Health Care Workforce Financing, Education, and Training

Graduate medical education: Publicly funded subsidies for physicians’ graduate medical education (GME) in teaching hospitals come mainly from Medicare. Many states also support GME through Medicaid.

The Medicare Payment Advisory Commission has consistently found that Medicare’s GME subsidies do not result in a provider workforce that is prepared to provide high-quality, high-value, and affordable care. Medical residency programs are primarily based in acute-care teaching hospitals where training time is focused on inpatient care. Yet, most of the medical conditions that practicing physicians have to deal with should be managed in nonhospital settings such as offices or clinics. In 2015, the Medicare Payment Advisory Commission (MedPAC) recommended that GME payments be performance-based to foster greater accountability for Medicare’s GME dollars. In addition to greater accountability, MedPAC recommended greater transparency to recognize Medicare’s significant investment in residency education and training.

Content of clinical education: Research indicates that a lack of communication between patients and clinicians about complementary and integrative medicine can be risky. When a clinician is unaware of a patient’s use, dangerous and even life-threatening interactions between conventional medicine and complementary and integrative medicine can occur. One reason for this communication gap is that many clinicians do not ask about possible complementary and integrative medicine use as they have limited knowledge of such therapies. Clinicians with proper training can better advise their patients to make safe and appropriate choices about it (see also Quality and Safety in Health Care—Medical Research).

Nursing education: To continue to improve health care for all Americans, we need to increase the numbers of highly trained nurses and the proportion of nurses who attain these levels. Nurses need to be educated and empowered to lead change and advance health care efforts. A bachelor of science in nursing education helps nurses master the complexities of care and advanced technology, enhancing clinical care in the community and increasing their leadership on acute-care teams.

The 2008 report, Retooling for an Aging America: Building the Health Care Workforce, by the Institute of Medicine or IOM—now known as the National Academy of Medicine—should be heeded and its recommendations implemented. This study underscored the need for more medical and nursing educators and increased federal funding for such faculty positions. The findings and major recommendations of the IOM’s October 2010 report, The Future of Nursing: Leading Change, Advancing Health should be similarly followed. The report provided a blueprint for action to develop a nursing workforce prepared to deliver patient-centered care in the 21st century. The IOM emphasized that nurses are essential to providing higher-quality care, both as leaders and as clinicians. It also notes that any effort to improve the system requires their continued, comprehensive contributions.

Bachelor of science in nursing and higher degrees prepare nurses for a rapidly evolving health care system by increasing their knowledge and expertise in health policy, health care financing, community and public health, leadership, quality improvement, and systems thinking.

The Affordable Care Act-mandated Graduate Nurse Education Demonstration supports training of Advance Practice Registered Nurses in five states and is administered by the Centers for Medicare & Medicaid Services. This would increase access to primary care and expand the number of health professionals who are skilled in geriatrics.

Teamwork and diversity: In addition to having the right number and mix of providers, all providers should have the skills needed to provide high-quality, efficient care to a diverse aging population, including the ability to function effectively in teams. The IOM, in its 2012 report Core Principles & Values of Effective Team-Based Health Care, cited a high-performing team as “an essential tool for constructing a more patient-centered, coordinated, and effective health care delivery system.”

Furthermore, as our society becomes more culturally and ethnically diverse, providers should be skilled in providing care to a diverse range of patients. Patients from different cultures and ethnic groups bring with them traditions and sensitivities that affect how they interact with the health care system. In general, providers lack knowledge about the health care views of these patients. This impedes communication and decreases the likelihood of successful patient outcomes. In addition, a perceived lack of understanding and respect for varying traditions and sensitivities may discourage those from different cultures and ethnic groups from even seeking appropriate health care. The necessary skills for providing high-quality care to a diverse range of patients should be learned first during medical school/residency, nursing school, and other professional education and training sites. Learning should continue throughout one’s career. Responsibility for ensuring that providers have the necessary training lies not only with medical or nursing schools but also with state licensing agencies, provider boards, and other professional organizations.

Past efforts to bring more people from racial and ethnic groups that have experienced discrimination into the health workforce have had limited success. The Association of American Medical Colleges has long worked to increase the number of individuals in medical school from underrepresented, historically disadvantaged groups. Despite these efforts, there has been little growth in the number of ethnically diverse medical school graduates. Mentorship programs for at-risk students have been a successful strategy to increase graduation rates and test scores.

Lack of diversity is also a challenge for the nursing profession. A 2013 survey conducted by the National Council of State Boards of Nursing and the Forum of State Nursing Workforce Centers found nurses from racial and ethnic groups that have experienced discrimination represent 19 percent of the registered nurse workforce. The survey found that 6 percent of nurses are African American, 6 percent are Asian American, 1 percent are Alaskan Native or Native American, and 3 percent are Hispanic. The survey also found that men represent 7 percent of all nurses. However, a 2014 survey by the American Association of Colleges of Nursing found that representation from racial and ethnic groups that have experienced discrimination is improving among nursing students: members of such groups now constitute 35 percent of students in Bachelor of Science nursing programs and 37 percent of master’s students (see also Long-Term Services and Supports).