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    Testimony

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    Statement by
    Deborah L. Parham, Ph.D., R.N.
    Acting Associate Administrator, HIV/AIDS Bureau, Health Resources and Services Administration
    on
    HRSA's Role in Eliminating Racial and Ethnic Disparities in Health
    before the
    Congressional Black Caucus, the Congressional Hispanic Caucus, and the Congressional Asian Pacific American Caucus

    April 12, 2002

    Madame Chairwoman (Representative/Dr. Donna Christian-Christensen) and Members of the Congressional Black, Hispanic, and Asian Pacific American Caucuses:

    I am pleased to appear before you today to discuss the Health Resources and Services Administration's (HRSA) progress toward eliminating racial and ethnic health disparities.

    We at HRSA are dedicated to searching for better ways to deliver quality health care services to all Americans -- to get the job done for the millions of Americans who count on us for vital health care services.

    Our mission at the Health Resources and Services Administration is to improve the nation's health by assuring equal access to comprehensive, culturally competent, quality health care for all. Our work is focused on the fulfillment of this mission and how it fits into the comprehensive strategy within the Department of Health and Human Services to improve the delivery of health care to America's uninsured and underserved individuals and families.

    The health care environment is constantly changing, and we must be ready to respond to emerging trends and challenges. This braintrust hearing gives us an opportunity to discuss and share ideas so that our programs at HRSA will do an even better job in meeting this Nation's diverse workforce needs.

    All of you, I assume, saw the recent news stories on the Institute of Medicine (IOM) study which found that minorities in America receive lower-quality health care than whites. This IOM report cited a HRSA-funded project, "The Provider's Guide to Quality & Culture," as a resource for health care professionals seeking to provide high-quality, culturally appropriate care. This guide focuses on safety, effectiveness, patient-centeredness and equity, was developed in response to the 2001 IOM report "Crossing the Quality Chasm: A New Health System." The interactive web-based tool helps health care providers examine their own cultural beliefs, attitudes and biases as well as learn about how cultural differences may affect clinical outcomes, and offers tips to help health care professionals provide culturally appropriate care. HRSA programs throughout the agency are working to eliminate these regional and National health disparities, and endeavoring to enlist greater numbers of minority and disadvantaged health professionals to play key roles in this effort.

    To the outside world, the question might arise: "What is the connection between diversity and access?" At HRSA, we know that access to quality affordable health care is directly linked to the availability of a well-trained and diverse workforce able to provide appropriate services where needed most. Because we know that minority health care providers are more likely to serve the underserved: African American physicians are five times more likely than other physicians to treat African American patients; Hispanic physicians are 2.5 times more likely to treat more likely to treat Hispanic patients.

    The bottom line is clear -- if we improve the diversity of the health workforce, we will improve access to care for the underserved groups that these health professionals are part of.

    President Bush and Health and Human Services Secretary Tommy Thompson are both convinced that the best way to boost access to care and eliminate health disparities is to get more direct health care to the people who need it most. HRSA plays a central role in that strategy. The President and the Secretary decided to focus on HRSA safety-net programs that we know work well and use them to gradually and persistently expand access to care.

    Community health centers and the National Health Service Corps (NHSC) are at the heart of President Bush's multi-year plan to expand health care services to America's neediest citizens. Locally controlled and culturally competent, the health centers are driven by a need to demonstrate high quality primary care for the underserved, and the results show that. The collaborative approach to disease management has produced quality results, and the 64% minority population base of the health centers has benefitted dramatically given the starting point disparities: health centers serve low income and minority populations that experience much higher rates of many diseases including diabetes, cardiovascular disease, asthma, cancer, and HIV/AIDS than the National average. Yet everyday, health centers work to reduce health disparities by: reducing disease and morbidity/mortality in targeted clinical areas; increasing health care utilization for underserved populations; adapting services to meet population needs; building and maintaining a diversified health care workforce; increasing the cultural competence of their health care workforce; enhancing and establishing new partnerships; translating clinical knowledge into clinical practice; improving the patient visit; and enhancing clinical data collection on health outcomes. In short, health centers equal a rising level of quality of care.

