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The federal role in health manpower: A new proposal
The Federal Role in Health Manpower:
JAMES
F. DICKSON
Washington,
III, MD
0. C.
My remarks will be focused on developments in the federal health manpower program that clearly will have a major impact on every branch and specialty of medicine, and, I should think, on the ability of the profession to define and address manpower needs across the board. We have had our differences of opinion within the executive branch as to how health manpower programs ought to be structured. Now, finally, those differences have been ironed out, and the administration proposal for new health manpower legislation was presented at congressional hearings about 3 weeks ago. We believe that the changing nature of the health manpower problem demands a significant change in federal policy and in the way federal funds are used to support and influence both health training and the career decisions of those who provide health care, especially physicians. Our judgment is that federal health manpower dollars should be directed to new programs that promise to be effective, and that funds should be withdrawn from programs that do not seem to be moving the nation toward solution of its health manpower problems. There is no longer any question of the need for federal support of academic health institutions. These institutions not only provide trained health manpower, but also conduct the bulk of federally financed biomedical research, and they deliver a substantial amount of the nation’s hospital-based patient care, of which 27 percent is paid for with federal funds. Likewise, it is clear that student assistance must be continued because it can offer a workable and equitable approach to correcting imbalances in minority representation in the health manpower pool and to stimulating the output of specific kinds of health manpower that are in short supply. These two basic premises form the conceptual basis for our legislative proposal, and I should like to discuss each of them. Federal
Support of Academic
made available only to those schools that agree to meet critical national objectives. For schools that elect not to participate, capitation would be phased out over 3 years. Given the crucial importance of medical and dental schools in determining the type, distribution and quality of health care personnel, a stable and continuing federal partnership is essential. We view capitation support that contains no conditions as a subsidy to students. However, once meaningful national priority conditions are attached to capitation, such funds can no longer be viewed as simply a student subsidy. Medical, osteopathic and dental schools will be asked to help solve the geographic and primary care problems in exchange for capitation support. We propose that for those schools participating, the new incentive capitation levels be established at $1,50O/year for each medical, osteopathic and dental student. Capitation would be terminated for pharmacy and phased out over the next 3 years for veterinary medicine, optometry and podiatry. To help correct geographic maldistribution, each medical and dental school will be asked to set aside an annually increasing percentage of its first year places for qualified students who voluntarily agree to practice in an underserved area. Such a requirement would commence at 15 percent in fiscal year 1977, increasing to 25 percent in fiscal year 1979. The special admissions criteria would be linked to capitation support in order to:
Institutions
There is no longer any thought of doing away with capitation for schools of medicine, dentistry or osteopathy. However, we have proposed that capitation be
952
A New Proposal
May 1976
The American Journal of CARDIOLOGY
Volume 37
l Yield a system-wide response to a critical health manpower problem and the need for a physician draft. l Assure that not only the lowest income students provide public service. . Make schools more aware in the admissions process of the national importance of accepting and training persons willing to fill gaps in health service. l Provide in each school a large enough pool of committed students so that the curricular changes necessary for preparing students for service in rural and inner city areas would occur.
Other conditions attached to capitation linked to increased primary care training.
would be
FEDERAL ROLE IN HEALTH MANPOWER-DICKSON
All medical schools would be asked to establish an administrative training unit in family practice or primary care and to have a high proportion, eventually 50 percent, of their filled affiliated residencies in primary care. These conditions were included in recognition of the importance of medical school environment on specialty choice. By requiring medical schools to have a high percentage of their filled affiliated residencies in primary care, we will be able to bring about a better balance between the number of residencies in primary and nonprimary care without restructuring all graduate medical education or having the federal government regulate the size, composition and geographic distribution of residency programs-something that I think is both undesirable and unnecessary.
