Regulatory and Legislative Action Since the September 2010 Membership Meeting:

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1 MEMBERSHIP MEETING January 19, 2011 Delivery System Reform: Healthcare Workforce Issue: The passage of health reform will bring millions of newly insured individuals into the system and drive patients to primary care. The system will increasingly rely on allied health professionals to treat and care for patients. These professionals must have adequate training to be granted appropriate licensure through federal, state, and local requirements, as well as be adequately reimbursed. Additionally, shortages in specialty care are likely to occur. This evolution in the healthcare workforce will in many cases exacerbate shortages. However, the state of the economy has resulted in fewer vacancies, with many healthcare professionals postponing retirement and others returning to the workforce for financial reasons. While the recession has alleviated some of the workforce shortages, it has not resolved the underlying problems of a growing U.S. population and increasing health demands among baby boomers. HLC Position: HLC is one of the few organizations examining the healthcare workforce and its effect on healthcare delivery from a multi-sectoral perspective. Ensuring an adequate workforce requires a comprehensive national workforce strategy that includes efforts to recruit and train new healthcare workers, faculty to teach them, and improved retention of existing workers. HLC believes that patients must receive quality care from a diversified and qualified workforce that is well-trained to meet the needs and challenges of patients. Equally important, our workforce must be appropriately reimbursed to ensure workforce retention and recruitment of the best qualified and skilled individuals. Regulatory barriers also must be removed in order to realign successfully the healthcare workforce. HLC also supports efforts beginning in elementary school to foster an interest in science and math in order to recruit a qualified workforce that can handle the complexities of today s and tomorrow s healthcare system. Regulatory and Legislative Action Since the September 2010 Membership Meeting: The final report of the National Commission on Fiscal Responsibility and Reform recommended $60 billion in cuts over 10 years to Medicare payments for graduate medical education. On December 6, the Health Resources and Services Administration requested nominations to fill eight vacancies on the National Advisory Council on Nurse Education and Practice (NACNEP). Nominations were due by December 22. On December 1, the American Association of Colleges of Nursing (AACN) released preliminary survey data showing that enrollment in entry-level baccalaureate nursing Page 1 of 5

2 programs increased by 6.1 percent from 2009 to 2010, which marks the 10th consecutive year of enrollment growth in professional registered nurse (RN) programs. Though enrollment is growing, nursing schools point to a shortage of faculty and clinical education sites as the primary barriers to future expansion. A recent Lancet Commission report, Health Professionals for a New Century, has called for major reform in the training of doctors and other healthcare professionals to equip them for the 21st century. The report, written by 20 professional and academic leaders, said changes are needed because of fragmented, outdated, and static curricula that produce ill-equipped graduates. On November 2, CMS posted the final rule for the Outpatient Prospective Payment System (OPPS). It included updates to the policies and payment rates for covered hospital outpatient department services in The final rule implemented the graduate medical education (GME) provisions of the Affordable Care Act (ACA). Under ACA, CMS is required to identify unused residency slots and redistribute them to certain hospitals with qualified residency programs, with special emphasis on increasing the number of primary care physicians. CMS is also required to redistribute residency slots from hospitals that close down to other teaching hospitals, giving preference to hospitals in the same or a contiguous area as the closed hospital. On October 28, Health Resources and Services Administration (HRSA) requested comments on a National Health Services Corps (NHSC) information follow-up form the NHSC will use when exhibiting at national and regional conferences, as well as presenting on campuses to health profession students. On October 26, HHS announced the availability of up to $335 million for existing community health centers under the Expanded Services initiative, as part of ACA. These funds aim to increase preventive and primary healthcare, including dental and behavioral health, pharmacy, and vision, at existing centers. On October 20, the Massachusetts Medical Society released its ninth annual Physician Workforce Study, noting that 10 physician specialties are operating under severe labor shortages. On October 5, the Institute of Medicine in collaboration with the Robert Wood Johnson Foundation, released a proposal for renovating current nurses roles. In October, the Medicare Payment Advisory Commission released a study that examines the uniqueness of retainer physicians and their patients, as well as the relationship to state and federal laws and regulations and the impact of this model on Medicare beneficiaries. On September 30, the Government Accountability Office announced the appointment of 15 members to the new national Health Care Workforce Commission. The commission will serve as a resource for Congress, the administration, and states and localities as well as communicate and coordinate with federal agencies. On September 30, HRSA announced $17 million to support 99 grants to bolster primary care training in communities across the nation. The grants will support 21 Area Health Education Centers, 68 Geriatric Academic Career awards, and 10 Nursing Assistant and Home Health Aide Program awards. On September 27, the Department of Health and Human Services announced $320 million in grants under the Affordable Care Act to strengthen the healthcare workforce. Page 2 of 5

