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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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).
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce “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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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)
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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).
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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,
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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.
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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
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In The Nation’s Compelling Interest: Ensuring Diversity in the Health-Care Workforce 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) REFERENCES Advisory Committee on Training in Primary Care Medicine and Dentistry. 2001. Comprehensive Review and Recommendations, Title VII, Section 747 of the Public Health Service Act. Report to Secretary of the U.S. Department of Health and Human Services, and Congress. [Online]. Available: http://www.bhpr.hrsa.gov/medicine-dentistry/actpcmd/report2001.htm [accessed March 29, 2003]. Pp. 19 67, 69. AAMC (Association of American Medical Colleges). 2003. AAMC’s Project 3000 by 2000 Announces New Grants to Prepare Minorities for Health Professions Careers. [Online]. Available: http://www.aamc.org/newsroom/pressrel/1999/990209.htm [accessed August 28, 2003]. AMA (American Medical Association). 2001. Total Physicians by Race/Ethnicity—2001. [Online]. Available: http://www.ama-assn.org/ama/pub/article/168-187.html [accessed May 18, 2003]. APA (American Psychological Association). 2002. National Health Service Corps Reauthorization. [Online]. Available: http://www.apa.org/ppo/issues/enhscupd.html [accessed May 19, 2003]. P. 1. Catalog of Federal Domestic Assistance. 2003. Extramural Loan Repayment for Individuals from Disadvantaged Backgrounds Conducting Clinical Research. [Online]. Available: http://www.cfda.gov/static/93308.htm [accessed August 29, 2003]. CMS (Centers for Medicare and Medicaid Services), U.S. Department of Health and Human Services. 2002. November 12. Health Care Industry Market Update. Acute Care Hospitals, Vol. 2. Appendix: Medicare Payment Systems. [Online]. Available: http://www.cms.hhs.gov/reports/hcimu/hcimu_04292002_append.pdf [accessed August 28, 2003]. P. 6. COGME (Council on Graduate Medical Education). 1998. Twelfth Report. Rockville, MD: Health Resources and Services Administration, U.S. Department of Health and Human Services. P. 19. __________. 2002. 2002 Summary Report. Rockville, MD: Health Resources and Services Administration, U.S. Department of Health and Human Services. Pp. 6-7, 8–9. Cohen JJ, Gabriel BA, Terrell C. 2002. The case for diversity in the health care workforce. Health Affairs 21(5):91. Distributed Communications Corporation. 1998. Health Resources and Services Administration: Assessment of Historically Black Medical Schools; Participation in HRSA-Supported Health Professions Training Programs. [Online]. Available: http://www.hrsa.gov/OMH/HBMS/cover-contents-execsummary.doc [accessed May 23, 2003]. P. xv. Duke EM. 2002. Remarks to a Meeting of Health Careers Opportunity Program Directors. [Online]. Available: http://newsroom.hrsa.gov/speeches/2002speeches/hcop.htm [accessed May 19, 2003]. P. 4. __________. 2003. Statement on Fiscal Year 2004 President’s Budget Request for the Health Resources and Services Administration. [Online]. Available: http://www.hhs.gov/budget/testify/b20030326c.html [accessed May 21, 2003]. P. 3.
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Representative terms from entire chapter: