Health Professions Education Programs
Gao ID: GAO-06-55 February 28, 2006For fiscal years 1999 through 2005, the Health Resources and Services Administration (HRSA), an agency within the Department of Health and Human Services (HHS), spent about $2.7 billion to fund the more than 40 health professions education programs authorized under title VII and title VIII of the Public Health Service Act. These programs include those providing grants to institutions, direct assistance to students, and funding for health workforce analyses. Title VII includes programs related to the education of providers, such as primary care physicians. Title VIII includes programs related to nursing education. Most of these programs were last reauthorized in 1998. GAO reviewed changes in funding and in the number of these programs since 1998, HRSA's goals and assessment of the programs, and HRSA's national health professions workforce projections. GAO reviewed relevant laws and agency documents and data, and interviewed HRSA officials and representatives of health professions education associations.
Funding for title VII and title VIII programs increased from about $300 million in fiscal year 1999 to more than $450 million in fiscal year 2005, and the overall number of these programs also increased since reauthorization in 1998. From fiscal years 1999 through 2005, funding for title VII programs rose by about one-fourth, while that for title VIII programs more than doubled. The overall numbers of title VII and title VIII programs administered by HRSA increased from 46 in fiscal year 1998 to 50 in fiscal year 2004. The number of title VII programs remained the same, while the number of title VIII programs increased. HRSA has published performance goals for title VII and title VIII health professions education programs but cannot fully assess the programs' effectiveness because the goals do not apply to all the health professions education programs, and the data for tracking progress are problematic. Recognizing the need for a better means of measuring the results of title VII and title VIII programs, HRSA is developing new performance goals and measures for them. The effectiveness of these efforts will depend upon the agency's ability to collect complete and timely data to assess progress toward these new goals. HRSA has published few recent national workforce projections. In the past decade, the agency has published national supply and demand projections for the nurse and pharmacist workforces but no national projections for the physician and dentist workforces. Yet regular reassessment of future health workforce supply and demand is key to setting policies as the nation's health care needs change.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Kathleen M. King Team: Government Accountability Office: Health Care Phone: (312) 220-7767GAO-06-55, Health Professions Education Programs
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
February 2006:
Health Professions Education Programs:
Action Still Needed to Measure Impact:
GAO-06-55:
GAO Highlights:
Highlights of GAO-06-55, a report to congressional requesters:
Why GAO Did This Study:
For fiscal years 1999 through 2005, the Health Resources and Services
Administration (HRSA), an agency within the Department of Health and
Human Services (HHS), spent about $2.7 billion to fund the more than 40
health professions education programs authorized under title VII and
title VIII of the Public Health Service Act. These programs include
those providing grants to institutions, direct assistance to students,
and funding for health workforce analyses. Title VII includes programs
related to the education of providers, such as primary care physicians.
Title VIII includes programs related to nursing education. Most of
these programs were last reauthorized in 1998. GAO reviewed changes in
funding and in the number of these programs since 1998, HRSA‘s goals
and assessment of the programs, and HRSA‘s national health professions
workforce projections.
GAO reviewed relevant laws and agency documents and data, and
interviewed HRSA officials and representatives of health professions
education associations.
What GAO Found:
Funding for title VII and title VIII programs increased from about $300
million in fiscal year 1999 to more than $450 million in fiscal year
2005, and the overall number of these programs also increased since
reauthorization in 1998. From fiscal years 1999 through 2005, funding
for title VII programs rose by about one-fourth, while that for title
VIII programs more than doubled. The overall numbers of title VII and
title VIII programs administered by HRSA increased from 46 in fiscal
year 1998 to 50 in fiscal year 2004. The number of title VII programs
remained the same, while the number of title VIII programs increased.
HRSA has published performance goals for title VII and title VIII
health professions education programs but cannot fully assess the
programs‘ effectiveness because the goals do not apply to all the
health professions education programs, and the data for tracking
progress are problematic. Recognizing the need for a better means of
measuring the results of title VII and title VIII programs, HRSA is
developing new performance goals and measures for them. The
effectiveness of these efforts will depend upon the agency‘s ability to
collect complete and timely data to assess progress toward these new
goals.
HRSA has published few recent national workforce projections. In the
past decade, the agency has published national supply and demand
projections for the nurse and pharmacist workforces but no national
projections for the physician and dentist workforces. Yet regular
reassessment of future health workforce supply and demand is key to
setting policies as the nation‘s health care needs change.
Funding for Title VII and Title VIII Programs, Fiscal Years 1999–2005:
[See PDF for image]
[End of figure]
What GAO Recommends:
GAO recommends that HRSA develop a strategy and time frames to
regularly update and publish national health professions workforce
projections. HRSA agreed with GAO‘s conclusion that updated workforce
supply and demand projections are vital for informed decision making
about health professions programs.
www.gao.gov/cgi-bin/getrpt?GAO-06-55.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Leslie G. Aronovitz at
(312) 220-7600 or aronovitzl@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Funding for and Overall Number of Title VII and Title VIII Health
Professions Education Programs Increased:
HRSA's Goals Do Not Apply to All Title VII and Title VIII Programs, and
Data Are Problematic, but Agency Is Developing Alternatives:
HRSA Has Published Few National Workforce Projections in Recent Years:
Conclusions:
Recommendation for Executive Action:
Agency Comments:
Appendix I: Examples of Additional Sources of Federal Funding for
Health Professions Education:
Appendix II: Title VII and Title VIII Clusters and Programs, Fiscal
Year 2004:
Appendix III: Additional Performance Goals and Targets for Health
Professions and Nursing Education Programs:
Appendix IV: Comments from the Health Resources and Services
Administration:
Appendix V: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Title VII and Title VIII Programs in Existence Before, and
Organized into Clusters After, 1998 Reauthorization:
Table 2: Performance Goals and Targets for the Health Professions and
Nursing Education and Training Programs Funded under Title VII and
Title VIII:
Table 3: HRSA's Most Recent Reports Containing National Workforce
Supply and Demand Projections for Physicians, Dentists, Nurses, and
Pharmacists:
Table 4: Examples of Federal Funding Sources, besides Title VII and
Title VIII Programs, for Postsecondary Education and Training
Specifically Targeted for Health Professions:
Table 5: Examples of Federal Funding Sources for General Postsecondary
Education and Training Including, but Not Exclusive to, Health
Professions:
Figures:
Figure 1: Funding for Title VII and Title VIII Health Professions
Education Programs, Fiscal Years 1999-2005:
Figure 2: Funding for Title VII Health Professions Education Programs,
Fiscal Years 1999-2005:
Figure 3: Title VII Funding for New and Competitive Continuation Grants
and for Noncompetitive Continuations, Fiscal Years 1999-2004:
Figure 4: Title VIII Funding for New and Competitive Continuation
Grants and for Noncompetitive Continuations, Fiscal Years 1999-2004:
Abbreviations:
AMA: American Medical Association:
CMS: Centers for Medicare & Medicaid Services:
COGME: Council on Graduate Medical Education:
GPRA: Government Performance and Results Act:
HHS: Department of Health and Human Services:
HRSA: Health Resources and Services Administration:
NELRP: Nursing Education Loan Repayment Program:
OMB: Office of Management and Budget:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
February 28, 2006:
The Honorable Michael B. Enzi:
Chairman:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
The Honorable Judd Gregg:
United States Senate:
An appropriate supply, mix, and distribution of health professionals--
today and in the future--is vital to ensuring that all Americans have
adequate access to health care. For fiscal years 1999 through 2005, the
Health Resources and Services Administration (HRSA), an agency within
the Department of Health and Human Services (HHS), spent about $2.7
billion to fund health professions education programs authorized under
title VII and title VIII of the Public Health Service Act. Administered
by HRSA, the many title VII and title VIII programs include those
providing grants to institutions training health professionals; direct
assistance to students in the form of scholarships, loans, or repayment
of educational loans; and funding for health workforce analyses. Title
VII programs include those related to the education of providers, such
as primary care physicians, physician assistants, general dentists,
pediatric dentists, and allied health practitioners; [Footnote 1]
programs related to education of the public health workforce; and
programs related to the analysis of health workforce issues, such as
estimates of supply and demand. Title VIII programs include those
related to basic and advanced nursing education programs, which are
designed to increase nursing workforce diversity, promote career
advancement, and improve retention. Most of the health professions
education programs were last reauthorized in 1998. [Footnote 2]
For more than a decade, our reviews of title VII and title VIII
programs have raised questions about HRSA's ability to assess the
programs' effectiveness. [Footnote 3] For example, before the 1998
reauthorization, we noted that the programs' effectiveness would remain
difficult to measure as long as the health professions education
programs were authorized to support a broad range of health care
objectives. [Footnote 4] For fiscal years 2002 through 2005, HRSA's
budget justifications have questioned the need for continued federal
support of many of these health professions education programs, and a
review by the Office of Management and Budget (OMB) for the fiscal year
2004 budget questioned their effectiveness. [Footnote 5]
In preparation for congressional consideration of the next
reauthorization of title VII and title VIII programs, you asked us to
review the programs, including changes after the 1998 reauthorization.
In this report, we provide information on (1) changes in funding and in
the number of title VII and title VIII health professions education
programs since the 1998 reauthorization; (2) HRSA's stated goals for
the programs and the agency's efforts to measure progress toward
meeting them; and (3) national health professions workforce projections
developed by HRSA.
To conduct our work, we analyzed pertinent agency documents and
interviewed HRSA officials. We also analyzed data from HRSA's grants
management system, reviewed relevant laws, and interviewed
representatives of the Health Professions and Nursing Education
Coalition and the Federation of Associations of Schools of the Health
Professions. We examined funding for title VII and title VIII programs
for fiscal years 1999 through 2005. [Footnote 6] To analyze the number
of title VII and title VIII programs HRSA administered, we counted (1)
programs that awarded funds competitively through grants or cooperative
agreements [Footnote 7] and that announced funding availability
separately or had a separate selection panel [Footnote 8] and (2)
programs providing direct assistance, such as student loans to
individuals, regardless of whether the loan program was using current
appropriations. [Footnote 9]
For information on HRSA's stated goals and measures of performance in
meeting these goals and on the agency's plans for the future, we
reviewed HRSA's annual performance plans, budget justifications, and
strategic planning documents, and we attended HRSA's Bureau of Health
Professions' first all-grantee conference in June 2005. Regarding the
workforce supply and demand projections HRSA developed, we focused on
the most recent projected estimates of national supply and demand for
physicians, dentists, nurses, and pharmacists. [Footnote 10] We also
reviewed physician workforce reports published by the Council on
Graduate Medical Education (COGME), [Footnote 11] which based its
physician workforce projections on HRSA-developed methodologies. We
assessed the reliability of grants and other funding data used in our
review by discussing with agency officials validation and internal
controls for HRSA grants data and comparing the aggregate data with
similar aggregate data from other sources. We determined that the
funding data were sufficiently reliable for our purposes. Although we
identified problems with the reliability of other agency data, such as
those used to measure program performance, we included them for
illustrative purposes. We conducted our work in accordance with
generally accepted government auditing standards from June 2004 through
January 2006.
