15c TACKLING WORKFORCE CONSTRAINTS…
FOR DIGNIFIED, PERSON-CENTERED CARE
AMIDST DEMOGRAPHIC CHANGE
THE CHALLENGE
Wealthy countries are aging rapidly, driving higher usage of health
services. Most members countries in the Organisation for Economic Co-operation and
Development (OECD) have expanded medical education to proactively address growing
demand, rapidly expanding their health workforce over the last two decades. Nonetheless,
their health systems are struggling to direct newly trained physicians and nurses to frontline
specialties—general practice, family medicine, and geriatrics—where they are needed most.
Exacerbating the challenge, demographic change is happening in a context where lower pay
and perceived lack of prestige deter entry into primary care specialties, creating chronic
physician shortages on the frontline. To respond to demographic transformation and
longstanding primary care deficits, mature health systems will need to incentivize entry into
frontline specialties and better prioritize physicians’ scarce time.
THE HEALTH WORKFORCE IS EXPANDING,
BUT PRIMARY CARE REMAINS NEGLECTED
Since at least the 1980s, population ageing has progressively increased the share of the
population over age 60 in OECD countries. By 2050, people aged 60 and over will comprise
40% or more of the population in several large wealthy countries, including Japan, Spain,
South Korea, and Italy.i Elderly populations suffer disproportionately from disabilities, chronic
health conditions, and co-morbidities, placing greater demands on health workforces. Most
OECD countries have rapidly expanded their health workforces in preparation for future
demand; OECD countries increased the proportion of physicians per 1,000 people from 2.7 in
2000 to 3.3. in 2013, and nurses from 7.8 to 9.1 per 1,000 during the same period.ii
Nonetheless, generalists continue to decline as a share of all physicians, and in some
countries the number of geriatric trainees has stagnated.iii Further, day-to-day care for the
elderly and people with disabilities has historically been provided by unpaid family members,
often women.iv But with greater more women entering the paid workforce, aging populations
will require a larger cohort of home health care workers. Some countries, especially in
Southern and Eastern Europe, have not yet developed comprehensive strategies to build the
needed workforce for the long-term.v
Japan Trust Fund for
OCTOBER 2018 Scaling Up Nutrition
TACKLING WORKFORCE CONSTRAINTS…
FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE
Incentives Drive Medical Students to More Lucrative Specialties
When applying to residency programs, medical students face strong financial incentives to
By 2050, people avoid general practice or geriatrics and to choose more lucrative specialties instead. In the
aged 60 and over United States, doctor surveys show that primary care physicians earn more than $100,000
will comprise at per year less than specialists;vi in the United Kingdom physician salaries show more parity, but
40% or more of generalists still earn about 11% less than their specialist counterparts.vii Across the OECD,
growth in specialist salaries almost always outpaces growth in generalist pay.viii With
the population in
unfavorable incentives, primary care residency programs find it difficult to fill the open slots,
several large even when they expand available slots. As of 2014, U.S. internal medicine and family medicine
wealthy countries, programs filled under half of available fellowship positions—the lowest rate for any
placing greater specialties.ix Geriatric practitioners are particularly financially disadvantaged in the U.S. due to
demands on the the preponderance of Medicare enrollees in their practices with depressed reimbursement
health workforce rates.x Between 2000 and 2007 the number of first-year geriatric medicine fellowship
and requiring positions in the U.S. almost doubled, yet the number of filled fellowships stayed roughly the
same.xi
more home health
workers.
THE PATH FORWARD: TACKLING
WORKFORCE CONSTRAINTS
Improve Incentives for Physician Specialties in Frontline Care
Several incentive
Shortages in primary care doctors are well recognized, and many OECD countries have
approaches can be introduced initiatives to increase their rates of recruitment and training. However, generalists
used to attract continue to decline as a portion of physicians, with many fellowship slots remaining unfilled.
medical students The inadequacy of simple training expansion demands alternative approaches to attract
into general medical students to the field. Several incentive approaches can be used, including lower costs
practice including to obtain certification, subsidized medical education, or adjusted reimbursement rates from
lowering central payers to lower the salary differentials.
