Two Views on Health Reform and Workforce

1. Thomas C. Ricketts, PhD, MPH Two Views on Health Reform and Workforce

2. The negative, cynical view • Congress added to the existing macro-policy of “nudging” workforce market behavior through profession- specific, producer-focused, grant-structured programs. • Little assessment of past performance • No unifying goals stated • A Policy-Recommending Commission has been created with no clear guidance over how they are to influence policy—and no appropriation. • A potential rival to the GME “1000-pound gorilla” may emerge in the Community Health Center Trust. Teaching centers and primary care extensions may create conflict.

3. The positive, constructive view • Experimentation is encouraged viamany new approaches • Teaching health centers, a naturalextension of current activities givesmomentum to multiple programs • Outreach structures, that can build on successful AHEC-like activities, can unify the system • There is a potential for the expanded programs to create a “tipping-point” for primary care • Institutionalizing nurse leadership and acceptance of new professional roles will help meet needs and produce efficiencies • Structures for coordination across (all) workforce stakeholders are recognized if not encouraged

4. Doctors and Reform: New Stuff • New support for Trauma Care (a bona fide success) • New incentive for surgeons in HPSAs • Pediatric subspecialist loan repayment • Redistribute GME slots to primary care, count OPT time • ACA has a strong primary care bent and assumes primary care can Lower costs and Improve Outomes • NHSC and Teaching Health Centers • Primary Care Grants to schools • Bonus to primary care • Primary Care Extension Centers (AHRQ)

5. Doctors and Reform: Unresolved • Regulatory • ACOs and balance between generalists and specialists • Medical Homes and the same • Geographic adjustments to payment • Relative Value (RVUs) and Bundling • Legislative • SGR and Medicare payments • Tort reform • GME in general

6. Meanwhile…medicine will be affected by… • Policy for Nurse Practice: A big report from some nursing advocates lays claim to an expanded share of the primary care need. • Medicine replies with a strong demurral, but in the words of a leader of one discipline: “We haven’t solved the primary care problem ourselves” • Expansion “on the edge” continues with • new medical schools, programs and plans • CNPs (Creative New Practitioners) emerging to soak up the prevention benefit under Medicare

7. Who, what where, when, why, how? • Who: Will program advocacy define roles (Grinch) • What: Is there potential for a new interprofessional policy culture? (Pollyanna) • Where: The states have wildly different cultures and conditions that affect the “mix” of policy approaches • When: The urgency of “reform” runs up against the realities of training cycles—inevitable frustration. • Why: Have we turned a corner to patient and community centered-ness? Will we now have clearer workforce policy • How: Will the money run out? Will it get off the ground?

8. Grinch or Pollyanna, you choose Thomas Ricketts (919) 966-5541 ricketts@schsr.unc.edu