Addressing a Workforce Crisis in Primary Care Made More Severe by the COVID-19 Pandemic

[DIANE RITTENHOUSE]

The job has become untenable in some ways. You don’t just take care of the patient who comes in and presents with a problem, I have back pain, I have a sprained wrist, or whatever. Then you’re asked to take care of all the patients who don’t even come in but who are a part of your community or part of your population. The one physician model is just not going to work where one physician does it all. It takes a team.

[J.B. WOGAN]

I’m J.B Wogan from Mathematica, and welcome back to On the Evidence, a show that examines what we know about today’s most urgent challenges and how we can make progress in addressing them.

[Music].

[J.B. WOGAN]

On this episode, we’re going to talk about the primary care workforce crisis, a complex multifaceted problem, made all the worse by the COVID-19 pandemic. The crisis, as my guests will explain, is about more than simply a mismatch between the supply of primary care service providers and demand. It’s about retention, burnout, pay, not attracting enough providers in the right places, not having enough diversity in the field, and more. We have excellent guests to guide this conversation.

Luci Leykum is a general internist who was involved in the creation of a report last year from the National Academies of Sciences, Engineering, and Medicine that looked at ways to strengthen the primary care field. That report built on the recommendations of a 1966 report by the Institute of Medicine by providing an implementation plan for high-quality primary care in the United States. Luci is also the executive associate chair at the Department of Internal Medicine at UT Austin’s Dell Medical School and she serves as the center lead and principal investigator for the Elizabeth Dole Center of Excellence for Veterans and Caregiver Research for the Department of Veterans Affairs through the South Texas Veterans Healthcare System.

Sue Lin is the deputy office director of the Office of Quality Improvement within the Bureau of Primary Healthcare at the Health Resources and Services Administration, better known by the acronym HRSA. She also helped get sponsorships for the National Academies reports we’ll be discussing.

Julie Schilz is a senior director on the Clinical and Quality Partners team at the Primary Care Development Corporation, which recently published a data brief on Investing in Primary Care to Achieve Better Health and Equity in the United States. Aside from her current role, Julie is a registered nurse and brings that perspective to the conversation.

Diane Rittenhouse is a family physician by training and a senior fellow at Mathematica, where she co-authored a report for the California Health Care Foundation that reviewed evidence that could inform health policy’s aim at increasing the size and diversity of the primary care workforce in California.

I should also note that if you want to learn even more about this topic after the episode, Mathematica is also cohosting a Twitter chat later this month, on June 23rd, from 2:00 p.m. to 3:00 p.m. Eastern Standard Time on Challenges and Opportunities for the Primary Care Workforce.

You can find that chat as well as past Twitter chats about primary care using the hashtag #PrimaryCarePolicyChat, all one word. If you have questions for our guests, both Julie and Diane will be participating in the chat and would be happy to answer any burning questions that we didn’t get to in this conversation. A full transcript of the episode, along with links to any research we reference in the conversation, will be listed in the episode’s show notes and on a blog at Mathematica.org. I hope you enjoy the conversation.

[J.B. WOGAN]

So, we can jump right in.

Luci, I keep seeing headlines about the primary care workforce crisis. Sometimes the story focusses specifically on the workforce shortage. But in preparing for today’s conversation, I’ve learned that the problem is multidimensional. Would you mind kicking off this conversation by briefly describing, or rather, briefly defining the problem. What is the primary care workforce crisis?

[LUCI LEYKUM]

Sure. Thanks for that great question. You know, I think on the simplest level, one way to describe it is that more people are leaving the practice of primary care than are entering the field. And let me give you some numbers to help define what that looks like. So, I’ll start speaking from the physician perspective.

About ten years ago, in 2010, there were almost 250,000 physicians in the U.S. who were primary care physicians, according to the AMA. Now, ten years later, we’ve lost about 20 percent of that workforce. For physicians, it’s just over 200,000. More than 50 percent of physicians report burnout, and that number is from 50 to 70 percent in primary care specifically. In the last two years, even more attention has been paid to this issue and one in five primary care physicians are thinking about leaving practice in the next two years. Besides thinking about leaving practice, a large number are going part time. So that’s sort of the leaving aspect.

And then when we look at people coming in, physicians coming in, we see more people choosing non-primary care specialties coming out of medical school. So fewer people going into family medicine and internal medicine. And pediatrics, a little more stability there. Within internal medicine, five to ten years ago, 50 percent of internal medicine residents went into primary care. Now that number is far less. More people specializing, more people going into hospital medicine. And these are multifactorial problems. But the numbers certainly are concerning.

