A Dire Shortage and Getting Worse (S. Hrg. 117-188, May 20, 2021)
Summary
Transcript of S. Hrg. 117-188, a May 20, 2021 hearing of the Subcommittee on Primary Health and Retirement Security of the Committee on Health, Education, Labor, and Pensions on the crisis in the health care workforce. Subcommittee Chairman Bernie Sanders and Ranking Member Susan Collins gave opening statements. Witnesses were David J. Skorton of the Association of American Medical Colleges, Leon McDougle of the National Medical Association, Shelley Spires of Albany Area Primary Health Care and James D. Herbert of the University of New England. A closing AAMC letter says the cost of inaction today will result in higher costs and a less healthy population tomorrow; the hearing concluded at 11:58 a.m.
Summary drafted by a model from the document's text below and checked by script against that text before publication. It is a navigation aid, not a reading of what the document proves. Where AI is used
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[Senate Hearing 117-188]
[From the U.S. Government Publishing Office]
S. Hrg. 117-188
A DIRE SHORTAGE AND GETTING WORSE:
SOLVING THE CRISIS IN THE HEALTH CARE WORKFORCE
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING SOLVING THE CRISIS IN THE HEALTH CARE WORKFORCE
__________
MAY 20, 2021
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
___________
U.S. GOVERNMENT PUBLISHING OFFICE
46-768 PDF WASHINGTON : 2022
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont RICHARD BURR, North Carolina,
ROBERT P. CASEY, JR., Pennsylvania Ranking Member
TAMMY BALDWIN, Wisconsin RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut SUSAN M. COLLINS, Maine
TIM KAINE, Virginia BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota MIKE BRAUN, Indiana
JACKY ROSEN, Nevada ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado MITT ROMNEY, Utah
TOMMY TUBERVILLE, Alabama
JERRY MORAN, Kansas
Evan T. Schatz, Staff Director
David P. Cleary, Republican Staff Director
John Righter, Deputy Staff Director
------
SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY
BERNIE SANDERS (I), Vermont, Chairman
ROBERT P. CASEY, JR., Pennsylvania SUSAN M. COLLINS, Maine, Ranking
TAMMY BALDWIN, Wisconsin Member
CHRISTOPHER S. MURPHY, Connecticut RAND PAUL, M.D., Kentucky
TIM KAINE, Virginia LISA MURKOWSKI, Alaska
MAGGIE HASSAN, New Hampshire ROGER MARSHALL, M.D., Kansas
JACKY ROSEN, Nevada TIM SCOTT, South Carolina
BEN RAY LUJAN, New Mexico JERRY MORAN, Kansas
PATTY MURRAY, Washington (ex BILL CASSIDY, M.D., Louisiana
officio) MIKE BRAUN, Indiana
RICHARD BURR, North Carolina (ex
officio)
C O N T E N T S
----------
STATEMENTS
THURSDAY, MAY 20, 2021
Page
Committee Members
Sanders, Hon. Bernie, Chairman, Subcommittee on Primary Health
and Retirement Security, Opening statement..................... 1
Collins, Hon. Susan, Ranking Member, a U.S. Senator from the
State of Maine, Opening statement.............................. 3
Witnesses
Skorton, David J., M.D., President and Chief Executive Officer,
Association of American Medical Colleges, Washington, DC....... 5
Prepared statement........................................... 7
McDougle, Leon, M.D., MPH, President, National Medical
Association, Columbus, OH...................................... 14
Prepared statement........................................... 15
Spires, Shelley, Chief Executive Officer, Albany Area Primary
Health Care, Albany, GA........................................ 18
Prepared statement........................................... 20
Herbert, James D., Ph.D., President, University of New England,
Biddeford and Portland, ME..................................... 25
Prepared statement........................................... 27
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.
Sanders, Hon. Bernie:
Nine Letters from Healthcare Orginizations................... 48
QUESTIONS AND ANSWERS
Response by James Herbert to questions of:
Senator Casey................................................ 78
Response by Leon McDougle to questions of:
Senator Hassan............................................... 80
Senator Casey................................................ 83
Response by David Skorton to questions of:
Senator Casey................................................ 90
A DIRE SHORTAGE AND GETTING WORSE:
SOLVING THE CRISIS IN THE HEALTH CARE WORKFORCE
----------
Thursday, May 20, 2021
U.S. Senate,
Subcommittee on Primary Health and Retirement Security,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10:37 a.m., in
room 430, Dirksen Senate Office Building, Hon. Bernie Sanders,
Chairman of the Committee, presiding.
Present: Senators Sanders [presiding], Casey, Baldwin,
Murphy, Kaine, Hassan, Rosen, Collins, Marshall, Cassidy,
Braun, and Burr.
OPENING STATEMENT OF SENATOR SANDERS
The Chairman. Thank you again for being here. Let me thank
Senator Collins and her staff for helping us put together this
hearing on an issue that I consider to be enormously important.
Let me thank our panelists, two of whom are here with us,
and two of them, we see you clearly through modern technology.
Thank you all for being here. We look forward to your
testimony.
It is no secret that our Country faces many healthcare
crises. Too many of our people are uninsured or underinsured.
We pay, by far, the highest cost for healthcare of any major
country on earth. The costs of prescription drugs are off the
wall, and many people cannot afford that.
In the midst of all of that, for whatever reason, and I
think we will delve into that today, our Nation, the richest
country in the history of the world, simply does not have
enough doctors, nurses, dentists, and other medical
professionals. And why that is so, I am not sure, but I hope we
can learn something about that.
But, the result is that, according to the Association of
American Medical Colleges, by 2033, the United States will have
a shortage of up to 139,000 physicians. And primary care
physicians, we already have a crisis in terms of access to
primary care for many people throughout this Country. Primary
care alone will be facing a shortage of up to 55,000
physicians.
By the way, as we all know, this does not take into account
what COVID-19 has done to the health profession. Anecdotally, I
have heard from hospitals, many nurses just exhausted, leaving
the profession. Hundreds and hundreds of medical professionals
have died as heroes and heroines fighting COVID-19 and
protecting the American people. But, no question that
healthcare professionals have taken a very big hit as a result
of COVID-19.
The Federal Government, as we all know, plays an enormously
important role in how many physicians we have because, through
the Medicare Graduate Medical Education program, we fund the
vast majority of residency slots in this Country. In 2015, the
most recent data available indicates we spent about $16 billion
on Graduate Medical Education, providing for roughly 31,000
residency slots a year. Last year, Congress added 1,000
additional slots. That is a step forward, but it is nowhere
near enough, I think, to address the crisis that we face.
Very importantly, I think--maybe we can discuss this a
little bit today--in addition to expanding those slots,
Congress did expand the Teaching Health Center Graduate Medical
Education program. That is a much smaller program than what
Medicare does, but it focuses directly on the needs to get
doctors and others into medically underserved areas.
Very shortly, I will be introducing legislation to address
the multiple crises we face, and I just want to very briefly
touch on what that legislation will look like.
No. 1--and I hope some of our panelists will speak to this
issue, as well. I learned--Senator Collins, I learned recently,
calling up New England medical schools, as a matter of fact,
that the number of medical students per class is a lot smaller
than you would think. For example, if you look at Dartmouth or
UVM Medical School, we are talking about 90 or 100 students per
class.
Now, I know that it is an intensive effort to train a
doctor, but I would think maybe we would want to explore
whether we can produce more doctors through larger medical
school classes. Ninety or 100 per class seems a little bit
small to me.
Clearly, we also--and there is I think widespread,
bipartisan support for the understanding that we need to
increase payments for direct graduate medical education. The
legislation that I will be introducing picks up on work being
done by Senators Schumer, Boozman, Menendez, and others, would
authorize 14,000 new Medicare-supported medical residency
programs--positions over 7 years. Two thousand a year in
addition to what we have.
Further, and very importantly, what our legislation would
do is to establish new criteria for how the new GME training
positions would be allotted to qualifying hospitals with a
minimum of 50 percent of new slots going toward primary care.
In other words, the crisis we face is not only a shortage
of doctors; it is where those doctors are. They are not in
rural Maine, they are not in rural Kansas, and they are not in
rural Vermont. We have a hard time attracting them. We do not
necessarily need more dermatologists on Park Avenue in New York
City. I do not know if we do or not. Probably not. But, we do
need them in rural areas all over the Country, and we have to
make sure that Medicare understands that.
Another issue that maybe panelists can pick up on, I think
we all know that residents are really underpaid. You go 4 years
for medical school, you do a year of internship, and the
average pay for a resident is $63,000 a year. So, you have
medical debit, right? You have got a few hundred thousand
dollars in debt.
Senator Marshall. That is triple since I was in medical
school.
The Chairman. Oh, is that right? But costs have gone up a
little bit, too. But, if you are living in a big city----
You were making 20,000?
Senator Marshall. Twenty-five.
The Chairman. Working long hours, I expect.
Senator Marshall.
[Inaudible]
The Chairman. All right. Well, that is the whole--that is
another story. But, here is one thing that gets to me. While
the average resident earns 63,000, which I think is inadequate,
primary care residents earn 58,000. So, the discrimination
starts right there in the residency program, not to mention
what salaries are paid. It does not make a whole lot of sense
to me. I think we should increase it.
Our bill will significantly increase funding for the
Teaching Health Center Graduate Medical Education program. We
have made progress, I am happy to say. And in the American
Rescue Plan, some of us worked very hard to double funding for
community health centers and triple funding for the National
Health Service Corps, and I think we have to continue that
effort.
That says to somebody, if you are going to be graduating
medical school $300,000 in debt, you are not going to rural
Maine, frankly, all right, and we are going to help you pay off
that debt if you do go to rural Maine or rural Vermont or rural
anyplace.
That is some of my thoughts, and I look forward to this
serious discussion.
Senator Collins.
OPENING STATEMENT OF SENATOR COLLINS
Senator Collins. Mr. Chairman, thank you so much for
holding this very important hearing today.
Our Country is tremendously grateful to the medical
community for its colossal efforts during the past year. Many
healthcare professionals are exhausted by the physical and
emotional toll of caring for COVID patients, and that burden, I
think it is important to note, did not fall solely on the
medical workers themselves, but also on many members of their
families, who have had to cope with separation, long hours,
health risks, and stress from closed schools.
In many areas of the Country, there is a fierce competition
for nurses, nursing assistants, other medical professionals,
and physicians. And as the Chairman has mentioned, for those of
us who represent rural states, the competition is particularly
stiff. The situation is particularly acute in our nursing homes
where low Medicaid reimbursement levels often translate into
low wages.
This workforce shortage has been with us long before COVID.
It is frustrating to watch year after year. Tens of thousands
of qualified nursing school applicants are turned away each
year due to a lack of a sufficient number of faculty and a
shortage of clinical sites.
We need to break that cycle. At a time when our Nation is
aging, and as more and more people are living longer with
increasing health needs, these shortages have serious
consequences.
Growing up in northern Maine, I know the vital role that
nurse practitioners and physician assistants, in particular,
play in our healthcare system in rural areas. That is why one
of my highest priorities in the Senate has always been to
increase funding for workforce programs.
The bipartisan work that the HELP Committee has
accomplished to support healthcare workforce training has made
a difference. Both the Title VII health professions training
and the Title VIII nursing workforce programs were reauthorized
by the CARES Act last year. We need to make sure that they are
sufficiently funded.
While many health professions desperately need to attract
more students, several disciplines stand out. One is addiction
medicine, a theme that we heard in the excellent Committee
hearing on mental health last month. In March, researchers from
Stamford University wrote in the Journal of the American
Medical Association Psychiatry that opioid overdoses likely
reached a record high in 2020 because COVID has exacerbated
stress and social isolation, and interfered with opioid
treatment, addiction treatment.
That is certainly true in the State of Maine. Last year, a
record 502 Mainers died from overdoses, a tragic toll that
exceeded even the deaths caused by COVID-19. Senator Hassan and
I recently reintroduced the Opioid Workforce Act, legislation
that would create 1,000 new medical residency positions focused
on addiction medicine at teaching hospitals. And we are
grateful to the American Association of Medical Colleges, which
is represented here today, for its endorsement of our
legislation.
Another area of unmet need is geriatric medicine. In Maine,
there are more than a quarter of a million Mainers who are over
the age of 65, and we only have 40 geriatricians. There is an
acute need to quickly train more geriatric health professionals
and direct service workers to meet the growing demand. And I
agree with the Chairman that we need to provide incentives to
get them into rural areas through partial forgiveness of their
medical school debts.
Last year, the CARES Act included my legislation with
Senator Casey to formally establish and authorize funding for
the Geriatrics Workforce Enhancement program, the only Federal
program designed to increase the number of healthcare
professionals with the training to care for older people.
Today, there are 48 Geriatrics Workforce Enhancement programs
in 35 states, including a terrific program at the University of
New England. And I am very pleased that UNE's president, Dr.
James Herbert, is testifying today.
Increasing the overall number of healthcare professionals
is just part of the shortage equation. Another, as I have
mentioned, is making sure that they practice in communities
across the Country, including in rural areas. And one way we
can do that is expanding where medical residents train.
The December Omnibus Appropriations bill contained a three-
year authorization of Teaching Health Centers Graduate Medical
Education program, a program that I have championed with
Senator Tester. Teaching Health Centers train medical residents
in community-based settings, including low-income, underserved
rural and urban neighborhoods. Why does this matter? It matters
because we know that people are much more likely to stay where
they train. And if we can get people out to underserved areas
to do their residencies, they are much more likely to practice
there.
I know that I could go on and on. Let me just end by saying
that I think telehealth is another avenue to address the
mismatch in supply and demand, particularly in behavioral
health. The determination and compassion that leads students to
choose a career in healthcare are needed now more than ever.
I very much appreciate this hearing, and I look forward to
hearing from our excellent witnesses.
Thank you, Mr. Chairman.
The Chairman. Well, thank you, Senator Collins. This does
appear to be an issue where there may be a bipartisan approach
to a very serious problem.
We have a great panel, and let me begin with Dr. David
Skorton. Dr. Skorton is the President and CEO of the
Association of American Medical Colleges, which represents the
Nation's medical schools, teaching hospitals, and health
systems, and academic societies.
Dr. Skorton, thanks so much for being with us.
STATEMENT OF DAVID J. SKORTON, M.D., PRESIDENT AND CHIEF
EXECUTIVE OFFICER, ASSOCIATION OF AMERICAN MEDICAL COLLEGES,
WASHINGTON, DC
Dr. Skorton. Thank you, Chairman Sanders and Ranking Member
Collins for holding this hearing. I am honored to be included
among this distinguished panel, and I look forward to
discussing challenges related to the physician workforce.
I am proud to represent academic physicians who daily teach
our next generation of doctors, perform life-saving research,
and care for some of the Nation's most vulnerable and complex
patients. And just one example: Years of federally funded
research led to the scientific underpinnings for the mRNA
COVID-19 vaccines that are now saving so many lives.
Addressing the Nation's physician workforce shortages and
related challenges will require a multi-pronged, public-private
approach, including innovation, such as team-based care and
better use of technology, in addition to increasing the overall
number of physicians.
Our annual workforce report continues to project that
demand for physicians will outstrip supply, leading, as the
Chairman mentioned, to a projected total physician shortage
between 54,100 and 139,000 physicians by 2033, including both
primary care and non-primary care specialties. The range
reflects a variety of scenarios that may affect the exact
future needs, including population shifts, delivery pattern
changes, and increased use of physician assistants and advanced
practice registered nurses.
The fact is, we have a current and projected shortage of
physicians that is ominous and requires our best efforts and
your support. Though our report focuses on physicians, I
underscore the major contributions of other health
professionals.
Not surprisingly, the Nation's growing aging population
continues to be the main driver of increasing demand for
physicians over the next 15 years, on top of current stressors,
including behavioral health needs, substance use disorders,
and, of course, COVID-19.
Our physician workforce also is aging, and a large
proportion are nearing the traditional age of retirement, thus
affecting supply, as do physician well-being and our work hour
patterns.
It can take more than a decade for a physician to complete
medical school and residency training, also known as Graduate
Medical Education, or GME. This post-graduate training is
required to become licensed for independent practice. U.S.
medical schools have increased enrollment by 35 percent and
opened 30 new schools since 2002. However, this growth will not
increase the workforce without increasing residency training
slots, which have not increased enough to address the shortage.
The AAMC has endorsed the Resident Physician Shortage
Reduction Act that would raise the cap on Medicare's support
for GME and help train approximately 3,500 more physicians each
year. We also believe that Children's Hospital and Teaching
Health Center GME, as you heard, are critical programs
complementary to Medicare GME.
We must also increase private and public efforts to help
shape the primary care workforce, increase community-based
training and rural practice, and improve workforce diversity.
Many successful programs already exist at the Health Resources
and Services Administration, but in our view, they need
additional investment to increase their scope and reach.
The AAMC convenes the Health Professions and Nursing
Education Coalition, which calls for a doubling of HRSA Title
VII funding in Fiscal Year 2022.
Furthermore, public service scholarship and loan repayment
programs can be effective, targeted incentives for recruiting
physicians to help specific vulnerable populations. And I thank
you, Senator Sanders, for championing the recent historic
investment in the National Health Service Corps.
Intervention earlier in the education pipeline is necessary
to increase the number of students from rural, underserved, low
income, minorities, and other disadvantaged backgrounds. The
programs I have already mentioned will be more successful if we
recruit students who are more likely to practice primary care
in underserved communities, including those from diverse racial
and ethnic backgrounds.
I am very concerned there has been minimal progress in
increasing physician workforce diversity. In 1980, when I began
my first faculty appointment, Black men made up 3.4 percent of
entering U.S. medical students. Today, Black males are 3.6
percent of all U.S. med students. It is inexcusable that we
have not moved the numbers in 40 years.
Beyond the efforts of our Nation's medical schools, I would
encourage this Committee to speak with families and students
from kindergarten through college to better identify and
address barriers so that we can work together to expose young
people to science, particularly those who are currently
underrepresented in medicine.
I thank you again for the opportunity to testify. We stand
ready to work with this Committee, with Congress, and with my
distinguished colleagues on this panel to improve the Nation's
healthcare workforce.
Thank you very much.
[The prepared statement of Dr. Skorton follows:]
prepared statement of david skorton
I am pleased to testify on behalf of the AAMC (Association of
American Medical Colleges) on physician workforce challenges and
primary care access across the United States, including projected
physician workforce shortages as well as policies and programs that
seek to improve and diversify our health care workforce and ensure we
have enough providers in underserved areas.
The AAMC is a not-for-profit association dedicated to transforming
health through medical education, health care, medical research, and
community collaborations. Its members are all 155 accredited U.S. and
17 accredited Canadian medical schools; more than 400 teaching
hospitals and health systems, including Department of Veterans Affairs
medical centers; and more than 70 academic societies. Through these
institutions and organizations, the AAMC leads and serves America's
medical schools and teaching hospitals and their more than 179,000
full-time faculty members, 92,000 medical students, 140,000 resident
physicians, and 60,000 graduate students and postdoctoral researchers
in the biomedical sciences. \1\
---------------------------------------------------------------------------
\1\ For background on physician education and training, see AAMC's
The Road to Becoming a Doctor.
