5
Strengthen the HHS and U.S. Public Health and Health Care Workforces

The single biggest constraint on the success of (any) organization is the ability to get and to hang on to enough of the right people.

Jim Collins (2001)

RECOMMENDATION 4

Strengthen the HHS and U.S. Public Health and Health Care Workforces

The secretary should place a high priority on developing a strategy and tools for workforce improvement (1) in HHS, (2) in the public health and health care professions nationwide, and (3) in the biosciences.

  1. The secretary should immediately strengthen workforce planning in the department and develop a comprehensive strategy to recruit highly qualified public- and private-sector individuals in order to offset the large number of experienced staff expected to retire soon.

  2. Congress should authorize the department, in cooperation with the Office of Personnel Management, to assemble a package of current and innovative programs and benefits designed to encourage talented, experienced individuals to transition back and forth between government and private-sector service, thereby identifying ways to leverage the best of both.

  3. Congress should provide the secretary with additional authority to reward performance, innovation, and the achievement of results, through



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5 Strengthen the HHS and U.S. Public Health and Health Care Workforces The single biggest constraint on the success of (any) or- ganization is the ability to get and to hang on to enough of the right people. Jim Collins (2001) RECOMMENDATION 4 Strengthen the HHS and U.S. Public Health and Health Care Workforces The secretary should place a high priority on developing a strat- egy and tools for workforce improvement (1) in HHS, (2) in the pub- lic health and health care professions nationwide, and (3) in the biosciences. The secretary should immediately strengthen a. workforce planning in the department and de- velop a comprehensive strategy to recruit highly qualified public- and private-sector individuals in order to offset the large number of experi- enced staff expected to retire soon. Congress should authorize the department, in b. cooperation with the Office of Personnel Man- agement, to assemble a package of current and innovative programs and benefits designed to encourage talented, experienced individuals to transition back and forth between government and private-sector service, thereby identifying ways to leverage the best of both. Congress should provide the secretary with addi- c. tional authority to reward performance, innova- tion, and the achievement of results, through 105

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106 HHS IN THE 21ST CENTURY bonuses, merit-based pay, recognition awards, or other mechanisms of proven effectiveness. The secretary, in concert with other public and d. private partners, should develop a comprehensive national strategy to assess and address current and projected gaps in the number, professional mix, geographic distribution, and diversity of the U.S. public health and health care workforces. To help close projected gaps, the department e. should evaluate existing health care professional training programs, continued education pro- grams, and graduate medical education funding and should encourage Congress to invest in pro- grams with proven effectiveness. Congress should give the secretary authority to f. create new programs that invest in the future generation of biomedical and health services re- searchers, enabling the continued discovery of new, more effective methods of preventing, treat- ing, and curing disease; promoting health; im- proving health care delivery and organization; and controlling health system costs. SCOPE OF THE CHALLENGES The Institute of Medicine (IOM) committee was charged with con- sidering how the activities of the department and its constituent agencies relate to the public health, health care quality, and health care cost chal- lenges facing our nation. In each of these arenas, the Department of Health and Human Services (HHS) must interact with other organiza- tions and, of course, their people. As this chapter documents, there ap- pear to be impending shortages of people with the right backgrounds, training, and skills within the department’s senior levels, within the na- tion’s health care workforce generally, within state and local public health agencies, and within the science establishment. These shortages will cripple the ability of the department to carry out its work and nega- tively affect health care delivery, even as demands are increasing. An array of new health challenges—not to mention the ongoing triad of access, quality, and cost control—confront the department just as a

