the health care workforce: key trends, challenges, and strategies bram b. briggance, ph.d. ucsf...
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The Health Care Workforce: The Health Care Workforce: Key Trends, Challenges, and Key Trends, Challenges, and Strategies Strategies
Bram B. Briggance, Ph.D.UCSF Center for the Health Professions
Briggance # 2
Why Workforce Reform Is Cardinal
60-70% of health care is labor costsBig part of any employment sector10.5% of U.S. workforce (14,653,661) It limits access, spurs cost increases, and
directly affects qualityCrisis is looming for health workforce, but
it has more to do with lack of innovation, than with shortage of workers
Briggance # 3
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
Briggance # 4
Demography ― AgingAging Population
Percentage of population 65-84 years of age
4 57
9 1011
14
17
0
5
10
15
20
1900 1920 1940 1960 1980 2000 2020 2040
Per
cen
tag
e
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
Briggance # 5
Demography ― Aging
IssuesImpact on demand for health careRising cost of careAdequate workforceIntergenerational equityUneven across the nation
Source: Center for the Health Professions, 2003.
Briggance # 6
SOURCE: CA Dept of Finance
Demography ― Diversity
From a majority culture...
To diversity...
To multicultural.
0
10
20
30
40
50
60
70
80
Perc
entag
e
White Black Hispanic Asian/PI Am Indian
Percentage Ethnicity of U.S. Population, 95, 05, 25
199520052025
Briggance # 7
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.
Briggance # 8
Demography - Distribution
Source: US Census Bureau, Population and Change, April 2001.
10 largest states have
54% of population. 10 smallest have less than 3%.
Briggance # 9
EpidemiologyU.S. Life Expectancy at Birth by Gender, 1900-90
5548
807977757371
6562
52
74727067676661
58
48
54
46
30
50
70
90
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
Yea
rs
WomenMen
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
Briggance # 10
30
32
34
36
38
40
Per
cent
1997 1999 2000 2001
Limitation of Activity Caused by Chronic Condition, >65
Epidemiology
SOURCE: Health US, 2003, USHHS, CDC,NCHCS, October 2003, 56.
Briggance # 11
Trend: Epidemiology
IssuesDominantly chronicExpensively acuteBipolar patterns of disease and healthLess and less to do with health careCompression of morbidity
Source: Center for the Health Professions, 2003.
Briggance # 12
SOURCE: Congressional Budget Office, Center on Budget and Policy Priorities, September 23, 2003.
Economic Disparity
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
Ave
rage
Dol
lars
Lowest Second Middle Fourth Highest
Average After Tax Income by Income Group
(in 2000 dollars)
1979
2000
8.7%8.7%
68.3%68.3%
24.1%24.1%15.1%15.1%
13.3%13.3%
% Change
% Change
Briggance # 13
Consumer Price Index (CPI) and CPI Health Care
0
100
200
300
1960 1970 1980 1990 2002
CP
I
SOURCE: Health US, 2003, USHHS, CDC,NCHCS, October 2003, 113.
Cost
All Items
All Items
Health
Care
Health
Care
Briggance # 14
Economic Disparity
IssuesLarger and larger number cannot afford
health careIncumbents in health care become wealthierHealth policy and markets driven to serve
those that have, rather than needImpact back on patterns of health and
outcomesSource: Center for the Health Professions, 2003.
Briggance # 15
3.93.0
4.8 4.25.5 5.26.0 6.0
8.7 8.9 9.2
12.6
6.7 7.3
10.4 9.6 9
13.5
7.3 7.8
10.69.5 9.1
13.3
0.00
4.00
8.00
12.00
16.00
U.K. JAPAN GERMANY FRANCE CANADA U.S.
PERC
ENT
60 90 97 2000
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, 2000CostCost
Globalization
Briggance # 16
Globalization
Source: Center for the Health Professions, 2003.
IssuesEmployment and coverage shrinkingLoss of traditional manufacturing job baseHealth workforce and work globalizedCompetitiveness with other service
economies
Briggance # 17
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.
Next generation of technology promises to reduce cost, move care to ambulatory settings, and improve outcomes.
Briggance # 18
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 CompaniesOver 200,000 Jobs
How the Market Is Betting:Market Capitalization Biotech, pharmaceuticals,
equipment = $1,300B Rest of health care = $169B
Briggance # 19
Knowledge BusinessKnowledge Business
33 million admissions 4.8 billion claims 505 million outpatient
visits 1.7 billion prescriptions
filledHealthcare Infirmities, December 1995, p15.
3 2.9
2
1.7
1
0
0.5
1
1.5
2
2.5
3
Well
point
Found
ation
United
Pacifi
care
Hum
ana
Percent of Premium Rev. Spent on IT, 1997
MCW, March 30, 1998,
Technology ― IT
Information
Briggance # 20
Technology ― IT
Source: Center for the Health Professions, 2003.