KEY FINDINGS FROM THE ANNUAL AAMC PHYSICIAN WORKFORCE PROJECTIONS
Since 2008, the AAMC has produced reports of national physician
workforce projections, including annual reports prepared by independent
experts since 2015 leading up to The Complexities of Physician Supply
and Demand: Projections from 2018-2033. We expect to release a 2021
update to this report in June.
The report's microsimulation model projects the future supply of
physicians based on the number and characteristics of the current
physician workforce, new physicians trained each year, hours-worked
patterns, and retirement patterns. The model projects demand for
physicians based on current patterns of health care use, population
growth and changing demographics, potential changes to delivery
systems--including greater use of managed-care, retail clinics, and
increased use of advanced practice registered nurses and physician
assistants--and achieving certain population health goals to illustrate
the potential impact of improved preventive care. The large projection
ranges presented in the report and cited below are the result of
comparing a multitude of scenarios and reflect the data challenges and
uncertainties of projecting future workforce supply and demand.
AAMC continues to project that physician demand will grow faster
than supply, leading to a projected total physician shortage between
54,100 and 139,000 physicians by 2033. We also project:
A shortage of primary care physicians between 21,400
and 55,200 by 2033.
A shortage of non-primary care specialty physicians
between 33,700 and 86,700 by 2033, including:
Y Between 17,100 and 28,700 for surgical specialties.
Y Between 9,300 and 17,800 for medical specialties.
Between 17,100 and 41,900 for the other specialties
category.
Demographics--specifically, population growth and aging--continue
to be the primary driver of increasing demand for physicians from 2018
to 2033. During this period, the U.S. population is projected to grow
by 10.4 percent from about 327 million to 361 million. The U.S.
population under age 18 is projected to grow by 3.9 percent, while the
population aged 65 and over is projected to grow by 45.1 percent by
2033. Therefore, demand for physician specialties that predominantly
care for older Americans will continue to increase. This projected
increase in demand for physicians is on top of current stressors that
we see driving demand today, such as increased behavioral health needs,
substance use disorder, and of course, COVID-19.
On the supply side, a large portion of the physician workforce is
nearing traditional retirement age, and supply projections are
sensitive to the workforce decisions of older physicians. More than 2
of 5 currently active physicians will be 65 or older within the next
decade. Shifts in retirement patterns over that time could have large
implications for the supply of physicians to meet health care demands.
Also, growing concerns about physician burnout suggest physicians may
be more likely to accelerate, rather than delay, retirement.
While the AAMC annual report projects future shortages, the
association also includes a separate ``Health Care Utilization Equity''
scenario that provides additional context to current physician shortage
estimates. In 2018, the Health Resources and Services Administration
(HRSA) estimated that the Nation requires about 14,900 more primary
care practitioners and 6,894 mental health practitioners to eliminate
all federally designated Health Professional Shortage Areas (HPSAs).
The HPSA designation identifies an area, population, or facility
experiencing a shortage of primary care or mental health care services,
but does not consider non-primary care physician specialty shortages
also projected by HRSA, such as cardiology, \2\ neurology, \3\ and
orthopedic surgery. \4\
---------------------------------------------------------------------------
\2\ U.S. Department of Health and Human Services, Health Resources
and Services Administration, National Center for Health Workforce
Analysis. 2016. Supply and Demand Projections for Internal Medicine
Subspecialties: 2013-2025.
\3\ U.S. Department of Health and Human Services, Health Resources
and Services Administration, National Center for Health Workforce
Analysis. 2017. Health Workforce Projections: Neurology Physicians and
Physician Assistants.
\4\ U.S. Department of Health and Human Services, Health Resources
and Services Administration, National Center for Health Workforce
Analysis. 2016. National and Regional Projections of Supply and Demand
for Surgical Specialty Practitioners: 2013-2025.
The ``Health Care Utilization Equity'' scenario finds that if
underserved populations were to experience the same health care use
patterns as populations with fewer barriers to access, the US would
need an additional 74,100 to 145,500 physicians just to meet current
demand. This analysis underscores the systematic differences in annual
use of health care services by insured and uninsured individuals,
individuals in urban and rural locations, and individuals of differing
races and ethnicities. These estimates, which are separate from the
2033 shortage-projection ranges, help illuminate the magnitude of
current barriers to care and provide an additional reference point when
gauging the adequacy of physician workforce supply.
APPROACHES TO ADDRESSING OR EVEN SOLVING PHYSICIAN WORKFORCE SHORTAGES
AND CHALLENGES
Addressing or solving the Nation's physician workforce shortages
and challenges requires a multipronged private-public approach,
including innovations such as team-based care and better use of
technology in addition to increasing the overall number of physicians.
Below are physician workforce policies, programs, and actions the AAMC,
its member medical schools and teaching hospitals, our Federal
partners, and the Nation can build on to improve access to health care
for all and help address gaping health inequities.
Overall Physician Shortages
Over the last two decades, the worsening physician shortage has
demonstrated the need to increase the number of physicians to help
ensure access to care for people, including during the COVID-19
pandemic and into the future. Academic medicine has responded and,
since 2002, the number of first-year students in medical schools has
grown by nearly 35 percent as schools have expanded class sizes and 30
new schools have opened. \5\ While medical schools continue to increase
enrollment, this will not be sufficient. To be licensed to practice
independently, graduate physicians must undergo further, graduate
medical education (GME).
---------------------------------------------------------------------------
\5\ AAMC Medical School Enrollment Survey: 2019 Results, September
2020. https://www.aamc.org/media/47726/download.
Currently, Medicare caps the number of GME positions it supports at
each teaching hospital. One key element of addressing the physician
shortage is increasing Medicare support for GME, which will help boost
access to high-quality care, particularly for underserved populations
in rural communities and urban areas that have been disproportionately
---------------------------------------------------------------------------
affected by the pandemic.
A broad bipartisan coalition of Members of Congress worked together
to provide 1,000 new Medicare-supported GME positions--the first
increase of its kind in nearly 25 years--in the Consolidated
Appropriations Act, 2021 (P.L. 116-260), which the AAMC estimates will
add approximately 1,600 new physicians by 2033. This increase was an
important initial investment, but more still needs to be done to help
ensure everyone can access the primary and specialty care they need.
To meet this need, Senators Robert Menendez (D-NJ) and John Boozman
(R-AR) and Majority Leader Charles Schumer (D-NY) introduced the AAMC-
endorsed bipartisan Resident Physician Shortage Reduction Act of 2021
(S. 834), which would gradually raise the number of Medicare-supported
GME positions by 2,000 per year for 7 years, for a total of 14,000 new
slots. Much like the year-end package, these positions would be
targeted to hospitals with diverse needs, including hospitals in rural
areas, hospitals serving patients from federally designated HPSAs,
hospitals in states with new medical schools or branch campuses, and
hospitals already training over their caps. The legislation has broad
stakeholder support and has been endorsed by over seventy members of
the GME Advocacy Coalition representing the broad range of disciplines.
Many of these stakeholder groups also recommend the bill's inclusion in
upcoming efforts to rebuild and improve the Nation's infrastructure.
The Opioid Workforce Act (S. 1483), introduced by Senators Maggie
Hassan (D-NH) and Susan Collins (R-ME) would similarly increase the
number of Medicare-supported GME positions, but would target those
positions to increase the number of residents training in addiction
medicine, addiction psychiatry, and pain medicine. As the Nation
continues to fight the opioid epidemic, it is crucial that we increase
access to physicians with focused expertise in treating substance use
disorders.
GME programs administered by HRSA, including Children's Hospitals
GME (CHGME), Teaching Health Center GME (THCGME), and the Rural
Residency Program, help increase the number of residents training in
children's hospitals, federally Qualified Health Centers (FQHC), and
rural areas, respectively. The AAMC continues to urge Congress to
increase annual appropriations for these GME programs in fiscal year
2022, including $485 million for CHGME. We also appreciate the $330
million in supplemental funding for THCGME included in the American
Rescue Plan (P.L. 117-2).
Primary Care
While the country still faces primary care physician shortages, the
AAMC is encouraged to see increases over the last several years in the
number of residents matching to primary care residency programs, the
number of primary care resident positions offered in the Match, and the
percentage of primary care positions as a proportion of total matches.
\6\ The National Residency Matching Program (NRMP) \7\ reports, ``In
2020, primary care specialties offered record-high numbers of positions
and had high position fill rates,'' and ``Family Medicine has
experienced position increases every year since 2009. In 2020, Family
Medicine offered 4,662 positions and filled 4,313 (92.5 percent).'' \8\
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\6\ Results and Data: 2020 Main Residency Match, Table 9, All
Applicants Matched to PGY-1 Positions by Specialty, 2016-2020, NRMP,
May 2020.
\7\ For additional background on NRMP and the Match see: https://
www.nrmp.org/intro-to-main-residency-match/.
\8\ Results and Data: 2020 Main Residency Match, NRMP, May 2020.
To help shape the physician workforce, and specifically primary
care, the AAMC recommends doubling funding for the HRSA workforce
development programs under Title VII and Title VIII of the Public
Health Service Act. Under Title VII, the AAMC supports increased
Federal funding for the HRSA Title VII Primary Care Training and
Enhancement (PCTE) and Medical Student Education programs. PCTE
supports training programs for physicians and physician assistants to
encourage practice in primary care, promote leadership in health care
transformation, and enhance teaching in community-based settings. In AY
2018-19, PCTE grantees trained over 13,000 individuals at nearly 1,000
sites, with 61 percent in medically underserved communities and 30
percent in rural areas. \9\
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\9\ Health Resources and Services Administration. Department of
Health and Human Services Fiscal Year 2021 Justification of Estimates
for Appropriations Committees. hrsa.gov/ sites/default/files/hrsa/
about/budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.
The HRSA Title VII Medical Student Education is a new program that
supports the primary care pipeline by expanding training for medical
students to become primary care clinicians, targeting institutions of
higher education in states with the highest primary care workforce
shortages. Through grants, the program develops partnerships among
institutions, federally recognized tribes, and community-based
organizations to train medical students to provide care that improves
health outcomes for those living on tribal reservations or in rural and
underserved communities. AAMC believes earlier intervention in the
educational continuum is also necessary to support additional medical
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school applicants that are more likely to enter primary care.
Medical education costs can be a significant burden for individuals
interested in medicine. While non-financial factors appear to have a
greater impact on the specialty choice of medical students, \10\ the
AAMC is concerned about the impact these costs may have on the
physician pipeline. Medical schools and their leadership across the
country are committed to reducing this burden and have increased
institutional aid, some committing to eliminate debt or tuition
altogether in the hopes of increasing interest in primary care. \11\
The AAMC also supports Federal efforts to ensure financial stability of
primary care providers, including the HRSA Title VII Primary Care Loan,
which provides low interest loans to medical students planning to enter
primary care. Additionally, the AAMC applauds the recent historic
investment of $800 million in the National Health Service Corps (NHSC)
under the American Rescue Plan (P.L. 117-2) to help recruit primary
care providers to underserved communities through scholarship and loan
repayment.
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\10\ Physician Education Debt and the Cost to Attend Medical
School: 2020 Update, Section Six: Debt and Specialty Choice, AAMC,
October 2020. https://store.aamc.org/downloadable/download/sample/
sample-id/368/.
\11\ Will free medical school lead to more primary care
physicians? Ken Budd, Special to AAMCNews, December 2019. https://
www.aamc.org/news-insights/will-free-medical-school-lead-more-primary-
care-physicians.
Workforce Diversity
A diverse health workforce contributes to culturally responsive
care, helps to mitigate bias, and improves access and quality of care
to reduce health disparities, such as those seen during COVID-19. It
also improves primary care and access as underrepresented students are
more likely to choose primary care specialties.
A common theme across several physician workforce challenges is the
need to diversify the population of students entering medical school.
According to the AAMC Medical School Enrollment Survey, \12\ virtually
all medical schools have specific programs or policies designed to
recruit a more diverse student body. The majority of respondents to
that survey had established or expected to establish programs/policies
geared toward minorities underrepresented in medicine, students from
disadvantaged backgrounds, and students from underserved communities.
Schools also reported a variety of approaches, with a focus on outreach
at high schools and local 4-year colleges and admission strategies such
as holistic review. In addition to these efforts, AAMC believes earlier
and greater intervention is necessary to diversify the physician
workforce.
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\12\ Results of the AAMC Medical School Enrollment Survey: 2017,
May 2018. https://www.aamc.org/media/8276/download.
For myriad reasons, there has been minimal progress in increasing
the number of physicians from diverse racial and ethnic backgrounds. We
need more assertive efforts to cultivate a more diverse and culturally
prepared workforce. We need to better understand how systemic barriers
such as racism and inconsistent access to quality education, beginning
with pre-K, negatively affect diversity in academic medicine. And we
must design bolder interventions to address the growing absence of
Black men and the near-invisibility of American Indians and Alaska
Natives in medical school and the physician workforce, which are
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national crises.
The AAMC is committed to increasing significantly the number of
diverse medical school applicants and matriculants, and last year
launched a new strategic plan that will take a multitiered approach
with sustained investment, collaboration, and attention over time to
significantly increase the diversity of medical students. Our goal is
to keep increasing the number of students from underrepresented groups
until they are no longer underrepresented in medicine. While AAMC
enrollment data show we are moving slowly in the right direction to
recruit more students from underrepresented groups entering medical
school, there is still much work to be done across academic medicine to
ensure our diverse nation is reflected in a diverse physician
workforce.
In 2020, the total number of first-year students identifying as
Black or African American, Hispanic, Latino, or of Spanish origin, and
American Indian or Alaska Native increased. However, this growth was
concentrated at a small number of medical schools, reflecting the
important contributions historically Black colleges and universities
and Hispanic-serving institutions make to the diversity of the
physician workforce. In recent years, the AAMC released two reports,
Altering the Course: Black Males in Medicine \13\ (2015) and Reshaping
the Journey: American Indians and Alaska Natives in Medicine \14\
(2018), to further explore why diversity efforts have not been more
successful. As discussed in these reports, not all racial and ethnic
groups saw notable increases in medical school applicants and
matriculants. In particular, the reports demonstrated that the numbers
of Black or African American medical school applicants and American
Indian or Alaska Native medical school applicants had remained
relatively stagnant. Even more concerning was the finding reported in
the Altering the Course report that the number of Black or African
American male medical school applicants and matriculants had actually
decreased since 1978. While there have been some increases in the
number of Black or African American male medical school applicants and
matriculants in the six-years since that report was published, Black or
African American male students continue to be woefully underrepresented
compared with other medical student groups.
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\13\ https://store.aamc.org/downloadable/download/sample/sample-
id/84/.
\14\ https://store.aamc.org/downloadable/download/sample/sample-
id/243/.
The HRSA Title VII health professions and Title VIII nursing
programs play an important role in improving the diversity of the
health workforce and connecting students to health careers by enhancing
recruitment, education, training, and mentorship opportunities.
Inclusive and diverse education and training experiences expose
students and providers to backgrounds and perspectives other than their
own and heighten cultural awareness in health care, resulting in
benefits for all patients and providers. Studies also show that
underrepresented students are more likely to serve patients from those
backgrounds. \15\
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\15\ Stewart, K., Brown, S. L., Wrensford, G., & Hurley, M. M.
(2020). Creating a Comprehensive Approach to Exposing Underrepresented
Pre-health Professions Students to Clinical Medicine and Health
Research. Journal of the National Medical Association, 112(1), 36-43.
doi:10.1016/j.jnma.2019.12.003.
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Title VII's health professions diversity programs include:
Health Careers Opportunity Program (HCOP), which
invests in K-16 health outreach and education programs through
partnerships between health professions schools and local
community-based organizations;
Centers of Excellence (COE) program, which provides
grants for higher education mentorship and training programs
for underrepresented health professions students and faculty;
Faculty Loan Repayment, which provides loan repayment
awards to retain minority health professions faculty in
academic settings to serve as mentors to the next generation of
providers; and
Scholarships for Disadvantaged Students (SDS), which
grants scholarships for health professions students from
minority and/or socioeconomically disadvantaged backgrounds.
Studies have demonstrated the effectiveness of such pipeline
programs in strengthening students' academic records, improving test
scores, and helping racial and ethnic minority and students who are
economically disadvantaged pursue careers in the health professions.
\16\ Title VII diversity pipeline programs reached over 10,000 students
in the 2018-2019 academic year (AY), with HCOP reaching more than 4,000
disadvantaged trainees, SDS graduating nearly 1,400 students and COE
reaching more than 5,600 health professionals; 56 percent of whom were
located in medically underserved communities. \17\ This success is even
more impressive considering that only 20 schools have HCOP grants and
only 17 have COE grants--down from 80 HCOP programs and 34 COE programs
in 2005 before the programs' funding was cut substantially.
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\16\ Ojo, K. (2020). Preparing Minority Students For Careers in
Health: A Case Study Investigation of a Health Careers Opportunity
Program (HCOP) (Temple University Press). Temple University.
doi:https://scholarshare.temple.edu/handle/20.500.12613/287.
\17\ Health Resources and Services Administration. Department of
Health and Human Services Fiscal Year 2021 Justification of Estimates
for Appropriations Committees. hrsa.gov/ sites/default/files/hrsa/
about/budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.
Title VIII's Nursing Workforce Diversity Program increases nursing
education opportunities for individuals from disadvantaged backgrounds,
through stipends and scholarships, and a variety of pre-entry and
advanced education preparation. In AY 2018-19, the program supported
more than 11,000 students, with approximately 46 percent of the
training sites located in underserved communities. \18\
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\18\ Id.
The AAMC appreciates that Congress reauthorized the HRSA Title VII
and Title VIII programs in the Coronavirus Aid, Relief, and Economic
Security (CARES) Act (P.L. 116-136). However, increased funding is
necessary for these programs to reach their full potential. For fiscal
year 2022, AAMC joined an alliance of over 90 national organizations,
the Health Professions and Nursing Education Coalition (HPNEC), in
recommending $1.51 billion for Title VII and Title VIII, which includes
doubling funding for the HRSA diversity pipeline programs.
Rural Access
Access issues persist in rural communities. While 20 percent of the
U.S. population lives in rural communities, only 11 percent of
physicians practice in such areas. The Centers for Disease Control and
Prevention (CDC) reports that Americans living in rural areas are more
likely to die from health issues like cardiovascular disease,
unintentional injury requiring emergency services, and chronic lung
disease than city-dwellers. \19\ People living in rural communities
also tend to be diagnosed with cancer at later stages and have worse
outcomes.
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\19\ Rural Americans at higher risk of death from five leading
causes. CDC, January 2017, https://www.cdc.gov/media/releases/2017/
p0112-rural-death-risk.html.
We know that medical students who grow up in rural communities are
much more likely to return to them, and physicians who train in rural
areas are ten times more likely to practice full time in those
communities. \20\ As previously discussed, many medical schools aim to
identify potential candidates from rural communities and encourage them
to take up medicine; \21\ however, in 2016 and 2017, students from
rural backgrounds made up less than 5 percent of the incoming medical
student body. \22\
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\20\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5007145/.
\21\ Attracting the next generation of physicians to rural
medicine, Peter Jaret, special to AAMCNews, February 2020. https://
www.aamc.org/news-insights/attracting-next-generation-physicians-rural-
medicine.