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107 STRENGTHEN THE HHS AND U.S. PUBLIC HEALTH AND HEALTH CARE WORKFORCES large portion of its own workforce is near retirement. A similar pattern is also occurring in state and local public health agencies. Outside the pub- lic health world, problems in the number, mix, and composition of the nation’s health workforce also have a negative impact on the department and its agenda: • The United States has an overall imbalance between specialist and primary care physicians, and the higher costs that result from an overreliance on specialist care fall heavily on Medicare and Medicaid. • It would take 16,261 additional primary care physicians to meet the need in currently underserved areas, where federally funded safety net programs struggle to fill the gaps (HRSA, 2008). • A recent survey of medical school students revealed that a mere two percent are planning a career in general internal medicine (Hauer et al., 2008). • Nationally, minority groups are underrepresented among doctors, nurses, and other clinical disciplines, which affects access to care, especially for the vulnerable populations that are a high de- partment priority (Sullivan Commission on Diversity in the Healthcare Workforce, 2004). • Rural areas and low-income communities are especially affected by shortages of health professionals, so, again, publicly funded health clinics try to pick up the slack. • At a time when there is a greater emphasis on improving the sci- ence base in many federal agencies, the nation faces a shortage of talent in the biological and other health sciences (National Science Board, 2008b). These examples show how public programs and publicly funded ser- vices are affected by workforce shortages in the private sphere. As a con- sequence, as it attempts to address some of the nation’s key health challenges described in this report, the department must look beyond its own resources to the health workforce capacity of the entire nation. De- veloping and maintaining the health professions workforce will require broad-based strategies that include participation by the states, the private sector, the academic community, and other federal departments with sub- stantial health system involvement.

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108 HHS IN THE 21ST CENTURY THE HHS WORKFORCE Structure and systems are vital to organizational health, but “success depends on having the right employees with the right competencies at the right time” (HHS Office of Human Resources and ASMB, 1999). A ma- jor stumbling block to strengthening the public health infrastructure is a shortfall in the number, and in some cases the qualifications, of the HHS and public health workforces. Within the five-year span that began in 2007, about half of all HHS managers are or will be eligible for retirement (HHS, 2007). Such a large loss of experienced managers, scientists, and other professionals in the HHS workforce will create a tremendous challenge to the secretary for many years to come. While bringing in new people with new skills and ideas may make it easier to refocus department priorities and align peo- ple to purpose, it may also make sense to devise benefit programs and work arrangements that encourage some potential retirees to stay, per- haps with shorter, more flexible hours, job sharing, or other arrange- ments. Shortages of person-power clearly place a tremendous burden on remaining staff, reduce efficiency and productivity, and make govern- ment less responsive to constituents. To recruit professionals with the appropriate managerial experience and scientific expertise, the department will have to engage in creative recruitment of at least some people with deep private-sector experience, as well as cultivate talented employees within the department who have the ability to move into more senior roles. It will also need to establish a robust recruitment program for experienced, well-qualified economists, health services researchers, statisticians and epidemiologists, clinical sci- entists, biomedical engineers, computer scientists, information systems engineers, and other such disciplines. Loss of Senior Leadership Since 2001, the HHS budget has included between 63,000 and 66,000 full-time equivalent employees, supplemented by a significant number of contract employees. On average, the age of the HHS work- force is increasing and is slightly older than federal government employ- ees in general. For these reasons, anticipated retirement rates have been a

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109 STRENGTHEN THE HHS AND U.S. PUBLIC HEALTH AND HEALTH CARE WORKFORCES concern for at least a decade, as reflected in the department’s workforce planning guide (HHS Office of Human Resources and ASMB, 1999). 1 In 2001, 1,067 individuals retired from HHS, 1.7 percent of its work- force; the average age at retirement was 60.3 years. These retirees were an experienced group, with 28 years’ service, on average; 22 were from the Senior Executive Service (SES); 370 were categorized as “profes- sional.” Three years later, in 2004, a somewhat larger number—1,700— of employees retired, 2.9 percent of the department’s workforce. On av- erage, these retirees were a little younger (59.9 years), but had served a little longer (29.5 years). Twenty-eight were from the SES, and a much larger number—470—were “professionals.” Experienced senior managers and professionals are not easy for gov- ernment agencies to replace. Retirees around age 60 are part of the gen- eration born from 1946–1964—the baby boom—and the following generation provides a pool of potential workers that is not only some- what smaller, but also less interested in public service careers (Light, 2007). This underscores the need for the secretary to establish “moon landing” type goals that inspire a new generation of Americans—one representing our nation’s diversity—to enter public service. The situation of the Centers for Disease Control and Prevention (CDC) offers a case in point. CDC had about 9,000 employees in 2007. In 2008, the Government Ac- countability Office estimated that 27 percent of CDC’s workforce, which includes a great many highly skilled employees—statisticians, epidemiologists, and labora- tory scientists—would be eligible to retire within five years, as would more than a third of its hard-to-replace medical officers. (GAO, 2008a) Several nonprofit, nonpartisan organizations have emerged that at- tempt to encourage public-sector careers (see, for example, Partnership for Public Service, http://www.ourpublicservice.org/OPS/; the Demos Center for the Public Sector, http://www.demos.org, which encourages a “reenvisioning” of the public sector; and the Council for Excellence in Government, http://www.excelgov.org/). Academic institutions could also play a critical role in encouraging public service. 1 The Office of Personnel Management projects that 18.5 percent of the government- wide full-time permanent workforce will have retired between 2006 and 2010.