Results in Brief:
After reauthorization in 1998, overall funding for title VII and title
VIII programs increased from about $300 million in fiscal year 1999 to
more than $450 million in fiscal year 2005, and the overall number of
these programs also increased. From fiscal years 1999 through 2005,
funding for title VII programs rose by about one-fourth, while that for
title VIII programs more than doubled. The overall number of title VII
and title VIII programs administered by HRSA increased from 46 in
fiscal year 1998 to 50 in fiscal year 2004; this overall increase was
due to an increase in the number of title VIII programs.
HRSA has published performance goals for the title VII and title VIII
health professions education programs, but these goals do not apply to
all the health professions education programs, and the data for
tracking progress are problematic. These performance goals, prepared as
part of HHS's annual reporting under the Government Performance and
Results Act (GPRA) process, [Footnote 12] are spelled out in HRSA's
fiscal year 2006 budget justification. In measuring progress toward
meeting these goals, the agency relies on data we and others have found
to be problematic. For example, although one performance goal is to
increase the proportion of health professionals supported by title VII
and title VIII programs who enter practice in underserved areas, HRSA
does not have complete data that track the practice locations of these
health professionals. Recognizing the need for a better means of
measuring the results of title VII and title VIII programs, HRSA has
since 2002 been developing a new strategic plan for the health
professions education programs, which includes program goals and
information on how the agency proposes to measure performance.
Although HRSA is responsible for providing health professions workforce
information to policymakers, HRSA has in the past decade published
national supply and demand projections for the nurse and pharmacist
workforces but no national projections for the physician and dentist
workforces. According to HRSA officials, the agency is preparing a
report to Congress that will provide information about the health
workforce for 30 health professions, including national supply and
demand projections for physicians, pharmacists, and nurses. Estimating
future health workforce supply and demand on a regular basis is
important because estimates need to be revised periodically to reflect
changes in the health care environment. In 2005, an HHS advisory
council strongly recommended that the nation develop systems to track
physician workforce supply, demand, and distribution and undertake a
comprehensive reassessment within the following 4 years to guide future
decisions on medical education capacity.
We are recommending that HRSA develop a strategy and time frames to
regularly update and publish national health professions workforce
projections. In commenting on a draft of this report, HRSA agreed with
our conclusion that updated workforce supply and demand projections are
vital for informed decision making about health professions programs.
Background:
In response to a shortage of health care providers, Congress amended
title VII of the Public Health Service Act in 1963 [Footnote 13] and
established title VIII in 1964. [Footnote 14] These titles have been
amended over time and now authorize funding for a variety of programs
with diverse objectives. As noted in the Senate report accompanying the
1998 reauthorization legislation, by the mid-1970s, two specific areas
of need had emerged: overall shortages in rural and inner-city
communities and an imbalance in the supply of primary care providers as
compared with specialists. Subsequent revisions to title VII focused on
encouraging health care workers to practice in underserved areas,
increasing the number of primary care providers, increasing enrollment
of minority and disadvantaged students, and developing faculty.
Revisions to title VIII focused on training advanced practice nurses;
enrolling disadvantaged students; strengthening basic nurse education
and practice; and, most recently, fostering nurse retention by
promoting career development and improving patient care delivery
systems.
The 1998 reauthorization resulted in the grouping of the more than 40
programs in existence at the time into seven clusters. The Senate
report accompanying the reauthorization legislation stated that "the
bureaucracy required to administer the existing programs should be
simplified and reduced" and also stated the purpose for each cluster
(see table 1). [Footnote 15] According to the Senate report, one
purpose of five of the seven clusters was to provide administrative
flexibility and simplification. The report also stated that one
objective of the reauthorization was to allow for "better targeting of
limited resources to address national health workforce training and
distribution deficits."
Table 1: Title VII and Title VIII Programs in Existence Before, and
Organized into Clusters After, 1998 Reauthorization:
Title VII:
Programs in place before 1998 reauthorization[A]:
* Health Education Assistance Loans;
* Health Professions Student Loans;
* Loans for Disadvantaged Students;
* Primary Care Loans;
Cluster name[B]: Student Loans;
Cluster purpose[C]: Continue (1) loan programs that do not require
federal appropriations or guarantee the availability of loans for
health professions students and (2) a loan program for the
disadvantaged[D].
Programs in place before 1998 reauthorization[A]:
* Centers of Excellence;
* Exceptional Financial Need Scholarships;
* Faculty Loan Repayment Program;
* Financial Assistance for Disadvantaged Health Professions Students;
* Health Careers Opportunity Program;
* Minority Faculty Fellowship Program;
* Cooperative Agreements for Partnerships for Health Professions
Education;
* Scholarships for Disadvantaged Students Program;
Cluster name[B]: Health Professions Training for Diversity;
Cluster purpose[C]: Provide for the training of minority and
disadvantaged health professionals to improve health care access in
underserved areas and to improve representation in the health
professions[D].
Programs in place before 1998 reauthorization[A]:
* Departments of Family Medicine;
* Faculty Development in Family Medicine;
* Faculty Development in General Internal Medicine and General
Pediatrics;
* Graduate Training in Family Medicine;
* Physician Assistants Training;
* Pre- doctoral Training in Family Medicine;
* Residencies and Advanced Education in the Practice of General
Dentistry;
* Residency Training in General Internal Medicine and General
Pediatrics;
Cluster name[B]: Training in Family Medicine, General Internal
Medicine, General Pediatrics, Physician Assistants, General Dentistry,
and Pediatric Dentistry;
Cluster purpose[C]: Provide for the training of family physicians,
general internists, general pediatricians, physician assistants,
general dentists, and pediatric dentists to improve access to and
quality of health care in underserved areas and to assure outside input
regarding primary care training programs[D].
Programs in place before 1998 reauthorization[A]:
* Allied Health Project Grants;
* Basic/Core Area Health Education Centers;
* Chiropractic Demonstration Project Grants;
* Geriatric Education Centers;
* Geriatric Fellowships;
* Health Education and Training Centers;
* Podiatric Primary Care Residency Training;
* Grants for Interdisciplinary Training for Health Care for Rural
Areas;
* State-Supported Model Area Health Education Centers;
Cluster name[B]: Interdisciplinary, Community-Based Linkages;
Cluster purpose[C]: Provide support for (1) training centers remote
from health professions schools to improve and maintain the
distribution of health providers in underserved areas, (2) geriatric
education and geriatric faculty fellowships, and (3) interdisciplinary
training projects[D].
Programs in place before 1998 reauthorization[A]:
* Center for Health Workforce;
Cluster name[B]: Health Professions Workforce Information and Analysis;
Cluster purpose[C]: Provide for (1) the development of information on
the health professions workforce and the analysis of workforce-related
issues, (2) the development of necessary information for decision
making regarding future directions in health professions and nursing
programs, and (3) continued analysis of issues affecting graduate
medical education.
Programs in place before 1998 reauthorization[A]:
* Cooperative Agreement to Support Innovative Projects Relating to
Public Health Education and Services[E];
* Dental Public Health Specialty Training Grants;
* Health Administration Traineeships and Special Projects;
* Residency Training in Preventive Medicine;
* Public Health Special Project Grants;
* Public Health Traineeships to Schools of Public Health and Other
Public and Nonprofit Private Institutions;
Cluster name[B]: Public Health Workforce;
Cluster purpose[C]: Provide for an increase in the number of
individuals in the public health workforce and enhance the quality of
this workforce.
Programs in place before 1998 reauthorization[A]:
* Title VIII.
Programs in place before 1998 reauthorization[A]:
* Advanced Nurse Education;
* Nurse Anesthetist Program: Program Grants;
* Nurse Anesthetist Program: Fellowships;
* Nurse Anesthetist Program: Traineeships;
* Nurse Practitioner/Nurse Midwifery;
* Nursing Education Loan Repayment Program;
* Nursing Education Opportunities for Individuals from Disadvantaged
Backgrounds;
* Nursing Special Projects;
* Nursing Student Loans[F];
* Professional Nurse Traineeships;
Cluster name[B]: Nursing Workforce Development;
Cluster purpose[C]: Provide for the training of basic and advanced-
degree nurses to improve access to and quality of health care in
underserved medical and public health areas[D].
Source: GAO analysis.
[A] Include (1) programs that awarded funds competitively through
grants or cooperative agreements and that announced funding
availability separately and (2) programs providing direct assistance,
such as student loans to individuals, regardless of whether the loan
program was using current appropriations. Table does not include two
advisory groups, COGME and the National Advisory Council on Nurse
Education and Practice, operating in fiscal year 1998. Names for grant
and cooperative agreement programs reflect those used in the Federal
Register or other program announcements.
[B] Cluster names reflect headings of parts and subparts of title VII
and of title VIII of the Public Health Service Act, as amended by Pub.
L. No. 105-392, and in some cases differ slightly from those in Senate
Report No. 105-220.
[C]Cluster purposes as provided in Senate Report No. 105-220.
[D] Another purpose for this cluster, cited in Senate Report No. 105-
220, was to provide administrative flexibility and simplification.
[E] This program includes a cooperative agreement with the Association
of Schools of Public Health (ASPH) to provide information to, and
coordinate with, the schools of public health that inquire about grant
funding opportunities under this program. HRSA has discretion to
determine whether projects are funded.
[F] Senate Report No. 105-220 included the Nursing Student Loans
program in the student loans cluster. Because this program is
authorized under title VIII, however, we included it in the nursing
workforce development cluster.
[End of table]
The programs within each cluster are tied to similar purposes. For
example, one cluster--Health Professions Training for Diversity--
includes programs targeting minorities or disadvantaged individuals.
Another cluster--Health Professions Workforce Information and Analysis--
includes work conducted by and for HRSA on health workforce issues,
including HRSA's National Center for Health Workforce Analysis, which
received less than $1 million per year in fiscal years 1999 through
2005. [Footnote 16] Title VII also authorizes COGME, which provides
advice and recommendations to the Secretary of HHS and Congress on the
supply and distribution of physicians in the United States and other
issues. [Footnote 17] According to COGME's charter, "the Council
periodically shall prepare and transmit a report, to the Secretary and
to the Committee on Health, Education, Labor and Pensions (formerly the
Committee on Labor and Human Resources) of the Senate, and the
Committee on Commerce (formerly the Committee on Energy and Commerce)
of the House of Representatives" with respect to supply and
distribution of physicians in the United States and other issues.
