It’s been my contention for several years that workforce issues will ultimately displace concerns about revenue and finance as the number one focus of healthcare boards and managers. I think that time has come. Across the country, providers of care in small town and rural America face the growing challenge of finding enough staff to continue to grow while they offer care that measures up to the standards they must meet. Rural health systems are struggling to hire the doctors that they needed to meet their revenue projections. Their workforce challenges are quickly moving beyond being a theoretical concern for future revenue growth to being an issue that must be dealt with on a daily and weekly basis. Now they face the daily challenge of finding the nurses they need to adequately staff their patient care floors, ORs, ambulatory practices, and EWs.
A workforce problem is a challenge to quality, a threat to patient safety, a certain decrement to patient satisfaction, the origin of access issues, and an undermining reality to any attempt to improve efficiency. All these issues can be characterized as theoretical, or a challenge to be tackled by a creative chief of nursing, but what most certainly gets a board’s attention are the financial losses associated with increased labor costs with the threat of continuing losses. I sense that we have passed that moment with many rural healthcare systems when staffing shortages are just an annoyance. Now the workforce issues are a daily threat to performance and a matter of concern every time the board meets to review financial performance. Near where I live, a community hospital and the associated practices are experiencing substantial financial distress. I don’t know the exact origin of their difficulty, but it is quite likely that increasing staffing costs in the face of falling reimbursement is a major part of their problem. If we ignore a problem until we see its impact on a balance sheet, we are behind before we begin an earnest search for solution.
Let me provide the larger picture of the current state in many of our rural health systems. The explanation begins with the fact that despite the knowledge that we have been discussing the shift in reimbursement from volume to value for at least a decade, most organizations still build their budgets on surgical projections, projected admissions, and visit volumes. They have not really done much to prepare for the shift to value based reimbursement. When MACRA was passed and put into play, these systems chose the MIPS fee for service arm that put them into a zero sum competition with other systems for the size of their annual increases in reimbursement from Medicare. Medicare income is more than 50% of revenue for most systems. Facing the reality that with MIPS they will always in the future get increases that are likely to be smaller than the rise in their costs, they are forced to try to do even more volume to stay above water. To hit those growing numbers that compensate for their cost increases that are rising faster than their reimbursement rates, they need to hit projected growth numbers in their physician staffs while they cut programs like OB Gyn and pediatric services that are poorly reimbursed in comparison to their basic costs.
Many health systems that serve small towns and rural communities are faced with the double challenge of attracting professionals to their systems to first replace the physicians who are retiring, and secondly to replace those who no longer feel that the small town environment is for them. Turnover rates in some systems exceed 15% of physicians each year. Those slots from physician losses must be filled before the system can contemplate the growth that balances their falling revenues. Creative strategies to solve these workforce problems like loan repayment offers, expanded training programs, and using more nurse practitioners and physician assistants all seem plausible, and can be effective, but they simultaneously add to costs and take time to develop.
While the focus has been on finding and hiring physicians, a more acute problem has been evolving that is not a revenue problem. It is a cost issue which is of equal if not greater concern than a revenue problem. The shortage of physicians that can fill beds and do procedures that generate revenue is a problem, but that is not the whole story or even most of the source of the current financial pain that is evolving. The acute problem that is the source of the greatest challenge is finding and hiring the nurses that are needed everyday to staff existing activities. Like the “solutions” to the physician shortages, there are a variety of ways to solve the nurse staffing issues that challenge so many systems across the country. A system can offer attractive training options. They can “import” nurses from foreign sources. They can use Lean to redesign processes of care that will better utilize the nurses that they have. All of these solutions take time to develop and come at a cost. What happens in the interim is that hospitals and health systems pay agencies substantial fees for temporary nurses who are willing to come to their organizations for a few months at a time. They also pay other agencies to try to find nurses that they might hire permanently. While they develop strategies and search for solutions they pay increasingly large amounts of overtime pay on top of all their attempts to expand staff.
