At the Intersection of Health, Health Care and Policy Cite this article as: Peter I. Buerhaus and Sheldon M. Retchin The Dormant National Health Care Workforce Commission Needs Congressional Funding To Fulfill Its Promise Health Affairs, 32, no.11 (2013):2021-2024 doi: 10.1377/hlthaff.2013.0385
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/32/11/2021.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2013 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on March 13, 2015 at UNIV OF ILLINOIS LIBRARY
Workforce Commission By Peter I. Buerhaus and Sheldon M. Retchin
A N A LYS I S
&
10.1377/hlthaff.2013.0385 HEALTH AFFAIRS 32, NO. 11 (2013): 2021–2024 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
C O M M E N TARY
The Dormant National Health Care Workforce Commission Needs Congressional Funding To Fulfill Its Promise
Peter I. Buerhaus (peter [email protected]) is the Valere Potter Professor of Nursing and director of the Center for Interdisciplinary Health Workforce Studies, Department of Health Policy, Institute for Medicine and Public Health, Vanderbilt University, in Nashville, Tennessee, and chair of the National Health Care Workforce Commission.
Congress established the National Health Care Workforce Commission under section 5101 of the Affordable Care Act to provide data on the health care workforce and policy advice to both Congress and the administration. Although members of the Workforce Commission were appointed September 30, 2010, Congress has been unable to appropriate the $3 million requested by the administration to fund the commission. Consequently, the commission has never met and is not operational. As a new era of insurance coverage, care delivery, and payment reforms unfolds, the commission is needed to recommend policies that would help the nation achieve the goals of increased access to high-quality care and better preparation, configuration, and distribution of the nation’s health workforce. In a climate where fiscal policy is dominated by spending on health care, the commission can also stimulate innovations aimed at reducing the cost of health care and achieving greater value and transparency. ABSTRACT
P
roviding health care services to a nation of more than 310 million people is labor intensive and costly. In 2011 the United States spent an estimated $2.7 trillion on health care.1 Data from a year earlier indicate that the wages of health care workers accounted for 56 percent of total spending.2 Approximately 13 percent of the nation’s workforce (one in eight people) is employed in the health care sector, and nearly a third of all professional degrees in the United States are in health care.3 Although the rate of growth in total spending on health care has been constrained in recent years, increasing at roughly the same rate as the growth of the gross domestic product for the past three years, health spending may increase once again as the economy recovers, health insurance expansions are implemented, and the demand for health care increases over the long term.4
Sheldon M. Retchin is the senior vice president for health sciences at Virginia Commonwealth University, in Richmond, and vice chair of the National Health Care Workforce Commission.
Numerous efforts are under way to improve the performance of the private health care marketplace and to reform state-funded and federally funded health care delivery and education programs. However, these efforts are unlikely to fully achieve their intended outcomes if issues affecting the capacity and effectiveness of the workforce are not addressed. Among the most pressing issues are current and projected shortages of physicians (primary care physicians, general surgeons, and various specialty physicians); the persistent geographic maldistribution of the physician workforce; large expenditures on graduate medical education that do not appear to produce the physician workforce needed to address the population’s health care needs; looming shortages of registered nurses and other providers; chronic lack of access to health care for millions; and the need for innovation, greater teamwork, coordination, and quality improveN ov e m b e r 2 0 1 3
32 : 1 1
Downloaded from content.healthaffairs.org by Health Affairs on March 13, 2015 at UNIV OF ILLINOIS LIBRARY
Health A ffairs
2021
Workforce Commission ment throughout the health care workforce. One might think that the weight of these and other workforce issues would have led long ago to the establishment of a formal advisory body that would offer policy guidance to strengthen the nation’s health workforce. Government advisory groups, however, have been established to focus on specific components of the workforce. For example, the Council on Graduate Medical Education focuses on physician training policies; the Medicare Payment Advisory Commission has concentrated on Medicare payment policy; and the Medicaid and CHIP Payment and Access Commission considers care for adults and children. But because of the absence of a national workforce advisory body, there has been little coordination of payment and access recommendations with workforce policy.
