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Report to Congressional Requesters: 

United States Government Accountability Office: 

GAO: 

February 2006: 

Health Professions Education Programs: 

Action Still Needed to Measure Impact: 

GAO-06-55: 

GAO Highlights: 

Highlights of GAO-06-55, a report to congressional requesters: 

Why GAO Did This Study: 

For fiscal years 1999 through 2005, the Health Resources and Services 
Administration (HRSA), an agency within the Department of Health and 
Human Services (HHS), spent about $2.7 billion to fund the more than 40 
health professions education programs authorized under title VII and 
title VIII of the Public Health Service Act. These programs include 
those providing grants to institutions, direct assistance to students, 
and funding for health workforce analyses. Title VII includes programs 
related to the education of providers, such as primary care physicians. 
Title VIII includes programs related to nursing education. Most of 
these programs were last reauthorized in 1998. GAO reviewed changes in 
funding and in the number of these programs since 1998, HRSA’s goals 
and assessment of the programs, and HRSA’s national health professions 
workforce projections. 

GAO reviewed relevant laws and agency documents and data, and 
interviewed HRSA officials and representatives of health professions 
education associations. 

What GAO Found: 

Funding for title VII and title VIII programs increased from about $300 
million in fiscal year 1999 to more than $450 million in fiscal year 
2005, and the overall number of these programs also increased since 
reauthorization in 1998. From fiscal years 1999 through 2005, funding 
for title VII programs rose by about one-fourth, while that for title 
VIII programs more than doubled. The overall numbers of title VII and 
title VIII programs administered by HRSA increased from 46 in fiscal 
year 1998 to 50 in fiscal year 2004. The number of title VII programs 
remained the same, while the number of title VIII programs increased. 

HRSA has published performance goals for title VII and title VIII 
health professions education programs but cannot fully assess the 
programs’ effectiveness because the goals do not apply to all the 
health professions education programs, and the data for tracking 
progress are problematic. Recognizing the need for a better means of 
measuring the results of title VII and title VIII programs, HRSA is 
developing new performance goals and measures for them. The 
effectiveness of these efforts will depend upon the agency’s ability to 
collect complete and timely data to assess progress toward these new 
goals. 

HRSA has published few recent national workforce projections. In the 
past decade, the agency has published national supply and demand 
projections for the nurse and pharmacist workforces but no national 
projections for the physician and dentist workforces. Yet regular 
reassessment of future health workforce supply and demand is key to 
setting policies as the nation’s health care needs change. 

Funding for Title VII and Title VIII Programs, Fiscal Years 1999–2005: 

[See PDF for image] 

[End of figure] 

What GAO Recommends: 

GAO recommends that HRSA develop a strategy and time frames to 
regularly update and publish national health professions workforce 
projections. HRSA agreed with GAO’s conclusion that updated workforce 
supply and demand projections are vital for informed decision making 
about health professions programs. 

www.gao.gov/cgi-bin/getrpt?GAO-06-55. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Leslie G. Aronovitz at 
(312) 220-7600 or aronovitzl@gao.gov. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

Funding for and Overall Number of Title VII and Title VIII Health 
Professions Education Programs Increased: 

HRSA's Goals Do Not Apply to All Title VII and Title VIII Programs, and 
Data Are Problematic, but Agency Is Developing Alternatives: 

HRSA Has Published Few National Workforce Projections in Recent Years: 

Conclusions: 

Recommendation for Executive Action: 

Agency Comments: 

Appendix I: Examples of Additional Sources of Federal Funding for 
Health Professions Education: 

Appendix II: Title VII and Title VIII Clusters and Programs, Fiscal 
Year 2004: 

Appendix III: Additional Performance Goals and Targets for Health 
Professions and Nursing Education Programs: 

Appendix IV: Comments from the Health Resources and Services 
Administration: 

Appendix V: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Title VII and Title VIII Programs in Existence Before, and 
Organized into Clusters After, 1998 Reauthorization: 

Table 2: Performance Goals and Targets for the Health Professions and 
Nursing Education and Training Programs Funded under Title VII and 
Title VIII: 

Table 3: HRSA's Most Recent Reports Containing National Workforce 
Supply and Demand Projections for Physicians, Dentists, Nurses, and 
Pharmacists: 

Table 4: Examples of Federal Funding Sources, besides Title VII and 
Title VIII Programs, for Postsecondary Education and Training 
Specifically Targeted for Health Professions: 

Table 5: Examples of Federal Funding Sources for General Postsecondary 
Education and Training Including, but Not Exclusive to, Health 
Professions: 

Figures: 

Figure 1: Funding for Title VII and Title VIII Health Professions 
Education Programs, Fiscal Years 1999-2005: 

Figure 2: Funding for Title VII Health Professions Education Programs, 
Fiscal Years 1999-2005: 

Figure 3: Title VII Funding for New and Competitive Continuation Grants 
and for Noncompetitive Continuations, Fiscal Years 1999-2004: 

Figure 4: Title VIII Funding for New and Competitive Continuation 
Grants and for Noncompetitive Continuations, Fiscal Years 1999-2004: 

Abbreviations: 

AMA: American Medical Association: 
CMS: Centers for Medicare & Medicaid Services: 
COGME: Council on Graduate Medical Education: 
GPRA: Government Performance and Results Act: 
HHS: Department of Health and Human Services: 
HRSA: Health Resources and Services Administration: 
NELRP: Nursing Education Loan Repayment Program: 
OMB: Office of Management and Budget: 

[End of section] 

United States Government Accountability Office: 

Washington, DC 20548: 

February 28, 2006: 

The Honorable Michael B. Enzi: 
Chairman: 
Committee on Health, Education, Labor, and Pensions: 
United States Senate: 

The Honorable Judd Gregg: 
United States Senate: 

An appropriate supply, mix, and distribution of health professionals-- 
today and in the future--is vital to ensuring that all Americans have 
adequate access to health care. For fiscal years 1999 through 2005, the 
Health Resources and Services Administration (HRSA), an agency within 
the Department of Health and Human Services (HHS), spent about $2.7 
billion to fund health professions education programs authorized under 
title VII and title VIII of the Public Health Service Act. Administered 
by HRSA, the many title VII and title VIII programs include those 
providing grants to institutions training health professionals; direct 
assistance to students in the form of scholarships, loans, or repayment 
of educational loans; and funding for health workforce analyses. Title 
VII programs include those related to the education of providers, such 
as primary care physicians, physician assistants, general dentists, 
pediatric dentists, and allied health practitioners; [Footnote 1] 
programs related to education of the public health workforce; and 
programs related to the analysis of health workforce issues, such as 
estimates of supply and demand. Title VIII programs include those 
related to basic and advanced nursing education programs, which are 
designed to increase nursing workforce diversity, promote career 
advancement, and improve retention. Most of the health professions 
education programs were last reauthorized in 1998. [Footnote 2] 

For more than a decade, our reviews of title VII and title VIII 
programs have raised questions about HRSA's ability to assess the 
programs' effectiveness. [Footnote 3] For example, before the 1998 
reauthorization, we noted that the programs' effectiveness would remain 
difficult to measure as long as the health professions education 
programs were authorized to support a broad range of health care 
objectives. [Footnote 4] For fiscal years 2002 through 2005, HRSA's 
budget justifications have questioned the need for continued federal 
support of many of these health professions education programs, and a 
review by the Office of Management and Budget (OMB) for the fiscal year 
2004 budget questioned their effectiveness. [Footnote 5] 

In preparation for congressional consideration of the next 
reauthorization of title VII and title VIII programs, you asked us to 
review the programs, including changes after the 1998 reauthorization. 
In this report, we provide information on (1) changes in funding and in 
the number of title VII and title VIII health professions education 
programs since the 1998 reauthorization; (2) HRSA's stated goals for 
the programs and the agency's efforts to measure progress toward 
meeting them; and (3) national health professions workforce projections 
developed by HRSA. 

To conduct our work, we analyzed pertinent agency documents and 
interviewed HRSA officials. We also analyzed data from HRSA's grants 
management system, reviewed relevant laws, and interviewed 
representatives of the Health Professions and Nursing Education 
Coalition and the Federation of Associations of Schools of the Health 
Professions. We examined funding for title VII and title VIII programs 
for fiscal years 1999 through 2005. [Footnote 6] To analyze the number 
of title VII and title VIII programs HRSA administered, we counted (1) 
programs that awarded funds competitively through grants or cooperative 
agreements [Footnote 7] and that announced funding availability 
separately or had a separate selection panel [Footnote 8] and (2) 
programs providing direct assistance, such as student loans to 
individuals, regardless of whether the loan program was using current 
appropriations. [Footnote 9] 

For information on HRSA's stated goals and measures of performance in 
meeting these goals and on the agency's plans for the future, we 
reviewed HRSA's annual performance plans, budget justifications, and 
strategic planning documents, and we attended HRSA's Bureau of Health 
Professions' first all-grantee conference in June 2005. Regarding the 
workforce supply and demand projections HRSA developed, we focused on 
the most recent projected estimates of national supply and demand for 
physicians, dentists, nurses, and pharmacists. [Footnote 10] We also 
reviewed physician workforce reports published by the Council on 
Graduate Medical Education (COGME), [Footnote 11] which based its 
physician workforce projections on HRSA-developed methodologies. We 
assessed the reliability of grants and other funding data used in our 
review by discussing with agency officials validation and internal 
controls for HRSA grants data and comparing the aggregate data with 
similar aggregate data from other sources. We determined that the 
funding data were sufficiently reliable for our purposes. Although we 
identified problems with the reliability of other agency data, such as 
those used to measure program performance, we included them for 
illustrative purposes. We conducted our work in accordance with 
generally accepted government auditing standards from June 2004 through 
January 2006. 

Results in Brief: 

After reauthorization in 1998, overall funding for title VII and title 
VIII programs increased from about $300 million in fiscal year 1999 to 
more than $450 million in fiscal year 2005, and the overall number of 
these programs also increased. From fiscal years 1999 through 2005, 
funding for title VII programs rose by about one-fourth, while that for 
title VIII programs more than doubled. The overall number of title VII 
and title VIII programs administered by HRSA increased from 46 in 
fiscal year 1998 to 50 in fiscal year 2004; this overall increase was 
due to an increase in the number of title VIII programs. 

HRSA has published performance goals for the title VII and title VIII 
health professions education programs, but these goals do not apply to 
all the health professions education programs, and the data for 
tracking progress are problematic. These performance goals, prepared as 
part of HHS's annual reporting under the Government Performance and 
Results Act (GPRA) process, [Footnote 12] are spelled out in HRSA's 
fiscal year 2006 budget justification. In measuring progress toward 
meeting these goals, the agency relies on data we and others have found 
to be problematic. For example, although one performance goal is to 
increase the proportion of health professionals supported by title VII 
and title VIII programs who enter practice in underserved areas, HRSA 
does not have complete data that track the practice locations of these 
health professionals. Recognizing the need for a better means of 
measuring the results of title VII and title VIII programs, HRSA has 
since 2002 been developing a new strategic plan for the health 
professions education programs, which includes program goals and 
information on how the agency proposes to measure performance. 

