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In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce (2004)

Chapter: Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions

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Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
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Paper Contribution B
The Role of Public Financing in Improving Diversity in the Health Professions

Karen Matherlee

Public financing of the health professions in the United States is a labyrinth of federal and state initiatives, a maze of both “discretionary” and “mandatory” pathways. This paper follows that labyrinth to examine federal and state health professions programs that affect or encourage the participation of underrepresented minorities (URMs)1 in certain professions in the health workforce. Responding to the mandate of the Institute of Medicine’s (IOM’s) “Strategies for Increasing the Racial and Ethnic Diversity of the U.S. Health Care Workforce” project, the paper focuses on four health professions: medicine (allopathic and osteopathic), dentistry (general and pediatric), nursing, and professional psychology (clinical and counseling). In tracing public funding sources, the paper identifies barriers to and opportunities for changing financial incentives in order to expand URM participation in the four health professions.

1  

URM, a term established in 1970 by the Association of American Medical Colleges, refers to “the disparity between the proportion of health care providers from certain racial and ethnic groups and their total proportion in the U.S. population” (COGME, 1998). The term, as currently used by the U.S. Department of Health and Human Services, includes “Blacks or African Americans, Hispanics or Latinos, American Indians or Alaska Natives, Native Hawaiians or other Pacific Islanders, and Asian subpopulations (any Asians other than Chinese, Filipino, Japanese, Korean, Asian Indian, or Thai)” (U.S. DHHS, 2003b). Although the AAMC originally used the term to recognize the underrepresentation of certain ethnic groups, it recently revised its definition to refer to underrepresented in medicine: “those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population” (AAMC Executive Council, June 26, 2003).

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

“Following the dollars” is a straightforward way of checking out government’s commitment to encouraging diversity in the health workforce. For the most part, that means following the dollars that flow to health professions training, with its links to delivery of health services and conduct of biomedical research. However, because of the nature of the payment flows and unevenness of the available data, the dollars are not easy to follow.

On the federal side, funding for health professions programs comes from congressionally authorized and appropriated legislation—labeled “discretionary”—as well as from the “mandatory” Medicare entitlement program. The Department of Health and Human Services (DHHS) and Departments of Defense (DoD) and Veterans Affairs (VA) administer discretionary health professions programs, while DHHS is also responsible for the Medicare graduate medical education (GME) program. Various states spend grant and Medicaid funds on the health professions, while localities provide some support as well. (See Table PCB-1 for an overview of federal and state health professions funding.)

Although precise figures are difficult to obtain, there is a clear consensus in the health care field that minorities are underrepresented in the health professions. For example, according to the 2000 Census, African Americans made up 12.8 percent of the total U.S. population (U.S. Census Bureau, 2001) but, by the end of 2001, accounted for 2.5 percent of physicians in this country (AMA, 2001). Similarly, persons of Hispanic origin made up 11.8 percent of the population, but only 3.4 percent of physicians, and Native Americans were 0.9 percent of the population, but only 0.06 percent of physicians (U.S. Census Bureau, 2001; AMA, 2001). (The American Medical Association indicates, however, that race and ethnicity are unknown for a large number of physicians, so the percentages of URMs are probably higher.) Of dentists, according to data from the end of the 1990s, only 6.8 percent of U.S. dentists were African American, Hispanic, or Native American (Mertz and O’Neil, 2002).

In ferreting out URM participation in the field of nursing, the data also present a challenge. The summary, The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses, issued in March 2000, indicates that approximately 12 percent of the total number of registered nurses (RNs) “came from racial and ethnic minority backgrounds”: African American/black (non-Hispanic), Asian, Hispanic/Latino, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, and non-Hispanic of two or more races (Spratley et al., 2000).

The document also states that approximately 7.3 percent of the 2,694,540 RNs in the survey could be classified as advanced practitioners: clinical nurse specialists, nurse anesthetists, nurse midwives, and nurse practitioners (Spratley et al., 2000). Although these data do not indicate the

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

percentage of advanced practice nurses from racial and ethnic minority backgrounds (or, more pertinently, those characterized as URMs), they do point to underrepresentation. At the same time, the document notes that “Native Hawaiian and Other Pacific Islander, African American/Black, and white nurses were the racial/ethnic groups with the highest percentages of master’s or doctoral degrees” (Spratley et al., 2000).

For professional psychology, the American Psychological Association (APA) has data indicating that “racial and ethnic minority students represented approximately 18 percent of first-year enrollments” in graduate programs in psychology in 1999–2000 (Pate, 2001). Another study reported by the APA—on persons receiving doctorates in psychology and entering the workforce—found that the number of respondents self-reporting as minority rose from 7 percent in 1985 to nearly 15 percent in 1996. Hispanics and Asians made up about 4 percent each, African Americans fewer than 4 percent, and American Indians “or other” 1 percent, with about 1 percent “multiple race or ethnicity” (Kohout et al., 1999).

Although reams have been written on why underrepresentation is a problem, Jordan Cohen, M.D., president of the Association of American Medical Colleges (AAMC), and two AAMC colleagues recently summed up the “practical reasons” for greater health workforce diversity in a few lines: “(1) advancing cultural competency, (2) increasing access to high-quality health services, (3) strengthening the medical research agenda, and (4) ensuring optimal management of the health care system” (Cohen et al., 2002).

FEDERAL HEALTH PROFESSIONS FUNDING SOURCES

Discretionary Funds

Department of Health and Human Services

The Health Resources and Services Administration (HRSA) is the most prominent public funder of health professions programs in which URM participation is a direct goal or a grant factor. When the goal is direct, it is included in the legislation that authorized HRSA to implement the program. When the goal is a factor—whether a preference, a priority, or a special consideration (sometimes incorporated into grant review criteria)—it is one of several review criteria in HRSA’s grant process (Advisory Committee on Training in Primary Care Medicine and Dentistry, 2001).

HRSA administers Titles VII and VIII of the Public Health Service (PHS) Act. The titles authorize discretionary funds for a variety of programs affecting URM participation in medicine and dentistry (Title VII) and nursing (Title VIII). However, HRSA is dependent on Congress (with the approval of the President) for appropriations, so that specific programs

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

TABLE PCB-1 An Overview of Federal and State Health Professions Funding That Directly or Indirectly Affects Diversity in the Health Professions

Originating Source

Forms of Payment

Recipients

Department of Health and Human Services’ (DHHS’) Health Resources and Services Administration

 

 

Health Careers Opportunities Program

Grants

Medical, dental schools; programs in clinical psychology; other (but not nursing)

Centers of Excellence

Grants

Schools with URM enrollments above national average—medical, dental schools; clinical and counseling psychology; other (but not nursing)

Scholarships for Disadvantaged Students

Scholarships

Medical, dental, nursing, behavioral health (including clinical psychology), and various other schools

Faculty Loan Repayment Program

Loan repayments

Degree-trained health professionals

Nursing Workforce Diversity Program

Grants

Health professions schools

Nursing Education Repayment Program

Loan Loan repayments

Registered nurses

Area Health Education Center

Grants

Schools of medicine and (sometimes) nursing, consortia, parent institutions

Health Education Training Center

Grants

Schools of medicine and (sometimes) nursing

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

Intended Beneficiaries

Payback (if any)

Total Dollars*

Persons from disadvantaged backgrounds

 

FY 2002: $34.6 million

Minority individuals (students and faculty)

 

FY 2002: $32.7 million

Persons from disadvantaged backgrounds

 

FY 2002: $46.2 million

Persons from disadvantaged backgrounds

Service commitment of up to 2 years

FY 2002: $1.3 million (up to $20,000 a year paid on loans)

Persons from disadvantaged Backgrounds

 

FY 2002: $6.2 million

Areas of nursing shortage

Service commitment of up to 3 years

FY 2002: $10.2 million (60 percent of loan for 2 years; 25 percent more for third year)

Delivery of care in underserved areas through improvement of health workforce

 

FY 2002: $33.3 million

Improvement of health care of low-income racial and ethnic minorities in severely underserved areas

 

FY 2002: $4.4 million

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

Originating Source

Forms of Payment

Recipients

National Health Service Corps

Scholarships and loan repayments

Scholarships: persons pursuing medicine, dentistry, nurse practitioner, nurse midwife, physician assistant, psychology careers; loan repayment: same as above plus additional health professions

Children’s Hospitals Graduate Medical Education Program

Grants

Children’s hospitals

DHHS’ National Institutes of Health

 

 

Minority Access to Research Careers

Grants and fellowships

Research institutions with substantial minority enrollments

Minority Biomedical Research Support

Grants

Higher education institutions with 50 percent or more minority enrollment underrepresented in biomedical or behavioral research

Loan Repayment Program for Health Disparities Research

Loan repayments

Lenders (half of loan repayments earmarked for URMs)

Research Supplements for URMs

Grants

Research institutions

Extramural Loan Repayment for Individuals from Disadvantaged Backgrounds Conducting Clinical Research

Loan repayments

Persons with advanced health professions degrees who come from disadvantaged backgrounds

Undergraduate Scholarship Program

Scholarships

Persons from disadvantaged backgrounds

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

Intended Beneficiaries

Payback (if any)

Total Dollars*

Expansion of health care to persons in need (rural and inner city)

Scholarships: year of service for each year of support, with minimum of 2 years and maximum of 4 years; loan repayment: 2-year service requirement, with possibility of additional service

FY 2002: $46.2 million (field operations)

Training of pediatric and other residents in GME programs

 

