# Presentation: 138611

## The Health Care Workforce: Key Trends, Challenges, and Strategies 

**The Health Care Workforce: ****Key Trends, Challenges, and Strategies **

**Bram B. Briggance, Ph.D.**
**UCSF Center for the Health Professions**

## Why Workforce Reform Is Cardinal

- 60-70% of health care is labor costs
- Big part of any employment sector
- 10.5% of U.S. workforce (14,653,661)
- It limits access, spurs cost increases, and directly affects quality
- Crisis is looming for health workforce, but it has more to do with lack of innovation, than with shortage of workers

## Part I.Broad Trends Affecting the Health Care Workforce 

- Changing demographics
- Shifting epidemiology
- Economic disparity and cost
- Technological innovations
- Globalization
- Change from supply to market driven health system

## Demography ― Aging

**Demography ****―**** Aging**

******Aging Population**

**Source: National Center for Health Statistics, 1993. Hyattsville, MD: Public Health Service, 1994. US Bureau of the Census, Historical Statistics of the US , Colonial Times to 1970, Washington DC, 1975.**

_**Triple witching**_
**Aging workforce**
**Fewer new workers**
**Care demands and needs of an aging population**
**...****But the devil is in the details**

## Demography ― Aging

**Demography ― Aging**

- Issues
- Impact on demand for health care
- Rising cost of care
- Adequate workforce
- Intergenerational equity
- Uneven across the nation

**Source: Center for the Health Professions, 2003.**

## Demography ― Diversity

**SOURCE: **CA Dept of Finance

**Demography ****―**** Diversity**

**From a majority culture...**

**To diversity...**

**To multicultural.**

## Demography ― Diversity

**Demography ****―**** Diversity**

- Issues
- From diversity to multiculturalism
- Health
- Leadership
- Disparity in health outcomes
- Culturally competent care
- Distinctive market-consumer bias
- New politics, and it won’t be what you think

**Source: Center for the Health Professions, 2003.**

## Demography - Distribution

**Source: ****US Census Bureau, Population and Change, April 2001.**

**10 largest states have 54% of population. 10 smallest have less than 3%.**

## Epidemiology

**Epidemiology**

**Source: National Center for Health Statistics, 1993. Hyattsville, MD: Public Health Service, 1994. US Bureau of the Census, Historical Statistics of the US , Colonial Times to 1970, Washington DC, 1975.**

***A Generation Added in a Century***

## Epidemiology

**Epidemiology**

**SOURCE: Health US, 2003, USHHS, CDC,NCHCS, October 2003,  56.**

## Trend: Epidemiology

**Trend: Epidemiology**

- Issues
- Dominantly chronic
- Expensively acute
- Bipolar patterns of disease and health
- Less and less to do with health care
- Compression of morbidity

**Source: Center for the Health Professions, 2003.**

## Economic Disparity

**SOURCE: Congressional Budget Office, Center on Budget and Policy Priorities, September 23, 2003.**

**Economic Disparity**

**8.7%**

**68.3%**

**24.1%**

**15.1%**

**13.3%**

**% Change**

## Cost

**SOURCE: Health US, 2003, USHHS, CDC,NCHCS, October 2003,  113.**

**Cost**

**All Items**

**Health Care**

## Economic Disparity

**Economic Disparity**

- Issues
- Larger and larger number cannot afford health care
- Incumbents in health care become wealthier
- Health policy and markets driven to serve those that have, rather than need
- Impact back on patterns of health and outcomes

**Source: Center for the Health Professions, 2003.**

## Globalization

**SOURCE: “OECD Health Data 98: A Comparative Analysis of Twenty-Nine Countries.”  Paris: Organization of **
**Economic Cooperation and Development, 1998. Health US, 2003, USHHS, CDC, NCHCS, October 2003,  14.**
** **

**Percent GDP Health Care, 1960, ‘90, ‘97, 2000**

**Cost**

**Globalization**

## Globalization

**Globalization**

**Source: Center for the Health Professions, 2003.**

- Issues
- Employment and coverage shrinking
- Loss of traditional manufacturing job base
- Health workforce and work globalized
- Competitiveness with other service economies

