(Note: This is an unedited transcript. For direct quotes, please reference the video.)
SARAH DASH: I am really delighted to introduce now Julie Rovner, who is going to moderate our next panel on Delivery System Reform and the Healthcare Workforce. So continuing on Polly’s remarks and Julie is Senior Health Correspondent at Kaiser Health News and is going to introduce our next panel. Julie, thank you. And if the next panel, you guys shall be ready to go, come on up. Thank you.
JULIE ROVNER: Good morning. Good morning. I do still need my glasses. Thank you all for being here. I am honored to be here with this amazing panel to discuss delivery system reform and its effect on the healthcare workforce. I think Polly gave us some good things to think about as we go forward. As Sarah said, I’m Julie Rovner. I’m Chief Washington Correspondent at Kaiser Health News and before, oh, about a year ago this week, I was spending most of my professional time looking at health workforce issues, so it’s nice to dip that into it, at least temporarily. I’m still hoping that if things settle down, I can go back to what I was doing before, being interrupted by a new round of efforts by the federal government to remake the healthcare system.
I’m joined today by some really impressive health workforce experts. I’m kind of geeking out here. We’re going to spend the next 45 minutes talking about the intended and maybe some unintended impacts on healthcare providers of efforts to improve the delivery system. I’m going to interview these fine people for about a half an hour, then you will get your turn to ask questions. So, without further ado, here are our panelists. You have their full bios in the handouts, so this will be the clip notes version. Ann Greiner, who is in the middle, is President and Chief Executive Officer of the Patient-Centered Primary Care Coalition, which is working to advance an effect and efficient health system built on the strong foundation of primary care and the patient-centered medical home. Thomas Jenike is family physician and Senior Vice President and Chief Human Experience Officer for Novant Health, which is an integrated system of physician practices, hospitals, and clinics that serves North and South Carolina, Virginia, and Georgia. And Bob McNellis is Senior Advisor for Primary Care in the Center for Evidence and Practice Improvement at the U.S. Agency for Healthcare Research and Quality. He’s trained, practiced, and taught as a physician assistant over his career.
So, let’s get right into it. I want to ask each of you to answer this first question, which is: from your perspective, what are the biggest challenges facing the healthcare workforce right now?
THOMAS JENIKE: So my area of passion and expertise is around physician burnout, so when you ask the question what’s affecting healthcare right now, to me it’s just the rapid degree of change that physicians – I’m going to speak from a physician standpoint first because it’s what I am – is that we’ve always had a high degree of change and it’s always been hard to practice medicine and I think, in the current climate, that rapid changes have been coming so fast that people are starting to lose focus on why they even went into medicine. And I think one of the biggest challenges is, people are not necessarily quitting healthcare, but staying and quitting at the same time which I think you know what I mean by that. So I think that is a big risk, not only for the physician shortages that we talked about in the first couple of presentations, but for quality, safety, and all the like. So I don’t think it’s good for anyone if the physician themselves, or the care giver, isn’t taking care of themselves and is feeling burnout. So I think all the degree of changes is really threatening the delivery of healthcare for our communities and for the health of the provider.
JULIE ROVNER: Ann.
ANN GREINER: I think it’s a myriad of factors. I’ll just name a couple. This move to value and all that comes with that in terms of the reporting requirements, the regulations, redesigning your practice, very new territory for health professionals, and that’s quite stressful and takes a whole lot of time and the literature suggests that physicians and other health professionals are having less time with their patients because of really attending to all of these other things. And I think technology, too, is having a huge effect. I mean, EHRs, and then all the other technologies that are really beginning to become a part of practice.
ROBERT McNELLIS: Thank you, Julie, and it’s a pleasure to be with all of you today. At the risk of being redundant, I’m going to sort of take a slightly different perspective on this and I give a lot of talks, especially to students or professionals, and I have this slide that I show: Healthcare at a Crossroads. And it turns out that actually the talk that that title talk was given in 1988 by Ubay Langhart [ph] at George Washington University. Talked about Healthcare at a Crossroads. So what are today? We’re healthcare at a crossroads. I mean, we’ve used that every year for the last 30 years, right? And so, if you take the long view on it. There’s nothing new. I mean, there is lots of things new. It’s the rapidity of change that’s happened over the last 10 years, for sure, probably the last five years, I think, that has really put people off balance, and that’s where it’s at. But we’ve worked on this through other administrations have worked through health reform. I think the IOM report in ’99 and 2000, those two reports changed the way we think about healthcare—
ANN GREINER: Medi-Glare reports.
ROBERT McNELLIS: Exactly right. Actually, National Academy of Medicine now. But I’m thinking crossing the chasm, to err is human, and the response to those two reports, in particular, have changed the way we think about healthcare and put things into place very quickly without actually maybe we can sort of see far enough what some of those unintended consequences might be.
JULIE ROVNER: Well, I want to dig down into this a little bit and let’s talk about how delivery system reform, new models of care – I mean, as you mentioned, things have changed really rapidly that are being experienced by the healthcare workforce are really changing how they do their work and I’m talking, yes, physicians, but everybody along the spectrum of healthcare delivery, how is the rapid change impacting people. Ann, why don’t you start.
