Health Care Workforce: Comprehensive Planning by HHS Needed to Meet National Needs
Published: 2015-12-11T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: An adequate, well-trained, and diverse health care workforce is essential for providing access to quality health care services. The federal government—largely through HHS—funds programs to help ensure a sufficient supply and distribution of health care professionals. Some experts suggest that maintaining access to care could require an increase in the supply of providers, while others suggest access can be maintained by, among other things, greater use of technology.
GAO was asked to review HHS's workforce efforts. In this report, GAO examines (1) HHS's planning efforts for ensuring an adequate supply and distribution of the nation's health care workforce and (2) the extent to which individual HHS health care workforce programs contribute to meeting national needs. GAO reviewed strategic planning documents, workforce projection reports, and other related documents obtained from HHS agencies; interviewed HHS officials; and analyzed performance measures for the largest health care workforce programs operated by HHS.
section_title: What GAO Found
paragraphs: The Department of Health and Human Services (HHS) engages in some planning for the 72 health care workforce programs administered by its agencies, but lacks comprehensive planning and oversight to ensure that these efforts meet national health care workforce needs. HHS's current strategic plan includes broad strategies—such as improving access to comprehensive primary and preventive medical services in historically underserved areas and supporting federally funded health centers—to which department officials said the health care workforce programs relate. However, these strategies do not explicitly reference workforce issues or specify how these programs contribute towards HHS's current strategic goals and performance targets. The health care workforce performance measures tracked by HHS and its agencies are specific to individual workforce programs and do not fully assess the overall adequacy of the department's workforce efforts. The Office of the Secretary leads workforce planning efforts, but it does not have an ongoing formal effort to ensure that the workforce programs distributed across its different agencies are aligned with national needs. Multiple external stakeholders, such as the Institute of Medicine and the Council on Graduate Medical Education, have reported that graduate medical education (GME) funding lacks the oversight and infrastructure to track outcomes, reward performance, and respond to emerging workforce challenges and that a more coordinated effort could help to ensure an adequate supply and distribution of the health care workforce. Consistent with leading practices, a coordinated department-wide planning effort is important to ensure that these efforts are aligned and managed effectively to meet workforce needs.
While HHS's workforce programs support education and training for multiple health professions, its largest programs do not specifically target areas of workforce need, such as for primary care and rural providers. For example, its two Medicare GME programs accounted for about three-quarters of HHS's fiscal year 2014 obligations for health care workforce development. However, HHS cannot target existing Medicare GME program funds to projected workforce shortage areas because the programs were established by statute and funds are disbursed based on a statutory formula that is unrelated to projected workforce needs. HHS has limited legal authority to target certain existing programs to areas of emerging needs and has taken steps to do so within its existing authorities, such as the approval of certain demonstration projects to test new payment models for Medicaid GME funds. Further, the President's budget has proposed additional authorities that would allow HHS to implement new education and training programs and payment reforms intended to support primary care providers, but these authorities have not been enacted and officials did not know the extent to which they would be sufficient to address identified needs. External stakeholders have recommended additional reforms that would allow these programs to better targets areas of need. Without a comprehensive and coordinated planning approach, HHS cannot fully identify gaps and actions to address those gaps, including determining whether additional legislative proposals are needed to ensure that its programs fully meet workforce needs.
section_title: What GAO Recommends
paragraphs: GAO recommends that HHS develop a comprehensive and coordinated planning approach that includes performance measures, identifies any gaps between its workforce programs and national needs, and identifies actions to close these gaps. HHS concurred with GAO's recommendations and provided technical comments, which GAO incorporated as appropriate.

section_title: Letter
paragraphs: An adequate, well-trained, and diverse health care workforce is essential  for providing Americans with access to quality health care services.  According to some studies, a growing demand for services, an aging  population, population growth, and increased access to insurance  resulting from the implementation of the Patient Protection and Affordable  Care Act (PPACA) could result in provider shortages that could limit  patient access to care. In addition to current workforce shortages for  primary care and in rural areas, according to federal projections, by 2025,  there will be national or regional shortages in a number of health  professions, such as dentistry, psychiatry, general surgery, and nursing.  Some experts report that maintaining access to care could require an  increased supply of providers, while others suggest that access can be  improved through policy options. For example, they note that access to  care could be increased through greater use of technology, such as  telemedicine; changing the mix of providers delivering care; and changing  the pattern of practice, such as by providing more team-based care or by  eliminating currently provided care that is either unnecessary or of limited  value.
The federal government—largely through the Department of Health and  Human Services (HHS)—funds a large number of education and training  programs to help ensure a sufficient supply and distribution of physicians,  nurses, dentists, and other health care professionals who provide care  directly to patients. These programs are managed by multiple HHS  component agencies, but in fiscal year 2014 about 90 percent of funding  came through the Centers for Medicare & Medicaid Services (CMS) for  graduate medical education (GME) payments to hospitals and other  institutions that train physician residents. Most of the remaining HHS  workforce funding in 2014 was administered by the Health Resources and  Services Administration (HRSA) and generally offers financial assistance  to students or institutions to encourage students to train and work in  specific needed professions and regions. PPACA expanded many of  these programs, in addition to creating new ones to increase training in  direct health care professions and care in rural areas. Effective strategic  planning and timely workforce projections are important mechanisms for  HHS to manage its health care workforce programs, although we have  previously found that HHS has faced certain challenges in this area.
