Workforce Issues :

Patient Protection

& Affordable Care

Act - 2010

Linda Rae Murray M.D. MPH

Cook County Department of Public Health

8.6 million

health

professionals

4.2 million

health

professionals

4.5 million

other

workers

Health Care

Settings

Health

professions &

Occupations

U.S. HEALTH WORKFORCE, 2004

The U.S. health

workforce consists of

over 17 million

workers and

comprises almost

12% of the total

workforce.

* Americans have fewer

physicians

* We see them less often

* About 70% are specialists

and only 30% primary care

*Most OCED nations have

50-60% primary care

doctors

Number of Practicing Physicians per 1,000 Population, 2007

Average Annual Number of Physician Visits per Capita, 2007

7.5

7.0

6.3 6.3 6.3

5.85.7

5.0

4.7

4.03.8

2.8

0

1

2

3

4

5

6

7

8

GER ITA** AUS FR OECD

Median

CAN* NETH UK NZ SWITZ US* SWE*

2.2

3.9 3.9 3.9

3.73.6

3.53.4

3.2

2.8

2.52.4

2.3

0

1

2

3

4

NETH NOR SWITZ ITA SWE* GER FR OECD

Median

AUS* UK US NZ CAN

Mortality Amenable to Health CareObesity (BMI>30) Prevalence Among

Adult Population, 2007

34.3

26.5

24.0

15.4

13.6

11.210.5 10.2 9.9

9.08.1

0

5

10

15

20

25

30

35

US* NZ UK CAN GER** NETH FR* SWE ITA NOR SWITZ

19

2529

3133

35363637

64

99

0

20

40

60

80

100

US** NZ** NOR* SWE* OECD

Median

GER* NETH ITA* FR* UK SWITZ*

Potential Years of Life Lost Because of

Diabetes

per 100,000 Population, 2007

Generally speaking: the

health status of Americans is

WORSE than comparable

nations.

Flexner Report : 100 YearsFlexner Report : 100 Years

•• Published in June, 1910Published in June, 1910

•• Brother of the President of the Brother of the President of the

Rockerfeller InstituteRockerfeller Institute

•• Reformed medical educationReformed medical education

•• Modeled after John HopkinsModeled after John Hopkins

–– Which was modeled on GermanyWhich was modeled on Germany

•• Schools eagerly cooperated in Schools eagerly cooperated in

survey hoping for fundssurvey hoping for funds

Actual decrease in Medical Schools Actual decrease in Medical Schools

compared to recommendationscompared to recommendations

Impact of the Flexner ReportImpact of the Flexner Report

52

75

160 166

81

0

50

100

150

200

1850 1870 1900 1904 1922

Number of Medical

Schools •• Flexner report saw a Flexner report saw a

51% decrease in 51% decrease in

medical schools after medical schools after

it was issuedit was issued

•• Driven by a $500 Driven by a $500

million investment in million investment in

reforming medical reforming medical

schoolsschools

Flexner Report 1910

Flexner ReportFlexner Report

…… The Negro must be educated not for his own The Negro must be educated not for his own

sake, but for ours. He is, as far as the human eye sake, but for ours. He is, as far as the human eye

can see, a permanent factor in the nation. He has can see, a permanent factor in the nation. He has

rights and due value as an individual. But rights and due value as an individual. But he has he has

besides the tremendous importance that belongs besides the tremendous importance that belongs

to a potential source of contagionto a potential source of contagion…….... Of the seven Of the seven

medical schools for Negroes in the United States, medical schools for Negroes in the United States,

five are at this moment in no position to make any five are at this moment in no position to make any

contribution of value to the problemcontribution of value to the problem……

Flexner ReportFlexner Report

…… the upbuilding of Howard and Meharry the upbuilding of Howard and Meharry

profit the nation more than the profit the nation more than the

inadequate maintenance of a larger inadequate maintenance of a larger

number of schools. number of schools. They are of course, They are of course,

unequal to the need and opportunity.unequal to the need and opportunity.””

