the American Association of Colleges of Osteopathic Medicine

This analysis was prepared by McDermott+ Consulting, on behalf of AACOM.

PURPOSE

The purpose of this hearing is for the Senate Committee on Health, Education, Labor & Pensions to discuss the nation’s shortage of healthcare providers, specifically in rural and underserved communities, and possible solutions to address challenges with recruitment and retention.

MEMBERS PRESENT

Chairman Sanders, Ranking Member Cassidy, Senators Paul, Hassan, Collins, Hickenlooper, Romney, Kaine, Marshall, Markey, Budd, Baldwin, Murkowski, Smith, Braun, Lujan.

WITNESSES

James Herbert, PhD, President, University of New England
James E.K. Hildreth Sr., PhD, MD, President and CEO, Meharry Medical College
Sarah Szanton, PhD, RN, FAAN, Dean, Johns Hopkins School of Nursing
Leonardo Seoane, MD, FACP, Chief Academic Officer, Ochsner Health
Douglas Staiger, PhD, Professor, Dartmouth College

KEY TAKEAWAYS

Workforce shortages have led to rising costs and increased competition for qualified health professionals.
The COVID-19 pandemic exacerbated the challenges facing the healthcare system and led to provider burnout and workforce shortages. States have taken initiatives such as ‘Earn as You Learn’ programs, partnerships with community colleges, tuition support for physicians dedicated to working in primary care and behavioral health, and partnerships with HCBU’s to increase the number of underrepresented physicians in the U.S. and diversify the workforce.
The main concerns that need to be addressed for nurses are the shift of the RN workforce away from hospitals, decreased preparedness of those entering and exiting nursing schools, and the need to diversify the rural workforce and increase bachelor’s degrees among rural RN’s.

OPENING STATEMENTS

Due to livestream issues, we were unable to record the opening statements of Chairman Sanders (I-VT) and Ranking Member Cassidy (R-LA).

TESTIMONY

Due to livestream issues, we were unable to record Dr. Herbert’s opening statement, however it can be accessed here.

Dr. Hildreth discussed potential solutions to the health care workforce shortage. Majority of the students at Meharry Medical College are fully committed to working in rural communities and health care deserts. He narrated his own experiences with lack of access to medical care and caring for low-income individuals. He emphasized the need to increase the number of minority health care workers in the country by working with middle school and high school students to introduce them to medicine and programs for undergraduates who are dedicated to serving in rural areas post-medical school. He requested $5 billion over the next 5 years to improve the infrastructure of HCBU institutions that have been underfunded and to expand pipeline programs designed to increase the number of minorities in health care professions. He also requested that Medicare GME policy be amended to get expanded consideration to hospitals that train graduates from Black medical schools. Finally, he asked Congress to help ease the debt burden for students coming from lower income households.

Dr. Szanton discussed some of the factors contributing to the national nursing crisis and potential solutions. The country is facing a nursing shortage, and many are not working in settings that could provide the most value. The nursing field has been compromised mainly of women, so men struggle to see themselves fitting in that role. She reiterated that nursing schools turn down many applicants due to lack of space, resources, faculty, and scholarship funds for students. She urged the Committee to support the FAN Act when it is reintroduced to solve barriers for students, faculty, and enhance the infrastructure. She closed her statement by emphasizing the need to make the nursing profession more disability inclusive and focus on preventative care.

Dr. Seoane discussed the challenges for patients that come from low-income, rural, and historically underserved communities. Ochsner Health has taken various initiatives to recruit a pipeline of doctors, nurses, and allied health professionals but still have thousands of unfilled positions. Workforce shortages have forced Ochsner Health to close more than 100 beds across the health system, resulting in the need to hold more patients in the emergency department. He discussed two main reasons for the workforce shortage. First, a lack of training and educational capacity. Second, an enormous strain on the current workforce which is leading to the loss of bedside clinical nurses.