Given the increased demands facing the nation’s health care workforce  and the diversity of HHS’s existing programs, you asked us to study   HHS’s activities to ensure that federal funding is aligned with the nation’s  health care needs. In this report, we examine the following:  1.  HHS’s planning efforts for ensuring an adequate supply and  distribution of the nation’s health care workforce; and  2.  The extent to which individual HHS health care workforce programs  contribute to meeting national health care workforce needs.
To examine HHS’s planning efforts for ensuring an adequate supply and  distribution of the nation’s health care workforce, we analyzed current and  past HHS and component agency documents that contain information on  goals, objectives, strategies, and metrics related to health care workforce  planning and development. Specifically, we reviewed the four most recent  HHS strategic plans (covering the periods 2014-2018, 2010-2015, 2007- 2012, and 2004-2009), as well as the President’s recent budget proposals  for HHS and HHS’s annual performance plans and reports—which  include performance goals and measures—for fiscal years 2014, 2015,  and 2016. We also reviewed the most recent strategic plan for each HHS  agency responsible for health care workforce programs, and we  interviewed agency officials to determine how its health care workforce  strategies are aligned with related strategies in the most recent HHS  strategic plan. We also interviewed HHS officials to identify HHS’s  rationale for its current approach to strategic planning for the health care  workforce. We evaluated HHS’s strategic planning and other efforts  against the GPRA Modernization Act of 2010 (GPRAMA), as well as  leading practices for strategic planning and performance measurement  identified in prior GAO work. Finally, we reviewed recently published  reports by the Institute of Medicine (IOM) and other organizations that  have examined HHS’s health care workforce programs and made  recommendations.
To examine the extent to which individual HHS health care workforce  programs contribute to meeting national health care workforce needs, we  identified a list of 72 HHS programs that provided funding for workforce  development in fiscal year 2014. For each of these 72 programs, HHS  provided basic funding and performance information. From this listing, we  selected the 12 programs with the highest obligations—ranging from $42  million to $8 billion—in fiscal year 2014. These 12 programs accounted  for 96 percent of the total obligations of the 72 programs. Of these 12  programs, 7 are administered by HRSA, 4 are administered by CMS, and  1 is administered by the Administration for Children and Families (ACF).  (See app. I for a list of these 12 programs.) For each of these 12  programs we did the following:  reviewed performance measures to determine how they contribute  toward department and agency goals;  reviewed documentation and interviewed responsible officials to  determine how HHS monitors these programs and how the workforce  programs align with HHS strategic planning goals;  compared agency performance management practices to criteria from  GPRAMA as well as leading practices identified in prior GAO work; examined the extent to which these programs meet identified areas of  health care workforce need; to identify areas of need, we reviewed the  literature on the health care workforce, as well as workforce projection  reports issued by HRSA that estimate key future areas of shortages in  the nation’s health care workforce, examining the most recent HRSA  reports presenting projections for physicians, nurses, dentists, and  other clinical specialties;  reviewed documentation from HHS to identify changes that HHS has  made or proposed to the structure or allocation of program funds to  meet emerging health care workforce needs; and  reviewed the statutory requirements relevant to the permissible uses  of program funds and confirmed our understanding with agency  officials.
We conducted this performance audit from December 2014 to December  2015 in accordance with generally accepted government auditing  standards. These standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: HHS Strategic Planning
paragraphs: Strategic planning provides an important mechanism for HHS to establish  long-term goals and strategies to improve the performance of its many  health care workforce programs. HHS, as with all executive branch  agencies, is required by GPRAMA to engage in performance  management tasks, such as setting goals, measuring results, and  reporting progress toward these goals. As one of its GPRAMA  responsibilities, HHS issues a strategic plan at least every 4 years. HHS’s  most recent plan covers fiscal year 2014 through fiscal year 2018 and  describes four broad strategic goals:  1.  Strengthen health care.  2.  Advance scientific knowledge and innovation.  3.  Advance the health, safety, and well-being of the American people.  4.  Ensure efficiency, transparency, accountability, and effectiveness of  HHS programs.
Within each strategic goal, the plan presents specific objectives that are  linked to a set of strategies for accomplishing that objective, as well as a  representative set of performance goals or measures for assessing  progress. (See fig. 1.) Annually, HHS releases a performance report  that presents progress on the performance measures that contribute to its  strategic plan. According to HHS officials, the performance measures  included in this performance report are a small but representative subset  of HHS’s work as a whole and of the performance measures that HHS  tracks annually and publishes through other means.
