State Leaders: Setting the Pace Building a Transformed Health Care Workforce: Moving from Planning to Implementation Daniel Derksen M.D. Director, Center for Rural Health Health Workforce Policy Academy May 19 th, 2014 Washington D.C.
The Nation s Public Health Workforce Shortage - by 2020 >250,000 public health worker shortage by 2020 Challenges: Public health schools would have to triple the # of grads to meet projected needs Data - #, gaps, needs, competencies, accuracy Public Health Surveillance Workforce of the Future. CDC, MMWR: http://www.cdc.gov/mmwr/preview/mmwrhtml/su6103a6.htm Confronting the Public Health Workforce Crisis ASPH from: http://www.asph.org/userfiles/workforceshortage2010final.pdf
Strong Growth in Nursing Workforce Rapid growth new entrants, and in post licensure education Challenges One-third of workforce near retirement age Distribution uneven Dated, innaccurate data HRSA 1013: http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/nursingworkforce.pdf
The Nation s Physician Workforce By 2020, U.S. 91,500 physician shortage Strong growth in new allopathic & osteopathic med school entrants Challenges High needs shortages 21,400 general surgery 45,000 primary care Uneven distribution Cap # Federally Funded Residency Slots AAMC Accessed 5/17/14 at: http://www.aamc.org/newsroom/presskits/mdshortage1.pdf
HRSA PCP Shortage Est. 20,400 by 2020 Newly Certified Physician Assistants Accessed 5/17/14 at: http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/projectingprimarycare.pdf
Example: Access to Health Care 75% Pop. Lives in Phoenix, Tucson 86% Physicians in Phoenix, Tucson CHALLENGE: Distributing the health workforce to the areas of high need U.S. 89% Physicians in Urban Areas U.S. 84% NPs, PAs in Urban Areas 5.8% GME Grads - Rural Areas
ACA Coverage Provisions U.S. / AZ thru 4/19/14 New Coverage = New Demand Income < 138% Income >138% to <400% Medicaid 5.8 Million AHCCCS AZ Medicaid <138% FPL ($33,000 family of 4) Enrollment Period: 12 months 152,173 < 26 y.o. on Parents Plan 3 Million AZ <26 on Parent s Plan AZ: 69,000 AZ: 341,244 Covered Health Insurance Marketplace 8 Million AZ MARKETPLACE 138-400% FPL ($33,000 - $95,000) Enrollment Period: 6 months AZ: 120,071 http://kff.org/health-reform/state-indicator/total-medicaid-and-chip-enrollment-february-and-march-2014 / http://www.azahcccs.gov/reporting/downloads/populationstatistics/2014/may/ahcccs_population_by_category.pdf http://www.hhs.gov/healthcare/facts/bystate/az.html 5/19/14 05/09/14 Dan Dan Derksen, MD
Challenge: Health Disparities
Challenge: Health Insurance Coverage Disparities in Arizona Percent Uninsured American Indian 28% Hispanic/Latino 31% White 12% Outreach Programs Needed to Assist Populations with Low Participation Rates
Four US-Mexico Border States: 57% U.S. Hispanic Uninsured 47.3M US Total Uninsured 2012 15.3M US Total Uninsured Hispanics 8.7 M (57%) Uninsured Hispanics 4 Border States 505,518 (5.8%) Selected Marketplace Plan 7M uninsured total in CA 4.1M uninsured Hispanic 0.4M uninsured total in NM 0.2M uninsured Hispanic 1.1M uninsured total in AZ 0.7M uninsured Hispanic 6.2M uninsured total in TX 3.8M uninsured Hispanic Accessed 5/8/14 at: http://kff.org/uninsured/state-indicator/rate-by-raceethnicity/ 05/09/14 Dan Derksen, MD
State Pacesetters: Health Workforce Inter-professional Teaching Health Centers Claims Data to Inform Policy & Practice Tax Policy Workforce Data to Inform Policy, Create Jobs Health/Medical Homes Innovative Delivery & Payment Models
Rural Health Professions Tax Credit State Pacesetters Retains health professionals in rural areas. Licensed physicians, dentists, psychologists, nurse practitioners, and others are eligible for a tax credit up to $5,000 States: Oregon, New Mexico NM HB 638 Began 2007: http://www.nmlegis.gov/sessions/07%20regular/final/hb0638.pdf; OR: http://www.ohsu.edu/xd/outreach/oregon-rural-health/providers/provider-tax-credits/provider-faq.cfm
State Pacesetters Teaching Health Centers Move the primary care training pipeline to areas of need. Outcome: Grads more likely to practice in rural and medically underserved areas Accessed 5/17/14 at: http://bhpr.hrsa.gov/grants/teachinghealthcenters/index.html AL, AK, CA, CO, CT, FL, ID, IL, IA, KY, ME, MA, MI, MO, MT, NM, NY, NC, OK, PA, TX, TN, WA, WV
Reforming Health Professions Education Increase cap high need residency slots Create all payers health professions funding Establish fixed floor Direct GME payment for high needs residencies- primary care, general surgery in states with low per resident amounts Permanently fund Teaching Health Centers Expand, reallocate some Medicare, Medicaid GME to fund community-based, interprofessional THC training in high needs areas Vorhees, Prado, Epperly, Derksen: Family Medicine. March 2013. Accessed 8/18/13 at: http://www.stfm.org/fmhub/fm2013/march/kenton164.pdf
Health Workforce Data Collection, Analysis & Policy State Pacesetters Practice data obtained at license renewal, analyzed and used to inform health policy interventions to improve access to care. States: North Carolina, Oregon, New Mexico NM: http://www.nmlegis.gov/sessions/11%20regular/bills/senate/sb0014.html OR: http://www.theoma.org/advocacy/health-reform/workforce/data-collection-time-licensure NC Sheps Center: http://www.shepscenter.unc.edu