3 On September 23, in an effort to reduce administrative burdens for continuing education providers, the Institute for Healthcare Improvement and VHA Inc. were awarded joint accreditation to support team-based patient care. On September 17, HHS awarded $130 million in grants to boost the health professions workforce through six targeted areas: primary workforce training, oral health workforce training, equipment to enhance training across health professions, loan repayments for health professionals, health career opportunities for disadvantaged students, and patient navigator outreach and chronic disease prevention. Background and Additional Detail: The Patient Protection and Affordable Care Act (P.L ) and the Health Care and Education Reconciliation Act (P.L ), collectively known as the Affordable Care Act (ACA), include a number of provisions to address workforce supply, education and training, and workforce infrastructures. The provisions change how current unused residency slots are redistributed, reauthorize certain health professions programs, establish and strengthen loan repayment programs, provide grants for training programs, and seek to increase the number of physicians who practice in underserved rural communities, among other things. The ACA is expected to cover 32 million currently uninsured persons, thereby intensifying the need for more primary care clinicians and specialists. Without increased allocations of graduate medical education (GME) slots to increase the number of primary care clinicians, finding a provider could become increasingly difficult and wait times for appointments could lengthen. According to the American Academy of Family Physicians, the nation is currently short of 16,500 primary care doctors, and that number is projected to reach 140,000 by Primary care practitioners are frequently viewed as the linchpin of care coordination efforts, such as the medical home model. U.S. medical schools have increased their class sizes and created new medical schools. However, while many were hoping for an increased number of GME slots in proportion to the increased numbers of medical students, ACA instead redistributed existing unused GME slots to increase the training and supply of primary care providers. Furthermore, ACA authorized 10 percent bonus Medicare payments for five years, beginning in 2011, to primary care physicians and general surgeons operating in health professional shortage areas. Eighty-two residency programs nationwide will benefit from $167.3 million in HRSA Primary Care Residency Expansion grants. The five-year grants will help create residency slots in pediatrics, internal medicine, and family medicine, and were part of $320 million in awards HHS announced September 27 aimed at boosting the primary care work force. A recent Lancet Commission report, Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World, called for major reform in the training of doctors and other healthcare professionals to equip them for the 21st century. The report, written by 20 professional and academic leaders, said changes are needed because of fragmented, outdated, and static curricula that produce ill-equipped graduates. The report suggested a number of reforms, both instructional and institutional. Instructional reforms should generate a diverse student body with a competency-based curriculum, creative use of information technology, an emphasis on the realities of Page 3 of 5