Dr. Staiger focused on data regarding employment and earnings for nurses. His research has found 3 key issues. First, RN employment is now 5% higher than where it was before the pandemic and RN earnings have grown faster than inflation during the pandemic. However, there has been a shift of RN employment away from hospitals and more in outpatient settings such as schools which is why hospitals are reporting a shortage of nurses. He explained that actions are needed to improve the work environment and attract nurses back to working in hospitals or hospitals will need to be better supported to use a smaller nurse workforce. The second key issue is that applications to nursing schools have continued in an upward trend, however, the pandemic decreased academic preparedness for those entering nursing programs. The third key issue is the adequacy of the rural RN workforce. Rural nurses are less diverse than the population that they serve and are less likely to have bachelor’s degrees.

QUESTIONS AND ANSWERS

Chairman Sanders asked Dr. Herbert whether huge expenditures of traveling nurses and struggles with accommodating new students in nursing schools is a national issue. Dr. Herbert answered that it is a national issue and that there is a nurse educator problem and hospitals are struggling with workload issues in terms of reimbursements. He emphasized that clinical training sites such as hospitals need support to accommodate more trainees which could help with the problem. Chairman Sanders then asked Dr. Szanton how to increase the number of nurse educators. Dr. Szanton answered that increasing programs through HRSA such as Nurse Corps and passing the FAN Act would be quick ways to increase the nursing faculty abilities in the country. Chairman Sanders asked about the impact of having a diverse workforce. Dr. Hildreth answered that research shows that when the health care workforce reflects the population that they care for, health outcomes are better. Chairman Sanders asked Dr. Herbert about expanding teaching health centers GME programs. Dr. Herbert answered that it is a very good idea and that the caps of GME funding of encouraged states to directly fund GME through partnerships with teaching hospitals. Dr. Hebert added that GME is the key to addressing various issues such as closing of community and rural hospitals.

Senator Hassan (D-NH) asked Dr. Staiger whether offering tax free education would help address the workforce shortages. Dr. Staiger stated that is a good idea and they are like scholarships from employers, and it should be targeted in areas where we have particular need. Senator Hassan then asked Dr. Herbert about encouraging nurses to practice in rural areas. Dr. Herbert answered that it involves attracting students that reside in rural areas as those from rural areas are more likely to practice in a rural area, placing students in clinical sites in rural areas and smaller towns, and lastly, providing students with scholarships or loan repayment programs with a commitment to practice in those areas.

Senator Collins (R-ME) asked Dr. Herbert about applications for nursing schools being turned away due to nursing faculty shortage, how to bridge the faculty gap and examples of how the University of New England (UNE) is expanding training capacity. Dr. Herbert answered that practicing clinicians can be recruited to serve as faculty instructors in their existing workplaces. He added that UNE is working with Maine Health to provide professional development and support to on-site nurses for them to train students in the Maine Health hospital system.

Senator Hickenlooper (D-CO) asked Dr. Seoane about the impact of apprenticeship programs on addressing challenges. Dr. Seoane added that there are currently 350 students in Ochsner’s high school apprenticeship program and that Ochsner hired 600 MA’s through the MA Now program, where they recruited students from rural and underserved communities. The apprenticeship program encourages high school students to work as nurse apprentices and continue their education by providing them a free year of community college. Senator Hickenlooper will submit a written question for Dr. Herbert regarding the interprofessional education (IPE) model.

Senator Romney (R-UT) asked Dr. Herbert about the lack of interviews conducted by the government for immigrant clinicians due to fear of COVID-19. Dr. Herbert answered that he is not aware of this particular issue, but immigrants are essential to the health care workforce. He added that we need programs that take foreign trained doctors, dentists, or pharmacists and help them become eligible for American licenses.

Senator Kaine (D-VA) asked Dr. Herbert what we could do with an immigration reform that is focused on health care to address the challenges mentioned. Dr. Herbert replied that he is not an immigration expert, but he agrees that immigrants disproportionately go into health care and that they want to work but are not able to despite them being here legally. He emphasized that we need to encourage immigration. Dr. Hildreth added that there is untapped talent in our own country and we need to properly resource the schools that we have in order to fill the gap.

Senator Marshall (R-KS) questioned the panel about nurse burnout. Dr. Seoane answered that front-line nurses and physicians can never get away from the pandemic and there is a need to improve the working environment. Senator Marshall then asked about funding for primary care versus specialty residency programs. Dr. Seoane replied that primary care doctors are essential for any large health system and funding primary care community-based clinics would be beneficial for residency programs.