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110 HHS IN THE 21ST CENTURY As a potential partial response to the shortfall in personnel in the sen- ior ranks of government, Congress and the executive branch have initi- ated a number of small recruitment and retention initiatives. For example, a 2003 Presidential Executive Order (13318) authorized a Sen- ior Presidential Management Fellows program, intended “to provide for the recruitment and selection of outstanding employees for service in public-sector management” for terms of up to three years (Bush, 2003). 2 Individuals were to be selected through a merit-based system from among people with “extensive work experience” and “exceptional lead- ership or analytic ability.” Five years later, the program awaits imple- mentation guidance from the Office of Personnel Management before it can begin. However worthy in intent, fellowship programs make a small contribution, considering the size of the overall need. In addition to identifying highly qualified people within the depart- ment for promotion to senior ranks, 3 recruitment of the next generation of department leaders will have to look outside. The loss of scientific talent is particularly severe in some agencies. For example, a 2007 Insti- tute of Medicine report reviewing the future of drug safety recommended increasing the scientific capacity of the Food and Drug Administration (FDA) staff (IOM, 2007a): The IOM committee concluded that, in order to better plan and evaluate research on drug risks and benefits, the FDA’s Center for Drug Evaluation and Research needs “more expert staff, deeper expertise in the staff it already has, and different kinds of expertise.” (p. 127) Findings such as these suggest the need for a concerted effort at re- cruitment from academia and the private sector to obtain the depth and level of necessary expertise. In a survey, 23 percent of HHS staff them- selves believed that their work units were not “able to recruit people with the right skills” (HHS, 2007). 2 A separate Presidential Management Fellows program, intended for individuals with recent graduate degrees, is operational and provides HHS with about 50 Fellows annu- ally. The similar Emerging Leaders Program (ELP) also recruits among graduate stu- dents. 3 Promoting leadership and management skills could be accomplished through training opportunities offered through the HHS University or the expansion of internal programs, such as the Department’s Senior Executive Service Candidate Program.

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111 STRENGTHEN THE HHS AND U.S. PUBLIC HEALTH AND HEALTH CARE WORKFORCES Again, the CDC experience is germane. HHS agencies were asked to reduce the number of administrative man- agement and support positions by 15 percent, moving some of these workers into frontline public health work. However, these former administrative and support staff did not necessarily have the requisite public health edu- cation and experience. (GAO, 2004) The accountability and improved performance strategies envisioned by the committee and described in Chapter 6 would make the present shortfall in senior-level staff in the department even more acute. Improv- ing performance would require personnel with greater expertise in man- aging large organizations, deep familiarity with organizational quality improvement strategies, skill in managing and motivating staff, and ex- pertise in program assessment and evaluation. In addition, the commit- tee’s recommendations regarding greater use of information technology, noted especially in Chapter 4, will require a range of personnel who are trained in medical informatics. Medical informatics experts are in short supply across the nation, and HHS may need to take steps to ensure that these experts become available to both the public and private sectors. Congress and the Office of Personnel Management have taken steps to allow agencies more hiring flexibility, and these tools (including re- cruitment bonuses and special needs appointments above minimum sala- ries) should be fully utilized in recruiting the department’s next generation of managers. Streamlining cumbersome federal hiring practices would be another substantial aid to recruitment (Partnership for Public Service, 2008). Ac- cording to GAO, in recent years, the time required to hire a new em- ployee averaged between 73 and 92 days. One motivation for hiring contract workers is that this avoids the lengthy hiring process and allows the agency to bring workers on board more quickly to meet immediate needs (GAO, 2008a). To attract experienced professionals working in the private sector to a period—or a career—in public service will require administrative and congressional consideration of more competitive, innovative approaches to employment benefits, perhaps starting with discovery of what benefits and features this category of workers most values (McKinsey & Com- pany, 2005). At the same time, portable benefits and job security would enable public-sector employees to work for a time outside the federal

