Dick Merritt
Group Director,
Forum for State Health Policy Leadership
National Conference of State Legislatures
Tim Henderson
Director,
Center for Primary Care and Workforce Analysis
National Conference of State Legislatures
Sam Shekar, MD
Director,
Bureau of Health Professions
Health Resources and Services Administration
United States Department of Health and Human Services
I've already sort of put a bite on a few of the chairs this morning but those of you I haven't talked to personally I want to raise to your consciousness the NCSL Institutive for Health Professional Staff Development. This is an institute that NCSL created in partnership with the University of North Carolina at Chappell Hill, their School of Public Health three years ago and we are now recruiting applicants for the fourth graduating class of that institute. It's a week long program and it's like an accelerated master's level curriculum on state health policy. But in addition to that it really teaches staff new communication skills, analytical skills, etc. and graduates of this program so far have been just overwhelmingly positive about their experience. I know several of you in the room have already sent some of your staff but we're encouraging you to look around and see if there are others within your legislature, your chamber that could benefit from this program. Recruitment is going on right now. The applications need to be in by he end of May. We still have some scholarships available, so please help us out and get some recruits.
This morning we're going to complete our tour through the various federal health agencies with a stop at the Health Resources Services Administration, but before we do that, I told you one of the objectives of this conference was to get you a little more familiar with some of the NCSL staff here and so I'm going to introduce, Tim Henderson, who is our specialist really in primary care and health care work force issues and Tim is going to make a few remarks, leading us into the next discussion.
On this topic, in your notebooks we have, I believe it's Tab C, we have a list of NCSL health resources. There are four or five health related programs at NCSL that are here to provide technical assistance and support to you, not just the chairs project but you can benefit from all these different programs. Martha King in the back there is the Director of the Health Care Program in Denver. Tracy Hooker who was with us yesterday, I believe Tracy is still around but not in the room, is the Director of the Prevention Project program in Denver. Lee Dixon who was with us also I think yesterday is the Director of the Health Policy Tracking Service. Joy Johnson Wilson is the Staff Director of the Assembly on Federal Issues Health Committee and I am the Director of what's called The Forum for State Health Policy Leadership, under which the Health Chairs Project really is located. So you have several different entities within NCSL that are here to provide assistance to you. There is that tab there that describes kind of the various functions and purposes of each of those divisions and who the staff people are, so I really invite that to your attention. Now I'm going to introduce Tim Henderson to lead us into the discussion.
As you know you've been previewing a lot of the federal agencies this week and you've been hearing particularly a lot yesterday about coverage, insurance issues; at the same time many of us realize that having expanded coverage, getting increased payment rates for Medicare, Medicaid don't make a lot of difference if you don't have the volume and the access to the health care delivery system, the provider networks, rural areas, the work force that are all part of this. Many of you know we are experiencing some significant shortages in certain health professions and nurses in particular have got a lot of attention and we're going to be hearing a lot about that from Dr. Shekar this morning. We are also seeing evidence of growing shortages of dentists and pharmacists, particularly in rural areas, and you're going to be hearing from Marcia Brand about rural health policy issues.
I think it's important to note in the nursing area, we talk about shortages that are apparently existing now. There's every indication to believe, and I think you'll be hearing more about this from Dr. Shekar, but this problem is only going to get worse before it gets better. The estimates show that by 2010, which is not long off, 2008, 2010, we're going to reach the more acute level of this shortage problem in many areas of the country and you'll be seeing this information. So obviously the nursing work force is a major part of the hospital sector; major increasing part of the nursing home sector in this country. So, if it's not already something that's bubbling up in your state as a concern, it will be coming to you very soon.
Let me introduce our first speaker, Dr. Sam Shekar. Dr. Shekar is the Director of Bureau of Health Professions in HRSA, the bio's for each of our speakers this morning are in your notebooks so I won't belabor the point, but Dr. Shekar is an old friend of both primary care and of work force issues, health professions issues and we welcome him here today.
Thank you very much Tim. I appreciate the invitation to come and speak with you today. I'd like to thank Martha King and Tim for the great working relationships we've had with both of them through the years. We have a good relationship with NCSL and HRSA and we're very pleased to continue that today. I'd also like to recognize John McDonnough in the audience whom I got to know pretty well when I was up in Boston and John is a former state legislator who was, while he was in office and even afterwards and maybe even more afterwards, very focused on health policy issues; has continued to be his whole career and I'm very pleased to be associated with him too. This is nice running into you again today. I'd also like to announce one last acknowledgement before I start, the great work and the great efforts of Dr. Marilyn Biviano, who is sitting next to him, who is the head of our health work force activities. All the slides I'm going to show you today are from HRSA. She really does a great job of being that environmental scanner for us, telling us what's going on in the country, what's affecting your states and how we should be dealing with it. So I'm very pleased to have her as part of my senior staff.
