Care Delivery in the Future: The Role of the Health Care Workforce

Keynote - Emerging Health Workforce Issues in Times of System Transformation

(Note: This is an unedited transcript, for direct quotes, please see the video from this panel.)

SARAH DASH:  Well, we are really lucky to have an amazing group of speakers and panelists for today’s summit. Kicking it off, to discuss emerging health workforce issues in times of system transformation, is Polly Pittman. Polly is Professor of Health Policy and Management at the Milken Institute of Public Health at George Washington University. She’s the co-Director of the GW Health Workforce Institute, and the Director of the GW Health Workforce Research Center. So, we are delighted to have Polly here to frame some of today’s issues. I’m going to turn it over to Polly. Thank you.


POLLY PITTMAN:  Thank you. Good morning everyone. Oh, nice, the mic is working really well. This is great. It’s so nice to see so many friends in the audience. I hope I’m not preaching to the choir. I hope there are a few people here who don’t specialize in workforce policy research. But that is actually what I do, along with several of my colleagues that are here from GW.

The focus today is of course the healthcare workforce, but I think what I would like to do is frame this in a policy context. We often think about the healthcare workforce sort of as the landscape, almost as a sort of passive set of warm bodies that we need to have populate our healthcare systems. But it’s actually not just an issue of the numbers, or even of the distribution, or even of the racial and ethnic composition. It’s also a whole lot of choices that we usually take for granted around the configuration of the healthcare workforce. And to the extent that we are talking about payment policies, which are still thankfully an area of, I believe, as of today, relative bi-partisan agreement. This is an area that is going to continue to move forward. This is a really important area.

So, I wanted to begin the talk and end the talk with a question of payment policies and how they relate to the healthcare workforce. Again, the context obviously is that this is an area of rare bipartisan agreement. It’s not the only thing affecting the healthcare workforce configuration. Today, there are a lot of other issues, especially the growth of technology, all kinds of technologies that are affecting the healthcare workforce. Even though the debate is raging around coverage expansion, a lot of the uncertainty around what’s going to happen with coverage, I think is also relative to the issues that the workforce is facing. Financial uncertainty is a really strong driver of workforce changes. Essentially, the issue of efficiency is always a goal for the healthcare workforce, but I think the big driver in this case of payment policy, is a shift from what — and I recall what one nurse leader and an ACO described, they said, it’s a paradigm shift between a period when we were driving patients to doctors and hospitals, to a period when we are trying to keep patients away from doctors and hospitals; in their homes, in their communities, and healthier. So, that is no small change. That has a lot of implications in terms of how we configure the healthcare workforce. I’m not going to say today what we should be doing, but rather what appears to be happening as a result of that shift. What we know about whether or not it’s good, and what we might do to improve payment policies to promote or accelerate those aspects that seem to be good.

Again, no need to preach to the choir, but I do believe that all of these changes regarding payment mediated by the healthcare workers. They are the protagonists of the change. So, it is all about the healthcare workforce.

I’m going to touch on three issues:  How physician roles are changing in the context of teams and the diversification of those teams. What does this mean both in terms of intended and unintended consequences? Primarily, what are the questions around unintended consequences that we need to be attuned to? And then as we learn more about the effects of these changes on outcomes, what can we do to accelerate the positive changes in the context of payment policies?

On the evolving role of physicians and of others, I think that the major headline is what the Europeans would call “task shifting”. Just to begin with some data points that we generated at GW with support from NRSA and George Zangaro, who is the Director of the National Center for Health Workforce Data Analysis is actually our project lead in this area, and is funding seven centers around the country, doing different kinds of work on these issues. We are grateful to George for funding this work in particular. We have looked longitudinally at healthcare workforce in different settings. The community health centers are an interesting sort of sub-world, but they represent to some extent what is happening in primary care, certainly in the safety net for primary care. Overall, we are seeing an increase in staff, vis-à-vis patients. So, staff to patient ratios had gone up quite a bit, a full 10% in the last — 2007-2013 period. Interestingly, the rate of growth of different kinds of members of the healthcare workforce are not the same. So, where we see huge growth is with NPs and PAs. A growth at 74%. Medical assistance for an area of huge growth at 60%. Nurses at 43% and physicians are not keeping pace, at 34%. Now, this doesn’t mean that this was intentional. It could be an issue of shortages. But the fact is, primary care is being delivered with fewer and fewer physicians relative to the other kinds of providers that are in this basic medical team. That difference is even more notable if we compare it to the Allied Healthcare workforce. If you compare those four groups that I mentioned in the second bullet to Allied professionals, there is a 30% growth versus a 12% growth. Again, the story seems to be diversification. Then we are seeing a lot more colocation of behavioral health and dental health services in primary care, and that is also shifting the relationship of physicians to the entire team.

In hospitals, and in this care, we have been using premier data, so it’s a subset of hospitals, not all hospitals, we are seeing more and more hospitals are using NPs and PAs. It’s gone from 55 to 63% between 2010 and 2014. Hospitals have been using these professionals in vastly different ways. We just finished a study on hospital privileging that shows that there is absolutely no relationship with scope of practice, [inaudible] hospital level policies that vary tremendously, even within state, they vary tremendously. We are seeing the level of RNs remain relatively steady, probably because of the attention to the literature on RN to patient ratios. Even in states without laws that dictate these ratios are seeing that people are very reluctant to be reducing the diversification ratios.