FY 2002: $284.9 million

Increase in number and capabilities of URMs in biomedical research

 

FY 2002: About $3 million

Strengthen URM faculty, research environment, URM student capabilities

 

FY 2002: About $92 million

Conduct of research related to minority health disparities

2 years of research related to disparities, with possibility of extension

FY 2002: About $2 million (up to $35,000 a year, depending on loan debt)

Recruitment, and retention, of minority individuals to research

 

Unavailable

Recruitment and retention of health professionals from disadvantaged backgrounds to conduct clinical research

2 years of clinical research, with possibility of extension

FY 2002: Slightly more than $1.9 million

Pursuit of careers in research at NIH

1 year of employment at NIH for each scholarship year

FY 2002: $620,000 (up to $20,000 per year for up to 4 years)

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

Originating Source

Forms of Payment

Recipients

Department of Defense

Health Professions Scholarship Program

Scholarships

Persons joining Army, Navy, Air Force

Graduate Medical Education

Graduate training costs (in addition to salary)

Interns, residents, and fellows in Army, Navy, Air Force

Health Professions Loan Repayment Program

Loan repayments

Health professionals in Army

Department of Veterans Affairs

Clinical Training

Direct grants to students and indirect support to VA medical centers

Students and trainees in 4,000 education programs at 1,200 colleges and universities affiliated with VA

Mentored Minority Research Enhancement Coordinating Center

Grants

Minority-serving institutions

Mentored Minority Supplemental Award

Grants

VA-funded research projects

Mentored Minority Career Enhancement Award

Salaries

Mentored researchers in VA

National Science Foundation

Louis Stokes Alliances for Minority Participation

Grants

Research institutions

Alliances for Graduate Education and the Professoriate

Grants

Research institutions

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

Intended Beneficiaries

Payback (if any)

Total Dollars*

Ensurance of adequate number of active-duty health professionals

Up to 4 years and longer for graduates of Uniformed Services University of the Health Sciences

Not available (each service has its own budget)

Ensurance of adequate number of active-duty health professionals

Service commitment

FY 2002: Estimated $86 million in training costs ($222.4 million for salaries)

Ensurance of adequate number of active-duty health professionals

Service commitment (1 year for each annual loan repayment)

Not available

Ensurance of adequate number of health professionals to treat patients in VA facilities

 

FY 2002: $786 million ($438 million in direct costs and $348 million in indirect costs)

Mentoring

 

New program

Applied research training to students, high school through postdoctoral

 

New program

Nurturing of researchers

 

New program

Strengthen preparation of minority students in science, math, engineering, and technology

 

FY 2003: Approximately $6 million

Increase in number of URMs receiving doctorates in science, math, engineering, and technology

 

FY 2002: Approximately $1 million to $2 million

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

Originating Source

Forms of Payment

Recipients

Centers of Research Excellence in Science and Technology

Grants

Research institutions (minority serving)

Medicare Graduate Medical Education

Direct and indirect payments

Approximately 1,200 teaching hospitals (and limited other facilities)

States

 

 

Grants

Various grant initiatives for family physicians, rural underserved programs

Considerable variation from state to state

Medicaid Graduate Medical Education

Various forms of payment (e.g., direct and indirect, per case or per diem)

Teaching hospitals, medical schools; in some cases, managed care organizations

*FY 2002 figures are used when available for purposes of comparability.

SOURCE: Drawn from various online federal program descriptions and budget documents, including some of the references listed at the end of this paper.

in its budget (a Bush administration request of $6.4 billion for all HRSA operations in fiscal year 2004) (U.S. DHHS, 2003b) are often at risk.

According to HRSA Administrator Elizabeth M. Duke, Ph.D., “HRSA-supported training programs in the health care professions graduate two to five 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” (Duke, 2002). HRSA’s Office of Minority Health is involved in the four White House initiatives on Historically Black Colleges and Universities, Educational Excellence for Hispanic Americans, Tribal Colleges and Universities, and Asian Americans and Pacific Islanders, as well as the White House’s Hispanic Agenda for Action Initiative, Association of Hispanic-Serving Health Professions Schools, Minority Health Knowledge Management Initiative, Minority Management Development Program, Minority Training Programs Tracking System, and Cultural Competence Initiative (HRSA, 2003i).

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

Intended Beneficiaries

Payback (if any)

Total Dollars*

Development of outstanding research centers

 

FY 2003: Approximately $5 million

Recognition of costs of training physicians and limited other practitioners primarily in inpatient setting

 

FY 2002: Estimated $9 billion

Mainly expansion and distribution of practitioners to underserved areas

 

Not available

Primary care training, preparation of practitioners for underserved areas; New York: increase in number of URMs

 

Last estimate (1998) as result of survey: $2.3 to $2.4 billion

The most recent study of HRSA diversity programs, Strategies for Improving the Diversity of the Health Professions, was conducted by Kevin Grumbach, Janet Coffman, Claudia Muñoz, and Emily Rosenoff of the Center for California Health Workforce Studies, University of California at San Francisco (UCSF), and Patricia Gándara and Enrique Sepulveda of the Education Policy Center, University of California, Davis, and published by The California Endowment (Grumbach et al., 2003). Because most of the programs focus on “disadvantaged” students, the research team addressed whether or not there is a correlation between “disadvantaged” and “URM.” The researchers concluded that lack of basic educational opportunities for many minority groups leads fundamentally to the underrepresentation of these groups in the health professions. They also indicated that “URM students are more likely than non-URM students to come from low-income families, and are therefore disproportionately affected by the rising costs of higher education and adverse trends in the availability of financial aid” (Grumbach et al., 2003).

Following are HRSA programs in which URM participation is either a

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

direct goal or an influence on funding, such as a “disadvantaged/minority funding factor,” preference, or priority:

  • The Health Careers Opportunity Program (HCOP) is aimed at drawing a more diverse applicant pool to the health professions by providing students from disadvantaged backgrounds with opportunities to receive degrees from health professions programs. HCOP accounted for $36 million in FY 2003, with the funds awarded to allopathic and osteopathic schools of medicine, dental schools, and graduate programs in clinical psychology, as well as to other health institutions (HRSA, 2003b).

  • The Centers of Excellence (COE) program awards grants to health professions schools (allopathic and osteopathic medicine, dentistry, and graduate programs in clinical and counseling psychology, as well as clinical social work, marriage and family therapy, and pharmacy) with enrollments of URMs that are significantly above the national average. The COE program enables the schools to address their applicant pools, engage in faculty development, focus on minority issues in clinical education, promote faculty and student research in minority health, provide community-based clinical training involving significant numbers of racial and ethnic minorities, and offer stipends to URMs. The program also requires the grantee institutions to improve their recruitment and retention of URM faculty and to open up research opportunities for faculty as well as students (HRSA, 2003a). The COE program in FY 2003 accounted for approximately $34 million.

  • The Scholarships for Disadvantaged Students (SDS) program makes grants to health professions schools (allopathic and osteopathic medicine, dentistry, nursing, and behavioral health, including clinical psychology, as well as various other disciplines) to provide assistance to disadvantaged students (HRSA, 2003e). The SDS program was funded at nearly $48 million in FY 2003.

  • The Faculty Loan Repayment Program (FLRP) provides funds directly to degree-trained health professionals to pursue careers in academia. Directed at disadvantaged individuals (with “minority status in and of itself not a factor in determining disadvantaged background”), the program requires a service commitment of up to 2 years; HRSA pays up to $20,000 a year on the person’s educational loans in return (HRSA, 2003c). FLRP accounted for slightly over $1 million of HRSA’s budget in FY 2003.

    A 2001 evaluation by the DHHS Office of Inspector General (OIG) revealed that FLRP routinely waives the institutional matching requirement, which has “the potential impact of reducing the effectiveness of federal funds.” Participating institutions are supposed to match the federal loan repayment amount, unless they can demonstrate financial hardship.

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

“OIG found that waivers are routinely granted without an in-depth review of the institutions’ financial condition” (HRSA, 2003c).

  • The Nursing Workforce Diversity Program is HRSA’s principal program for “improving the racial and ethnic diversity of the basic nursing workforce.” The program is aimed primarily at expanding nursing education opportunities at the baccalaureate level for persons who come from disadvantaged backgrounds (“including racial and ethnic minorities underrepresented among registered nurses”) (HRSA, 2003h). In some respects, it parallels the HCOP, which is not open to nursing. Schools of nursing, nursing centers, academic health centers, state and local governments, and others receive funds to support academic preparation activities, retention efforts, and student stipends. The program received nearly $10 million in FY 2003.

  • The Nursing Education Loan Repayment Program (NELRP) offers registered nurses opportunities to pay back educational loans in exchange for service in health facilities in areas with nursing shortages. In return for a 2-year commitment, HRSA will pay 60 percent of a nurse’s loan. If the nurse serves a third year, HRSA pays an additional 25 percent. Among the approved health facilities are Indian Health Service and Native Hawaiian health centers, community health centers, migrant health centers, rural health clinics, and public health clinics (HRSA, 2003g). HRSA’s budget for NELRP was nearly $20 million in FY 2003.

  • The Area Health Education Center (AHEC) and Health Education and Training Center (HETC) programs are closely aligned. While the major mission of the AHEC program is “to improve the supply, distribution, quality, utilization, and efficiency of the health workforce to ultimately improve delivery of quality health care in underserved areas,” it has the related objective of improving health workforce diversity (Grumbach et al., 2003). The HETC program, which has the same mission as the AHEC program, focuses on Florida and states along the border between the United States and Mexico (Grumbach et al., 2003). HRSA uses minority and disadvantaged student funding factors in its grant processes for both. AHECs received approximately $33 million and HETCs obtained more than $4 million in FY 2003.

