Health Care Workforce Financing, Education, and Training

Achieving a robust health care workforce that is well-trained and prepared to meet the needs of a diverse population requires sufficient financial investment as well as ongoing education and training. 

Graduate medical education (GME): Publicly funded subsidies for physicians’ graduate medical education 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 medical conditions that practicing physicians 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 (see also this chapter’s section on Medical Research). 

Nursing education: To improve health care for all Americans, we need to increase the number 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. This enhances clinical care in the community and increases 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, and the subsequent 2020 National Academy of Medicine report, The Future of Nursing 2020-2030: Charting a Path to Health Equity, should be similarly followed. The report provided a blueprint for developing a nursing workforce prepared to deliver patient-centered care in the 21st century. The IOM emphasized that as leaders and clinicians, nurses are essential to delivering higher-quality care. It also notes that efforts to improve the system require their continued, comprehensive contributions. 

Bachelors of Science in nursing and higher degrees also help 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 skilled in geriatrics. 

Teamwork and diversity: In addition to having the right number and mix of providers, all providers should have the skills to provide high-quality, efficient care to a diverse aging population, including the ability to function effectively in teams. The IOM’s 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 patients from diverse backgrounds should be learned 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 groups that are discriminated against. Despite these efforts, there has been little growth in the number of ethnically diverse medical school graduates. Mentorship programs for students who have lacked opportunities have been successful in increasing graduation rates and test scores. 

Lack of diversity is also a challenge for the nursing profession. A 2020 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 found that 6.7 percent of nurses are Black American, 7.2 percent are Asian American,.05 percent are Alaskan Native or Native American, and 5.6 percent are Hispanic/Latino. 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).