The Impacts of the Affordable Care Act on Preparedness Resources and Programs: Workshop Summary (2014)

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4 The Evolving Health Workforce Highlights of Main Points Made by Individual Speakers1 • Care is increasingly being provided outside of the hospital setting, and mid-level practitioners (e.g., nurse practitioners, physician assistants, midwives, pharmacists) are beginning to take on expanded care roles in health care and public health, in some cases becoming the medical home for many patients. • Leveraging nonphysician clinicians can go a long way toward alleviating projected physician shortages. • An emerging care paradigm, referred to as mobile integrated health care practice or community paramedicine, centers on the concept of patient navigation to reduce preventable emergency department visits and readmissions and to increase capacity of the health care system. • Medical and public health preparedness programs could look to the military for lessons learned regarding successful team-based medical care and training providers in decision making under stress. As the Affordable Care Act (ACA) is implemented and the health care infrastructure evolves, the U.S. health care workforce is also changing. A key aspect of this transformation of health care delivery is the preparation of the workforce for expanded roles and training for positions that did not exist before, said Cairns of the University of North Carolina–Chapel Hill. As the demand for care increases, how many providers will be needed, in what roles, and in what geographic 1 This list is the rapporteurs’ summary of the main points made by individual speakers and participants, and does not reflect any consensus among workshop participants. 37 

38 IMPACTS OF THE ACA ON PREPAREDNESS distribution (rural, urban, suburban)? What are the workforce delivery models that will provide high-quality, efficient, effective, and low-cost care and will meet the needs of patients within a population across a defined geography, both routinely and in disasters? This chapter assesses what the current workforce looks like and how the ACA is establishing opportunities for expanded roles, new directions, and training needs to supplement expanded scopes of practice and ensure full availability of care across providers in a disaster. WORKFORCE IMPLICATIONS OF NEW CARE SETTINGS New care delivery models are being developed to meet the needs of the growing number of covered individuals seeking care, under the new paradigm of value-based reimbursement, Cairns explained. One example is community paramedics responding to 911 calls and providing direct care on-site. They are frequently able to direct patients to alternative care settings (i.e., somewhere other than the emergency department [ED]). Another example is a new category of providers called extensivists: hospital physicians who also practice outside of the hospital (e.g., at outpatient clinics, skilled nursing facilities) with the goal of facilitating care after hospital discharge and reducing readmissions.2 There are new care settings designed to bring care to people where they live, such as free-standing EDs that are not associated with hospitals, urgent care centers opened by insurers, minute clinics, and a variety of others, he said. As discussed previously, there is also a significant focus on the use of telemedicine and the ability to provide remote consultation and care for patients, both routinely and in disasters (telemedicine is discussed further in Chapter 5). Current and Future Assessments of Health Care Workers The United States has nearly 15 million health care providers,3 accounting for about one in nine U.S. jobs, said Ani Turner, deputy 2 Described in an Agency for Healthcare Research and Quality Health Care Innovations Exchange article, available at http://www.innovations.ahrq.gov/content.aspx?id=2903 (ac- cessed June 8, 2014). 3 For a more specific listing of all occupations included in the calculation of the U.S. health workforce, see Tables 4 and 5 in Turner and Hughes-Cromwick (2013). 

THE EVOLVING HEALTH WORKFORCE 39 director of the Center for Sustainable Health Spending at the Altarum Institute (Turner and Hughes-Cromwick, 2013). About 30 percent are employed in hospitals, about 45 percent are in various ambulatory settings (e.g., home health, physician offices, clinics), and just greater than 20 percent are in nursing and residential care. About 30 percent of that workforce is not a health care practitioner or a health care support person, but an administrative, business operations, facilities, or other nonhealth-trained person. The health sector, which has been an engine for job growth through recessions and recoveries, has grown by 1.5 million persons since December 2007, compared to nonhealth jobs, which are down by 3 million since then. Most of the growth has been in the ambulatory settings, including home health care. Implementation of the ACA will result in increased demand, with a resulting strain on the system, Turner said. There will be some workforce supply constraints, particularly for those professions that have a long lead time for training, as well as pressures to reduce costs, changes in incentives and the way that providers are paid, and increasing consolidation in the health care system. All of these have the potential to move us toward a more effective and efficient workforce. There is no lack of ideas for innovative workforce models, Turner said. Rather it is a matter of whether the payment incentives can be aligned to allow for and to reward innovation. Turner summarized how some of the health reform trends discussed are impacting the health workforce, both in the adequacy of the workforce to provide day-to-day care and the ability to flex and surge to manage increased demand in an emergency. • Overall growth in the health workforce across all occupations in health care delivery. All forecasts of the demand for physician services predict shortages in the coming years. The number of physicians is increasing roughly 1 percent per year. Medical school enrollments are growing faster, but there is a narrowing of the pipeline when they reach graduate medical education. In contrast, the number of nurse practitioners and physician assistants is increasing 5 or 6 percent per year. The educational pathway to becoming a physician is the longest of all health professions. Currently, about 75 percent of clinicians are physicians, but Turner predicted that if current trends continue, then it may be closer to two-thirds in the coming decades. 

40 IMPACTS OF THE ACA ON PREPAREDNESS Leveraging nonphysician clinicians can go a long way toward alleviating the projected physician shortages, Turner said. • Demand for services, leading to demand for workforce. Expanded coverage under the ACA is projected to increase demand for services. In addition, the population is growing at about 0.8 percent per year, and the population is aging. The increased demand for health care from baby boomers may not be fully felt for another decade or more, Turner noted, until they reach ages 75 to 85 or older. • Pressures to reduce costs and changes in reimbursement. There is continuing pressure to reduce health care spending and the rate of growth in health care spending. As a result, Ebeler added, there is a push for greater efficiency in the delivery of health care and a move away from fee-for-service and toward methods of payment that are value-based. The incentives are changing, allowing more flexibility in providing care (e.g., team- based care, new types of health professionals, expanded training). • Increasing consolidation and integration within the health care delivery system. Integration is occurring both vertically and horizontally. Physicians are grouping together into larger practices and single-physician practices are becoming rare. More practices are now owned or affiliated with hospitals. Most hospitals also now offer home health care services and hospice services. Additionally, providers are rearranging themselves with a goal of team-based care. In the context of preparedness, Turner said, greater integration would make it easier to communicate, mobilize, and coordinate care in an emergency situation. CHANGES IN HOSPITAL OPERATIONS IMPACTING WORKFORCE Hospitals are still the core of our surge management strategy, said Chad Priest, a senior executive advisor for MESH Coalition,4 and the surge management platform is still based on acute care capacity. 4 MESH is a nonprofit, public–private partnership focused on enabling health care providers to respond effectively to crisis events and remain viable through recovery. MESH does clinical education and training for providers, community-based planning, health care intelligence, and policy analysis. 

THE EVOLVING HEALTH WORKFORCE 41 However, hospitals are evolving to focus on complex life-threatening and intensive care in emergencies, with a dwindling focus on traditional medical/surgical capacity because the revenue and payer mix to support that is just not present, he said. Most medical care such as urgent care, long-term exposure screening, noncomplex “inpatient care,” and medical needs sheltering (emergency shelters that can provide basic medical care to keep people out of hospitals) could now be provided in many non- hospital locations. This was also discussed in a previous Institute of Medicine (IOM) summary on medical surge capacity in 2009 (IOM, 2010). Priest suggested the need to examine surge strategies in light of the ways hospitals are changing in response to health care reforms, perhaps relying more on alternative care facilities such as community health clinics and networks. One area impacted by reform is operations, Priest said. As shifts in care delivery and infrastructure are beginning, along with financial strains, some jobs are lost while others are created. Systems in some areas are losing talent and institutional knowledge while infrastructure is reorganized, and Priest cautioned that emergency management is one area that is likely to be impacted incrementally by the downward pressure on operations. For example, staff may not be released to attend emergency management trainings (because training is either not perceived as valuable, or is not specifically required to meet regulatory requirements). In many hospitals, those designated as emergency managers actually fill multiple roles (e.g., the safety officer may also be the preparedness representative, both of which are often in addition to their main clinical role). No patient satisfaction surveys are conducted for emergency management, Priest added, so it is difficult to justify this position in every hospital and staff training in this area when faced with strained budgets. The positive side of this downward pressure on operations is that hospitals will have to think differently about what it means to manage surge. It will be less about how many beds or how many staff can be made available, and more about pooling of shared services. As an example, Priest said that hospital systems in central Indiana recently purchased a linen services company and now provide themselves with their own linen services. He suggested that hospitals might also pool together to provide emergency management support to one another in much more meaningful and direct ways. “We are not used to talking about emergency management as a commodity,” Priest said, “but there is an opportunity here.” As highlighted in earlier chapters, the emphasis of 

