1. Thomas C. Ricketts, PhD, MPH Two Views on Health Reform and Workforce

2. The negative, cynical view Congress added to the existing macro-policy of “nudging” workforce market behavior through profession- specific, producer-focused, grant- structured programs.  Little assessment of past performance  No unifying goals stated A Policy-Recommending Commission has been created with no clear guidance over how they are to influence policy—and no appropriation. A potential rival to the GME “1000-pound gorilla” may emerge in the Community Health Center Trust. Teaching centers and primary care extensions may create conflict.

3. The positive, constructive view Experimentation is encouraged via many new approaches  Teaching health centers, a natural extension of current activities gives momentum to multiple programs  Outreach structures, that can build on successful AHEC-like activities, can unify the system  There is a potential for the expanded programs to create a “tipping-point” for primary care  Institutionalizing nurse leadership and acceptance of new professional roles will help meet needs and produce efficiencies Structures for coordination across (all) workforce stakeholders are recognized if not encouraged

4. Doctors and Reform: New Stuff New support for Trauma Care (a bona fide success) New incentive for surgeons in HPSAs Pediatric subspecialist loan repayment Redistribute GME slots to primary care, count OPT time ACA has a strong primary care bent and assumes primary care can Lower costs and Improve Outomes  NHSC and Teaching Health Centers  Primary Care Grants to schools  Bonus to primary care  Primary Care Extension Centers (AHRQ)

5. Doctors and Reform: Unresolved Regulatory  ACOs and balance between generalists and specialists  Medical Homes and the same  Geographic adjustments to payment  Relative Value (RVUs) and Bundling Legislative  SGR and Medicare payments  Tort reform  GME in general

6. Meanwhile…medicine will be affected by… Policy for Nurse Practice: A big report from some nursing advocates lays claim to an expanded share of the primary care need.  Medicine replies with a strong demurral, but in the words of a leader of one discipline: “We haven’t solved the primary care problem ourselves” Expansion “on the edge” continues with  new medical schools, programs and plans  CNPs (Creative New Practitioners) emerging to soak up the prevention benefit under Medicare

7. Who, what where, when, why, how? Who: Will program advocacy define roles (Grinch) What: Is there potential for a new interprofessional policy culture? (Pollyanna) Where: The states have wildly different cultures and conditions that affect the “mix” of policy approaches When: The urgency of “reform” runs up against the realities of training cycles—inevitable frustration. Why: Have we turned a corner to patient and community centered-ness? Will we now have clearer workforce policy How: Will the money run out? Will it get off the ground?

8. Grinch or Pollyanna, you choose Thomas Ricketts (919) 966-5541 ricketts@schsr.unc.edu