SB14 THE HEALTH CARE WORK FORCE DATA COLLECTION, ANALYSIS AND POLICY ACT NM last in access to health care 32/33 NM Co. Health Professions Shortage Areas HPSA scoring affects 30 federal programs Licensing data overestimates supply by 30-40% Challenges: Licensing Boards reluctant to collaborate; consensus difficult minimum data set; data sharing Status: Signed March 2011 by Governor Martinez NM: http://www.nmlegis.gov/sessions/11%20regular/bills/senate/sb0014.html
Messaging: Primary Care to Meet Demand Q: How could we increase primary care supply by 100 full time equivalents/yr for four years? Expand Family Medicine residencies (+50/yr) partner urban + community-based training Increase primary care PA+NP training (+25/yr) Provide conditional tuition remission for those that remain in state to practice in primary care (retain + 25/yr of med school graduates)
Workforce Development = Job Creation + Economic Development in Rural Areas Increasing primary care by 400 FTEs will: Improve access to quality care. Create 9,200 jobs Generate $600 million
Tailoring Messages - Data Imbued with Meaning Ex. AZ Physician Shortage AZ Physicians/100,000 Pop. (PCP) 220 (91) US Physicians/100,000 Pop. (PCP) 259 (77) AZ Needs 750 FTE Primary Care Physicians Adding 750 PCPs would generate 15,000 jobs in Arizona
Data to Inform Providers, Insurers, Consumers State Pacesetters All Payer Claims Database Claims data to inform consumers, payers & providers: cost drivers, readmissions, cost transparency, accountability States: Maine, Colorado Maine:http://www.nmlegis.gov/Sessions/11%20Regular/bills/senate/SB0014.html Colorado: http://www.theoma.org/advocacy/health-reform/workforce/data-collection-time-licensure
Challenges: Physician & Health Professions Supply in Rural & Urban Underserved Areas 21% U.S. pop. lives in a rural area 50 M in Health Professions Shortage Areas Only 10% physicians practice in rural areas U.S. pop. will increase 25 million/decade Number >65 y.o. will double btn. 2000-30 Those >65 have 2X doctor visits
Predictors of Retention Health professions trainees most likely to practice in rural and underserved areas: Receive training in rural or underserved area Are underrepresented minorities Graduate from primary care training programs Grew up in a rural area Attend high school, college, health professional school, internship / residency in state
Health Commons Medical Home Medical, Behavioral, Oral Health Services Overall NM Resident Grads 75% Leave State Pacesetters 1+2 Community-Based Family Medicine Residency: 50-75% Remain
Challenge: U.S. 130 million no dental insurance David Satcher, MD Oral Health #1 Unmet Health Need in Children, Top 5 Unmet Need for All Age Groups
South Valley Health Commons Oral Health Warm Handoff Ex: Patient with Diabetes Diabetic Exam $20 Collaboration with Medical, Behavioral & Other Services Improves Quality and Outcomes
South Valley Health Commons 5 Dentists 1 Dental Resident (No cap!) 3 Hygienists, 14 Assistants 16 Operatories 1,500 Visits/Mo. Medicaid Payment Increase: 85% Usual & Customary (increased dentist participation rate)
Challenge: Diversity of the U.S. Health Professions Workforce IOM: In the Nation s Compelling Interest: Institutional & Policy Level Strategies for Increasing Racial & Ethnic Diversity of the US Healthcare Workforce
Underrepresented Minorities Participation in Health Professions (IOM) Minority % U.S. Population 25.3% Nursing 7.4% Psychology 6.9% Dentistry 6.8% Medicine 6.1%
Interprofessional Oral Health Workforce Training Retention, Diversity UNM Dental Residency: 9/16 (56%) of Grads Remain in NM, 9/16 from URM
Teaching Health Centers - Health Commons Community Based, Team Based Education 50 to 75% Graduates of THCs Practice in State Training in community based, ambulatory, clinic settings balances traditional training in urban, tertiary care, teaching hospitals and doubles retention of graduates who stay to practice in the state
HB 710 Medicaid State Pacesetter Medical Homes 2009 In 2014, NM Legislature Appropriated $200,000 to create primary care residency slots in FQHCs using Medicaid GME No explicit federal guidelines on how states pay Medicaid GME
Telemedicine Payment State Pacesetter Parity 19 States Project Echo mission is to effectively treat chronic, common, and complex diseases in rural and underserved areas in 10 states
Patients Office Staff Health Providers Community Improved Outcomes Coordinated Care (ACO) Ex. MN SIM Patient Experience HCAHPS Family Medicine Foundation Meaningful Health Use IT EMR Ex. WI Epic Performance Measurement Public Reporting Primary Care State Transformation: Payment & Practice
ACA Title V Workforce Provisions Teaching Health Centers (Sec. 5508) $230m Advanced Practice Nurses $200m National Health Service Corps $1.5 Billion FQHC, RHC, CHC $9.5 Billion National Center for Health Care Workforce Analysis (Sec. 5103) State Health Care Workforce Dev. Grants (Sec. 5102) National Health Workforce Commission (Sec. 5101) United States Public Health Sciences Track (Sec. 5315)
Payment Reform Link PCMH to Payment: Balanced Approach to Increase Value 10% Payment for Qualified Medical/Health Homes Performance Measurement + Public Reporting 30% Pay for Performance (Per Member Per Month or Quarter) Defined Outcomes - Quality, Resource Use, Patient Experience 60% Transparent Fee-For-Service for Visits/Procedures
To travel hopefully is a better thing than to arrive. Robert Louis Stevenson