Joel Allison

CEO, Baylor

Scott & White

Health

Dr. Nancy Dickey

Professor, Texas

A&M University;

President

Emeritus,

Texas A&M

Health Science

Center

Edward Salsberg

Professor,

George

Washington

University School

of Public Health

and Health

Services

THE CHANGING HEALTHCARE

WORKFORCE

#MHBreakfast

#MHBreakfast

Agenda:

7:30-7:50 a.m. Registration & Networking

7:50-8:00 a.m. Opening & Speaker Introductions

8:00-9:00 a.m. Roundtable Presentation

9:00-9:30 a.m. Q&A & Closing

Panelists: Joel Allison

CEO, Baylor Scott & White Health

Joel Allison is Chief Executive Officer of Baylor Health Care System and Baylor Scott & White Health. Allison joined

Baylor Health Care System in 1993 and served as Baylor’s senior executive vice president and chief operating officer

before being promoted to president and CEO in 2000. Nationally, he serves on the Healthcare Leadership Council and

is a member of the United Surgical Partners, International board. In 2005 Allison was awarded Modern Healthcare’s

“CEO IT Achievement Award” and was awarded the Dallas Historical Society’s “Award for Excellence in

Community Service.”

Dr. Nancy Dickey

Professor, Texas A&M University, President Emeritus

Texas A&M Health Science Center

Dr. Nancy W. Dickey serves as a professor in the Department of Family and Community Medicine and the Department

of Medical Humanities in the College of Medicine, and as a professor in the Department of Health Policy and

Management in the School of Public Health, Texas A&M Health Science Center. She also is the President Emeritus of

the Health Science Center. Dr. Dickey assumed the role of president of the Texas A&M Health Science Center and vice

chancellor for health affairs for The Texas A&M University System in 2002, and served in that role until 2012. Prior to

her current appointment, she served as interim dean of the TAMHSC-College of Medicine. Dr. Dickey is a past president

of the American Medical Association, and the was the first woman to be elected to that role. She was elected to the

prestigious Institute of Medicine in 2007 and to the Texas Women’s Hall of Fame in 2010.

Edward Salsberg

Professor, George Washington University School of Public Health and Health Services

Edward Salsberg has been a national leader in health workforce research, policy and data for over 25 years. He is

currently on the faculty at George Washington University. Until recently, Mr. Salsberg was the founding director of

the National Center for Health Workforce Analysis in the U.S. Department of Health and Human Services. Mr.

Salsberg previously established and directed the Center for Workforce Studies at the Association of American Medical

Colleges and the Center for Health Workforce Studies at the University at Albany, State University of New York. All

three health workforce centers have been leaders in providing information on the supply, demand, distribution and

use of the healthcare workforce, and they have pioneered approaches to collecting health workforce data.

Moderator: Maureen McKinney

Editorial Programs Manager, Modern Healthcare

Maureen McKinney is the editorial programs manager for Modern Healthcare, overseeing webinars, conferences and

other healthcare leadership events. She also reports on timely issues affecting healthcare leaders, including clinical

and financial best practices. McKinney joined Modern Healthcare in 2010 as the magazine’s quality and patient safety

reporter. She has covered the healthcare industry for more than a decade.

A Modern Healthcare Briefing

Dallas, TX

May 6, 2014

Major Developments and

Trends Impacting the Health Workforce

• Demand for health care rising as the US population is growing and

aging and coverage expands

• Unsustainable cost increases

• Uncertainty about adequacy of health workforce supply

• Concern with inefficiencies and potential overuse

• Increasing interest in identifying ways to improve efficiency and

health outcomes

• Delivery system reforms and innovations and growing size of health

care organizations

States Are Central to Health Workforce Supply,

Distribution and Use

• State-supported education and training

• Scholarships and loan repayment

• State labor department- tracking employment and workforce

needs (LMI Directors)

• State Primary Care Offices

• Medicaid policies

• State employee health insurance

• Provision of state and local public health services

• Licensure and regulation of practitioners

• Regulation of service delivery

Delivery System Transformation and the

Workforce

• Pressure to do more with less

• The transformation is being driven by public policies as

well as the provider and payer community and patients

• The growing supply of PAs, NPs and other health care

practitioners will enable and stimulate the transformation

• Incentives to make better use of the workers we have;

• Teams and collaborative practice and education

• New categories/variations on support personnel

• Reassess scope of practice and scope of work

• Increased use of technology

• Comprehensive Primary

Care (CPC) Initiative

• Multi-Payer Advanced

Primary Care Practice

(MAPCP) Demonstration

• Federally Qualified Health

Center (FQHC) Advanced

Primary Care Practice

Demonstration

• Independence at Home

• Health Care Innovation

Awards

• State Innovation Models

• Graduate Nurse Education

Demonstration

Federal Initiatives Support Systems

Redesign

Source: CMMI

Federal Initiatives and the Workforce

• CMMI Health Care Innovation Awards

Care coordinators and better management of patients;

Use of inter-professional teams;

Use of patient navigators;

Use of community health workers;

Use of patient care technicians, advanced aides, assistants;

Improved care transitions and in home services.