ANN GREINER: Well, funny that you should mention the IOM reports because when I was at the Institute of Medicine, now the National Academy, I worked on a report about health professions’ education and what are the competencies needed for healthcare delivered, you know, in the vision of a quality chasm and a lot of the competencies are the same except that there are two that are novel that I think really suggest that there really has been this evolution, and that report came out in 2003. The two that are new are, you know, that I think are really competencies that health professionals need, are a focus on value in talking about cost of care and, you know, this is a whole new territory. But if we’re really going to get to, you know, the value that we all expect from our spend, we’ve got to deal with costs of care, and there’s some great new researchers that are coming online to help health professionals do that. And I think the other competency is really dealing with the social determinants of health, because now we know – we didn’t know then – how much that really contributes to patients’ outcomes, and so, you know, how do we teach those competencies in our health professions’ education? Not really. So we’re not really helping professionals to prepare for a world where they’re going to have to understand how do we address the social determinants of health, and that’s a big, big question.
JULIE ROVNER: And I want to talk about training in particular in a few minutes, but right now I want to sort of zero in on how professionals are experiencing the rapid change and what is – I mean, what does this mean on the ground, to members of the entire healthcare team?
ANN GREINER: Well, I think they’re pretty stressed. I mean, you do so much research on burnout and, you know, they know they’re not really able to meet their patient needs. They are spending a whole lot of time with entering data, either in the electronic health record or to report all the quality measures that they need to report, and they’re less satisfied. And, you know, I think we see it in turnover rates. I think we see it in burnout and workforce that – and it’s not just doctors; it’s nurses, it’s pharmacists, it’s across the gambit. And when they don’t feel, you know, able to really give their best selves, both their clinical skills but also their emotional skills, I mean, that’s such a big part of caring. If you’re depressed and you’ve got a lot of anxiety and you’re not able to show up, that really has an effect on patient outcomes, and there’s more and more research that’s showing that.
THOMAS JENIKE: Yes, so from my perspective I think the single biggest shift that’s changed the way that people deliver care on a daily basis is the electronic health record. I think that early on we talked about how are we going to pay for it, how are we going to put it in, how are we going to all be connected; I think the way – what we really missed was how it was going to change the day-to-day workflow of everyone on the team. The literally hours of additional time that everyone, including providers, take at data entry, quality metrics, and then getting nurses to start to assume some of those roles, too, so their roles have completely changed. They went from talking on the telephone to instant messaging patients. So everything has changed in the way that we care for people and that has been, I think, overlooked, and I think it is one of the biggest things that’s driving burnout and driving dissatisfaction and taking people away from the core of why they chose to go into healthcare.
ROBERT McNELLIS: Sure. And at the risk of being an advertisement for AHRQ, I’ll just say Agency for Healthcare Research is a small research agency of the federal government, small number of employees, but we do research on what works in health, services research in particular, and we’ve done some research on burnout and we recognize it’s a big problem but there are some solutions to it, as well. I can also say the EHRs are and have been a problem. We also have a large research project in small primary care practices called “Evidence.” Now, 1500 small primary care practices and understand what they’re seeing. We see pretty high levels of burnout, about 25% in physicians; 20% in MPAs, PAs, and some of the nurses working in those areas. But, you know what, EHRs can be targeted as some of the problems because it’s hard to get data in and really hard to get data out, but you know what, when they work they can work really well, and we’ve done some work to help people make them work and all of a sudden things go away. We see practices that are excelling in the care they deliver. They feel much better. They’re getting data about how well they’re doing. The trick is to getting them to work, and that takes actually some things that we’re going to talk about later about teams and outside and inside practice to get that to work. So I think there are some solutions, even though people are feeling the stress, I actually see some hope at the end. If we get this stuff to work people will be a lot better off.
JULIE ROVNER: You’ve anticipated my next question which is, obviously we’re focusing on problems because we’re trying to solve problems, but I mean, what are the things that technology has sort of – and the changing healthcare delivery system – has done that actually are making lives better both for patient and for providers? You already talked about it.
ROBERT McNELLIS: Oh, great. Thanks. Well, for providers, I mean, imagine a place where actually you can – imagine – and this may take a little imagination – where it’s actually easy to get data into the EHR, and there are some techniques out there, scribes, people who are dedicated, a lot of clinicians who really focus on the patient, and then you can have meetings with your team to bring together to see how well you’re doing on delivery of important care processes, and then you can work through solutions on how to do that better and there’s some intellectual joy to actually sort of solving those kinds of problems. I mean, that’s what healthcare providers were trained to do is solve problems in patients. We can help solve problems in practices by providing some of these external supports for them, as well.
JULIE ROVNER: You guys have been working on this, yes?
THOMAS JENIKE: So, I think what can really work with the electronic health record, and I don’t mean to demonize it because there’s no going back, so we get that.
JULIE ROVNER: And I’m not just talking about the electronic health records, by the way, although that does seem to be where everybody’s frustrations end up lying.
THOMAS JENIKE: So from the electronic health record perspective, for a physician, it can start to give us better insight on how to take care of patients. You know, for decades, for centuries, I could be practicing alongside a partner. I can be treating someone in a certain way and think I’m doing an awesome job and now we have data that’s out there that can say, okay, well, this is actually the best way to take care of patients. So if you can actually harness it in a way that it is easy to get to and say that this is the best way to take care of this patient with this problem and you don’t necessarily have to use the art of medicine so much when it comes to diagnosis, it really can be helpful. And from a patient’s perspective, we know that consumerism is a big deal. We know that the new generation of people getting healthcare want to get it through a hand-held device, so it is going to be easier for them if we can get it to work. So I really think that things can be better for everybody.