Although HRSA is responsible for providing health professions workforce 
information to policymakers, HRSA has in the past decade published 
national supply and demand projections for the nurse and pharmacist 
workforces but no national projections for the physician and dentist 
workforces. According to HRSA officials, the agency is preparing a 
report to Congress that will provide information about the health 
workforce for 30 health professions, including national supply and 
demand projections for physicians, pharmacists, and nurses. Estimating 
future health workforce supply and demand on a regular basis is 
important because estimates need to be revised periodically to reflect 
changes in the health care environment. In 2005, an HHS advisory 
council strongly recommended that the nation develop systems to track 
physician workforce supply, demand, and distribution and undertake a 
comprehensive reassessment within the following 4 years to guide future 
decisions on medical education capacity. 

We are recommending that HRSA develop a strategy and time frames to 
regularly update and publish national health professions workforce 
projections. In commenting on a draft of this report, HRSA agreed with 
our conclusion that updated workforce supply and demand projections are 
vital for informed decision making about health professions programs. 

Background: 

In response to a shortage of health care providers, Congress amended 
title VII of the Public Health Service Act in 1963 [Footnote 13] and 
established title VIII in 1964. [Footnote 14] These titles have been 
amended over time and now authorize funding for a variety of programs 
with diverse objectives. As noted in the Senate report accompanying the 
1998 reauthorization legislation, by the mid-1970s, two specific areas 
of need had emerged: overall shortages in rural and inner-city 
communities and an imbalance in the supply of primary care providers as 
compared with specialists. Subsequent revisions to title VII focused on 
encouraging health care workers to practice in underserved areas, 
increasing the number of primary care providers, increasing enrollment 
of minority and disadvantaged students, and developing faculty. 
Revisions to title VIII focused on training advanced practice nurses; 
enrolling disadvantaged students; strengthening basic nurse education 
and practice; and, most recently, fostering nurse retention by 
promoting career development and improving patient care delivery 
systems. 

The 1998 reauthorization resulted in the grouping of the more than 40 
programs in existence at the time into seven clusters. The Senate 
report accompanying the reauthorization legislation stated that "the 
bureaucracy required to administer the existing programs should be 
simplified and reduced" and also stated the purpose for each cluster 
(see table 1). [Footnote 15] According to the Senate report, one 
purpose of five of the seven clusters was to provide administrative 
flexibility and simplification. The report also stated that one 
objective of the reauthorization was to allow for "better targeting of 
limited resources to address national health workforce training and 
distribution deficits." 

Table 1: Title VII and Title VIII Programs in Existence Before, and 
Organized into Clusters After, 1998 Reauthorization: 

Title VII: 

Programs in place before 1998 reauthorization[A]: 
* Health Education Assistance Loans; 
* Health Professions Student Loans; 
* Loans for Disadvantaged Students; 
* Primary Care Loans; 
Cluster name[B]: Student Loans; 
Cluster purpose[C]: Continue (1) loan programs that do not require 
federal appropriations or guarantee the availability of loans for 
health professions students and (2) a loan program for the 
disadvantaged[D]. 

Programs in place before 1998 reauthorization[A]: 
* Centers of Excellence; 
* Exceptional Financial Need Scholarships; 
* Faculty Loan Repayment Program; 
* Financial Assistance for Disadvantaged Health Professions Students; 
* Health Careers Opportunity Program; 
* Minority Faculty Fellowship Program; 
* Cooperative Agreements for Partnerships for Health Professions 
Education; 
* Scholarships for Disadvantaged Students Program; 
Cluster name[B]: Health Professions Training for Diversity; 
Cluster purpose[C]: Provide for the training of minority and 
disadvantaged health professionals to improve health care access in 
underserved areas and to improve representation in the health 
professions[D]. 

Programs in place before 1998 reauthorization[A]: 
* Departments of Family Medicine; 
* Faculty Development in Family Medicine; 
* Faculty Development in General Internal Medicine and General 
Pediatrics; 
* Graduate Training in Family Medicine; 
* Physician Assistants Training; 
* Pre- doctoral Training in Family Medicine; 
* Residencies and Advanced Education in the Practice of General 
Dentistry; 
* Residency Training in General Internal Medicine and General 
Pediatrics; 
Cluster name[B]: Training in Family Medicine, General Internal 
Medicine, General Pediatrics, Physician Assistants, General Dentistry, 
and Pediatric Dentistry; 
Cluster purpose[C]: Provide for the training of family physicians, 
general internists, general pediatricians, physician assistants, 
general dentists, and pediatric dentists to improve access to and 
quality of health care in underserved areas and to assure outside input 
regarding primary care training programs[D]. 

Programs in place before 1998 reauthorization[A]: 
* Allied Health Project Grants; 
* Basic/Core Area Health Education Centers; 
* Chiropractic Demonstration Project Grants; 
* Geriatric Education Centers; 
* Geriatric Fellowships; 
* Health Education and Training Centers; 
* Podiatric Primary Care Residency Training; 
* Grants for Interdisciplinary Training for Health Care for Rural 
Areas; 
* State-Supported Model Area Health Education Centers; 
Cluster name[B]: Interdisciplinary, Community-Based Linkages; 
Cluster purpose[C]: Provide support for (1) training centers remote 
from health professions schools to improve and maintain the 
distribution of health providers in underserved areas, (2) geriatric 
education and geriatric faculty fellowships, and (3) interdisciplinary 
training projects[D]. 

Programs in place before 1998 reauthorization[A]: 
* Center for Health Workforce; 
Cluster name[B]: Health Professions Workforce Information and Analysis; 
Cluster purpose[C]: Provide for (1) the development of information on 
the health professions workforce and the analysis of workforce-related 
issues, (2) the development of necessary information for decision 
making regarding future directions in health professions and nursing 
programs, and (3) continued analysis of issues affecting graduate 
medical education. 

Programs in place before 1998 reauthorization[A]: 
* Cooperative Agreement to Support Innovative Projects Relating to 
Public Health Education and Services[E]; 
* Dental Public Health Specialty Training Grants; 
* Health Administration Traineeships and Special Projects; 
* Residency Training in Preventive Medicine; 
* Public Health Special Project Grants; 
* Public Health Traineeships to Schools of Public Health and Other 
Public and Nonprofit Private Institutions; 
Cluster name[B]: Public Health Workforce; 
Cluster purpose[C]: Provide for an increase in the number of 
individuals in the public health workforce and enhance the quality of 
this workforce. 

Programs in place before 1998 reauthorization[A]: 
* Title VIII. 

Programs in place before 1998 reauthorization[A]: 
* Advanced Nurse Education; 
* Nurse Anesthetist Program: Program Grants; 
* Nurse Anesthetist Program: Fellowships; 
* Nurse Anesthetist Program: Traineeships; 
* Nurse Practitioner/Nurse Midwifery; 
* Nursing Education Loan Repayment Program; 
* Nursing Education Opportunities for Individuals from Disadvantaged 
Backgrounds; 
* Nursing Special Projects; 
* Nursing Student Loans[F]; 
* Professional Nurse Traineeships; 
Cluster name[B]: Nursing Workforce Development; 
Cluster purpose[C]: Provide for the training of basic and advanced-
degree nurses to improve access to and quality of health care in 
underserved medical and public health areas[D]. 

Source: GAO analysis. 

[A] Include (1) programs that awarded funds competitively through 
grants or cooperative agreements and that announced funding 
availability separately and (2) programs providing direct assistance, 
such as student loans to individuals, regardless of whether the loan 
program was using current appropriations. Table does not include two 
advisory groups, COGME and the National Advisory Council on Nurse 
Education and Practice, operating in fiscal year 1998. Names for grant 
and cooperative agreement programs reflect those used in the Federal 
Register or other program announcements. 

[B] Cluster names reflect headings of parts and subparts of title VII 
and of title VIII of the Public Health Service Act, as amended by Pub. 
L. No. 105-392, and in some cases differ slightly from those in Senate 
Report No. 105-220. 

[C]Cluster purposes as provided in Senate Report No. 105-220. 

[D] Another purpose for this cluster, cited in Senate Report No. 105-
220, was to provide administrative flexibility and simplification. 

[E] This program includes a cooperative agreement with the Association 
of Schools of Public Health (ASPH) to provide information to, and 
coordinate with, the schools of public health that inquire about grant 
funding opportunities under this program. HRSA has discretion to 
determine whether projects are funded. 

[F] Senate Report No. 105-220 included the Nursing Student Loans 
program in the student loans cluster. Because this program is 
authorized under title VIII, however, we included it in the nursing 
workforce development cluster. 

[End of table] 

The programs within each cluster are tied to similar purposes. For 
example, one cluster--Health Professions Training for Diversity-- 
includes programs targeting minorities or disadvantaged individuals. 
Another cluster--Health Professions Workforce Information and Analysis--
includes work conducted by and for HRSA on health workforce issues, 
including HRSA's National Center for Health Workforce Analysis, which 
received less than $1 million per year in fiscal years 1999 through 
2005. [Footnote 16] Title VII also authorizes COGME, which provides 
advice and recommendations to the Secretary of HHS and Congress on the 
supply and distribution of physicians in the United States and other 
issues. [Footnote 17] According to COGME's charter, "the Council 
periodically shall prepare and transmit a report, to the Secretary and 
to the Committee on Health, Education, Labor and Pensions (formerly the 
Committee on Labor and Human Resources) of the Senate, and the 
Committee on Commerce (formerly the Committee on Energy and Commerce) 
of the House of Representatives" with respect to supply and 
distribution of physicians in the United States and other issues. 

For fiscal years 2002 through 2005, HRSA's budget justifications 
proposed reducing overall funding for the health professions education 
programs--reducing or eliminating funding for most of the title VII 
clusters while requesting increased funding for the title VIII nursing 
cluster. The agency's budget justification for fiscal year 2005 cited a 
number of reasons for reducing or eliminating federal funding for many 
title VII programs. [Footnote 18] These reasons included the 
availability of alternative sources of funding, such as larger federal 
programs and state, local, and private programs. For example, when 
discussing the reason for not requesting funds for geriatric education 
and training under title VII, HRSA's fiscal year 2005 budget 
justification stated that recipients of geriatric education grants can 
secure support from other sources, including other federal sources. As 
part of the Medicare program, HHS's Centers for Medicare & Medicaid 
Services (CMS) makes payments for graduate medical education totaling 
billions of dollars each year--nearly $8 billion in fiscal year 2004. 
[Footnote 19] The Department of Veterans Affairs and the Department of 
Labor administer additional programs that support health professions 
education. (See app. I for information on other federal sources of 
funding for health professions education.) 