  • The National Health Service Corps (NHSC) has a scholarship program for individuals entering medical, dental, family nurse practice, and certified nurse-midwifery programs (among others) and a loan repayment program for “a long list of medical professionals, among them physicians, nurses, and dentists” (Thompson, 2002). Reauthorization of the NHSC program in 2002 resulted in psychologists being listed as “primary care providers” in the scholarship program, along with physicians, dentists, and nurses (APA, 2002). (Practicing psychologists remained eligible for the loan repayment program.)

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

NHSC accounted for a total of $171 million of HRSA’s FY 2003 budget. Field operations amounted to nearly $46 million and NHSC recruitment to slightly more than $125 million.

While NHSC’s main purpose is to expand access to health services to persons most in need (especially in rural and inner city settings), the organization offers service opportunities to providers. HRSA reserves some of its funding to target recruitment of “URMs and other students and professionals from disadvantaged backgrounds into the program” (Duke, 2003). In its 2001 annual report, HRSA indicated that 25 percent of NHSC scholarship and loan repayment awards had gone to URMs (HRSA, 2001a).

An evaluation of the NHSC program in 2000 by researchers at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill and at Mathematica Policy Research, Inc., did not address the topic of URM inclusion and retention in NHSC. However, it did look at affirmation of cultural competence and cultural concordance in NHSC practice:

Over the years, NHSC clinicians have come to accept the affirmation of cultural competence as an important element in health care practice. On the other hand, they have been less receptive to the notion of cultural concordance through the matching of clinicians to communities. Nonetheless, cultural concordance finds greater support among members of racial and ethnic minority groups that have been historically underrepresented in the health professions. Moreover, women (compared with men) are also more likely to affirm the importance of cultural concordance and cultural competence (Konrad et al., 2000).

  • Some other HRSA programs affecting the four professions also take into account disadvantaged/minority funding factors in their grant processes. For example, the Geriatric Education Centers program grants 10 points if an applicant’s project has the potential to recruit and retain minority faculty members and trainees and improve access to a diverse and culturally competent workforce, according to HRSA’s FY 2003 application kit for the program. The Primary Care Medicine and Dentistry Grant Program grants 20 points for diversity, in terms of an applicant’s racial and socioeconomic makeup of trainees and faculty and its goal of increasing the proportions of both in the health professions workforce, according to that program’s application kit.

The Children’s Hospitals Graduate Medical Education (CHGME) program is a recently enacted initiative given to HRSA to administer. Congress authorized the program in 1999 in response to complaints that children’s hospitals received “$374 per resident in Medicare funds versus an average of $87,034 per resident for a non-children’s hospital” because of their low proportion of Medicare patients. CHGME provides funds to children’s

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

hospitals “to support the training of pediatric and other residents in GME programs” (Advisory Committee on Training in Primary Care Medicine and Dentistry, 2001). Rather than making CHGME permanent or mandatory (like Medicare GME), Congress established it as an interim discretionary program while it “examines the medical education funding system.” CHGME received $40 million in 2000, $235 million in 2001, $285 million in 2002, and $292 million in 2003. The President is requesting $199 million in 2004 (U.S. DHHS, 2003b).

The National Institutes of Health, through its National Institute of General Medical Sciences (NIGMS), has administered two programs for more than 20 years to increase the number of minority biomedical scientists. The programs support graduate and postdoctoral (as well as undergraduate) students, faculty members, and education and research infrastructure improvements in institutions in the United States. They are directed toward, but not limited to, “African Americans, Hispanic Americans, Native Americans (including Alaska Natives), and natives of the U.S. Pacific Islands” (NIGMS, 2002). Following are descriptions of the two programs:

  • Minority Access to Research Careers (MARC), one of the NIGMS programs, includes postbaccalaureate research education program awards, predoctoral fellowships, faculty predoctoral fellowships, and faculty senior fellowships, as well as an undergraduate student training award. The MARC program budget has been running at nearly $31 million a year. In 2001 (in addition to 647 students at undergraduate institutions), the program supported 45 students with MARC predoctoral fellowships and 75 NIH predoctoral fellows and 2 faculty members (NIGMS, 2002).

  • Minority Biomedical Research Support (MBRS), the other NIGMS program, makes awards to “two- or four-year colleges, universities, and health professional schools with 50 percent or more enrollments of minorities that have been determined by the grantee institution to be underrepresented in biomedical or behavioral research.” It may also provide awards to institutions that have enrollments of less than 50 percent if they “have a demonstrated commitment to the special encouragement and assistance of minority students” (NIGMS, 2002). The MBRS program, which operates with an approximate annual budget of $92 million, has three components: Support of Continuous Research Excellence (SCORE), which is faculty oriented; Research Initiative for Scientific Enhancement (RISE), which is environment centered; and Initiative for Minority Student Development, which is focused on undergraduate, graduate, and postdoctoral students (NIGMS, 2003).

In addition to being reviewed by Grumbach and his colleagues, the

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

MARC and MBRS programs are cited in the Council on Graduate Medical Education’s (COGME’s) Twelfth Report: Minorities in Medicine, issued in 1998. In addition, the MARC program was the subject of a lengthy evaluation covering cohorts for 1981–1985, 1986–1990, and 1991–1993 (NIGMS, 2000).

The NIH also has the following programs:

  • The Loan Repayment Program for Health Disparities Research, a program administered by the NIH National Center on Minority Health and Health Disparities, provides educational loan repayment to qualified individuals to engage in basic, clinical, or behavioral research that is related to minority health disparities. Half of the program’s awards are earmarked for persons from populations with health disparities. Participants may receive up to $35,000 per year, with the awards going directly to lenders.

  • This program emphasizes the recruitment of racial and ethnic minorities and other underrepresented individuals to conduct research because such emphasis “promotes a diverse and strong 21st century workforce” that is able to address society’s diverse needs. The program enables the NIH to support and facilitate the development of research programs that reflect an understanding of the variety of issues and problems associated with disparities in health status (National Center on Minority Health and Health Disparities, 2003). The Extramural Loan Repayment for Individuals from Disadvantaged Backgrounds Conducting Clinical Research program encourages qualified health professionals from minority backgrounds to enter and remain in clinical research careers. Participants commit to at least 2 years of conducting clinical research in return for having payments made to pay off their educational debts (Catalog of Federal Domestic Assistance, 2003).

  • The Extramural Associates Research Development Award program provides grants to minority and women’s educational institutions that are seeking to increase their participation in biomedical and behavioral research and training. Since 1994, the NIH has made grants to 44 institutions in this country. An evaluation of the program—due September 30, 2004—is under way (U.S. DHHS, 2003a).

  • Research Supplements for Underrepresented Minorities, a program initiated by the NIH in 1989, is designed to increase the number of URM scientists in biomedical research and the health-related sciences. The NIH established the program to encourage principal investigators with NIGMS grants to request supplemental funds to attract and retain minority individuals in biomedical research careers. Then, in 2001, the NIH, acknowledging that the need to expand research opportunities for URMs was as great as ever, renewed its call. The agency provided contacts for interested investigators in 18 of its institutes and the National Library of Medicine,

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

National Center for Research Resources, Fogarty International Center, National Center for Complementary and Alternative Medicine, and Office of Behavioral and Social Sciences Research (NIH, 2001).

  • The Undergraduate Scholarship Program is aimed at students who want to pursue “careers in biomedical, behavioral, and social science research at the NIH.” The program pays up to $20,000 per year (for a maximum of 4 years, with annual renewal required) (NIH, 2003). The program has a service commitment of a year’s employment at the NIH for each scholarship year. The program is for persons from disadvantaged backgrounds. “Disadvantaged” is defined as coming from a low-income family. The program is neutral as to race and ethnicity.

Department of Defense2

DoD provides support for health professions education through the Armed Forces Health Professions Scholarship Program (HPSP), authorized by the Uniformed Services Health Professions Revitalization Act of 1972. The purpose of the program is to obtain adequate numbers of qualified active-duty health professionals (U.S. Navy Medical Education and Training Command, 2003). Up to 5,000 HPSP scholarships are authorized across the Army, Navy, and Air Force, with each of the services having its own budget allocation, operating its own HPSP, and determining the disciplines to be eligible and the number of scholarships to be made available. These parameters may vary over time.

HPSP scholarships provide full tuition, laboratory fees, books, insurance, and a living stipend for education in medicine, dentistry, nursing, and other health professions such as veterinary medicine, optometry, psychology, pharmacy, and clinical psychology (U.S. Navy Medical Department, 2003). For example, the Army currently sponsors 1,511 HPSP scholarships in five disciplines, of which 1,065 (about one-third) are in medical training (personal communication, K. Raines, Director, Medical Education, Medical Corps, Department of the Army, August 28, 2003). Scholarships are granted to participants in return for their performing subsequent service as active-duty health professionals on a year-for-year basis, with up to 4 years of commitment beyond training and a longer period for graduates of the Uniformed Services University of the Health Sciences.

DoD also carries out a significant program in GME. It is responsible for

2  

The author gratefully acknowledges the contributions (research and writing) of F. Lawrence Clare, M.D., a private consultant, to the Department of Defense section of this paper.

