Health care Workforce Shortages and Reform Resolutions
The U.S. faces steep health care challenges as the “baby boom” generation enters retirement and as health care reform increases demand for services. America’s health care professionals directly influence the cost and quality of health care through their diagnoses, orders, prescriptions, and treatments. Analysts are projecting a nationwide shortage of as many as 100,000 to 200,000 physicians and 250,000 public health professionals by 2020 (Dill & Salsberg, 2008), and 260,000 nurses by 2025 (Buerhaus, 2009a). Rural Americans and those living in other underserved areas across the country are especially vulnerable to health workforce shortages.
While the nursing shortage has been long-standing, Buerhaus (2009b) notes that although it is temporary, the recession has eased the shortage of hospital nurses, but large shortages are still expected in the next decade. The initial findings from the 2008 HRSA (USDHHS, 2010a) national survey of registered nurses released in 2010 also reports that the number of licensed registered nurses in the U.S. increased to a new high of 3.1 million between 2004 and 2008 reflecting a 5% increase. The ability to meet the country’s demand for nurses remains a daunting goal. Over the past decade, numerous initiatives to recruit more nurses into the profession have been launched, and many are successful. While interest today in a nursing career is growing, with almost 50,000 qualified applicants turned away in 2008, this increase in demand reveals the complex problem of a low supply of nursing faculty as a primary barrier in the education pipeline for preparing the numbers and types of nurses so badly needed (AACN, 2009).
As policy efforts are developed to assure an adequate health care workforce, the question is whether the problem is a shortage of health professionals overall, or is it only with the distribution of certain types of health professionals in certain areas of need? The answer is both. Assessing, projecting, and planning health workforce needs is complicated, and no single entity in the U.S. is in charge of workforce planning (Derksen & Whelan, 2009). The absence of a cohesive approach to workforce shortages, training of health professionals across disciplines, and distribution of health professionals to areas of need must be addressed if health care reform policy is to be successfully implemented.
The federal government pays for health care workforce development through funding of two broad training categories. The first and largest payment comes from Medicare and Medicaid, which provide support for Graduate Medical Education (GME) by subsidizing hospital training through add-on payments. Teaching hospitals are reimbursed to train physicians in residency programs and for hospital-based nursing diploma education. Today with only 7% of nurses receiving their education in a hospital-based setting, nurses receive little benefit from this funding stream. Combining the last data available from 2007, approximately $12 billion was provided in GME subsidies (Derksen & Whelan, 2009). Medicare still pays about $150 million per year to these hospitals for nurses’ training (Livsey, 2007).
The second and more modest funding component is provided through Health Resources and Services Administration (HRSA), an agency in the Department of Health and Human Services that administers health workforce programs. With a 2010 budget of $7.2 billion, HRSA programs train health care professionals and place them where they are most needed. Grants support scholarship and loan repayment programs at colleges and universities to meet critical workforce shortages and promote diversity within the health professions.
Congress and the Obama administration began addressing workforce shortage issues by allocating $500 million to workforce development from the 2009 American Recovery and Reinvestment Act (ARRA). $200 million went to programs authorized by Titles VII (Health Professions) and VIII (Nurse Training) of the Public Health Service Act to expand training and educational opportunities. These sections of the Act include primary care medicine and dentistry programs, public health and preventive medicine programs, and scholarship and loan repayment programs. Of the $80 million awarded to date, about half has gone to students, health professionals, and faculty from minority and disadvantaged backgrounds. The other $300 million is being used to increase the capacity of the National Health Service Corps (NHSC). The NHSC, which is authorized through PHSA Title III, provides scholarships and loan repayment to health professionals who agree to work in areas with too few health professionals. It is worth noting that historically, for every federal dollar spent on HRSA’s primary care, nursing, and dental workforce programs, teaching hospitals were paid $24 by Medicare and Medicaid to subsidize physician training. This reflects the severe funding inequities, as physician education and hospitals are strongly supported with GME funds, and nursing and other health professionals are minimally funded by comparison through HRSA dollars. The final Health Care Reform legislation includes important changes to this chronic issue as graduate nurse education and postgraduate experience demonstrations will be funded through Medicare funds (Kaiser Family Foundation, 2010).
The Patient Protection and Affordable Care Act (P.L.111-148) provides long-term strategies for improving health care workforce shortages. The first broad strategy authorizes the establishment of a multi-stakeholder Workforce Advisory Committee to develop a national workforce strategy. The second strategy entails an expansion of Medicaid to fiscally pay for health promotion and disease prevention as well as increases in Medicare payments for primary care physicians. Likewise, the laws and regulations that govern GME funding will expand from the strict hospital-based setting to the use of outpatient settings for residency training, and it will give priority to states with the largest rural and underserved areas as well as to primary care and surgery providers. Teaching Health Centers will be established that will be eligible for Medicare payments for operating primary care residency programs in 2010.
Another health reform workforce initiative includes support for the development of training programs that focus on primary care models such as medical homes, team management of chronic diseases, and those that integrate physical and mental health services. This initiative has a 5-year authorization. A complementary initiative provides training to family nurse practitioners who provide primary care in federally qualified health centers and nurse-managed clinics, again a 5-year authorization. Not only are these initiatives authorized for longer periods of time providing stronger program evaluation, they represent a realignment of federal incentives for improving our nation’s health workforce capacity and quality. As the federal government has been looking at health reform from a national perspective, states have been struggling with the same issues locally.