and the Health Workforce Chapter 9: Health Professionals and the Health Workforce

Introduction What is Meant by Primary, Secondary and Tertiary Care? How Are Clinical Health Professionals Rewarded and Compensated for Their Services? How Can We Ensure the System Has the Right Number of Health Professionals?

Scenarios Health Professionals and the Health Workforce In the hospital the nurse specialist examines you and consults with the radiologists, the gastroenterologist, and the general surgeon. Your medication is reviewed by the PharmD, and your meals by the clinical nutritionist. Throughout your hospitalization you are followed by a hospitalist. Once you get back home the home care team comes to see you regularly for the first two weeks and the physician assistant and registered nurse see you in the office. You realize that health care is no longer just about doctors and nurses. You ask yourself, what roles do all of these health professions play?

Scenarios Health Professionals and the Health Workforce Jenna decides that after college she wants to become a doctor and practice medicine, thinking there was only one kind of doctor who could diagnose disease and prescribe medicine. Not so any more, says her advisor. There are allopathic and osteopathic physicians. In addition there are nurse practitioners who are often authorized to diagnose and prescribe medication as well as physician assistants who do the same under a physician’s supervision. Doctors now include doctors of nursing practice as well as others with doctoral degrees such as pharmacists and physical therapists. Understanding careers in health care can be as difficult for students as it is for patients, you think to yourself. Now she understands why her advisor asked: “What do you mean by practice? What do you mean by doctor?”

Scenarios Health Professionals and the Health Workforce Sarah was about to begin medical school and was expecting two years of “preclinical” classroom lectures focusing on the basic sciences followed by the study of clinical diseases. Then she expected two years of clinical hospital” rotations” and electives checking out specialties like she’d heard about from her physician dad. She is surprised to find that medical school has changed. There are small group, problem-based learning sessions where she needs to be able to locate and read the research literature. There is contact with patients and their problems right from the beginning. There is increasingly a four year approach instead of a preclinical and clinical approach to medical education. She wonders: are these changes for the better? What else needs to be done to improve medical education?

Scenarios Health Professionals and the Health Workforce You are interested in clinical care as well as public health. “I need to make a choice you think to yourself.” “Not necessarily,” your advisor says, “there are many ways to combine clinical care with public health.” After a little investigation you find out that undergraduate public health education is increasingly seen as preparation for clinical education, and clinical prevention & population health is increasingly becoming part of clinical care. In addition many careers from health administration to health policy to clinical research combine the individual orientation of clinical care with the population perspective of public health. So what’s the best pathway to public health for you?

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Allergy and Immunology Allergy and Immunology   American Board of Anesthesiology Anesthesiology Critical Care Medicine Hospice and Palliative Medicine1 Pain Medicine American Board of Colon and Rectal Surgery Colon and Rectal Surgery

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Dermatology Dermatology Clinical and Laboratory Dermatological Immunology Dermatopathology Pediatric Dermatology American Board of Emergency Medicine Emergency Medicine Hospice and Palliative Medicine1 Medical Toxicology Pediatric Emergency Medicine Sports Medicine Undersea and Hyperbaric Medicine American Board of Family Medicine Family Medicine Adolescent Medicine Geriatric Medicine Hospice and Palliative Medicine1 Sleep Medicine Sports Medicine

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Internal Medicine Internal Medicine Adolescent Medicine Cardiovascular Disease Clinical Cardiac Electrophysiology Critical Care Medicine Endocrinology, Diabetes and Metabolism Gastroenterology Geriatric Medicine Hematology Hospice and Palliative Medicine1 Infectious Disease Interventional Cardiology Medical Oncology Nephrology Pulmonary Disease Rheumatology Sleep Medicine Sports Medicine Transplant Hepatology

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Medical Genetics Clinical Biochemical Genetics Clinical Cytogenetics Clinical Genetics (MD) Clinical Molecular Genetics PhD Medical Genetics Medical Biochemical Genetics4 Molecular Genetic Pathology American Board of Neurological Surgery Neurological Surgery   American Board of Nuclear Medicine Nuclear Medicine

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Obstetrics and Gynecology Obstetrics and Gynecology Critical Care Medicine Gynecologic Oncology Hospice and Palliative Medicine1 Maternal and Fetal Medicine Reproductive Endocrinology/Infertility American Board of Ophthalmology Ophthalmology   American Board of Orthopaedic Surgery Orthopaedic Surgery Orthopaedic Sports Medicine Surgery of the Hand

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Otolaryngology Otolaryngology Neurotology Pediatric Otolaryngology Plastic Surgery Within the Head and Neck Sleep Medicine American Board of Pathology Anatomic Pathology and Clinical Pathology Pathology - Anatomic Pathology - Clinical Blood Banking/Transfusion Medicine Chemical Pathology Cytopathology Dermatopathology Forensic Pathology Hematology Medical Microbiology Molecular Genetic Pathology Neuropathology Pediatric Pathology