    In addition, I am asking for your support of a new interdisciplinary services demonstration program that will concentrate on the prevention of (and accompanying disparity elimination of) the three most rapidly increasing diseases in the United States: diabetes, asthma, and obesity.

    To highlight the critical need for more nurses, Secretary Thompson and Education Secretary Rod Paige recently visited a junior high school in Washington, D.C. to launch a national campaign to encourage school children to consider careers in nursing and other health professions. At that time we released the "Kids into Health Careers" tool kit which has information on more than 270 health careers, including nurses, physical therapists, x-ray technicians, and emergency medical technicians. We are very excited about this innovative program and expect tremendous results in minority outreach as we go forward.

    I cannot emphasize enough that the health professions agenda is a critical component of all that we do at HRSA. Millions of Americans face barriers to quality health care because the right mix of health care professionals is not available to serve them.

    HRSA's Bureau of Health Professions works to ensure that an adequate and competent health care workforce is available to meet the health care needs of all Americas, regardless of where they live or how much they make. Assuring an adequate health care workforce requires:

    • Workforce planning and analyses to make sure we're training the right people;
    • High quality education programs to ensure that health professionals have the right skills; and
    • Equitable distribution efforts to make sure professionals are serving in the right places.

    We expect that the demand for health professionals will grow at the twice the rate of all occupations between 1998-2008. The greatest demand is expected for the largest group in the health care workforce: health service occupations. Tending to the health of the growing number of elderly Americans will call for many more nursing aides and home health care aides. The Census Bureau estimates that some 40 million Americans will be over 65 in 2010, 5 million more than currently. By 2030, the number is expected to grow to 66 million as a result of the aging of the large number of baby boomers born between 1946 and 1964.

    One looming problem is apparent among registered nurses. Demand for their services is expected to grow 22% between 1998 and 2008, yet the RN workforce is characterized by declining entrants and an aging population. We predict that a national nursing shortage -- that is, the point at which demand exceeds supply -- will begin in 2007.

    We also are confronting a national pharmacist shortage. In recent years, the growth in the number of prescriptions has been four times that of the growth in the number of pharmacists. In the last two years, the number of vacancies for pharmacists has doubled. Factors contributing to the shortage -- beyond the increased use of prescription medication -- include increased market competition among pharmacy companies and an increase in the time needed to verify third-party coverage. The gap between supply and demand for pharmacists is growing by about 7.5% each year. By 2005, the U.S. will need 35% more pharmacists than we expect to have at that time.

    But distribution of the health care workforce, too, is a problem. Some 50 million people live in more than 2,900 health professions shortage areas; 29 million people are underserved, most of them in predominantly rural counties. To fill alleviate these gaps in access to basic health care, we would need 13,000 primary care physicians willing to serve in these areas.

    Incidentally, we have received from these underserved communities more than 2,900 requests for assistance to recruit National Health Service Corps clinicians. [NHSC became part of the Bureau of Health Professions earlier this year as part of an internal HRSA reorganization.] Yet we estimate we'd need more than 21,000 NHSC clinicians to provide an adequate level of access to health care for all Americans? That's a huge gap. Right now, we only have about 2,400 clinicians serving in needy areas nationwide. The problem of distribution is a national one, but it's especially acute in primarily rural states like Texas. While the U.S. has an average of 59 active primary care physicians per 100,000 population, Texas has only 48 per 100,000 people. More than two-thirds of Texas' 254 counties have fewer primary care physicians than even the state average.

    Diversity, as you know, is an important factor in a nation whose minority populations are expected to reach almost 50% of the total population by 2050. Especially large increases are expected among Hispanics and Asians. Still, in the ranks of physicians, dentists and registered nurses, the percentage of minorities -- and especially of African Americans and Hispanics -- continues to lag behind their percentage of the overall labor force. HRSA responds to the diversity gap by using targeted funding mechanisms to ensure that our funds support programs that are successful in graduating a greater-than-average proportion of minority students. For example, in 2000:

    • The Centers of Excellence program at the University of Kansas Medical Center graduated 107 students, 94 of whom (88%)were minorities;

    • The Nursing Workforce Diversity program at East Tennessee State University graduated 63 students, all of whom were minorities;

    • The University of Michigan's Predoctoral Program in Family Medicine graduated 374 students, half of whom were minorities; and

    • The University of California at Fresno's Area Health Education Center had 469 program completers, 286 of whom (61%) were minorities.