\22\ The Decline In Rural Medical Students: A Growing Gap In
Geographic Diversity Threatens The Rural Physician Workforce, Health
Affairs, December 2019, https://www.healthaffairs.org/doi/abs/10.1377/
hlthaff.2019.00924 (Note--this study does not include osteopathic
medical school matriculation and enrollment).
As Congress considers improving the Nation's health infrastructure,
there is an opportunity to invest in the rural workforce pipeline. AAMC
supports The Expanding Medical Education Act (H.R. 801), which would
authorize grants to enhance current and establish new regional medical
campuses (RMCs), thereby helping expose more future providers to rural
and other underserved settings. RMCs are important settings for medical
schools to expand their reach and help fulfill their unique missions.
Approximately 30 percent of medical schools already have at least one
branch campus. \23\ RMCs often have targeted missions, such as training
future providers in primary care and in rural settings. The funds
authorized in this bill would help with the construction of new branch
campuses and assist current RMCs in enhancing their facilities,
expanding their enrollment, recruiting new faculty, developing
curriculum, and planning for accreditation.
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\23\ Association of American Medical Colleges. Regional Campuses
at US Medical Schools. Liaison Committee on Medical Education (LCME)
Annual Questionnaire Part II, https://www.aamc.org/data-reports/
curriculum-reports/interactive-data/regional-campuses-us-medical-
schools.
To facilitate new rural residency programs, the HRSA Office of
Rural Health Policy provides technical assistance and startup funding
to rural hospitals under the Rural Residency Planning and Development
(RRPD) programs. Specifically, the Rural Training Track required in the
RRPD program places residents in rural locations for greater than 50
percent of their GME training and focuses on producing physicians who
will practice in rural communities. In fiscal year 2019, the RRPD
program provided 27 rural health facilities with funding for graduate
medical education. \24\ The AAMC supports increasing the $10.5 million
Federal investment in the HRSA RRPD.
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\24\ Health Resources and Services Administration. Department of
Health and Human Services Fiscal Year 2021 Justification of Estimates
for Appropriations Committees. hrsa.gov/ sites/default/files/hrsa/
about/budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.
The HRSA Title VII health professions programs have also proven to
be successful in guiding students toward careers in rural and
underserved areas. Area Health Education Centers (AHECs) specifically
focus on recruiting and training future physicians in rural areas, as
well as providing interdisciplinary health care delivery sites. In AY
2018-19, AHEC grantees partnered with community health centers,
hospitals, and ambulatory practice sites to train future physicians,
with 44 percent of the training sites located in rural areas. \25\ AHEC
training sites focused on interprofessional networks that address
social determinants of health and incorporate field placement programs
for rural and medically underserved populations. With over 2,700 AHEC
scholars in 2018-2019, 36 percent of the scholars came from rural
backgrounds, and over half of the scholars received training in rural
settings. \26\ The AAMC supports doubling AHECs in fiscal year 22 as
part of our recommendation for HRSA Title VII funding.
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\25\ Id.
\26\ Id.
Underserved Communities
Additionally, public service loan repayment programs offered by
HRSA, the National Institutes of Health, the Department of Education,
the Department of Veterans Affairs, the Department of Defense, and the
Indian Health Service are effective, targeted incentives for recruiting
physicians and other health professionals to serve specific vulnerable
populations. Increasing Federal investment in these programs is a
proven way to increase the supply of health professionals serving
HPSAs, nonprofit facilities, and other underserved communities. For
example, the Public Service Loan Forgiveness (PSLF) program
administered by the Department of Education encourages physicians to
pursue careers that benefit communities in need. In an annual AAMC
survey of graduating medical students, over one-third of 2020 medical
school graduates indicate an interest in pursuing PSLF. \27\ The AAMC
supports preserving physician eligibility for PSLF to help vulnerable
patients and nonprofit medical facilities that use the program as a
provider recruitment incentive.
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\27\ Medical School Graduation Questionnaire: 2020 All Schools
Summary Report (Rep.). (2020). https://www.aamc.org/media/46851/
download.
The NHSC in particular has played a significant role in recruiting
primary care physicians to federally designated HPSAs through
scholarship and loan repayment options. With a field strength of 13,053
in 2019, including 2,418 physicians, more than 13 million patients
relied on NHSC providers for health care. \28\ Despite the NHSC's
success, it still falls far short of fulfilling the health care needs
of all HPSAs due to growing demand for health professionals across the
country. Again, we are pleased Congress recognized the vital role the
NHSC has in caring for our Nation's most vulnerable patients by
providing the program with $800 million in supplemental funding in the
American Rescue Plan. The AAMC supports continued growth for the NHSC
in fiscal year 2022 appropriations, and we urge Congress to provide a
level of funding for the NHSC that would fulfill the needs of all
current HPSAs.
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\28\ Health Resources and Services Administration. Department of
Health and Human Services Fiscal Year 2021 Justification of Estimates
for Appropriations Committees. hrsa.gov/ sites/default/files/hrsa/
about/budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.
Similar to the NHSC, the State Conrad 30 J-1 visa waiver program
has been a highly successful program for underserved communities to
recruit both primary care and specialty physicians after they complete
their medical residency training. Conrad 30 allows physicians to remain
in the U.S. in an underserved community after completing medical
residency on a J-1 ``exchange visitor'' visa (the most common visa for
GME), which otherwise requires physicians to return to their home
country for at least 2 years. Over the last 15 years, the Conrad 30
program has brought more than 15,000 physicians to underserved areas--
comparable to (if not more than) the NHSC, at no cost to the Federal
---------------------------------------------------------------------------
Government.
As the 117th Congress considers immigration reform, the AAMC
endorses the bipartisan Conrad State 30 and Physician Access
Reauthorization Act (S. 948 in the 116th Congress), which among other
improvements would allow Conrad 30 to expand beyond 30 slots per state
if certain nationwide thresholds are met. We applaud this bipartisan
reauthorization proposal for recognizing immigrating physicians as a
critical element of our Nation's health care infrastructure, and we
support the expansion of Conrad 30 to help overcome hurdles that have
stymied growth of the physician workforce.
Physician Well-being
Physicians and other health professionals dedicate their careers to
keeping people healthy, but too often they do not receive the care they
need to address their own well-being. AAMC data show that, like the
overall U.S. physician population, a large percentage of medical school
faculty have experienced higher levels of stress (particularly
underrepresented minorities), and nearly a third of medical faculty
face one or more symptoms of burnout. \29\ In addition to their
detrimental effect on health professionals and their families, burnout,
stress, and other behavioral health issues negatively affect patient
care, patient experience, and overall health outcomes.
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\29\ https://www.aamc.org/system/files/reports/1/
february2019burnoutamongusmedicalschoolfaculty.pdf.
There are numerous systemic and other sources for the high levels
of stress and burnout that have long plagued health professionals, and
the COVID-19 pandemic is only exacerbating the problem. Yet, stigma,
bias, and other barriers can hinder health professionals from seeking
and receiving care for new or ongoing mental and behavioral health
---------------------------------------------------------------------------
challenges.
The AAMC has endorsed the Dr. Lorna Breen Health Care Provider
Protection Act (S. 610), which would take steps to reverse these
troubling trends through investments to prevent suicide, reduce
burnout, and promote care for mental and behavioral health conditions
among health care professionals. While the ability of any single
educational intervention on its own to overcome pervasive systemic
challenges is limited, we believe that the bill's grants to help train
health professionals in strategies to reduce stress and burnout would
represent an important effort to raise awareness among health care
professionals about the need to prioritize their well-being,
particularly if teaching hospitals also are eligible for such awards.
We also appreciate the inclusion of grants to promote use of mental and
behavioral health care services among health professionals and the
bill's two studies to identify the factors contributing to such
challenges and evidence-based best practices for reducing and
preventing self-harm and burnout.
In addition to support for this important legislation, the AAMC is
also part of the National Academies of Medicine's Action Collaborative
on Clinician Well-being and Resilience, which aims to expand our
understanding of the factors affecting clinician well-being and promote
evidence-based solutions to address clinician stress and burnout.
CONCLUSION
The AAMC appreciates the subcommittee's attention to the important
topic of physician workforce shortages and the challenges the country
faces. We believe there must be a private-public, multipronged approach
to bolstering the physician workforce and the diversity of the
physician workforce. Academic medicine is committed to working to
address the challenges and has made significant investment in both
these areas. At the same time, we believe there must be a corresponding
increase in the Federal Government's investments for a variety of
Federal programs that are already working. The cost of inaction today
will result in higher costs and a less healthy population tomorrow. We
look forward to continuing to work with you and the Senate HELP
Committee to achieve this goal. If you have any further questions
please contact me or Matthew Shick, Senior Director, AAMC Government
Relations.
______
The Chairman. Dr. Skorton, thank you very much.
Our next witness is Dr. Leon McDougle. Dr. McDougle is the
121st President of the National Medical Association, and the
first African American professor with tenure in the Ohio State
University Department of Family Medicine.
Dr. McDougle, thanks so much for being with us.
STATEMENT OF LEON MCDOUGLE, M.D., MPH, PRESIDENT, NATIONAL
MEDICAL ASSOCIATION, COLUMBUS, OHIO
Dr. McDougle. Hello. I want to thank the Chairman, Senator
Bernie Sanders, and Ranking Member, Senator Susan Collins, and
other Members of the Subcommittee for the opportunity to
discuss the healthcare workforce crisis facing U.S.
communities.
The COVID-19 pandemic has served as a stress test for
communities made vulnerable by racism, bias, geography,
disability, and socioeconomics. Improving social determinants
of health, primary care access, and workforce diversity are
central to any solutions that enable communities to overcome a
failed stress test and barriers to health equity.
We know that primary care access results in cost savings
and improved health disparities and outcomes. Well, why is
that? Primary care physicians take a person-focused, as opposed
to disease-focused, approach to healthcare. Rural and urban
populations with higher ratios of primary care physicians have
lower rates of mortality for all causes.
The supply of primary care physicians also improves
disparities and health outcomes related to income inequality.
In addition, after controlling poor income, inequality, and
socioeconomic characteristics, a higher supply of primary care
physicians is associated with a four-times greater lowering of
total mortality among African Americans.
In regards to specialty selection and healthcare access, we
know that African American, Hispanic/Latino, and American
Indian physicians are more likely to become primary care
physicians and provide care in underserved communities.
Ranked No. 1, No. 2, and No. 3, Morehouse School of
Medicine, Meharry Medical College, and Howard University
College of Medicine have the highest social mission scores for
medical schools. The combined composite, taking into account
the percentage of graduates who practice primary care, work in
health professional shortage areas, and who are
underrepresented in medicine.
Proposed remedies. Yes, I am in agreement with everyone
here. Priority should be given to funding more primary care GME
positions for hospitals within rural and urban health
professional shortage areas, or medically underserved areas.
Yes, priority should also be given to funding more primary
care GME positions for hospitals affiliated with medical
schools with higher social mission scores.
In addition, I want to focus on a program that the National
Medical Association and the Association of American Medical
Colleges have collaborated on. It is the Action Collaborative
for Black Men in Medicine. A recent study revealed that the
percentage of Black men who were physicians has remained at
about 2.6 percent for the past 80 years.
In closing, thank you for providing me the opportunity to
offer my thoughts and suggestions to improve the healthcare
crisis in this Country so that all of our communities can
benefit from accessible and empathetic healthcare. The National
Medical Association stands ready to assist you in any way that
we can to achieve this goal.
[The prepared statement of Dr. McDougle follows:]
prepared statement of leon mcdougle
My name is Dr Leon McDougle. I am the 121st President of the
National Medical Association, Professor of Family Medicine and Chief
Diversity Officer for the Ohio State University Wexner Medical Center.
The views I express in this testimony are my own and should not be
construed as representing any official positon of the National Medical
Association or the Ohio State University.
I want to thank the Chairman, Senator Bernie Sanders, and Ranking
Member, Senator Susan Collins, and other Members of the Subcommittee
for the opportunity to discuss the health care workforce crisis facing
U.S. communities.
The COVID-19 pandemic has served as a stress test for communities
made vulnerable by racism, bias, geography, disability, and
socioeconomics. Improving social determinants of health, primary care
access and workforce diversity are central to any solutions that enable
communities to overcome a failed stress test and barriers to health
equity.
1. Primary care cost savings and improved health disparities
and outcomes:
(A) Primary care physicians take a person-focused, as
opposed to disease-focused approach to health care. \1\
Communities with higher ratios of primary care
physicians have much lower total health care costs,
partly because of better preventive care and lower
hospitalization rates. \2\
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\1\ Starfield B. Family Medicine Should Shape Reform, Not Vice
Versa. Fam Pract Manag. 2009 Jul-Aug;16(4):6-7. https://www.aafp.org/
fpm/2009/0700/p6.html.
\2\ Starfield B, Shi L, Macinko J. Contribution of Primary Care to
Health Systems and Health. Milbank Q. 2005 Sep; 83(3): 457-502. https:/
/www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145/.
(B) Rural and urban populations with higher ratios of
primary care physicians (defined as family physicians,
general internists, and general pediatricians) have
better health outcomes, including lower rates of
mortality for all causes, heart disease, cancer,
stroke, infant mortality, low birth weight, and poor
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self-reported health.
(C) The supply of primary care physicians also improves
disparities in health outcomes related to income
inequality. In addition, after controlling for income
inequality and socioeconomic characteristics
(metropolitan area, education level, and percent
unemployed) a higher supply of primary care physicians
is associated with a four times greater lowering of
total mortality among African Americans as compared to
the white majority population.
(D) In regard to specialty selection, 45 percent of
Black physicians, 43 percent of Hispanic/Latino
physicians, 46 percent of American Indian physicians,
and 41 percent of Asian physicians were practicing
primary care as compared to 35 percent of White
physicians. \3\
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\3\ AAMC Analysis in Brief. Analyzing Physician Workforce Racial
and Ethnic Composition Associations: Physician Specialties (Part I).
Volume 14, Number 8. August 2014. https://www.aamc.org/media/7616/
download.
3(E) In regard to health care access, nearly 50 percent
of Black, Hispanic/Latino, and American Indian
physicians were practicing in primary care Health
Professional Shortage Areas or Medically Underserved
Areas as compared to 33 percent of Asian physicians and
38 percent of White physicians. \4\
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\4\ AAMC Analysis in Brief. Analyzing Physician Workforce Racial
and Ethnic Composition Associations: Geographic Distribution (Part II).
Volume 14, Number 9. August 2014. https://www.aamc.org/media/7621/
download.
(F) Ranked number 1, 2 and 3, Morehouse School of
Medicine, Meharry Medical College and Howard University
College of Medicine, have the highest social mission
scores for medical schools. The combined composite
taking into account the percentage of graduates who
practice primary care, work in Health Professional
Shortage Areas, and who are underrepresented in
medicine, form the social mission score. \5\
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\5\ Mullen F, Chen C, Peterson S, Kolsky G, Spagnola M. The Social
Mission of Medical Education: Ranking the Schools. Ann Intern Med.
2010;152:804-811.
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2. Proposed remedies for primary care crisis:
(A) Increase access to primary care, mental health and
dental services by establishing more federally
Qualified Health Centers in rural and urban health
professional shortage areas and medically underserved
areas and populations.
(B) Fund additional Graduate Medical Education (GME)
residency positions to support training of primary care
residents/fellows who agree to a service obligation in
a Health Professional Shortage Areas or Medically
Underserved Areas or Populations after completion of
residency/fellowship training.
Priority should be given to funding more primary care
GME positions for hospitals within rural and urban
health professional shortage areas or medically
underserved areas and populations.
Priority should also be given to funding more primary
care GME positions for hospitals affiliated with
medical schools with higher social mission scores.
Require all persons involved with GME selection of
residents and fellows, along with medical school
admissions committee members and application screeners
to undergo implicit bias awareness and mitigation
training and adopt holistic review best practices.
(C) Support HRSA programs such as the Health Career
Opportunity Program and Center of Excellence grants and
Scholarships for Disadvantaged Students to ensure
sustainability and growth of a diverse health care
workforce.
(D) Incentivize universities and medical schools to
partner with under-resourced urban and rural school
systems to establish K-12 health sciences academies to
increase the number students from disadvantaged
backgrounds, (e.g. homeless, in foster care, or qualify
for a free or reduced-priced lunch in elementary or
high school, whose parents never graduated from
college, persons with a disability) entering physician,
biomedical science, and other health professions
careers.
(E) Involve residents of HPSA and MUA/P neighborhoods
in decisions about those who best provide needed
resources or attributes in their communities when
determining recipients of National Health Service Corps
Scholarships.
(F) Expand the number of National Health Service Corps
Scholarships and provide additional incentives for
physicians to remain in the community once their
obligated service time has expired.
(G) Expand National Health Service Corps loan repayment
availability as an additional incentive for physicians
to remain in the community once their obligated service
time has expired.
(H) Establish HRSA funding to support the Association
of American Medical Colleges (AAMC) and National
Medical Association (NMA) Action Collaborative for
Black Men in Medicine. A recent study of the historical
trends of African American physicians from 1900 to
2018, revealed that the percentage of physicians who
were African American has increased by only 4 percent
in 120 years, from 1.3 percent in 1900, 2.8 percent in
1940 to 5.4 percent in 2018. \6\
---------------------------------------------------------------------------
\6\ Ly DP. Historical Trends in the Representativeness and Incomes
of Black Physicians, 1900-2018. J Gen Intern Med. 2021 Apr 19. doi:
10.1007/s11606-21-06745-1. https://www.newswise.com/pdf-docs/
161860566877749-LyJGIM-4-19-21.pdf.
In addition, the percentage of African American men who were
physicians has remained about 2.6 percent for the past 80
years. https://www.aamc.org/what-we-do/diversity-inclusion/
---------------------------------------------------------------------------
action-collaborative-black-men-medicine.
(I) Support THE ANTI-RACISM IN PUBLIC HEALTH ACT OF
2021
Y Create a ``National Center for Anti-Racism''
at the Centers for Disease Control and
Prevention (CDC).
Y Create a Law Enforcement Violence Prevention
Program within the National Center for Injury
Prevention and Control at the CDC.
In closing, thank you for providing me the opportunity to offer my
thoughts and suggestions to improve the health care crisis in this
country so that all of our communities can benefit from accessible and
empathetic health care. The National Medical Association stands ready
to assist you in any way that we can to achieve this goal.
______
The Chairman. Well, Dr. McDougle, thanks very much for your
comments.
Now I would like to welcome our next witness, Ms. Shelley
Spires.
Ms. Spires.
[Brief silence]
The Chairman. Ms. Spires, we cannot hear you. You are on
mute.
Ms. Spires. Sorry.
The Chairman. Okay.
STATEMENT OF SHELLEY SPIRES, CHIEF EXECUTIVE OFFICER, ALBANY
AREA PRIMARY HEALTH CARE, ALBANY, GA
Ms. Spires. Good morning, Chairman Sanders, Ranking Member
Collins, and Members of the Subcommittee. Thank you for
inviting me to speak to you today on this very important topic.
I am here today on behalf of the Association of Clinicians
for the Underserved, known as the ACU, as a member of its board
of directors. The ACU is a non-profit, transdisciplinary
organization of clinicians, advocates, and healthcare
organizations united in common mission to improve the health of
America's underserved populations, and to enhance the
development and support of the healthcare clinicians serving
these same populations.
