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

2. 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?

3. 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?

4. 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?”

5. 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?

6. 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?

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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.

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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-

28. 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

29. 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

30. Health Care System Health Professionals Health Care Institutions
Financing