Strategies to Build and Support the Health Care Workforce

0:20

Good afternoon. I'm Cait Ellis, interim CEO at the National Institute for Health Care Management Foundation. On behalf of NIHCM, I would like to thank our audience and panelists for joining us today for this important discussion on building, supporting, and retaining the healthcare workforce. The United States is facing significant healthcare workforce shortages affecting nearly every sector of the industry. For example, by 2037, 47 states are projected to experience a shortage of primary care physicians. These shortages can have a serious impact on patient access to care, health outcomes, and the overall cost of care. Today, we'll hear from a prestigious panel of experts to learn more about the trends in the workforce and efforts underway at the federal, state, and local levels to retain and grow the workforce. Our panelists' bios, slides, and today's webinar agenda are available on NIHCM's website. These materials have also been posted to the Zoom webinar console. We invite you to join the conversation on x using the hashtag HealthCareWorkforce. Before we dive into the presentations, I would like to thank the NIHCM team for their work on today's event, including Mikayla Thompson, who led the development of this rich panel discussion. I am now pleased to introduce our first speaker, Michelle Washko. Dr. Washko serves as the Director of the National Center for Health Workforce Analysis at the Health Resources and Services Administration. In this role, she leads the federal government's efforts to broaden the evidence base around our nation's health care providers. We are so honored to have her with us today to help set the stage on the current workforce trends, including shortages and the maldistribution of workers. Michelle,

2:07

Thank you so much, Caitlin. I'm very excited to be here today and to speak with everyone.

So, to start high-quality health care, I'm sorry you can move to the first slide, the first content slide. High-quality health care starts with a well-trained, adequately supplied, and well-distributed healthcare workforce. Unfortunately, there are several challenges facing the workforce in the healthcare sector that have existed and persisted for a very long time, and that's what you'll see on this challenges screen. These primarily include issues around workforce shortages, maldistribution across the country, unequal access to care, and employment quality in this sector. However, on the upside, people and organizations have been attempting to combat these issues, delving a little bit deeper into the challenges we face. As you can see, first, we're facing these shortages in many, many occupations. My center and several others around the country release workforce projections annually, and shortages have been getting steadily worse. We've seen that in the trends, we need to balance supply with demand for care by expanding the number of individuals working in healthcare. Second, what we may perceive as shortages in smaller geographic areas are oftentimes the result of maldistribution. We need to improve workforce distribution from one area to another by encouraging training and working in underserved areas. And third, I'm sure you already know this, but access to care is a huge problem in this country. We need to increase and improve access, making it easier for people to get the type of health care that they need. And finally, labor market factors and employment characteristics can drive people out of this work. We need to improve the quality of employment. We need to address things like undercompensation, burnout, and workplace violence. Next slide, to give you a sense of the shortages we're facing as a nation, that very first top-left-hand bucket that was on the previous slide, 31 out of 35 of the major physician specialties are projected to have shortages in this country, with the combined shortage of 200,900 FTEs by the year 2037.

4:46

That's only 15 years from now, primary care physician specialties will continue to experience some of the worst shortages. And I mentioned primary care because they are such an important and integral part of the health care workforce. Registered nurses, our largest health profession in the healthcare workforce in the US, will experience a 6% shortage nationwide, and 10 of the 12 major Behavioral Health Occupations will also be in shortage. This is huge. Next slide, please. Another major challenge I mentioned on that first slide is distribution, or rather maldistribution. Sometimes we might have an occupation which appears to be an equilibrium at the national level, but if we look at smaller geographies, states, counties, rural versus urban areas, which I think my colleague, Dr. Erin Fraher, will be talking about, this maldistribution looks like shortages, and that shortage can be felt quite acutely depending on where you live. A good example of this is the outlook for registered nurses in the US. Their distribution demonstrates how gaps may differ widely on a state-by-state basis. And the map you see on this slide is a visual representation of that? Well, we are projecting a nationwide shortage of 6% nurses, of nurses by 2037 the story between individual states paints a much more dramatic picture, with some states projected to have massive over supplies by as much as 77% and others with shortages as as critical as nearly 23% redistribution of providers, using existing provider skills as expansively as possible, and harnessing technology are all parts of the bigger solution. Next slide, please. Now, the third thing I mentioned as a major challenge that we're facing in terms of the state of the healthcare workforce in this country is access difficulties. An acute example of how workforce mal-distribution negatively impacts care can be seen in women's health, where access is impacted; the US has high maternal mortality rates compared to other high-income nations. Furthermore, each year, as many as 60,000 women in our country experience severe maternal morbidity, resulting in short or long-term health problems. We are projecting there will be a 12% shortage of OBGYN by 2037. As of 2022, over 10 million women, almost 16% of all women over 18 in our country, live in counties with no OBGYN, coupled with primary care provider shortages. This leaves Women's Health insufficient or completely lacking in many parts of the US, and we know that, unfortunately, women are turning to other providers or just not accessing care. Next slide, please. Finally, there's quality, meaning, not only the quality of the workforce via, you know, solid and good training and education, of course, but really the quality of the employment conditions for healthcare workers. A great example of this is a primary care physician. Again, they have much lower wages when you compare them with other physician specialties; they also receive less reimbursement for treating patients who receive Medicaid and Medicare. This leads many medical school graduates to choose other specialties, leading to persistent shortages in primary care physician specialties like geriatrics and family medicine. So, as you can see on this map, the majority of US states are experiencing shortages for these providers, so even an attempt at redistribution doesn't fully solve the problem. Rather, an improved labor market and employment conditions are critical to solving this problem of uneven employment quality.

