future funding to noncompetitive continuations
           of existing grants: There are three types of health professions
           education grant awards: (1) new grants, which are awarded to
           institutions that do not have a current grant under a given
           program for a particular purpose; (2) noncompetitive continuations
           of existing grants, which provide funding for the second and
           subsequent years of projects approved for several years, such as
           for the second and third years of a 3-year project period; and (3)
           competitive continuations, which are awarded competitively to
           current grantees that have applied for additional funding for
           subsequent years. According to a HRSA official responsible for
           grants management, annual appropriations are applied to
           noncompetitive continuations of existing grants first; the
           remaining grant program funds are available for new and
           competitive continuation grant awards. In fiscal year 2004, for
           example, the share of funds committed to noncompetitive
           continuations amounted to about 75 percent of title VII grant
           funding, leaving about 25 percent for new and competitive
           continuation grants (see fig. 3). From fiscal years 1999 through
           2004, the proportion of the funds available for new and
           competitive continuation grants ranged from a high of about 41
           percent in fiscal year 1999 to a low of about 25 percent in fiscal
           year 2004.

           Figure 3: Title VII Funding for New and Competitive Continuation
           Grants and for Noncompetitive Continuations, Fiscal Years
           1999-2004

           The share of title VIII grant funding awarded to noncompetitive
           continuations was smaller (approximately 48 percent) in fiscal
           year 2004 than that of title VII, leaving about 52 percent of
           title VIII funds available for new and competitive continuation
           grants (see fig. 4). From fiscal years 1999 through 2004, the
           proportion of the title VIII grant funds available for new and
           competitive continuation grants ranged from a high of about 59
           percent to a low of about 52 percent.

           Figure 4: Title VIII Funding for New and Competitive Continuation
           Grants and for Noncompetitive Continuations, Fiscal Years
           1999-2004

           HRSA has stated goals but they are not comprehensive, and data for
           tracking progress toward meeting them are problematic. Recognizing
           these shortcomings, HRSA is developing new performance goals and
           measures. The effectiveness of these efforts will depend on the
           agency's ability to collect complete and timely data that it can
           use to assess its success in meeting these new goals.

           Although HRSA has published program goals and performance measures
           for the health professions and nursing education and training
           programs, these goals are not comprehensive, in that they cannot
           be used to assess the performance of all title VII and title VIII
           programs. Set forth in the budget justification for fiscal year
           2006 (see table 2 and app. III), the current goals and performance
           measures were prepared as part of HHS's annual reporting under the
           GPRA process.25 For example, one published performance goal is to
           increase the proportion of health professionals completing title
           VII- and title VIII-supported health professions education
           programs who are underrepresented minorities or from disadvantaged
           backgrounds. The budget justification also lists a long-term
           target for this goal of 50 percent by the year 2010 and targets
           for a number of interim years, such as 43 percent by 2005 and 44
           percent by 2006. HRSA officials stated that the agency's published
           goals and measures cover only a subset of title VII and title VIII
           programs; they do not, for example, apply directly to programs
           designed to develop curriculums or to recruit and retain faculty.

           Table 2: Performance Goals and Targets for the Health Professions
           and Nursing Education and Training Programs Funded under Title VII
           and Title VIII

           Source: Department of Health and Human Services, Health Resources
           and Services Administration, Fiscal Year 2006 Justification of
           Estimates for Appropriations Committees (Washington, D.C.: n.d.).

           Note: All years are fiscal years.

           aAccording to HRSA officials, HRSA has historically counted
           graduating students as belonging to the year in which their
           institution began receiving funding under a specific grant, not to
           the year in which the students graduated. For example, according
           to HRSA officials, data listed in the table as the baseline for
           2001 pertain to grants awarded in 2001, although the data were
           collected in 2003.

           bThe target for fiscal year 2004 was set before baseline data were
           available. Fiscal year 2005 and 2006 targets were adjusted to
           reflect the baseline.

           cThe baseline estimate is a partial one based on data submissions
           for fiscal year 2001.

           dGrantees in programs not designed to increase health
           professionals in underserved areas are not required to submit
           these data. HRSA's fiscal year 2006 budget justification indicates
           that the Bureau of Health Professions within HRSA intends to
           propose an alternative measure after work on a new strategic plan
           has been completed.

           According to HRSA officials, a number of HRSA's previous
           performance goals were deleted, and others added, in response to
           an OMB assessment of title VII and title VIII programs for the
           fiscal year 2004 budget. In its review, OMB noted a lack of
           consensus among various parties regarding the purpose of the
           health professions programs, stating, "The Administration has
           tended to focus on diversity and distribution [of health
           professionals]. Congressional committees often focus on the
           program as a means of helping rural areas. Advocates also
           emphasize the financial vulnerability of funded institutions."
           Further, OMB found little evidence that HRSA used performance data
           to adjust program priorities, to allocate resources, or to take
           other management actions.

           In reporting on progress toward meeting its published goals, HRSA
           relies in part on grantees' self-reported data, which HRSA
           acknowledges are problematic. The agency requires grantees to
           submit an annual progress report on accomplishments and movement
           toward achieving the objectives described in the original grant
           agreement.26 For example, some title VII and title VIII grantee
           institutions are required to determine the proportion of their
           graduates who go on to practice in certain areas, such as
           medically underserved communities. HRSA officials stated, however,
           that obtaining data on where graduates go after leaving training
           programs is not easy. For example, according to the officials,
           grantees rely on their graduates to voluntarily provide practice
           location information, and some do not do so. HRSA officials also
           said that some grantees do not provide information because of
           concerns related to state privacy laws.

