Transforming Health Care Workforce Challenges Opportunities Edward Salsberg

Transforming Health Care: Workforce Challenges & Opportunities Edward Salsberg, MPA Director, National Center for Health Workforce Analysis U. S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions GW Health Workforce Research Center Speaker Series October 24, 2013

Workforce Challenges • Potential shortages; specific areas of concern: • Primary Care, Chronic/Long Term Care, Behavioral Health, Oral health • Mal-distribution • Limited diversity • Using health workers to the maximum of their education and skills • Assessing the impact of a changing health care system on the need for individual health occupations • Developing comprehensive data to inform health workforce decisions 2

The Health Workforce Marketplace: Many Diverse Stakeholders • Federal and state policy makers (health, education and labor) • Schools, educational programs and training programs (both private and public) • Health workers and potential health workers • Employers (hospitals, practices, laboratories, etc) • Professional associations • Insurance providers • …and more 3 3

Key Components of Effective Health Workforce Planning Technical capacity • • Data Models/projections of future supply, need and demand Research and evaluation including to inform projections Dissemination to key decision makers Organizational Infrastructure • Leadership/assigned responsibility at the federal level • Federal-state collaboration • Public – private collaboration Levers to influence supply/demand 4

State Health Workforce Interests and Roles: Educational Opportunities and Health Care • State-supported education and training • Scholarships and loan repayment • State labor department- tracking employment and workforce needs (LMI Directors) • Access to health care for state residents • State employee health insurance and Medicaid policies • Provision of state and local public health services • Licensure and regulation of practitioners • Regulation of service delivery 5

Federal Roles • Data and information, including Census and the BLS • Funding for improvements and innovations in health professions education and training; i. e. Title VII and VIII, teaching health centers • Policies related to immigration/visas • Support for state workforce related activities of PCOs, PCAs, SORH, AHECs • Medicare and Medicaid reimbursement policies (including GME support and payment policies ) • National Health Service Corps • Support for delivery system reforms 6

NCHWA: Mission Created by the ACA to: • Support more informed public and private sector decision making related to the health workforce through expanded and improved health workforce data, projections and information. • To promote the supply and distribution of wellprepared health workers to ensure access to high quality, efficient care for the nation. 7

NCHWA : Core Activities 1. Expanded and improved health workforce data collection and analysis 2. Improved projections of supply and demand/need 3. Dissemination of findings, data and information especially to key stakeholders 4. Collaboration with states to collect and analyze health workforce data and identify needs 5. Co-lead for US on the Global Code of Practice on the International Recruitment of Health Personnel 8

Expand Improve Health Workforce Data Collection and Analysis • Build on existing sources of data including from federal agencies, states and professional associations • ACS, NAMCS, IPEDS, NPI, BLS, SOC, AMA-MF • New questions on NAMCS on non-physicians • Develop and promote the national minimum data set (MDS) • New National Sample Survey of NPs • Primary Care Service Areas (with Dartmouth) • New Health Workforce Research Centers • Update of the Standard Occupational Classification (SOC)9

Improved Projection Models for Supply and Demand/Need • Work under way on projections • • • Primary Care Practitioners Clinical specialties Nursing Oral health Cross health occupations • New micro-simulation models under development • Research on key factors impacting supply, demand distribution • Collaboration with CMS/CMMI to evaluate workforce components of innovations and new models of care 10

The Uncertain Future: Consider Primary Care What will the staffing of the PCMH look like*? A. If no delegation: 1 physician for 983 patients = 315, 000 PC physicians; Then significant shortage! B. If significant delegation: 1 physician for 1, 947 pts = 159, 000 PC physicians; Then significant surplus! But even with a national surplus there can be local shortages * “Estimating a Reasonable Patient Panel Size for Primary Care Physicians with Team Based Delegation”, Altschuler, Margolis, Bodenheimer and Grumbach; Annals of Family Medicine, Sept/Oct 2012 11

The Changing U. S. Health Workforce 12

Major Developments and Trends Impacting the Health Workforce • Demand rising as the US population is growing and aging • Health care reform to add insurance coverage for millions and improve coverage for millions more • Unsustainable cost increases • Uncertainty about health workforce needs • Concern with inefficiencies and potential overuse • Increasing interest in identifying ways to improve efficiency and health outcomes 13

Major Developments and Trends Impacting the Health Workforce, cont • Delivery system reforms and growing size of health care organizations • Disruptive innovations (e. g. increased use of nonphysician clinicians; retail clinics) • Technology • Increased attention on outcomes and metrics • Patient/consumer empowerment • Globalization and global responsibility 14

Some Federal Activities to Support Systems Redesign • • CMS Innovation Center CMMI Challenge grants State Innovation Models Medical home initiatives ACOs/Bundled payment Medicare 10% PC payment bump through 2015 Medicaid PC increase to at least Medicare levels for 2013 and 2014 • Workforce development: THCs, APRNs, NPs, Teams 15

National Health Care Labor Supply Employees per 100, 000 Population Health Employment per 100, 000 1950 -2010 Year Adapted from Kendix and Getzen and the Bureau of Labor Statistics by Richard Cooper 16

Team for Comprehensive Care Physicians Nurse practitioners Physician assistants Psychologists Optometrists Registered Nurses Pharmacists Case Managers Nutritionists/Dieticians Physical Therapists Community Health Workers …And more 17

NP Growth in NP 1 Graduates, 2002 -2012 15 500 14, 409 13 500 Graduates 12 273 11 500 11 135 9 698 9 500 8 865 8 014 7 500 7 583 6 526 6 979 6 611 2002 2003 6 900 5 500 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year Source: American Association of Colleges of Nursing Annual Surveys 1 Counts include master’s and post-master’s NP and NP/CNS graduates, and Baccalaureate-to-DNP graduates. 18

PA Growth Newly Certified PAs, 2001 - 2012 7000 6479 Newly Licensed PAs 6500 5979 6000 5823 5500 4989 5000 4500 4235 4337 4000 3500 4393 4512 5243 5215 4654 4009 3000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year Source: National Commission on Certification of Physician Assistants “Certified Physician Assistant Population Trends ”; 2012 data from personal communication with NCCPA January 16, 2013 19

Closing Observations (1) • Doing more with less (than the system wants) • Making better use of the workers we have • • Teams and collaborative practice and education New categories/variations on support personnel Reassess scope of practice and scope of work Increased use of technology • Increased efforts to align federal funds with health workforce needs 20

Closing Observations (2) • Growing awareness of the important role of the health workforce in health systems transformation • Period of workforce re-assessment and change • Developing the infrastructure for effective health workforce planning is time consuming and requires resources • Progress has been made on both the technical and organizational aspects of health workforce planning; the ACA was a major step forward 21

Some Questions to Consider • Should workforce planning be used as a tool to transform the health care system? If so, how? • Are we likely to face shortages or surpluses? • Is it better to err on the side of a surplus or shortage? • Can we accurately measure workforce impacts on quality and costs? • If overall physician supply is limited, what is the best use of physicians? Will physicians accept their changing role? • What is the appropriate role for the federal government? • What will be the impact of the changes in health care delivery on the supply/demand for health workers? What 22 are some good early indicators?

Contact Information Edward Salsberg, MPA Director, National Center for Health Workforce Analysis 301 -443 -9355 esalsberg@hrsa. gov 23