The Role of the Health Care Workforce in Delivery System Reform

12:00 – 12:10 p.m.      Welcome and Introductions

• Sarah Dash, MPH, President and CEO, Alliance for Health Policy
• Elizabeth Hall, Vice President, Federal Affairs, Anthem
• Kirsten Thistle, Campaign Director, Health is Primary

12:10 – 12:45 p.m.      Presentations

• Tim Dall, M.Sc.Eng, Managing Director, Life Sciences, IHS Markit
• Robert Phillips, M.D., M.S.P.H,Vice President of Research and Policy, American Board of Family Medicine
• Cheryl Phillips, M.D., President and CEO, Special Needs Plan Alliance (SNP Alliance)
• Blair Childs, Senior Vice President, Premier Inc.

12:45 – 1:30 p.m.        Question and Answer Session

(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 25^th 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