• CMMI State Innovation Models (SIMS)

• Medical home initiatives

• ACOs/Bundled payment

• Texas 1115 Health Care Transformation Waiver

Growing Evidence of Systems TransformationHealth Affairs Workforce Issue, Nov. 2013

• Primary Care: Proposed Solutions To the Primary Shortage Without

Training More Physicians by Bodenheimer and. Smith

• Nurse-Managed Health Centers And Patient-Centered Medical Homes

Could Mitigate Expected Primary Care Physician Shortage by Auerbach, et.al.

• Physician Assistants And Nurse Practitioners Perform Effective Roles on

Teams Caring For Medicare Patients With Diabetes by Everett, et. al.

• Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That

Can Be Achieved In Retail Clinics by Spetz, et.al.

• Primary Care Technicians: A Solution To The Primary Care Workforce

Gap by Kellermann,et. al.

• It Is time to Restructure Health Professions Scope-Of-Practice

Regulations To Remove Barriers To Care by Dower, et.al.

8

Team for Comprehensive Care

Physicians

Nurse practitioners

Physician assistants

Psychologists

Optometrists

Registered Nurses

Pharmacists

Case Managers

Nutritionists/Dieticians

Physical Therapists

Community Health Workers

…And more

Recent HRSA Report:

“Projecting the Supply and Demand for Primary Care

Practitioners through 2020”

• Demand for primary care services will increase due largely to

population growth and aging

• Demand for PC physicians will grow more rapidly than supply resulting

in a projected shortage of approximately 20,400 FTE physicians

• The supply of primary care NPs and PAs, is projected to grow rapidly

and could mitigate the projected shortage of physicians if NPs and

PAs continue to be effectively integrated into the delivery system

• Assuming full deployment of available NPs and PAs, the projected

shortage of PC Practitioners in 2020 (6,400 FTEs) is very close to the

estimated shortage in 2010 (7,500 FTEs).

• The national numbers can mask regional and local shortages.

7,261

6,979

6,611

6,5266,900

7,583

8,014

8,8659,698

11,135

12,273

14,310

16,031

5,500

7,500

9,500

11,500

13,500

15,500

17,500

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Source: American Association of Colleges of Nursing and National Organization of

Nurse Practitioner Faculties Annual Surveys1Counts include master’s and post-master’s NP and NP/CNS graduates, and

Baccalaureate-to-DNP graduates.

Gra

duate

s

Growth in Nurse Practitioner Graduates2001 - 2013

Physician Assistant Growth

Source: National Commission on Certification of Physician Assistants “Certified

Physician Assistant Population Trends ”; 2013 data from personal communication

with NCCPA January 2014

Newly Certified PAs, 2001 - 2013

New

ly L

icensed P

As

4235

4009

4337

4512

43934654

4989

5215

5243

5823

59796479

6,607

3000

3500

4000

4500

5000

5500

6000

6500

7000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Pharmacy School Graduation Trends2000 - 2015

Nu

mb

er

of

Gra

du

ate

s

* Graduation projection figure based on enrollment dataData represent first professional degrees including B.S. Pharmacy, B.Pharm., and Pharm.D.1 Source: AACP 2012 Enrollment Data

7,260

7,000

7,573

7,488

8,158

8,268

9,040 9,812

10,50010,988

11,487

11,931

12,71913,335

14,21314,930

4,000

6,000

8,000

10,000

12,000

14,000

16,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013* 2014* 2015*

Workforce Composition:

Growth of PAs/NPs Compared to Physicians

Source: Prepared by National Center for Health Workforce Analysis

Ratio of Types of Direct Patient Care Providers,

Supply and Production

82%

18%

In Practice in 2010

42%

58%

New Providers per Year

PAs/NPs

Physicians

What will the staffing of the Patient Centered Medical

Home look like*?

A. If no delegation: 1 physician for 983 patients =

315,000 PC physicians; Then significant shortage!

B. If significant delegation: 1 physician for 1,947 pts =

159,000 PC physicians; Then significant surplus!

But even with a national surplus, local shortages are likely !

