An Interview with the Deputy Director of the Cecil G. Sheps Center for Health Services Research and Professor of Health Policy and Management and Social Medicine at the University of North Carolina at Chapel Hill

By Laura Trude, HWIC Information Specialist

Patient Protection and Affordable Care Act and the Health Care and Education Affordability Reconciliation Act of 2010 has focused on what this legislation will mean for the general public or how increased coverage in an era of workforce shortages may impact access to health care. However, these bills contain numerous provisions that directly impact the health care workforce. Dr. Tom Ricketts highlights changes in graduate medical education, student loans, the Centers for Medicare & Medicaid Services innovation center and more, and offers his insights on what these provisions will mean for the future of the health workforce.

Now that the Patient Protection and Affordable Care Act and the Health Care and Education Affordability Reconciliation Act of 2010 have become law, how will the implementation of this legislation impact the health workforce?

First off, there are a number of components that attempt to improve the conditions for trainees such as loan options and expansion of programs for the placement of primary care practitioners. There’s really a bolstering of all the programs we already have in place and that have been generally successful, but this bill may bring us to a tipping point that may help us turn the corner in primary care.

We’ve got some new things, the teaching health centers that are going to allow us to do some more training and increase involvement with access-oriented health programs and community health centers–that formal integration is really going to provide some momentum for things people have done already, informally and in an unpaid way. This might actually allow some folks to expand the kind of work practitioners find satisfying as well as help with access problems in underserved communities.

We’re also paying attention to general surgeons. We’ve recognized that’s become a big problem for smaller hospitals, for emergency rooms, for many places that depend on them. We’ve had a real flattening out of production of general surgeons and they’re getting older, leaving many places without surgical services. So the bill put in a Medicare bonus payment for them. That’s going to be helpful, but I think we need to pay a little more attention to the structure of all of the specialty training we have. The system allows people to go into places where they feel they are going to do well for themselves and not necessarily for the needs of the nation. That’s not necessarily a bad thing for the individual, but it’s really creating misdistribution in the physician workforce.

Reading through the legislation, there’s training for public health that we haven’t had in a while.

There are fellowships, traineeships, support for demonstrations in dental-auxiliary programs. The expanded dental role has been tried before; it is very controversial, but it looks like now we might have the conditions where it might yield more positive results than in the past, at least in terms of acceptance.

What is health reform going to do to the health workforce overall? Well, I won’t necessarily call it a revolution, but I will call it a very rapid evolution.

You mentioned that teaching health centers are going to change training for practitioners. How else will the legislation change health care provider training?

We really do need to train people in management of chronic disease and get people involved and committed to that; there is support for medical homes and for accountable care organizations which will emphasize the medical home concept. The value people want to pay for is embedded in that kind of coordinated care, so we’re going to have to train people to provide that: teaching health centers is one way, medical homes is one way, the accountable care organizations is one way, the innovation programs that are called for are other ways. This is the team process that is mentioned in the legislation. Those are all things that are trying to provide the incentives–financial, organizational, and professional–to really meet those needs where we find there are gaps in the system: in the coordination of care, prevention, chronic disease. That’s where we need more emphasis. I’m looking at that to be something that might really help transform some of our training paradigms. We really need to think about training in a graduate medical education system that is more aligned with where we have needs—and that is chronic, primary, and ambulatory care.

What affect will the teaching health center legislation have on graduate medical education?

Graduate medical education under Medicare is paid for if you are being trained in a hospital, in general. So we’ve never really allowed much graduate medical education in outpatient settings. People do it in family medicine centers that are attached to a hospital, but now we’re talking about places that are more relevant for, say, rural and community-based settings; those are the places that will have these teaching centers. The contrast is that now we can pay for training and set up specific training structures that are out in communities where before those were more or less informal and were done with less than full support.

The legislation also includes changes to educational loans. How might these changes affect people interested in pursuing a degree in a health-care related field?

The bill actually changes the overall student loan structure. The loan structure will actually allow more people to choose to go into helping careers, especially things like allied health, dental assisting programs, or things like that, and not have big loan burdens. The National Health Service Corps is being expanded dramatically through the community health center fund with mandatory funding for the Corps, so that’s going to allow more people to come into it. It’s also giving people more options under the National Health Service Corps to do what are called half-time service waivers, which you have a longer period of service but you only do half-time service. They’re allowing teaching to count for some of the National Health Service Corps payoff. In the past you’d have very talented physicians go out and basically, they had to just see patients and couldn’t get compensated for teaching other doctors who could benefit from the clinical experience. So they changed the rules around the Corps that are going to make it more attractive, more flexible. That’s been one of the problems with the Corps; it’s been a really one-size-fits-all program and you’re either in or you’re out. Now you’ve got some options. I haven’t even touched on nursing because I’m not as knowledgeable of that, but there are a number of expansions of loan repayments in there across the gamut of the Title VIII programs.

How does the legislation promote the public health workforce?

I mentioned the public health workforce loan repayment. We used to have some public health service traineeships years ago. I had one thirty years ago, gosh maybe it’s been forty…it’s been quite a while; we’re moving back towards that to give folks training in that, because the public health system is really in need of people to work in many skilled positions and we haven’t been giving much federal support for that lately. We’ve got some mid-career public health scholarships. I really don’t know how they are going to work but it could give a chance for people to reorient themselves to work that is needed out in the public health system. We’ve got fellowship programs in epidemiology and lab science, preventative medicine is going to be expanded.

What does the health care legislation do to promote innovations in health care delivery? From a workforce perspective, how will these changes affect health care providers?

Medical homes are a work in progress: that is an innovation of itself, trying to organize properly coordinated care using information technology. But we have an innovation center that is being set up in CMS (Centers for Medicare & Medicaid Services). We have gotten good ideas and made them work when people are properly compensated for them. We’ve got some requirements for changing the way in which some services are paid, either organizationally, like with the accountable care organization structure, or in payment structures, bundling and episode-type grouping and things like that which are going to come out of this. It’s hard to say what exactly will come of this–the bill says: ‘Let’s get the best things that work, let’s find them, let’s make sure everybody knows about them, let’s prove that they work, let’s make them the way we do health care.’ I can’t say much more about how you can stimulate innovation than saying ‘We’re going to reward you for innovation, we’re going to allow you to do new things.’ There’s a lot in there about doing things differently, about doing things better.

This bill was finally passed through reconciliation. Are there any major health workforce issues the final legislation did not address?

Well, the Medicare payment problem with the sustainable growth rate (SGR) link that puts in automatic adjustments to payment to physicians is something that was left out and has implications for workforce, if you’re going to be cutting Medicare physician payments. It’s going to produce some changes in the incentive structure because the percentage won’t be applied uniformly. It will be applied according to the distribution of current charges which are maldistributed somewhat anyway. So that’s probably going to intensify problems. People are talking about payment issues, especially among specialties and primary care.

There’s some support for state demonstrations for tort reform but I think that we really do need to tackle that and make for a more stable, predictable, and fairer system in tort reform. I work with a lot of physicians; they really worry about this. We have a system that is somewhat haphazard. I work in other countries and I can tell you there’s a bit more predictability and probably some things run a little more effectively in terms of the way which other countries deal with problems like this. Our country has a very complex and punitive system that runs to extremes and that’s really not the best climate for any practitioner that has to live under that. I won’t necessarily say that the actual monetary effect or the response in terms of defensive medicine is as bad as people say, but I don’t have a conversation with a doctor for more than a few minutes where this doesn’t come up.

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.