1. Health Career Education: The United States’ System Leadership Summit International Hospital Federation Chicago, Illinois June 2, 2010 James Bentley, Ph.D. Silver Spring, Maryland

2. Core USA Environment NOT driven by a unified, national policy on workforce needs for health care INCREMENTAL policies based on: –Political pressures –Insurance product competitiveness –Cost containment initiatives –U.S. Constitution: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”

3. Underlying Policy Conflicts Is education for health careers: –Personal advancement or social need? Social need for workforce Social need for economic development –Personal financial benefit or enterprise financial investment?

4. Four Distinct Tiers Physicians and surgeons Registered Nurses, pharmacists Therapists, technologists Technicians, nursing assistants

5. Common Elements Accreditation of training programs by non- governmental organizations Licensure of individuals by state governments –Varying scope of practice laws –Varying reciprocity Certification of education and competence by non-governmental organizations

6. Physicians and Surgeons Undergraduate college and medical school –Limited direct federal support beyond student loans Indirect support through –Research grants –Faculty fees for professional services –Frequent state support for institution and in-state residents Residency and Fellowships –Accredited by private agency –Trainees paid by hospitals –Hospitals financed residency costs with multiple streams Medicare: explicit payments Medicaid: variety of payment mechanisms Commercial insurers: not explicit

7. Resident Education Payment Evolution #1 Before WWII –Residents received room and board –Staffed charity clinics –Volunteer faculty supervision 1946-1950s –Insurers paid hospital charges in full or part 1960s –Blue Cross plans in Northeast moved to cost reimbursement to compete and contain costs

8. Resident Education Payment Evolution #2 1965: Medicare –Adopted cost reimbursement for contain expenses –Residents included in hospital costs, not physician fees –Medicare would pay its share UNTIL community began supporting (if 1/3 of patients, 1/3 of costs) 1980s –Medicare moved to fee schedule for hospital care Included Direct Graduate Medical Education payments –for trainee stipends, faculty supervision, overhead Included Indirect Medical Education payments –for the atypical costs of teaching hospitals (including case mix)

9. Tier Two: Registered Nurses Pre-1960 –Primarily hospital-based diploma schools Room and Board Apprenticeship model –Limited college programs 1960-today –Primarily community colleges and university colleges –Payment Medicare: Limited payments for “clinical education” but not classroom education Other payers: No distinct payment

10. Tier Three: Therapists/Technologists Originally hospital-based program on apprentice mode Now, primarily college and university based Payment –Medicare: Limited payments for “clinical education” but not classroom education –Other payers: No distinct payment

11. Tier Four: Technicians/Assistants Originally hospital-based program on apprentice mode Now, primarily college and university based Hospital programs supported by general hospital revenues without distinct funding from payers

12. Current Policy Concerns Uneven geographic distribution Excessive specialization Rigid “scope of practice” rules Lack of articulation between careers Projected shortages Education for physicians –High student debt –Approriateness of work hours

13. Discussion and Questions