Building a Value-Based Workforce in North Carolina

Health care in the United States is likely to change more in the next 10 years than in any previous decade. However, changes in the workforce needed to support new care delivery and payment models will likely be slower and less dramatic. In this issue of the NCMJ, experts from education, practice, and policy reflect on the "state of the state" and what the future holds for multiple health professional groups. They write from a broad range of perspectives and disciplines, but all point toward the need for change-change in the way we educate, deploy, and recruit health professionals. The rapid pace of health system change in North Carolina means that the road map is being redrawn as we drive, but some general routes are evident. In this issue brief we suggest that, to make the workforce more effective, we need to broaden our definition of who is in the health workforce; focus on retooling and retraining the existing workforce; shift from training workers in acute settings to training them in community-based settings; and increase accountability in the system so that public funds spent on the health professions produce the workforce needed to meet the state's health care needs. North Carolina has arguably the best health workforce data system in the country; it has historically provided the data needed to inform policy change, but adequate and ongoing financial support for that system needs to be assured

When access-to-care indicators meet. Designated shortage areas and avoidable hospitalizations.

PARCHMAN AND Culler, in this issue of the ARCHIVES, explore the difficult terrain of primary health care system assessment. Their work integrates 2 important measures of the primary care delivery system: the health professional shortage area (HPSA) classification of primary care access and the ambulatory care–sensitive (ACS) admission count, an emerging outcome measure of the adequacy and effectiveness of primary care services. In controlled analyses, they found that among elderly patients in fair or poor health, those who lived in HPSAs had a greater likelihood of experiencing an ACS admission than similar individuals in nonshortage counties

Counting physicians in specialties: By what they do or how they train?

The number of actively practicing physicians in the United States is not precisely known, nor do we know the total number of physicians required to meet population needs. The possible gap between these two numbers is a controversial issue, especially for primary care physicians. Primary care physicians can be counted in more than one way, either by their "area of practice" (in other words, what they do) or by the specialty in which they train. Regulatory agencies and other health organizations see the area of practice as more relevant to understanding physician supply. In North Carolina, the counts of primary care physicians were historically based on specialty of training. In 2010, the way physicians were counted was changed from definition by specialty of training to definition by area of practice, which resulted in an apparent drop in the number of primary care physicians by more than 16% in a single year. When terms such as "hospitalist," "urgent care," "student health," and "integrative medicine" were added to describe additional practice areas of physicians, most of the loss was accounted for. Researchers, regulators and policy makers need to be aware of the effects of a shift in how physicians are counted and assigned to specialties to understand the extent of pending shortages

Future supply of pediatric surgeons

Objective: To describe the future supply and demand for pediatric surgeons using a physician supply model to determine what the future supply of pediatric surgeons will be over the next decade and a half and to compare that projected supply with potential indicators of demand and the growth of other subspecialties. Background: Anticipating the supply of physicians and surgeons in the future has met with varying levels of success. However, there remains a need to anticipate supply given the rapid growth of specialty and subspecialty fellowships. This analysis is intended to support decision making on the size of future fellowships in pediatric surgery. Methods: The model used in the study is an adaptation of the FutureDocs physician supply and need tool developed to anticipate future supply and need for all physician specialties. Data from national inventories of physicians by specialty, age, sex, activity, and location are combined with data from residency and fellowship programs and accrediting bodies in an agent-based or microsimulation projection model that considers movement into and among specialties. Exits from practice and the geographic distribution of physician and the patient population are also included in the model. Three scenarios for the annual entry into pediatric surgery fellowships (28, 34, and 56) are modeled and their effects on supply through 2030 are presented. Results: The FutureDocs model predicts a very rapid growth of the supply of surgeons who treat pediatric patients - including general pediatric surgeon and focused subspecialties. The supply of all pediatric surgeons will grow relatively rapidly through 2030 under current conditions. That growth is much faster than the rate of growth of the pediatric population. The volume of complex surgical cases will likely match this population growth rate meaning there will be many more surgeons trained for those procedures. The current entry rate into pediatric surgery fellowships (34 per year) will result in a slowing of growth after 2025, a rate of 56 will generate a continued growth through 2030 with a likely plateau after 2035. Conclusions: The rate of entry into pediatric surgery will continue to exceed population growth through 2030 under two likely scenarios. The very rapid anticipated growth in focused pediatric subspecialties will likely prove challenging to surgeons wishing to maintain their skills with complex cases as a larger and more diverse group of surgeons will also seek to care for many of the conditions and patients which the general pediatric surgeons and general surgeons now see. This means controlling the numbers of pediatric surgery fellowships in a way that recognizes problems with distribution, the volume of cases available to maintain proficiency, and the dynamics of retirement and shifts into other specialty practice