8:39

Next slide, please.

8:41

Of course, you know, it's one thing to identify the challenges, but to understand how to address them and identify where we're seeing successes, we need to understand the underlying causes. There are two primary reasons from a labor force perspective, and these are not the only ones. But again, this is from a labor force lens. First, there are major population shifts that have been afoot in the US for generations now. And second, labor market factors, some shared across the entire US labor force, play a role both as a problem and a solution.

9:13

Next slide, please.

9:16

First, our aging society is still the primary driver for demand growth in health care right now, about 17% of the US population is over age 65 by 2050 this will jump to around 23% same time, these older individuals are also leaving the workforce, and coupled with that, the US birth rate has fallen by 20% since 2007 additional additionally, net international migration into the US is at its lowest level in years, and these two kind of major factors contribute to the overall US labor shortage and an inability of the health workforce to be able to meet the growing healthcare demands required by an aging population.

10:01

Yes. Next slide, please.

10:05

I mentioned those large labor market factors and issues in employment that add to the challenges facing our health workers. There are issues with parts of our educational pipeline for health workers. For example, we're facing shortages of nursing faculty in this country. This means fewer people can be trained as nurses, resulting in a smaller addition of new workers into the supply on an annual basis. Undercompensation, wages are also an issue for occupations facing critical shortages, like, again, primary care, and for many easy entry occupations, as we call them, like direct care workers. In the latter case, they can get siphoned off into other industries, which can be a huge problem. And then there's the issue of poor working environments that produce high stress and burnout. These have been long-standing issues, and the COVID-19 pandemic further exacerbated them when workers experienced long hours, exhaustion, increased exposure to death and suffering, and fear for their own health and safety. Next slide, please. Now I appreciate the fact that the first half of my presentation has been very doom and gloom, but despite all of the challenges and underlying issues I've brought up, there are solutions, and many are within our reach, while we can't really change population drivers like aging and fewer births, we can increase supply and produce more providers if we can grow the number of students entering healthcare and graduating when it comes to distribution, what we can encourage providers to work in rural and underserved areas with incentives like loan repayment programs or or or practice incentives. We can also continue to encourage team-based and integrated care. While we can't solve all access problems with Workforce Solutions, we can continue to diversify our workforce, which will help us reach underserved communities further. We can continue to harness and use technology like telehealth and coming online AI to improve access. Last, we can promote provider resilience and healthy labor force conditions when employers actually invest in living wages and nurture the mental health and wellness of their staff. We have ultimately seen this in several research studies, which show that it reduces employer costs and improves workforce retention. Next slide, please. So going in a little bit deeper to these four solutions to the four problems I laid out, promising development in terms of shortages in the supply pipeline, growth varies considerably by gender, while the number of female an example of this is in medical school while the number of female medical school students has grown by 14% between 2019 and 2024 the number of male has decreased by over 3% as a result, female medical school students now constitute 55% of medical school enrollment, and that was In the year 23 to 24 that academic year, similarly, there are over 4 million RNs, including advanced practice, registered nurses and LPNs. As of 2023, the number of nurses increased by 5.3% between 2019 and 2023, and that is if you recall the pandemic period. And then during that same period, the number of MPs grew by 35% in some occupations, increasing foreign-educated workers may be able to alleviate supply issues. We've seen that with registered nurses in recent years. In fact, the NCLEX pass rates for foreign-trained nurses have doubled every year since 2022, and states are coming up with creative ways to encourage international medical school graduates to come and practice in the US. So statistics like these suggest that despite everything, there is a continued interest in healthcare careers and continued growth in the workforce, and we just perhaps need to lean into some of those solutions. More. Next slide, please. So another solution following the trends of the past several decades, as I mentioned earlier, all four primary care physician specialties are expected to experience even worse shortages by 2037 however, primary care nurse practitioners and physician assistants are not and they've experienced over supplies for many years now, those physician shortages will have a profound effect on those seeking primary care as well as those seeking behavioral health care and women's health care, because our primary care physicians and providers are providing that kind of care as well and those services. So while MPs and pas cannot supplant primary care doctors or psychiatrists, these surpluses in advanced practitioners can alleviate the physician shortages in the services that they provide, to an extent, by making up for some distributional imbalances. Next slide, please. Thank you. Another potential solution comes in the form of. Technology. For example, in 2022, SAMHSA, which is one of my sister agencies, its National Survey on Drug Use and Health found nearly a million adults in the US have a perceived unmet need for mental health services, meaning they want to access behavioral and mental health care but can't. But the pandemic offered us a huge solution in the form of telehealth. Telebehavioral services, as we know, can help overcome accessibility barriers for individuals in underserved areas, as well as provide benefits for urban dwellers. Less than 1% of the behavioral health outpatient visits were conducted via telehealth prior to the pandemic. From March 2020 through August 2022, the use of telehealth was enabled by, you know, improved regulation and waivers and things like that. For behavioral health outpatient visits, it reached 40% of all visits. Primary care physicians also use telehealth more during the pandemic than in 2020, so these trends, while they've gone down a bit, they've they have remained higher today than pre-pandemic, and this does not even take into account the coming online of artificial intelligence and what that means for the healthcare workforce.