I am the CEO for Albany Area Primary Health Care in Albany,
Georgia. We serve over 45,000 patients.
Prior to serving as CEO, I spent most of my career in human
resources, which has allowed me to have experience at
delivering care to the underserved and recruiting and retaining
the workforce to support these needs.
Three things that I would like to talk about today that can
work as a foundation to my experience is, one, the people who
do this work are committed, they are mission-driven, and they
are dedicated. The patients who receive the care, they are
resilient, smart, and inspiring. Federal support for these
people are critical and pays huge dividends.
Let me give you a little more detail about each of these.
I tell you about the people that are committed, mission-
driven, and dedicated. It makes more sense to kind of give you
some ideas about the realities of working in an underserved
population.
Many patients have a chronic condition, sometimes untreated
and neglected. This makes for a more intense and long, ongoing
complex care given to this complexity of patients.
High numbers of our patients are low income and living in
poverty. Ninety-one percent of health center patients are at or
below 200 percent of the Federal poverty level.
Most of our patients are members of ethnic and racial
minority groups. This supports the fact that culturally
competent care is vital to effectively care for their specific
needs.
Working in systems of high quality, patient-centered work
surrounded by colleagues that share the same goals and mission
has defined the Association of Clinicians for the Underserved.
Being a board member, that is one of the things that drove me
to providing a service under the board based on the fact that
we spearhead advocacy for the National Service Corps and
support the workforce retention and recruitment efforts.
The term ``burnout'' among healthcare providers was a huge
topic prior to COVID. It did not go away. Unfortunately, those
new demands placed on providers as a result of the pandemic
have only exasperated the impact of burnout.
While burnout is important overall with a real impact on
staff retention, the other side of the human capital coin is
recruitment. Recruiting staff to work in underserved areas is,
in a word, tough. This goes for all staff, and particular
focusing on clinical staff.
The good news is we have existing programs that help with
these challenges, but these systems could always have some
additional investment. Among the programs that can always
benefit from more investment that can provide a substantial
return are your National Service Corps and your Nurse Corps
programs. Since its inception in 1972, the NHSC has expanded
not only in numbers of clinicians, but the types of clinicians,
which shows we continue to adapt to the needs of the healthcare
system, which is reflected in its workforce.
While there are countless examples of the National Service
Corps and what it has done for addressing the workforce
shortages, it is vital to recognize that the health equity and
health equality are key components of Federal health policy.
The NHSC is an important vehicle to achieve these goals by
delivering services to our underserved areas and through the
workforce that delivers these services.
Ensuring greater racial and ethnic diversity of the
healthcare workforce is essential for increasing access to
culturally competent care for all of our Nation's communities.
Just to give a better context or better picture, the latest
data shows African Americans make up 6 percent of the U.S.
physicians; 4.4 percent Hispanic and Latino. This data in
contrast to the Corps' demographics is 7.2 percent African
Americans; 18.2 percent Hispanic and Latino.
Unfortunately, historically, there has been insufficient
funding to support all clinicians who are interested in the
National Service Corps. In recent years, 10 percent were
awarded the scholarship. Forty percent were awarded loan
repayment programs. The result aided in not being able to fund
applicants in some of America's most neediest communities.
While the current field strength of the NHSC is greater
than 16,000, serving more than 16 million people, there is
still a shortage. Statistics indicate that nearly 33,000
additional clinicians across disciplines are needed to care for
hundreds of millions of people who reside in these shortage
areas.
Another component is our THCs, our teaching health centers.
They are located in community-based, ambulatory care settings
and serve a large number of Medicaid patients. It has been
stated many times before, people who train in these underserved
areas are likely to remain in practice in the same similar
setting, remembering that residency often trains individuals
and predicts the practice style regarding quality and cost.
I would also like to call your attention to barriers to
some of the other issues that we face in recruiting healthcare
professionals--behavioral health. Most FQHCs and RHCs are not
positioned financially to take on such large salaries. This
salary is very hard to offset when you are serving underserved,
uninsured, and an underinsured population. These are the people
in most need.
I happened to have at least four psychiatrists to interview
and decline due to salary. The interest is there because of the
mission of what we do, but the salary is the barrier.
Colleagues across the Country continue to collaborate on ideas
how to share resources to meet these needs.
I would like to leave you with just a few concrete
suggestions and actions for Congress.
Increase funding for National Service Corps and Nurse
Corps. We estimate total annual program costs for the NHSC to
be $1.5 billion, taking into account existing funding and
minimum of 400 million in Fiscal Year 2022. Annual
appropriations is needed in order to address the need.
Support the creation of state loan repayment and increase
funding or re-appropriate funding for teaching health centers.
The NHSC program has proven time and time again to be an
effective program.
I appreciate the opportunity to testify before you today,
and thank you for recognizing the urgent need that we face
amongst our workforce.
[The prepared statement of Ms. Spires follows:]
prepared statement of shelley spires
Chairman Sanders, Ranking Member Collins, and Members of the
Committee.
Thank you for inviting me to speak to you today on this very
important topic. My name is Shelley Spires, I am here today on behalf
of the Association of Clinicians for the Underserved--the ACU--as a
member of its Board of Directors. The ACU is a non-profit,
transdisciplinary organization of clinicians, advocates and health care
organizations united in a common mission to improve the health of
America's underserved populations and to enhance the development and
support of the health care clinicians serving these populations. I am
also the Chief Executive Officer of Albany Area Primary Health Care,
Inc., a rural federally Qualified Health Center serving over 45,000
patients in Albany, Georgia. Prior to serving as CEO, I spent most of
my career in human resources at the same institution. My professional
experience has made me an expert at delivering care to the underserved
and recruiting and retaining the workforce to support these efforts.
To begin, I'd like to share three important things that are
foundational to my experience serving the underserved:
The people who do this work are committed, mission driven and
dedicated.
The patients they care for are resilient, smart, and inspiring.
Federal support for all of these people is critical and pays
huge dividends.
Let me give you a little more detail about each of these.
The people who do this work are committed, mission driven and
dedicated. In my experience working at the health center, I've
witnessed this more times than I can count, but most recently with the
pandemic. While the Albany area had numerous private outpatient
practices close their doors due to the risk of the pandemic, AAPHC kept
our doors open to continue serving patients. One of the critical
resources that enabled us to continue to do that successfully is our
providers. Our providers understand what it means to address a
situation head on instead of running from it. They were troopers and
were standing strong on the front lines of this pandemic battle we were
fighting and continue to fight to this day.
When I tell you that the people who do this work are committed,
mission driven and dedicated, it may be helpful for me share a more
about the realities of working in and with underserved populations.
Many patients live with chronic conditions, sometimes long untreated or
neglected, making their initial care more intensive and their ongoing
care more complex. High numbers of our patients are low income or
living in poverty. Nationally more than 91 percent of health center
patients are at or below 200 percent of the Federal poverty level. Most
of our patients are members of ethnic and racial minority groups. This,
along with many other factors, makes culturally competent care
absolutely vital to understanding and effectively caring for their
specific needs. In my own community, we witness these and other
realities on a daily basis. In fact, during a vicious COVID outbreak
early on in the pandemic, our community faced incredible hardship.
People were dying every day, we had an employee and spouses of
employees die, and yet we stood strong. My team pulled together to
eliminate barriers, use innovative ideas to continue caring for our
patients, and made sure that the quality of care never deteriorated. At
the end of the day, it was our team, our model of patient centered
care, and our commitment to our collective mission to care for those in
need that carried us through one of the worst challenges we have faced.
Working in systems that support high quality, patient-centered
work--surrounded by a network of colleagues with shared ideals and
goals--has defined the Association of Clinicians for the Underserved
since its inception. This is part of what drew me to join the Board of
ACU and it is these shared ideas and goals have driven ACU to lead and
spearhead advocacy for the National Health Service Corps (NHSC), to
support workforce retention and recruitment. The NHSC has always been
an invaluable tool for recruitment and retention of clinicians to
underserved areas. However, it is worth noting that as the health care
system has evolved, so too have the demands placed on clinicians. These
demands are evident in the needs of the patients and the requirements
in the way that they provide care.
The term ``burnout'' among healthcare providers was a huge topic of
discussion prior to COVID. It did not go away during the pandemic.
While health care providers may have forced the burnout that existed
prior to COVID into the background as the pandemic provided a big shot
of adrenaline, the longstanding burnout problem lingered, and the new
demands placed on providers as a result of the pandemic exacerbated the
impact of burnout. While the light at the end of the tunnel *may* be in
sight for COVID, the pandemic of provider burnout continues and is
likely to strike our health care workforce with a vengeance. We are
already seeing this and in fact, burnout is now a bona fide medical
diagnosis. The World Health Organization has noted that the syndrome of
burnout is characterized by three dimensions: (1) feelings of energy
depletion or exhaustion; (2) increased mental distance from one's job,
or feelings of negativism or cynicism related to one's job; and (3)
reduced professional efficacy.
Burnout has an impact on patient care: it not only produces less
engaged employees, but also is linked to reduced patient satisfaction,
reduced quality and value of care that is delivered--and it increases
the risk for a healthcare error or mistake. Burnout costs our
healthcare system millions of dollars, a cost that is well beyond the
loss of organizational knowledge that results from employee change. We
need serious efforts to measure--and perhaps mitigate--burnout
recognizing all of these impacts. Patients are also beginning to demand
that the problem be addressed. They simply want safe more engaged care,
delivered by more empathetic care teams, something all of us should
want.
While burnout is important overall, with a real impact on staff
retention, the other side of the human capital coin--recruitment--is
also difficult in the underserved setting. Recruiting staff to work in
underserved areas is, in a word: tough! This goes for all staff, with a
particular focus on our clinical staff. New graduate family practice,
internal medicine or pediatric physicians, many with an average of
125,000 dollars in debt, can work in a hospital and make 30-40 thousand
dollars a year more compared to what we can offer in a community health
center. Market forces, in general, don't lift up the underserved.
I can speak to the challenges of recruitment and retention, both in
my current capacity as CEO and in my experience in my former position
with HR. Challenges that come with rural areas include the geographic
location, a lack of many services and amenities that new, younger
providers are looking for, the burden of student debt, and the need to
understand our population. I make a conscious effort to pay attention
to my providers and what they are telling me about ``burnout''. I have
spent time over the last couple of years trying to develop systems that
allow us to work smarter and not harder. Trying to research ways to
make patient care, patient flow, and the clinic environment a place
that my staff enjoy coming to work. There is a lot of stress associated
with the underserved population--high risk patients, managing multiple
chronic illnesses with limited resources, and documenting in an
Electronic Medical Record.
The good news is that we have existing, functional programs that
can help with recruitment, retention, and workforce shortages, but
these systems need additional investment.
Among the programs that can always benefit from more investment and
can provide a substantial return on that investment are the National
Health Service Corps (NHSC) and Nurse Corps programs. Since its
inception in 1972, the NHSC has expanded not only in numbers of
clinicians but also in types of clinicians. Notably, the Corps--which
initially counted physicians as its dominant workforce component--now
counts behavioral health clinicians as its largest workforce component.
In 2009, a majority of the Corps was physicians (35 percent); in 2017,
behavioral health providers made up the majority of clinicians in the
NHSC (30 percent), with nurse practitioners taking second place at 23
percent and physician participation down to 20 percent. The NHSC
continues to adapt to the needs of the U.S. healthcare system and
reflects that in its workforce.
Over the past several years the program has expanded to respond to
national crises such as the Zika outbreak (in 2017) and the substance
abuse disorder crisis (in 2019). What began as one program--a
scholarship program--now encompasses six complementary but distinct
opportunities to serve under the NHSC: The scholarship program and
multiple loan repayment programs including the students to service
program.
While there are countless examples within the NHSC that can be
cited to highlight its long-standing record of success in addressing
workforce shortages in medically underserved areas, it's vital to
recognize that health equity and health equality are key components of
Federal health policy. To this end, the NHSC is an important vehicle to
achieve these goals: both by delivering services to underserved areas,
and through the workforce that delivers these services. A study by the
Robert Graham Center documenting the impact that the NHSC has had on
health equality during its first 30 years showed that the NHSC has
assigned its resources preferentially--and delivered its most
consistent service--to counties with large minority populations.
Ensuring greater racial and ethnic diversity of the health care
workforce is essential for increasing access to culturally competent
care for all of our Nation's communities. A more diverse workforce
delivers better results in many settings, including healthcare
settings, and is better suited to meeting the overall needs of our
Nation's diverse population, particularly in the most underserved
areas. Historically and currently, many racial and ethnic and minority
groups are underrepresented nationally within the major health
professions. As a result, the NHSC is a success story and is deliberate
in continuing its work to increase the number of minority clinicians.
To provide greater context to the present statistics on clinical
workforce diversity, the latest data available shows that African
Americans make up 13 percent of the U.S. population but they comprise
only 6.9 percent of U.S. advanced practice nurses (nurse practitioners
and nurse midwives) and 4 percent of U.S. physicians. Of actively
practicing advanced practice nurses in the US in 2018, 81.8 percent
were white, 7.9 percent were Asian and 0.2 percent were American Indian
or Alaska Native. Data on practicing physicians in the United States in
2013 showed that 48.9 percent were white, 11.7 percent were Asian, 4.4
percent were Hispanic or Latino, and 0.4 percent were American Indian
or Alaska Native. These statistics are in contrast to the composition
of the NHSC: 13 percent are African American, 10 percent are Hispanic,
7 percent are Asian or Pacific Islander, and 2 percent are American
Indian or Alaska Native.
In the Corps' physician workforce, in 2016, African American
physicians accounted for 17.2 percent and Hispanic or Latino physicians
18.2 percent. Unfortunately, there are no currently available workforce
data on national estimates of LGBTQ+ or other under-represented
minority groups. Historically there has been insufficient funding to
support all clinicians interested in participating in the NHSC. In
recent years an average of just 10 percent of Scholarship Program
applicants 40 percent of Loan Repayment Program applicants have been
funded. There remains a large gap in terms demand versus opportunity.
The result is that with large numbers of applicants not being funded,
thousands of positions needed to provide clinical care to America's
neediest communities remain unfilled. In 2018, there were nearly 5,000
open NHSC-approved positions in Health Profession Shortage Areas across
the country that remained unfilled due to inadequate field strength--
this has been a persistent problem each year since.
While the current field strength of the NHSC is greater than
16,000, which serves more than 16 million people, severe workforce
shortages persist in every corner of the Nation. The most recent
Designated Health Profession Shortage Area Statistics indicate that
nearly 33,000 additional clinicians across disciplines are needed to
care for hundreds of millions of people who reside in health profession
shortage areas. While we are incredibly grateful for the infusion of
funding invested into the NHSC through the American Recovery Act, much
more needs to be done to truly address the clinical workforce shortages
that remain.
In addition to the NHSC, there are other programs worth considering
as a part of the solution in addressing workforce shortage issues
across the Nation. For example, the Federal Government also oversees
graduate physician training--so called Graduate Medical Education, or
GME. A Government Accountability Office report in 2017 showed that
training of residents remains concentrated in urban areas, which
continued to account for 99 percent of residents, despite some growth
in rural areas from, 2005 through 2015. Given that many residents stay
in the same communities where they train, investment of GME dollars
both for rural hospitals, but also for primary care training, is
critical. But investing in hospital-based training programs--where many
hospitals train residents in traditionally primary care specialties
like internal medicine or pediatrics--is not a complete solution to
this problem. Most of these residents go on to specialize, and
hospitals are not required to track and report on career paths of
graduates who work in primary care or underserved settings.
Another component needed to create a workforce dedicated to the
underserved is further investment in teaching health centers (THCs).
Initially supported under the ACA, the Teaching Health Centers program
began development and evaluation in 2011, and now exist in a majority
of states and train close to 1,000 residents a year.
THC programs are located in community-based ambulatory care
settings and serve a large number of Medicaid patients. From a
workforce perspective, those who train in these underserved areas are
likely to remain in practice in the same or similar settings, with
location of residency training often predicting practice style
regarding quality and cost. If additional Medicare GME funding was
unavailable, reallocating approximately 5 percent of the current $6.5
billion per year that funds Centers for Medicaid and Medicare Services
indirect medical education would achieve budget neutrality to expand
THCs significantly. There is a real opportunity to impact CMS deciding
on GME slots that benefit the national need, and not just slots that
generate higher incomes for academic medical centers.
I would also call to your attention to some state laws that provide
barriers to care, especially behavioral health care, at a time in our
Nation when the behavioral health crisis is worsening every day. In
many states, laws or regulations require organizations to employ a
psychiatrist to oversee behavioral health programs. This needs to
change and no longer be a requirement in any state. While it is true
that all behavioral health clinics would benefit from psychiatrist
oversight, recruiting one and retaining one even for several hours a
week is a barrier to care. We have seen, during the COVID public health
emergency, that overdoses have increased, and mental health has
worsened. There is a national psychiatric prescriber shortage. When
these providers can--and often do--make $200 an hour in private
practice, it is all but impossible for a community health center to
recruit a psychiatrist even with a starting salary of $250,000 and loan
repayment opportunities. The result is that there are no behavioral
health programs at many institutions that need them, effectively
restricting access to care for thousands upon thousands of high need
individuals.
This issue is one that is very real to Albany Area Primary Health
Care. The conversation around Behavioral Health and the needs in our
area and our country is continuous. Most federally Qualified Health
Centers and Rural Health Centers are not financially sound enough to
take on a salary for a Psychiatrist. This salary is very hard to offset
when you are serving underserved, uninsured, and underinsured
populations. These are the people who need it most and we struggle to
meet the needs. I have had at least four Psychiatrists interview and
ultimately decline an offer due to the salary. I can get them to
interview because of their interest in the mission of our organization,
but the salary is always insufficient to keep them. I and my colleagues
across the country continue to try and be innovative and creative with
trying to meet these needs through collaborations and partnerships
because we believe persistence pays off. However, my goal is to hire a
psychiatrist to be a part of our team and the challenges in doing so
remain significant and unrelenting.
Toward this same end, we need HRSA to change how it makes program
awards. At present, awards are made on an annual basis. This is
convenient for the government but does not address the real world of
provider recruitment in the field. You see, when I try to hire new
graduate doctors, perhaps I can offer $30,000 in loan repayment, IF
they apply AFTER I hire them and IF that loan gets granted 6 months
down the road. My competition for that newly minted doctor is the local
hospital, which can guarantee prior to signing an extra $30,000 loan
repayment, and a higher salary. This is all done in an age where
twenty-somethings can get whatever they want delivered to their
doorstep in a day. The competition has changed. We need systems to
change to support this.
Again, to give you a personal example of the reality of what this
challenge looks like in practice, I have had a couple of physicians
that declined our offer due to the competition offering a sign on bonus
(which would equate to loan repayment), pay off their loans to relieve
the interest, and commit to a 5-year contract. FQHC's just do not have
that kind of money, so the idea of creating more than one application
cycle would be a fabulous way to market our organization and clinicians
wouldn't have to wait for the reward and can prevent the interest from
accruing while awaiting the award.
