United States General Accounting Office

GAO Testimony

Before the Subcommittee on Public Health and Safety,

Committee on Labor and Human Resources, U.S. Senate

For Release on Delivery

Expected at 9:30 a.m.

Friday, April 25, 1997

HEALTH PROFESSIONS

EDUCATION

Clarifying the Role of Title

VII and VIII Programs Could

Improve Accountability

Statement for the Record by Bernice Steinhardt, Director

Health Services Quality and Public Health Issues

Health, Education, and Human Services Division

GAO/T-HEHS-97-117

Health Professions Education: Clarifying the

Role of Title VII and VIII Programs Could

Improve Accountability

Mr. Chairman and Members of the Subcommittee:

We are pleased to contribute this statement for the Subcommittee’s

deliberations on reauthorizing health professions education programs

established under titles VII and VIII of the Public Health Service Act.1

 In

fiscal year 1996, the Congress provided nearly $300 million for about 40

programs under these titles. These programs, administered through the

Department of Health and Human Services (HHS),2

 provide direct student

assistance, such as loans, as well as grants to institutions for expansion or

maintenance of health professions education and training.

When it last reauthorized titles VII and VIII in 1992, the Congress required

us to report on whether these programs were effective in advancing three

key purposes—increasing the numbers of health professionals, improving

their distribution in locations that have a shortage of health professionals,

and adding minorities to their ranks. Since our 1994 report,3

 two important

developments have occurred with regard to these programs. First, the

Government Performance and Results Act of 1993 (GPRA), which was

newly enacted when we issued our report, requires federal agencies to be

more accountable for the results of their efforts. Second, both the

Congress and the administration have proposed placing many existing

Title VII and VIII programs into five or six “clusters” as part of efforts to

streamline government. In preparing this statement, we relied on our

earlier report and conducted a limited amount of follow-up work to review

the current status of the Title VII and VIII programs and to place our

earlier findings in the context of these new developments.

Our comments will focus on (1) problems we identified in linking these

programs to changes in the supply, distribution, and minority

representation of health professionals and the impact of these changes on

access to care; (2) the potential for implementation of GPRA to address

these problems; and (3) the opportunities associated with consolidating

the separate programs into program clusters.

In brief, we found that the effectiveness of Title VII and VIII programs will

remain difficult to measure as long as they are authorized to support a

broad range of health care objectives without common goals, outcome

1

42 U.S.C. 292-298b-7 (1994).

2

HHS’ Health Resources and Services Administration (HRSA) administers these programs.

3

Health Professions Education: Role of Title VII/VIII Programs in Improving Access to Care Is Unclear

(GAO/HEHS-94-164, July 8, 1994).

Page 1 GAO/T-HEHS-97-117
Health Professions Education: Clarifying the

Role of Title VII and VIII Programs Could

Improve Accountability

measures, and reporting requirements. The implementation of GPRA and

the “clustering” concept offer an opportunity to address these problems by

providing the framework and flexibility to clarify the role of Title VII and

VIII programs and direct federal efforts to achieve desired outcomes.

However, unless steps are taken with a clear eye to addressing the

problems, these developments could meet with little success.

Role of Programs in

Improving Access Is

Unclear

In 1994, we reported that the supply of nearly all types of health

professionals had increased faster than the population. Moreover, the

number of underrepresented minorities in health professions education

for which data were available4

 had increased faster than the number for all

races combined. For most professions, however, data were not available

to demonstrate whether this increased supply and minority representation

translated into more access to care in rural and underserved areas. For the

two professions with the most data available—primary care physicians

and general dentists—supply increased in many rural areas but not in

those urban and rural areas where the greatest shortages existed.

We also reported that evaluations of Title VII and VIII programs have not

linked these programs to the changes in the supply, distribution, and

minority representation of health professionals. HHS is not required to

evaluate the effectiveness of each program, and 6 of the 23 programs

established before 1990 have never been evaluated.5

 Evaluations

conducted on the remaining programs generally addressed the impact at

individual institutions and found that the programs have assisted schools

in improving or enhancing curricula, funding innovative projects, and

providing seed money for starting new programs. However, the results of

virtually all of these evaluations could not be generalized to determine the

national impact of the programs in the three key areas. Such a relationship

is difficult to establish for several reasons, including (1) the wide variety of

often unrelated objectives that the programs addressed and (2) problems

with the data and criteria used to measure the outcomes of what the

programs were accomplishing.

4

HHS has identified African-Americans, Native Americans, and Hispanics as underrepresented in the

health professions. Only data for physicians, dentists, and registered nurses were available for

minority applicants, first-year enrollments, and graduates of health professions schools.

5

The Secretary of HHS is authorized by statute to set aside up to 1 percent of Public Health Service

(PHS) appropriations for evaluations. We previously reported that implementation of this set-aside has

been less than fully effective in providing information to the Congress on PHS programs. See Public

Health Service: Evaluation Set-Aside Has Not Realized Its Potential to Inform the Congress

(GAO/PEMD-93-13, Apr. 8, 1993).

Page 2 GAO/T-HEHS-97-117
Health Professions Education: Clarifying the

Role of Title VII and VIII Programs Could

Improve Accountability

Multiple Program

Objectives

While over the past 2 decades congressional interest in Title VII and VIII

programs has focused on their utility in adding to the number of health

care professionals, placing these professionals in underserved areas, and

training more minority health professionals, the programs themselves have

a variety of objectives. Titles VII and VIII, established in 1963 and 1964 and

amended over time, authorize funding for a number of programs with

diverse objectives. While most of the programs address at least one of the

three key areas of improving the supply, distribution, and minority

representation of health professionals, they also address other objectives

as well. These other objectives, such as improving the quality of education

and training, may only indirectly result in improvements to the three key

areas. Furthermore, HHS officials identified some programs, including

grants for chiropractic demonstration projects, that do not have objectives

related to any of the three key areas.

The large number and piecemeal approach of Title VII and VIII program

objectives make evaluating program impact difficult. For example, one

institution received a $300,590 family medicine grant to further the

achievement of 12 separate objectives. One of the 12 objectives was to

directly improve distribution and minority representation; none was for

increasing supply. The other 11 were for various curricula improvements,

such as expanding the behavioral science curriculum and maintaining the

physician practice-management curriculum. While these 11 other

objectives may be valuable in their own right, they represent federally

funded activities that could not be directly linked to, and thus evaluated as

affecting, these three key areas.

Problems With Outcome

Measures

Another problem hindering evaluation was that none of the Title VII and

VIII programs at the time of our review had established specific program

outcome measures—that is, the desired results—against which to gauge

their effectiveness. Establishing results-oriented measures is difficult

because to set such measures, HHS must move beyond what it

controls—that is, the activities—to focus on what it merely

influences—the results. We found that some grantees reported on the

process they established to achieve results, rather than on the results

themselves. For example, a grantee reported that it instituted a

recruitment activity but did not report how many students were actually

recruited through federal funding of this activity.

We also identified problems in the cases in which HHS had begun collecting

data to measure program outcomes. For example, data provided to HHS to

Page 3 GAO/T-HEHS-97-117
Health Professions Education: Clarifying the

Role of Title VII and VIII Programs Could

Improve Accountability

qualify for a funding preference for placing graduates in medically

underserved communities were not necessarily complete or comparable

among schools, and HHS had not established a way to validate the data

provided. Even if these data problems are resolved, other work we have

conducted shows that the underlying criteria used to identify some

medically underserved communities are outdated and flawed.6

 For

example, more than half of the locations designated as underserved may

be invalid because the data are outdated or do not consider a significant

number of primary care providers, such as nurse practitioners or physician

assistants. Without valid criteria and data against which to measure

grantee performance, it is difficult to determine whether grantee efforts

under Title VII and VIII programs are needed and will be successful, or if

other federal programs would be more appropriate.

Implementation of the

Government

Performance and

Results Act Provides

an Opportunity to

Address Identified

Problems

GPRA was intended, in part, to deal with the types of problems we

identified and provides HHS and the Congress with an opportunity to

address them. Concerned that federal agencies such as HHS have not

always effectively managed their activities to ensure accountability, the

Congress has created a legislative framework to address long-standing

management challenges throughout the federal government. The

centerpiece of this framework is GPRA. Under GPRA, every major federal

agency must now ask some basic questions: What is our mission? What are

our goals and how can we achieve them? How can we measure our

performance? How will we use that information to improve? GPRA requires

a strategic plan to be prepared in consultation with the Congress—this

plan is due in September 1997.

Since HHS is still finalizing its required plans, it is unclear whether

implementation of GPRA for the Title VII and VIII programs will resolve the

problems we identified regarding the number and variation of program

goals. One unresolved issue is the degree to which Title VII and VIII

program goals will be considered in relationship to the other HHS programs

for health professions education and training. Because HHS’ influence on

education and training involves multiple efforts spanning several of its

agencies, Title VII and VIII programs should not be considered in a

vacuum. HHS officials responsible for administering Title VII and VIII

programs cite the influences of other, larger HHS programs on health

professions education and training programs. For example, the officials

said they believe the incentives for primary care education and training

6

More specifically, the designation systems we evaluated were the Health Professional Shortage Areas

and Medically Underserved Areas. See Health Care Shortage Areas: Designations Not a Useful Tool for

Directing Resources to the Underserved (GAO/HEHS-95-200, Sept. 8, 1995).

Page 4 GAO/T-HEHS-97-117
Health Professions Education: Clarifying the

Role of Title VII and VIII Programs Could

Improve Accountability

provided by Title VII programs are counteracted by the billions of dollars

of federal funding from the Medicare program to support the training of

specialists and from the National Institutes of Health to support

biomedical research at medical schools. HHS officials added that goals of

improving supply, distribution, or minority representation nationally are

unrealistic for the few hundred million dollars that fund Title VII and VIII

programs given the multibillion dollar training environment. Clarifying the

intended nature and extent of the impact of Title VII and VIII programs

remains an important step in overcoming the problems we identified.

