Health & Medicine Policy Research Group hosted a forum, “Health Reform and the Health Care Safety Net: Challenges and Opportunities,” on July 9 to explore the potential impact of health reform on the health care safety net nationally and in Illinois specifically. The forum explored challenges and opportunities presented by health reform in Illinois, and examined the impact on community health centers, safety net hospitals, the health workforce, and vulnerable populations. Speakers included *Michael McRaith, Director, Illinois Department of Insurance *Julie Hamos, Director, Illinois Department of Healthcare and Family Services *Claudine Swartz, Assistant Vice President for Policy, National Association of Public Hospitals and Health Systems (NAPH) *Bill Foley, CEO, Cook County Health & Hospitals System *Philippe Largent, VP for Government Affairs, IL Primary Healthcare Association *Linda Murray, Chief Medical Officer, Cook County Department of Public Health, President-Elect, APHA *Roberta Rakove, Senior Vice President, Government Affairs, Sinai Health System

1. Workforce Issues :
Patient Protection
& Affordable Care
Act - 2010
Linda Rae Murray M.D. MPH
Cook County Department of Public Health

2. U.S. HEALTH WORKFORCE, 2004
Health
professions &
Health Care Occupations
Settings
4.5 million 4.2 million
8.6 million
other health
health
workers professionals
professionals The U.S. health
workforce consists of
over 17 million
workers and
comprises almost
12% of the total
workforce.

3. Average Annual Number of
Physician Visits per Capita, 2007
8
7.5
7.0
7
6.3 6.3 6.3
* Americans have fewer 6
5
5.8
5.7
5.0
4.7
physicians 4
4.0
3.8
2.8
3
2
* We see them less often 1
0
GER ITA** AUS FR OECD CAN* NETH UK NZ SWITZ US* SWE*
Median
* About 70% are specialists Number of Practicing Physicians
per 1,000 Population, 2007
and only 30% primary care
4 3.9 3.9 3.9
3.7
3.6
3.5
3.4
3.2
*Most OCED nations have 3 2.8
2.5
2.4
2.3
2.2
50-60% primary care 2
doctors 1
0
NETH NOR SWITZ ITA SWE* GER FR OECD AUS* UK US NZ CAN
Median

4. Obesity (BMI>30) Prevalence Among
Mortality Amenable to Health Care Adult Population, 2007
34.3
35
30
26.5
25 24.0
20
15.4
15 13.6
11.2
10.5 10.2 9.9
10 9.0
8.1
5
0
US* NZ UK CAN GER** NETH FR* SWE ITA NOR SWITZ
Potential Years of Life Lost Because of
Diabetes
per 100,000 Population, 2007
99
100
80
64
60
Generally speaking: the
37
health status of Americans is 40 36 36 35 33 31 29
25
WORSE than comparable 20
19
nations. 0
US** NZ** NOR* SWE* OECD GER* NETH ITA* FR* UK SWITZ*
Median

5. Flexner Report : 100 Years
• Published in June, 1910
• Brother of the President of the
Rockerfeller Institute
• Reformed medical education
• Modeled after John Hopkins
– Which was modeled on Germany
• Schools eagerly cooperated in
survey hoping for funds

6. Actual decrease in Medical Schools
compared to recommendations

7. Impact of the Flexner Report
Number of Medical
Schools • Flexner report saw a
51% decrease in
200
160 166 medical schools after
150 it was issued
Flexner Report 1910
100 81
• Driven by a $500
75
52 million investment in
50 reforming medical
schools
0
1850 1870 1900 1904 1922

8. Flexner Report
… The Negro must be educated not for his own
sake, but for ours. He is, as far as the human eye
can see, a permanent factor in the nation. He has
rights and due value as an individual. But he has
besides the tremendous importance that belongs
to a potential source of contagion….. Of the seven
medical schools for Negroes in the United States,
five are at this moment in no position to make any
contribution of value to the problem…

9. Flexner Report
… the upbuilding of Howard and Meharry
profit the nation more than the
inadequate maintenance of a larger
number of schools. They are of course,
unequal to the need and opportunity.”

10. Patient Protection & Affordable Care Act:
TITLE V - Health Workforce Provisions
• National Workforce Commission
• Increasing supply of health care workforce
• Enhancing education & training
• Public Health Sciences Track
• Supporting Existing Workforce
• Strengthening Primary Care & other
workforce improvements
• Other stuff

11. National Workforce Commission
• Establishes a National Health Care Workforce Commission to serve as a national
resource to:
– Determine whether the demand for health care workers is being met;
– Identify barriers to coordination and encourage innovation;
– Disseminate information on retention practices for health care professionals and;
– Shall review current and projected health care workforce supply and demand and
make recommendations regarding healthcare workforce priorities, goals and policies.
• The Commission shall communicate and coordinate with a variety of federal
agencies and departments……. Public health professionals are included in the
definition of health care workforce and the definition of health professionals.
Public health workforce capacity is also included in the high priority areas list.

12. National Workforce Commission
• State Health Care Workforce Development Grants: Establishes a
competitive healthcare workforce development grant program to enable
State partnerships to complete comprehensive planning and to carry out
activities leading to coherent and comprehensive health care workforce
development strategies at the State and local levels.
– Authorizes $8 million for planning grants and $150 million for
implementation grants for FY 2010 and such sums for each subsequent
year.
• Health Care Workforce Assessment: Codifies the existing National Center
for Health Care Workforce Analysis (HRSA) to provide for the development
of information describing the health care workforce and the analysis of
related issues and collect, analyze and report data related to programs
under this title. The National Center and relevant regional and State
centers and agencies shall collect labor and workforce information and
provide analyses and reports to the Commission.