For fiscal years 2002 through 2005, HRSA's budget justifications
proposed reducing overall funding for the health professions education
programs--reducing or eliminating funding for most of the title VII
clusters while requesting increased funding for the title VIII nursing
cluster. The agency's budget justification for fiscal year 2005 cited a
number of reasons for reducing or eliminating federal funding for many
title VII programs. [Footnote 18] These reasons included the
availability of alternative sources of funding, such as larger federal
programs and state, local, and private programs. For example, when
discussing the reason for not requesting funds for geriatric education
and training under title VII, HRSA's fiscal year 2005 budget
justification stated that recipients of geriatric education grants can
secure support from other sources, including other federal sources. As
part of the Medicare program, HHS's Centers for Medicare & Medicaid
Services (CMS) makes payments for graduate medical education totaling
billions of dollars each year--nearly $8 billion in fiscal year 2004.
[Footnote 19] The Department of Veterans Affairs and the Department of
Labor administer additional programs that support health professions
education. (See app. I for information on other federal sources of
funding for health professions education.)
Funding for and Overall Number of Title VII and Title VIII Health
Professions Education Programs Increased:
After the 1998 reauthorization, overall funding for title VII and title
VIII programs generally increased, as did the total number of programs.
From fiscal years 1999 through 2005, overall funding for these programs
rose by 48 percent, from about $304 million to slightly more than $450
million. The overall number of title VII and title VIII programs
administered by HRSA also increased, from 46 programs before
reauthorization to 50 programs in fiscal year 2004, because of an
increase in the number of title VIII programs. The allocation of
funding for these programs is affected by factors such as statutory
formulas and commitments of future funding to grant recipients.
Over the period from fiscal years 1999 through 2005, funding for both
title VII and title VIII programs increased (see fig. 1). Title VII
funding increased from about $236 million to about $300 million, or 27
percent, and title VIII funding increased from about $68 million to
about $151 million, or 122 percent.
Figure 1: Funding for Title VII and Title VIII Health Professions
Education Programs, Fiscal Years 1999-2005:
[See PDF for image]
Note: Graph excludes student loan programs. The Health Education
Assistance Loans program was not authorized to guarantee new loans to
student borrowers during this period. The remaining loan programs have
received no new federal funds since fiscal year 1998.
[End of figure]
Among title VII's five program clusters--those other than the cluster
for student loans [Footnote 20]--the proportion of funding allocated to
each cluster changed little from fiscal year 1999 through 2005.
Throughout this period, one of the clusters--Health Professions
Training for Diversity--received the largest share (around 39 percent
annually) of title VII funding (see fig. 2).
Figure 2: Funding for Title VII Health Professions Education Programs,
Fiscal Years 1999-2005:
[See PDF for image]
Note: Graph excludes student loan programs. The Health Education
Assistance Loans program was not authorized to guarantee new loans to
student borrowers during this period. The remaining loan programs have
received no new federal funds since fiscal year 1998.
[End of figure]
Although the Senate report accompanying the 1998 reauthorization
legislation indicated that one of the purposes of five of the seven
clusters was to provide administrative flexibility and simplification,
the 1998 reauthorization may not have had this effect. The overall
number of title VII and title VIII programs administered by HRSA
increased. The number of title VII programs HRSA administered (36) was
the same in fiscal year 1998 before reauthorization as in fiscal year
2004. Over the same period, the number of title VIII programs HRSA
administered increased from 10 to 14. [Footnote 21] (App. II lists
programs that HRSA administered in 2004.) [Footnote 22] Regarding
flexibility, several factors-- including provisions of the Public
Health Service Act that specify how some program funds must be
allocated and commitments of future funding to grant recipients--affect
how HRSA allocates available funds among and within the health
professions programs.
* Statutory formulas for allocating funding: The Public Health Service
Act, as amended by the 1998 reauthorization, specifies how funds are to
be allocated among the institutions and individuals that apply for and
receive certain health professions education program grant awards. For
example, the act authorizes funding for grants within the cluster for
training in family medicine, general internal medicine, general
pediatrics, physician assistants, general dentistry, and pediatric
dentistry by allocating it among programs within various disciplines
according to a specified formula. [Footnote 23] Another example is the
formula for allocating grant funding among recipients of one of the
programs-- Centers of Excellence--within the Health Professions
Training for Diversity cluster. This program assists schools in
supporting health professions education for underrepresented
minorities. The Public Health Service Act specifies formulas for
allocating funding among (1) centers of excellence at certain
historically black colleges and universities, (2) Hispanic centers of
excellence, (3) Native American centers of excellence, and (4) centers
of excellence at other institutions. [Footnote 24]
* Commitments of future funding to noncompetitive continuations of
existing grants: There are three types of health professions education
grant awards: (1) new grants, which are awarded to institutions that do
not have a current grant under a given program for a particular
purpose; (2) noncompetitive continuations of existing grants, which
provide funding for the second and subsequent years of projects
approved for several years, such as for the second and third years of a
3-year project period; and (3) competitive continuations, which are
awarded competitively to current grantees that have applied for
additional funding for subsequent years. According to a HRSA official
responsible for grants management, annual appropriations are applied to
noncompetitive continuations of existing grants first; the remaining
grant program funds are available for new and competitive continuation
grant awards. In fiscal year 2004, for example, the share of funds
committed to noncompetitive continuations amounted to about 75 percent
of title VII grant funding, leaving about 25 percent for new and
competitive continuation grants (see fig. 3). From fiscal years 1999
through 2004, the proportion of the funds available for new and
competitive continuation grants ranged from a high of about 41 percent
in fiscal year 1999 to a low of about 25 percent in fiscal year 2004.
Figure 3: Title VII Funding for New and Competitive Continuation Grants
and for Noncompetitive Continuations, Fiscal Years 1999-2004:
[See PDF for image]
[End of figure]
The share of title VIII grant funding awarded to noncompetitive
continuations was smaller (approximately 48 percent) in fiscal year
2004 than that of title VII, leaving about 52 percent of title VIII
funds available for new and competitive continuation grants (see fig.
4). From fiscal years 1999 through 2004, the proportion of the title
VIII grant funds available for new and competitive continuation grants
ranged from a high of about 59 percent to a low of about 52 percent.
Figure 4: Title VIII Funding for New and Competitive Continuation
Grants and for Noncompetitive Continuations, Fiscal Years 1999-2004:
[See PDF for image]
[End of figure]
HRSA's Goals Do Not Apply to All Title VII and Title VIII Programs, and
Data Are Problematic, but Agency Is Developing Alternatives:
HRSA has stated goals but they are not comprehensive, and data for
tracking progress toward meeting them are problematic. Recognizing
these shortcomings, HRSA is developing new performance goals and
measures. The effectiveness of these efforts will depend on the
agency's ability to collect complete and timely data that it can use to
assess its success in meeting these new goals.
HRSA's Goals Are Not Comprehensive, and Data to Assess Performance Are
Problematic:
Although HRSA has published program goals and performance measures for
the health professions and nursing education and training programs,
these goals are not comprehensive, in that they cannot be used to
assess the performance of all title VII and title VIII programs. Set
forth in the budget justification for fiscal year 2006 (see table 2 and
app. III), the current goals and performance measures were prepared as
part of HHS's annual reporting under the GPRA process. [Footnote 25]
For example, one published performance goal is to increase the
proportion of health professionals completing title VII-and title VIII-
supported health professions education programs who are
underrepresented minorities or from disadvantaged backgrounds. The
budget justification also lists a long-term target for this goal of 50
percent by the year 2010 and targets for a number of interim years,
such as 43 percent by 2005 and 44 percent by 2006. HRSA officials
stated that the agency's published goals and measures cover only a
subset of title VII and title VIII programs; they do not, for example,
apply directly to programs designed to develop curriculums or to
recruit and retain faculty.
Table 2: Performance Goals and Targets for the Health Professions and
Nursing Education and Training Programs Funded under Title VII and
Title VIII:
GPRA performance goals: Increase the proportion of health professionals
graduating from or completing title VII-and title VIII-supported health
professions education programs who are underrepresented minorities or
from disadvantaged backgrounds;
Long-term and interim targets:
* 50% in 2010;
* 44% in 2006[B];
* 43% in 2005[B];
* 40% in 2004[B];
Available data for year[A]: 42% for 2001 (baseline)[C].
GPRA performance goals: Increase the proportion of persons in the
United States who have a specific source of ongoing care;
Long-term and interim targets:
* 96% in 2010;
Available data for year[A]: 87% in 1998 (baseline); 88% in 2003
(estimate).
GPRA performance goals: Increase the proportion of health professionals
trained in programs supported by titles VII and VIII who are serving in
medically underserved communities;
Long-term and interim targets:
* 40% in 2010;
Available data for year[A]: Average, 19% for 1999-2001 (baseline)[D].
GPRA performance goals: Increase the proportion of trainees in programs
supported by titles VII and VIII who are training in medically
underserved communities;
Long-term and interim targets:
* 54% in 2006[B];
* 53% in 2005[B];
* 30% in 2004[B];
Available data for year[A]: Average, 52% for 1999-2001 (baseline)[D].
GPRA performance goals: Increase the proportion of health professionals
in programs supported by titles VII and VIII programs who enter
practice in underserved areas;
Long-term and interim targets:
* 21% in 2006[B];
* 20% in 2005[B];
* 30% in 2004[B];
Available data for year[A]: Average, 19% for 1999-2001 (baseline)[D].
Source: Department of Health and Human Services, Health Resources and
Services Administration, Fiscal Year 2006 Justification of Estimates
for Appropriations Committees (Washington, D.C.: n.d.)
Note: All years are fiscal years.
[A] According to HRSA officials, HRSA has historically counted
graduating students as belonging to the year in which their institution
began receiving funding under a specific grant, not to the year in
which the students graduated. For example, according to HRSA officials,
data listed in the table as the baseline for 2001 pertain to grants
awarded in 2001, although the data were collected in 2003.
[B] The target for fiscal year 2004 was set before baseline data were
available. Fiscal year 2005 and 2006 targets were adjusted to reflect
the baseline.
[C] The baseline estimate is a partial one based on data submissions
for fiscal year 2001.
[D] Grantees in programs not designed to increase health professionals
in underserved areas are not required to submit these data. HRSA's
fiscal year 2006 budget justification indicates that the Bureau of
Health Professions within HRSA intends to propose an alternative
measure after work on a new strategic plan has been completed.
