HRSA's Wakefield on CHCs, ACOs and Strengthening the Health Workforce

Eli Y. Adashi, MD, MS, CPE, FACOG; Mary Wakefield, PhD, RN


January 10, 2012

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Eli Y. Adashi, MD, MS, CPE, FACOG: Hello, I am Eli Adashi, professor of medical science at Brown University and host of Medscape One-on-One. Joining me today is Dr. Mary Wakefield, administrator of the Health Resources and Services Administration (HRSA). An agency of the Department of Health and Human Services, HRSA is committed to improving access to healthcare services for some of our nation's most vulnerable citizens. Welcome.

Mary Wakefield, PhD, RN: Thank you. It's nice to be here.

What Are Community Health Centers

Dr. Adashi: We recognize that community health centers (CHCs) must be a huge piece of your charge. They also figure in a big way into the Affordable Care Act or the healthcare reform bill. What is a CHC for short?

Dr. Wakefield: You can find CHCs in every state of the union. We have more than 1100 community health centers in urban and rural areas across the United States. But many of those health centers have additional, related sites so right now we have more than 8100 sites in the United States.

Dr. Adashi: Is there an estimate of the total number of patients that CHCs might be caring for?

Dr. Wakefield: About 19.5 million patients are seen in CHCs. Interestingly that number went up just over the last couple of years. That's probably due to economic circumstances, people losing their jobs, and then losing their health insurance coverage. So this infrastructure across the United States, that safety net infrastructure, became even more important recently.

The Affordable Care Act and CHCs

Dr. Adashi: If and when the Affordable Care Act, the healthcare reform bill, goes through as originally envisioned, how many patients are likely to be cared for by the CHCs?

Dr. Wakefield: We'll likely see millions more patients than we are currently seeing. The Affordable Care Act provides a very significant investment in CHCs. An investment that rolls out over the course of about the next 4 years to help support operations of health centers, to help with construction, and to help with expanded services. Health centers, for example, are a little bit atypical. They provide behavioral health services frequently, they provide healthcare services, and then of course typical or traditional primary care and illness prevention relation services. The Affordable Care Act allows many of the health centers to expand their services, to expand their sites, and to engage in renovation or construction; all of those investments through the Affordable Care Act over the course of the next few years are made with the expectation that we'll have millions more patients being seen in them.

Dr. Adashi: That would make the CHCs responsible for a very substantial fraction of the total population.

Dr. Wakefield: Yes.

Care Coordination

Dr. Adashi: One element that is dominant in the Affordable Care Act and throughout the nation these days is of course the emphasis on care coordination, and it's easy to see how the CHCs could be the perfect sites for such efforts in terms of primary care coordination. Is HRSA focused on that part of the equation in some way? Is it issuing grants to encourage that activity? What can you tell us in that context?

Dr. Wakefield: You're right care coordination is really critical to the way CHCs operate, and through our grants we're trying to encourage even more of that. For example, we have an array of different types of healthcare providers that work together even within a CHC. The expectation is that nurse practitioners, doctors, dentists, psychologists, and others are all working together to coordinate care around a patient or a patient and their family. In addition CHCs have an obligation to make referrals for patients when they need to see specialists or when they need something other than a primary care physician. That's part of the package in the way a CHC operates. In fact, CHCs already have a lot of the elements of patient-centered medical homes with the deployment of health information technology, team-based care, and a heavy emphasis on care coordination. It's an expectation, and it's an expectation that we'll build out even from the coordination that currently occurs.

Dr. Adashi: In many ways the CHCs may be ahead of the curve and the transition for them might be more natural and easier than for some.

Dr. Wakefield: I would say you're probably right because in many of those settings you find an array of services and an array of service providers that are not always typical in our traditional clinics.

How Do CHCs Fit Into the Accountable Care Organization Concept?

Dr. Adashi: Another key element of the Affordable Care Act is the Accountable Care Organization (ACO) concept. Do the CHCs fit into that overall concept? Are they expected to be part of ACOs wherever they may be?

Dr. Wakefield: We certainly expect that some of the CHCs will absolutely step up and participate in the ACO provisions of the Affordable Care Act. They're allowed to by law and in some cases they can choose to form networks even among CHCs. So, yes, they have a place at that table.

What Is the Health Service Corps?

Dr. Adashi: Some of the staffing of the CHCs is done by the National Health Service Corps, which is a little known part of the health workforce. Could you tell our viewers what the National Health Service Corp is, and how is it fairing these days?

Dr. Wakefield: The National Health Service Corp is a really important program that the federal government supports. It provides scholarships and loan repayment to primary care clinicians, for example, that are willing to practice once they graduate in underserved rural or urban areas. In our health profession shortage areas across the United States, of which there are many, this is a really important program because it focuses on the deployment or the distribution of primary care providers to ensure that the communities that need them the most, whether you're talking about downtown Baltimore, downtown Miami, or you're talking about my home state, North Dakota, and rural communities there. It really helps to ensure that these areas have access to key frontline providers.