Health Manpower
Scholarship
Program
Geographic maldistribution of health manpower represents one of the greater barriers to access to quality health care. Despite increases in the total number of health manpower personnel, geographic maldistribution has increased in the last 10 years. Without appropriate direct federal intervention, this condition, primarily affecting rural and inner city areas, is not likely to improve. Existing scholarship programs might continue to handle these problems; however, much more could be accomplished through a single broad and conditional health manpower scholarship program. The broadened program we have proposed would serve as a mechanism for handling geographic distribution, fulfilling various internal health manpower requirements of the Department of Health, Education, and Welfare and would offer the potential, at least, for treating problems associated with the maldistribution of medical specialties. A conditional scholarship program would also be consistent with the principle that the public is ordinarily entitled to public service, or service meeting a public need, from persons who receive special scholarship assistance while preparing for a degree in the health professions. We propose to consolidate the existing programs for Public Health and National Health Service Corps Scholarships and Physician Shortage Area Scholarships into one broadened conditional scholarship program. Under the program, participants could be assigned to a federal health service or other areas of critical need. Certain participants could serve in the National Health Service Corps; others could serve elsewhere in the Department of Health, Education, and Welfare, in other federal agencies, or in state or local government. All participants would have to be involved directly in the delivery of health care services, although the broadened authority would permit a service obligation to be fulfilled by persons practicing as private practitioners. Our proposal again recommends that ceilings on student loans for graduate education be increased from $2,500 to $7,000. Most students should have little difficulty in paying back these increased loans. A payback provision in lieu of service would be available, but it would be designed as a disincentive. Payback would be equal to twice the cost of support (minus any time
equivalent already fulfilled), plus compound interest at prevailing market rates dating back to the first year recipients received scholarship funds. Payback could be waived by the Secretary of Health, Education, and Welfare in the case of death of the recipient or in other cases in which payback would be against equity and good conscience. One additional point about scholarships: There has been significant underrepresentation in health professions schools of students who are financially or otherwise disadvantaged because of socioeconomic factors. This has been a major factor in the underrepresentation of racial minorities in the health professions. In recent years significant progress has been made. The percentage of minority students in the first year classes of medical schools has risen steadily. These students are largely from families of low income; 20 percent are from families with an income of less than $5,000 and 67 percent from families with an annual income of less than $10,000. Regardless of the gains made through improved educational opportunities in the preparation of such students for entry into health profession schools, these young people remain the most vulnerable in terms of educational and economic risks. We propose to establish a special preadmission and scholarship program for the disadvantaged enrolled in postbaccalaureate programs. It would provide up to 2 years of stipends for students in preadmission programs and scholarships for students from disadvantaged backgrounds for their entry year in medical or dental school. The scholarship would be limited to the entry year because, upon successful completion of the 1st year in school, students become more willing and able to take out loans.
Special
Projects Grants and Contracts
Targeted special projects grants and contracts provide one of the most effective means for carrying out specific federal initiatives. In this way, support can be directed to specific high priority objectives, and efforts can be more effectively traced and evaluated. We believe that discretionary funds should be used only to stimulate action to achieve national goals not likely to be addressed adequately from other sources. Discretionary funds should not become basic institutional support but should provide a short-range stimulus in areas such as: Family medicine residencies and training. Primary care residencies and training. l Curricular and other improvements at schools of veterinary medicine, optometry, pharmacy and podiatry. l Training of public health professionals. l Improvement in the training of allied health professionals, especially with respect to training that is crucial to the support of primary care practitioners. l Training of physician and dentist extenders. l
l
To ameliorate the effect of geographic maldistribution, we would make grants for community-based health manpower education programs, medical school-based area health education centers and communications technology projects establishing data transmission and
May 1976
The American
Journal
of CARDIOLOGY
Volume 37
953
FEDERAL ROLE IN HEALTH MANPOWER-DICKSON
backup consultation links between medical schools and remotely based rural physicians. Support would be provided for community-based training of students, regional systems of continuing education and rotation of faculty and,programs to upgrade the teaching skills of local professionals. We would also authorize grants to schools of medicine and osteopathy for programs to assist United States students now enrolled in foreign medical schools to qualify for transfer to United States medical schools with advanced standing. To upgrade the skills of foreign medical graduates already in this country, we would make grants to hospitals to provide foreign medical graduate residents with intensive clinical instruction through contracts with medical schools and intensive instruction in the English language. In addition to supporting activities that we know will be effective in resolving the distribution problems facing us, we need to develop new and improved approaches to the education of health professionals. Such investments are necessary if we are to develop long-range solutions to the difficult manpower issues confronting us today. We need to develop, demonstrate and evaluate new approaches to health manpower education and training or substantially improve existing approaches. Examples of such activities would include the development of regional training facilities, the “schools without walls” concept, methods of reducing costs of training, evaluating changes in admission criteria to select persons more likely to practice in medically underserved areas, innovative curricula and various forms of interdisciplinary training. Financial distress grants would continue to be available to health professions schools. However, priority would be given to schools receiving capitation under the proposed law and, in any given year, a school could receive no more than 75 percent of the amount received in the preceding year. Implications