16:11

Next slide, please.

16:14

And finally, there's the issue, or rather solution, of provider resiliency. Physician burnout has been a long-standing issue in the medical community. A study by the RAND Corporation recently quantified that wellness programs reduced an employer's average health care cost by about $360 per member per year. Employers are beginning to realize that the cost of supporting their workforce will lead to reduced costs, recruitment, and increased retention. So these four things I have mentioned, while there are major issues we are facing in terms of the state of the healthcare workforce in the US, we do have solutions within reach. Next slide, please. And so in conclusion, while we have these challenges facing our country, facing the health care, labor force, and they are persistent. Many have been around a very long time, and the underlying factors that drive them are big. They are not completely insurmountable. There are successful ways to address these challenges, if we are willing to continue to be creative, opportunistic, and try new strategies, and with that, I conclude my presentation. Thank you so much.

17:26

Thank you so much. Dr. Washko for setting the stage on the challenges facing the healthcare workforce, the drivers, and the promising strategies to address these challenges. Next, we'll hear from Erin Fraher. Dr. Fraher serves as a professor in the Department of Family Medicine at the University of North Carolina at Chapel Hill, and as Deputy Director for Policy and director of the program on health workforce Research and Policy at the Cecil G Sheps Center for Health Services, research, doctors, research and expertise on the training, regulation and payment of the nation's health workforce has helped inform and guide state and federal policy makers in their decision making. We are grateful. She is with us today to share more about disparities in rural-urban care environments and state-based approaches to reducing shortages. Erin?

18:15

Thank you so much for having me. It is great to be here. So next slide, please. So today I'm gonna talk about both what federal, state, and local policymakers can do. It really builds well on Dr. Washko's presentation. Next slide, please. I always like to start with a disclosure of gratitude for the support of the Health Resources and Services Administration, which supports some of this work, as well as the North Carolina AHEC program, but nothing I say should be attributed to them or construed as the official views of them. I'm also hugely grateful to the collaborators and team with whom I work here at Chapel Hill. Next slide, please. So you're all busy. Virtual presentations are hard because there are lots of distractions, and I get to work with legislators a lot, and so I've developed this strategy where I like to summarize my entire presentation in one slide, in case your phone rings, in case there's some sort of policy crisis. Here it is. And Michelle already talked about this. We talk a lot about the physician shortage narrative, but really, what I want to talk about is these growing disparities between rural and urban communities. And talk about, when we're talking about the shortage, really nuancing it into talking about rural-urban disparities. I also want to talk about this concept of what federalism is, this concept that the responsibility for shaping the size, distribution, and composition of the health workforce is really shared between federal and state policymakers, and states are becoming even more active in passing policy. So the National Council of State Legislatures has been tracking through their bill tracker, and the number of bills at the state legislatures around the workforce has more than doubled in the last year. I'm going to give you. Three examples. I'm going to talk about the ways that states are engaged in graduate medical education, international medical graduates, and pathways to practice and workplace violence. I'm also briefly, at the end of my presentation, going to talk about something that's a passion of mine, and that is that state and federal policymakers spend a lot of time, I would argue, focused on the early end of the health professional career trajectory, but those mid to late career behaviors, temporary workforce exit, burnout, retirement re entry, are not really well understood. And then I'm going to share with you some new data from North Carolina that shows that female physicians are two to five times more likely to drop out of the workforce, either due to early retirement or temporarily exiting the workforce in each age group, and this really speaks to not only retention, but re-engagement. So with that, please hang on for the rest of the presentation, but now you have my key takeaways. Okay, next slide, please. So this is the chart. This is the chart that shows the supply of physicians per capita, even after adjusting for population growth in the United States, but states are really feeling shortages. Next slide, why is this? These are data from my state and home state of North Carolina, where you can see that in the year 2000, the upper orange line is the ratio of physicians per 10,000 population in metropolitan communities. That green line is the ratio of physicians per 10,000 population in rural communities. That gap used to be that metro counties had 10 more, 9.5 more physicians. They now have 14 more physicians than rural communities, adjusting for population. So remember, you just saw that line increasing in supply. Well, that's happening at the same time that the gap between rural and urban communities is actually increasing. Next slide, why is this part of the reason? Annual Medicare funding for graduate medical education in the United States is provided by the Congressional Research Service, which, thanks to a recent report, we know is up to $21.2 billion in the United States. Most of those funds go to hospitals, and much of the care is now taking place outside of hospitals. Only 2% of that Medicare funding for graduate medical education goes to rural communities. There's limited generally in the National Academies of medicine that have studied this and others, transparency and accountability for how that money is spent, and changes to Medicare GME require an act of Congress. So next slide, please. So even though Medicare GME has been fixed, we have seen some congressional action recently through the Consolidated Appropriations Act. Many of you may know that in that Act, Congress created 1000 new residency slots, and those residency slots were aimed to meet the needs in high-need communities. We colleagues of mine, Jacob Rains, Mark Holmes, and others, looked at where those slots ended up going, and in the first 100 rounds, that was where 100 slots were awarded. In that first round, in February of 2023 only 5% of those slots trained their residents in rural primary care, health professional shortage areas for at least half the time, and that number was even lower, down to 3% so I say this as a way to saying we're trying very hard to address this rural urban disparity, but some of the traditional mechanisms that we are using are not reaching these communities in terms of growing The graduate medical education training capacity, and we know where residents train, they are more likely to practice, and that's why where you invest these dollars matters. Next slide, please. So I wanted to point out to you that this was some data that we updated from a classic paper by Fitzhugh Mullen and Candace Chen that looked at the maldistribution of graduate medical education funding in the United States, and we updated their analysis. What do you take away from this table? Let's look at it. So, drilling down, the average graduate medical education funding per person in the United States is about $50 in 2020, so that's the average spending. But some places get more money than others. And so in Washington, DC, New York, and Massachusetts, you're seeing, they're getting about $200 per person, $100 $110, $109 in New York. And look, they have higher numbers of physicians to start with, right? DC has 871 physicians per 100,000 population. But go to the bottom of that list, and you see those are the top five places getting GME funding from Medicare. Look at the bottom five. Texas is getting $12.34 per 10,000 population, or per person, rather. And then our what we call our whammy region, or our western region, is getting less. The point of this slide is really to say to you, these are because Medicare funding is fixed. We've had population shifts. I'm going to talk about this in a minute. You're seeing, again, not just a growing disparity between rural and urban. You're seeing a growing disparity between states in terms of where that funding is. Next slide, please. So if you look at it cartographically, visually, we like maps at UNC Chapel Hill and our workforce center. You can see, these are the Medicare dollars per person. So the purple states have higher dollars per person, the lighter blue less. So you see, where's the money? Concentrated mostly in the Northeast and the Midwest. Next slide, please. Where's the population moving? If you look, these are data from Brookings that I really like. It shows that that within this is within the United States, the population is changing. They're moving south. And you can see that in the last few censuses, the South is really the region that has grown. To show you the contrast of where we invest and where the population is growing. Next slide, please. So, the states I mentioned are increasingly important loci. This was a nice paper by the Heritage Foundation in 2010 that really sort of tried to tackle this issue. I want to also point out this work from Harvard more recently, both of them are speaking to this concept of the role of states and health workforce policy, and saying, Hey, look, the federal government has an incredibly important role, and so do states. And in some ways, states may be, in some situations, better equipped, because they're closer to their population. There's a large heterogeneity between states, as Michelle pointed out, and it gives more states more flexibility to experiment. Next slide.