National Health Care Workforce Commission To provide data on the health care workforce and offer impartial advice to Congress and the administration on workforce policy, the National Health Care Workforce Commission was established under section 5101 of the Affordable Care Act. Among a formidable set of activities outlined in the law, the Workforce Commission is charged with communicating and coordinating with different government agencies over workforce policies; developing and commissioning evaluations of workforce education and training programs; identifying barriers to improve coordination of federal, state, and local workforce policies; encouraging workforce innovations to address population health needs; and producing two reports annually on key workforce issues. The Workforce Commission is to be staffed by an executive director supported by workforce analysts, not unlike the organization of the Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission. To fund the Workforce Commission, the law authorized “such sums as may be necessary to carry out this section” of the act. Although various amounts have been discussed, ranging as high as $10 million, the appropriations language included in continuing budget resolutions over the past two years has requested $3 million annually. In addition to obtaining space and staff, these funds could be used to fund studies and gather data on timely workforce issues; interact with the health professions to address barriers to improvement; communicate with public- and private-sector policy makers; and develop workforce information needed by Congress, the administration, and the states. 2022
H e a lt h A f fai r s
November 2013
32:11
Concerns about the adequacy of the health care workforce have been universal themes voiced by many organizations representing health professions and by both political parties. Health professional organizations have stressed that the health workforce is undersized and inadequately prepared to both provide care for the large number of aging baby boomers and contribute to the successful implementation of health reform. As recently as May 2013, three dozen organizations signed a letter encouraging House and Senate appropriations committees to provide $3 million to fund the Workforce Commission in fiscal year 2014. The creation of the National Health Care Workforce Commission as part of the Affordable Care Act came at a time of deep ideological and political divisions within Congress. Subsequent calls for Congress to fund the Workforce Commission have become embroiled in the enduring political wrangling over any number of provisions of the health reform law and concerns over the fast-approaching implementation of insurance reforms. Further, the prolonged slow recovery from the Great Recession and the rapid growth of the national debt have helped create a political environment averse to any new spending. Consequently, Congress has been unwilling to fund the National Health Care Workforce Commission. Although the commission’s fifteen members were appointed in September 2010 by the acting comptroller general, the body has never met. Under federal appropriations law, until Congress appropriates funds, the Workforce Commission is prohibited from meeting or discussing health care workforce policies in any capacity.5
Priorities And Challenges Because the health care workforce directly affects the cost, quality, and efficiency of the nation’s health care delivery system, there is no dearth of matters that need attention by the National Health Care Workforce Commission. High on the commission’s agenda would be the development of objective and policy-relevant data on the future workforce and understanding the impending demand for health care services in the context of current and projected labor supply.6 The demand for health care professionals is expected to increase over the next two decades because of a growing population, an aging baby-boomer generation, the growing prevalence of chronic illnesses, and insurance expansions associated with the Affordable Care Act. Increasing demand for health care will not only place upward pressure on costs and prices but will also converge with delivery and payment
Downloaded from content.healthaffairs.org by Health Affairs on March 13, 2015 at UNIV OF ILLINOIS LIBRARY
The remodeling of the workforce needs to keep pace with innovations in technology and education.
reforms to further challenge the nation’s health care workforce. To be sure, the development of medical homes and accountable care organizations, along with bundled payment for episodes of care, will require analysis of their impact on health care labor markets and how best to develop a workforce better prepared for a much different future. Another priority facing the Workforce Commission is to address persistent concerns over the size, distribution, and configuration of the nation’s health care workforce—from primary care physicians and specialists alike, nurses and advanced-practice nurses, dentists, physician assistants, public health and communitybased providers, mental health professionals, lay providers, technicians, aides, counselors, and many others. Current and projected shortages of many types of health care workers suggests that rebalancing the roles and activities performed by each will be important to maximize the productivity and coherence of the entire workforce. Nowhere is there a greater need to rethink the workforce than in primary care. Currently, there are 5,900 designated Primary Care Health Professional Shortage Areas—defined as having a physician-to-population ratio of 1:3,500.7 Using this ratio to calculate a primary care shortage area, the Health Resources and Services Administration reports that it would take approximately 7,550 additional primary care physicians to eliminate the current primary care shortage designations. (Based on different ratios of providers to population, the Health Resources and Services Administration estimates 4,600 dental and 3,800 mental health shortage areas.) The National Association of Community Health Centers reports that fifty-eight million Americans lack access to primary care services.8 Because so many areas of the country are underserved by primary care health care professionals, there are many advocates of rap-
