National Workforce Policy Development
Posted on October 3, 2010 | No Comments
Strengthening and modernizing the health care workforce was a major goal of the Patient Protection and Affordable Care Act (PPACA). The health reform law contains dozens of provisions related to health care workforce issues, including national workforce policy development (what the law refers to as workforce “innovations”), increasing the supply of health care workers, education and training of the workforce, strengthening primary care, and other supports and improvements to the existing workforce. This Implementation Brief focuses on national workforce policy; future Briefs will focus on the other topics listed.
More than 800,000 physicians are currently in practice in the United States. This physician “density” amounts to 272 physicians per 100,000 people in the U.S., a number slightly below the Organization for Economic Cooperation and Development average of 320 per 100,000 (for comparison purposes, France and Germany have a density of 340 and 350 physicians, respectively, while Canada and the United Kingdom rank at 210 and 250 physicians per 100,000 people, respectively). Additionally, there are approximately 100,000 nurse practitioners and 70,000 physician assistants currently practicing in the U.S.
While experts disagree on whether the absolute number of physicians and allied health professionals in the U.S. is sufficient to address the country’s health care needs, there is considerable agreement on several significant problems with the healthcare workforce. Among other concerns: the distribution of physicians in the U.S. heavily favors metropolitan areas (which claim 2-5 times as many physicians as non-metropolitan areas); economically disadvantaged areas are significantly more likely to suffer from physician access problems; nearly two-thirds of U.S. physicians practice as specialists, with only 37% of practicing physicians working in primary care (family medicine, general internal medicine, and general pediatrics); and the number of medical students and residents interested in primary care has sharply declined over the past 15 years (with both the number of nationwide training positions in family medicine and the percentage of family medicine residency positions being selected by U.S. (as opposed to international) graduates continuing to fall).
Despite these problems—and the fact that funding for various health care workforce programs (e.g., primary health care, dentistry, nursing) flows from multiple federal agencies—there exists no single, national approach dedicated to analyzing, and making policy recommendations about, the health care workforce.
The health reform law made three major changes with respect to national workforce policy development:
- The law established a new National Health Care Workforce Commission to serve as a resource for federal and state governments, to encourage innovation, to identify barriers to improved coordination at the federal, state, and local levels, and to make recommendations to Congress and the Administration regarding relevant workforce priorities, goals, and policies.A total of 15 members must be named to the Commission by the Comptroller General by September 30, 2010 to serve staggered three-year terms and with at least one representative from each of the following categories:
- health care workforce or health care professionals;
- educational institutions (elementary or higher);
- third-party payers;
- individuals skilled in health care services and health economics research;
- representatives of consumers;
- labor unions; and
- state or local workforce investment boards.
- Additionally, Commission members should have various professional perspectives, broad geographic representation, and a balance of rural/urban/suburban/frontier perspectives. Specifically, the Commission will:
- review current and projected health care workforce supply and demand issues, including: workforce distribution, workforce education and training capacity, the education loan and grant programs in Titles VII and VIII of the Public Health Service Act, the implications of new and existing federal policies which affect the health care workforce, the workforce needs of special populations, and whether to create or revise national loan repayment programs and schedules. The Commission shall submit (by October 1 of each year, starting in 2011) a report to Congress and the Administration containing discussion and recommendations in these areas;
- submit (by April 1st of each year, starting in 2011) to Congress and the Administration an annual report that reviews and makes recommendations about certain “high priority” areas, including: integrated health care workforce planning; the nature, scopes of practice, and demands for health care workers in the enhanced information technology and management workplace; how to align Medicare and Medicaid graduate medical education policies with national workforce goals; eliminating barriers to entering and staying in primary care; and education and training capacity, demands, and integration with the delivery system of the nursing, oral health care, mental and behavioral health care, allied health, public health, and emergency medical service workforces;
- study effective mechanisms for financing education and training for careers in health care, including public health and allied health;
- make recommendations to Congress on how to improve the safety and health of the health care workforce in the workplace; and
- review the implementation and performance of the State Health Care Workforce Development Grant program (see #3 below).
- The law also created the National Center for Health Care Workforce Analysisto analyze and assess the nation’s health care workforce in conjunction the National Health Care Workforce Commission, state and local agencies, and other relevant organizations. This new center replaces the existing national center for collecting and analyzing health workforce information and will be established by the Secretary of the federal Department of Health and Human Services (HHS). Specifically, the new Center will:
- develop comprehensive information describing and analyzing the health workforce and workforce-related issues;
- create a uniform health professions data reporting system;
- conduct annual evaluations of and develop performance measures for relevant programs; and
- establish and maintain a national online registry of Title VII grants and a database for longitudinal performance data.
In addition to the National Center, the law established State and Regional Centers for Health Workforce Analysis for the purposes of “collecting, analyzing, and reporting data regarding programs . . . to the National Center and to the public” and “providing technical assistance to local and regional entities on the collection, analysis, and reporting of data.”