26:40

So I love this graphic. It's modified from work we've done, is sort of saying, okay, policy makers, you're out there, you've got your current workforce, and you've got your future workforce. How do you shape that future workforce based on your current workforce? You can, you can massage the number of new entrants to your workforce. You can try to shape where people go. That's diffusion, whether that's geographic or setting. You can deal with out-of-country supply for international medical graduates or foreign-trained nurses. You can focus on what Dr. Washko really talked about on retention and well-being. You can talk about payment policy in terms of the quality, quantity, and types of services provided. And these are your levers. Next slide, we're going to focus really quickly on new entrants. Next slide, I know if you've been tracking, in fact, recently, so I mentioned Medicare, but let's talk about what HRSA has been doing, the Health Resources and Services Administration has invested through the rural residency Planning and Development Program and the teaching health center program, significantly in addressing these rural GME training issues. And in fact, those programs we look tracking over time, this is work done by Emily Hawes and colleagues, show that the number of residency programs in rural areas has actually increased from 120 to about 412 in 2023 24 and more than a fifth of that new growth, not just in rural communities, but in federally qualified health centers has taken place because of those HRSA investments. So those are the federal investments, next slide. Meanwhile, states are still scrambling. States are saying, Wait a minute, we've got shortages. We're going to invest Medicaid dollars in graduate medical education. We're going to invest state appropriations. And those appropriations have actually increased up to about seven and a half billion dollars in 2022, so a significant amount of money, and they're doing it for a lot of different reasons, to address this maldistribution, to meet the growing needs of their population, to offset the potential loss of teaching health center funds, because those are not guaranteed. So states and feds are working together on this next slide. Let's talk about out-of-country supply. What's that lever about? Next slide, please. So one of the things we've been tracking, and again, Dr. Washko mentioned this, some states are pursuing alternative pathways to licensure and practice for international medical graduates. These are physicians who have completed their medical education outside the United States or Canada. Traditionally, those people have had to do a US residency. An increasing number of states, including Tennessee, are seeking ways to allow these international medical graduates, these foreign-trained physicians, to actually pursue alternative pathways to practice that do not involve doing a US residency. I like to use this as an example of federalism, this dynamic cooperation between the federal government and the state government, because if you think about the federal government overseeing visas, H1 B, and J1 visas that are required for training and practice, and the Conrad 30 program, which allows IMGs to stay in the United States immediately after graduating from residency. But state legislatures have an important lever, and that is, they have the regulatory authority to expand these pathways and allow these IMGs to practice. And so you're seeing this dynamic playing out in state legislatures next slid,e and when we are currently thanks to HRSA funded to do a study to look at these bills, look at that before 2020 there were a couple of states that were sort of thinking about the role that IMGs could play in their workforce, but it is up to 31 states that are implementing some kind of legislation. It might be a commission to study the issue. It might be an actual pathway to practice, or they might be img supports, including training dollars and curriculum supports to help them transition into the workforce. So this is a place where you're seeing a lot of legislation exploding quickly. Next slide, please. Let's talk about retention and well-being. Next slide. So, working with Dr. Brianna Lombardi in our office, again funded by HRSA, we are looking at the number of states that are implementing workplace violence legislation. What is this? This chart, showing you, this chart is what we took the workplace violence legislation, we looked at it across all the states. Said, let's try to categorize this workplace violence legislation. What are states in the legislative intent of what they're trying to do in implementing workplace violence prevention legislation? And historically, so we look from the pre-2015 period through June of 2024, and you can look on that left-hand side, most states traditionally have had a penalty, either a misdemeanor or a felony penalty, for committing an act of workplace violence against a healthcare worker. So these were the most common forms of workplace violence legislation. But look what happened between 2015 and 2024, you see this growth in legislation around prevention, things like signage, having plans for addressing workplace violence, this act of trying to let's not just penalize it when it happens. Let's prevent it from happening in an increasing number of states. So that's gone, the prevention has gone from 11 states to 27 