Toward a Strategic Plan for California’s Health Care Workforce

Introduction 

Although America spends far more than any other nation on health care, our health outcomes are suboptimal, lagging those of many other industrialized nations. Our health system produces too much waste, delivers care that is inequitable, and fails to produce better outcomes and patient experience at a sustainable cost. To address these shortcomings, public and private purchasers, payers and providers are shifting towards value-based models which promote healthy behaviors, incentivize person-centered, coordinated care, improve equity and outcomes, and reduce unnecessary treatment. 

These efforts have been hampered by a mismatch between the health workforce of today and the workforce required to fully deploy the health care delivery system of tomorrow. To successfully deliver care in these new modalities, California will need to recruit, educate, and sustain a diverse health and health care workforce that is skilled in working collaboratively in interdisciplinary teams, is technically competent, and is adept at using modern health information technology. In addition, a workforce committed to improving population health will require new roles and expertise, such as skills in assessing and addressing social determinants of health, knowledge of effective prevention strategies, and the ability to communicate to an increasingly diverse state population. 

One major barrier to improvement is the state’s lack of a contemporary overarching strategy or “master plan” to provide for an evolving and high-performing health workforce. The current federal environment makes this challenge even greater. While the expansions in coverage and care brought by the Affordable Care Act (ACA) have driven material growth in the health care economy, future federal policy portends constricted funding, amidst questions about state flexibility, less regulation, care delivery transformation, and pay-for-value efforts. 

The time is right for California to embrace a comprehensive workforce strategy to ensure that the state’s health workforce is able to provide high-quality, person-centered care for all Californians. Absent a broadly-shared set of aims and a cohesive strategy, the efforts of organizations across the care delivery spectrum to address changes proffered by the new federal administration, and workforce issues, in particular, are diffuse and less powerful than what could be gained through collective action. 

There is no entity at the state or federal level that is accountable for assuring that an adequate workforce exists to meet the health needs of the state’s diverse population. For example, while California meets the national average of 251 physicians per 100,000 population, primary care physicians are in critically short supply in many places; and Latinos make up just 4% of the physician workforce, compared to nearly 40% of the state’s population. 

There are many challenges inherent in ensuring a robust health workforce in California, including insufficient government funding for training and innovation, the extremely high cost of training, talent gaps at multiple levels, specialty and geographic misdistribution, changing dynamics in care delivery, the constant flow of new technology and medical innovations, a paucity of language and cultural diversity in the workforce, educational pipeline barriers for many low-income students and students of color, and the changing demographics of California’s population. 

Acknowledging the complexity of the aforementioned challenges, California’s leading health philanthropies are committing to work together in 2017 for a modern and stronger health workforce. Health foundation leaders are seeking to join with colleagues from government, education, labor, and other sectors to catalyze the development of a Strategic Plan for California’s Health Workforce and the will to implement it. 

Objectives 

The goal of this collaboration is to support the development of a strategic plan for building the health workforce to meet California’s future needs in anticipation of new state leadership in 2019. This Plan will promote a set of practical short, medium, and longer-term solutions that could be adopted and implemented by the state, educational institutions, employers, and other stakeholders to address current and future gaps in the health workforce. Another key goal is to establish a forum, structure, and process for effective plan implementation, with ongoing adjustment as needs change and with results reporting and accountability. 

Principles 

There are several principles that will need to underpin this work, including: 

Health workforce planning is a forward-looking venture. The Plan should take into consideration the state’s workforce needs in the medium (through 2025) to longer term (beyond 2025). 

  • Careful consideration should be given to ensure the “future forward” look is as practical as possible, and rooted in the most likely scenarios given what is known today — yet be flexible and iterative so that course corrections can be anticipated. 
  • The Plan should consider the economic benefits of a robust health workforce for the state. 
  • The Plan will need to build an understanding of the educational enablers for the health workforce of the future. This will need to include students at public and private institutions, community college and four-year students, health professions school students (medicine, public health, pharmacy, nursing). 
  • To the extent policymakers and others in California are developing comprehensive plans for the education sector, alignment and harmonization of the two planning efforts could optimize the success of both. 
  • The Plan should address workforce for both health care (including medical, dental, and mental health) and population health (including community, environmental, and public health) in the public, nonprofit, and private sectors. 
  • The Plan should be guided by an overarching goal for equity (social justice), address the needs of the underserved and disadvantaged (including Native Americans and other racial/ethnic minorities, the continuing uninsured, and remote rural populations), and seek to eliminate disparities in health outcomes. Another overarching goal should be to provide greater educational, employment, and economic opportunity for California residents to become the next generation of diverse health leaders and professionals who positively impact the health of their communities. 

Scope and Considerations 

The Plan must emphasize changes in policy, practice, and education/training that are already underway today, as well as those that can be anticipated, including these:

  • Examination of policies and practices that determine the sufficiency of the pipeline for developing students to become health professionals; 
  • Examination of policies and practices that determine the quality and quantity of training programs for health professionals; 
  • Evolution of value-based care, alternative payment models (APMs) and focus on the Triple Aim, and what this might mean for the workforce of the future; 
  • Movement toward team-based care, integrated systems for clinical and community services, and the changing role of primary care in care coordination and care management; 
  • Increased focus on prevention and the role of the health workforce and strategic partnerships (e.g., community organizations, public health) in addressing the social determinants of health; 
  • More fully developing the role of all staff in helping patients achieve health and well-being (e.g., medical and clinical assistants, community health workers, and peer specialists); 
  • Integration of physical and behavioral health, as well as integration across the health care continuum for individuals with complex care needs, developmental disabilities, the frail elderly, and those who are dually eligible; 
  • The advancement of technology — both medical/clinical innovations (including telemedicine and e-consult) and the continuing development and adoption of health information technology (HIT); 
  • Numerous promising California health workforce, education, and pathway programs that can have greater impact by increasing their scale, replication, funding, and sustainability; 

Other factors affecting the supply and/or distribution of the health workforce, including these:

  • The need for the health workforce to reflect the demographics of the state, including race, ethnic background, and language skills at all levels of practice; 
  • The evolving needs of safety-net providers and their position in the overall health care landscape, including relationships between public and private providers and alignment and integration of safety-net and mainstream providers; 
  • Any anticipated changes to institutional composition or business models that may drive supply-side changes (e.g., mergers and acquisitions, vertical integration, APMs); 
  • The current and future state of medical and clinical education and training opportunities in the state; 
  • The policy environment and scope of practice regulations in the state; 
  • Clinical workforce attrition due to retirements as well as fatigue, movement to more lucrative opportunities, administrative burden, etc.; 
  • A huge wave of baby boomer retirements of public and private sector health leaders and professionals; 
  • Regional differences across the California health workforce and the ability to educate, recruit, train, and develop a sufficient health workforce; 
  • Intense competition among employers for a shrinking pool of qualified talent and significant differences in ability to recruit and retain workers; 

Further, the Plan must also consider the changes in health care demand over the next 10-20 years, including these:

  • Demographic shifts, particularly the increases in absolute number of residents over age 85, and changes in immigration/ex-migration; 
  • Anticipated shifts in prevalence and incidence of major diseases and conditions; 
  • Changes in family dynamics, which contribute to shifts in natural supports available, particularly for seniors; 
  • The way that changes in care patterns, scope of practice, and team-based care might impact demand for different types of health professionals; 
  • Increasing expectations for patient-centered and consumer-directed care, including shared decision making, collaborative planning, health advocacy, etc.; 
  • Changes in business models and expectations for private, public, and nonprofit providers driven by developments in payment mechanisms, regulation, and financial incentives; 
  • The broader economic and education climate, and implications based on the size and shape, including geographic distribution, of California’s population; 
  • Any regulatory or market considerations that may impact the extent or comprehensiveness of insurance coverage, and therefore affect demand. 

Governance, Structure, and Process 

An expert and representative group of some civic weight is needed to steer development and implementation of the Plan. This group will oversee the gathering and review of information, decide strategic priorities, promote and monitor its implementation, and represent the Plan to the public. The group should be representative of California’s diversity and include educators and accreditors, health professionals, policymakers, business and labor leaders (including payers and providers), and consumer groups. The group should include representatives with economic as well as health, equity, and community expertise. Collectively, this group must be able to deliver material, cross-sectoral influence and bring resources to the table. The group will function as a private commission, with strong public participation and endorsement. The California Future Health Workforce Commission will run from Q2 2017 through Q4 2018. As catalysts, the health foundations will identify potential co-chairs for the group and will solicit their participation. 

Jeff Oxendine from UC Berkeley and Kevin Barnett from Public Health Institute and a small team have been identified to serve as the key contact point for the efforts, to support the group’s meetings, to prepare background materials, and to organize the work of grantees (technical consultants). This team will ensure co-chairs and commissioners are fully staffed and supported. The core staff team will further coordinate topical experts, academics, and technical consultants to ensure facts, analysis and a diverse base of opinions and voices are brought to the Commission for consideration. 

A coalition of California’s health funders, including The California Endowment (TCE), California Health Care Foundation (CHCF), The California Wellness Foundation (TCWF) and the Blue Shield of California Foundation (BSCF), is working to catalyze development of the Plan, and to provide funding for the staff effort supporting the work