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.
A caricature of how philanthropy stimulated social change in “the good old days,” derisively called Philanthropy 1.0, describes the process this way: first, private funding helped successfully develop an innovation; the innovation then gained recognition; and finally the government rushed in to adopt it and take it to scale. (If you build a better mouse-trap, the world will beat a path to your door.) In the cynical modern perspective, this process of adoption, if it ever really happened, stopped with the Great Society programs of the Johnson administration.
Today, in the supposedly more complicated age of Philanthropy 2.0, program sustainability is thought to derive from complex business plans (e.g., combining government support with earned revenue and public fundraising) or from political advocacy processes, including stakeholder capacity development, lobbying, and ultimately, legislative action.
But the world is wide, and every once in a while, if you do build a better mousetrap, work hard to polish it, connect it to stakeholders, and remain patient—the world will come to your door. This week we are celebrating a new partnership with the National Institute on Aging, our third, to sustain the Jahnigen and the Williams career development awards, two programs pioneered by the Hartford Foundation over the last 10 years through a new R03 award mechanism entitled GEMSSTAR—Grants for Early Medical/Surgical Subspecialists’ Transition to Aging Research.
What will it take to ensure that all physicians are competent to care for their large and growing numbers of older patients?
Despite being only 13 percent of the population, older adults (those over 65) are big users of health care. For example, they make up 35 percent of office visits to the average general internist, 50 percent of visits to cardiologists, and 55 percent of visits to ophthalmologists. Except for pediatricians, all physicians will encounter older adults in their practice. But medical training does not reflect these demographic and epidemiological realities; standards of medical education do not require geriatric clinical training experiences (clerkships) during medical school. Yet medical education continues to require all doctors in training to treat children and deliver babies, regardless of future specialty.
(l to r): Michael Bleich, Linda Cronenwett, M. Elaine Tagliareni, Terry Fulmer, Marla Salmon
Last year, the Robert Wood Johnson Foundation commissioned an Institute of Medicine (IOM) initiative on The Future of Nursing. The goal of this initiative is to define a clear agenda and blueprint for action that identifies vital roles for nurses in implementing a more effective and efficient health care system. To do so, the IOM has hosted three forums on the future of nursing in November, December, and last Monday, February 22, 2010. From these meetings, a report will be released in October 2010. This third and final hearing focused on nursing education. Discussions centered on “What We Should Teach,” “How We Should Teach,” and “Where We Should Teach.”
Gerontological nursing advocates Elaine Taglierini, EdD, RN, president of the National League for Nursing, and Terry Fulmer, PhD, RN, dean of the New York University College of Nursing, spoke in the first discussion, “What We Should Teach.” They presented compelling testimony about the importance of educating nurses to care for older adults and set the tone for the meeting, which featured themes of aging and interdisciplinary collaboration throughout all the panels. As a representative of a funder focused on aging and health, I found this incredibly rewarding.
In our efforts to improve the health of older adults, we often feel quite alone, even isolated. While we are fortunate to work with and provide support to many, many committed grantees in the health professions and service delivery, many other stakeholders seem to view the Foundation’s work with mixtures of incomprehension, incredulity, and even hostility.
Even though Americans are becoming increasingly aware of the need to improve care for people with chronic disease, the fact that chronic disease, and particularly multiple chronic disease, is disproportionately a problem of older adults seems lost on most people and even many health care professionals.
Certainly our primary strategy of increasing the amount of geriatrics training future health professionals receive seems to puzzle most observers. I think this stems in part from our American assurance that we already have the best health care in the world. If you believe this, then it follows that our professionals must already have all the skills they need.
Most people agree that loan forgiveness for medical students who agree to undergo geriatrics training would be a good thing. The American Geriatrics Society has a nice summary of the topic here. However, the idea has yet to be practically implemented… with the exception of South Carolina. Click here to read about South Carolina’s program, which forgives up to $35,000 in debt for each year of geriatrics training if doctors agree to establish a geriatrics practice in the state.
Interestingly, the Senate version of the current health reform legislation includes several different loan repayment provisions. Some are intended to help increase the pediatric health care workforce. Some are aimed at dentistry and dental faculty. There is also a fairly robust nursing faculty loan forgiveness program. And finally, there is reasonable attention to public health workers. However, as far as I can see, loan repayments are not offered to geriatric physicians (or even to the broader group of “primary care provider” physicians.) Since the Senate’s bill incorporates what remains of Wisconsin Senator Kohl’s “Retooling for an Aging America Act,” I think it is a more likely vehicle than the House bill, but I could be wrong.
