The Affordable Care Act and Colorado’s Health Care Workforce

1. The Affordable Care Act and Colorado’s Health Care Workforce What impact will health reform have on Colorado’s health professions workforce and access to primary care? Hot Issues in Health Care Legislative Conference November 11-12, 2010 Garden of the Gods Club Colorado Springs, CO

2. What can Colorado expect in numbers of newly insured? Once the ACA has been fully implemented, CHI has estimated that: • Over 550,000 Coloradans will be newly insured • 238,000 will remain uninsured

3. Health insurance is just the beginning step on the path to access to health care Access to health insurance Access to health care

4. Factors affecting access to health care In addition to having a health insurance card, access to care also depends on the: • Absolute supply of the health care workforce • Specialty distribution of health care providers • Geographic distributionof health care resources • Policies governing provider practices

5. Lessons from Massachusetts “Expanding access to health insurance without expanding access to care can turn a positive development into widespread patient and practitioner frustration.” SOURCE: Bodenheimer, T and Hoangmai Pham. (2010) “Primary care: current problems and proposed solutions.” Health Affairs 29(5):799-805.

6. TITLE V of the Affordable Care Act: Health Care Workforce

7. Title V: Health care workforce provisions • The purpose of this section of the Affordable Care Act is to: “Improve access to and the delivery of health care services for all individuals, particularly low-income, underserved, uninsured, minority, health disparity, and rural populations.”

8. Overview of Title V provisions • Establishes a National Health Care Workforce Commission • Establishes a Health Care Workforce Development grant program • Establishes the National Center for Health Care Workforce Analysis

9. Overview of Title V provisions (cont.) Other provisions include: • Authorizes funds to encourage expansion of the health care workforce • Authorizes grants and programs to enhance health professions’ education and training • Appropriates funds for scholarships and grants to support existing health care workforce • Authorizes grants to academic heath centers to establish new or expanded primary care residency programs

10. Strategic state workforce planning in Colorado involves… • Deciding where Colorado needs to go to create the preferred health care system and workforce • Determining what we need to know to get us there • Developing an action plan that will enable Colorado to achieve the preferred system

11. Physician supplymodel CURRENT WORKFORCE Current active physician workforce [36 medical specialties, year of medical school graduation, gender, medical school location (U.S./Canada vs. all other countries), type of degree (MD/DO), major professional activity (direct patient care vs. others] NEW ENTRANTS New entrants [1styear residents + physician in-migration into Colorado] EXITS FROM THE WORKFORCE Separation from workforce [out-of-state migration + retirement + death] Physician Supply DATA SOURCE: HRSA Model – 2005 AMA Physician Master File

12. Counting is only the beginning… In addition to knowing how many physicians we have in Colorado, we need to know: • The ratio of primary care to specialty care providers • What other health care professionals provide primary and specialty care? In what capacity? In what quantity? • The distribution of the health professions’ workforce geographically

13. Primary care practitioners include: Health Care System Primary care is the foundation of the health care system Family practice physicians, internists, geriatricians, general pediatricians, nurse practitioners and physician assistants

14. Why primary care matters… The Four Pillars of Primary Care: First Continuity Whole Coordination Contact of person of Care Care Care Care SOURCE: Starfield B. (1998). Primary care: balancing health needs, services, and technology.. New York: Oxford University Press.

15. Promising models of primary care delivery • Patient centered medical homes • Collaborative interdisciplinary teams • School-based health centers • Improved provider coordination via Electronic Health Records (EHR)

16. Primary care supply, Colorado and the U.S. COLORADO U.S. 35% of all U.S. physicians identify themselves as primary care practitioners 49% of U. S. rural physicians identify themselves as primary care practitioners • 29% of all Colorado physicians identify themselves as primary care providers • 47 % of Colorado’s rural physicians identify themselves as primary care providers

17. Primary care physician supply and demand:Status quo + universal coverage, 2005-2025 DATA SOURCE: 2005 AMA Physician Master File

18. Declining interest in primary care specialties among physicians A 2007 survey of fourth year medical students at eleven U.S. medical schools found: • 2% were planning a career in general internal medicine • 5% were planning a career in family medicine • 12% were planning a career in general pediatrics SOURCE: Hauer, K. et.al. (2008). “Factors associated with medical student’s career choices regarding internal medicine.” Journal of the American Medical Association 300(10): 1154-64.