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112 HHS IN THE 21ST CENTURY government. Consideration should be given to work arrangements and benefits that appeal to mature workers, such as flexible work schedules and other arrangements, telecommuting, phased retirement with pension protection, and family and medical leave programs. Related Recommendations The secretary should immediately strengthen a. workforce planning in the department and de- velop a comprehensive strategy to recruit highly qualified public- and private-sector individuals, in order to offset the large number of experienced staff expected to retire soon. b. Congress should authorize the department, in co- operation with the Office of Personnel Manage- ment, to assemble a package of current and innovative programs and benefits designed to en- courage talented, experienced individuals to transi- tion back and forth between government and private-sector service, thereby identifying ways to leverage the best of both. Rewarding Performance Congress has taken measures to help combat the problem of lower federal salaries that impedes efforts to recruit and retain experienced per- sonnel and has directed the administration to create several different pay systems, separate from the 15 grades in the traditional General Schedule (GS) system. The intent is to give agencies more flexibility in setting employees’ salaries, especially the ability to base pay increases on per- formance rather than merely tenure. Still, most federal employees are paid under the more rigid GS system. Just over 400 HHS employees are members of the SES, which now uses a performance-based pay system. Results of a survey of SES em- ployees, published in May 2008, indicated some skepticism about the effects of this program. While more than 90 percent of the department’s SES employees support the notion of performance-based pay, only 44 percent believe it has improved their organization’s performance, and

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113 STRENGTHEN THE HHS AND U.S. PUBLIC HEALTH AND HEALTH CARE WORKFORCES only 65 percent say they understand how their own recent salary increase was determined (OPM, 2008). This suggests that the new performance- based pay system may need strengthening and clarification in order to achieve its desired effects. For HHS, efforts to ensure the quantity and quality of the workforce should support the other fundamental organizational activities already touched upon in this report—the alignment of vision, mission, and goals, monitoring performance, and assuring effectiveness. Related Recommendation Congress should provide the secretary with addi- c. tional authority to reward performance, innova- tion, and the achievement of results, through bonuses, merit-based pay, recognition awards, or other mechanisms of proven effectiveness. THE U.S. HEALTH WORKFORCE The total U.S. health workforce includes all the categories of work- ers and professionals who provide services related to the care of individ- ual patients; the state and local public health workforce; and the scientists who perform basic biomedical, health services, and other re- search related to the prevention, tracking, and treatment of disease and disability. A number of problems in the number, mix, and distribution of the various components of this total workforce are straining today’s health system, and the trends bode ill for the future. The Clinical Care Workforce The following problems in the clinical care workforce affect access to health services: • 63 million Americans live in a primary care practitioner shortage area. • 47 million live in a dental practitioner shortage area.

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114 HHS IN THE 21ST CENTURY • 76 million live in a mental health care practitioner shortage area (HRSA, 2008). • Shortages are particularly acute in rural and low-income areas. • In 2004, community health centers had vacancy rates for family practice and internist positions of 13 and 21 percent, respec- tively; 19 percent vacancy rates for dentists; and 11 percent va- cancy rates for nurses and pharmacists (NACHC, 2007). These problems in the workforce affect the quality of care and patient outcomes: • Numerous studies indicate a population’s health outcomes, in- cluding mortality, improve as the number of primary care physi- cians—but not specialty physicians—increases (Starfield et al., 2005a). • Yet, the supply of primary care physicians is not keeping up with demand, while the proportion of medical specialists in the U.S. grew from 32 to 38 percent between 1996 and 2004, the propor- tion of primary care physicians decreased from 39 to 37 percent over those same years (Tu and O’Malley, 2007). • Much research links higher hospital registered nurse (RN) staff- ing with improved patient outcomes and even reduced costs (AcademyHealth, 2006), but recent predictions suggest that the national shortage of RNs in the nursing workforce will be be- tween 220,000 and 450,000 in 2020 (Buerhaus et al., 2009).. If today’s health workforce supply problems weren’t serious enough, demands for health care are rising quickly. The leading edge of the baby boom generation will turn 65 in 2011, and the population of Americans 85 and older continues to grow. Between 40 and 50 percent of all Ameri- cans have at least one chronic condition, such as hypertension, asthma, arthritis, diabetes, or a psychiatric disorder. The number and severity of chronic conditions increase with age, and people over 65 generally have more than one chronic disorder. Treatment of chronic conditions is ex- pensive, accounting for almost 80 percent of the nation’s $2 trillion in annual health care expenses (Kovner and Knickman, 2008). While the aging population will require many kinds of health ser- vices, it will encounter a severe shortage of professionals prepared to provide specialized geriatric care. A new IOM report recommends an

