Healthcare Quality Summit: Building the Health Care Workforce of the Future (Part 1 of 2)

bjbjLULU Dr. Marcia Brand: This is the session on Building the Health Care Workforce of the
Future. My name is Marcia Brand. I m the deputy administrator of health resources and services
administration. We re hoping to talk about issues such as workforce diversity, health
professions training and lifelong learning in supporting the provision of high quality
care. We have an extraordinary panel this afternoon. I d like to introduce them to you.
To my immediate right is Dr. Linda Aiken. She directs the Center for Health Outcomes
and Policy Research, and is the Claire M. Fagin Leadership professor of nursing and
sociology at University of Pennsylvania. Next to her is Dr. Marie Bernard. She s the deputy
director of the National Institute of Aging. Next to Marie is Dr. Richard Cooper -- one
Z -- not two. He s the professor of medicine and senior fellow in the Leonard David Institute
of Health Economics at the University of Pennsylvania. Doug Cropper has served as president and CEO
of Genesis Health Systems since 2008. Dr. Jack Rowe is a professor in the department
of Health Policy and Management at the Columbia University Mailman School of Public Health.
Previously he served as chairman and CEO of Aetna and as president and CEO of Mount Sinai,
NYU Health at Mount Sinai Hospital and the Mount Sinai School of Medicine in New York
City. And Dr. Antonia Villarruel is the professor and associate dean for research at the University
of Michigan, School of Nursing. And so this panel will follow the similar format with
those earlier in the day. And we will have the opportunity for some questions with our
-- that our panelists will respond to, and then there will be the opportunity for question-answer.
So we ll go ahead and get started. I d like to begin by asking our panelists how they
think public policy and action can be used strategically to achieve a featured health
care workforce that meets the demands of the national health care agenda. And so, Linda,
we ll start with you. Dr. Linda Aiken: Well, Secretary Sebelius started out this morning,
I think, with a challenge. She said that health care reform creates an opportunity and a platform
for transforming the U.S. health care system, and the workforce is the infrastructure for
health care delivery. And so there s no more important place to look in terms of transformation
to the workforce. In my limited time, I have for my opening comment -- I m going to focus
on the nursing workforce. Nursing is very important in all areas of health care delivery,
but is really an important engine for innovation. We need only to look at the staffing of the
largest expansion in community health centers since the Great Society Program [unintelligible]
nursing. We only need to look at the development of more than a thousand retail clinics staffed
by nurse practitioners to see the important role that nursing has and innovation. m going
to comment on three points related to nursing. They all three relate to supply, but two of
them in a different way than the third. We have a shortage of nurse faculty that if we
don t fix it, it s going to cripple our entire national supply of nursing, and so I to address
that. Secondly, we re not producing enough advanced practice nurses to meet demand. We
have about 700 -- 7,500 nurse practitioners graduating every year, and we use that many
nurses -- a whole year s supply of new nurse practitioners just to make it possible for
us to meet the 80-hour work week for resident physicians. And we can, you know, come up
with 20 or 30 more of those using nurse practitioners at 7,000 a clip. So we re not producing enough.
And the third area that I want to focus on is the shortage of primary care services.
And there I d like to make a different kind of point on the supply, and the point is that
we have a very strong and large group of non-physicians in the country; they provide a third of all
the ambulatory visits. We re not utilizing them totally, so here we are with a shortage
of primary care services. We have a very large and competent primary care workforce, and
we re really preventing them to work to the extent of their capacities. So on the policy
side -- I want to be very specific -- I think the single most important focus in public
policy decision making that we need to do right now is to take all the new money for
nursing education and incentivize all the schools of nursing to move up to a baccalaureate
education of basic nursing education. And to do that without requiring the graduates
to take any more time in getting their education or to spend any more money -- and the reason
I say this is because right now we have two-thirds of all of our new nurses that are graduating
from associate degree programs. That s 80,000 new associate degree graduates every year.
Out of those 80,000, only 5,000 will ever, ever in 25 years -- based on cohort studies
-- get at least a masters degree. Only 5,000 out of 80,000 will ever be a nurse practitioner,
ever be a faculty member. So we re not going to solve those two problems that are so serious
for our supply unless we move the whole entry level up to the baccalaureate degree. And
that has to do with the fact that associate degree folks are not lacking in the ability
to move up. It s just that you can t keep getting degrees all your life. You know, these
people have a life. They go for an option to get a job, and they have children and families,
and they can t get back into the workforce. So it would be possible taking all of our
new public policy money at the federal level and the state level to make it possible for
every nurse that enters a nursing program, anywhere, community college or anywhere else,
to graduate with a baccalaureate degree so that we can have a larger stream of nurses
to eventually become faculty and nurse practitioners. Otherwise it s mathematically impossible to
solve the problem. I think we re going to talk to a greater extent on nurse practitioners,
but let me just say a few things about specific areas of money that we have at the federal
disposal too, that could be used to steer the workforce. I should say that unlike patient
care dollars, an educational policy has really never used their money to steer the workforce
towards the kind of people, particularly nursing, that we need. And so we have Title 8 money
that we generally think of as the main source of money for nursing education, and HRSA says
that it has a priority and baccalaureate education, but it s a pretty limited priority. And new
monies are available to HRSA, and I believe that those monies should really be focused
more specifically. But HRSA has the smallest amount of money of any of the other sources
of nursing education dollars. The biggest one, Carl Perkins money to the department
of education -- $8 billion a year, totally outside of any of the planning capacity of
the health care workforce -- that money could be mobilized to make it possible for every
nursing student who enters a community college, could get in the same period of time on the
same amount of money, a baccalaureate degree. We also have Medicare expenditures for nursing
education. About a $170 million a year in Medicare payments for nursing education --
this is a little known fact. It s larger than Title 8. It almost prohibits any baccalaureate
education, and certainly almost any graduate education. There have been a number of high
level commissions, including the IOM, that it s been recommended that all of those Medicare
monies to be realigned and be spent as they are for physicians in training master-level
nurse practitioners. Also, the states need to be incentivized to be more creative in
the money they re pouring in to solve their nursing shortages. And you could talk about
specific ways to do that, but certainly the federal government through loan forgiveness,
through various ways could incentivize the states to not give all their money on a formula
basis to all their existing schools in the state, but to set priorities so that 10 years
from now, we will have enough faculty and enough advanced practiced nurses. Dr. Marcia
Brand: Dr. Bernard, your thoughts about using public policy in action. Dr. Marie Bernard:
Greetings from the National Institute on Aging. We re one of the 27 institutes and centers
at the National Institutes of Health, and because I am a public employee, I need to
provide the disclaimer that what I m now going to say to you is my personal opinion based
upon me, a board certified [unintelligible], former chairman of the Department of Geriatric
Medicine at University of Oklahoma, and does not represent NIH policies, et cetera. Relative
to this question, I think that we have a number of wonderful opportunities, particularly with
the passage of the Affordable Care Act, and much of this has already been discussed during
this meeting. I think that once we go down the line to listen to all of the speakers,
you re going to hear reiteration, the same sorts of concepts. I think in terms of public
policies that can strategically help us to achieve the health care workforce that we
need for the future -- first of all, we need to look at our systems of care, and make them
much more efficient systems of care. There are health care professionals at every level
who are doing things that potentially could be done by other individuals in the team or
that could be assisted as a result of technology that could be provided to help those individuals.
And we need to look at how we can reconfigure things to take advantage of that. I ll also
say that I was privileged to serve on an Institute of Medicine panel, building an intricate health
care workforce for our aging society, which Jack Rowe chaired, and much of what I shared
is from the recommendations of that report. I think that we, from the policy perspective,
can support the development of technologies above and beyond electronic medical record.
Things like personal motion technologies that can track when you have a frail older individual
who may have had a fall or who may be about to fall, things that can track whether or
not a person s taking their medications or can assist them to remember to take their
medications, that can decrease the need for as many health care professionals as we are
projecting, currently needed in the system as currently configured. And we can have technologies
available to help direct care workers to be more efficient and less likely to injure themselves
as they re providing their services. And I think that we can reform -- have policies
in place, very much as Linda has said, to incentivize young individuals who are entering
the health care professions [unintelligible] go in directions that are most needed within
our health care system. She s very eloquently addressed the issue with regards to nurses,
but with regards to physicians, dieticians, physical therapists. In every area, those
individuals who are appropriately trained and particularly focused on providing primary
care are insufficient, and there are means by which -- or we could potentially look at
reforming our system, particularly our Medicare graduate medical education dollars to help
incentivize people to go in the direction of supporting those fields. I think that we
need to look at, as well, providing compensation in the fashion that would incentivize the
interdisciplinary team. Much of what s been talked about in terms of bundling payments
is that it ll hopefully accomplish that, but that s something that we need to be thoughtful
about as we re developing our future health care workforce. Not only in terms of the services
that they provide, but in terms of their education, so that they can be educated in an interdisciplinary
[unintelligible]. And I think I ll leave it at that, so that other panelists can make
their comments. And I d be happy to [unintelligible]. Dr. Marcia Brand: Dr. Cooper. Dr. Richard
Cooper: Well, a lot of what I might have said has been said already, so I ll be brief. I
think we have to address both near-term and long-term problems. Near term, we can t address
the provider shortage. It takes too long. So for force, we have to deal with systems.
We have among physicians, what you see is what you get. You re not going to see anymore,
and over the next decade, every year fewer per capita. Now, if you believe that the country
would be well served by having fewer physicians per capita, then you ll be -- you ll feel
rewarded. I don t share that belief. I don t really believe that the health care system
will contract, and therefore need fewer positions. Rather I believe that the demands on physicians
will expand as new forms of therapy for untreatable circumstances are developed. And every Saturday
and Sunday, or at least every Sunday, in Philadelphia there s a march of -- a run or a march or
something down the parkway raising money for one or the other. So the public expects that
multiple sclerosis and muscular dystrophy and on and on and on and Alzheimer s Disease
all will have ways of approaching therapeutically. And the genetic revolution, personalized care
creates the expectation that there will actually be people who know how to do that when the
care is made available. So the demand for highly trained individuals, highly trained
physicians is going to only increase over time. In the absence of an increase in those
numbers, then other physicians who might otherwise work at levels that are more general and less
specific will be drawn into the more specific areas. In the last analysis, you absolutely
have to have a surgeon to take out your appendix. You don t absolutely have to have a physician
to advise you on losing weight. So the priorities are set not by administrative fiat, they re
set by the realities of what must transpire. What must transpire is care that is a highly
technical nature to which advanced practitioners, physicians, nurse practitioners, and physician
assistants in particular will be increasingly drawn. And the result of it is, over the short
term, over the near term because there s no other place to get that workforce, except
to drain those who can be more general and to those who can provide more advanced care.
Long term, it can only be created by expanding the education system, building new medical
schools, expanding programs for advanced practice nurses. You heard Linda say already that we
ve been fixed at around 75 or around 8,000 approximately nurse practitioners a year and
that s been for many years. It s far from sufficient. That has to be revved up enormously.
And on the physician side as well, we need probably 30 more -- 30 percent more that are
now being trained. But all the while, while we re waiting for that to happen and lamenting
the shortages in primary care, the primary care shortages will increase more and more
and more because those who are the principal providers of primary care -- primary care
physicians, nurse practitioners, and physicians assistants -- will perforce be drawn by the
circumstances, and I honestly don t believe this is seeking monetary reward. They ll be
drawn by the circumstances of demand to do what they must do. Now, the primary care area
is probably the most fragmented, inefficient [unintelligible] of our society. There are
primary care physicians with panel sizes of 800 and others with panel sizes of 2,800.
There are individual practices, solo, two people. I mean, if Wal-Mart came into the
primary care world, as they did into the hardware store and household goods world, it would
disappear overnight. If there was really some way for someone to actually make some money
doing that, and then there s somebody hopefully will figure it out. But if they can t, we
ll have to help them figure it out through some sort of incentives that create systems
of primary care. Now, the pressure is for more primary care physicians. What we need
is better primary care systems that utilize fewer physicians because they won t exist.
No matter how much anyone wants them, they just won t exist. It s not that you shouldn
t want them, you just can t have them because they re not going to be there. So it s not
that you re not well intended, it s just that the reality is such -- I deal with my grandchildren
about this, about a whole host of things all the time. [laughter] So those are the realities.
So we re going to have to rev up training for the future out there, a decade from now,
because if we don t, it s a disaster, but it won t help much before a decade from now.
And in the mean time, we re going to have to wash this continual shift of highly trained
individuals more and more into what is recognized as specialty care and find ways to build systems
of primary care that involve a host of individuals including advanced practice nurses and physician
s assistants to physicians and others. In the Delta of Mississippi they were experimenting
with community health workers. Wow, what an amazing thing to think of that people in the
community can serve an educational role with their neighbors and actually provide services
that we identify as primary care. So we had to get some really good thinking about what
s going to really work, and I suppose that in the process break ourselves from the desire
of professions -- individual professions to retain turf in one or another area, but collapse
everybody to make the system work. Dr. Marcia Brand: Thank you. Doug? Doug Cropper: Well,
first of all, let me just state that I m honored to be a part of this panel and honored to
be here. Genesis Health System that I m CEO of is located right in the middle of the country.