Funding for and Overall Number of Title VII and Title VIII Health 
Professions Education Programs Increased: 

After the 1998 reauthorization, overall funding for title VII and title 
VIII programs generally increased, as did the total number of programs. 
From fiscal years 1999 through 2005, overall funding for these programs 
rose by 48 percent, from about $304 million to slightly more than $450 
million. The overall number of title VII and title VIII programs 
administered by HRSA also increased, from 46 programs before 
reauthorization to 50 programs in fiscal year 2004, because of an 
increase in the number of title VIII programs. The allocation of 
funding for these programs is affected by factors such as statutory 
formulas and commitments of future funding to grant recipients. 

Over the period from fiscal years 1999 through 2005, funding for both 
title VII and title VIII programs increased (see fig. 1). Title VII 
funding increased from about $236 million to about $300 million, or 27 
percent, and title VIII funding increased from about $68 million to 
about $151 million, or 122 percent. 

Figure 1: Funding for Title VII and Title VIII Health Professions 
Education Programs, Fiscal Years 1999-2005: 

[See PDF for image] 

Note: Graph excludes student loan programs. The Health Education 
Assistance Loans program was not authorized to guarantee new loans to 
student borrowers during this period. The remaining loan programs have 
received no new federal funds since fiscal year 1998. 

[End of figure] 

Among title VII's five program clusters--those other than the cluster 
for student loans [Footnote 20]--the proportion of funding allocated to 
each cluster changed little from fiscal year 1999 through 2005. 
Throughout this period, one of the clusters--Health Professions 
Training for Diversity--received the largest share (around 39 percent 
annually) of title VII funding (see fig. 2). 

Figure 2: Funding for Title VII Health Professions Education Programs, 
Fiscal Years 1999-2005: 

[See PDF for image] 

Note: Graph excludes student loan programs. The Health Education 
Assistance Loans program was not authorized to guarantee new loans to 
student borrowers during this period. The remaining loan programs have 
received no new federal funds since fiscal year 1998. 

[End of figure] 

Although the Senate report accompanying the 1998 reauthorization 
legislation indicated that one of the purposes of five of the seven 
clusters was to provide administrative flexibility and simplification, 
the 1998 reauthorization may not have had this effect. The overall 
number of title VII and title VIII programs administered by HRSA 
increased. The number of title VII programs HRSA administered (36) was 
the same in fiscal year 1998 before reauthorization as in fiscal year 
2004. Over the same period, the number of title VIII programs HRSA 
administered increased from 10 to 14. [Footnote 21] (App. II lists 
programs that HRSA administered in 2004.) [Footnote 22] Regarding 
flexibility, several factors-- including provisions of the Public 
Health Service Act that specify how some program funds must be 
allocated and commitments of future funding to grant recipients--affect 
how HRSA allocates available funds among and within the health 
professions programs. 

* Statutory formulas for allocating funding: The Public Health Service 
Act, as amended by the 1998 reauthorization, specifies how funds are to 
be allocated among the institutions and individuals that apply for and 
receive certain health professions education program grant awards. For 
example, the act authorizes funding for grants within the cluster for 
training in family medicine, general internal medicine, general 
pediatrics, physician assistants, general dentistry, and pediatric 
dentistry by allocating it among programs within various disciplines 
according to a specified formula. [Footnote 23] Another example is the 
formula for allocating grant funding among recipients of one of the 
programs-- Centers of Excellence--within the Health Professions 
Training for Diversity cluster. This program assists schools in 
supporting health professions education for underrepresented 
minorities. The Public Health Service Act specifies formulas for 
allocating funding among (1) centers of excellence at certain 
historically black colleges and universities, (2) Hispanic centers of 
excellence, (3) Native American centers of excellence, and (4) centers 
of excellence at other institutions. [Footnote 24] 

* Commitments of future funding to noncompetitive continuations of 
existing grants: There are three types of health professions education 
grant awards: (1) new grants, which are awarded to institutions that do 
not have a current grant under a given program for a particular 
purpose; (2) noncompetitive continuations of existing grants, which 
provide funding for the second and subsequent years of projects 
approved for several years, such as for the second and third years of a 
3-year project period; and (3) competitive continuations, which are 
awarded competitively to current grantees that have applied for 
additional funding for subsequent years. According to a HRSA official 
responsible for grants management, annual appropriations are applied to 
noncompetitive continuations of existing grants first; the remaining 
grant program funds are available for new and competitive continuation 
grant awards. In fiscal year 2004, for example, the share of funds 
committed to noncompetitive continuations amounted to about 75 percent 
of title VII grant funding, leaving about 25 percent for new and 
competitive continuation grants (see fig. 3). From fiscal years 1999 
through 2004, the proportion of the funds available for new and 
competitive continuation grants ranged from a high of about 41 percent 
in fiscal year 1999 to a low of about 25 percent in fiscal year 2004. 

Figure 3: Title VII Funding for New and Competitive Continuation Grants 
and for Noncompetitive Continuations, Fiscal Years 1999-2004: 

[See PDF for image] 

[End of figure] 

The share of title VIII grant funding awarded to noncompetitive 
continuations was smaller (approximately 48 percent) in fiscal year 
2004 than that of title VII, leaving about 52 percent of title VIII 
funds available for new and competitive continuation grants (see fig. 
4). From fiscal years 1999 through 2004, the proportion of the title 
VIII grant funds available for new and competitive continuation grants 
ranged from a high of about 59 percent to a low of about 52 percent. 

Figure 4: Title VIII Funding for New and Competitive Continuation 
Grants and for Noncompetitive Continuations, Fiscal Years 1999-2004: 

[See PDF for image] 

[End of figure] 

HRSA's Goals Do Not Apply to All Title VII and Title VIII Programs, and 
Data Are Problematic, but Agency Is Developing Alternatives: 

HRSA has stated goals but they are not comprehensive, and data for 
tracking progress toward meeting them are problematic. Recognizing 
these shortcomings, HRSA is developing new performance goals and 
measures. The effectiveness of these efforts will depend on the 
agency's ability to collect complete and timely data that it can use to 
assess its success in meeting these new goals. 

HRSA's Goals Are Not Comprehensive, and Data to Assess Performance Are 
Problematic: 

Although HRSA has published program goals and performance measures for 
the health professions and nursing education and training programs, 
these goals are not comprehensive, in that they cannot be used to 
assess the performance of all title VII and title VIII programs. Set 
forth in the budget justification for fiscal year 2006 (see table 2 and 
app. III), the current goals and performance measures were prepared as 
part of HHS's annual reporting under the GPRA process. [Footnote 25] 
For example, one published performance goal is to increase the 
proportion of health professionals completing title VII-and title VIII-
supported health professions education programs who are 
underrepresented minorities or from disadvantaged backgrounds. The 
budget justification also lists a long-term target for this goal of 50 
percent by the year 2010 and targets for a number of interim years, 
such as 43 percent by 2005 and 44 percent by 2006. HRSA officials 
stated that the agency's published goals and measures cover only a 
subset of title VII and title VIII programs; they do not, for example, 
apply directly to programs designed to develop curriculums or to 
recruit and retain faculty. 

Table 2: Performance Goals and Targets for the Health Professions and 
Nursing Education and Training Programs Funded under Title VII and 
Title VIII: 

GPRA performance goals: Increase the proportion of health professionals 
graduating from or completing title VII-and title VIII-supported health 
professions education programs who are underrepresented minorities or 
from disadvantaged backgrounds; 
Long-term and interim targets: 
* 50% in 2010; 
* 44% in 2006[B]; 
* 43% in 2005[B]; 
* 40% in 2004[B]; 
Available data for year[A]: 42% for 2001 (baseline)[C]. 

GPRA performance goals: Increase the proportion of persons in the 
United States who have a specific source of ongoing care; 
Long-term and interim targets: 
* 96% in 2010; 
Available data for year[A]: 87% in 1998 (baseline); 88% in 2003 
(estimate). 

GPRA performance goals: Increase the proportion of health professionals 
trained in programs supported by titles VII and VIII who are serving in 
medically underserved communities; 
Long-term and interim targets: 
* 40% in 2010; 
Available data for year[A]: Average, 19% for 1999-2001 (baseline)[D]. 

GPRA performance goals: Increase the proportion of trainees in programs 
supported by titles VII and VIII who are training in medically 
underserved communities; 
Long-term and interim targets: 
* 54% in 2006[B]; 
* 53% in 2005[B]; 
* 30% in 2004[B]; 
Available data for year[A]: Average, 52% for 1999-2001 (baseline)[D]. 

GPRA performance goals: Increase the proportion of health professionals 
in programs supported by titles VII and VIII programs who enter 
practice in underserved areas; 
Long-term and interim targets: 
* 21% in 2006[B]; 
* 20% in 2005[B]; 
* 30% in 2004[B]; 
Available data for year[A]: Average, 19% for 1999-2001 (baseline)[D]. 

Source: Department of Health and Human Services, Health Resources and 
Services Administration, Fiscal Year 2006 Justification of Estimates 
for Appropriations Committees (Washington, D.C.: n.d.) 

Note: All years are fiscal years. 

[A] According to HRSA officials, HRSA has historically counted 
graduating students as belonging to the year in which their institution 
began receiving funding under a specific grant, not to the year in 
which the students graduated. For example, according to HRSA officials, 
data listed in the table as the baseline for 2001 pertain to grants 
awarded in 2001, although the data were collected in 2003. 

[B] The target for fiscal year 2004 was set before baseline data were 
available. Fiscal year 2005 and 2006 targets were adjusted to reflect 
the baseline. 

[C] The baseline estimate is a partial one based on data submissions 
for fiscal year 2001. 

[D] Grantees in programs not designed to increase health professionals 
in underserved areas are not required to submit these data. HRSA's 
fiscal year 2006 budget justification indicates that the Bureau of 
Health Professions within HRSA intends to propose an alternative 
measure after work on a new strategic plan has been completed. 

[End of table] 

According to HRSA officials, a number of HRSA's previous performance 
goals were deleted, and others added, in response to an OMB assessment 
of title VII and title VIII programs for the fiscal year 2004 budget. 
In its review, OMB noted a lack of consensus among various parties 
regarding the purpose of the health professions programs, stating, "The 
Administration has tended to focus on diversity and distribution [of 
health professionals]. Congressional committees often focus on the 
program as a means of helping rural areas. Advocates also emphasize the 
financial vulnerability of funded institutions." Further, OMB found 
little evidence that HRSA used performance data to adjust program 
priorities, to allocate resources, or to take other management actions. 

In reporting on progress toward meeting its published goals, HRSA 
relies in part on grantees' self-reported data, which HRSA acknowledges 
are problematic. The agency requires grantees to submit an annual 
progress report on accomplishments and movement toward achieving the 
objectives described in the original grant agreement. [Footnote 26] For 
example, some title VII and title VIII grantee institutions are 
required to determine the proportion of their graduates who go on to 
practice in certain areas, such as medically underserved communities. 
HRSA officials stated, however, that obtaining data on where graduates 
go after leaving training programs is not easy. For example, according 
to the officials, grantees rely on their graduates to voluntarily 
provide practice location information, and some do not do so. HRSA 
officials also said that some grantees do not provide information 
because of concerns related to state privacy laws. 

