The Richard and Hinda Rosenthal Lecture 2007: Transforming Today's Health Care Workforce to Meet Tomorrow's Demands (2008)

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Discussion* ❧ QUESTION about involving patients in their care. DR. GRUMBACH:  Certainly self-management of chronic illness is the sine qua non for making progress in this area to empower and activate patients. QUESTION about whether doctors are doing much work with patient self-management? DR. GRUMBACH:  Not as much as we would like. Some programs in medical education are taking Kate Lorig’s work with patient empower- ment, group visit models, and the chronic care model and incorporating those concepts and skills in the training of health professionals. It requires health professionals to get out of the mindset that you are just imparting knowledge—what you are trying to do is to activate the patient. And that is a big mind shift, away from the idea that you have information, you are going to tell this information, and the patient is going to leave and somehow do better. The key is much less about information than about how somebody can gain self-efficacy. Helping patients with self-directed action plans is where a lot of the thinking is now. Instead of telling the patient, “Yes, you have a lousy diet, eat better,” the approach is, “Okay, yes, you eat those four pan dulces every morning. What if you could just eat three?” What is doable? What is a place to start so that *See pages 19-23 for the discussion based on Marla Salmon’s presentation. 33 

34 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE people can gain some sense of efficacy, some mastery, and begin to make a difference? We actually have forms in our clinic now to help work with a patient to identify the self-management activity they want to work on and to help them build the confidence to take these small steps. It turns out that most doctors are not very good at this approach. Medical assistants and nurses are frankly are much better at it, probably because they are not so control oriented. So we keep trying with physicians in training, but I think lay educa- tors and health workers are also going to be some of the key folks to work on this approach. I see it happening. I am not so skeptical; I do see some of this stuff happening. The other question, which is a more threatening question for primary care, is, “Who needs a primary care doctor or nurse practitioner anyway? I will just go on the Internet and find something when I need it, and I will decide if I need to go to the specialist.” But I think even the most empow- ered and educated person needs help integrating all of this information. I think there is still a need, even for an educated, empowered patient, for a primary care medical home that is responsive to their needs and that can work with an activated patient to get them what they need. QUESTION about educating and training physicians in different types of settings. DR. GRUMBACH:  Maybe Fitz Mullan has some ideas on the internation- al issues. At the residency training level for physicians, it was a brilliant idea to link payment for medical education to hospitals. That was a very forward and progressive way to do it. Sarcasm aside, we are stuck with this model where all the money, the federal funds that support training at the residency level, go to the hospital, not to the training program per se. And then it is actually up to the hospital how they allocate the funds for educational purposes. I think you have to uncouple training funds from hospitals. Now you can get out of that model and get waivers so that a community health center can actually get the Medicare graduate medi- cal education money, but it is a fairly cumbersome process. You would need much more flexibility from the Centers for Medicare and Medicaid Services to unlink Medicare graduate medical education payments from hospitals. Fitz Mullan was leading that charge in the Clinton administra- tion, thinking about regional consortia for graduate medical education. The consortia would have received the money and then would have dis- tributed it with a regional plan for workforce development. That is prob- ably the type of model you have to get to. You know who the opposition is to that; I don’t have to tell you. It is every leader of an academic health 

DISCUSSION 35 center. So it is a huge challenge. There would have to be the political will to take those interests on. Now at the medical school level or the nursing school level, a related question is whether it really helps to train people in rural settings. How ef- fective is that in getting people to stay in those areas after they are trained? I think there is still a little debate on that. It is probably somewhat effec- tive, but unless you have the incentives and other support there for rural practice, you can train somebody in a rural community only to have them say, well, there is no infrastructure here and no job for my spouse, so I’m heading for the city. I think it always has to be coupled with looking at the broader picture. There are people who have developed rural training tracks, at the University of New Mexico, for example. Australia has built a whole new rural-based medical school. Canada also has developed a decentralized medical school for rural training. I think it will be really in- teresting to see whether they retain students when they graduate in those areas or not. I think it is a bit of an open question. DR. MULLAN:  Just to follow up on that, clearly the Medicare graduate medical education payments are a huge barrier to innovation of any sup- port. As you know, the hospitals don’t get paid if the individual is not working in a sanctioned hospital or hospital-owned facility. This inhibits all kinds of off-site training—short term, long term, et cetera. There are waivers, but it takes a month of Sundays to get them. We must take off the lock that hospitals have on both the graduate medical education money and the entire support that comes with direct and indirect subsidies. There should be a whole subsidy system, but hospitals are invested in keeping it the way it is. I think this problem is due to hospitals more than medical schools. Some deans would happily see it go in the other directions, but they are locked into the hospitals. There are some interesting innovations taking place, though. There is a new osteopathic school just opened in Phoenix whose model will be totally community health center training. And there are a number of osteopathic schools located in rural areas like Paint Branch, Kentucky—and there is one now open in Harlem. So they are trying, but there has been more in- novation in the osteopathic community. There are also some very interesting offshore innovations. The Univer- sity of Negev in Israel has a medical school that is an international school of medicine affiliated with Columbia and that is populated mostly by Americans. They are trained in Israel. They do three months of clerkship— I think it is three months in their senior year—in one of five universities in developing countries. They go to work as medical students on the wards in South Africa, Nigeria, and elsewhere. They are certified by the Education Commission for Foreign Medical Graduates, and they come back to the 