The consultation process under GPRA gives the Congress and HHS an

opportunity to reach an understanding of what role Title VII and VIII

programs should play in this broader context of programs—and what

goals and desired outcomes should be set specifically for Title VII and VIII

programs. In discussing the challenges of GPRA implementation, HHS

officials noted that funding for Title VII and VIII programs is often

intended to have impact at the margin—that is, to affect an individual

institution or recipient—and therefore long-term outcomes solely

attributable to funding these programs are difficult to measure. HHS

officials are currently developing cross-cutting goals and indicators for the

Title VII and VIII programs. Although benchmarks and specific goals

against which to measure the success of these programs have not yet been

established, the officials said they plan on measuring the impact on

projects that receive Title VII and VIII funding, such as counting the

number of enrollees at program-supported institutions, rather than

measuring changes in national indicators.

For successful GPRA implementation, performance information must be

used to direct resources where federal intervention would have a greater

impact. One area that would benefit from this process is HHS’ goal of

increasing minority representation in the health professions. Although

some minority groups are underrepresented in the health professions

when compared with their overall percentage in the U.S. population, some

groups are not underrepresented when the comparison is based more

narrowly on the segment of the population with the necessary educational

background to enter into health professions education and training. This

may mean that federal efforts could be better spent on bringing more

minority students to the point of being able to enter health professions

education, instead of on helping the relatively few who already have those

qualifications. GPRA, with its emphasis on targeting federal efforts on more

cost-effective ways to achieve agreed-upon goals, could help to surface

such considerations.

Page 5 GAO/T-HEHS-97-117
Health Professions Education: Clarifying the

Role of Title VII and VIII Programs Could

Improve Accountability

Proposals to Cluster

Title VII and VIII

Programs Could

Provide Flexibility to

Target Resources

Like GPRA, recent legislative proposals provide an opportunity to focus

Title VII and VIII moneys in the most effective ways. In response to

national efforts to streamline government, recent reauthorization

proposals by the Senate and the administration combine about 40 Title VII

and VIII categorical programs into 5 or 6 program clusters.7

 Under such an

approach, the Congress could authorize and appropriate funds for each

cluster of programs instead of authorizing and appropriating funds for

each program. HHS could have the authority to fund programs within the

cluster but would no longer be required to fund each individual program.

This would give HHS more flexibility, in conjunction with GPRA, to

determine how to spend the money to achieve stated goals.

This cluster concept could provide greater flexibility to target resources to

the most effective programs and to discontinue federal support when

agreed-upon goals have been achieved. However, as with GPRA, achieving

greater success with this approach is not automatic. Increased agency

flexibility and related discretion would make it even more critical that the

desired outcomes of the programs be clarified so that resources could be

allocated on the basis of the need for and effectiveness of specific

programs. Unless these issues are addressed, the risk continues that

money will be spent without a clear idea of what is being

accomplished—and whether spending it differently would produce greater

results.

Concluding

Observations

An appropriate number and mix of health professionals are vital to

ensuring that all Americans have adequate access to health care. Our work

points to the need to clarify the role of Title VII and VIII programs in

improving the supply, distribution, and minority representation of health

professionals and whether these programs are intended to affect the

health professions at the national level. If these programs are to

specifically improve supply, distribution, and minority representation of

health professionals, federal efforts need to be directed to activities that

clearly support those goals and whose results can be measured and

reported in terms of those goals. Similarly, if the programs are to meet

other goals, such as improving curricula to address emerging national

health issues, federal efforts need to be directed to the most effective

means of achieving them. Regardless of which direction is chosen, once

goals are defined, performance measures and targets are critical to

7

The Senate proposal would also combine a Title III program, the National Health Service Corps, with

the Title VII and VIII programs in one cluster.

Page 6 GAO/T-HEHS-97-117
Health Professions Education: Clarifying the

Role of Title VII and VIII Programs Could

Improve Accountability

determine when federal intervention is no longer required, or when federal

strategies are not successful and should be redirected.

The implementation of GPRA and reauthorization of the programs provide

an ideal opportunity to identify where Title VII and VIII programs fit within

the federal government’s overall strategy for addressing national health

workforce issues. In doing so, HHS and the Congress can establish vital

national goals and common outcome measures for HHS programs and

allocate limited federal funds to those programs, including programs

outside of Title VII and VIII, based on demonstrated effect and relative

need in meeting national goals.

Contributors This statement was prepared under the direction of Bernice Steinhardt,

Director, Health Services Quality and Public Health Issues, who may be

reached at (202) 512-7119 if there are any questions. Other key

contributors include Frank Pasquier, Assistant Director, and Lacinda

Baumgartner, Kim Yamane, and Stan Stenersen, Evaluators.

(108326) Page 7 GAO/T-HEHS-97-117
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