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Question. In total, what funds are available to medical students, dental students, nursing, and allied health programs and students?

Answer. The FY 1992 BHPr budget request provides $40.3 million for student assistance and includes: $17 million for the Exceptional Financial Need Scholarships; $8.3 million for Scholarships for Disadvantaged Students; and $15 million for new capital contribution to the Health Profession Student Loan program. Also available is $185 million from the Health Education Assistance Loan program and approximately $78 million in the Health Profession Student and Nursing Student Loan programs revolving fund.

Question. What is the definition of the term "disadvantaged" in Title VII and VIII authorizations used by HRSA? Has there been any change during the past several years in the definition, or in the weight or preference given to "disadvantaged" students?

Answer. The HRSA is in the process of redefining the term "disadvantaged". A proposed redefinition will be published in the Program Announcement (Federal Register Notice) for each of the relevant programs. In each announcement interested persons will be Invited to comment on the proposed redefinition. All comments received will be considered before the final redefinition is established.

The current definition for the term "disadvantaged" is as follows:

"(1) Comes from an environment that has inhibited the individual from obtaining the knowledge, skill, and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession; or

(2) Comes from a family with an annual income below a level based on low income thresholds according to family size published by the U.S. Bureau of the Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary for use in all health professions programs. The Secretary will periodically publish these income levels in the FEDERAL REGISTER."

(45 FR 73052, Nov. 4, 1980, as amended at 47 FR 54438, Dec. 3, 1992)

Question. Please provide the Committee with detailed information on which schools are receiving funds from health professions programs targeted to disadvantaged students.

Answer.

The information was provided to the Committee.

ORGAN TRANSPLANT DIVISION

A very disturbing Inspector General's report notes that blacks wait nearly twice as long for donated kidneys as whites -- 13.9 months as opposed to 7.6 months. And while there are fewer black organ donors, the relative risk of end-stage renal disease is about fourfold higher for blacks than for whites. Clearly, we need to pay much more attention to these organ transplant issues.

A recent evaluation of the United Network for Organ Sharing (UNOS) conducted by Abt Associates found that UNOS has been unable to monitor and enforce appropriate allocations of organs.

Question. What actions has HRSA taken in response to these reports?

Answer. The Department is requiring that the contractor for the Organ Procurement and Transplantation Network (OPTN), UNOS, further study the medical and non-medical reasons for the disparity in transplantation waiting list waiting times for transplantation. This study is due to be completed during this fiscal year. In addition, the Assistant Secretary for Planning and Evaluation is supporting a followup study to the Inspector General's report under contract with the Rand Corporation. Data will be provided by UNOS to the Rand Corporation by April and July of 1991. Anticipated completion of the study will be in late 1991.

Regarding enforcement of organ allocation policies, Section 1138 of the Social Security Act makes membership in UNOS and compliance with its rules and requirements mandatory for transplant hospitals and organ procurement organizations (OPOs). The penalty for non-compliance with membership requirements is loss of Medicare and Medicaid reimbursement for the entire hospital. As a result, UNOS policies have the same effect as Medicare conditions of participation. Consequently, the Department has determined that all mandatory UNOS policies are subject to the Federal rulemaking process and must be codified as Federal regulations before they can be enforceable. A Notice of Proposed Rule Making (NPRM) is currently undergoing Departmental clearance but until it is published in final, membership in the OPTN and conformance with its policies is voluntary.

With respect to the Abt Report, many of the recommendations included in the report were incorporated in the new OPTN contract which was signed at the end FY 1990. Among the recommendations included were data verification and compliance monitoring. HRSA is working with UNOS in the implementation of these new systems.

Question. The Abt Associates report recommends that the HRSA's Division of Organ Transplantation should focus on improving donation rates, transplantation outcomes, cutting costs, and Increasing access to organs for minorities and rural patients. What suggestions do you have to achieve these goals?

Answer. There are also three current contracts within the Division of Organ Transplantation with objectives to educate the Black community about organ transplantation, and in the longer run, to increase minority organ donation. These contracts specifically aim to: (1) find and disseminate successful public education efforts directed toward the Black population, (2) develop a culturallysensitive education program for organ donation requestors, and (3) train Black clergy to educate their congregations about organ donation and transplantation.

In addition, the Division's grant program continues to focus on projects that lead to greater participation of minority communities in organ donation and transplantation.

Question. Given the work established for the Division of Organ Transplant, how can you justify a funding cut?

Answer. The Division of Organ Transplantation has coordinated the establishment of a consortium of organizations interested in organ donation with the goal of consolidating and coordinating organ donor awareness activities. This collaboration is expected to be a most effective mechanism for ensuring consistency in organ donation efforts and in reducing costly and often confusing public and professional education efforts.

NATIONAL HEALTH SERVICE CORPS

Question. Specifically, how is the Division of National Health Service Corps implementing the requirement to spend 10 percent of funds on non-physician health providers?

Answer. The Department will comply with the legislative requirement by allocating at least 10 percent of the funding for new scholarships for non-physicians such as nurse practitioner, nurse midwife, and physician assistants.

Question. How many scholarships will be given to nonphysician providers in FY 1991, and how many are proposed for FY 1992?