    HRSA-supported training programs in the health care professions graduate 2-5 times more minority and disadvantaged students than training programs that receive no HRSA funds. And we know that these minority health care providers are more likely to practice in underserved areas. A diverse health professions workforce ensures that our most vulnerable citizens get the health services they need in the communities where they live. Professionals who know and understand the culture, the language, and habits of the people they serve produce better health outcomes and more satisfied patients. Our goal is a diverse health professions workforce that reflects not only present demographics in the United States, but also one that will reflect what we will look like in the future -- that's why we look so closely at the Census Bureau's population projections.

    Our work tracking health professions workforce trends makes it possible for those of us in the health care community to look ahead and identify and address future needs. Being able to make accurate future projections has a tremendous impact on how we provide health care as a nation. Take geriatrics and genetics practitioners for example: to meet this growing health care need, we must improve the training of geriatric health professionals. HRSA-supported Geriatric Education Centers provide the only national network that trains health care providers to serve a diverse community of older Americans. We will be working to increase support for geriatric faculty training for all health providers, which will ultimately strengthen the health care services available to our older citizens.

    We also expect the dramatic advances in genetic medicine and technology to have a profound impact on the development of new services that will prevent disease and reduce death rates from inherited conditions. Tomorrow's health professionals must have in-depth training on a variety of issues that can blend genetics information into primary care practice.

    The HRSA Center for Quality has the lead responsibility within the Agency for coordinating health care quality-related activities. Through collaboration with the various Bureaus and Offices, the Center promotes broader use of evidence-based medicine that is patient-centered and culturally appropriate. This is especially important in trying to assure that patients are full partners in working towards improved health outcomes. It is also crucial in supporting increased access to up-to-date clinical guidelines for health professionals in our health centers, Ryan White CARE Act service sites, and other HRSA programs. In consideration of the age, race, ethnicity, gender, sexual orientation, and other characteristics of the patient or health professional, or the clinical diagnosis, we are working towards improvement in health status and satisfaction with the quality of care.

    Our telehealth program is also a vital and growing part of HRSA's outreach efforts. HRSA intends to ensure that telehealth consultation and distance-learning are not just innovative grant programs in their own right -- which will continue -- but that they rapidly become vital parts of all HRSA services. We want to use telehealth technologies to fill the gaps for people and communities who might otherwise go without critical health care. This is especially important since September 11, with our new focus on public health preparedness. The President's budget priorities and the Department's new concerns with confronting bioterrorist threats make telehealth an important part of our response.

    HRSA also administers the Ryan White CARE Act which authorizes an array of programs which provide essential HIV/AIDS health care and drugs, and a wide range of support services to those with HIV/AIDS who are underinsured and uninsured-services including medical care, case managment, assistance in obtaining medications, home-based and hospice care, substance abuse and mental health, and other related services. As the African-American community is now bearing the brunt of new cases of AIDS across the country, no HRSA program is more crucially important to the African-American community at this time. The majority of those served in the general Ryan White CARE Act programs are African-Americans. The Minority AIDS Initiative, which was sponsored by the Congressional Black Caucus, specifically targets assistance to underserved and unserved minority communities, both to provide care and services to those infected with HIV/AIDS and to provide needed assistance in training health care providers for these communities and in developing the health care and support services infrastructure necessary to provide care and treatment.

    The reauthorization of the Ryan White CARE Act in 2000 reflected the efforts of the Congressional Black Caucus to focus needed additional efforts on services to minority communities. The 2000 legislation directs reduction of health disparities by mandating service priorities to those now suffering inequality of services: minorities, rural areas, women, children, and adolescents, including authorizing supplementing limited local resources in order to develop HIV care infrastructure in these communities.

    I would like to mention a few of the Ryan White CARE Act efforts to carry out the mandates of the new law and the Congressional Black Caucus/Minority AIDS Initiative.