Patient Protection & Affordable Care Act:

TITLE V - Health Workforce Provisions

• National Workforce Commission

• Increasing supply of health care workforce

• Enhancing education & training

• Public Health Sciences Track

• Supporting Existing Workforce

• Strengthening Primary Care & other workforce improvements

• Other stuff

National Workforce Commission

• Establishes a National Health Care Workforce Commission to serve as a national resource to:

– Determine whether the demand for health care workers is being met;

– Identify barriers to coordination and encourage innovation;

– Disseminate information on retention practices for health care professionals and;

– Shall review current and projected health care workforce supply and demand and make recommendations regarding healthcare workforce priorities, goals and policies.

• The Commission shall communicate and coordinate with a variety of federal agencies and departments……. Public health professionals are included in the definition of health care workforce and the definition of health professionals. Public health workforce capacity is also included in the high priority areas list.

National Workforce Commission

• State Health Care Workforce Development Grants: Establishes a competitive healthcare workforce development grant program to enable State partnerships to complete comprehensive planning and to carry out activities leading to coherent and comprehensive health care workforce development strategies at the State and local levels.

– Authorizes $8 million for planning grants and $150 million for implementation grants for FY 2010 and such sums for each subsequent year.

• Health Care Workforce Assessment: Codifies the existing National Center for Health Care Workforce Analysis (HRSA) to provide for the development of information describing the health care workforce and the analysis of related issues and collect, analyze and report data related to programs under this title. The National Center and relevant regional and State centers and agencies shall collect labor and workforce information and provide analyses and reports to the Commission.

Increasing Supply of Health Care

Workforce

• Support for pediatrics, pediatric sub-specialties, child, adolescent mental & behavioral health

• Establishes a public health & allied health workforce loan repayment program to eliminate critical public health workforce shortages in Federal, State, local and tribal public health agencies.

• Authorizes the Secretary to make grants or enter into contracts to award scholarships to mid-career public health and allied health professionals to enroll in degree or professional training programs. Authorizes $60 million for these programs in FY 2010 and such sums as necessary for FY 2011 - 2015.

• Strengthens National Health Service Corps

• Support for Nurse Managed Health Clinics

Enhancing education & training• Primary care training

– Medical students, residents, physician assistants , CME for primary care physicians

• Training for faculty to teach primary care

• Training in community based settings

• Plan, develop and operate interdisciplinary graduate degree programs in public health and other health professions

• Capacity building in primary care– Direct care worker, dentistry (general, pediatric & public health) as doctors

and mid-level

– Geriatric training

– Mental & Behavioral health

– Cultural competency, prevention, public health proficiency

– Nursing education (midwives, faculty)

– Community Health workers

Public Health Sciences Track

• Directs the Secretary (subject to the availability of appropriations) to establish an Epidemiology and Laboratory Capacity Grant Program to award grants to eligible entities to assist public health agencies in improving surveillance for and response to infectious diseases and other conditions of public health importance. Authorizes $190 million for each year of fiscal years 2010 - 2013 to carry out this section.

• Authorizes funding for fellowship training in applied public health epidemiology, public health laboratory science, public health informatics, and expansion of the epidemic intelligence service in order to address documented workforce shortages in State and local health departments. Authorizes, for each of fiscal years 2010 through 2013, $5 million for epidemiology fellowship training programs, $5 million for laboratory fellowship training programs; $5 million for the Public Health Informatics Fellowship Program;and $24,500,000 for expanding the Epidemic Intelligence Service

Support existing workforce

• Loan repayments & fellowships

– Medically underserved areas

• Area Health Education Centers

• Workforce Diversity

• Primary Care provider training

– Training in public health, health promotion,

chronic disease management, mental and

behavioral health

Other Workforce Improvements

• Family to family health information centers

• Training of Personal or Home Care Aides

• Teaching Health Centers Development grants

• Increased payments to primary care providers

• Rural physician training

• School based health centers

• Patient Navigator programs

• Increased funding Community Health Centers

• Increased funding Trauma Centers (40% for safety net centers)