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115 STRENGTHEN THE HHS AND U.S. PUBLIC HEALTH AND HEALTH CARE WORKFORCES array of measures to improve the health workforce’s competency in geri- atrics (IOM, 2008). For many years, health care experts have called for an increase in primary care practitioners. These generalist physicians—general inter- nists, family practitioners, obstetrician-gynecologists, and pediatri- cians—provide holistic, patient-centered care that should be patients’ “first line of defense” in preventing and treating many illnesses. Instead, our health care system, unlike systems in many other nations, is skewed toward much more costly specialist care. As important as it is to control costs, another reason to change this pattern is even more potent: it is harmful to patients. People living in geographic areas served by larger numbers of primary care providers have better health outcomes (Starfield et al., 2005b). Conversely, research shows a “weak link” between the number of physicians per capita and health outcomes, except for studies of the supply of primary care physicians. Further, “health systems with primary care as the foundation of care provide the best outcomes at the lowest costs” (Goodman and Grumbach, 2008). Ironically, several Centers for Medicare and Medicaid Services’ (CMS’s) policies discourage physicians-in-training from pursuing pri- mary care careers. First, Medicare is the largest source of funding for graduate medical education (physicians’ residency programs) (HRSA, 2007). Medicare rules limit support for residencies that take place in “nontraditional” and ambulatory sites, where generalists tend to train and practice; instead, the rules favor hospital-based residencies where spe- cialists traditionally receive their training. The result, according to the Council on Graduate Medical Education, is that “current training models are not preparing physicians for the demands of future practice.” Once primary and specialist physicians complete their residencies— generally with substantial educational debt—Medicare payments are much higher for specialists, which means that those who choose a gener- alist career will have a much greater financial struggle (Tu and O’Mal- ley, 2007). A variety of strategies have been employed in an attempt to encourage young physicians to choose generalist careers with little long- term success. More effective strategies, involving CMS’s reimbursement system, should be attempted (Colwill et al., 2008). This is an example of how different parts of HHS could be brought into greater alignment. Advanced practice nurses (clinical nurse specialists, nurse practitio- ners, nurse midwives, and nurse anesthetists) and physician assistants can fill part of the gap in primary care access, and the country had

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116 HHS IN THE 21ST CENTURY 240,000 advanced practice nurses and 66,000 physician assistants in 2004–2006. Over the years, these midlevel practitioners have increas- ingly gained the ability to obtain reimbursement for their services, but they still face considerable state-to-state variation in scope-of-practice laws, particularly in the amount of physician oversight they must have and whether they are allowed to write prescriptions. Many of these prac- titioners have found a congenial home in managed care or in large physi- cian practices where they can perform triage, initial and simple treatment, referral, and patient education roles that improve physician productivity. A disadvantage of substituting these “midlevel” practitio- ners for physicians is that they may lack physicians’ wide range of diag- nostic and therapeutic knowledge. Another longstanding problem is the lack of racial and ethnic diver- sity in the nation’s health professional workforce. The lack of minorities in the professions is important for several reasons. Minority professionals are more likely to serve minority patients, increasing access to care for some underserved groups; in turn, many minority patients prefer being cared for by professionals of their own ethnicity and generally are more satisfied with the care received (IOM, 2004). Health care professionals who share their patients’ background and language are more likely to provide culturally competent services, which is especially important for patients who are recent immigrants or lack English proficiency. African Americans, Hispanic Americans, and Native Americans con- stitute more than a quarter of the U.S. population, but are only nine per- cent of the nation’s nurses, six percent of physicians, and five percent of dentists (Sullivan Commission on Diversity in the Healthcare Workforce, 2004). Shortages of Asian-American health professionals are often ig- nored, because the number of Asian-American (or Asian international graduates) health professionals appears relatively high, compared to the size of the Asian-American population. This is misleading, because the Asian-American demographic category covers more than a dozen ethnic groups with starkly different cultures and languages—from Pakistan to Taiwan and Mongolia to Malaysia. Simply having an “Asian” health care provider does not necessarily meet the needs of individual Asian- American patients for culturally competent care. At a time of workforce shortages, minority groups may represent a large, relatively untapped pool of potential health professionals. A 2004 IOM report recommended assessment of the effectiveness of the Health Resources and Services Administration (HRSA) workforce educational programs in increasing the number of minority graduates and additional