HHS’s strategic planning efforts are led by staff offices that report directly  to the Secretary of Health and Human Services. Specifically, the office of  the Assistant Secretary for Planning and Evaluation (ASPE) is  responsible for the strategic plan, and the office of the Assistant Secretary  for Financial Resources (ASFR) is responsible for monitoring  performance of HHS’s various efforts and programs. ASPE and ASFR are  to coordinate with HHS agencies to facilitate department-wide strategic  planning and performance measurement efforts looking across all of  HHS’s programs and initiatives, including health-workforce related efforts.  These agencies include HRSA, CMS, ACF, the Indian Health Service  (IHS), and the Substance Abuse and Mental Health Services  Administration (SAMHSA). (See fig. 2.) In addition, HHS has several  advisory bodies that make recommendations to the Secretary about  several topics. For example, the Council on Graduate Medical Education  (COGME), supported by HRSA, provides an ongoing assessment of  physician workforce needs, training issues, and financing policies and  recommends appropriate federal and private sector efforts to address  identified needs.
section_title: HHS Workforce Activities
paragraphs: In fiscal year 2014, HHS obligated about $14 billion to 72 health care  workforce education, training, and payment programs administered  primarily through five of its agencies. HRSA manages the most programs  related to health care workforce development, while CMS, ACF, IHS, and  SAMHSA also oversee other such programs.
HRSA managed 49 of the 72 HHS workforce programs in fiscal year  2014. These programs generally provide financial assistance to  students and institutions—in the form of scholarships, loan  repayments, or grants—to encourage students to train and work in  needed professions and regions. These programs accounted for  about 8 percent of HHS’s $14 billion in obligations for workforce  development programs.
In contrast, CMS managed 3 GME payment programs that together  accounted for about 89 percent of this funding. These payments  reimburse hospitals for the cost of training medical residents and are  calculated, in part, based on the number of residents at the hospital.  Some of these payments are included as part of each payment that  CMS makes to reimburse hospitals that train residents for care to  eligible patients. CMS also manages 1 additional payment program  that supports the training of nurses and allied health professionals,  which accounts for about 2 percent of total HHS workforce funding.
The remaining agencies collectively managed 19 programs,  accounting for about 1 percent of total HHS workforce funding. (See  fig. 3.)
In addition to funding health care workforce programs, HHS examines  information about the future demand for health care services, as well as  the related supply and distribution of health professionals. Specifically,  HRSA periodically publishes health care workforce projections regarding  the supply and demand of the health care workforce. We previously  found that the agency’s projections had not been updated and  recommended that the agency develop a strategy and time frames to  update national health care workforce projections regularly. Following  that, HRSA awarded a contract to develop a new model, which according  to officials has enabled more accurate estimates of workforce projections  as well as workforce projections for a wider array of health professions.
The agency subsequently issued many of those projections later in 2014  and in 2015.
section_title: HHS Planning Efforts to Coordinate and Oversee Its Health Care Workforce Programs Do Not Ensure That National Needs Are Fully Addressed
paragraphs: HHS’s current strategic plan lacks specificity regarding how health care  workforce programs contribute to its strategic plan goals. Additionally, the  performance targets that HHS publicly reports do not comprehensively  assess the department’s progress towards achieving its broader strategic  plan goals regarding the health care workforce. Finally, the department  engages in some coordinated planning, but lacks comprehensive  planning and oversight to ensure that its many workforce efforts address  identified national needs.
subsections: section_title: HHS’s Strategic Plan Lacks Specific Strategies for Its Health Care Workforce Programs Related to Their Effect on Access and Quality
paragraphs: HHS’s strategic plan includes broad strategies to which the department’s  health care workforce efforts relate, but these strategies do not focus  specifically on workforce issues. For example, the current 2014-2018  HHS strategic plan does not have a goal or objective specifically  dedicated to health care workforce. Instead, HHS officials stated that  workforce development efforts are distributed across various broad  access and quality objectives within the plan’s goal of strengthening  health care. Specifically, the plan includes seven strategies that contain  a health care workforce component and that are distributed among three  broad objectives. These strategies generally do not explicitly reference  health care workforce training or education, but instead use broad  statements that concurrently encompass numerous different components  and methods for improving access to and quality of health care. For  example, as part of one strategy, HHS seeks to improve access to  comprehensive primary and preventative medical services in historically  underserved areas and to support federally funded health centers. While  not explicit in the plan, HHS officials indicated that developing the health  care workforce is one element that contributes to these strategies. (See  app. II for more details about the strategic plan.)
Past HHS strategic plans included more specific strategies and objectives  related to the department’s workforce programs. However, HHS officials  told us that the department decided to remove most of workforce-specific  language when developing the current plan. The prior HHS strategic plan  (2010-2015) included a dedicated goal related to workforce development,  with one objective and six corresponding strategies that were specific to  health care workforce planning. Further, while an earlier HHS strategic  plan (2007-2012) did not have a workforce-specific strategic goal, it also  had one objective and corresponding strategies on health care workforce  planning, similar to the detailed strategies in the 2010-2015 plan.  However, HHS officials told us that in developing the current strategic  plan, the department decided to remove most of the workforce-specific  language because it determined that workforce development was an  intermediate step in achieving the department’s broader strategic goals of  improving access to and quality of health care. They also noted that, due  to the size of HHS—for fiscal year 2015, HHS spent over $1 trillion  through its operating divisions—its strategic plan has to be high level and  not too specific about any one topic.