And when you look at nurse practitioners, the numbers of nurse practitioners going to primary care has increased, looking at nurse practitioners through graduating with primary care training. But that rate of increase has actually slowed over the last five years as well.

[J.B. WOGAN]

Diane, I want to turn to you now. Beyond the increasing number of overall workers, and this gets back to this idea of the nuances of supply and demand and whether we don’t have enough, besides just the number of overall workers, how do the geographic location, demographics, language proficiency, cultural competencies of primary care workers factor into concerns about building up the pipeline of future primary care providers?

[DIANE RITTENHOUSE]

That’s a great question, and those are all really important points. I think that the overarching issue that we often think about is shortage. But there’s also geographic maldistribution, and there is the mismatch between who’s practicing primary care and who needs a primary care clinician in the population.

And so, for example, in California, 40 percent of people in California are Latino or Latinx, and seven percent of physicians are Latino or Latinx, so there’s just a mismatch there between the population and the cultural background of the physicians in training. There’s also a tendency for people to go into practice. We have a lot of residency programs in urban areas. A lot of people will stay, then, in urban areas, and we have a hard time drawing primary care workforce into rural areas without some real good thought about the pipeline.

So, we know that there are some ways to increase the chances that someone will end up in a rural area, but without concentrated thought and policies, we see physicians grouping in urban areas, and there’s an underinvestment, and the primary care specialties are under-resourced, and so for clinicians to choose to practice in primary care and take care of the underserved, to go to an urban underserved area or a rural underserved area, often, they will have to be paid less, when, in fact, the demand is higher for physicians and clinicians in those areas. So, the market doesn’t exactly work in terms of the workforce for primary care physicians.

[J.B. WOGAN]

Before we move beyond just defining the problem, I want to make sure, is there anything else that our listeners should know about the current crisis? What’s in your mind when you’re thinking about what that phrase, “primary care workforce crisis,” means?

[LUCI LEYKUM]

I would just underscore the geographic variability issue. It is orders of magnitude difference. Like, you know, five times as many, ten times as many primary care clinicians in urban areas versus rural areas.

[J.B. WOGAN]

I was fishing around. I found a website that looked like it’s produced from HRSA. They were projecting that by 2030, there would be reduced supply for rural areas for, I think, internal medicine providers, and there would be increased demand in rural areas, and I believe it also showed increased demand in urban areas, but still an increase of supply but not an increase supply to keep up with the demand.

[SUE LIN]

J.B., I think you’re talking about our Health Workforce Research Center.

[J.B. WOGAN]

Yes.

[SUE LIN]

That supports projections. I think, you know, the crisis that Diane and Luci spoke about was a strong impetus for HRSA to support and be a co-sponsor on the National Academies of Science report, implementing quality of care, rebuilding the foundation of health. Fundamentally, you know, we have to be able to support primary care, and then in our space, primary care safety net programs, and support an environment where young professionals can feel and identify, where they can drive and commit, as many of our clinicians that joined the National Health Service Corps have dedicated decades of their career to this profession, and supporting the underserved communities. So, recognizing the crisis, but we also hold onto what can we optimistically effect change as the National and federal level to make things better moving forward.

[J.B. WOGAN]

I’m glad you flagged that report, because I do want to discuss it. In fact, I wanted to reference it in my next question. My impression is that the pandemic has made obvious why changes needed in how we invest in primary care in this country, and I was struck by a quote from the report last year on primary care from the National Academies of Sciences, Engineering, and Medicine, which I think maybe we can refer to as NASEM, if you want, or the National Academies, something more shorthand going forward.

But the report makes the argument that primary care should be treated as a common good, and to quote from the report, it says that, “Responsible public policy requires that a common good, be it public education, grazing grounds for farm animals, or the capacity of primary care to meet the needs of the population merits some degree of public policy for oversight and monitoring, and in the absence of that, the good is depleted and not available when the need for it increases. Such has been the case for primary care during the Covid-19 pandemic.” That’s the end of the quote.

So, Julie, did the pandemic simply reveal problems that already existed in the primary care workforce, like that our public policies don’t treat primary care as a common good, or would you say that it exacerbated the preexisting crisis.

[JULIE SCHILZ]

I would say that it exacerbated the previous crisis, and I think Diane mentioned the crisis in the workforce underscored that primary care is under-resourced, and we’ve kind of alluded to the concept that we’ve been underinvesting in primary care, and we haven’t looked clearly and consistently at how we can invest in primary care in a variety of ways, and these are all outlined in the NASEM report, about how we use a variety of policy mechanisms, as well as payment mechanisms, to pay primary care so that primary care can have teams of individuals working with them to be able to deliver care to a variety of patient populations.