certification costs, In the United States, where medical school debts can be extremely high, loan forgiveness has
subsidizing been a popular approach with mixed results. The U.S. National Health Service Corps (NHSC)
education, and was first created in 1970 to address frontline shortages in rural and underserved areas. The
adjusting program offers loan forgiveness to primary care clinicians with at least 2–3 years of service in
underserved regions. NHSC has had some success in attracting physicians to underserved
reimbursement
areas but fails to fill all available program slots, in part because of competition from other loan
rates to reduce forgiveness programs without specialization or service requirements.xii In 2005, South
salary differentials. Carolina enacted legislation to create the first loan forgiveness program for trainees in
geriatric medicine; in its first year the program appeared to help attract more qualified
applicants to the fellowship program.xiii
Payers—particularly national health insurance programs—can also use reimbursement rates
as a lever to influence staffing levels and specialty choice. Though difficult to measure directly,
choice of entry into primary care appears closely related to anticipated income.xiv In the U.S.,
historical rates of preference for family medicine closely mirror anticipated income vis-à-vis a
specialist career path.xv This suggests that direct financial incentives can be a powerful means
to encourage entry into frontline specialties. Economic research has found an association
between higher Medicaid reimbursement rates and access to primary care,xvi while increases
OCTOBER 2018 2
TACKLING WORKFORCE CONSTRAINTS…
FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE
in Medicaid reimbursement rates have also been associated with better staffing levels at U.S.
nursing homes (see Spotlight).
Creative Strategies Can Build and Expand Cadres of In-Demand
Health Workers
New types of workers can provide long-term care in residential facilities or help in assisted
Telehealth, living situations. In the United States, nurse practitioners have played an important role in
including virtual providing geriatric care; these cadres can obtain initial certification and recertification with
home health care less time commitment and at lower cost than geriatricians.xvii A systematic review suggests
and guidance for that such substitutions can be effective, as nurse practitioners provide care that is equivalent
health workers, to and in some cases better than low-acuity care provided by physicians.xviii
can rationalize use International recruitment has also been a popular strategy for countries facing acute
of scarce physician workforce shortages, but smarter processes can increase the benefits of health worker
time. A Cochrane migration for all parties. A Global Skills Partnership (GSP)xix consists of a bilateral agreement in
which migrant-destination countries and migrant-origin countries share the benefits and
review found 50%
costs of skilled migration. Responding to a nursing shortage in Germany combined with a
of calls taken by
surplus of recent graduates in China, one pilot program aimed to train and place 150 Chinese
doctors or nurses nurses within German nursing homes up to 5 years. Before their migration, the nurses
could be handled received an 8-month intensive training course and language instruction to ease their entry
without a into the German health system and society.xx
subsequent
hospital visit. Prioritize and Rationalize the Use of Scarce Physician Time
Where physician shortages cannot be addressed in the immediate term, technological
solutions can help prioritize and rationalize the use of scarce physician time. Telehealth
involves the use of telecommunications and virtual technology to deliver health care outside
of traditional health care facilities.xxi It includes virtual home health care, where patients can
receive medical advice and guidance from their own homes, plus virtual guidance for health
workers in providing diagnosis, care, and referral of patients. Telehealth can connect health
care providers with mobility-constrained patients and offer more efficient routine care in non-
emergency situations, for example among patients with chronic conditions. Systematic
reviews find that proactive telephone support or case management over the phone can
improve clinical outcomes and reduce symptoms in people with heart disease, diabetes, or
asthma,xxii while regular phone calls from nurses can reduce hospital admissions and costs.xxiii
A Cochrane review similarly concluded that 50% of calls taken by doctors or nurses could be
handled over the phone without a subsequent hospital visit.xxiv
SPOTLIGHT
Global Skills Partnerships
► In a proposed Global Skills Partnership (GSP),xxv employers or governments in a migrant-
destination country cover the costs of training an incoming migrant in their country of
origin. Since the costs of training are lower in the country of origin, the sponsoring
employer or government then applies the savings to cross-subsidize training of a non-
migrant in the same country—helping build up the local health workforce in the
migrant-origin country. Employers recapture their investment through a subsequent
work commitment or post-migration repayment.
OCTOBER 2018 3
TACKLING WORKFORCE CONSTRAINTS…
FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE
No pure GSP has been applied in practice, but variations on the proposal have been
rolled out at small scale. In addition to case described above (Chinese nurse
placements in German nursing homes), in 2013 Germany developed a similar
agreement with Vietnam to train and place 100 care assistants for the elderly; a
second cohort of 100 students started their intensive group training in Germany in
August 2015.xxvi Given the small size of the Chinese and Vietnamese programs, the
initiatives have not been empirically evaluated. However, cost-benefit analysis of a
hypothetical GSP between the United Kingdom and Malawi suggests potentially
large savings even under conservative assumptions.xxvii
Medicaid Reimbursement Rates and Nursing Home Care Staffing
► Medicaid is the primary payer for long-term care in the U.S. and covers 6 in 10 nursing
home residents.xxviii Studies have identified a positive relationship between
reimbursement and staffing levels in nursing homes,xxix suggesting that increased
reimbursement rates can help attract human resources to areas of acute need. For
example, one analysis of Pennsylvania’s nursing home industry found that a universal
10% increase in Medicaid reimbursement rates was associated with an 8.8% increase in
the number of skilled nurses per resident.xxx Though the evidence is less robust, some
studies show a plausible connection between higher Medicaid reimbursement rates and
health outcomes. A 2004 study from 10 American metropolitan areas found that a 13%
increase in Medicaid reimbursement rates led to a 9% lower risk of hospitalization for
nursing home residents,xxxi while another study found that the change from a flat
reimbursement rate to a cost-based, facility-specific rate in California was associated with
improvements in the rates of pressure ulcers.xxxii
ENDNOTES
i United Nations, Department of Economic and Social Affairs, Population Division, “World
Population Ageing 2017 - Highlights” (United Nations, 2017),
http://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2017_Highlig
hts.pdf.
