Health-policy educator and researcher Patricia (“Polly”) Pittman, PhD, co-founded the GW Health Workforce Institute at George Washington University (GWHWI) in April 2015. As part of its mission to strengthen health workforce policies in the United States and around the world, the Institute is now one of six health workforce research centers awarded federal funding to help determine the staffing needs of U.S. healthcare in the years ahead.
Each research center works with a particular focus; GW concentrates on “novel and flexible uses of healthcare workers” to improve care delivery and efficiency. As part of a conversation with Medical Imaging Review, Pittman shared her insights gained by studying her own operation’s research data, as well as peer research and quantitative information from the Bureau of Labor Statistics. Key excerpts follow.
Q. With 10,000 baby boomers retiring and adding to the Medicare roles daily — around 4 million per year — what is the projected impact on healthcare staffing needs going forward?
Pittman: To the extent that payment reforms are moving us toward primary and team-based care, and to the extent that we are caring for more and more elderly people, the physician is no longer as central in the health workforce story. We are seeing shifts at several levels.
For example, we are seeing demand for more advanced practice providers (APPs), including nurse practitioners, physician assistants and clinical nurse specialists. And in a relationship that looks like substitution, for example at the level of community health centers, the number of physicians has actually gone down over the last 15 years, while the number of APPs has gone up.
The second part of the story is with the support staff, primarily in the area of home care. But it also is in community care and primary care where you see sicker patients now. There you see the role of what you might call the “clinical nonlicensed personnel” growing, particularly the nonlicensed personnel who are doing things that can be delegated by nurses.
Q. You have forecast an increase in the use of telemedicine. Can you put workforce numbers to that?
Pittman: We are in the midst of doing a study right now, looking at the use of telemedicine by National Health Service Corps doctors. Our preliminary analysis shows that utilization is still relatively low. If you take that sample of physicians, fewer than a quarter are engaged in some form of telemedicine.
Those who are so engaged tend to cluster in the places that are the most progressive in terms of reimbursement and financial support—Delaware, Maine, Mississippi, New Mexico, Nevada, Oklahoma, Tennessee, Virginia and Washington, D.C. These are the same places that got an “A” in the latest rankings from the American Telemedicine Association.
Our study is very preliminary, and it’s not representative of all sectors within the healthcare industry—but it is interesting that there is a correlation between high utilization and states that are more progressive in terms of payment policies.
What this suggests is that there is enormous room for growth. And certainly the business sector, which is always an interesting source of information about what will happen in the future, is expecting growth. Forbes magazine, for example, recently reported on market research projecting growth in the telehealth industry of more than 18% over the next few years. So telehealth is a robust business sector. There’s no question about that.
Q. Do you see this translating to more telehealth-related jobs within provider organizations as well?
Pittman: We don’t really know yet. Certainly doctors and nurses who are telehealth-savvy, who have some experience with telehealth technologies, are going to be in high demand, as opposed to those who are either unwilling or unable to participate in the technology. That much is clear already, and I think there will be additional jobs—everything from telehealth technicians to sort of multipurpose, mid-level individuals who must be very savvy with telehealth, as well as, more generally, health IT technologies.
It’s funny, because health IT training tends to cut across a lot of occupations as sort of an add-on. But certainly the ICD coders, patient navigators, care coordinators, population management executives—all of those people will have to have much better health IT training.
Part of the health IT story is, of course, telemedicine. It’s not just analysis of big data, but also imagining how to have communication across settings and be more efficient. So I think those kinds of jobs, such as care coordinators and community health workers, not just physicians and nurses, will likely have to get up to speed with telemedicine.
Q. What might be the ramifications of greater use of telemedicine for hospital-based physician workforces, including specialties that tend to be more telehealth-savvy, such as radiology?
Pittman: One observes an increase in hospitals directly hiring physicians. Radiologists have certainly been a part of that, and that has affected the autonomy of the radiology profession. That part is driven, in large part, by payment reforms.
The accountable care organizations are really putting an emphasis on care coordination and primary care, and of course trying to tighten their belts in all areas. Presumably, one way to tighten the belt is to do radiology reads offsite. Another is to have employees who are radiologists. Both of these represent significant changes to the business model of radiology that we saw in the past.
Q: In what ways will hospitals and IDNs have to modify their workforce strategies in order to avoid getting too tightly squeezed by volume-to-value payment changes?
Pittman: Part of the shift has to be moving care closer to the patient, being more patient-centric. We’ll see a shift toward the home and the community and, perhaps an increase in new forms of primary care that do not involve the traditional clinic. It might be in some kind of a telephone booth on a corner. We will have to begin to re-imagine primary care. But from a payment perspective, the policies are trying to achieve a mentality shift from driving patients to physicians and hospitals, to essentially trying to ensure that they don’t need physicians and hospitals.
If this works, hospitals are going to get smaller. And here the experience of what happened with the Pioneer ACOs is telling. ACOs are figuring out how to keep people out of hospitals. And then the question is, how are hospitals going to adjust from a financial perspective? How are they going to shift their model? Can they compensate by investing in other kinds of care settings?
Q. What factors might help determine the answers to those kinds of questions?
Pittman: I think the patient population in hospitals will be sicker, but overall patient days will decline. There will be fewer hospitals, as we already seen with all the mergers and acquisitions. I think standalone hospitals are going to disappear, so you may end up having to have a highly skilled workforce in hospitals. You’re certainly not going to go in the opposite direction. Hopefully the workers will become more and more skilled.
And mechanisms like telehealth allow the very specialized providers to work across geographically separate settings so they don’t have to be anchored in one hospital. That probably will make a lot of sense. The specialists can have consultations, provider to provider, on an as-needed basis. We’ve already seen that in some states. We are certainly seeing it in critical access hospitals.
I imagine this [cross-setting collaboration] will also occur across all specialties and all sorts of occupations within individual hospitals. And again, hospitals that are part of a larger system will have an advantage. They won’t have to have as many specialists on staff because they can access them by other mechanisms such as telehealth and other options.
Q. One especially bright note in all this is that these are boom times for healthcare as a whole.
Pittman: Yes, that’s certainly what the Bureau of Labor Statistics is telling us. They’re projecting 26.5% growth in jobs in the health sector compared to 8.9% elsewhere. So there are going to be a lot of jobs. They’re not necessarily the high-paying jobs any longer, though. We are going to need to study, and have better data, about the low-paying jobs. A lot of the lower-paying support jobs are going to be the ones that are growing.
I suppose that, from a public policy perspective, the important thing is to make sure these support jobs don’t become bad jobs with high turnover rates, as we see in the retail industry and the fast-food industry. We have to have jobs that provide good career ladders for people to move up and earn decent, living wages.