Problems with HRSA's data to measure progress toward meeting its stated 
goals are longstanding. For example, in 1997, we reported that data 
provided to HRSA by grantees about graduates placed in medically 
underserved communities were not necessarily complete or comparable 
among schools, and the agency had not established a way to validate the 
data provided. [Footnote 27] Five years later, these problems remained. 
In 2002, an evaluation of grantees' data collection processes prepared 
for HRSA found that 56 percent of grantees collected and submitted data 
on the number of their graduates who were employed in medically 
underserved communities in fiscal year 2000. [Footnote 28] Although 
almost all the grantees that were not collecting these data reported 
that they planned to do so in the future, a few reported that they had 
no plans to do so because they lacked the staff, their students were 
not yet employed, or their program was too new. Of grantees able to 
report the information, 36 percent relied in part on their former 
students to "self-report" whether they were employed in a medically 
underserved community. The 2002 evaluation also reported that grantees 
had difficulties understanding or interpreting the definition of 
"medically underserved community" and recommended that HRSA clarify the 
term in its instructions to grantees. As a result, HRSA could not be 
sure that the self-reported data followed consistent criteria, making 
the results unreliable. 

HRSA Is Developing New Goals and Performance Measures: 

Since fall 2002, HRSA has been developing a new strategic plan that 
includes goals for title VII and title VIII programs and a description 
of how the agency proposes to measure performance. The HRSA official 
overseeing this effort noted that reviews by both GAO and OMB made it 
clear that HRSA needed to come up with an effective means of measuring 
the results of title VII and title VIII programs and communicating 
these results to the public. According to HRSA, implementing the new 
strategic plan will enable the agency to " better . . . capture the 
accomplishments of title VII's and title VIII's diverse portfolio of 
programs." HRSA released a draft of its new strategic plan and its 
proposed performance measures during a June 2005 all-grantee conference 
attended by title VII and title VIII grant recipients. According to 
officials in HRSA's Bureau of Health Professions, a primary purpose of 
the conference was to introduce the draft of the newly revised 
strategic plan and proposed performance measures to grantees and 
receive feedback as to whether the proposed revised measures were 
practicable. The plan contained 118 proposed program measures (specific 
performance measures for each title VII and title VIII program); 17 
proposed core measures (performance measures common to a number of 
health professions programs with similar goals); and 14 national 
measures (national indicators sensitive to access to primary care, such 
as the immunization rate among children 19-35 months old or mammography 
rates among women 40 years old or older). [Footnote 29] 

Once HRSA has finalized the updated goals and performance measures, 
identifying and obtaining the necessary data will be key. The quality, 
completeness, and timeliness of the data used to calculate baseline 
values, as well as to measure actual performance and track the progress 
the programs are making in meeting their goals, will be critical. 
Without comprehensive goals, performance measures, and data, the agency 
will be unable to target federal resources to the most effective 
programs. 

As of October 2005, a performance measurement working group in HRSA had 
begun to catalog the data needed to implement the proposed performance 
measures; to reconcile these needs with the data HRSA currently 
collects from its grantees; and, according to the group's lead 
official, to recommend improvements to the agency's grantee data 
collection and monitoring system. HRSA officials said that their 
schedule called for finalizing and testing the new measures, developing 
forms for collecting the data, and updating the data collection and 
monitoring system by October 2006. [Footnote 30] According to agency 
officials, the new approach would improve the quality, timeliness, and 
relevance of the agency's performance data. 

HRSA Has Published Few National Workforce Projections in Recent Years: 

One of HRSA's tasks is to supply information to policymakers on a broad 
range of health workforce issues, including forecasts of supply and 
demand for physicians, dentists, nurses, and pharmacists. The agency 
has, however, published few recent national health professions 
workforce projections. For example, its projections for the physician 
and dentist workforces are more than a decade old. Yet regular 
reassessment of health workforce supply and demand is key to setting 
policies as health care needs change. 

HRSA Has Not Regularly Published National Health Professions Workforce 
Projections: 

HRSA's fiscal year 2006 budget justification states that a goal of the 
Health Professions Workforce Information and Analysis cluster is to 
"provide health workforce information and analyses to national, state, 
and local policymakers and researchers on a broad range of issues, such 
as shortages of registered nurses, shortages of pharmacists, and the 
distribution of health care workers in underserved areas." [Footnote 
31] Although HRSA maintains a variety of indicators and statistics on 
the health care workforce, in the past decade the agency has published 
no national supply and demand projections for the physician or dentist 
workforces. [Footnote 32] The most recent HRSA national nursing 
workforce projections were published in 2002, and the latest HRSA 
report containing national pharmacist workforce projections was 
published in 2000. The agency's most recent national physician and 
dentist workforce projections were published in 1991. Table 3 
summarizes HRSA's latest publications containing national workforce 
projections for physicians, dentists, nurses, and pharmacists. 

Table 3: HRSA's Most Recent Reports Containing National Workforce 
Supply and Demand Projections for Physicians, Dentists, Nurses, and 
Pharmacists: 

Health profession: Physicians; 
Latest workforce projections published by HRSA: Health Personnel in the 
United States: Eighth Report to Congress (1991); 
Discussion of models and data used to make projections: HRSA developed 
physician supply and demand models. HRSA's current supply model uses 
data from sources such as the American Medical Association (AMA) 
Physician Masterfile[A] to project national estimates of physician 
supply by 36 medical specialties through the year 2020. HRSA's current 
physician demand model uses Census Bureau population projections, plus 
data from sources such as the National Ambulatory Medical Care 
Survey[B] and the Nationwide Inpatient Sample,[C] to project demand for 
physicians in 18 medical specialties to the year 2020. 

Health profession: Dentists; 
Latest workforce projections published by HRSA: Health Personnel in the 
United States: Eighth Report to Congress (1991); 
Discussion of models and data used to make projections: According to 
HRSA officials, the supply and demand models for dentists are out of 
date, and HRSA plans to update them. HRSA has a cooperative agreement 
with the American Dental Association to develop dentist supply and 
demand estimates. 

Health profession: Nurses; 
Latest workforce projections published by HRSA: Projected Supply, 
Demand, and Shortages of Registered Nurses: 2002-2020 (2002); 
Discussion of models and data used to make projections: HRSA collects 
data on the nurse workforce through its National Sample Survey of 
Registered Nurses, which is conducted every 4 years, and generally 
publishes nurse workforce projections after the most recent survey. The 
agency's nursing supply model projects the state-level registered nurse 
supply through 2020. The nursing demand model projects state-level 
demand for registered nurses, licensed practical nurses, and nursing 
and home health aides through 2020 in a number of employment settings, 
such as hospitals, nursing facilities, and doctors' offices. As of 
December 2005, the nursing supply and demand models were being updated 
to incorporate data from the most recently completed National Sample 
Survey of Registered Nurses (2004).[D]. 

Health profession: Pharmacists; 
Latest workforce projections published by HRSA: The Pharmacist 
Workforce: A Study of the Supply and Demand for Pharmacists (2000); 
Discussion of models and data used to make projections: HRSA created a 
pharmacist supply model to generate estimates of pharmacist numbers in 
the United States through 2020. But because the pharmacy profession 
lacks a comprehensive database like the physician database maintained 
by AMA, the pharmacist model uses a base- year count of active 
pharmacists from a 1992 pharmacist census. The model then projects the 
number of practicing pharmacists into the future by adding, each year, 
the projected number of new entrants and subtracting, each year, the 
projected number of pharmacists who will die or retire. For the 
pharmacist projection published in 2000, HRSA did not develop a 
pharmacist demand model per se but instead described issues affecting 
the demand for pharmacists, such as the number of retail prescriptions 
dispensed and the growth in demand for pharmacists in hospitals. 
According to HRSA officials, as of 2005, the agency had begun updating 
the pharmacist supply model. 

Source: HRSA. 

Note: Table lists most recent reports as of October 2005. In addition, 
the agency published a report containing preliminary forecasts, 
developed using the agency's physician and nursing demand models, of 
the impact of changing demographics on the demand for physicians, 
nurses, and other health professions. See Department of Health and 
Human Services, Health Resources and Services Administration, Changing 
Demographics: Implications for Physicians, Nurses, and Other Health 
Workers (Rockville, Md.: 2003). 

[A] The AMA Physician Masterfile is a computer database of physicians 
that includes current and historical data on physicians, including AMA 
members and nonmembers and graduates of foreign medical schools who 
reside in the United States and who have met the educational and 
credentialing requirements necessary for recognition as physicians. 

[B] Administered by the Centers for Disease Control and Prevention's 
National Center for Health Statistics, the National Ambulatory Medical 
Care Survey is a nationwide survey based on a sample of visits to 
nonfederally employed office-based physicians who are engaged primarily 
in direct patient care. The survey was conducted annually from 1973 to 
1981, in 1985, and annually since 1989. 

[C] The Nationwide Inpatient Sample, part of the Healthcare Cost and 
Utilization Project sponsored by the Agency for Healthcare Research and 
Quality, is a database of hospital inpatient stays. It contains data on 
about 7 million hospital stays taken from a sample of about 1,000 U.S. 
community hospitals. 

[D] The seventh National Sample Survey of Registered Nurses was 
conducted in 2000, and the results were published on February 22, 2002. 
The eighth National Sample Survey of Registered Nurses was conducted in 
2004; as of December 2005, HRSA had posted preliminary results on its 
Web site but had not published any updated national nursing supply or 
demand projections. The survey collects information on the number of 
registered nurses; their educational background and specialty areas; 
their employment status, including type of employment setting, position 
level, and salaries; their geographic distribution; and their personal 
characteristics, including gender, racial or ethnic background, age, 
and family status. 

[End of table] 

Although HRSA has not published national projections for the physician 
workforce in the past decade, agency officials noted that individual 
HRSA staff members have contributed articles to journals, [Footnote 33] 
and COGME, which advises the Secretary of HHS and congressional 
committees, used HRSA's models to develop physician workforce 
projections through 2020 for COGME's January 2005 report. [Footnote 34] 
HRSA officials said they have not contributed to any similar national 
projections for the dentist workforce in the past decade. 