[End of table]
According to HRSA officials, a number of HRSA's previous performance
goals were deleted, and others added, in response to an OMB assessment
of title VII and title VIII programs for the fiscal year 2004 budget.
In its review, OMB noted a lack of consensus among various parties
regarding the purpose of the health professions programs, stating, "The
Administration has tended to focus on diversity and distribution [of
health professionals]. Congressional committees often focus on the
program as a means of helping rural areas. Advocates also emphasize the
financial vulnerability of funded institutions." Further, OMB found
little evidence that HRSA used performance data to adjust program
priorities, to allocate resources, or to take other management actions.
In reporting on progress toward meeting its published goals, HRSA
relies in part on grantees' self-reported data, which HRSA acknowledges
are problematic. The agency requires grantees to submit an annual
progress report on accomplishments and movement toward achieving the
objectives described in the original grant agreement. [Footnote 26] For
example, some title VII and title VIII grantee institutions are
required to determine the proportion of their graduates who go on to
practice in certain areas, such as medically underserved communities.
HRSA officials stated, however, that obtaining data on where graduates
go after leaving training programs is not easy. For example, according
to the officials, grantees rely on their graduates to voluntarily
provide practice location information, and some do not do so. HRSA
officials also said that some grantees do not provide information
because of concerns related to state privacy laws.
Problems with HRSA's data to measure progress toward meeting its stated
goals are longstanding. For example, in 1997, we reported that data
provided to HRSA by grantees about graduates placed in medically
underserved communities were not necessarily complete or comparable
among schools, and the agency had not established a way to validate the
data provided. [Footnote 27] Five years later, these problems remained.
In 2002, an evaluation of grantees' data collection processes prepared
for HRSA found that 56 percent of grantees collected and submitted data
on the number of their graduates who were employed in medically
underserved communities in fiscal year 2000. [Footnote 28] Although
almost all the grantees that were not collecting these data reported
that they planned to do so in the future, a few reported that they had
no plans to do so because they lacked the staff, their students were
not yet employed, or their program was too new. Of grantees able to
report the information, 36 percent relied in part on their former
students to "self-report" whether they were employed in a medically
underserved community. The 2002 evaluation also reported that grantees
had difficulties understanding or interpreting the definition of
"medically underserved community" and recommended that HRSA clarify the
term in its instructions to grantees. As a result, HRSA could not be
sure that the self-reported data followed consistent criteria, making
the results unreliable.
HRSA Is Developing New Goals and Performance Measures:
Since fall 2002, HRSA has been developing a new strategic plan that
includes goals for title VII and title VIII programs and a description
of how the agency proposes to measure performance. The HRSA official
overseeing this effort noted that reviews by both GAO and OMB made it
clear that HRSA needed to come up with an effective means of measuring
the results of title VII and title VIII programs and communicating
these results to the public. According to HRSA, implementing the new
strategic plan will enable the agency to " better . . . capture the
accomplishments of title VII's and title VIII's diverse portfolio of
programs." HRSA released a draft of its new strategic plan and its
proposed performance measures during a June 2005 all-grantee conference
attended by title VII and title VIII grant recipients. According to
officials in HRSA's Bureau of Health Professions, a primary purpose of
the conference was to introduce the draft of the newly revised
strategic plan and proposed performance measures to grantees and
receive feedback as to whether the proposed revised measures were
practicable. The plan contained 118 proposed program measures (specific
performance measures for each title VII and title VIII program); 17
proposed core measures (performance measures common to a number of
health professions programs with similar goals); and 14 national
measures (national indicators sensitive to access to primary care, such
as the immunization rate among children 19-35 months old or mammography
rates among women 40 years old or older). [Footnote 29]
Once HRSA has finalized the updated goals and performance measures,
identifying and obtaining the necessary data will be key. The quality,
completeness, and timeliness of the data used to calculate baseline
values, as well as to measure actual performance and track the progress
the programs are making in meeting their goals, will be critical.
Without comprehensive goals, performance measures, and data, the agency
will be unable to target federal resources to the most effective
programs.
As of October 2005, a performance measurement working group in HRSA had
begun to catalog the data needed to implement the proposed performance
measures; to reconcile these needs with the data HRSA currently
collects from its grantees; and, according to the group's lead
official, to recommend improvements to the agency's grantee data
collection and monitoring system. HRSA officials said that their
schedule called for finalizing and testing the new measures, developing
forms for collecting the data, and updating the data collection and
monitoring system by October 2006. [Footnote 30] According to agency
officials, the new approach would improve the quality, timeliness, and
relevance of the agency's performance data.
HRSA Has Published Few National Workforce Projections in Recent Years:
One of HRSA's tasks is to supply information to policymakers on a broad
range of health workforce issues, including forecasts of supply and
demand for physicians, dentists, nurses, and pharmacists. The agency
has, however, published few recent national health professions
workforce projections. For example, its projections for the physician
and dentist workforces are more than a decade old. Yet regular
reassessment of health workforce supply and demand is key to setting
policies as health care needs change.
HRSA Has Not Regularly Published National Health Professions Workforce
Projections:
HRSA's fiscal year 2006 budget justification states that a goal of the
Health Professions Workforce Information and Analysis cluster is to
"provide health workforce information and analyses to national, state,
and local policymakers and researchers on a broad range of issues, such
as shortages of registered nurses, shortages of pharmacists, and the
distribution of health care workers in underserved areas." [Footnote
31] Although HRSA maintains a variety of indicators and statistics on
the health care workforce, in the past decade the agency has published
no national supply and demand projections for the physician or dentist
workforces. [Footnote 32] The most recent HRSA national nursing
workforce projections were published in 2002, and the latest HRSA
report containing national pharmacist workforce projections was
published in 2000. The agency's most recent national physician and
dentist workforce projections were published in 1991. Table 3
summarizes HRSA's latest publications containing national workforce
projections for physicians, dentists, nurses, and pharmacists.
Table 3: HRSA's Most Recent Reports Containing National Workforce
Supply and Demand Projections for Physicians, Dentists, Nurses, and
Pharmacists:
Health profession: Physicians;
Latest workforce projections published by HRSA: Health Personnel in the
United States: Eighth Report to Congress (1991);
Discussion of models and data used to make projections: HRSA developed
physician supply and demand models. HRSA's current supply model uses
data from sources such as the American Medical Association (AMA)
Physician Masterfile[A] to project national estimates of physician
supply by 36 medical specialties through the year 2020. HRSA's current
physician demand model uses Census Bureau population projections, plus
data from sources such as the National Ambulatory Medical Care
Survey[B] and the Nationwide Inpatient Sample,[C] to project demand for
physicians in 18 medical specialties to the year 2020.
Health profession: Dentists;
Latest workforce projections published by HRSA: Health Personnel in the
United States: Eighth Report to Congress (1991);
Discussion of models and data used to make projections: According to
HRSA officials, the supply and demand models for dentists are out of
date, and HRSA plans to update them. HRSA has a cooperative agreement
with the American Dental Association to develop dentist supply and
demand estimates.
Health profession: Nurses;
Latest workforce projections published by HRSA: Projected Supply,
Demand, and Shortages of Registered Nurses: 2002-2020 (2002);
Discussion of models and data used to make projections: HRSA collects
data on the nurse workforce through its National Sample Survey of
Registered Nurses, which is conducted every 4 years, and generally
publishes nurse workforce projections after the most recent survey. The
agency's nursing supply model projects the state-level registered nurse
supply through 2020. The nursing demand model projects state-level
demand for registered nurses, licensed practical nurses, and nursing
and home health aides through 2020 in a number of employment settings,
such as hospitals, nursing facilities, and doctors' offices. As of
December 2005, the nursing supply and demand models were being updated
to incorporate data from the most recently completed National Sample
Survey of Registered Nurses (2004).[D].
Health profession: Pharmacists;
Latest workforce projections published by HRSA: The Pharmacist
Workforce: A Study of the Supply and Demand for Pharmacists (2000);
Discussion of models and data used to make projections: HRSA created a
pharmacist supply model to generate estimates of pharmacist numbers in
the United States through 2020. But because the pharmacy profession
lacks a comprehensive database like the physician database maintained
by AMA, the pharmacist model uses a base- year count of active
pharmacists from a 1992 pharmacist census. The model then projects the
number of practicing pharmacists into the future by adding, each year,
the projected number of new entrants and subtracting, each year, the
projected number of pharmacists who will die or retire. For the
pharmacist projection published in 2000, HRSA did not develop a
pharmacist demand model per se but instead described issues affecting
the demand for pharmacists, such as the number of retail prescriptions
dispensed and the growth in demand for pharmacists in hospitals.
According to HRSA officials, as of 2005, the agency had begun updating
the pharmacist supply model.
Source: HRSA.
Note: Table lists most recent reports as of October 2005. In addition,
the agency published a report containing preliminary forecasts,
developed using the agency's physician and nursing demand models, of
the impact of changing demographics on the demand for physicians,
nurses, and other health professions. See Department of Health and
Human Services, Health Resources and Services Administration, Changing
Demographics: Implications for Physicians, Nurses, and Other Health
Workers (Rockville, Md.: 2003).
[A] The AMA Physician Masterfile is a computer database of physicians
that includes current and historical data on physicians, including AMA
members and nonmembers and graduates of foreign medical schools who
reside in the United States and who have met the educational and
credentialing requirements necessary for recognition as physicians.
[B] Administered by the Centers for Disease Control and Prevention's
National Center for Health Statistics, the National Ambulatory Medical
Care Survey is a nationwide survey based on a sample of visits to
nonfederally employed office-based physicians who are engaged primarily
in direct patient care. The survey was conducted annually from 1973 to
1981, in 1985, and annually since 1989.
[C] The Nationwide Inpatient Sample, part of the Healthcare Cost and
Utilization Project sponsored by the Agency for Healthcare Research and
Quality, is a database of hospital inpatient stays. It contains data on
about 7 million hospital stays taken from a sample of about 1,000 U.S.
community hospitals.
[D] The seventh National Sample Survey of Registered Nurses was
conducted in 2000, and the results were published on February 22, 2002.
The eighth National Sample Survey of Registered Nurses was conducted in
2004; as of December 2005, HRSA had posted preliminary results on its
Web site but had not published any updated national nursing supply or
demand projections. The survey collects information on the number of
registered nurses; their educational background and specialty areas;
their employment status, including type of employment setting, position
level, and salaries; their geographic distribution; and their personal
characteristics, including gender, racial or ethnic background, age,
and family status.