The Importance of the Team in Assuring

Access to Primary Care Services

* “Estimating a Reasonable Patient Panel Size for Primary Care Physicians

with Team Based Delegation”, Altschuler, Margolis, Bodenheimer and Grumbach; Annals of Family Medicine, Sept/Oct 2012

• Geographic and specialty mal-distribution is a serious

problem

• For many professions and many physician specialties,

the national supply may look adequate but there are

serious access problems for many people due to the

distribution of the supply

• Different strategies needed to address mal-distribution

compared to general shortages

• Targeted investments are needed

The Problem of Mal-distribution

• Demand is rising but it is usually for services not a

particular profession; there are multiple ways of

assuring access to care.

• Health systems transformation will drive changes in the

health workforce, including the mix and configuration of

the workforce, responsibilities and roles, and supply

and distribution.

• The increasing supply of non-physician clinicians and

other caregivers will facilitate delivery system change.

• While there are many unknowns related to the future

delivery system, we do know that more practitioners will

work in teams.

Closing Comments

Edward Salsbergesalsberg@gwu.edu

Joel Allison

CEO, Baylor

Scott & White

Health

Dr. Nancy Dickey

Professor, Texas

A&M University;

President

Emeritus,

Texas A&M

Health Science

Center

Edward Salsberg

Professor,

George

Washington

University School

of Public Health

and Health

Services

THE CHANGING HEALTHCARE

WORKFORCE

#MHBreakfast

Modern Healthcare Leadership BreakfastMay 6, 2014

Dallas, TX

Nancy W Dickey, MDPresident Emeritus, Texas A&M Health Science

Center

The Future of the Healthcare Workforce

Factors impacting workforce:

1. “Baby Boomers” born between 1946 and 1964 will turn 65, when health care utilization historically doubles.

2. Nation’s growing population3. Growing burden of chronic diseases4. Continued scientific progress and tech innovation5. New health care payment models6. Younger professionals desire a different lifestyle – life/work

balance7. In the US, the supply of physicians and nurses is projected to

decrease (retirement, leaving the field)a. We are producing more annuallyb. The supply measure is numbers of professionals per

population) over the next 15 yearsc. Productivity/hours worked per professional have decreased

6 0

%4 0

%

5 0

%

5 0

%

5 0

%

5 0

%

5 5

%

4 5

%

6 7

%

3 3

%

Canada France Singapore

Thailand Britain U.S.

Primary Care

Specialists

Primary Care/Specialty Mix

Current US System

Most

Highly

Specialized

Specialist

Generalist

Non-Physician Provider

Community Health

Worker

Patient Driven System Driven Professional Driven

Preferred System ?

Most

Highly

Specialized

Specialist

Generalist

Non-Physician Provider

Community Health

Worker

System Supported Professional Supported

What’s Next?

1. Several things exacerbating shortages in the next decades2. Takes a long time to expand the workforce

as it is currently composed3. Solution may be to change the “needs” by

changing the make up of the workforce4. More work as teams

Teams…Increased Efficiency, Everyone Working to Their Full Potential

• Need to identify appropriate ways to utilize a broader group of care givers –– Many requiring shorter/different

training periods

• Potential for changes of scopes of practice

• Imperative that traditional practitioners become more collaborative, communicative

AAHC’s recommendation

• Solution is more complex than simply increasing the numbers of providers

• Issues of:– which specialties– geographic distribution– training to enhance work as

interdisciplinary teams• Past due in preparing for future health

workforce

•

Without Planning…

• Currently we turn spigot off & on

• ACA included the establishment of a National Health Care Workforce Commission

• ACA also provided for state health care workforce development grants to address shortages in each state

Going Forward…

PlanningChanges in training

Incentives to encourage efficiency & quality

Joel Allison

CEO, Baylor

Scott & White

Health

Dr. Nancy Dickey

Professor, Texas

A&M University;

President

Emeritus,

Texas A&M

Health Science

Center

Edward Salsberg

Professor,

George

Washington

University School

of Public Health

and Health

Services

THE CHANGING HEALTHCARE

WORKFORCE

#MHBreakfast

Modern Healthcare

The Changing Healthcare Workforce

Tuesday, May 6, 2014

Joel T. Allison, FACHEChief Executive Officer

32

Baylor Scott & White Health

Combined Assetsand Clinical Footprint/Access

33

• $8.6 billion in assets, based on most recent audited financial statements

• $6.3 billion in total operating revenues

• Includes:

– 43 hospitals

– 500+ patient care sites

– 6,000+ affiliated physicians

– 36,000 employees

– Scott & White Health Plan

• Provided more than $850 million in community benefit FY13

Population Health

• Managing population health is critical to the future of Baylor Scott & White Health.