I have a question. What is the likelihood that all the systems in country will be able to find the physicians and the nurses they need to fill their staffs to allow them to continue to deliver care at a cost that will allow them to have a margin using the same approaches to hospital care and practice that we have used over the last fifty years since we launched Medicare and Medicaid into a world of commercial insurance in a fee for service environment? It is not going to be easy. Herbert Stein, the economist wisely said, “If it something can’t go on forever, it won’t.”
Care redesign is easier to say than to do, but people are working on the problem. Innovations will come. In the rural environment there is a growing use of telehealth. The eventual shift away from fee for service payment to value based payment based on population health considerations and risk contracts will provide funding sources for the development of programs of care that use professional resources in more efficient ways. All these things will gradually change how we deliver care. The ultimate challenge will be how do we maintain meaningful human connections to the people we serve as more and more of what we do is automated or done remotely.
We all have heard the phrase that “everyone should be working at the top of their license.” What does that really mean? For several years it has meant to me that there is substantial opportunity to more effectively bring doctors and nurses together with patients and families. Chronic disease care and management consumes huge personnel resources in the hospital and in the ambulatory practice. It has been estimated that more than 25% of hospital days are used for admissions that result from the failure to adequately manage the ambulatory sensitive issues of chronic disease. We tend to think about those unnecessary or “wasted” admissions in terms of dollars. In a fee for service system they are “revenue.” In a value based system they are a source of wasteful cost. As we think in terms of dollars we should imagine the human costs and losses associated with avoidable hospitalization. Do we imagine the risk from exposure to hospital acquired infections like c. diff that a patient who is the victim of a failure of chronic disease management encounters when hospitalized? What we rarely imagine is how many nurses could be alternatively deployed to more beneficial activities if we could only manage patients more effectively in the ambulatory practice.
For sometime now innovative practices have considered the use of Community Health Workers (CHWs) as a way of mitigating workforce issues with medical professionals. The NIH describes the potential benefit of using CHWs.
Community health workers (CHWs) are lay members of the community who work either for pay or as volunteers in association with the local health care system in both urban and rural environments. CHWs usually share ethnicity, language, socioeconomic status, and life experiences with the community members they serve. They have been identified by many titles, such as community health advisors, lay health advocates, promotoras, outreach educators, community health representatives, peer health promoters, and peer health educators. CHWs offer interpretation and translation services, provide culturally appropriate health education and information, help people get the care they need, give informal counseling and guidance on health behaviors, advocate for individual and community health needs, and provide some direct services such as first aid and blood pressure screening.
Since CHWs typically reside in the community they serve, they have the unique ability to bring information where it is needed most. They can reach community residents where they live, eat, play, work, and worship. CHWs are frontline agents of change, helping to reduce health disparities in underserved communities…
Among the many known outcomes of CHWs’ service are the following:
- Improved access to health care services.
- Increased health and screening.
- Better understanding between community members and the health and social service system.
- Enhanced communication between community members and health providers.
- Increased use of health care services.
- Improved adherence to health recommendations.
- Reduced need for emergency and specialty services.
Eight years ago (January 2011) Atul Gawande described the effective use of CHWs by Iora Health in his widely read New Yorker article, “The Hot Spotters: Can we lower medical costs by giving the neediest patients better care?” I described my own experience with Iora Health in a posting back in August 2016. There is now substantial literature documenting the effective use of CHWs in the management of chronic disease in populations that are challenged by the social determinants of health. Is there any good reason why we should not try to take advantage of this success with all patients who have chronic disease no matter what their resources might be?
Back in 2011 at Atrius Health, we were ramping up our population health and chronic disease management efforts in response to the Blue Cross Alternative Quality Contract and in expectation of ACO opportunities while Gawande was writing his “Hot Spotters” article. We had not used CHWs in direct patient care situations, but we were discovering that there were many very bright people in the community who were not traditional “healthcare professionals,” but who were very connected to the communities we served, and who had abilities and talents that we could use to support our efforts. I was a practitioner of “management by walking around” or as we say in Lean terms, “going to the gemba,” the place where things are happening. One my favorite activities was to walk around our sites to see the innovative approaches that were evolving and talk with our staff about their concerns. I liked seeing “management for daily improvement” in action. These notes that I write each week were a product of those activities. Every Friday I would write about what I had learned from those visits to the gemba. I imagined that I was spreading the good news of the efforts and accomplishments that I saw.