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

about 3 percent of all U.S. medical residents. The department currently supports 2,965 interns, residents, and fellows in military GME programs, at an annual level of $104,000 each. While that support amounts to $308.4 million per year, $70,000 to $80,000 per individual is for salary, which DoD does not consider to be part of graduate training costs. When $222.4 million (based on $75,000 each) is subtracted, DoD estimates its annual training cost at $86 million (personal communication, J. Powers, Director, Clinical and Medical Education, Assistant Secretary of Defense for Health Affairs, June 3, 2003).

A considerable portion of the new entrants in military GME programs are there because they have HPSP scholarship obligations. In the Navy’s 58 in-service GME programs, for example, graduating HPSP scholarship recipients fill about 200 of the service’s 258 first-year GME positions. The Navy has more than 900 total in-service positions and another 120 in civilian GME programs (U.S. Navy Medical Department, 2003).

The Army also uses a Health Professions Loan Repayment Program to enhance recruitment of needed health professionals. The program provides annual grants to qualified practitioners in many health professions to help them repay their educational loans, in exchange for a year of service commitment for each grant (U.S. Army, 2003b).

At the college or undergraduate level, each service has a Reserve Officer Training Corps (ROTC) program, which can help facilitate entry into health professions education through ROTC scholarships. The Army, for example, provides ROTC scholarships at more than 600 schools. The scholarships provide payments for tuition and fees, monthly stipends, and book allowances, in return for a service commitment after completion of education (U.S. Army, 2003c). Graduating ROTC cadets may apply for HPSP scholarships, and HPSP recipients receive delays in entering required service. Air Force ROTC “pre-health” scholarship recipients are specifically guaranteed HPSP scholarship awards after acceptance to medical school. In addition, it is not necessary for a graduating ROTC cadet to have an HPSP scholarship to receive a delay in the service obligation if he or she enters health professions training. Specific nurse ROTC programs are available from both the Army and the Navy (U.S. Army, 2003c).

Because DoD’s health professions programs are insular—conducted for the purpose of having sufficient numbers of health professionals for the various services—and because they are compartmentalized by service, it is difficult to get a profile of the numbers of URMs participating in the programs. However, minorities are overrepresented in the military relative to their share of the overall population: They account for 40.8 percent of Army, 35.6 percent of Navy, 32.4 percent of Marine Corps, and 29.4 percent of Air Force personnel, according to 2000 data. African Americans, for example, make up 26.4 percent of Army personnel, compared to 12.8

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

percent of the general population. However, African Americans constitute only 11.3 percent of Army officers (physicians, dentists, nurses, and other health professionals tend to be in the officer ranks). Overall, omitting warrant officers, 20.6 percent of Army, 16.9 percent of Navy, 14.8 percent of Marine Corps, and 14.1 percent of Air Force officers are minority (Minorities in Uniform, 2000).

Department of Veterans Affairs (VA)

The VA, which serves a veteran population of more than 25 million men and women, has been training health care professionals for more than 50 years, in part to recruit personnel to and retain them in the VA health care system. The VA is the largest single provider of clinical health services in the United States and is second only to DHHS’ Centers for Medicare and Medicaid Services (CMS), which administers Medicare GME, as a federal funder of health professions education. The VA supports 8,800 physician resident positions and accounts for approximately 9 percent of GME in this country (U.S. VA, 2003a).

“Each year, over 76,000 students and trainees receive some or all of their clinical training in VA through affiliations with over 4,000 education programs at 1,200 colleges and universities”(personal communication, G. J. Holland, Special Assistant to the Chief Academic Affiliations Officer, VA, April 4, 2003). Those in training include medical, dental, nursing, and clinical psychology interns, as well as other health professionals. Rather than providing awards to the institutions themselves, the VA provides direct support for students receiving training in the VA. Direct support includes the salary and fringe benefits paid directly to medical residents and associated health trainees. The VA also provides indirect support in its medical centers through VA staff who serve as instructors and through various administrative costs that are associated with its health professions programs. In 2002, the VA’s education and training budget was $786 million: $438 million in direct costs and $348 million in indirect costs (personal communication, Holland, 2003).

The VA generally does not have breakdowns by race and ethnicity for participants in its clinical training programs. However, the VA does have statistics for participants (all of whom, of course, are not URMs) from the historically black colleges, historically Hispanic-serving institutions, and tribal colleges and universities with which it has affiliation agreements. Thirty-two historically black colleges have affiliations with the VA, resulting in 1,102 of their students having received clinical training in VA facilities in 2002. These included 166 medical residents, 5 specialized fellows, and 78 medical students. They also included 22 dental residents, 457 professional nurses, and 1 in mental health (not otherwise specified). Thirty-

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

four historically Hispanic institutions have affiliations with the VA, with 3,395 of their students having gotten part of their clinical training in VA facilities in 2002. These included 1,283 medical residents, 1 specialized fellow, and 471 medical students; 32 dental residents; 694 professional nurses; and 53 in mental health. Two tribal colleges and universities have VA affiliations, resulting in 10 of their students having received clinical training in 2002. Of these, 9 were professional nurses (personal communication, Holland, 2003).

The VA is unveiling three new research training programs in 2003. The programs expand the collaboration between VA health facilities and historically black colleges and universities, Hispanic-serving institutions, and tribal colleges and universities to include several minority-oriented national organizations and “institutions of higher education with sizeable concentrations of Asian Americans, Pacific Islanders, Native Hawaiians, Native Americans, Alaskan Natives, or persons with disabilities” (U.S. VA, 2002).

The three new programs (U.S. VA, 2002) include the following:

  • Mentored Minority Research Enhancement Coordinating Center, to support collaboration between the VA and minority-serving institutions, with students and faculty from the institutions partnering with mentors from the VA.

  • Mentored Minority Supplemental Award, to provide applied research training with investigators on VA-funded research projects, with high school, undergraduate, graduate, and predoctoral students eligible.

  • Mentored Minority Career Enhancement Award, to provide full salary for 3 years to mentored researchers in the VA.

National Science Foundation

The National Science Foundation (NSF), a freestanding entity in the federal budget, funds basic research as an underpinning of other science and engineering government functions. “Although the NSF represents less than 4 percent of the total federal budget for research and development, it accounts for approximately 13 percent of all federal support for basic research and 40 percent of non-life-science basic research at U.S. academic institutions.” About 95 percent of the NSF’s budget goes directly to educational and research institutions and contractors (OMB, 2003).

The NSF’s efforts “include the recruitment and retention of minority students into doctoral science, mathematics, engineering, and technology programs, recruitment of minority faculty, and the strengthening of research capabilities of historically African American colleges and universities.” Its programs include the Louis Stokes Alliances for Minority Partici-

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

pation, Alliances for Graduate Education and the Professoriate, and Centers of Research Excellence in Science and Technology, plus an undergraduate-level program at historically black colleges and universities (Grumbach et al., 2003).

Mandatory Funds: DHHS’ Medicare GME Program

The premier health professions program in terms of dollars spent is Medicare GME, administered by CMS.3 Because Medicare is a service delivery program for eligible persons 65 and older and for younger people with disability determinations, its GME program is viewed within the rubric of patient care. Outlays for the GME program are estimated at $9 billion for FY 2002 (CMS, 2002). Medicare GME funding, paid to teaching hospitals under Part A of the Medicare program, has two components: direct and indirect. Direct GME funds cover allopathic, osteopathic, podiatric, and dental residents’ salaries and fringe benefits; allocated hospital overhead connected with training programs; and other costs (such as teaching physicians’ supervisory costs). Although podiatrists and dentists (for example, those doing inpatient surgery) who choose hospital residencies and those that may be part of certain ambulatory arrangements are included in Medicare GME, the program centers predominately on physicians.

Indirect GME funds recognize the added costs teaching hospitals incur as a result of their teaching programs. Indirect medical education payments began in FY 1984, as part of the new inpatient prospective payment system (PPS). Add-ons to the diagnosis-related-group rates upon which the inpatient PPS operates, indirect payments are currently paid at the rate of 5.5 percent per 0.1 intern/resident per bed (IRB).

Medicare GME funds, which go to approximately 1,200 teaching hospitals across the country, are concentrated in about 120 major teaching hospitals that have high IRB ratios. These hospitals have about half of all residents and receive approximately two-thirds of all indirect payments. There are some nursing and allied health expenditures in the Medicare GME program, but they are modest amounts (approximately $300 million), given the billions in outlays for the program. As hospitals close diploma schools of nursing and related educational programs, the amounts are dwindling rather than growing.

3  

For a description of Medicare GME within the context of the Medicare program, see Matherlee K. 2003. The U.S. Health Workforce: Definitions, Dollars, and Dilemmas. Washington, DC: National Health Policy Forum, George Washington University. Pp. 6-11. Much of the Medicare GME description is drawn from that document.

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

The Medicare GME program has not been involved in efforts to increase the participation of URM physicians, podiatrists, or dentists—or any other URM health professionals—in the health workforce. From a policy standpoint, however, Congress has linked the program to attempts to control physician supply by capping the number of physician residents per teaching hospital effective the start of each hospital’s 1996 fiscal year (with podiatric and dental residents excluded from the cap). Congress has also linked the program to efforts to shift training from inpatient hospital to outpatient settings by authorizing direct (but not indirect) payments to organizations such as community health centers, rural health clinics, and certain managed care organizations if they incur the costs of operating approved residency programs. Moreover, Congress has linked the program to primary care training incentives.