• Not enough primary care physicians; only 20% of all physicians in US

• Need to focus on growing, recruiting and retaining PCPs

• Specialists may need to become medical homes for some patients.

34

Quality AllianceFocused on patient-centered clinical integration across all points of care

Entry Point Redesign:

Primary Care strength, PCP PCMH; physician-designed best care and quality improvement processes, access & capacity challenge.

Care Integration/Specialty Alignment:

Standardized order sets, clinical protocols, care redesign. Large scale physician partnering, EHR adoption, and connectivity via HIE challenges.

Population Health Infrastructure:

Predictive analytics, comparative effectiveness, care coordination and population health management.

Financing: New innovative payment models, product & benefit redesign, data repository and control.

Entry Point Redesign

CI/ Specialty Alignment

Population Health

Infrastructure

Financing

Intended consequences: QualityImprovement, patient satisfaction and

cost reduction – otherwise unachievable

Staffing the Population Health Model

36

PCMH of the Future

• Typical physician practice will include:

– Physician

– Nurse practitioner

– Three medical assistants

– Care coordinator

– Receptionist

• Will be taking care of 4,000 patients instead of 2,200

37

Outpatient Growth

• Moving from hospital-focused world to an outpatient clinic world

– More folks will be needed to keep you out of the hospital as opposed to in it.

– New jobs created in outpatient medical labs and diagnostic imaging centers; i.e., lab techs, sonographers, etc.

38

More Mid-levels

• Care coordinators (more elaborate care coordination needed)

– R.N. w/several years clinical experience• Good communication skills• Broad knowledge• Comfortable working in different environments, i.e., in

person, telephonic, etc.

39

• #9: Occupational therapist

• #10: Speech pathologist

• #11: Dietitians

• #14: Optometrist

• #15: Physical therapist

• #17: Medical lab technician

• #23: Medical records technician

• #24: Medical technologist

• #29: Podiatrist

• #31: Physiologist

• #33: Pharmacist

• #34: Chiropractor

• #39: Optician

40

Top Healthcare Jobs

CareerCast’s Annual Report of Top 40 Jobs in America includes the following thirteen healthcare jobs:

No health careers ranked among the 20 worst careers.

High-demand Healthcare JobsProjected growth, 2012-20

Total27% Healthcare social workers19% RNs11% All occupations

Ambulatory care jobs52% Social workers41% RNs

Acute-care hospitals15% RNs14% Social workers

Home health52% Social workers43% RNs

Source: US Bureau of Labor Statistics Occupational HandbookModern Healthcare Magazine, March 31, 2014

Transformation of Top Administrative Healthcare Positions

• Addition of executive roles that previously did not exist

– Chief medical information officer

– Chief population officer

– Chief population health officer

– Chief patient experience officer

42

Technology

• Surge in demand for technology experts to install, upgrade and maintain IT infrastructure

– Population-centric data– Need better ways to take care of the population

through technology – especially for younger patients

• Growing number of hospitals could not hire IT workers fast enough to meet demand in 2012, with 67% of surveyed hospitals reporting a shortage.*

43

*College of Healthcare Information Mgmt Executives

Big Data

• Analytics

– Rising demand for workers who can understand and manipulate data

– Companies paying richly for those with quantitative skills

44

Triple Aim

Big dataData analytics & predictive modelingSocial/community supportTransportation/housingPriority setting“The Mediterranean Diet”

Delivery redesignScope of practiceLowest cost site of careTelehealthDigital substitutionSelf-carePalliative care

TransparencyCQI/LeanShared decision-makingStandardizationClinical guidelines and Care paths

Triple AimInformationIncentivesIntegration

Integrity

Better Health

Better Health Care Lower Per Capita Costs

Nate Kaufman, Kaufman Strategic Advisors, LLC

The New Winners:

46

• Well-capitalized health systems with high functioning, data driven, digitally connected, physician-lead TEAMS delivering evidence-based, patient-centered health care

• Able to treat higher volumes of patients

• At lower predictable costs per episode

• Demonstrating consistent measurable high quality

Questions/Discussion

47

Joel Allison

CEO, Baylor

Scott & White

Health

Dr. Nancy Dickey

Professor, Texas

A&M University;

President

Emeritus,

Texas A&M

Health Science

Center

Edward Salsberg

Professor,

George

Washington

University School

of Public Health

and Health

Services

THE CHANGING HEALTHCARE

WORKFORCE

#MHBreakfast