JULIE ROVNER: Ann, what’s good? What’s good about it, delivery reform?
ANN GREINER: I think in systems where the HIT is working well it can help really to facilitate team-based care because you’re really helping everybody on the care team to get the information they need to take care of the patient in front of them, and you know, who’s on first will depend upon what that patient’s need is and, you know, who’s delivering the care that is constantly shifting, particularly in primary care. So I think there are bright spots where that is really working well and people are still seeing the promise of technology to help with care integration and communication and really what’s best for the patient.
ROBERT McNELLIS: And if I could just – I’m sorry, Julie – just bring the patient’s voice into it, as well.
JULIE ROVNER: Which was my next question, so go ahead. [Laughter] You’re doing really well.
ROBERT McNELLIS: Well, it’s just, I mean, I just saw my primary care doc recently and I had my lab results and I can pull them up online. You know, in a paper-based world it’s really hard to do that, and I think that decreases their load as well, so there are opportunities for patients to be more engaged in their care they’re getting, I think, through the use of technology. There are other things around delivery system reform that I think are positives in addition to the EHR, the potential for the EHR is population health, focus on populations. I mean, I often say that we’re not going to get to the kind of quality we want in this country one patient at a time. We have to think about groups of patients and groups of people in communities and having that kind of data around community really helps you manage your entire population, not just the patient in front of you at the moment. So I think there’s a tremendous opportunity there, as well.
JULIE ROVNER: So how is the patient experiencing delivery system reform? I know, for most patients, it’s just there’s now a computer between you and your practitioner. Sometimes the doctor, sometimes the MP, the PA, you know, or, as you said, there are now opportunities, although, you know, speaking for the end of one, me, every doctor I go to has a different patient portal. I mean, you know, I can’t – when you sign up for it you can’t remember the passwords, I mean, and literally every single system is different and that which is not, so, you know, I get the feeling that there’s a lot that patients aren’t seeing a lot of the good that’s supposedly going on in improving the healthcare system, and I assume that that, then, you know, reverberates back on providers and probably not in a good way.
THOMAS JENIKE: So, from my perspective, I think patients are seeing more of the upside than the healthcare providing team. I think they see an increased transparency, you know, the fact that you can see your health record, that you can get your labs in a timely manner. I think the fact that they can do online scheduling, they can do video visits, eVisits. I think most of the things have been beneficial for patient care for patients. So I think that patients, if you ask them, they say this is going the way we would like it to go, from my perspective. I think it is patient-centered. It just wasn’t really thought through on how it was going to impact the whole team.
JULIE ROVNER: And how is it going in the private care world?
ANN GREINER: I mean, I think it depends. You know, we’re in a messy period. There’s a lot of change happening, and there is certainly practices, as you described, where you can do an eVisit, I can email my doc, I can, you know, jump on and get a tele-visit at 10 o’clock at night if I wish, lots of other places that’s not – that’s not occurring, and so, you know, I think so much is dependent on the market you’re in and the practice you’re able to go to. I think also, you know, all that’s happening in the insurance market has an effect on patients because when you’re in a high-deductible health plan and you have a very large deductible to meet, you just may not be taking advantage of the primary care services you need for health promotion and prevention, even chronic disease management, and so, that also factors in here. You can’t disentangle that environment has an effect on patients as well. And, as we’re all moving to value-based payment, so, you know, what’s going on in the insurance markets has a profound effect.
JULIE ROVNER: I want to talk a little bit more specifically about burnout – burnout among the entire, you know, care-giving team. You’re working on this particularly, obviously, we’re in a trying time, although, as we’ve heard, it’s always been a trying time in healthcare. You know, healthcare is at a crossroads all of the time. But this does seem to be a time of particular asking people to do more with less, or asking people to do things in a very different way than they were perhaps trained for. How, in this very sort of churning situation, do you work to make the caregivers resilient, as I think is the word you like to use.
THOMAS JENIKE: Yes. So, you know, I think when, it might have been Glenda this morning that talked about the triple aim, you know, I think the quadruple aim is having the healthcare providers find joy in practice. And for me, the way we think about this, we have a position on burnout, and we don’t feel like we need to do much more research. We know it’s there. So we really want to start tackling the problem. And the way that we are looking at burnout is that there is a whole bunch of external forces and factors that affect the healthcare team, and much of what which we have talked about today. And we believe there’s a whole bunch of internal factors inside the provider that also can lead to burnout. So what we have taken the approach on over the last five years over thousands of physicians is to really address what’s going on inside of you, because we’re going to confront and admit that the changes are not going to stop happening. So if we’re just going to try to damp down the changes in hopes that it makes you feel a little bit better, we know the next change is going to happen. So then what our approach is to work from, what I’ll call the inside out, and have people have a degree of awareness of their patterns around all these changes. What is that making them feel? How is making them experience their work? And understand that this hamster wheel that we feel like we’re on a lot, that, in some cases, as a physician, I’m the one turning the wheel. Like, I literally am the one turning the wheel because I have this success, by the way, I have to be the best. I can never make a mistake. I’m a perfectionist, and all this comes from my training and this was what allowed me to be successful. So we want people to stop and look at what is their contribution to their own burnout. And you would think that that would be met with a lot of resistance and hostility and, oh, you’re blaming me? But what we find is that people feel a new sense of meaning. They can reconnect to why they went into healthcare. They can now find things that recharge them and restore them outside of the healthcare world, and we’re building communities of physicians who are looking out for each other. All this in service of them being more resilient so that they can go into a high pressure environment every day, which we know it’s going to be, and give their best and then go home and give their best to their lives. And that’s what, for us, has really been transformational. And once we’ve done that, they have been much more willing to stop becoming the victims of this medical machine, but to really be an active participant in trying to diminish some of those external forces. So we’ve seen tremendous success over the last five years by using that approach, starting with the individual and then working around it, rather than just trying to dampen down some of those external forces.