19. “Show me the money…” The Primary Care Wage Gap Specialists % above primary care • Surgeons 48% • Internal medicine & pediatric 36% sub-specialists • Other Specialists 45% SOURCE: Leigh, JP, et.al. (2010). “Physician Wages Across Specialties.” American Medical Association 170(19):1728-1734.

20. Rural physician wage gap in Colorado • 49% of Colorado’s rural physicians in a FT primary care practice reported an income of less than $150,000/year • 23% of Colorado’s rural physicians in a FT specialty practice reported an income of less than $150,000/year Source: 2009 Rural Physician Survey, Colorado Health Institute,

21. Between a rock and a hard place… “A primary care physician with an average panel of 2,000 patients would spend 17.4 hours per day providing recommended acute, chronic, and preventative care.” “Given current fee schedules, primary care practices would fail financially with considerably smaller patient panels.” SOURCE: Bodenheimer, T and Hoangmai Pham. (2010). “Primary care: current problems and proposed solutions.” Health Affairs 29(5):799-805.

22. Factors affecting access to primary care Models of care and scope of practice matters… • Utilization of nurse practitioners and physician assistants can expand the supply of the primary care workforce without sacrificing quality

23. Supply/demand model: Primary care PAs 2005-2025 485 SHORTAGE 399 270 131 DATA SOURCE: 2005 PA data, Peregrine Management Corporation

24. Supply/demand model: Primary care APNs 2005-2025 SHORTAGE DATA SOURCE: 2005 APN Data, Peregrine Management Corporation

25. Geography matters… The primary care workforce-to-population ratios vary significantly depending on where one lives in Colorado

27. Provider practice policies matter… • Have practices adopted a collaborative model of care that includes advanced practice nurses and physician assistants as primary care providers? • What types of insurance types practices accept? • Are practices are accepting new patients? What types of patients?

28. Colorado’s rural physicians report… Payer Source% reporting Practice closed to Medicaid adults 24% Practice closed to Medicaid children 21% Practice closed to CHP+ children 18% and pregnant women Practice closed to Medicare patients 11% SOURCE: 2009 Rural Physician Survey, Colorado Health Institute

29. Other health care providers critical to ensuring comprehensive primary care • Registered nurses • Dentists • Dental hygienists • Physical therapists • Occupational therapists • Clinical pharmacists • Clinical psychologists, clinical social workers and other mental health providers

30. Understanding supply and demand factors related to mental health care supply: Where to start? • Count ‘em up…distribution of mental health providers by county • 11 Colorado counties have no LCSWs or Clinical Psychologists; another 16 counties have 3 or less • A second cut…provider-to-population ratios • Excluding 0s; mental health professionals rates range from a high of 23.3 in Boulder to a low of less than 2 per 10,000 in Conejos, Crowley, Elbert, Prowers, Rio Grande and Saguache counties

31. Putting all the workforce pieces together Access to insurance coverage is just the beginning • What gets counted matters • Provider specialty choice matters • Provider policies matter • Models of care and scope of practice matters • Geography/distribution matters

32. Workforce issues in Colorado aided by provisions in Title V of ACA • Appropriates $1.5B to National Health Service Corps to recruit primary care providers in health shortage areas • Awards grants to expand primary care training programs • Awards grants to train physicians committed to serving in underserved rural communities • Awards grants to academic health centers to expand primary care residency programs in community and rural health clinics • Redistributes Medicare-funded residency slots for primary care and general surgery

33. Expansion of training programs for allied primary care workforce • Grants for training programs in generalist, pediatric and public health dentistry • Demonstration grants to train or employ alternative dental health care providers • Grants for training programs in geriatrics, chronic care management and long-term care • Grants for recruiting and training of mental/behavior health providers for children and adolescents • Loan repayment program for public health and allied health professionals

34. What role for state policymakers? • Regulatory • Incentives • Community solutions • Let the market figure it out • Workforce planning

35. What do you think?