STATE HEALTH PROFESSIONS FUNDING SOURCES

Various states have health professions initiatives, both in grant form and as part of Medicaid, the federal-state program that provides health services to certain persons and families with low incomes and assets. Although the challenge of keeping up with health professions programs that vary state by state is daunting, Tim Henderson, director of the Institute for Primary Care and Workforce Analysis, National Conference of State Legislatures, has tracked them for more than a decade. He was joined several years ago by HRSA’s National Center for Health Workforce Analysis, which has Regional Centers for Health Workforce Studies at UCSF, State University of New York at Albany (SUNY at Albany), University of Illinois at Chicago (UIC), University of Washington (UW), and University of Texas (UT) to collect data on state practices and policies. The National Center for Health Workforce Analysis is tracking activities in 10 states: California, Connecticut, Florida, Illinois, Iowa, Texas, Utah, Washington, West Virginia, and Wisconsin.

Grant Funds

Data from the Institute for Primary Care and Workforce Analysis

The Institute for Primary Care and Workforce Analysis distinguishes three states that are using innovative financing approaches in addressing state health workforce needs. They are Arkansas, Colorado, and Texas. The states use appropriated funds for family practice residencies aimed at increasing the number of physicians who provide primary health care in underserved areas. Although the programs do not have explicit goals re-

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

garding URM physicians, they do exemplify the use of funds to address specific workforce goals.

Arkansas has had a program of community family physician residency programs for more than 25 years. The goal of the program is to distribute physicians to underserved populations throughout the state. Developed in collaboration with the state’s AHEC, the program has six community-based family medicine residency practices outside Little Rock, the state’s largest city. Credited with providing most of the state’s rural physicians, it provides opportunities for 45 percent of graduating medical residents to practice in communities with populations of less than 20,000.

The Arkansas state legislature recently agreed to appropriate $4 million of the state’s tobacco settlement to support the community residency programs. According to Henderson, the legislature is interested in tying the program to the state’s Medicaid GME program in order to receive additional federal Medicaid matching funds for the teaching hospitals that are affiliated with the community residencies.

Colorado, which has had a program for 25 years, directs its efforts to the needs of rural and urban underserved communities for family physicians. Run by a committee of academic, provider, and consumer representatives, the program includes 10 family practice residencies that currently train approximately 200 residents. While 80 percent of the residents in the program are from medical schools outside Colorado, two-thirds of the graduates remain in the state to practice, with about 25 to 30 percent opting for a rural or urban underserved area practice. The Colorado legislature makes an annual appropriation of about $2.4 million to the program.

Texas has a program, also 25 years old, to fund postgraduate training in family medicine. By the late 1990s, the state provided approximately $11 million to 26 programs for more than 700 positions, sponsored by medical schools in the state. It requires the schools to have substantial support from other sources, such as patient revenues and local funds.

Statistics from the National Center for Health Workforce Analysis

The National Center for Health Workforce Analysis offers the following statistics for 1994–1998 on allopathic medical school graduates characterized as URMs, with 10.5 being the U.S. average and Texas providing the only overlap with Henderson’s analysis (National Center for Health Workforce Analysis, 2001):

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×
  • California—16.7

  • Connecticut—13.1

  • Florida—7.6

  • Iowa—8.0

  • Illinois—8.8

  • Texas—12.7

  • Utah—2.5

  • Washington—7.4

  • West Virginia—1.0

  • Wisconsin—8.3

Medicaid GME

Even before the Medicaid program was enacted in the mid-1960s, most states had some expenditures for medical education, mainly for undergraduate training. After Medicaid’s inception, states became contributors of the second largest amount of explicit GME funding. According to a study that Henderson conducted for the AAMC in 1998 and 1999:

  • A total of 45 states and the District of Columbia paid for GME at some level.

  • Of the 45 states and the District of Columbia, 43 paid for GME in their fee-for-service (FFS) programs. Of these, 24 made both direct and indirect payments and 11 did not distinguish between the two. Thirty-five of the states that paid for GME under FFS did so through hospital per-case or per-diem rates.

  • Of the 42 states and the District of Columbia that reported capitated Medicaid arrangements, 16 states and the District of Columbia made explicit Medicaid GME payments to teaching hospitals or teaching programs. Seventeen other states included the payments in managed care organizations’ capitated rates. Teaching hospitals were the recipients of most states’ GME payments, although, in Oklahoma and Tennessee, medical schools were the only training programs to receive them directly under managed care.

  • While medical residents were predominantly eligible for Medicaid GME payments, nurses and other health professions students were eligible under managed care (or there was no distinction among the health professions) in eight states and the District of Columbia.

  • Of the five states—Alaska, Idaho, Illinois, Montana, and South Dakota—that either did not report or indicated they did not provide Medicaid GME support, only Illinois had significant residency programs. (In the case of Illinois, how the state labels “Medicaid GME support” may mask funds that go to support GME.) South Dakota did not report any GME payments

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

to its teaching hospital or medical school. Puerto Rico also indicated no Medicaid GME support (Henderson, 2000).

Henderson estimated total state Medicaid expenditures on GME in 1998 at $2.3 to $2.4 billion.

In a summary prepared earlier this year, Henderson singled out four states—Georgia, Michigan, Tennessee, and Utah—as particularly noteworthy relative to their linking Medicaid payments to state workforce goals, and two states—Minnesota and New York—for being especially creative in pooling Medicaid and other payment sources:

  • Georgia’s Medicaid program began paying a lump sum to the Medical College of Georgia in 2000 to support core clinical training activities in the state’s five AHECs. Through an intergovernmental transfer (IGT), the sum—part of an appropriated budget for the AHEC program—was used to draw down additional federal Medicaid matching funds for clinical training of physician residents needed by the state’s medically underserved regions. Currently the total value of this “new money” is $1.45 million.

  • Michigan established three Medicaid GME pools in 1997 in order “to bring physician education more in line with its specific public policy goals to train appropriate numbers of primary care providers, enhance training in rural areas, and support education in ways of particular importance in the treatment of the Medicaid-eligible population.” For the first 3 years, there were a historic cost pool to reimburse each hospital based on what it had received in 1995; a primary care pool to encourage the training of young physicians in primary care fields (general practice, family practice, preventive medicine, obstetrics, and geriatrics) based on a hospital’s residents in primary care and its share of Medicaid patients; and an Innovations in Health Professions Education Grant Fund.

The innovations fund, financed with GME dollars that formerly were included in capitation payments to managed care organizations, was designed to foster innovations in health professions education. Funds are available only to consortia consisting of at least a hospital, a university, and a managed care plan. Examples of initiatives funded include curriculum changes to add exposure to managed care, development of evidence-based-medicine teaching experiences, and interdisciplinary efforts among different health professions.

The state started using a new Medicaid GME formula that considered characteristics of the state’s Medicaid population. It also began to require hospital participation in a managed care plan in order to receive GME funds. In addition, it opened the program to third- and fourth-year dental students to increase the participation of dentists in Medicaid and agreed to

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

use the IGT mechanism to develop physician residency programs in psychiatry to provide training in community mental health settings.

  • When Tennessee replaced its Medicaid program with TennCare in 1996, it became the only state to require that Medicaid GME funds go directly to medical schools. Under this stipulation, GME funds follow residents to training sites and are distributed by the state’s medical schools to pay residents’ basic stipends and supplements for primary care training in community sites (as well as underserved areas). By July 1, 2000, half of the aggregate residency positions under the sponsorship of the state’s four medical schools were to be in one of the primary care specialties.

    Although the program has experienced problems in recruitment and retention, TennCare has extended the program through 2007. It has set aside $2 million to support new efforts by the state’s medical schools to recruit and retain residents interested in rural practice. Other uses that have been suggested include support for training other health professionals that are in short supply, such as dentists, advanced practice nurses, and psychologists.

  • Utah has a federal waiver from CMS to conduct a Medicare GME demonstration. Originally, the state proposed that it include Medicaid and other state funds as well, but CMS limited the demonstration to Medicare. Effective January 2003, all Medicare funds for direct and indirect Medicare GME are paid to a statewide council. The council is responsible for creating a new formula for distributing indirect GME payments based on actual documented costs and development of a statewide physician resident rotation information system to assist with payment verification.

    On the Medicaid side, the state is using the IGT mechanism—with state medical school funds as the state share—to draw down federal matching funds to increase Medicaid support for GME at its three teaching hospitals. The total amount in the Medicaid GME pool is estimated at close to $20 million. Funds in the pool are used not only for medical but also for dental and podiatry residents at the hospitals. They are also weighted toward physician specialties that are in short supply.

  • Minnesota established a Medical Education and Research Cost (MERC) trust fund in 1996 to capture new and existing state sources of medical education funds. The state legislature appropriated $5 million in new funding from the state’s general fund and took $3.5 million from an existing state health-care provider tax pool for the fund (there was some IGT federal matching for one year only). Institutions that receive financing from the trust fund distribute the money to the more than 300 training sites, including nonhospital settings, that train physicians, dentists, advanced practice nurses, and some other health professionals. GME funds have also been carved out from Medicaid managed care rates. The trust fund has experienced increased funding, with its current sources including tobacco

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

settlement dollars, Medicaid matching funds, state general fund payments, and Medicaid managed care carve-out amounts.

MERC funds support 2,000 full-time-equivalent trainees at 400 training sites. To date, the distribution of payments is not linked to state workforce goals because state officials do not believe they have enough good data to determine objectives and incentives.

