U.S. Department of Health & Human Services
Health Resources and Services Administration

HRSA Press Office: (301) 443-3376
http://newsroom.hrsa.gov

by HRSA Administrator Mary K. Wakefield

June 27, 2012
Washington, D.C.

I’m told that I’m the first HRSA administrator to speak to this meeting – which is, perhaps, a bit unfortunate, since your member universities and HRSA have, I think, much in common. We share similar views of the challenges we face and the steps we need to take to confront them.

I know that some of the universities represented here today have won HRSA grants in the past, and I know, too, that some of your representatives have consulted with some of HRSA’s leadership, including Jan Heinrich and other staff at our Bureau of Health Professions as you developed your Urban Universities for HEALTH (Health Equity through Alignment, Leadership and Transformation of the Health Workforce) project, for which you won a five-year, $4.2 million grant from NIH last year. Congratulations on that!

So we do have some working relationships, but I’m sure we can do more because we share some of the same aims: to improve access to health care services, to boost minority participation in the health care workforce, and to eliminate disparities in health outcomes among U.S. population groups.

HRSA’s organizational mission – the one we post on our website – is to improve health and achieve health equity through access to quality services, a skilled health workforce and innovative programs. Given the focus of some of your organizations, that should sound familiar. To meet that mission, we have four goals:

• Improve access to quality health care and services;
• Strengthen the health workforce;
• Build healthy communities; and
• Improve health equity.

A very high priority is to build a health workforce that is trained to provide high-quality, culturally and linguistically appropriate care, using an interprofessional, team approach. We want that workforce to be diverse and more representative of the U.S. population, and we want to reduce disparities in care quality across populations and communities.

We also want to deploy our resources – to the extent possible – in partnership with diverse communities to create, develop, and disseminate innovative community-based health equity solutions, with a particular focus on populations with the greatest health disparities.

And we want to leverage our programs and policies to further integrate services and address the social determinants of health. A lot of our programs incorporate some of that now – wrap-around services, transportation, and child care while Ryan White patients are being seen. From that I think you can see we’re natural partners: we’re all headed in the same direction.

We’re interested in what goes on in the patient exam room, but frankly – as you know – that’s a small intervention. Because of these areas of focus, I’m very glad to be here to explain in greater detail the range of work we do. As I do, I hope you’ll be thinking of ways we can complement each other and pull together to leverage our resources to collectively focus on the task of eliminating health disparities and improving the health of the diverse populations we serve.

Let me briefly give you a snapshot of what HRSA does. We have an $8.2 billion portfolio of 80 different grant programs. Among the programs and activities we support are these:

• Our Maternal and Child Health block grants to states help 6 out of every 10 women who give birth and their infants.
• Our Office of Rural Health Policy is actually the full Department of Health and Human Services’ main repository of expertise on rural health issues. The office works to bolster rural hospitals and coordinate health care among rural coalitions.
• HRSA also funds Poison Control Centers, the National Vaccine Injury Compensation Program, and federal organ procurement and donation systems.

These programs are just part of what we do. Where the interests and aspirations of HRSA and urban universities intersect most strongly are in our health center, Ryan White HIV/AIDS, and health professions programs.

Let me take them one by one, beginning with health centers.

Our health centers deliver primary and preventive care to more than 20 million patients at more than 8,500 service delivery sites around the country. Patients are charged on a sliding scale according to income. About half of all health center sites are in urban areas.

Of the 20 million patients served during 2011 (2011 UDS data):

• More than a quarter (25.2%) were African American and over a third (34.5%) were Hispanic;
• Another 3.4% were Asian and 1.5% were American Indian/Alaska Native.

A week ago I was in Columbus, Ohio – is anyone from OSU here today? – to announce the award of a $900,000 grant to the Columbus Neighborhood Health Center to provide primary care and enabling services to an additional 3,000 patients on Columbus’ South Side. The grant will help combat high levels of diabetes, hypertension, infant mortality and cancer in the area. I know that Ohio State is a Coalition member – I enjoyed my brief stay in your hometown, and was happy to add HRSA’s contribution to the wealth of assets your great university makes available to residents of Central Ohio and the entire state

The Columbus health center grant was part of $129 million in grants we released to create
219 new health center sites nationwide. All of the grants were made possible by the Affordable Care Act, which invests $11 billion in health centers. With last week’s awards, those health centers soon will be able to care for more than 1.25 million new patients across America, and they’ll employ about 5,600 new staff – including health professionals – across those 219 sites.