states. Remediation. We only had eight states that had any form of remediation after the Workplace Violence Act took place, up to 23, and these are things like allowing the victim to use their business address rather than their home address, requiring reporting. So again, a place where there's a lot of state action. Next slide, please. So this is an incredibly busy slide, but what I want you to take away from this is to think about any health professional career, but let's talk about physicians, because that's what this slide is about. So you have, you know, efforts focused on colleges and universities, scholarships, pathway programs, and recruitment. You've got medical school scholarships, you know, all sorts of things. You got training tracks, residency, and development. We've talked about Medicare, talked about Medicaid, we talked about HRSA, we talked about loan repayment, you know, being a way to shape where people practice. Look at the billions of dollars invested in where we get the physician to go initially. What do we do? What Dr. Washko was saying was that to really improve those employment conditions and ongoing practice, we're actually woefully underinvesting in retention, and what about physician reentry? Next slide, please. Because we have tended to sort of assume that people go through their career and they just retire, but in fact, a lot of people exit due to burnout, moral distress, retirement, caregiving, and they may re-enter. But we don't actually study that. We don't understand it. We don't have programs aimed specifically at recruiting those people back. Next slide, please. These were data. We're incredibly lucky in North Carolina; we have 25 years of annual data on physicians so we can see what happens to them every single year, whether they're in clinical practice, whether they have said they are retired, or whether they have said they're temporarily out of practice. And we've been working to actually model transitions out of practice and try to understand who is transitioning out of practice. And when we run some logistic regressions that account for the physician specialty, their age, their sex, their generational cohort, whether they're a boomer, a Gen X or a millennial, we account for whether they practice in rural we account for what year it is across all of these models, women in all age groups were two to five times more likely than male counterparts at the same age to either retire and retire between 36 and 45 up to 56 to 45 or had higher odds of temporary leaving the workforce. So look at this chart. So women's odds are highest when they're younger, and they decrease, whereas men's odds are lower when they're younger, and increase, so you're seeing these very gender affected effects. Next slide, and this is my last slide. Why watch a second last slide? Why does it matter? In North Carolina, this workforce makes up 20% the retired or temporarily out of the workforce in any given year. Makes up to 20% of our workforce. What are we doing to entice them back to practice? What could be done to potentially entice them back to practice? The magnitude of this workforce is quite large, and I would argue that we need to focus on it. This is my next slide, the last slide. So, for all of you out there thinking about crafting policy, this was some work we did in our center, sort of thinking about the three-legged stool of workforce policy when you think about how to address a behavioral health workforce shortage, a primary care workforce shortage, a maternal health care workforce shortage, you're thinking about all sorts of things. Remember, it takes three components to address you've got to address education and workforce development. You've got to increase the pathway into practice. You've got to educate people for the kinds of things you need them to do. You've got to have a scope of practice that enables them to do that, and license them to do that, and most importantly, you kind of pay them to be able to do that. And we often see that this three-legged stool is not aligned. We train people to do things we don't pay them for. We train people to do things we don't regulate them to do and allow them to do so. Three-legged stool. Thank you very much for giving me that. Opportunity to speak with you today, and that's in these we're going to give you some resources. In the slide, nine centers are working on this, so we'll give you those slides. Thank you very much.

36:15

Thank you so much, Erin, for walking us through the new research on female physicians, providing us with the framework and levers around shaping the future workforce, and sharing how federal and state policymakers are working to address healthcare workforce shortages. Next, we'll hear from Christine Bracamonte Wiggs. Dr. Wiggs serves as the Vice President of Community and Health Advancement at Blue Cross Blue Shield of Arizona and as President of the Arizona Blue Foundation. In her roles, Dr. Wiggs leads the organization's corporate social responsibility, philanthropic investment and public health initiatives, and spearheads multifaceted strategies that support and elevate the health of members community organizations and Arizona and statewide, we are so honored to have her with us today to Help us understand Blue Cross, Blue Shield of Arizona, multi pronged approach to strengthening the healthcare workforce in their state. Christine?

