TITLE V: Health Care Workforce

1. TITLE V: Health Care Workforce Innovation, Business and Law Colloquium September 9, 2010 Ann M. Rhodes

2. What is the most important element of health care delivery? • The people who deliver the care

3. What are the most important issues regarding workforce? • Number • Preparation • Access • Distribution

4. Current system for preparation: • Decentralized • Based in universities, colleges, community colleges, on-the-job training • Standards dictated by accrediting bodies, professional organizations, or employer needs • Health care workforce education is expensive, selective

5. Current system for distribution • Based on supply and demand • Economics • Environmental factors: where you want to live, where can you make the best living—remember you have massive student loans to repay

6. Health Professional Education • Is expensive • Labor/faculty intensive • Complicated: theory, practice • Requires lots of resources: lab, simulation facilities, clinical facilities, faculty for didactic, mentoring, clinical supervision

7. Changing Curriculum • Lengthy, complicated process • Consequences are significant • Essential to get it right • Like the titanic

8. Increasing the Health Care Workforce • Means increasing the output of health care professionals • Increasing enrollment in professional schools • Increasing the number prepared in specific specialties

9. Query: • Does the Patient protection and Affordable care Act do this?

10. Currently… • Federal government supports healthcare workforce development in 2 ways: • 1. Payment to teaching hospitals to support GME • 2. Through grants and incentives for providers (primary care, general dentistry, nursing) to work in medically underserved communities and in shortage specialties

11. Keep in Mind: • We don’t know the exact formula for the most cost-effective way to provide health care for people (20 miles?) • Most health care dollars go to pay for high-tech care in hospitals, chronic illness treatment and end-of-life care • No evidence for what is the correct distribution of primary and specialty care givers

12. Back to TITLE V…..

13. Development Grants • 1. Teaching Health centers development Grants: for purpose of establishing new accredited or expanded primary care residencies (Section 749A) • 2. Graduate Nurse Demonstration: funds up to 5 hospitals for reasonable costs of training advanced practice nurses in primary care (Section 5509)

14. Main Provisions: • 1.Innovation in the health care work force • 2. Increasing the supply of health care workers • 3. Enhancing health care workforce education and training • 4.Supporting the existing health care workforce • 5. Improving access to health care services

15. In addition: • 1. Part D establishes United States Public Health Services Track • 2. Subpart XI addresses support of GME in Qualified Teaching Health Centers (residencies) • 3. Other workforce provisions in other Titles of Act

16. Purpose of TITLE V: • “The purpose of this title is to improve access to and the delivery of health care services for all individuals, particularly low income, underserved, uninsured, minority, • health disparity, and rural populations by- • Gathering and assessing data • Increasing the supply of qualified health care workers • Enhancing health care workforce education and training • Providing support to the existing health care workforce

17. Subtitle A • States Purpose • And Definitions

18. Goals: • Create more workers • Improve existing workers • Distribute workforce better • Know more about what we’ve got and what we need

19. Subtitle B: Innovations in the Health Care Workforce • Creates National Health Care Workforce Commission • 15-member commission • Required to submit 2 annual reports to Congress and the President • One will be a strategic plan for achieving the priorities and goals of the commission • The other will address high-priority areas targeted by the commission or Congress

20. Commission will address • Need for additional primary care practitioners • Controversial issues: supply, distribution, education and training capacity • Gap in income between primary care and specialties • Innovative delivery models

21. Specifically…. • Will examine workforce demographics • Education and training capacity • Faculty needs • Education and training infrastructure • National student loan policies • Scope of practice • Geographic distribution • For the next 10 to 25 years

22. Creates State Grant Program • Can award competitive planning grants to states • Complicated application process • Lots of requirements • State match required • Many reports

23. Conduct Assessments • Establish National Center for Health Workforce Analysis • State and federal cooperation • Multiple elements to this • Emphasis on primary care • Interdisciplinary and community based care • Interagency Task Force to Assess and Improve Access to Health Care in the State of Alaska • Lack of access is a critical problem in AK • Submit report, develop strategy and disband

24. Emphasis: • Primary Care • Interdisciplinary Care • Community based • Graduate Medical Education

25. Subtitle C: Increasing the Supply of the Health Care Workforce • 1.Primary Care Student Loans: Medical School • Limits service obligation to 10 years • Needy students • Must practice in primary care until low-interest loan is repaid (or 10 years) • Failure to comply: loan accrues interest at 7% (a reduction in penalty for non-compliance) • Parental income information no longer required

26. Subtitle C:Increasing Workforce • Nursing Student loans • Maximum loan amounts are increased from $2,500 per year to $3,300 per year and for the final 2 years from $4,000 to $5,200 • Aggregate total increased from $13,000 to $17,000 • Dates relating to financial need requirement and loan cancellations are updated