  • New York is the only state that explicitly ties its GME payments to increasing the number of URMs. The state’s GME Reform Incentive Pool also seeks to reduce the number of physician trainees, increase the number of primary care physicians, and promote residency training in ambulatory sites. Distribution of the funds, which may be to individual hospitals or a consortium of hospitals, is based on performance in meeting the goals. Increasing the proportion of URMs has a weight of 0.15, while expanding the proportions of minority faculty and linkages with pipeline programs have weights of 0.75 each (personal communication, J. Betancourt, Senior Scientist, Institute for Health Policy, and Director, Multicultural Education, Massachusetts General Hospital, May 23, 2003).

PUBLIC FINANCING BARRIERS TO URM HEALTH PROFESSIONS DEMAND INITIATIVES

Scarcity of Evaluations on Effectiveness of Initiatives to Increase URMs in the Health Professions

Evaluative studies of programs to increase the numbers of URM health professionals do not seem to be a public priority. At DHHS, for example, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) has responsibility for “policy coordination, legislation development, strategic planning, policy research and evaluation, and economic analysis.” A review of the ASPE Policy Information Center website (http://aspe.hhs.gov/pic/), which indexes studies, turns up a handful of evaluations in the past 5 years, four of which are cited in this paper:

  • “Historically Black Medical Colleges’ Participation in HRSA-Supported Health Professions Training Programs,” September 30, 2000;

  • “Evaluation of the Health Resources and Services Administration’s National Health Service Corps Program,” September 30, 2000;

  • “Faculty Loan Repayment Program—Making More Effective Use of Program Funds,” January 29, 2001; and

  • “Evaluation of the Extramural Associates Research Development Award Program” (in progress).

The other key evaluations include the following:

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×
  • “Strategies for the Recruitment, Retention, and Graduation of Hispanics into the Baccalaureate Level of Nursing,” September 30, 1998 (U.S. DHHS, 1998);

  • “Midcourse Assessment of the Research Infrastructure in Minority Institution Programs,” January 30, 2000 (NIH, 2000b);

  • “Evaluation of the Research Centers in Minority Institutions Program: Final Report,” April 30, 2000 (NIH, 2000a); and

  • “Professional Nurse Traineeship Grants: Who Gets Them and Where Do They Work After Graduation?” July 31, 2001 (HRSA, 2001b).

Public sources such as the Bureau of the Census, General Accounting Office (GAO), Office of Management and Budget, and individual agencies (through, for example, annual reports and internal evaluations, such as the 2001 review of Title VII by the HRSA Advisory Committee on Training in Primary Care Medicine and Dentistry) provide valuable information on the operations of federal programs. However, evaluations of specific URM programs, the roles of specific agencies in administering programs targeted at URMs, and especially cross-cutting or comprehensive federal efforts to address URMs in the health professions are rare.

Unpredictability of Health Professions Discretionary Funding

The distinction between discretionary and mandatory funding is extremely important, especially because success in achieving a policy goal tends to take a considerable period of time. Most of the federal government’s programs to increase the participation of URMs in the health professions are in HRSA, which must seek periodic reauthorization of its programs and undergo annual appropriations struggles for its funding. This tends to be an annual budget game in which the President—Republican or Democrat—zeroes out or reduces certain HRSA programs in the administration budget proposal and defers to interest groups to lobby Congress for their reinstatement. When Congress responds, it takes responsibility for the additional dollars.

A review of HRSA’s FY 2003 grants website (last updated November 4, 2002, more than a month after the beginning of federal FY 2003) was particularly telling. While some programs had application due dates, others, such as HCOP, COE, and Basic/Core and Model AHECs, had the following message: “This program is not included in the President’s budget for FY 2003 and is provisional until final Congressional action on appropriations is taken” (HRSA, 2002). This injects uncertainty into HRSA’s commitment to URM progress in the health professions, despite the intent and rhetoric of the programs.

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×
“Siloing” of Small Discretionary URM Programs

Former Senator Everett Dirksen (R–IL) is well known for having said something like “a billion here, a billion there, and pretty soon you’re talking about real money.” Unlike the Medicare GME program, where billions of dollars are concentrated in a mandatory program, efforts to increase URMs in the health professions are “siloed” in HRSA, the National Institutes of Health, the National Science Foundation, and other agencies of the federal government and represent relatively small efforts from state to state.

Given the existence of various pots of money—many of them modest—and the lack of incentives for coordination, it is difficult to see the impact of the federal commitment to increasing URM participation. This is apparent in the Grumbach et al. evaluation that is cited numerous times in this paper and in some of the less comprehensive examinations that are available.

For example, a 1998 evaluation of historically black medical schools’ participation in HRSA-supported health professions training programs says that “both within HRSA and the black medical schools, there is a lack of communication, coordination, and resources to encourage and maintain teamwork.” The evaluation compares the various components of the agency to a medical school, where “faculty in one department may not know what is occurring in another department” (Distributed Communications Corporation, 1998).

Lack of Recognition of the Importance of DoD and VA Health Professions Programs

Although DoD and the VA have significant health professions programs of potential benefit to URMs, the programs’ purposes are to recruit and retain health professionals to care for military and veteran populations, respectively, not to address URM workforce goals. However, the three new initiatives that the VA announced this year (Mentored Minority Research Enhancement Coordinating Center, Mentored Minority Supplemental Award, and Mentored Minority Career Enhancement Award) reflect the department’s growing awareness of the importance of URMs in its workforce.

The federal dollars expended on the DoD and VA health professions education and training programs are considerable and should be recognized for the influence they have in shaping the health workforce. For example, as noted earlier, DoD trains 3 percent of U.S. medical residents and the VA trains 9 percent. As the proportions of URMs serving in the military and subsequently becoming veterans swell, the policy issue of having health professionals who reflect the minority populations needing health services becomes ever more important.

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

Compartmentalization, whether by agency or congressional staff or by health researchers, often leads to tunnel vision, with those involved with HRSA’s discretionary health professions programs or Medicare’s GME program generally focusing only on their own areas, with little recognition of other federal contributions (such as those of DoD and the VA) to health professions training. This precludes any sort of coordination or collaboration, which suits agencies’ and congressional committees’ tendencies to protect their jurisdictions but places a heavy burden on URMs and others interested in finding out the options open to them.

Absence of Health Workforce Goals in the Medicare GME Program

Because the Medicare GME program has such a large pot of money, it tends to be targeted by various advocates of reform. Thus far, the teaching hospitals that receive Medicare GME funds and their proponents in Congress and the White House have resisted most attempts at reform. While the number of medical residents has been capped and there have been some inroads toward ambulatory training and managed and primary care, the program has, for the most part, remained as it was established by the Social Security Amendments of 1983.

Medicare is payment oriented, administered by CMS and Medicare fiscal intermediaries and carriers as a public insurance program. Although the program, because of its size, helps to define the health workforce by its coverage and benefit policies, it has not made overt attempts, through GME or other mechanisms, to influence workforce policy. Medicare GME is hospital based, physician focused, and service oriented, with patient care and medical training dollars commingled.

One area of controversy is the amount of money that Medicare GME devotes to training of international medical graduates (IMGs), who tend to boost the IRBs of teaching hospitals, particularly in states such as New York and Massachusetts. According to COGME, 2001 National Resident Matching Program data show that IMGs filled approximately 36 percent of family medicine positions and 36 percent of general internal medicine positions. COGME points out that “IMGs, compared with U.S. medical graduates, consistently fill gaps in the physician workforce in counties having poor scores on a number of health status and economic indicators” (COGME, 2002). While some argue that IMGs increase the diversity of the health professions (although few fit the definition of URM), others say that they take places that might otherwise go to the native born, including URMs.

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×
Uneven Efforts from State to State in Using Grant and Medicaid Funds to Achieve URM Policy Goals

Just as states vary in their grant programs and in the levels of poverty and optional benefits in their Medicaid programs, they differ significantly in their support of the health professions and in their efforts to increase health workforce diversity. While some states’ grant and Medicaid initiatives may indirectly affect the participation of URMs in the four professions, only New York explicitly weights its GME pool dollars to URM residents and faculty.

In view of changing demographics, it remains to be seen whether New York will serve as a model for other states, or whether states that have clear policy aims in increasing certain types of practitioners (for example, primary care physicians and advanced practice nurses) will adopt URM initiatives.

High Debt Loads of Newly Trained Physicians and Dentists

The costs of higher education pose an obvious barrier to URM health professions participation; provision of financial aid is a strategy to leap the barrier. As pointed out by Grumbach et al., most of the studies that have focused on the cost barrier have looked at college entry and retention rather than health professions training for physicians, nurses, and others in this IOM study on diversity. It is important to note, as Grumbach and colleagues do, that “low income” is not synonymous with “minority” or “URM,” so that “financial aid based on economic need is not a strategy that selectively targets URMs…. Need-based financial aid will benefit many students who are not URMs, and will not reach those URMs who are not from lower income families” (Grumbach et al., 2003).

Medical school graduates have debts of between $70,000 and $100,000, and one in four has debt that exceeds $100,000, according to an IOM report (IOM, 2001a). URM graduates tend to have higher debt levels. COGME pointed out that “the average debt for both URMs and white indebted students was nearly $20,000 in 1981.” It increased by approximately 250 percent by 1995, “reaching an average $71,364 debt for URMs and $68,910 for nonminorities.” COGME indicated that URM students’ “greater length of time between matriculation and graduation is one of the factors contributing to the differential in debt level for URM students.” COGME also indicated that, while 35 percent of all students rely on high-cost unsubsidized loans, 40 percent of URMs do.

