Research and Reality: Mind the Gap
Mark Doescher, MD MSPH, Director
University of Washington Center for Health Workforce
Studies/WWAMI Rural Health Research Center
Workforce Interest Group Meeting
AcademyHealth
y
Annual Research Conference
June 27, 2009
Chicago, IL
Why Is Health Care Workforce
Planning Important?
The health care
workforce of the
y will
20th Century
not meet the health
care needs of the
21st Century.
Why Is Health Care Workforce
Planning Important?
• We are in an era of rapidly changing health care
workforce dynamics.
• Planners need to grapple with a host of factors:
– Growth and aging of the population
– Possibility of expansion in health insurance
coverage through health care reform
– Explosion
p
in health care technology
gy
– Rise of team-based health care
– New regulations and reimbursement mechanisms
Our Current Health Care
Workforce
Form follows function.
Do we want
a health care
system that
looks like
this?
The Ideal Health Care Workforce
Or one that looks more like this?
Why Is Health Care Workforce
Planning Important?
Where’s the data?
Comparisons of the effectiveness and costs of
various workforce configurations are needed,
but…
data for workforce planning are often lacking.
Form
1 Workforce size.
1.
size
2. Workforce distribution.
3. Provider roles and relationships.
Forecasting the “Optimal”
Optimal Size
of the Workforce
“It
It is a daunting enterprise to estimate the
physician surplus or shortage one or two
decades into the future
future. Any of the
variables in the equation can change over
time sometimes in unforeseen ways.
time,
ways ”
Reinhart, 2002
Forecasting the Configuration and
Distribution of the Workforce
• Even when overall workforce supply appears
adequate, provider maldistribution may
impact health care.
• The “inverse care law” states: “the availability
of good medical care tends to vary inversely
with the need for it in the population served”
(Hart 1971).
1971)
Evaluating Provider Roles
and Relationships
• What p
providers do and how they
y interact has
not been a routine part of health care
workforce planning. Factors include:
– Workload — patients seen per week, hours
worked per week, staffing levels, caseload, time
spent at work,
work “burnout”
burnout
– Organizational characteristics — provider age,
gender, race, group size, payer mix, bed capacity,
specialty mix
Evaluating Provider Roles
and Relationships
– Activities p
performed - what health care p
providers
do on a daily or hourly basis in different settings
and how activities overlap across provider types
– Team-based
Team based care — structure at the group
group- rather
than individual-level.
– HIT
Structure Process Outcome
• Structural Attributes of the Workforce should be
correlated with health care processes and outcomes.
–
–
–
–
–
–
–
–
–
Health care accessibility
Acute, preventive and chronic care services
Service intensity (e.g., length of stay)
Health-related
Health
related quality of life
Intermediate end-points (e.g., blood pressure control)
Satisfaction with care
Adverse events/re-hospitalization
events/re hospitalization
Death (e.g., years of potential life lost)
Health care costs
Challenges for Structure, Process,
Outcome Workforce Research
Challenges for Structure
Structure, Process
Process,
Outcome Workforce Research
• Conceptual issues:
– What outcome is health workforce
research aiming to help achieve?
– Who makes up
p the health care workforce?
– What is the validity of examining the supply
of a specific provider g
group in isolation
from the overall context of the work
situation?
Challenges for Structure
Structure, Process
Process,
Outcome Workforce Research
• Methodological issues:
– Workforce supply data (“head counts”) lacking
• N
National
ti
l workforce
kf
supply
l data
d t are available
il bl ffor some,
but not all, health care professions
• National estimates of provider supply are often out of
date or biased in ways that yield undercounts and
overcounts
• Regional data are collected sporadically, if at all
– Workforce role and relationship data lacking
• Functional overlap
• Variability in scope of practice
• Non-clinical
Non clinical roles
Challenges for Structure
Structure, Process
Process,
Outcome Workforce Research
• Methodological issues:
–
–
–
–
Ecological fallacy/unit of analysis issues
Confounding
Causality
R
Reverse
causality
lit
Challenges for Structure
Structure, Process
Process,
Outcome Workforce Research
• Political issues:
– The absence of a strong federal role in
workforce planning undermines the
effectiveness of workforce planning.
– Vested interests: The professional groups
that fund and often conduct health care
workforce p
projections
j
frequently
q
y have a
vested interest in the outcome of the
assessment.
Challenges for Structure
Structure, Process
Process,
Outcome Workforce Research
• Political issues:
– Separation of funding sources: Funding
streams and methodological traditions are
bifurcated, with HRSA supporting
projections and AHRQ and RWJF
supporting workplace studies. The result
has been that workforce researchers have
lagged in keeping up with health services
research outcomes methodology
methodology.
Recommendations
• Infrastructure — a permanent home for
workforce research is needed.
– A national workforce research and planning center
should be created to serve as a focal point for
data collection,
collection extramural research
research, and
dissemination activities.
– Regional centers and centers focusing on highneed populations, such as low-income and
racial/ethnic minority groups, should be created to
address variability in workforce distribution.
Recommendations
• Data collection.
– A recurring, national workforce survey should be
administered by the national workforce center and integrated
with other national data sets, such as the Medical
Expenditure Panel Survey or the National Health Care
Surveys.
– Collection of detailed claims data and time/motion audits are
needed to strengthen workforce research.
– Collection of workforce supply data using common data
elements (minimum data sets) across the range of health
professions should occur nationally.
Recommendations
• Analysis.
– Federal research infrastructure should be
reorganized to fund independent, comparative
effectiveness research exploring the relationships
among workforce structures, processes and
outcomes
– This funding should encourage bridging the gaps
b t
between
workforce
kf
supply-demand
l d
d projections
j ti
and health services outcomes.
Recommendations
• Dissemination.
Dissemination
– There should be more knowledge transfer
funding to enable researchers to interact
with policymakers.