7 Major Healthcare Workforce Changes not Caused by the PPACA

The storm of changes underway in healthcare is severely buffeting the healthcare workforce.

While the public debate about the healthcare transformation now underway focuses almost entirely on the Patient Protection and Affordable Care Act, the fact is that most of the current changes long predate the healthcare reform law. At the Healthcare Workforce Summit in Dallas, I led an expert panel examining industry trends with the greatest impact on the workforce. Of nine trends, seven began long before the PPACA:

1. Focus on cost control. Efforts to control costs were underway in the 1970s and then again in the early 1990s. The rise of HMOs was a response to escalating costs, and so were failed national healthcare reform efforts by Presidents Richard Nixon and Bill Clinton. The latest iteration is the PPACA, whose pay incentives for value instead of volume and new models of team-based care to contain costs have tremendous impact on the work lives of clinicians.

2. Rise of technology. Experiments with automating health records began in the 1950s. In 2004, Pres. George W. Bush launched a national electronic health record project. But the real boost came with the multibillion-dollar 2009 HITECH Act, which incentivized EHR adoption, launched prior to and separate from the PPACA. Workforce dissatisfaction with EHRs is high, and workforce engagement is a necessity for health IT adoption. But time may solve this problem: A recent survey showed that younger nurses are far more accepting of health IT than older nurses.

3. Consumer health movement. When baby boomers came of age, they initiated the consumer movement through demands for more choices, control and involvement, and this assertive attitude eventually encompassed healthcare. Today, these 'boomers' children expect even more immediacy, connectivity and transparency. And providers face increasing pressure to comply. In large part, it will be up to physicians, nurses and allied health professionals to give consumers what they want.  

4. Working at top of license. Scope-of-practice battles, mostly notably between physicians and nurse practitioners, are raging in all of the  states. To control costs, clinicians must provide the highest level of care their licenses allow, so we are not paying physicians to treat the common cold. This movement began in the 1960s, when nurse practitioners began providing primary care for underserved populations. Today, nonphysician practitioners have far greater involvement in patient care, and that trend will grow.

5. Growth of retail care. The first retail care clinic opened in 2000. Today, there are more than 1,500 and growing. They're becoming common fixtures at chain pharmacies, big box retailers and even grocery stores.  For the healthcare workforce, retail clinics represent a major cultural shift from hospitals and doctor offices, and they're often staffed by nurse practitioners and physician assistants, which keeps down costs and increases demand for these clinicians.

6. Physician employment. More than 60 percent of physicians are employed by health systems, up from only 25 percent a decade ago. Long before that, though, physicians began to be driven out of practices due to rising business expenses, managed care and declining reimbursements. Going from private practice to employment represents a major change in professional culture for physicians. The change affects healthcare management as well because research shows employed physicians work shorter hours and treat fewer patients.

7. Migration from inpatient to outpatient. Outpatient care has been rising for decades, driven by the fact that costs are less and revenue potential has been greater compared to inpatient care. Today, home healthcare is one of the fastest growing employment areas in the healthcare industry. One main reason is the aging of our population and the resulting increase in chronic disease, which can be more economically treated outside of hospitals. This shift from inpatient to outpatient and home health is resulting in a big increase in nonhospital healthcare workers who help manage chronic illnesses rather than treat acute conditions. It also means that hospital workers will be dealing with sicker patients who often have multiple conditions.

The PPACA didn't launch most of the changes underway in healthcare today. Instead, it's only the latest response to trends that have been going on for years or decades. And these trends have the greatest impact on the healthcare workforce, greater even than on the patient population itself.

Ralph Henderson is president of healthcare staffing at AMN Healthcare, an innovator in healthcare workforce solutions and staffing services. He has 25 years of managed services and strategic staffing experience, working with leading healthcare systems and Fortune 500 companies.

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