Opportunity or Peril

The cover of Business Week last year captured it all. Against a familiar cartoon image of Rosie the Riveter, now draped in nursing garb, the headline trumpeted that over the past five years the US health care system created 1.7 million new jobs, while the rest of the US economy had offered up a net of zero growth: as many jobs had been lost as had been created. For those of us who encourage young people to consider careers in health care this was encouraging news. The opportunity would continue to grow in these jobs, most of which afforded a good income, an opportunity to serve, and the ability to learn new skills in order to master the seemingly endless array of new technologies and demands needed to be successful.

So you might rightly ask, “Where is the peril in this opportunity?” Accompanying this article and the general celebration of the health workforce opportunity was the year long spate of obituaries for the American auto industry. Every one of them pointed the first finger of blame at an unresponsive management which failed to recognize that new models and engineering were needed and that execution of a quality production function was essential for survival in today’s market. There were lessons there for US health care of course. But the second finger pointed to the cost of the US health care system and how that burden put the car manufactures at a serious disadvantage when competing internationally. Since then, their point that the cost of health care in the US is not sustainable has been joined by a greater chorus from the private sector and even those in the public sector. For the first time those that are trying to expand access through public payment are looking at the seemingly intractable growth of the cost of care as a critical issue to address. As labor costs are sixty to seventy percent of the cost of care, they represent some of the problems and any changes in how health care is done in the US will impact employment.

So while the opportunity of jobs in health care represents a bright spot on the employment future, it may not be as bright if management, labor and education just assume that it will be business as usual indefinitely out into the future. I am sure this is just what the auto manufacturers and the UAW once thought as well. Already we are seeing consumers move to lower cost non-traditional providers whether that is primary care services in a big box retail outlet or paying out of pocket for a complimentary or alternative provider such as a naturopathic physician in lieu of an internist or family physician. People still go to Canada for some pharmaceuticals even with Medicare Part D, which hasn’t made drugs less expensive (it has just moved the bill to the public purse), and there are a growing number of firms that focus on taking you and your family on an exotic vacation out of the country that also includes as part of the package a new hip at the end of the trip. Slowly the ice is breaking around the megalith we call health care in this country and as it shifts it will be the source of peril to that opportunity that seemed so bright just last year.

It doesn’t have to be that way, but there are some things which management, labor and education can begin to do now to change the prospects for the future. The important work here will be those things that the three sectors do together.

The management in our big systems of care, which are the largest employers in health care, need to develop a strategic workforce plan which identifies where and how they will grow, the losses they will take from retirements with the aging Boomers, the changes in their practice models to meet quality demands and respond to the demands and opportunities of new technologies, and where and how they access new workers into their systems. Most places have something of a plan, but most of what I have seen is little more than a quick look back to the past six months and an overly optimistic projection of the future. A key to any solid approach here is to have a good sense of what current health care workers see as their future career directions and the skills and abilities that they bring to the table. Management will also need to lead the effort to change the practice or delivery model. This will need to be done in concert with labor organizations because all successful efforts at workplace redesign have such partnerships. In health care this partnership will be essential because it will need to be accompanied with significant shifts in the financing system, so that we pay for the new ways that care is delivered and we stop investing in activity which is not efficient or useful.

Labor will need to be the first on the line to examine how old labor rules from the industrial era hamper job change and stability in health care. In a manufacturing setting much of the quality comes from design and machine. The worker was the interchangeable input, so rules like seniority, equal pay and no assessment of quality work made perfect sense for protecting workers and jobs. Today, much of the quality of health care depends on the skills, values and attitudes of individual workers. Labor has to join with management to lead efforts to ensure that all workers have the abilities to do their job, but when they don’t labor should take the lead in ensuring that other places or ways are found for these workers to be productive. With management labor will need to sit down and design the new delivery models. This will need to be done with a clear commitment making the production of health care efficient, not protecting jobs or not changing work rules. If these latter concerns become the priority in this process, then the process begins the dance on the slippery slopes of where the auto industry was two decades ago, with disastrous consequences.

Education’s role in all of this will need to be that of a supportive partner. Once management and labor have decided where the changes need to be and what new skills will be in demand, education should start with a fresh look at where school is taught, who is credentialed as a faculty member, what focus research work should take in health care and how easy is it for the student as consumer to move through the program in a timely and efficient manner. There has been much activity over the past decade in education, but it is important to stop now and ask students, employers and labor how they see their needs unfolding over the next decade.

All three of these sectors in health care, management, labor and education, will necessarily be a part of the response to ensure that health care work remains attractive to individuals and responsive to the nation’s needs. This work is all essentially local and anyone who reads this can begin the discussion today with the other two parts of the equation.