42 IMPACTS OF THE ACA ON PREPAREDNESS the ACA on coordination and out of hospital infrastructure could help to spur innovation in rethinking surge management capacities. OPPORTUNITIES FOR NEW PROVIDER ROLES IN HEALTH CARE AND PREPAREDNESS Under the ACA, health care is becoming more integrated and care is increasingly being provided outside the hospital setting. Mid-level practitioners (e.g., nurse practitioners, physician assistants, midwives, pharmacists, etc.) are beginning to take on expanded care roles in health care and public health and in some cases are becoming the medical home for many patients. There is a new focus on a team care approach, and to achieve this, Priest suggested looking to the military for lessons, adding that, “the military is one of the few places where team care has been extraordinarily implemented for a very long time.” Ellen Embrey, managing partner at Stratitia and former deputy assistant secretary of defense, added that planning for the health needs of the population involves setting up structures and a concept of operations that defines the roles for each element of the health care team, how they will accomplish their roles, and what information is necessary to coordinate care across the elements of the team. She agreed that the military has done this consistently for many years. Mobile Integrated Health Care: Community Paramedicine and Patient Navigation As an example of new provider roles in the community, Matt Zavadsky, Director of Public Affairs at the MedStar Mobile Community Health Program, described how MedStar is evolving from an emergency medical services (EMS) organization into a mobile integrated health care organization, and how this has impacted the workforce and local community. With the ACA emphasis on shifting the payer matrix (the way that different payment and reimbursement models are set up within health care) and moving away from a fee-for-service model, as well as the population health management focus, employing providers within the community to assist in the effort to decrease 30-day readmissions and improve health outcomes could be a desirable method for the future. In addition, these paramedics and emergency medical technicians (EMTs) 

THE EVOLVING HEALTH WORKFORCE 43 are gaining valuable knowledge of the needs of the population in their community should a disaster occur. For years, EMS has been viewed as a transportation benefit, not a health care benefit, Zavadsky explained. Without funding, revenue has historically been generated by transporting people to the hospital, creating the incentive to use the highest cost transport available to take someone to the highest cost care facility available. Medicare and most private payers do not provide reimbursement for EMS response, triage, and treatment unless the patient is transported to an ED (Munjal and Carr, 2013). In its billing guide, the Centers for Medicare & Medicaid Services state, “The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service” (CMS, 2010, Chapter 10). However, the ACA and health care financing reform creates an environment for innovation and the opportunity for a new EMS role as a mobile integrated health care practice, or “community paramedicine.” As the demand for health care services increases, the Association of American Medical Colleges predicts that by 2025, there will be a shortage of more than 130,000 physicians (AAMC, 2010). There is an opportunity for EMS to help fill this gap and extend health workforce capabilities in the community, outside hospital environments. MedStar is a governmental agency that is the exclusive emergency and nonemergency mobile health care provider (i.e., ambulance service) for more than 880,000 residents in 15 cities in Tarrant County, Texas. External oversight is provided by a medical control board that includes the medical directors from all area EDs.5 Most calls to 911 are for true emergencies, but Zavadsky noted that more than one-third of the calls received are nonemergency calls, and EMS has been a health care safety net for nonemergent health care for decades. According to the National Association of State EMS Officials, there are 37 million EMS house calls per year across the country, and about 30 percent of those patients do not go to the hospital (e.g., a hypoglycemic diabetic patient who is treated on scene). The programs in the mobile integrated health care practice are centered on the concept of patient navigation and are designed to align incentives and risk sharing, reduce preventable ED visits and readmissions, and increase capacity of the health care system. Together, all of the programs of the mobile integrated health care practice are 5 A report on the MedStar program has been posted in the Agency for Healthcare Research and Quality Health Care Innovations Exchange, available at http://www. innovations.ahrq.gov/content.aspx?id=3343 (accessed June 8, 2014). 

