In the Nation's Compelling Interest Ensuring Diversity in the Health-Care Workforce (2004) / Chapter Skim
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Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions
Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions
Pages 273-316
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1 in certain professions in the health workforce. Responding to the mandate of the Institute of Medicine's (IOM's)
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and Veterans Affairs (VA) administer discretionary health professions programs, while DHHS is also responsible for the Medicare graduate medical education (GME)
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, and two AAMC colleagues recently summed up the "practical reasons" for greater health workforce diversity in a few lines: "(1) advancing cultural competency, (2)
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, and various other schools Faculty Loan Repayment Loan repayments Degree-trained health Program professionals Nursing Workforce Grants Health professions schools Diversity Program Nursing Education Loan Loan repayments Registered nurses Repayment Program Area Health Education Grants Schools of medicine and Center (sometimes) nursing, consortia, parent institutions Health Education Grants Schools of medicine and Training Center (sometimes)
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Persons from disadvantaged FY 2002: $6.2 million Backgrounds Areas of nursing shortage Service commitment of FY 2002: $10.2 million up to 3 years (60 percent of loan for 2 years; 25 percent more for third year) Delivery of care in FY 2002: $33.3 million underserved areas through improvement of health workforce Improvement of health care FY 2002: $4.4 million of low-income racial and ethnic minorities in severely underserved areas Continued
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278 IN THE NATION'S COMPELLING INTEREST TABLE PCB-1 Continued Originating Source Forms of Payment Recipients National Health Service Scholarships and loan Scholarships: persons Corps repayments pursuing medicine, dentistry, nurse practitioner, nurse midwife, physician assistant, psychology careers; loan repayment: same as above plus additional health professions Children's Hospitals Grants Children's hospitals Graduate Medical Education Program DHHS' National Institutes of Health Minority Access Grants and fellowships Research institutions with to Research Careers substantial minority enrollments Minority Biomedical Grants Higher education institutions Research Support with 50 percent or more minority enrollment underrepresented in biomedical or behavioral research Loan Repayment Program Loan repayments Lenders (half of loan for Health Disparities repayments earmarked Research for URMs) Research Supplements Grants Research institutions for URMs Extramural Loan Loan repayments Persons with advanced health Repayment for Individuals professions degrees who from Disadvantaged come from disadvantaged Backgrounds Conducting backgrounds Clinical Research Undergraduate Scholarship Scholarships Persons from disadvantaged Program backgrounds
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support, with minimum of 2 years and maximum of 4 years; loan repayment: 2-year service requirement, with possibility of additional service Training of pediatric and FY 2002: $284.9 million other residents in GME programs Increase in number and FY 2002: About $3 capabilities of URMs in million biomedical research Strengthen URM faculty, FY 2002: About $92 research environment, URM million student capabilities Conduct of research related 2 years of research FY 2002: About $2 to minority health disparities related to disparities, with million (up to $35,000 a possibility of extension year, depending on loan debt) Recruitment, and retention, of Unavailable minority individuals to research Recruitment and retention of 2 years of clinical FY 2002: Slightly more health professionals from research, with possibility than $1.9 million disadvantaged backgrounds of extension to conduct clinical research Pursuit of careers in 1 year of employment FY 2002: $620,000 (up research at NIH at NIH for each to $20,000 per year for scholarship year up to 4 years)
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280 IN THE NATION'S COMPELLING INTEREST TABLE PCB-1 Continued Originating Source Forms of Payment Recipients Department of Defense Health Professions Scholarships Persons joining Army, Scholarship Program Navy, Air Force Graduate Medical Education Graduate training Interns, residents, and costs (in addition fellows in Army, Navy, to salary) Air Force Health Professions Loan Loan repayments Health professionals in Army Repayment Program Department of Veterans Affairs Clinical Training Direct grants to Students and trainees in students and indirect 4,000 education programs support to VA at 1,200 colleges and medical centers universities affiliated with VA Mentored Minority Grants Minority-serving institutions Research Enhancement Coordinating Center Mentored Minority Grants VA-funded research projects Supplemental Award Mentored Minority Salaries Mentored researchers in VA Career Enhancement Award National Science Foundation Louis Stokes Alliances for Grants Research institutions Minority Participation Alliances for Graduate Grants Research institutions Education and the Professoriate
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Ensurance of adequate Up to 4 years and longer Not available (each number of active-duty for graduates of service has its own health professionals Uniformed Services budget) University of the Health Sciences Ensurance of adequate Service commitment FY 2002: Estimated number of active-duty $86 million in training health professionals costs ($222.4 million for salaries)
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. HRSA's Office of Minority Health is involved in the four White House initiatives on Historically Black Colleges and Universities, Educational Excellence for Hispanic Americans, Tribal Colleges and Universities, and Asian Americans and Pacific Islanders, as well as the White House's Hispanic Agenda for Action Initiative, Association of HispanicServing Health Professions Schools, Minority Health Knowledge Management Initiative, Minority Management Development Program, Minority Training Programs Tracking System, and Cultural Competence Initiative (HRSA, 2003i)
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Development of outstanding FY 2003: Approximately research centers $5 million Recognition of costs of FY 2002: Estimated $9 training physicians and billion limited other practitioners primarily in inpatient setting Mainly expansion and Not available distribution of practitioners to underserved areas Primary care training, Last estimate (1998) as preparation of practitioners result of survey: $2.3 to for underserved areas; $2.4 billion New York: increase in number of URMs The most recent study of HRSA diversity programs, Strategies for Improving the Diversity of the Health Professions, was conducted by Kevin Grumbach, Janet Coffman, Claudia Muñoz, and Emily Rosenoff of the Center for California Health Workforce Studies, University of California at San Francisco (UCSF)
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· The Faculty Loan Repayment Program (FLRP) provides funds directly to degree-trained health professionals to pursue careers in academia.