From the 1970s through the early 1990s, HRSA periodically provided 
health professions workforce information by producing a series of 
legislatively mandated reports to Congress on the supply and 
distribution of health personnel, including recommendations for 
improving health care in the nation. Some but not all of these reports 
included original national workforce supply and demand projections. For 
example, the eighth report, dated 1991, did include such projections, 
but the ninth report did not. The mandated reporting requirement was 
eliminated by the Federal Reports Elimination and Sunset Act of 1995, 
which took effect in December 1999; the last of HRSA's reports, 
however, was issued 4 years earlier, in 1995. [Footnote 35] 

According to a HRSA official involved in reporting on workforce issues, 
the agency began work on a tenth report to Congress in 1995 after 
releasing the ninth report, but because of passage of the Federal 
Reports Elimination and Sunset Act, the report effort was given few 
resources. HRSA officials said that the tenth report would provide 
information about the health workforce for 30 key health professions, 
including national supply and demand projections for physicians, 
pharmacists, and nurses. Information on dentists would be more limited. 
While HRSA has not planned to include supply or demand projections for 
other health professions, such as dental hygienists, dental assistants, 
and physical or occupational therapists, agency officials said they 
planned to report on issues and trends relevant to those health 
professions. As of October 2005, HRSA officials said they were revising 
major sections of the tenth report. According to the officials, the 
agency had no specific plans to publish reports like the tenth report 
in the future, but the National Center for Health Workforce Analysis 
did plan to continue publishing analyses of selected health 
professions, including profiles of the health workforce within a state 
at a given time. [Footnote 36] 

Regular Reassessment of Health Workforce Predictions Is Critical 
Because of a Changing Health Care Environment: 

Estimating future health workforce supply and demand on a regular basis 
is important because estimates need to be updated as circumstances 
change. For example, estimates prepared in the 1980s and early 1990s 
led to concern about an impending surplus of physicians overall but a 
shortage of physicians trained in primary care. This anticipated 
shortage of primary care physicians resulted in part from an assumption 
that the nation would need fewer specialty physicians because of an 
increase in managed care, which makes use of primary care 
"gatekeepers." The assumption was that the gatekeepers would limit 
patients' use of specialist care. Partly because the assumption about 
growth in managed care proved incorrect, however, the projected 
shortage of primary care physicians failed to materialize. [Footnote 
37] 

COGME's January 2005 report recognized the uncertainty inherent in any 
effort to forecast the physician workforce many years into the future. 
COGME's report showed, for example, that physician supply and demand 
could shift because changing lifestyles may prompt new physicians to 
work fewer hours than their predecessors, an increase in the nation's 
wealth could contribute to continued increases in the use of medical 
services, or an increased supply of nurse practitioners and other 
nonphysician clinicians could reduce the demand for physicians. Given 
this uncertainty, as well as the costs to expand medical education and 
training capacity, COGME strongly recommended that the nation develop 
systems to track physician workforce supply, demand, and distribution 
and undertake a comprehensive reassessment within the next 4 years to 
guide future decisions on medical education capacity. 

Conclusions: 

Our work continues to point to the need for better information to 
assess the performance of title VII and title VIII programs. The 
agency's current published goals and measures are not comprehensive, 
and the data to measure performance in meeting them have been 
problematic. As a result, HHS cannot fully inform Congress or the 
public about the value of title VII and title VIII health professions 
education programs. It remains to be seen whether HRSA's current 
strategic planning and associated data collection efforts will remedy 
these shortcomings. 

In addition, the ability of HHS and Congress to target federal 
resources to appropriate health professions education programs will 
remain limited without useful information on future health workforce 
needs. Updated workforce supply and demand projections are vital for 
informed decision making about health professions programs. Without 
relevant goals and performance measures, coupled with key data, HHS and 
Congress will lack information that would enable them to target federal 
funds effectively to those health professions education programs most 
critical to meeting the nation's anticipated need for health 
professionals. 

Recommendation for Executive Action: 

We recommend that the Administrator of HRSA develop a strategy and 
establish time frames to more regularly update and publish national 
workforce projections for the health professions. 

Agency Comments: 

In written comments on a draft of this report (see app. IV), HRSA 
agreed with the need for clear, relevant goals and performance measures 
backed by timely and complete data, and it agreed with the importance 
of updated workforce supply and demand projections. HRSA stated that 
completing development of the agency's new performance goals and 
measures and integrating these new goals and measures into the agency's 
data collection systems are a top priority. HRSA also agreed with our 
conclusion that updated workforce supply and demand projections are 
vital for informed decision making in the changing health care 
environment. 

The agency commented, however, on the scope of our work. First, HRSA 
commented that the draft report did not include the many objectives 
authorized for funding under title VII and title VIII of the Public 
Health Service Act. Although we reviewed the act's provisions for 
background purposes, our scope was to examine HRSA's stated goals for 
the title VII and title VIII programs and the agency's efforts to 
measure progress toward meeting those goals. According to HRSA 
officials, the GPRA goals in the fiscal year 2006 budget justification 
were the agency's published goals for the programs at the time of our 
review. While we were aware of, and reported on, the agency's efforts 
to develop a new strategic plan and associated goals, measures, and 
data, they were in draft form at the time of our review, and HRSA had 
yet to formally adopt or finalize them. Since the agency provided 
technical comments including time frames associated with these efforts, 
we removed a recommendation that the agency establish such time frames. 

Second, regarding workforce analyses, the agency commented that our 
draft report did not discuss the considerable body of work produced by 
regional workforce centers and advisory committees that receive title 
VII and title VIII funding from HRSA. Because the scope of our review 
regarding workforce issues was limited to the most recent projected 
estimates (completed and published) of national supply and demand for 
physicians, dentists, nurses, and pharmacists, we did not include other 
reports produced or drafted by or for HRSA, its regional workforce 
centers, or its advisory groups. We did, however, acknowledge that 
HRSA's National Center for Health Workforce Analysis conducts a variety 
of activities other than national supply and demand projections. We 
incorporated HRSA's technical comments as appropriate. 

As agreed with your offices, unless you publicly announce the contents 
of this report earlier, we plan no further distribution of it until 30 
days after its issue date. At that time, we will send copies to the 
Secretary of HHS, the Administrator of HRSA, and appropriate 
congressional committees. We will also provide copies to others upon 
request. In addition, the report is available at no charge on the GAO 
Web site at http://www.gao.gov. 

If you or your staff have any questions regarding this report, please 
contact me at (312) 220-7600 or aronovitzl@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major contributions 
to this report are listed in appendix V. 

Signed by: 

Leslie G. Aronovitz: 
Director, Health Care: 

[End of section] 

Appendix I: Examples of Additional Sources of Federal Funding for 
Health Professions Education: 

Table 4: Examples of Federal Funding Sources, besides Title VII and 
Title VIII Programs, for Postsecondary Education and Training 
Specifically Targeted for Health Professions: 

Agency: Department of Health and Human Services; 
Program: Centers for Medicare & Medicaid Services: Medicare payments 
for graduate medical education[A]; 
2004 funding (millions of dollars): $7,900. 

Program: Centers for Medicare & Medicaid Services: Medicaid payments 
for graduate medical education; 
2004 funding (millions of dollars): [B]. 

Program: Health Resources and Services Administration: Children's 
Hospitals Graduate Medical Education Payment Program; 
2004 funding (millions of dollars): $303. 

Program: Health Resources and Services Administration: National Health 
Service Corps; 
2004 funding (millions of dollars): $170. 

Program: Health Resources and Services Administration: Bioterrorism 
Training and Curriculum Development Program; 
2004 funding (millions of dollars): $28. 

Program: Indian Health Service: Loan Repayment Program; 
2004 funding (millions of dollars): $12. 

Agency: Department of Defense; 
Program: Defense Health Program: health professions scholarship program 
and education and training; 
2004 funding (millions of dollars): $318. 

Agency: Department of Labor; 
Program: Employment and Training Administration: President's High 
Growth Job Training Initiative (health care); 
2004 funding (millions of dollars): [C]. 

Agency: Department of Veterans Affairs; 
Program: Veterans Health Administration: education and training 
programs for health professions students and residents; 
2004 funding (millions of dollars): $493. 

Source: GAO. 

[A] Medicare's graduate medical education payments are made to teaching 
hospitals for both direct and indirect graduate medical education costs 
on the basis of factors such as the number of physicians being trained, 
Medicare's share of patient days in the hospital, and the hospital's 
ratio of residents to beds. 

[B] Citing a 50-state survey conducted for the Association of American 
Medical Colleges, COGME reported that Medicaid provided teaching 
hospitals between $2.5 and $2.7 billion in 2002. See Council on 
Graduate Medical Education, Department of Health and Human Services, 
Health Resources and Services Administration, State and Managed Care 
Support for Graduate Medical Education: Innovations and Implications 
for Federal Policy (Rockville, Md.: July 2004). 

[C] This initiative focuses on 14 targeted sectors, one of which is 
health care. As part of this initiative, the Secretary of Labor 
announced awards of more than $24 million in grants to counter health 
care labor shortages in 2004. 

[End of table] 

Table 5: Examples of Federal Funding Sources for General Postsecondary 
Education and Training Including, but Not Exclusive to, Health 
Professions: 

Agency: Department of Education; 
Source: Federal student aid programs[A]; 
2004 funding (millions of dollars): $20,544. 

Agency: Department of Health and Human Services; 
Source: National Institutes of Health: NIH Extramural Loan Repayment 
Programs; 
2004 funding (millions of dollars): $73. 

Agency: Department of Labor; 
Source: Employment and Training Administration: Job Corps[B]; 
2004 funding (millions of dollars): $1,537. 

Source: GAO. 

[A] Include programs such as the Department's Federal Family Education 
Loan Program, Federal Pell Grant Program, Federal Perkins Loan Program, 
Federal Supplemental Educational Opportunity Grant Program, and Federal 
Work-Study Program. 

[B] As of May 2004, according to an official in the Department of 
Labor's Employment and Training Administration, 105 Job Corps centers 
provided training in one or more of 12 different health-related 
training programs. 

[End of table] 

[End of section] 

Appendix II: Title VII and Title VIII Clusters and Programs, Fiscal 
Year 2004: 

Title VII. 

Cluster name[A]: Student Loans; 
Programs funded in fiscal year 2004[B]: 
* Health Professions Student Loans; 
* Loans for Disadvantaged Students; 
* Primary Care Loans. 

Cluster name[A]: Health Professions Training for Diversity; 
Programs funded in fiscal year 2004[B]: 
* Centers of Excellence; 
* Faculty Loan Repayment Program; 
* Health Careers Adopt a School Demonstration Program; 
* Health Careers Opportunity Program; 
* Minority Faculty Fellowship Program; 
* Scholarships for Disadvantaged Students Program. 

Cluster name[A]: Training in Family Medicine, General Internal 
Medicine, General Pediatrics, Physician Assistants, General Dentistry, 
and Pediatric Dentistry; 
Programs funded in fiscal year 2004[B]: 
* Academic Administrative Units in Primary Care; 
* Cooperative Agreement to Plan, Develop, Implement and Operate a 
Continuing Clinical Education Program in the Pacific Basin; 
* Faculty Development in Primary Care; 
* Physician Assistant Training in Primary Care; 
* Predoctoral Training in Primary Care; 
* Residency Training in General and Pediatric Dentistry; 
* Residency Training in Primary Care; 
* Training in Primary Care Medicine and Dentistry. 

Cluster name[A]: Interdisciplinary, Community-Based Linkages; 
Programs funded in fiscal year 2004[B]: 
* Allied Health Projects; 
* Basic/Core Area Health Education Centers; 
* Chiropractic Demonstration Project Grants; 
* Geriatric Academic Career Awards; 
* Geriatric Education Centers; 
* Geriatric Training for Physicians, Dentists, and Behavioral and 
Mental Health Professionals; 
* Graduate Geropsychology Education Program; 
* Graduate Psychology Education Program; 
* Health Education and Training Centers; 
* Model State-Supported Area Health Education Centers; 
* Podiatric Residency Training in Primary Care; 
* Quentin N. Burdick Program for Rural Interdisciplinary Training. 

