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Help wanted in health care: Student recruitment, telehealth expansion and changes in scope of practices among strategies pursued by Midwest's states

by Jon Davis ~ October 2017 ~ Stateline Midwest »
It seems a recipe for health care disaster: Combine population growth with an aging population, add expanded health insurance coverage, and … hope for the best? The growing need for health care workers of all disciplines is well recognized. Midwestern states have already moved to address the growing crisis with recruitment and retention strategies, as well as by redefining professionals’ scopes of work and expanding the use of new applications of technology such as telehealth.
The baseline problem is daunting. In its July/August 2016 edition of Capitol Ideas, The Council of State Governments’ bimonthly national magazine noted that Georgetown University’s Center on Education and the Workforce predicts that “demand for health care services will grow twice as fast as the national economy over the next decade.”
The Association of American Medical Colleges forecasts a national primary care physician shortage of between 15,000 and 35,000 by 2025. And while there seems to be some good news regarding the number of nurses — the U.S. Health Resources and Services Administration projects strong growth in the supply of nurse practitioners through 2020 — the American Nurses Association says a combination of demographic factors and expanded access to health care “will create a renewed critical shortage for nurses.”
This workforce problem is most acute in many of the Midwest’s rural areas. In a 2012 policy paper, the Kansas-based National Rural Health Association forecast prolonged rural shortages of full-time physicians, registered nurses, mental health professionals, pharmacists and dentists.
“The shortage does go all the way across [the spectrum of health care professions],” says Dr. Raymond Christensen, associate dean for rural health and associate director of the Rural Physician Associate Program at the University of Minnesota Duluth.
In Minnesota, for example, the final report of the Legislative Health Care Workforce Commission, released in December 2016, noted that while the statewide percentage of all occupations currently open is 3.6 percent, the rates are much higher in health care fields — 6 percent for physical therapists and nurse practitioners, 14 percent for internists and general physicians, and 18 percent for psychiatrists.
In a recent ongoing series of stories, the (Madison) Wisconsin State Journal cited data from the state Department of Workforce Development showing that by 2024, “analysts expect there will be nearly 52,000 more job openings than in 2014 in the health care and social assistance fields — more than twice as many as the next-largest sector.”
The biggest need will be for registered nurses (more than 5,000), physical therapists (616) and doctors (376), the newspaper reported. The State Journal also cited state and federal data showing “a need for other health care workers, including more than 4,600 certified nursing assistants and more than 2,000 home health aides. Those are 13 percent and 28 percent increases from 2014, compared with a 10 percent increase for nurses.”
And as South Dakota Sen. Deb Soholt noted in the May edition of Stateline Midwest, 43 percent of residents in her state live in a designated primary care shortage area; her state needs to increase its primary care workforce 27 percent by 2030 to meet projected demand, while 45 percent of current-day practicing physicians are older than 50.
The recruit-and-retain strategy
Perhaps the most widespread recruitment/retention program is loan repayment, under which medical students who agree to provide services in a designated “health professional shortage area” (usually rural) qualify for funds to help pay down their student debt. All Midwest states have at least one such program; Minnesota has nine.
The Kansas State Loan Repayment Program offers up to $25,000 for physicians and dentists ($20,000 for other providers) in exchange for at least two years’ work at a site in a federally designated Health Professional Shortage Area, while the Kansas Bridging Plan offers up to $26,000 for physicians in Kansas residency programs who agree to practice full-time in a rural community for three continuous years upon completion of their residencies.
Likewise, Nebraska’s Rural Health Student Loan Program awards medical, dental or psychology students up to $30,000 for up to four years (or $15,000 for two years to master’s level mental health students); students must agree to practice full-time in state-designated shortage areas for one year for each year the loan was awarded. They also must accept Medicaid patients.
Additionally, the National Health Service Corps operates a Student Loan Repayment Program with participating states (which are required to provide matching funds). All Midwestern states except Indiana and South Dakota are participants While loan forgiveness programs are “reasonably effective,” Dr. Christensen says, the cap on medical residencies funded by Medicare — established by the U.S. Congress in 1997 — is a bottleneck in the current system.
Generally, the federal government funds residencies for direct costs such as salaries, benefits and teaching, as well as indirect costs associated with the assumed greater inefficiency of trainees. (Indirect cost coverage is determined by a formula set by U.S. Congress and the U.S. Centers for Medicare & Medicaid Services. States can add funding, too.)
