2023 Signature Series Public Congressional Briefing: The Role of the U.S. Health Care Workforce in Achieving a Person-Centered Health System

November 1, 2023
12:00 pm-

1:30 pm

Event Description

A robust health care workforce is key to achieving a person-first health system. However, an increasing level of burnout among providers and growing concerns around projected labor shortages present new challenges to building and maintaining a diverse and resilient workforce.

This in-person event provided federal policymakers with a foundational understanding of the current health care workforce, identified key challenges that create barriers to advancing person-centered care, and explored potential opportunities for policy change. This briefing was the final event of the Alliance’s Signature Series, a yearlong program that engages key stakeholders in solutions-focused dialogue to envision a person-first health system.

This ticketed event was FREE and open to the general public. Attendees enjoyed a boxed lunch.


Patricia (Polly) Pittman, Ph.D.

Professor of Health Policy and Management, George Washington University
Patricia (Polly) Pittman is the Fitzhugh Mullan Professor of Health Workforce Equity at the Milken Institute School of Public Health, George Washington University, and director of the Mullan Institute for Health Workforce Equity. Professor Pittman built an extensive research enterprise focusing on policies that enable the health workforce to better address health equity, including protection of labor rights of health workers themselves. Her current portfolio includes directing a HRSA-supported Health Workforce Research Center and co-principal investigator for the National Technical Assistance Center to Address workforce Burnout (renamed the “Workplace Change Collaborative”), as well as several foundation-supported grants.

April Damian, PhD, MSc

Vice President and Director, Weitzman Institute
Dr. April Joy Damian is a psychiatric epidemiologist, health services researcher, and classically trained public health professional with expertise in health equity, social determinants of health, and mixed methods. She currently serves as the Vice President and Director of the Weitzman Institute, a national research, education, and policy center dedicated to innovation and impact in primary care for the underserved. Dr. Damian concurrently serves as a Senior Scholar for Health Equity at AcademyHealth, and holds a faculty appointment at Johns Hopkins Bloomberg School of Public Health. She is a well sought after speaker and thought leader in health equity, and serves in multiple leadership positions in the field, including on the National Academies Board of Children, Youth, and Families, Forum for Children's Well-Being, and AcademyHealth’s Board of Directors Standing Committee on Advocacy and Public Policy. Dr. Damian was most recently the inaugural Vice Chair of the Health Equity/PRO/Community Engagement Committee for NIH’s RECOVER (Researching COVID to Enhance Recovery) Initiative. Dr. Damian also previously served as the Director of Quality Innovation at the National Quality Forum (NQF) where she spearheaded the expansion of NQF’s portfolio on SDOH quality measures, and co-led the NQF Measure Incubator®, an innovative effort that facilitates efficient measure development and testing through collaboration and partnership, and addresses important aspects of care for which quality measures are underdeveloped or non-existent. Dr. Damian completed her PhD in the Department of Mental Health at Johns Hopkins Bloomberg School of Public Health and Master’s in Medical Sciences at Harvard Medical School. She graduated Phi Beta Kappa from the University of California, Berkeley with a Bachelor of Arts in Ethnic Studies, Highest Honors. She has worked with several reputable governing bodies, including the U.S. Department of Veterans Affairs (VA), International Organization for Migration (IOM), as well as local health departments, on policy and programs relating to improving healthcare access and quality for medically underserved communities. She is an inducted member of the Sigma Xi Scientific Honor Society, and has received numerous recognitions in honor of her role as a social change agent, including the Harry S. Truman Scholarship and the Robert Wood Johnson Foundation-funded Community Well-Being Warrior Award.

Murielle Beene, DNP, MBA, MPH, MS, RN-BC

Senior Vice President and Chief Health Informatics Officer, Trinity Health
Dr. Murielle Beene is senior vice president and chief health informatics officer at Trinity Health. She is responsible for strategic and visionary leadership in communicating complex trends to influence change to improve the impact of informatics on the systems of care. She also advances the activities of health informatics and analytics in support efficiency and effectiveness of healthcare operations with the primary goal of advancing evidence-based health practice through data, information and dissemination of knowledge and wisdom. Dr. Beene has over 20 years of health informatics and analytics experience in various positions. Previously, she served as chief nursing informatics officer for Trinity Health. She also spent 10 years serving as chief nursing informatics officer at the Department of Veterans Affairs. Dr. Beene also held health informatics positions at PriceWaterhouseCoopers, Matria Healthcare and Adventist Health. Dr. Beene holds a Doctor of Nursing Practice degree with a concentration in Health Information Systems and a Master of Science in Public Health from the University of Massachusetts at Amherst. She also holds a Master of Nursing Informatics degree from the University of Maryland and an MBA from Walden University. In addition, Beene holds certifications in Project Management from the Project Management Institute (PMP), Nursing Informatics from American Nursing Credentialing Center (RN-BC) and is a Fellow of the American Academy of Nursing (FAAN).

Farida Ahmed, MHS

Associate Program Officer, National Academy of Sciences
Farida Ahmed is an Associate Program Officer on the Action Collaborative for Clinician Wellbeing and Resilience at the National Academy of Medicine. Farida earned her Master of Health Science in Environmental Health with a focus on Healthcare Epidemiology and Risk Sciences at the Johns Hopkins Bloomberg School of Public Health. Prior to that, Farida worked as a social worker/ intensive care coordinator at the National Association of Drug Abuse Problems (NADAP). Farida worked as an Emergency Medical Technician in New York City before and during the pandemic. Farida also administered COVID-19 vaccines at Javits Center during the pandemic. Farida’s passion and dedication toward the well-being of the health workforce align with the vision of the Action Collaborative on Clinician Wellbeing and her long-term goal of being a physician and researcher.

Sheila Pradia-Williams, MBA

Deputy Associate Administrator, Bureau of Health Workforce, Health Resources and Services Administration (HRSA)
Sheila Pradia-Williams is the Deputy Associate Administrator in the Bureau of Health Workforce (BHW), Health Resources and Services Administration (HRSA), Department of Health and Human Services, where she provides overarching leadership alongside the BHW Associate Administrator. Before assuming her role in June 2022, Ms. Pradia-Williams was the Director for BHW’s Office of Strategy, Programs, and Partnerships, where she led implementation of strategic priorities and programs funded through the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the American Rescue Plan Act. Ms. Pradia-Williams has a passion for HRSA’s mission to improve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs. She previously served in leadership roles within BHW and its predecessor bureaus and with HRSA’s HIV/AIDS bureau. Over the span of her 28-year career as an officer in the U. S. Public Health Service, Ms. Pradia-Williams served in positions across the Department. She helped to coordinate and plan the confirmations of the Assistant Secretary of Health and Surgeon General, and managed the regulatory process for blood and biological products within the Center for Biologics Evaluation and Review at the Food and Drug Administration. Before joining the federal workforce, Ms. Pradia-Williams was a hospital pharmacist at George Washington University Hospital. She holds degrees in Biochemistry and Pharmacy from Xavier University of New Orleans and a Masters of Business Administration from the Robert H. Smith School of Business, University of Maryland.

Presentation: Congressional Briefing

Thank you to our 2023 Sponsors!






Sarah Dash: Good afternoon everybody. Hello. Welcome. I hope everyone had a fun Halloween night or whatever we all celebrate. Happy November. Welcome. So glad you’re here in person. My name is Sarah Dash, I am president and CEO of this amazing Alliance for Health Policy, and as we like to say at the Alliance, this is really your alliance. We are created by and for congressional staff, the health policy community in a very bipartisan way, in a stakeholder neutral way as much as possible. We appreciate you all being here in person and braving the blustery day. How many people is this your first Alliance briefing? Welcome. All right, welcome for venturing out.

Thank you if you’ve been to an Alliance briefing before, maybe you can take some time to meet a new person. We’re really honored to have you here. For 30 years, the Alliance has been a trusted educational resource for current and future health policy leaders, and we take that role really seriously. We look forward to continuing to convene meaningful conversations on pervasive health policy challenges, like the ones we’re going to be talking about today. If you don’t already follow us at allhealthpolicy.org or on LinkedIn, definitely check us out. One of the things we take very seriously at the Alliance is our role to listen first.

In a town where a lot of folks are trying to get their opinions through and for very good reasons, we get that, we have the role of being listeners and listening to multiple perspectives, and that includes your perspectives. Then, we try to incorporate that into our programming. I’m really excited for today’s program, which I’m always going to be like a failure at tech. Oh, there. Oh, look at that. That was cool. Okay, so today’s briefing is the culmination of what we call our Signature Series. The Signature Series that the Alliance does is a year long focus on a particular issue. This year, our series has been focused on the idea of envisioning a person-first health system. What does that mean?

Well, you might hear the terms patient-centered, patient-first, we went through a lot of conversations and really landed on this idea of person-first. How many of you have ever had to respond to a constituent letter? Anyone? Constituent? Yup. Okay. All right. Listen to your relatives complaint about healthcare. Anyone? Raise your hand. Raise your hand. All right, come on. It’s almost Thanksgiving, you all. You have a month to get ready, because I know they’re going to be asking you questions about our healthcare system. This idea of a person-first health system really comes about with the idea of when we say people, we are talking about Republicans, Democrats, no matter where you live, rural, urban.

No matter your race, ethnicity, gender, gender identity, age, any of that stuff. How do we collectively create a system that works for people? That is our responsibility as people in the policy community. What we did as part of our Signature Series is we brought together a very diverse group of thought leaders and experts and community leaders and people, and came together in two very interactive workshops. You can see the evidence there, exhibit A. There were sticky notes and it was very exciting. What came out of those two convenings really consisted of personal stories, people trying to navigate the healthcare system, what the public truly needs.

We asked this idea of what does good look like? I am sure you all have your own ideas of what good looks like, to navigate the care system, the role that innovation can play, and what we’re here to talk about today, the critical role that the healthcare workforce can play and needs to play. Because we cannot have, and our thought leaders were very clear, we cannot have a person-first healthcare system unless we have a workforce that is supported and capable of delivering that person-first care. Then, by listening to those of you in our bipartisan health policy community, we knew that you really wanted to explore these ideas about the workforce and how you as policy makers and people who hold the pen can really help.

We are thrilled today to have an expert panel that is going to be talking about these issues. It is going to be an on-the-record conversation. A recording will be available on our website. This wonderful gentleman in the back is going to make sure of that. You can follow us on LinkedIn, et cetera. Okay. We are going to have a really exciting keynote speaker who I’m going to introduce in a moment. Followed by this amazing panel which will be expertly moderated by Farida Ahmed, who is right here. She is associate program officer at the National Academy of Science. She’s going to introduce our panelists. Before we get to our panel, I am now pleased to introduce Sheila Pradia-Williams, Deputy Associate Administrator of the Bureau of Health Workforce at HRSA, the Health Research and Services Administration at HHS.

She’s going to be our keynote speaker. She has an amazing resume. She provides incredible leadership. She has a passion for her mission, as I’m sure you are going to hear, to achieve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs. She previously served in leadership roles within the Bureau of Health Workforce and its predecessor bureaus, and with HRSA’s HIV-AIDS bureau. Sheila, thank you so much for joining us today. Really appreciate you.

Sheila Pradia-Williams: Thank you for that wonderful introduction. I’m very pleased to be here today to talk about just that, the workforce and patient-centered care, and how the workforce certainly is a necessary part of that if we want to enforce that and strengthen it in here in the United States. Basically, in my role as the deputy, I’m co-lead of the Bureau of Health Workforce, and in HRSA, Health Resources and Services Administration, a big part of the work we do is around health equity. Making sure that underserved communities, those who are geographically isolated, who have economic issues as well, and really need access to healthcare, to make sure that they can have access to healthcare in a number of ways.

The way in which I’m particularly involved is through the workforce, making sure that that workforce is prepared to do it. Next slide, please. Oh, I’m sorry. I’m sure it will come as no surprise to anyone that we have health shortages. I think it’s everywhere. It’s been in the news and it’s in the newspapers, it’s in when you open your iPhone and you get updates. There’s usually something going on around health workforce and the shortages that exist there. It’s no surprise as well that we already had some workforce shortages and some supply issues, but COVID really exacerbated that in a number of ways. About 79% actually of the healthcare workforce has been affected by shortages.

It is something that we in HRSA and the Bureau of Health Workforce are really engaged in and trying to address. If you’re going to have patient-centered care, you certainly need to have an adequate supply. We talk a lot about adequacy, about having enough of, so where the supply meets the demand and people can actually access that care. When we look at some of our projections, so we have our National Center for Workforce Analysis, we provide projections on some key areas of workforce. Those include primary care, which we see now. We’ve just updated these numbers, and so our projections were just updated this past last week, and so this is fresh.

But I want to caution even when I give the numbers that it may not show the full effect of the pandemic. We still are looking at how COVID even changed the behaviors of those who are seeking care as well as how it’s affect the workforce in terms of burnout, retention, and those things. When we look at primary care physicians, we see that we have a 68,000 plus shortage of providers. We see that in behavioral health we also have quite a substantial shortage of providers as well as in oral health, in maternal care and OB GYNs, as well as LPN nursing. One of the points that I’d like to make is that we see these shortages in terms of the supply versus the demand.

But we also see that the shortages are more acute and, well chronic as well, in non-metro areas. The adequacy is even less so in non-metro areas, an area for us that we really pay attention to in the bureau. As we look at addressing these issues in the Bureau of Health Workforce, we have certain areas and certain aims that we want to achieve. One is to increase the supply. In our programs and in our funding, usually you’ll see one of these levers being pulled in order for us to try to rightsize the workforce, if you will. One is supply, which is dealing with the pathways in which individuals go into the health workforce and become providers.

We have a lot of programs that are, well, some programs, I wouldn’t say a lot, but quite a few programs that are focused on that pathways, getting folks into the health careers and increasing that supply. The other is about distribution. Sometimes with some of the health professions, it is really not about the actual supply, but the fact that there’s a maldistribution. You have some areas of the country that may have an oversupply while other areas of the country may not have enough. That’s another issue that we look at through some of our program. Especially our direct service scholarship and loan programs like National Health Service Corps, nurse corps.

Those are programs that address that maldistribution, through loan repayment and scholarship. We also seek to advance health equity. Another part of that is, where is this workforce coming from? Is it diverse? Are we pulling and bringing people into the workforce who are from rural and underserved communities? Do you have people who speak different languages or the languages of the population that they’re serving? Those are the kinds of things that we’re also focusing on. Then, of course, really trying to promote the resiliency of the workforce, looking at those systems type issues that sometimes cause burnout and cause people to leave the field.

We do know that during COVID quite a number of folks also left the health professions, especially in nursing and some other professions. Then, of course, we try to amplify our impact by making sure that that whole pipeline, from training, from education to training in service, we fill in that whole pipeline so that we have individuals who are prepared, who’ve practiced and trained in community-based settings to go back and work in the areas where we need them to work. Some of the drivers for success. When we look at how are we going to improve the workforce, the quality, the supply, there’s a whole different, a bunch of different levers that we will employ.

One is to recruit students from the communities where we want them to serve, because we know that that makes an impact. Individuals are more likely, if they’re from a disadvantaged background or if they’re from a shortage, to go back and work into those areas. We know that is one of the things that we seek to do and one of the targets that we have in a lot of our programming, is to target individuals from the communities where we want them to serve. Another is to train students in underserved communities as well as to support community-based training. All of that flows together. Then, to leverage our loan and scholarship program.

A lot of times what we hear is that individuals who come from economically disadvantaged backgrounds are hesitant to take on student debt. If you can provide scholarships and loan repayment in return for service, that is very helpful. Then, of course, when we look at how do we combine or integrate things like behavioral and primary care, how do we make sure that folks are trained in a team-based environment? A lot of our programming aims to do that as well. When we look at some of our outcomes, this next slide really is about some of the outputs and the outcomes that we have had in the programs. When we look at our pipeline and diversity programs, much like what I talked about earlier, these are some of the numbers.

We’ve trained over almost 300,000 in our pipeline programs. Meaning, taking people who were either students or who may even have been in a paraprofessional area of practice, maybe CNAs, like your certified nurse assistants or something. Then, taking them through a career pathways where they can become maybe a nurse or maybe they can become a behavioral health specialist. The other thing is in our loans and scholarships programs we also have seen quite a big jump in our numbers. Especially with the ARP dollars. We had a lot of individuals who came through the programs who are now able to practice and we had a field strength of over 24,000, which is the first time in history that we’ve had that many individuals actually practicing in those areas.

Then, so you can go and see, these are just our training numbers for medicine, our behavioral health, nursing. These are individuals that are either entering into the profession, most of them entering into the profession through our training programs. Also, some individuals who are then already health professionals, but then who are being steered into either primary care or being steered into underserved areas. When we look at some of our cross-cutting measures for the program, we know that, so we have targets for our program. About 77% of our programs or clinicians who have been provided training in community-based settings.

Again, as we set targets, we set targets for people to train in these underserved areas. We set targets for them to be in underserved communities and training sites. This is the outcomes of what we’ve been able to achieve through our programming. These are very important benchmarks that we try to meet. We have some that we are still developing. Sorry. If you see the number of completers and graduates who are minorities, this is going a long way to increase the diversity of the health workforce. About 46% of all of the people who came through our programs were underrepresented minorities or they came from disadvantaged backgrounds, as well as 59% of our alumni go on to serve in underserved communities.

That’s a baseline there for us. In future years, we want to achieve even more than that. One of the things that we really focused on is our partnerships. In order to make all of this happen, it’s not sufficient to have just academic institutions providing education, but you’ve got to piece the whole pipeline together, the pathway together, which means there has to be partnership at the academic level. There needs to be partnership with the clinical sites, and there needs to be partnerships with community colleges. All of these come together, our federally qualified health centers, rural health centers, and the like, our tribal, they’re very important partners for us.

We’ve looked at ways in which our funding can extend to them because many times when they’re able to train, they’re able to retain those providers. We know that it’s a very critical point for our programs and something that we’ve continued to do and to focus on as we go forward. Some of our programs, and I’ll go through them very quickly, so some of our priorities are around supporting mental health and especially youth mental health. One of our policies is to make sure that there’s no wrong door. Behavioral health and primary care integration is very important. These are some of the programs that we’ve funded through the Bipartisan Safer Communities Act.

We funded primary care training and enhancement program in January for about, I think we’ve funded about $58 million in that program. The others are our behavioral health workforce and education program for child, adolescent, and young adults, and our pediatric specialty loan repayment. All of these are expanding providers to deal with mental health, especially when it comes to youth. In terms of expanding access to primary care, again, we have a constellation of programs that have been funded in PCTE, we call it PCTE, and especially our teaching health center, which is up for reauthorization right now. But that program is residency and it takes the residency training out of hospitals and puts it in communities.

Again, doubling down on how do we get primary care providers in communities. Then, of course, growing our nursing workforce. In August, we announced about a hundred million dollars to increase the number of nurses, our registered nurses, advanced practice nurses, nurse midwives, LPNs, who largely work in long-term care facilities. We’ve not only looked at creating a pathway for individuals to go into nursing, but also looked at how we could train and to strengthen the nursing faculty component and nursing clinical preceptor component. The same thing with public health. We really look, when we talk about patient-centered care, we invested a lot, $244 million in community health worker program.

Those are the individuals who are the trusted individuals in the community that connect people with care. We also provided scholarships through the public health workforce, through the public health training centers, and then funded preventative medicine residency programs. Certainly, here are some of our resources that you’re welcome to take advantage of to get data. We have dashboards on the workforce and we invite you to connect there and get more information and data. Thank you.

Sarah Dash: All right. Thank you so much, Sheila. That’s amazing work and thank you for sharing some of those results. Now, I’ll turn it over to you, Farida, for moderating our panel. Thank you. Let me give you the clicker. There you go. Fabulous.

Farida Ahmed: Hi, everyone. My name is Farida Ahmed. I’m the Associate Program Officer on the Action Collaborative for Clinician Wellbeing and Resilience at the National Academy of Medicine. Prior to this, I was an emergency medical technician and associate worker in New York City. I also obtained my master’s in health science with a focus on healthcare epidemiology and risk sciences at the Johns Hopkins Bloomberg School of Public Health. I’m very happy to be here today with you all. In today’s event, as Sarah spoke about, we’ll focus on giving a practical overview and take a look about the healthcare workforce in order to be able to give that person-first health system.

We’re going to explore the opportunities and challenges of envisioning a person-first health system that prioritizes the healthcare workers. We are going to also discuss the current realities of the healthcare workforce, address workforce shortages, discuss optimizing workers to the best of their abilities and how to build a robust workforce for the future. You’re going to hear from four amazing speakers, including myself, and I’m going to give a brief introduction of all these speakers. First, we have Dr. Patricia Pittman, who’s the Fitzhugh Mullan Professor of Health Workforce Equity at the Milken Institute School of Public Health, George Washington, and the director of the Mullan Institute for Health Workforce Equity.

Dr. Pittman built an extensive research enterprise focusing on policies that enable the health workforce to better address health equity, including protection of labor rights of health workers themselves. She’s currently working, she directed the HRSA supported Health Workforce Research Center that is now called the Workplace Collaborative, among several initiatives that she’s worked on. Next, we are going to hear from Dr. Murielle Beene, who is the Senior Vice President and Chief Health Informatics Officer at Trinity Health. Dr. Beene is responsible for strategic and visionary leadership in communicating complex strength to influence change, to improve the impact of informatics in the system of care.

She also advances the activities of health informatics and analytics and support efficiency and effectiveness in the healthcare operations with the primary goal of advancing evidence-based health practice through data information and dissemination of knowledge and wisdom. Finally, we are going to hear from Dr. April Joy Damian. Dr. Damian is a psychiatric epidemiologist, health service researcher, and classically trained public health professional with expertise in health equity, social determinants of health, and mixed methods. She currently serves as the vice president and director of Weitzman Institute, which is a national research education and policy center dedicated to innovation and impact in primary care for the underserved.

Dr. Damian also is a senior scholar for health equity at academy health and also holds a faculty appointment at Johns Hopkins School of Public Health, my alma mater. Before I turn it over, I’m going to give a brief overview of what we do at the National Academy of Medicine and the Action Collaborative for Clinician Wellbeing. I titled it Activating a National Movement for Health Workforce Wellbeing, because in order to be able to have that person-first health system, you need to prioritize the wellbeing of the health workforce. I know we’ve spoken a lot about data, and so sometimes I’m very hesitant to talk about data and to talk about the burnout crisis.

Because I feel like we already know, and so I think it’s about time we talk about solution, talk about moving forward and what next in the future. I’m just going to skip over this and give a brief background on the National Academy Clinician, which now is the health workforce because we want to be very inclusive. This was established in 2017 as a public private partnership committed to reversing trends in the burnout that we see in the health workforce. We have the coaches, Dr. Victor Dzau, who’s the president of the National Academy of Medicine, Dr. Darrell Kirch, president emeritus of AAMC, Dr. Vivek Murthy, who is the Surgeon General, and Dr. Thomas Nasca, who is the CEO of ACGME.

The goals of this collaborative was to raise the visibility of clinician burnout, depression, moral injury, and suicide, improve the understanding of challenges to health workforce wellbeing, advanced evidence-based multidisciplinary solutions that will improve patient care by caring for the caregiver, and also laying the foundation for long-term culture change. That’s what we are really focusing on this time. We have different members, including some of the sponsors for this series that are part of our collaborative, because it’s a joint effort. Our steering committee comprised of members from the government, different professional societies, health IT companies, and all.

As I said in the goals, before I go into this, it was always academia research consensus report. In 2019, the collaborative published a consensus report that was titled Taking Action Against Clinician Burnout, which is a systems approach to professional wellbeing. But that was talking about frameworks and systems, level of changes that could be done. We felt like we needed to move forward, we needed to have action plans. In 2022, the Office of the Surgeon General, and our president usually jokes as it being like a one-two punch, released the advisory on building a thriving health workforce. We had the national plan for health workforce wellbeing.

The vision of the national plan was that people are cared for by a health workforce that is thriving in an environment that fosters their wellbeing as they improve population health. Enhance the care experience, reduce cost, and advance health equity, and therefore achieving the principle in which everyone wants to achieve. One of the things that really inspired us is we want to have collective action because it takes different actor groups. We are inspiring collective action to provide a roadmap to improve the wellbeing of the health workforce in order to ensure that health workers can properly care for their patient.

Promote population health while we are also at the back promoting their health and making sure that we are prioritizing the wellbeing of the health workforce. The national plan, and Dr. Sheila spoke about the drivers for success, the national plan has seven priority areas, and that’s what you see on the screen. The first one is to create and sustain a positive work and learning environment and culture, to invest in measurement, assessment, strategies and research, to support mental health and reduce stigma, address compliance, regulatory and policy barriers for daily work, engaging with effective technology tools, institutionalizing wellbeing as a long-term value.

That ties with the laying the foundation for a long-term culture change. Finally, recruiting and retaining a diverse and inclusive health workforce. These are the priority areas. The national plan has goals and actions and just gives some guidelines on how to be able to move these forward. Like I said earlier, the goal is to inspire that collective action. The national plan calls out different active groups that will be able to move these levers forward and ensure that the health workforce is being prioritized and their wellbeing is being prioritized. Some of these include the federal, state, and local government, and we have health IT companies, we have patients themselves.

We also need to hear from the health workers themselves. We are including everybody. As I’m ending, we have different stakeholders that we are working with to ensure that this work is moving forward, and we are not just having the national plan. We are moving forward, we’re making sure it’s being implemented. In October last month, we celebrated our first anniversary of the national plans release. Since its release, we’ve been working behind the scenes with different stakeholders, as I mentioned earlier, to ensure that they’re moving these forward and they’re prioritizing the health workforce. Actually, we launched our changemakers campaign.

That is meant to be able to spark a national movement to support the health workforce wellbeing. We have different events and convening that talks about different workforce issues in rural areas and different settings. Also, something that is very exciting is that we are planning a national day for health workforce wellbeing. We are working with the federal government and national partners to be able to make this a truly interprofessional day for everybody, so that we are including the whole health workforce and we are propelling solutions and driving it forward. As I end with this, I just wanted to end with a quote that the National Academy has in all their publication. Knowing is not enough, we must apply.

Willing is not enough, we must do. This is by Goethe. As I transition to Dr. Pittman, I just want us to also have this quote at the back of your mind. I will turn it over to Dr. Pittman.

Patricia Pittman: Thank you so much. Good morning everybody, or good afternoon. Are we past the noon hour? I guess good afternoon. I will try to provide perhaps a deeper dive on a few of the issues that Sheila mentioned. The programs that HRSA has that really target the maldistribution and the problems of access are critical to this nation. They’re very different than the programs coming out of other parts of HHS. They’re primarily focused on primary care, which is what we need to have built up. But I do want to just have a moment of recognition of just how critical the work is that HRSA is doing. I don’t do this, say this as a grantee or a friend. I say this as a American who really caress about the healthcare workforce.

HRSA does an incredible job of helping us redirect the workforce to population needs. I’m going to talk a little about maldistribution and attrition and some of the policy levers to address them. This is a framework that we use at the Mullan Institute at GW, and the idea is that health workforce issues are more than just a shortage. There are all kinds of issues, from who enters, how they’re trained, how and where they’re deployed, whom they serve, how they practice and under what working conditions. Workforce is a broad area of policy. It’s not just produce more warm bodies. On the issue of the physician shortage, there are lots of projections and the new projections out of HRSA are really interesting and important to look at.

But we know that we spend a lot of money training physicians, and this is just… Where we go. This is just a summary of the different programs and what they amount to. We spend annually almost $21 billion training physicians in this country. This is apart from what HRSA does on pediatric training and the teaching health centers, which is teaching residency and community health centers that are very important and distinct. It’s really important to see what we get for that. These are the residency matching numbers from 2023. What you can see here obviously is that family medicine, internal medicine are not as popular. We have a problem of graduating physicians who are not as interested in going into primary care.

This is an age old problem. It’s not a new problem, but it is chronic and we are having a difficult time addressing it. COGME recommends about 40% of our physician workforce should be primary care. When we are graduating folks from the residency, it actually adds up to about 54%, but after the residency, so we have a problem in residency and matching, when you include OB GYN and peds, it actually goes up to 54 and then we lose them through the specialization process. This is largely driven by the issue of income. We have a problem in the way we pay physicians because it’s driving the maldistribution by specialty. It also is driven by geography.

If you look for example at the Millbank’s scorecard on the number of primary care physicians per 100,000 just really briefly, you can see that there are incredible differences across states in terms of access to primary care. We have a huge problem of geographic inequality. When you think about this other dimension of whom they serve, we also have a problem of physicians and organizations that physicians work in not being willing to serve Medicaid patients. You can see here, this is a tracker that we’ve just released at the Mullan Institute. You can look by profession on the left hand side, family medicine, internal medicine, pediatrics, OB GYN, and click and the map will change into the density as well as in the volume of Medicaid patients that they see.

But it’s really important to note that there are many professions that have, there are about 30% of their clinicians are actually not seeing Medicaid patients, and that’s a problem. Whom they serve also really matters. It’s not just having the warm bodies in a particular district. What are the policy levers? Obviously, we’ve got a lot of money at stake here, if you think about the graduate medical education bucket. There’s a lot that could be done to make sure that we get more on that investment in terms of meeting the population needs. There’s an IOM report, now called National Academies of Medicine, that lists many, many recommendations that were produced by experts and researchers.

Those recommendations have sat on a shelf for over 10 years, and really there’s very little movement in this area. The targeted health workforce programs that HRSA does are incredibly important, community partnerships that HRSA does are incredibly important. Then, on the practice side, we need to really be thinking in a much more focused way on advocating for higher pay for what matters. In particular, primary care, mental care, care in rural areas, and care for the underserved. We need targeted practice supports. The ECHO Project, which provides educational support in real time to clinicians in underserved and rural areas is a real stunning success.

Telehealth, obviously, holds lots of promise as well, and scope of practice reform, so that nurse practitioners and other kinds of advanced practice nurses and PAs can practice to the full extent of their education and license. Just to focus briefly on nurses, the story is rather different. I think that many people today would agree that it’s largely a problem of the working conditions. We have a lot of nurses in this country and almost a million of them are not practicing. They’re licensed nurses. We have a pipeline problem, yes, but what we really have is a problem of attrition. On the issue of distribution, like medicine, it is not the same across states.

HRSA’s projections show that in particular the shortfall is greatest in Washington. We do have oversupply nevertheless in a few other states. Looking at distribution again for the nurse workforce is really important. But basically in terms of the pipeline, we are not far from meeting our needs. If we produced 195,000 nurses a year, we would be meeting our needs going forward. We actually produce in the high 180s now, and we have in the last 20 years been increasing the number every year. The programs that are addressing the bottlenecks in the pipeline that HRSA does, including the nurse faculty positions, are really important, but it’s not the main problem.

The main problem is the leaky bucket. We know that in 2021 we had over a hundred thousand full-time nurses that left nursing, and that most of those nurses were under 35. Most of that attrition happened in hospitals and the hospital vacancy rates continue to be really high. We know that 39% of nurses are planning to leave in the next year and 28% plan to reduce hours. Now, plans are not always materialized, but these are what people say in surveys. 60% of critical care nurses in ICUs are planning to leave in the next year. We have a real problem in terms of attrition. The number one reason that people say they’re leaving is inadequate staffing.

There are a couple of other things that are worth noting in some of the surveys. Of those who reported frequent mandatory overtime, they were 72% more likely to have quit in the last two years. As you all know, some states have mandatory overtime prohibited and others don’t. Those who reported less favorable work environments were 55% less likely to have quit. Moving on here, because we’re running out of time, I think the main policy levels here are safe staffing ratios for hospitals. This can happen through Medicaid, it can happen through legislation at the state or at the federal level. We need to measure staffing, staffing levels. We need to measure turnover, and we need to include it in comparative hospital statistics like HospitalCompare.

Eventually, I think about including it in value-based payment schemes. We need to reduce burdensome regulatory and accreditation processes. We need to have better protections against violence and harassment, whistleblower protections. Then, we need to incentivize organizational change. We can talk more about that perhaps in the Q&A, but there are lots of ideas of ways that the federal government could encourage healthcare organizations to do a better job in terms of both staffing and other more general working conditions. Thank you.

Murielle Beene: Good afternoon everyone. I told you I was going to do this. I wanted to first say good afternoon. I wanted to first provide a brief overview of our healthcare system. Trinity Health, who I represent, is one of the largest Catholic healthcare systems in the United States. We are a family. We’re a family of 123,000 colleagues that come together, and more than 26,000 clinicians caring for diverse communities across 26 states, or 27 states. We’re nationally recognized for care and experience, and that includes our 101 hospitals and 126 care locations. We also have our PACE program that is also the second largest program of all inclusive elderly program in the country as well.

I know that we’ve talked a lot about our healthcare shortages in the country, and what Sheila has said and what Dr. Pittman has already articulated, these things are not new. We did come together at Trinity to try to think about our workforce just a little differently because, as Dr. Pittman has outlined, these issues are multifactorial. It’s not something that is a one size fits all, as we think about workforce challenges as it relates to healthcare and our healthcare professionals across all disciplines. At Trinity, we thought about all of the communities that we serve. We thought about how could we start to look at this and think about this differently.

What we do know, even though there are ways to look at the nursing shortages differently, we do know we have a problem. What we started to think through is saying, “Okay, what could we do to at least look at our workforce for nursing differently?” We thought about the innovative approach that we can take together, we call our approach Together Team or Together Team Virtual Connected Care. It’s a three-person care team model where we have a bedside RN, an RN partner, and a virtual nurse. The value of all of the teams or these people, these actors working together in on this team is that the team look at, when they’re working together as a team, they look at workload.

Their workload is balanced through the team and how they take care of the patients that they have. The other piece of the virtual nurse specifically is that that virtual nurse can also provide that experienced nurse to earlier career nurses that may be on that team. Also, provide that mentoring, that early mentoring that that new career nurse may need. These are the four tenets of the model, culture, people, technology, processes, and these are things that are not new to anybody who’s looked at processes and technology and culture, as you look at anything with workflows or when you look at any type of initiative such as this one.

The innovation actually comes in when we start to think about the way that the model is implemented, the way the team looks at their workload, and how they bring these actual pieces together. We are committed to listening to our colleagues who are nurses. We are invested in the culture to keep our nurses safe psychologically and in their environments. We want to make sure that they feel empowered to take care of the patients in the communities that we serve. At the current moment, we are live in eight states and we have approximately 173 virtual nurses on board. The one thing that you learn through an innovative model is that you learn something literally every single day.

We are pivoting, learning, reincorporating our learnings every day, literally. We are teaching and just reinnovating as we implement, as we move along. These measures are our leading and lagging indicators. We look at the areas of impact to our colleagues and to our patients. These are ones that we’ve just defined in this phase of our innovation. But again, as we learn forward and as we lean into what we define as our pathway to success, we learn from our measures and we definitely will reroute or redefine them as we learn into our new model. One thing to mention too, as we start to look at some of the earlier insights that we’ve learned from our program, we do have decreased, we’ve seen that we have decreased RN turnover.

We do have increased patient satisfaction. But like I said, these are very, very early insights into what we’ve learned today. One quick, I won’t read the whole slide, but this is one of what innovation actually looks like when things start to come together. This individual was somebody who was a skeptic. He actually was a person, Steven was one of the maintenance mechanic that actually helped us install the very cameras that we used in our program. He ended up being a person who was a patient in one of our hospitals. Then, while he was implementing this, helping us implement this program, he got ill. This actually make him, he became a believer after he actually experienced the model.

He became a skeptic. He was skeptic and then actually experienced the model and then figured out that, “Wait a minute, this wasn’t half bad.” It was interesting to see that and hear that from him, especially working as closely as we did with him. Really quickly, what could be done and what levers can be pulled or used in support of what we’re trying to do is to really fund these type of initiatives. They’re really important as we start to think through all of our workforce challenges. I know Sheila and Dr. Pittman talked about all the good work that HRSA is doing with building that strong pipeline.

We continue to support those type of programs that would help a lot to help in this space as well. Also, building up that resilience in the workforce and in the existing workforce as well. Now, we’ll turn it over to April.

April Joy Damian: Okay. Always a challenge to be the last speaker when people just finished lunch, so I will try my best. As mentioned earlier, so I oversee the Weitzman Institute, which is a research education policy center. We have different offices. I’m based in one here at D.C, and our priorities are to focus on optimizing health outcomes, particularly in vulnerable populations. Our three priority areas are in social determinants of health, workforce development, and systems transformation. Our founding, the Weitzman Institute, we were found out of a federally qualified health center, Community Health Center Inc, in 2007, which is based in Connecticut.

We continue to focus on FQHCs, which arguably are the backbone of America’s safety net system. If you’re less familiar with FQHCs, just a brief background. FQHCs nationwide serve about 31.5 million Americans, largely vulnerable, marginalized populations. Two thirds identify as people of color, 68% or another two thirds fall below, a hundred percent below the poverty line. About half are on Medicare and another quarter are uninsured. During the pandemic, I know we’ve heard about workforce shortages, it’s actually gotten worse. The latest workforce survey that was done by the National Association of Community Health Centers or NACHC, noted that 68% of health centers across the country reported a 25% attrition rate.

They lost up to 25% of their workforce during the pandemic. I think it’s important to note this because when you have a workforce that is working with the most chronically complex patients in the country, it’s important to know, how do we support this workforce? Today, as part of talking about patient-first healthcare system, I really want to focus in on community health workers, or I’ll be referring to them as CHWs, probably not new to this crowd. To really understand what their role is in building a robust healthcare workforce, that not only supports the workforce, but also patients most in need.

Part of the challenge right now with us falling short of a person-first healthcare system is that leadership, as well as those who are patient facing, don’t necessarily relate to or represent the lived experiences of the patient populations that they’re serving. It’s particularly true in marginalized and vulnerable populations. There needs to be some bridge building in terms of how do we make the workforce that is facing patients better relate to or representative of the patient populations that they’re serving? CHWs, which are now a bonafide workforce according to the Bureau of Labor Statistics, there’s 86,000 CHWs nationwide. In the American Rescue Plan, there was a call from the White House to add another a hundred thousand CHWs.

They usually share, as noted in the keynote, the ethnicity, language, socioeconomic status, and life experiences of the communities that they’re serving. About 45% being bilingual and another 75% identifying as a person of color. CHWs, as you may know, have recently garnered a lot of attention because of the increased attention towards health equity. Particularly social determinants of health, and realizing that CHWs can play a role in addressing and moving the needle on to health disparities. When I was approached with this topic, I wanted to make sure that when we are talking about a person-first health system that we talk about or include the voices of patients themselves.

A lot of all the quotes that you’ll see in the next few slides come from a study that we did at Community Health Center Inc. Where we actually interviewed patients, diabetic patients who are managed by one of our CHWs, Leonore. I’ve noted the citation of our article there if you’re interested. Over the next three slides, going over how CHWs add value to the system through three areas. One, addressing social determinants of health or SDOH, improving health outcomes, and last but not least, restoring the healthcare’s system trustworthiness. Before I joined Weitzman, I actually oversaw the SDOH portfolio at the National Quality Forum. I oversaw the development of the first quality measures in SDOH.

As many of you know, SDOH being the factors, the upstream factors where we work, live, pray, play, and age account for 70% to 80% of healthcare outcomes. It’s not enough to focus on the four walls of clinical practice, but looking upstream. I remember one of the challenges when I was working at NQF, that was brought to my attention from clinicians, is saying, “Okay, even if we screen patients for SDOH and we identify patients who are positive for housing insecurity, food insecurity, and other challenges, how in the world do you expect us to address these and close the loop on referrals in a 15-minute visit with a billion other quality measures that we’re expected to report back to our funders or to health plans?”

Just knowing that CHWs are really a trusted members of the community, they have nuanced understanding of community resources and how to address these different social challenges. During the interviews that I conducted with Leonore’s patients, some of them talked about having challenges with transportation. The reason that Leonore is able to find out from them, that the reason they were missing their appointments was because of lack of transportation, or that these appointments were being done in the middle of the day and that they couldn’t take time out of work, being hourly workers, to be able to make their appointments.

When our healthcare system would otherwise label these patients as non-compliant or no shows, really understanding what are the root causes of why these patients aren’t able to make their visits. I attempted to include a quote here that captures that notion. By addressing these root causes, CHWs have been shown to save Medicaid $4,246 per beneficiary. If we scale that up to 15% of US Medicaid beneficiaries, it would save taxpayers $47 billion annually. I just captured here, you can take a screenshot, that there have been RCTs and different studies that have been done to show the return on investment when we really look at CHWs.

I included a quote here in terms of diabetic patients whose hemoglobin A1C significantly dropped as a result of working with Leonore. My last point about CHWs is the importance of restoring the health system’s trustworthiness. Note that I didn’t say having patients better trust our healthcare systems, and really the onus is on us, in knowing that trust cannot be earned overnight. 15-minute visits with their healthcare systems or with the healthcare teams is not enough to build trust. What does it mean for CHWs who mirror the demographic makeup of the patient populations they’re serving? To be able to have the linguistic and cultural sensitivity of the patients they’re serving to actually be part of a team-based care model.

Really understanding, how do we recruit a more diverse, robust workforce that better looks like the patient populations that they’re serving. In closing, I wanted to note three recommendations of where do we go from here. One is proper training, right? At Weitzman, we do a lot of upskilling. Dr. Pittman talked about Project ECHO. We provide those services with CHWs and knowing that we need to… Something happened to the slide. Okay. I’m not sure what happened.

Sarah Dash: I think we’re working through some tech issues.

April Joy Damian: Okay.

Sarah Dash: It’s not you.

April Joy Damian: Okay. Yeah, so understanding that we need to invest in CHWs, right? It’s not enough to recruit them, but also retention is important, upskilling, making sure that we are investing the proper resources so that CHWs feel as a valued part of the healthcare team. I’d say the second is expanding the scope of practice. Really understanding that there have been recent studies in terms of the role of CHWs, not just in addressing the upstream factors of SDOH, but also addressing major challenges from mental health, substance use disorder, maternal child health. Then, the third, selfishly as a health services researcher, knowing that we need to improve and invest in building the evidence for CHWs.

To be able to advocate for CHW workforce sustainability means building the evidence of how do CHWs work in what capacity and for what health conditions. Knowing that by investing in the CHW workforce is really helping to advance health equity and also our person-first system. Thank you.

Farida Ahmed: Thank you so much. Can we all give them a round of applause for this wonderful… Thanks. We got to hear, and thank you once again for setting the stage and giving us context and a wealth of information. We heard mainly that this is a multifactorial issue and there’s a lot of things that could be done. There’s no one way of going around and solving this problem. As I kick off today’s Q&A, I just wanted to start with this question, acknowledging that is a bit dreamy, but then we can hope. What is that one action or what is that one strategy that can thread everything together in order to move the wheel and help us get to that person-first health system? I think Dr. Patricia, would you like to start it off?

Patricia Pittman: What a question. Oh my goodness. To get one thing that has to do with the workforce shortages that relate to person-first?

Farida Ahmed: Yes.

Patricia Pittman: Well, I would go to where the money is first, to tell you the truth. I would go to GME and I’d unpack that and I’d rebuild it.

Farida Ahmed: Is there anybody else that would like to address this?

Murielle Beene: I agree.

Farida Ahmed: Yeah, I definitely agree also with, you have to go where the money is and be able to distribute it through a health equity lens as well. With that, I’ll just open it up to the audience and take some questions if there are questions. You also have some white sheets on your table, so you could write your question as well if you’d like. Yeah, we open it up.

Sarah Dash: I’ll ask the question because I’m not shy. Okay. You have these, if you’re shy, you can write your question down and someone will come pick it up. But if you’re not shy, then we welcome everybody. I have a question. Thank you all so much for your presentations, for working on this. I’ll just go right to where some of the controversy is, around scope of practice, right? We can talk about shortages in absolute numbers, but then you mentioned CHW scope of practice. This has been a conversation that’s been stuck for a really long time, right? Do you see any movement in it?

Do you think we’re starting to get to the point where we’re in a place where we can actually have some movement to help people, to free and liberate the people to practice at the top of their licenses and really then thus free up the time of the people with the most specialization to do what they really need to be doing? What does that conversation look like as we move forward? So that the people who are on the front lines of dealing with it from a policy perspective, how do they start to address some of these questions?

Patricia Pittman: You want me to go for it? There actually has been a lot of movement on scope of practice, particularly for nurse practitioners and physician assistants, or now physician associates. Less so with nurse anesthetists because of the opposition of anesthesiologists. I think it’s one of the few areas of health policy where there’s bipartisan support. It’s an issue of the free market. The problem, of course, the AAMA is seeing that this is happening and they’ve just stood up this big campaign to oppose reforming scope of practice laws in the states that still have restricted laws. It’s something that I think is really felt by their grassroots membership. It’s an authentic concern.

Their concern is that this is cheap labor replacing them. I personally believe that the evidence is incredibly robust, that nurse practitioners and physician assistants can do a really good job, particularly in primary care, and supplant some of the work that physicians are doing. But it’s been such an either/or debate that it’s really been hard to get at what are the best ways to put together teams? What are the best ways to… how does this relate to comparing actual care delivery models and looking at outcomes over time? We need more evidence on that, not just the all or nothing scope of practice issue, I think is a really important thing.

But there’s no denying that the train left the station in terms of the number of clinicians, primary care clinicians that are growing in this country. It is nurse practitioners. It is not physicians. The physicians have been flat, nurse practitioners have taken off. In terms of the people who actually see poor people, Medicaid, 95% of the growth of the primary care Medicaid workforce are nurse practitioners and physician assistants. It just is happening. It’s happened. I think it would be helpful for the AAMA to change gears and begin to talk about how do we make this happen in a way that is best for all clinicians and for patients, and not just, absolutely not, we’re not going to look at this issue at all. No, no, no, no.

Murielle Beene: The one comment that I would add to what Dr. Pittman said is that also allowing the permission or the space or that innovative space to allow these type of models to grow and to enculturate as well. Because that’s the only way that we’re going to learn of how people can use and work at the top of their license. Then, giving that permission to then having the right people doing that right work within those models. Then, to Dr. Pittman’s point of studying that and looking what the impacts are on outcomes. We need the permission and space and we need the funding to support those type of efforts.

Those things are pretty much far and few between. People are doing them on the side of their desk. If we had a concerted effort of how we could get that type of work more organized to do that, it would help as well.

Patricia Pittman: The other thing is, the graduate medical education versus what NPs and PAs are getting post-graduation is shocking and scary. HRSA does have a primary care nurse practitioner residency program, but it’s peanuts. I think graduates, and Margaret Flinter leads it, and I don’t know, maybe 60 or 70 NPs graduate a year. They are true believers that that makes all the difference in terms of patient outcomes and patient safety, and the nurse practitioners feeling confident in their roles. But as a federal government, we’re not investing in any real way in graduate nurse practitioner or physician assistant education. The contrast with how we use taxpayer dollars for physicians is shocking.

April Joy Damia…: I’ll just add in terms of CHWs that I had to mention in the beginning of my talking points that they’re now recognized in the Bureau of Laborer Statistics. But CHWs are not new to the workforce in general. I think the US is actually behind a lot of low middle income countries. CHWs have been around for decades, promotoras, health promoters, lay workers, this is not new. It’s new to us, but not new to the rest of the world. We wrote actually an article in Health Affairs, you can look up. We just laid out the evidence. We couldn’t take a position because it’s very challenging because some of this varies by state in terms of CHW certification and competencies.

The American Public Health Association has had an interest group on CHWs for decades. To your question, it’s progressing, but very slowly. The White House explicitly calling out the need for CHWs in response to the pandemic, whether that be educating to counter misinformation, to administering vaccinations, so we’re seeing more traction. The challenge is that it’s still not agreed upon in terms of what exactly do CHWs do and don’t do. Knowing that at the end of the day, it comes back to the money, like, what is billable services? Who’s going to pay for these CHWs?

They sound like a great idea, but if you don’t have a Medicaid 1115 waiver to cover the SDOH related efforts, how are you going to pay for CHWs to retain them? I think that’s part of the challenge with the workforce shortage and scope of practice, that we do a lot in terms of recruitment, but retaining the workforce I think is where we start bleeding a lot. Not investing in CHWs and how do you pay for services that they provide? Because certainly with Leonore, we had to pay for it creatively, I would say, through a state-based grant. It’s very challenging in terms of how do you build out a robust CHW workforce within a busy practice.

Farida Ahmed: Thank you. We have a question.

Speaker 7: Thank you. Building on the comments that you just discussed. I’m a nurse practitioner and I wonder if the shift to accountable care payment arrangements is going to facilitate team-based care. I’m also a palliative care nurse practitioner, so I’m used to practicing with physicians, social workers, communicate the health workers. I think if we could shift to a model that paid for teams, we could figure out who needs to be on the team and then who needs to see what patient. Physicians would have an important role on that, although, I might add not as the leader, the automatic leader of the team. That’s something that interdisciplinary teams often don’t need a leader.

But I think that there’s a way to work collaboratively and let everyone practice not only to their highest scope of practice, but also move the work down to the right level. There are things that nurses could do that neither physicians nor NPs should be doing, but under the current fee for service system, we do because we get to bill and they don’t. Can you comment on, am I just waiting for a future that’s not going to happen, or do you think that might be one solution?

Patricia Pittman: I’m interested to hear if Trinity is shifting the way they use NPs as a result of any participating in ACOs or any other kind of value-based payment. But in general, I think 10 years ago when ACOs began, everyone thought that it was going to have this incredible change in terms of how the workforce was configured. That we would be using RNs and primary care and that NPs would be going much more integrated teams. I think in general, people have been disappointed that there hasn’t been as much transformation of the care delivery as they thought. However, actually, we just finished one study that shows that you do see much more home care from NPs and physicians in ACOs than those that are not under the Medicaid ACOs, which is interesting and encouraging.

That’s a big change. But I think that the problem is that it is because payment is so fragmented with all the different payers. Even if you are an ACO under Medicaid or Medicare, or a private insurer, it doesn’t relate to your entire patient population and therefore the incentives, we just haven’t gotten to the tipping point. I think that’s the story with value-based payment in general and why it hasn’t affected the workforce as much. I’ve been an advocate for having more proximal outcomes in our value-based payment. If you want to have a social worker on the team, don’t just pay for outcomes, pay for or require that there be a social worker or that there be a community health worker.

I think that that goes against the grain of, the economists don’t like to dictate what folks should do. They want to just provide a reward at the end of the rainbow. But the problem is, it’s just not enough money to change behaviors. If you have very little money, you might as well tell them what you want.

Farida Ahmed: Dr. Beene, do you have anything to add onto that?

Murielle Beene: Actually, I was going to ask my colleague that’s in the audience that probably knows a little bit more than I do, for her to respond.

Farida Ahmed: Sure.

Murielle Beene: Maggie. She’s a little bit more closer to these type of policy matters.

Maggie: Thanks, Murielle. Actually, Trinity Health is one of the leading systems in value-based care, I guess if we call it that. I think that’s even a question of what do we even call it? But yeah, we have clinically integrated networks in most of our states and we have some really strong experts in population health, and how do we do this and make it sustainable? I think that’s the biggest problem, is our system is still so fee for service heavy. To think about a 27-state system trying to make this sustainable and to be doing this all day every day is just, we’re just not there yet.

We always try and think about how can we focus on our APMs that we’re working on now and were in every model that CMMI has ever put out, but how do we focus on being sustainable now while we bridge to that future where hopefully ACOs and other APMs are the norm. It’s really tough time for hospitals. How do you get to that phase? Because for a model like Together Team Virtual Connected Care, that’s the whole point, is really to be able to have that team-based care and have the work where it should be. But we are far away from being in a payment system that fully supports that.

Farida Ahmed: Thank you so much for that. We have a question right here. I think it goes to Trinity Health. Are there any estimates of how much money, or Dr. Pittman can answer this as well, how much money is wasted when we lose these healthcare workers, when we are not able to retain them? How much does it cost to go and recruit again in that turnover rate?

Murielle Beene: Yeah, the general estimates, I would have to look up though because we had just done this analysis, so if I could have a minute, I can look it up actually.

Farida Ahmed: Sure.

Patricia Pittma…: In the meantime, there’s a NBER paper that just came out that tries to quantify the cost to healthcare systems of attrition due to burnout. The first thing that they measure, which is traditional, is the cost of a turnover. In the case of nurses, it’s about 52,000 a year as of 2023. But in addition, what they did, which was innovative, is they looked at the effect on patient satisfaction and the effect on, I think there was another outcome as well, and translated that into payments that systems would not be receiving as a result of falls, declines in their quality scores. Anyway, it’s a whole methodology, if anybody’s interested. I know Sisi Hu is an author, Tiffany Chan is an author, NBER. You can Google it.

Farida Ahmed: Thank you for that.

Murielle Beene: Our organization, same with just Dr. Pittman just said, we looked at a whole host of, and they’re still doing the analysis that’s why I don’t have it. Because we look at not only the cost of turnover, but there’s a lot of things that go into the quantification of how much that actually costs the organization every time that we have RN turnover. I know the estimates were almost about $70,000 per RN turnover, which is pretty high if you start to do the multiplication over 27 states times thinking of the units, times, times, times. You could also think exponentially how much that costs a healthcare system.

Farida Ahmed: Yeah, I think that’s why it’s very important to retain the health workforce system. Also, show this to leadership, if you’re trying to obtain leadership buy-in, and emphasize that return on investment when they retain that members. I think we are out of time right now, but is there a last question? Yes, we have a last question here. Yes.

Speaker 9: Sorry. I have a final question. I’m really interested in the concept of telehealth and how that might possibly help with some of the workforce shortages, but I also understand state licensing restrictions and interstate practice issues and all of that would come into play. Is there anything that can be done at the federal level to help alleviate some of that?

Patricia Pittma…: Well, there’s a movement towards compact licensure, and that’s really going to help. It’s largely a result of recognizing the importance of telehealth. But I think the issue of parody and payment for telehealth is huge, and that’s absolutely a Medicare issue and a Medicaid issue. But I think we saw during the pandemic there was this skyrocketing in the use of telehealth and it was actually really beneficial in terms of improving access. It’s now come down a little, but as a result, consumer’s and provider’s attitudes have changed. I think there’s a lot of excitement about making sure that the payment is adequate to be able to continue the incentive.

I think there are some concerns about fraud that it could be overused. MedPAC is concerned about fraud, so there’d have to be some checks and balances, but I think overall it’s really promising in terms of addressing some of the workforce shortages for sure.

Farida Ahmed: Thank you for that. I think we have time for one more question right there.

Speaker 10: I have one question for clarity. Someone said that there were more nurses in Washington. Did you mean Washington State or Washington, D.C?

Patricia Pittma…: Oh, state.

Speaker 10: State?

Patricia Pittma…: They’re going to have a shortage. They’re one of the worst shortages. Yeah.

Farida Ahmed: I think we have time for one more question. I saw your head.

Speaker 11: I was just curious. Could you talk about the role of patient reported outcomes and patient reported outcome measures in person centered care, things like tools that Phreesia and Promis are developing? I’m curious, specifically with Dr. Beene, if you see a role in some of the new models that Trinity is working on in Promis.

Murielle Beene: There’s definitely a role in that and, actually, it’s in our second phase because we’re thinking about that. We’ve been working with our EHR vendor on how to think about patient reported outcomes. It’s one of the pieces of stabilization that I think will be critical. I know it’s a very hard concept for people to get their hands around, but it is definitely something that we have framed in our second phase of our implementation. Thank you for the question.

Farida Ahmed: Well, I think we are time. Thank you so much to everybody for your time and thank you to our wonderful panelists for your input and insight. I’ll turn it over to Sarah right now.

Sarah Dash: Great. Thank you. Thank you so much, Farida. Thank you so much for our panels. Can we give them one more round of applause? Thank you. Thank you. I think it’s so clear that we are asking so much of our healthcare workforce and to really see the numbers really puts it in just our perspective. It’s really heartening to hear about some of the innovations to try to both build the pipeline and retain the workforce, but also, I think it’s obviously so clear that we have our work cut out for us. We’re, again, grateful to all of you and to Sheila who was here earlier for an enlightening discussion. Thanks to all of you for your questions too.

I just want to encourage you to think of the Alliance for Health Policy as a resource. Check us out online. Send us a note. If you have questions about whether it be telehealth licensure or patient reported outcomes. Chances are we’ve done a briefing on it at one point. We know experts on it. We have a database of hundreds and hundreds of experts from across the country that our team will try to get back to you as quickly as possible with information and resources or connect you to someone who does have the answer to your questions. Again, do check us out. Also, all of our past briefings are pretty much available and free online.

If you want to check out our archives at allhealthpolicy.org. We’ve done, I know someone for you and I know some people for you too, so check us out. Okay, so this has been the final briefing in our 2023 Signature Series on envisioning a person-first health system. We’re really excited that we will, in the coming couple of weeks, months, we will be issuing a report of the 2023 Signature Series. It’s going to include some of the hallmarks that our thought leaders really came up with. I think you’ll be very interested and surprised to see how much alignment there is across multiple sectors of the healthcare system, industries, community leaders, et cetera.

There really is quite a lot of alignment and I’m hopeful that you will all take the time to read that when it comes out and really consider how it might be useful in your work. In the meantime, we have some quizzes on the tables. Those are really just evaluation forms. We would love for you to fill that out. You will also get an email if you prefer to do it electronically. We just like to combine the old world and the new world here, paper versus electronics. But do fill it out. We like to consider ourselves a learning organization, so we take it all into account.

With that, stay network a little bit longer, grab some food if there’s still some left. Come back to our future briefings. Let us know what you want to hear about and learn about. We take that all into account in our programming. Thanks again.