idly expanding the supply of primary care physicians, pointing out that the United States is atypical among developed countries with its dominance of a specialty-trained physician workforce.9 Others have shown that although having more primary care physicians may lead to more favorable outcomes, costs are not necessarily lower.10 Still others urge expanding the supply and roles of nurse practitioners and physician assistants, increasing technology and telehealth, and more effectively integrating community-based organizations and the lay workforce into the mainstream of health workforce policy and care delivery systems.11,12 The Workforce Commission is charged with identifying and showcasing workforce innovations that would take advantage of new technologies and reviewing the adequacy of the faculty pipeline for educational and training programs. Advances in diagnostic, treatment, and monitoring technologies offer the potential for disruptive innovations that could positively or negatively affect workforce efficiencies. For instance, the office of the National Coordinator for Health Information Technology is leading efforts to achieve a nationwide interoperable, privacyprotected health information technology infrastructure. The modernization of the information technology infrastructure will likely change the productive capacity of the workforce. From electronic health records to telemedicine, newer platforms for communication have already begun to stimulate different modes of interprofessional practice. Other advances, such as clinical simulation, offer novel educational models that are altering approaches to health care education. Clearly, the remodeling of the workforce needs to keep pace with innovations in technology and education. Although the Workforce Commission was authorized as a federal advisory body, many of the policies that determine the configuration of the workforce, such as scope of practice, are under state jurisdiction. The commission will work closely with the states to better understand variations in workforce policies and their impact on access to care across regions and subpopulations. The US investment in the education and training of the nation’s health care workforce is prodigious. Together, Medicare, Medicaid, the Department of Veterans Affairs, and the Department of Defense spend more than $13 billion in direct and indirect expenditures for graduate medical education alone. Dozens of other funding programs also target the workforce, including the National Health Service Corps, titles VII and VIII of the Public Health Service Act, and the Workforce Investment Act. N ov em b e r 2 0 1 3
32:11
Downloaded from content.healthaffairs.org by Health Affairs on March 13, 2015 at UNIV OF ILLINOIS LIBRARY
◀
7,550 Primary care MDs It would take approximately 7,550 additional primary care physicians to eliminate current primary care shortage designations by the federal government.
Health Affa irs
2023
Workforce Commission However, it is unclear how these programs, and many others, overlap and whether they are in concert with policies affecting care delivery and payment reforms. The Workforce Commission will assess current federal funding levels in the nation’s health workforce, evaluate the return on that investment in terms of explicit measurable outcomes, and increase the transparency and accountability for this public outlay in health workforce training. The public’s financial support of the US health care workforce should be validated by ensuring that workforce education and training programs are aligned with an efficient and effective delivery system to meet the health care needs of the nation. The slow jobs recovery following the Great Recession, along with increasing federal debt, have made clear that the nation’s long-term prosperity depends on lowering the rate of growth in public spending on health care while achieving greater value for the services provided. And yet it is highly unlikely that the growth of health care costs will ever be constrained in an enduring fashion unless the workforce is more deeply involved and committed to these goals. The Workforce Commission, once funded, will shine a bright light on the need for the workforce to achieve greater value; gather data on the cur-
rent and future supply and demand of health professions; provide critical analysis of key workforce issues to enable Congress, the administration, and the private sector to have a clear picture of workforce trends and needs; and reassure the public that the nation’s health care workforce will be a key component of payment and investment policies. Those selected to serve on the commission have ample expertise in the health care labor market, financing and economics, system management, health care underwriting, education, and training and include a mix of professional perspectives and geographic representation.13 However, without funding, the Workforce Commission’s work remains unfulfilled.