In addition, COGME reported that “more than 83 percent of graduating URMs, compared with 51 percent of non-URMs” said they had received scholarships or grants during medical school. Whereas URMs were

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

more likely than non-URMs to receive assistance from “School-Based Scholarships for the Disadvantaged, Financial Aid for Disadvantaged Health Professions Students, National Medical Fellowships, the Exceptional Financial Need program, and the NHSC,” non-URM students tended to draw upon “need-based school scholarships, school merit scholarships, and Armed Forces scholarships” (COGME, 1998).

HRSA’s Advisory Committee on Training in Primary Care Medicine and Dentistry reports that dental tuition and fees “have risen annually by an average of 5 percent per year for residents and nearly 6 percent for nonresidents.” They were 55 percent higher in 1997–1998 than in 1989–1990. “The average dental graduate with debt in 2000 had a debt load of $106,000” (Advisory Committee on Training in Primary Care Medicine and Dentistry, 2001). In large part because of the debt load, only a third of dental graduates go on to postgraduate training.

Reluctance to Fund New URM Initiatives Due to the Rising Federal Budget Deficit and State Budget Crises

As this country has moved from a balanced budget to deficit financing and to priority status for Department of Homeland Security and DoD spending, funds for various initiatives, particularly for social spending, have become increasingly competitive at the federal level. The same is true at the state level, where rising deficits are resulting in budget downsizing and, at times, tax increases. Existing programs designed to increase the participation of URMs in the health professions seem either stagnant or at risk in terms of their funding levels, and the possibility of public financing for new initiatives appears to be low.

OPPORTUNITIES FOR CHANGING FINANCIAL INCENTIVES TO INCREASE URM HEALTH PROFESSIONS PARTICIPATION

Conduct of Studies to Evaluate Federal URM Workforce Initiatives

The paucity of studies on federal strategies to increase URM participation in the health professions hinders policy makers. Whether due to lack of funding, absence of political will, opposition to affirmative action, or other reasons, lack of evidence on the efficacy of public incentive programs and the transfer of private incentive models, such as the AAMC’s “Project 3000 by 2000 Health Professions Partnership Initiative” (AAMC, 2003), to the public sector takes the winds out of the sails of the proponents of such activities. However, the mechanisms exist for a research agenda to be undertaken and funded.

For example, at DHHS, evaluation may be done either directly through

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

program funds or through a legislatively mandated set-aside. The most significant set-aside

is one established for evaluations conducted by several agencies of the … PHS (Agency for Healthcare Research and Quality, Centers for Disease Control [and Prevention], HRSA, NIH, and Substance Abuse and Mental Health Services Administration), ASPE, and the Office of Public Health and Science in the Office of the Secretary. The mechanism is called the PHS evaluation set-aside legislative authority, which is provided for in Section 241 of the PHS Act. This authority was established in 1970, when the Congress amended the Act to permit the HHS Secretary to use up to 1 percent of appropriated funds to evaluate authorized programs. Section 206 of the FY 2002 Labor, HHS, and Education Appropriations Act increases the amount the Secretary may use for evaluation to 1.25 percent. Section 241 limits the base from which 1.25 percent of appropriated funds can be reserved for evaluations of programs authorized by the PHS Act (Policy Information Center, 2002).

For another DHHS example, at CMS, evaluation of the role of URM health providers in serving an increasingly diverse Medicare population could be conducted by the Office of Research, Development, and Information, which carries out various studies and demonstrations on the agency’s programs. Bureau of the Census predictions on diversity show that, by 2025, “racial and ethnic minority Americans will more than double as a share of the elderly, rising from 14 percent to 35 percent and representing one in three seniors.” Latinos are expected to account for 18 percent, African Americans for 10 percent, and other races for 7 percent of the minority elderly population (Henry J. Kaiser Family Foundation, 1999).

For a final example, evaluation at the VA is the responsibility of the Office of Policy, Planning, and Preparedness. None of the recent evaluations completed by the office dealt with URMs in the health professions, although one (“An Evaluation of Leadership VA”) touched on changing veteran demographics and leadership responses (U.S. VA, 2003b).

Private as well as public funders should recognize the importance of conducting high-quality studies and evaluations that rigorously examine federal URM health professions programs. Studies are needed to document the programs’ effectiveness or lack of effectiveness over time and their outcomes relative to program participants’ lives and contributions to the health professions.

Greater Support for the National Center for Health Workforce Analysis and Its Regional Centers in URM Data Collection and Analysis

Obtaining data to provide supporting documentation for initiatives to increase URM participation in the health professions has been a major

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

barrier. Establishment of the National Center for Health Workforce Analysis and its regional centers at UCSF, SUNY at Albany, UIC, UW, and UT is a significant step forward in collecting and analyzing data on national and state practices and policies. The center’s mission is to collect and analyze health professions data, assist in state and local workforce planning efforts, conduct workforce issues analyses, evaluate health professions training programs, and develop tools for and conduct research on the health workforce. It is the only federal effort that focuses on health workforce supply, demand, and related issues.

The National Center for Health Workforce Analysis has ambitious goals, given its modest budget ($819,000 for FY 2003, down from $824,000 in FY 2002). These goals are the following (HRSA, 2003f):

  • Assess the nation’s supply of and requirements for health professionals and paraprofessionals and analyze how they are affected by internal and external changes in the health care system.

  • Carry out technical and analytic activities regarding the adequacy of the health professions workforce in meeting the nation’s need for an appropriately sized and trained health workforce that is suitably diversified by specialty, race, and gender, and is geographically balanced.

  • Conduct research studies, data collection, and technical modeling.

  • Assist regional workforce planning efforts.

  • Evaluate the success of HRSA Bureau of Health Professions training programs.

  • Include physicians, registered nurses, licensed practical nurses, certified nursing assistants, pharmacists, optometrists, chiropractors, allied health personnel, and public health personnel.

  • Compile limited data on national health expenditures.

Obviously, if the center is to fulfill its promise, its budget, which competes with various other activities in HRSA, agencies in DHHS, and departments in the federal government for funds, has to be sufficient for its staff and subcontractors to gather the needed data and analyze them. Instead, the budget seems to be on a downward, rather than upward, trajectory, at a time when having and assessing workforce data have never been more important.

Improved Response to Demographic Changes by Federal and State Health Agencies

Just as various agencies at DHHS and the VA are aware of the growing burden on their health and social insurance resources caused by aging of the baby boomers (people born between 1946 and 1964), their administrators

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

are becoming increasingly sensitive to the racial and ethnic demographic changes occurring in this country. Given the prediction that, by 2050, “one of every two U.S. workers [of all types] will be African American, Hispanic, Asian American, Pacific Islander, or Native American” (IOM, 2001b), officials in both the federal and state governments face a number of challenges. One challenge is the significance of cultural competence—and perhaps cultural concordance—in the delivery of quality care. Another is the disproportionate impact of certain illnesses—hypertension, diabetes, heart disease, and asthma, for example—in certain minority groups. Still another is preparation of a health workforce to care for an increasingly diverse population.

Various efforts are underway to respond to the challenges—providing patients who have limited English skills with access to interpreters or native-speaking providers; tying health status goals and indicators to ethnicity (as in Healthy People 2000 and 2010); assessing cultural competency of providers in government-funded health settings; conducting clinical and quality studies of services provided to individuals in various racial and ethnic groups; making sure that Medicaid managed care contractors meet culturally appropriate standards; and tracking Medicaid patients relative to demographic data on ethnicity and cultural characteristics. Crucial as well are broad-based efforts to project the needs of increasingly diverse Medicare and Medicaid beneficiaries and discretionary program clients; to provide incentives to attract URMs to health professions careers; to strengthen scholarship, loan, mentoring, and other aspects that relate to health professions education and training; and to put greater emphasis on nurturing URM health professions faculty, administrators, researchers, and other health leaders.

Strategies such as multiyear authorizations and appropriations to give greater certainty to program funding, interagency coordinating councils to share information and seek common threads among compartmentalized programs, and joint efforts (such as the clinical partnership that DoD and the VA have in sites such as Albuquerque) would enhance federal responses to the demographic evolution that the United States is undergoing.

Initiation of Research and Demonstrations by CMS on URM Relationships to the Medicare and Medicaid Programs

Although DHHS’ Health Care Financing Administration (now CMS) waxed and waned over time regarding Medicare and Medicaid waiver authority, there seems to be greater receptivity at this time to demonstrations in both programs. CMS can grant waivers applicable to both Medicare and Medicaid regarding provider reimbursement, prospective payment, and social health maintenance organization projects. Under Medicaid

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

alone, CMS can give states program flexibility: “freedom of choice” waivers for development of case management and managed care arrangements and home- and community-based waivers for provision of services outside hospital and nursing-home settings. Under Medicaid, CMS can also encourage states to experiment and conduct research through Section 1115 waivers that allow them to depart from federal Medicaid requirements; states have been pushing the envelope in using the waivers to address innovative policy goals.

It is unclear how far CMS might go in the testing of new policy approaches in the Medicare program, such as in targeting some Medicare GME funds to increasing URM participation in medical residencies, perhaps by developing additional incentives for teaching hospitals that have been successful in mentoring URM residents. Nevertheless, CMS has the tools for experimentation, although it may take congressional bill or report language to give priority to it.

