Assignment: Analysis of a Pertinent Healthcare Issue

By Thomas C. Ricketts and Erin P. Fraher

Reconfiguring Health Workforce Policy So That Education, Training, And Actual Delivery Of Care Are Closely Connected

ABSTRACT There is growing consensus that the health care workforce in the United States needs to be reconfigured to meet the needs of a health care system that is being rapidly and permanently redesigned. Accountable care organizations and patient-centered medical homes, for instance, will greatly alter the mix of caregivers needed and create new roles for existing health care workers. The focus of health system innovation, however, has largely been on reorganizing care delivery processes, reengineering workflows, and adopting electronic technology to improve outcomes. Little attention has been paid to training workers to adapt to these systems and deliver patient care in ever more coordinated systems, such as integrated health care networks that harmonize primary care with acute inpatient and postacute long-term care. This article highlights how neither regulatory policies nor market forces are keeping up with a rapidly changing delivery system and argues that training and education should be connected more closely to the actual delivery of care.

H ealth care professionals are be- ing challenged to find new ways to organize care and develop systems that hold providers ac- countable for the quality, cost,

and patient experience of care.1 The once in- cremental pace of change is accelerating, and there is evidence that long-standing paradigms are dramatically shifting.2 For example, the rela- tively slow acceptance of prepaid and managed care systems is being replaced by the rapid adop- tion of bundled and risk-based payment mod- els.3,4 Early adopters of accountable care organi- zations (ACOs) are finding that their workforce is shifting from acute care to community- and home-based settings with increasing roles for physicians, nurses, social workers, patient navi- gators and outreach coordinators, and other clinicians in providing enhanced care coordina- tion, better medication management, and im- proved care transitions.5

The training of health professionals, however, lags behind these reforms because it remains largely insulated from change behind the walls of schools ofmedicine, dentistry, pharmacy, and nursing. Medical training is done primarily in hospitals, while the greatest challenges are found in coordinating care in multiple out- patient settings. This article describes how health workforce policy was done in the past. It illustrates some of the specific changes under way and how they are changing the health care workforce. Further, it suggests that closer links should be built between the day-to-day caring for patients and the training of the people who de- liver that care.

Workforce Policy Center Stage Again Health workforce policy took center stage in an earlier Health Affairs thematic issue in 2002.6

Articles in that issue described future efforts to

doi: 10.1377/hlthaff.2013.0531 HEALTH AFFAIRS 32, NO. 11 (2013): 1874–1880 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.

Thomas C. Ricketts (tom_ ricketts@unc.edu) is the deputy director of the Cecil G. Sheps Center for Health Services Research and a professor in the Departments of Health Policy and Management and Social Medicine at the University of North Carolina at Chapel Hill.

Erin P. Fraher is an assistant professor in the Departments of Family Medicine and Surgery, University of North Carolina at Chapel Hill.

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Overview

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shape the clinical workforce as a “dream”7 or subject to “hand-to-hand” combat.8 The “hands” in this caseweredescribedbyKevinGrumbachas the “heavy hand” of government regulation and the “invisible hand” of market forces that con- stantly pushed the United States into a rolling series of surpluses followed by shortages.8 The “dream,” as Uwe Reinhardt saw it, was that reg- ulation and control could actually work. He of- fered in its place a change in policy to expose physicians to the actual costs of their training while pushing them to the right places and spe- cialties with judiciously targeted tax-financed loan repayment.7

In much of the rest of the world, coordinated workforce planning that develops national and regional goals has long been accepted as a legiti- mate policy exercise. This work is achieved by pairing technical workforce experts and policy makers with clinicians and patients to guide the structure of the health workforce—in both num- bers and skill mix—to meet the needs of delivery systemsand thepopulation.9 In theUnitedStates a mix of government policies and professional guidelines combine with strongmarket forces to shape the health care workforce; the latter al- most invariably dominates but with a recogni- tion among most stakeholders that regulation is necessary.10