37:06

Caitlin, thank you, and thank you to the NIHCM team for inviting Blue Cross, Blue Shield of Arizona, to be part of this really important conversation. And my gratitude to Drs. Washko and Fraher for really laying out the foundation for providing a great understanding from the macro perspective of what the situation is, what some of the challenges and potential opportunities are. And Dr. Fraher for really keying up, you know, those additional nuanced considerations when we think about what some of those solutions are to addressing the healthcare workforce, and it's not just pipeline and early career, but perhaps reentry and some of those other really important considerations. So what I'm going to do here today is really share what is happening where the rubber meets the road here in Arizona. Blue Cross, Blue Shield of Arizona, is a locally owned and operated plan. We've been here for 86 years, and we are committed to the state, the health of our state, because we live here, and the AZ Blue Foundation allows us to use philanthropic investment to really power the impact of public health. And so as we look at the next slide, really the opportunity for Arizona should be grounded in first understanding what the statistics show us. So when we look at 2024, America's health rankings, and we think of some of those considerations that both Dr. Washko and Fraher laid out. We think about access to healthcare, with regard to primary care physicians, mental health providers, as well as the percentage of uninsured individuals. So when we take a deep dive into the data here in Arizona, Arizona is ranked 41st with regard to the number of primary care providers to serve the needs of Arizonans here. And so that ranking of 41st means that we have about 258 primary care providers per 100,000 to serve the needs of our state. So again, an area of greater need, and perhaps that nuanced approach about where those providers should be and are currently located, when we look at it in terms of the number of or percentage of individuals who are Arizona really impacting access to care, can any can an uninsured individual be able to find opportunities to find a provider and pay for those services? And so here in Arizona, that ranking of 42 means that about 10% of our population, according to the 2024 America's health rankings, is that 10% is really experiencing that level of uninsured. And then when we got our ranking with regard to mental health providers, that ranking of 47th is really impactful in that we know in our state, we only have about 204 mental health providers per 100,000 to serve the current needs of our state. We know those needs around anxiety, depression, and other mental health-related concerns and conditions continue to increase, and so really focusing on how we impact and increase that health care workforce here is really important. And the next slide shows us as we look into the data. Again, a little more specifically about being here in Arizona. These are really, or these illustrations are really, to direct your attention to the amount of our state that is colored blue, and those are our primary care areas that are identified and assessed by the Arizona Department of Health Services as being medically underserved areas. So of the 126 primary care areas in our state, we see that about 83 are identified as medically underserved. So that's about 66% of all of our communities across the state are identified as medically underserved, of note and of importance. 12 of those 83 medically underserved areas are in tribal communities. So, a tremendous opportunity and a vital need for us to think about how we continue to promote the primary care workforce here in Arizona, the next slide gives us a little bit of a deep dive into health professional shortage areas when we think about mental health providers. Again, the idea of these illustrations is just to draw your attention to the need across the state. And Dr Freyer talked about looking at the need when we think about rural versus urban, and here we think about certainly rural versus urban, but also those urban underserved areas, drawing your attention to the illustrations around metro Phoenix and Metro Tucson, we still know that these are some of our largest urban areas here in Arizona, but there's still so much urban underserved area about mental health providers in our state, Blue Cross, Blue Shield of Arizona, we know we play a really important role in The ecosystem, both as a health plan and a payer, but also as a foundation. Through our private non-operating foundation, we know we have an opportunity to really put AZ blue into action to respond to the need to expand access to care. And so as we look at the next slide, I'm going to share a couple of examples around what we're doing here. I'll first start from the health plan and payer side of the house. We know that access to care is critical, and I'm going to do a deep dive on mental health for a little bit. Over the last several years, we've really had a targeted focus on increasing awareness and education and campaigns around reducing stigma related to mental health. We wanted to increase the provider workforce with regard to Mental Health here in Arizona, and we're really proud of the progress that we made, but we know there's so much more to do. Since 2022, we have been able to increase our provider network by an additional 25% which means there are an additional 2190 mental health providers here in the state of Arizona to serve the needs of Arizonans. We know that that's not enough yet, and we need to continue to grow that network, but it's a critical first step. Part of our role here as an insurer is really to increase access to care by expanding our network of providers, but also ensuring that our members and our customers understand the importance of actually accessing healthcare, right? So part of the strategy is to build a network so that care can be accessed when people need it the most. But we also want individuals to seek care. We want individuals to know if they're suffering, if they're struggling, that they should be seeking out care in their local communities. And we're proud to have several campaigns that may be supporting individuals and seeking that care as part of our expanding our healthcare access and our workforce, what we're doing is ensuring that there are a multitude of ways for individuals to access care, so increasing the network, creating search tools and online tools to make it easier to find a provider in your local community. Here in Arizona, we're also using virtual modalities, so telehealth is going to be really critical for individuals who have that capability, but bandwidth and connectivity across our state continue to be an issue. So it's not the sole solution to just increase the number of virtual sessions we know or virtual appointments. We know that many communities across our state do not have broadband or connectivity, and so again, that multi pronged approach here in Arizona is going to be so critical, and we want to make sure that individuals can seek care from providers here in Arizona, and again, that they're able to do it in person and virtual based on their level of comfort and their level of availability. As we move to the next slide, I want to highlight what we're doing in terms of, again, trying to increase that conversation, and creating a space around talking about the importance of overall well-being, which is comprised of both mental health and physical health, and seeking care. So, really reducing stigma, having campaigns to increase education and awareness. Can we build a network that is strategic in terms of providers, both rural and urban, and in those urban, underserved communities, and can we create spaces and places to have more conversations about the importance of that integrated care model, where we're looking at both physical health and behavioral health? Next slide, please. I will circle back to this at the end of my presentation. This is an example of one of our campaigns where we're really trying to get out there and boldly talk about stigma and addressing stigma, so really stopping and trying to encourage individuals to join us, to link arms, and really talk more openly about the importance of addressing rural health considerations.