I'd like to leave you with some concrete suggestions of actions
that Congress can take to make a noticeable, needed, and meaningful
impact to address the Nation's workforce shortage and to support people
in underserved areas:
1. Increase funding for the national health service corps and
nurse service corps. We estimate total annual program cost for
the NHSC to be $1.5 billion. Taking into account funding
already in place for the NHSC, $310 million in mandatory
funding and $800 million via the American Recovery Act, a
minimum of $400 million in fiscal year 2022 annual
appropriations is needed in order to address existing need
within health profession shortage areas.
2. Support the creation of state loan repayment programs in all
states and territories with dedicated funding to enhance
workforce recruitment and retention on a state-by-state basis.
3. Increase funding, or reappropriate funding, for Teaching
Health Centers to at least double the size of the program and
corresponding funding in the coming year.
4. Congress passed a historic increase to the Medicare graduate
medical education (GME) program at the close of last year--the
first increase to the program in nearly 25 years. The expansion
was part of the year-end Consolidated Appropriations Act, 2021.
The legislation includes 1,000 new Medicare-supported GME
positions. Congress should direct future expansions to
enhancing the primary care and behavioral health workforce.
5. Allow providers working in an FQHC the ability to waive DEA
fees--this could be modeled from the present Veteran's
Administration (VA) system.
6. Similarly, consider expanding the VA approach and policy to
redeploy workforce to areas of need via telemedicine, apply the
same concept to support areas of higher need for the
underserved. Unfortunately, cross-state licensure as well as
payer reimbursement prohibits this at present.
7. Allow federally qualified health centers to participate in
government supported insurance programs. Many health centers
that serve the underserved are smaller organizations and are
forced to spend a significant amount of operational dollars on
health insurance. Allowing FQHCs the opportunity to participate
in government support insurance programs would enable these
health centers to invest a greater percentage of their
operating revenue in salaries for recruitment and retention.
Conclusion
As a nation we are facing an urgent and critical issue with
clinical workforce shortages, one that is predicted to worsen in the
coming years. The Association of American Medical Colleges predicts
that we will see a shortage of up to 55,000 primary care clinicians
within the next 10 years--this is to say nothing of the damages and
additional strain placed on primary care workforce as a result of the
pandemic and chronic burnout faced by countless numbers of providers.
Today, more than 16,000 NHSC clinicians serve 16 million people across
the country. I stand before you as someone who has personally witnessed
the incredible impact, value and effectiveness of this program. We are
hopeful that we can strengthen and grow the National Health Service
Corps and other key programs to help address the urgent need of
millions of people who need access to primary health care services.
Let us all take a moment to remember that these people have faces
and names, they have families and children, and they have hopes and
dreams. These are the people and patients we care for every day at
Albany Area Primary Health Care. They are our neighbors. They are your
constituents. They are the babies that our team welcomes to this world,
they are the hands we hold as they manage their chronic illnesses and
persevere, and they are the faces we hold in our hearts as they make
their final transition from this life. The NHSC program has proven time
and time again to be an effective program. I can assure you as someone
working in an underserved community to care for those in need, in my
opinion, the NHSC is one of the best programs this country has devised
to incentivize primary care medical providers to be able to choose
primary care and to serve in underserved communities. I appreciate the
opportunity to testify before you today. We thank you for recognizing
the urgent need to do more to address the Nation's clinical workforce
shortages and making the National Health Service Corps a priority as we
work collectively to solve this critical issue. I would be glad to
answer any questions you may have.
______
The Chairman. Well, thank you very much, Ms. Spires.
Senator Collins will introduce the next panelist.
Senator Collins. Thank you, Mr. Chairman.
I am delighted to introduce Dr. James Herbert of the
University of New England, who is here to testify. He is the
sixth president of the University of New England. During his
tenure, UNE has launched a Center for Excellence in Public
Health, which has strengthened its partnership with external
clinical partners and has built a health workforce pipeline to
underserved areas in New England.
He has a long and distinguished record. He is an
internationally renowned psychologist who has done research
into the treatment of mood and anxiety disorders and is a
fellow of the Institute for Science and Medicine, the
Association for Contextual Behavioral Science, and several
other groups.
I am going to stop so that he can get to his testimony.
But, suffice it to say that we are delighted to have him
leading UNE in the State of Maine and here with us today.
STATEMENT OF JAMES D. HERBERT, PH.D., PRESIDENT, UNIVERSITY OF
NEW ENGLAND, BIDDEFORD AND PORTLAND, ME
Dr. Herbert. Thank you so much, Chairman Sanders and
Ranking Member Collins. I appreciate the kind introduction.
Just by way of context, the University of New England is
Maine's largest private university. We have campuses in
Biddeford and Portland, Maine, and in Tangier, Morocco, and we
consider ourselves--although a private university, we very much
have a public mission.
As you probably know, Maine has the oldest population in
the Nation, and we are tied with Vermont as being the most
rural state. We also have one of the oldest healthcare forces
in the Nation, and the challenges that we face in Maine are
harbingers of what the rest of the Country is not only facing,
but will increasingly face as our Nation ages and as
urbanization creates pockets of need not only in urban areas,
but especially in our remote, rural areas.
I would like to address five specific strategies that I
believe can go a long way to addressing the healthcare
workforce crisis. At the University of New England, we are
trying to act on each of these five strategies, and I would be
happy to share any--answer any questions or share any ideas
about what we are trying to do. But, let me hasten to add that
I am not suggesting that we have all the answers that we
figured it out. But, what we have found is that the key to
moving the needle forward, regardless of strategy, are
strategic partnerships between higher education, government,
business, and the non-profit sector.
The first thing we need to do--and Senator Sanders, you
touched on this exactly--is we simply need to increase the
number of healthcare professionals we train, including doctors.
The single biggest challenge to doing that is the limited
availability of clinical training opportunities, as you both
have noted and as my fellow panelists have noted.
As financial margins have tightened over the past three
decades, practicing clinicians have less time to devote to
clinical training. We must support partnerships between
universities and healthcare systems to develop additional GME
and other clinical training opportunities.
Now, this is not the only infrastructure limitation.
Standing up new educational facilities or expanding existing
ones involves significant startup costs. This is true both in
the case of GME, but also in the case of expanding the size of
medical schools. For example, at UNE right now, we are looking
to expand the size of our medical school significantly, but
that involves building new facilities.
The Chairman. How large is your medical school now?
Dr. Herbert. One hundred and sixty-five, and we are looking
to go to 200, and then a little beyond 200.
Another barrier is the difficulty in hiring and retaining
qualified faculty members who can typically earn more in direct
care clinical services than they can as university professors.
Support, such as that displayed by both of you, Senators
Sanders and Collins, for strategic healthcare funding for
faculty is vitally important to continuing those programs.
The second thing we must do is we must train more
healthcare students who look like the communities that they
serve. It is well established that individuals from
underrepresented groups are more likely to seek out
practitioners who share their identities and backgrounds.
Studies have found that minority patients who are treated by
clinicians who look like them are more likely to use needed
health services and less likely to delay care.
Now, it is not enough if you both--as you have both noted,
it is not enough to merely train more professionals. We must
encourage them to practice in underserved areas following
graduation, especially in rural and tribal communities. Like
Maine, most states have vast rural areas with highly
distributed populations, and these communities have far less
access to healthcare.
Programs that provide financial support in terms of loan
repayment programs, there are Federal programs administered by
HRSA. There are state programs, a new one in Maine. These kinds
of programs are absolutely critical, and I thank you for your
continued support of them.
Fourth, we must leverage the power of technology to serve
underserved communities. Digital health and emerging
developments in telemedicine have enormous potential to
transform healthcare delivery. Of course, these tools depend
upon reliable and robust broadband systems, and I am delighted
that the most recent COVID-19 stimulus legislation included
funding for broadband infrastructure.
Finally, we must fundamentally change the prevailing
educational model. Anyone who has recently been a patient in a
hospital or has cared for a hospitalized loved one understands
how siloed the practice of healthcare tends to be.
In response, a new educational model has emerged in which
students from diverse disciplines are explicitly trained to
work together, across traditional boundaries, in
multidisciplinary teams. This is known as interprofessional
education, or IPE for short, and this model has been shown to
improve clinical outcomes, to reduce medical errors, to
increase patient satisfaction, and to decrease provider
burnout.
One particular area that highlights the importance of this
kind of collaborative, team-based approach is geriatrics.
Diseases of aging often encompass a broad scope of conditions:
heart disease and diabetes treated by primary care
practitioners, isolation by social workers, oral health by
dentists and hygienists, and so on.
At UNE, we are weaving geriatric training throughout all of
our healthcare professionals. So, rather than just merely
training more geriatricians, we are weaving training in
geriatrics and in behavioral health across all of our
healthcare professionals in this team-based approach.
I am pleased that working together with Maine's junior
senator, Angus King, and the University of Maine and other
statewide partners, we are one of 48 organizations to have
received funding through HRSA's Geriatric Workforce Education
program.
In conclusion, successfully addressing America's healthcare
workforce crisis will require not merely acting on each of
these five strategies in isolation, but seamlessly integrating
them. And strategic investment of resources will be required,
but much of the work reflects cultural changes that will
require strong leadership, a willingness to innovate, and
coordinated partnership, again, between academia, government,
industry, and the non-profit sector.
I am grateful for your time and happy to address any
questions.
Thank you very much.
[The prepared statement of Dr. Herbert follows:]
prepared statement of james herbert
Thank you for the opportunity to speak with you today. It's a
sincere honor to share some thoughts on strategies for addressing our
Nation's healthcare workforce crisis.
My name is James Herbert, and I am the president of the University
of New England (UNE). UNE is Maine's largest private university, with
campuses in Biddeford and Portland Maine and in Tangier Morocco. We are
a comprehensive university that houses Maine's only medical school and
only physician assistant program, and northern New England's only
dental school. We're the largest provider of healthcare professionals
to the state of Maine, \1\ and we take great pride in being a private
university with a public mission.
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\1\ UNE offers programs in 14 health professions, including
osteopathic medicine, dental medicine, pharmacy, physician assistant,
nursing, nurse anesthesia, dental hygiene, occupational therapy,
physical therapy, social work, nutrition, athletic training, applied
exercise science, and public health.
As you probably know, Maine is the oldest state in the Nation, \2\
and is tied with Vermont as being the most rural \3\ state. We also
have one of the oldest healthcare workforces in the country. \4\ The
challenges we face are in some sense harbingers of what the rest of the
country will increasingly confront as our Nation ages and as
urbanization creates pockets underserved populations in our cities as
well as in our vast remote rural areas.
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\2\ Maine has the highest median age in the U.S.: 45.1 relative to
the national average of 38.5 (US Census Bureau, 2019a). At 21.3 percent
Maine also has the highest percentage of citizens over 65 in the U.S.
(US Census Bureau, 2019b).
\3\ US Census Bureau, 2019b
\4\ At 36 percent, Maine ranks 5th in the Nation for the
percentage of active physicians who are age 60 or older (AAMC, 2019).
In 9 of 16 Maine counties, 50 percent or more of physicians are 55 or
older (Skillman & Stover, 2018). Over 50 percent of Maine's registered
nurses are 50 or older (Maine Nursing Action Coalition, Center for
Health Affairs NEONI, 2017). Approximately 60 percent of Maine's
dentists are older than 55 (State of Maine Board of Dental Practice,
2019). Maine ranks in the top quartile of states with geriatrician
shortages (Maine Senior Guide, 2019).
I won't repeat the testimony of my colleagues about the growing
shortage of healthcare professionals across our country, as I'm sure
you already appreciate the scope of the problem. Rather, I will offer
five specific strategies that I believe can go a long way to addressing
the crisis. I will also offer some examples of how we at UNE are
attempting to implement each of these strategies. This is not to imply
that we've figured out all the best solutions, but rather to provide
some specific examples of how higher education can partner productively
with government, business, and nonprofit sectors to move the needle in
---------------------------------------------------------------------------
important ways on this critical problem.
First, we need to increase the number of doctors, nurses, and other
healthcare professionals we educate. Although there are a number of
challenges to doing so, by far the most important is the availability
of clinical training experiences, which has been well documented by the
Department of Health and Human Services Health Resources and Services
Administration (HRSA). \5\ As financial margins have tightened and
clinician workloads have increased over the past three decades,
practicing clinicians in various healthcare settings have less time to
devote to training students. \6\ The single most important thing we can
do to increase the number of healthcare providers is to support
partnerships between universities and healthcare systems to develop
additional residencies, clerkships, practica, and other training
opportunities.
---------------------------------------------------------------------------
\5\ U.S. Congress: Advisory Committee on Interdisciplinary,
Community-Based Linkages. (2018).
\6\ Benbassat, 2020; Cox & Desai, 2019; Hanna, 2019; Graziano et
al., 2018; Konrad et al., 2010; Krehnbrink et al, 2020; de Villiers et
al., 2018; Rodriguez, 2013.
At UNE, one way we have expanded clinical training opportunities is
by working with partners in rural and underserved primary care sites
and federally Qualified Health Centers. One advantage of such
placements is that students learn how to deliver compassionate care to
Maine's most vulnerable residents, many of whom are uninsured and also
navigate chronic physical and mental health conditions. The precepting
clinicians in these settings are dedicated to treating underserved
patients, sometimes with limited access to specialized professional
support. \7\ These settings afford students exposure to a broad range
of conditions and allow them to perform a wider variety of procedures
than they might in more specialized urban settings.
---------------------------------------------------------------------------
\7\ Hempel et al., 2015; Lee et al., 2016.
Clinical training opportunities are not the only infrastructure
limitation to producing more healthcare professionals. Standing up new
educational facilities, or expanding existing ones, involves
considerable startup costs. Recognizing the region's significant unmet
oral healthcare needs and the fact that there was no dental school in
all of northern New England, in 2013 we partnered with both Federal and
state governments, regional industry, non-profits, and philanthropists
to establish a dental school. Senator Collins was critical in helping
to secure Federal support for that project. And the people of Maine
passed a $3.5 million bond to support not only creation of the school
itself, but also community dental clinics around the state to help them
increase their capacity to provide dental care and to take our students
on rotation. The school was created with an explicit focus on
addressing underserved populations, as reflected in its mission
statement: `` . . . to improve the oral health of northern New England
---------------------------------------------------------------------------
and rural and underserved populations.''
Another barrier to training more healthcare professionals is the
difficulty hiring and retaining qualified faculty members, who can
typically earn more in direct care clinical settings and yet require a
higher level of training and credentialing than those working
clinically. \8\ At UNE, we are developing a specialized track within
our dental program to educate students who are interested in pursuing
an academic career. \9\ Support such as that displayed by Senators
Collins, Sanders, and others for strategic loan repayment programs
targeting those assuming faculty positions in dentistry, nursing, and
other allied health professions is critical to ensuring the future of
the healthcare workforce. Loan repayment programs improve access to
graduate/doctoral education by encouraging qualified individuals to
advance their education and subsequently become employed as faculty.
---------------------------------------------------------------------------
\8\ Christmas et al., 2010; Feldman et al., 2015; Girod et al.,
2017; Nauseen et al., 2018.
\9\ McAndrew et al., 2011.
Second, we must intentionally recruit more students who look like
the communities we need to serve. It is well established that
individuals from underrepresented groups are more likely to seek out
practitioners who share their identities and backgrounds. \10\ Studies
have found that minority patients who are treated by race/ethnic-
concordant clinicians are more likely to use needed health services and
are less likely to delay seeking care. \11\
---------------------------------------------------------------------------
\10\ Shen et al., 2018; LaVeist et al., 2003.
\11\ Saha et al., 2000; LaVeist & Nuru-Jeter, 2002.
In Maine, we have a growing immigrant population, especially from
Central and Eastern Africa, and not surprisingly, this community
experiences significant healthcare discrepancies relative to the
broader population. \12\ To address this issue, not only has UNE
increased recruitment efforts targeting students of color across the
entire university, we recently began ``Advanced Standing'' programs in
dentistry and pharmacy, designed to accelerate the time it takes for
foreign-trained immigrant professionals to achieve a U.S. degree and
become eligible for licensure. We have also developed partnerships with
local community colleges to matriculate students from our immigrant
communities into certain healthcare programs (e.g., dental hygiene).
\13\
---------------------------------------------------------------------------
\12\ Drewniak et al., 2017.
\13\ National Academies of Sciences, Engineering and Medicine,
2021.
Third, it's not enough merely to train more professionals, we must
encourage them to practice in underserved areas following graduation,
such as in rural, medically underserved, and tribal communities. Like
Maine, most states have vast rural areas with highly distributed
populations, and these communities have far less access to healthcare.
\14\ The U.S. Government has invested in programs, administered through
the Health Resources and Services Administration, that provide
financial support in the form of loan repayment to graduates who serve
in disadvantaged areas. These programs are absolutely critical, and we
thank congressional leadership for their ongoing support.
---------------------------------------------------------------------------
\14\ The US Department of Health and Human Services has designated
nearly 200 geographic areas in Maine as health professional shortage
areas for primary care, dental medicine, and mental health (US DHHS,
2019). Maine also has 51 medically underserved areas/populations,
defined as areas having too few primary care providers, high infant
mortality, high poverty, and/or a high elderly population (US DHHS,
2019). Nearly all of Maine's medically underserved areas are in Maine's
congressional District Two, the second most rural congressional
district in the country (US DHHS, 2019).
At UNE, we have successfully used various strategies to encourage
our graduates to practice in rural areas. We intentionally recruit
students from rural areas, both from Maine and around the country.
Students from small towns and other nonurban areas are more likely to
return to such communities after graduation. \15\ Regardless of where
they come from, we place students in clinical training sites in
underserved rural areas as part of their education to give them a taste
of rural practice and lifestyle.
---------------------------------------------------------------------------
\15\ American Academy of Family Physicians, 2016; Lee et al.,
2021; University of Wisconsin, 2020;
---------------------------------------------------------------------------
Each year, many graduates exposed to these crucial settings during
rotations return for employment, inspired by the commitment to quality
patient care they witnessed, as well as their love of small-town life.
\16\ Finally, in concert with state and philanthropic partners, we have
developed loan repayment and scholarship programs to incentivize
practice in rural settings. These efforts have paid off; over the past
decade we have made dramatic inroads in addressing the needs of rural
communities. For example, 40 percent of UNE medical school graduates
who practice in Maine do so in health profession shortage areas (HPSAs)
designated by the U.S. Government, positively impacting the HPSA
designation of five counties. \17\ And in our dental school's first
four graduating classes (2017-2020), we educated 250 dentists, 63 of
whom are currently practicing in Maine. Nearly one in five is employed
in a federally Qualified Health Center, a non-profit community clinic,
or the Veteran's Administration, and four in ten are practicing in
Maine's most disadvantaged areas. \18\
---------------------------------------------------------------------------
\16\ UNE's dental school clinical model is an excellent example of
success in this regard. UNE places students in up to two 12-week
clinical rotations in settings throughout northern New England, working
in collaboration with a network of FQHCs, community clinics, and even
private dental offices. Students provide billable services while
receiving supervision from the preceptor and most importantly, learning
about the community they serve. We are grateful for the U.S. Department
of Health and Human Services on-going funding to Maine's network of
health centers providing access to many of our marginalized residents,
while also offering much-needed clinical placements to students.