Wisconsin’s newly approved budget includes two measures advanced by the Wisconsin Rural Initiative, a group of state legislators promoting rural development, to improve access to care in underserved areas. One of the measures establishes a grant program for hospitals, health systems or schools that create education and training programs for individuals seeking careers as therapists, medical technicians or other “allied health professionals.” The second grant is for hospitals and health clinics that provide more training opportunities in advanced-practice nursing.
Minnesota this year considered establishing tax credits for medical preceptors (doctors who volunteer to train or supervise medical students), an idea that came from Tennessee. That idea didn’t advance this year, says Sen. Greg Clauson, who sat on the state’s Legislative Health Care Workforce Commission.
In its final report, that panel recommended expanding residency slots in rural areas, especially for mental health, geriatric care and psychiatry, along with expanding the use of telehealth, identifying underserved regions and increasing funding to the University of Minnesota Medical School, in part for physician workforce programs.
“We’re continuing to monitor those things to see how it’s going,” Clauson says.
Kansas this year approved SB 32, which added general and child psychiatry to the list of residencies covered by the state’s Medical Student Loan Act and eligible for the Kansas Medical Residency Bridging Program. As important as passage, the bill was also funded, says Rep. Susan Concannon, who serves as co-chair of the Midwestern Legislative Conference’s Health and Human Services Committee.
Kansas legislators are also working on a measure to allow nurse practitioners to have practices independent of supervision by physicians, but the votes aren’t there yet, Concannon adds. That step already was taken in Nebraska in 2015, when LB 107 was signed into law. It allows licensed nurse practitioners to practice fully, without a written agreement with a doctor. Similar legislation (SB 61) was signed into law this year in South Dakota.
“It really helps to deal with the primary care practitioner shortage,” since 44 percent of LNPs practice in rural areas, says Sen. Sue Crawford, who is vice chair of the MLC’s Health and Human Services Committee.
Nebraska’s Unicameral Legislature in 2009 created the Behavioral Health Education Center of Nebraska (part of the University of Nebraska Medical Center) to recruit and retain students and professionals to address behavioral health shortages in rural counties, as part of its broad strategy to address rural health needs.
Now, however, Crawford says, “Our primary strategy is passing laws to improve the integration of care.” That includes the improvement and expansion of telehealth — the use of electronic information technology to support long-distance health care, patient/provider interaction and health administration.
“You’re maximizing what your current health professionals can do with technology,” Crawford adds.
Minnesota is at the cutting edge of telehealth legislation, according to the Advisory Board, a Washington, D.C.-based medical consultancy firm. In a blog post published in January identifying major legislative trends, the firm noted that Minnesota had
Wages low, needs high in home health
While most of these efforts focus on building up the supply of direct health care providers, jobs in service/support positions like home health workers go unfulfilled mainly because of low pay, says Paul Osterman, a professor at the Sloan School at the Massachusetts Institute of Technology, whose latest book, “Who Will Care for Us? Long-Term Care and the Long-Term Workforce,” addresses this topic.
“Loan forgiveness programs aren’t really relevant to a lot of these folks because the amount of training they get is negligible,” Osterman says, adding that with compensation generally around $10 an hour, “they might as well go to work in a department store. It’s an easier job.”
Normally, the market would correct that and wages would rise, but home health aides are reimbursed by Medicaid, and state legislatures control that, he says. There is room to raise workers’ pay — as states such as Illinois and Wisconsin have done in their new budgets — but not by just spending more money, Osterman says.
The key, he says, is to make workers more productive by increasing their training and the scope of work they’re allowed to do; that will lower overall costs by reducing the need for higher-priced specialists. Some of those savings can then be used for raises.
In 2016, New York legislators created the new job category of “advanced home health care aide”; the state’s Department of Health is now in the process of drafting regulations for it. These aides will work under a licensed registered nurse’s supervision to perform tasks such as “administering routine or pre-filled medications that are easy to give … as well as other tasks to be defined in regulations.”
According to PHI PolicyWorks, the new law will make jobs in home health care more attractive by filling two caregiving gaps — first, by giving home health aides a new opportunity for advancement; and second, by allowing them to perform tasks that currently can typically only be done by licensed personnel, family members or individuals in Medicaid’s Consumer Directed Personal Assistance Services program.
Osterman says the issues of home health workers’ pay and professional development don’t get much traction.
One reason: It’s often assumed that as a fallback provision, family members will care for patients. “With baby boomers retiring, the ‘muddling through’ option is becoming less and less attractive,” Osterman adds. “We were told to prepare for the ‘silver tsunami’ but, human nature being what it is, we put it off and put it off and put it off.”