13. Increasing Supply of Health Care
Workforce
• Support for pediatrics, pediatric sub-specialties, child, adolescent
mental & behavioral health
• Establishes a public health & allied health workforce loan
repayment program to eliminate critical public health workforce
shortages in Federal, State, local and tribal public health agencies.
• Authorizes the Secretary to make grants or enter into contracts to
award scholarships to mid-career public health and allied health
professionals to enroll in degree or professional training programs.
Authorizes $60 million for these programs in FY 2010 and such
sums as necessary for FY 2011 - 2015.
• Strengthens National Health Service Corps
• Support for Nurse Managed Health Clinics

14. Enhancing education & training
• Primary care training
– Medical students, residents, physician assistants , CME for primary care
physicians
• Training for faculty to teach primary care
• Training in community based settings
• Plan, develop and operate interdisciplinary graduate degree programs in
public health and other health professions
• Capacity building in primary care
– Direct care worker, dentistry (general, pediatric & public health) as doctors
and mid-level
– Geriatric training
– Mental & Behavioral health
– Cultural competency, prevention, public health proficiency
– Nursing education (midwives, faculty)
– Community Health workers

15. Public Health Sciences Track
• Directs the Secretary (subject to the availability of appropriations)
to establish an Epidemiology and Laboratory Capacity Grant
Program to award grants to eligible entities to assist public health
agencies in improving surveillance for and response to infectious
diseases and other conditions of public health importance.
Authorizes $190 million for each year of fiscal years 2010 - 2013 to
carry out this section.
• Authorizes funding for fellowship training in applied public health
epidemiology, public health laboratory science, public health
informatics, and expansion of the epidemic intelligence service in
order to address documented workforce shortages in State and
local health departments. Authorizes, for each of fiscal years 2010
through 2013, $5 million for epidemiology fellowship training
programs, $5 million for laboratory fellowship training programs;
$5 million for the Public Health Informatics Fellowship Program;
and $24,500,000 for expanding the Epidemic Intelligence Service

16. Support existing workforce
• Loan repayments & fellowships
– Medically underserved areas
• Area Health Education Centers
• Workforce Diversity
• Primary Care provider training
– Training in public health, health promotion,
chronic disease management, mental and
behavioral health

17. Other Workforce Improvements
• Family to family health information centers
• Training of Personal or Home Care Aides
• Teaching Health Centers Development grants
• Increased payments to primary care providers
• Rural physician training
• School based health centers
• Patient Navigator programs
• Increased funding Community Health Centers
• Increased funding Trauma Centers (40% for
safety net centers)

18. Source: Steinecke, Acad Med. 2010, Vol 85 (2) p 236

19. Paul Bertau Cornely M.D. MPH
1906 - 2002
• First Black DrPH
(University of Mich)
• First Black doctorate in
anatomy
• First Black President of
American Public Health
Association
• First Black President of
Physician’s Forum
• One of the founders of
the Medical Committee
for Human Rights

20. Status of Black Physicians in 1932
• Blacks were 2.5% of
all physicians
• Population ratios
MD: Pop
– 1 Black doc : 2,988
Blacks
– 1 white doc : 727
whites

21. Golden Period for Black Physicians
1900 - 1920
• Number of Black physicians DOUBLED
– 1900 : 1,734 Black physicians
– 1920 : 3,885 Black physicians
• HIGH POINT 1920
– Blacks were 2.68% of all physicians
– 1 Black MD : 2,694 Black people
• UNTIL around 1970-80
• Today : 2010
– 4.0% of all U.S. physicians are Black (30,598)

22. Under-represented Minority Medical School Graduates by Race & Ethnicity 1972 - 2007

23. Under-represented Minority Medical School Graduates by Race & Ethnicity 1972 - 2007

24. Source: AAMC

26. ALL DELIBERATE
SPEED:
In 2005 African-
Americans, Native
Americans and
Latinos made up
25% of the U.S.
population…. But
comprised only 6%
of the physician
population.

28. Percentage of Mental Health
Workforce by Race , Ethnicity 2005
Race, Total U.S. Physicians Psychiatrists Psychologists Social
Ethnicity Population Workers
White 67.0 77 81 93 92
Latino 14.0 4 5 3 3
Black 13.0 5 3 2 4
Asian 5 14 11 2 1
American 1.5 0.1 0.1 0.3 0.2
Indian/Alask
Source: Miranda, J. (2008) American Journal of Psychiatry 165:1102

29. Standard Primary Care Year
Estimates for 2008 Graduates
Source: Bowman : Rural & Remote Health 2008 : 8(3)

30. Principles of Patient-Centered Medical Home*
• Personal Physician: on going relationship providing first
contact, continuous & comprehensive care
• Physician-directed medical practice: physician leads team
• Whole person orientation: responsible for directing all care
and arranging for referrals
• Coordination and/or integration of care: across all types of
care (ambulatory – nursing home)
• Quality & Safety: care plans, evidence based medicine,
performance measures, mutual participation
• Enhanced access: open scheduling, expanded hours, use
new tech methods for communication
• Payment: added value of medical care home
* American Academy of Family Physicians, American Academy of Pediatrics,
American College of Physicians, American Osteopathic Association

31. Crisis in the Workforce
• Still feudal crafts
• Medical home vs. primary care
• Accountable care organizations
• Not simply a question of
shortages & mal-distribution
• Need to transform how we
practice
• Requires fundamental
transformation of our Medical
Care System into a Health Care
System
• Health care is a human right
• Requires a “Flexnerian”
investment in education across
disciplines