Answer. In FY 1991 and FY 1992 we estimate that approximately 160 and 180 non-physician health providers, respectively, will be supported.

NURSE LOAN REPAYMENT

The Committee has requested an evaluation of the two nursing loan repayment programs funded over the past two years, those authorized by Sections 836(h) and 847 of the Public Health Service Act.

Question. Please provide that report for the Committee, and summarize its findings.

Answer. The report is currently being finalized and will be submitted soon. In summary, an evaluation of the two programs indicates that the direct loan program would only require about $100,000 of the $700,000 recommended for this program in FY 1991. With regard to the 836(H) program, as of April 25, 1991 we have approved applications totalling $794,973. Applications are still being received, with one more review cycle planned for on/about July 1, 1991.

HIV

Question. Dr. Harmon, how much money did HRSA request of the Assistant Secretary for HIV programs, as compared to the final level forwarded in the President's budget? If it was more, what program areas were cut to meet the President's level?

Answer. Our request to the Assistant Secretary for the HIV programs was $197,649,000 which was less than the President's Budget.

QUESTIONS SUBMITTTED BY SENATOR ARLEN SPECTER

HEALTH PROFESSIONS

Question. Dr. Harmon, in your professional judgment have the shortages of trained health care professionals, such as nurses, been eliminated? If not, how can the elimination of the majority of health professions training program be justified?

Answer. The overall National supply of physicians appears to be more than adequate. However, there appear to be shortages of general and family practitioners as well as obstetricians. Rural and inner cities are also having difficulties obtaining physician services.

The latest available data from surveys of employers in various fields of registered nurse employment suggest a continuing high level of budgeted vacant positions. Based on these data there may be about 126,000-158,000 additional full-time equivalent registered nurses needed, although in March 1988, more nurses were employed than ever before 1.627 million (1.363 full-time equivalent registered nurses). Also, proportionately more nurses, 80 percent, were in the work force more than ever before. Secretary Bowen's Commission on Nursing assessed the cause of the nursing shortage as stemming from the increases in employer demand which could not be satisfied by the available supply.

: ستا غة فى شدة ختمة

Data for allied and public health disciplines is much less reliable. However, the available data do point to shortages of many of the allied and public health occupations. Shortages of physical therapists, occupational therapists, epidemiologists, diostatisticians, environmental health personnel and public health physicians are especially acute.

Very difficult choices among priorities for Federal funds must be made in order to meet budget targets for the FY 1992 budget request. The FY 1992 proposed budget request would provide a well balanced approach to addressing the disparities in the health status of minorities and their underrepresentation in the health professions and represents BHPr's highest priority.

ORGAN DONATION

Question. Dr. Harmon, last year the Conference Committee provided your agency with $600,000 to establish a pilot program to address the shortage of organ donation. Would you summarize for the Subcommittee what specific steps you have taken to implement this program?

Answer. The House Appropriations Committee did refer to a specific pilot program in its July 12, 1990 Report on an FY 1991 Appropriations Bill and proposed an amount for it. The Conference Committee's Report was broader, noting that the $600,000 was for special projects to increase the supply of donated organs. Although we have not taken steps to implement the pilot program mentioned in the House Report we continue to address organ donation awareness issues.

The focus is on organ donation awareness and education activities for both the public and for health and health related

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professionals, through grants to Organ Procurement Organizations and other non-profit private entities for projects that are both local and national in scope. Increasing minority awareness of organ donation and transplantation is a program priority.

Question. Are funds included for this initiative in the President's FY92 budget? If so, how much?

Answer. The FY 1992 request includes $250,000 for organ donation awareness activities. It does not include funds for a pilot program.

Question. In your professional judgment, is there an organ shortage and are additional funds to the Division of Organ Transplantation necessary to effectively address the problem?

Answer. Yes, there is an organ shortage. More than 23,000 people are currently on the transplant waiting list, however, there are only about 4,000 cadaveric donors each year. Many people wait years for a transplant and many others die while waiting. For example, between January 1, 1990 and September 30, 1990, 1,601 patients on the waiting list died before receiving an organ transplant. While it can be said that additional funds could be used to address the issue of organ donation, nevertheless, the President's FY 1992 Request is based on the limited resources available and competing program needs.

QUESTIONS SUBMITTTED BY SENATOR THAD COCHRAN

INFANT MORTALITY

Dr. Harmon, the programs in your agency are very important in my state of Mississippi. We have one of the highest infant mortality rates, one of the highest teenage pregnancy rates, and a severe shortage of health professionals.

We derive substantial benefits in our state from the programs administered by your agency to deal with these problems.

I am concerned about some of the proposals of the Administration that come under your jurisdiction. Mississippi's infant mortality rate has been improving over the past few years because of initiatives that are working. Other states are achieving success as well.

I understand that you intend to use the "target cities" approach in the infant mortality initiative to develop prototypes that can eventually be used on a national scale.

Question. Do you feel that the programs currently being administered by states are not effective enough to use on a national scale?

Answer. The infant mortality rate in the United States declined significantly during the 1960's and 1970's. Part of this decline was due to state programs such as those supported by the Maternal and Child Health Block Grant. During the 1980's however,

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