Article written by Jon Davis, CSG Midwest staff liaison for the Midwestern Legislative Conference Health & Human Services Committee.


Recent state legislation, investments to address workforce shortages in health care


As part of the state budget that became law in July, Illinois lawmakers approved an hourly raise of 48 cents for home health workers in the state’s Home Services Program, which provides services to individuals with severe disabilities. It was due to take effect 30 days after enactment of the budget. A class-action lawsuit was filed in September alleging the state had failed to make good on that raise.
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SB 538, introduced in January, called for a legislative study “concerning the shortage of health care providers in Indiana.” As part of that study, lawmakers would examine numerous facets of the shortage: for example, the effectiveness of using scholarships, tuition reimbursement, and loan forgiveness programs; the capacity of higher education institutions to train health care providers; and funding sources used by states to increase their supply of workers. SB 538 did not advance.
HF 275, introduced in February, would have instructed the Iowa Department of Health to lead a coordinated effort to address the recruitment and retention of direct-care and other health care professionals.” The proposed bill (it did not advance in 2017) would have built on work already being done through the state’s Direct Care Workforce Initiative, the goal of which is to improve training opportunities and career pathways. Under HF 275, the department also would have led a study of ways to attract and retain health care workers.
SB 32, signed into law in March, adds general and child psychiatry to the list of residencies covered by Kansas’s Medical Student Loan Act and eligible for the Kansas Medical Residency Bridging Program. These state initiatives provide loan repayments to medical students who practice in the state. SB 32 also requires the University of Kansas Medical Center to provide three residents in general or child psychiatry with residency bridging loans. The idea for SB 32 came from a Kansas work group focused on improving rural health care.
SB 541 would authorize a new type of mid-level professional, dental therapist (a role like that of physician assistants), to address a shortage of oral health care professionals in parts of Michigan. The legislation was introduced in September. Additionally, the state’s current budget includes capital funding for schools/universities to expand facilities that train health care workers, as well as funds to raise the pay of direct care workers (50 cents per hour) in the state’s behavioral health system.
Minnesota’s new health and human services budget (SF 2 from the Legislature’s special session in 2017) creates a grant program to support educational programs that provide clinical training for the following health professions: advanced-practice registered nurses, dental therapists, mental health professionals, pharmacists and physician assistants. More than $1 million is being appropriated over the next two years to expand the availability of clinical training in the state.
Nebraska legislators this year passed LB 92, which bars health insurers from excluding a service “solely because the service is provided via telemedicine and is not provided through in-person consultation or contact between a licensed health care provider and patient.” A second part of the bill removes a restriction that had not allowed Medicaid to cover child behavioral health services if they were delivered via telehealth and if the child had access to comparable services within 30 miles of his or her home.
As the result of a more than $120 million appropriation by the North Dakota Legislative Assembly in 2013 and 2015, a new School of Medicine & Health Sciences opened last fall on the campus of the University of North Dakota. With this new facility in place, the school’s graduating classes of students will rise by 25 percent, an increase that state leaders hope eases the current shortage of health care providers. According to the school’s Center for Rural Health, 46 percent of the primary-care physicians practicing in North Dakota completed their residencies in the state.
Bills in Ohio (similar to Michigan’s SB 541, see above) have sought to improve access to oral health care by creating the state-licensed position of dental therapist. As of January 2017, according to the Pew Charitable Trusts, only one Midwestern state, Minnesota, had laws allowing dentists to hire dental therapists. Ohio’s SB 98 was introduced in March. The Ohio Dental Association opposes the bill, saying it would allow “undertrained individuals to perform irreversible surgical procedures.”
Under SB 61, signed into law in February, nurse practitioners and midwives in South Dakota are now licensed and regulated only by the state’s Board of Nursing (rather than by it and the Board of Medical and Osteopathic Examiners). They no longer need career-long collaborative agreements with physicians to practice. Currently in South Dakota, one in five residents lives in a primary-care shortage area.
Wisconsin’s new budget includes $500,000 in 2018 for a grant program that encourages hospitals, health systems and educational entities to form education and training consortiums that increase the supply of “allied health professionals” (health care workers who are not physicians, dentists, nurses or pharmacists). A second grant program (also $500,000) also has been established to expand clinician training opportunities for individuals seeking to become physician assistants or advanced-practice nurses.