Conclusion The president’s fiscal year 2014 federal budget requests Congress to fund the Workforce Commission for $3 million. This amount would allow it to become operational and begin its work to help ensure the nation’s common interest in a well-prepared, well-configured, and more evenly distributed health care workforce that is able to provide access and quality in a constrained fiscal environment. ▪
NOTES 1 Centers for Medicare and Medicaid Services. National health expenditures 2011 highlights [Internet]. Baltimore (MD): CMS; 2013 [cited 2013 Sep 26]. Available from: http:// www.cms.gov/Research-StatisticsData-and-Systems/Statistics-Trendsand-Reports/NationalHealthExpend Data/Downloads/highlights.pdf 2 Kocher R, Sahni NR. Rethinking health care labor. N Engl J Med. 2011;365(15):1370–2. 3 Jones N. Health care in America: follow the money. Shots: Health News from NPR [blog on the Internet]. 2012 Mar 19 [cited 26 Sep 26]. Available from: http:// www.npr.org/blogs/health/2012/ 03/19/148932689/health-care-inamerica-follow-the-money 4 Hartman M, Martin AB, Benson J, Catlin ANational Health Expenditure Accounts Team. National health spending in 2011: overall growth remains low, but some payers and services show signs of acceleration. Health Aff (Millwood). 2013;
2024
H ea lt h A f fai r s
November 2013
32:11
32(1):87–99. 5 Office of the General Counsel, Government Accountability Office. Principles of federal appropriations law: third edition, volume II. Washington (DC): GAO; 2006 Feb 1. p. 6-34–166. (Pub No. GAO-06382SP). 6 Staiger DO, Auerbach DI, Buerhaus PI. Comparison of physician workforce estimates and supply projections. JAMA. 2009;302(15): 1674–80. 7 Health Resources and Services Administration. Shortage designation: Health Professional Shortage Areas and Medically Underserved Areas/Populations [Internet]. Rockville (MD): HRSA; [cited 2013 Sep 26]. Available from: http:// www.hrsa.gov/shortage/ 8 National Association of Community Health Centers. Primary care access: an essential building block of health reform [Internet]. Bethesda (MD): NACHC; 2009 Mar [cited 2013 Sep 26]. Available from: http://
9
10
11
12
13
Downloaded from content.healthaffairs.org by Health Affairs on March 13, 2015 at UNIV OF ILLINOIS LIBRARY
www.nachc.com/client/documents/ pressreleases/PrimaryCareAccess RPT.pdf Phillips RL Jr., Bazemore AW. Primary care and why it matters for U.S. health system reform. Health Aff (Millwood). 2010;29(5):806–10. Chang CH, Stukel TA, Flood AB, Goodman DC. Primary care physician workforce and Medicare beneficiaries’ health outcomes. JAMA. 2011;305(2):2096–104. Institute of Medicine. The future of nursing: leading change, advancing health. Washington (DC): National Academies Press; 2011. Green LV, Savin S, Lu Y. Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication. Health Aff (Millwood). 2013;32(1):11–9. Iglehart JK. Despite tight budgets, boosting US health workforce may be policy that is “just right.” Health Aff (Millwood). 2011;30(2):191–2.
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/32/11/2021.full.html
For Reprints, Links & Permissions: http://healthaffairs.org/1340_reprints.php E-mail Alerts : http://content.healthaffairs.org/subscriptions/etoc.dtl To Subscribe: http://content.healthaffairs.org/subscriptions/online.shtml
Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2013 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
Not for commercial use or unauthorized distribution Downloaded from content.healthaffairs.org by Health Affairs on March 13, 2015 at UNIV OF ILLINOIS LIBRARY
Workforce Commission By Peter I. Buerhaus and Sheldon M. Retchin
A N A LYS I S
&
10.1377/hlthaff.2013.0385 HEALTH AFFAIRS 32, NO. 11 (2013): 2021–2024 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
C O M M E N TARY
The Dormant National Health Care Workforce Commission Needs Congressional Funding To Fulfill Its Promise
Peter I. Buerhaus (peter [email protected]) is the Valere Potter Professor of Nursing and director of the Center for Interdisciplinary Health Workforce Studies, Department of Health Policy, Institute for Medicine and Public Health, Vanderbilt University, in Nashville, Tennessee, and chair of the National Health Care Workforce Commission.
Congress established the National Health Care Workforce Commission under section 5101 of the Affordable Care Act to provide data on the health care workforce and policy advice to both Congress and the administration. Although members of the Workforce Commission were appointed September 30, 2010, Congress has been unable to appropriate the $3 million requested by the administration to fund the commission. Consequently, the commission has never met and is not operational. As a new era of insurance coverage, care delivery, and payment reforms unfolds, the commission is needed to recommend policies that would help the nation achieve the goals of increased access to high-quality care and better preparation, configuration, and distribution of the nation’s health workforce. In a climate where fiscal policy is dominated by spending on health care, the commission can also stimulate innovations aimed at reducing the cost of health care and achieving greater value and transparency. ABSTRACT
P
roviding health care services to a nation of more than 310 million people is labor intensive and costly. In 2011 the United States spent an estimated $2.7 trillion on health care.1 Data from a year earlier indicate that the wages of health care workers accounted for 56 percent of total spending.2 Approximately 13 percent of the nation’s workforce (one in eight people) is employed in the health care sector, and nearly a third of all professional degrees in the United States are in health care.3 Although the rate of growth in total spending on health care has been constrained in recent years, increasing at roughly the same rate as the growth of the gross domestic product for the past three years, health spending may increase once again as the economy recovers, health insurance expansions are implemented, and the demand for health care increases over the long term.4
Sheldon M. Retchin is the senior vice president for health sciences at Virginia Commonwealth University, in Richmond, and vice chair of the National Health Care Workforce Commission.