Most big cities have a health center site, or multiple sites. If your university doesn’t have a working relationship with a local health center, you might consider building one. I remember that I specifically asked the leadership of the Columbus health center about training opportunities.

Certainly, you can refer local residents to health centers for care. With their large minority patient base, health centers are leaders in providing culturally competent care. Many grantees have multiple translators to deliver care in the native language of the patient. Language skills are often critical: one in four health center patients are best served in a language other than English.

Health centers are also great places for medical and nursing school students, and students in behavioral and mental health disciplines to get experience providing community-based care to medically underserved populations. In 2011, nearly 40 percent of health center patients had no health insurance. It doesn’t get much more medically underserved than that.

The Affordable Care Act invests $230 million to certify certain health centers as teaching facilities. The 11 health centers that are currently part of this program are expected to train 300 primary care medical residents in 2013 alone. Most the teaching health center grantees, however, are in rural areas, which is very good for them, since rural areas are chronically short of health care professionals. In large metro areas, we have single teaching health center grantees in New York City and Chicago.

The model itself, though, is one I recommend to you, since health centers can be an important platform for training the primary care workforce and creating more opportunities to prepare nurses, physicians, dentists and others to deliver primary care in community-based settings. We know that physicians trained in health centers are more likely to work in a health center or in an underserved area than those not trained at health centers.

Let me know move on to the Ryan White HIV/AIDS program, another HRSA program with a major impact in urban areas. Ryan White grantees provide top-quality primary medical care, essential pharmaceuticals, and vital support services to more than 500,000 people living with HIV/AIDS – that’s about half the estimated total population in the U.S. living with the disease.

People living with HIV are, on average, poorer than the general population, and Ryan White HIV/AIDS Program clients are poorer still. For them, the Ryan White is the payor of last resort because they are uninsured or have inadequate insurance and cannot cover the costs of care on their own, and because no other source of payment for services, public or private, is available.

About a third of the $2.2 billion in annual Ryan White funds go directly to eligible large metropolitan areas with high rates of HIV/AIDS, and much of the rest of the money – while directed initially to state authorities – eventually is invested in urban areas.

About 7 in 10 of the more than half a million people treated every year through Ryan White-supported programs are minorities. About half of all Ryan White clients are African American, with another 20 percent Hispanic.

And some of them may be your clients. Of the more than 2,100 entities that provided Ryan White services in FY 2008, 370 providers, or 17 percent of the total, were hospital or university-based clinics.

Currently HRSA is orienting our HIV/AIDS work to the goals of President Obama’s National HIV/AIDS Strategy, which he announced two years ago next month. The Strategy has three primary goals:

• Reducing the incidence of HIV;
• Increasing access to care and optimizing health outcomes; and
• Reducing HIV-related health disparities.

On this last goal, HRSA is working with CDC on a five-year project to retain HIV-positive patients in medical care by testing interventions at six HIV clinics serving predominantly minority populations. Early findings have been positive, with overall improvements in clinic attendance by patients.

At the full Department level, HHS’s work on the National Strategy has a strong urban component.

A major element of HHS’s responsibility to implement the National Strategy is its “12 Cities Project,” an effort to support comprehensive HIV/AIDS planning and cross-agency response in 12 communities hit hard by HIV/AIDS: Atlanta, Baltimore, Chicago, Dallas, Houston, Los Angeles, Miami, New York City, Philadelphia, San Francisco, San Juan, and Washington, D.C. These 12 metro areas account for about 44 percent of the total estimated persons living with AIDS in the United States.

So the 12 Cities demonstration concentrates HHS resources from CMS (Medicare and Medicaid pay for 62 percent of all HHS-supported HIV/AIDS care and treatment), HRSA (15 percent through Ryan White), and CDC on these areas, coordinates federal resources and actions across categorical program lines, and scales up effective HIV prevention and treatment strategies.

If you’re from one of those 12 metro areas and want to know more about how your university can get involved, call my office. We’ll put you in touch with the right people both here in Washington and at your local level.

Now let me move on to HRSA’s efforts to expand the diversity of the health professions workforce, which is a topic in which all of our organizations are deeply engaged.

As you know, the USU initiative on urban health, for example, seeks to reduce pervasive health disparities that result, in part, from, as you say, “an insufficient and ethnically imbalanced health workforce.”