[End of table]
Although HRSA has not published national projections for the physician
workforce in the past decade, agency officials noted that individual
HRSA staff members have contributed articles to journals, [Footnote 33]
and COGME, which advises the Secretary of HHS and congressional
committees, used HRSA's models to develop physician workforce
projections through 2020 for COGME's January 2005 report. [Footnote 34]
HRSA officials said they have not contributed to any similar national
projections for the dentist workforce in the past decade.
From the 1970s through the early 1990s, HRSA periodically provided
health professions workforce information by producing a series of
legislatively mandated reports to Congress on the supply and
distribution of health personnel, including recommendations for
improving health care in the nation. Some but not all of these reports
included original national workforce supply and demand projections. For
example, the eighth report, dated 1991, did include such projections,
but the ninth report did not. The mandated reporting requirement was
eliminated by the Federal Reports Elimination and Sunset Act of 1995,
which took effect in December 1999; the last of HRSA's reports,
however, was issued 4 years earlier, in 1995. [Footnote 35]
According to a HRSA official involved in reporting on workforce issues,
the agency began work on a tenth report to Congress in 1995 after
releasing the ninth report, but because of passage of the Federal
Reports Elimination and Sunset Act, the report effort was given few
resources. HRSA officials said that the tenth report would provide
information about the health workforce for 30 key health professions,
including national supply and demand projections for physicians,
pharmacists, and nurses. Information on dentists would be more limited.
While HRSA has not planned to include supply or demand projections for
other health professions, such as dental hygienists, dental assistants,
and physical or occupational therapists, agency officials said they
planned to report on issues and trends relevant to those health
professions. As of October 2005, HRSA officials said they were revising
major sections of the tenth report. According to the officials, the
agency had no specific plans to publish reports like the tenth report
in the future, but the National Center for Health Workforce Analysis
did plan to continue publishing analyses of selected health
professions, including profiles of the health workforce within a state
at a given time. [Footnote 36]
Regular Reassessment of Health Workforce Predictions Is Critical
Because of a Changing Health Care Environment:
Estimating future health workforce supply and demand on a regular basis
is important because estimates need to be updated as circumstances
change. For example, estimates prepared in the 1980s and early 1990s
led to concern about an impending surplus of physicians overall but a
shortage of physicians trained in primary care. This anticipated
shortage of primary care physicians resulted in part from an assumption
that the nation would need fewer specialty physicians because of an
increase in managed care, which makes use of primary care
"gatekeepers." The assumption was that the gatekeepers would limit
patients' use of specialist care. Partly because the assumption about
growth in managed care proved incorrect, however, the projected
shortage of primary care physicians failed to materialize. [Footnote
37]
COGME's January 2005 report recognized the uncertainty inherent in any
effort to forecast the physician workforce many years into the future.
COGME's report showed, for example, that physician supply and demand
could shift because changing lifestyles may prompt new physicians to
work fewer hours than their predecessors, an increase in the nation's
wealth could contribute to continued increases in the use of medical
services, or an increased supply of nurse practitioners and other
nonphysician clinicians could reduce the demand for physicians. Given
this uncertainty, as well as the costs to expand medical education and
training capacity, COGME strongly recommended that the nation develop
systems to track physician workforce supply, demand, and distribution
and undertake a comprehensive reassessment within the next 4 years to
guide future decisions on medical education capacity.
Conclusions:
Our work continues to point to the need for better information to
assess the performance of title VII and title VIII programs. The
agency's current published goals and measures are not comprehensive,
and the data to measure performance in meeting them have been
problematic. As a result, HHS cannot fully inform Congress or the
public about the value of title VII and title VIII health professions
education programs. It remains to be seen whether HRSA's current
strategic planning and associated data collection efforts will remedy
these shortcomings.
In addition, the ability of HHS and Congress to target federal
resources to appropriate health professions education programs will
remain limited without useful information on future health workforce
needs. Updated workforce supply and demand projections are vital for
informed decision making about health professions programs. Without
relevant goals and performance measures, coupled with key data, HHS and
Congress will lack information that would enable them to target federal
funds effectively to those health professions education programs most
critical to meeting the nation's anticipated need for health
professionals.
Recommendation for Executive Action:
We recommend that the Administrator of HRSA develop a strategy and
establish time frames to more regularly update and publish national
workforce projections for the health professions.
Agency Comments:
In written comments on a draft of this report (see app. IV), HRSA
agreed with the need for clear, relevant goals and performance measures
backed by timely and complete data, and it agreed with the importance
of updated workforce supply and demand projections. HRSA stated that
completing development of the agency's new performance goals and
measures and integrating these new goals and measures into the agency's
data collection systems are a top priority. HRSA also agreed with our
conclusion that updated workforce supply and demand projections are
vital for informed decision making in the changing health care
environment.
The agency commented, however, on the scope of our work. First, HRSA
commented that the draft report did not include the many objectives
authorized for funding under title VII and title VIII of the Public
Health Service Act. Although we reviewed the act's provisions for
background purposes, our scope was to examine HRSA's stated goals for
the title VII and title VIII programs and the agency's efforts to
measure progress toward meeting those goals. According to HRSA
officials, the GPRA goals in the fiscal year 2006 budget justification
were the agency's published goals for the programs at the time of our
review. While we were aware of, and reported on, the agency's efforts
to develop a new strategic plan and associated goals, measures, and
data, they were in draft form at the time of our review, and HRSA had
yet to formally adopt or finalize them. Since the agency provided
technical comments including time frames associated with these efforts,
we removed a recommendation that the agency establish such time frames.
Second, regarding workforce analyses, the agency commented that our
draft report did not discuss the considerable body of work produced by
regional workforce centers and advisory committees that receive title
VII and title VIII funding from HRSA. Because the scope of our review
regarding workforce issues was limited to the most recent projected
estimates (completed and published) of national supply and demand for
physicians, dentists, nurses, and pharmacists, we did not include other
reports produced or drafted by or for HRSA, its regional workforce
centers, or its advisory groups. We did, however, acknowledge that
HRSA's National Center for Health Workforce Analysis conducts a variety
of activities other than national supply and demand projections. We
incorporated HRSA's technical comments as appropriate.
As agreed with your offices, unless you publicly announce the contents
of this report earlier, we plan no further distribution of it until 30
days after its issue date. At that time, we will send copies to the
Secretary of HHS, the Administrator of HRSA, and appropriate
congressional committees. We will also provide copies to others upon
request. In addition, the report is available at no charge on the GAO
Web site at http://www.gao.gov.
If you or your staff have any questions regarding this report, please
contact me at (312) 220-7600 or aronovitzl@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major contributions
to this report are listed in appendix V.
Signed by:
Leslie G. Aronovitz:
Director, Health Care:
[End of section]
Appendix I: Examples of Additional Sources of Federal Funding for
Health Professions Education:
Table 4: Examples of Federal Funding Sources, besides Title VII and
Title VIII Programs, for Postsecondary Education and Training
Specifically Targeted for Health Professions:
Agency: Department of Health and Human Services;
Program: Centers for Medicare & Medicaid Services: Medicare payments
for graduate medical education[A];
2004 funding (millions of dollars): $7,900.
Program: Centers for Medicare & Medicaid Services: Medicaid payments
for graduate medical education;
2004 funding (millions of dollars): [B].
Program: Health Resources and Services Administration: Children's
Hospitals Graduate Medical Education Payment Program;
2004 funding (millions of dollars): $303.
Program: Health Resources and Services Administration: National Health
Service Corps;
2004 funding (millions of dollars): $170.
Program: Health Resources and Services Administration: Bioterrorism
Training and Curriculum Development Program;
2004 funding (millions of dollars): $28.
Program: Indian Health Service: Loan Repayment Program;
2004 funding (millions of dollars): $12.
Agency: Department of Defense;
Program: Defense Health Program: health professions scholarship program
and education and training;
2004 funding (millions of dollars): $318.
Agency: Department of Labor;
Program: Employment and Training Administration: President's High
Growth Job Training Initiative (health care);
2004 funding (millions of dollars): [C].
Agency: Department of Veterans Affairs;
Program: Veterans Health Administration: education and training
programs for health professions students and residents;
2004 funding (millions of dollars): $493.
Source: GAO.
[A] Medicare's graduate medical education payments are made to teaching
hospitals for both direct and indirect graduate medical education costs
on the basis of factors such as the number of physicians being trained,
Medicare's share of patient days in the hospital, and the hospital's
ratio of residents to beds.
[B] Citing a 50-state survey conducted for the Association of American
Medical Colleges, COGME reported that Medicaid provided teaching
hospitals between $2.5 and $2.7 billion in 2002. See Council on
Graduate Medical Education, Department of Health and Human Services,
Health Resources and Services Administration, State and Managed Care
Support for Graduate Medical Education: Innovations and Implications
for Federal Policy (Rockville, Md.: July 2004).
[C] This initiative focuses on 14 targeted sectors, one of which is
health care. As part of this initiative, the Secretary of Labor
announced awards of more than $24 million in grants to counter health
care labor shortages in 2004.
[End of table]
Table 5: Examples of Federal Funding Sources for General Postsecondary
Education and Training Including, but Not Exclusive to, Health
Professions:
Agency: Department of Education;
Source: Federal student aid programs[A];
2004 funding (millions of dollars): $20,544.
Agency: Department of Health and Human Services;
Source: National Institutes of Health: NIH Extramural Loan Repayment
Programs;
2004 funding (millions of dollars): $73.
Agency: Department of Labor;
Source: Employment and Training Administration: Job Corps[B];
2004 funding (millions of dollars): $1,537.
Source: GAO.
[A] Include programs such as the Department's Federal Family Education
Loan Program, Federal Pell Grant Program, Federal Perkins Loan Program,
Federal Supplemental Educational Opportunity Grant Program, and Federal
Work-Study Program.
[B] As of May 2004, according to an official in the Department of
Labor's Employment and Training Administration, 105 Job Corps centers
provided training in one or more of 12 different health-related
training programs.
[End of table]
[End of section]
Appendix II: Title VII and Title VIII Clusters and Programs, Fiscal
Year 2004:
Title VII.
Cluster name[A]: Student Loans;
Programs funded in fiscal year 2004[B]:
* Health Professions Student Loans;
* Loans for Disadvantaged Students;
* Primary Care Loans.
Cluster name[A]: Health Professions Training for Diversity;
Programs funded in fiscal year 2004[B]:
* Centers of Excellence;
* Faculty Loan Repayment Program;
* Health Careers Adopt a School Demonstration Program;
* Health Careers Opportunity Program;
* Minority Faculty Fellowship Program;
* Scholarships for Disadvantaged Students Program.