44 IMPACTS OF THE ACA ON PREPAREDNESS geared toward meeting the Institute for Healthcare Improvement triple aim,6 Zavadsky said. This not only can build efficiencies in day-to-day responses, but also helps to ensure health systems are not already burdened at the time of an emergency. Reducing Nonemergent EMS Transports to the Hospital The MedStar Community Health Program was designed to reduce nonemergent EMS calls and connect patients to resources in the community. Regular callers to 911 (those who call 911 15 or more times in 90 days) are enrolled in the program and receive home visits from mobile health providers to educate them on alternative resources and how to better manage their health. Zavadsky said that 262 patients have been through the program since it began in 2009, and there has been a sustained 86 percent reduction in their use of 911. This translates to 989 ambulance transports to the emergency room avoided, 6,000 bed hours returned to the ED, and $1.2 million in payer expenditures saved. In addition, patient satisfaction with the program has been very high, he said (see Figure 4-1). Priest commented that although many tasks could be offloaded to community paramedicine or other providers from a technical standpoint, he wondered if care in the home would result in missed opportunities for a more comprehensive clinical view. Zavadsky explained that feedback to the primary care mechanism is a foundation of the program. All of the treatment decisions made onsite by the mobile health care paramedics are communicated from their primary care physician. If the primary care physician cannot be reached, then the MedStar medical director will provide medical oversight or the paramedics will follow standing orders (e.g., for diuresis). Another program described by Zavadsky is the 911 Nurse Triage, in which a specially trained nurse navigates low-acuity (or low-severity) 911 calls to the most appropriate resource. The program is funded by the hospitals, who benefit from the resulting reduced overcrowding in busy urban emergency rooms, as well as financially, because many of the low- acuity patients do not have coverage. About 43 percent of the patients that talk to the nurse are referred to alternate resources. Again, customer satisfaction is very high, and there are multiple potential applications for the use of this program in a pandemic or other disaster in the community. 6 See http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx (accessed May 10, 2014). 

THE EV VOLVING HEAL LTH WORKFOR RCE 45 FIGUR RE 4-1 Resultts of patient satisfaction s surrvey of Medsttar’s Communnity Health Program on a scale of 1-5, with w 1 being thee least satisfiedd and 5 being tthe most saatisfied. SOURC CE: Zavadsky presentation, November N 18, 2013. Extend ding the Heallth Care Workkforce Frrom a workfforce perspecctive, MedSttar has beenn able to traain commu unity parameedics and otther providerrs who are very adept at manag ging patients through t a heaalth care crisiis. Those mobbile health caare providders are able to t treat patien nts, refer themm to the approopriate place in the fieeld, and avo oid preventaable emergenncy room viisits, Zavadskky commented. This “navigation-re “ eady” workfoorce adds valuue to the heallth care sy ystem daily and a can be reeady to assesss, treat, and rrefer in a largge- scale incident i as well. w Other disciplines thatt could be traained to extennd the wo orkforce in an a emergency y, or on a daaily basis, innclude medical, nursing, and allied health studeents; home hhealth agencyy personnel; or retired d health caree workers. Additionally, A , working w with the staate licensiing agencies to identify tyypes of healtth care professsional licensses that have h common n or similar skill sets, organizationss can facilitaate expanssion of the scope of practice p in eemergency ssituations, annd trainin ng certain nonntraditional providers p (e.gg., ski patrolllers, lifeguardds, veterinnarians) in emmergency preparedness bbasic skills aand procedurees. Availaable resourcees can be ussed in multipple ways. A As an example, Zavadsky described a mobile clinic acquirred through a grant for tthe 

46 IMPACTS OF THE ACA ON PREPAREDNESS purposes of bringing flu vaccines to the community that was used to transport patients following a tornado. In another scenario, ski patrollers can act as first responders off the mountain during a flood incident, another example of weaving preparedness tools into everyday care delivery and vice versa. The Mobile Integrated Health Care program has helped the community by increasing the capacity of the hospital and the health care system, returning thousands of ED and inpatient bed hours, in other words, freeing up beds and staff time that were previously used because all 911 calls resulted in transports to the hospital. It has improved collaboration across the health care continuum, and providers in the program work very closely with primary care and ED physicians. Zavadsky noted that these programs were made possible through the reforms in the ACA. Hospitals are now financially incentivized to use these types of programs, mainly due to the desire to reduce 30-day readmission rates and the increased focus on patient satisfaction as a part of the value-based purchasing model and patient-centered care (Hooten and Zavadsky, 2014). Patient Care in the Home A few participants discussed further the concept of moving care out of the hospital and into the home. It was noted that historically, medical care began in homes, and then moved to hospitals and centers where medical technology (including computers) was located. Now, technology can be almost anywhere, and most people do not receive their care in hospitals. An advantage of care in the home, Embrey said, is a greater involvement of and support from the family with regard to compliance and follow-up. Turner said one valuable aspect of care is the time of the provider, because it may be more efficient in general for patients to go to where the doctor is located. However, there are a number of reasons why it might be better for the provider to go to the community or to the patient directly, and she added that with the models that community practitioners discussed, there is potential to reach previously underserved populations in their homes. Priest suggested payment drives where care is delivered, not what is the most efficacious route of delivery. The move toward community-based care is a result of evolving payment paradigms under the ACA. Workshop co-chair Georges Benjamin, executive director of the American Public Health Association, alerted participants that state-based 