ii OECD, Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places (Paris:
OECD Health Policy Studies, 2016).
iii OECD.
iv Shereen Hussein and Jill Manthorpe, “An International Review of the Long-Term Care Workforce,”
Journal of Aging & Social Policy 17, no. 4 (November 1, 2005): 75–94,
https://doi.org/10.1300/J031v17n04_05; Robyn Stone and Mary F. Harahan, “Improving the Long-
Term Care Workforce Serving Older Adults,” Health Affairs 29, no. 1 (January 2010),
https://doi.org/10.1377/hlthaff.2009.0554.
v Hussein and Manthorpe, “An International Review of the Long-Term Care Workforce.”
vi Leslie Kane, “Medscape Physician Compensation Report 2018” (Medscape, April 11, 2018),
https://www.medscape.com/slideshow/2018-compensation-overview-6009667#2.
vii Tim Locke and Véronique Duquéroy, “UK Doctors’ Salary Report” (Medscape, October 3, 2018),
https://www.medscape.com/slideshow/uk-doctors-salary-report-6009730#14.
viii OECD, Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places.
ix David A. Faber, Shivam Joshi, and Mark H. Ebell, “US Residency Competitiveness, Future Salary,
and Burnout in Primary Care vs Specialty Fields,” JAMA Internal Medicine 176, no. 10 (October 1,
2016): 1561–63, https://doi.org/10.1001/jamainternmed.2016.4642.
OCTOBER 2018 4
TACKLING WORKFORCE CONSTRAINTS…
FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE
x Victor A. Hirth, G. Paul Eleazer, and Maureen Dever-Bumba, “A Step toward Solving the
Geriatrician Shortage,” The American Journal of Medicine 121, no. 3 (March 1, 2008): 247–51,
https://doi.org/10.1016/j.amjmed.2007.10.030.
xi Institute of Medicine of the National Academies of Sciences, Engineering and Medicine, Committee
on the Future Health Care Workforce for Older Americans, “The Professional Health Care
Workforce,” in Retooling for an Aging America: Building the Health Care Workforce (Washington,
DC: National Academies Press, 2008), https://www.ncbi.nlm.nih.gov/books/NBK215402/.
xii Douglas B. Kamerow, “Is the National Health Service Corps the Answer? (For Placing Family
Doctors in Underserved Areas),” The Journal of the American Board of Family Medicine 31, no. 4
(July 1, 2018): 499–500, https://doi.org/10.3122/jabfm.2018.04.180153; Meera Nagaraj, Megan
Coffman, and Andrew Bazemore, “30% of Recent Family Medicine Graduates Report Participation
in Loan Repayment Programs,” The Journal of the American Board of Family Medicine 31, no. 4
(July 1, 2018): 501–2, https://doi.org/10.3122/jabfm.2018.04.180002.
xiii Hirth, Eleazer, and Dever-Bumba, “A Step toward Solving the Geriatrician Shortage.”
xiv OECD, Health Workforce Policies in OECD Countries: Right Jobs, Right Skills, Right Places.
xv Council on Graduate Medical Education, “Advancing Primary Care” (Council of Graduate Medical
Education, December 2010),
https://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/twentiethreport.pdf.
xvi Diane Alexander and Molly Schnell, “Closing the Gap: The Impact of the Medicaid Primary Care
Rate Increase on Access and Health,” October 31, 2016, http://www.sole-jole.org/17681.pdf.
xvii Adam G. Golden, Michael A. Silverman, and S. Barry Issenberg, “Addressing the Shortage of
Geriatricians: What Medical Educators Can Learn From the Nurse Practitioner Training Model,”
Academic Medicine: Journal of the Association of American Medical Colleges 90, no. 9 (September
2015): 1236–40, https://doi.org/10.1097/ACM.0000000000000822.
xviii Miranda Laurant et al., “Nurses as Substitutes for Doctors in Primary Care,” Cochrane Database of
Systematic Reviews, no. 7 (2018), https://doi.org/10.1002/14651858.CD001271.pub3.