We straddle the Mississippi River, and we have six hospital campuses that are in both
Illinois and in Iowa as well as the rest of what makes up that common health care system.
We were mixed both rural and urban facilities, three of our hospital campuses are urban and
three are critical access. So I m both a token hospital owner, health care system CEO on
the panel, as well the token rural person here. m going to do two things with my time.
First of all, give you a little bit about my perspective that I bring to the table here
and then share with you five recommendations that I have. My perspective is on mid-sized
and rural markets. Now, I ve been executive vice president of a health care system in
this area as well, but I m mostly concerned about rural and urban markets. And my concern
is, maybe similar to Buz s, that we spend a lot of money and still not address the issue.
The challenge is that -- if you look at what we face in mid-sized and rural markets, we
truly have shortages of physicians and shortages of supply. And if you go back to -- and this
has been mentioned in other sessions, if you go back to why that is, you have to just think
of, Why would a physician -- let s say that they re trained at Penn -- want to come to
the state of Iowa to practice or the state of Minnesota for that matter, where both physician
and hospital reimbursement is incredibly low in comparison to other parts of the country
and deal with the challenges of having to pay back all those loans. So until we increase
-- until we address issues like reimbursement and other issues, we re not simply going to
address the issues of supply. We re not going to increase the greater numbers of individuals
choosing markets like Iowa or Minnesota unless we fix those kind of issues. The other perspective
I have is the solution, and I truly believe what s been talked about today is an accountable
care and or organizational models that can help us address the demand for health care
in total. If you look at studies that were referenced today by Harvard or Geisinger,
where they ve reduced admissions by 25 percent in chronic populations, we can truly change
the demand for health care. Genesis Health System has 8,000 covered lives in self-insured
model, and we ve been at this for four years where we ve been promoting health and wellness.
And we ve reduced the demand in our model by 25 percent, and we ve held our costs flat
over the last four years for our employee health plan per enrollee basis. So I think
we have to do something about promoting health care and preparing our workforce for the future
-- future models, not train people for the existing model today, but train people for
the future model and address some of these other issues. That s my perspective. Now,
let me give you five recommendations, some of which have been touched on already, and
so I will be brief and quick. Number one, I think we need to have educational partnerships.
Genesis Health System established a partnership with Saint Ambrose University, the only BSN
nursing program [unintelligible] in the Quad Cities area. They built a new nursing school
on our campus. That partnership between us and them will result in 50 percent more nurses
of that type, being graduated in the future. I think we need more of that in the country.
Second, we need to promote community-based health. A concept was talked about earlier,
Ambulatory Intensive Care Units. So if somebody s in the hospital, and they re really, really
sick, we d always put them in an ICU, why don t we do that in the community? Why don
t we have people with chronic disease treated in an ambulatory-care-type setting? How do
we train and educate people for that? Third, we need to invest in primary care, and we
need to shift this balance from specialty care to primary care, promoting primary care.
We still may not have enough primary care physicians, but we can do better. We can have
it -- Buz has talked about that, we can have them practice in groups. We can do things
like loan forgiveness. We need more primary care physicians working in systems. And forth,
Linda talked about this, the promotion of nurse practitioners and physician s assistances
because we re going to need all those people working in systems to care of everybody in
the future. And lastly, maybe more philosophically, we need teach people how to work in teams
in health care. Earlier, a comment was made by one health system, I believe it was Mercy
Health Partners, when they talked about thinking about the teams of emergency physicians, hospitalists,
and primary care working together, where in the chronic model, it may be the physician
with the social worker, nutritionist, case management, and health care. I can tell you,
I started my undergraduate degree in [unintelligible] -- undergraduate career preparing myself
to be a doctor, and I was taught how to be successful in competing with other people,
not how to collaborate with other people. And then I went to -- I changed my interests,
and I went to graduate school in health care administration and had to learn in the first
semester how to work in teams. And it was like night and day for me. So we have to teach
people how to work in teams, because it doesn t come natural, and yet it can have a huge
impact on the health care system. So those are my recommendations. Dr. Marcia Brand:
Dr. Rowe. Dr. Jack Rowe: Thank you very much. It s a pleasure to be here. As did Marie,
I will comment on some issues that came out of the Institute of Medicine report on retooling
for an aging America. Assuming that we re talking about development of workforce that
can meet the needs of future patients and the evolving health care system, we need to
be aware that older persons, [unintelligible] 12 percent of the population, utilizing 30
percent of the health care dollar, will soon be 20 percent of the population and probably
use half of the health care dollar. There are two aspects of this I want to touch on.