Cluster name[A]: Training in Family Medicine, General Internal
Medicine, General Pediatrics, Physician Assistants, General Dentistry,
and Pediatric Dentistry;
Programs funded in fiscal year 2004[B]:
* Academic Administrative Units in Primary Care;
* Cooperative Agreement to Plan, Develop, Implement and Operate a
Continuing Clinical Education Program in the Pacific Basin;
* Faculty Development in Primary Care;
* Physician Assistant Training in Primary Care;
* Predoctoral Training in Primary Care;
* Residency Training in General and Pediatric Dentistry;
* Residency Training in Primary Care;
* Training in Primary Care Medicine and Dentistry.
Cluster name[A]: Interdisciplinary, Community-Based Linkages;
Programs funded in fiscal year 2004[B]:
* Allied Health Projects;
* Basic/Core Area Health Education Centers;
* Chiropractic Demonstration Project Grants;
* Geriatric Academic Career Awards;
* Geriatric Education Centers;
* Geriatric Training for Physicians, Dentists, and Behavioral and
Mental Health Professionals;
* Graduate Geropsychology Education Program;
* Graduate Psychology Education Program;
* Health Education and Training Centers;
* Model State-Supported Area Health Education Centers;
* Podiatric Residency Training in Primary Care;
* Quentin N. Burdick Program for Rural Interdisciplinary Training.
Cluster name[A]: Health Professions Workforce Information and Analysis;
Programs funded in fiscal year 2004[B]:
* Center for Health Workforce.
Cluster name[A]: Public Health Workforce;
Programs funded in fiscal year 2004[B]:
* ASPH [Association of Schools of Public Health] Cooperative
Agreement[C];
* Dental Public Health Residency Training Grants;
* Health Administration Traineeships and Special Projects;
* Preventive Medicine Residency Program;
* Public Health Traineeships;
* Public Health Training Centers Grant Program.
Title VIII:
Cluster name[A]: Nursing Workforce Development;
Programs funded in fiscal year 2004[B]:
* Advanced Education Nursing Program;
* Advanced Education Nursing Traineeships;
* Basic Nurse Education and Practice Grants;
* Clinical Experience in Federally-Funded Community Health Centers for
Nurse Practitioners and/or Nurse-Midwifery Students;
* Comprehensive Geriatrics Education Program;
* Nurse Anesthetist Traineeships;
* Nurse Education, Practice, and Retention Grant Program: Grants for
Career Ladder Programs;
* Nurse Education, Practice, and Retention Grant Program: Grants for
Enhancing Patient Care Delivery System Program;
* Nurse Education, Practice, and Retention Grant Program: Grants for
Internships and Residency Programs;
* Nurse Faculty Loan Program;
* Nursing Education Loan Repayment Program;
* Nursing Scholarship Program;
* Nursing Student Loans;
* Nursing Workforce Diversity Grants.
Source: GAO analysis.
[A] Cluster names reflect headings of parts and subparts of title VII
and of title VIII of the Public Health Service Act, as amended by Pub.
L. No. 105-392, and in some cases differ slightly from those in Senate
Report No. 105-220.
[B] Include (1) programs that awarded funds competitively through
grants or cooperative agreements and that announced funding
availability separately or had a separate selection panel and (2)
programs providing direct assistance, such as student loans to
individuals, regardless of whether the loan program received any new
appropriations. Table does not include four advisory groups--COGME, the
National Advisory Council on Nurse Education and Practice, the Advisory
Committee on Training in Primary Care Medicine and Dentistry, and the
Advisory Committee on Interdisciplinary, Community-Based Linkages--
operating in fiscal year 2004. Names for grant and cooperative
agreement programs reflect those used in the Federal Register or other
program announcements.
[C] This program, which allows schools of public health to apply for
HRSA funding to support certain special projects, includes a
cooperative agreement with ASPH to provide information to, and
coordinate with, the schools of public health that inquire about grant
opportunities under this program. HRSA has sole discretion to determine
whether projects are funded.
[End of table]
[End of section]
Appendix III: Additional Performance Goals and Targets for Health
Professions and Nursing Education Programs:
Health Education Assistance Loans Program:
GPRA performance goals: Phase out the outstanding loan portfolio,
resulting in a reduction in the federal liability associated with the
Health Education Assistance Loans Program;
Long-term and interim targets:
* $1.7 million in 2006;
* $1.9 million in 2005;
* $2.6 million in 2004;
* $2.7 million in 2003;
* $3.3 million in 2002;
* $3.4 million in 2001;
* $3.6 million in 2000;
Available data for year:
* $2.0 million in 2004;
* $2.3 million in 2003;
* $2.7 million in 2002;
* $3.2 million in 2001;
* $3.5 million in 2000.
Health Professions Workforce Information and Analysis:
GPRA performance goals: Annually produce results of data collection and
analysis activities to inform the market regarding issues relevant to
health professions and nursing workforce (number of reports);
Long-term and interim targets:
* 25 reports in 2006;
* 25 reports in 2005;
* 23 reports in 2004;
* 23 reports in 2003;
* 11 reports in 2002;
* 10 reports in 2001;
Available data for year:
* 21 reports in 2004;
* 23 reports in 2003;
* 14 reports in 2002;
* 10 reports in 2001.
Nursing Education Loan Repayment Program (NELRP) and Scholarship
Program:
GPRA performance goals: Increase the number of individuals enrolled in
professional nursing education programs;
Long-term and interim targets:
* Baseline + 10% in 2010;
Available data for year:
* Estimated 240,500 in 2004 (baseline)[A].
GPRA performance goals: Increase the proportion of nursing scholarship
recipients who, within 4 months of licensure, are working in a facility
with a critical shortage of nurses;
Long-term and interim targets:
* 85% in 2006;
* 80% in 2005;
* 75% in 2004;
Available data for year:
* 23% in 2004[B].
GPRA performance goals: Increase the proportion of NELRP participants
working in shortage facilities, such as disproportionate share
hospitals for Medicare and Medicaid, nursing homes, public health
departments (state and local), and public health clinics within these
departments;
Long-term and interim targets:
* 85% in 2010:[C];
* 90% in 2006[C];
* 85% in 2005[C];
* 65% in 2004[C];
Available data for year:
* 100% in 2004;
* 100% in 2003.
GPRA performance goals: Increase the proportion of states in which
NELRP contract recipients work;
Long-term and interim targets:
* 93% in 2006;
* 93% in 2005;
* 85% in 2004;
* 65% in 2003;
* 50% in 2002;
Available data for year:
* 98% in 2004;
* 88% in 2003;
* 82% in 2002.
GPRA performance goals: Increase the proportion of NELRP participants
who remain employed at a critical-shortage facility for at least 1 year
beyond termination of their NELRP service;
Long-term and interim targets:
* 28% in 2010;
* 11% in 2006;
* 11% in 2005;
* 10% in 2004;
Available data for year:
* 40% in 2004[D].
GPRA performance goals: Reduce the federal investment per year of
direct support by increasing the proportion of program participants who
extend their service contracts and commit to work at a critical-
shortage facility for an additional year;
Long-term and interim targets:
* 45% in 2006;
* 40% in 2005;
* 22% in 2004;
Available data for year:
* 44% in 2004;
* 18% in 2001 (baseline).
Source: Department of Health and Human Services, Health Resources and
Services Administration, Fiscal Year 2006 Justification of Estimates
for Appropriations Committees (Washington, D.C.: n.d.).
Note: All years are fiscal years.
[A] Number of students in all prelicensure registered nursing programs
in the 2002-03 academic year.
[B] The target was based on the assumption that all scholars would
complete programs and enter service at the same time. According to the
Health Resources and Services Administration, 23 percent of the 2003
scholarship recipients had completed programs in fiscal year 2004 and
entered into service.
[C] The actual performance greatly exceeded the original targets
because a large number of applicants worked in facilities with the most
critical shortages. As a result, the agency increased the targets for
2005 and 2006.
[D] Preliminary estimate. HRSA's fiscal year 2006 budget justification
indicates that targets will be revised once the fiscal year 2004 data
are finalized.
[End of table]
[End of section]
Appendix IV: Comments from the Health Resources and Services
Administration:
DEPARTMENT OF HEALTH & HUMAN SERVICES:
Health Resources and Services Administration:
Rockville MD 20857:
DEC 30 2005:
TO: Leslie G. Aronovitz:
Director, Health Care:
FROM: Administrator:
SUBJECT: Government Accountability Office Draft Report: "Health
Professions Education Programs: Action Still Needed to Measure Impact"
(GAO-06-55):
Thank you for the opportunity to provide a response to the above titled
draft report. Attached please find our comments.
Questions may be referred to Ms. Gail Lipton in HRSA's Office of
Federal Assistance Management at (301) 443-6509.
Signed by:
Betty James Duke:
Attachment:
Health Resources and Services Administration's Comments on the
Government Accountability Offices' Draft Report: "Health Professions
Education Programs: Action Still Needed to Measure Impact" Code # GAO-
06-55:
The Health Resources and Services Administration (HRSA) appreciates the
opportunity to comment on the Government Accountability Office (GAO)
assessment of Title VII and Title VIII. We believe it is a worthy
effort, however, in attempting to summarize this complex piece of
legislation, GAO has overlooked some of the important differences and
emphases among the many programs that are authorized within these
sections of the Public Health Service Act. Additionally, we provide an
update on Agency efforts to improve performance measurement and data
collection systems, and expand on GAO's discussion of HRSA's role in
the development of health workforce information and analysis.
The Goals of Titles VII and VIII of the Public Health Service Act:
As GAO points out, Title VII was first enacted in 1963, and Title V111
in 1964, when there were concerns about impending shortages of
physicians and nurses. Since then, the U.S. health care system has
changed a lot. Advances in science have brought about new ways to treat
disease. There have also been changes in economics and demographics.
Economic changes have altered the incentives and the barriers to
entering health careers. Demographic changes have altered the
geographic distribution and racial/ethnic distribution of the
population. Greater longevity and the aging of the population have also
brought new challenges. And all of these changes have had implications
for the education and training of physicians, nurses, dentists, and the
increasing number of other types of health professionals, which
Congress in the early 1960s could not have foreseen.