Cluster name[A]: Health Professions Workforce Information and Analysis; 
Programs funded in fiscal year 2004[B]: 
* Center for Health Workforce. 

Cluster name[A]: Public Health Workforce; 
Programs funded in fiscal year 2004[B]: 
* ASPH [Association of Schools of Public Health] Cooperative 
Agreement[C]; 
* Dental Public Health Residency Training Grants; 
* Health Administration Traineeships and Special Projects; 
* Preventive Medicine Residency Program; 
* Public Health Traineeships; 
* Public Health Training Centers Grant Program. 

Title VIII: 

Cluster name[A]: Nursing Workforce Development; 
Programs funded in fiscal year 2004[B]: 
* Advanced Education Nursing Program; 
* Advanced Education Nursing Traineeships; 
* Basic Nurse Education and Practice Grants; 
* Clinical Experience in Federally-Funded Community Health Centers for 
Nurse Practitioners and/or Nurse-Midwifery Students; 
* Comprehensive Geriatrics Education Program; 
* Nurse Anesthetist Traineeships; 
* Nurse Education, Practice, and Retention Grant Program: Grants for 
Career Ladder Programs; 
* Nurse Education, Practice, and Retention Grant Program: Grants for 
Enhancing Patient Care Delivery System Program; 
* Nurse Education, Practice, and Retention Grant Program: Grants for 
Internships and Residency Programs; 
* Nurse Faculty Loan Program; 
* Nursing Education Loan Repayment Program; 
* Nursing Scholarship Program; 
* Nursing Student Loans; 
* Nursing Workforce Diversity Grants. 

Source: GAO analysis. 

[A] Cluster names reflect headings of parts and subparts of title VII 
and of title VIII of the Public Health Service Act, as amended by Pub. 
L. No. 105-392, and in some cases differ slightly from those in Senate 
Report No. 105-220. 

[B] Include (1) programs that awarded funds competitively through 
grants or cooperative agreements and that announced funding 
availability separately or had a separate selection panel and (2) 
programs providing direct assistance, such as student loans to 
individuals, regardless of whether the loan program received any new 
appropriations. Table does not include four advisory groups--COGME, the 
National Advisory Council on Nurse Education and Practice, the Advisory 
Committee on Training in Primary Care Medicine and Dentistry, and the 
Advisory Committee on Interdisciplinary, Community-Based Linkages-- 
operating in fiscal year 2004. Names for grant and cooperative 
agreement programs reflect those used in the Federal Register or other 
program announcements. 

[C] This program, which allows schools of public health to apply for 
HRSA funding to support certain special projects, includes a 
cooperative agreement with ASPH to provide information to, and 
coordinate with, the schools of public health that inquire about grant 
opportunities under this program. HRSA has sole discretion to determine 
whether projects are funded. 

[End of table] 

[End of section] 

Appendix III: Additional Performance Goals and Targets for Health 
Professions and Nursing Education Programs: 

Health Education Assistance Loans Program: 

GPRA performance goals: Phase out the outstanding loan portfolio, 
resulting in a reduction in the federal liability associated with the 
Health Education Assistance Loans Program; 
Long-term and interim targets: 
* $1.7 million in 2006; 
* $1.9 million in 2005; 
* $2.6 million in 2004; 
* $2.7 million in 2003; 
* $3.3 million in 2002; 
* $3.4 million in 2001; 
* $3.6 million in 2000; 
Available data for year: 
* $2.0 million in 2004; 
* $2.3 million in 2003; 
* $2.7 million in 2002; 
* $3.2 million in 2001; 
* $3.5 million in 2000. 

Health Professions Workforce Information and Analysis: 

GPRA performance goals: Annually produce results of data collection and 
analysis activities to inform the market regarding issues relevant to 
health professions and nursing workforce (number of reports); 
Long-term and interim targets: 
* 25 reports in 2006; 
* 25 reports in 2005; 
* 23 reports in 2004; 
* 23 reports in 2003; 
* 11 reports in 2002; 
* 10 reports in 2001; 
Available data for year: 
* 21 reports in 2004; 
* 23 reports in 2003; 
* 14 reports in 2002; 
* 10 reports in 2001. 

Nursing Education Loan Repayment Program (NELRP) and Scholarship 
Program: 

GPRA performance goals: Increase the number of individuals enrolled in 
professional nursing education programs; 
Long-term and interim targets: 
* Baseline + 10% in 2010; 
Available data for year: 
* Estimated 240,500 in 2004 (baseline)[A]. 

GPRA performance goals: Increase the proportion of nursing scholarship 
recipients who, within 4 months of licensure, are working in a facility 
with a critical shortage of nurses; 
Long-term and interim targets: 
* 85% in 2006; 
* 80% in 2005; 
* 75% in 2004; 
Available data for year: 
* 23% in 2004[B]. 

GPRA performance goals: Increase the proportion of NELRP participants 
working in shortage facilities, such as disproportionate share 
hospitals for Medicare and Medicaid, nursing homes, public health 
departments (state and local), and public health clinics within these 
departments; 
Long-term and interim targets: 
* 85% in 2010:[C]; 
* 90% in 2006[C]; 
* 85% in 2005[C]; 
* 65% in 2004[C]; 
Available data for year: 
* 100% in 2004; 
* 100% in 2003. 

GPRA performance goals: Increase the proportion of states in which 
NELRP contract recipients work; 
Long-term and interim targets: 
* 93% in 2006; 
* 93% in 2005; 
* 85% in 2004; 
* 65% in 2003; 
* 50% in 2002; 
Available data for year: 
* 98% in 2004; 
* 88% in 2003; 
* 82% in 2002. 

GPRA performance goals: Increase the proportion of NELRP participants 
who remain employed at a critical-shortage facility for at least 1 year 
beyond termination of their NELRP service; 
Long-term and interim targets: 
* 28% in 2010; 
* 11% in 2006; 
* 11% in 2005; 
* 10% in 2004; 
Available data for year: 
* 40% in 2004[D]. 

GPRA performance goals: Reduce the federal investment per year of 
direct support by increasing the proportion of program participants who 
extend their service contracts and commit to work at a critical- 
shortage facility for an additional year; 
Long-term and interim targets: 
* 45% in 2006; 
* 40% in 2005; 
* 22% in 2004; 
Available data for year: 
* 44% in 2004; 
* 18% in 2001 (baseline). 

Source: Department of Health and Human Services, Health Resources and 
Services Administration, Fiscal Year 2006 Justification of Estimates 
for Appropriations Committees (Washington, D.C.: n.d.). 

Note: All years are fiscal years. 

[A] Number of students in all prelicensure registered nursing programs 
in the 2002-03 academic year. 

[B] The target was based on the assumption that all scholars would 
complete programs and enter service at the same time. According to the 
Health Resources and Services Administration, 23 percent of the 2003 
scholarship recipients had completed programs in fiscal year 2004 and 
entered into service. 

[C] The actual performance greatly exceeded the original targets 
because a large number of applicants worked in facilities with the most 
critical shortages. As a result, the agency increased the targets for 
2005 and 2006. 

[D] Preliminary estimate. HRSA's fiscal year 2006 budget justification 
indicates that targets will be revised once the fiscal year 2004 data 
are finalized. 

[End of table] 

[End of section] 

Appendix IV: Comments from the Health Resources and Services 
Administration: 

DEPARTMENT OF HEALTH & HUMAN SERVICES: 
Health Resources and Services Administration: 
Rockville MD 20857: 

DEC 30 2005: 

TO: Leslie G. Aronovitz: 
Director, Health Care: 

FROM: Administrator: 

SUBJECT: Government Accountability Office Draft Report: "Health 
Professions Education Programs: Action Still Needed to Measure Impact" 
(GAO-06-55): 

Thank you for the opportunity to provide a response to the above titled 
draft report. Attached please find our comments. 

Questions may be referred to Ms. Gail Lipton in HRSA's Office of 
Federal Assistance Management at (301) 443-6509. 

Signed by: 

Betty James Duke: 

Attachment: 

Health Resources and Services Administration's Comments on the 
Government Accountability Offices' Draft Report: "Health Professions 
Education Programs: Action Still Needed to Measure Impact" Code # GAO- 
06-55: 

The Health Resources and Services Administration (HRSA) appreciates the 
opportunity to comment on the Government Accountability Office (GAO) 
assessment of Title VII and Title VIII. We believe it is a worthy 
effort, however, in attempting to summarize this complex piece of 
legislation, GAO has overlooked some of the important differences and 
emphases among the many programs that are authorized within these 
sections of the Public Health Service Act. Additionally, we provide an 
update on Agency efforts to improve performance measurement and data 
collection systems, and expand on GAO's discussion of HRSA's role in 
the development of health workforce information and analysis. 

The Goals of Titles VII and VIII of the Public Health Service Act: 

As GAO points out, Title VII was first enacted in 1963, and Title V111 
in 1964, when there were concerns about impending shortages of 
physicians and nurses. Since then, the U.S. health care system has 
changed a lot. Advances in science have brought about new ways to treat 
disease. There have also been changes in economics and demographics. 
Economic changes have altered the incentives and the barriers to 
entering health careers. Demographic changes have altered the 
geographic distribution and racial/ethnic distribution of the 
population. Greater longevity and the aging of the population have also 
brought new challenges. And all of these changes have had implications 
for the education and training of physicians, nurses, dentists, and the 
increasing number of other types of health professionals, which 
Congress in the early 1960s could not have foreseen. 

Over time, the law has been amended piecemeal to accommodate the 
changing environment of U.S. healthcare, but its interpretation often 
remains rooted in the language of physician, nurse, and dentist 
shortages for which it was originally created. A careful perusal of the 
law would specifically identify many purposes and objectives of the 
Title VII and Title VIII legislation beyond those identified by GAO in 
its report. In addition to the problems of supply, demand, and 
distribution of health care professionals, and the balance between 
generalist and specialist providers, the law also includes (but is not 
limited to) specific references to the following objectives: 

* Developing a competitive applicant pool for health professions 
education programs; 

* Enhancing the academic performance of underrepresented minorities; 

* Improving recruitment and retention of minority faculty; 

* Improving institutions' information resources as they relate to 
minority health issues; 

* Facilitating faculty and student research on health issues affecting 
underrepresented minority groups; 

* Expanding enrollments in allied health professions with the greatest 
shortages or whose services are most needed by the elderly; 

* Providing rapid transition training programs in allied health fields 
to individuals who have baccalaureate degrees in health-related 
sciences; 

* Establishing community-based allied health training programs that 
link academic centers to rural clinical settings; 

* Providing career advancement training for practicing allied health 
professionals; 

* Developing curriculum that will emphasize knowledge and practice in 
the areas of prevention and health promotion, geriatrics, long-term 
care, home health and hospice care, and ethics; 

* Expanding or establishing interdisciplinary training programs that 
promote the effectiveness of allied health practitioners in geriatric 
assessment and the rehabilitation of the elderly; 

* Expanding or establishing demonstration centers to emphasize 
innovative models to link allied health clinical practice, education, 
and research; 

* Improving the training of health professionals in geriatrics, 
including geriatric residencies, traineeships, or fellowships; 

* Developing and disseminating curricula relating to the treatment of 
the health problems of elderly individuals; 

* Supporting the training and retraining of faculty to provide 
instruction in geriatrics; 

* Supporting continuing education of health professionals who provide 
geriatric care; 

* Providing students with clinical training in geriatrics in nursing 
homes, chronic and acute disease hospitals, ambulatory care centers, 
and senior centers. 