As a result, the United States has forgone any substantial investment in workforce planning except for the veterans’ health system.11 The United States has left it up to states, professional associations, employers, payers, and other stakeholders to negotiate their interests via the market and the political process. The result is a complex and uncoordinated web of training in- stitutions efforts, licensing board rules, place- ment programs such as the National Health Service Corps, and payment regimes. These are not compared or evaluated to determine if they are producing the right people for the right work to meet patients’ needs. With many observers asking if there will be

enough providers to meet the needs of rapidly innovating systems, this laissez-faire system is now in flux. The Centers for Medicare and Medicaid Services has funded numerous pilots to identify new models for workforce develop- ment and payment to support health system in- novation. These pilots, however, are relatively isolated and have not been linked in any system- atic way to broader systems or structures that govern the way we train, regulate, or deploy the health workforce. The earlierHealth Affairs thematic issue raised

many familiar, unanswered questions, including a fundamental one: How many of what kinds of professionals with what competencies are need-

ed to care for our population? This issue asks the same questions but adds another: What has changed over the past ten years? The Affordable Care Act has created a new

vocabulary to describe networks of providers tied together to offer enhanced care coordina- tion. The ACO and the patient-centered medical home have become seemingly ubiquitous mod- els for holding systems accountable for the care provided to patients across community, ambula- tory, and acute care settings. These emerging models of integrated care have been abetted by increasing market concentration in health care delivery systems. ACOs, which take on risk by having a portion

of their reimbursements tied to the outcomes of care for a predetermined Medicare population, are seeking to reduce costs and improve care by ramping up screening and preventive care and the coordination of services. This restructuring will have far-reaching implications for how clin- ical work is organized and compensated, with more work shifting to lower-paid and allied health workers who provide care in less costly community- and home-based settings.

Teams And Workforce Almost all of the new arrangements include plans or structures that call for more “team- based care” and make use of “enhanced” roles for various professions, despite a lack of consen- sus on what those two terms really mean. Teams have been described as groups of people whose roles continuously shift in response to internal and external forces, including patient expecta- tions; policy and payment changes; organiza- tional factors; geographic proximity of other providers; andprofessional regulation, training, and attitudes.12,13 Broadly conceptualized, roles within teams fall into two categories: lower-cost health professionals acting as substitutes for higher-cost ones (for example, nurse practi- tioners for physicians), or lower-cost health professionals functioning as supplements who extend and enhance the work of others (for example, navigators to coordinate care or dis- charge planners to help patients make the tran- sition from acute to postacute care). Despite the numerous calls for more team-based models of care, relatively little attention has been given to how to prepare physicians, nurses, therapists, technicians, and others already in the workforce to practice in accountable or reformed teams. Health care professionals havebeen seenmore

as parts of a puzzle that need to be carefully fit together into a transformed system of care than as fungible resources that can be crafted or re- made to help build a truly reformed and more

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effective health care delivery system. For exam- ple, although the use of electronic health records (EHRs) has burgeoned with the implementation of the federal program to certify and reward the meaningful use of health information technolo- gy, there is limited understanding of how health professionals can work with EHRs to change the flowofworkorhowwork shouldbe reconfigured and reallocated among teammembers. EHRs are shaping the work of clinicians as much as they are being adopted for and adapted to current practices. To be optimally effective, EHRs re- quire broad and rapid adoption, practitioners must pay constant attention to data entry, and care patterns have to be reengineered to accom- modate EHRs’ use.14,15

Projecting Supply, Demand, Need, And Requirements That workforce projections are controversial should come as no surprise; any projection will inevitably be ambushed by unknown or un- expected factors and events that affect future workforce supply and demand. The surprising thing is that projections, whether based on em- piricalmodels or “expert” opinion, are criticized for not correctly predicting the futurewhen their purpose is almost always to change policies and practices. Projections, when accepted as roughly correct, are often followed by policy shifts that, in turn, change the future supply or pipeline of workforce production. Projections turn out to be wrong either be-

cause it is not knownhowmany physicians there are16 or because there is a lack of understanding of the true relationship between physician supply and health outcomes.17 They are, in one sense, “projectiles” shot across the bows of policy makers to stimulate action; they paint a picture of what is likely to happen if some desir- able policy is not implemented. If a policy is changed, then the projection is likely to turn out wrong because it helped cause changes in the factors that drove the model. For example, the Graduate Medical Education