Over time, the law has been amended piecemeal to accommodate the
changing environment of U.S. healthcare, but its interpretation often
remains rooted in the language of physician, nurse, and dentist
shortages for which it was originally created. A careful perusal of the
law would specifically identify many purposes and objectives of the
Title VII and Title VIII legislation beyond those identified by GAO in
its report. In addition to the problems of supply, demand, and
distribution of health care professionals, and the balance between
generalist and specialist providers, the law also includes (but is not
limited to) specific references to the following objectives:
* Developing a competitive applicant pool for health professions
education programs;
* Enhancing the academic performance of underrepresented minorities;
* Improving recruitment and retention of minority faculty;
* Improving institutions' information resources as they relate to
minority health issues;
* Facilitating faculty and student research on health issues affecting
underrepresented minority groups;
* Expanding enrollments in allied health professions with the greatest
shortages or whose services are most needed by the elderly;
* Providing rapid transition training programs in allied health fields
to individuals who have baccalaureate degrees in health-related
sciences;
* Establishing community-based allied health training programs that
link academic centers to rural clinical settings;
* Providing career advancement training for practicing allied health
professionals;
* Developing curriculum that will emphasize knowledge and practice in
the areas of prevention and health promotion, geriatrics, long-term
care, home health and hospice care, and ethics;
* Expanding or establishing interdisciplinary training programs that
promote the effectiveness of allied health practitioners in geriatric
assessment and the rehabilitation of the elderly;
* Expanding or establishing demonstration centers to emphasize
innovative models to link allied health clinical practice, education,
and research;
* Improving the training of health professionals in geriatrics,
including geriatric residencies, traineeships, or fellowships;
* Developing and disseminating curricula relating to the treatment of
the health problems of elderly individuals;
* Supporting the training and retraining of faculty to provide
instruction in geriatrics;
* Supporting continuing education of health professionals who provide
geriatric care;
* Providing students with clinical training in geriatrics in nursing
homes, chronic and acute disease hospitals, ambulatory care centers,
and senior centers.
It is worth noting, further, that while Title VII and Title VIII
usually provide for preferences in awarding funds to institutions that
tailor their programs to the care of the vulnerable and underserved, or
to individuals committed to serving the underserved, these are
explicitly educational rather than service objectives.
Data Collection and Performance Measurement:
GAO also comments on HRSA's inability to provide data with which to
measure the attainment of Title VII and Title VIII objectives dating
back to an earlier GAO report, and speculates that this will continue
to be an issue in the future.
We would like to point out that many changes have occurred since the
publication of GAO's 1997 report: Health Professions Education:
Clarifying the Role of Title VII and VIII Programs Could Improve
Accountability.
HRSA immediately took vigorous steps to address the issues identified
in the Report. These first efforts led to the development of a
Comprehensive Performance Management System and Uniform Progress Report
(CPMS/UPR), which has been continuously reporting data since 1999. HRSA
has acknowledged that there were issues with the completeness and
timeliness of the data, but progress has been steady. The 2005 CPMS/UPR
data include a record 95% of all expected data submissions.
Implementation of a web-based system drastically reduced the amount of
time required to enter and process the data, which is more efficient
for both grantees and HRSA staff. Performance measures developed by
HRSA in tandem with the CPMS/UPR have been reporting data for 5 years.
These measures were replaced with new ones at the request of the Office
of Management and Budget in August 2002, for the FY 04 budget cycle.
Since the CPMS/UPR was not optimally designed to address the new OMB-
required measures, and to better capture the diverse objectives of
Title VII and Title VIII programs, HRSA is currently working on a new
Performance Measurement System (PMS). The new system was presented to
HRSA program constituents and stakeholders in a conference that took
place in June 2005. We are currently consolidating some of the
measures, incorporating comments received at the conference, pilot
testing the measures, and planning system changes. We expect to submit
the PMS to OMB for Paperwork Reduction Act clearance by July 2006.
HRSA's Role in the Development of Health Workforce Information and
Analysis:
We would like to expand on GAO's discussion of HRSA's role in the
development of workforce information and analysis.
In addressing workforce information and analysis, GAO focuses its
attention on publications by HRSA's National Center for Workforce
Information and Analysis (NCHWA) and finds that HRSA has not published
many workforce projections for physicians, nurses, and dentists in
recent years. GAO does not include in its discussion the considerable
body of work produced by the Regional Workforce Centers that receive
Title VII funding from HRSA, nor (with the exception of the Council on
Graduate Medical Education -COGME), does it acknowledge the
contributions of the various Advisory Councils and Committees
specifically authorized by Title VII and Title VIII, funded out of
Title VII and Title VIII appropriations, and which receive significant
staff support from NCHWA and the programs.
Additional committees or councils performing valuable work in support
of the Title VII and Title VIII program goals include:
National Advisory Council on Nursing Education and Practice (NACNEP):
* Advisory Committee on Training in Primary Care Medicine and Dentistry
(ACTPCMD):
* Advisory Committee on Interdisciplinary and Community-Based Linkages
(ACICBL).
Each of these groups has produced a regular series of reports on
pertinent workforce issues. For example, ACTPCMD (authorized by Section
748 [2931] of the Health Professions Education Partnership Act of 1998)
issued a report in November 2004: Preparing Primary Healthcare
Providers to Meet America's Future Healthcare Needs: The Critical Role
of Title VII, Section 747. This is its Fourth Annual Report to the
Secretary of Health and Human Services and to Congress. It contains a
large number of references that support the role of Title VII, section
747 in guiding the content and capacity of primary care education and
training in the United States to meet the healthcare needs of the
future. A fifth report is nearing completion. NACNEP also released a
report in November 2002 that focuses on the nursing workforce as well
as the faculty shortage. Another ACTPCMD report entitled: "Evaluating
the Impact of Title VII Section 747 Programs" is nearing completion. We
believe that HRSA's role in the production of workforce analyses cannot
be fully understood by limiting discussion solely to NCHWA, and we
question the decision to exclude from consideration all Title VII and
Title VIII advisory groups except for COGME.
Furthermore, we believe that the legislated goal of providing "health
workforce information and analysis to national, State, and local
policymakers and researchers on a broad range of issues, such as
shortages of registered nurses, shortages of pharmacists, and the
distribution of healthcare workers in underserved areas" is broader
than what GAO's exclusive focus on supply and demand projections for
physicians, nurses, and dentists would allow.
Since 1999, NCHWA and its regional centers have produced well over 100
reports. The following list of published reports documents the breadth
of purpose of Title VII Section 762, and provides evidence of HRSA's
accomplishments. HRSA has also made information widely available
through staff-written articles in major health journals, reports on
specific health professions, and special reports. This listing does not
include all reports and studies conducted by the Regional Workforce
Centers with Title VII funding. A comprehensive list of NCHWA reports
is available at: http://bhpr.hrsa.gov/healthworkforce/reports:
* The Clinical Laboratory Workforce: The Changing Picture of Supply,
Demand, Education, and Practice (Published July 2005):
* State Health Profiles for 50 States, the District of Columbia, Puerto
Rico, and the Virgin Islands that include information about the supply,
demand, distribution, education and use of physicians, nurses, dentists
and 20 other health professionals in each State and the District of
Columbia (published 2004 and 2000):
* The Health Care Workforce: Education, Practice & Policy provides in-
depth assessments of the health workforce in 26 selected States and an
Interstate Comparison that assesses data and influences across the
States. Both studies were conducted for HRSA by the National Conference
of State Legislatures.
A Comparison of Changes in the Professional Practice of Nurse
Practitioners, Physician Assistants, and Certified Nurse Midwives: 1992
and 2000 (published February 2004):
* Effects of the Workforce Investment Act of 1998 on Health Workforce
Development in the States (November 2004).
* Supply, Demand, and Use of Licensed Practical Nurses (Published
November 2004):
* The Professional Practice Environment of Dental Hygienists in the
Fifty States and the District of Columbia (published April 2004):
* Health Care Occupations - National and Local Workforce Shortages and
Associated Data Needs (published February 2004):
* State Responses to Health Worker Shortages: Results of 2002 Survey of
States, profiles of each state's response to health workforce
shortages, details of current initiatives and links to Web sites and
State contacts (published May 2003).
Some of the reports produced by HRSA are of special significance
because they helped to change the landscape of health professional
training nationally to promote the attainment of Title VII objectives.
The following were particularly significant:
* Undergraduate Medical Education for the 21st Century (UME-21): A
National Medical Education Project. Family Medicine 2004:36S: SI-150.
This resulted from a project, the objective of which was to stimulate
the introduction of new educational opportunities, focusing on nine
content areas during the third year of the curriculum, with outcomes
demonstrating that medical students acquire the knowledge, skills, and
attitudes needed to perform effectively.
* Challenging Sociocultural Health Disparities: A Collaborative and
Interdisciplinary Model Podogeriatric Curriculum Plan. This is a 154-
chapter teaching module developed as part of a program to establish and
disseminate an interdisciplinary graduate physician training program
for podiatry, family practice, and internal medicine residents
concerning foot care for older patients.
Topics for other reports and current research include:
* Racial and ethnic diversity of the workforce:
* Provision of geriatric health care:
* Implications of the aging of the U.S. population and the healthcare
workforce:
* Health workforce preparedness in genetics and emerging health
technologies:
* Health workforce preparedness for emergency response to terrorism:
* U.S.-Mexico border health and Border Health Profiles:
* Mental health:
* Oral health:
* State and regional health care system financing:
In addition to the reports and projects listed above, NCHWA produces
other resources that are valuable to analysts and researchers inside
and outside of HRSA. An example is the Area Resource File (ARF) which
is a regularly updated compilation of a national, county-level database
on the health workforce. ARF is very widely used by national, State,
regional, and local policymakers, researchers, and workforce analysts.
A search for "Area Resource File" or "ARF" in the Web of Science
database produced over 100 citations of the ARF in recently published
medical and health literature.
NCHWA also supports evaluation studies on current workforce topics.
Currently, HRSA is compiling an evaluation of the likelihood that
physicians exposed to Title VII funded programs during training will
practice in federally-designated health centers, including Community
Health Centers.
A report on the Critical Care Workforce, which is based on the
HRSA/NCHWA physician models, estimates the supply, need, and
distribution of the critical care workforce and is currently in the
clearance process.
We agree with GAO that in the changing health care environment, updated
workforce supply and demand projections are vital for informed decision
making about health professions programs. We also agree on the
importance of clear and relevant goals and performance measures, backed
by timely and complete data. Completion of the Performance Measurement
System and its integration into data collection systems are a top
priority for HRSA, and we thank GAO for this opportunity to comment and
expand on some of these issues.
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Leslie G. Aronovitz at (312) 220-7600 or aronovitzl@gao.gov:
Acknowledgments:
In addition to the person named above, Kim Yamane, Assistant Director;
George Bogart; Matt Byer; Ellen W. Chu; and Karlin Richardson made key
contributions to this report.