45:28

Since we have this pledge here in Arizona to be stigma-free, AZ means happy to share more details at the end of my presentation, but as we move on to the next slide, I'm going to shift my focus a little bit and talk about the work that we've done here through the AZ Blue Foundation. Again, our plan is 86 years old, locally owned, and operated. Our Foundation was established in early 2022 again, just to amplify the opportunity to make an impact using that philanthropic approach as well towards driving to greater public health outcomes for all Arizonans, not just our customers and our members, and so our foundation really focuses on four key areas. Those four key areas of health include chronic health conditions, health equity, mental health, and substance use disorder. Next slide really proud to highlight what we've done over the last several years with mental health being our flagship focus, again, thinking about our role in the healthcare ecosystem, broadening the network of providers, but also encouraging individuals to seek more care, also encouraging our network of community organizations, so nonprofits and educational institutions to receive grant dollars through the AZ Blue Foundation to drive more impact. Because they're expanding their programs. They're expanding services. Maybe they're creating more applied research programs and evidence to build out, not only to expand access to care and to expand how telehealth services are being provided, but to look at those intersections of substance use disorder and mental health, to look at health care provider burnout, and really think about what are those things that we're doing, not only to get health care providers into the workforce pipeline, but how are we keeping them nurtured? How are we keeping those providers in the workforce? And to Dr. Fraher's point, if they've dropped out, how do we create opportunities for them to reenter so our grantees, again, through the foundation, we funded well over $5 million over the last several years alone, focused on mental health. Again, that's to expand access to care. So that is Grant. Those are dollars going to grantees who are providing opportunities for youth in after-school programs or positive youth development settings to have co-location of behavioral health providers there so they can seek treatment and environments where they are consistently participating. It also allows them to provide training to their staff to prevent burnout. It also provides opportunities to prevent burnout of health care providers throughout the whole ecosystem. Next slide, please, for driving principles about what we're doing here in AZ Blue is really focused on at the core. What we're doing is through funding, we're creating those opportunities to drive the mission and activities of organizations. But we're also here to partner. We're also here to use our Blue Cross, Blue Shield of employees, to have that volunteerism and to support organizations statewide, and at the end of the day, we really see our role as being a connector. Next slide, please. A couple of examples of what we're doing here in Arizona. One is around partnering with the Arizona Department of Health Services, and so you heard previously presenters talking about the state loan repayment program. So Blue Cross, Blue Shield of Arizona is the first payer or health plan to reach out to the Arizona department of health services to say we would like to invest in the state loan repayment program to augment that pool of funds so that more individuals have the opportunity to be recruited and retained in communities, particularly those health professional shortage areas, and we're so proud to know that through our partnership with the Arizona department of health services, we've been able to increase the number of providers by 34 who are serving communities who are often rural, underserved and in need of these services. The next slide highlights another example of the work that we're doing with Northern Arizona University. So, as we advance to the next slide, the College of Nursing, led by Dean Johnson, is really doing incredibly innovative work, and one of the partnerships that we recently engaged in at the beginning of this year is to work with the College of Nursing at NAU to help them launch their global BSN program. So this program allows for individuals who are interested in joining the BSN program, but who are living, particularly in those rural communities, to matriculate into a program that was started this fall. So they had their first cohort this fall. They live in these rural communities. They're able to virtually attend. Classes, but there are opportunities for the cohort to have some peer support. There is not that social isolation, but really that social connectedness with their cohort. And the idea is to recruit from rural communities so that those students, after they're turned out into the workforce, stay in the rural community and serve the rural community. So through these dollars, NAU has been able to get a course developed. So you can see 22 courses as a part-time instructional designer. The next slide really highlights what they've been able to do in such a short amount of time under Dean Johnson's leadership. So in their first class this fall, they had 28 students matriculate. And what is so impressive is that this is an accelerated timeline. So these students who matriculated this fall 2025 will be out in the workforce by spring of 2027, and the importance of really focusing on rural communities is that these students will have the opportunity to have clinical placements in rural communities. And so you can see that the highlight of three communities, we have communities in Lake Havasu, Verde Valley, and Cottonwood, Arizona, as well as La Paz Regional Medical Center in Parker, so that those clinical placements happen, and ideally, students will see the need in those communities and hopefully stay in those communities serving those needs.

51:15

Next slide, please.

51:18

In addition to our partnership in helping launch that global BSN, we're proud to support scholarships. And so through our support, eight additional scholarships for the psychiatric mental health nurse practitioner program are supported. The College of Nursing is keenly aware of our Foundation’s goals by 2029 at minimum, having an additional 75 providers in the healthcare workforce pipeline. Through our partnership alone, we'll have 36 providers by 2027, so again, it's finding these eager partners, who are dynamic and who are motivated by the challenge, and going out there and doing incredible work in our community. Next slide please, and just wrapping up by highlighting this partnership with neu is not only getting individuals into the workforce, but it really starts with those early exposures to young people in high school to pre nursing, really cultivating individuals who are in community colleges, nurturing their interests and nurturing that transition, supporting individuals who don't get admitted to the nursing program, but maybe other programs are complementary, and so maybe there are other ways for them to get into the nursing program later on, and so many more supports. But again, just really proud to highlight this partnership. I think this next slide really just brings us back to that campaign as a health plan, as a foundation. We know that we play an important role in this ecosystem. So proud to partner with such an innovator, innovator partners across the state. And again, just want to thank everyone for their time and attention today. Thank you,

52:55

Thank you so much, Christine, for highlighting how Blue Cross, Blue Shield of Arizona, and the Foundation are working to strengthen the state's healthcare workforce and improve access to care, including mental health care. We would like to use the remaining time to engage in a Q&A session with our audience. I welcome our panelists to come back on video, and I will turn to the first question, so we have the opportunity to really dive into efforts around the behavioral health workforce and some of the other specialties. We did have a few questions come in around the maternal health workforce. And Michelle, I know you touched on this briefly, but I'm wondering if anyone can expand on that for our audience. What are we seeing with the trends there, and any specific strategies or initiatives that you see as emerging to support that workforce?