Rather than include specificity in HHS’s strategic plan, the department  expects that the strategic plans of its agencies will contain additional  detail about their health care workforce efforts, as is consistent with their  mission, budget, and authorities. However, we found that these agency  plans did not always contain this additional detail and were not always  updated in a timely manner. For example, while HRSA’s 2016-2018  strategic plan contains a dedicated health care workforce goal with three  related objectives and eleven strategies, CMS’s current 2013-2017 plan  did not elaborate on any health care workforce issues presented in the  HHS strategic plan, nor did it contain other related strategies. Moreover,  IHS’s strategic plan was last updated in 2006, and agency officials stated  that the agency was not working to update the plan. (See app. III for  more details about agency strategic plans.) Consistent with GPRAMA  leading practices, for strategic planning to achieve meaningful results on  a crosscutting topic like workforce development, it is important that  planning efforts across these agencies be coordinated with those of the  department.
In addition to developing its quadrennial strategic plans, HHS has  previously developed other planning documents and workforce  development efforts. For example, HHS has published a series of  strategic initiatives outlining the Secretary’s priorities. In 2014, one of  these priorities was developing the health care workforce. This  document identified specific strategies for developing the health care  workforce, such as targeting resources to areas of high need and  strengthening the primary care workforce. The paper also discussed the  need for reform to payment policy to better support emerging health care  delivery models. However, as of November 2015, HHS had not released  an update to this series of initiatives since the new Secretary assumed  office in June 2014. In addition, previous presidential annual budgets  have included proposals for improving HHS’s health care workforce  programs. Moreover, in conjunction with the President’s fiscal year 2015  budget, HHS released a report in February 2014 providing additional  information about the fiscal year 2015 proposals. The report described  the challenges to ensuring more diversity among and a better distribution  of health care professionals and explained the costs and benefits  associated with each of the proposals.
section_title: HHS Generally Assesses Progress of Individual Health Care Workforce Programs, But Lacks a Comprehensive Assessment of These Efforts Towards Achieving Broader Goals
paragraphs: HHS has identified a subset of performance measures that are intended  to represent the effect that all existing health care workforce programs  have on the department’s broader goal of strengthening health care by  improving access and quality. Among other places, HHS reports these  workforce performance measures in its annual performance plan and  report, which indicate progress towards achieving HHS strategic planning  goals. From fiscal year 2014 to 2016, the number of healthcare  workforce performance measures tracked by HHS within its annual  performance report dropped from five to two, and they are focused on a  small percentage of programs. Specifically, for fiscal year 2016, the two  measures assess progress related to several HRSA programs— 4  National Health Service Corps (NHSC) programs and 14 Bureau of  Health Workforce primary care training programs—that combined  represent about 3 percent of the overall funding for all HHS health care  workforce programs in fiscal year 2014. According to HHS officials, the  department chooses not to include as part of the annual performance  report all of the performance measures tracked by HHS agencies.  Officials said that these two measures were chosen to be tracked in the  strategic plan and annual report because HHS identified them as part of a  subset of measures that are representative of the department’s overall  programming efforts. However, these measures are specific to the 18  programs and do not fully assess the adequacy of the department’s  broader workforce efforts.
Moreover, HHS has no stated targets to assess the effectiveness of  existing health care workforce programs on achieving the department’s  broader goal of strengthening health care by improving access and  quality. As part of a larger measurement project, HHS tracks data on  workforce that it indicates are closely related to the supply of trained  health care providers. Specifically, HHS tracks (1) the percentage of  individuals that have a usual source of medical care and (2) the number  of primary care practitioners (such as physicians, nurse practitioners, and  physician assistants). However, neither of these broad workforce  indicators has a stated target related to necessary provider levels.
GPRAMA leading practices indicate that for performance measures to be  effective, agencies need to set specific targets. While it is important to  have specific performance measures that assess individual programs,  health care workforce is an issue that straddles many different programs  and HHS agencies, and therefore it is also important to have broader  measures that assess how these individual programs contribute to the  department’s overall effectiveness in developing the health care  workforce to improve access to care. In the absence of these broader  measures, HHS lacks information to help it comprehensively determine  the extent to which programs are meeting the department’s goal of  strengthening health care or identify gaps between current health care  workforce programs and unmet health care needs.
According to HHS, over three-quarters of the 72 health care workforce  programs had performance measures tracked by the relevant HHS  agency. HHS indicated that its smaller health care workforce programs  generally had performance measures and targets. For example, HRSA’s  7 largest health care workforce programs, which accounted for about 5  percent of HHS’s health care workforce obligations in fiscal year 2014,  each had related performance measures. For most of these 7 programs,  HRSA reported meeting or exceeding its performance targets in fiscal  year 2014. For example, according to HRSA, the NHSC and Advanced  Nurse Education programs exceeded their performance targets for fiscal  year 2014, and the Children’s Hospital GME program met or exceeded its  fiscal year 2014 performance targets. (See app. I for more information  about the performance measures of the 12 largest health care workforce  programs.)