[End of section]
Related GAO Products:
Physician Workforce: Physician Supply Increased in Metropolitan and
Nonmetropolitan Areas but Geographic Disparities Persisted. GAO-04-
124. Washington, D.C.: October 31, 2003.
Health Care: Adequacy of Pharmacy, Laboratory, and Radiology Workforce
Supply Difficult to Determine. GAO-02-137R. Washington, D.C.: October
10, 2001.
Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors.
GAO-01-944. Washington, D.C.: July 10, 2001.
Health Professions Education: Clarifying the Role of Title VII and VIII
Programs Could Improve Accountability. GAO/T-HEHS-97-117. Washington,
D.C.: April 25, 1997.
Health Professions Education: Role of Title VII/VIII Programs in
Improving Access to Care Is Unclear. GAO/HEHS-94-164. Washington, D.C.:
July 8, 1994.
[End of section]
FOOTNOTES:
[1] Allied health practitioners include, for example, audiologists,
dental hygienists, clinical laboratory technicians, occupational
therapists, physical therapists, medical imaging technologists, and
speech pathologists.
[2] Most title VII and title VIII programs were last reauthorized by
the Health Professions Education Partnership Act of 1998, Pub. L. No.
105-392, 112 Stat. 3524. Some nursing programs were authorized or
reauthorized by the Nurse Reinvestment Act of 2002, Pub. L. No. 107-
205, 116 Stat. 811.
[3] See ’Related GAO Products“ at the end of this report.
[4] GAO, Health Professions Education: Clarifying the Role of Title VII
and VIII Programs Could Improve Accountability, GAO/T-HEHS-97-117
(Washington, D.C.: Apr. 25, 1997).
[5] Office of Management and Budget, Program Assessment Rating Tool,
http://www.whitehouse.gov/omb/budget/fy2006/pma/hhs.pdf, downloaded
Aug. 9, 2005. The most recent OMB assessment of the health professions
programs took place for the fiscal year 2004 budget.
[6] We excluding funding for one title VII program”Health Education
Assistance Loans”because the program was not authorized to guarantee
new loans to student borrowers during that period.
[7] Referred to as ’grants“ in this report.
[8] We used the separate selection panel criterion only for programs
funded in fiscal year 2004.
[9] We excluded advisory groups authorized under title VII or title
VIII from our counts of programs.
[10] In addition to the national workforce projections discussed in
this report, HRSA and its six regional centers issue reports”such as
state health workforce profiles for each state, the District of
Columbia, Puerto Rico, and the Virgin Islands”containing information
about the supply; demand; distribution; education; and use of
physicians, nurses, dentists, and 20 other health professionals. The
scope of our review was limited to HRSA‘s estimates of national supply
and demand.
[11] COGME, established under title VII, is required to make
recommendations to the Secretary of HHS and Congress on several issues,
including the supply and distribution of physicians in the United
States; current and future shortages or excesses of physicians in
medical and surgical specialties and subspecialties and appropriate
federal policies with respect to such supply, distribution, shortages,
or excesses; and deficiencies in and needs for improvement in databases
concerning the supply and distribution of physicians in the United
States. Public Health Service Act § 762 (codified at 42 U.S.C. § 294o).
The views expressed in COGME‘s reports are solely those of the council
and do not necessarily represent the views of HRSA or the U.S.
government.
[12] The Government Performance and Results Act of 1993 requires
executive agencies to develop agencywide performance goals and
indicators and to report progress annually. Pub. L. No. 103–62, § 4,
107 Stat. 285, 286.
[13] Health Professions Educational Assistance Act of 1963, Pub. L. No.
88-128, 77 Stat. 164. See S. Rep. No. 88-485, at 3 (1963).
[14] Nurse Training Act of 1964, Pub. L. No. 88-581, 78 Stat. 1035. See
S. Rep. No. 88-1378, at 3 (1964).
[15] Senate Report No. 105-220 at 13 and 19 (1998) (accompanied
legislation that became Health Professions Education Partnership Act of
1998, Pub. L. No. 105-392, 112 Stat. 3524). The Senate report is the
only congressional report accompanying Pub. L. No. 105-392.
[16] The national center also supports work by six regional centers,
which conduct cross-disciplinary assessments of the health workforce,
focusing on issues at the state and regional levels. In addition, the
national center facilitates research projects contracted and funded by
programs within other clusters; for example, the national center
facilitates nursing workforce research. The congressional conference
agreement for the Department of Health and Human Services‘
appropriation for fiscal year 2006 did not include funding for the
Health Professions Workforce Information and Analysis cluster. H.R.
Conf. Rep. No. 109-337 at 135 (2005).
[17] Three advisory groups besides COGME have received contract and
staff support from HRSA and have produced a series of reports on
workforce issues. These groups, authorized by title VII or title VIII
of the Public Health Service Act, are the National Advisory Council on
Nurse Education and Practice; the Advisory Committee on Training in
Primary Care Medicine and Dentistry; and the Advisory Committee on
Interdisciplinary, Community-Based Linkages.
[18] Department of Health and Human Services, Health Resources and
Services Administration, Fiscal Year 2005 Justification of Estimates
for Appropriations Committees, vol. I, Budget (Washington, D.C.: n.d.).
[19] Medicare‘s graduate medical education payments are made to
teaching hospitals for both direct and indirect graduate medical
education costs on the basis of factors such as the number of
physicians being trained, Medicare‘s share of patient days in the
hospital, and the hospital‘s ratio of residents to beds.
[20] We excluded the student loan cluster from this analysis. The
Health Education Assistance Loans program was not authorized to
guarantee new loans to student borrowers during this period. The
remaining loan programs have received no new federal funds since fiscal
year 1998, although HRSA continues to administer them.
[21] The Nurse Reinvestment Act of 2002 authorized additional title
VIII programs. Pub. L. No. 107-205, §§ 103, 201, 202, 116 Stat. 811,
813, 815, 816 (2002).
[22] We used HRSA‘s database to identify the title VII and title VIII
grant programs that received funding in fiscal year 2004. Fiscal year
2004 was the most recent year for which data were available at the time
of our analysis. We also contacted HRSA officials to obtain information
on other title VII and title VIII programs, such as scholarship
programs, that HRSA administered in those years. We counted (1)
programs that awarded funds competitively through grants or cooperative
agreements and that announced funding availability separately or had a
separate selection panel and (2) programs providing direct assistance,
such as student loans to individuals, regardless of whether the loan
program received any new appropriations.
[23] The act specifies that, of the $78.3 million authorized to be
appropriated for fiscal year 1998, not less than $49.3 million be made
available to programs of family medicine, of which not less than $8.6
million be made available for family medicine academic administrative
units, not less than $17.7 million be made available to programs of
general internal medicine and general pediatrics, not less than $6.8
million be made available to programs related to physician assistants,
and not less than $4.5 million be made available to programs of general
or pediatric dentistry. If the amounts appropriated in subsequent
fiscal years are less than the amount authorized to be appropriated for
1998, the act directs the secretary to reduce the amounts made
available to the programs on a proportional basis. See Public Health
Service Act, § 747, as amended (codifed at 42 U.S.C. § 293k).
[24] See Public Health Service Act, § 736, as amended (codified at 42
U.S.C. § 293).
[25] Department of Health and Human Services, Health Resources and
Services Administration, Fiscal Year 2006 Justification of Estimates
for Appropriations Committees (Washington, D.C.: n.d.). In addition to
the broad performance goals for health professions and nursing
education and training programs shown in table 2, the budget
justification also lists goals and performance measures for specific
programs, such as Health Education Assistance Loans, Health Professions
Workforce Information and Analysis, and the Nursing Education Loan
Repayment and Nursing Scholarship Programs (see app. III).
[26] To collect these data, HRSA developed its comprehensive
performance management system and uniform progress report.
[27] GAO/T-HEHS-97-117.
[28] Mia Cahill et al., Evaluation of Data Collection Processes Used by
the Bureau of Health Professions‘ Grantees to Determine the Number of
Graduates and Program Completers Practicing in Medically Underserved
Communities, final report prepared for HRSA (Princeton, N.J.:
Mathematica Policy Research, Mar. 31, 2002).
[29] HRSA officials acknowledged that such proposed national indicators
are driven by a number of factors other than funding support from title
VII and title VIII programs.
[30] HRSA officials noted that the agency must seek approval from OMB
for any change in reporting requirements for grantees, and that they
expected to submit their plans to OMB by spring 2006.
[31] Other goals include federal-state collaborative efforts directed
at assessing the adequacy of the current and future heath care
workforce from federal, state, and local perspectives and developing
strategies for improving the diversity and distribution of the health
workforce. See Department of Health and Human Services, Health
Resources and Services Administration, Fiscal Year 2006 Justification
of Estimates for Appropriations Committees.
[32] In addition to national workforce projections and other reports
issued by HRSA and its six regional centers, HRSA supports a database,
the Area Resource File, containing statistics on health professions,
health training programs, health facilities, measures of resource
scarcity, and health status. This information is derived from existing
data sources, such as the National Center for Health Statistics and
American Hospital Association.
[33] See, for example, Jack M. Colwill and James M. Cultice, ’The
Future Supply of Family Physicians: Implications for Rural America,“
Health Affairs, vol. 22, no. 1 (2003), and Robert M. Politzer et al.,
’Matching Physician Supply and Requirements: Testing Policy
Recommendations,“ Inquiry, vol. 33: 181–194 (1996).
[34] Council on Graduate Medical Education, Department of Health and
Human Services, Health Resources and Services Administration, Physician
Workforce: Policy Guidelines for the United States, 2000–2020
(Rockville, Md.: January 2005). The views expressed in COGME‘s report
are solely those of the council and do not necessarily represent the
views of HRSA or the U.S. government.
[35] The Public Health Service Act required that HRSA report to
Congress in 1993 and every 2 years thereafter; see §792, codified at 42
U.S.C. §295k. After submitting the ninth report to Congress in 1995,
HRSA did not submit additional biennial reports before the requirement
was eliminated in 1999 by the Federal Reports Elimination and Sunset
Act of 1995. Pub. L. No. 104-66, §303, 109 Stat. 707, 734.
[36] The most recent state profiles compiled 2000 data on levels of
employment, projected growth, and key environmental factors affecting
demand for health care. Because these profiles did not include national
workforce projections, they were outside of the scope of our review.
See http://bhpr.hrsa.gov/healthworkforce/reports/profiles/, downloaded
September 7, 2005.
[37] More recent workforce research has again raised concerns that the
nation is likely to face a shortage of physicians. For example, in
October 2003, AMA noted that several published studies have
demonstrated that the expected oversupply had not appeared. COGME, in a
January 2005 report, has also acknowledged that the nation may face a
physician shortage by the year 2020.
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