Senator Markey (D-MA) asked Dr. Herbert about challenges and potential solutions for accessing behavioral health treatment. Dr. Herbert answered that there is a critical shortage of psychiatrists, and we are never going to be able to train enough psychiatrists to meet the psychiatric needs of underserved areas. However, some solutions include training nurse practitioners to be psychiatric nurse practitioners and investments in the full range of behavioral health services including credentials for undergraduates to practice in nursing homes or schools. Senator Markey then asked Dr. Seoane about the impact of the climate crisis on a community’s health care resources. Dr. Seoane answered that Louisiana faces a lot of natural disasters and they have learned how to adapt such occurrences.

Senator Budd (R-NC) asked Dr. Seoane about new credentials and educational opportunities for workers to join the health care workforce. Dr. Seoane discussed the MA Now program where they partner with communities with high unemployment to introduce workers into the health system as medical assistants. They also work with community colleges to support these new medical assistants and give them free tuition to become LPN’s and get their associate degrees.

Senator Baldwin (D-WI) discussed physical and verbal violence faced by health care workers and asked Dr. Szanton and Dr. Seoane how this violence has contributed to workforce shortages. Dr. Szanton answered that nurses have suffered verbal and physical abuse and a shift to more at-home care and lower-cost settings may dissipate some of that violence. Dr. Seoane added that he is working with state legislators to ensure that violence towards health care workers is a felony. Senator Baldwin then asked Dr. Seoane about the importance of providing training for physicians to teach and how additional training can alleviate burnout. Dr. Seoane replied that teaching residents skills about how to manage patients and have difficult conversations had mental health benefits as students were able to debrief what they had experienced.

Senator Murkowski (R-AK) asked Dr. Seoane about virtual nursing education and telehealth education. Dr. Seoane replied that telehealth is a critical component of reaching rural communities. Dr. Herbert added that there are people in Iceland that are leading the world in telehealth development that we can learn from them. He emphasized the importance that state level regulations, accrediting bodies, government reimbursement, etc. need to keep up with changes in telehealth. His concern is that with incredible innovation that entities are falling behind, which creates delays the full utilization of digital medicine.

Senator Smith (D-MN) asked Dr. Herbert about the importance of loan repayment programs and how they should be designed. Dr. Herbert answered that we need to make sure that we train people in primary care who are not mental health specialists to do mental health first aid and make appropriate referrals. He added that loan repayment programs can work well if done strategically and there should be a strong contingency where they need to practice in underserved areas. Senator Smith then asked about how lack of resources and diversity impacts disparities in maternal mortality. Dr. Hildreth replied that when the provider can relate to the patient in terms of culture, race, etc., the patient has better outcomes. Studies show that Black women who are cared for by Black OBGYN’s have better maternal and infant outcomes and getting the resources would improve health outcomes for racially and ethnically diverse patients.

Senator Lujan (D-NM) asked Dr. Herbert how to better utilize and innovate models like Project ECHO to expand access to life-saving medical care. Dr. Herbert answered that it touches on the importance of prevention, early assessment and intervention, training primary care professionals to stretch their scope of practice, etc. Universities have a role in providing continuing education for existing providers and students by using tools like Project ECHO to make sure that our primary care workers are equipped to address a broader range of concerns. Senator Lujan then asked Dr. Hildreth about retention efforts for behavioral health workers. Dr. Hildreth replied that retention is an important part of the strategy but also giving behavioral health training to primary care doctors can help address mental health service shortages.

Ranking Member Cassidy asked Dr. Staiger about the factors that are affecting low pass rates among nursing students. Dr. Staiger replied that they are still analyzing the data but people who are not passing the licensure exams are those who were in nursing school during the pandemic. Ranking Member Cassidy then asked Dr. Hildreth about a more fundamental way to reduce the demand on the healthcare system other than more nursing schools. Dr. Hildreth answered that we need to focus on the social determinants of health and preventative care rather than ‘sick care.’ He added that we need more investment in public health and the integration of public health and primary care.

CLOSING STATEMENTS

Chairman Sanders thanked the witnesses for their time at the hearing. He indicated the record will be open for 10 days for Members to submit questions for the record. He then concluded by entering 19 stakeholder comments into the record (although did not specify the organizations associated with those comments).