Compared to whites, minority populations have less access to health care, receive lower-quality health care, and experience higher rates of chronic disease, higher mortality, and poorer health outcomes. At HRSA, we agree with you that one key strategy we should employ to reverse these trends is to increase the number of minority health professionals.

We agree because evidence suggests that minority health professionals are more likely to serve in areas with a high proportion of uninsured and underrepresented racial and ethnic groups. Greater diversity among health professionals is also associated with improved access to care for racial and ethnic minority patients, greater patient choice and satisfaction, and better patient-clinician communication.

These are issues that some of HRSA’s health professions programs have addressed for many years. For example, our Nursing Workforce Diversity and Scholarships for Disadvantaged Students Programs are specifically designed to increase diversity among health professionals. Morgan State (Md.), Wichita State (Kan.) and Cleveland State (Ohio) (all USU members) are three of many universities that received Scholarships for Disadvantaged Students grants from HRSA last year.

Under President Obama, issues of disparities and health equity are getting far more attention than they did in the past. Last year HHS Secretary Kathleen Sebelius launched a National Partnership for Action to End Health Disparities to improve nationwide coordination of strategies to eliminate health disparities and achieve health equity.

HRSA is a grant-making agency. Our mission is carried out by our grantees all over the country. HRSA, of course, selects grantees through open competitions; then we oversee their work to make sure it carries out the will of Congress and the executive.

So to further the Secretary’s plan, we instituted a new grant policy: since last year, all applicants for almost all of our health professions grants must include in their proposals innovative strategies to develop and retain a diverse and culturally competent workforce. Potential applicants must describe plans to recruit, retain, and graduate students from underrepresented minority groups and students from educationally and economically disadvantaged backgrounds. And they must show that these plans are effective in reaching proposed goals.

In one workforce program in particular, our determined efforts to encourage diversity are trending favorably. In HRSA’s National Health Service Corps, we’re making progress in expanding minority participation.

The Corps now has about 8,700 primary care professionals practicing in medically underserved areas, many of which are in urban areas. They represent a range of disciplines – advanced practice nurses, physicians and dentists, among a larger group. In exchange for their service, clinicians receive federal loan repayments along with a competitive salary.

Nationally, African Americans and Hispanics represent 26 percent of the U.S. population but only about 11 percent of the physician workforce.

In the NHSC, however, African Americans and Hispanics total more than 27 percent of the Corps’ 2,150 physicians: more than 14 percent are African American and 13 percent are Hispanic. So for physicians in the NHSC, African American and Hispanic representation is about equal to their percentage of the U.S. population – and more than double their percentage of the national physician workforce.

And, financially, the NHSC is a great deal for Corps members. Health professionals who work in the very neediest areas can qualify for up to $60,000 in annual loan repayments, and even those who practice in less needy areas get up to $40,000 in loan repayments. Many of your health professions training program can and should be sharing this information with your students.

If your universities have academic medical centers – and I’m told a third of USU members have them – I urge you to recommend the Corps to students and graduates who want to do well and do good at the same time. You can find out more about the benefits of joining the NHSC from the HRSA website at www.hrsa.gov.

Your universities’ interests and aims also coincide with HRSA’s on the importance of collecting reliable workforce data to inform institutional efforts to develop a culturally sensitive, diverse workforce.

And the emphasis you’ve placed on strengthening metrics, disseminating best practices and, importantly, measuring outcomes in your Urban Universities for HEALTH grant from NIH is right in line with HRSA’s trajectory.

You want to build an evidence base for “what works” to develop a health workforce that reduces health disparities, and we, as a Federal agency, must focus like a laser on verifiable performance if we want to retain funding in this difficult budget environment. “What works” is what we’re focused on, and I’m glad to see that your member universities and your partner, the Association of American Medical Colleges, have the same focus in the UU-HEALTH project.

As your work on UU-HEALTH develops, our National Center for Health Workforce Analysis – a creation of the Affordable Care Act – can help you. The Center is headed by Ed Salsburg, formerly of the AAMC, so I imagine many of you know him and his work.