    Our success in narrowing health disparities is based in part on our ability to track HIV/AIDS trends which indicate increasing need by minorities, and to incorporate state and local surveillance and epidemiologic and program data into more effective planning and targeting of services and resources. As part of its mission, HRSA is routinely providing its grantees and partners with this vitally needed information and thus providing them with an essential tool in their annual planning and setting of priorities. HRSA is also continuing its development of an HIV/AIDS Bureau database to document, track, and evaluate outcomes through service performance statistics. This latter information can break down service data to provide much needed information on a rural/urban, racial or ethnic basis. This development and sharing of data is essential in identifying and targeting resources to those populations experiencing the greatest need and disparity in services across the country.

    In overcoming the disparities in health manpower available to under-and-unserved populations, the HAB AIDS Education and Training Center continues to provide for the continued development of trained and qualified healthcare professionals. CBC/MAI funding has provided critical focus in these AETC efforts, and the numbers trained attest both to the need for and the success of these trainings: In the past year ending in March, 2002, 1491 MDs, 165 PAs, 2,500 nurses, 415 pharmacists, 700 dentists, and 1,859 other health care professionals received training. The latter included social workers, other medical and dental professionals, technicians, etc.

    The HIV/AIDS Bureau's technical assistance efforts have also focused across all its programs on capacity development in underserved communities. As part of these efforts, HAB has utilized national partnerships to develop effective outreach and technical assistance to health care and support service providers -- and potential providers -- in underserved populations --including technical assistance on how to participate in and become part of HRSA's HIV/AIDS services network.

    One of these partnerships which has been especially productive has been one with the National Minority AIDS Council to implement regional trainings for community-based, AIDS service organizations serving racial and ethnic minority populations -- trainings in organizational assessment, infrastructure development, and resources management. This effort will thus build upon the extremely strong and effective community-based organizations already existing in minority communities. Another initiative in this partnership has developed a multimedia web site incorporating new technologies and making a wide variety of technical assistance widely available across the country to communities developing HIV/AIDS services.

    In efforts to close health disparities, it is crucial to focus on the quality as well as the quantify of services for underserved populations. The reauthorization of the CARE Act brought formal, Congressional mandate for HAB's efforts to assure the quality of services funded by the CARE Act across all CARE Act programs-efforts of crucial importance in view of the many reports of less-than-state-of-the-art care for many minority populations. Requirements that Ryan White CARE Act Titles I and II programs develop, implement, and monitor quality management programs are now in effect. As part of these requirements, quality management programs must assure that demographic, clinical, and health care utilization information is used to monitor the spectrum of the disease and the trends in the local epidemic. There are now ongoing efforts at HRSA to developing quality management tools for grantees, and assuring their use. Their importance in assisting states, communities, and providers in developing and gauging the success -- and the gaps in their programs, is obvious. And their role in assuring quality services as essential as HRSA monitoring grantees for compliance with quality requirements.

    While the challenges ahead are substantial, I want to emphasize that HRSA is ready to meet them. We have identified priority areas for our Agency activities. For example, in infant mortality, HRSA's Low Birth Weight Best Practices Pilot Project utilizes site visits and patient satisfaction to reduce low birth weight for infants of color. To address cancer disparities, HRSA is funding a study designed to develop and test the effectiveness of a community-based model that will increase the number of first-time cancer screenings and follow-up visits among African American residents in five catchment areas in Baltimore for prostate, colon, and breast cancer. To address diabetes disparities, HRSA will continue to support the demonstration project, Innovative Approaches to Promoting Positive Health Behaviors in Women, in Nogales, Arizona. This diabetes-focused border community project provides an interactive health promotion education curriculum for low-income Hispanic women. To address HIV/AIDS disparities, HRSA is attempting to reduce the risk of HIV and STD transmission behaviors among female substance users; enabling Native American communities to care for Native Americans with HIV disease; fund models that promote access to high quality HIV medical care for historically disenfranchised populations; and fund models to ensure the availability of a continuum of HIV services for border communities with high incidence of HIV infection. These are just some examples of future demands that must be met. There will be many others.

    In closing, let me say that working together, we can succeed in our common mission. Let us continue working together to build a diverse health care workforce that can one day serve an America that does not experience the pain of inequitable health care disparities.


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Last revised: April 29, 2002