Numerous efforts are under way to improve the performance of the private health care marketplace and to reform state-funded and federally funded health care delivery and education programs. However, these efforts are unlikely to fully achieve their intended outcomes if issues affecting the capacity and effectiveness of the workforce are not addressed. Among the most pressing issues are current and projected shortages of physicians (primary care physicians, general surgeons, and various specialty physicians); the persistent geographic maldistribution of the physician workforce; large expenditures on graduate medical education that do not appear to produce the physician workforce needed to address the population’s health care needs; looming shortages of registered nurses and other providers; chronic lack of access to health care for millions; and the need for innovation, greater teamwork, coordination, and quality improveN ov e m b e r 2 0 1 3
32 : 1 1
Downloaded from content.healthaffairs.org by Health Affairs on March 13, 2015 at UNIV OF ILLINOIS LIBRARY
Health A ffairs
2021
Workforce Commission ment throughout the health care workforce. One might think that the weight of these and other workforce issues would have led long ago to the establishment of a formal advisory body that would offer policy guidance to strengthen the nation’s health workforce. Government advisory groups, however, have been established to focus on specific components of the workforce. For example, the Council on Graduate Medical Education focuses on physician training policies; the Medicare Payment Advisory Commission has concentrated on Medicare payment policy; and the Medicaid and CHIP Payment and Access Commission considers care for adults and children. But because of the absence of a national workforce advisory body, there has been little coordination of payment and access recommendations with workforce policy.
National Health Care Workforce Commission To provide data on the health care workforce and offer impartial advice to Congress and the administration on workforce policy, the National Health Care Workforce Commission was established under section 5101 of the Affordable Care Act. Among a formidable set of activities outlined in the law, the Workforce Commission is charged with communicating and coordinating with different government agencies over workforce policies; developing and commissioning evaluations of workforce education and training programs; identifying barriers to improve coordination of federal, state, and local workforce policies; encouraging workforce innovations to address population health needs; and producing two reports annually on key workforce issues. The Workforce Commission is to be staffed by an executive director supported by workforce analysts, not unlike the organization of the Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission. To fund the Workforce Commission, the law authorized “such sums as may be necessary to carry out this section” of the act. Although various amounts have been discussed, ranging as high as $10 million, the appropriations language included in continuing budget resolutions over the past two years has requested $3 million annually. In addition to obtaining space and staff, these funds could be used to fund studies and gather data on timely workforce issues; interact with the health professions to address barriers to improvement; communicate with public- and private-sector policy makers; and develop workforce information needed by Congress, the administration, and the states. 2022
H e a lt h A f fai r s
November 2013
32:11
Concerns about the adequacy of the health care workforce have been universal themes voiced by many organizations representing health professions and by both political parties. Health professional organizations have stressed that the health workforce is undersized and inadequately prepared to both provide care for the large number of aging baby boomers and contribute to the successful implementation of health reform. As recently as May 2013, three dozen organizations signed a letter encouraging House and Senate appropriations committees to provide $3 million to fund the Workforce Commission in fiscal year 2014. The creation of the National Health Care Workforce Commission as part of the Affordable Care Act came at a time of deep ideological and political divisions within Congress. Subsequent calls for Congress to fund the Workforce Commission have become embroiled in the enduring political wrangling over any number of provisions of the health reform law and concerns over the fast-approaching implementation of insurance reforms. Further, the prolonged slow recovery from the Great Recession and the rapid growth of the national debt have helped create a political environment averse to any new spending. Consequently, Congress has been unwilling to fund the National Health Care Workforce Commission. Although the commission’s fifteen members were appointed in September 2010 by the acting comptroller general, the body has never met. Under federal appropriations law, until Congress appropriates funds, the Workforce Commission is prohibited from meeting or discussing health care workforce policies in any capacity.5
Priorities And Challenges Because the health care workforce directly affects the cost, quality, and efficiency of the nation’s health care delivery system, there is no dearth of matters that need attention by the National Health Care Workforce Commission. High on the commission’s agenda would be the development of objective and policy-relevant data on the future workforce and understanding the impending demand for health care services in the context of current and projected labor supply.6 The demand for health care professionals is expected to increase over the next two decades because of a growing population, an aging baby-boomer generation, the growing prevalence of chronic illnesses, and insurance expansions associated with the Affordable Care Act. Increasing demand for health care will not only place upward pressure on costs and prices but will also converge with delivery and payment
Downloaded from content.healthaffairs.org by Health Affairs on March 13, 2015 at UNIV OF ILLINOIS LIBRARY
The remodeling of the workforce needs to keep pace with innovations in technology and education.