27. Subtitle C: Increasing the Workforce • Loan repayment program for physicians who go into pediatric subspecialties • Pediatric medical or surgical subspecialty • Child and adolescent mental/behavioral health inc. substance abuse • For licensed MD’s receiving specialized training • (residency or fellowship) • Must be US citizen • Must agree to work in underserved area

28. Subtitle C: Increasing Workforce • Public Health Workforce loan repayment program (epidemiology, lab science, environmental science, vet public health, nursing) • Student in final year of program • $35,000 per year for each year of service plus 39% to cover tax

29. Subtitle C: Increasing Workforce • Allied health program workforce: adds allied health workers to those eligible for loan repayment under the Higher Education Act of 1965 • Provides scholarship funds for mid-career professionals to receive additional training in public health

30. Subtitle C: Increasing Workforce • Funds the development and operation of nurse-managed health clinics • Managed by advanced-practice nurses • Provides primary care or wellness services • To underserved or vulnerable populations • And that is associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency

31. Nurse-managed Clinics • Can receive grants. To be eligible must be • Nurse-managed • Provide comprehensive primary care services without regard to income • Must establish a community advisory board with majority of members being people served

32. Subtitle D: Enhancing Health Care Workforce Education and Training • Primary Care Training and Enhancement • Supports grants to programs in family medicine, general internal medicine, general pediatrics for medical students, interns, residents or practicing physicians • To provide training • To build capacity • Appropriates $125,000,000 for FY 2010

33. At last.. • This might increase capacity • Strenuous accreditation process for new residency programs as well as language for eligibility for funding in PPACA

34. Building Training capacity…. • Requires accreditation • LCME: Liaison Committee on Medical Education • ACGME: Accreditation Council for Graduate Medical Education • RRC: Residency Review Committee • AMA-CME: American Medical Association Council on Medical Education • NBME: National Board of State Medical Examiners

35. Subtitle D: Enhancing Workforce Training • Provides authority to award grants to fund training opportunities for direct care workers: workers in long term care settings

36. Subtitle D: Enhancing Workforce Training • Supports training in general, pediatric and public health dentistry • Faculty loan repayment program • Demonstration program to train alternative dental health providers at up to 15 sites • What is this? “Community dental health coordinators, advance practice dental hygienists, primary care physicians, dental therapists, dental health aides and any other health professional that the Secretary dtermines appropriate.”

37. Subtitle D: Workforce Training • Supports training in geriatrics (funds for fellowships, CME) • Mental and behavioral health education and training grants • Support programs in social work • Externships in counseling • Emphasis on vulnerable and historically underserved populations

38. Subtitle D: Workforce Training • Training in cultural competency, prevention, reducing health disparities, training for working with people with disabilities • Collaborate with professional organizations, advocacy groups • Create model curricula

39. Subtitle D: Workforce Training • Nurse education, practice and retention Grants • Creates nurse retention programs • Creates nurse faculty loan program

40. Subtitle D: Workforce Training • Authorizes CDC to award grants to eligible entities to support community health workers • In medically underserved communities • To promote positive health behaviors and outcomes • “community health worker” defined by services provided

41. Subtitle D: Workforce Training, • Establishes program to address documented workforce shortages in applied public health epidemiology and public health laboratory science and informatics • May expand the Epidemic Intelligence Service

42. Subtitle D: Workforce Training • Distribution of additional residency positions • Counting resident time • Resident time: didactic vs. clinical

43. Subtitle D: Workforce Training • Demonstration projects to provide training opportunities for low-income individuals in positions that address health care workforce needs

44. Subtitle D: Workforce Training • Payments to teaching hospitals for additional costs for new GME • Payments for direct and indirect costs of GME (in addition to Medicare payment adjustment)

45. Subtitle E: Supporting the Existing Health Care Workforce • Centers of excellence • Training for diversity • Area Health Education Centers • Continuing education for professionals serving in underserved communities • Primary Care Extension Program

46. Subtitle G: Improving Access to Health Care Services • Appropriates funds for federally qualified health centers • Serving “medically underserved” in “health professional shortage areas” • Provides incentives for co-location of services • Establishes Commission on Key National Indicators (of what? Commission decides)

47. Subtitle F: Strengthening Primary Care and Other Workforce Improvements • Expanding access to primary care services and general surgery services • Increases payments by 10% • Incentive payments of 10% in “designated shortage areas” for “major surgical procedures” • Expansion of Medicare coverage for some preventive services

48. Subtitle F: Residency Requirements • Distribution of residency positions • Counting resident time • Preservation of resident positions from close hospitals • Demonstration project to address health professions workforce needs • Increasing teaching capacity • Demonstration project for graduate nurse education

49. Subtitle H: General Provisions • Reports required

50. United States Public Health Sciences Track • Part D, Section 271 establishes a United States Public Health Sciences Track at sites to be selected by the Secretary, with authority to grant appropriate advanced degrees in a manner that uniquely emphasizes team-based service, public health, epidemiology, and emergency preparedness and response. It shall be so organized as to graduate not less than--