Introduction to State Health Policy: A Seminar for New State Legislators

Slide Presentation by Bram B. Briggance, Ph.D.

On April 3, 2005, Bram B. Briggance made a presentation in a seminar entitled Introduction to State Health Policy.

This is the text version of Dr. Briggance's slide presentation. Select to access the PowerPoint® Slides (584 KB).

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

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

Slide 1

Why Workforce Reform Is Cardinal

• 60 to 70 percent of health care is labor costs.
• Big part of any employment sector.
• 10.5 percent 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.

Slide 2

Part 1: 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.

Slide 3

Demography: Aging

At the upper left, a box contains a rightward arrow pointing to the words Aging Population. Below is a bar graph titled Percentage of population 65 to 84 years of age. The x-axis represents years from 1900 to 2040 at 20-year intervals, and the y-axis represents percentages.

• The percentages are 4 in 1900, 5 in 1920, 7 in 1940, 9 in 1960, 10 in 1980, 11 in 2000, 14 in 2020, and 17 in 2040.
• At the right is a box that says Triple Witching:
  • Aging workforce.
  • Fewer new workers.
  • Care demands and needs of an aging population.
  • But the devil is in the details.

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

Slide 4

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

Slide 5

Demography: Diversity

At the left are three boxes saying:

• From a majority culture...;
• To diversity...;
• To multicultural.

At the right is a bar graph titled Percentage Ethnicity of U.S. Population, 95, 05, 25. The x-axis lists races, and the y-axis presents percentages.

• White shows about 74 percent in 1995, 69 percent in 2005, and 62 percent in 2025.
• Black shows about 12 percent in both 1995 and 2005 and 13 percent in 2025.
• Hispanic shows about 10 percent in 1995, 13 percent in 2005, and 18 percent in 2025.
• Asian and Pacific Islander shows about 3 percent in 1995, 4 percent in 2005, and 6 percent in 2025.
• American Indian shows about 1 percent for all three years.

Source: California Department of Finance

Slide 6

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.

Slide 7

Demography: Distribution

Taking up most of the slide is Figure 2: Percent Population Change, 1990 to 2000. Underneath the figure title is a parenthetical remark: For more information on confidentiality protection, non-sampling error and definitions, see http://www.census.gov/prod/cen2000/doc/pl94-171.pdf.

At the upper right is a map of the United States titled Percent change in total population from 1990 to 2000 by State. Arizona, Colorado, Georgia, Idaho, Nevada, and Utah had 25.0 to 66.3 percent population gains. Alaska, Arkansas, California, Florida, Hawaii, New Mexico, North Carolina, Oregon, South Carolina, Tennessee, Texas, Virginia, and Washington had 13.2 to 24.9 percent gains. The District of Columbia had a 5.7 percent loss. The rest of the States had 0.0 to 13.1 percent gains.

Taking up most of the figure is a map of the United States, including Puerto Rico, titled Percent change in total population from 1990 to 2000 by county. The counties are color coded for a 50.0 to 191.0 percent gain, a 25.0 to 49.9 percent gain, a 13.2 to 24.9 percent gain, a 0.0 to 13.1 percent gain, a 0.1 to 9.9 percent loss, or a 10.0 to 42.3 percent loss. To read this information in ASCII format go to: http://www.census.gov/population/cen2000/phc-t4/tab04.txt.

To the left of the figure is a box that says, 10 largest States have 54 percent of the population. Ten smallest have less than 3 percent.

Source: U.S. Census Bureau, Population and Change, April 2001.

Slide 8

Epidemiology

A line graph is titled U.S. Life Expectancy at Birth by Gender, 1900 to 90. The x-axis represents decades from 1900 to 2000, and the y-axis represents life expectancies. Precise values are written for each decade.

• A line titled Men shows life expectancies of 46 in 1900, 48 in 1910, 54 in 1920, 58 in 1930, 61 in 1940, 66 in 1950, 67 in 1960, 67 in 1970, 70 in 1980, 72 in 1990, and 74 in 2000.
• A line titled Women shows life expectancies of 48 in 1900, 52 in 1910, 55 in 1920, 62 in 1930, 65 in 1940, 71 in 1950, 73 in 1960, 75 in 1970, 77 in 1980, 79 in 1990, and 80 in 2000.
• Within the graph is a box that says, A Generation Added in a Century.

Sources: National Center for Health Statistics, 1993. Hyattsville, Maryland: Public Health Service, 1994. U.S. Bureau of the Census: Historical Statistics of the U.S., Colonial Times to 1970. Washington DC, 1975.

Slide 9

Epidemiology

A bar graph is titled Limitation of Activity Caused by Chronic Condition, more than 65. The x-axis represents given years, and the y-axis represents percentages. They are about 38.7 percent in 1997, 35.6 percent in 1999, 34.7 percent in 2000, and 34.5 percent in 2001.

Source: Health U.S., 2003, USHHS, CDC, NCHCS, October 2003, 56.

Slide 10

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

Slide 11

Economic Disparity

A bar graph is titled Average After-Tax Income by Income Group, in 2000 dollars. The x-axis represents income groups, and the y-axis represents average dollars. The bars come in pairs, labeled 1979 and 2000, with boxes overhead to indicate the percent change between those years.