           Problems with HRSA's data to measure progress toward meeting its
           stated goals are longstanding. For example, in 1997, we reported
           that data provided to HRSA by grantees about graduates placed in
           medically underserved communities were not necessarily complete or
           comparable among schools, and the agency had not established a way
           to validate the data provided.27 Five years later, these problems
           remained. In 2002, an evaluation of grantees' data collection
           processes prepared for HRSA found that 56 percent of grantees
           collected and submitted data on the number of their graduates who
           were employed in medically underserved communities in fiscal year
           2000.28 Although almost all the grantees that were not collecting
           these data reported that they planned to do so in the future, a
           few reported that they had no plans to do so because they lacked
           the staff, their students were not yet employed, or their program
           was too new. Of grantees able to report the information, 36
           percent relied in part on their former students to "self-report"
           whether they were employed in a medically underserved community.
           The 2002 evaluation also reported that grantees had difficulties
           understanding or interpreting the definition of "medically
           underserved community" and recommended that HRSA clarify the term
           in its instructions to grantees. As a result, HRSA could not be
           sure that the self-reported data followed consistent criteria,
           making the results unreliable.

           Since fall 2002, HRSA has been developing a new strategic plan
           that includes goals for title VII and title VIII programs and a
           description of how the agency proposes to measure performance. The
           HRSA official overseeing this effort noted that reviews by both
           GAO and OMB made it clear that HRSA needed to come up with an
           effective means of measuring the results of title VII and title
           VIII programs and communicating these results to the public.
           According to HRSA, implementing the new strategic plan will enable
           the agency to " better . . . capture the accomplishments of title
           VII's and title VIII's diverse portfolio of programs." HRSA
           released a draft of its new strategic plan and its proposed
           performance measures during a June 2005 all-grantee conference
           attended by title VII and title VIII grant recipients. According
           to officials in HRSA's Bureau of Health Professions, a primary
           purpose of the conference was to introduce the draft of the newly
           revised strategic plan and proposed performance measures to
           grantees and receive feedback as to whether the proposed revised
           measures were practicable. The plan contained 118 proposed program
           measures (specific performance measures for each title VII and
           title VIII program); 17 proposed core measures (performance
           measures common to a number of health professions programs with
           similar goals); and 14 national measures (national indicators
           sensitive to access to primary care, such as the immunization rate
           among children 19-35 months old or mammography rates among women
           40 years old or older29).

           Once HRSA has finalized the updated goals and performance
           measures, identifying and obtaining the necessary data will be
           key. The quality, completeness, and timeliness of the data used to
           calculate baseline values, as well as to measure actual
           performance and track the progress the programs are making in
           meeting their goals, will be critical. Without comprehensive
           goals, performance measures, and data, the agency will be unable
           to target federal resources to the most effective programs.

           As of October 2005, a performance measurement working group in
           HRSA had begun to catalog the data needed to implement the
           proposed performance measures; to reconcile these needs with the
           data HRSA currently collects from its grantees; and, according to
           the group's lead official, to recommend improvements to the
           agency's grantee data collection and monitoring system. HRSA
           officials said that their schedule called for finalizing and
           testing the new measures, developing forms for collecting the
           data, and updating the data collection and monitoring system by
           October 2006.30 According to agency officials, the new approach
           would improve the quality, timeliness, and relevance of the
           agency's performance data.

           One of HRSA's tasks is to supply information to policymakers on a
           broad range of health workforce issues, including forecasts of
           supply and demand for physicians, dentists, nurses, and
           pharmacists. The agency has, however, published few recent
           national health professions workforce projections. For example,
           its projections for the physician and dentist workforces are more
           than a decade old. Yet regular reassessment of health workforce
           supply and demand is key to setting policies as health care needs
           change.

           HRSA's fiscal year 2006 budget justification states that a goal of
           the Health Professions Workforce Information and Analysis cluster
           is to "provide health workforce information and analyses to
           national, state, and local policymakers and researchers on a broad
           range of issues, such as shortages of registered nurses, shortages
           of pharmacists, and the distribution of health care workers in
           underserved areas."31 Although HRSA maintains a variety of
           indicators and statistics on the health care workforce, in the
           past decade the agency has published no national supply and demand
           projections for the physician or dentist workforces.32 The most
           recent HRSA national nursing workforce projections were published
           in 2002, and the latest HRSA report containing national pharmacist
           workforce projections was published in 2000. The agency's most
           recent national physician and dentist workforce projections were
           published in 1991. Table 3 summarizes HRSA's latest publications
           containing national workforce projections for physicians,
           dentists, nurses, and pharmacists.

21The Nurse Reinvestment Act of 2002 authorized additional title VIII
programs. Pub. L. No. 107-205, S:S: 103, 201, 202, 116 Stat. 811, 813,
815, 816 (2002).

22We used HRSA's database to identify the title VII and title VIII grant
programs that received funding in fiscal year 2004. Fiscal year 2004 was
the most recent year for which data were available at the time of our
analysis. We also contacted HRSA officials to obtain information on other
title VII and title VIII programs, such as scholarship programs, that HRSA
administered in those years. We counted (1) programs that awarded funds
competitively through grants or cooperative agreements and that announced
funding availability separately or had a separate selection panel and (2)
programs providing direct assistance, such as student loans to
individuals, regardless of whether the loan program received any new
appropriations.