But you asked me, J.B., about how the pandemic really surfaced and exacerbated many of the elements of the workforce crisis. And one of the things that happened is that primary care had to change on a dime because of what the pandemic was doing. So the pandemic really meant that primary care had to change how they were delivering care, changing from seeing patients in person to seeing patients virtually. So, when you have to make those changes, and you have very limited staffing to be able to do that, it makes it even that much more difficult without those resources, people resources, to be able to change the way you’re delivering care, being able to engage your patients in a different way.

So, that’s just one example of how, when you have the limited resources, you’re kind of managing your patient population on a shoestring as it is, and then you have a pandemic that you’re not in a position to already know how to manage, and needing to then change the way you deliver care and manage from that perspective day in and day out, without any respite.

So, I think Luci, you had mentioned the burnout that happens from that.

[LUCI LEYKUM]

You know, part of that whole, we need to change how we’re doing our care became a real reliance on non-face-to-face interactions, virtual care, more telephone care, and in some ways that’s been a real plus, but in some ways, that’s actually been a problem, because not all patients can access those modalities for care delivery, and, generally, there’s been a lot of discussion about worsened health disparities during the pandemic, and that access to digital health has been part of it, and primary care clinicians have been on the frontline are sort of experiencing that difficulty, and I think there’s been a real sense of moral injury among primary care clinicians in terms of not being able to take care of patients equitably, not being able to provide the types of supports that are needed that has really worsened the burnout.

And when we think about the level of chaos in people’s lives during the pandemic and just the number of mental and behavioral health issues that were really exacerbated across society by the pandemic, Julie talked about how primary care was sort of operating on a shoestring and barely able to, in a lot of places, provide the holistic care that clinicians want to provide. And when more and more of your patients have more and more of those health issues and life issues, again, that just makes it really hard, really challenging for primary care clinicians to function. They feel like they can’t meet the needs of their patients. Their own lives are more chaotic. Their own kids are also not in school. And it really just truly created a perfect storm of inability to practice the way we want, an inability to really balance the work-life aspects of practice that came together.

[JULIE SCHILZ]

And as Luci mentioned, you know, as we think about the pandemic and as we’re entering into a different phase within the pandemic now, but primary care will be dealing with the effects of long COVID, and what does that mean, and how will the symptoms of long COVID impact the patient population and change care delivery from that perspective, and how will that impact the needs of their patient population, and what will the differences be related to different patient populations, urban versus rural? And those are some real consequences of COVID that will be long-lasting. So, while some of the initial phases of COVID will be coming through and there will be a time when we can say the pandemic is over, there will still be long-lasting impacts for primary care that they will be dealing with.

[SUE LIN]

The COVID-19 presented unprecedented challenges for our health centers that are in the medically underserved communities. I think in 2020, you know, we learned that one in eight health center staff tested positive for COVID. On average, about seven percent of health center staff were unable to come to work. And then at the peak, it was more than 10 percent, 14 percent. And then with the availability of vaccinations, health centers were not just called to support public health mass testing efforts, also vaccination efforts.

And I think, in the process of us trying to figure out how to support the health centers, we stood up a vaccine logistic distribution process that we had never really encountered before at HRSA, so working with CDC, we got an allocation of vaccines that then were really focused on the special populations that we served in the agricultural worker population [inaudible], individuals experiencing homelessness, residents of public housing, and then patients with limited language proficiency.

So, I really think, you know, just given the level engagement and then the call from states, Departments of Health, of health centers, systems of public health, emergency, we need be very thoughtful as we go into the recovery phase, especially as Julie mentioned, long COVID. There’s so much for us to figure out and learn and how health centers, primary care overall is going to be need to be in the community to support the patients that we collectively serve in the COVID recovery.

[J.B. WOGAN]

Your comments remind me of one of my close friends from college. He works in the internal medicine. And I remember him feeling a little frustrated that a lot of the media coverage early on in the pandemic was casting a positive spotlight on those who work in emergency rooms and urgent care but maybe not lifting up those in primary care who were playing a really important role in combatting the pandemic. And it’s interesting, the interplay of primary care and public health, and the parallel conversations happening there around rebuilding the infrastructure in both fields, and how the two need to cooperate and be more integrated.

[SUE LIN]

Collectively, we are primary care champions, participating in this podcast. The best chance for patients to be safe in their community is for our primary care to thrive; right? That’s how our clinical providers can keep folks safe and not overwhelm the hospitals and ICU beds, as we saw during earlier parts of COVID.