\17\ NCAHD's Enhanced State Licensure Data, 2016; The Robert
Graham Center, 2012.
\18\ This is particularly noteworthy given that Maine has the
fewest dental providers participating in Medicaid or CHIP in the entire
country, according to research by the American Dental Association's
Health Policy Institute.
Fourth, we must leverage the power of technology to reach
underserved communities. The COVID-19 pandemic has introduced many
Americans for the first time to the value of telehealth, as we all
learned to access healthcare providers via videoconferencing. \19\
Telehealth and digital medicine have enormous potential to transform
healthcare delivery, particularly in underserved areas. \20\ In
addition to patients accessing their providers through secure
videoconferencing platforms, primary care providers in remote locations
can themselves access specialist colleagues in urban tertiary care
hospitals and university health centers for expert consultation. And
emerging digital medicine and artificial intelligence technologies will
increasingly allow clinicians to monitor patient symptoms and even
deliver certain treatments remotely over the internet. These
technologies can also enhance the reach and effectiveness of continuing
medical education programs. At UNE, we are moving toward integrating
robust telehealth training for all of our health profession students in
close partnership with our various training sites. Of course,
telehealth and digital medicine services are only as available as the
broadband network that supports them, and like much of the country,
many of Maine's most rural counties lack sufficient and reliable
connectivity. I am delighted that the most recent COVID-19 stimulus
legislation included funding for broadband infrastructure, a portion of
which is headed to our rural state. This will make an enormous
difference in narrowing Maine's digital divide, and will ensure rural
Maine residents can benefit from UNE's clinical and educational
expertise, regardless of where they live.
---------------------------------------------------------------------------
\19\ Wosik et al., 2020.
\20\ Kichloo et al., 2020.
Finally, we must fundamentally change the prevailing educational
model. Anyone who has recently been a patient in a hospital, or who has
cared for a hospitalized loved one, understands how siloed the practice
of healthcare tends to be. One often gets the sense that the various
professionals are all practicing their respective crafts with little
coordination or communication among themselves. This siloed practice is
a result, at least in part, of the traditional discipline-centered
model of educating healthcare professionals. In 2001, the Institute of
Medicine issued a groundbreaking report, Crossing the Quality Chasm: A
New Health System for the 21st Century, which laid out the case for
dramatic, systemic changes to health care organization and delivery. In
response, stakeholders from academia, health systems, and government
convened to determine how best to address the Institute's
recommendations. In 2012, these efforts led to the development of a new
educational model in which students from diverse disciplines are
explicitly trained to work together, across traditional boundaries, in
multi-disciplinary teams. Known as ``interprofessional education'' \21\
or ``IPE'' for short, this training model prepares students with team-
based competencies, attitudes, and skills that complement distinctive
disciplinary knowledge. Interprofessional health care teams offer more
than any one discipline can achieve alone, and this is especially
critical as patients' health conditions are becoming increasingly
complex. \22\ Growing evidence suggests that interprofessional
collaborative practice \23\ improves clinical outcomes, \24\ reduces
medical errors, \25\ increases patient satisfaction, \26\ and decreases
provider burnout. \27\
---------------------------------------------------------------------------
\21\ Interprofessional Education occurs when two or more
professions learn about, from, and with each other to improve
collaboration and the quality of patient care.
\22\ Mayo & Williams-Woolley, 2016.
\23\ According to the World Health Organization, interprofessional
collaborative practice happens when multiple health workers from
different professional backgrounds work together with patients,
families, care givers, and communities to deliver the highest quality
of care (World Health Organization, 2010).
\24\ Lutfiyya et al., 2019.
\25\ Anderson & Lakhan, 2016; Hardisty et al., 2014; Irajpour et
al, 2019; Lygre et al., 2017; Wilson et al., 2016.
\26\ Will et al, 2019.
\27\ Cain et al., 2017; Dow et al., 2019.
The IPE training model, especially when paired with digital health
technologies, can be instrumental in meeting the needs of underserved
communities. The combination of IPE and telehealth allows doctors, mid-
level practitioners, and other primary care practitioners to
effectively expand their scope of practice, while also extending
---------------------------------------------------------------------------
specialist care to those for whom it is otherwise out of reach.
One particular area of healthcare that exemplifies the value of
this kind of collaborative approach is geriatrics. Diseases of aging
often encompass a broad scope of conditions and disciplines: heart
disease and diabetes treated by primary care practitioners; mobility
issues by physical and occupational therapists; isolation by social
workers; oral health by dentists and hygienists, and so on. At UNE, we
weave training in geriatrics throughout all of our health profession
programs. Thanks to legislation sponsored by Senator Collins and
supported by Maine's Junior Senator Angus King, and working closely the
University of Maine and multiple statewide partners, UNE is one of 48
organizations nationally to have received funding through HRSA's
Geriatrics Workforce Education Program, which aims to create a more
age-friendly health system by transforming primary care practices and
engaging and empowering older adults.
At UNE, we have been pioneers in IPE over the past decade for all
of our healthcare programs, and, once again in close coordination with
our clinical partners, we are now standing up a university-wide
Institute to deepen our commitment to this training model.
In conclusion, successfully addressing America's healthcare
workforce crisis will require not merely acting on each of these five
strategies in isolation, but seamlessly integrating them. Although
strategic investment of resources will be required, much of the work we
confront reflects cultural changes that will require strong leadership,
a willingness to innovate, and coordinated partnership between
academia, government, industry, and the nonprofit sector.
I am grateful for the committee's time and attention, and
appreciate your efforts to address our Nation's healthcare workforce
crisis. Thank you.
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The Chairman. Thank you very much, Dr. Herbert.
I have been impressed that, from the panelists and from the
Members here, I think there is a general consensus about what
the crisis is and probably the direction that we have to go
forward.
I have about 400 questions, but I have time for three or
four. Let me start with--Dr. McDougle made an interesting
point, which we do not talk about enough, and I would like each
of you to tell me whether you think he is right.
We are losing, as I understand it, 50, 60,000 people a year
because they do not get to the doctor when they should. But,
interestingly enough, when you have more primary care
physicians, it not only saves lives, it saves money, as well.
That is my impression. So, you get to a doctor when you are
sick, you do not end up in the hospital or the emergency room.
Is that a true assertion, that in the long run, having--
giving people more access to primary healthcare not only keeps
them healthier, probably saves the system more money?
Let's go to everybody. Dr. Skorton, you want to begin?
Dr. Skorton. Thank you. Permit me 15 seconds to thank and
congratulate the other panelists on their very important
contributions, not only with the panel today, but in general.
I agree with what you just said, Chairman, but I want to
add one thing, and let me just give you my bona fides. I ran a
general medical--general medicine division for 5 years at the
University of Iowa in which we were a primary care provider, as
well as rural health provider. And, so, I could not be more
simpatico with the importance of rural health and rural
healthcare and changing the calculus.
However, we need clinicians in specialty areas, as well.
And it is very, very important that we do not put those two
things off sort of butting heads against each other. We need
more of a variety of things. And, so, that is one thing that I
would comment on.
Then, second, I would say that there is no question that
primary care and preventive care go together, just as Dr.
McDougle stated. I will be very quick, Mr. Chairman. But, I do
want to say that depending on the issue, the idea of
interprofessional teams are very, very important. So, we have
to think about things beyond the physician workforce.
Overall, we continue to hope that you will help to do
things like the Residency Act to have more GME slots in
general; duty incentives to bring them to rural areas in
primary care, but fill out all the areas that we need.
The Chairman. Sorry to be rude, but there is not a lot of
time and I wanted everybody to comment, and I have some other
questions.
Dr. McDougle, do you agree with yourself?
Dr. McDougle. Yes, I do. And we spoke to geriatrics
earlier. I am a geriatrics physician by trade. Most of the
patients I see are older, so using the skills that I developed
and learned in residency and so forth have allowed me to serve
in that role.
The Chairman. Okay. Ms. Spires.
Ms. Spires. Yes, and thank you. I would certainly agree
with that comment. I have seen it firsthand and with patients
who, if it had not been for the primary care physician and in a
setting such as a federally qualified health center,
potentially would not have received the care they needed.
The ongoing idea of the diagnosis would certainly lead to
hospitalization. And, so, when you are looking at things such
as chronic illnesses, which we face every day, which if it is
managed, will decrease expenses as it relates to Medicare and
Medicaid, putting people into the hospital.
When you are looking at a primary care physician, who is
the individual responsible for managing that chronic illness
for that patient, it truly--if we do what we are supposed to do
from our standpoint, it does truly decrease the cost from a
bigger picture standpoint by being able to provide that care.
The Chairman. Okay. Dr. Herbert.
Dr. Herbert. The answer is absolutely yes. There is no
question. It is not even up for debate. There is research
showing very clearly that those investments in primary care
pay.
I would add two quick things. One is primary care involves
more than just family practitioners, doctors. It also involves
psychiatry, OBGYN, which are desperately needed.
The second thing I would mention are mid-level
practitioners, so-called physician extenders, PAs, nurse
practitioners, those folks can be critical in meeting unmet
needs in rural areas.
The Chairman. I am running out of time, but one quick
question here and I would like all four of you to comment on
it.
Explain to me why when primary care physicians often work
so hard, crazy hours, why are they paid substantially less than
other specialists? Does that make any sense at all?
Dr. Skorton.
Dr. Skorton. It is going to be hard to answer that question
briefly.
The Chairman. Well, you have to do it briefly. I have got
16 seconds here. Very briefly.
Dr. Skorton. Okay. It has to do with the way our payment
systems are set up, and it is not directly linked to the
quality or the importance of care.
The Chairman. But it does say something about the system
that primary care physicians receive substantially less than
surgeons, for example?
Dr. Skorton. That is right.
The Chairman. Okay. Dr. McDougle.
Dr. McDougle. We are not a procedure-based specialty. We
are a person-focused specialty, and that does not necessarily
lead to increased revenue, but an increased cost savings that
does not necessarily reflect in pay.
The Chairman. Ms. Spires.
Ms. Spires. Absolutely. Yes, I think that they are
certainly underpaid, not just from the standpoint of being a
specialty service, but they actually take care of the entire
person. I mean, we are looking at a holistic approach. And, so,
they are managing multiple issues versus one dedicated issue.
The Chairman. Dr. Herbert.
Dr. Herbert. Our payment system is based on procedure and
visit codes. That is what you get paid for. If a primary care
physician spends 50 minutes counseling a patient on their diet,
lifestyle, exercise, this sort of thing, a patient with chronic
disease, they are going to get paid less than if they--they
will get paid one-tenth to half what they would get paid if
they did an EKG, maybe a catheterization, gave them some
medications. It is--the payment system is flawed and it
incentivizes the wrong things.
The Chairman. Thanks very much.
Senator Collins.
Senator Collins. Thank you, Mr. Chairman.
Dr. Herbert, U.S. nursing schools turned away more than
80,000 qualified applicants from baccalaureate and graduate
nursing programs in 2019, and faculty shortages were cited as
the top reason. So, think about that. Eighty thousand qualified
applicants who wanted to be either initial RNs or advanced
practice nurses turned away because of a lack of faculty.
How can Congress help with the faculty side of the equation
that is creating this bottleneck and contributing to the
shortages?
Dr. Herbert. Thank you, Senator Collins, for the question.
It is a challenge with nursing faculty in particular. I would
say all of the faculty disciplines, it is a challenge, but
nursing in particular. One of the things that many places, UNE
being one that we are doing, is training our own now. So, we
are standing up a program to train nurse educators who in turn
will become our own faculty because there is not enough nurse
educators out there.
The second thing, the loan repayment programs are
absolutely critical. There are a number of programs out there.
I know you have sponsored many of these, and I am deeply
grateful for that. I know right now that at least four of my
nursing faculty are taking advantage of those programs, and
these are individuals who would not have gone into nursing
teaching were it not for those programs.
Then, fundamentally, a big challenge is that nurses can
simply make more out in practice than we can pay them at
universities. And, of course, the easy answer would be, well,
just pay them more, right? But, I have to balance my budget,
and I have to live within a balanced budget, and if I--I do not
want to charge my students higher tuition or to decrease their
financial aid, the institutional aid, that we offer them in
order to pay them more. So, therein lies the dilemma.
Support on any one of those three initiatives would be
phenomenal to help with this problem.
Senator Collins. Thank you. I am very intrigued that you
are training your own educators. I think that is a very
innovative idea.
Dr. McDougle, it is really distressing to hear from you
that the number of Black physicians has remained flat for I
think you said 80 years. I held what I believe to have been the
first hearing in the Senate to look at the racial disparities
in the COVID cases. And even as a state with a small Black
population like Maine, we see that disparity. I get a report on
it each and every day from the Maine CDC.
I had at that hearing Morehouse University testify about
what could be done, and they echoed what was said here, that we
need to be training more people who look like the community
that they are serving. That is clearly true, and it would help
overcome the legacy of mistrust between the Black population
and medical professionals that exists in some areas.
But, how can we get more Black Americans, Hispanic
Americans, Native Americans to apply to medical school and to
see that as a career path?
Dr. McDougle. Very good question. We need to go to our
elementary schools, pre-K through 12th graders.
We have a program at the Ohio State University called
Health Sciences Academies where there is a cascading mentorship
model involved with partnering with the teachers and parents of
students who are in feeder schools into Columbus East High
School, which is right across the street from Ohio State East
Hospital.
I think those types of initiatives where we have that
expertise at the academic health center, at our seven health
professions colleges, and we partner with the elementary,
middle, and high schools to create that pathway of opportunity.
And I think that is one example in addition to the existing
HCOP programs and the other pathways funded through HRSA.
Very good question. Thank you.
Senator Collins. Thank you for an excellent answer.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Collins.
I have on my list Senator Braun, Senator Kaine, Senator
Hassan, Senator Baldwin. Senator Baldwin, are you there, Tammy?
Senator Baldwin. I am.
The Chairman. Where are you? I do not see you.
Senator Baldwin. I am virtual.
The Chairman. All right. There you are.
Senator Baldwin. Hello, Mr. Chairman. Thank you for the
recognition. And I want to thank our panelists. What an
important hearing.
I wanted to focus in on the importance of training in the
area of palliative and Hospice care.
Dr. McDougle, you just stated that you are not a procedure-
based specialty, your area of practice in geriatrics. You are a
person-based specialty. And I would argue the same is true in
palliative and Hospice care.
One of the challenges in preparing health professionals for
careers in palliative care is the lack of support for trained
professionals to serve as faculty and dedicate time to the
educational function. There is an urgent need to build our
workforce, but we cannot do it without building the workforce
training infrastructure.
I have introduced bipartisan legislation with my colleague,
Senator Shelley Moore Capito, called the Palliative Care and
Hospice Education and Training Act, and we are working to re-
introduce it this year, shortly. It would grow and improve the
palliative and Hospice care workforce by supporting the full
pipeline of physician training in the subspecialty, including
through academic career awards and fellowships for providers.
I want to start with a question for Dr. Skorton. How can we
better address the need for programs that train health
professionals, and how does the idea of training the trainer
support our healthcare workforce overall?
Dr. Skorton. First of all, Senator, we want to thank you. I
appreciate your leadership on working to authorize these new
Title VII programs to train future physicians in palliative and
Hospice care. It is incredibly important.
In these Title VII type programs, including geriatric and
mental and behavioral health, have a longstanding history in
training health professionals to treat our most vulnerable
Americans. So, I would take the--very, very quickly mention
that we are supporting an investment of $1.5 billion in Title
VII and Title VIII programs and hope that Congress will think
carefully about that. Not only about this issue, but many of
the things that we are talking about today would develop a
great boost by more funding going into HRSA programs, Title VII
and Title VIII, and I think that would speak directly to your
question.
Thank you for the question and for your creativity in this
sphere.
Senator Baldwin. Thank you.
Dr. McDougle, this will go to you. As many of the witnesses
have noted, the current healthcare workforce shortages that we
face today are only going to continue to grow, and research
projects an impending palliative care workforce crisis over the
next 20 years. In the shorter time, by 2030, we could see a
ratio of only one palliative care physician for every 26,000
seriously ill patients. Part of why we urgently need to grow
the palliative care workforce is to ensure that more Americans
and their families have access to this type of care when they
need it the most, and it is a matter of healthcare equity in my
mind.
Dr. McDougle, can you speak to how support for workforce
development programs and provider training works to advance
health equity and help us make sure that more Americans have
access to the quality care and culturally competent care that
meets their needs?
Dr. McDougle. Another very good question. So, we know from
research and data that physicians from underrepresented groups
have a concordance with patients that they are caring for in
the population, and we have seen where this has led to
increased compliance with preventive care, even flu shots. And,
so, that is important. And that visibility in the community,
becoming a trusted messenger in the community, was also
important and continues to be during this pandemic.
In regards to palliative care, I think there is also a need
for just broader public education, and I would recommend to the
audience a book recently published by Dr. Dan Morhaim entitled
Preparing for a Better End. He speaks to the importance of
palliative care, and actually, I will read some of this.
It means a practice where a patient suffering a serious
illness will not--will have not only a medical team focusing on
a cure, but also a team focusing on symptoms, pain, and quality
of life.
Many people do not know the difference between Hospice care
and palliative care, so I thank you so much for lifting this
important topic up because more discussion and education is
needed, especially in the community.
Senator Baldwin. Thank you. Mr. Chairman, I yield back.
The Chairman. Thank you, Senator Baldwin.
Senator Braun.
Senator Braun. Thank you, Mr. Chairman.
Healthcare has been the thing I have been most interested
in since I have been here in the Senate and trying to reform it
from the top down. I think it has evolved into a--I do not like
to even call it free enterprise because there are so many
things that bother me about it.
It has gotten increasingly concentrated with large
corporations. You have an urban, rural divide. I am from
Indiana. A lot of our rural hospitals are in peril. Sometimes,
they have to end up getting bought by an urban chain, and then
it seems like it gets even worse.
A lot of--and running a business for 37 years before I got
here, you have to have transparency, competition. Things have
got to work well. I harp on that all the time.
Here, I would love to hear your comments, Dr. Herbert and
Dr. Skorton, about on the workforce side of it. I have a
healthcare advisory group that meets three times a year.
Doctors and nurses are kind of tiring of the profession almost
because it used to be they had a family practice or they had a
viable rural hospital to work for. Now, it is working for a
huge corporation that seems to have a disproportionate amount
of wealth, will not accept transparency and competition. The
insurance companies are along with them. They tell me that it
has a lot to do with why we are having trouble getting nurses
or even doctors. When they want to form their own hospital,
cannot do it due to the big guys having regulations in place.
How much of the nature of the industry evolving the way it
has do you think has to play into the lack of people wanting to
get into the profession when it is some of the highest paid
jobs you could have out there?
Dr. Skorton. Nobody wants to jump in first on this one, but
it is a very, very important point that you make. And, I would
say that right now is a great time to rethink all of these
disincentives. We have an increasing interest in going to
medical school across the Country. A lot more people want to go
to medical school. Perhaps the work of those who were on the
front lines in COVID had a little bit to do with that. Who
knows?
Whatever it is, it is a very positive trend. There is a lot
of enthusiasm. Young people who want to go out there and do the
right thing. Leaders like my fellow panelists today who are
showing the right way to point to specific areas that need to
be done. So, I think there is a great wave of optimism and
desire to do things in the public interest.