23The act specifies that, of the $78.3 million authorized to be
appropriated for fiscal year 1998, not less than $49.3 million be made
available to programs of family medicine, of which not less than $8.6
million be made available for family medicine academic administrative
units, not less than $17.7 million be made available to programs of
general internal medicine and general pediatrics, not less than $6.8
million be made available to programs related to physician assistants, and
not less than $4.5 million be made available to programs of general or
pediatric dentistry. If the amounts appropriated in subsequent fiscal
years are less than the amount authorized to be appropriated for 1998, the
act directs the secretary to reduce the amounts made available to the
programs on a proportional basis. See Public Health Service Act, S: 747,
as amended (codifed at 42 U.S.C. S: 293k).

24See Public Health Service Act, S: 736, as amended (codified at 42 U.S.C.
S: 293).

HRSA's Goals Do Not Apply to All Title VII and Title VIII Programs, and Data Are
               Problematic, but Agency Is Developing Alternatives

HRSA's Goals Are Not Comprehensive, and Data to Assess Performance Are
Problematic

25Department of Health and Human Services, Health Resources and Services
Administration, Fiscal Year 2006 Justification of Estimates for
Appropriations Committees (Washington, D.C.: n.d.). In addition to the
broad performance goals for health professions and nursing education and
training programs shown in table 2, the budget justification also lists
goals and performance measures for specific programs, such as Health
Education Assistance Loans, Health Professions Workforce Information and
Analysis, and the Nursing Education Loan Repayment and Nursing Scholarship
Programs (see app. III).

                                             Long-term and Available data for 
GPRA performance goals                  interim targets              yeara 
Increase the proportion of health          50% in 2010:       42% for 2001 
professionals graduating from or                               (baseline)c 
completing title VII- and title        44% in 2006b 43% 
VIII-supported health professions       in 2005b 40% in 
education programs who are                        2004b 
underrepresented minorities or from                     
disadvantaged backgrounds                               
Increase the proportion of persons in       96% in 2010        87% in 1998 
the United States who have a specific                     (baseline)88% in 
source of ongoing care                                     2003 (estimate) 
Increase the proportion of health          40% in 2010:   Average, 19% for 
professionals trained in programs                                1999-2001 
supported by titles VII and VIII who                           (baseline)d 
are serving in medically underserved                    
communities                                             
Increase the proportion of trainees in 54% in 2006b 53%   Average, 52% for 
programs supported by titles VII and    in 2005b 30% in          1999-2001 
VIII who are training in medically                2004b        (baseline)d 
underserved communities                                 
Increase the proportion of health      21% in 2006b 20%   Average, 19% for 
professionals in programs supported by  in 2005b 30% in          1999-2001 
titles VII and VIII programs who enter            2004b        (baseline)d 
practice in underserved areas                           

26To collect these data, HRSA developed its comprehensive performance
management system and uniform progress report.

27 GAO/T-HEHS-97-117 .

HRSA Is Developing New Goals and Performance Measures

28Mia Cahill et al., Evaluation of Data Collection Processes Used by the
Bureau of Health Professions' Grantees to Determine the Number of
Graduates and Program Completers Practicing in Medically Underserved
Communities, final report prepared for HRSA (Princeton, N.J.: Mathematica
Policy Research, Mar. 31, 2002).

     HRSA Has Published Few National Workforce Projections in Recent Years

29HRSA officials acknowledged that such proposed national indicators are
driven by a number of factors other than funding support from title VII
and title VIII programs.

30HRSA officials noted that the agency must seek approval from OMB for any
change in reporting requirements for grantees, and that they expected to
submit their plans to OMB by spring 2006.

HRSA Has Not Regularly Published National Health Professions Workforce
Projections

31Other goals include federal-state collaborative efforts directed at
assessing the adequacy of the current and future heath care workforce from
federal, state, and local perspectives and developing strategies for
improving the diversity and distribution of the health workforce. See
Department of Health and Human Services, Health Resources and Services
Administration, Fiscal Year 2006 Justification of Estimates for
Appropriations Committees.

32In addition to national workforce projections and other reports issued
by HRSA and its six regional centers, HRSA supports a database, the Area
Resource File, containing statistics on health professions, health
training programs, health facilities, measures of resource scarcity, and
health status. This information is derived from existing data sources,
such as the National Center for Health Statistics and American Hospital
Association.

Table 3: HRSA's Most Recent Reports Containing National Workforce Supply
and Demand Projections for Physicians, Dentists, Nurses, and Pharmacists