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117 STRENGTHEN THE HHS AND U.S. PUBLIC HEALTH AND HEALTH CARE WORKFORCES support for educational programs working well (IOM, 2004). Certainly this makes sense in light of how essential these programs could be to as- suring a workforce that can better meet patients’ needs, enhance quality care, and practice in a manner that manages costs. The Public Health Workforce The workforce needs of the public health sector often take a back seat, though it is worth remembering that 25 of the 30 years of improve- ment in longevity in the United States in the twentieth century are attrib- uted to public health improvements (Turnock, 2004). The inadequate number and training of the nation’s public health workforce was brought vividly to national attention following September 11, the anthrax attacks of autumn 2001, and Hurricanes Katrina and Rita (Gebbie and Turnock, 2006; Lister, 2008). Unfortunately, HRSA’s workforce training programs may at present be an undervalued asset. Public health workforce training, in particular, has dramatically declined since 2002. That year, Title VII support for public health, preventive medicine, and dental public health stood at $10.5 million, declining to under $8 million in 2006, and zeroed out in the President’s 2009 budget request. A recent IOM committee justly concluded, “the future of Title VII remains unclear” (IOM, 2007b). In 2005, only 6 percent of local health departments were large— serving populations over 500,000—whereas 41 percent served fewer than 25,000 people. On average (median), these small departments had four professional staff (NACCHO, 2006). Of necessity these individuals must wear many hats, and not all of them fit. They inspect restaurants and other food service establishments as well as environmental health problems; track diseases and intervene in disease outbreaks; improve emergency preparedness through complicated drills and exercises; main- tain vital statistics; provide health education; and even, in some cases, provide mental health care, immunizations, school health services, home health services, maternal and child health services, migrant health screenings, and many other functions for vulnerable populations and community residents at large. Finally, in rural areas they spend remark- able amounts of time driving to outlying areas of their jurisdictions. De- spite federal expectations, their capacity to respond in a major emergency (“surge capacity”) is limited (GAO, 2008b).

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118 HHS IN THE 21ST CENTURY Data differ considerably regarding the number of people employed in the nation’s 57 state and territorial health departments and nearly 2,900 local health departments. According to a 2007 survey by the Association of State and Territorial Health Officials (ASTHO, 2008), more than 100,000 individuals work in state public health agencies, 34 percent of whom are administrative and clerical personnel. According to a 2005 survey, local health departments employ approximately 160,000 public health workers, again approximately 34 percent of whom are administra- tive and clerical personnel (NACCHO, 2006). 4 State and local health department workers are “graying” (Tilson and Berkowitz, 2006), and replacements—if they can be found—too often lack public health training and adequate science backgrounds. Public health careers are unattractive to new recruits because of “low salaries, poor benefits, adverse working conditions, and low status” (Tilson and Berkowitz, 2006). Severely constrained state budgets and rigid hiring practices pose additional barriers to recruitment (Gebbie and Turnock, 2006). Having a sufficient number of employees is not enough; they also need the right education and skills to carry out their vital functions (Sa- linsky and Gursky, 2006). The public health workforce—federal, state, and local—continues to be widely criticized for lacking basic science preparation and appropriate public health knowledge and skills, prompt- ing a previous IOM committee to recommend that public health workers should “demonstrate mastery of the core public health competencies ap- propriate to their jobs” (IOM, 2002). In local public health agencies, “Skill deficits are less apparent than worker shortages but may be more consequential in adversely affecting the quantity and quality of public health services” (Draper et al., 2008). Aware of these problems, public health schools are moving toward credentialing their graduates through the new National Board of Public Health Examiners, which may help public health agencies identify more qualified job candidates. (The two national organizations representing public health departments—ASTHO and National Association of County and City Health Officials [NACCHO]—hope to launch accreditation programs for public health agencies, as well.) State and local health departments, like the health care system gener- ally, lack racial and ethnic diversity among their employees. The 4 These survey results report data from, in the former instance, 43 states and the District of Columbia, and, in the latter case, 80 percent of local departments, so the figures do not represent a complete accounting.