The theme of the Foundation’s annual report this year was leadership–leadership to change the way the US health system prepares health professionals to care for older adults and the resulting quality of care they receive. These are big changes because of the size of the industry involved (16% of GDP and growing) and the counter-cultural nature of the issues–aging of the population, problems in everyday quality of care, and the need for an enhanced workforce–none of which are “sexy” issues.
This week we are very proud of the leadership shown by Lewis A. Lipsitz, MD of Harvard Medical School, Hebrew Senior Life, and the Beth Israel Deaconess Medical Center in Boston. Dr. Lipsitz, Director of the Hartford Center of Excellence in Geriatric Medicine and Training at Harvard University, is a long-time Foundation grantee and advisor. Recently he issued a clarion call for change in an op-ed in the Boston Globe talking about the need to strengthen geriatric medicine, improve care of older adults, and ensure that all physicians have basic competence in their care.
Right now, as we stand on the brink of health care reform, we are locked in a battle to increase the number of health care professionals trained in geriatrics. What would victory look like? To me, victory would be major increases in the number of geriatricians, geriatric nurse practitioners, and geriatric social workers and a significant focus on geriatrics in curriculums for training all health care professionals. Are we there yet? Not even close. That’s why we keep citing the Institute of Medicine report, Retooling for an Aging America: Building the Health Care Workforce. The more this insightful report is discussed and disseminated, the better.
Thankfully, although over a year old now, the report continues to receive attention, even internationally. For example, the International Association of Gerontology and Geriatrics (IAGG) Conference in Paris in July included a workshop on “Building a health care workforce to serve an aging America.” Domestically, in May the annual Princeton Conference on health care economics and policy also focused on the older population. Titled “How Will We Meet the Health Service Needs of an Aging America?” one of the main areas of discussion focused on how to finance health care reform.
Of course the hot button items were bundling of payments and the cost of rehospitalizations. Most panelists agreed that the system of assigning costs to health care and determining the best methods for reimbursement need to change, but there was little agreement on the best methods of change and how to implement them. It’s no wonder that members of Congress, who don’t have the academic background on these issues as the Princeton speakers have, are struggling to design a system palatable to everyone. My suggestion to Congress is to provide the best plan for most and find creative ways to finance it; don’t let it get diluted until it is almost ineffective. According to the presentations and discussions at the conference, there are many ways to finance health care. The brouhaha about it being too expensive is just diversionary tactics from reform opponents. I don’t believe that we can’t afford it; I do believe that we can’t afford to continue with the health care non-system that we have.
As part of its theory of change, the Foundation has made big bets on the specialty of geriatric medicine. (Click here for a nice summary of what geriatricians do.) Unfortunately, we are losing the numbers game. Geriatric medicine is the only specialty in which a physician takes a pay cut in return for additional advanced training. Why? Because almost all older adults are covered by Medicare, and Medicare pays relatively poorly for the core services of geriatric medicine: office-based evaluation and management services (diagnosing, adjusting medicines, referring to specialties, coordinating care, educating patients and family members). Therefore, geriatricians make about 10 percent less than generalists who treat older adults, but not exclusively older adults, and of course much, much less than specialists in the procedural areas such as dermatology, radiology, or gastroenterology.
It gets worse. To provide real geriatric care, the physician needs to work with a team of professionals: social workers, nurses, physical and occupational therapists, nutritionists, and others. Many of these services cannot be billed directly to Medicare and need to be covered out of (already meager) practice revenues. Finally, to add insult to injury,
On July 15, at Macomb Community College (Warren, Michigan), President Barack Obama offered a new plan to commit $12 billion in federal funds to community college education across the nation. The plan, called The American Graduation Initiative, would provide funding to help these schools establish partnerships with businesses, coordinate their programs with high schools and four-year colleges, and perhaps most importantly, encourage the many students who drop out of community colleges to complete their degrees.
From the Hartford Foundation’s perspective, this initiative addresses a critical issue in helping meet the nation’s expanding health care needs over the coming decades—filling more than a half-million new positions in nursing over the next few years. The majority of these nurses will prepare for their professions in pre-licensure associate degree programs. The Foundation has taken an active role in this area through the Fostering Geriatrics in Associate Degree Nursing Education project, a national program based at Community College of Philadelphia under the leadership of Elaine Tagliareni, EdD, RN.
David Brooks, in a recent OpEd piece for The New York Times, welcomed the president’s initiative and underscored the importance of community college education in the nation’s economic recovery. We felt that the Foundation’s perspective with regard to health care would add a critical perspective to Mr. Brooks’s column, and I submitted a response to the Times, which was published in the July 20 edition of the paper.