It is worth noting, further, that while Title VII and Title VIII 
usually provide for preferences in awarding funds to institutions that 
tailor their programs to the care of the vulnerable and underserved, or 
to individuals committed to serving the underserved, these are 
explicitly educational rather than service objectives. 

Data Collection and Performance Measurement: 

GAO also comments on HRSA's inability to provide data with which to 
measure the attainment of Title VII and Title VIII objectives dating 
back to an earlier GAO report, and speculates that this will continue 
to be an issue in the future. 

We would like to point out that many changes have occurred since the 
publication of GAO's 1997 report: Health Professions Education: 
Clarifying the Role of Title VII and VIII Programs Could Improve 
Accountability. 

HRSA immediately took vigorous steps to address the issues identified 
in the Report. These first efforts led to the development of a 
Comprehensive Performance Management System and Uniform Progress Report 
(CPMS/UPR), which has been continuously reporting data since 1999. HRSA 
has acknowledged that there were issues with the completeness and 
timeliness of the data, but progress has been steady. The 2005 CPMS/UPR 
data include a record 95% of all expected data submissions. 
Implementation of a web-based system drastically reduced the amount of 
time required to enter and process the data, which is more efficient 
for both grantees and HRSA staff. Performance measures developed by 
HRSA in tandem with the CPMS/UPR have been reporting data for 5 years. 
These measures were replaced with new ones at the request of the Office 
of Management and Budget in August 2002, for the FY 04 budget cycle. 
Since the CPMS/UPR was not optimally designed to address the new OMB- 
required measures, and to better capture the diverse objectives of 
Title VII and Title VIII programs, HRSA is currently working on a new 
Performance Measurement System (PMS). The new system was presented to 
HRSA program constituents and stakeholders in a conference that took 
place in June 2005. We are currently consolidating some of the 
measures, incorporating comments received at the conference, pilot 
testing the measures, and planning system changes. We expect to submit 
the PMS to OMB for Paperwork Reduction Act clearance by July 2006. 

HRSA's Role in the Development of Health Workforce Information and 
Analysis: 

We would like to expand on GAO's discussion of HRSA's role in the 
development of workforce information and analysis. 

In addressing workforce information and analysis, GAO focuses its 
attention on publications by HRSA's National Center for Workforce 
Information and Analysis (NCHWA) and finds that HRSA has not published 
many workforce projections for physicians, nurses, and dentists in 
recent years. GAO does not include in its discussion the considerable 
body of work produced by the Regional Workforce Centers that receive 
Title VII funding from HRSA, nor (with the exception of the Council on 
Graduate Medical Education -COGME), does it acknowledge the 
contributions of the various Advisory Councils and Committees 
specifically authorized by Title VII and Title VIII, funded out of 
Title VII and Title VIII appropriations, and which receive significant 
staff support from NCHWA and the programs. 

Additional committees or councils performing valuable work in support 
of the Title VII and Title VIII program goals include: 

National Advisory Council on Nursing Education and Practice (NACNEP): 

* Advisory Committee on Training in Primary Care Medicine and Dentistry 
(ACTPCMD): 

* Advisory Committee on Interdisciplinary and Community-Based Linkages 
(ACICBL). 

Each of these groups has produced a regular series of reports on 
pertinent workforce issues. For example, ACTPCMD (authorized by Section 
748 [2931] of the Health Professions Education Partnership Act of 1998) 
issued a report in November 2004: Preparing Primary Healthcare 
Providers to Meet America's Future Healthcare Needs: The Critical Role 
of Title VII, Section 747. This is its Fourth Annual Report to the 
Secretary of Health and Human Services and to Congress. It contains a 
large number of references that support the role of Title VII, section 
747 in guiding the content and capacity of primary care education and 
training in the United States to meet the healthcare needs of the 
future. A fifth report is nearing completion. NACNEP also released a 
report in November 2002 that focuses on the nursing workforce as well 
as the faculty shortage. Another ACTPCMD report entitled: "Evaluating 
the Impact of Title VII Section 747 Programs" is nearing completion. We 
believe that HRSA's role in the production of workforce analyses cannot 
be fully understood by limiting discussion solely to NCHWA, and we 
question the decision to exclude from consideration all Title VII and 
Title VIII advisory groups except for COGME. 

Furthermore, we believe that the legislated goal of providing "health 
workforce information and analysis to national, State, and local 
policymakers and researchers on a broad range of issues, such as 
shortages of registered nurses, shortages of pharmacists, and the 
distribution of healthcare workers in underserved areas" is broader 
than what GAO's exclusive focus on supply and demand projections for 
physicians, nurses, and dentists would allow. 

Since 1999, NCHWA and its regional centers have produced well over 100 
reports. The following list of published reports documents the breadth 
of purpose of Title VII Section 762, and provides evidence of HRSA's 
accomplishments. HRSA has also made information widely available 
through staff-written articles in major health journals, reports on 
specific health professions, and special reports. This listing does not 
include all reports and studies conducted by the Regional Workforce 
Centers with Title VII funding. A comprehensive list of NCHWA reports 
is available at: http://bhpr.hrsa.gov/healthworkforce/reports: 

* The Clinical Laboratory Workforce: The Changing Picture of Supply, 
Demand, Education, and Practice (Published July 2005): 

* State Health Profiles for 50 States, the District of Columbia, Puerto 
Rico, and the Virgin Islands that include information about the supply, 
demand, distribution, education and use of physicians, nurses, dentists 
and 20 other health professionals in each State and the District of 
Columbia (published 2004 and 2000): 

* The Health Care Workforce: Education, Practice & Policy provides in- 
depth assessments of the health workforce in 26 selected States and an 
Interstate Comparison that assesses data and influences across the 
States. Both studies were conducted for HRSA by the National Conference 
of State Legislatures. 

A Comparison of Changes in the Professional Practice of Nurse 
Practitioners, Physician Assistants, and Certified Nurse Midwives: 1992 
and 2000 (published February 2004): 

* Effects of the Workforce Investment Act of 1998 on Health Workforce 
Development in the States (November 2004). 

* Supply, Demand, and Use of Licensed Practical Nurses (Published 
November 2004): 

* The Professional Practice Environment of Dental Hygienists in the 
Fifty States and the District of Columbia (published April 2004): 

* Health Care Occupations - National and Local Workforce Shortages and 
Associated Data Needs (published February 2004): 

* State Responses to Health Worker Shortages: Results of 2002 Survey of 
States, profiles of each state's response to health workforce 
shortages, details of current initiatives and links to Web sites and 
State contacts (published May 2003). 

Some of the reports produced by HRSA are of special significance 
because they helped to change the landscape of health professional 
training nationally to promote the attainment of Title VII objectives. 
The following were particularly significant: 

* Undergraduate Medical Education for the 21st Century (UME-21): A 
National Medical Education Project. Family Medicine 2004:36S: SI-150. 
This resulted from a project, the objective of which was to stimulate 
the introduction of new educational opportunities, focusing on nine 
content areas during the third year of the curriculum, with outcomes 
demonstrating that medical students acquire the knowledge, skills, and 
attitudes needed to perform effectively. 

* Challenging Sociocultural Health Disparities: A Collaborative and 
Interdisciplinary Model Podogeriatric Curriculum Plan. This is a 154- 
chapter teaching module developed as part of a program to establish and 
disseminate an interdisciplinary graduate physician training program 
for podiatry, family practice, and internal medicine residents 
concerning foot care for older patients. 

Topics for other reports and current research include: 

* Racial and ethnic diversity of the workforce: 

* Provision of geriatric health care: 

* Implications of the aging of the U.S. population and the healthcare 
workforce: 

* Health workforce preparedness in genetics and emerging health 
technologies: 

* Health workforce preparedness for emergency response to terrorism: 

* U.S.-Mexico border health and Border Health Profiles: 

* Mental health: 

* Oral health: 

* State and regional health care system financing: 

In addition to the reports and projects listed above, NCHWA produces 
other resources that are valuable to analysts and researchers inside 
and outside of HRSA. An example is the Area Resource File (ARF) which 
is a regularly updated compilation of a national, county-level database 
on the health workforce. ARF is very widely used by national, State, 
regional, and local policymakers, researchers, and workforce analysts. 
A search for "Area Resource File" or "ARF" in the Web of Science 
database produced over 100 citations of the ARF in recently published 
medical and health literature. 

NCHWA also supports evaluation studies on current workforce topics. 
Currently, HRSA is compiling an evaluation of the likelihood that 
physicians exposed to Title VII funded programs during training will 
practice in federally-designated health centers, including Community 
Health Centers. 

A report on the Critical Care Workforce, which is based on the 
HRSA/NCHWA physician models, estimates the supply, need, and 
distribution of the critical care workforce and is currently in the 
clearance process. 

We agree with GAO that in the changing health care environment, updated 
workforce supply and demand projections are vital for informed decision 
making about health professions programs. We also agree on the 
importance of clear and relevant goals and performance measures, backed 
by timely and complete data. Completion of the Performance Measurement 
System and its integration into data collection systems are a top 
priority for HRSA, and we thank GAO for this opportunity to comment and 
expand on some of these issues. 

[End of section] 

Appendix V: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Leslie G. Aronovitz at (312) 220-7600 or aronovitzl@gao.gov: 

Acknowledgments: 

In addition to the person named above, Kim Yamane, Assistant Director; 
George Bogart; Matt Byer; Ellen W. Chu; and Karlin Richardson made key 
contributions to this report. 

[End of section] 

Related GAO Products: 

Physician Workforce: Physician Supply Increased in Metropolitan and 
Nonmetropolitan Areas but Geographic Disparities Persisted. GAO-04- 
124. Washington, D.C.: October 31, 2003. 

Health Care: Adequacy of Pharmacy, Laboratory, and Radiology Workforce 
Supply Difficult to Determine. GAO-02-137R. Washington, D.C.: October 
10, 2001. 

Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors. 
GAO-01-944. Washington, D.C.: July 10, 2001. 

Health Professions Education: Clarifying the Role of Title VII and VIII 
Programs Could Improve Accountability. GAO/T-HEHS-97-117. Washington, 
D.C.: April 25, 1997. 