IssuesCapitalizationDriving value and consumer purchaseGrafting expensive technology on top or
rotten processPrivacyOnly way to aggregate value of population,
behavior, environment, and genome
Briggance # 21
• Cost
• Consumer satisfaction
• Quality
From Supply Based to Demand DrivenFrom Supply Based to Demand Driven
Demand
Market-Driven Health
Values
Briggance # 22
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:New challenge: Changes needed:Changes needed:
Briggance # 23
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
Briggance # 24
Part II.A Glance at Three Challenges
Continued disequilibrium in health careThe war for talentUnimaginative scopes of practice and
professional models
Briggance # 25
Continued Disequilibrium in Health Care
CostCost• Total system costs are
a huge burden
VariationVariation• Enormous range in
definition of quality
DuplicationDuplication • Substitutable inputs
CapacityCapacity• Over/or undersupply
of care providers, hospitals, insurers.
• +15% uninsuredAccessAccess
Briggance # 26
Continued Disequilibrium in Health Care
0
5
10
15
20
Per
cent
1980 1999 2001
U.S. Annual Percent Growth in Expenditures by Input
Hospital MD DrugSource: HHS, CMS, www.cms.hhs.gov/statistics/nhe/default.asp
Briggance # 27
Continued Disequilibrium in Health Care
Spending on Physicians and Drugs, 1999
184.0
375.0
237.0298.0
761.0
218.0289.0 337.0
258.0344.0
0
200
400
600
800
U.K. GERMANY FRANCE CANADA U.S.PE
R C
AP
ITA
DO
LL
AR
S
MD Drug
Source: OECD, Health Reports, 2001.
Briggance # 28
Continued Disequilibrium in Health Care
14.315.3 15.9
17.4 16.5 16.1 16.8 16.2
02468
1012141618
Per
cent
age
1984 1989 1995 1997 1998 1999 2000 2001
Percent Without Health Insurance, 1987 - 2001
Source: CDC, NCHS, Health United States, 2003, p331.
Briggance # 29
War for Talent
Health GDP and Hypothetical Worker Supply
4
10
35 35
45.6
5.5
9.7
11.512.4
14
5
7
9
11
13
15
1960 1970 1980 1990 2000
Per
Cap
ita E
xpen
ditu
res,
U
.S. $
05101520253035404550
Ove
r or
Und
ersu
pply
of
Wor
kers
Workers Expenditures
Briggance # 30
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
Briggance # 31
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
Briggance # 32
What is driving the issue?
Changing nature of work Faster Flatter Flexible
Trends
• Market economy
• Technology
• Globalization
• Changing values
Briggance # 33
What is driving the issue?
Changing demographics Race/ethnicity Aging population
New values Women in labor market Gen-X workers
Briggance # 34
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
Briggance # 35
Unimaginativescopes of practice
and professional modelsare
absolutely crippling!!!
Briggance # 36
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
Briggance # 37
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
Briggance # 38
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
Briggance # 39
Transition Dynamics in Health CareCan 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 ---------------------- IntegratedSource: Pew Health Professions Commission, 1991,1993.
Briggance # 40
We Need to Re-Examine Professional Models
Scopes of practiceSpecialist – generalist relationshipOrganization of professional governanceFinancing of care servicesTraining and specializationNew skill acquisitionContinuing competence
Briggance # 41
Strategy #1: Be Bold Make sure what you do is…
Transformational in nature, nothing else worth doing
An agenda worth advancingDrawn from core competencies and assetsDeveloped with clear and honest
assessment of environment Given adequate time to develop, mature,
and be realizedCreating context for subsequent work
Briggance # 42
Strategy #2: Assume Responsibility
Make workforce a fundamental strategic issue
Integrate solutions with communities servedMine what exists within present systemAssume partnerships will be necessary and
create them!
Briggance # 43
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
Briggance # 44
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
Briggance # 45
Strategy #5: Create Opportunity
Economic DisparityPerhaps the most important health
workforce issue is…
K-12 Education
Perhaps the most important health issue is…
Briggance # 46
Parting Shots
Most change is PSYCHOLOGICAL Partnerships are ABSOLUTELY necessaryImportant that we NOT enfranchise the
status quo
Center for the Health Professions,Center for the Health Professions, University of California, University of California,
San Francisco San Francisco
For more information, please contact:For more information, please contact:
Bram B. Briggance, Ph.D.Bram B. Briggance, Ph.D.UCSF Center for the Health ProfessionsUCSF Center for the Health Professions3333 California Street, Suite 4103333 California Street, Suite 410San Francisco, CA 94118San Francisco, CA 94118415/476-8181415/476-8181
HTTP://FUTUREHEALTH.UCSF.EDUHTTP://[email protected]@itsa.ucsf.edu
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