                     Latest workforce                                         
                     projections         Discussion of models and data used   
Health profession published by HRSA   to make projections
Physicians        Health Personnel in HRSA developed physician supply and  
                     the United States:  demand models. HRSA's current supply 
                     Eighth Report to    model uses data from sources such as 
                     Congress (1991)     the American Medical Association     
                                         (AMA) Physician Masterfilea to       
                                         project national estimates of        
                                         physician supply by 36 medical       
                                         specialties through the year 2020.   
                                         HRSA's current physician demand      
                                         model uses Census Bureau population  
                                         projections, plus data from sources  
                                         such as the National Ambulatory      
                                         Medical Care Surveyb and the         
                                         Nationwide Inpatient Sample,c to     
                                         project demand for physicians in 18  
                                         medical specialties to the year      
                                         2020.                                
Dentists          Health Personnel in According to HRSA officials, the     
                     the United States:  supply and demand models for         
                     Eighth Report to    dentists are out of date, and HRSA   
                     Congress (1991)     plans to update them. HRSA has a     
                                         cooperative agreement with the       
                                         American Dental Association to       
                                         develop dentist supply and demand    
                                         estimates.                           
Nurses            Projected Supply,   HRSA collects data on the nurse      
                     Demand, and         workforce through its National       
                     Shortages of        Sample Survey of Registered Nurses,  
                     Registered Nurses:  which is conducted every 4 years,    
                     2002-2020 (2002)    and generally publishes nurse        
                                         workforce projections after the most 
                                         recent survey. The agency's nursing  
                                         supply model projects the            
                                         state-level registered nurse supply  
                                         through 2020. The nursing demand     
                                         model projects state-level demand    
                                         for registered nurses, licensed      
                                         practical nurses, and nursing and    
                                         home health aides through 2020 in a  
                                         number of employment settings, such  
                                         as hospitals, nursing facilities,    
                                         and doctors' offices. As of December 
                                         2005, the nursing supply and demand  
                                         models were being updated to         
                                         incorporate data from the most       
                                         recently completed National Sample   
                                         Survey of Registered Nurses (2004).d 
Pharmacists       The Pharmacist      HRSA created a pharmacist supply     
                     Workforce: A Study  model to generate estimates of       
                     of the Supply and   pharmacist numbers in the United     
                     Demand for          States through 2020. But because the 
                     Pharmacists (2000)  pharmacy profession lacks a          
                                         comprehensive database like the      
                                         physician database maintained by     
                                         AMA, the pharmacist model uses a     
                                         base-year count of active            
                                         pharmacists from a 1992 pharmacist   
                                         census. The model then projects the  
                                         number of practicing pharmacists     
                                         into the future by adding, each      
                                         year, the projected number of new    
                                         entrants and subtracting, each year, 
                                         the projected number of pharmacists  
                                         who will die or retire. For the      
                                         pharmacist projection published in   
                                         2000, HRSA did not develop a         
                                         pharmacist demand model per se but   
                                         instead described issues affecting   
                                         the demand for pharmacists, such as  
                                         the number of retail prescriptions   
                                         dispensed and the growth in demand   
                                         for pharmacists in hospitals.        
                                         According to HRSA officials, as of   
                                         2005, the agency had begun updating  
                                         the pharmacist supply model.         

Source: HRSA.

Note: Table lists most recent reports as of October 2005. In addition, the
agency published a report containing preliminary forecasts, developed
using the agency's physician and nursing demand models, of the impact of
changing demographics on the demand for physicians, nurses, and other
health professions. See Department of Health and Human Services, Health
Resources and Services Administration, Changing Demographics: Implications
for Physicians, Nurses, and Other Health Workers (Rockville, Md.: 2003).

aThe AMA Physician Masterfile is a computer database of physicians that
includes current and historical data on physicians, including AMA members
and nonmembers and graduates of foreign medical schools who reside in the
United States and who have met the educational and credentialing
requirements necessary for recognition as physicians.

bAdministered by the Centers for Disease Control and Prevention's National
Center for Health Statistics, the National Ambulatory Medical Care Survey
is a nationwide survey based on a sample of visits to nonfederally
employed office-based physicians who are engaged primarily in direct
patient care. The survey was conducted annually from 1973 to 1981, in
1985, and annually since 1989.

cThe Nationwide Inpatient Sample, part of the Healthcare Cost and
Utilization Project sponsored by the Agency for Healthcare Research and
Quality, is a database of hospital inpatient stays. It contains data on
about 7 million hospital stays taken from a sample of about 1,000 U.S.
community hospitals.

dThe seventh National Sample Survey of Registered Nurses was conducted in
2000, and the results were published on February 22, 2002. The eighth
National Sample Survey of Registered Nurses was conducted in 2004; as of
December 2005, HRSA had posted preliminary results on its Web site but had
not published any updated national nursing supply or demand projections.
The survey collects information on the number of registered nurses; their
educational background and specialty areas; their employment status,
including type of employment setting, position level, and salaries; their
geographic distribution; and their personal characteristics, including
gender, racial or ethnic background, age, and family status.

Although HRSA has not published national projections for the physician
workforce in the past decade, agency officials noted that individual HRSA
staff members have contributed articles to journals,33 and COGME, which
advises the Secretary of HHS and congressional committees, used HRSA's
models to develop physician workforce projections through 2020 for COGME's
January 2005 report.34 HRSA officials said they have not contributed to
any similar national projections for the dentist workforce in the past
decade.

From the 1970s through the early 1990s, HRSA periodically provided health
professions workforce information by producing a series of legislatively
mandated reports to Congress on the supply and distribution of health
personnel, including recommendations for improving health care in the
nation. Some but not all of these reports included original national
workforce supply and demand projections. For example, the eighth report,
dated 1991, did include such projections, but the ninth report did not.
The mandated reporting requirement was eliminated by the Federal Reports
Elimination and Sunset Act of 1995, which took effect in December 1999;
the last of HRSA's reports, however, was issued 4 years earlier, in
1995.35

33See, for example, Jack M. Colwill and James M. Cultice, "The Future
Supply of Family Physicians: Implications for Rural America," Health
Affairs, vol. 22, no. 1 (2003), and Robert M. Politzer et al., "Matching
Physician Supply and Requirements: Testing Policy Recommendations,"
Inquiry, vol. 33: 181-194 (1996).

34Council on Graduate Medical Education, Department of Health and Human
Services, Health Resources and Services Administration, Physician
Workforce: Policy Guidelines for the United States, 2000-2020 (Rockville,
Md.: January 2005). The views expressed in COGME's report are solely those
of the council and do not necessarily represent the views of HRSA or the
U.S. government.