However, HHS lacks performance measures related to workforce  development for their largest programs. Specifically, HHS’s 2 largest  health care workforce programs—the Medicare GME programs run by  CMS, accounting for 77 percent of obligations in fiscal year 2014—did not  have performance measures directly aligned with areas of health care  workforce needs identified in HRSA’s workforce projection reports.  According to HHS officials, the GME programs are not aligned with the  workforce objectives in HHS’s strategic plan. Leading practices identified  in prior GAO work show that for individual programs to address strategic  goals and objectives, it is important that the programs be aligned with  these goals, and that these goals influence the daily operation of the  programs.
section_title: HHS Coordinates Some Health Care Workforce Planning, but Lacks Comprehensive and Ongoing Oversight to Ensure Needs Are Fully Addressed
paragraphs: HHS does not have a consistent and ongoing effort to coordinate all of  the workforce planning efforts and resources that are distributed across  the department’s various offices and agencies. According to HHS  officials, HHS delegates responsibility for many of its health care  workforce planning efforts to its component agencies, based on each  agency’s mission and expertise. These agencies also collaborate with  each other occasionally on various health care workforce development  efforts, such as projection reports and workforce programs. Officials  said that HHS’s coordination of these efforts generally occurs during the  department’s larger planning and budget process.
Within the HHS Office of the Secretary, ASFR coordinates the annual  budget development process, and ASPE coordinates the quadrennial  strategic planning process, and, in doing so, both lead activities to include  workforce development in these efforts. In addition, ASPE occasionally  collaborates with HHS advisory bodies, such as COGME, supports  research on the health care workforce, and periodically creates  interagency workgroups to discuss specific priorities that support the  development of its budget proposals. However, outside of the context of  these strategic planning and budgetary processes, ASPE does not have  an ongoing formal effort to coordinate the workforce planning efforts of  HHS agencies. Additionally, it does not regularly monitor or facilitate HHS  interagency collaborations on workforce efforts or fully communicate  identified gaps to stakeholders. A separate entity within the Office of the  Secretary, ASFR, coordinates the monitoring of those performance  measures for health care workforce programs that the department tracks  in its annual performance plan and report. Similar to ASPE, according to  officials, ASFR engages in these coordinating and monitoring efforts  primarily within the context of developing the annual performance report.
To achieve meaningful results, GPRAMA leading practices emphasize  the importance of coordinating planning efforts across agencies and  departments. Leading practices state that when multiple federal  programs that address a similar issue are spread over many agencies  and departments, a coordinated planning approach is important to  ensuring that efforts across multiple agencies are aligned. Specifically, a  coordinated planning approach is essential to (1) setting targets for these  workforce programs and other efforts; (2) identifying and communicating  whether there are gaps between existing workforce programs and future  needs; and (3) determining whether agencies have the necessary  information to assess the reach and effectiveness of their programs.  While coordination at the program level is important, it does not take the  place of, or achieve the level of, overall department coordination that we  have previously found to be the key to successful coordination.
Recently, multiple stakeholders reported that a more coordinated federal  effort—possibly managed at the department level—could help to ensure a  more adequate supply and distribution of the health care workforce,  especially given changes in the delivery of care. For example, in  examining federal GME funding, IOM and COGME each stated that the  GME program lacks the oversight and infrastructure to track outcomes,  reward performance, and respond to emerging workforce challenges.  IOM’s recommendations for reforming GME include developing a  strategic plan for oversight of GME funding, as well as taking steps to  modernize GME payment methods based on performance to ensure  program oversight and accountability. Both entities suggested that GME  payments are neither sustainable in the long run nor the most effective  method to developing the health care workforce to meet future projected  health care needs. In each case, the organization recommended the  creation of a new entity to provide oversight of national workforce  efforts. Moreover, Congress also recognized the need for greater  coordinated attention to workforce planning when it authorized the  creation of the National Health Care Workforce Commission. Although the  Commission has not received an appropriation, it was authorized to  provide advice to HHS and Congress about workforce supply and  demand and to study various mechanisms to finance education and  training. According to HHS officials, to the extent possible, the department  has been able to complete work related to a number of the Commission’s  planned functions, but certain critical functions remain unaddressed. For  example, the Commission would have been required to submit an annual  report to Congress and the administration that would include, among  other things, information on implications of current federal policies  affecting the health care workforce and on workforce needs of  underserved populations. Without a comprehensive and consistently  coordinated approach, it will be difficult for HHS to ensure that workforce  funding and other resources are aligned with future health needs and to  provide effective oversight of this funding.
section_title: Some of HHS’s Largest Health Care Workforce Programs Do Not Target Areas of Need, but HHS Has Made Some Improvements Within Statutory Limitations
paragraphs: Some of HHS’s largest health care workforce programs do not target  areas of identified workforce needs. While HHS’s ability to adjust existing  programs to target areas of emerging needs is subject to certain statutory  limitations, the department has taken some steps and proposed new  authorities that would allow it to better align certain programs to areas of  national need. However, the proposed authorities may not fully address  the alignment of HHS’s largest workforce programs with national needs.
subsections: section_title: HHS’s Largest Health Care Workforce Programs Do Not Target Areas of Identified Need, Although Smaller Programs Do
paragraphs: Our review showed that although HHS’s health care workforce programs  support education and training for multiple professions, the biggest  programs do not specifically target areas of workforce need. The two  CMS Medicare GME programs, which accounted for 77 percent of HHS’s  fiscal year 2014 obligations for health care workforce development,  support hospital-based training of the many different types of physician  specialties. However, HHS cannot specifically target existing Medicare  GME program funds to projected workforce needs—such as primary care  and rural areas— because the disbursement of these funds is governed  by requirements unrelated to workforce shortages. As a result, the  majority of Medicare GME funding is disbursed based on historical  patterns. Therefore the Medicare-supported residency slots, supported by  this Medicare GME funding, are most highly concentrated in northeastern  states. However, the areas of emerging health workforce need identified  by HRSA in its health care workforce projection reports include the supply  of primary care physicians, as well as various physician and non- physician providers in rural communities as well as ambulatory settings  across the country. According to the Rand Corporation, between 1996  and 2011, the number of primary care residents has increased 8.4  percent, while there has been a 10.3 percent increase in other specialties  and a 61.1 percent increase in subspecialty residents, such as cardiology.