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119 STRENGTHEN THE HHS AND U.S. PUBLIC HEALTH AND HEALTH CARE WORKFORCES NACCHO reports that some 70 percent of local health department work- forces are less diverse than the population they serve (Draper et al., 2008). Telemedicine and Telehealth in a Comprehensive Workforce Strategy A potentially important mechanism for meeting the health workforce needs of the future could be the extensive application of telemedicine and telehealth 5 services. Such systems have already been deployed in rural, urban, multistate, and international settings to meet the need for specialist and primary care services and for education, training, and su- pervision of clinical and related health workers. Telehealth systems also can help patients self-manage chronic diseases and conditions. Leading provider organizations have demonstrated the potential of carefully designed telemedicine programs to improve the productivity of the professional workforce, reduce costs, and improve access to needed services. The success of these efforts led to a recent Federal Communica- tions Commission (FCC) program to fund telemedicine projects, but in scale and ambition it is far short of the potential and the need for such investment. A strong collaboration among HHS, the Veterans Health Administration, the Department of Defense, the FCC, and private-sector organizations around a focused, well-funded initiative could expand tele- health systems as a component of strategies to address health workforce shortages. Related Recommendations d. The secretary, in concert with other public and private partners, should develop a comprehensive national strategy to assess and address current and projected gaps in the number, professional mix, 5 The terms telehealth and telemedicine overlap and are often used interchangeably. In this report, telehealth refers to the delivery of health-related services and information via telecommunications technologies, while telemedicine generally focuses on the use of remote electronic communication and transmission of images and documents between clinicians.

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120 HHS IN THE 21ST CENTURY geographic distribution, and diversity of the U.S. public health and health care workforces. To help close projected gaps, the department e. should evaluate existing health care professional training programs, continued education pro- grams, and graduate medical education funding and encourage Congress to invest in programs with proven effectiveness. THE SCIENCE-BASED PROFESSIONS American bioscientists and bioengineers have made innumerable contributions to the prevention, treatment, and cure of many diseases and to mitigating disability by developing advanced prosthetics and other supportive technologies. A strong, well-educated scientific workforce is critical to maintaining America’s economic leadership in the high-tech, knowledge-intensive industries of the twenty-first century. 6 The number of U.S. workers in science and engineering overall has steadily grown over the past 50 years, with between 4.5 and 5 million working in the “life sciences” in 2000. Our homegrown workforce has been substantially augmented by foreign-born scientists and engineers. However, the Bureau of Labor Statistics projects that the increase in de- mand for scientists and engineers will be nearly double that for other oc- cupations by 2014. Workforce analysts worry that the country will not be able to meet that rate of growth in demand, given large numbers of im- pending retirements, a need for greater and greater knowledge and skills among young scientists, and unstable funding for many programs. Women, Latinos, and African Americans remain underrepresented in these fields (National Science Board, 2008b). Another barrier to building our science and engineering workforce are restrictions and administrative complexities facing international students and scholars who want to im- migrate to the United States (NRC, 2007). To address the nation’s current health problems, we need not only bench scientists working on new ideas, but a new generation of health 6 The American public professes interest in scientific discoveries, especially medical ones, and a 2006 survey said they support government funding of basic research (87 per- cent) and are confident in the nation’s scientific leaders. In a 2005 survey, 71 percent of Americans supported development of biotechnology, specifically (National Science Board, 2008b).

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121 STRENGTHEN THE HHS AND U.S. PUBLIC HEALTH AND HEALTH CARE WORKFORCES economists, biostatisticians, epidemiologists, and health care researchers geared to tracking disease trends, assessing programs and payment strategies, and finding the best ways to deliver the fruits of our nation’s enormous investment in knowledge. The problem of workforce shortfalls actually begins at the earliest grade levels. By the time American students reach their teen years, their math and science skills compare poorly to those of students from other developed countries. Meanwhile, students’ interest in advanced educa- tion in the natural sciences and engineering has declined steadily in re- cent decades. While other countries are increasing the numbers and skills of their young scientists, America is not (National Science Board, 2006). Recent real-dollar cutbacks in federal and private-sector support for scientific research, including biomedical research (National Science Board, 2008a), send a signal “to international and American students who may be deterred from pursuing science and engineering careers in this country,” warned National Science Board Chairman Dr. Steven Beering in February 2008 (Beering, 2008). Related Recommendation Congress should give the secretary authority to f. create new programs that invest in the future generation of biomedical and health services re- searchers, enabling the continued discovery of new, more effective methods of preventing, treat- ing, and curing disease, promoting health, im- proving health care delivery and organization, and controlling health system costs. REFERENCES AcademyHealth. 2006. 2006 HSR impact awardee: The business case for nurse staffing. Washington, DC: AcademyHealth. ASTHO (Association of State and Territorial Health Officials). 2008. 2007 state public health workforce survey results. Washington, DC: ASTHO. Beering, S. 2008. Testimony before the Research and Science Education Sub- committee, House Committee on Science and Technology. Arlington, VA: Na- tional Science Foundation.