According to a HRSA official involved in reporting on workforce issues,
the agency began work on a tenth report to Congress in 1995 after
releasing the ninth report, but because of passage of the Federal Reports
Elimination and Sunset Act, the report effort was given few resources.
HRSA officials said that the tenth report would provide information about
the health workforce for 30 key health professions, including national
supply and demand projections for physicians, pharmacists, and nurses.
Information on dentists would be more limited. While HRSA has not planned
to include supply or demand projections for other health professions, such
as dental hygienists, dental assistants, and physical or occupational
therapists, agency officials said they planned to report on issues and
trends relevant to those health professions. As of October 2005, HRSA
officials said they were revising major sections of the tenth report.
According to the officials, the agency had no specific plans to publish
reports like the tenth report in the future, but the National Center for
Health Workforce Analysis did plan to continue publishing analyses of
selected health professions, including profiles of the health workforce
within a state at a given time.36

Regular Reassessment of Health Workforce Predictions Is Critical Because of a
Changing Health Care Environment

Estimating future health workforce supply and demand on a regular basis is
important because estimates need to be updated as circumstances change.
For example, estimates prepared in the 1980s and early 1990s led to
concern about an impending surplus of physicians overall but a shortage of
physicians trained in primary care. This anticipated shortage of primary
care physicians resulted in part from an assumption that the nation would
need fewer specialty physicians because of an increase in managed care,
which makes use of primary care "gatekeepers." The assumption was that the
gatekeepers would limit patients' use of specialist care. Partly because
the assumption about growth in managed care proved incorrect, however, the
projected shortage of primary care physicians failed to materialize.37

35The Public Health Service Act required that HRSA report to Congress in
1993 and every 2 years thereafter; see S:792, codified at 42 U.S.C.
S:295k. After submitting the ninth report to Congress in 1995, HRSA did
not submit additional biennial reports before the requirement was
eliminated in 1999 by the Federal Reports Elimination and Sunset Act of
1995. Pub. L. No. 104-66, S:303, 109 Stat. 707, 734.

36The most recent state profiles compiled 2000 data on levels of
employment, projected growth, and key environmental factors affecting
demand for health care. Because these profiles did not include national
workforce projections, they were outside of the scope of our review. See
http://bhpr.hrsa.gov/healthworkforce/reports/profiles/, downloaded
September 7, 2005.

COGME's January 2005 report recognized the uncertainty inherent in any
effort to forecast the physician workforce many years into the future.
COGME's report showed, for example, that physician supply and demand could
shift because changing lifestyles may prompt new physicians to work fewer
hours than their predecessors, an increase in the nation's wealth could
contribute to continued increases in the use of medical services, or an
increased supply of nurse practitioners and other nonphysician clinicians
could reduce the demand for physicians. Given this uncertainty, as well as
the costs to expand medical education and training capacity, COGME
strongly recommended that the nation develop systems to track physician
workforce supply, demand, and distribution and undertake a comprehensive
reassessment within the next 4 years to guide future decisions on medical
education capacity.

                                  Conclusions

Our work continues to point to the need for better information to assess
the performance of title VII and title VIII programs. The agency's current
published goals and measures are not comprehensive, and the data to
measure performance in meeting them have been problematic. As a result,
HHS cannot fully inform Congress or the public about the value of title
VII and title VIII health professions education programs. It remains to be
seen whether HRSA's current strategic planning and associated data
collection efforts will remedy these shortcomings.

In addition, the ability of HHS and Congress to target federal resources
to appropriate health professions education programs will remain limited
without useful information on future health workforce needs. Updated
workforce supply and demand projections are vital for informed decision
making about health professions programs. Without relevant goals and
performance measures, coupled with key data, HHS and Congress will lack
information that would enable them to target federal funds effectively to
those health professions education programs most critical to meeting the
nation's anticipated need for health professionals.

37More recent workforce research has again raised concerns that the nation
is likely to face a shortage of physicians. For example, in October 2003,
AMA noted that several published studies have demonstrated that the
expected oversupply had not appeared. COGME, in a January 2005 report, has
also acknowledged that the nation may face a physician shortage by the
year 2020.

                      Recommendation for Executive Action

We recommend that the Administrator of HRSA develop a strategy and
establish time frames to more regularly update and publish national
workforce projections for the health professions.

                                Agency Comments

In written comments on a draft of this report (see app. IV), HRSA agreed
with the need for clear, relevant goals and performance measures backed by
timely and complete data, and it agreed with the importance of updated
workforce supply and demand projections. HRSA stated that completing
development of the agency's new performance goals and measures and
integrating these new goals and measures into the agency's data collection
systems are a top priority. HRSA also agreed with our conclusion that
updated workforce supply and demand projections are vital for informed
decision making in the changing health care environment.

The agency commented, however, on the scope of our work. First, HRSA
commented that the draft report did not include the many objectives
authorized for funding under title VII and title VIII of the Public Health
Service Act. Although we reviewed the act's provisions for background
purposes, our scope was to examine HRSA's stated goals for the title VII
and title VIII programs and the agency's efforts to measure progress
toward meeting those goals. According to HRSA officials, the GPRA goals in
the fiscal year 2006 budget justification were the agency's published
goals for the programs at the time of our review. While we were aware of,
and reported on, the agency's efforts to develop a new strategic plan and
associated goals, measures, and data, they were in draft form at the time
of our review, and HRSA had yet to formally adopt or finalize them. Since
the agency provided technical comments including time frames associated
with these efforts, we removed a recommendation that the agency establish
such time frames.