4 teamwork, and the opportunity for flexible career paths. Institutional reforms should align national efforts through joint planning especially in the education and health sectors, engage all stakeholders in the reform process, extend academic learning sites into communities, develop global collaborative networks, and lead in promotion of the culture of critical inquiry and public reasoning. On October 20, the Massachusetts Medical Society released its ninth annual Physician Workforce Study. The study found that 10 physician specialties (dermatology, emergency medicine, family medicine, general surgery, internal medicine, neurology, orthopedics, psychiatry, urology, and vascular surgery) in Massachusetts are operating under severe labor shortages. Primary care continues to be in short supply for the fifth straight year and internists and family medicine physicians report the longest appointment wait times for new patients (29 days and 53 days, respectively). Consequently, 54 percent of family medicine physicians are not accepting new patients and 49 percent of internists are not accepting new patients. On October 5, the Institute of Medicine issued a blueprint for transforming nursing roles, responsibilities, and education to meet the promise of a reformed healthcare system and the nation s health needs. The Future of Nursing: Leading Change, Advancing Health, was developed in collaboration with the Robert Wood Johnson Foundation and called for state and federal policies that allow nurses to practice to the full extent of their education and training, residency programs to help those with nursing degrees move into clinical practice, and more opportunities for nurses to lead collaborative improvement efforts. The report also recommended increasing the proportion of nurses with a bachelor s degree to 80 percent by 2020, doubling the number of nurses with a doctorate, and improving the collection and analysis of healthcare workforce data. The Medicare Payment Advisory Commission study, Retainer-Based Physicians: Characteristics, Impact, and Policy Considerations, released in October, examined the characteristics of retainer physicians and their patients, as well as the impact of this practice model on Medicare beneficiaries and its relationship to state and federal laws and regulations. The study found most retainer physicians are in primary care and offer an indepth annual physical, lasting an hour or longer and focusing on preventive care. The practices also emphasize that their patients have increased access to their physicians, including longer office visits, same-day visits, and access to physicians cell phone numbers. These physicians may also visit patients in the hospital or at home more often than in a nonretainer setting. Because retainer physicians are more accessible and have longer visits, they also tend to have a smaller patient pool than their non-retainer colleagues. The study found these practices have a wide range of Medicare beneficiaries in their patient population, representing anywhere between 20 percent and 60 percent. In September, the Government Accountability Office announced the selection of 15 members to the new National Health Care Workforce Commission, which will act as a resource for Congress, the administration, and states and localities while also communicating and coordinating with the federal departments. Other responsibilities include: developing commission evaluations of education and training activities; communicating and coordinating with federal departments; identifying barriers to improved coordination with the federal, state, and local levels and recommending ways to address Page 4 of 5

5 them; and encouraging innovations that address population needs, changing technology and other environmental factors. In September, HHS announced $320 million in grants to reinforce the healthcare workforce. Of those grants, $253 million will go to improve and expand the primary care workforce under the Prevention and Public Health Fund, providing funding to the Primary Care Residency Expansion program, expansion of physician assistant training, the Advanced Nursing Education Expansion program, the program for Nurse Managed Health Clinics, state health workforce development and Personal and Home Care Aide State Training. The remaining $67 million will fund 32 grants to entities in 23 states under the Health Profession Opportunity Grants to provide low-income individuals with education, training, and supportive services that will help them prepare to enter and advance their careers in healthcare. On September 23, the Accreditation Council for Graduate Medical Education (ACGME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) joined to award joint accreditation to organizations practicing team-based care. The joint process is meant to decrease the administrative burdens for continuing education providers, allowing them to take advantage of one unified, streamlined process rather than obtaining three different accreditations. To be eligible for joint accreditation, an organization must already be accredited by at least two of three accreditors, have a mission statement highlighting healthcare team education, and have at least 25 percent of its educational activities designed by and for healthcare teams. The Institute for Healthcare Improvement and VHA Inc. were the first two organizations to be awarded joint accreditation. HLC Activity in 2010: HLC nominated two HLC members to serve on the National Health Care Workforce Commission. HLC established its Workforce and Care Coordination Workgroup to develop a workforce health reform implementation plan and to update HLC s broader objectives in this area. Thus far, the workgroup has hosted several guest speakers and is finalizing an action plan and principles. HLC has continued to serve on the U.S. House Science, Technology, Engineering, and Math (STEM) Education Caucus steering committee, in order to work with diverse constituencies. HLC successfully advocated for substituting references to physicians with the more encompassing term clinicians in order to ensure nurse practitioners and other allied health professionals were included in numerous health reform provisions. HLC continues to advocate for adequate payments for hospitals, clinics, doctors, laboratories, and other providers as a vital part of solving healthcare workforce shortages. HLC also continues to advocate for health information technology improvements and adoption. Studies show that organizations that have effectively implemented electronic medical records and other technologies see a marked decrease in staff turnover. Page 5 of 5