The first is geriatric specialists and then the general competence of the workforce with
respect to aging. The issue with geriatric specialists is really dire. There are about
7,000 geriatricians in the United States. The number declines each year because the
number of individuals finishing fellowship and becoming board certified is actually less
than the number of people who are not recertified in geriatrics. One of the reasons is that
if you finish internal medicine training, for instance, and then do extra training in
geriatric medicine, your income falls about 30 to $35,000 on average. The reason for that
is that a usual general internist has a mix of payers for his or her patient population,
whereas a geriatrician has all Medicare patients, and private insurance pay eight to 10 percent
more nationwide than Medicare. So you have more debt and more training, and you make
less money. Nurses -- well, actual general psychiatrists are the work -- this situation
is the worst. There s one general psychiatrist for every 20,000 older people whether she
needs it or not. Nurses -- we have about two percent of advanced practice nurses are geriatric
specialists, 98 percent are not. Social workers it s got to be better, right? I thought they
were all geriatric social workers. Four percent of social workers are specialists in geriatrics.
Well, we could pay them more, that would be a start. Talking about policy, loan forgiveness,
scholarships, National Geriatric Service Corps, a variety of options are being considered,
but obviously we re not going to create enough geriatric specialists to take care of older
people. [unintelligible] does every old person need a cardiologist, they need a geriatrician
rather more than anyone who has a heartbeat needs a cardiologist. I mean, you don t need
a geriatrician, but we need geriatricians to train the general practitioners with respect
to expertise and taking care of the common problems of an older person. Every psychiatrist
should be very familiar with geriatric-psychiatric problems and how to manage them, particularly
with respect to medications, et cetera. So let s talk about the general, general health
care workforce. It s got to be better, right? Let s start at the bottom, direct care workers.
People who actually take care of the patients, in nursing homes, in-home care -- the requirements
for training in most states for a direct-care geriatric worker are less than for dog groomers,
crossing guards, and cosmetologists, less training for the people taking care of your
parents and grandparents than for a dog groomer. Schools of social work that offer masters
programs in social work, 80 percent of the curriculum have zero geriatric contact, no
courses; 80 percent have no courses. Nursing, much better, 70 percent have no courses. Linda
Riley [spelled phonetically] says we need more nurses with Bachelor s degrees in nursing.
But if they re trained in the current schools -- in the current curricula, 70 percent of
them will have no exposure to geriatrics. Medicine has actually done a [unintelligible]
job. Medicine has done a pretty good job of including geriatrics in medical school and
particularly in residency programs, and many hospitals -- Dr. Parson s [spelled phonetically]
here runs one of the nation s leading hospitals. Every one of his medical interns goes to one
of his hospitals, which is basically a geriatric hospital, for a required rotation. I m familiar
with that program. So hospitals and medical schools, I think, are doing better. How would
we get around competence of the general practitioning public? A couple of ideas. We could just simply
require that for a license or certification or maintenance of certification every state
would require that an individual demonstrate competence with respect to managing the common
problems of the elderly. If you do that that will drive the curriculum. I was once on a
board -- the American Board of Internal Medicine. We started putting geriatric medicine questions
on our board exam. All of a sudden the internal medicine programs had rotations in geriatrics
to make sure that the residents were trained in geriatric medicine to get their boards.
So that can work. In addition, training standards -- this business about dog walkers and crossing
guards, something has to be done about this. The federal government can require that if
states want money for their various programs that they can increase -- or at least establish
some meaningful training standards. And so we think there are substantial policy levers
that are available that can assure that the future work force has the competency to train
the future -- to teach and train and care for the future patient population. Thank you.
Dr. Marcia Brand: Dr. Villarruel? Dr. Antonia Villarruel: Thank you for the invitation to
be here. I m going to keep my remarks very brief because that s both the benefit and
disadvantage of being last on the panel. I also heard Secretary Sebelius charge here.