• The lowest income group went from about 12,600 to 13,700 dollars, an 8.7 percent increase.
• The second income group went from about 25,600 to 29,000 dollars, a 13.3 percent increase.
• The middle income group went from about 36,400 to 41,900 dollars, a 15.1 percent increase.
• The fourth income group went from about 47,700 to 59,200 dollars, a 24.1 percent increase.
• The highest income group went from about 84,000 to 141,400 dollars, a 68.3 percent increase.

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

Slide 12

Cost

A line graph is titled Consumer Price Index, CPI, and CPI Health Care. The x-axis represents given years, and the y-axis represents CPIs.

• A line labeled Health Care shows CPIs of about 22.3 in 1960, 34 in 1970, 72 in 1980, 162 in 1990, and 285 in 2002.
• A line labeled All Items shows CPIs of about 29.6 in 1960, 38.8 in 1970, 82.4 in 1980, 130.7 in 1990, and 179.9 in 2002.

Source: Health U.S., 2003, USHHS, CDC, NCHCS, October 2003, 113.

Slide 13

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.

Slide 14

Globalization

A bar graph is titled Percent GDP Health Care, 1960, 90, 97, 2000. To the right and slightly upward of the title, a box reads Cost. The x-axis represents selected countries, and the y-axis represents percentages. Each country has four bars representing different years, all with their precise values written above.

• The United Kingdom shows 3.9 percent in 1960, 6.0 percent in 1990, 6.7 percent in 1997, and 7.3 percent in 2000.
• Japan shows 3.0 percent in 1960, 6.0 percent in 1990, 7.3 percent in 1997, and 7.8 percent in 2000.
• Germany shows 4.8 percent in 1960, 8.7 percent in 1990, 10.4 percent in 1997, and 10.6 percent in 2000.
• France shows 4.2 percent in 1960, 8.9 percent in 1990, 9.6 percent in 1997, and 9.5 percent in 2000.
• Canada shows 5.5 percent in 1960, 9.2 percent in 1990, 9 percent in 1997, and 9.1 percent in 2000.
• The United States shows 5.2 percent in 1960, 12.6 percent in 1990, 13.5 percent in 1997, and 13.3 percent in 2000.

Source: OECD Health Data 1998: A Comparative Analysis of Twenty-Nine Countries. Paris: Organization of Economic Cooperation and Development, 1998. Health U.S., 2003, USHHS, CDC, NCHCS, October 2003, 14.

Slide 15

Globalization

Issues

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

Slide 16

Technology

Next generation of technology promises to reduce costs, move care to ambulatory settings, and improve outcomes. Near the center of the slide is an equalized balance scale.

At the left is written: Increase cost:

• Imaging.
• Transplant.
• Open heart.
• Lung reduction.

At the right is written Decrease cost:

• Statin drugs.
• Protease inhibitors.
• Photodynamic therapy.
• Amino biphosphonate drugs.

Source: Center for Disease Control, Health U.S.

Slide 17

Technology: Biotech

• U.S. owns 85 percent of intellectual property in biotechnology.
• Only "industry policy" followed consistently by both parties.
• Consumer demand and expectation growing.
• Morph from biotech to care management technology.
• How the Market Is Betting: Market Capitalization.
• Biotech, pharmaceuticals, equipment equals 1300 billion dollars.
• Rest of health care equals 169 billion dollars.
• Over 1,300 new biotech companies; over 200,000 jobs.

Slide 18

Technology: IT

At the upper left is a box containing a rightward arrow left of the word Information. Below appears the words: Knowledge Business

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

Source: Healthcare Infirmities, December 1995, page 15.

At the right, a bar graph is titled Percent of Premium Revenue Spent on IT, 1997. The x-axis represents health care providers, and the y-axis represents percentages. Precise values are given above all bars.

• Wellpoint shows 3 percent.
• Foundation, 2.9 percent.
• United, 2 percent.
• Pacificare, 1.7 percent.
• Humana, 1 percent.

Source: MCW, March 30, 1998.

Slide 19

Technology: IT

• 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.

Source: Center for the Health Professions, 2003.

Slide 20

Market-Driven Health

At the upper left is a box containing a rightward arrow left of the word Values. Below is a box that says From Supply Based to Demand Driven. At the lower left is written Demand. To the right is a rightward arrow that gets slimmer going left to right. To the right of the arrow are three bullet points:

• Cost.
• Consumer satisfaction.
• Quality.

Slide 21

Market Pressures

• New challenge: How to balance the tradition of individualism with the needs of:
  • Population health.
  • System outcomes.
  • Broader social needs.
  • Desire to balance equity and choice.
• Changes needed:
  • Public understanding and expectation.
  • Legal framework.
  • Financing system.
  • Provider expectations.
  • Funded and deployed public system.

Slide 22

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.

Slide 23

Part 2: A Glance at Three Challenges

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

Slide 24

Continued Disequilibrium in Health Care

This slide features keywords on the left, corresponding illustrations in the middle, and corresponding bullet points on the right.