36 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE States. But they are, in theory, designated as international health experts. We will see how that all plays out. But I think the interesting thing is that these are all occurring out- side the traditional allopathic model, which is still very locked in on the academic health center and a very traditional approach to training. We need to let a thousand flowers bloom, and we certainly need to open up support systems. QUESTION about whether part of the problem is payment and regula- tions, where non-physicians can’t bill for services. DR. GRUMBACH:  That is a great question. Money drives a lot of this, right? For independent clinicians such as advanced practice nurses and physician assistants, Medicare will reimburse their services. There is the ability for these clinicians to bill independently for Medicare and Medicaid payment in many states as well as in some private plans. I think it is very interesting to look at the politics around non-physicians billing third-party payers. There is the perception that physicians are always resistant to ex- panded scope of practice and independent billing for nurse practitioners, but it is really the professional societies that are worked up about it. We surveyed a random sample of physicians in California, and we found out that to them it was not that big an issue, partly because all the primary care physicians are so overworked. You can’t on the one hand say, “I am overworked, I have all this demand I can’t cope with,” and on the other say, “Don’t let the nurse practitioner move into my neighborhood and start practicing.” There is a little bit of intellectual inconsistency there. Not that that has stopped people before from making those arguments. The place where I think the policy needs to go with more traction is actually in regard to the non-professional staff in primary care. The prob- lem is that whether you are a nurse practitioner or a physician, if a patient comes into your practice or clinic and sees only the medical assistant and not you, it is not a billable visit. That is where there has to be much more flexibility, whether it is getting back partly to the old model of capitation or some new payment arrangement. Bob Berenson has proposed some innovative payment models for primary care. That is where the real critical reforms have to happen in Medicare and in private plans. The reform probably needs to be some amalgam that is a little bit capitation and a little bit fee for service to enable billing for non-direct encounters, whether it is e-mail encounters, virtual visits, or group visits. I think that is where there has been a lot of slowness in reforming payment policies. Payment is so locked into the notion that if a physician, or frankly, a nurse practitioner or clinical pharmacist, doesn’t see the patient, it is not a bill- able service. That is a huge hang-up right now, I would say. I don’t know 

DISCUSSION 37 if that resonates with what you said, but I think that is the fundamental problem right now. QUESTION about what the trends are in first year family medicine resi- dency positions. DR. MULLAN:  Kevin can probably answer better than I. In family medi- cine the trends have collapsed. The fill rate for PGY-1 positions is down to 50 percent U.S. graduates. DR. GRUMBACH:  But graduates of U.S. osteopathic schools fill another 15 percent of first-year family medicine residency positions. So it is about 35 percent to 40 percent international medical graduates. DR. MULLAN:  U.S. allopathic graduates’ interest in family medicine has decreased a lot. The overall interest and the overall slots filled by U.S. graduates in internal medicine have remained high, but the sub-specializa- tion rates have increased a lot. Whereas you had many people previously going in to be general internists, up to 80 percent are now specializing and going on for fellowships. These trends are being backfilled to some extent by international graduates and osteopathic graduates, which are holding the line for the moment. But there has also been some falloff in the number of family practice positions offered, has there not? DR. GRUMBACH:  A little bit, about 10 percent fewer positions annually compared with 10 years ago. DR. MULLAN:  At some point the family practice community begins to pull back. In terms of canaries in the mine shaft, these are not good omens for the future of primary care. QUESTION about whether, if the numbers of graduates coming out of allopathic schools increases quickly, there will be more competition for internship slots among osteopathic graduates, Caribbean medical school graduates, and international medical graduates for residency positions. DR. MULLAN:  Yes, access to graduate medical education (internship slots) will become more competitive. It is competitive right now. The ECFMG certifies probably about 8,000 international medical graduates every year (although the number does vary from year to year), and there are only about 6,000 slots. So a lot of international graduates are not get- ting positions. There is already very hot competition, and it will get hotter. The question I am often asked is, “Will U.S. graduates not get a position?” 

38 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE Surely at some point, if that gets closer, there will be some smart residency director who says, “This graduate from here or there is a more attractive candidate than somebody coming from a U.S. school.” It will ultimately become an issue that will have political legs of its own. But I think we need to take that on, and the only way to get to a higher level of self-sufficiency is to move closer to training the number of folks that we have residency slots for, and that will make it a hotter competition. DR. GRUMBACH:  You include the osteopathic grads in your numbers, right? DR. MULLAN:  They are not included in the 6,000—they are included in the 18,000. So they are already included. DR. FINEBERG:  This is obviously a rich and very, very complicated topic. We have touched the surface in a number of areas and probed deeply in a few. I do want to mention that there is an IOM report that will be forthcoming early next year, which will be particularly directed at workforce related to the growing needs of an aging population. There is more information, if you would like it, at the desk as we go out tonight. Please join me in thanking our panelists again for a wonderful presenta- tion. Thank you both.