53:51

Well, I can comment on the trends.

53:55

And you know, sitting in HRSA, we obviously, for several years now, have not only colleagues in the Maternal and Child Health Care Bureau who have, you know, invested in this issue and are acutely aware of it, but the Bureau of Health Workforce has as well. In recent years, since the pandemic, we have, within the Bureau of Health Workforce, identified maternal care target areas. So that is a designation that does free up some dollars for areas that are facing some of, you know, the dire labor force shortages around the maternal care workforce. But you know, beyond that, in terms of trends, you know, what we're seeing is really that it, and I think the audience probably knows this, that it's other providers who are stepping in to fill when we have a gap in care because there's no access to something like an OB GYN or a certified nurse midwife, and it's falling to our family physicians and nurse practitioners and others. So in terms of solutions, I'll let my other colleagues chime in here too, because I think a lot of solutions are actually coming at the state and local level.

55:10

Happy to share examples of what's happening in Arizona. So, in addition to the traditional set of providers in Arizona, there's really a push around supporting and expanding that workforce to include midwives and the doula Association here in Arizona, not only certification, but the opportunity for reimbursement for doulas is really important. Recently here through the AZ blue Foundation, we just funded a nonprofit partner who is using certified doulas to create villages to provide not only support prenatally, but post and really creating those opportunities to support parents and to support mothers post partum, so that they have this ability to tap into not only a network of accurate information, education and support for their health related physical health related concerns, but also their mental health related concerns and emotional concerns. So, really creating that supportive network of connectedness. So, I'm really excited about the work that's being done here in Arizona.

56:20

Thank you. Erin, did you have anything you wanted to add?

56:23

No, I just quickly add. This is where investment in rural training programs really does pay off, because we know from HRSA investments through the teaching health center and through the rural residency Planning and Development Program, if you can actually train OBs and family medicine, docs, and others to provide care for maternal care in rural communities, it really does address an access issue. I also really want to point out we spent a lot of time talking about CNMs, OB gyns and FMS, if that's enough acronyms for you. But you know, one of the rate-limiting factors in providing maternal care is nurses, labor and delivery, and also anesthesiology. So, remembering it's sort of a team sport, and trying to make sure that as you're building these initiatives, thinking about how you're going to support the entire workforce needed for a maternity care unit.

57:08

Thank you all so much for those thoughtful answers. We also had a few questions come in around the growing aging population and the increase in chronic disease rates that we are seeing. And Michelle, you touched on this briefly in your presentation, talking about the increased demand for care. I'm wondering if anyone can speak to how we prepare the workforce to meet the needs that they're going to be seeing over the coming years, while they're also grappling with just trying to retain the workforce?

57:43

I can jump in here. Go ahead. Michelle.

57:45

No, no, you go right ahead. I was just going to

57:51

I was just going to say. So, in full disclosure, I am actually a PhD gerontologist, and so this is a passion of mine, and I think some of that is already happening; it is not necessarily happening widespread or in a uniform way, but there is training happening within the labor force for various occupations around treating an aging patient population. So, for example, for many years now, the Bureau of Health Workforce has run our geriatric workforce programs. You know, and there are various ones within that, that appropriation line. So I think it is happening. That doesn't mean there couldn't be more. And we actually have an entire agency within HHS that is devoted to treating this population, who is encouraging a lot of this, and they partner a lot with CMS in terms of getting those providers, you know, the right care and reimbursement and things like that. So it's a very high federal answer.

58:51

So if you don't know that capable program out of Hopkins, and it's an amazing program, where they've actually developed teams that go into older folks' homes, and so we're talking about not just geriatricians and nurses. We're talking about occupational therapists to make sure that the house is safe. We're talking about pharmacists for medication management. We're talking about social workers to deal with isolation, anxiety, depression, and social agitation. So I just want to encourage you again to think about this as a team-based approach, and as you're thinking about how to expand this workforce, the capable model is a fantastic model that actually has Medicaid support for it, and is a really good one as you're thinking about chronic disease and in our aging population.

59:35

Yeah, investing in care coordination, to your point. Erin, that is so huge for this population, that coordination, you know, it does get fragmented, and it seems to happen so easily when you're treating this population, because you need to access the services of so many different kinds of healthcare providers, like the ones that you mentioned. So that is definitely an area where there has been investment, but there needs to be care. Continued attention. Excellent.

60:00

Unfortunately, we are out of time today. I would like to thank our excellent panel of speakers for being with us and sharing their valuable work and perspectives. And thank you to our audience for joining this discussion. Your feedback is important -- please take a moment to complete a brief survey that will open on your screen after the event. Please also check out other resources available on our website, including our recent infographic on addressing health care workforce shortages. Thank you again for joining us today.