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Pediatrics Pediatrics Adolescent Medicine Child Abuse Pediatrics2 Developmental-Behavioral Pediatrics Hospice and Palliative Medicine1 Medical Toxicology Neonatal-Perinatal Medicine Neurodevelopmental Disabilities Pediatric Cardiology Pediatric Critical Care Medicine Pediatric Emergency Medicine Pediatric Endocrinology Pediatric Gastroenterology Pediatric Hematology-Oncology Pediatric Infectious Diseases Pediatric Nephrology Pediatric Pulmonology Pediatric Rheumatology Pediatric Transplant Hepatology Sleep Medicine Sports Medicine

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Physical Medicine and Rehabilitation Physical Medicine and Rehabilitation Hospice and Palliative Medicine1 Neuromuscular Medicine3 Pain Medicine Pediatric Rehabilitation Medicine Spinal Cord Injury Medicine Sports Medicine American Board of Plastic Surgery Plastic Surgery Plastic Surgery Within the Head and Neck Surgery of the Hand

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Preventive Medicine Aerospace Medicine Occupational Medicine Public Health and General Preventive Medicine Medical Toxicology Undersea and Hyperbaric Medicine

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Psychiatry and Neurology Psychiatry Neurology Neurology with Special Qualifications in Child Neurology Addiction Psychiatry Child and Adolescent Psychiatry Clinical Neurophysiology Forensic Psychiatry Geriatric Psychiatry Hospice and Palliative Medicine1 Neurodevelopmental Disabilities Neuromuscular Medicine3 Pain Medicine Psychosomatic Medicine Sleep Medicine Vascular Neurology

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Radiology Diagnostic Radiology Radiation Oncology Radiologic Physics Hospice and Palliative Medicine1 Neuroradiology Nuclear Radiology Pediatric Radiology Vascular and Interventional Radiology American Board of Surgery Surgery Vascular Surgery Hospice and Palliative Medicine1 Pediatric Surgery Surgery of the Hand Surgical Critical Care

Selected Specialties and Sub-specialties of Medicine General Certificate(s) Subspecialty Certificates American Board of Thoracic Surgery Thoracic Surgery Congenital Cardiac Surgery4 American Board of Urology Urology Pediatric Urology

Ideals and Realities of Primary Care Primary care ideals Realities Contact The point of first contact  with the health care system—the entry point Patients enter the health care systems through many disconnected points including: ER, specialists, urgent care centers, nontraditional practitioners, etc.

Ideals and Realities of Primary Care Primary care ideals Realities Comprehensive Primary care intends to be able to diagnose and treat the great majority of problems Rapid increase in possible treatments and high-volume practices increase proportion of patient problems that are referred to specialists

Ideals and Realities of Primary Care Primary care ideals Realities Coordinated Primary care intends to be the focal point for diagnosis and treatment with coordination through referral to specialists for consultation and feedback Primary care physicians increasingly being replaced by "hospitalists," who are full time in the hospital and provide care for inpatients and direct patient access to specialists

Ideals and Realities of Primary Care Primary care ideals Realities Continuity Patient followed over many years—continuous care provision Patients increasingly required or encouraged to change physicians/providers for insurance purposes

Ideals and Realities of Primary Care Primary care ideals Realities Caring Individualized care based on individual relationships Primary care increasingly becoming an administrative entity without long-term individual relationship

Ideals and Realities of Primary Care Primary care ideals Realities Community Primary care designed to connect the individual patient with community resources and community requirements (required examinations, reportable diseases, vaccinations, driver’s licenses, etc.) Health care professionals and public health have long history of distant and—at times—contentious relationships  [J1][AU – Contract or contact?] contact

Methods of Financial Compensation to Providers of Health Services Compensation method Meaning Examples Advantages Disadvantages Fee-for-service Clinician paid for each covered service Physicians often paid for medical visits and procedure, but may not be paid for counseling for prevention Reward linked directly to work Performed Encourages efficiency of delivery of services May encourage unnecessary, as well as Necessary

Methods of Financial Compensation to Providers of Health Services Meaning Examples Advantages Disadvantages Capitation Clinician is paid a set amount per time period for each patient for whom they are responsible, regardless of level of use of services Primary care physicians in health plans may be paid a set amount per patient per month and are expected to provide all primary care Discourages Unnecessary care, may Encourage preventive care, allows for Predictable budgeting May Discourage necessary care, may encourage referral to Specialists unless specialty care is financially discouraged

Methods of Financial Compensation to Providers of Health Services Meaning Examples Advantages Disadvantages Episode of care Institution or clinician is paid a set amount for providing Comprehensive services, such as hospital treatment based on the patient’s diagnosis Medicare pays for hospital care based on Diagnosis Related Groups (DRGs) Allowing defined number of days per condition Encourages rapid and Efficient delivery of care May encourage discharge prior to ability to provide self-

Methods of Financial Compensation to Providers of Health Services Compensation method Meaning Examples Advantages Disadvantages Salary Set amount per time period Governmental facilities generally pay clinicians on a seniority-based salary May allow focus on quality May discourage efficiency

Methods of Financial Compensation to Providers of Health Services Meaning Examples Advantages Disadvantages Pay for Performance “P4P” adjusted based on measures of the quality of care delivered Additional for adherence to evidence Based guidelines Links income with quality Providing Strong incentive for quality Difficult to measure quality Outcomes maybe related to factors Outside clinician’s control

Health Care System Health Professionals Health Care Institutions Financing