[DIANE RITTENHOUSE]

And that will only be successful if primary care and public health are integrated, as you mentioned J.B. And I think that when you take two areas, two sectors, if you will, that are chronically under-resourced and kind of never quite given what they need to do their job well, that’s primary care and public health, and then you put a stress on that, when they’re already -- primary care was also suffering from burnout, already suffering from not enough people going in, already geographic maldistributions, et cetera, and you take public health, that we sort of tend to ignore, and it tends to have sort of anemic budgets and not enough support because we like to think, well, as long as everything is going well, we don’t want to think about public health and we don’t want to finance it. And then you take those two and you want to integrate them to support something like a pandemic, at the beginning of the pandemic, primary care doctors couldn’t even get protective gear. You know, they couldn’t get payment to see patients online. They couldn’t get -- they weren’t part of the program in terms of responding to the pandemic.

And what we’ve learned is how essential it is to have your primary care clinicians talking to patients to help, because they have those trusted relationships and they can actually go that extra mile to help patients understand the science, for example, and make sense of what they’re hearing in the news and whether or not it’s safe to get a vaccination and what a vaccination might or might not help them with, and why they’re being asked to stay at home or why they’re being asked to wear masks, or a lot of that explaining lands on the primary care doctor who has -- or the primary care team that has trusted relationships in the community.

[J.B. WOGAN]

Diane, I want to stick with you. We’ve been talking about problems, but this podcast doesn’t just stop at problems. We try to surface evidence-based solutions or things that could make things better. And you co-authored an evidence review for the California Health Care Foundation last year that looked specifically at the primary care workforce crisis in the State of California, and using past research as a guide, looked at what could help address the crisis. So, based on your research, where could policy changes make a positive difference?

[DIANE RITTENHOUSE]

Thanks for that. We were asked by the state government in California to provide some evidence to help them with their policy-making decisions. There actually had been a commission for the future health workforce in California, which is a very high-profile commission, a couple of years ago, that was both private and public, and came together, and made a bunch of recommendations about how to better support the health workforce in California.

Some of the things that -- or the question that still remained after that report was published was, well, where do we put our first dollar? We had a huge budget surplus the last couple of years in California, and it’s clear that investing in the health workforce not only helped health care and could improve health outcomes but can help the economy of the State of California, and if we work with the educational sector, we can really make changes to prep the health workforce for the future.

They wanted to know, well, where should we put our money? We have all these ideas but we just don’t know where. So we reviewed the evidence, and, you know, it was a bit of a mixed bag in that the answer was a little bit all of the above, which may be dissatisfying to someone who wants to make a quick decision. But we found that there are interventions that you can do at the high school and college level, which are typically called pipeline interventions, because they really start early on. And we were looking at the professional health workforce, so these are people who have to go through many, many, many years of school and training to come out as health professionals at the end.

And health professionals is really where we don’t have a diverse workforce or a language concordant workforce in California, so we were specifically focused on the health professions. And when you start at high school and college, you have an opportunity to gather a diverse group of people, to bring in people who speak other languages and to have the workforce pipeline better match the population.

Then there’s opportunities for scholarships, and the state and federal government can provide scholarships to college students, to graduate students, and people in training, which helps decrease the burden on someone coming from a more disadvantaged background, for example, and ease that path, because people will say, I cannot go into that field. I cannot become that sort of health professional because I am hearing that it will cost me so much money for training, and I just can’t make ends meet, given that I’m either helping to support my family or I come from a background that doesn’t have the resources. And so just the idea of the cost will scare people away, and scholarships can help with that.

Then there’s specialized training tracks and programs, where you can bring people into graduate school from certain areas of the state. You can teach them with certain emphases, saying we’re going to have a rural track program or we’re going to have an urban underserved program, we’re going to have a Spanish-speaking track, so you can really expand the training capacity in those particular tracks within the training. And then once people get out into practice, you can pay off their loans, you know. There are some really great loan repayment programs.

The question that was posed to us is, well, which of these should we invest in. And our answer was a little bit, well, it depends on what you’re trying to achieve, and you can’t only invest in one or the other. You need to sort of invest along the pipeline, because if you pay people to go practice in a certain area or you pay off their loans to get them to go practice in a certain area, that works, to some extent, in the short run. But if you want to diversify the workforce, the professional workforce over time, or you want the professional workforce, over time, to become culturally competent or language concordant, you really need to invest in those early programs and support those students all the way through their training. So lots that can be done and good evidence that supports it, but it’s not only a short-term solution. There are also long-term investments that need to be made.