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· The Nursing Education Loan Repayment Program (NELRP) offers registered nurses opportunities to pay back educational loans in exchange for service in health facilities in areas with nursing shortages.
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The Children's Hospitals Graduate Medical Education (CHGME) program is a recently enacted initiative given to HRSA to administer.
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. Rather than making CHGME permanent or mandatory (like Medicare GME)
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. The Extramural Loan Repayment for Individuals from Disadvantaged Backgrounds Conducting Clinical Research program encourages qualified health professionals from minority backgrounds to enter and remain in clinical research careers.
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Navy Medical Education and Training Command, 2003)
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. The Army also uses a Health Professions Loan Repayment Program to enhance recruitment of needed health professionals.
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, which administers Medicare GME, as a federal funder of health professions education. The VA supports 8,800 physician resident positions and accounts for approximately 9 percent of GME in this country (U.S.
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The programs expand the collaboration between VA health facilities and historically black colleges and universities, Hispanic-serving institutions, and tribal colleges and universities to include several minority-oriented national organizations and "institutions of higher education with sizeable concentrations of Asian Americans, Pacific Islanders, Native Hawaiians, Native Americans, Alaskan Natives, or persons with disabilities" (U.S.
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who choose hospital residencies and those that may be part of certain ambulatory arrangements are included in Medicare GME, the program centers predominately on physicians. Indirect GME funds recognize the added costs teaching hospitals incur as a result of their teaching programs.
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He was joined several years ago by HRSA's National Center for Health Workforce Analysis, which has Regional Centers for Health Workforce Studies at UCSF, State University of New York at Albany (SUNY at Albany) , University of Illinois at Chicago (UIC)
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Statistics from the National Center for Health Workforce Analysis The National Center for Health Workforce Analysis offers the following statistics for 19941998 on allopathic medical school graduates characterized as URMs, with 10.5 being the U.S. average and Texas providing the only overlap with Henderson's analysis (National Center for Health Workforce Analysis, 2001)
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Seventeen other states included the payments in managed care organizations' capitated rates. Teaching hospitals were the recipients of most states' GME payments, although, in Oklahoma and Tennessee, medical schools were the only training programs to receive them directly under managed care.
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· Michigan established three Medicaid GME pools in 1997 in order "to bring physician education more in line with its specific public policy goals to train appropriate numbers of primary care providers, enhance training in rural areas, and support education in ways of particular importance in the treatment of the Medicaid-eligible population." For the first 3 years, there were a historic cost pool to reimburse each hospital based on what it had received in 1995; a primary care pool to encourage the training of young physicians in primary care fields (general practice, family practice, preventive medicine, obstetrics, and geriatrics) based on a hospital's residents in primary care and its share of Medicaid patients; and an Innovations in Health Professions Education Grant Fund.
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Other uses that have been suggested include support for training other health professionals that are in short supply, such as dentists, advanced practice nurses, and psychologists. · Utah has a federal waiver from CMS to conduct a Medicare GME demonstration.
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, which indexes studies, turns up a handful of evaluations in the past 5 years, four of which are cited in this paper: · "Historically Black Medical Colleges' Participation in HRSA-Supported Health Professions Training Programs," September 30, 2000; · "Evaluation of the Health Resources and Services Administration's National Health Service Corps Program," September 30, 2000; · "Faculty Loan Repayment Program -- Making More Effective Use of Program Funds," January 29, 2001; and · "Evaluation of the Extramural Associates Research Development Award Program" (in progress)
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, Office of Management and Budget, and individual agencies (through, for example, annual reports and internal evaluations, such as the 2001 review of Title VII by the HRSA Advisory Committee on Training in Primary Care Medicine and Dentistry) provide valuable information on the operations of federal programs.
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. Lack of Recognition of the Importance of DoD and VA Health Professions Programs Although DoD and the VA have significant health professions programs of potential benefit to URMs, the programs' purposes are to recruit and retain health professionals to care for military and veteran populations, respectively, not to address URM workforce goals.
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This precludes any sort of coordination or collaboration, which suits agencies' and congressional committees' tendencies to protect their jurisdictions but places a heavy burden on URMs and others interested in finding out the options open to them. Absence of Health Workforce Goals in the Medicare GME Program Because the Medicare GME program has such a large pot of money, it tends to be targeted by various advocates of reform.
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High Debt Loads of Newly Trained Physicians and Dentists The costs of higher education pose an obvious barrier to URM health professions participation; provision of financial aid is a strategy to leap the barrier. As pointed out by Grumbach et al., most of the studies that have focused on the cost barrier have looked at college entry and retention rather than health professions training for physicians, nurses, and others in this IOM study on diversity.
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Existing programs designed to increase the participation of URMs in the health professions seem either stagnant or at risk in terms of their funding levels, and the possibility of public financing for new initiatives appears to be low. OPPORTUNITIES FOR CHANGING FINANCIAL INCENTIVES TO INCREASE URM HEALTH PROFESSIONS PARTICIPATION Conduct of Studies to Evaluate Federal URM Workforce Initiatives The paucity of studies on federal strategies to increase URM participation in the health professions hinders policy makers.
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Studies are needed to document the programs' effectiveness or lack of effectiveness over time and their outcomes relative to program participants' lives and contributions to the health professions. Greater Support for the National Center for Health Workforce Analysis and Its Regional Centers in URM Data Collection and Analysis Obtaining data to provide supporting documentation for initiatives to increase URM participation in the health professions has been a major
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: · Assess the nation's supply of and requirements for health professionals and paraprofessionals and analyze how they are affected by internal and external changes in the health care system. · Carry out technical and analytic activities regarding the adequacy of the health professions workforce in meeting the nation's need for an appropriately sized and trained health workforce that is suitably diversified by specialty, race, and gender, and is geographically balanced.
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Another is the disproportionate impact of certain illnesses -- hypertension, diabetes, heart disease, and asthma, for example -- in certain minority groups. Still another is preparation of a health workforce to care for an increasingly diverse population.
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It is unclear how far CMS might go in the testing of new policy approaches in the Medicare program, such as in targeting some Medicare GME funds to increasing URM participation in medical residencies, perhaps by developing additional incentives for teaching hospitals that have been successful in mentoring URM residents. Nevertheless, CMS has the tools for experimentation, although it may take congressional bill or report language to give priority to it.
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In addition, state-focused foundations, such as the California HealthCare Foundation and The California Endowment, have been involved, especially in states in which minorities have become or are about to become majorities. Given key foundations' interest in URM health workforce issues,
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Responses to GAO Recommendations to Increase Diversity of the Senior Executive Service In increasing URM participation in the health professions, leadership is clearly important to the formulation of goals, development of programs, and directing of dollars. The GAO reported on diversity -- defined by race, ethnicity, and gender -- in the federal "senior corps," the Senior Executive Service (SES)
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· By providing greater support to the National Center for Health Workforce Analysis and its regional centers to address URM health professions issues at both the national and state levels. · By strengthening existing and developing new public programs-federal and state -- dedicated to educating, training, and nurturing URMs in medicine, dentistry, nursing, professional psychology, and other health professions.
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312 IN THE NATION'S COMPELLING INTEREST GLOSSARY AAMC = Association of American Medical Colleges AHEC = Area Health Education Center APA = American Psychological Association ASPE = Assistant Secretary for Planning and Evaluation CHGME = Children's Hospitals Graduate Medical Education CMS = Centers for Medicare and Medicaid Services COE = Centers of Excellence COGME = Council on Graduate Medical Education DHHS = Department of Health and Human Services DoD = Department of Defense FFS = fee for service FLRP = Faculty Loan Repayment Program GAO = General Accounting Office GME = Graduate Medical Education HCOP = Health Careers Opportunity Program HETC = Health Education and Training Center HPSP = Health Professions Scholarship Program HRSA = Health Resources and Services Administration IGT = intergovernmental transfer IMG = international medical graduate IOM = Institute of Medicine IRB = intern/resident per bed MARC = Minority Access to Research Careers MBRS = Minority Biomedical Research Support MedPAC = Medicare Payment Advisory Commission MERC = Medical Education and Research Cost NELRP = Nursing Education Loan Repayment Program NHSC = National Health Service Corps NIGMS = National Institute of General Medical Sciences NIH = National Institutes of Health NSF = National Science Foundation OIG = Office of Inspector General PHS = Public Health Service PPS = prospective payment system RISE = Research Initiative for Scientific Enhancement RN = registered nurse ROTC = Reserve Officer Training Corps SCORE = Support of Continuous Research Excellence SDS = Scholarships for Disadvantaged Students SES = Senior Executive Service SUNY = State University of New York
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1998. Health Resources and Services Administra tion: Assessment of Historically Black Medical Schools; Participation in HRSA-Sup ported Health Professions Training Programs.
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2003f. National Center for Health Workforce Analysis Areas of Focus.
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. National Center for Health Workforce Analysis, Health Resources and Services Administra tion.
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2003a. Graduate Medical Education.
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