National Advisory Committee’s 1980 projection of a physician surplus was used to justify cut- backs in federal support to medical education, thus changing medical school growth trends. That policy shift reduced production and even- tually led to a perceived shortage.18 The more recent Association of AmericanMedical Colleges forecasts of shortages of physicians have similar- ly prompted the expansion of existing and the opening of new medical schools and have put strong pressure on the debate over how to sup- port graduate medical education to provide the additional training necessary to produce practic-

ing physicians.19

Recent work has focused on developing dy- namic projection models that are amenable to changes in the assumptions on which they are based and that allow policy makers to simulate the effects of potential policy scenarios20 on workforce supply and demand. This type of work is supported by the National Center for Health Workforce Analysis in the Department of Health and Human Services, but the center struggles with a lack of both up-to-date inventories of ex- isting health professionals and a common data set to measure practitioner capacity or simply identify the location of practice.21,22

The modeling field in the United States and other countries23 is moving toward using projec- tions not as a method for generating one “right” answerbut as away to educate health profession- als and their associations, policy makers, and other workforce stakeholders about the com- plexity of projecting future workforce needs and the effects of the policy options they have at hand. Engaging stakeholders—particularly clinicians—in themodelingprocess cangenerate numerous desirable results, including a better understanding of how rapid health system change affects workforce deployment and im- proved communication between the professions and policy makers. Having clinicians involved in modeling can also serve as a check on the “face validity” of model outputs and can generate clin- ical input in areas where data inputs are weak. Stakeholders engaged in modeling can also help identify ways to redesign care processes to ad- dress workforce shortfalls or surpluses. Models and projection thus cannot provide a

single “right” answer in a system that is rapidly changing.The important thing is to have amodel that can be used to simulate the effect of policy change and educate stakeholders about the effects of policy options. For example, a model might show that increasing graduate medical education slots will likely have a relatively small effect on the overall match of supply to need compared to increasing productivity and delay- ing retirement. Efforts to model the nursing workforce have

been complicated by nursing’s persistent sine- wave pattern of shortages prompting policy ac- tions that, in turn, stimulate rapid growth lead- ing to surpluses.24 Analyses of nurse supply and demand remain doggedly unconnected to physi- cian workforce projections. There are no exam- ples of national models that simultaneously project the supply of both professions despite their substantial overlap in providing care. Combining the two in projections is now an im- perative given nurses’ complementary and sup- plementary roles in delivering or supporting

Overview

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many of the new services required by ACOs and patient-centered medical homes, such as care coordination, patient navigation, transition care, and population health management. An obvious link would be in the production

and deployment of nurse practitioners and their impact on the “effective supply” of primary care practitioners,25,26 but including “nonphysicians” in physician supply-demand calculations has proved difficult. For example, in the develop- ment of an index to identify shortage areas for federal support, an intense battle was fought in a special “negotiated rulemaking” committee mandated by the Affordable Care Act over how to count nurse practitioners and physician assis- tants in a formula for proposed new Health Professional Shortage Areas and Medically Underserved Populations.27 Advocates from the nurse practitioner and physician assistant pro- fessions felt strongly that they should be as- signed a weight of at least 0.75 full-time-equiva- lent of a primary care physician to account for their contribution to community-based primary care. Counting them would often increase the local supply above a shortage threshold, making the community or population lose its designa- tion and thus its eligibility for federal support.

Productivity In The Health Care Workforce The promise of technology as theway to improve the quality of care and lower costs, especially via the EHR, has been promoted on the basis of its potential to improve productivity in the system by making care more efficient and effective.28

This is essentially an economic calculus: Can more be done and done better and at lower cost? That question remains to be answered. What the United States has done is rapidly

increase thenumber of people and types ofwork- ers who are delivering care. Employment in the health care sector grew rapidly between 2000 and 2010—at a rate of greater than 3 percent annually—and even faster growth has been projected for the following decade, but there are signs of a slowdown in that growth.29 This is in contrast to overall employment, which shrank by 0.2 percent per year in the first decade of this century and is projected to grow by only 1.3 percent during 2010–20. Employment growth in ambulatory health

services has been strong at 3.3 percent per year, with an anticipated increase to 3.7 percent. These labor inputs may be growing faster than patient care needs, thus making the overall workforce less productive and efficient. On the other hand, that same expandingworkforcemay be generating greater value by improving out-

comes through better coordination and greater intensityof care.Whether the system isbecoming more or less efficient in terms of value formoney because of the addition of new specialties or new professions has seldom been asked30 and even less often answered.31