And what I heard her say and what I believe is that we need a transformation in our education,
training, and utilization of health care professionals. As we start thinking about the policies that
we need to enact I think first and foremost what we have to think about is the families
that we serve and the patients that we serve in the communities in which they live. The
answers to the health care challenges that are before us don belong to any discipline.
Primary care belongs to everyone. The care of geriatric patients belong to everybody.
The management of medical homes, which we like to call health care homes, are not under
the purview of any one discipline. What it is going to take is a concerted effort of,
again, a multidisciplinary team working in a system in which everyone has full utilization
and is utilized to undertake and to practice in their full scope of practice. One of the
things that I do think that we need as we think about varying abilities and changes
that need to happen, whether they re in rural settings or urban settings, is better data
so that we can project what the work force needs are both now and in the future. And
I think that is what needs to direct us in terms of the flexibility that we need. We
may have a different solution in a rural area than we have in urban areas and under [unintelligible]
communities. And again, we need data to be able to move those forward. Thank you. Dr.
Marcia Brand: Clearly there is a need to address primary care. There are also some challenges
in insuring an adequate supply of medical specialists and Dr. Cooper alluded to this.
How do you -- how do we assure that all specialties have an adequate supply? [unintelligible]
Dr. Richard Cooper: m reminded, hearing all the comments, of a book from the early s by
Jonathan Kozol, Rachel s Children , about the homeless. And like the panel so far, he
offered a tremendous number of solutions to the problem of the homeless. When he began
his book by saying, m going to do that. I m going to offer a lot of solutions to the
problem. But don t lose sight of the fact that the reason -- the underlying reason for
homelessness is we don t have enough homes. Now, we can talk about the way we re going
to -- and I used to go from meeting to meeting talking about work force. I talked to the
allergists and they were going to recruit better, they were going to have dinners for
the residents. Then I would talk to the surgeons and they were going to recruit better. They
were going to do something even more. And I would go from specialty to specialty and
I d tell them, Look, this is a zero sum game. If you re going to geriatricians, terrific.
But in the meanwhile, why do you think that the pediatricians are any worse at recruiting
than you are? They might even be better, they might even recruit the people you re trying
to recruit to be geriatricians. The problem is, there s not a big enough pool to recruit
from. So it s not that I m disinterested in the whole notion of how we re going to work
the system, but I can tell you categorically that unless we increase PA, advance practice
nurse, and physician training programs it will be -- yes, a lot of people [unintelligible]
a lot to talk about, how to get market share one from the other, but it s not going to
work. So we have that problem most of all. Now the problem will be solved by the specialists
because they have an advantage in drawing -- in building teams. I think many specialists,
if not most, are intrinsically team builders. The residents coming out of the specialty
training programs expect to be working with clinical nurse specialists or PA s or nurse
practitioners or somebody because that s who they work with in their training programs.
You talk to a surgeon coming out of residency, they assume they ll have a physician assistant
to work with. It s just assumed. So the notion of teams, I think, is sort of into the culture
of medicine, but the personnel to build the teams isn t as Linda points out. [unintelligible]
in one place or another, they just aren t there. And they won t be there, but the first
draw on a pool [spelled phonetically] of physicians -- and physicians specialize in different
ways. We don t think of hospitalists as specialists, but they are. Hospitalists do what cardiologists
-- for example -- used to do. Cardiologists used to be the hospital based doctor who knew
a lot about heart disease and kind of covered other people s patients that were admitted.
Well now hospitalists do that. So hospitalists have relieved specialists from doing what
they used to do in hospitals. And other kinds of people -- other designations will be invented
to fill this need for the care of a specialty patient whether it s by newly named physician
specialties -- if you want to call hospitalists a specialists of sorts. Tracks, jobs, or drawing
-- statistically one point six percent of PA s of the total pool move from primary care
specialists every year throughout [unintelligible] data. One point six percent a year [unintelligible]
over many, many years. So it s a general movement. So in answer to your question, what will happen
in the specialties -- the specialties will to the extent possible, solve their problem.
That they hit the wall because there are certain things that physicians actually have to do,
that they re actually licensed to do that because it s dangerous for other people to
do them. That s actually why we have medical schools, so we can actually train a whole
bunch of people to do something and then license them and regulate them to do it. And they
re called doctors and we don t have enough. And a lot of them are specialist that for
sure we don t have enough. And we have fewer and fewer because a lot of them are very old,
almost as old as I am. [laughter] And unlike me they re retiring. So specialties will navigate
around and they re drain the primary care resource in doing it. But they ll hit the
wall by simply not having enough -- ultimately [unintelligible] to try to figure out the
most effective systems and [unintelligible] care systems or whatever. The most effective
multi-specialty systems -- it comes down to systems managers to make up the gap for the
time being until an actual work force can be built do it all. And then we can have fewer
long term than we might otherwise need, because of what the systems will create short term.