In contrast, HHS’s smaller health care workforce programs typically target  emerging health care workforce needs. For example, HRSA’s five largest  health care workforce education and training programs, which accounted  for about 4 percent of HHS’s workforce obligations in fiscal year 2014,  targeted the health professions identified as areas of need, such as  primary care physicians and nurse professions, including registered  nurses.
section_title: HHS Has Limited Authority to Target Health Care Workforce Programs to Areas of Need and Has Taken Some Steps To Do So
paragraphs: According to HHS officials, the department generally has limited authority  to better target workforce programs to address projected health care  workforce needs. Our review showed that funding for many of the largest  HHS health care workforce programs—for example, CMS’s Medicare  GME program—are governed by statutory requirements unrelated to  workforce needs. Specifically, the funding formulas for 5 of the 12 largest  programs that we reviewed do not provide HHS with authority to realign  funding for these specific programs to address projected workforce  needs, while the remaining 7 programs provided the department with  some flexibility to realign funding. For all of these 7 programs, HRSA  officials reported that the agency has been able to exercise some  flexibility in reallocating resources within a program or between similar  programs, subject to existing law.
HHS officials stated that although they have no authority to realign  funding for programs governed by formula, the department has utilized  other authorities to better align resources with health care needs.  According to these officials, the agency has used demonstration  authorities to test new payment models for the Medicaid GME program.  HHS officials identified several demonstration projects approved by CMS  for states and residency programs using their GME funds. For example,  the State Innovation Model demonstration at the Center for Medicare and  Medicaid Innovation is providing financial and technical support to states  for the development and testing of state-led, multi-payer health care  payment and service delivery models that are intended to improve health  system performance, increase quality of care, and decrease costs for  Medicare, Medicaid, and Children’s Health Insurance Program  beneficiaries–and for residents of participating states. According to  HHS, a number of states are using the opportunity of participating in the  demonstration to reform GME and make investments in the physician  training more accountable. Both Vermont and Connecticut have been  awarded funding as “model testing states” based on their state innovation  proposals. HHS indicated that these states proposed innovative GME  mechanisms, outside of those traditionally supported by CMS, to help  better meet their health workforce needs.
HHS officials also reported that the Center for Medicare & Medicaid  Innovation conducted demonstrations to test new approaches to paying  providers. For example, in 2012, the center initiated the graduate nurse  education demonstration to increase the number of graduate nursing  students enrolled in advance practice registered nurse training programs.
The demonstration increased reimbursement for their clinical training by  $200 million over 4 years.
section_title: HHS’s Proposed Authorities May Not Fully Address Alignment of Its Largest Workforce Programs with National Needs
paragraphs: HHS has proposed additional authorities intended to help address  changing health care workforce needs, although they may not fully align  the department’s programs with national needs. In both fiscal years 2015  and 2016, the President’s budget proposed to reduce a portion of  Medicare’s GME payments made to hospitals by 10 percent. It also  proposed investing in a new program to provide additional GME funding  for primary care and rural communities. The 10-year, $5.3 billion “targeted  support” grant to be run by HRSA would build upon the work of HRSA’s  Teaching Health Centers Graduate Medical Education Payment Program  and would train 13,000 physicians in primary care or other high-need  specialties in teaching hospitals and other community-based health care  facilities, with a focus on ambulatory and preventive care. According to  HHS officials, these proposals are intended to serve as a first step to  improve the alignment of GME funding with health care needs. The fiscal  year 2016 budget also proposed continuation of programs, authorized  under PPACA and Health Care and Education Reconciliation Act of 2010  (HCERA), to provide primary care providers with higher Medicare and  Medicaid payments as a way to incentivize health care providers to offer  primary care services to Medicare and Medicaid beneficiaries. HHS  officials indicated that the implementation of these proposals would help  officials recognize any successes and gaps, and, if necessary, they could  then develop any additional proposals to supplement the programs.  However, while implementing these proposed programs would provide  greater funding to some areas of need, HHS officials stated that they do  not know the full extent to which these proposals are sufficient to address  identified health care workforce needs. While HHS officials indicated that  the department planned to determine their sufficiency and identify  remaining gaps after these proposals were enacted, the department does  not have a comprehensive plan from which to evaluate the impact of the  new programs or make a complete assessment of any gaps.