Below nurses is where we are actually beginning to see some more change, and I think this also relates to the issue of task shifting. So, we see a slight decline, not a significant — [loud audio noises].  So, a slight decline in the support staff for nurses, which is not a huge number. However, when we look at the composition of the support staff, in particular the support staff that are either supervised by nurses, or for whom nurses have to fill in, we see a big fall in the number of the higher educated and higher paid staffed persons and a very significant increase in the lower level jobs that are less well paid. So, there are a lot of substitution happening in that large group of support staff. Just a sort of factoid for those of you who focus mostly on nurses and physicians, which most of us have done for most of our careers. It turns out that nurses and physicians are only about 25% of the entire healthcare workforce. So, what’s happening in this large group of support staff, is really of interest from a jobs perspective, from an efficiency perspective, from an outcomes perspective as well. Even though most of our research is always focused on physicians and nurses.

Lastly, you see hospitals and health systems hiring obviously more care coordinators, more community health workers, more social workers. Those kinds of staff that might be referred to as a social needs health workforce.

I don’t do as much work in the area of long term care or behavioral health. We have other centers that focus on these areas. But I can speculate. I think that one thing that we’ve heard loud and clear from people in ACOs is that they recognize that the lack of alignment between the kinds of transformations that are occurring in hospitals and in primary care, with the long-term care and the home care sector, is probably the single largest area of waste. And they are struggling with how to get their heads around what to do. I think there are a few interesting stories. One of the interesting stories in home care is the use of NPs for home visits, particularly for Medicare patients, because there is a financial incentive for that. And because, obviously, it’s more expensive to send physicians into the home, because you are paying for their time during transportation. So, that’s an interesting model that has emerged. But largely as many of you know and even more than I, because this is your area of expertise, it’s basically an issue of workforce develop that is relating to low pay, and lack of support in the job. So, again, this issue of payment could be really central to making change happen, even though we are not observing any change at this point. It could be an interesting area to think about. I think in behavioral health, there are similar kinds of challenges in terms of aligning both a level of payment, and the alignment of payment with the rest of the healthcare system. One additional sort of observation, not related to behavioral or home health particularly, but obviously the use of NPs in retail clinics is exploding, and that has sort of a spillover effect in terms of utilization of other kinds of services.

So, what does all of this mean? The short answer is: I don’t know. We are working on trying to carve out questions that are answerable, little by little. Obviously, it has implications for education and pipeline programs. For example, do we think we are actually going to be able to produce the number of NPs and PAs that the system seems to be demanding, both in primary care and in hospital care, and to some extent, in home care. There are questions as well about physician burnout; how the shift here and the diversification is changing the role of physicians and teams. Are they seeing the most complex patients, and therefore, essentially have no downtime? Is this creating a lot of stress for physicians? How can we deal with that? Are there ways to alleviate that stress by having additional sort of technological support, or internet type support, and I think we are going to be hearing from the ECHO project later this morning, and that may be one of the strategies for alleviating stress. So, I think there are a lot of questions around burnout. By the way, it’s not just physician burnout, it’s also nurse burnout and frontline worker’s burnout. So, that issue of how these changes are affecting sort of the — not just the retention, but also the health of these workers.

There are a lot of other questions related to how technology is interacting with these changes. So, obviously technology may mean that we need more training. It could mean that there is a lower level of utilization of services if patients begin to use more self-care kind of technologies. It could also mean additional acceleration of task shifting downwards. So, in Keiser Permanente, for example, they are creating a new kind of worker called the “multi-functional worker” that is going to be in kiosks that are sort of like phone booths in neighborhoods, and they are going to sort of plug themselves into all of these machines and have this multi-functional worker who’s talking to somebody else at the other end of the line about the results. But there will be new jobs emerging and shifting of tasks to new settings and to new kinds of workers. Then of course, there is the possibility of job loss with technology, and obviously there are people concerned about that, particularly on the administrative side, what the implications of all of that will be.

Just to close here, I think that circling back to payment policy issues, the story that we are hearing from ACO leaders is that they are making these changes in an intentional way. They know the direction of where they want to go. But that the level of uncertainty around whether the payments will actually arrive 18 months later, means that they must proceed with extreme caution, and that not everyone within these organizations is entirely onboard with taking these risks in terms of changing how they configure the workforce, both in terms of more social care kinds of workers, and in terms of the task shifting. There is a program in Washington D.C. that just began in July, that I have been watching closely, because they are using payment policy to actually accelerate what they believe to be the right kinds of changes in the workforce configuration. And it’s the Medicaid Health Program, which in D.C. is called My Health GPS. So, they provide an upfront payment to hire a social worker, or a community health worker, and they pay for transportation for the beneficiaries. These are Medicaid patients with three or more chronic conditions. Then they continue to pay along the way, according to the level of interaction with healthcare services. So, they are not waiting to the very end to have this big bonus based on performance. So, it will be interesting to see what the providers, what the healthcare workforce, think about this program, and whether this actually facilitates accelerating the changes that they believe are the right way to go. If this works, it raises the question of whether it could be applied to other sectors. For example, long term care or home care, where you could restructure payment so that you are incentivizing the hiring or the re-configuration or the workforce development kinds of programs that you think you need.

I think an interesting question for this group to think about in the course of the morning is, to what extent could this be woven into payment policies for long-term care? To what extent could it be woven into payment policies for behavioral health as well? I also think in the area of NPs and PAs, where we focused for a long time on scope of practice laws, and there is a lot of progress, we are still facing this issue of organizational changes being delayed. And there could be payment policies around that as well. Around issues of privileging, around issues of who does what within the team that could help advance that.

Those are some thoughts to kind of kick us off in the morning, and I hope we will continue to have a conversation around this. Obviously, there are a lot of vested interests in the healthcare workforce, not everybody sees eye to eye on these issues. And that’s why we are working hard to try to generate an evidence base that will help us facilitate this conversation, the way it’s a little more fruitful. So, thank you very much.