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New Ideas to Redesign US Healthcare Workforce

Posted by Phillipa on November 19, 2013, at 19:33:13


New Ideas Aim to Redesign the US Healthcare Workforce

Miriam E. Tucker
November 16, 2013




Washington, DC The US healthcare workforce needs a major redesign to align with the dramatic shifts in the delivery system prompted by the Affordable Care Act and the aging population, health policy experts say.

"We realize there are going to be changes in our healthcare delivery system.... We have to be able to deliver care to a larger, sicker population, and we have to be able to do it without spending more money. So we have to think about how we can change the way we train our future doctors so they're prepared," David P. Sklar, MD, editor-in-chief of Academic Medicine, told Medscape Medical News.

The November 2013 issue of Health Affairs and the December 2013 issue of Academic Medicine both explore the workforce issue from a range of policy perspectives. On November 14, the 2 journals cosponsored a briefing in which experts discussed new ideas for transforming graduate medical education (GME), including funding more residency slots and shifting training to prepare new physicians to work in team settings in partnership with nurse practitioners, physician assistants, and other professionals.

The Association of American Medical Colleges (AAMC) predicts a shortage of about 63,000 physicians by 2015, jumping to 130,000 by 2025. However, that prediction, made in 2011, assumes no changes in the current delivery system, Dr. Sklar said

"There are so many factors beyond just how many doctors, nurses, and physician assistants we have today and how many will we need 10 years from now, because we don't know the care systems they're going to be practicing in," he said.

In an entertaining opening address, renowned health policy expert Uwe E. Reinhardt, PhD, the James Madison Professor of Economy and Professor of Economics and Public Affairs at Princeton University in New Jersey, traced the rollercoaster history of attempts to foresee the need for physicians. There were predictions of shortage in the 1960s through the 1980s, which then shifted to predictions of surplus in the mid-1990s, when health maintenance organizations were supposed to have dominated healthcare. The switch back to shortage predictions, and shortages of primary care providers in particular, began in the early 2000s.

"My conclusion is that heath workforce forecasting exercises are relatively cheap and are basically harmless, as long as policy makers do not take them too seriously," Dr. Reinhardt quipped.

Atul Grover, MD, PhD, chief public policy officer at the AAMC, said his organization supports bills now before Congress that would lift the current cap on the number of Medicare-supported residency positions to train 3000 to 4000 more physicians a year. That figure represents an approximate 15% increase over current training levels and would address about a third of the expected shortages.

"We know there's a shortage of primary care physicians and of many other specialities. AAMC policy is to add incrementally, to just keep up with the growth in population, and use every other member of the team, including pharmacists, social workers, nurse practitioners, billing clerks...everybody can take some role on the team that perhaps they're not taking at this point," Dr. Grover said.

George E. Thibault, MD, president of the Josiah Macy Jr. Foundation in New York City, described the organization's mission to better align health professions education with healthcare delivery. Priorities include interprofessional education to prepare students for team-based care, outpatient/community-based training focusing on chronic illness management, and a shift from time-based to competency-based, individualized training.

"We need to break down silos and barriers that have separated the education world from the delivery world. Education reform has to be informed by delivery reform," Dr. Thibault said.

Competitive Funding

David C. Goodman, MD, professor of pediatrics and health policy at the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, outlined a novel proposal for competitive GME funding. Public priorities for specialty numbers and training content would be set annually, and new training programs would compete with existing ones for funding. Programs that best met the current priorities would receive funds, and weaker programs would see a decrease. Ten percent of all programs would be reviewed each year.

This paradigm would address the prediction problem, Dr. Goodman said, as well as some of the entrenched old ways of teaching. "How we're funding GME, in many ways, is lagging in time...particularly with regard to the specialty mix." With competitive bidding, in contrast, "we have the ability to change the priorities with each succeeding year, with opportunities for new ideas and new programs."

Sheldon M. Retchin, MD, senior vice president for Health Sciences of Virginia Commonwealth University and chief executive officer of the Virginia Commonwealth University Health System in Richmond, presented data from a study of 27,000 uninsured patients cared for in the university's Virginia Coordinated Care Program. The system partners with 50 community-based physicians to provide "medical homes" for uninsured patents with incomes lower than 200% of the federal poverty line.

The researchers found that although the top 9% of care-uses incurred 39.5% of total annual costs ($15,104), the bottom 63% accounted for just 14% of the cost ($733 or less). This distribution is similar to the US population except that overall spending for the uninsured is lower, he noted.

Very different in this group, however, was that mental health/substance abuse was the predominant reason for care use, making up 27.4% of the total population. Coronary artery disease was next, at 18.9%, followed by diabetes, at 16.9%. "Mental health problems are prodigious in this population," Dr. Retchin said.

In all, he said this model could inform workforce policy for the current Medicaid population and the 8.5 to 22 million people in 26 states who are expected to be added with the Affordable Care Act. Nonphysician providers could furnish the majority of care for those in the lowest-use group, whereas interprofessional teams could provide care for people with chronic conditions.

Information from Industry

Medical case management might work best for those with mental illness and substance abuse, although "clearly, we have a workforce problem in this particular population," Dr. Retchin said.

Commenting on the Virginia model for Medscape Medical News, Dr. Sklar said the way they divided up the population by use category "is a new way of seeing things... I think if we can tailor and target our care and create teams that are able to address the care of each population, to me that's an exciting idea."

Dr. Sklar said innovative models such as these are working around the country, and "we probably need to publicize them better. As an editor of a journal, I look forward to hearing about them and getting them out into public discourse so we know what's working and everybody can then learn from them."

The briefing and the Health Affairs issue were supported by the Robert Wood Johnson Foundation, the Josiah Macy Jr Foundation, the AAMC, the American Association of Colleges of Nursing, the American Association of Colleges of Osteopathic Medicine, the American Osteopathic Association, the American Association of Colleges of Pharmacy, the American Nurses Association, and others

 

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