I'm pleased to talk to you today, as quickly as I can, about a number of different issues that are very important to all of you and to the country we're serving in terms of providing health care to America's patients and in this short presentation, I'm going to try and cover a number of things. Bureau of Health Professions within HRSA, our mission, functions and programs; our health work force employment and projections for the country, a direct focus, a specific focus looking at nursing. What's behind the shortage and what are we doing about it and what can we do about it in the future. Some notification of some exciting work we're going to be releasing this summer and then I won't talk about these, but these are in the back, two appendices; one on RN's by state and RN population ratios which I think will be very helpful to you, as well as a bunch of data, just sort of a panoply of different disciplines but at the state directed level. Time does not permit me to get into very specific issues about California or New York or Texas or Alaska or whatever, but that is in the back and we have lots more of this. In fact we have state profiles for every state in the United States available not only in hard copy, but also on the web. If any of you are interested in getting that information, which is pretty thick and gives you everything you probably want to know about work force in your states, please see Dr. Boviano sitting right there.
Well, I've described a lot and I sort of feel like this guy. Where do I begin? I've got a lot to do in 30 minute but I'm going to try my best. What we do is very simple; very simple: right people, right skills, right places. We need to use work force planning and analysis to train the right people. We need high quality education to give them the right skills and we need equitable distribution; a particular important rule is as my colleague Dr. Brand will be describing for you shortly; in the right places, in all the places.
I won't go through this slide in depth but just simply to focus on the box. The mission: to increase health care access by assuring the health professions work force that meets the needs of the public. Simply said, difficult to achieve. Well how do we try to do that? We have a wide range of responsibilities and functions. In fact in FY'02, this fiscal year, HRSA, through BHPR will spend almost $800 million across the country to support, through 1800 grants, to thousands of institutions, the training of health care professionals. We also through our national service corp. try and put health professionals in under-served populations, in under-served areas, and we also try and insure the quality of health care through the tracking and reporting of adverse actions taken against health care providers, as well as trying to work with our colleagues and IOM and other places to improve health care quality and safety.
Specifically we do this through a variety of programs and I won't go through this in depth. If you have questions we can come back to it later. We have a full slide looking at diversity, making sure that we have _______ represent minorities, working in and being part of the health care work force. We work on primary care medicine and dentistry to make sure we have more doctors and dentists out there and PA's. We work on trying to get the professions to work together. It's a strange concept but we try and get the disciplines to work together in a harmonious way and that's called our interdisciplinary activities and we also are focused on public health, to try to make sure that we take care of the nation's health as well as patient's health.
In nursing we have a number of programs; again, very briefly, it's about $93 million this past year in FY'02. We support basic nurse education through many of the community colleges in the states and nursing schools. We support nursing work force diversity assisting minority and disadvantaged students to enter into nurse education programs. We support advanced education nursing; nurse practitioners, nurse midwives, nurse anesthetists to make sure that that level of nursing quality is kept up and supported. We also have expanded a program called the Nurse Education Loaner Program, which we're really excited about because this allows us to help support nurses in practice in under-served areas and/or serving under-served populations and this program has gone from a $2.3 million budget to a $10 million budget in FY'02 and it's slated by the President in the coming years, FY'03 cycle for $15 million. What we did last year is through this program support over 400 nurses across the country to work in a number of institutions that needed that care and provided essentially over 1000 years of service through those nurses that will then be going out there, that may not otherwise have been there if that program hadn't been in place.
Children's Hospital GME, we helped support children's pediatric and other types of training at independent, free-standing children's hospitals. The National Health Service Corp. that I mentioned earlier making sure that we put as many people as we can into health provider shortage areas, many of which are in the states that you represent.
We're very excited to talk about something that's coming up in FY'03. The President's budget has established $60 million in FY'03 for a new initiative in Bureau Health Professions to provide incentives and curriculum development and training on bio-terrorism and on emergency preparedness and this will teach future public health and health care system workers on how to engage with their public health system to respond effectively to terrorists and other types of incidents and we're looking forward to working on that. We're working on that very diligently and some of our area health education centers are, even as we speak, working on issues at the state level. In fact I just addressed a meeting in Las Vegas about three weeks ago. Nevada is really working very hard to insure that the folks in Las Vegas are prepared for any unfortunate incident that might occur and I can also mention our Florida AHEC is doing a lot of good work as well.
Finally in terms of this broad overview of Bureau Health Professions, last but not least, the group that Dr. Biviano heads up, National Center for Health Work Force Analysis, it's the only federal effort that focuses on health work force supply and demand specifically. Through our national center located here in the Washington area, as well as through our regional centers, which you see below, scattered across the country, we provide and obtain this information that I'm presenting to you today and much more information beyond.
I'll go as quickly as I can to tell you where we are in terms of health work force in this country. This is a very important statistic and one that I think a lot of people don't really realize until it hits them. More than one out of ten American's who work, work in health care across the country. And if you look at the bottom line, U.S. health work force, that's in bold, 10.3% of the U.S. labor force is in health care in one way or another, whether they're a health professional looking at the middle circle, this is a nice diagram, the middle circle are health professionals in health service settings. This would be something like a physician in a health clinic. Well that's obvious, that makes sense, they're in health care. But let's also think about the other two parts of the circles. You have health professionals working in other settings and that's like registered nurses working in public schools as a school nurse. You also have other workers who are in health service centers and that's like administrators or medical coders who work in hospitals. When you put it all together, the health care industry supports nearly 10% of America's labor of work force. You can see the numbers there, 15.1 million workers; 10.3% of the work force. So it's an important issue, not just from a health perspective but a labor perspective.
