new in the united states? - oecd.org - oecd presentation...national experiences in health workforce...
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National Experiences in Health Workforce Modeling: What’s
New in the United States?
Erin P. Fraher PhD MPP Assistant Professor, Departments of Family Medicine and Surgery
University of North Carolina at Chapel Hill
OECD Expert Meeting on Health Workforce Planning 17 September 2012
This project is funded by a grant from the Physicians Foundation.
Caveat: Health Workforce Modeling in the United States Not Directly Connected to Policy Decisions
Even with workforce pressures of health reform, the United States does not “workforce plan”
Reform legislation created: National Health Workforce
Commission (not funded)
Center for Health Workforce Analysis
Modeling efforts underway by government, academia and private sector
This project is funded by a grant from the Physicians Foundation.
And Even in a Country That Does Workforce Planning, They Say….
Some of the so-called ‘failures’ of workforce planning…have been less about problems with planning and more about
unrealistic expectations on the part of policy-makers, who have not recognised
the limitations... Nevertheless, the system can be improved…
Imison C, Buchan J, Xavier S. “NHS Workforce Planning: Limitations and Possibilities.” The Kings Fund, 2009. http://www.kingsfund.org.uk/publications/nhs_workforce.html
This project is funded by a grant from the Physicians Foundation.
Modeling Efforts Underway by United States Federal Government
Center for Workforce Analysis is a center within the Health Resources and Services Administration
Schedule for Health Workforce Forecasting in the U.S.
2012: Design integrated model for physicians, nurse practitioners, and physician assistants
2013: Redesigning nursing and oral health workforce models
2014: Updating model for physicians, NPs, and PAs
2015: Designing new model for allied health workforce
2016: Update nursing models and projections
This project is funded by a grant from the Physicians Foundation.
Federal Health Workforce Forecasting Priorities in the U.S.
Integrated Forecasting Systems – currently bringing together projections of physicians, nurse practitioners, and physician assistants
Allows simulation of team-based care and substitution
Enhanced Scenario Modeling – future will emphasize need for nimble, flexible models
Allows models to simulate effect of various scenarios
Identify specific metrics to track scenarios
This project is funded by a grant from the Physicians Foundation.
Federal Health Workforce Forecasting Priorities in the U.S. (continued)
Distributional Issues – moving toward modeling at sub-national levels
National figures mask significant variation at the state and local level.
Microsimulation – contracts awarded in September 2012 to build supply and demand models that simulate employment and care-seeking behavior of individual practitioners and patients
Hope to improve accuracy, facilitate local-area modeling, and enhance options for scenario-building
This project is funded by a grant from the Physicians Foundation.
Federal Health Workforce Forecasting Priorities in the U.S. (continued)
Supply/Demand Interactions – quantify ways in which workforce supply and demand interact
Goal: produce more realistic assessments of how labor markets adapt to shortages and build dynamic models accounting for interactions
Economic Impacts – define impact of recession on employment and care-seeking behavior
Goal: understand influence of economic drivers on workforce participation rates for physicians and nurses in 2012
This project is funded by a grant from the Physicians Foundation.
Critiquing Current Models (a partial list of overgeneralizations and limitations)
“Stock and flow” models assume relatively homogenous physician stocks “Can’t be a little bit pregnant”
National models
Silo-based by physician specialty, do not allow for:
Heterogeneity in scope of services within specialties (not all doctors have similar scope of service)
Degree of heterogeneity varies between specialties (some specialties have doctors with similar scopes)
Proprietary (read: black box) & uncustomizable models
Limited ability to evaluate and compare scenarios
This project is funded by a grant from the Physicians Foundation.
UNC’s Physician Projection Model Aims to Build, and Improve, on Past Models
Goal: Create open source physician projection model that incorporates numerous innovations
Conceptual: concept of “plasticity”—multiple potential configurations of specialties can meet community’s health care needs
Methods: agent-based modeling reflects “real world” uncertainty of individual physicians’ decisions about how much, where and in what clinical areas to practice
Process: model NOT based on full data availability; incorporates clinical input to check “face validity” of findings
Usability: open source design facilitates interactions and (debate!) among workforce policy stakeholders
This project is funded by a grant from the Physicians Foundation.
Model Framework in Three Pieces
This project is funded by a grant from the Physicians Foundation.
Forecasting the Utilization of Physician Services
Modeling utilization, not demand and not need
Forecasting use of physician services for population in defined geography:
in four medical settings: physician offices, hospital inpatient settings, hospital outpatient settings and emergency departments
for 18 Clinical Service Areas (e.g. respiratory conditions, circulatory conditions, endocrinology, mental health, etc.)
This project is funded by a grant from the Physicians Foundation.
Aggregating from Individual to Estimates of County Utilization
Using data on patient-level characteristics and health care utilization patterns, we extrapolate from individual- to county-level utilization
Example: If males use 1.5 visits and females use 2.5 visits, then if 40% of the county is male, the mean visits for the area is .4 * 1.5 + .6 * 2.5 = 2.1 visits
This project is funded by a grant from the Physicians Foundation.
