CHAPTER 11: HEALTHCARE WORKFORCE

SUMMARY

With the onset of Covid, some of the existing challenges facing the healthcare workforce were both laid bare and exacerbated. Burnout and exhaustion have increased, demoralizing many healthcare workers and endangering the system. To get to the next normal, the United States must have a fully functional healthcare system in which routine visits, tests, and treatments can be provided across the full range of illnesses. This requires supporting the health care workforce through improved wages, health benefits (including mental health), tuition assistance, loan forgiveness, and safe working conditions. Additionally, the U.S. should incentivize the automation of routine chores and paperwork. To institutionalize and expand both telemedicine and various forms of home care, the U.S. government should make emergency regulatory (including licensure) and reimbursement flexibility permanent. Finally, ensuring a flexible pool of workers available in emergencies is also necessary.

A Courageous Two Years

Healthcare workers labored valiantly to serve patients during the Covid pandemic, sometimes with inadequate supplies of protective equipment, ventilators, beds, and most importantly other colleagues. Currently, there are a record number of health care jobs unfilled and burnout among those working is dangerously high.

About 22 million people work in the American healthcare system, three-quarters of them women and one-quarter Black. Many faced dangerous conditions, particularly in long term care facilities and home care. Hundreds of thousands were infected by SARS-CoV-2 and thousands died from work-related exposures. Despite such profound risks, pay is so low for some that they must work more than one job to make ends meet.

Not surprisingly, many healthcare workers are experiencing burnout and others have exited the field or are considering doing so. About 3 in 10 health care workers considered leaving their profession over the past two years, and about 6 in 10 said pandemic-related stress had harmed their mental health, according to a recent poll. Among physicians, half recently reported feeling burned out.

Covid-related exhaustion and staff shortages have disrupted all forms of healthcare for Americans. For example, the volume of preventive cancer screenings dropped sharply during the onset of the pandemic.89 Despite a recent rebound, such checks remain well below pre-pandemic levels. As a result, the number of newly diagnosed cancers has also dropped signifcantly.90 The worry is that many of these missing cases will be detected at a more advanced stage, leading to more suffering and death. This lack of preventive screening, diagnosis, and treatment extends to many other areas of health.

Staffing shortages are the main limit on the health care system’s ability to provide quality care. The limitation on “beds” is often not the lack of physical space for a patient, but rather the staffing of these beds with appropriate physicians, nurses, respiratory technologists, perfusionists, and other personnel.

More Telemedicine and At-home Monitoring, Less Paperwork

Fixing the systemic stressors requires moving to institutionalize and normalize many effective practices that were rapidly adopted during Covid, including virtual care and telemedicine, remote at-home monitoring and home care, and automation of repetitive tasks. The pandemic demonstrated that virtual care and telemedicine can be effective interventions for patients and providers alike, lowering stress and expenses for all. The regulatory and reimbursement changes that allowed for the rapid adoption of virtual care and telemedicine during the pandemic need to be made permanent.

At-home monitoring tools, like pulse-oximetry, traditional telemetry, and home testing, were widely and effectively embraced by patients from a variety of educational backgrounds. The pandemic showed that even more complex care, including cancer chemotherapy and wound care, can be safely provided at home. Regulatory bodies and insurers must do more to support these shifts.

The American healthcare system is drowning in paperwork, and administrative costs in the United States are higher than in any other industrialized nation. The price of this avalanche of red tape extends far beyond dollars and cents, since it is also an important cause of staff burnout, early retirement, and turnover. That many of the forms are now electronic rather than physical doesn’t change the enervating and demoralizing effect they have on physicians, nurses, assistants, and others. Rapid efforts to adopt more automation of rote tasks and efforts to simplify processing of patient registration, insurance eligibility determinations, and quality reporting are urgently needed.

The existing workforce should be better supported. Wages in low-paying jobs at many facilities need to be increased so that everyone receives a livable wage. Full time permanent employment with full benefits should be expanded. Educational loan forgiveness and paid training programs would enable a greater number of low-income and minority individuals to pursue careers and bolster the overall workforce. Expanding the number of community health workers will help address the needs of at-risk patients and vulnerable communities, as well as reduce burdens on emergency departments and other acute care sites.