Action on Medicare GME Proposals by the Council on Graduate Medical Education and the Medicare Payment Advisory Commission

Both COGME and the Medicare Payment Advisory Commission (MedPAC) have proposals on the table to address discretionary and Medicare GME financial incentives. COGME, authorized in 1986 to advise both Congress and the Secretary of Health and Human Services and housed in HRSA’s Bureau of Health Professions, has made various recommendations over the years in a series of reports. COGME dealt specifically with minority representation in the physician workforce in 1990 and 1998. Its recommendations on minority representation are summarized in COGME’s 2002 Summary Report. In addition to suggesting supply approaches, COGME “urged that federal funding priority be given to medical schools and teaching hospitals that have demonstrated success in recruiting and retaining underrepresented minority students.” It also urged expansion of public-and private-sector scholarship and loan programs and of the NHSC “to allow targeted opportunities for minority students.”

Noting that “Native Americans, Blacks, Hispanics, or Latinos comprise only 6.2 percent of faculty in U.S. medical schools,” COGME also recommended that the federal government “support programs that encourage minorities to pursue careers in academic medicine and provide incentives to medical schools that are successful in recruiting and retaining minority faculty” (COGME, 2002).

MedPAC, an amalgam of the Prospective Payment Assessment Commission and Physician Payment Review Commission that was created in 1997, is responsible for reporting to Congress and the Secretary of Health and Human Services on Medicare payment policies. It recommended a

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

couple of years ago that Medicare GME policy be reformed, especially in terms of combining direct and indirect Medicare GME payments to hospitals to encompass patient care and teaching physician expenses. At the same time, it has shied away from targeting specific health professions workforce goals, such as physician supply or specialty mix, through the Medicare program. Nonetheless, opening the door to changes in how Medicare direct and indirect dollars are dispersed would mean opportunities to tie the payment of funds to specific workforce goals, including those involving URMs.

Development of Clearinghouse on Federal Program Options for URMs in the Health Professions

The lack of centralization, coordination, and collaboration among public funding entities involved in initiatives that directly or indirectly affect URMs in the health professions has a chilling effect on opportunities for individuals interested in, training for, or entering medical, dental, nursing, psychology, and other health careers. Having a clearinghouse of information on federal program criteria, key contact persons, evaluative studies, workforce data, and other topics would be one means of addressing the problem.

A model for such a clearinghouse might be the IOM’s Clinical Research Roundtable, which has as one of its aims developing the clinical research workforce (IOM, 2001a). Spurred by the AAMC and leaders in the medical community and housed at the IOM, the roundtable’s mission is to explore challenges facing clinical research, including workforce issues.

Leadership of Key Organizations

Several organizations have worked to spearhead public-private partnerships committed to increasing URM participation in the health professions. Both the W.K. Kellogg Foundation and the Robert Wood Johnson Foundation, at times working with the AAMC, Association of Academic Health Centers, American Association of Colleges of Nursing, the IOM, and other organizations, have funded initiatives on the supply and demand sides to increase minority representation in medicine, nursing, dentistry, and other health professions. Other national foundations, such as the Henry J. Kaiser Family Foundation and Pew Charitable Trusts, have also provided leadership. In addition, state-focused foundations, such as the California HealthCare Foundation and The California Endowment, have been involved, especially in states in which minorities have become or are about to become majorities.

Given key foundations’ interest in URM health workforce issues,

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

public-private partnerships should be encouraged. Such partnerships might include hosting conferences to bring private initiatives to the attention of federal and state officials, researching and demonstrating model incentive programs, disseminating information on federal health professions options of all types for URMs, or other initiatives.

Responses to GAO Recommendations to Increase Diversity of the Senior Executive Service

In increasing URM participation in the health professions, leadership is clearly important to the formulation of goals, development of programs, and directing of dollars. The GAO reported on diversity—defined by race, ethnicity, and gender—in the federal “senior corps,” the Senior Executive Service (SES), in a January 2003 report (GAO, 2003), concluding that efforts need to be made to make it more diverse. GAO indicated that “more than half of the 6,100 career SES members employed on October 1, 2000, will have left service by October 1, 2007.”

Of the 6,100, minority women and men made up about 14 percent, “white women about 19 percent, and white men about 67 percent.” Based on current SES employment trends, GAO projected what the employment profile would be if appointment trends do not change. It found that “the only significant changes in diversity will be an increase in the number of white women and an essentially equal decrease in white men. The proportions of minority women and men will remain virtually unchanged in the SES corps.” The increase in racial and ethnic minorities is only 0.7 percent, with that of white women at 4 percent; the decrease in white men is projected at 5 percent.

While commitment to goals of diversity in the health professions goes beyond race and ethnicity, there is reason to question federal dedication to the goals if its own leadership is so skewed. The GAO study implies that it is skewed and is likely to remain so. Although GAO likely will monitor development of the workforce over time, the topic of URM participation in SES needs to be addressed as quickly as possible, with a focus on recruitment, leadership training, mentoring, and retention issues. Although the project might fall within the rubric of a public–private partnership or a foundation program, it has ramifications not only for 2007 but also for the years that follow.

CONCLUSION

This paper provides an overview of various programs in the federal government and in the states that address the health professions, particularly medicine, nursing, dentistry, and professional psychology. It seeks to

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

follow the financial trails of these federal and state programs: to indicate direct URM goals, when they exist, and indirect URM goals, when they are apparent. It also seeks to identify health professions programs that might serve as models and policies that might be pursued to increase the participation of URMs in the health professions.

The paper relies on various evaluations of federal health professions programs, some of which are URM centered and some of which are not. It also draws from numerous other sources, including program descriptions and overviews from both public and private sources, many drawn from the World Wide Web. An analysis of the evaluations and sources reveals various barriers to increasing URM participation in the health professions. The opportunities section provides pathways that might be taken to expand such participation:

  • By using existing authorities and pursuing new funding sources to conduct studies at the federal level on increasing URM participation in the health professions, particularly medicine, dentistry, nursing, and professional psychology.

  • By providing greater support to the National Center for Health Workforce Analysis and its regional centers to address URM health professions issues at both the national and state levels.

  • By strengthening existing and developing new public programs—federal and state—dedicated to educating, training, and nurturing URMs in medicine, dentistry, nursing, professional psychology, and other health professions.

  • By encouraging and perhaps mandating CMS to do research and demonstrations on the relationship between URM health professionals and its programs.

  • By adopting COGME’s recommendations for improving the participation of URMs in medicine and responding to MedPAC’s criticisms of current Medicare GME policy.

  • By creating a clearinghouse to collect and disseminate information on various aspects of URM preparation for and participation in the health professions.

  • By seeking public-private partnerships and foundation initiatives that relate to URM participation in the health workforce.

  • By undertaking an initiative that focuses on increasing URM entry into and retention in SES in order to strengthen the leadership that is essential to making federal government officials more representative of the population they serve.

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

GLOSSARY


AAMC =

Association of American Medical Colleges

AHEC =

Area Health Education Center

APA =

American Psychological Association

ASPE =

Assistant Secretary for Planning and Evaluation


CHGME =

Children’s Hospitals Graduate Medical Education

CMS =

Centers for Medicare and Medicaid Services

COE =

Centers of Excellence

COGME =

Council on Graduate Medical Education


DHHS =

Department of Health and Human Services

DoD =

Department of Defense


FFS =

fee for service

FLRP =

Faculty Loan Repayment Program


GAO =

General Accounting Office

GME =

Graduate Medical Education


HCOP =

Health Careers Opportunity Program

HETC =

Health Education and Training Center

HPSP =

Health Professions Scholarship Program

HRSA =

Health Resources and Services Administration


IGT =

intergovernmental transfer

IMG =

international medical graduate

IOM =

Institute of Medicine

IRB =

intern/resident per bed


MARC =

Minority Access to Research Careers

MBRS =

Minority Biomedical Research Support

MedPAC =

Medicare Payment Advisory Commission

MERC =

Medical Education and Research Cost


NELRP =

Nursing Education Loan Repayment Program

NHSC =

National Health Service Corps

NIGMS =

National Institute of General Medical Sciences

NIH =

National Institutes of Health

NSF =

National Science Foundation


OIG =

Office of Inspector General


PHS =

Public Health Service

PPS =

prospective payment system


RISE =

Research Initiative for Scientific Enhancement

RN =

registered nurse

ROTC =

Reserve Officer Training Corps


SCORE =

Support of Continuous Research Excellence

SDS =

Scholarships for Disadvantaged Students

SES =

Senior Executive Service

SUNY =

State University of New York

Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
×

UCSF =

University of California, San Francisco

UIC =

University of Illinois at Chicago

URM =

underrepresented minority

UT =

Utah or University of Texas (depending on context)

UW =

University of Washington


VA =

Department of Veterans Affairs or Virginia (depending on context)

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Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
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Suggested Citation:"Contribution B: The Role of Public Financing in Improving Diversity in the Health Professions." Institute of Medicine. 2004. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. Washington, DC: The National Academies Press. doi: 10.17226/10885.
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The United States is rapidly transforming into one of the most racially and ethnically diverse nations in the world. Groups commonly referred to as minorities--including Asian Americans, Pacific Islanders, African Americans, Hispanics, American Indians, and Alaska Natives--are the fastest growing segments of the population and emerging as the nation's majority. Despite the rapid growth of racial and ethnic minority groups, their representation among the nation’s health professionals has grown only modestly in the past 25 years. This alarming disparity has prompted the recent creation of initiatives to increase diversity in health professions.

In the Nation's Compelling Interest considers the benefits of greater racial and ethnic diversity, and identifies institutional and policy-level mechanisms to garner broad support among health professions leaders, community members, and other key stakeholders to implement these strategies. Assessing the potential benefits of greater racial and ethnic diversity among health professionals will improve the access to and quality of healthcare for all Americans.

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