[JULIE SCHILZ]

Diane, I think that part of that work and the history that your research helped to support really is part of a legacy, particularly in California, that has just created such wonderful momentum that continues, even today, to continue to support primary care and bringing the state and multiple stakeholders together in California, and it really focuses on looking at what other states are doing as well. So, the NASEM report really created a lot of energy. But there are other states; Oregon and Rhode Island that is creating an almost virtuous cycle within other states. And we got news that in New York, they just passed legislation to start a primary care commission that is intended to then move towards looking at further investments in primary care. So I think these efforts, built on research and evaluation and some of the policy levers that can be supported by all of these efforts, really help to support the continued momentum and efforts and movement.

But to your point, which ones are the right ones, sometimes we say all health care is local, so I do think it depends on what the dynamics are and what is the right levers to pull within a state. But your work was quite foundational and, I think, helped to drive the work we’re seeing today in California.

[J.B. WOGAN]

Julie, could I pick up on one thing? You mentioned some states like Rhode Island, that are investing more in primary care. And I imagine some listeners might be thinking that the direction we should be going in simply that we should all be -- every state, nationally, we should be spending more on health care, or at least more on primary care. And so I wanted to put this question to you, and maybe to others in the group, how should listeners think about the current level of investment in primary care and the allocation of dollars primary care services? Is it just a question of more or is it about spending smarter or in different ways than we currently are?

[JULIE SCHILZ]

Yes to all of the above. You know, I think when you look at where the level spending is at within your state, it’s a matter of where are you at now. What my organization has done has looked at New York. It was around five to six to seven percent, and if you look at the research, and in some cases, comparing it to some of the states that have increased spending within primary care and then you’re comparing that to other costs, then you can look at where should we be at and know that we’re getting better outcomes and value with our increased primary care spending. So I’m hedging a little bit on what the right number is, because I think you have to look at your data, you have to look at your patient population, and you have to look at where might the right investment be. But the number of around five percent, generally speaking, seems to be a level that suggests there’s an opportunity to do a higher level of investment and have better outcomes in your patient population.

[LUCI LEYKUM]

Just to pick up on that, you know, it is five to six percent of the spend nationally, and it’s 30 percent of the activity, so there is a huge mismatch between spend and activity. And when we look at the places where we’re spending money in the acute and post-acute setting, a lot of that spending could be mitigated if there was more investment on the primary care side.

[J.B. WOGAN]

Luci, to stick with you, you were part of the committee that released that report from NASEM last year on implementing high-quality primary care, and the report included a chapter on preparing the future primary care workforce. So, sticking with this idea of some solutions, what were some of the committee’s high-level conclusions and recommendations around training the primary care workforce of tomorrow?

[LUCI LEYKUM]

Yeah, you know, on the highest level, it’s saying we have to train people in high-functioning primary care settings that reflect and are integrated in the communities that they serve. And there are a lot of bright spots out there with regard to primary care that could be models for what this looks like, and when you look at some of the characteristics of those settings, true team-based care with expanded teams that can take care of the whole patient and adjusting the workflows to minimize unnecessary administrative work is such a key part of burnout.

And more specifically, the NASEM report pointed to two things. So, first, expanding and diversifying the primary care workforce, particularly in areas that are underserved, which, I think, picks up on what Diane and Julie were talking about, but more diverse trainees that really look like and are embedded in the communities that they serve. There were some recommendations about what team structures look like, with a core team that include patients, families, and caregivers, an extended health care team that includes community health workers, behavioral health, pharmacy, dental, social work, all the professions that make most sense based on the community being served, and then in this expanded community care team that brings in the other services that are relevant in each community.

And, really, what this is saying is we need to move from a physician-based model to a team-based model really, one that reflects the community. And then by doing this, we’ll allow learners and trainees to have really authentic team-based experiences that make them want to work in the setting, which leads to the second specific recommendation around CMS, VA, and HRSA redeploying and augmenting how they currently fund residency training. You know, so much of that funding goes to hospital systems. And a lot of those hospital systems have expanded and include primary care services, but it’s not quite the same as real community-embedded primary care. And so, you know, how can we redeploy dollars to go to actual hospital primary care sites and not hospital systems, and how can we make some of those funding sources more consistent from year to year? Sometimes states do have initiatives that will only be around for three years, and training programs eed to have more sustained funding in that to really invest in that workforce. So, those two recommendations around expanding and diversifying the workforce in really authentic community settings and changing the funding to support those training locations were the two recommendations in the report.

[J.B. WOGAN]

You anticipated my next question, which was, I was going to ask specifically about the relationship between creating interprofessional primary care teams and these issues around burnout and shortages in the field. Is there anything else to say here? Julie, I know this is a priority of your organization, is greater integration in primary care. How might burnout be addressed if there were bigger teams or teams that worked better together?