Physical, cultural distance complicates health worker shortage for Native American tribes

by Jon Davis ~ October 2017 ~ Stateline Midwest »


Problematic as the national and regional health care worker shortage is, it’s even more dire for Native American tribal governments. The federal Indian Health Service, the agency responsible for providing federal health services to the tribes, is chronically understaffed, and a U.S. Government Accountability Office report issued in February added IHS to its “high-risk list,” saying it has “ineffectively administered” health care programs and noting that 39 of 41 previously issued recommendations for improvement — some of which dated to 2012 — had not been implemented.
“You talk about the impact that has mentally, spiritually and culturally, it hits all of us,” Hunter Genia, a licensed master social worker and member of the Michigan-based Saginaw, Swan Creek, Black River Band of Chippewa and Grand River Band of Ottawa, says about the impact of inadequate care.
Even so, Genia — who sits on the Native American Advisory Board for Grand Valley State University in Allendale, Mich., and also served on the National Tribal Advisory Committee for IHS in the Bemidji Region (Illinois, Indiana, Michigan, Minnesota and Wisconsin) — notes that one of the tribes’ biggest problems is numbers. It’s tough to compete for qualified health care applicants when Native Americans are 1.3 percent of the country’s total population and might account for 1 percent of jobs in any given field, he says.
Genia suggests that tribes forge relationships with nearby colleges, university medical schools, or behavioral health and social work programs. Tribes also should aggressively pursue grants, he adds, but should read the fine print carefully, as grant rules are not always sensitive to tribal practices and protocols for wellness.
Native Americans regained sovereignty over, and control of, their health and education systems only 40-odd years ago. As a result, Dr. Mary Owen says, the pipeline for Native American students interested in sciences and medicine must be rebuilt — from kindergarten through college. Many tribal schools, too, lack strong science programs.
The top needs are more scholarships and training sites so students can know what it’s like to work in rural/tribal areas, as well as having more Native Americans in academia, generally, she says.
“If you have people in academia whom you can relate to, you’re more likely to go,” says Owen, director of the Center of American Indian and Minority Health at the University of Minnesota Duluth and a member of the Tlingit nation from southeast Alaska.
Owen and Genia say states should ask the tribes what they want from their health care systems, and take tribes’ cultural and traditional approaches into account when drafting bill language for grants. But South Dakota Rep. Sean Bordeaux, a member of the Rosebud Sioux tribe (Sicangu Lakota) and director of the Institute of Tribal Lands at Sinte Glesca University, says he doesn’t completely buy the argument that tribes’ cultural differences from the general population (and from one another) are that big a barrier.
Participants in the Teach for America program are on the Rosebud reservation, for example, he says. “People come from all over the place and they do fine,” Bordeaux says, adding that the problem is they don’t want to stay after two or three years because of the isolation of life on tribal land.
“It’s really tough here,” he says. “We have great deer hunting, pheasant hunting and that, but people don’t really want to live here for a full year.” Better, he says, to invest in Medicaid expansion and find ways to deliver medical services to tribal lands — for example, flying doctors in for 72-hour shifts.