The January 25th draft of the bipartisan PREVENT Pandemics Act proposes reauthorizing the Public Health Workforce Loan Repayment Program to support staff joining state and local public health agencies. It directs funding towards community health worker recruitment and training, as well as removes substantial barriers to up to 250 HHS appointments during public health emergencies. While necessary, these measures will not be sufficient, given the substantial labor shortages and burnout confronting the system.

Healthcare Workforce Strategic Goals

1. Fund HHS to evaluate opportunities to facilitate care provision in both normal and emergency circumstances and engage states to do the same.

a. Revise regulations and reimbursement requirements for home and community-based services and virtual care to enable continued access for all patients in any geography on an ongoing basis.

b. Maintain flexibility on existing visas for health care workers working in the United States.

2. Direct the DOL and HHS to ensure the healthcare workforce is protected from physical and mental health threats during crises.

a. Require or recommend that all healthcare facilities and enterprises provide workers with fit-tested reusable N95 FFR equivalent or more protective respirators (see Chapter 5: Personal Protective Equipment).

b. Require healthcare facilities to meet revised requirements for adequate ventilation and air filtration (see Chapter 4: Cleaner, Safer Indoor Air).

c. Defend the mandate that all healthcare workers at all health providers receiving federal resources be fully vaccinated (see Chapter 6: Vaccines).

d. Direct OSHA to issue a final, permanent Covid standard for all healthcare workplaces, including respiratory protection, ventilation requirements, and mandated medical removal protection (see Chapter 14: Worker Safety).

e. Enact legislation that ensures all workers have access to paid medical (sick) and family leave for mental health care needs (see Chapter 14: Worker Safety).

f. Use advance purchasing agreements, requirements on provider procurement processes, and other mechanisms to ensure the supply chains for relevant medical supplies are resilient to loss of foreign producers.

g. Improve the wellbeing of the healthcare workforce via wellbeing programming, as well as improved training, assessments, licensing, insurance, telemedicine coverage, and access to mental health treatment.

h. Enact legislation raising the minimum wage in nursing homes, long term care facilities, and other healthcare facilities that receive federal funds to $15 per hour.

3. Direct HHS to require that all healthcare institutions receiving federal funds adopt programs supporting healthcare workforce wellbeing.

a. Require that all healthcare facilities implement a systematic program for worker wellbeing, such as that outlined in ALL IN: WellBeing First for Healthcare.

b. Require that all healthcare facilities provide training to organization leaders on workforce wellbeing.

c. Require bi-annual assessment of healthcare workforce wellbeing beginning in 2022, leveraging financial incentives to promote wellbeing investments.

d. Require that healthcare facilities’ employee health plans fully cover mental health care (and potentially exclude these services from the deductible during PHEs), including allowing employees to seek mental health treatment outside of the system in which they are employed without financial penalty.

e. Require that licensing forms for all health worker applications and renewals in all states be consistent with the Americans with Disabilities Act.

f. Modify medical malpractice insurance regulations to eliminate reporting requirements for mental health history or limit inquiries to conditions that currently impair clinicians’ ability to perform their job.

4. Direct HHS and/or FEMA to leverage financial incentives and regulatory requirements to augment the healthcare workforce.

a. Fund the establishment of a pool of flexible health care workers to deploy in emergencies.

b. Fund the establishment of a voluntary reserve list of trained health care workers —similar to the National Guard —to be deployed in emergencies.

c. Augment investments in existing emergency workforce pools, including the National Disaster Medical System and the Medical Reserve Corps.

d. Create a ‘national service’ financial incentive for retired health care workers to re-enter the workforce during emergencies.

e. Incentivize within-region shared labor pools across health systems to help flex resources to communities in need.

f. Modify regulations and reimbursement models to allow for within-region sharing of labor pools and physical capacity across health systems and nursing homes during public health emergencies.

g. Expand educational loan forgiveness programs and develop additional financial incentives to bolster enrollment in healthcare worker training programs for physicians, nurses, respiratory support staff, lab technicians, nursing home workers, and other critical staff, with a specific focus on low-income and minority trainees.

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89 Mast C, Munoz del Rio A. Delayed cancer screenings —a second look. Cosmos Study Update. Published July 17, 2020. Accessed February 25, 2022. https://epicresearch.org/ articles/delayed-cancer-screenings-a-second-look

90 Kaufman H, Chen Z, Niles J, et al. Changes in the number of US patients with newly identified cancer before and during the coronavirus disease 2019 (Covid-19) pandemic. JAMA. 2020; 3(8). doi:10.1001/jamanetworkopen.2020.17267