Second, regarding workforce analyses, the agency commented that our draft
report did not discuss the considerable body of work produced by regional
workforce centers and advisory committees that receive title VII and title
VIII funding from HRSA. Because the scope of our review regarding
workforce issues was limited to the most recent projected estimates
(completed and published) of national supply and demand for physicians,
dentists, nurses, and pharmacists, we did not include other reports
produced or drafted by or for HRSA, its regional workforce centers, or its
advisory groups. We did, however, acknowledge that HRSA's National Center
for Health Workforce Analysis conducts a variety of activities other than
national supply and demand projections. We incorporated HRSA's technical
comments as appropriate.

As agreed with your offices, unless you publicly announce the contents of
this report earlier, we plan no further distribution of it until 30 days
after its issue date. At that time, we will send copies to the Secretary
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If you or your staff have any questions regarding this report, please
contact me at (312) 220-7600 or [email protected]. Contact points for our
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last page of this report. GAO staff who made major contributions to this
report are listed in appendix V.

Leslie G. Aronovitz Director, Health Care

Appendix I: Examples of Additional Sources of Federal Funding for Health
Professions Education Appendix I: Examples of Additional Sources of
Federal Funding for Health Professions Education

Table 4: Examples of Federal Funding Sources, besides Title VII and Title
VIII Programs, for Postsecondary Education and Training Specifically
Targeted for Health Professions

                                                                 2004 funding 
                                                                 (millions of 
Agency               Program                                      dollars) 
Department of Health Centers for Medicare & Medicaid                       
and Human Services   Services: Medicare payments for graduate 
                        medical educationa                             $7,900
                        Centers for Medicare & Medicaid                       
                        Services: Medicaid payments for graduate 
                        medical education                                   b
                        Health Resources and Services                         
                        Administration: Children's Hospitals     
                        Graduate Medical Education Payment       
                        Program                                          $303
                        Health Resources and Services                         
                        Administration: National Health Service  
                        Corps                                            $170
                        Health Resources and Services                         
                        Administration: Bioterrorism Training    
                        and Curriculum Development Program                $28
                        Indian Health Service: Loan Repayment                 
                        Program                                           $12
Department of        Defense Health Program: health                        
Defense              professions scholarship program and      
                        education and training                           $318
Department of Labor  Employment and Training Administration:               
                        President's High Growth Job Training     
                        Initiative (health care)                            c
Department of        Veterans Health Administration:                       
Veterans Affairs     education and training programs for      
                        health professions students and          
                        residents                                        $493

Source: GAO.

aMedicare's graduate medical education payments are made to teaching
hospitals for both direct and indirect graduate medical education costs on
the basis of factors such as the number of physicians being trained,
Medicare's share of patient days in the hospital, and the hospital's ratio
of residents to beds.

bCiting a 50-state survey conducted for the Association of American
Medical Colleges, COGME reported that Medicaid provided teaching hospitals
between $2.5 and $2.7 billion in 2002. See Council on Graduate Medical
Education, Department of Health and Human Services, Health Resources and
Services Administration, State and Managed Care Support for Graduate
Medical Education: Innovations and Implications for Federal Policy
(Rockville, Md.: July 2004).

cThis initiative focuses on 14 targeted sectors, one of which is health
care. As part of this initiative, the Secretary of Labor announced awards
of more than $24 million in grants to counter health care labor shortages
in 2004.

Table 5: Examples of Federal Funding Sources for General Postsecondary
Education and Training Including, but Not Exclusive to, Health Professions

                                                     2004 funding(millions of 
Agency               Source                                       dollars) 
Department of        Federal student aid                                   
Education            programsa                                     $20,544
Department of Health National Institutes of                                
and Human Services   Health: NIH Extramural Loan  
                        Repayment Programs                                $73
Department of Labor  Employment and Training                               
                        Administration: Job Corpsb                     $1,537

Source: GAO.

aInclude programs such as the Department's Federal Family Education Loan
Program, Federal Pell Grant Program, Federal Perkins Loan Program, Federal
Supplemental Educational Opportunity Grant Program, and Federal Work-Study
Program.

bAs of May 2004, according to an official in the Department of Labor's
Employment and Training Administration, 105 Job Corps centers provided
training in one or more of 12 different health-related training programs.

Appendix II: Title VII and Title VIII Clusters and Programs, Fiscal Year
2004 Appendix II: Title VII and Title VIII Clusters and Programs, Fiscal
Year 2004

