Last month, after months of waiting and insider speculation, the Government Accountability Office announced the members of the National Health Care Workforce Advisory Commission, in accordance with PPACA section 5101. Their challenge will be to make recommendations on the numbers, nature, and deployment of the health care workforce. These recommendations will be essential to making a reality of the promises of expanded access and coverage under health reform. Their work will also be vital to the reform of the delivery system, which is essential to improving our mediocre health care performance while increasing efficiency so that we can stop health care’s so far inexorable devouring of federal and state budgets.

When you put it that way, I am glad that my nomination to the commission was not successful. (There had been a suggestion in the law that in addition to representation of providers and consumers, having representatives of “health care philanthropy” on the commission might be appropriate, so I threw in my hat.)

Nonetheless, I will offer some free advice to the commission (me and the entire health policy world, I’m sure): carefully consider not just the size of the workforce in all its various components but also what it is trained to do and the systems of care into which it is deployed. Given our fragmented, inefficient health care system, it would be a mistake just to scale up our current workforce in proportion to the need. If we do, we should not be surprised to get the same mediocre quality of care at ever-increasing costs.

Unfortunately, many stakeholders in the health care system argue for just this—more, much more, of the same. The same week that the commission unveiled its membership, the Association of American Medical Colleges issued a press release arguing that the aging of the population means that we are facing a physician shortage and argued that the shortage “is not just among primary care physicians.” This position obviously is an objection to any “over”-emphasis on the primary care workforce, yet it makes no mention of adding any special geriatric or gerontology education (or even chronic care focus) to any physician's preparation. I wish this were the only time I had seen arguments in this form, but it is not. Many stakeholders are very willing to use the aging of the population and its burden of multiple chronic illness as a rationale for increased public funding for and increased size of a profession, but few are willing to pursue the point to its logical conclusion: the content of training must change to properly serve the aging population. Because caring for older people is the core business of health care, geriatrics has to become a core requirement in health professions education.

Beyond considering the training content, we also need to reflect carefully on what health professionals are expected to do and how. One of the most ignored recommendations in the Foundation-supported Institute of Medicine report Retooling the Healthcare Workforce for an Aging America is number 3.3, on delegating responsibilities for care “down” the training hierarchy. Ignoring the needlessly condescending notion that there is such a linear hierarchy, it should be clear that we cannot successfully meet the health care needs of our aging population with just more of the same. We need every member of the health care “team” to really be that—a member of a high-functioning team, not just a mob of professionals jockeying for pride of place. We desperately need every provider to work at the top of his or her license—that is, to do only that which only they can do—and necessarily to give up the rest to others who can do it more cost effectively. Of course, this differentiation of function, while efficient, can only lead to higher quality when there are also strong mechanisms in place to maintain coordination of communication among providers.

To paraphrase the words of Jack Rowe, MD, Chair of the Institute of Medicine's committee on Retooling the Health Care Workforce for an Aging America, we need doctors to relinquish some of their work to nurses, nurses to paraprofessionals, paraprofessionals to family members, and for patients to take better care of themselves. Such models of team work are threatening and scary to both professional prerogatives and to our very real concern to give the best care. But what choice do we have? Right now, our health care system is providing only 30 percent of recommended care for older adults with common conditions like dementia, fall in juries, depression, etc. The only way to be sure that missing 70 percent gets done is to radically retrain and redeploy the health care workforce. No mere increase in the size of the workforce can do anything other than scale up a deeply unacceptable status quo.