External stakeholders—such as IOM, Medicare Payment Advisory  Commission (MedPAC), and COGME—have identified various reforms to  HHS’s largest health care workforce programs to better target these  programs to emerging areas of health care workforce need. HHS officials  told us that some of the reforms proposed by these stakeholders were the  basis for some of the department’s past budget and legislative proposals.  For example, IOM convened a panel of experts that recommended  restructuring Medicare GME payments to help align the programs to the  health needs of the nation. In its 2014 report, IOM proposed, among  other things, (a) developing a new center at CMS to administer GME  program payment reform and manage demonstrations of new GME  payment models and (b) the creation of a transformation fund within the  GME programs to finance payment demonstrations. In a report released  in 2014, COGME concurred with IOM that there is a need to reform GME  payments and, among other things, recommended expanding the GME  program’s clinical training environment into the ambulatory and  community setting. While an advocate for teaching hospitals— Association of American Medical Colleges (AAMC)—has cautioned  against reductions in GME funding, it has also proposed reforms to the  GME program and Medicare payment policy to bolster primary care  training and reduce geographic disparities.
section_title: Conclusions
paragraphs: While HHS maintains that developing an adequate supply and distribution  of the health care workforce is a priority for the department, it has  removed explicit language about goals and objectives related to  workforce issues from its current strategic plan, which is the primary  planning mechanism to address this issue. HHS’s lack of specific  planning goals for the health workforce in its current strategic plan makes  it challenging for the department to plan and to maintain accountability.  Moreover, the department does not currently have a comprehensive set  of performance measures and targets to assess whether its workforce  efforts and the specific individual workforce programs managed by its  agencies are collectively meeting the department’s broader strategic goal  of strengthening health care by improving access and quality.
Because the responsibilities for HHS’s workforce efforts, programs, and  resources are dispersed among many agencies, it is important that HHS  have a department-wide approach regarding its strategies and the actions  needed to ensure an adequate supply and distribution of the nation’s  workforce. For example, while HRSA manages the largest number of  workforce programs and the development of workforce projections, the  vast majority of workforce development funds are administered by CMS— for which workforce planning is not a key mission. It is also important for  HHS to comprehensively assess the extent to which its many workforce  programs, collectively, are adequate to address changing health care  workforce needs. Multiple stakeholders have made recommendations to  improve these programs. However, because the majority of workforce  funds must be dispersed based on statutory requirements unrelated to  projected workforce needs, HHS has limited options to retarget them.  HHS has proposed additional authorities in the past, but these have not  been enacted, and HHS officials acknowledge that these additional  authorities may not be sufficient to fully address the existing program  limitations identified by stakeholders. Without a comprehensive and  coordinated approach to program planning, HHS cannot fully identify the  gaps between existing programs and national needs, identify actions  needed to address these gaps, or determine whether additional legislative  proposals are needed to ensure that its programs fully meet workforce  needs.
section_title: Recommendation for Executive Action
paragraphs: To ensure that HHS workforce efforts meet national needs, we  recommend that the Secretary of Health and Human Services develop a  comprehensive and coordinated planning approach to guide HHS’s health  care workforce development programs—including education, training, and  payment programs—that  includes performance measures to more clearly determine the extent  to which these programs are meeting the department’s strategic goal  of strengthening health care;  identifies and communicates to stakeholders any gaps between  existing programs and future health care workforce needs identified in  HRSA’s workforce projection reports;  identifies actions needed to address identified gaps; and  identifies and communicates to Congress the legislative authority, if  any, the Department needs to implement the identified actions.
section_title: Agency Comments and our Evaluation
paragraphs: We provided a draft copy of this report to HHS for its review and HHS  provided written comments, which are reprinted in appendix IV. In  commenting on this draft, HHS concurred with our recommendation that it  is important that the department have a comprehensive and coordinated  approach to guide its health care workforce development programs. HHS  identified areas where comprehensive and coordinated planning efforts  are already underway and where additional efforts are needed.
HHS identified several health care workforce planning efforts related to  the elements of our recommendation, many of which we described in the  draft report. For example, HHS noted that it coordinates workforce  planning efforts through the HHS department-level and agency-specific  budget, legislative development, health policy research and innovation  work, performance management, and strategic planning. HHS also  indicated that the National Health Care Workforce Commission, created  under PPACA, has the potential to enhance HHS’s ability to implement a  more comprehensive and coordinated planning approach, but that the  commission has not received federal appropriations. In the absence of  appropriations for this commission, HHS stated that it has undertaken  some of the commission’s health care workforce planning and  coordination activities, to the extent possible. In response to our  recommendation, HHS indicated that it could convene an interagency  group to assess (a) existing workforce programs, (b) performance  measurement, (c) budgetary and other proposals, (d) gaps in workforce  programs, and (e) potential requests to the Congress for modified or  expanded legislative authority. We agree that a regular and ongoing  initiative focused on the coordination of health care workforce programs  could provide an important first step toward ensuring a more  comprehensive and coordinated planning approach.
HHS also reiterated that its health care workforce programs contribute to  its broad goals of access and quality from its strategic plan, as was  described in our draft report. However, it indicated that, in response to our  recommendation, the department plans to add two new workforce-specific  strategies to its strategic plan when it next updates the plan.
HHS also provided technical comments, which we incorporated as  appropriate.
