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 (MedPAC) 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 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 alternative medicine (CAM) can be risky. When a clinician is unaware of a patient’s CAM use, dangerous and even life-threatening interactions between conventional medicine and CAM can occur. One reason for this communication gap is that many clinicians do not ask about possible CAM 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 CAM (see also this chapter’s section on Quality, Safety, and Research—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.
AARP endorses the April 2008 report by the Institute of Medicine (IOM)—now known as the National Academy of Medicine—Retooling for an Aging America: Building the Health Care Workforce. This study underscores the need for more medical and nursing educators and increased federal funding for such faculty positions. AARP also endorses the findings and major recommendations of the IOM’s October 2010 report, The Future of Nursing: Leading Change, Advancing Health. The report provides a blueprint for action to develop a nursing workforce that is prepared to deliver patient-centered care in the 21st century. The IOM emphasizes 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, providers should be skilled in providing care to a diverse range of patients as our society becomes more culturally and ethnically diverse. 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, which 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 Chapter 8, Long-Term Services and Supports).
HEALTH CARE WORKFORCE FINANCING, EDUCATION, AND TRAINING: Policy
Graduate medical education (GME) program
All payers in both the public and private sectors should gradually begin to contribute financial support GME rather than it being the sole responsibility of Medicare.
This should occur gradually to allow the system to adjust.
Medicare’s support for GME should:
- be tied to specific goals for residency training: physicians skilled in providing high-quality, efficient care, who can function in interdisciplinary teams, accountable care organizations, and medical homes;
- have higher subsidies for primary care and specialties such as geriatrics that experience larger provider shortages, and for those programs most successful in training physicians willing to work in underserved areas, including rural communities and those with low incomes; and
- include reforms to Medicare payments for nursing education to substantially increase the number and diversity of graduate-educated nurses to help increase access to primary care in shortage areas, expand the number of expert chronic-care managers, and increase the number of nurses skilled in geriatrics.
The Department of Health and Human Services should establish standards for distributing GME funds that specify ambitious goals for practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice, including integration of community-based care with hospital care.
Congress should reduce Medicare’s current indirect medical education (IME) payments in favor of funding performance-based medical education subsidies. Only those programs that meet the new standards described above should receive IME funds.
Funding and availability of training for nurses
The federal and state governments should provide incentives through student loan forgiveness to encourage nurses with master’s and other advanced degrees to become faculty members.
States should supplement Title VIII nursing education funding to promote education progression and advancement and a more highly educated nursing workforce. Funding goals include:
- increasing the relatively small number of community colleges offering Bachelor of Science in Nursing (BSN) degrees;
- increasing enrollments in degree programs, from Associate Degrees to Master of Science in Nursing (MSN), in the nation’s universities;
- increasing the spread of partnerships between degree programs in nursing;
- increasing options for advanced degrees in nursing, including Doctorate in Nursing degrees; and
- increasing the number of accelerated BSN and MSN programs for students with degrees in other fields. Accelerated MSN programs are much less common than BSN programs and should be an area of focus;
- online competency-based BSN programs, with local clinical placements and mentoring;
- increased enrollments in generic BSN programs or entry-level MSN programs in the nation’s universities; and
- university nursing programs that provide evidence of interprofessional training opportunities.
- CMS could also create incentives for inter-professional teamwork through targeted support of interdisciplinary initiatives from the Center for Medicare & Medicaid Innovation.
Medicare should support funding for Graduate Nursing Education (GNE).
Mandatory funding for graduate nursing education would ensure that there are enough primary care providers and chronic-care managers to meet the needs of an aging population. Mandatory sources of funding for nursing education should also include incentives for advanced-degree nurses to become nursing educators.
Medicare funding for graduate nursing education should be targeted to achieve specific goals related to workforce composition, including preparing nurses to work in and lead interdisciplinary teams, community-based nurse-led clinics, medical homes, and underserved areas.
Education and training in geriatrics
States should explore funding and loan forgiveness programs to encourage students to train in geriatrics. When states employ financial incentives, they should be provided for all health professions where there is need.
More emphasis should be placed on geriatrics and the special needs of older patients in all medical and nursing school recruitment and core curricula. In order to ensure this, significant increases are needed in the number of medical and nursing faculty appropriately qualified to provide education and instruction in the care of older people.
More geriatric-specific in-service training is needed to prepare health care workers in both institutional and noninstitutional settings to meet the physical and psychological needs of an increasing older adult population.
Both primary care clinicians and mental health professionals should be trained in recognizing, diagnosing, and treating the mental health problems of older people and should learn how to refer patients with complex needs for interdisciplinary geriatric assessment when appropriate.
Health care providers should receive training in effective suicide prevention strategies for older adults that include guidelines for recognizing, assessing, and managing at-risk behaviors.
The development of the primary care and behavioral health care workforce should be integrated, so people with mental or substance use disorders receive the same care regardless of setting.
The National Academy of Medicine (formerly the Institute of Medicine) recommendations on strengthening the geriatric mental health and substance use workforce should be implemented.
To encourage geriatric education for providers, states should:
- mandate that professional schools with health and human services curricula require education in geriatrics and gerontology;
- require providers renewing their professional license to submit proof of continuing education in geriatrics if they treat older adults; and
- establish and enforce appropriate educational, training, and continuing competency standards for all health care providers, including those who represent themselves as having a specialty in geriatrics.
States should make grants available to establish divisions of, or centers for, geriatric medicine; support biomedical research on aging; and develop geriatric curricula for training use in chronic-care institutions.
Research and educational facilities
States should establish and expand research and educational facilities to meet the unique needs of older adults and people with disabilities, emphasizing the needs of older members of historically disadvantaged groups and older women.
States should partner with hospitals and should offer incentives to colleges and universities to partner with hospitals, to create public-private partnerships that would fund nursing faculty positions.
In addition to stepping up recruitment and retention of students from racial and ethnic groups that have experienced discrimination, health professional curricula should increase and improve understanding of, and sensitivity to, cultural and ethnic differences that may affect the health care needs and outcomes of increasingly diverse patient populations.