reforms to further challenge the nation’s health care workforce. To be sure, the development of medical homes and accountable care organizations, along with bundled payment for episodes of care, will require analysis of their impact on health care labor markets and how best to develop a workforce better prepared for a much different future. Another priority facing the Workforce Commission is to address persistent concerns over the size, distribution, and configuration of the nation’s health care workforce—from primary care physicians and specialists alike, nurses and advanced-practice nurses, dentists, physician assistants, public health and communitybased providers, mental health professionals, lay providers, technicians, aides, counselors, and many others. Current and projected shortages of many types of health care workers suggests that rebalancing the roles and activities performed by each will be important to maximize the productivity and coherence of the entire workforce. Nowhere is there a greater need to rethink the workforce than in primary care. Currently, there are 5,900 designated Primary Care Health Professional Shortage Areas—defined as having a physician-to-population ratio of 1:3,500.7 Using this ratio to calculate a primary care shortage area, the Health Resources and Services Administration reports that it would take approximately 7,550 additional primary care physicians to eliminate the current primary care shortage designations. (Based on different ratios of providers to population, the Health Resources and Services Administration estimates 4,600 dental and 3,800 mental health shortage areas.) The National Association of Community Health Centers reports that fifty-eight million Americans lack access to primary care services.8 Because so many areas of the country are underserved by primary care health care professionals, there are many advocates of rap-
idly expanding the supply of primary care physicians, pointing out that the United States is atypical among developed countries with its dominance of a specialty-trained physician workforce.9 Others have shown that although having more primary care physicians may lead to more favorable outcomes, costs are not necessarily lower.10 Still others urge expanding the supply and roles of nurse practitioners and physician assistants, increasing technology and telehealth, and more effectively integrating community-based organizations and the lay workforce into the mainstream of health workforce policy and care delivery systems.11,12 The Workforce Commission is charged with identifying and showcasing workforce innovations that would take advantage of new technologies and reviewing the adequacy of the faculty pipeline for educational and training programs. Advances in diagnostic, treatment, and monitoring technologies offer the potential for disruptive innovations that could positively or negatively affect workforce efficiencies. For instance, the office of the National Coordinator for Health Information Technology is leading efforts to achieve a nationwide interoperable, privacyprotected health information technology infrastructure. The modernization of the information technology infrastructure will likely change the productive capacity of the workforce. From electronic health records to telemedicine, newer platforms for communication have already begun to stimulate different modes of interprofessional practice. Other advances, such as clinical simulation, offer novel educational models that are altering approaches to health care education. Clearly, the remodeling of the workforce needs to keep pace with innovations in technology and education. Although the Workforce Commission was authorized as a federal advisory body, many of the policies that determine the configuration of the workforce, such as scope of practice, are under state jurisdiction. The commission will work closely with the states to better understand variations in workforce policies and their impact on access to care across regions and subpopulations. The US investment in the education and training of the nation’s health care workforce is prodigious. Together, Medicare, Medicaid, the Department of Veterans Affairs, and the Department of Defense spend more than $13 billion in direct and indirect expenditures for graduate medical education alone. Dozens of other funding programs also target the workforce, including the National Health Service Corps, titles VII and VIII of the Public Health Service Act, and the Workforce Investment Act. N ov em b e r 2 0 1 3
32:11
Downloaded from content.healthaffairs.org by Health Affairs on March 13, 2015 at UNIV OF ILLINOIS LIBRARY
◀
7,550 Primary care MDs It would take approximately 7,550 additional primary care physicians to eliminate current primary care shortage designations by the federal government.
