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Health Workforce: A Call For A National Policy



July 23rd, 2008

Government policymakers and private-sector stakeholders have been crafting the nation’s health care workforce for years without answering definitively a question that lies at the heart of the matter: should policymaking follow the values of many Americans and rely on market-based solutions, or — in this instance — does more prescriptive government regulation make more sense? Without a clear preference, the history of policymaking that addresses the size and composition of the nation’s health care workforce is, at best, checkered. An array of private and public organizations play a wide variety of roles in shaping the workforce, but there is no overall design or policy that guides it.

Given this split, a prescription set out in a new report by the Association of Academic Health Centers (AAHC) comes down decidedly, if not definitively, in favor of one direction. The report calls for the creation of a “new health workforce planning body to ensure development and implementation” of a “comprehensive and coordinated national health workforce policy.” 

The report is blunt in its criticism of workforce processes, characterizing them as “inconsistent, uncoordinated and fragmented among literally hundreds of federal, state and private regulatory and standards-setting bodies.” It goes on to say, “With an absence of overarching national leadership . . . numerous educational, accrediting, and licensure bodies — all well-intentioned — emerged and contributed to a Tower of Babel in the health-care community.” In its place, the association’s report calls for development of “an integrated, comprehensive national health workforce policy that recognizes and compensates for the inherent weaknesses and vulnerabilities of current decentralized and distributed multi-stakeholder decision making.”

With A Small But Prestigious Membership,
The AAHC Could Jump-Start The Debate

As health care organizations that advocate for one cause or another go in Washington, the AAHC is small as measured by its annual budget (about $3 million) and its staff (a dozen or so), but its 100 member institutions include some of the nation’s most prestigious academic health centers: Baylor, Cornell, Duke, Emory, Georgetown, Harvard, Johns Hopkins, NYU, Northwestern, the University of Pennsylvania, Stanford, Texas, Vanderbilt, Virginia, Washington, Wisconsin, and Yale. Among its other members are an array of academic centers — large and small, private and public — all dedicated in a variety of ways to health professions education, patient care, and clinical research. Given its elite lineup of members, the AAHC’s sharp criticism of the chaotic way in which health workforce policy is made and its call for a new national health planning apparatus could reopen the many issues surrounding the matter. This prospect could enliven the debate in 2009, should Congress seek to expand coverage to the nation’s large and growing uninsured population only to find that there are not enough physicians, nurses, and allied professionals to care for newly insured people — at least as the system is currently structured.

At a National Press Club briefing (July 17), Dr. Steven A. Wartman, president of the AAHC, introduced the report, which was supported in part by the Josiah Macy Jr. Foundation. A panel of three physicians who are leaders in academic health centers in Georgia, Texas, and Virginia described various dimensions of the report and how its recommendations could provoke a new dialogue over how the nation’s health workforce might be better configured for the demands of the twenty-first century.

Wartman summarized the four key recommendations of the report: (1) make health workforce a national priority issue; (2) develop a comprehensive and coordinated national health workforce policy; (3) create a new health workforce planning body that would provide advice and assist in implementation of a comprehensive national policy; and (4) act now to “avert impending crises.”

Wartman explained: “One of the key elements missing from our current health workforce policy is any effective mechanism or structure to consistently coordinate and integrate policymaking and planning by a multitude of stakeholders.” The recommended national health workforce planning body is intended to serve that missing integrative role, and to do so on a permanent basis (in contrast to a temporary commission). The report does not specify a particular model for this body, but Wartman cited three possibilities: a nonprofit membership organization model, a federally chartered private corporation model, or an independent government agency model.

Dr. Daniel Rahn, president of the Medical College of Georgia and senior vice chancellor of health and medical programs for the University System of George, chaired the advisory group that helped produce the AAHC’s report. In developing the report, Rahn said the association encountered many workforce issues that have been largely untended, including current and projected shortages in personnel, a decline in the attractiveness of health careers, critical faculty shortages in the health sciences, and the high cost and length of health professions education. As a result of these and other issues, Rahn said, the AAHC concluded that “our current lack of a comprehensive, coordinated national health workforce policy” is contributing to society’s failure to address them. He added, “Therefore, the report calls for a fundamental reconsideration and reinvention of how we make and implement health workforce policy.”

Another panelist, Dr. Sheldon Retchin, vice president for health sciences and CEO of the Virginia Commonwealth University (VCU) Health System, spoke about the complexities of the current matrix of government and private-sector entities that pose multiple challenges to his Richmond-based institution. Retchin said: “Like other top academic health centers, VCU recruits talent nationally, and too often my efforts are further frustrated by the same kind of barriers to health professions mobility that prevent communities from addressing their own shortages: complexity and inconsistency in our patchwork health professions regulatory and professional standards. State-by-state variation in scope of practice, licensing, accreditation, and related requirements create additional hurdles. They make it harder for faculty to move; they limit our ability to develop innovative curricula; they limit the job prospects of our graduates. In short, the lack of harmonization across jurisdictions adds an incremental burden to an already overburdened health workforce, and makes the missions of academic health centers more difficult to achieve.”

The third panelist, Dr. Nancy Dickey, vice chancellor for health affairs and president of the Texas A&M University System Health Science Center, said the AAHC considered various options for achieving a comprehensive and coordinated approach, including “federalizing health workforce policymaking and planning. We concluded that was not the direction to go, both because it is important to ensure all stakeholders have input into the policymaking process, as well as the practical realization that current stakeholders are so deeply embedded in the system that any effort to restructure their customary jurisdiction was likely to fail.” Using a national approach to network every stakeholder invested in improving the way health workforce policy is shaped was considered the best option.

“Therefore,” Dickey concluded, “AAHC’s first order of business is to encourage other stakeholders to come to terms with what it will take to create and implement truly effective solutions, not just tinkering at the margins, and join AAHC in building consensus for a national health workforce policy agenda.”

Health Workforce Has Been A
Frequent Topic In Health Affairs

Since its launch in 1981, Health Affairs has paid particular attention to health workforce policy issues, having devoted a thematic issue to the subject in 2002 and having published countless individual papers to these subjects over 27 years of publication. Indeed, when I typed the words “health workforce” to gain entry to the journal’s vast archive, no fewer than 691 entries came up. Examples include papers by Gebbie and TurnockGoodman, Stukel, Chang and Wennberg; Isaccs, Sandy, and Schroeder; and Salsberg and Forte. The papers have included the works of scholars who believe in more government regulation or market-based solutions as the best answer or a blended approach, some which discuss the strengths and weaknesses of different ways to address the issue.

After Dr. Fitzhugh Mullan retired in 1995 as director of the Bureau of Health Professions at the Department of Health and Human Services, I encouraged him to join our staff in our continuing efforts to shine a light on this most neglected but critically important subject, if the American approach to delivering and financing health care is to be improved. Mullan has written some of the most provocative papers on subjects that encircle health workforce policymaking and also has been a perceptive reviewer of many other papers on this subject.

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