Source: Steinecke, Acad Med. 2010, Vol 85 (2) p 236

Paul Bertau Cornely M.D. MPHPaul Bertau Cornely M.D. MPH

1906 1906 -- 20022002

•• First Black DrPH First Black DrPH (University of Mich)(University of Mich)

•• First Black doctorate in First Black doctorate in anatomyanatomy

•• First Black President of First Black President of American Public Health American Public Health AssociationAssociation

•• First Black President of First Black President of PhysicianPhysician’’s Forums Forum

•• One of the founders of One of the founders of the Medical Committee the Medical Committee for Human Rightsfor Human Rights

Status of Black Physicians in 1932Status of Black Physicians in 1932

•• Blacks were 2.5% of Blacks were 2.5% of

all physiciansall physicians

•• Population ratios Population ratios

MD: PopMD: Pop

–– 1 Black doc : 2,988 1 Black doc : 2,988

BlacksBlacks

–– 1 white doc : 727 1 white doc : 727

whiteswhites

Golden Period for Black PhysiciansGolden Period for Black Physicians

1900 1900 -- 19201920

•• Number of Black physicians DOUBLEDNumber of Black physicians DOUBLED–– 1900 : 1,734 Black physicians1900 : 1,734 Black physicians

–– 1920 : 3,885 Black physicians1920 : 3,885 Black physicians

•• HIGH POINT 1920HIGH POINT 1920–– Blacks were 2.68% of all physiciansBlacks were 2.68% of all physicians

–– 1 Black MD : 2,694 Black people1 Black MD : 2,694 Black people

•• UNTIL around 1970UNTIL around 1970--8080

•• Today : 2010Today : 2010–– 4.0% of all U.S. physicians are Black (30,598)4.0% of all U.S. physicians are Black (30,598)

Under-represented Minority Medical School Graduates by Race & Ethnicity 1972 - 2007

Under-represented Minority Medical School Graduates by Race & Ethnicity 1972 - 2007

Source: AAMC

ALL DELIBERATE

SPEED:

In 2005 African-

Americans, Native

Americans and

Latinos made up

25% of the U.S.

population…. But

comprised only 6%

of the physician

population.

Percentage of Mental Health

Workforce by Race , Ethnicity 2005Race,

Ethnicity

Total U.S.

Population

Physicians Psychiatrists Psychologists Social

Workers

White 67.0 77 81 93 92

Latino 14.0 4 5 3 3

Black 13.0 5 3 2 4

Asian 5 14 11 2 1

American

Indian/Alask

1.5 0.1 0.1 0.3 0.2

Source: Miranda, J. (2008) American Journal of Psychiatry 165:1102

Source: Bowman : Rural & Remote Health 2008 : 8(3)

Standard Primary Care Year

Estimates for 2008 Graduates

Principles of Patient-Centered Medical Home*

• Personal Physician: on going relationship providing first contact, continuous & comprehensive care

• Physician-directed medical practice: physician leads team

• Whole person orientation: responsible for directing all care and arranging for referrals

• Coordination and/or integration of care: across all types of care (ambulatory – nursing home)

• Quality & Safety: care plans, evidence based medicine, performance measures, mutual participation

• Enhanced access: open scheduling, expanded hours, use new tech methods for communication

• Payment: added value of medical care home

* American Academy of Family Physicians, American Academy of Pediatrics,

American College of Physicians, American Osteopathic Association

Crisis in the Workforce• Still feudal crafts

• Medical home vs. primary care

• Accountable care organizations

• Not simply a question of shortages & mal-distribution

• Need to transform how we practice

• Requires fundamental transformation of our Medical Care System into a Health Care System

• Health care is a human right

• Requires a “Flexnerian”investment in education across disciplines