[JULIE SCHILZ]

Yeah, you know, I think we’ve learned about this as we’ve started to look at care delivery models, such as patient-centered medical home or accountable care models, and it’s also been the structure of federally qualified healthcare centers or community health care clinics, and in their structure. You know, historically, there was an idea that the physician had to do everything to be able to deliver care. But as patients’ health care needs became much more complex, we learned that utilizing the team, and as we really help support physicians to be able to care for their patients, and we added technology in the process as well, so the team-based care delivery also provided that support as well, and utilizing a team to be able to really become that support entity, not only for patients and their families but for the physicians as well.

But I do think, as you think about federally qualified health care centers, the idea of integrating care, whether it’s behavioral health, mental health, and as we move to addressing social determinants of health in communities, or adding oral health as well, even starting to think about vision care, really creating a care delivery that is structured to be supportive of patients and their families in the community is how we will deliver health care in a way that truly delivers health, versus fragmented care delivery that is structured to be fragmented and a very difficult system to maneuver.

[J.B. WOGAN]

I’m remembering there’s a part in the NASEM report where they’re defining high quality primary care, and the report emphasizes sustained relationships or sustained partnerships, and it explains that these relationships include families and communities. I think it also includes just more than just physicians. It envisions nurses, nurse practitioners, perhaps social workers. So that was educational for me, as somebody coming not a health care professional, not a physician, learning about how we define primary care now, and what our vision should be for the future.

[DIANE RITTENHOUSE]

So back to the problem, the job has become untenable in some ways. It’s become a job where you don’t just take care of the patient who comes in and presents with a problem -- I have back pain, I have a headache, I have a sprained wrist, or whatever -- you are being asked, as a primary care practice, to address not only the people with the conditions that they present with but all of the conditions they don’t present with, you know, all the screening, high cholesterol, or screening for diabetes, or screening for breast cancer, cervical cancer, et cetera, and then you’re asked to take care of all the patients who don’t even come into your practice but who are a part of your community or part of your population and bring those patients in for screening, or interact with them in some way to improve overall population health. So, we’re moving towards that.

But the one physician model is just not going to work, where one physician does it all. So it’s really this movement towards it takes a team. It really takes somebody who has expertise, like a pharmacist, to help someone go through their medications and get rid of medications they no longer need or cite medications causing side effects, or interactions that are problematic, or you need a social worker for the patients or populations who housing is really their issue, or food insecurity is really their issue. You may need an MA to help contact all of those patients who have diabetes but have not been coming in for care, et cetera. So it really is this team effort that I think the NASEM report emphasizes. And the FQHCs, the Federally Qualified Health Centers, have really been standout in being able to address issues in that way, and I know Sue Lin can really speak to that.

[J.B. WOGAN]

To stick with the solutions’ theme in the second half of this episode, what federal policy levers are being used or could be used to build back the pipeline in primary care workers? And to tack on a couple of additional questions that are related but maybe you’ll have to tackle them separately, how can we do it in a way that is inclusive of different demographic features, language proficiencies, cultural competencies, and why might greater inclusivity be important for high-quality care, higher-quality care.

[SUE LIN]

Yeah, J.B., thanks for the question. And, Diane, thanks for the comment on the health centers and the patient-centered medical home transformation. I think, you know, we tackle this on a federal level from the – so, in the NASEM report, they identified five key areas; right, payment, access, workforce, individual health, and accountability. In our space, we field the call to action to engage in all areas, even if it’s not especially under our legislative authority to do so.

In the payment space, you know, the report is clear that we’re moving towards value-based case. But negotiating and partnering with our colleagues at the Center for Medicare and Medicare Services on how that design will mean for health centers, will mean for primary care, is critically important to us. And we are just excited that in their most recent report, on looking at the innovation strategy that they want to implement, that health equity is a key focus, and federally qualified health centers and rural health clinics are part of that innovation strategy.

On the access piece, access is a core to the mission of our Bureau of Primary Health Care, and so in designing our funding opportunities, we continue to have that as our guiding principle and North Star in getting access to primary care to communities that have not had access to primary care before.

The workforce space, I think Diane’s report really, really articulated the different strategies that we have been trying to support across the country, with National Health Service Corps, loan repayment programs, Nurse Corps, having a health workforce connector where health centers can post positions that then can be open to anybody who is looking to serve in medically underserved communities. So, we have not left any possibility for partnership unturned in this process.

And I think in the digital health space, we knew that, at the time, you know, when folks were deferring here in 2020 pandemic, that we needed to somehow figure out a way to support bridging the digital health divide in some way. So I think, you know, in terms of making investments, you know, we have been very, very privileged to put some investments to pilot with nearly 500 health centers to support hypertension control with remote monitoring during COVID in some of the health centers. Even in very rural Alaska is showing incredible success for that.

