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Health Affairs Explores Issues Facing Health Care Workforce in Era of Rapid Change


November articles examine how different providers can help meet demand for care


Bethesda, MD -- The November issue of Health Affairs traces how the US health care workforce can respond to the Affordable Care Act's expanded coverage and new models of care, as well as an aging population. A featured article addresses the specific crisis in mental health and addiction workforce development.


Don't overlook the aging population's implications for specialty care and primary care. A featured study by Timothy M. Dall of IHS Inc. and coauthors forecasts future demand for health care services and providers based on projected demographics and other predictive changes, including the expected effects of expanded health insurance coverage under the Affordable Care Act. The authors project that demand for adult primary care services will grow by roughly 14 percent between 2013 and 2015, and demand for certain specialty care services will grow even faster at a high of 31 percent growth for vascular surgery. Cardiology (20 percent) and neurological surgery, radiology, and general surgery (each 18 percent) round out the list of the top five. They caution that failure to address the inadequate number and inappropriate mix of specialty care providers will further contribute to long wait times, reduce access to care, and decrease patients' quality of life.


Diabetes patients in patient-centered medical homes are well served by nonphysicians and physicians alike. In this first study to compare the effectiveness of physician assistants (PA) and nurse practitioners (NP) roles to physician-only care for patients with chronic disease, Christine Everett of Duke University and coauthors found that patient outcomes were generally the same in thirteen comparisons. In four comparisons, PA and NP care was found to be superior; in three, the physician-only outcomes were higher. The authors used Medicare claims and electronic health record data from visits made to 32 internal medicine, family practice, and geriatric clinics in a Midwestern county and identified 2,576 Medicare patients with diabetes. They measured patient outcomes based on hemoglobin tests, glycemic control, and numbers of emergency department visits and hospitalizations. Results of the study support previous findings that PAs and NPs can perform a range of effective roles in primary care, yet they indicate that patient characteristics and other factors should inform precisely how these practitioners should be deployed. The authors recommend that system redesign policies allow for flexible approaches to team implementation that can maximize PA and NP roles on primary care teams.


Want to reduce health care costs? Let nurse practitioners practice independently in retail clinics. Joanne Spetz of the University of California, San Francisco, and coauthors analyzed the effects of NP-run retail clinics on costs of care across 27 states and found that compared to settings such as physician offices, urgent care clinics, and emergency departments with a per episode average cost of $704, retail clinics had a cost of $543 with no NP independence; $484 when NPs can practice independently; and $509 per episode when NPs can both practice and prescribe independently. The authors estimate an added potential savings of $810 million nationwide in 2014 if all states allowed NPs to practice independently. They refer to predictions of 5,000 retail clinics being in operation by 2015 and recommend that scope-of-practice laws permit NPs to operate to the fullest extent of their abilities to both improve access to care and decrease costs within the health care system.


The issues plaguing the mental health and substance abuse workforce won't get fixed without real leadership from the federal government. In this commentary, Michael A. Hoge of the Yale School of Medicine and coauthors summarize the substantial and growing body of evidence that the current mental health and substance abuse workforce is seriously inadequate with regard to the number of practitioners, lack of diversity in its composition, and overall preparation. The authors recognize that, with a growing number of older and ethnically diverse Americans who are at high risk for behavioral health disorders, combined with the sheer influx of the newly insured, the system is at a point of crisis. They call on the federal government to scale up and actually implement already identified "broad strategies and specific actions necessary" to grow and strengthen the mental health and substance abuse workforce to meet the challenges it faces now and in the future.


The November issue received support from the Robert Wood Johnson Foundation, Josiah Macy Jr. Foundation, Association of American Medical Colleges, American Association of Colleges of Nursing, American Osteopathic Association, American Association of Colleges of Osteopathic Medicine, American Association of Nurse Anesthetists, American Organization of Nurse Executives, American Nurses Association, American Nurses Credentialing Center, and American Association of Colleges of Pharmacy.

About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print, with additional Web First papers published periodically at The full text of each Health Affairs Web First paper is available free of charge to all website visitors for a one-week period following posting, after which it switches to pay-per-view for nonsubscribers. Web First papers are supported in part by a grant from The Commonwealth Fund. You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download our podcasts, including monthly Narrative Matters essays, on iTunes. Tap into Health Affairs content with the new iPad app.