And Allows Contextual Factors to Have Differing Effects Across Types of Services
Predicted Mental Health and Respiratory Office-Based Visits (OBV) Per Capita
.3
.35
.4
.45
OB
V p
er
cap
tia
10 15 20 25 30 County poverty rate
Mental Health
Respiratory
North Carolina counties (N=100). Predicted utilization based on MEPS 2009 and county-level data.
OBV per capita
This project is funded by a grant from the Physicians Foundation.
Forecasting the Supply of Physician Services
Retirements Attrition
Training Pipeline Ratio
HC/FTE
Current
workforce
Projected
future
workforce
Diffusion
Re-entry
This project is funded by a grant from the Physicians Foundation.
Forecasting Physician Supply
Uses agent-based modeling to simulate location choices, workforce participation rates and decisions about which clinical services physicians provide
Forecast supply by headcount and full-time equivalents for 35 specialty groupings
Newly trained and existing workforce are diffused out to different geographies according to different “push” and “pull” factors
This project is funded by a grant from the Physicians Foundation.
County A
County B
County C County D
2012
This doc retires
This project is funded by a grant from the Physicians Foundation.
2013 County A
County B
County C County D
Spike in demand for services provided by
Squares
This project is funded by a grant from the Physicians Foundation.
2014
No substantive changes – stay where I am, maybe I reduce my
hours because I had a baby
County A
County B
County C County D
This project is funded by a grant from the Physicians Foundation.
2015 A new square finishes residency and moves to the area
Decrease in relative demand in County B makes County A more appealing
County A
County B
County C County D
This project is funded by a grant from the Physicians Foundation.
2016
Approaching retirement age. County D (a rural area) has more appealing amenities for near-retirement age
County A
County B
County C County D
This project is funded by a grant from the Physicians Foundation.
2017
Retirement
County A
County B
County C County D
This project is funded by a grant from the Physicians Foundation.
Mapping Services to Providers
Key decision: no silo-based modeling
Recognize that services provided vary across, and within, specialties
How to model a specialist’s range of services?
We refer to this concept as “plasticity”
This project is funded by a grant from the Physicians Foundation.
Scopes of Services for 10 GP/FP in NAMCS
Respiratory
Circulatory
Endocrine
Skin
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10
Endocrine/immunity
Mental
Nervous system
Circulatory
Respiratory
Skin
Musculoskeletal
Symptoms & signs
Other
A Random Sample of Ten GPs/FPs has Heterogenous Scopes of Services
Individual GP/FP
Services Provided
Pe
rce
nt
of
Vis
its
This project is funded by a grant from the Physicians Foundation.
Infectious
Neoplasms
Skin
Symptoms & Signs
Other
Services Provided
…But Dermatologists Provide Relatively Similar Scopes of Services
Scopes of Services for 10 Dermatologists in NAMCS
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10
Pe
rce
nt
of
Vis
its
Individual Dermatologists
…mostly “skin” and cancer.
This project is funded by a grant from the Physicians Foundation.
Takeaway on “Plasticity”
Heterogeneity in scope of service varies within specialty (not all doctors have similar scope of service)
Degree of heterogeneity varies across specialty (some specialties have more similar doctors)
Key question: What determines the specific scope of services among physicians with similar training?
Are they responsive to relative local demands? How much?
This project is funded by a grant from the Physicians Foundation.
Our Approach to Modeling Plasticity: A Sample Matrix
SPECIALTY Neoplasms Circulatory Respiratory Pregnancy/ch
CARDIOLOGY (HEART) 145,802 23,684,068 593,326 898
DERMATOLOGY (SKIN) 11,913,249 154,326 187,179 16,234
FAMILY PRACTICE 1,772,218 26,485,370 19,943,025 1,264,030
GYNECOLOGY/OBSTETRICS 2,575,715 496,124 17,533 29,821,750
INTERNAL MEDICINE 1,545,030 18,097,752 5,496,049 32,315
Within a CSA, how are visits distributed across specialties
34%
0%
38%
1%
26%4% 54% 40% 3%
Within a specialty, how are visits distributed across CSAs?
This project is funded by a grant from the Physicians Foundation.
How Do We Map Services to Providers? A Five-Step Process
Step 1: Model health care utilization of community as function of individual- and contextual-level factors
Step 2: Collect data on local physician supply
Step 3: Allocate physician visits across specialties according to national averages
Step 4: Allow physicians to adjust their service portfolio to account for variations in local utilization of services and availability of other providers in area
Step 5: Compare capacity for visits for a particular Clinical Service Area to the predicted utilization of that health service
This project is funded by a grant from the Physicians Foundation.
How Does the Model Account for Uncertainty?
Best guess is shown, but can also see range of likely outcomes
This project is funded by a grant from the Physicians Foundation.
Comparing Policies
Comparing status quo with a new policy
Short run versus longer term
Sense of “how sure” policy will make difference
800
09
00
01
00
00
110
00
120
00
Ph
ysic
ian
s
2012 2014 2016 2018 2020 2022Year
Status Quo Policy A
This project is funded by a grant from the Physicians Foundation.
Contact info
Erin Fraher, PhD
Principal Investigator
919-966-5012
http://www.healthworkforce.unc.edu