I spent a significant part of my professional career pursuing “rational” policies to guide the numbers of health workers needed. I now understand that most of these moves on the policy side were fool’s errands, when measured against the powerful corrective forces of the labor and education markets.
In fact, the elasticity of these markets has been generally unanticipated by most of the workforce models. For instance, few recognized the shrinkage of incoming nursing classes in the waning years of the 20th century. It was only in 2001, when the number of nurses passing the licensing exam fell to 28 percent, less than it had been just six years before, that alarm bells went off. New policies spurred the creation of schools, existing programs were expanded, and a raft of workplace changes were put in place to make nursing more attractive and sustainable. By 2005, more candidates passed the exam than in 1995, the previous high water mark. By 2009, the number had increased by 38 percent.
Similar unexpected market responses have been reflected in such trends as the growth of osteopathic medical colleges, expansion of proprietary allied health education, delayed retirement by many professionals, and a host of second-career entries into health professional work.
These trends should make us more open to thinking creatively about how we produce and utilize health professionals. Several new reports from the California HealthCare Foundation remind us that the use of health services is a function of the availability of health care professionals and how they are educated, organized, paid, and regulated.
The problem with ratios
It is tempting to look at population-to-provider numbers and conclude we need a bigger workforce. In fact, we have used the presence or absence of health professionals as a proxy measure for both access and quality. A workforce infographic released by CHCF compares California’s San Joaquin Valley to the Greater Bay Area in terms of health status, income, insurance coverage, and the physician-to-population ratio. It shows that the Valley significantly lags behind the Bay Area in access to both primary care doctors and specialists.
While an influx of physicians to the Valley could benefit the population, even at a most aggregated level such ratios of providers to population are meaningful only within a broad band or range. There probably is a low level of the ratio at which negative impact on access and quality can be measured, but there is as well an upper level at which overtreatment, duplication, and cost serve to deteriorate the overall quality of care.
For instance, the ratio of physicians to population in Iowa is half of what it is in Connecticut and has been for many years. But the health status of the two states has been—and remains—about the same. Is Iowa seriously under-doctored, or are there superfluous physicians in Connecticut? There are probably elements of truth in both statements. But if we only focus on provider ratios, we are likely to miss the opportunity presented by health reform to think creatively about how services are arranged and provided. Making these types of changes holds the promise of fundamentally changing the health care landscape.
For much of the past few years our imagination has been captured by issues of insurance coverage, finance, integration, and rationalization of the services that make up health care in the US. If any attention has been paid to health workforce matters, it has surrounded the debate over whether there would be an adequate supply to meet the new demand for care generated by health reform.
This is a legitimate concern, but one that masks an assumption that the optimal way to use health professional resources has been achieved, and that growing the insured population by more than 10 million people requires a corresponding increase in health professionals.
This tacit endorsement of the status quo would be fine, if the status quo worked. But we know that is not the case. It is precisely the uneven quality, unsustainable costs, and poor consumer satisfaction that drive the need for reforms like the ACA.
Despite the enormous diversity of American’s care needs, our health care system evolved to an amazing level of standardization. Most of the value is delivered in an office visit, hospital admission, or the filling of a prescription. Unfortunately, as the nation ages, the weakness of this approach is beginning to show real cracks. While attention should be focused on the millions of patients with chronic conditions, the current model does not. This won’t change with the addition of more health providers of any type.
A knowledge business
As a first step, we should think about health care less as a set of procedural services – billed when activated by patient demand – and more as a “knowledge business” that examines a specific population and provides the best combination of preventive, diagnostic, treatment, and management services to maintain or restore health.
Such a shift would open health care to the power of information and communications technology, which has shifted how we work, manage savings and investments, and buy goods and services. It would also engage the patient as an active consumer, driving the nascent movement calling for culturally competent care down to a more specific proposal for individually responsive care.
A knowledge-based and individually focused system of care could also match the remarkable advances being made in genomics and information technology. And it would prevent us from continuing to graft 21st century developments onto a delivery infrastructure stuck in the middle part of the last century. The ACA provides incentives to create systems of care driven more by outcomes and compensated by global budgets.
It is going to be critical to change the practice model that exists within these systems. If the health professions’ only contribution to this transformation is to count the number of practitioners, adjust for a growing insured population, and call for more investment in professional education, the health professions will see their influence dwindle. Decisions about the best ways to bring effectiveness and efficiency will be driven more by non-clinical perspectives of the organization and the way it is financed. This would be unfortunate for the nation’s health professionals, but a tragedy for the health consuming public.
The real question over the next two decades is not “Will we have enough?” The labor market for professional talent in this arena has aptly demonstrated its elasticity.
The real issue is whether we educate the next generation of health professionals with the perspectives, skills, and values to create new models of care. To do so, we need to put in place the right policies that regulate, compensate, and otherwise shape professional practice and encourage the innovation and creativity needed. It’s helpful to remember that once upon a time FBI agents had law degrees; flight attendants were required to be registered nurses; and computer programmers left college with electrical engineering degrees.
Technology changes, knowledge drifts down in society, and consumers demand new services which are satisfied in new ways.