- Finally, the law established State Health Care Workforce Development Grants, a competitive program to enable “State partnerships to complete comprehensive planning and to carry out activities leading to coherent and comprehensive health care workforce development strategies at the State and local levels.”The program will be administered by the federal Health Resources and Services Administration (HRSA, part of HHS) in consultation with the above-mentioned Commission. The program includes both planning and implementation grants. Planning grantees shall:
- analyze state labor market information;
- identify current and projected high-demand health care sectors;
- identify existing federal, state, and private resources for health workforce recruitment, education, training, and retention;
- describe academic and health care industry skill standards;
- describe state secondary and postsecondary education and training policies;
- identify federal or state policies or rules to developing a coherent and comprehensive health care workforce strategy; and
- participate in the Administration’s evaluation and reporting activities.
- Implementation grantees shall, among other things:
- identify and convene regional leadership to discuss opportunities to engage in statewide workforce development planning;
- take steps to reduce federal, state, or local barriers to a comprehensive and coherent workforce strategy;
- develop and disseminate a preliminary statewide strategy;
- collect and assess data on the performance benchmarks selected for implementation activities; an
- participate in the Administration’s evaluation and reporting activities.
The new Commission will communicate and coordinate with the federal Departments of Health and Human Services, Labor, Veterans Affairs, Homeland Security, and Education. HRSA is the fiscal and administrative agent for the state grants program.
The health reform law does not provide specific direction to HHS regarding the administrative process used to implement the law. The agency therefore has the discretion to use a range of tools to implement the statute, such as publishing regulations in the Federal Register with a public notice and comment period, or using other types of approaches such as posted policy instructions, funding availability announcements (where applicable), official letters to affected entities (such as letters to state Medicaid agencies), and posted rulings and notices. Agency websites can be checked regularly for updates.
- Respective Responsibilities: The law indicates that the overall goal of the Commission is to provide comprehensive information to federal political leaders about how best to align federal resources with health care needs; that said, will the Commission and the Center have overlapping responsibilities? How will their respective work be divvied up, and will it be done in the most efficient way possible?
- Health Professions Reporting System: Through what mechanisms will the National Center create the uniform health professions data reporting system? Will the Center coordinate with state licensing databases? How will it guarantee participation? Will states/professionals be incentivized to participate?
- Performance Measures: What performance measures will be used to measure the success of workforce programs? How will these be coordinated with current HRSA monitoring and evaluation strategies?
- Grant Awards: What standards will be used in the awarding of state workforce grants? How will the state development grants be coordinated with the state/regional analysis centers and with the National Center and Commission?
- Appointment of Commission members: How will the Government Accountability Office (GAO) ensure fair representation on the Commission of the many health care workforce professions, while also getting the requisite expertise and limiting the political nature of the appointments?
- Commission Funding: The law requires appointment of the National Commission members by September 30, 2010, and the Commission’s reporting requirements begin in 2011–but because the law also requires that appropriations for the Commission must be requested by the Commission itself, how will the Commission begin its work without appropriated funding in place?
Recent Agency Action
On May 7, 2010, the GAO published in the Federal Register a “Notice on letters of nomination” for the 15 members to the National Health Care Workforce Commission. The Notice stated that letters of nomination and resumes should be submitted by June 30th, 2010 to ensure adequate opportunity for review and consideration of nominees prior to appointment of members.
Authorized Funding Levels
For the Commission: According to the law, “[t]he Commission shall submit requests for appropriations in the same manner as the Comptroller General of the United States submits requests for appropriations.” The law then authorizes to be appropriated such sums as may be necessary to carry out the work of the Commission.
For the National Center: $7.5 million per year is authorized through fiscal year 2014, plus another $4.5 million per year for state/regional centers through 2014. The law also authorizes “such sums as may be necessary” for longitudinal evaluations.
For the State Health Care Workforce Development Planning Grants: $8 million is authorized to be appropriated for fiscal 2010, and such sums as necessary for each subsequent year. For the State Health Care Workforce Development Implementation Grants, $150 million is authorized to be appropriated for fiscal 2010, and such sums as necessary for each subsequent year.
 Fitzhugh Mullan, “Workforce Issues in Health Care Reform: Assessing the Present and Preparing for the Future,” testimony before the U.S. Senate Finance Committee, March 12, 2009.
 See, e.g., id.
 § 5101(a).
 § 5101(d)(4).
 § 5103.
 § 5103(c)(1)(A).
 § 5103(c)(1)(B).
 § 5102.
 § 5102(a).
 § 5102(c)(5).
 § 5102(d)(6)(B).
 To read the Notice, go to: http://edocket.access.gpo.gov/2010/pdf/2010-10829.pdf.
 § 5101(h)(1).