of Federal Involvement Needs
in Manpower
I have touched briefly on the key elements of the proposed manpower legislation, particularly as they relate to problems of specialty and geographic maldis-
954
May 1976
The American Journal of CARDIOLOGY
Volume 37
tribution. Many other elements of the proposal merit attention. But rather than spell them out, I will discuss briefly the important implications of federal involvement in meeting health manpower needs. Health manpower is a national resource and, as such, it is properly the concern of the public and of government. But health manpower-and specifically physician manpower-is also a profession made up of men and women who tend to be somewhat individualistic, who have devoted a dozen or more years of their lives to a rigorous educational process and who quite properly place a high value on the skills they have acquired and on their freedom to employ those skills as they think best, for their patients and for themselves. Given this somewhat conflicting set of circumstances, it is obvious, that government and medicine will often be in disagreement about many things-about how best to define and achieve a balance between supply and demand, how to assess and improve quality and, obviously, how government imposes direct or implicit regulation on health care and the practice of medicine. Government alone does not have the ability to make all the proper decisions in a subject as complex, subtle and personal as health care. We have made some serious mistakes in the past, and we are by no means immune to making mistakes in the future. This is one of the reasons, by no means the only one, why the exhaustive cardiology manpower study under discussion today is of such surpassing importance to the profession, the federal health enterprise and ultimately to the public. The data that have been accumulated and the inferences and recommendations developed from these data are precisely the kind of input that must form the basis of any sound manpower strategy for health. One of the most encouraging signs is the appearance of this and several other similar studies being carried out by the health profession itself through its various specialty societies. We have made some serious manpower mistakes in the past. But I think the risk of future mistakes is sharply reduced simply because so many persons and organizations are at last taking an enlight,ened and realistic look at the complex problems in the health manpower field. And that is an absolutely essential step toward solving those problems.
JAMES
F. DICKSON
Washington,
III, MD
0. C.
My remarks will be focused on developments in the federal health manpower program that clearly will have a major impact on every branch and specialty of medicine, and, I should think, on the ability of the profession to define and address manpower needs across the board. We have had our differences of opinion within the executive branch as to how health manpower programs ought to be structured. Now, finally, those differences have been ironed out, and the administration proposal for new health manpower legislation was presented at congressional hearings about 3 weeks ago. We believe that the changing nature of the health manpower problem demands a significant change in federal policy and in the way federal funds are used to support and influence both health training and the career decisions of those who provide health care, especially physicians. Our judgment is that federal health manpower dollars should be directed to new programs that promise to be effective, and that funds should be withdrawn from programs that do not seem to be moving the nation toward solution of its health manpower problems. There is no longer any question of the need for federal support of academic health institutions. These institutions not only provide trained health manpower, but also conduct the bulk of federally financed biomedical research, and they deliver a substantial amount of the nation’s hospital-based patient care, of which 27 percent is paid for with federal funds. Likewise, it is clear that student assistance must be continued because it can offer a workable and equitable approach to correcting imbalances in minority representation in the health manpower pool and to stimulating the output of specific kinds of health manpower that are in short supply. These two basic premises form the conceptual basis for our legislative proposal, and I should like to discuss each of them. Federal
Support of Academic
made available only to those schools that agree to meet critical national objectives. For schools that elect not to participate, capitation would be phased out over 3 years. Given the crucial importance of medical and dental schools in determining the type, distribution and quality of health care personnel, a stable and continuing federal partnership is essential. We view capitation support that contains no conditions as a subsidy to students. However, once meaningful national priority conditions are attached to capitation, such funds can no longer be viewed as simply a student subsidy. Medical, osteopathic and dental schools will be asked to help solve the geographic and primary care problems in exchange for capitation support. We propose that for those schools participating, the new incentive capitation levels be established at $1,50O/year for each medical, osteopathic and dental student. Capitation would be terminated for pharmacy and phased out over the next 3 years for veterinary medicine, optometry and podiatry. To help correct geographic maldistribution, each medical and dental school will be asked to set aside an annually increasing percentage of its first year places for qualified students who voluntarily agree to practice in an underserved area. Such a requirement would commence at 15 percent in fiscal year 1977, increasing to 25 percent in fiscal year 1979. The special admissions criteria would be linked to capitation support in order to:
Institutions
There is no longer any thought of doing away with capitation for schools of medicine, dentistry or osteopathy. However, we have proposed that capitation be
952
A New Proposal
May 1976
The American Journal of CARDIOLOGY
Volume 37
l Yield a system-wide response to a critical health manpower problem and the need for a physician draft. l Assure that not only the lowest income students provide public service. . Make schools more aware in the admissions process of the national importance of accepting and training persons willing to fill gaps in health service. l Provide in each school a large enough pool of committed students so that the curricular changes necessary for preparing students for service in rural and inner city areas would occur.
Other conditions attached to capitation linked to increased primary care training.
would be
FEDERAL ROLE IN HEALTH MANPOWER-DICKSON
All medical schools would be asked to establish an administrative training unit in family practice or primary care and to have a high proportion, eventually 50 percent, of their filled affiliated residencies in primary care. These conditions were included in recognition of the importance of medical school environment on specialty choice. By requiring medical schools to have a high percentage of their filled affiliated residencies in primary care, we will be able to bring about a better balance between the number of residencies in primary and nonprimary care without restructuring all graduate medical education or having the federal government regulate the size, composition and geographic distribution of residency programs-something that I think is both undesirable and unnecessary.
Health Manpower
Scholarship
Program
Geographic maldistribution of health manpower represents one of the greater barriers to access to quality health care. Despite increases in the total number of health manpower personnel, geographic maldistribution has increased in the last 10 years. Without appropriate direct federal intervention, this condition, primarily affecting rural and inner city areas, is not likely to improve. Existing scholarship programs might continue to handle these problems; however, much more could be accomplished through a single broad and conditional health manpower scholarship program. The broadened program we have proposed would serve as a mechanism for handling geographic distribution, fulfilling various internal health manpower requirements of the Department of Health, Education, and Welfare and would offer the potential, at least, for treating problems associated with the maldistribution of medical specialties. A conditional scholarship program would also be consistent with the principle that the public is ordinarily entitled to public service, or service meeting a public need, from persons who receive special scholarship assistance while preparing for a degree in the health professions. We propose to consolidate the existing programs for Public Health and National Health Service Corps Scholarships and Physician Shortage Area Scholarships into one broadened conditional scholarship program. Under the program, participants could be assigned to a federal health service or other areas of critical need. Certain participants could serve in the National Health Service Corps; others could serve elsewhere in the Department of Health, Education, and Welfare, in other federal agencies, or in state or local government. All participants would have to be involved directly in the delivery of health care services, although the broadened authority would permit a service obligation to be fulfilled by persons practicing as private practitioners. Our proposal again recommends that ceilings on student loans for graduate education be increased from $2,500 to $7,000. Most students should have little difficulty in paying back these increased loans. A payback provision in lieu of service would be available, but it would be designed as a disincentive. Payback would be equal to twice the cost of support (minus any time
equivalent already fulfilled), plus compound interest at prevailing market rates dating back to the first year recipients received scholarship funds. Payback could be waived by the Secretary of Health, Education, and Welfare in the case of death of the recipient or in other cases in which payback would be against equity and good conscience. One additional point about scholarships: There has been significant underrepresentation in health professions schools of students who are financially or otherwise disadvantaged because of socioeconomic factors. This has been a major factor in the underrepresentation of racial minorities in the health professions. In recent years significant progress has been made. The percentage of minority students in the first year classes of medical schools has risen steadily. These students are largely from families of low income; 20 percent are from families with an income of less than $5,000 and 67 percent from families with an annual income of less than $10,000. Regardless of the gains made through improved educational opportunities in the preparation of such students for entry into health profession schools, these young people remain the most vulnerable in terms of educational and economic risks. We propose to establish a special preadmission and scholarship program for the disadvantaged enrolled in postbaccalaureate programs. It would provide up to 2 years of stipends for students in preadmission programs and scholarships for students from disadvantaged backgrounds for their entry year in medical or dental school. The scholarship would be limited to the entry year because, upon successful completion of the 1st year in school, students become more willing and able to take out loans.