Cluster namea                 Programs funded in fiscal year 2004b         
Title VII                     
Student Loans                 Health Professions Student Loans Loans for   
                                 Disadvantaged Students Primary Care Loans    
Health Professions Training   Centers of Excellence Faculty Loan Repayment 
for Diversity                 Program Health Careers Adopt a School        
                                 Demonstration Program Health Careers         
                                 Opportunity Program Minority Faculty         
                                 Fellowship Program Scholarships for          
                                 Disadvantaged Students Program               
Training in Family Medicine,  Academic Administrative Units in Primary     
General Internal Medicine,    Care Cooperative Agreement to Plan, Develop, 
General Pediatrics, Physician Implement and Operate a Continuing Clinical  
Assistants, General           Education Program in the Pacific Basin       
Dentistry, and Pediatric      Faculty Development in Primary Care          
Dentistry                     Physician Assistant Training in Primary Care 
                                 Predoctoral Training in Primary Care         
                                 Residency Training in General and Pediatric  
                                 Dentistry Residency Training in Primary Care 
                                 Training in Primary Care Medicine and        
                                 Dentistry                                    
Interdisciplinary,            Allied Health Projects Basic/Core Area       
Community-Based Linkages      Health Education Centers Chiropractic        
                                 Demonstration Project Grants Geriatric       
                                 Academic Career Awards Geriatric Education   
                                 Centers Geriatric Training for Physicians,   
                                 Dentists, and Behavioral and Mental Health   
                                 Professionals Graduate Geropsychology        
                                 Education Program Graduate Psychology        
                                 Education Program Health Education and       
                                 Training Centers Model State-Supported Area  
                                 Health Education Centers Podiatric Residency 
                                 Training in Primary Care Quentin N. Burdick  
                                 Program for Rural Interdisciplinary Training 
Health Professions Workforce  Center for Health Workforce                  
Information and Analysis      
Public Health Workforce       ASPH [Association of Schools of Public       
                                 Health] Cooperative Agreementc Dental Public 
                                 Health Residency Training Grants Health      
                                 Administration Traineeships and Special      
                                 Projects Preventive Medicine Residency       
                                 Program Public Health Traineeships Public    
                                 Health Training Centers Grant Program        
Title VIII                    
Nursing Workforce Development Advanced Education Nursing Program Advanced  
                                 Education Nursing Traineeships Basic Nurse   
                                 Education and Practice Grants Clinical       
                                 Experience in Federally-Funded Community     
                                 Health Centers for Nurse Practitioners       
                                 and/or Nurse-Midwifery Students              
                                 Comprehensive Geriatrics Education Program   
                                 Nurse Anesthetist Traineeships Nurse         
                                 Education, Practice, and Retention Grant     
                                 Program: Grants for Career Ladder Programs   
                                 Nurse Education, Practice, and Retention     
                                 Grant Program: Grants for Enhancing Patient  
                                 Care Delivery System Program Nurse           
                                 Education, Practice, and Retention Grant     
                                 Program: Grants for Internships and          
                                 Residency Programs Nurse Faculty Loan        
                                 Program Nursing Education Loan Repayment     
                                 Program Nursing Scholarship Program Nursing  
                                 Student Loans Nursing Workforce Diversity    
                                 Grants                                       

Source: GAO analysis.

aCluster names reflect headings of parts and subparts of title VII and of
title VIII of the Public Health Service Act, as amended by Pub. L. No.
105-392, and in some cases differ slightly from those in Senate Report No.
105-220.

bInclude (1) programs that awarded funds competitively through grants or
cooperative agreements and that announced funding availability separately
or had a separate selection panel and (2) programs providing direct
assistance, such as student loans to individuals, regardless of whether
the loan program received any new appropriations. Table does not include
four advisory groups-COGME, the National Advisory Council on Nurse
Education and Practice, the Advisory Committee on Training in Primary Care
Medicine and Dentistry, and the Advisory Committee on Interdisciplinary,
Community-Based Linkages-operating in fiscal year 2004. Names for grant
and cooperative agreement programs reflect those used in the Federal
Register or other program announcements.

cThis program, which allows schools of public health to apply for HRSA
funding to support certain special projects, includes a cooperative
agreement with ASPH to provide information to, and coordinate with, the
schools of public health that inquire about grant opportunities under this
program. HRSA has sole discretion to determine whether projects are
funded.

Appendix III: Additional Performance Goals and Targets for Health
Professions and Nursing Education Programs Appendix III: Additional
Performance Goals and Targets for Health Professions and Nursing Education
Programs

                                            Long-term and  Available data for 
GPRA performance goals                 interim targets                year 
Health Education Assistance Loans Program
Phase out the outstanding loan    $1.7 million in 2006     $2.0 million in 
portfolio, resulting in a         $1.9 million in 2005 2004$2.3 million in 
reduction in the federal          $2.6 million in 2004 2003$2.7 million in 
liability associated with the     $2.7 million in 2003 2002$3.2 million in 
Health Education Assistance Loans $3.3 million in 2002 2001$3.5 million in 
Program                           $3.4 million in 2001                2000 
                                     $3.6 million in 2000 
Health Professions Workforce Information and Analysis
Annually produce results of data    25 reports in 2006       21 reports in 
collection and analysis             25 reports in 2005   200423 reports in 
activities to inform the market     23 reports in 2004   200314 reports in 
regarding issues relevant to        23 reports in 2003   200210 reports in 
health professions and nursing      11 reports in 2002                2001 
workforce (number of reports)       10 reports in 2001 
Nursing Education Loan Repayment Program (NELRP) and Scholarship Program
Increase the number of               Baseline + 10% in   Estimated 240,500 
individuals enrolled in                           2010 in 2004 (baseline)a 
professional nursing education                         
programs                                               
Increase the proportion of          85% in 2006 80% in        23% in 2004b 
nursing scholarship recipients        2005 75% in 2004 
who, within 4 months of                                
licensure, are working in a                            
facility with a critical shortage                      
of nurses                                              
Increase the proportion of NELRP         85% in 2010:c 100% in 2004100% in 
participants working in shortage                                      2003 
facilities, such as                90% in 2006c 85% in 
disproportionate share hospitals    2005c 65% in 2004c 
for Medicare and Medicaid,                             
nursing homes, public health                           
departments (state and local),                         
and public health clinics within                       
these departments                                      
Increase the proportion of states   93% in 2006 93% in   98% in 200488% in 
in which NELRP contract           2005 85% in 2004 65%     200382% in 2002 
recipients work                    in 2003 50% in 2002 
Increase the proportion of NELRP          28% in 2010:        40% in 2004d 
participants who remain employed                       
at a critical-shortage facility     11% in 2006 11% in 
for at least 1 year beyond            2005 10% in 2004 
termination of their NELRP                             
service                                                
Reduce the federal investment per   45% in 2006 40% in   44% in 200418% in 
year of direct support by             2005 22% in 2004     2001 (baseline) 
increasing the proportion of                           
program participants who extend                        
their service contracts and                            
commit to work at a                                    
critical-shortage facility for an                      
additional year                                        

Source: Department of Health and Human Services, Health Resources and
Services Administration, Fiscal Year 2006 Justification of Estimates for
Appropriations Committees (Washington, D.C.: n.d.).

Note: All years are fiscal years.

aNumber of students in all prelicensure registered nursing programs in the
2002-03 academic year.

bThe target was based on the assumption that all scholars would complete
programs and enter service at the same time. According to the Health
Resources and Services Administration, 23 percent of the 2003 scholarship
recipients had completed programs in fiscal year 2004 and entered into
service.

cThe actual performance greatly exceeded the original targets because a
large number of applicants worked in facilities with the most critical
shortages. As a result, the agency increased the targets for 2005 and
2006.

dPreliminary estimate. HRSA's fiscal year 2006 budget justification
indicates that targets will be revised once the fiscal year 2004 data are
finalized.

Appendix IV: Comments from the Health Resources and Services
Administration Appendix IV: Comments from the Health Resources and
Services Administration

A Appendix V: GAO Contact and Staff Acknowledgments

                                  GAO Contact

Leslie G. Aronovitz at (312) 220-7600 or [email protected]

                                Acknowledgments

In addition to the person named above, Kim Yamane, Assistant Director;
George Bogart; Matt Byer; Ellen W. Chu; and Karlin Richardson made key
contributions to this report.

Related GA Related GAO Products

Physician Workforce: Physician Supply Increased in Metropolitan and
Nonmetropolitan Areas but Geographic Disparities Persisted. GAO-04-124 .
Washington, D.C.: October 31, 2003.

Health Care: Adequacy of Pharmacy, Laboratory, and Radiology Workforce
Supply Difficult to Determine. GAO-02-137R . Washington, D.C.: October 10,
2001.

Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors.
GAO-01-944 . Washington, D.C.: July 10, 2001.

Health Professions Education: Clarifying the Role of Title VII and VIII
Programs Could Improve Accountability. GAO/T-HEHS-97-117 . Washington,
D.C.: April 25, 1997.

Health Professions Education: Role of Title VII/VIII Programs in Improving
Access to Care Is Unclear. GAO/HEHS-94-164 . Washington, D.C.: July 8,
1994.

(290382)

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Highlights of GAO-06-55 , a report to congressional requesters

February 2006

HEALTH PROFESSIONS EDUCATION PROGRAMS

Action Still Needed to Measure Impact

For fiscal years 1999 through 2005, the Health Resources and Services
Administration (HRSA), an agency within the Department of Health and Human
Services (HHS), spent about $2.7 billion to fund the more than 40 health
professions education programs authorized under title VII and title VIII
of the Public Health Service Act. These programs include those providing
grants to institutions, direct assistance to students, and funding for
health workforce analyses. Title VII includes programs related to the
education of providers, such as primary care physicians. Title VIII
includes programs related to nursing education. Most of these programs
were last reauthorized in 1998. GAO reviewed changes in funding and in the
number of these programs since 1998, HRSA's goals and assessment of the
programs, and HRSA's national health professions workforce projections.

GAO reviewed relevant laws and agency documents and data, and interviewed
HRSA officials and representatives of health professions education
associations.

What GAO Recommends

GAO recommends that HRSA develop a strategy and time frames to regularly
update and publish national health professions workforce projections. HRSA
agreed with GAO's conclusion that updated workforce supply and demand
projections are vital for informed decision making about health
professions programs.

Funding for title VII and title VIII programs increased from about $300
million in fiscal year 1999 to more than $450 million in fiscal year 2005,
and the overall number of these programs also increased since
reauthorization in 1998. From fiscal years 1999 through 2005, funding for
title VII programs rose by about one-fourth, while that for title VIII
programs more than doubled. The overall numbers of title VII and title
VIII programs administered by HRSA increased from 46 in fiscal year 1998
to 50 in fiscal year 2004. The number of title VII programs remained the
same, while the number of title VIII programs increased.

HRSA has published performance goals for title VII and title VIII health
professions education programs but cannot fully assess the programs'
effectiveness because the goals do not apply to all the health professions
education programs, and the data for tracking progress are problematic.
Recognizing the need for a better means of measuring the results of title
VII and title VIII programs, HRSA is developing new performance goals and
measures for them. The effectiveness of these efforts will depend upon the
agency's ability to collect complete and timely data to assess progress
toward these new goals.

HRSA has published few recent national workforce projections. In the past
decade, the agency has published national supply and demand projections
for the nurse and pharmacist workforces but no national projections for
the physician and dentist workforces. Yet regular reassessment of future
health workforce supply and demand is key to setting policies as the
nation's health care needs change.

Funding for Title VII and Title VIII Programs, Fiscal Years 1999-2005
*** End of document. ***