It’s time to focus on the staffs that will care for patients in the new era.
By Ralph Henderson
Healthcare reform, the biggest transformation in that sector in our nation’s history, is fundamentally a workforce-related initiative. Yet you don’t hear much very much about the healthcare workforce in the national debate over the complex Patient Protection and Affordable Care Act (ACA). The media focus tends to be on who will receive what benefits and where the money will come from, not on who will deliver the care.
But a growing body of research evidence has shown that staffing problems are key factors that affect fundamentals of the industry: quality and cost of care; patient safety; length of stay; readmissions; and patient, physician, and staff satisfaction, turnover, and vacancy rates. These issues are at the core of healthcare reform; they must be addressed to bring down high healthcare costs in the United States while raising quality of care for everyone. Now that state and federal governments are only months away from signing up millions of new clients for coverage, attention needs to be focused on preparing the workforce that will care for patients in the new healthcare era.
The need for greater attention to healthcare workforce issues can be seen in the continually high percentages of physicians who surveys show are pessimistic about the future of their profession and consumers who are uncertain what healthcare reform will mean to them. The reason in both cases might be that the changed roles of physicians and nurses under healthcare reform haven’t been made clear. Both clinicians and consumers know that major changes are in the works, but exactly what those changes will look like in the doctor’s office, surgery suite, or hospital room are not known.
Major workforce issues lie at the heart of healthcare reform:
• Physician and nurse shortages. Obviously, this is a workforce issue. But what’s not so obvious is how the shortage of primary care clinicians can undermine the new healthcare models that are supposed to reduce costs and improve care. These models are predicated on every patient having a primary care doctor who anchors a team approach to care. This is called an integrated care delivery system, and the primary care doctor is at the center of patients’ coordinated care that can also include specialists, therapists, behavioral health providers, and others. The Association of American Medical Colleges estimates a shortage of 45,000 primary care physicians by 2020. And there’s a problem with the proffered scenario under which nurse practitioners and physician assistants fill in the gaps in primary care. Shortages exist for both of them, too. A recent survey by Staff Care, a physician staffing company that’s part of AMN Healthcare, concluded that, “there are not enough physician assistants and nurse practitioners to make up for provider shortages in primary care and other areas.”
• Quality and patient safety. Another basic tenet of healthcare reform is improving the quality of care and patient safety. These measures are as much based on healthcare staffing—and particularly nurse staffing—as they are on new care or compensation models. A survey just released on nurse understaffing found that two-thirds of nurses report they had nearly made a mistake at work because of fatigue, and more than a quarter say they had made a fatigue-related error. Appropriate levels of nurse staffing are associated with fewer medical complications, fewer patient deaths, shorter lengths of stay for patients, and a whole range of positive patient outcomes. Negative events at hospitals are also costly, so workforce issues not only relate to quality and patient safety but also to cost.
• Switching from volume to value. Compensation is a universal concern for every workforce, and healthcare reform creates fundamental changes in how almost every clinician is paid. Reimbursement from private and public medical plans is the most critical component of the viability of healthcare systems. Until very recently, health plan reimbursements have been based entirely on the volume of patients and procedures at a doctor’s office or healthcare facility and the cost of each treatment. This system occasionally created incentives that drove up the overall cost of healthcare. Under healthcare reform, the new metrics for compensation and reimbursement will be value-based rather than volume-based, and will include patient satisfaction, readmission rates, health risk assessments, patient wellness, physician reporting on quality measures, electronic prescriptions for medication, smoking cessation services, and other new qualitative measures. These are changing year by year, with new value-based payments added annually. Note that all of these require significant action and buy-in by the healthcare workforce; they are not just billing changes. Physicians, nurses and other healthcare staff must carry them out.
• Electronic health records. Incentives for healthcare systems to switch to electronic health records (EHR) actually come from earlier legislation, the HITECH sections of the American Recovery and Reinvestment Act of 2009. But the ACA certainly emphasizes the use of EHR, and the health information technology transformation includes a critical workforce component. While a health system, hospital, or clinic might purchase the best health IT money can buy, workforce acceptance and use of the system are key to its success. Eight years ago, the American Health Information Management Association and American Medical Informatics Association issued key recommendations that adequate health IT training, education, encouragement, and support for the healthcare workforce are crucial, because the workforce can decide the success or failure of an EHR implementation. That recommendation is even more important today. Many recent surveys show persistently high levels of dissatisfaction about EHRs among clinicians. This might indicate that workforce training and preparation needs to be a greater priority in EHR planning and implementation.
We’re now on the eve of a tremendous experiment in changing our nation’s healthcare system to make it cost-effective, efficient, accountable, and proficient. The healthcare workforce implications should not be overlooked if we hope to achieve these goals.
Ralph Henderson is the president of healthcare staffing at AMN Healthcare Services, Inc.