Ed tells me that three reports from the National Center that we hope to release later this year or early in 2013 that will be of interest and relevance to you and your work:

• The first is a report tentatively titled “Diversity in the Health Professions 2012.” The report will include data on more than 30 health professions by race, ethnicity and sex for practitioners and new graduates. It also will include data on faculty diversity for some of the professions.
• The second report is a state-by-state health workforce data base, including data on workforce diversity, something we’ve been working on for some time.
• Finally, the National Center will produce a series of reports that project workforce needs by occupation. First up is a report on physicians, nurse practitioners and physician assistants by clinical area. That will be followed by biennial projections for a wide range of professions beginning in late 2013. We are significantly increasing our efforts to produce regular projections on future supply and demand by health profession.

Before I close, I’d like to discuss the growing recognition – codified in the Affordable Care Act –that team-based health care represents the best path for improving quality care, delivering patient-based care, and keeping costs in check.

During this transformational time, it is, I believe, essential that we engage different key stakeholders – from university faculty to clinicians to students and residents – in a dialogue about how we educate the current and next generation of providers to work in team-based environments.

There is great value in having this conversation across professions and across sectors, so that it impacts both academe and practice. We must make the boundaries between professions and between sectors more porous.

This recognition – while not always easy to execute – is, I think, an essential underpinning to move health and health care from where we are to where we need to go.

To show you how this orientation is resonating at high levels, it’s where HHS Secretary Sebelius sees us going, too. Last year she told the Senate Finance Committee, quote:

“Too often, health care takes place in a series of fragments or episodes. We need to make it possible for entirely new levels of seamlessness, coordination, and cooperation to emerge among the people and the entities that provide health care … over time and in different places.” [end quote]

To achieve the shift that the Secretary and many other public and private sector representatives talk about requires both health professional educators and clinical leaders working together across disciplines to create the training and the care models that achieve this vision.

From the exam room to the board room, health care systems must embrace the changes needed to incorporate this orientation.

Earlier this month I spoke to a meeting in Chicago, convened by the AAMC, on delivering quality care. The meeting invited health professionals from a broad array of disciplines; as a result, multiple perspectives were present at the table seeking to fashion a way forward.

People at the meeting recognized that change really begins “upstream,” with new ways and focus in educating the health workforce with the skills to deliver health care that has quality and safety and their requisite attributes of care coordination and team engagement at the core of safe, high-quality care.

In an effort to do our part to reduce the “fragmented and episodic” care that Secretary Sebelius lamented, HRSA has become deeply involved in efforts across the health care spectrum to push forward the concept of interprofessional education and team practice.

For example, right now we are soliciting applications for the creation of a Coordinating Center for Interprofessional Education and Collaborative Practice. Competition for the $800,000 grant ends July 20. The focus of the Center is to help advance the evolution of the health care delivery system to one that encourages collaborative, team-based practice informed by interprofessional education.

And, illustrative of our work and with other partners on this agency, HRSA and representatives of the Interprofessional Education Consortium in May of last year announced the creation of a set of interprofessional competencies that have been disseminated for use in health professions education and practice. We’ll soon be announcing more activity to drive this agenda forward.

So let me bring this to a close by summarizing the current state of affairs between HRSA and your universities and by pointing the way to closer future relationships:

• To those universities that currently are HRSA grantees, I thank you for working with us to improve minority representation in the health professions, to expand access to quality health care, and to push for greater health equity. And we look forward to continuing those relationships.
• To those of you who are not HRSA grantees, I encourage you to investigate the many ways our work overlaps and consider whether a grantee relationship would further your own efforts. Please visit our website and click on the “Grants” tab at the top of the page. There you’ll see all the funding competitions that are open at the present time. And you can go to “HRSA in Your State” and see the funding streams and programs that you may be able to align with.
• To keep abreast of our workforce research, feel free to stay in touch with Jan Heinrich of the Bureau of Health Professions and Ed Salsburg at the National Center for Health Workforce Analysis. We are always happy to respond to inquiries, and we’d like to complement and support your work on the UU-HEALTH project in whatever way you see fit.
• If you’d like to learn more about HRSA grantees in your community, we have 10 regional offices; go online to find them or call me at my office and we’ll put you in touch with them. Our local grantees aren’t always easy to identify, since they don’t have HRSA in their names. And in many cases, HRSA is only one of several funding sources they count on.
• And you can also call me at my office if you have any questions about HRSA programs or policies or if you want to discuss ways we can all work together more closely as partners to make the U.S. health care system more accessible, more just – and more representative of and response to – all of our people.

Thank you for the invitation to talk with you about HRSA’s focus and how it overlaps with some of your work. I hope I made it clear that we would more than welcome additional opportunities to work together.

Thank you again.