Arkansas Gov. Mike Beebe had a clear directive for the state’s health care leaders: Develop a strategic plan to ensure the state’s medical workforce is ready, willing and able to handle the overall growing needs of Arkansans in the most efficient, state-of-the-art and effective way possible.
The answer was found in the creation of the Arkansas Health Workforce Initiative. Project leaders began dissecting an expanse of statistics and reports, holding public forums, and seeking input from countless state agencies and institutions. The result was delivery of the most comprehensive strategy for health care reform in the state’s history.
The workforce initiative was led by co-chairs UAMS Chancellor Dan Rahn, M.D., and Arkansas Department of Health Director Paul Halverson, Dr.P.H., with principal support being provided by Arkansas Surgeon General Joe Thompson, M.D., and the Arkansas Center for Health Improvement. Their work has laid the foundation for the future of health care in Arkansas with the completion of the Arkansas Health Workforce Strategic Plan, which can be found at http://ua.ms/workforceroadmap.
The workforce initiative is one component of a four-pronged strategy directed by Beebe to reform the state’s health system, which includes efforts for insurance, information technology and payment reform.
“We have many Arkansans who don’t have the ability to get access to a provider, who don’tget a referral in a timely way and aren’t getting the preventive care to keep them healthy,” Thompson said. “What this group initially struggled with was, ‘How are we going to get people the care they need, the preventive services to keep them healthy, the sick care services when they need them in greatest time of need, and how do we put it all together to wrap a team around a patient to keep them well?”
Shortages and misdistribution of physicians and other health care professionals is a national trend. In Arkansas, given its higher rate of disease and rural communities, the problem is even more ominous.
More than 500,000 Arkansans live in areas designated by the Health Resources and Services Administration (HRSA) as having shortages of primary medical care, dental or mental health providers. More than half of the 75 counties in Arkansas are identified with a primary care deficiency.
In 2011, with its high prevalence of chronic disease and unhealthy behaviors, Arkansas was ranked one of the unhealthiest states in the country.
“Smoking, obesity, diabetes, immunization coverage, prenatal care, and the list goes on and on where the state’s health burden is a staggering challenge,” Rahn said. “Arkansans living in areas with a shortage of health providers have severe problems in accessing care that can address their most basic health needs. We found that the existing health workforce is challenged to meet the health needs of Arkansans by almost every measure.”
The initiative noted an abundant effort across the state to tackle these demands, ranging from telemedicine programs to increasing medical school graduates to new education programs, but a shortage of health workers remains a challenge.
In addition, Arkansas has one of the oldest populations in the country, a limited pipeline to train new providers and an extremely low health literacy rate, which will overwhelm the already strained system unless a strategic plan is quickly identified and adopted.
Perhaps the most daunting challenge ahead is pursuant to the federal Patient Protection and Affordable Care Act, which means that come 2014, 500,000 uninsured Arkansans will become eligible for either public or private insurance.
“People with insurance tend to use it,” said Jay Bradford, Arkansas insurance commissioner. “Though many will remain uninsured, it’s likely that about 350,000 people will be newly insured, placing an additional strain on the workforce with an initial surge from those who have been without.”
Transition to Team-Based Care
It’s paramount to transition to a new model of health care delivery, with patients at the center and a team of professionals around them in a continuous, coordinated, comprehensive approach.
Halverson said the group first worked to adopt a definition of a “patient-centered medical home” before agreeing to adopt the Agency for Healthcare Research and Quality’s recommendation.
A patient-centered medical home puts the patient at the center of the health care universe with a team of highly trained medical professionals operating around them, Halverson said. The key to making that transition is ensuring that all are operating at the top of their license and optimally contributing their skills to maximize
care and efficiency.
“Patient-centered medical homes are more than just physical locations,” Rahn said. “They are manners of delivering care that embrace a team-based approach for all patients. We will move toward addressing our workforce needs with this in mind and encourage the adoption of this type of delivery.”
The plan recommends that reimbursement reward those using a team-based approach, which includes using nurses and physician assistants to help deliver primary care.
It includes many mechanisms to ease the transition to a team-based care model, including health literacy and community health worker programs, addressing behavioral change and counseling components, and employing and expanding mobile health units.
Enhance Health Information
This includes patient electronic medical records, clinical support systems, computerized medication delivery and telemedicine equipment and connections.
“The technology component is a complex one, but the benefits can be a dramatic shift in savings, safety and improved care,” said Ray Scott, state health information technology coordinator. “The goal is to provide timely access to patient information and efficiently communicate that information to providers and patients.”
The major part of this goal, Scott said, is to acquire the trained professionals needed to install, operate and maintain the health information technology efforts as well as acquire the software and hardware.
Arkansas is ahead of the curve in some areas, such as telemedicine and broadband implementation, which will need to be expanded.
Provider Education and Training
Thompson said Arkansas is experiencing modest increases in the supply levels of most health care fields, but not nearly enough to keep pace with the sea change the initiative is proposing.
Increasing the minority workforce will help reach underserved populations. The number of medical residencies in primary and preventive care, especially among those dedicated to rural practice, need to be expanded, Rahn said.
“We can also address the rural Arkansas issue by establishing a Rural Scholars Program, increasing collaborations with two- and four-year colleges and expanding the recruitment of international medical graduates into rural and primary care residency positions,” Rahn said. “Reaching potential contributors to the workforce who already reside in rural and underserved areas is key to enhancing care in those areas.”
Payment and Reimbursement
Making the proposed drastic changes in the state’s health care structure would be incomplete without restructuring the ways providers are compensated.
The initiative says that this includes adopting reimbursement strategies that incentivize team-based care and value preventive and efficient care coordination efforts, along with rewarding those using health information technology to full capacity. Those developing and maintaining practices in rural or underserved areas should also be rewarded.
“Through improved efficiency and coordination, team-based care can help physicians see more patients, provide the specialty services they are trained to provide and generally achieve better outcomes,” Thompson said. “It will also be essential to provide incentive packages and options to bring more specialists out to the rural areas where care is needed most.”
Most counseling for behavioral health issues traditionally has not been reimbursable to providers, but under the Patient Protection and Affordable Care Act it is required that all insurers, including Medicaid and Medicare, cover those services at no out-of-pocket cost to insured patients.
“That’s one example where by simply educating primary care providers they can possibly increase revenue by billing for what they already do,” Thompson said. “So there is an education component to this as well.”