Health Affa irs
2023
Workforce Commission However, it is unclear how these programs, and many others, overlap and whether they are in concert with policies affecting care delivery and payment reforms. The Workforce Commission will assess current federal funding levels in the nation’s health workforce, evaluate the return on that investment in terms of explicit measurable outcomes, and increase the transparency and accountability for this public outlay in health workforce training. The public’s financial support of the US health care workforce should be validated by ensuring that workforce education and training programs are aligned with an efficient and effective delivery system to meet the health care needs of the nation. The slow jobs recovery following the Great Recession, along with increasing federal debt, have made clear that the nation’s long-term prosperity depends on lowering the rate of growth in public spending on health care while achieving greater value for the services provided. And yet it is highly unlikely that the growth of health care costs will ever be constrained in an enduring fashion unless the workforce is more deeply involved and committed to these goals. The Workforce Commission, once funded, will shine a bright light on the need for the workforce to achieve greater value; gather data on the cur-
rent and future supply and demand of health professions; provide critical analysis of key workforce issues to enable Congress, the administration, and the private sector to have a clear picture of workforce trends and needs; and reassure the public that the nation’s health care workforce will be a key component of payment and investment policies. Those selected to serve on the commission have ample expertise in the health care labor market, financing and economics, system management, health care underwriting, education, and training and include a mix of professional perspectives and geographic representation.13 However, without funding, the Workforce Commission’s work remains unfulfilled.
Conclusion The president’s fiscal year 2014 federal budget requests Congress to fund the Workforce Commission for $3 million. This amount would allow it to become operational and begin its work to help ensure the nation’s common interest in a well-prepared, well-configured, and more evenly distributed health care workforce that is able to provide access and quality in a constrained fiscal environment. ▪
NOTES 1 Centers for Medicare and Medicaid Services. National health expenditures 2011 highlights [Internet]. Baltimore (MD): CMS; 2013 [cited 2013 Sep 26]. Available from: http:// www.cms.gov/Research-StatisticsData-and-Systems/Statistics-Trendsand-Reports/NationalHealthExpend Data/Downloads/highlights.pdf 2 Kocher R, Sahni NR. Rethinking health care labor. N Engl J Med. 2011;365(15):1370–2. 3 Jones N. Health care in America: follow the money. Shots: Health News from NPR [blog on the Internet]. 2012 Mar 19 [cited 26 Sep 26]. Available from: http:// www.npr.org/blogs/health/2012/ 03/19/148932689/health-care-inamerica-follow-the-money 4 Hartman M, Martin AB, Benson J, Catlin ANational Health Expenditure Accounts Team. National health spending in 2011: overall growth remains low, but some payers and services show signs of acceleration. Health Aff (Millwood). 2013;
2024
H ea lt h A f fai r s
November 2013
32:11
32(1):87–99. 5 Office of the General Counsel, Government Accountability Office. Principles of federal appropriations law: third edition, volume II. Washington (DC): GAO; 2006 Feb 1. p. 6-34–166. (Pub No. GAO-06382SP). 6 Staiger DO, Auerbach DI, Buerhaus PI. Comparison of physician workforce estimates and supply projections. JAMA. 2009;302(15): 1674–80. 7 Health Resources and Services Administration. Shortage designation: Health Professional Shortage Areas and Medically Underserved Areas/Populations [Internet]. Rockville (MD): HRSA; [cited 2013 Sep 26]. Available from: http:// www.hrsa.gov/shortage/ 8 National Association of Community Health Centers. Primary care access: an essential building block of health reform [Internet]. Bethesda (MD): NACHC; 2009 Mar [cited 2013 Sep 26]. Available from: http://
9
10
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12
13
Downloaded from content.healthaffairs.org by Health Affairs on March 13, 2015 at UNIV OF ILLINOIS LIBRARY
www.nachc.com/client/documents/ pressreleases/PrimaryCareAccess RPT.pdf Phillips RL Jr., Bazemore AW. Primary care and why it matters for U.S. health system reform. Health Aff (Millwood). 2010;29(5):806–10. Chang CH, Stukel TA, Flood AB, Goodman DC. Primary care physician workforce and Medicare beneficiaries’ health outcomes. JAMA. 2011;305(2):2096–104. Institute of Medicine. The future of nursing: leading change, advancing health. Washington (DC): National Academies Press; 2011. Green LV, Savin S, Lu Y. Primary care physician shortages could be eliminated through use of teams, nonphysicians, and electronic communication. Health Aff (Millwood). 2013;32(1):11–9. Iglehart JK. Despite tight budgets, boosting US health workforce may be policy that is “just right.” Health Aff (Millwood). 2011;30(2):191–2.
