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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to the Secretary of Health and Human Services and other interested parties. In addition, the report will be available at no charge on GAO’s website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at kingk@gao.gov. Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report. Other major contributors to this report are listed in appendix V. 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) 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. 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. 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.

Summary: 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. 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. 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.