Professions Unto Themselves The United States accepts in policy and practice the idea of “sovereign” and self-regulating pro- fessions that have substantial control over their place in the health care system. This approach hasmeant that workforce policy has been largely shaped around the demands of the professions and not around the needs of the patients. The question of whether the professions should con- trol entry into their respective realms through self-regulation remains largely out of the main- stream of debate but is raised from time to time by libertarian thinkers.32 There are very intense battles over scope-of-practice rules, with ad- vanced-practice nurses making strong claims on primary care, nurse anesthetists being chal- lenged over their contributions by anesthesiolo- gists, and the development of dental therapists’ work being challenged by dentists. These con- flicts are becoming sharper despite a body of evidence that shows that most of these work and professional roles are effective in saving money and maintaining or improving quality.33

New and different types of health profession- als—community health workers, patient navi- gators, health coaches, care coordinators, and more—are attempting to create their own space in the health care delivery system as their con- tributions to the new payment and organiza- tional models become more apparent. The emergence of new professions runs counter to theories of howhealth care workers should func- tion in teams adapting and “upskilling” existing professional or paraprofessional roles to meet patients’ needs.34

The progressive division of labor and the crea- tion of specialized labor categories that are able to do one focused job more efficiently than a range of work has been the pathway to greater productivity in manufacturing and other sectors but to a lesser extent in health services. In the health care realm, increasing specialization is reflected in the growing complexity of how a hospital is staffed to care for patients—a process that has given us hospitalists, intensivists, noc- turnalists, and other types of practitioners who are defined by their functional role asmuch as by their disciplinary specialization.35 The prolifera- tion of new professions and professional roles does not necessarily lead to greater efficiency because, as David Meltzer and Jeanette Chung

◀

3% Employment growth Employment in the health care sector grew more than 3 percent a year during 2000–10, compared to a 0.2 percent annual shrinkage in overall employment growth in the same decade.

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point out, there are real costs associated with coordination.35 Those costs have not been calcu- lated or even anticipated in most of the calls for reorganization using teams. The rise of additional specialists and profes-

sions within the health care “team” in new mod- els of care have made Irving Zola and Stephen Miller’s description of long-term care common- place: “In the courseof…long termdisorders, the doctor recedes further and further into the back- ground, eventually assuming the role of occa- sional medical consultant.With this, the physio- therapist, visiting nurse, dietician, prosthetist becomes essentially ‘the doctor’ not only in terms of primary day-to-day management, but in terms of the transference relationship as well.”36

The career paths for physicians, nurses, and evendentists aremultiplying. They involve serial training in fellowships to acquire new techni- ques and skills; adapt to shifts in practice focus; and, more often, prepare them for a return or to introduce them to a type of practice that is more flexible—essentially a return to a generalist role.37 At the simplest level of care, the nature of labor fordirect careworkerswho feed,move, and clean patients has become dominated by part- time jobs with fewer and fewer benefits.38 To achieve true integration, teams must accommo- date the multiple needs of the people working around the patient, including highly trained physicians who seek professional satisfaction andhigh rewards aswell asunlicensedpersonnel whose formal connection to the system is tenu- ous but whose practical training and skills are often crucial in generating quality care and pa- tient satisfaction. The pressure to coordinate, or perhaps simply

serve as a traffic cop controlling, the flow of practitioners around the patient, has emerged as a true challenge. Atul Gawande’s description ofhismother’s careduringherknee replacement gives a sense of what a contemporary hospital- based team is like: It is large, potentially irratio- nal, and likely to grow.39 We know far less about what makes for an effective team of ambulatory caregivers when it comes to managing transi- tions for patients with complex chronic illnesses from community to acute care settings and back. If the workforce needs of the future are to be adequately assessed, it is necessary to first get a better handle on who will make up the work- force in each setting in the future.