## Technology

**Technology**

- Imaging
- Transplant
- Open heart
- Lung reduction

**Source: Center for Disease Control, *****Health US.***

_**Increase cost**_

_**Decrease cost**_

- Statin drugs
- Protease inhibitors
- Photodynamic therapy
- Amino bisphosphonate drugs

**Next generation of technology promises to reduce cost, move care to ambulatory settings, and improve outcomes.**

**Notes:**
Downs, JR, Clearfield M, Weis, S, Whiney E, Shaprio, DR, Beere, PA, Langendorfer A, Stein EA, Kruyer W, Gotto AM, Primary Prevnetionof Acute Coronary Events with Lovastation in Men and Women with Average Cholesteril Levels, JAMA 279:20 (May 27, 1998): 1615-1622.

## Technology ― Biotech

- U.S. owns 85% of intellectual property in biotechnology
- Only “industrial policy” followed consistently by both political parties
- Consumer demand and expectation growing
- Morph from biotech to care management technology

**Over 1,300 New Biotech Companies**
**Over 200,000 Jobs**

**How the Market Is Betting:**
**Market Capitalization **
**Biotech, pharmaceuticals, equipment = $1,300B**
**Rest of health care = $169B**

## Knowledge Business

- 33 million admissions
- 4.8 billion claims
- 505 million outpatient visits
- 1.7 billion prescriptions filled

**Healthcare Infirmities, December 1995, p15.**

**MCW, March 30, 1998, **

**Technology ****―**** IT**

****** ****Information**

## Technology ― IT

**Technology ****―**** IT**

**Source: Center for the Health Professions, 2003.**

- Issues
- Capitalization
- Driving value and consumer purchase
- Grafting expensive technology on top or rotten process
- Privacy
- Only way to aggregate value of population, behavior, environment, and genome

**Cost**
**Consumer satisfaction**
**Quality**

**From ****Supply Based**** to ****Demand Driven**

**Demand**

**Market-Driven Health**

** ****Values**

## Market Pressures

**Market Pressures**

- How to balance the tradition of individualism with the needs of:
- Population health
- System outcomes
- Broader social needs
- Desire to balance equity and choice

- Public understanding and expectation
- Legal framework
- Financing system
- Provider expectations
- Funded and deployed public system

**New challenge:**

**Changes needed:**

## Consumer

- Issues
- Wants choice ....*but at what price*?
- Increasingly willing to buy value... *quality, access, and cost*
- Needs are more segmented than care systems acknowledge... *build it and they will come*
- Inevitable exposure to more costs ... *will look for help to address *

## Part II.A Glance at Three Challenges

- Continued disequilibrium in health care
- The war for talent
- Unimaginative scopes of practice and   professional models

## Continued Disequilibrium in Health Care

## Continued Disequilibrium in Health Care

- Source: HHS, **CMS, www.cms.hhs.gov/statistics/nhe/default.asp**

## Continued Disequilibrium in Health Care

- Source: **OECD, Health Reports, 2001.**

## Continued Disequilibrium in Health Care

**Continued Disequilibrium in Health Care**

**Source: CDC, NCHS, Health United States, 2003, p331.**

## War for Talent

## How Did This Emerge?

**Past**
- Constantly expanding health system
- Agreement on mission and structure
- Clear and shared patterns of action
- Little accountability ― cost or quality
- Benefits of stability

**Transition from simple and independent to complex and highly interdependent**

## What is driving the issue?

- Stressed care delivery system and institutions
- Tighter resources
- Lack of direction
- Greater demands
- Technology
- Quality
- Job cuts
- Uncertainty
- Inability to adapt and change rapidly
- Half-born revolution

## What is driving the issue?

- Changing nature of work
- Faster
- Flatter
- Flexible

_**Trends**_
**Market economy**
**Technology**
**Globalization**
**Changing values**

## What is driving the issue?

- Changing demographics
- Race/ethnicity
- Aging population
- New values
- Women in labor market
- Gen-X workers

## New Values

- Next Generation
- Worker Desires
- Service oriented
- Anti-institutional
- Not hierarchical
- Flexible, change welcoming
- Diversity
- Technology
- New skills
- Community of work