But a lot of attention -- short term to systems -- but meanwhile if we don t plant the trees
for the future, the systems won t be able to keep up either. Unless we train more for
the future the systems changes are one time deals. We ll make it efficient, make it better,
but then we ve done that, and what s your next act? So systems, now, begin training
now, ultimately expanded workforce in the future using today s modernized -- Dr. Marcia
Brand: So, Dr. Cooper, sounds as though teams are going to be very important going forward,
and I would direct this question to Marie and perhaps others, might be able to share
their views. Dr. Bernard, what do you think our health professions education systems need
to change in order to promote interdisciplinary care teams? What do you see federal rule in
getting -- in doing this? Dr. Marie Bernard: I think that interdisciplinary care teams
are vital, particularly when you re dealing with people with multiple chronic illnesses,
people who are frail, whether cognitively or physically frail, and there s a lot that
we could potentially do. Now, much of that needs to be done at the level of the educational
systems themselves. Having spent most of my life as an academician, I can tell you that
in order for faculty to move up in rank, colleges of medicine, colleges of nursing, et cetera
-- generally they are expected to have obtained research grant funding and published. And
in those settings, it s based upon them being the PI in the grant, then the lead person
or the senior author on an article, and that s not very conducive to interdisciplinary
interactions. Those people who worked in interdisciplinary fashion will often not fare as well when the
[unintelligible] system was applied to them because they could not claim to be that lead
author or that PI in the grant. That s getting somewhat better with the opportunity for multiple
PIs through my current organization, but the system is slow to change. So that s something
that needs to be attended to. There need to be opportunities for people to -- for the
teachers who are going to be taking care of these health care professionals to advance
based upon their work in an interdisciplinary fashion. Additionally there need to be opportunities
for them to teach in that interdisciplinary setting. Yes, there are many physicians who
graduate from medical school these days who expect that they may work with a nurse practitioner
or they may work with a physician s assistant, but they -- as Dr. Cooper said, they do not
necessarily consistently get that exposure. It s difficult to arrange of the schedules
of social workers, nurses, physicians in a way that will allow them to work in that interdisciplinary
setting. And with our current system of care there is not good compensation for that, usually
the compensation goes to a member of that team, and that member of the team is usually
the physician, and it makes it very difficult to bring together those other members of the
team to allow for that training. Again, with the Affordable Care Act that is subject to
considerable change, and that s going to be a great opportunity to ensure that the teachers
of our future, health care professionals can bring their trainees into those interdisciplinary
settings. And then finally from a federal perspective, again, we have a great lever
with Medicare compensation, the G of E portion [spelled phonetically], to make sure that
those funds are configured in a fashion to support those interdisciplinary teams and
support interdisciplinary training, and that has not heretofore been the case. So there
s a great opportunity there. Dr. Marcia Brand: Linda, do you want to make another comment?
Dr. Linda Aiken: Yeah, if I could just make two points. I would argue that non-physicians
are much more team oriented; they re committed to teams, nurses in particular, their whole
way of approaching things are through teams. So they don t have to be taught the value
of teams; they already know teams. And so acting on a basis of that would lead to policies
that would open all the new innovative care-delivery systems, not only to participation by non-physician
providers, but to leadership and design so that we have the possibility of nurses and
others designing and leading new innovations. And there was a huge battle about that so-called
medical homes, which I prefer to call health care homes, just to get provider neutral language
in health reform. And we can point to many examples, Mary Naylor, who s in the audience,
already spoke earlier. She has a nurse-led innovation that has had a tremendous impact
on cost and outcomes. So the point being, let s let the people that believe in teams
design these new systems and lead them. And I want to come back to Buz s point, which
is kind of on this issue. We ve been, I think, pretty rigid in thinking about these new organizations
with regard the type of provider -- there s a presumption in the case of the medical
care homes, or health care homes the way I talk about them, is that these are primary
care. I think there s a disconnect there, because the people that are in the most need
of having care coordination, many of them are in the office of specialists. gdB) gdB)
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