Training And Education As Field Of Reform Training professionals for the future of team- based care has been recognized as a real chal-

lenge. The Institute of Medicine is currently supporting a committee, the Global Forum on Innovation in Health Professional Education, to explore how best to promote “transdisciplinary professionalism.” The group recognizes the challenges of integrating the diverse cultures and skill sets of the various professions, the problem of teaching “followership” and leader- ship, and the practical problem of measuring how well a team works. The National Center for Interprofessional

Practice and Education has been funded by the Health Resources and Services Administration to do similar work. These efforts follow on a series of precursor programs in interdisciplinary training that never quite found traction in for- mal policy or in health professions training.40

Thecentral task for reformedhealth caredelivery may indeed be to create and sustain teams of different professional pedigrees. The question is whether teams can be constructed around a template or whether it must happen in practice with ad hoc teams forming around the patient and their needs.

Innovations In Training And Education The ways in which health care professionals are taught are changing rapidly. Additionally, there is pressure to streamline pathways into profes- sions.41 Online courses, clinical simulators, and learning teams have made education more flexi- ble. Still, little is known about what constitutes efficient andeffective clinical training.42 The true costs of preparing health professions are being revealed by the rapid growth in the number of private, including for-profit, health professions institutions that have sprung up tomeet demand from prospective students.43 These include oste- opathic medical schools and physician assistant programs and umbrella “Health Science” schools that provide training for nurses, thera- pists, and technicians. Public community col- leges in some states fill this niche, but themarket

Training professionals for the future of team-based care has been recognized as a real challenge.

Overview

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has also responded vigorously to train workers, especially allied health workers, for reformed, if not fully coordinated, systems.44

The “safety net” of public clinics, hospitals, and private charity caregivers is one place where innovation in role assignment and integration of multiple professions has been welcomed,45 but the benefits are difficult to calculate. Community health centers (also known as federally qualified health centers) have become testing grounds for a new approach to graduate medical education through the TeachingHealth Centers Program.46

Through this program, the new centers are funded as temporary demonstrations whose long-term outlook depends on future appropria- tions.47 They do offer a new approach to meeting the growing need for locations to provide grad- uate medical education given the recent rapid rise in the number of US medical school gradu- ates and the apparent “bottleneck” that has slowed growth in residency training and thus physicians’ progression into the workforce. Revolutionary changes in the nature and form

of health care delivery are reverberating back- ward into medical education as leaders of the new practice organizations demand that the ed- ucational mission be responsive to their needs for practitioners who can work with teams in more flexible and changing organizations. In the face of this pressure, the traditional response of health educators—that they should have au- tonomy in defining the educational mission—is no longer viable. Instead, more explicit, formal, and systemic linkages between practice and ed- ucational institutions that are coordinated with maintenance of certification and licensing are inevitable.48 There are proposals to base certifi- cation and licensure on actual performance and patient care outcomes instead of on simplymeet-

ing additional education and training require- ments. 49 This new pressure to make medical education at all levelsmore accountable topublic and patient needs means that we must measure how medical education affects medical care out- comes, not just the outputs of the programs and institutions.

Conclusion We often hear how the United States has a non- systemofhealth care—a fair characterizationof a very adaptable sector of the economy that com- bines rigid professional norms, rapid shifts in staffing and deployment of workers to capture funding streams, and the constant creation of new work roles and employment opportunities. It is largely these characteristics of theworkforce that have both constrained the coordination of health care and allowed the system to grow very rapidly. To blunt rising costs, it seems necessary to find ways to temper this professional and oc- cupational exuberance to achieve both greater efficiency and effectiveness. To anticipate these changes and prepare the

workforce for new roles, it will be necessary to invest inworkforce planning but not solely at the macro level of overall supply. Investments are needed in research and implementation studies to help foster greater understanding about the actual content of care that is required in the new systems. Investments in researchare alsoneeded to identify how best to allocate new caring roles among a set of professions and disciplines that are trained and deployed in a coordinated fash- ion.Workforce planning needs to be more “bot- tom up” as it seeks to identify the “right kind” and the “right number” of workers. ▪

This work was supported in part by contracts with the American College of Surgeons and the Physicians Foundation. The authors thank Laura Trude and Kelly

Quigley of the Health Workforce Information Center at the University of North Dakota for their assistance.

NOTES

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