xix Michael Clemens, “Global Skill Partnerships: A Proposal for Technical Training in a Mobile World
(Brief)” (Center for Global Development, October 11, 2017),
https://www.cgdev.org/publication/global-skill-partnerships-proposal-technical-training-in-
mobile-world-brief.
xx Tobias Oelmaier, “Germany Looks to China for Nursing Support,” DW, October 17, 2012,
https://www.dw.com/en/germany-looks-to-china-for-nursing-support/a-16310640.
xxi World Health Organization, “Health and Sustainable Development: Telehealth,” WHO, 2018,
http://www.who.int/sustainable-development/health-sector/strategies/telehealth/en/.
xxii James Barlow et al., “A Systematic Review of the Benefits of Home Telecare for Frail Elderly People
and Those with Long-Term Conditions,” Journal of Telemedicine and Telecare 13, no. 4 (2007):
172–79, https://doi.org/10.1258/135763307780908058.
xxiii Rebecca Lake et al., “The Quality, Safety and Governance of Telephone Triage and Advice Services
– an Overview of Evidence from Systematic Reviews,” BMC Health Services Research 17, no. 1
(August 30, 2017): 614, https://doi.org/10.1186/s12913-017-2564-x.
xxiv Lake et al.
xxv Michael A. Clemens, “Global Skill Partnerships: A Proposal for Technical Training in a Mobile
World,” CGD Policy Paper (Washington, DC: Center for Global Development, December 2015),
http://www.izajolp.com/content/4/1/2.
xxvi giz, “Training Nurses from Viet Nam to Become Geriatric Nurses in Germany,” giz, 2014,
https://www.giz.de/en/worldwide/18715.html.
xxvii Michael Anderson, Caitlin McKee, and Theodore Talbot, “Investing UK Aid in a Global Skills
Partnership: Better Health at Home and Abroad,” CGD Policy Paper (Washington, DC: Center for
Global Development, June 2017), https://www.cgdev.org/sites/default/files/investing-uk-aid-
global-skills-partnership-better-health-home-and-abroad.pdf.
xxviii Kaiser Family Foundation, “Medicaid’s Role in Nursing Home Care” (Kaiser Family Foundation, June
20, 2017), https://www.kff.org/infographic/medicaids-role-in-nursing-home-care/.
xxix Orna Intrator and Vincent Mor, “Effect of State Medicaid Reimbursement Rates on
Hospitalizations from Nursing Homes,” Journal of the American Geriatrics Society 52, no. 3 (March
1, 2004): 393–98, https://doi.org/10.1111/j.1532-5415.2004.52111.x.
OCTOBER 2018 5
TACKLING WORKFORCE CONSTRAINTS…
FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE
xxx Martin B. Hackmann, “Incentivizing Better Quality of Care: The Role of Medicaid and Competition
in the Nursing Home Industry,” Working Paper (National Bureau of Economic Research, December
2017), https://doi.org/10.3386/w24133.
xxxi Intrator and Mor, “Effect of State Medicaid Reimbursement Rates on Hospitalizations from
Nursing Homes.”
xxxii Jingping Xing et al., “Medicaid Reimbursement and the Quality of Nursing Home Care: A Case
Study of Medi‐Cal Long‐Term Care Reimbursement Act of 2004 in California,” World Medical &
Health Policy 8, no. 3 (September 1, 2016): 329–43, https://doi.org/10.1002/wmh3.194.
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1561–63. https://doi.org/10.1001/jamainternmed.2016.4642.
GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit). “Training Nurses from Viet Nam to
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Golden, Adam G., Michael A. Silverman, and S. Barry Issenberg. “Addressing the Shortage of
Geriatricians: What Medical Educators Can Learn From the Nurse Practitioner Training Model.”
Academic Medicine: Journal of the Association of American Medical Colleges 90, no. 9 (September
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Nursing Home Industry.” Working Paper. National Bureau of Economic Research, December 2017.
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Hirth, Victor A., G. Paul Eleazer, and Maureen Dever-Bumba. “A Step toward Solving the Geriatrician
Shortage.” The American Journal of Medicine 121, no. 3 (March 1, 2008): 247–51.
https://doi.org/10.1016/j.amjmed.2007.10.030.
Hussein, Shereen, and Jill Manthorpe. “An International Review of the Long-Term Care Workforce.”
Journal of Aging & Social Policy 17, no. 4 (November 1, 2005): 75–94.
https://doi.org/10.1300/J031v17n04_05.
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FOR DIGNIFIED, PERSON-CENTERED CARE AMIDST DEMOGRAPHIC CHANGE
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OCTOBER 2018 7