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122 HHS IN THE 21ST CENTURY Buerhaus, P., D. Staiger, and D. Auerbach. 2009. The future of the nursing workforce in the United States: Data, trends, and implications. Sudbury, MA: Jones and Bartlett Publishers. Bush, G. 2003. Executive order: Presidential management fellows program. http://www.whitehouse.gov/news/releases/2003/11/print/20031121-7.html (ac- cessed September 8, 2008). Collins, J. 2001. Good to great: Why some companies make the leap—and oth- ers don’t. New York: HarperBusiness. Colwill, J. M., J. M. Cultice, and R. L. Kruse. 2008. Will generalist physician supply meet demands of an increasing and aging population? Health Affairs 27(3):w232-w241. Draper, D., R. Hurley, and J. Lauer. 2008. Public health workforce shortages imperil nation’s health. Washington, DC: Center for Studying Health System Change. GAO (Government Accountability Office). 2004. Centers for Disease Control and Prevention: Agency leadership taking steps to improve management and planning, but challenges remain. Washington, DC: GAO. GAO. 2008a. Centers for Disease Control and Prevention: Human capital plan- ning has improved, but strategic view of contractor workforce is needed. Washington, DC: GAO. GAO. 2008b. States are planning for medical surge, but could benefit from shared guidance for allocating scarce resources. Washington, DC: GAO. Gebbie, K., and B. Turnock. 2006. The public health workforce, 2006: New challenges. Health Affairs 25(4):923-933. Goodman, D., and K. Grumbach. 2008. Does having more physicians lead to better health system performance? Journal of the American Medical Associa- tion 299(3):335-337. Hauer, K. E., S. J. Durning, W. N. Kernan, M. J. Fagan, M. Mintz, P. S. O’Sulli- van, M. Battistone, T. DeFer, M. Elnicki, H. Harrell, S. Reddy, C. K. Boscar- din, and M. D. Schwartz. 2008. Factors associated with medical students’ career choices regarding internal medicine. Journal of the American Medical Association 300(10):1154-1164. HHS (Department of Health and Human Services). 2007. HHS human capital survey—2007. Washington, DC: HHS. HHS Office of Human Resources and ASMB (Assistant Secretary for Manage- ment and Budget). 1999. Building successful organizations: Workforce plan- ning in HHS. http://www.hhs.gov/ohr/workforce/wfpguide.html (accessed August 19, 2008). HRSA (Health Resources and Services Administration). 2007. Nineteenth re- port: Enhancing flexibility in graduate medical education. Rockville, MD: Bureau of Health Professions Council on Graduate Medical Education. HRSA. 2008. Shortage designation: HPSAs, MUAs, & MUPs. http://bhpr.hrsa. gov/shortage/ (accessed October 9, 2008).

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124 HHS IN THE 21ST CENTURY Starfield, B., L. Shi, A. Grover, and J. Macinko. 2005a. The effects of specialist supply on populations’ health: Assessing the evidence. Health Affairs Web Exclusive w5-97–w95-107. Starfield, B., L. Shi, and J. Macinko. 2005b. Contribution of primary care to health systems and health. Milbank Quarterly 83(3):457-502. Sullivan Commission on Diversity in the Healthcare Workforce. 2004. Missing persons: Minorities in the health professions. Washington, DC: Sullivan Commission on Diversity in the Healthcare Workforce. Tilson, H., and B. Berkowitz. 2006. The public health enterprise: Examining our twenty-first-century policy challenges. Health Affairs 25(4):900-910. Tu, H., and A. O’Malley. 2007. Exodus of male physicians from primary care drives shift to specialty practice. Washington, DC: Center for Studying Health System Change. Turnock, B. J. 2004. Public health: What it is and how it works, 3rd ed. Sud- bury, MA: Jones and Bartlett Publishers.