1. Health Care Workforce PA 574: Health Systems Organization Session 7– May 15,2013

2. How is Health Care Workforce Different? • Inappropriate or inept healthcare can be harmful • Health care in not “contractual”: • Consumer does not have enough information to fully determine “appropriate” care • Why malpractice is tort and not contract law based • Leads to legal, policy based definitions of healthcare workforce • Specialized training • Licensure

3. Implications of HC Workforce “Differences” • Leads to a “rational” but not very “open” system • Can’t just create any position/workforce type you want (ad hoc) • Those who are “in” are supported by system resources (billing capability) • Both hard to get “in” and those “in” want to protect the turf they have • How do we promote workforce innovation while protecting patient safety? • What would an open system of workforce development look like and how would it work?

4. Typical Bases of HC Workforce Types • General diagnostic capability • Really where “centrality” of MDs based • Disease/health conditions • Oncology, psychiatry, etc • Body parts/areas • Dermatology, ENT • Health care processes • Surgeon • Facility/work location • Hospitalist, “classic” RN

5. Tensions and Pitfalls of “Typical” Workforce Definitions • Need generalists – but who can know everything? • Specialization can improve (local) quality – but how do you treat the whole person • Who decides what healthcare is and thus limits of HC workforce? • Aren’t these “rational” categories really developed “naturally” and then cast in stone? And to whose benefit?

6. What Would the Triple Aims Suggest? • Health of Populations • Workforce defined by ability to produce health (broadly) • Health educators, “alternative and complementary” providers, allied health professionals (e.g. dieticians, physiologists) should all have equal opportunity • Importance of (unbiased) comparative effectiveness research across professions/disciplines/treatment types

7. What Would the Triple Aims Suggest? • Individual Experience of Care • Workforce is designed to meet whole person needs – if specialization then coordination • Competencies in communication (with patient and other providers – teamwork) not just technical know how • If coordination is important who creates/helps the individual with this? • Community Health Workers, Case Managers, Home Health Workers, Health Navigators are all recognition of this important role

8. What Would the Triple Aims Suggest? • Reducing Per Capita Costs • Getting the best at least cost • Working to (top of) scope of practice • Creating substitutes (specialists of a sort) where scope can be divided (PAs and NPs) • Creating organizations/systems and financing that support “top of scope”, coordinated care • One size does not fit all (Rural Health Clinics, developing nation health systems)

9. So How Do We Get a Triple Aims Workforce? • Creating Triple Aim organizations has helped • CCOs and CHWs • But desperation has been the mother of workforce innovation (resource limitations) • CHWs as “developing nation” workforce • Dental Assistants from Alaska • “Find the Psychiatrist” in a public mental health system • Basing innovation on resource limitations could stint quality(?)

10. Getting a Triple Aim Workforce • Need a “rational” but “open” workforce development “system” • Workforce types based on outcome not concepts of process or structure • Evidence based procedures for assessing acceptability and scope of practice • Financing that is based on what you do, not who you are • So how do we get this done – and who does it?