2003
Primary Health Care Policy Fellowship

Reauthorizing Title VII and Title VIII:
Options for Outcomes and Evaluation

 

Lynette A. Ament, PhD, CNM, RN
American College of Nurse-Midwives

James F. Cawley, MPH, PA-C
Association of Schools of Public Health

Mary Anne Dumas, PhD, RN, CFNP
National Organization of Nurse Practitioner Faculties

Eduardo Ortiz, MD, MPH
Agency for Healthcare Research and Quality

Robert L. Phillips, Jr., MD, MSPH
North American Primary Care Research Group

Nina Tumosa, PhD
National Association of Geriatric Education Centers

Reauthorizing Title VII and Title VIII:
Options for Outcomes and Evaluation

Titles VII and VIII of the Health Professions Education Partnership Act have improved access to primary care and nursing for 25 years. These programs have not fully achieved their legislated intent due to their dependency on Administration goal-setting and inadequate evaluation. The Secretary of Health and Human Services is responsible for adequately evaluating these programs. Absent accountable evaluation from the Secretary, we recommend that Congress develop its own outcome measures and designate new, accountable evaluators of the Title VII and VIII programs.

The purpose of the Health Professions Education Partnership Act has historically been to address the failure of the market to assure adequate access to healthcare providers for all Americans.1  Titles VII and VIII of this Act address primary care medical, nursing, physician assistant, and dental workforces.

Over the 25-year history of these programs, extensive data have been collected but have not been effectively used to scientifically assess their impact. For a decade, the Office of Management and Budget and the General Accounting Office have repeatedly criticized the Health Resources and Services Administration for failing to perform regular, objective, comprehensive evaluations.2  Evaluation of the programs has also been hampered due to a lack of legislated outcome measures and their reliance on the prevailing Administration's priorities. When it has been possible to collect data relevant to Administration priorities, for example, to assess Titles VII and VIII impact on access to care in either health centers or through the National Health Service Corps, these data have not been collected. For Title VII, this evaluation failure has meant a decade of Administration budget recommendations for no funding. For Title VIII, it has meant insufficient funding and nursing shortages.

Title VII programs are helping millions of Americans receive primary care services, especially in rural and underserved areas. Independent evaluations of Title VII using national datasets have revealed significant improvements in the number and distribution of primary care providers.3, 4, 5, 6, 7  There are two decades worth of studies demonstrating improved health outcomes and reduced disparities with better access to primary care services.8, 9, 10, 11, 12, 13, 14

Title VIII funding has not met long-term nursing workforce requirements.15   The result is high patient to nurse ratios, with implications for patient safety, burnout, and the nursing shortage.16

The Secretary of Health and Human Services is responsible for seeing that adequate evaluations of these programs are conducted. The Secretary could direct HRSA to reshape these programs to collect data that matter and hold HRSA accountable for regular, robust evaluation. We applaud Congress' continued support of Title VII and Title VIII programs, and absent the Secretary embracing this responsibility, we recommend that Congress develop legislative outcome measures and a new, accountable evaluation process. Americans' access to quality, equitable healthcare depends on it.

We recommend that Congress:

  1. Designate an evaluator that is directly accountable to the Congress to:
  2. Request that adequate data be collected to evaluate the impact of Titles VII and VIII on the distribution and deployment of the healthcare workforce in settings like Federally Qualified Health Centers, the National Health Service Corps, and other underserved communities.
  1. The Council on Graduate Medical Education. Fifteenth Report: Financing Graduate Medical Education in a Changing Health Care Environment. Rockville, Maryland: Department of Health and Human Services, December, 2000. pp 36-37.
  2. Office of Management and Budget. Program Assessment Rating Tool. Department of Health and Human Services; Health Professions Competitive Grant Programs. 2004 budget cycle. January, 2003. www.omb.gov.
  3. Politzer, R. M., Horab, S., Fernandez, E., Gamliel, S., Kahn, N., & Mullan, F. The impact of Title VII departmental and predoctoral support on the production of generalist physicians in private medical schools. Archives of Family Medicine. 1997;6(6):531-5.
  4. Strelnick, A. H., Bateman, W. B., Schorow, M., & Freeman, K. Assessing the Impact of a Title VII Residency Program on Specialty Choice and Practice Location. Office of Health Policy, Analysis and Research, Health Resources and Services Administration (HRSA 93-811[P]). 1994;87(5), 817-822.
  5. Politzer, R., Hardwick, K., Cultice, J., & Bazell C. Eliminating primary care health professional shortage areas: The impact of Title VII generalist physician education. Journal of Rural Health 1999;15(1):11-20.
  6. Rosenblatt, R. A., Whitcomb, M., Cullen, T., Lishner, D., & Hart, L. The effect of federal grants on medical schools' production of primary care physicians. American Journal of Public Health. 1993;83(3):322-8.
  7. Fryer, G. E., Meyers, D. S., Krol, D. M., Phillips, R. L., Green, L. A., Dovey, S. M., & Miyoshi, T. J. The Association of Title VII Funding to Departments of Family Medicine with Choice of Physician Specialty and Practice Location. Family Medicine. 2002;34:436-40.
  8. Gonnella, J., Cattani, J., Louis, D., et al. Use of Outcome Measures in Ambulatory Care Evaluation. In: G. Giebink, N. White, & E. Short, eds. Ambulatory Medical Care-Quality Assurance, 1977. La Jolla, California: La Jolla Health Science Publications, 1977.
  9. Wasson, J. H., Sauvigne, A. E., Mogielnicki, P., et al. Continuity of outpatient medical care in elderly men: a randomized trial. JAMA. 1984;252:2413-2417.
  10. Parchman, M. L. & Culler, S. Primary care physicians and avoidable hospitalization. Journal of Family Practice. 1994;39:123-128.
  11. Bindman, A. B., Grumbach, K., Osmond, D., et al. Preventable hospitalizations and access to health care. JAMA. 1995;274:305-311.
  12. Lohr, K. N., Brook, R. H., Kamberg, C.J., et al. Use of medical care in the Rand Health Insurance Experiment: diagnosis- and service-specific analyses in a randomized controlled trial. Medical Care. 1986;24:S1-S87.
  13. Shi, L. The relationship between primary care and life chances. Journal of Health Care for the Poor and Underserved. 1992;3:321-335.
  14. Shi, L., Starfield, B., Kennedy, B., & Ichiro, K. Income inequality, primary care, and health indicators. Journal of Family Practice. 1999;48:275-284.
  15. Buerhaus, P. I., Staiger, D. O., & Auerbach, D. I. Implications of an aging registered nurse workforce. JAMA. 2000;283(22):2948-54.
  16. Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987-93.

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