• Cost, illustrated by money coming out of a wallet: Total system costs are a huge burden.
• Variation, illustrated by a curling parchment with an official seal: Enormous range in definition of quality.
• Capacity, illustrated by multiple doctors and multiple buildings: Over or undersupply of care providers, hospitals, insurers.
• Duplication, illustrated by two doctors working near a hospital bed and a container marked RX: Substitutable inputs.
• Access, illustrated by a line of four people on a city street, three of them whispering to whoever is in front of them: plus 15 percent uninsured.

Slide 25

Continued Disequilibrium in Health Care

A bar graph is titled U.S. Annual Percent Growth in Expenditures by Input. The x-axis represents given years, and the y-axis represents percentages.

• A bar labeled Hospital shows about 14 percent in 1980, 4 percent in 1999, and 8 percent in 2001.
• A bar labeled MD-medical services-shows about 13 percent in 1980, 5 percent in 1999, and 9 percent in 2001.
• A bar labeled Drug shows about 8 percent in 1980, 20 percent in 1999, and 16 percent in 2001.

Source: HHS, CMS, www.cms.hhs.gov/statistics/hhe/default.asp

Slide 26

Continued Disequilibrium in Health Care

A bar graph is titled Spending on Physicians and Drugs, 1999. The x-axis represents selected countries, and the y-axis represents per capita dollars. Each country has one bar for MD and one for Drug, both with precise values written above.

• The UK spent 184 dollars on physicians and 218 on drugs per capita.
• Germany spent 375 dollars on physicians and 289 on drugs per capita.
• France spent 237 dollars on physicians and 337 on drugs per capita.
• Canada spent 298 dollars on physicians and 258 on drugs per capita.
• The United States spent 761 dollars on physicians and 344 on drugs per capita.

Source: OECD, Health Reports, 2001.

Slide 27

Continued Disequilibrium in Health Care

A bar graph is titled Percent without Health Insurance, 1987 to 2001. The x-axis represents given years, and the y-axis represents percentages. Precise values are written above the bars. They are 14.3 percent in 1984, 15.3 percent in 1989, 15.9 percent in 1995, 17.4 percent in 1997, 16.5 percent in 1998, 16.1 percent in 1999, 16.8 percent in 2000, and 16.2 percent in 2001.

Source: CDC, NCHS, Health United States, 2003, page 331.

Slide 28

War for Talent

A dual line graph is titled Health GDP and Hypothetical Worker Supply. The x-axis represents years from 1960 to 2000, one y-axis represents per capita expenditures in U.S. dollars, and the other y-axis represents over or undersupply of workers.

• A line labeled Workers has precise worker numbers written at ten-year intervals, while a line labeled Expenditures has precise expenditures written at the same intervals.
• The Workers line shows 5.5 in 1960, 10 in 1970, 35 in 1980, 45.6 in 1990, and 35 in 2000.
• The Expenditures line shows 4 in 1960, 9.7 in 1970, 11.5 in 1980, 12.4 in 1990, and 14 in 2000.

Slide 29

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.

Slide 30

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.

A man with a suitcase is shown puzzling over a large map.

Slide 31

What is driving the issue?

• Changing nature of work
  • Faster.
  • Flatter.
  • Flexible.
• Trends
  • Market economy.
  • Technology.
  • Globalization.
  • Changing values.

Slide 32

What is driving the issue?

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

A man with the sun behind him is shown clutching the side of his face as though in awe.

Slide 33

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.

Slide 34

Unimaginative scopes of practice and professional models are absolutely crippling!

Slide 35

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.

Slide 36

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.

In the upper right corner is a sketch of a man looking at a bomb with a burning fuse.

Slide 37

Environment, continued

• 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.

In the upper right corner is a sketch of a man carrying a large dollar sign.

Slide 38

Transition Dynamics in Health Care

Can our professional models survive?

• Cost unaware: Cost accountable.
• Technology driven: Humanely balanced.
• Institution based: Community focused.
• Professional: Managerial.
• Individual: Population.
• Acute: Chronic.
• Treatment: Management and prevention.
• Individual provider: Team.
• Competition: Cooperation.
• Disaggregated: Integrated.

Slide 39

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.

Slide 40

Strategy Number 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.

Slide 41

Strategy Number 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!

Slide 42

Strategy Number 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.

Slide 43

Strategy Number 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.

Slide 44

Strategy Number 5: Create Opportunity

• Perhaps the most important health issue is: Economic Disparity.
• Perhaps the most important health workforce issue is: K to 12 Education.

Slide 45

Parting Shots

• Most change is psychological.
• Partnerships are absolutely necessary.
• Important that we not enfranchise the status quo.

Slide 46

We are here to help.

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, California, 94118
415-476-8181
http://futurehealth.ucsf.edu
bbb@itsa.ucsf.edu

The upper left corner has the logo of the Center for the Health Professions

Current as of October 2005

Internet Citation:

The Health Care Workforce: Key Trends, Challenges, and Strategies. Text version of a slide presentation at Introduction to State Health Policy: A Seminar for New State Legislators. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/statepolicy/briggancetxt.htm

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