Health Resources and Services Administration

 The Health Care Workforce Crisis:  A Summit on the Future of Primary Care in Rural and Urban America

August 10-12, 2009

The Health Resources and Services Administration held a Summit in August to address the health care workforce as the country approaches health reform.  HRSA Director Mary Wakefield and her staff put together a three-day summit that included numerous breakout sessions addressing trends in the primary care work force, building a diverse primary care work force, innovative practices, meeting a broad range of patient needs, community driven medical education: healers of the future, rural primary care workforce: what we need to know about the need and what needs to be done, the National Health Service Corps session, the changing face for primary care and implications for the work force, work force development and health reform. 

My primary reason for attending was to get chiropractic on the map as much as I could.  I attended as a Board Member of the Association for Clinicians for the Underserved (ACU) www.clinicians.org. 

I spoke to many HRSA staff and several keynote speakers including J. Lloyd Michener, MD, clinical professor and chair of the Department of Community and Family Medicine, Duke University Medical Center, to make sure that chiropractic was not an afterthought and that our profession would be included in whatever future work force policies were to come out of this meeting.

One of the highlights of the meeting was meeting directly with the HRSA staff and speaking frankly about where we are with the demonstration project and why we need to go through this again, what Congress will do and what the future looks like for our profession.  I had many conversations with Rick Smith, who is the director of the National Health Service Corps and Bureau of Clinician Recruitment and Services.  One good thing that came out of my conversations and constant reminder that chiropractic needed to be at the table with health care work force policies was the closing remarks on the final day of the summit.   Rick Smith included chiropractic in his closing statement, which is a step forward.  Poor Rick – he will never get rid of me until we get chiropractic permanently in the National Health Service Corps.

This was an excellent meeting as it made people think out of the box and look for creative solutions to the health care work force shortage.  We know that there will be primary care shortages in this country.  Unfortunately, HRSA staff still thinks in the old paradigm of medical silos.  It is my recommendation to HRSA and all that we start broadening our horizons and think of care under the umbrella of health which includes everyone (chiropractors, optometrists, dentists, nurses, midwifes, massage therapists, acupuncturists, social workers and the like) so that we are all on an equal footing and the patient has the choice to see who ever they want.  In addition, the primary care shortage can only be helped if HRSA recognizes that these shortages are due to multiple factors that will not change for years to come:  the cost of education, the cost of setting up a private practice, the lack of information in a physician’s medical education on health policy, public health, nutrition, etc.  Physicians cannot be everything to everyone.  Other professional disciplines can work in tandem with primary care specialists to make sure that patients are receiving the care that they need.

What could HHS/HRSA be doing now to address primary care workforce issues and shortages?

·         Stop addressing primary care in silos.  We have to start opening up the doors to other health care professionals who provide service and are part of the delivery of “primary care.”  If you want to really think “outside the box,” then think of the human body and all of the systems that make up who we are:  Structure, Nutrition, Mental Health, Dental and Vision with special attention given to our body’s systems when it needs it (Cardio, Lung, Gastro, Ear/Nose/Throat, etc.). This is what care is all about – taking stock in how we can help keep our body healthy, in good spirit and in the most optimal state it can be in.

·         The power of opening up the silos will allow people to have choice and access to care that they have been denied for years in both rural, urban and underserved communities.

·         Although this is not under the domain of HRSA – the United States Public Health Service Commissioned Corps has an age limitation – you cannot serve if you are older than 44.  Sixty-five is the new 44, and this could help a great deal with the shortages that the United States is experiencing in under-served and rural communities.  There are plenty of middle aged American providers who would like to work in underserved communities throughout the US but are locked out because of the age barrier.  These productive, well seasoned providers are considered “too old.”  This is a waste of a good, useful, available, trained and plentiful work force.

·         To date, HHS has announced the availability of nearly $200 million in ARRA workf orce funds, of a total $300 million, to expand HRSA’s National Health Service Corps.  The funds will pay for student loan repayments for primary care medical dental and mental health clinicians who wish to practice, for a minimum of two years, in NHSC sites that treat underserved and uninsured people.  Chiropractic was not included. 

What important "next generation" ideas do you have that you think HHS/HRSA needs to consider about the primary care work force in the future?

·         Change the cost of education.  This is one of the factors that influences our health care system.  If we keep raising the cost to become a “primary care professional,” we will lose the opportunity for anyone to be able to practice or to work with the under-served communities.  Mounting educational debt is part of the health care problem in this country.  This financial burden now plagues most professional students throughout their adult life, competing with housing, food and other basic necessities.

·         It is also difficult for primary care physicians to survive if they feel that working with the under-served is a rescue mission that they are being thrown into without support. Without a transdisciplinary approach to primary care involving nutrition, nursing, chiropractic, podiatry, optometry, etc., the system is set up to fail.  A single person only has so much time, but a team can support one another and provide 360 degree care for a patient without overburdening anyone.  Many primary care physicians are struggling to keep small practices alive and cannot manage the necessary work and still meet their expenses. In order to provide better quality of care, it is necessary to have a transdisciplinary approach and all resources in place. 

As the nation moves closer to health reform, we must continue to work closely with HRSA staff to ensure that chiropractic has a permanent place not only the National Health Service Corps but in federal policies related to health reform and work force development.