Through your wisdom, in consultation with us, we think, in
the private sector, as well, as Dr. Herbert mentioned, we need
to talk over these specific areas that are disincentives and
see how we can focus on those specific areas. Throwing the
whole system out, while it might be tempting in some ways,
would be chaotic in a Country as large as ours.
But, through your wisdom and our experience, I think we
could work together to find those areas that cause
disincentives for the profession in general. And we would be
glad offline to talk with you and your staff about that if it
would be of interest.
Over to you, Dr. Herbert.
Dr. Herbert. Thank you. This is a big problem and I do not
pretend to have all the answers. I will mention a couple of
things.
The payment structure issue that we just mentioned creates
incentives for doing certain kinds of procedures that is not as
well aligned. I think that is part of the burnout issue. I
mentioned before that there are actually compelling data that
the interprofessional training model can actually reduce
provider burnout.
The other thing I would say is with some of these rural
hospitals is that we need the--to help them develop GME so that
they can become teaching hospitals. There are many rural
hospitals out there that would like to do that. The problem is
the investment, the upfront costs, to develop a GME program in
a virgin, a so-called virgin hospital that has never had GME.
The price tag just to begin the process, to get it through
ACGME, the accreditation body, is between 1.5 and $3.5 million.
And, that is not taking into account the first few years of
having a residency program when the CMS payments are not going
to be as high as they will be once it is at full steam.
There is--and it may not sound like a lot of money in the
grand scheme of things, but if you are a small, rural hospital,
three million bucks is a lot of money. But, that small
investment could be just enough to develop a GME program, to
develop a new residency program. Suddenly, now there is new
energy. It brings a cultural change in many positive ways to
these hospitals.
There is a way that I think the Federal Government could
help substantially, just getting us over that hump. We are
partnering right now with a hospital in Maine trying to do
exactly this. But, three million bucks is a lot of money, so--
--
Senator Braun. Thank you for that. And I think for this to
really be solved holistically before we get more government
involved with it, the industry has obviously in itself evolved
in a way that I do not think is good.
Transparency, transparency, transparency. Let the consumer
see things. Get the hidden veil that insurance companies, and
especially hospitals have out there that frustrate nurses,
doctors, and especially stakeholders like myself where I have
wrestled with it in my own business prior to coming here. It
does work. When you do those things, engage your healthcare
employee, make them into a consumer, a lot of these other
things start to fall in place.
Thank you.
The Chairman. Senator Kaine.
Senator Kaine. Thank you, Mr. Chairman and Senator Collins.
What a wonderful hearing.
Dr. Skorton, the AAMC did a report that came out last June,
I believe, that predicted a shortage of 139,000 physicians by
2033. A report dated June 2020 was probably done a few months
before and probably did not even take into account the pandemic
effect. I understand that you are looking at an update of that
report.
My prediction, before I read the update, is that number
will not have decreased because a pandemic that has now
infected more than 30 million Americans with COVID, and 10 to
20 percent are claiming to have long-term effects after COVID.
I am one of those 10 to 20 percent. And, then, there has been a
mental health impact of COVID, which has also been significant,
very significant. I doubt that the number of the shortage is
going to go down.
Recruiting people in is important. You have addressed
strategies on that. I really want to focus on keeping people in
the profession once they are in.
Dr. Skorton, I appreciate your testimony today focusing on
the Lorna Breen Act that I have introduced with Dr. Cassidy and
other colleagues. The problem of keeping our healers healthy,
the mental health, the frontline health providers is so
important.
Lorna Breen was a New York emergency room physician with
family in Virginia, who died by suicide in April, in the early
days of the pandemic, as she was, just facing an onslaught of
sickness and death. And, then, she got COVID herself, and,
then, tried to get back to work but was worried about seeking
mental health counseling because she felt like there would be a
stigma, she might lose her license, she might lose her
practice, ability to practice.
We have to do things to break down any stigma about seeking
mental health training among our professionals, and we have to
come up with novel strategies so that we can keep our healers
healthy.
I have even, Mr. Chairman, started a rankle when I hear
people talking about our healthcare workers as heroes because
sometimes heroes are people we put up on a pedestal, and that
might make it even harder for somebody to seek help. They are
healers. That is a good enough word, and we have got to keep
our healers healthy.
Chairman Murray has noted the Lorna Breen Act for action in
our next Committee markup. It is very widely supported on both
sides of the aisle. And I hope my colleagues will join me in
doing something really important for the healthcare of our
healers.
A mental health issue I want to ask each of you about is
this. As we are talking about shortage of healthcare workers,
let's talk about mental health workers. The National Council
for Behavioral Health reported, also in a 2020 report that was
done before COVID, that 77 percent of the counties in the
United States are experiencing a severe shortage of mental
health providers. The Virginia Healthcare Foundation indicates
that much of Virginia is essentially a mental health
professional desert, a shortage area. And these were before
COVID.
The after effects of COVID, people having lost loved ones,
people having lost income, lost their jobs, seen so much
suffering, these mental health needs are not going down.
Many in Virginia who were participating in substance use
group therapy sessions or other modes of treatment to try to
deal with substance use issues saw those treatments become more
difficult. Zoom sessions are not as good as in-person sessions,
et cetera.
If we had a 77 percent shortage of mental health providers
pre-COVID, or 77 percent of counties were sort of short of
mental health providers pre-COVID, it is going to be more after
COVID. What can we do to make sure that the Nation has the
mental health workforce that we need? And I would offer that to
any of the witnesses.
Dr. Skorton. First of all, let me thank you for the Lorna
Breen Act. It is very important. She was at Allen Hospital--
rest in peace--which is part of the New York Presbyterian world
where I practiced, saw patients, and taught up to about 2 years
ago. So, I very much appreciate what you have done.
In terms of long COVID, we are working on research to
understand what is going on. Please stay tuned and stay of good
cheer because we are going to figure this out like we have
figured everything else about COVID.
This mental health issue is dramatic and getting worse.
There is no question about it. I think two Members of the
Subcommittee who have developed the Opioid Workforce Act, which
is incredibly, incredibly important because, as the Ranking
Member mentioned--and thank you, Senator Hassan, for that, as
well--we are really suffering with all of those things related
to substance abuse throughout America, urban, rural areas, you
name it.
But, to focus specifically on stigma, which is probably the
biggest single issue, I am afraid to say that healthcare
workers, like many other people, are afraid to come forward and
say, I need help. Very afraid to do that. Afraid for the
stigma, afraid perhaps even to be limited in their practice
prerogatives.
This is something the profession itself really has to work
on. This is not something we can unload on Congress. We have to
develop ways to reduce that stigma and to make sure that coming
forward does not result in something that will limit someone's
professional choices. And I have had some experience with that,
friends and personally, and would be glad to talk to you
offline.
But, we thank you or the Lorna Breen Act. I hope that comes
to completion and that we can do all of these things together,
and the Opioid Workforce Act. Those things, I believe, would
come together, both the providers and to reduce stigma.
Thank you for all you are doing.
Senator Kaine. I yield back, Mr. Chairman. Thank you.
The Chairman. Thank you.
Senator Hassan.
Senator Hassan. I want to thank the Chairman and Ranking
Member for holding this hearing. And to all of the panelists,
thank you for being here. Thank you for your work.
I want to start with a question to Dr. McDougle. I have
heard heartbreaking firsthand accounts from K through 12
students in New Hampshire about their own struggles with mental
health during the pandemic or their worries about their
friends.
Maybe the silver lining here, to follow-up on what Dr.
Skorton was just saying, is that last week in a meeting with
them in person, I was tiptoeing around the issue. I was not
sure fifth graders and high school students would want to talk
to me about mental health. They had no inhibitions about
talking to me about mental health. They are worried about it
for themselves, for their friends, and the pandemic has really
obviously exacerbated it.
In 2020, mental health related emergency department visits
for children increased dramatically. And we know because of the
pandemic, it has been harder for them to get in to see their
primary care docs or to get to school in person to have the
kind of mental health supports that school might provide. So,
we have to do better for our kids.
Dr. McDougle, what steps can Congress take to ensure that
pediatricians and primary care providers are prepared to
respond to the pediatric mental health crisis we are
experiencing as a result of the pandemic? And what can we do in
Congress to improve access to mental health services for kids
through their communities, including their schools?
Dr. McDougle. Very good question. As primary care
physicians, we many times are the first persons who are talked
to about the mental health concerns. In some cases, we are able
to manage the mental health concerns. That being said,
typically it may involve referral to a psychologist or a
licensed social worker to work in concert with us.
Someone mentioned earlier about the importance of
telehealth. Congress has to continue funding of telehealth.
That has to continue. And we need to also prioritize training
of licensed social workers, psychologists, and psychiatrists.
A strong message needs to be sent to our medical schools,
our health professions schools, that this is a national crisis
that we all need to step up to.
Those are my initial thoughts.
Senator Hassan. Thank you very much for those initial
thoughts. They are great ones.
I want to--I am just going to comment quickly that I thank
all of the panelists for the support that you have all
expressed for boosting the behavioral workforce and the
workforce to treat substance use disorder. And I am pleased and
honored to work with Senator Collins on the Opioid Workforce
Act and we will continue to push that through.
Dr. Herbert, under the American Rescue Plan, Congress
increased Federal funding for home-and community-based services
to help more people access the care they need in the setting
that best suits their needs.
But, this funding increase is temporary. Congress needs to
make long-term, sustainable investments in the home health and
community-based workforce that is going to ensure access to
quality, comprehensive health services for older adults and
individuals with disabilities who choose to remain in their
homes.
Doctor, can you speak to the role that home health workers
play in improving care for older adults and individuals with
disabilities? And how will additional sustained investments in
home-and community-based health workers strengthen our
healthcare system?
Dr. Herbert. I think you nailed it. We need additional
funding to support--it is absolutely critical, the home
healthcare workforce, in terms of maintaining the health,
especially of our older populations.
If I--so, I would simply support your assertion that
funding needs to continue post-COVID.
Could I add something about----
Senator Hassan. Sure.
Dr. Herbert [continuing]. Behavioral health----
Senator Hassan. Yes.
Dr. Herbert [continuing]. Since you brought that up?
As a clinical psychologist by training, I could go on for
hours on this topic, but I will try to just keep it very brief.
It is absolutely critical that we train more behavioral
health professionals, there is no question, at all levels; not
just doctoral level trained people, but masters level
counselors, social workers.
At the same time, what we also need to do is--and this gets
back to that interprofessional model I was talking about. We
need to train all healthcare professionals----
Senator Hassan. Right.
Dr. Herbert [continuing]. Including dentists, to
recognize--and OBGYNs, for example----
Senator Hassan. Yes.
Dr. Herbert [continuing]. To recognize and diagnose
behavioral health problems. And there are behavioral health
interventions that those non-expert providers can also learn to
provide.
Also, I would add that we have made tremendous progress
over the past 30 years in non-pharmacological treatments that
in many cases have longer lasting effects, but they are still
not widely practiced.
Senator Hassan. Right.
Dr. Herbert. Because it is much easier to just give
somebody a pill.
Senator Hassan. Okay.
Dr. Herbert. I am not suggesting there are not appropriate
places for pharmacological intervention.
Senator Hassan. Sure. No, I understand that. I appreciate
that.
I realize I am out of time. I am just going to say I am
going to submit a question for the record to the panel because,
Mr. Chairman, one of the things I think we really also need to
focus on is a partnership between our primary care docs and
community health workers to help address the social
determinants of health. Because it is so critical if people--
docs who are treating, can actually get the nutrition
assistance or housing that they need. That can be a big step
forward, too.
Thank you.
The Chairman. Thank you.
Senator Rosen.
Senator Rosen. Well, thank you, Chairman Sanders, Ranking
Member Collins. I really appreciate this hearing. It is just so
important. And the witnesses for your work, your compassion,
and caring. I really appreciate that.
The entire State of Nevada has shortages of healthcare
providers. It is especially true for our rural areas; of
course, of rural areas probably across this Country. We
desperately need more doctors and nurses. We have to support
our existing medical providers who choose to care for those
patients in rural and underserved areas so that they stay in
those communities.
One of the things my office has heard from Nevada primary
care physicians, that they could use more support from
specialists to meet the needs of their patients. That is why I
introduced the bipartisan Improving Access to Healthcare in
Rural and Underserved Areas with Senator Murkowski. It is going
to provide additional support for primary care providers in
community health centers or rural health clinics through
specialist support and accredited continuing medical education.
Ms. Spires, as the leader of a large community health
center, could you please speak a little bit about the
challenges patients have accessing the center, specialty care,
and how having the option for concurrent visits with both their
primary care and a specialist might really improve those
patient outcomes that of course we all want? And what kind of
Federal support would you like to see going forward to
potentiate positive outcomes for patients? That is what we all
want; right?
Ms. Spires. Absolutely. I would certainly be glad to
address that.
As far as being in a community health center and access
available to our patients, we do have the barrier of resources,
special--subspecialties, if you will.
One of the things that we try to do is integrate
interdisciplinary teams into our organization as much as
possible. So, we have included in that podiatry, optometry, and
some of those things that--thinking particularly about a
diabetic population, when you look at them and you start
looking at foot exams and retinal exams and things like that,
indicative of the holistic care of that diabetic patient.
One of the things we also started was when we were looking
at endocrinology, which is kind of connected with that, as
well, and having limited resources. And, so, we continue to
face that challenge.
Transportation is an issue as we, all know, as well. So,
when I have remote areas, such as 40 miles away, it is how do
we get those patients in to be seen?
I think funding that would support some opportunity for
collaboration and partnerships with some of the subspecialties,
if you will. One of the things we have done is actually we have
corroborated with our local hospital to see what some of those
specialties that they have hired, how do we take our mobile
units on the road and go to some of these rural areas. And I do
primary care and then they handle specialty care, just so that
we can continue to control cost. Because if we can get out
there and see them, when you are looking at the issue of
finances available, then that is going to ultimately save the
tax dollars money, as well.
We are continuing to work on that. But, I think one
suggestion would be is to continue to have inside conversations
with those individuals and organizations that do have good
partnerships and relationships and decide how can we address
this issue. But, I would love to see that happen. That would be
great for our patients.
Senator Rosen. Thank you. I appreciate what you are doing.
I will tell you, I am also so proud that, of course, Dr.
Skorton, UNLV graduated its very first medical school class.
Ninety-five percent of the graduates were from Nevada; twenty-
six percent first generation college students.
We passed bipartisan legislation to support 1,000 new
Medicare-funded Graduate Medical Education residency positions.
Of course, really important because we have got to address the
workforce shortage so we can use things like mobile units,
collaborative care, comprehensive care. And, so, we have to
work on these GME slots, especially maybe redistributing some
of those unused slots.
Dr. Skorton, in this short time I have left, even though we
did increase the GME slots by 1,000, some of them are not
always a match. And, so, there soon will be qualified medical
school graduates. How can we utilize these while they may be
perhaps on a gap year waiting for a residency, to potentiate
some of our rural and underserved areas? What options do you
think we might use?
Dr. Skorton. Well, first I want to tell you that I had the
honor of giving the commencement speech at UNLV--it was
recorded about 2 weeks ago--to congratulate them on their first
class, as well as UNR. And they are doing a lot of very
interesting, important things.
The idea of volunteerism and other things that people can
do while they are awaiting the next step in their careers is
one that our medical schools themselves are working on.
By the way, in the State of Nevada, both in Reno and in Las
Vegas, there is a lot of very innovative things happening to
connect the medical school itself with the community.
I would like to get back with you offline, Senator, with
some ideas about that business of the gap year. There are some
of our schools in other states that are also thinking about
that. And if it is acceptable, I would like to get back to you
on that.
Senator Rosen. I would love to have that conversation
because I--we have such a shortage of medical resources across
the spectrum and across the Country. We have to do everything
we can to promote, protect, and enhance our collaborative
models for patient care. So, I look forward to that.
My time is expired. Thank you.
The Chairman. Thank you, Senator Rosen.
Let me conclude by thanking all of the Senators for their
questioning. I perceive that there really is a general
consensus. We may not agree on every detail, but I think there
is a general understanding that we have a crisis. I think we
have a pretty good understanding of where we want to go and
have to go.
This is a solvable problem. I mean, this is the wealthiest
country. Yes, we can have enough doctors, and we can have
doctors and nurses in the places that we need them. I think we
can do this. And I think the Congress and the medical
profession have got to be working together on this. So, I just
look forward to working with my colleagues here.
I want to thank the panelists for their great testimony,
Senator Collins for her help on this.
I would ask unanimous consent to put into the record
letters from nine different healthcare organizations who are
interested in this issue.
[The following information can be found on page 48 in
Additional Material]
Okay. Well, thank you all very much. This was, I think, a
great hearing, and let's go forward together on this.
Thank you all.
ADDITIONAL MATERIAL
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
QUESTIONS AND ANSWERS
Response by Dr. James Herbert to questions of Senator Casey
senator casey
Question 1. The primary care physician shortage is particularly
acute in rural areas such as the one you serve. Access to mental health
care is also severely challenged and has been called a crisis,
particularly for the underserved. Increasingly, primary care providers,
if properly trained, have been seen as part of the remedy to help
address mental health needs. You spoke to the importance of considering
not only physicians as part of our primary care workforce, but the
necessity and benefits of an interprofessional approach. Please
elaborate on the roles of nurses and other providers to extend primary
and mental health care. How might we best increase the capacity of
rural providers, including physicians, nurses and others to meet our
Nation's mental health and social care needs?
Answer 1. I completely concur regarding the problem of access to
behavioral healthcare. As with the healthcare workforce more broadly,
this is reflected by an undersupply of mental health professionals and
maldistribution of the workforce. The National Center for Health
Workforce Analysis projected that by 2025 there will be a nationwide
shortage of at least 10,000 FTEs in each of six categories of
behavioral health practitioners (e.g., psychiatrists, psychologists,
social workers, counselors, etc.). In addition, most practitioners are
concentrated in urban areas, leaving large rural areas without access.
According to a 2020 report by the Health Resources and Services
Administration, 119 million Americans currently live in behavioral
health care professional shortage areas. The problem of access to
behavioral healthcare in rural areas is compounded by higher rates of
uninsured or underinsured populations in these areas. And experts
predict that the behavioral health care workforce shortage will be
exacerbated in the aftermath of the COVID-19 pandemic (Bryant, 2020).
Early identification, assessment, and treatment of mental health
problems is critical to reducing morbidity. Most mental health problems
do not remit without treatment and many progress with respect to
morbidity and functional impairments. Efforts are needed to train more
behavioral health practitioners and to incentivize clinicians to
practice in underserved areas, for example through loan repayment
programs. But it is unlikely that these efforts alone will solve the
problem. An alternative model of health care education that stresses
collaborative, cross-disciplinary training and practice has the
potential to help address our country's unmet behavioral health needs.
The collaborative, team-based approach to healthcare education
known as Interprofessional education (IPE) can help address the
behavioral health workforce crisis. At its core, IPE is an education
model designed to bring students from various health care disciplines
together to learn with, from, and about each other with the goal of
improving patient care (Rubin, Cohen Konrad, Nimmagadda, Scheyett, &
Dunn, 2017). Collaborative training includes reviewing roles and
responsibilities of various disciplines, shared didactics, shadowing
professionals from diverse disciplines, participating in cross-
disciplinary clinical simulations and other experiential learning
activities with peers and professionals. In addition to classroom and
simulation experiences, students participate in collaborative
experiences in actual healthcare settings.
Especially when paired with telehealth, interprofessional training
has the potential to positively impact gaps in behavioral health
workforce. One model is behavioral health integration, in which a
mental health professional is embedded within a primary care practice,
allowing for early assessment and intervention and referral to more
specialized or long-term care as needed (Talley et al., 2021). Whereas
this model can work well, it is not always possible to place a
behavioral health specialist in all settings, especially in the most
remote, rural areas. Another model is to train primary care
practitioners themselves, including family practice physicians and mid-
level practitioners (physician assistants, nurse practitioners), to
screen for and mental disorders and even offer basic interventions in
partnership with specialist clinicians located remotely from the
primary care provider.
This expanded scope of practice is made possible by telehealth and
related digital tools. Primary care clinicians can use
videoconferencing tools to consult with psychiatrists, psychologists,
and other behavioral health experts located in distant universities and
medical centers. Using secure videoconferencing tools, these
practitioners can introduce patients to distant therapists, help
socialize them to telehealth interventions, and then the therapist can
provide expert care remotely. The local clinician and remote therapists
can then coordinate ongoing care with the former periodically seeing
the patient in person to encourage ongoing engagement with treatment
and to provide in-person assessments.
Finally, primary care practitioners can themselves learn not only
to screen and assess for psychological problems, but also to provide
certain interventions themselves. In addition to psychotropic
medications, certain forms of brief, semi-structured cognitive
behavioral psychotherapy lend themselves to provision by non-
specialists (Weisberg & Magidson, 2014). For example, a treatment known
as behavioral activation can be highly effective in treating mild to
moderate depression, which is one of the most common conditions seen in
primary care. Another example is "SBIRT" (Screening, Brief
Intervention, and Referral for Treatment), an evidence-based program
targeting substance abuse. These interventions, and many others like
them, can be successfully provided by physicians, nurses, and other
primary care practitioners who are appropriately trained and who
practice in an interprofessional model, thereby greatly extending the
reach of behavioral health services.
The University of New England (UNE) is Maine's largest private
university and home to Maine's only medical school, only physician
assistant program, Northern New England's only dental school, Maine's
largest nursing program, and many other health care programs. The
University is Maine's largest provider of health care professionals.
UNE is known nationally for its innovations in interprofessional
education, and is currently expanding programming to further integrate
telehealth into our interprofessional training to address behavioral
health programs.
References
Bryant, B. (2020). COVID-19 likely to worsen behavioral health
workforce shortage. Behavioral Health Business, March 13, 2020.
Bureau of Health Workforce, Health Resources and Services
Administration (HRSA), U.S. Department of Health & Human Services.
Designated Health Professional Shortage Areas Statistics: Designated
HPSA Quarterly Summary, September 30, 2020.
Health Resources and Services Administration/National Center for
Health Workforce Analysis (2015). Substance Abuse and Mental Health
Services Administration/Office of Policy, Planning, and Innovation.
National Projections of Supply and Demand for Behavioral Health
Practitioners: 2013-2025. Rockville, Maryland.
Rubin, M., Cohen Konrad, S., Nimmagadda, J., Scheyet, A., & Dunn,
K. (2017). Social work and Interprofessional Education: Integration,
intersectionality, and institutional leadership. Social Work Education,
1-17.
Talley, M., Williams, Srivatsan, Y., Li, P., Frank, J. S., Selleck,
C. (2021). Integrating behavioral health into two primary care clinics
serving vulnerable populations. Journal of Interprofessional Education
& Practice, 24.
Weisberg, R. B., & Magidson, J. F. (2014). Integrating cognitive
behavioral therapy into primary care settings. Cognitive and Behavior
Practice, 21(3), 247-251
______
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Response by Dr. David Skorton to questions of Senator Casey
senator casey
Question 1. Dr. Skorton, you shared data predicting a substantial
10 to 12 year physician shortage, ranging from over 50,000 to nearly
140,000. Even today there is a shortage in rural and other underserved
areas. The AAMC report accounts for the 45 percent growth of our U.S.
population over age 65 years, in the face of an also aging physician
workforce. However, it does not fully account for equal health care
access and utilization by underserved populations, highlighting that
removal of barriers for these populations would mean nearly a doubling
of the predicted shortage. As health care access improves health
outcomes, we will want to remove barriers for the underserved. The
report suggests several steps to mitigate the predicted shortage.
Focusing on disparity reduction for the underserved, what additional
steps are necessary to reduce health inequity, to increase not just the
number of physicians, but the number of physicians who will serve the
underserved?
Answer 1. The 2021 version of the AAMC report includes estimates
that if marginalized minority populations, people living in rural
communities, and people without health insurance had the same health
care use patterns as populations with fewer barriers to access, an
additional 102,400 to 180,400 physicians would be needed now. \1\
COVID-19 has put a spotlight on disparities in health and access to
care among underserved populations, and this analysis underscores the
systematic differences in health care services by insured and uninsured
individuals, individuals in urban and rural locations, and individuals
of differing races and ethnicities. These estimates, which are separate
from the shortage projection ranges, help illuminate the magnitude of
current barriers to care and provide an additional reference point when
gauging the adequacy of physician workforce supply.
---------------------------------------------------------------------------
\1\ The 2020 version of the AAMC report estimated 74,100 to
145,500 physicians would be need now to address health care utilization
equity scenario.
Even before the COVID-19 pandemic, physician shortages were being
felt by patients across the country. In 2019, the U.S. Health Resources
& Services Administration estimated that an additional 13,758 primary
care physicians and 6,100 psychiatrists would have been needed to
remove Health Professional Shortage Area designations for areas with
primary care and mental health shortages. According to public opinion
research conducted by the AAMC in 2019, 35% of survey respondents said
they or someone they knew had trouble finding a doctor in the past year
or two. This is a 10-point increase from when the question was asked in
---------------------------------------------------------------------------
2015.
At the end of 2020, Congress took an important step to address the
physician shortage by adding 1,000 new Medicare-supported graduate
medical education (GME) positions--200 per year for five years--
targeted at underserved rural and urban communities and other teaching
hospitals nationwide, ending a nearly 25-year freeze on Medicare
support for GME. Bipartisan legislation recently introduced in both the
U.S. House of Representatives and the Senate, the Resident Physician
Shortage Reduction Act of 2021, would build upon this historic
investment and help expand the physician workforce by adding 2,000
federally supported medical residency positions annually for seven
years.
In addition to increasing the number of physicians to reduce
workforce shortages and access barriers, AAMC supports several federal
programs to help shape the physician workforce and target underserved
communities. In particular, the Health Resources and Service
Administration (HRSA) Title VII pipeline programs (discussed in greater
detail in response to question (2) play an important role in improving
the diversity of the health workforce. Studies show that students from
underserved communities are more likely to serve patients from similar
communities in practice. \2\
---------------------------------------------------------------------------
\2\ Stewart, K., Brown, S. L., Wrensford, G., & Hurley, M. M.
(2020). Creating a Comprehensive Approach to Exposing Underrepresented
Pre-health Professions Students to Clinical Medicine and Health
Research. Journal of the National Medical Association, 112(1), 36-43.
doi:10.1016/j.jnma.2019.12.003.
Additionally, students and physicians who train in underserved
areas are more likely to practice in those communities. Regional
medical campuses, teaching health center graduate medical education
(THCGME), and rural training tracks help expose students and residents
to underserved communities. AAMC supports investing in these training
opportunities as part of a multi-pronged approach to addressing
physician workforce shortages. As Congress considers improving the
Nation's health infrastructure, AAMC supports the Expanding Medical
Education Act (H.R. 801), which would authorize grants to enhance
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current and establish new regional medical campuses (RMCs).
Finally, public service loan repayment programs offered by HRSA,
the Department of Education, the Department of Veterans Affairs, the
Department of Defense, and the Indian Health Service are effective,
targeted incentives for recruiting physicians and other health
professionals to serve specific vulnerable populations. Increasing
federal investment in these programs is a proven way to increase the
supply of health professionals serving HPSAs, nonprofit facilities, and
other underserved communities.
For example, the Public Service Loan Forgiveness (PSLF) program
administered by the Department of Education encourages physicians to
pursue careers that benefit communities in need. In an annual AAMC
survey of graduating medical students, over one-third of 2020 medical
school graduates indicate an interest in pursuing PSLF. \3\ The AAMC
supports preserving physician eligibility for PSLF to help vulnerable
patients and nonprofit medical facilities that use the program as a
provider recruitment incentive.
---------------------------------------------------------------------------
\3\ Medical School Graduation Questionnaire: 2020 All Schools
Summary Report (Rep.). (2020). https://www.aamc.org/media/46851/
download.
The NHSC in particular has played a significant role in recruiting
primary care physicians to federally designated HPSAs through
scholarship and loan repayment options. With a field strength of 13,053
in 2019, including 2,418 physicians, more than 13 million patients
relied on NHSC providers for health care. \4\ Despite the NHSC's
success, it still falls far short of fulfilling the health care needs
of all HPSAs due to growing demand for health professionals across the
country. We are pleased Congress recognized the vital role the NHSC has
in caring for our nation's most vulnerable patients by providing the
program with $800 million in supplemental funding in the American
Rescue Plan. The AAMC supports continued growth for the NHSC in FY 2022
appropriations, and we urge Congress to provide a level of funding for
the NHSC that would fulfill the needs of all current HPSAs.
---------------------------------------------------------------------------
\4\ Health Resources and Services Administration. Department of
Health and Human Services Fiscal Year 2021 Justification of Estimates
for Appropriations Committees. hrsa.gov/sites/default/files/hrsa/about/
budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.
Similar to the NHSC, the State Conrad 30 J-1 visa waiver program
has been a highly successful program for underserved communities to
recruit both primary care and specialty physicians. Conrad 30 allows
physicians to remain in the U.S. in an underserved community after
completing medical residency on a J-1 ``exchange visitor'' visa (the
most common nonimmigrant visa for GME), which otherwise requires
physicians to return to their home country for at least 2 years. Over
the last 15 years, the Conrad 30 program has brought more than 15,000
physicians to underserved areas--comparable to (if not more than) the
---------------------------------------------------------------------------
NHSC, at no cost to the federal government.
As the 117th Congress considers immigration reform, the AAMC
endorses the bipartisan Conrad State 30 and Physician Access
Reauthorization Act (S.1810, H.R. 3541), which among other improvements
would allow Conrad 30 to expand beyond 30 slots per state if certain
nationwide thresholds are met. We applaud this bipartisan
reauthorization proposal for recognizing immigrating physicians as a
critical element of our Nation's health care infrastructure, and we
support the expansion of Conrad 30 to help overcome hurdles that have
stymied growth of the physician workforce.
Question 2. Continuing to focus on the goal of improving care
through equitable health care, increased diversity of the physician
workforce has been strongly recommended, not only as an end in and of
itself, but because minority physicians are more likely to choose
primary care and to serve the underserved. African Americans are not
proportionally represented among the profession nor its training
programs. Rectifying that will likely require complementary solutions.
Would you please speak to how we can increase the pipeline to assure
that more minority students apply to medical school? What steps are
needed? Who is responsible to make the change? What role do American
medical schools play now and how will they expand that role?
Answer 2. Over the past year, the COVID-19 pandemic has laid bare
the existing health inequities harming our Nation's racial and ethnic
minority communities, exposing the structures, systems, and policies
that create social and economic conditions that lead to health
disparities, poor health outcomes, and lower life expectancy. Your
questions importantly highlight these persistent challenges and the
need for academic medicine's ongoing work with communities to eliminate
health disparities. A diverse and inclusive health workforce
contributes to culturally responsive care, helps to mitigate bias, and
improves access and quality of care to reduce health disparities, such
as those seen during COVID-19. Improving diversity of our workforce
requires both private and public ownership of the problems and
contributions to the solutions.
The AAMC is committed to increasing significantly the number of
diverse medical school applicants and matriculants, and last year
launched a new strategic plan that will take a multitiered approach
with sustained investment, collaboration, and attention over time to
significantly increase the diversity of medical students. Our goal is
to keep increasing the number of students from underrepresented groups
until they are no longer underrepresented in medicine.
According to the AAMC Medical School Enrollment Survey, \5\
virtually all medical schools have specific programs or policies
designed to recruit a more diverse student body. The majority of
respondents to that survey had established or expected to establish
programs/policies geared toward minorities underrepresented in
medicine, students from disadvantaged backgrounds, and students from
underserved communities. Schools also reported a variety of approaches,
with a focus on outreach at high schools and local four-year colleges
and admission strategies such as holistic review. Holistic Review
refers to mission-aligned admissions or selection processes that take
into consideration applicants' experiences, attributes, and academic
metrics as well as the value an applicant would contribute to learning,
practice, and teaching. In addition to these efforts, AAMC believes
earlier and greater intervention prior to the medical school admissions
process is necessary to diversify the physician workforce.
---------------------------------------------------------------------------
\5\ Results of the AAMC Medical School Enrollment Survey: 2017,
May 2018. https://www.aamc.org/media/8276/download.
In particular, pipeline programs play an important role in
improving the diversity of the health workforce and connecting
unrepresented students to health careers by enhancing recruitment,
education, training, and mentorship opportunities. Inclusive and
diverse education and training experiences also expose students and
providers to backgrounds and perspectives other than their own and
heighten cultural awareness in health care, resulting in benefits for
all patients and providers. One example is the Summer Health
Professions Education Program (SHPEP), a free summer enrichment program
focused on improving access to information and resources for college
students interested in the health professions. SHPEP is a national
program funded by the Robert Wood Johnson Foundation with direction and
technical assistance provided by the Association of American Medical
Colleges (AAMC) and the American Dental Education Association (ADEA).
SHPEP's goal is to strengthen the academic proficiency and career
development of students underrepresented in the health professions and
prepare them for a successful application and matriculation to health
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professions schools.
Likewise, the federal HRSA Title VII health professions diversity
programs help support medical schools and students:
Health Careers Opportunity Program (HCOP), which
invests in K-16 health outreach and education programs through
partnerships between health professions schools and local
community-based organizations;
Centers of Excellence (COE) program, which provides
grants for higher education mentorship and training programs
for underrepresented health professions students and faculty;
Faculty Loan Repayment, which provides loan repayment
awards to retain minority health professions faculty in
academic settings to serve as mentors to the next generation of
providers; and
Scholarships for Disadvantaged Students (SDS), which
grants scholarships for health professions students from
minority and/or socioeconomically disadvantaged backgrounds.
Studies have demonstrated the effectiveness of such pipeline
programs in strengthening students' academic records, improving test
scores, and helping racial and ethnic minority and students who are
economically disadvantaged pursue careers in the health professions.
\6\ Title VII diversity pipeline programs reached over 10,000 students
in the 2018-2019 academic year (AY), with HCOP reaching more than 4,000
disadvantaged trainees, SDS graduating nearly 1,400 students and COE
reaching more than 5,600 health professionals; 56% of whom were located
in medically underserved communities. \7\ This success is even more
impressive considering that only 20 schools have HCOP grants and only
17 have COE grants--down from 80 HCOP programs and 34 COE programs in
2005 before the programs' funding was cut substantially.
---------------------------------------------------------------------------
\6\ Ojo, K. (2020). Preparing Minority Students For Careers in
Health: A Case Study Investigation of a Health Careers Opportunity
Program (HCOP) (Temple University Press). Temple University.
doi:https://scholarshare.temple.edu/handle/20.500.12613/287.
\7\ Health Resources and Services Administration. Department of
Health and Human Services Fiscal Year 2021 Justification of Estimates
for Appropriations Committees. hrsa.gov/ sites/default/files/hrsa/
about/budget/budget-justification-fy2021.pdf. Accessed Feb. 10, 2020.
The AAMC appreciates that Congress reauthorized the HRSA Title VII
and Title VIII programs in the Coronavirus Aid, Relief, and Economic
Security (CARES) Act (P.L. 116-136). However, increased funding is
necessary for these programs to reach their full potential. For FY
2022, AAMC joined an alliance of over 90 national organizations, the
Health Professions and Nursing Education Coalition (HPNEC), in
recommending $1.51 billion for Title VII and Title VIII, which includes
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doubling funding for the HRSA diversity pipeline programs.
In addition to pipeline programs, the AAMC works continuously with
the academic medicine community to advance equity, diversity, and
inclusion. We would be happy to discuss any of the following AAMC led
or supported initiatives in greater detail:
Action Collaborative for Black Men in Medicine - The
Action Collaborative will be a network community that will
focus on systemic solutions to increase the representation and
success of Black men interested in medicine sponsored by the
AAMC and the National Medical Association (NMA).
CDC Cooperative Agreement - The Centers for Disease
Control and Prevention's Academic Partnerships to Improve
Health focuses on improving the health of individuals and
communities through alliances among academic associations,
universities, and CDC.
Health Equity Research and Policy - Funding and
training opportunities, case studies and best practices, and
solutions-focused research initiatives for AAMC member
institutions to move their communities--and the Nation--toward
health equity.
Improving Sexual and Gender Minority Health - These
resources help promote the health of people who are lesbian,
gay, bisexual, transgender (LGBT), gender nonconforming (GNC),
and/or born with differences of sex development (DSD).
Medical Career Fairs - Medical career fairs offer
workshops on medical school admissions, opportunities to meet
admissions officers and current medical students, as well as
hands-on activities.
Population Health Education -The AAMC seeks to
improve the integration of public health concepts into medical
education and enhance and expand a diverse and culturally
prepared health workforce.
Promising Practices to Improve Hispanic Health - This
webinar series is designed to increase awareness, foster
discussion, and catalyze further research among health
professions faculty on how to best advance Hispanic health.
Sexual and Gender Harassment - These AAMC resources
contain key terms, findings, recommendations, and general
information from the National Academies of Science,
Engineering, and Medicine (NASEM) report Sexual Harassment of
Women: Climate, Culture, and Consequences in Academic Sciences,
Engineering, and Medicine.
Unconscious Bias - At medical schools and teaching
hospitals, unconscious biases can compromise diversity and
inclusion efforts across the board. The AAMC provides resources
and trainings to help members address unconscious biases.
Urban Universities for HEALTH - Urban Universities
for HEALTH (Health Equity through Alignment, Leadership, and
Transformation of the Health Workforce) aims to enhance and
expand a culturally sensitive, diverse, and prepared health
workforce that improves health in urban communities.
Thank you again for your questions and leadership on the important
topic of physician workforce shortages and the challenges the country
faces. We believe there must be a private-public, multipronged approach
to bolstering the physician workforce and the diversity of the
physician workforce. Academic medicine is committed to working to
address the challenges and has made significant investment in both
these areas. At the same time, we believe there must be a corresponding
increase in the federal government's investments for a variety of
federal programs that are already working. The cost of inaction today
will result in higher costs and a less healthy population tomorrow. We
look forward to continuing to work with you and the Senate HELP
Committee to achieve this goal. If you have any further questions
please contact Matthew Shick, Senior Director, AAMC Government
Relations.
______
[Whereupon, the hearing was concluded at 11:58 a.m.]
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