We are now coning down just to the health occupations and in the health occupations you can see some interesting statistics here. The most important plan I want to leave with you on this slide is that nurses are the single largest discipline as represented in the work force; 22% of the work force. Physicians, although we often think about them, when we think about health work force, are really only 6% of that work force. 22%, the single largest discipline is registered nurses. And you see some higher percentages but those are for groups that are combinations of disciplines. So again, the single largest discipline is nursing.
This is an important point to leave with you and if I can leave nothing else with you today, this is the most important slide. The demand for health professionals based on everything we know will grow at twice the rate of all occupations between 2000 and 2010. Tim Henderson eluded to that earlier. If you look at the total U.S. employment and this is information not from us, this is information from the Department of Labor, Bureau of Labor Statistics, it is expected that from 2000 to 2010 the percent growth in U.S. employment will be about 15%. But that for health occupations will be essentially double that, 29%. And you can see below for various categories how that may break out so that some may be lower than that, such as dentists at 6% growth, some may be much higher than that, such as health service occupations, 33%. But in general, you're talking about double-digit needs and increases, twice that of U.S. employment for health care.
And why is that? The single most important factor is the aging of America. If you look at this study and you look at this graph that I'm showing you, you can see that over the next 25 years the population over 65 will grow at a rate 5 times that of those under 65. In fact, the population that's over 85 is the fastest growing segment of the U.S. population and there are many, many healthy 65 year olds. But when you get to 85 you generally need some degree of health care and that's going to help fuel the need for all these health services and health providers. In fact, by 2015 every single day 10,000 more Americans will turn 65, every single day.
Another major issue is technology and I'm using specifically the issue of genetics. But as technology continues to advance in the laboratories that information will have to disperse out to health care settings and as that disperses out, technology will drive an increase for health providers who are every more specialized in certain ways to understand that technology, to help get that information over to the population to the patients to all Americans and as a result, you're going to have a tremendous need for bringing people up to speed and that technology, I didn't show you in the slide here, but technology will have a major impact. I won't show the slide but just to let you know, for pharmacists, one of the major reasons why there's a shortage of pharmacists in the United States today is not because there's a dwindling supply of pharmacists; in fact, the supply of pharmacists has been relatively stable. The reason there's a shortage is because the growth of prescriptions, all those you see advertised on television, the growth of prescriptions has grown four-fold in the last 10 years and as a result, a typical pharmacists now fills 33% more prescriptions, everything else above the job is separate; just that typical pharmacists fills 33% more prescriptions every day than they used to 10 years ago. More demand on their time; more need and I haven't even talked about things like retail pharmacies opening up 24 hours a day, the growing educational life cycle of pharmacists, etc. But all those factors will have an impact on technology; the number of drugs that are out there has definitely been a major fueler for the need for pharmacists.
Very quickly: nursing, what's behind the shortage and I'll go through these as fast as I can. Tim eluded to the nursing shortage that we have projected to begin in 2007. This is based on 1996 data. At that time the rate of nurses entering the nursing profession was three times greater than it is today. We are on the verge of having some information for the 2000, which I think will significantly impact these projections. I would say that most likely it will certainly not predict a shortage that's later than 2007. In fact it could be earlier but we don't have the final data on that yet. But I will say, and this is a fact, that the rate of people entering nursing was three times greater in 1996 when this slide that you see here was put together, than it is today. That will have an impact if you have fewer nurses coming in; that will have an impact on shortages.
The West and Southwest have the lowest RN to population ratios in the country, so there is a distributional fact. The nursing shortage is not equally felt everywhere and that's an important point also for all of you obviously to know and to realize and to take back and I'd like to make sure that people understand that this is not a one size fits all shortage. In certain areas it's much worse than in others and you see some of the information here.
In addition, one of the factors why the nursing shortage is occurring is the nursing population themselves is getting older. In fact, over the last 20 years, and over the next 20 years, you can see that the typical or average age of nurses in practice will go up essentially the same number of years. The end result is as we speak today, only 10% of registered nurses in the United States are 30 years of age or below. The median age of a nurse today in the United States is 45 years old and as you can see from the slide projecting out to 2020, if we keep going the same course we're going on, that median age will get up into the high 50's. This is the population that will be helping you to take care of the 85 year olds and others who are the patients with the hip problems and everything else and that is a sobering statistic.
Unfortunately, we've had a reduction in the number of RN graduates and whether it's associate degree diploma, BSN, the trend lines are all going downwards in terms of the supply of nurses going into these programs. And at the same time we have alternative careers that are offering attractive salaries that affect supply. The top line is that of annual salary, annual earnings for elementary school teachers. Now we could have done this with high school teachers; we could have done this with a number of groups, but what you see here is the top line shows you the growth and earnings for elementary school teachers during this time period from 1983 to 2000. The pink line is that of registered nurses and their annual earnings. It's lower, obviously than it is for the teachers. So if all other things are equal and they're making decisions in terms of entering a profession based on salary, elementary school teachers provide a more lucrative career for them than being a registered nurse. What's worse is if you look at the light blue line, where in the light blue line, this is the actual earnings of nurses adjusted for inflation and you can really see the gap there.