The providers in this program include family medicine physicians, oral hygienists, dentists, physician assistants, and other providers. In exchange for service in underserved communities, individuals can receive loan repayment or scholarships. The loan repayment, just to give you an example, it runs about $60,000 for 2 years of service, and scholarships help to support tuition, cost of books and fees for students, and the program has grown markedly in the course of the last 2 years, and it will continue to grow through Affordable Care Act investments. Frankly, it was fairly anemically funded up until just a couple of years ago. We've been able to more than double the size of the National Health Service Corp. It's very exciting; now more than 10,000 clinicians are being fielded to underserved communities. In many cases, that means that a community of individuals who would have had difficulty accessing a pediatrician for example, now may well have one courtesy of the National Health Service Corp. It's a very important investment of the Affordable Care Act; about $1.5 billion is being spent, as a matter of fact.

Teaching Health Centers

Dr. Adashi: Remarkable. Another novelty that is not widely recognized is the so-called teaching health centers, which are finding homes in CHCs. Can you share some insight as to what these teaching health centers are, how they are coming along, and how they are expected to change the healthcare workforce?

Dr. Wakefield: The teaching health centers program has been stood up through the Affordable Care Act. It's an extremely important investment because what it does is really support the training of primary care physicians, for example, in community-based settings. Often times those community-based settings are CHCs, so it really drives the training of our next generation of primary care providers to where most patients are seen. Hospital training is certainly important and these residents would also receive that, but it really focuses on encouraging residency training in a community-based setting. We fund about 17 teaching health centers now, and there was a little bit of concern about a decrease in interest from some graduating medical students in primary care. There was a bit of a concern about whether we'd be able to fill the slots. I'm really pleased to say we've been able to fill all the slots, and the applications have exceeded the resources that we have available. It's a really good start for a very important program that's supported through the Affordable Care Act.

Strengthening the Healthcare Workforce

Dr. Adashi: In this context I believe it is true that HRSA is one of the Health and Human Services agencies that is most concerned with the healthcare workforce, the size thereof, the makeup thereof, etc. What do you in your leadership position have to do in that regard? What keeps you awake at night? Where do you invest? What should we be looking for in terms of future activities on the part of the agency?

Dr. Wakefield: Part of the equation that I pay most attention to is certainly around issues of supply. Primarily I'm concerned with the supply of primary care providers, but not just primary care providers, because we do have a portfolio of health professions workforce training programs that invest in scholarships for students. We also invest in curricula, trying to drive new innovative curricula across health professions training programs. We have health workforce programs that invest in the next generation of healthcare providers that will be making services available to our elderly. We have an array, really a broad portfolio, of workforce programs based within the HRSA. The good news is that those programs are highly valued by this administration, having received significant support during the past couple of years, focusing on both supply and distribution of providers.

One of the areas we've been paying a lot of attention to recently is ensuring that we're doing our part to incentivize training programs to train clinicians with competencies that will allow them to practice even more effectively in teams, which makes sense when you talk ACOs and reengineering our healthcare delivery system so that we really capitalize on the full array of services to individuals and their families. It's about supply and demand but it's also about how we are preparing that next generation of clinicians. Probably one other point worth noting is that we take our role very seriously in terms of the contribution of all our programs to strengthening the nation's healthcare workforce, but we're not doing it alone. We're working very closely with health professionals, training programs, and universities and colleges. Also we work a lot with national associations that represent medical school faculty for example, and maybe at least as important if not more, we work closely with states.

Support for Pediatric Medicine

Dr. Adashi: Finally and mostly for the benefit of the pediatricians among our viewers, there has been some concern about the future of graduate medical education support of pediatric residency slots. Do we have any clarity on that issue? What can we tell members of this discipline about the future support of pediatric residency positions?

Dr. Wakefield: First of all we recognize they are extremely important. That's a critically important provider. Secondly, we do support pediatric residency training through some of the programs that I've already mentioned including the National Health Service Corp, as well as other programs. We've also supported pediatricians and pediatrician residency training through investments of the Affordable Care Act. HRSA has been responsible for implementing the Children's Hospital Graduate Medical Education (CHGME) Program -- that might be the program that you're asking specifically about. There were no funds in the president's budget for fiscal year 2012. However, there is activity on Capitol Hill, and as we watch the appropriations process unfold there, there certainly are efforts around CHGME to reauthorize that particular program.

Dr. Adashi: It's probably fair to say that it's a little bit out of our collective hands. It's on the hill and it's subject to the vagaries of the budget process. On this note a sincere thanks to Dr. Wakefield and to you our viewers for joining Medscape One on One. Until next time, I am Eli Adashi.


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