Special
Projects Grants and Contracts
Targeted special projects grants and contracts provide one of the most effective means for carrying out specific federal initiatives. In this way, support can be directed to specific high priority objectives, and efforts can be more effectively traced and evaluated. We believe that discretionary funds should be used only to stimulate action to achieve national goals not likely to be addressed adequately from other sources. Discretionary funds should not become basic institutional support but should provide a short-range stimulus in areas such as: Family medicine residencies and training. Primary care residencies and training. l Curricular and other improvements at schools of veterinary medicine, optometry, pharmacy and podiatry. l Training of public health professionals. l Improvement in the training of allied health professionals, especially with respect to training that is crucial to the support of primary care practitioners. l Training of physician and dentist extenders. l
l
To ameliorate the effect of geographic maldistribution, we would make grants for community-based health manpower education programs, medical school-based area health education centers and communications technology projects establishing data transmission and
May 1976
The American
Journal
of CARDIOLOGY
Volume 37
953
FEDERAL ROLE IN HEALTH MANPOWER-DICKSON
backup consultation links between medical schools and remotely based rural physicians. Support would be provided for community-based training of students, regional systems of continuing education and rotation of faculty and,programs to upgrade the teaching skills of local professionals. We would also authorize grants to schools of medicine and osteopathy for programs to assist United States students now enrolled in foreign medical schools to qualify for transfer to United States medical schools with advanced standing. To upgrade the skills of foreign medical graduates already in this country, we would make grants to hospitals to provide foreign medical graduate residents with intensive clinical instruction through contracts with medical schools and intensive instruction in the English language. In addition to supporting activities that we know will be effective in resolving the distribution problems facing us, we need to develop new and improved approaches to the education of health professionals. Such investments are necessary if we are to develop long-range solutions to the difficult manpower issues confronting us today. We need to develop, demonstrate and evaluate new approaches to health manpower education and training or substantially improve existing approaches. Examples of such activities would include the development of regional training facilities, the “schools without walls” concept, methods of reducing costs of training, evaluating changes in admission criteria to select persons more likely to practice in medically underserved areas, innovative curricula and various forms of interdisciplinary training. Financial distress grants would continue to be available to health professions schools. However, priority would be given to schools receiving capitation under the proposed law and, in any given year, a school could receive no more than 75 percent of the amount received in the preceding year. Implications
of Federal Involvement Needs
in Manpower
I have touched briefly on the key elements of the proposed manpower legislation, particularly as they relate to problems of specialty and geographic maldis-
954
May 1976
The American Journal of CARDIOLOGY
Volume 37
tribution. Many other elements of the proposal merit attention. But rather than spell them out, I will discuss briefly the important implications of federal involvement in meeting health manpower needs. Health manpower is a national resource and, as such, it is properly the concern of the public and of government. But health manpower-and specifically physician manpower-is also a profession made up of men and women who tend to be somewhat individualistic, who have devoted a dozen or more years of their lives to a rigorous educational process and who quite properly place a high value on the skills they have acquired and on their freedom to employ those skills as they think best, for their patients and for themselves. Given this somewhat conflicting set of circumstances, it is obvious, that government and medicine will often be in disagreement about many things-about how best to define and achieve a balance between supply and demand, how to assess and improve quality and, obviously, how government imposes direct or implicit regulation on health care and the practice of medicine. Government alone does not have the ability to make all the proper decisions in a subject as complex, subtle and personal as health care. We have made some serious mistakes in the past, and we are by no means immune to making mistakes in the future. This is one of the reasons, by no means the only one, why the exhaustive cardiology manpower study under discussion today is of such surpassing importance to the profession, the federal health enterprise and ultimately to the public. The data that have been accumulated and the inferences and recommendations developed from these data are precisely the kind of input that must form the basis of any sound manpower strategy for health. One of the most encouraging signs is the appearance of this and several other similar studies being carried out by the health profession itself through its various specialty societies. We have made some serious manpower mistakes in the past. But I think the risk of future mistakes is sharply reduced simply because so many persons and organizations are at last taking an enlight,ened and realistic look at the complex problems in the health manpower field. And that is an absolutely essential step toward solving those problems.