Visiting our Concord site was always a great source of enlightenment. Concord is an affluent community and not the first place you would look if your concern was improving the care of the underserved. On one trip I was visiting “the mission control room” and was talking with the woman who was busily updating the white board that was loaded with data about individual diabetic patients who needed close monitoring. As she explained her work I was impressed with her grasp of the important concepts in the management of diabetes. I asked her about her educational background and previous work experience. She responded that she was a graduate of the local high school, and that last year, before she we hired her, she was working at the Dunkin Donuts shop down the road. I was fascinated and asked for a more detailed description of what she was doing. She was calling patients and talking with them about their disease and its management. She was reminding them to get their labs done. She was getting them the appointments they needed for eye exams. She made sure to speak to them when they came in for an appointment. She was building relationships and creating easier connections for them to their doctors and nurses. She told me that she knew many of the patients from the community and could relate to their circumstances and concerns. She told me that she knew her work was important because there were several members of her family who had suffered some of the complications of uncontrolled diabetes.
After I left the site and was driving back to my office, I could not stop thinking about the “door” she had opened in my mind. She was proving in real time that there was a better way to practice if we were willing to open the door to exploring the use “non traditional” healthcare workers. In a time of professional shortages we could find a win-win by offering this bright young woman a career as a healthcare professional. I was a little conflicted because she was doing such a great job that I wanted her to continue. Her work with diabetics had convinced her to go back to school and continue her education. She was considering a career in nursing.
This week’s (May 23, 2019) New England Journal is not yet online at the time of this writing, but the postman has delivered my copy. There is a terrific article in the “Perspectives Section” written by Adrienne Lapidos Ph.D. and others at the University of Michigan entitled, “Realizing the Value of Community Health Workers–New Opportunities for Sustainable Financing.” In the article the authors review some of the literature that documents the success of CHWs doing a variety of patient facing activities, especially in chronic disease management. They write:
They [CHWs] help address underlying inequities in health care access and quality by participating in culturally congruent interventions, including outreach,advocacy, education, counseling, and linkages to social services… CHW-led interventions have been shown to be both effective and cost effective for managing certain chronic health conditions among vulnerable populations.
The benefit of CHWs seems to be established. What strikes me as sad are the barriers to taking full advantage of what CHWs have to offer. In a system of care that is funded by “alternative finance mechanisms” the savings and associated outcomes improvements that can be achieved using CHWs are attractive. In a fee for service system of payment the issue is whether or not the activities of CHWs will be reimbursed. That is the point of the article. It seems frustrating to realize that in an era where we are searching for ways to do more with limited professional resources, we are slow to recognize that once again fee for service volume based payment is a drag on innovation. The authors conclude by saying:
CHWs are an underused resource in a system that is actively seeking effective strategies for increasing the value of health care. Their potential lies in their ability to remedy inequities in health care access and quality by means of culturally congruent interventions and advocacy in their communities. New opportunities to sustainably finance CHW activities within current and future payment structures can help realize this potential. Stable funding of CHW programs could improve access to high value care for people facing barriers to engaging in such care and accelerate research to determine the most effective CHW practice models.
Opportunities for care improvement that circumvent or at least ameliorate our emerging workforce issues that further add to the cost of care are knocking on our door. Will we have the collective wisdom to open the door? Solutions to big problems require the courage to embrace change. It is depressing to think of our wasted opportunities since more effectively using CHWs are a change that we have spent over a decade considering. It’s good to remember that good people who could help us with what may be the greatest challenge to healthcare quality may be as close as the nearest Dunkin’ Donuts shop that is just down the street.