THE EVOLVING HEALTH WORKFORCE 47 professional associations have a lot of control over what types of providers can offer what types of services. Despite demand for various types of providers, if the associations do not allow them, then they will not happen. He cited the example of the position of dental therapist, which has been successful in reaching underserved populations in Alaska, but has been met with significant resistance in other states. Challenges such as these may continue to be a barrier to workforce innovations unless buy-in happens on a broad level. TRAINING The ACA has a variety of health workforce training provisions that can be divided into five main sections: Health Workforce Training, Public Health Infrastructure, New Public Health Programming, Health Workforce Analysis and Planning, and Funding (APHA, 2011). One example of these is Section 5314-5315 under Title 5, where the law creates a public health sciences track at selected health educational institutions to merge public health and clinical practice and emphasize team-based service. The grants program for fellowship training in public health has also been expanded, and there are public health recruitment and retention programs, including a loan repayment program. Turner said that although it is useful to look at the big picture broadly across the country, one must then take into account the reality at each location on the ground. With regard to physician supply, for example, big-picture planning helps to coordinate training programs and funding to educate new physicians, but there is also the opportunity to better align supply and demand in geographic area or across specialties. In terms of defining roles, Turner said there is a spectrum of health care services that is required by an individual or a population, from advanced subspecialty care to interventions that can be performed by someone with hardly any medical training. At each step along the way, various people can perform any of those functions, with overlap across roles. There is not necessarily one right way to define roles, she said, and incentives need to be in place to measure innovation when defining new health care roles and take care that they are financially feasible. A participant suggested that there needs to be training elements and credentials for the new and expanded roles described so that, for example, different systems talking about “community paramedicine” can be sure they are talking about the same type of provider with the same skills and qualifications. 

48 IMPACTS OF THE ACA ON PREPAREDNESS Procedural Knowledge Needs DeSalvo raised two related concerns about the training of the physician workforce. First, physicians are generally not trained in incident command management principles or emergency preparedness. As a result, they often arrive at the site ready to volunteer, but do not know who to contact, where they fit in, or how to be the most useful. Second, physicians are becoming more and more distanced from basic skills and procedures in their everyday work (e.g., drawing blood, giving vaccinations) that may be necessary in response to an emergency. Cairns concurred and cited a study of the procedural experience of medical students entering residency programs. The study found that less than 10 percent had ever inserted a central line, and half had never started an intravenous (IV) line (Promes et al., 2009). To have a prepared workforce, it is important to ensure that medical schools are training doctors in these basic procedures, and not just first responders. As they become more distanced from these basic procedures, their ability to give help and support on the ground lags, which could limit capacity to respond in a disaster. By contrast, Cairns said the special operations medics at Fort Bragg have each inserted hundreds of central lines and must insert about six or seven IVs and central lines during training to be considered competent. Priest agreed, but cautioned that there is currently no real evidence base for what skills are needed. Citing his own experiences, Priest noted that the military focuses on stress inoculation, preparing the medical responder to make a good decision under difficult conditions. Priest suggested that there are pedagogical ways to teach this that do not take a lot of time, and that could be incorporated into different courses in professional schools. A key element of making hospitals safe, he said, is ensuring the providers inside those hospitals know what to do “when all hell breaks loose,” and these are the circumstances for which we are probably least prepared. Embrey said that in a crisis normal standards of care may not be possible, and there needs to be a training to prepare providers and the community for this possibility. Although such training is specified in guidelines from the Assistant Secretary for Preparedness and Response (ASPR), the Department of Homeland Security, and others, it is not consistent. While specific training may not be standardized, many communities have begun to have conversations within their health care coalitions about dev- eloping standards of care for allocation of scarce resources. The IOM, along with ASPR, has put together several resources to support this effort 

THE EVOLVING HEALTH WORKFORCE 49 that can be used by a variety of disciplines, including state and local health departments, health care coalitions, and EMS/pre-hospital care.7 She also said the military conducts exercises in which people must make decisions with incomplete or ambiguous information. Making decisions with incomplete information when lives are at risk is a part of emergency medicine, Cairns added. Expanding health care workforce training to include some of these important pieces, at all levels of practice, can augment responding capabilities in an emergency, as well as contribute to more streamlined routine care. 7 Reports, workshops, and other resources on crisis standards of care can be found at http://www.iom.edu/crisisstandards.