JULIE ROVNER: Is this just for physicians?
THOMAS JENIKE: No, we started with physicians, moved on to our advanced practicing clinicians, and this year we had the same type of program for over 900 bedside nurses, with amazing results and, which I can share if you want to, at some point.
JULIE ROVNER: Are they less perfect? If they give up perfectionism?
THOMAS JENIKE: What we invite them to do is to choose to not always be in perfection mode. Like there’s times, if my—
JULIE ROVNER: I mean, from a patient’s point of view. I’m not sure I’m down with this whole thing.
THOMAS JENIKE: Yeah, exactly.
JULIE ROVNER: Or asking my practitioners to not be perfect.
THOMAS JENIKE: What we ask them to be is versatile. So if I have to have a neurosurgeon see me, I want them to be perfect. However, if they’re going to go on vacation with their family, they don’t need to be so perfect. They don’t need to take the same model that works in their professional life and apply it to everything in their life, which is what we often do as human beings. As we do some things we do all things. So as a provider, we like to be in control, we like to be independent and we find that that’s a big barrier to finding joy in life because if you’re locked into that you could be – I could have my feet in the sand at some awesome beach and, in my head, I can still be grinding on work back home. But we’re asking them to be more versatile.
JULIE ROVNER: Ann.
ANN GREINER: I’ve been struck, in working with physicians over the years, how much responsibility and ownership they take on for everything. So if something’s not right in the practice or on the hospital ward, it is their fault, and they’ve got to fix it and they’ve got to rescue it. And when you start to do some of the work, and I’ve worked some with IHI where it’s like no, we’re actually going to solve these problems together as a team and, oh, by the way, we’re going to invite patients and families in to help us figure out, you know, how we might change delivery to make it work better for everybody. And they begin to see that it’s not just you, doc’s, responsibility to solve it all for everybody, and I know it’s the way we’ve been trained. It really does help to lessen that burden because we all want change in the system and that means we’ve got to do this collectively, and it’s no one person’s job. And I mean, I was heartened to hear your remarks, because I think it really can help when people feel like they’re not in it alone.
THOMAS JENIKE: And I think you’re right. I think team-based care is the way out and oftentimes the barrier to that is the physician. Even though it’s the best thing for them, they have a mindset of control, so just having them see that, to your point, it doesn’t have to be you. They have to grapple with that a little bit because it’s been like that for so long. So it’s a mindset shift that we are in this together and when you can do that, it does take the burden off.
ROBERT McNELLIS: And, you know, Tom, what you shared was wonderful and I value, you know, the perspective from that, but I think I definitely agree that team-based care has some opportunities, great opportunities with it. Personally, I’ve worked on some great teams, and it’s been when I’ve been most fulfilled in my life is working on great teams. They weren’t always in healthcare. Sometimes they were in other areas. But I’ve definitely seen it work in healthcare as well. The challenge is that, you’re right, some people don’t know how to work on teams and all I can say is there’s some good stuff, another AHRQ advertisement, there’s something called Team Steps, which is a program that we put together, sort of mostly in response to patient safety issues, but now we’ve expanded it into ambulatory care and primary care settings to help train people up about how to do it. How can you work best? And it’s really about relationship building is what teams is, and good communication. And if you can just bring about relationship-centered care, whether it’s with the patient or their team members and about having good communication, that goes a long way towards building the kind of teams that, you know, where you need trust and accountability. Everybody on the team needs to be accountable, and we can share. I share your pain, Tom, and we’ll do it together, you know? Those kinds of things I think can go a long way.
JULIE ROVNER: So let’s talk about team-based care and training the next generation. Obviously, one of the difficulties and one of the reasons we have so much burnout is that so much has changed so fast and people who are trained, you know, many years ago, or even a few years ago, are having to completely overhaul the way they were trained and their mindset. So how do we, now that we sort of know and understand that the generation that’s being trained today in health professions, is not going to practice in the system as it is now. They’re going to practice in a system that’s changed in ways that we don’t even necessarily know, so given that, how do we adapt training programs to help practitioners be more, I guess, adaptable to change is sort of the key here, right?
ANN GREINER: I think it’s a really big and challenging question and any place in the healthcare system I think, the education system has been the most allergic to change. [Laughter] I mean, it really has been. And so lots of change going on in delivery, not as much change going on in education and training and, unfortunately, they’re kind of in separate orbits. Even though CMS oversees, in terms of, you know, Medicare payment both, but they offer it very, very separately and so there needs to be much more integration so that, you know, care delivery is really informing what we need to do with respect to education and training. Education and training should have the triple aim as their goal, you know, and that’s what they should be thinking about. How do we train? We should be training through the quadruple aim, excuse me. The quadruple aim. So I think, you know, that’s like the very – that’s at the highest level. I mean, still health professionals, by and large, and there are bright lights out there and, you know, the new Kaiser Permanente School and University of Florida and Colorado and, you know, Oklahoma – lots of bright lights. But, by and large, professionals are – health professionals are trained in their silo and then we ask them to go work in a team. Well, they don’t know how to work in a team. They don’t know the first thing about, you know, what are your competencies? What do you bring to the table? So we’ve got a ways to go, Julie.
ROBERT McNELLIS: And I can talk just briefly. You know, so I worked at George Washington University many years ago and I worked in the PA program and taught a variety of health professions, but here’s what did work. We throw all of them into the same classroom for a couple of courses. So the PAs were there, the MPs were there, the docs were all there, all listening to this material. Having people sit in the same room together is not encouraged team-based care. Might be good for happy hour, but it wasn’t great for team-based care. What does work, as there’s some great movements around, inter-professional education now that’s certainly been happening over the last roughly 10 years or so, where we’re starting to see what are those core competencies that we share across professions, how can we understand better what each are doing. I think there’s some real efforts to really move in that direction. I think one way they did it at some institutions is by getting them to work in a student-run clinic together, and then you can see how that all plays out in shared responsibilities. In places where that’s been done, people have much better recognition. Okay, here’s I work with the pharmacist. Here is where I work with the behavioral health person. Here’s how the medical assistant can help me do my work better. And that’s really been, I think, has tremendous value and we just need to sort of expand those kinds of efforts, I think, to some degree.
JULIE ROVNER: I think that was our experience. I did a story on this last year. I was at Case Western and so one of the things I did was sit at one of these workshops where, I mean, they do have a student-run clinic, but there were medical student, dental student, pharmacy student, social work student, nursing student all sitting around a table and they gave them some cases and they actually talked through what they could do. And it was interesting because I could see the students but I didn’t know who was who and, at the end, I was trying to figure out which student was which, and I was completely wrong.
ANN GREINER: Well, that’s a good thing, right?
JULIE ROVNER: Yeah. No, I – yeah, I considered that a good thing.
THOMAS JENIKE: I think from my perspective, you have to go back to the beginning of the training and I think it may be individual institutions or it may be some sort of government thing, but someone needs to put a flag in the ground for this is the way we are going to practice medicine in the future. The days when we practice in silos, practice independently, those days are over. And understand the why behind that, because it’s better for you, as a healthcare provider; it’s better for their patients; it’s where our healthcare is going. So someone has to put a flag in the ground and say this is the way we’re going to start training people. And I don’t know who has the clout to do that, the courage to do that, but – and it may come in pockets like the organizations you said.
ANN GREINER: Well, think about the federal investment in, you know, graduate education. I mean, that’s, what, $12 billion, is that right, Julie?
JULIE ROVNER: Something like that.
ANN GREINER: So it’s a lot of money.
THOMAS JENIKE: That’s power.
ANN GREINER: Yeah. [Laughter]
JULIE ROVNER: Although the National Academy of Medicine tried to take a whack at it and immediately got smacked down, so I mean, there are lot of entrenched interests, I guess, and that which leads me to my next question: What’s the thing that’s been left out of healthcare delivery system reform from a provider point of view, really needs to be included? What aren’t we doing that we should be doing more of, or what are we doing that we should maybe be doing less of?
THOMAS JENIKE: So, I guess, trying to think about the learnings I’ve had over the last couple years, one of the things that seems to be lacking and can certainly be enhanced is having physicians understand that they are leaders. So, and they are a leader, whether they have a formal role or an informal role, every space they step into they are a leader. Every healthcare professional, for that matter, is a leader. So leadership training, starting with how can you lead your own life, how can you influence a team, how can you work well as a team, and then, how can you influence a broader spectrum whether it be your healthcare system, your society. So I think investment into communication, self awareness, how to function as a team, and understand that you, walking into every room, whether it be a patient room, an operating room, your living room is never a neutral event. And I think having practitioners understand that and be trained in that will go a long way to help us to increase resiliency, decrease burnout, and increase team work.
ANN GREINER: I think there’s a whole lot of competencies that we need to teach, but I think, in general, we focused on delivery and payment as the two big buckets, and we haven’t spent enough time thinking about the workforce, which is why we’re having this panel and it’s a great discussion. You know, it seems to me that one of the key competencies that we still, by and large, correct me if I’m wrong, but I don’t believe our teaching is really quality improvement science, and so, you know, practitioners are getting back this data and they desperately want to improve their, you know, change their delivery system so they can improve in a value-based world, but they don’t know how to go about doing it. They need a whole lot of training and support. And that is the kind of activity that is generative. It’s a wonderful vicious circle. You know, if you’re getting trained on something to improve the system and then you’re improving the system and then, you know, you’re able to do better in a value-based world, well that’s a win-win for everybody. So all of these competencies relate to team-based care and patient and family engagement and, you know, how to use technology better and cost of care, those are all really important. But I see the quality improvement science as really, you know, just a crucial piece of what we need to do to help health professionals really be prepared for this new world we’re in.
JULIE ROVNER: Is that a world for AHRQ?
ROBERT McNELLIS: We’re a research agency. Happy to fund research along those lines, but what I will say, just to pick up on what Tom and Ann said is, you know, I agree with the leadership and quality improvement science and I think hand-in-hand with the leadership part is a culture, and building that culture that you care about quality improvement, that that is integral to what part of your mission is. And there have been efforts by the Feds and others to do that. You know, CDC, the Competence of Primary Care program, Transforming Primary Care initiative. I mean, those things all really try to help practices move in that direction. Some of the work that we’ve done around building quality improvement, but what we need to do, there actually needs to be some resources from outside to help people get that because you can’t teach everything in medical school or PA school or nursing school. A lot of this is stuff you have to learn after you’re out there working, and having some resources to bear on that, I think, can have great effect and that’s probably where we need to invest some money, as well.
JULIE ROVNER: I’ve been doing this for 30 years, and one of the things, one of the continuing – I love the sort of that we’re always at a crossroads, you know, we’re having, yet again, a national debate over the role of the federal government in healthcare, which is, you know, we’re a little bit pregnant on that front at the moment. [Laughter] It would be very hard to back the federal government out of its role in healthcare, but there’s also all of these competing, you know, power centers. And I think that’s one of the reasons that healthcare sort of tends to grow as it grows. There’s nobody with a hand on the rudder because there’s everybody fighting to put their hand on the rudder. So is there a way to – if you actually sat everybody down and said quality improvement, you know, having the right workforce, are obviously, you know, sort of the keys to having a functioning healthcare system, is there a convening authority, place, way to do this where people could actually sit down and discuss this that didn’t – so we can get over this sort of hand-to-hand combat?
ROBERT McNELLIS: So here we are, Julie. [Laughter] You know, these are the folks who need to control that destiny to some degree. You know, certainly the federal government has some role in that. I mean, it’s one of the largest payers. I’ve heard it described as an insurance company with an army. [Laughter] It’s – you know, there are lots of drivers there, as well, and you know, as we talked about. Administrations will come and go. Policy will change. Healthcare will need to be provided to people. You know, disease, death, and disability are not going away any time soon. So one way or another I think we’ll work through this. What do they that Americans will try every possible event till they find the one that ultimately works, but I don’t know. You know, we don’t have yet that kind of body to do that. And I was reflecting on the way over here that once upon a time there was an idea to put together a commission to think about deliberate health workforce, what it should look like, where it should be, and that didn’t go anywhere either.
JULIE ROVNER: There have been so many of those.
ROBERT McNELLIS: There have, and we’ll continue to wrestle with that, but that’s our way, perhaps.
JULIE ROVNER: Ann?
ANN GREINER: Well, I think that uber is we’ve got to change payment because if we were actually incenting for patient outcomes and for reduced costs and for better health of the population and, you know, joy of the health professionals, it would be a very different delivery system. So we’re going to be waving that big magic wand. You know, that’s a big one. But I also think, you know, at the micro level the food fights don’t happen as much or as rigorously when you have patients and families in the room.
THOMAS JENIKE: Yeah, that’s a great point.
ANN GREINER: And, you know, because then the focus is on what are we doing to improve care for that patient? And it’s embarrassing to, you know, have the fights about who does what and all of that, and so I think that is a really important and transformative lever and I appreciate that CMS and the private sector increasingly, you know, you look, this is really a growing movement not just in acute care settings but also now moving into primary care and all kinds of settings to really bring that patient voice in. And, you know, we’re in early days on this. We have lots to learn about how to do that successfully but I think it can be transformative.
THOMAS JENIKE: So I have no idea what the body is, but I agree—
JULIE ROVNER: That’s why I asked. [Laughter]
THOMAS JENIKE: But I agree with Ann.
JULIE ROVNER: How could there be such a body?
THOMAS JENIKE: And I feel this probably has to be driven by healthcare professionals themselves rather than people that are just making policy, and I do believe – I agree totally with you, that I think until we address the reimbursement that it is contradictory to what we’re – like, we are still, right now, I’m getting reimbursed in a way that is incongruent with what we’re telling people that’s important. That’s just a mismatch and it creates a lot of mixed signals, it creates a lot of mixed emotions and motives. So until we get that I don’t think we’re going to be able to be aligned, and my sense is that it’s going to have to come from the consumers of healthcare and the deliverers of them, rather than just people that are writing laws. That’s just my sense.
ROBERT McNELLIS: And maybe there’s a role for AHRQ here, just say, because we’ve done a little bit of work on what kind of work force – what is the composition of people you need in primary care and how much do you pay them to go, and we’ve started to model that a little bit and we’re still tweaking it and we’ll get it out there, but in a primary care practice that serves 10,000 adults actively, if you have sort of roughly eight clinicians of various sorts, physicians and MPs and PAs and a variety of other health professionals to provide comprehensive high quality care at about – I think we kind of figure about $45 a month will build you a team that can deliver high quality care. And if we’re not paying that much per month per patient in that panel we’re not paying enough to get high quality comprehensive care. And I think we’ll do a lot of work to tweak that, but that’s the kind of work that might need to be done to figure out what is a rational payment policy for some of the things that we’re hoping to get out of healthcare.
JULIE ROVNER: For someone who’s ready to create a rational payment policy. I’m going to open it up to the audience and is there a microphone? Over here. I’ll get you next. And please tell us who you are.
RICK BLAKE: Rick Blake, the Institute of Family Health in New York and, by extension, the Icahn School of Medicine. Sixty-eight percent of our 800,000 patient visits are Medicaid and we are extremely – the first speaker in the panel spoke to the issues of payment and burnout and stress, but on the other hand, most of our doctors and residents are committed because of who we are and the kind of patient population we serve. So the payment issues related – right now, in Congress, I think Robert, you related to them, are pitting family health centers against DSH hospitals for the payment reductions. So we’re bundled into the CHIP bill, so we actually, in order to preserve the 79 teaching health centers around the nation, the DSH hospitals have to – the bill passed, number 1, but we are put in a really bad position and it’s not theoretical for us. We’re put in a very bad position in terms of retaining residents. We have to pay out $4 million – we have 40 residents, and most of them are residents of color or other ethnicities – the highest rate in the country. So these issues are not theoretical to federally qualified health centers as large as these do for family health, so my point is this. Given the current environment, because that is what’s shaping us all, frankly, how are we going to resolve not just the issues of physician burnout, but the possibility of rationing healthcare for those most in need.
JULIE ROVNER: Can I just stipulate, before you guys answers this, that it is curious for Congress to create a residency program with funding that’s shorter than a residency[Laughter]
ANN GREINER: Curious is a good word.
JULIE ROVNER: I don’t write the laws.
ROBERT McNELLIS: You’re looking at me. Everybody’s looking at me. [Laughter] I’m not quite sure where to go with that except I feel your pain. And, you know, I spent actually – it’s interesting. It’s been a meeting week for me. Last week at PCORI, so I heard a lot about the patient voice in research. Last couple days I spent talking about FQHCs and really how to support them in the work that they do, and I know they are doing God’s work. I mean, they’re there because they want to be there, but making ends meet and keeping the lights on are important and I don’t have a solution except that I think it’s important to think about that. We haven’t talked at all about delivering care in vulnerable populations and what that means, and I think that’s really, really an important part of the conversation that is getting skipped over, as well. So I’m afraid I don’t have a solution except to say that folks need to think about that.
JULIE ROVNER: Next question. Over here.
VIVIAN: Hi. I’m Vivian, I’m a family physician recently graduated from residency, so I’ve worked both in an underserved settings as well as in private clinic settings, and I wanted to ask – I know it’s something you guys alluded to, but if you could address more specifically consumerism and that involvement in the healthcare delivery. So there is my job, which is making sure my patients are healthy, and then there are some patients that, you know, rightly so, I demand to have my labs done. I want to know – and I have friends and family, one of them fractured his back jumping off a roof when he was a teenager, and he’s in back pain. He’s like, I want an x-ray just to know what it looks like. And some people, they have a headache, I want an MRI just to know what it looks like, and I don’t know how to say no. I mean, I get that, you know, but also I don’t think that’s the best care but then there’s also this consumerism aspect and part of me says, if you can pay $50 million go ahead and do that. How do you guys meet those things?
ANN GREINER: There is a great nonprofit called Costs of Care and they are international. They started here in the U.S.
JULIE ROVNER: By medical students.
ANN GREINER: What did you say?
JULIE ROVNER: Neel Shah was a medical student when he started it.
ANN GREINER: Yeah. And he’s a great guy, and they’re really, really helping health professionals to figure out how to have those costs of care discussions because that is not something that you learned, I imagine, when you went to medical school, and it’s tricky. And so they have three very basic things. They say that you need to do a screening of all of your patients to understand where they are financially. And it’s just the way you take the sort of – you know, any concern about doing that is it’s applied to everybody and you have that information and so you know, you know, do they have difficulty paying for their drugs, you know, what’s their insurance deductible – you have that information. Two, that the clinician actually has some basic knowledge about the treatment modalities and the various costs, so you have some information, and then, three, is that you’re customizing a plan. And they have these great vignettes on their website that really helps clinicians to have those kinds of conversations, because each of those conversations obviously then contributes to are they moving towards value? And it’s both sides of the equation. It’s the decisions that the physicians and other health professionals are making, and it’s, you know, what patients want. And so Choosing Wisely is a great campaign to help in the education of that. At the Patient Centered Primary Care Collaborative, we are in the SIMA grant, TCPI, and for years 3 and 4 of that grant we are going to be integrating Choosing Wisely into the patient family engagement work that we do to really help on that consumer side of the equation.
THOMAS JENIKE: So, from my perspective they do some of the hardest questions that you have to face day in and day out. I know when I worked in residency I worked in an underserved population and then when I worked in private – as in private practice I worked with a more affluent base. So I always kid that when I was in residency I was always trying to convince people they were sick, and now I’m trying to convince people they are not sick. So it’s a really difficult challenge and, you know, I believe that this whole thing of consumerism we’re just getting started. This is not going into U-turn, it’s only going to get more powerful. And I think one of the things for us, as providers, is to not be in resistance of it, just to understand this is just part of the landscape now and I think this not an easy answer, but I think part of it is just based on relationships, communicating, and then having data that we are now going to be able to use to explain to patients, this is the best thing for you. I know it may not be what you have to agree with, but based on millions of points of data, this is what’s best for you and best for your wallet. So, I mean, I think it’s just honest conversations, but it takes trust, it takes relationships, it takes time, which, of course, is harder and harder to do now in this fast-paced environment.
ROBERT McNELLIS: I have little to add except actually good for the patient for feeling empowered to ask for something from care, although I think it’s a negative they’re asking for inappropriate things. I think it’s good that, you know, patients feel empowered to ask – and good for you for knowing what’s appropriate and what’s not. And then what’s left is the conversation to bring those views together. And part of it is a relationship, and it’s going to depend on what your situation is, but I think those are two powerful forces that need to continue to move is people asking for things that they need and then you sort of helping guide them as to what is really helpful and what’s not. Those are two important things, I think.
JULIE ROVNER: Next question back there.
TAMMIE MAYO-BLAKE: Hi. My name is Tammie Mayo-Blake and I am with HRSA, the Bureau of Health Workforce, and I have a question about the team-based and interprofessional care. A lot of the grants in my division we give to medical schools, schools of allied health, and we are trying to push or urge them to integrate this into their curriculum and I just wanted to ask what kinds of things your organizations are doing to work with medical schools and schools of allied and behavioral health to help guide them to the idea of training their students in team-based interprofessional care?
ROBERT McNELLIS: I’ll just say, we don’t work directly with medical schools and actually we look to HRSA for workforce things. We think about workforce as it relates to who do you need to deliver the highest quality care. But what we do create are tools and resources that come out of some of the research that we do. So, Tammie, call me and I’ll point you in the right direction to, you know, whether it’s our team-based care stuff, or I think we have some good tools. You know, shared decision making and we have a variety of different things that might be helpful to you. But we don’t work directly with them, and if you do and you’re a vehicle to get that out, I’m happy to work with you or anybody here to get those materials out.
THOMAS JENIKE: So, for our healthcare system, which is a very big integrated healthcare system, if I think back five years ago, there was a lot of reluctance to do what you’re talking about, and a lot aligned with – sat within the physician, to be honest. Like, I can’t work in a team like this. I’m in control. I’m responsible. And what we have found over time, as we have started to help people understand why they’re burning out and then starting to lean in and say, okay, we want to help solve the solution, they’re much more amenable to now working with teams. So we now have a number of think tanks within our medical group that are saying how can we provide the future of primary care? What does that look like? And we’ve partnered with nursing schools, with advanced practice clinician schools like PA and MP schools where we now have them as rotating students, so already start to integrate them. We see this as the way out. And now there’s a lot less resistance from that because people really understand the why, both from a provider team standpoint and from a patient care standpoint.
JULIE ROVNER: Maybe one more question. Right there in the middle.
AMY YORK: Hi. I’m Amy York, and I’m with the Elder Care Workforce Alliance and I haven’t heard the word aging on this panel yet and I think it’s probably the elephant in the room, and a lot of what you’ve been talking about is training that’s been happening in geriatrics for years, and I’m wondering can we both train in geriatrics and team care at the same time because it’s really the entire workforce that’s going to need to be trained in geriatrics because of demographics, and what are ways you are seeing this happen? And the other piece is, too, that there are lots of opportunities I think in geriatrics for training opportunities for students, especially in the VA, is an interesting thing that I think could be really interesting, and that’s where a lot of folks have trained in geriatrics, so just a lot of thoughts and wonder where you guys are at on that.
ANN GREINER: Well, we obviously have such a shortage of geriatricians and I agree with you. I mean, if our policies related to residency slots don’t change I don’t think that’s going to change, so the notion of everyone having a basic skill set related to geriatrics makes a whole lot of sense to me. And I know some institutions think that way. I know of organizations that are doing this with primary care, which is also, you know, something that a patient presents and if they have a primary care need, in the KP system, for example, if it’s a surgeon, if it’s a radiologist, whoever it is, if you have the information in front of you and this patient has a primary care need, you attend to it. So it’s sort of like it’s everybody’s business because, you know, it’s the opportunity to address the patient need. And I think if we brought that same mindset to treating of elderly patients that, you know, everyone who touches them has an opportunity to provide the kind of more general geriatric care, we might be able to address these shortages.
THOMAS JENIKE: What I want to share is a novel thing, I’m sure, especially for you, but one of the things we are doing now is doing more intensive risk stratification based on health determinants and how people are – how healthy they are. Obviously, the elder generation typically fall into the higher degree of that, so we are trying to surround them with more services that aren’t just me as the provider, so care coordinators, social workers, all that are assigned to a pool of patients, specifically, in this case, geriatric patients so that they’re getting surrounded and enveloped with a whole coordinated care that it’s not dependent on the physician to, and his or her nurse, just to do it. So I think that’s one of the things that we’re trying to do is we understand that that is a high utilization thing, and those are the people that need the most services. They’re trying to wrap a whole continuum of care around that patient or that family, seems to really help take the burden off of the provider, spread some of the love to that geriatric patient, and give them better care. So that’s one of the things we’re doing at our institution.
ROBERT McNELLIS: And I’ll just close. You know, and I’ll say, perhaps we didn’t talk about it too much because there’s a whole ‘nother panel on older folks, but I would say that everything we talked about is applicable to older populations. As an aging Baby Boomer, myself, and having spent a lot of time in the VA, yeah, you know, I mean, I recognize that. I think our focus has been on sort of people with multiple chronic conditions, and how to take care of complex patients, which I think is directly applicable to older patients. So I think we’re doing some work on that and, you’re right, it’s coming. It’s going to be big.
JULIE ROVNER: Well, thank you all. With that I think we’re going to wrap up and move on.