- Hospital Image
- Staff is on strike, laid-off, or “angels of mercy”
- Large, cold, unresponsive institutions
- Work is stressful, highly structured, and un-fun
- Tied to a professional career, not open to change

## Unimaginativescopes of practiceand professional modelsare absolutely crippling!!!

## Beware Professional Interests:

- Policy history is guided by the interests of individual professions
- Population health concerns are secondary
- Partnerships are accepted reluctantly
- Guild mentality pervades everything
- The future of health care should NOT be determined by internecine struggles
- Most are subject to the same demographic, social, and economic pressures

## Environment

**Professions (Science)**
- Advances society by application of knowledge
- Seeks exclusive control of system
- Can become myopic and reductionist
- Can become self-interested
- Many are reactionary

**Community (Consumers)**
- Seeks publicly defined social outcomes
- Values consumer satisfaction
- Seeks to balance cost of care with real and opportunity costs
- Values informed but autonomous decision making

## Environment (cont.)

**Markets (Profit)**
- Allocate resources efficiently if not brutally
- Driven by potential profits, entrepreneurial zeal
- Considerable market failure
- May generate unpalatable externalities
- Effective in many social enterprises, but suspect in health care

**Policy (Cost)**
- Corrects market failure
- Focuses on cost reduction
- Seeks to distribute justice by expanding care
- Uses expert knowledge, run through a political ringer
- Slow and reductionist

## Transition Dynamics in Health CareCan our professional models survive?

**Transition Dynamics in Health Care****Can our professional models survive?**

**Cost unaware ----------------------****	****Cost accountable**
**Technologically driven**** ****----------****	****Humanely balanced**
**Institution based ------------------****	****Community focused**
**Professional ------------------------****	****Managerial**
**Individual --------------------------****	****Population**
**Acute --------------------------------****	****Chronic**
**Treatment --------------------------****	****Management/prevention**
**Individual provider --------------****	****Team **
**Competition -----------------------****	****Cooperation**
**Disaggregated ----------------------****	****Integrated**

**Source: Pew Health Professions Commission, 1991,1993.**

## We Need to Re-Examine Professional Models

- Scopes of practice
- Specialist – generalist relationship
- Organization of professional governance
- Financing of care services
- Training and specialization
- New skill acquisition
- Continuing competence

## Strategy #1: Be Bold Make sure what you do is...

- Transformational in nature, nothing else worth doing
- An agenda worth advancing
- Drawn from core competencies and assets
- Developed with clear and honest assessment of environment
- Given adequate time to develop, mature, and be realized
- Creating context for subsequent work

## Strategy #2: Assume Responsibility

- Make workforce a fundamental strategic issue
- Integrate solutions with communities served
- Mine what exists within present system
- Assume partnerships will be necessary and *create them!*

## Strategy #3:  Foster Innovation Act, Evaluate, Act Again

- Build programs that can experiment and learn
- Enlarge data collection, analysis, dissemination, BUT...
- Don’t wait for a complete picture to develop, it will never happen
- Experimentation is often much more efficient than research
- Remember to calculate the cost of nonperformance

## Strategy #4:  Be Jeffersonian

**Strategy #4:  Be Jeffersonian**

- The strength of the fabric of American culture is diversity and diffusion of power ― harness it
- Call attention to emerging local issues
- Convene diverse stakeholders to problem solve at local level
- Invest in leadership development at all levels and across professions and institutions

## Strategy #5: Create Opportunity

- Economic Disparity

- Perhaps the most important health
- workforce issue is...

- K-12 Education

- Perhaps the most important health issue is...

## Parting Shots

- Most change is PSYCHOLOGICAL
- Partnerships are ABSOLUTELY necessary
- Important that we NOT enfranchise the status quo

## Center for the Health Professions, University of California, San Francisco

**Center for the Health Professions,**** University of California,**** San Francisco**

***For more information, please contact:***
**Bram B. Briggance, Ph.D.**
**UCSF Center for the Health Professions**
**3333 California Street, Suite 410**
**San Francisco, CA 94118**
**415/476-8181**
**HTTP://FUTUREHEALTH.UCSF.EDU**
**bbb@itsa.ucsf.edu**

- We are here to help.