Health Professions Education: Role of Title VII/VIII Programs in 
Improving Access to Care Is Unclear. GAO/HEHS-94-164. Washington, D.C.: 
July 8, 1994. 

[End of section] 

FOOTNOTES: 

[1] Allied health practitioners include, for example, audiologists, 
dental hygienists, clinical laboratory technicians, occupational 
therapists, physical therapists, medical imaging technologists, and 
speech pathologists. 

[2] Most title VII and title VIII programs were last reauthorized by 
the Health Professions Education Partnership Act of 1998, Pub. L. No. 
105-392, 112 Stat. 3524. Some nursing programs were authorized or 
reauthorized by the Nurse Reinvestment Act of 2002, Pub. L. No. 107-
205, 116 Stat. 811. 

[3] See “Related GAO Products” at the end of this report. 

[4] GAO, Health Professions Education: Clarifying the Role of Title VII 
and VIII Programs Could Improve Accountability, GAO/T-HEHS-97-117 
(Washington, D.C.: Apr. 25, 1997). 

[5] Office of Management and Budget, Program Assessment Rating Tool, 
http://www.whitehouse.gov/omb/budget/fy2006/pma/hhs.pdf, downloaded 
Aug. 9, 2005. The most recent OMB assessment of the health professions 
programs took place for the fiscal year 2004 budget. 

[6] We excluding funding for one title VII program—Health Education 
Assistance Loans—because the program was not authorized to guarantee 
new loans to student borrowers during that period. 

[7] Referred to as “grants” in this report. 

[8] We used the separate selection panel criterion only for programs 
funded in fiscal year 2004. 

[9] We excluded advisory groups authorized under title VII or title 
VIII from our counts of programs. 

[10] In addition to the national workforce projections discussed in 
this report, HRSA and its six regional centers issue reports—such as 
state health workforce profiles for each state, the District of 
Columbia, Puerto Rico, and the Virgin Islands—containing information 
about the supply; demand; distribution; education; and use of 
physicians, nurses, dentists, and 20 other health professionals. The 
scope of our review was limited to HRSA’s estimates of national supply 
and demand. 

[11] COGME, established under title VII, is required to make 
recommendations to the Secretary of HHS and Congress on several issues, 
including the supply and distribution of physicians in the United 
States; current and future shortages or excesses of physicians in 
medical and surgical specialties and subspecialties and appropriate 
federal policies with respect to such supply, distribution, shortages, 
or excesses; and deficiencies in and needs for improvement in databases 
concerning the supply and distribution of physicians in the United 
States. Public Health Service Act § 762 (codified at 42 U.S.C. § 294o). 
The views expressed in COGME’s reports are solely those of the council 
and do not necessarily represent the views of HRSA or the U.S. 
government. 

[12] The Government Performance and Results Act of 1993 requires 
executive agencies to develop agencywide performance goals and 
indicators and to report progress annually. Pub. L. No. 103–62, § 4, 
107 Stat. 285, 286. 

[13] Health Professions Educational Assistance Act of 1963, Pub. L. No. 
88-128, 77 Stat. 164. See S. Rep. No. 88-485, at 3 (1963). 

[14] Nurse Training Act of 1964, Pub. L. No. 88-581, 78 Stat. 1035. See 
S. Rep. No. 88-1378, at 3 (1964). 

[15] Senate Report No. 105-220 at 13 and 19 (1998) (accompanied 
legislation that became Health Professions Education Partnership Act of 
1998, Pub. L. No. 105-392, 112 Stat. 3524). The Senate report is the 
only congressional report accompanying Pub. L. No. 105-392. 

[16] The national center also supports work by six regional centers, 
which conduct cross-disciplinary assessments of the health workforce, 
focusing on issues at the state and regional levels. In addition, the 
national center facilitates research projects contracted and funded by 
programs within other clusters; for example, the national center 
facilitates nursing workforce research. The congressional conference 
agreement for the Department of Health and Human Services’ 
appropriation for fiscal year 2006 did not include funding for the 
Health Professions Workforce Information and Analysis cluster. H.R. 
Conf. Rep. No. 109-337 at 135 (2005). 

[17] Three advisory groups besides COGME have received contract and 
staff support from HRSA and have produced a series of reports on 
workforce issues. These groups, authorized by title VII or title VIII 
of the Public Health Service Act, are the National Advisory Council on 
Nurse Education and Practice; the Advisory Committee on Training in 
Primary Care Medicine and Dentistry; and the Advisory Committee on 
Interdisciplinary, Community-Based Linkages. 

[18] Department of Health and Human Services, Health Resources and 
Services Administration, Fiscal Year 2005 Justification of Estimates 
for Appropriations Committees, vol. I, Budget (Washington, D.C.: n.d.). 

[19] Medicare’s graduate medical education payments are made to 
teaching hospitals for both direct and indirect graduate medical 
education costs on the basis of factors such as the number of 
physicians being trained, Medicare’s share of patient days in the 
hospital, and the hospital’s ratio of residents to beds. 

[20] We excluded the student loan cluster from this analysis. The 
Health Education Assistance Loans program was not authorized to 
guarantee new loans to student borrowers during this period. The 
remaining loan programs have received no new federal funds since fiscal 
year 1998, although HRSA continues to administer them. 

[21] The Nurse Reinvestment Act of 2002 authorized additional title 
VIII programs. Pub. L. No. 107-205, §§ 103, 201, 202, 116 Stat. 811, 
813, 815, 816 (2002). 

[22] We used HRSA’s database to identify the title VII and title VIII 
grant programs that received funding in fiscal year 2004. Fiscal year 
2004 was the most recent year for which data were available at the time 
of our analysis. We also contacted HRSA officials to obtain information 
on other title VII and title VIII programs, such as scholarship 
programs, that HRSA administered in those years. We counted (1) 
programs that awarded funds competitively through grants or cooperative 
agreements and that announced funding availability separately or had a 
separate selection panel and (2) programs providing direct assistance, 
such as student loans to individuals, regardless of whether the loan 
program received any new appropriations. 

[23] The act specifies that, of the $78.3 million authorized to be 
appropriated for fiscal year 1998, not less than $49.3 million be made 
available to programs of family medicine, of which not less than $8.6 
million be made available for family medicine academic administrative 
units, not less than $17.7 million be made available to programs of 
general internal medicine and general pediatrics, not less than $6.8 
million be made available to programs related to physician assistants, 
and not less than $4.5 million be made available to programs of general 
or pediatric dentistry. If the amounts appropriated in subsequent 
fiscal years are less than the amount authorized to be appropriated for 
1998, the act directs the secretary to reduce the amounts made 
available to the programs on a proportional basis. See Public Health 
Service Act, § 747, as amended (codifed at 42 U.S.C. § 293k). 

[24] See Public Health Service Act, § 736, as amended (codified at 42 
U.S.C. § 293). 

[25] Department of Health and Human Services, Health Resources and 
Services Administration, Fiscal Year 2006 Justification of Estimates 
for Appropriations Committees (Washington, D.C.: n.d.). In addition to 
the broad performance goals for health professions and nursing 
education and training programs shown in table 2, the budget 
justification also lists goals and performance measures for specific 
programs, such as Health Education Assistance Loans, Health Professions 
Workforce Information and Analysis, and the Nursing Education Loan 
Repayment and Nursing Scholarship Programs (see app. III). 

[26] To collect these data, HRSA developed its comprehensive 
performance management system and uniform progress report. 

[27] GAO/T-HEHS-97-117. 

[28] Mia Cahill et al., Evaluation of Data Collection Processes Used by 
the Bureau of Health Professions’ Grantees to Determine the Number of 
Graduates and Program Completers Practicing in Medically Underserved 
Communities, final report prepared for HRSA (Princeton, N.J.: 
Mathematica Policy Research, Mar. 31, 2002). 

[29] HRSA officials acknowledged that such proposed national indicators 
are driven by a number of factors other than funding support from title 
VII and title VIII programs. 

[30] HRSA officials noted that the agency must seek approval from OMB 
for any change in reporting requirements for grantees, and that they 
expected to submit their plans to OMB by spring 2006. 

[31] Other goals include federal-state collaborative efforts directed 
at assessing the adequacy of the current and future heath care 
workforce from federal, state, and local perspectives and developing 
strategies for improving the diversity and distribution of the health 
workforce. See Department of Health and Human Services, Health 
Resources and Services Administration, Fiscal Year 2006 Justification 
of Estimates for Appropriations Committees. 

[32] In addition to national workforce projections and other reports 
issued by HRSA and its six regional centers, HRSA supports a database, 
the Area Resource File, containing statistics on health professions, 
health training programs, health facilities, measures of resource 
scarcity, and health status. This information is derived from existing 
data sources, such as the National Center for Health Statistics and 
American Hospital Association. 

[33] See, for example, Jack M. Colwill and James M. Cultice, “The 
Future Supply of Family Physicians: Implications for Rural America,” 
Health Affairs, vol. 22, no. 1 (2003), and Robert M. Politzer et al., 
“Matching Physician Supply and Requirements: Testing Policy 
Recommendations,” Inquiry, vol. 33: 181–194 (1996). 

[34] Council on Graduate Medical Education, Department of Health and 
Human Services, Health Resources and Services Administration, Physician 
Workforce: Policy Guidelines for the United States, 2000–2020 
(Rockville, Md.: January 2005). The views expressed in COGME’s report 
are solely those of the council and do not necessarily represent the 
views of HRSA or the U.S. government. 

[35] The Public Health Service Act required that HRSA report to 
Congress in 1993 and every 2 years thereafter; see §792, codified at 42 
U.S.C. §295k. After submitting the ninth report to Congress in 1995, 
HRSA did not submit additional biennial reports before the requirement 
was eliminated in 1999 by the Federal Reports Elimination and Sunset 
Act of 1995. Pub. L. No. 104-66, §303, 109 Stat. 707, 734. 

[36] The most recent state profiles compiled 2000 data on levels of 
employment, projected growth, and key environmental factors affecting 
demand for health care. Because these profiles did not include national 
workforce projections, they were outside of the scope of our review. 
See http://bhpr.hrsa.gov/healthworkforce/reports/profiles/, downloaded 
September 7, 2005. 

[37] More recent workforce research has again raised concerns that the 
nation is likely to face a shortage of physicians. For example, in 
October 2003, AMA noted that several published studies have 
demonstrated that the expected oversupply had not appeared. COGME, in a 
January 2005 report, has also acknowledged that the nation may face a 
physician shortage by the year 2020. 

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441 G Street NW, Room LM 

Washington, D.C. 20548: 

To order by Phone: 

Voice: (202) 512-6000: 

TDD: (202) 512-2537: 

Fax: (202) 512-6061: 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm 

E-mail: fraudnet@gao.gov 

Automated answering system: (800) 424-5454 or (202) 512-7470: 

Public Affairs: 

Jeff Nelligan, managing director, 

NelliganJ@gao.gov 

(202) 512-4800 

U.S. Government Accountability Office, 

441 G Street NW, Room 7149 

Washington, D.C. 20548: