The Role of the Health Care Workforce in Delivery System Reform

(Please note this is an unedited transcript, please refer to the video of the event for direct quotes.)

SARAH DASH:  Good afternoon, everybody. Hi, thank you so much for joining us today. I’m Sarah Dash, President and CEO of the Alliance for Health Policy, and on behalf of our staff and on behalf of our staff and board of directors, thank you all for coming to today’s briefing on the role of the healthcare workforce, and delivery system reform.


For those who are not familiar with the Alliance, we are a non-partisan organization that is dedicated to advancing knowledge and understanding of health policy issues and we want to invite you, if you want to tweet at today’s briefing, at #futureofhealthcare, to go ahead and do so.


A couple words about this briefing, it’s the final briefing in what has been a three-part series on the healthcare workforce, and it’s the final briefing in a year-long program that we’ve done on the future of healthcare; both in conjunction with our 25th anniversary as an organization and wanting to look at some of the broader issues that are important to our healthcare system, beyond the day-to-day that we may all focus on. So, we are really thrilled to be here. I want to thank the sponsors of the year-long series — Anthem, Ascension and Health is Primary, for their support throughout the year, as well as those who have supported the workforce summit series, the AAMC — the American Association of Medical Colleges, Leading Age, and the Eldercare Workforce Alliance, for their support. So, thank you very much.


I’m going to briefly turn the mic over to Elizabeth Hall, Vice President of Federal Affairs at Anthem, for a couple of opening remarks.


ELIZABETH HALL:  Thank you so much, Sarah. On behalf of Anthem, we are really excited to be partnered with the Alliance and their other sponsors on the Future of Health series. The future is very exciting, and on behalf of our 53,000 employees and over 3,000 clinician employees, we know that it is the people who really put “care” in healthcare.  As I said, it’s really a very, very exciting time, and we are really interested to hear the insights that the panelists have to offer today, because we are taking those insights, and we are applying them faster and more effectively than we ever have been able to before. And I’m just going to note one thing that we are working on at Anthem through our CareMore subsidiary, is that we have challenged every member of our team to help us address social isolation amongst seniors. We are just about six months into this project. We have amazing anecdotal results from that project, and we can’t wait to share with everyone the clinical outcomes that we have found. But that takes our clinicians, as well every part of our workforce. So, again, we are very excited to hear the insights today, and to be able to take those and apply them. Thank you.


SARAH DASH:   Thanks so much, Liz. Next, I will turn the mic over to Kirsten Thistle, representing the Health is Primary campaign.


KIRSTEN THISTLE:  Thanks, Sarah. Again, I’m Kirsten Thistle, I’m the campaign director of Health is Primary, and I know Sarah is probably sick of hearing me ask this, but how many people have heard of the Health is Primary campaign, Alright. It gets better every time. Health is Primary, for those of you who don’t know, is a collaboration of the eight family medicine organizations in the U.S. Our goal really is to showcase the value of primary care and highlight the tremendous innovation and transformation that’s happening, and delivery system.  I just want to give a shout-out — I don’t know if Liz just left, but we have been featuring a lot of the work that CareMore, the Anthem subsidiary, has been doing, just in terms of integration, it’s really great work. Some of their case studies are featured on our website. It is pretty extraordinary, when you look at the value of primary care. We have data that shows that for every dollar spent in primary care, there are $13 saved in downstream costs, which is a pretty extraordinary ROI. But we certainly can’t do it without a strong primary care workforce. I know hopefully everyone is aware that there are issues on primary care shortage, so certainly important that we are talking about this today, and hard to believe that we are at the end of this journey with the series, but I think lots more to do next year. Never a dull moment in healthcare. So, thanks again, Sarah, to your team, and to the Alliance for putting this event together.


SARAH DASH:   Alright, well, thank you again. You’ve heard a little bit of background of why we are doing this briefing. For those who maybe have been following the Alliance’s work over the last couple of months, we’ve done several briefings around delivery system reform, and we often talk about delivery system reform and value-based care in one bucket, and workforce — supply, demand, shortages, team-based care, kind of in another bucket. So, part of the purpose of today’s briefing, is really to try to bring those two topics together and talk about the people who are in fact delivering on the delivery system reform, and what that means for them, and what delivery system reform means for improving both the way that care is delivered, and the impact on the workforce, and what kind of workforce that we need to achieve a high-performance healthcare system.


We have a really excellent panel today to help us explore these issues, and I’m going to go ahead and introduce them, before they give their presentations and we get into a Q&A.


To my right, to your left, is Tim Dall. Tim is Managing Director for HIS Life Sciences Consulting, and has more than 20 years of experience conducting research and policy analysis in the areas of health economics, health workforce, healthcare delivery, and disease cost and prevention. Tim earned his Master of Science in Labor Economics from the University of Wisconsin Madison, and his Bachelor of Science in Economics from Utah State University.


Next, we’ll hear from Bob Phillips, who is Vice President for Research and Policy for the American Board of Family Medicine. He’s also a part time practicing physician in a community-based residency program in Fairfax, Virginia, and a professor of family medicine at Georgetown University, and Virginia of Commonwealth University.  He obtained his medical degree from University of Florida College of Medicine, Master of Science in Public Health from University of Missouri, Columbia School of Medicine, and his Bachelors from the Missouri University of Science and Technology. Welcome.


Next, we’ll hear from Cheryl Phillips. Cheryl is President and CEO of the Special Needs Plans or SNP Alliance, a National Leadership Association for Special Needs and Medicare and Medicaid plans serving vulnerable adults. Prior to this, Cheryl served as Senior Vice President for Public Policy and Health Services, at Leading Age. She obtained her medical degree from Loma Linda University School of Medicine, and Bachelor’s Degree from University of the Pacific. Welcome.


Next, finally, we will hear from Blair Childs, who is Senior Vice President of Public Affairs for Premier Inc. Blair is the primary spokesperson and communication strategist for Premier, on key issues impacting healthcare costs and quality. Previously, was Executive Vice President of Strategic Planning and Implementation for AvaMed, the Advanced Medical Technology Association. And Blair holds a bachelor degree in History from Middlebury College.


Welcome to all of you. We are excited for today’s discussion, and I’m going to go ahead and turn it over to Tim Dall, to kick things off. Thanks.


TIM DALL:   Great. Thank you for the introduction. The work that I do, is a lot of work for the Federal Government, for state governments, and various associations and other entities on modeling the health workforce.


To get started, I will just briefly describe how we do the modeling, and then talk about what some of our findings are. The purpose of course, of modeling, is to make sure we are training the right number and mix of health professionals to meet the demand for services. I’m going to be talking just about at the national level, but recognizing that across the U.S., there is a substantial geographic variation and adequacy of supply. But I will focus on the national level for today. In terms of workforce supply modeling, it’s fairly straight forward. You start with the current workforce, you model how many people are retiring, you model how many new people are entering, and how many will be there the next year, and you keep simulating this over time. Even though it’s fairly straight forward, as you might imagine, there is always data issues that you are encountering, and unknowns such as:  Are there shifts in trends in retirement, and hours worked patterns? Taking into account the changing demographics of the health workforce, and what the supply will be in the future. On the demand side, it’s a little more complicated, and the way we do it is we first need to model what are the characteristics of the population both now and into the future? What we do is, we use mostly national data sources, some state data sources, and create a representative sample of the population. For each person, we know things like their demographics, the presence of disease like diabetes, heart disease, lifestyle choices, like:  Do they smoke? Are they obese? Information about their household income and insurance. And we know this and project it out into the future. Then, what we do, is we look at current patterns of healthcare use and staffing to develop a baseline or status quo scenario, which is, if we don’t charge how care is used and delivered, what will be the demand for providers out into the future? Then that allows us to do those “what if” scenarios. What if we change the way that people use healthcare services, or how it’s delivered, and what would be the implications for the health workforce?


This graph right here shows some different scenarios on the demand side that we did for physicians. There are a lot of lines there. Basically, the solid lines are the demand projections, and the dotted lines are the supply projections. The main point to take away here, is that under the various scenarios that we model, in most cases the demand for physicians is above the supply. And that leads us to believe that, as we go out over time, that we have a growing shortfall of physicians. This is at the national level. If you have a growing shortfall at the national level, it will tend to exacerbate problems at the local level, especially for those areas that are already having challenges recruiting and retaining providers. We’ll look at the nurse supply, this is work done for HERSA. We get the exact opposite. A decade ago we were training about 75,000 nurses a year, now we are training close to 160,000 a year and we seem to have overshot the mark. Whereas, a decade ago, we said we would be short a million nurses by 2020, and now we are projecting that we are training too many.


As we think about, what exactly does it mean to model a high-performing healthcare system? There are a number of organizations that have helped to define what exactly that means. It boils down to a handful of things. Coordinating care across delivery settings, and across provider types, targeting the high-risk population and managing their chronic disease, meeting various population health goals, and improving the efficiency with which we provide care. And you can kind of break this down into two major categories. One is, those clinical things that effect people’s health, and then more of the behavioral things, or the staffing that affects people’s use of healthcare services, or how the care is delivered.


I’m going to present some results from our clinical modeling, and the part on healthcare use and delivery patterns, it’s an ongoing process that we hope to have some results within the next month, and it should be published in the spring.


Let me go back a slide here. What we modeled on the clinical side was some achievable outcomes. If we can get people who are overweight and obese to lose five percent body weight; the recommendation is 10 percent, but if we can get them to lose five percent. If we can get people to better manage their blood pressure, their cholesterol, the blood glucose levels, along the lines that we have seen in the published literature. If we can get 25 percent of the people to stop smoking — which is an achievable goal, although there is a high attrition rate in terms of a recidivism rate. What we are still working on is, if we can divert people out of hospitals and emergency departments, back into the community, and there are things that will keep them — change how they use the care. If we were to meet those population goals that were very manageable, that I mentioned, what happens is, everybody gets a little bit healthier, but people live longer. That’s a good thing. But by 2030, if we had met these goals within the past year or so, by 2030, we modeled that there would be an additional 6.3 million people alive. These are mostly elderly people, most of them are age 75 or over, and most of them have chronic conditions, but they are better managing them. So, what does that mean for the health workforce? In the short term, for physicians, what it means is that you might get by with fewer physicians because everyone is a little healthier, and they are not using the services. But over time as the population grows faster than what the census bureau projects, because people are living longer, you need more providers. Such that by 2030. We calculate that if we can live a healthier life, we will have more doctors in the future, by about 15 to 16,000. Percentage wise, it’s not a whole lot compared to an estimated 950,000 or so positions that we might need at that time, but it means more.


Similar with the nurses, we model that. If we were to meet these kinds of goals by 2030, we’d need about an additional 100,000 registered nurses beyond what we would need if we didn’t meet these kinds of goals.


So, conclusions. People think that by changing the way we deliver care, we can save money, we can reduce the demands on the healthcare system. And there is a lot of truth to that, especially in the short term.  What we estimate, is that in the long term, you would actually need a larger workforce, because the truth is, if you can keep people alive, they need more healthcare services than people that are dead. So, sometimes people, when they’ve looked at some of our workforce projections, and they say, you are overestimating the demand because everybody is going to be healthier as we transform the healthcare system. And that really only works in the short term. What we find is, in the long term, under this scenario, you actually would need fewer of certain types of specialties. For example, endocrinologists. We could reduce the demand for endocrinologists by about 10 percent. For physicians like cardiologists, you might not have too much of an increase in demand, because everybody is healthier, but they are living longer. For other things, like geriatric medicine, you might need to increase — demand might increase by about 10 percent, relative to what you would need otherwise, because people are living longer. So, I think those are the main takeaways. Is that healthcare reform and ways of better managing care is good. Extending life is good. Having people live healthier is good. But it doesn’t necessarily mean we need fewer doctors and nurses, and other health professionals in the long term. Thanks.


SARAH DASH:   Thank you.




Go ahead, Bob.


ROBERT PHILLIPS:  Thank you. So, I’m going to talk about this question about whether training means practice, and practice means training. I want to start with — Kirsten introduced Health is Primary, and the fact that eight family medicine organizations across the country have come together to lay out both the communication and the strategic plan.  And at the start of that, five years ago, they asked a group of us to develop a 100-word definition; a role definition of what a family physician should be, in order to really work in a reformed health system.


I want to start with something we developed in the course of that, we called the foil definition. It’s kind of holding a mirror up to the profession to say what they are doing now. But before I do that, just to lay out what I’m going to talk about, I’m going to talk about what robust primary care is, and why it matters to a reformed health system. Asking the question of whether the market knows the value of robust primary care, and is ready for a prepared workforce. Then finally, some evidence about the fact that we train physicians to do robust primary care, and we need to let them do it. So, the foil definition starts like this:  That the role of the U.S. family physician is to provide episodic, outpatient care in 15-minute blocks with coincidental continuity, and reducing scope of care. The family physician surrenders care coordination to care management functions that are divorced from their practices, and they work in small, ill-defined teams whose members have little training, and few in-depth relationships with the physician and patients. The family physician stars as the agent of a larger system whose role is to feed patients to some specialty services and hospital beds. And the family physician is not responsible for patient panel management, community health, or collaboration with public health.


I’ve done this talk across the country, with this foil definition, and I hear gasps, I hear chuckles, because a lot of family docs come up to me afterwards and say, that is exactly what I do. That is what my health system, my employer in particular, expects from me. And that’s not what the reformed health system needs. In fact, Farzad Mostashari, the former Director of the Office of National Coordinator of Health Information Technology, last year published a paper summarizing some of the evidence around robust primary care, and what it can accomplish. And he said, recent evidence suggests that small physician owned practices, while providing a greater level of personalization and responsiveness to patient needs, also have lower average cost per patients, fewer preventable hospitalizations, and lower re-admission rates than do larger, even independent and hospital owned practices. Yes, we are driving increasingly, primary care physicians into these larger and hospital owned practiced. Interestingly, the quality payment program seems to be doing that quite a bit, because these small practices are incredibly fearful of surviving in a value-based payment model, largely because they can’t report their data, not because they can’t deliver better outcomes.


In terms of a robust primary care, it’s usually characterized as delivering comprehensive, high continuity, strong care coordination, and first contact care. That is a definition developed by Barbara Starfield, and studied by her over the years, and we’ve tried to now translate some of those four C’s into measures. And so, we actually published a paper in 2015 around comprehensive care with the Robert Graham Center, and we were able to demonstrate, as care comprehensiveness increases, hospitalizations go down, and expenses go down. And not just Part B Medicare expenses, which are the payments to the physicians, but Part A, the hospital based costs go down. And we have a paper under review right now, showing that as you increase continuity, as you deepen the relationships between providers and patients, that costs go down as well. In fact, we demonstrated a 15 percent reduction in costs, 35 percent reduction in hospitalizations, with high comprehensive care, and we have another paper coming out demonstrating that physicians who do in-patient care and deliver babies, actually have a 30% lower risk of burnout. So, you are hitting on two of the quadruple goals of lowering costs and improving joy of practice. Then continuity reduces the risks of costs in hospitalizations, both by 13 percent, if you can get to a high level of continuity. So, the things we need those primary care docs to do, that they can do right now in small practices in particular, actually helped the health system.


The American Board of Family Medicine surveys all graduating residents as they are coming out. It’s really a cross-sectional census. They have to answer these questions in order to sit for their boards. What we learned is, almost a quarter of them want to deliver babies. They were trained to do, and they feel competent, and want to do it. Over half want to see their patients in the hospital, and over half want to take care of women when they are pregnant, even if they don’t ultimately deliver them. Then when you do the same questionnaire later of physicians in actual practice, we find that less than 8 percent are delivering babies now, and that’s going down. Less than 10 percent are doing prenatal care, and only about a third are able to see their patients in the hospital. The message that we had in JAMA two years ago about this, was that we are preparing a workforce for a model practice they can’t find. We’ve started to ask them about that specifically. What we’re finding, is they are coming out of training, about 90 percent of them go directly into an employed position. 40 percent of those folks tell us they could not find a broad scope job. They couldn’t find one that would allow them to do what they trained to do.


Now I want to switch really quickly to something we call “imprinting”. In the literature, this is talked about with parents imprinting on their children about behaviors that they learned just by association and watching their parent’s behavior. This actually happens in medical school in residency training too. We study this. We ask the question, “Can we identify the cost behaviors of an institution and see if their trainees going out into practice continue to operate that way?” And the answer is, yes. So, we study general internal medicine and family medicine trainees, and looked at the hospital referral region in which they trained, to see if that pattern of cost behaviors was carried over. And what we found is that, physicians who trained in low cost areas, became low cost physicians. That’s the column over on the left. And those who train in high cost hospital referral regions, became high cost physicians. And if you put a low cost trained physician into a high cost area, the difference between their behaviors, and their peers, right next door to them, was about a thousand dollars per year, per Medicare beneficiary. When we go the areas down even smaller to hospital service areas — so, you are looking at single training institutions, the difference is almost $2,000. And the first one, we published in JAMA, the second in the Annals of Family Medicine. And the striking thing is that this behavior pattern lasts for up to 15 years. So, I can be working right next to another physician we trained in a different cost basis, and we will practice differently for up to 15 years before we start to look like each other. So, it is a long impact. So, my question is, why not harness this? If we know we can imprint certain behaviors — and I will tell you, in our second paper, we showed we do not imprint quality behaviors. So, the thing we try to teach, we don’t actually imprint. The thing that is done culturally, and sociologically, we do imprint very strongly. But why can’t we harness this and continue to train a physician workforce that does exactly what we need them to do in terms of what a reformed health system needs? But the second problem is that we have to give them a place to do that. And so that’s the real opportunity. I think we are training a lot of physicians who are prepared to work in a reformed health system, and the challenge next is finding them jobs that will let them do it. Thank you.




SARAH DASH:  Thank you. I want to ask a quick follow-up question. Bob, you mentioned the quadruple aim; and for those who maybe haven’t — can you just explain that a little bit more? What is the quadruple aim?


ROBERT PHILLIPS:  Sure. So, it grew out of the triple aim, which was lower costs, better care, and can anybody tell me the third one? Hope? More satisfaction. But mostly for the patients. See, the quadruple aim really then builds on, well, what about the providers? That became kind of joy of practice, which Krisinski, who is an AMA, has really championed. It’s:  Can we do all of the other things, and make it a better experience for the providers? So, when I brought up the quadruple aim, we can demonstrate that we are touching on at least two of those in high functioning primary care, and the rest we have to study further.


SARAH DASH:   Great, thank you. Maybe we will get to some of those questions around the physicians and workforce experience of practice and burnout versus joy of practice, which seems like a great goal. Before we turn to Cheryl Philips, I’m going to apologize for a brief technical message. If some of you are trying to get on wi-fi, I think the papers on your tables are incorrect. It’s “resolution” singular, so just in time for your New Year’s resolution. Maybe. Thank you, Cheryl.


CHERYL PHILLIPS: Thank you all for being here. I’m going to shift directions just a little bit. So, just a context background about me.  I’m a geriatric physician. Geriatrics sort of balances between the primary care specialty world — but as a past president of the American Geriatric Society, AGS is very involved in workforce, including the Geriatric Workforce Policy Center, and focus on home and community based care. When we talk about what is needed in the environment of home and community, physicians are critically important. We probably need to train over a thousand geriatricians a year to catch up by 2030, and we train about 240 a year. So, we’ve got a gap. But it’s not a physician issue alone. The success of home and community based care is that wonderful powerful intersection of the entire team. And I know we say that kind of like jargon, like, oh yeah, it’s team-based care, but that’s what the richness of home and community based service is. And we have a challenge with workforce.


So, I’m going to talk a little bit about direct care workforce. Direct care workers, also known as personal care workers, and sometimes misassigned as unskilled, unlicensed, non-professional, which are all the wrong terms, because the direct care workforce is phenomenally important, and increasingly so. So, we are going to talk about some of the challenges — I will start with the problems, but then I want to get into what are some of the exciting solutions and how we can better use. Every geriatrician has to have the demographic slide, that’s required, otherwise they take away our board certification.


So, this just shows what all of you know, is that the senior population is growing, and we are here. This is also — and I want to thank Leading Age for some of these slides — Susan Hildebrand will make a more formal connection later, but Leading Age has been working on workforce, and has provided some of these slides. But this is some of the workforce needs, particularly in areas of growth. And you will notice that the number one area of new jobs projected are personal care aides, or the personal care workers. The growing demand in the U.S. — this is the percentage of increase between 2010 and 2030, and it’s estimated that we need over a million personal care aides by 2030. And we are going to talk a little bit about why this matters. So, the shift from — and I hate using the “F” word, facilities, but the moving away from congregate settings like nursing homes, where people want to manage their lives, age in place, as we say, in the community. We have an incredibly rich ethnically diverse both population of older Americans, but also a population of workforce. We also have an increasingly demanding — and I say that with a positive deed, not a negative, of older Americans who now have greater expectations of what their services are, and as well as their complexity of care needs. And we need lots of policy solutions, and that’s why we’re here.


We could spend an entire time talking about that. I want to call out the Leading Age Center for Workforce Solutions, because there are solutions to some of these challenges. But let’s talk about what the power of these home and community-based models can be. First of all, I’m just going to frame it with, what are special needs plans? Special needs plans, for those of you who aren’t familiar, are a specialized form of Medicare and Medicaid managed care, but they target high-risk, high-need populations. So, dually eligible — those who are dually eligible for Medicare and Medicaid. Those who have serious life-threatening chronic conditions, or those who are at an institutional, or a nursing home level of care. So, these are the three type of special needs plans, and they represent right now about almost two and a half million beneficiaries enrolled. One of the special needs plans providers is called South Country, in Minnesota. This is just a little bit about their geography. They have focused on taking very high-risk, high-complex needs individuals, particularly those with complex medical needs and behavioral health needs. Talk about a challenge. This is their enrollment, and we are going to look at a particular group of an age band — 50 to 59 years. What they do is they look at the integration of home and community-based services, and this is kind of the — so, when you look at a high-risk population, this definition would be there. Low income, have multiple co-morbid conditions, and have psycho-social or behavioral health challenges as well. What this program does is integrate home and community-based workers, both care coordinators, community workers, which is kind of a whole area of workforce that we haven’t tapped into. Community workers can be social workers, they can be public health workers, they can also be non-clinical community workers that align services. This health plan works with a coordination of the primary care team, these community-based workers, and directly working with the individuals. And not just helping them with medication management and things like that, but truly coordinating their life aspects. You know, we can talk a lot about medical costs, but if you can’t get transportation, or you can’t afford your meds, or you don’t even have a place to live, all of those other things about controlling your diabetes become way secondary in your priorities.


So, this is some of the demographics, these are the examples of how the model links to community workers, and who these community workers are. So, in this model, they use social workers, public health nurses, registered nurses, and they align with nurse practitioners and physicians. They also work closely with the veteran services, and they work a lot with the broader integration of community services within the counties that they serve. They focus specifically on needs, but not just healthcare needs, because they know that when they have the infrastructure, they know that these workers need more frequent high-intensity visits, and yet, they find that when they do these high-intensity person-centered visits, oftentimes coordinated through direct care workers, the overall medical care costs for the health plan go down.


So, when we talk about a partnership for primary care and the workforce needs, let’s think a little bit bigger. That can be — we have health plans that are working with direct care workers that are intaking information via tablet to triage centers in acute care settings, to decide on post-operative people, who needs a higher level of follow-up. We have service coordinators and low-income housing that are working directly with primary care teams — physicians, nurses, and social workers. And we talked about the community health worker models that are tying in and coordinating services for very vulnerable high-risk populations. That to me is the power of what we can do with community health teams, and the challenges we have to have the home and community based workforce to meet that need. Thank you.




BLAIR CHILDS:  Great. Thanks, Cheryl. So, I’m going to take a little different perspective. This is a great panel, because you are hearing from a lot of different vantage points here. I’ve got to start off by saying, I do like the Yogi Berra quote here, which is: “I never like to make predictions, especially about the future.” So, what I’m going to do is I’m going to bring to you some perspectives from folks who are leading some of these successful new care models, and new payment models that are out there.


So, just very quickly, what Premier does, for those who don’t understand, or know who we are, we work with a very large footprint in the healthcare system. And the wonderful this is that we’ve got a small group of our members who want to always be ahead of everybody else. So, we help them succeed in that by using data, by building collaboratives where we actually get them working together, and sharing best practices in a more effective fashion. And then we bring that back to policy makers from — through the policy making process. We have been organizing for the last 20 years these collaboratives on hospital performance improvement, bundled payment, and ACOs, as we think about the evolution that’s going on in healthcare from a payment standpoint. Moving from fee-for-service to new care models and risk. The exciting thing is that these organizations, these collaboratives that we do, have consistently performed significantly better than everybody else in the healthcare system. So, our ACO collaborative actually has performed two to three times better in terms of shared savings, then all of the other ACOs in the country, consistently, since 2012. We have between 6 and 10 percent of the ACOs in the country, in our collaborative. So, we’ve been able to differentiate and do very well in those bundled payment collaboratives, actually, performing 35 percent better than all of the other bundled payment organizations that are out there. This is a simplified way of what we try to do with our members. It’s about value-based care, redesign, and specifically these are the components of that, which match up with the different payment models that are out there. So, I’m going to just skip over this quickly.


Some overarching data that is out there, I think everyone is aware that healthcare, because of all of the points that have been made about the aging of the population and so forth, as much as there is a lot of pressure to bring down healthcare spending overall, and I think we are seeing some very positive trends in that, I think the labor force is liable to be one of the big growth areas overall. This is the quadruple aim that was referenced earlier. This is an area — I share this because I want to focus on what we’re seeing specifically happening right now with our members who are leading this change, and being successful at it. One of the areas of focus, a theme that we hear from almost all of our members, is it’s really about this idea of addressing physician — not entirely, obviously, it’s the triple aim, but then it’s this fourth component to that, which is physician satisfaction. There is physician burnout; it’s a major concern. You are not going to be successful in this care transition if you don’t have individuals delivering the care who are satisfied, and who are feeling good about their jobs. They will not be as successful. So, this is a very important theme that is out there. These are just some of the general messages.


We held a round table discussion recently with a number of our primary care, our ACO leaders, and one of the themes that came through loud and clear, was the pairing of advance practice providers, or advance practice clinicians. It’s interesting, one of the things that I was thinking about on all of the other presentations, is just how different terminology gets used to describe different kinds of positions that exist. But what’s very clear is that there is a significant growth in the use of advanced practice clinicians assisting the primary care physician and the other providers, but particularly the primary care side is what I want to focus on. So, because making predictions is risky, I didn’t want to go there. So, what I did, is I did a quick poll survey of our ACO leaders, to look at what are they seeing right now? These are the organizations that are out there. Very large ACOs undertaking these changes right now. These care delivery models and these changes are — yes, it’s Medicare shared savings, but it’s also looking well past that. They are doing this with commercial payers as well. So, we looked at three areas:  One is the in-patient side, and what do they see going on? I think you all can see these relatively reasonably, but basically on the physician side, what we are seeing is — and what our members are planning for, is that most all of the clinician physician positions are stable, there is no real change that they are seeing, with the exception of cancer, cardiovascular, general surgeons, geriatrics, and hospitalists. And those are the growth areas that they are anticipating right now. Then in the advanced practice providers, on the in-patient side — this is all in-patient — care navigators, social work, and community liaisons, were the areas that were growing the most rapidly.  So, I think the community liaisons relate most to what Cheryl was talking about a little bit ago. The other point that hasn’t been raised, that we are seeing a lot of demand in, is around analytics. So, this is much more focused, obviously, on the clinical side, but our members are investing substantially in clinical informatics, and other analysts, to look at the data, and understand the data. This is measurement from a clinical quality vantage point as well as a cost vantage point. So, lots of focus in that area right now. And it’s really shifting from an implementation of the HRs, to much more using the data and understanding the data overall.


On the ambulatory side, this gives you a sense there is really no stability, it’s all growth. So, unlike the in-patient side, where you are seeing maybe keeping things the same with the specialists with the exception of those categories I mentioned. On the ambulatory side, everything is pretty much growing in terms of what is anticipated for the next three to five years. With the real biggest focus growth areas in behavioral health and primary care. So, not really shocking there, but you do get a sense of the relative magnitude. I would add too, that we actually — if there is anybody in the press who wants the more updated slides, I’ve got more of these responses in, so I can provide you even more updated. But it does not change the overall direction of these slides. This gives you a sense across the care navigators, transition care nurses, disease management, social workers, behavioral health, community health workers, sort of where the focus and growth areas are. Again, all of them are growing. It’s a degree; it’s a level of growth.


Then the last areas, the post-acute care side that we inquired about. This is looking at “SNFists”, which is sort of a new term that’s being used by our members. These are folks who are actually working hand in glove with the skilled nursing facilities, home care, rehab, community liaison, social work, and behavioral health workers. And everything again here, is growing with the exception of rehab, which is actually stable or declining, I would say. And then, the other areas are growing with the greatest growth areas in social work and behavioral health. So, that is a sort of on-the-ground look at what’s happening right now from some health systems that are at the leading edge of change and successfully working in these areas of change.


SARAH DASH:  Great. Thank you.




Thanks, Blair. And I think you’ve heard from four very different vantage points, but I think all pointing to perhaps some need to look at — how are we looking at the workforce going forward, to create that high-performance system?  So, I want to ask one kick-off question, and then I want to invite the audience — you guys are on it. You guys already have your questions. But if you think of questions, please write them on a green card, and someone will pick up your card and bring it up to me. If you want to ask a question at the mic, there are a couple of mics there. I want to ask — and Blair, your presentation was interesting in that you identified a number of providers that I think were new to me. We haven’t heard of SNFists or — you mentioned several different kinds of nurses. I want to ask kind of a general question:  Do you see — anyone on the panel — do you see a growth in these different kinds of providers growing and sort of for what purpose? Is there anyone we are missing in the lineup? Maybe feel free to answer.


CHERYL PHILLIPS:   I will jump in. I had a SNFist contract in 1992, being a long-term care physician, but they thought I was an allergist. They had written it as “sniff”. Anyway. You know, the one workforce area that — because what I was focused on were these models, but we absolutely have to acknowledge, and that is the informal — the family care giver — that is the largest workforce in this country, and it’s the one that is not recognized, not adequately prepared for. We assume that because you have a family member somewhere in town, that they will default and be your caregivers. The workforce dollars, the prep that we just assume is out there, to me, that is a huge gap in workforce, and there is an area of policy. I know we have several representatives here — I see Katherine Kelly hiding around in the back. Focusing on, how do we address policy for the informal workforce, that being family caregivers. Family is defined by whom I choose to have as my personal caregiver. So, that’s a workforce challenge.


SARAH DASH:  Liz Hall earlier mentioned kind of social isolation, and I wonder if some of the care transition nurses — are they intended to help bridge some of these gaps?


BLAIR CHILDS:  I think without question. I think the thing that is interesting is, you know, are there new positions? First off, we have changed — I mean, things in healthcare have changed rapidly. I mean, you made this comment in the beginning, Sarah. It’s really pretty remarkable how quickly we’ve seen changes among our members in terms of how they are approaching the healthcare delivery process. In terms of getting community workers actually involved in a way that they have never — they’ve never even hired them in the past, and now we actually have some of our health systems who are starting to think about social determinants on health, and we did a study recently on this, which was fascinating to see that some of our members are beginning to really think about, how do they coordinate care across all of these social agencies that exist? So, senior centers and so forth. And they are not coordinated in the communities right now, and investment goes all over the place. So, they are actually investing in individuals to work on those in a way that they’ve never done before. So, there are a lot of new positions. That’s why I think it’s interesting when I look at these different terms that we’ve been using on this panel, it’s all over the place in a lot of ways. So, in some ways, standardizing some of this terminology would probably give us a much more — a much clearer picture about what’s going on in the workforce.  I think your use of the term “direct care workers” is really an important part of it as well.


ROBERT PHILLIPS:   I really — Blair, I really appreciate the responses you got from the ACO’s, and I’m going to focus on the out-patient setting for just a minute. We certainly need a lot more of those community care workers, social workers, care coordinators, community based nurses, behavioral health specialists. I would submit that we need — we not only need them, but we need them to develop relationships with our community based providers too. My “for example” is that we had an insurance provider that put care coordinators into our practice. They were there two days a week, tried to work remotely by phone. They would tag off on patients rather than develop relationships with them, and didn’t really spend a lot of time with us. What we kept hearing is:  Well, I can’t take care of that patient there, it’s way too complex. We said, that’s exactly why you’re here. The problem was that we never developed the relationships with the care coordinators or the patients, or the care coordinators and the physicians, to try and help us all deal with really complex patients. My other for example is:  I think the Vermont blueprint for health has done this really well under their Medicare waiver. So, you have small practices that can’t afford to bring those people in, so they created a community resource. So, they embedded these social workers and behavioral health folks, and community care teams in the community, and then had them develop the relationships with the practices and the patients, so that no one had to own that infrastructure, but they all owned it in a relationship way, and that’s, I think, really executed nicely. So, it is about more of those workers, but the relationships have to set up, or they just can’t execute on what they need to do.


TIM DALL:   If I could just add one thing. For many of these health occupations, we do need more. The question is:  Are we training enough to meet that more? Are we training too many? Or too few? In the case of registered nurses, we do need a lot more nurses, but we are probably over training. In the case of licensed practical nurses, we do need more, but we are probably not training as much right now. In the case of some of the direct care workforce, it’s really hard to actually model the future supply, because you can train many of these occupations relatively quickly to ramp up, but it becomes more along the lines of, are you willing to pay for them? So, if you are willing to pay for them, you will have the supply, but if you are not willing to pay for those services, then there won’t be enough.


SARAH DASH:  And there was actually a question on the green card about your point about nurses, and the questioner cites that there is some research that shows a lack of nurses in the long-term care space, and you talked about kind of overtraining nurses. So, the question was — you mentioned a couple different types of nurses just now, and we know there are many different kinds of degrees and things like that in the nursing profession, but could you maybe speak a little bit more to that, and are there nurses in different settings? Or maybe there just isn’t the right kind of distribution, or that kind of thing?


TIM DALL:  So, on the demand side, the demand for nurses is growing more rapidly in some settings versus others. And we’ve seen, for example, in the hospital in-patient setting, that will still continue to be the dominant employer of registered nurses, but it’s not growing perhaps as fast as other settings. But also, in the case of long-term care, it becomes not so much that we don’t have enough nurses, it’s just that in that setting, we are not paying nurses well enough to attract them into that setting, and retain them, because a nurse might come out of school, and perhaps is having a little difficulty finding a job. They said they go into long term care, and then a position opens up that pays more, and then they leave.


ROBERT PHILLIPS:  I was on the National Academy of Medicine study — the lookback at the Robert Wood Johnson focus on nursing. What was stunning to me on that, was that less than five percent of RNs are in outpatient setting, and probably less than half of them in primary care, which we desperately need nurses, especially high skilled nurses, in primary care right now. So, it is a payment issues, and it’s a priority issue. How do we actually get a higher trained workforce — nursing and otherwise, into a setting where we can help stave off the higher cost later, and keep them healthier and living longer? And it’s really hard to pull them in with what we can pay them now.


CHERYL PHILLIPS:   I would agree. The reference was to salary, which was a huge issue, but there is more than that, why people don’t stay in long-term care. It’s is not recognized as a value career. Whether you are a nurse, a social worker, a therapist, a direct care worker, a physician, a nurse practitioner. As soon as you say, I work in nursing homes, the look is like, well, gee, I thought you were smart, couldn’t you get a job somewhere else? We don’t value it as a healthcare system. Payment hasn’t valued it, payers haven’t valued it, hospitals haven’t valued it, healthcare training hasn’t valued it. I daresay that few healthcare professionals, regardless of your discipline, ever even put a foot in the nursing home. So, there is a whole lot more. Then you throw on crappy pay and gee, I wonder why it’s — like, how else was the play, Mrs. Lincoln? There is a lot of forces. Yet, this is where a real growth of workforce — not just nursing homes, but in the broader sense of long-term care supports and services. We have to professionalize it, we have to give adequate resource and training, salaries are a big piece of it, but there is more to the professionalism and recognition of value. Salary is part of it.


SARAH DASH:  And Blair, you mentioned — you had a whole slide just on the post-acute space, and recognizing that long-term care goes beyond the post-acute space, but do you think that with the focus on higher value care on delivery system reform, particularly within the Medicare and Medicaid program, is there a growing recognition of the need to address some of the issues that we are talking about in terms of that connection between health and long-term care, and we’ve talked a lot about the dual-eligibles for example, and sort of their high-cost, high-need population. Is there going to be a movement and more of a push towards better integration or coordination or policy changes around that area?


BLAIR CHILDS:  All of those positions, I would say, in the post-acute care’s side of that slide, those are all focused on really coordinating better the care delivery process. I mean, the thing that we’ve seen with our membership, is there is huge variation — I’m not saying anything that people don’t realize — huge variation in the way post-acute care is delivered across the country, and what we have — we actually have a data system that we use, it has over a million claims records from the Medicare ACOs, that looks at all of these different ACOs that we have. We have about 50 ACOs in this claims database, and we look at how they array against one another in terms of the way care is being delivered, and where the costs are, and so forth, so we can look at in-patient, ED stays, or ED visits. Every component — post-acute care, home health, SNF, all the sides of post-acute care, as well as ambulatory care costs. And then we compare our members to one another in all of those different areas. The area that is — so, every community is going to be different; no surprise there. But we see consistently huge variation on the post-acute care side, and it impacts so many parts of the healthcare system. So, it impacts the re-admissions to the hospitals. So, the SNFist positions are largely around managing trying to reduce the re-admissions to the hospitals, is really what the focus is there, as well as ED visits. So, it’s really coordinating the care, and making sure that we don’t have additional costs that occur as a result of somebody who is in a skilled nursing facility, oftentimes — I mean, one of the things that we’ve seen with our members is that on Mondays, there is a huge number of patients who end up in the hospital, because over the weekend and — I know this is somewhat anecdotal, but it’s actually happened in a lot of communities where the skilled nursing facility isn’t doing rehab, it may not be staffed as much, and so we have a lot more patients that end up in the ED or back in the hospital for some reason. So, that’s just an illustration of what we are seeing in these ACOs. So, the post-acute care area is where, in many cases, the ACO is actually hiring the person to do this additional work. In other cases, they are setting up what we call high value networks with post-acute care providers, so they are working more closely with certain post-acute care providers who are investing in those additional resources. So, that’s where we get that information from, and in some cases, they actually own those post-acute care resources, and so they are directly involved in the employment process through that. Does that make sense?


SARAH DASH:  Does anyone want to weigh in?  Amy, did you have a question?


AUDIENCE MEMBER:   Yes, I did. I’m Amy York, and I’m with the Elder Care Workforce Alliance. We’re a coalition of 31 different organizations collaborating to really make sure there is an adequate workforce to provide quality care for older adults. There has been some mention of training, but not specific to older adults. I’m curious how much you all have invested in training and re-training, really, because a lot of the workforce has never been trained in geriatrics or in the care of older adults. There are not enough geriatricians and will never be enough geriatricians out there to provide this care, or geriatrically trained professionals. What are the types of things you all are looking at in terms of training the entire work force to care for this aging population?


TIM DALL: Maybe I can make a comment about that, because last time I had a conference call with a group of geriatricians out in Florida that comment with something like this:  Tim, you stabbed us in the back here. Because a lot of times things are misunderstood in terms of the demand for healthcare providers. When we look at older adults, the large majority of care provided to them is provided by general internists, not geriatricians. And so, when we look at the demand for geriatricians over time, the question becomes not so much about the aging of the workforce, which is important — the aging of the population, which is important, it becomes more of, how much of that care will be provided by a geriatrician versus a general internist, because what happens sometimes, as you might imagine, it’s a person that starts with a general internist when they are younger, and they stay with them, and they tend not to go to see the geriatrician until they have to actually, physically move to a setting where they are no longer with their general internist. And that makes it a little bit difficult to model future demand for them. So, what we tend to do is just look at the demand for the older population in general, and then let the specialties kind of duke it up among themselves. Who’s actually going to provide that care?


ROBERT PHILLIPS:  So, family medicine sponsors about a third of the geriatrics trainings programs, and internal medicine is about two-thirds. With a reduction in OB care and pediatric care, we’ve seen in family medicine, the average age of patients shifts a great deal. In rural communities it’s almost all family physicians and nurse practitioners and PAs taking care of that population. What I’ve noticed in working in Northern Virginia with a fairly affluent population, is the greatest shortage we have are geriatric psychiatrists. It is incredibly hard to get a patient in to a geriatric psychiatrist and even in an affluent area. So, we have shortages in providers of all kinds in the geriatric realm. For a lot of the reasons that Cheryl mentioned. It is an acute need.


CHERYL PHILLIPS:  As a fellowship trained geriatrician, I sort of feel obligated to jump in to some of the conversation. We know that it’s more than a physician issue, so I want to make sure as I’m taking about geriatrics, a solution is not just physicians. But there is a reason — I think the geriatric shortage is very real, and part of the — I’m not denigrating my internal medicine colleagues. I’m a family medicine trained and then fellowship trained geriatrician. Geriatricians and health professionals know things and do things differently than general or primary care providers do. It doesn’t mean that they are better or worse. They understand falls, they understand poly pharmacy, they understand medication management and the frail elder, they better understand early signs of cognition, they understand the intersection of function and medical issues in a way that very often a disease focused approach. So, getting back to your point, Amy, I think the answer is, you’re right. When we train 243 geriatricians a year, we are not going to create the gap, but we can help with the geriatric health profession training across the board, so that all nurses, all RNs, should have time on aging services. That all primary care physicians should not just have the token six hours of elder care, but should actually have experienced of older person care in varieties of settings, including home based care, assisted living, nursing homes, post-acute. The same with social workers, the same with physical therapists. There are also some very novel and very productive programs for family caregiver training. So, some of the states — I will even use Arkansas, has a wonderful model of training direct care workers and family caregivers, in the unique aspects of care for individuals with dementing illnesses. And sometimes, the related — we call them “behaviors”, frankly it happens to be the way that people with dementia often need to express themselves, but teaching family caregivers how to do that well. So, there are training models out there and they aren’t free. And any time you have an add-on, there is a cost to someone. Medicaid at the state level is rarely picking up these kinds of costs, except in a few novel kinds of programs. Post-acute and long-term care providers are struggling to keep up with the training demands, but without reimbursement for the workforce to do that. So, we have the needs, we have some solutions, we have some great models, we need to pull it together in new ways of thinking of how do we train all healthcare and direct care workers in the care of particularly frail and vulnerable older adults.


AUDIENCE MEMBER:  I just had one follow-up. We were talking to folks about the Geriatric Workforce Enhancement Program, and I just wanted to mention that, because it’s the only federal program that does training in geriatrics. I don’t know if all of you are familiar with it, but it’s really an important program, and we have some representatives from programs, if you are interested in learning more about it.


SARAH DASH:   I have kind of a related question that came from one of the cards and then I’m going to go to a different set of questions that came in, kind of switching topics. This is something perhaps Cheryl might be able to answer. In terms of the growth of different healthcare jobs, a lot of the growth seemed to be in the lower paid professions. You mentioned direct care. The question was:  Are there training initiatives? How much is there a focus on a career ladder, and how much of it is a career ladder issue versus just a pay issue from the get-go. If you could comment on that?


CHERYL PHILLIPS:  I’m going to be brief because I’m sure there are others that want to as well, but that’s part of where the solution lies. There are some states that are doing remarkably innovative things in career ladder. It is more than salary; salary is important, but it’s also a recognition of professionalism, it’s a recognition of skillsets, it’s a recognition of, I have some place to move to in a career path. The state of Minnesota has done some exceptional things in identifying both career paths, training gaps, peer training — I’m a firm believer in one of the ways that we elevate the professionalism is when we have — to use the jargon “train the trainer”. How do we do peer training models? Where do we look for workforce investment in particular shortage areas? Again, Minnesota has done some exceptional things. I would also encourage you to go to the Leading Age website, as I’m seeing Susan there, so, and then look for “workforce” and there is a number of model solutions on how we can approach some of these great things.


SARAH DASH:  Thank you. So, we had a number of questions come in around payment, and since you mentioned it’s not just pay, it’s a workforce ladder issue, and we’ve also talked about satisfaction. Part of — there are several questions under the umbrella of, how does payment of clinicians affect some of the statistics that were mentioned in the presentations? One person mentioned the MACRA, the quality payment program, which we had a lengthy briefing on last week. But talking about some of MedPAC’s recommendations to kind of — as this person says, “split the physician fee payment red tape”, and use sort of some different methods of payment. So, there is that piece of a question. And then another person asks about differences in pay, which is an issue we’ve been talking about for a long time around pay for procedure base versus non-procedure based, and kind of — there is kind of a lot of different things wrapped up in those questions, but I guess I would ask the panel to maybe comment on, does payment affect these issues around — and I would say, payment, not just in terms of levels, but in terms of how we pay, in the sense of payment reform. How does that affect how the workforce is able to be prepared to deliver this high-performance health system?


ROBERT PHILLIPS:  It’s an important question. The differential particularly between the cognitive and interventional specialties is not just a physician issue, it’s across the board. We did a study a few years ago that showed that the differential between primary care or cognitive specialists and surgeons and interventionalists, has grown so large, that it reduces the likelihood that a student entering medical school will go into one of those lower paid specialties by over half. So, it’s like losing half of your training pipeline to the cognitive specialties.  It just continues to grow. So, there is a big issue there, and it’s also affecting our nurse practitioner and our PA pipelines. Only about a third of PAs now are in primary care, and less than half of NPs, and we need them desperately. But they can be paid more. Then there is the issue that Cheryl brings up, that payment often gets intractably intertwined with perception and value. It’s not just about payment, it’s that you’re smarter than that, or your career ladder ends, and so we have this compounding effect where we can’t keep people in the specialties and in the arenas where we need them; particularly to take care of an aging population. The value based payment systems, you know, when you are offered a bonus of four to nine percent, it’s not going to really put a huge dent in it, and when there is a risk of a loss of equal amounts, it really — that’s what’s driving small practice people to be employed. Then you have an added problem there that the value based payment process; quality payment program, is not really about quality, because it’s budget neutral. It’s about differentiating winners from losers. So, they have to be equal number of losers to pay the winners a differential bonus payment. So, we are starting to see quality measures top out. And it speaks to these cognitive specialists that, oh, that measure is no longer important, I have to chase this one now. And so, it creates a burnout cycle for those folks if they are constantly chasing something new and shiny, in order to stay afloat. Not really get a substantial bonus. So, we have a number of problems, even around the new payment system.


SARAH DASH:   I guess I want to ask — and Tim, some of your modeling around population health and what the potential demand would be. I was a little disappointed, because I was hoping if I just eat my broccoli and play tennis, that we won’t need so many doctors, but if I’m understanding your statistics correctly, the demand for specialists is still very much going to be there, even if we achieve some modest population health improvements over time, which doesn’t — I don’t know how optimistic we are about that. I think if I’m interpreting Blair, what you are saying about the staffing needs for inpatient professions, there is still going to be a demand and need for certain specialists and I think you mentioned cancer and cardiovascular in particular. Am I getting that right? What can you say about that?


TIM DALL:  Well, you know, it always gets tricky when you talk about dying here, but the ideal way to die is, you live a long, healthy life, and then when you die, you die quickly at an old age, right? And what you can see, for example, like if people are smokers, they might die younger, and they might die relatively quickly from cancer or something. And if you — and that’s all very bad — but if you can get them to stop smoking, instead of dying at age 65, quickly, what they might do is die at age 75 or 80 from another disease. So, what we see is this trade off between, well, I’m not going to die of cancer, I’m going to die of heart disease or diabetes, or Alzheimer’s or something. So, you see the shifting of different health occupations, but in general it doesn’t really reduce the demand overall, it just extends it out to a person’s later years in life.


SARAH DASH:  We had one stand-alone question about telemedicine, which was:  What role will the increased use of telemedicine play in addressing projected shortages? So, if you could speak to that and the impact of telemedicine on shortages and perhaps any other aspect of workforce that you would like to.


TIM DALL:   Well, for telemedicine, we’ve tried to model the workforce implications of telemedicine, and it’s actually very difficult because of just lack of data. The type of literature that’s published tends to be:  It works, people like it, they are happy with it, but it tends not to say, the physician is going to spend so much more time, or less time per patient. And so, it’s really hard to quantify what the impact will be. But one has to believe at least on the access side, it opens up lots of opportunities to people that geographically live in areas where they have a limited access. It’s just hard to quantify the impact on the workforce.


CHERYL PHILLIPS:   I think one workforce, we made reference to behavioral and mental health issues. The ability to leverage behavioral health and mental health services through telehealth, particularly in congregate settings, home and community based settings, adult based centers, nursing homes, things like that, is very powerful. There are a number of challenges. With the Chronic Care Act, that the Senate passed with unanimous consent, there are some real opportunities for telehealth, and I think for targeted service areas, telehealth has a huge impact on expanding our workforce challenge gaps. And we will use behavioral and mental health as a good example of that.


BLAIR CHILDS:  Let me just add one thing there. So, a lot of this conversation has been around the challenge from a payment vantage point, with the way the system is paid today, versus the labor requirements of the future. So, it’s challenging because everybody is being paid a certain way today, and it’s based on the services that are provided and of course, we are looking at a very different way of delivering care overall. So, when you think about the organizations who are making the greatest change — and that’s who I’m really speaking to, is these are the organizations who have — they may be aligned with commercial payers, plus they are in Medicare. Next Gen kinds of models, or MSSP, or one of those more advanced models. They’re really trying to change the way the care is being delivered overall. So, hospital in the home. And that uses a lot of telehealth. Telehealth comes in a lot of different varieties and our members are trying to test a lot of different things that they can — strategies to use less expensive, less intensive sites of care, to deliver high quality care and better outcomes. So, I was mentioning earlier about the change in the workforce in the skilled nursing facility and the variation and care across the post-acute side. What is a clear trend in the leaders is a movement to more home health, and that’s including using telehealth as one of the enabling features of that. Trying to limit the length of stay in some skilled nursing facilities in particular, because there is huge variation. That’s where we see enormous variation. So, limit the length of stay, or make sure that the length of stay is appropriate, and then shift to more home health settings. And then again, use technology where possible.


SARAH DASH:  Thank you. Joyce?


AUDIENCE MEMBER:   Yeah, Joyce Freedon from Med Page Today. I wanted to ask a little bit about the other end of the pipeline. Like, if we are changing the types of people that we need in the healthcare workforce, are medical schools or nursing schools going to be able to react and train people in the specialties that are needed or encourage more people to go into primary care, and kind of what are people seeing on the other end?


TIM DALL:   One of the challenges — let me start with nursing.  One of the challenges with nursing is that there is no one coordinating how many are being trained, right? Individual universities and programs say, we want to build or expand our nursing program, and they do so. Sometimes what happens is, it takes a while. You get nurses coming out into the workforce, they are having trouble finding a job and it takes time for it to filter back into people that maybe were considering nurses as a career, that maybe I’m a little late jumping into the game, because they’ve already ramped up the number being trained. So, there is that issue. We did a study for the veterinarians a few years back, and their concern was that they were just over training veterinarians. And the challenge for the association was, will we get into legal problems if we tell the universities to cut back on how many we’re training? So, the associations were very conscious of giving that kind of direction about restraining the number of people being trained. So, in general though, I think many of the professional associations, they are aware of needs among their members in trying to put out information that we need to be training more, need to be training fewer, given that there are still a lot of unknowns, and you don’t want to over train or undertrain, because there is a cost to society. If you over train, that means people will not have as productive of a career as they could have found, if they had found a job or career where there is more demand for their services. Of course, if we undertrain, then it puts patients at risk.


SARAH DASH:  Tim, if I could just ask you to clarify; in contrast to nursing, where you said there is kind of no one overseeing — where in medicine you have a little different system?


TIM DALL:   I think with medicine, with the whole GME program, you have caps and how much money are we going to spend in graduate medical education. So, that does put some restrictions on how many you train.


CHERYL PHILLIPS:  If I can just add — but it doesn’t restrict — so, if I’m a medical student, and I’m making my choice on economics — if I’m the first one to the Easter egg hunt, and I get into radiology or dermatology, and I win, then the ones that didn’t — so, we have a bizarre skewing. But I want to get back — the biggest predictor of healthcare professionals who will work in aging services, is if they have a mentor that teaches them. So, if you have an engaged nurse who loves elder care services and inspires his or her nursing students to have practical experience that talks about the value of it. If you are a physician in training, and you work with a primary care physician that loves their practice and particularly if they have a geriatric practice, those are the things that predict better than — we have to integrate real training into all of our nursing, social work, therapy, physician programs, but we also need to imbed passionate mentors.


SARAH DASH:   How do you do that?


CHERYL PHILLIPS:   You make it of value to the mentors to teach. Right now, let’s be honest, medicine — and I say “medicine” not just as doctors; is a business and form follows finance. If A, we don’t value aging services; two, we don’t particularly value teaching all that much; and we really don’t value teaching about aging services, then you are not going to have a lot of invested mentors to support mentees. So, part of it is recognition. Then it all goes back to the entire cycle. Do we value workers who create their career paths to serve older Americans? Older adults?  And to the extent that we don’t, then we don’t raise up all of those workers who choose to make that their career path. So, part of it is how we value, and I think that demand and need, and some of the new models, which is why I wanted to talk about the community based models — as we raise the professionalism, that’s going to help.


SARAH DASH: Thank you. Okay, we have a question at the mic, and then we had a question from Twitter, and then I think we’re going to wrap it up pretty quickly. Go ahead.


AUDIENCE MEMBER:  I’m Robin Gold, and I’m from Rush University Medical Center in Chicago; and we have a couple of social work based models that we’re wrapping around primary care to create that community based primary care concept that one of you spoke about, as well as wrapping around the hospital. We’ve been replicating these models nationally as part of our sustainability plan, where the new CPT codes in the last couple of years, related to transitional care and care coordination — the CCMTCM code.  Just in the last week, we found out that unless you are co-located in the physician’s practice, you really can’t be part of those reimbursements. So, as we are talking about team, as we are talking about bridging the hospital to the community, how can we look at these codes that are so physician centric? I don’t know if anyone has a response, but — or reaction.


ROBERT PHILLIPS:   Well, Robin, it’s a huge problem. I’m hoping that some of the models that Blair mentioned specifically, where you are getting paid to take care of a population, will shift the reimbursement to social workers and the community in particular. It’s not about a transaction. It’s about a relationship. And it’s about helping that person solve their housing stability, which is what keeps them out of the emergency room, keeps them going to substance abuse treatment, and keeps them from showing up in the hospital two years from now with infections. The social workers are so important on the front line, and to make it a transactional fee-for-service type of service, is really hard to sustain.




BLAIR CHILDS:  The only thing I wanted to say is; we haven’t talked at all about behavioral health. That came out in our survey loud and clear and I just want to underscore that. That is another — when we looked at the drivers of cost with our members, patients who have behavior health challenges — I guess we mentioned it in terms of the geriatric psychologist, but psychiatrists and psychologists — it is a major issue from a cost vantage point, and from a care delivery vantage point, that we’re increasing — our members are very, very focused on this. The ones who are again, leading edge, really trying to change care delivery in their communities.


CHERYL PHILLIPS:  That was actually why I targeted the south country model, because they focus on dually eligible individuals with behavioral health problems. So, it’s that co-morbid, if you will, medical problems, and behavioral mental problems, and how do you create a team-based infrastructure that works within the unique model of primary care? The impact to be able to reduce cost, but not just reduce cost, improve people’s lives, is profound.


BLAIR CHILDS:   Some of the stories that we have around this from our members, it’s amazing when you hear them, about what they’re doing, with patients who’ve shown up at the ED 200 plus times over the course of a year. They have behavioral health problems, and where they go and they address the root problem, and remedy the ED at admits and so forth, it’s amazing.


SARAH DASH:  Thank you. I do want to get in — this is maybe more of a statement from Twitter. It gets to that point about valuing and professionalism, which is kind of — why not apply the Zappos model to healthcare. So, the model of, good customer service, and if you treat clinicians with respect and value, and support them, then good healthcare for patients will follow; is the statement here. I guess maybe the question I would ask the panel is, you know, distilling everything you all have said, which is a lot, what are some of the key elements that you think are critical to good models of care that support — maybe I could say like, a healthy workforce, and therefore, a good patient care. And what are some of the critical elements in your view? Maybe since we only have a few minutes left, I will ask you, is there something you wish policy makers knew that would help support that?


ROBERT PHILLIPS:  I think it’s teams and relationships. You are increasingly asking a primary care and geriatric workforce to take care of more and more complex problems to keep people out of the emergency room, and out of the hospitals. What we’ve found is, as you build a team around those people to off-load the work of the physicians so that they can do what they do very well, but also have relationships with the people they work with, so the behavioral health is imbedded in primary care. That social workers are imbedded in primary care. It not only off-loads the work, it enhances the work they can do, and what Chris [name] work has shown, and Tom [name] work, is that it’s incredibly rewarding, because you recognize you are really making a difference. Particularly around the social determinants of health and behavioral health issues, where we’ve been very unempowered. We suddenly have resources. That’s really important to improving the joy of practice — and the joy of practice is important for all the reasons you mentioned, and to Cheryl’s point about having mentors who are passionate and engaged about what they do, so the next generation sees that that’s a viable option for them.


CHERYL PHILLIPS:   We often use the phrase, “Having a workforce that is adequately prepared and resourced.” And really, in those two words, is kind of the summation. So, the workforce being that very broad — not just physicians or nurses, but the broad — and adequately prepared — have they had the training, the resources that they need? Do they have the connection to things like behavioral health support? And are they adequately resourced not only with their own salary, but with career ladders, with mentors, with peer training relationships, with access to continuous learning, and to professional recognition. That’s from the direct care workers on up through. So, I think being resourced and adequately prepared. And there are policy solutions in each one of those. There are workforce training grants. There are ways to look at a variety of policy enhancements at both the state and the federal level to make sure we have an adequately resourced and prepared workforce.


BLAIR CHILDS:   Just to build on that, Sarah, if I may. The interesting thing — we’ve all been hearing about HCAP surveys and patient satisfaction surveys for a number of years. What has been interesting with our members is how much we’ve seen a growth in the use of the physician satisfaction surveys. So, they are equally weighted, equally important, and a lot of focus on that, in terms of who’s being successful in achieving more satisfied physicians. So, it’s another element to this discussion we’re having, but I totally agree with what we said earlier about the support and doing — we’ve all heard about the right care by the right person, the right time, all of that kind of language. But from a policy vantage point, I just underscore that what I said earlier, we really need to get out of this very micromanaging healthcare system, and to something which is a more flexible system that allows the innovation that we need in healthcare, and I think we all realize that. It’s just the transition is extraordinarily difficult and it’s taking a long time. But the organizations that are really innovating are the ones who are the most liberated from a payment vantage point. They either have their own health plans, so they are able to innovate with their own health plans, or they are — they’ve taken risk almost entirely, with a very large portion of their patient population. So, it’s not just a fraction of it, it’s a much larger commercial Medicare — their own employees, kind of population that they are looking at.


TIM DALL:  I would just echo what Blair said. As we look into the future, there is an enormous amount of work that needs to be done to take care of the future healthcare needs of an aging and growing population, and by getting away from the micromanagement, as Blair mentioned, by breaking down some of these artificial barriers that we created due to how we reimburse care, scope of practice, legal constraints. They are all put in there for a purpose, but they are hindering, becoming more efficient as a healthcare system.


SARAH DASH: Thank you very much. We are out of time, so I want to ask you to join me in thanking our panel.




Thank you. And thank you all for being here for what is also the very last Alliance briefing of 2017. Please fill out your blue evaluations. You don’t get off the hook with that. Thank you all for being here and have a wonderful holiday and we will see you in the new year. Thanks.