I think in terms of moving forward, I will say that I tend to be an optimist. For us, we are launching a workforce well-being initiative, and it’s for all of the workforce across the health centers. So, we know that the patient experience begins as they enter into the health center, and then all the way into the exam room, so it is front of mind for us to support all of the workforce across the health center, all 250,000 FTEs. I think, you know, we want to be able to understand further what well-being will look like for our health center staff and then support with training and technical assistance, and the rapid deployment of promising strategies and practices to get the support to our health centers.

I think I talked about sort of the levers, federal agency collaboration, I think the NASEM report and activities at the Office of the Secretary of Health is leading the effort in that process, so that’s something that we’re really excited to be a participant in. And I think, you know, the workforce area, I think we need to think beyond HHS. So, also think about how Department of Labor, Department of Ed, you know, can be another federal partner in this process. And then I think, you know, how can we be inclusive with different demographic features and cultural competencies in our health centers.

I will say that in the Covid response, I’ve had the opportunity to meet some amazing community health workers that some have went door to door to talk to patients, talk to their families about what is the COVID vaccine, and provide just excellent health education for what they’re doing. And, you know, we call our vaccine program the “Last Mile Program,” because our touch base is over 70 percent racial ethnic minorities that have received vaccinations in our program. So that entire team-based care, from community health worker, pharmacist, social worker, to medical assistants, dental assistants, everybody that is supporting primary care integration in our clinics are critical to all of the supports, creating a wonderful patient experience.

So, I think for us, where we sit, we want to continue to support. We want to continue to invest in different demonstration quality improvement programs to help us to learn what will really, really work for our collective health center program across the country. But we’re trying out a lot of different efforts. And I think the state models that we see are incredibly informative, that Julie alluded to.

So, I will say that I previously served in two state governments prior to joining federal service. I’m a huge believer that a state-based initiative serves as a blueprint for what we can adopt at the federal level, and so those innovations and those programs that are implemented at the state level are critically important for us to learn what we can implement at the federal level.

[J.B. WOGAN]

They’re the laboratories of democracy, right? So, you’ve already kind of started us down this path. The last question I wanted to ask was, where do you see progress happening in addressing the primary care workforce crisis? Sue, you already identified a few different areas where I think people would have reason to feel optimistic. Is there anything else you would want to flag for listeners?

[SUE LIN]

Every primary care physician that I meet, and the team members, they care about everything and everybody. And so, you know, to be called upon to address the hardest problems that we have facing our community, facing public health is something that I think every passionate primary care physician that I’ve known has always said yes before there are even resources. But I think it’s really important for us to figure out the resources to sustain that, and to build momentum to really, really improve the overall population health, and just would invite everybody to be fully engaged in that dialogue and collectively think through what can we do together.

[J.B. WOGAN]

Okay. Perfect. Thank you, Sue. Luci, let me turn to you and put the same question to you. Where where do you find signs for optimism? Where do you see progress happening in strengthening primary care?

[LUCI LEYKUM]

Yeah, you know, I think there's four different areas that we could think about in terms of reasons for hope and optimism here. And the first is that there are lots of examples of success so despite, you know, what we were talking about in terms of the overall picture looking concerning, there are lots of examples of bright spots where you see really robust and vibrant primary care practices that are really well integrated into their communities and where people are flourishing and there's not a lot of turnover.

And so I think that as a field, people are becoming more aware of the bright spots and and thinking about how we can learn from them. So that's sort of area number one. The second is that there's continued evolution in reimbursement And, you know, for many of us, that's not happening fast enough. But the more we move away from a fee for service, you know, piecemeal reimbursement for primary care to something where there's a more global payment that actually supports all the infrastructure and activities for primary care, the more we do that the better.

And in fact, that was one of the key recommendations also in the NASEM report to really change that reimbursement methodology for primary care more quickly. And that's happening. The third is that we have made progress generally in implementation science. And that's really this field of how do we take things that work in one setting and apply them to another.

And so that is what helps us really learn from those bright spots as we're more and more aware of them to say, okay, you know, this works in Alaska or This works in Boston or this works in Colorado, how would we put it in our local context? And what are sort of the key themes that we can learn from their success that would work for us here?

And we're getting better and better able to do that. And finally, the professional societies are becoming much more actively engaged and involved in this issue of burnout because it's such a key issue for their constituents across the professions. And as one example, the AMA, the American Medical Association, has actually made this a major initiative in terms of combating physician burnout.