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section_title: Appendix I: Performance Measures for Selected HHS Health Care Workforce Programs, 2014
subsections: section_title: Administration for Children and Families Health Profession Opportunity Grants
section_title: Appendix II: Goals, Objectives, Strategies, and Metrics from the HHS 2014-2018 Strategic Plan That Are Related to Health Care Workforce Development
paragraphs: Related Objectives  Objective E: Ensure access  to quality, culturally  competent care, including  long-term services and  support, for vulnerable  populations  (1 of 6 Objectives in Goal 1)
Field strength of the  National Health Service  Corps through scholarship  and loan repayment  agreements.  Percentage of individuals  supported by Bureau of  Health Workforce Programs  who completed a primary  care training program and  are currently employed in  underserved areas. across population groups, and work with  federal, state, local, tribal, urban Indian,  and nongovernmental actors to address  observed disparities and to encourage  and facilitate consultation and  collaboration among them.  Evaluate the impact of the Affordable  Care Act provisions on access to and  quality of care for vulnerable populations,  as well as on disparities in access and  quality.  Promote access to primary oral health  care services and oral disease  preventive services in settings including  federally funded health centers, school- based health centers, and Indian Health  Services-funded programs that have  comprehensive primary oral health care  services, and state and community- based programs that improve oral health,  especially for children, pregnant women,  older adults, and people with disabilities. (2 of 13 Metrics in Objective E)
Help eliminate disparities in health care  by educating and training physicians,  nurses, and allied health professionals  on disparities and cultural competency,  while increasing workforce diversity in  medical and allied health care  professions.  Improve access to comprehensive  primary and preventive medical services  to historically underserved areas and  support federally funded health centers,  the range of services offered by these  centers, and increased coordination with  partners including the Aging Services  Network.  (5 of 18 Strategies in Objective E)
Objective F: Improve health  care and population health  through meaningful use of  health information  technology  (1 of 6 Objectives in Goal 1)
Expand the adoption of telemedicine  technologies, including more remote  patient monitoring, electronic intensive  care units, home health, and  telemedicine networks, to increase  access to health care services for people  living in tribal, rural, and other  underserved communities, and other  vulnerable and hard-to-reach  populations.  (1 of 18 Strategies in Objective F)
Related Objectives  Objective C: Invest in the  HHS workforce to help meet  America’s health and human  services needs  (1 of 4 Objectives in Goal 4)
Promote the Commissioned Corps as a  health resource to provide public health  services in hard-to-fill assignments as  well as to respond to public health  emergencies.  (1 of 13 Strategies in Objective C)
section_title: Appendix III: Goals and Strategies from HHS Agency Strategic Plans That Are Related to Health Care Workforce Development
paragraphs: Related Strategies  We will promote efforts to increase family  economic security and stability by supporting  our state, tribal, and community grantee  partners in designing and implementing  programs that focus simultaneously on  parental employment and child and family  well-being, including drawing from promising  models in health and career pathways  demonstrations.
Support curriculum development and the  training of health professionals to ensure  the learning, enhancement, and updating  of essential knowledge and skills.  Support training and other activities that  enhance the health workforce’s  competency in providing culturally and  linguistically appropriate care.  Expand the number and type of training  and technical assistance opportunities  that educate students and providers to  work in interprofessional teams and  participate in practice transformations.  Support technical assistance, training,  and other opportunities to help safety-net  providers expand, coordinate, and  effectively use health information  technology to support service delivery  and quality improvement.  Provide information and technical  assistance to ensure that HRSA- supported safety-net providers know and  use current treatment guidelines,  appropriate promising practices, and  evidence-based models of care.  Facilitate and support the recruitment,  placement, and retention of primary care  and other providers in underserved  communities in order to address  shortages and improve the distribution of  the health workforce.  Support outreach and other activities to  increase the recruitment, training,  placement, and retention of under- represented groups in the health  workforce.
Field strength of the  National Health  Service Corps  through scholarship  and loan repayment  agreements.  Percentage of  individuals  supported by the  Bureau of Health  Workforce who  completed a primary  care training  program and are  currently employed  in underserved  areas.  Percentage of  trainees in Bureau of  Health Workforce- supported health  professions training  programs who  receive training in  medically  underserved  communities.  Percentage of  trainees in Bureau of  Health Workforce  programs who are  underrepresented  minorities and/or  from disadvantaged  backgrounds.
subsections: section_title: Year Goal
paragraphs: Support pre-entry academic advising,  mentoring, and enrichment activities for  underrepresented groups in order to  promote successful health professions  training and career development.  Promote training opportunities within  community-based settings for health  professions students and residents by  enhancing partnerships with  organizations serving the underserved.
Develop and employ approaches to  monitoring, forecasting, and meeting  long-term health workforce needs.  Provide policy makers, researchers, and  the public with information on health  workforce trends, supply, demand, and  policy issues.
2015  Goal Six: Workforce
Develop and disseminate workforce  training and education tools and core  competencies to address behavioral  health issues.
Develop and support deployment of peer  providers in all public health and health  care delivery settings.
Develop consistent data collection  methods to identify and track behavioral  health care workforce needs.
Increase the number  of behavioral health  providers  (professional,  paraprofessional,  and peers)  addressing children,  adolescents, and  transitional-age  youth.  Increase the number  of individuals trained  as behavioral health  peer providers.
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, William Hadley, Assistant  Director; N. Rotimi Adebonojo; Arushi Kumar; Jennifer Whitworth; and  Beth Morrison made key contributions to this report.