So what are we doing about the nursing shortage; what are you and your colleges, your universities, your constituents and our grantees doing to help improve the nursing picture in the United States? In this year, our bureau and our grantees, your universities are supporting nurse training programs with, as mentioned, $93 million which is 11% more than we had in FY'01 and you can see the breakdown by the various groups. Again, we're very proud of what we're doing with the nurse education loaner payment program and we see growth for that.
We also have additional programs that help support the training of nurses. Scholarships for disadvantaged students; $13 million that went out to support people who were economically and educationally disadvantaged, regardless of race or ethnic background; economically and educationally disadvantaged to get out there and hopefully become nurses. We also have a nursing student loan program and we have a scholarship and loaner payment program for national service corp., which helps support nurse practitioners and certified nurse midwives.
The end result is that this past year, FY'01, our program has ultimately supported the training of over 26,000 registered nurses across the country. Again, we can talk more about this if Q's and A's come up on that.
I just want to give you a headline on something that's coming up. We're real excited about it and I think it will be very helpful to you. The tenth report on the status of health professionals will be coming out this summer. The goals of the tenth report are to identify major work force issues for each occupation and provide 15 year projections of supply and demand for each health occupation. You can see on the right, we will be able to get some information out there about what we think in 15 years this country will need and how many of a certain discipline they may need and we're not just going to limit it to nurses. In fact, we're going to have all these occupations that you see here listed in that report. We think this will be very valuable information for the country and for each of the states as we go along and start thinking about and planning for the future of the folks who take care of all of us.
I'd like to conclude with one comment, which I think is a very interesting one and one that I really focus on quite a bit in my bureau. If you want one year of prosperity, grow grain. In health care I'd like to think of this as services. You get a flu shot, you pay for a flu shot, the flu shot is given, patient walks away, hopefully not with a sore arm, and it's done. That's grain; you have one year of prosperity. If you want 10 years of prosperity, grow trees. Have a health facility; make sure that people can go somewhere where they can get those health services so that they have a place to go. We wouldn't want to give health services in this room; we'd want it in a good location. That's like trees. We want to make sure that these things are there to stay and they have a place where they can get their care. But if you want 100 years of prosperity, grow people. And that ultimately comes to the final point. We can have health insurance and we can have health facilities, but if we don't have health care providers, ultimately at the end of the day when it's the patient and a clinician in that room, if we don't have health care providers, we don't have health care; no matter how many supplies we may have, no matter what that insurance card says. So we all need to think about where we're going in this country in the future and making sure that our patients and all of us as we get care have the health providers we need. Thank you.
QUESTION: Elizabeth Roberts, Rhode Island. I'm actually from a state with one of the highest ratios on your map, but we're also a state that still struggles with the ability to fill nursing vacancies in hospitals, that we have a lot of nurses who don't want to work in hospitals and so we're ending up with emergency room problems because we can't move people to the floors. We don't have increasing numbers of beds; we've actually had an increased number of nurses when you look at your statistics. What do we do about this issue of nurses actually wanting to work where we need them? I mean how do we improve working conditions, improve the type of work so that the nurses that we have want to continue working where we really need them to work.
Absolutely. That's a very important fact and we need to make sure that we get people into health professions and then we do all we can to retain them, so recruitment is one piece of it and retention is another. We also have activities in our bureau and hopefully can be emulated in other places and we can do more in our bureau to help focus on retention. Just one example; we have programs through our basic nurse education activity that set up career ladders and career ladders are, you're nodding your head and some of the others may know, the career ladders are activities that allow someone to go from an LPN to an RN status, from an RN status to an advanced nurse status. The end result is they get support; financial, educational and mentoring support, to increase their levels of responsibilities and their level of authority and one would assume, levels of job satisfaction while they're working in their environment and that's just one example of what we can do to help increase retention.
I will say that the Departments of Labor and Education as well as Health, are very concerned and very focused on the issues of nursing and we plan to do more in the future to help think about the whole range of issues associated with it. So recruitment is very important, that's one piece of it; retention is also very important. Career Ladders is an example of what can be done to help get more people to stay in nursing. It's very interesting because, and I'll just throw out one other statistic; out of that 2.5 million or so nurses that we have, registered nurses we have in the United States, half a million aren't practicing. They have their degree but they're not practicing nursing. Now they're doing some wonderful things out there with what they're doing in their lives, but it's not providing clinical nursing services. So we have a significant percentage, 20%, of our registered nurse population in the United States not practicing clinical nursing. We need to do something to get them back in.
QUESTION: I have two questions. I wonder sometimes if we're not stumbling over each other whether it's federal, state or even private for that matter with the tools that we're sort of used. We're on a kind of a paradigm, if you offer more scholarships or you offer whatever those kinds of things and it seems like it's all kinds of things, and we've done it too; we're all sort of chasing this thing. So I wonder if some place if there's any kind of an inventory. I've served on a foundation board and even private resources are incredible. I mean if you want to get a scholarship and you want to go into nursing or something, they're all over the place. The second part is I didn't see anything in yours as to where I really think the problem is. The problem I don't think is as much in that end frankly as it is on the way of the front end, in middle school. Well first of all, sheer numbers, because you've got to look at the numbers of young people that there are in the work force but secondly it's the choices that are made when they're in middle school as to whether or not they're choosing the technical courses, the right kind of base that opens the door for these kind of careers and whether or not they perceive these health careers as something positive. It seems like there's a lot more force among young people making choices on what the image is. If the Mom who is or the father who is a nurse comes home and says don't you dare go into this dumb career, it's those kind of signals out there, or if we send signals in nursing homes that it's not a good place to work because there's so many bad things. What are we doing on the very front end to make these careers something positive, attractive, and then the first question was about inventory.
Well, I'm really glad you asked that question, because I can talk about it and I can talk about something that we launched this February. In fact it was a joint launch of the Dept. of Health and Dept. of Education. Both Secretary's Thompson of HHS and Paige of Education, got together and launched something called Kids Into Health Careers, and that's an initiative through our agency and our bureau which is directly requesting our grantees, and again, we have over 1700 of them, to go out and adopt a school, a local school, a high school, a junior high school, an elementary school; talk to them at least 6 times in some way and get the students, the parents, the teachers and the counselors to understand the value of health professions careers. There are over 270 health professions careers in the United States and you can enter it straight out of high school, all the way to having 12 years of study before you actually end up being on your own post-school or post-residency training. So there's a huge range of health careers that are available to people and we want to make sure that as many kids know about it as possible. We agree with you. We do not think we can just simply say okay, you've graduated college, now let's talk to you about health careers. That's was the old way and I don't think we're going to be able to make a dent in trying to identify some of our shortage issues and fix them unless we go, as you said, very aptly right into the very beginning of the cycle and look at kids and start talking to them from their 4th grade, 5th grade on and to have them be aware of what health careers are. So we're going to use our grantees to do that.
Excuse me, what state are you from?
REPLY: Minnesota.
Okay, so we're going to ask the University of Minnesota to go and talk to local schools in their area and talk to them about what it means to be a nurse; what it means to be a physician; what it means to be a hematologist; what it means to be a phebotomotist; what it means to be a home health care aide and what does that involve. In the Kids Into Health Careers, and by the way that's on a website that's available through our agency and again, Dr. Biviano can get that to you, all this information that we have is downloadable off the web. We have information about the professions. We have information about the salaries. We have financial aid information on it and we have career directions for it. So, all that information is available in hard copy as well as web and that can be downloaded and used across the country. It's called Kids Into Health Careers and we've proud of it and we want to really make some good efforts out of it.
QUESTION: Sen. Maggie Tinsman, Iowa. We have a very substantial nursing home industry and nurses are in shortage also in Iowa, but one of the most critical shortages is C N A's, certified nurse aides and that's where we need the help with education, with kind of like a career ladder that maybe if you start as a C N A then you can progress up but we really need help with not just recruitment but with education of C N A's and that's where one of the greatest shortage is because of the dropout rate. They seem to disappear real quickly and they're also doing the jobs that are the least glamorous.
I appreciate your saying that. About two weeks ago, Dr. Brand and I, as well as our boss, Dr. Betty Duke who is the administrator of HRSA, we went up there along with Jenny Gunderson from the Secretary's office, to Alaska and we did a number of things while we were up there for that week. One of the things we did was hear over and over again and see over and over again the value of community health aides and helping to provide outreach to the community, being from the community, as well as providing basic level of health care services and how that was so relied upon by the folks up there. So if I'm hearing that from Iowa as well, I think that that shows us that the aides in general, however you may call them; whether they're called community health workers, whether they're called certified nurse aides, whether they're called community health aides, whatever they're called in the border of this country, promodoras; however you want to call it, that that level needs to be looked at much more seriously in terms of how do we make sure that our patients needs are taken care. We are going to be starting to do that and looking at that as we go along. We focus most on the professional side but we need to make sure the whole range of health care is looked at.
SEN. TINSMAN: The one's I'm talking about actually are in the nursing homes; they're not in the community. But they are just critical to the whole working of either the assisted living or nursing home.
I will certainly take that back and some of the community health aides we saw in Alaska were working in the health clinics and hospitals. They're from the community or at that level of community, but that doesn't mean necessarily that they're only in the community. But certainly we need to look at that aspect too. Speaking of Kids Into Health Careers, that's a perfect thing for someone to do out of high school. So there's this myth that in order to be a health professional you have to have twenty-five hundred years of schooling. That is true in some of the professions, certainly; but in many others it isn't and we can do a lot to get more Kids Into Health Careers all across the spectrum.
QUESTION: Rep. Carl Saunders, Utah. We studied this issue just a couple of weeks ago in our interim health committee and came out that there were many qualified students that want to go into nursing that are not being accepted because of the lack of qualified instructors, nursing instructors and low pay for nursing instructors and inadequate facilities, not having large enough classes, etc. to take all of the students that want to go into nursing. It looks to me like some of the financial aid ought to be directed towards that end as well as to the students themselves. I'm just wondering what's been done in that regard and the second part of my question is regarding scholarships for disadvantaged students. What are your criteria? Who determines which students are disadvantaged? What criteria are used for that?
Regarding the first question concerning faculty development, we have a very, very small program in our bureau called the Faculty Loan or Payment program. It's funded at about $1,000,000. But what that does is it specifically provides support, somewhere in the range of I think $20,000 a year to faculty of various disciplines to stay as faculty in those disciplines and help to train the next generation of their field. With that money we try and do our best to get out there and make sure that we can help provide that support. So there is a vehicle that allows us to do that. The issue of faculty is very critical and I would just give another example from pharmacy. We understand that many pharmacy faculties are moving into the retail sector. Their salaries are much higher; the hours may be better, I don't know all that, but certainly we're seeing a shifting of not only pharmacists going into the retail sector but also pharmacists who were in other places, such as hospitals, institutions, as well as in academia, moving over to the retail sector. That's great for the retail sector; that's wonderful and don't get me wrong, I think that's great that we have pharmacists serving patients in the retail sector but what we're getting is some gaps in the hospital side and in the faculty side. So we need to be thinking about all of us, hopefully thinking about not just getting people as you said into the professions but keeping them and also thinking about it from the fact that we respect it. So I share your concern. We have some programs that are there. We're doing what we can with them and I think that this is something that's a relevant issue for the nation and for the states.
QUESTION: Can we have our people apply for grants?
Absolutely. I mean we have a whole granting mechanism. We have a peer review system within my bureau, which is very similar to the one in NIH. I'm very happy to have that peer review system because it's an independent peer review system and it rates the quality of the applications and I have nothing to do with it. I'm very pleased that we have a system that allows the peers of those institutions to judge the value and the quality and the merit of applications that come in and then they rank them, and based on that ranking and based on what funds we have available, we can give out the grants. Certainly there's a form, there's a way to do it. I think this is kind of complicated and actually you're second question is going to take more time than I'm going to be able to provide I think here. But what I will do is I will give you my card and if you like you can follow up with me afterwards or with Dr. Biviano. I don't know if you're staying here after I go but we can get you the information on how to apply for grants and what the specific information is in terms of the definitions for the disadvantaged. As I mentioned it is educationally and economically disadvantaged as well as this upper category, which is an important, which is the minority set, some of them represent minority sets. But those are all separately considered and each has equal merit.
QUESTION: Are universities and institutions going to apply for grants as well as the individuals?
The way it works in general for these scholarships is that the university programs apply for these grants, if they're judged by the independent bureau to have sufficient merit; they're given a high score. If that high score is high up enough that there's enough funding that would get down there and cover it then it gets awarded a grant. Once that grant is given the money goes to the university and then the university with guidelines from us determines the individual students who would receive the funding. But they do it on the basis of guidelines and working with us but the university is the one that hands out the money to the individual students or faculty.
TIM HENDERSON: Let me just add, Rep. Saunders, Utah is actually one in five states that NCSL will be examining as part of a grant that we've received from the bureau to look at nurse training capacity. We will be site visiting your state along with four other states between now and the end of the year. We are looking at several criteria that will sort of address the issue you're talking about; why are there shortages of faculty in nursing schools at all levels, both at the RN and at the non-BSN or LPN level, and developing some policy guidelines as to how state lawmakers such as yourself may be able to address the problem. We're actually going to have a summit; people like yourself and nurse educators in your states to come together and address those issues and that would be some time early next year. We'll certainly keep you abreast of that project as it develops.
CARL SAUNDERS: Tim, the other thing I was thinking is I don't know if they get copies of the preview, HRSA preview. Is that something we could get to you and then you could distribute it out to everyone?
TH: Sure.
We tried and put all our grant announcements into one journal, one booklet and it's called the HRSA preview. So that might be very helpful. It includes most of the programs that we have in our agency and certainly on the nursing side those are all in there. So that's a one-stop shop. It makes it easy to look at all our different grant mechanisms because we certainly have a few of them.
QUESTION: Rep. Patricia Gray, Texas. Our state is also looking at this work force issue during the interim and our hearing was also just a couple of weeks ago. In fact, Tim came down and kind of gave us the big picture. With our state wide health coordinating council we're focusing in on where our shortages are within our own work force and what we need to do in the way of training. There were two things that came out of that day of hearing. One may be of particular interest to Sen. Tinsman. There is some research being done at the University of Texas Medical Branch in Galveston on how C N A's are trained to help increase their job satisfaction working in nursing homes. It doesn't get to the hospital question that Rep. Rogers raised. Because the training for C N A's is generally so much less, it needs to be very, very focused and the preliminary results of this research show that the changes in the training program are in fact making a difference, not only in work place satisfaction but also in retention rates for those folks. It focuses on just really teaching them about what geriatric patients are like. If it takes them longer to do something, you need to let them do it, which is of course a problem when you have a shortage of work force. It's the appreciation of moving slowing does not mean you've become a child again. You need the assistance but not the mentality treatment. I think that may be useful in working on some training issues. The other thing, in our last legislative session, was to look at shifting money in our higher education training, in our higher education dollars, so that schools of nursing could tap into what we call our dramatic increase growth fund which is what happens when there's this influx of students. We also had qualified applicants who were not able to come in but we had this kind of cart/horse deal that okay, you could admit the students but then you can't get reimbursed for the faculty until a year later. So it didn't really allow the schools to hire people that they needed and we reversed that so that they got the money upfront to hire faculty and to try to assure people that in fact their salaries would be taken care of so they felt a little safer about coming.
One thing I'd like to sort of suggest as I'm listening to those range of questions is that we have a wonderful in our bureau, which is a federal/state partnership called the Area Health Education Centers or AHEC. WE have 45 AHEC's in 42 states. So almost all the states in the United States, almost all of them; we'll get there eventually, but we have 42 states that have an AHEC whose job it is, whose mission it is, is to actually look at and deal with these work force issues, thinking about it from the state level and it's a federal/state partnership. There's federal money going in; there's state money going in and there's a great opportunity to connect up with and interact with them and they have a lot of information that's very state-specific, state-oriented, and their set up to actually provide that linkage between community and all those that represent the community and academia. So they're a perfect interdisciplinary community based group and university focus group that allows that linkage and allows that information to come forward and I think what we can do through Marilyn's office and through Tim, is get you a list of all the AHEC's and contact numbers and information so that you know, particularly as you're dealing with your states, and certainly Texas is a very good one, Florida is another one, where they can help you in identifying information that may be needed.
The other thing I wanted to point out and I flipped the slides back to let you know that these are all another great resource for all of you in looking at work force issues in your state or region. These are not set up as state centers but as regional centers. I'm pleased to announce that this past year, the Secretary announced the creation of our new, our fifth regional center for health work force studies and that's the one at the very bottom. You can see that it's so new that we didn't have a website at the time that we put this slide together, the University of Texas Health Science Center at San Antonio. But we also have it in Seattle, in Chicago, in Albany and in San Francisco and these are set up as regional centers. So they're another great opportunity and vehicle that you can consult with or your staff can consult with in terms of identifying health work force information that's not just national, but also specifically tailored to your interests and issues.
QUESTION: Sen. Jim Jensen, Nebraska. We did a study last year and we also did a study of all of our veteran's homes in Nebraska and we are one of the states that has really a high ratio of nurses for the capita, but I think we do a poor efficiency of our nurse work force. No. 1, as we looked at our veteran's homes we found out that we had yes, a high ratio of nurses but we have a number of nurses in administrative positions. I'm a building contractor. I would never take my best carpenter and put him in administration. I don't understand why we take our best technicians and put them in administrative positions. No other business does that except I believe medical fields. I don't know why we do that. Another thing, the paper work that a nurse performs daily is unbelievable. We allow them to do paper work rather than spend time at the bed. A staff nurse in a nursing home, will spend 50% of here time filling out paper. A charge nurse in a hospital will spend at least anywhere from 30% - 40% of their time filling out paper work rather than allow them at the bed side. We also have another thing that's going on in Nebraska, I know a lot of other states, Florida in particular, we have established all of these boutique hospitals or ambulatory service centers who are draining nurses from the hospitals into orthopedic centers, surgery centers that are working 7:00 - 3:00 or 8:00 - 5:00, very clean operation; they leave, they don't have to worry about night duty or anything else. That's tremendous competition for our hospital nurses. But are we doing anything at all nationally about efficiency of those people that we have in this profession?
Well your first comment cuts me to the quick, so I don't know what to say, whether I can respond to that one too well. To be honest, I think also there's some value in having people who have some background in these fields to be over it and help develop policies for it and I think whether it's, Dr. Brand is a dental hygienist by training so we have a number of health professionals who are working in these fields and I think that helps in terms of making sure that what we do makes sense. But getting beyond that, I think that we certainly need to have more people working in the clinical environment and it gets back to the issue about retention and what do we do to insure that the work place is one that people are attracted to. There are frustrations with any job as we know; the frustrations with anything anyone does but there's also great joys in it too and I think it's the balance of trading off the joys v the frustrations that makes one decide they'd go into a certain area or stay in a certain area. There are some interesting activities that are out there that are looking at the system overall. In fact, one book I might recommend to all of you just personally is, the Institute of Medicine came out with a report about a year and a half ago and it's called Crossing the Quality Chasm and I would highly recommend that to you or your staff that might be interested in perusing it. It talks about the system as a whole, the whole health care system and the IOM did this and as you know the Institute of Medicine is a very august institution and has put together a very good book and we in this agency are going to be looking at some of those issues that they raised and think about those as we continue our work. So, again, that's called Crossing the Quality Chasm. It's in the health policy field; a lot of people knew about it and they have sections that focus on various issues and in fact Chapter 9 focuses on the work force, but that's just one chapter and they have chapters looking at the administrative issues associated with just providing health services, with pharmaceuticals, the hours the clinicians work, the patient load factors, all the kinds of things that are associated with the health system. That's just one example of something that's out there that might be worth looking at. It's thinking about what do we have now in our system and where could we potentially go. There are many other things and I could give you a whole bibliography on that but I don't think that's relevant at this point. Yes, we're all part of that and trying to figure out how to improve the whole system. It's not going to be an easy thing to achieve. It's not going to be something we can do overnight but I think we're moving in the right direction. Certainly the Secretary is interested in doing more to increase our focus on prevention and trying to put our focus where we can get the best payoff.
QUESTION: Rep. Dennis Arakaki, Hawaii. I think in terms of the health care work shortages, a couple of issues that I hope you can comment on. I think as the demands grow, legislatures will be increasingly expected to look at scope of practice issues as well as things like prescriptive authority for nurses. I was wondering if you could comment on that and see how HRSA can help us in those terms. The second issue is in terms of foreign health care workers, both in recruitment and in certification or licensing of these foreign workers, also any resources in that area as well.
Our bailiwick is pretty much domestic so our focus is on trying to get more American graduates through institutions that we support in the United States. Our programs are set up really to focus on that. Certainly though, there's no question that there are significant numbers of international graduates of various health professions in the United States. In fact, an interesting statistic is that one out of every four doctors; one out of every four physicians in the United States is an international medical graduate. Those numbers, that percentage is lower for some of the other fields, but that's just an interesting statistic to be thinking about. Our programs are pretty much focused on trying to provide support to institutions that are in the United States to produce graduates so we can then go and practice in the United States and certainly, even more hopefully, in under-served areas of the U.S. and that's really where we are with that.
In terms of the scope of practice on those kinds of issues, as I think all of you clearly understand, that's a state level issue. That's really not the federal government's role and we certainly are available for consultation and can help in terms of interactions and just data that we have, facts that we have, but scope of practice and those kinds of issues and credentialing are a state and a professional association issue and that's something that we respect very significantly.
QUESTION: Sen. Judy Lee, North Dakota. Even though our numbers are among the highest on your graph we have the same challenges in distribution as much as anything, particularly with our rural health needs. We have required for several years a bachelor's degree for RN's and a two year program for LPN's and I think we may still be the only state or at least one of a few and that has become quite controversial as we try to meet the challenges of reduced numbers of nurses needed. Can you comment on those that are just licensed but without a bachelor's degree, diploma nurses, as compared to bachelor's degrees and whether or not you made any observations in your work?
We are dealing with the whole population, so if you're an RN, you're an RN. Our grants are to a variety of institutions. They produce RN's from different categories and you know that and you know there are different types of RN's but we focus on RN's, on NP's, nurse midwives, certified nurse anesthetist, etc. On our allied health side, we're looking at the LPN issues and things like that but we're not making distinctions on any. We certainly think that the BSN's are a very good way to get an RN degree. They certainly have a significant amount of educational training through nursing schools, which allows them to be as up to date as possible on what needs to be handled, whether it's the issues of 20th century or 21st like genetics and geriatrics.
QUESTION: Rep.Clara Sue Price, North Dakota. Like Sen. Lee said we require the baccalaureate degree and the two year for LPN; one thing we've started discussing, and I'd like to know if any other states are, is it possible, flexible use, even more flexibility of the TANF funds in furthering education in medical shortage areas such as this. Maybe they would allow some states, especially with the diverse population, we have a large Native American population in our TANF group. Maybe give us a little bit more flexibility to use some of those funds to try some things to see if that would help, particularly in those under-served areas.
Well, that's not really in my area of expertise but I'll certainly take that comment back inside of the department.
QUESTION: Dick Merritt, NCSL. You have a slide about nursing work force diversity and there wasn't really a description about it. I assume the focus is really on racial and ethnic issues, but I'm curious whether or not that extends to gender diversity and the other way of asking the question is, is there any focus in terms of trying to attract more males to the nursing profession.
For those of you who may not be aware, males represent roughly about 5% of the total U.S. nursing work force. It's a very small percentage and has been relatively stable over the last few years. We would like to obviously get more males into the nursing field and one of the things we'll be doing with our Kids Into Health Careers is try very hard to insure that the male students, as well as the female students, get equal exposure to the values of nursing and what it's about because it's certainly a great field for them. So there is going to be absolutely a sense and a desire to not bias gender any way shape or form towards any of the professionals. There should be no profession that is inherently a man's field or inherently a woman's field and that's exactly what we're going to try and do with all the work that we put out there.
I wanted to segue into Dr. Brand's presentation by just leaving you with one thought in a field that we didn't talk about much here today, but dentistry and just point out to you that distribution is a critical, critical issue and even when there isn't a shortage in a field, or even if there is, it's even exacerbated the concern about distribution. Here we have the state, California just to give one example and I'm not picking on California, I love California and I could tell you that we have this kind of picture in every other state in the country, but basically you have a wonderful state with a lot of great production of dentists and other health professionals and yet you have dental shortage areas because the rural areas of the state don't get the dentists they need to help support the population that's there. I wanted to leave you with that and I think that's a good segue into the issue of rural issues and distribution as it relates not just to work force but to facilities and all the other things that Dr. Brand is involved with. Thank you again.
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