And they are developing assessment tools that practices and health systems can use to assess themselves and benchmark how their clinicians are doing compared with clinicians across the country to say, oh, you know, we're in more danger here, or we're doing some things than they seem to be having a positive impact. And part of those assessment tools get pretty granular to say, okay, what are the parts of the workflow that aren't working for you?

What things would you change? Where could you see improvements? Again so organizations can really say, Okay, here are some things that we need to do. And then we can learn from each other for how to do that well. So, lots of reasons for optimism.

[J.B. WOGAN]

It may be a funny thing to say that something negative during the pandemic could also be a reason for optimism, but I'm curious, do you think that the pandemic and the problems that were made more obvious during the pandemic have raised the profile of the primary care workforce crisis and put it on people's radars is something that needs to be addressed in a way that it hasn't, at least in recent years.

[LUCI LEYKUM]

I do think that that has been the case and probably across many of the health professions, not just primary care. Now there's a much greater recognition of the general nursing shortage in the United States, for example, as a result of what's happened with COVID. The impact on primary care has been so dire that that has been getting more attention.

And it does seem to be getting some policymaker attention. So, for example, the fact that like the telehealth and virtual health regulation changes have been continued I think is a sign that people are hearing we need to work differently in primary care, as an example. And the other piece that I think is making this more apparent is just the mental health impacts on people and the recognition that the only way that we're going to be able to really successfully engage with people to help them be more healthy and feel better is to do it in the context of their communities and lives.

And the only way that's going to happen is in primary care.

[J.B. WOGAN]

Well, certainly, I think primary care workers are not the only ones who have been experiencing burnout during the pandemic. And perhaps that has created conditions or an environment where you have a more empathetic public who understands what it's like to be feeling burnt out in your job and needing some more resources and supports.

[LUCI LEYKUM]

Yes. Hopefully we're all a lot more empathetic about each other.

[J.B. WOGAN]

Same question, but to you, Julie, help us end on a helpful note, where do you see progress happening?

[JULIE SCHILZ]

Well, I think Sue Lin mentioned just the cross-collaboration. I’m seeing that on the federal level like I haven’t ever seen before. But I’m also seeing just such an openness, whether it’s in a local community, whether it’s across different disciplines, as Diane mentioned, between primary care and public health, whether it’s state to federal level, whether it’s one state with another state, different disciplines talking among each other. There’s a true cross-collaboration to focus on delivering quality care and really moving upstream, thinking about social determinants of health, supporting primary care, moving from an after-the-fact disease process focused, while we’re taking care of individuals from that perspective, but moving to prevention and wellness and community-focused care. And I think that’s just an incredible focus on health and helping communities that I’m seeing.

[J.B. WOGAN]

Diane, take us home. Where do you find optimism? Where are you seeing progress?

[DIANE RITTENHOUSE]

Well, I’m sitting in the most populous state in the country, and we have an enormous budget surplus, and so what I’m pleased to see is the investment in health and wellness across the state. And when it comes to the primary care workforce crisis, I see investments in behavioral health, counselors for youth, for example, in a new community health worker program. Some of these elements of the workforce are relatively new, not necessarily licensed, not necessarily certified, and it isn’t exactly clear how the primary care team is most efficiently laid out in particular settings. And I see experimentation with that.

I see a willingness to invest, at least at the state level. I see willingness to invest in new residency programs for primary care physicians, especially in areas of the state where there haven’t been them in the past, where people can train and stay close to where they train. So I see an openness and an awareness of the problem that I haven’t seen in the past, and a lot of credit in California goes to the foundations and philanthropy that funded the Future Health Workforce Commission and really got some of these ideas off the ground and created some momentum so that the state could then move to act.

[Music].

[J.B. WOGAN]

Thanks again to my guests, Sue Lin, Luci Leykum, Julie Schilz, and Diane Rittenhouse. And thanks to Rick Stoddard at Mathematica, who produced this episode and made us all sound so good. Finally, thank you for listening to another episode of On the Evidence, the Mathematica podcast. As I mentioned at the top of the episode, a full transcript of the episode, along with links to any research we referenced in the conversation, will be listed in the episode’s show notes and on a blog at Mathematica.org.

Mathematica is co-hosting a Twitter chat later this month on June 23rd from 2 p.m. to 3 p.m. Eastern Standard Time on challenges and opportunities for the primary care workforce; if the topic of this episode hits close to home, please consider participating in the Twitter chat. You can find that chat, as well as past Twitter chats about primary care, using the hashtag #PrimaryCarePolicyChat, all one word. Stay up to date on the primary care Twitter chat, as well as future episodes of the podcast, by following us on Twitter. I’m at JBWogan. Mathematica is at MathematicaNow.