Improving the Health Care Workforce

Improving the Health Care Workforce
Perspectives from Twenty-Four Years' Experience
By Stephen L. Isaacs, Lewis G. Sandy, Steven A. Schroeder

Today's health care workforce, about eleven million strong, includes people working in jobs ranging from laboratory technician to nurse and from speech pathologist to physician. It is the fastest growing segment of the nation's labor market, employing one out of every ten workers.

Typically, the Foundation looks at its programs one at a time. This chapter is a rare instance of stepping back and looking at the entire body of the Foundation's efforts in one specific area. This overview provides a broad-based perspective of a strategy that has lasted nearly twenty-five years, and it offers insights about the value of the strategy.

The chapter represents the effort of two senior Foundation officials and one outside analyst to make sense of what the Foundation has done and to examine the strengths and weaknesses of a large, long-term investment strategy. The lead author, Stephen L. Isaacs, is president of the Center for Health and Social Policy in Pelham, New York. Both Steven A. Schroeder, president of the Foundation, and Lewis G. Sandy, executive vice president of the Foundation, have had a long interest in, and have written about, workforce issues.

As the chapter notes, the impact of the Foundation's workforce programs is difficult to evaluate. Neither individually nor in the aggregate do they represent a large share of the programs, and other forces, that shape the health care workforce. Such programs often attempt to shape a system by supporting individuals, and it is hard to disentangle the many factors that produce effective professionals, let alone an entire workforce. Despite these analytical difficulties, the authors do come to some reasoned conclusions. More important, we hope that the chapter stimulates thinking about new possibilities and new challenges in this important area.

The Robert Wood Johnson Foundation began operating as a national philanthropy in 1972. It was the year that Henry Kissinger and Le Duc Tho held secret peace negotiations in Paris, Richard Nixon was elected to a second term, and many people thought that national health insurance was right around the corner. Surveys conducted in the early 1970s indicated that access to basic ambulatory care was the nation's number one health care concern. Such concern attracted the immediate attention of the new foundation, and in its 1972 annual report David Rogers, the Foundation's first president, noted the relationship between access to services and the health care workforce:

To increase Americans' access to a physician or some other health care professional, and to prepare for national health insurance, the Foundation made a commitment to expanding and improving the health care workforce--a commitment that continues to this day. The Foundation has funded programs to increase the number of health professionals who can provide primary care to communities in need: generalist physicians, nurse practitioners, physician assistants, and family dentists. In addition, it launched fellowship programs to develop a cadre of health care professionals with interdisciplinary knowledge and breadth of vision who could be leaders in shaping health care policy. Since 1972, the Foundation has allocated $520 million--more than one out of every five dollars it has awarded--to workforce programs. National programs carried out at a number of sites have received $419 million; these are listed and described in Exhibit 2.1 at the end of this chapter. Another $101 million has been given in ad hoc, or single site, grants.

The Foundation does not, of course, act in isolation. Other foundations also fund programs to make the health care workforce more responsive to national needs. For example, the W. K. Kellogg Foundation was an early supporter of family practice; the Commonwealth Fund supported innovative projects like the WAMI program, designed to bring primary care to underserved communities in Washington, Alaska, Montana, and Idaho; the Kaiser Family Foundation supported faculty fellowships in general internal medicine; and the Pew Charitable Trusts offer health policy fellowships and operate a Health Professions Commission that examines workforce issues.

Governments have also become more active in reshaping the workforce. Many states now promote primary care initiatives within their own borders. The federal government, through Titles VII and VIII of the Public Health Service Act, supports the education of health professionals. Through the National Health Service Corps, it places physicians in underserved areas in return for scholarships or forgiveness of student loans. The federal government currently spends more than $400 million a year in forty-four workforce initiatives that encourage health professionals to study primary care and to practice in underserved areas.² Even greater federal funding goes toward specialization and high technology. This includes $6 billion a year that Medicare spends annually for graduate medical education, and $8.5 billion that the National Institutes of Health spend annually for medical research and training.³

Then there are market forces--perhaps the most crucial factor in determining what and where health professionals practice. The rise of managed care, for example, is persuading an increasing number of medical students to consider careers as generalists. However, since there are few financial incentives to serve chronically ill, poor, or geographically isolated individuals, managed care may do little to increase access for underserved populations.

Although the resources of any one foundation may be relatively modest in terms of the total available for health care issues, philanthropy can play a unique and catalytic role. Rogers said of this role, "A foundation can offer people, institutions, and communities the opportunity to test a new approach and then give others the chance to prod it, examine it, and see if it fits their particular set of circumstances, and whether it can have yet broader application. Fear of the new is sometimes allayed by taking an idea out of the abstract and seeing it in operation."⁴

Since its earliest days, the Foundation has given high priority to promoting primary

care and making it a more attractive career for physicians. In the 1970s, it launched programs (Figure 2.1) intended to attract top internists and pediatricians to primary care, so as to enhance the credibility and the standing of primary care in the medical community. This approach--training a small number of key individuals, particularly academics, to serve as agents of change in a high-priority area--was to serve as a model for the Foundation. The Primary Care Residency Program, begun in 1973, gave training in primary care to general pediatric residents and internal medicine residents at nine hospitals and outpatient clinics. Six years later, the Foundation began the

General Pediatric Academic Development Program, which awarded two-year fellowships to prepare pediatric faculty members to conduct research on the more common childhood illnesses such as ear infections that were not, at the time, covered in medical school curricula. The third program, the Family Practice Fellowship Program, attempted to establish a firmer academic base for family medicine by training a small core of highly respected faculty members. Begun in 1978, it complemented the federal government's short-term fellowships in family practice by offering two-year postresidency fellowships in family medicine.

These three programs helped develop the field of primary care, giving it more respectability in academic medicine. The Primary Care Residency Program served as a model for the federal government, which began funding primary care training for internists and pediatricians in 1977. The General Pediatric Academic Development Program led to the inclusion of general pediatrics as a normal part of pediatricians' training. An evaluation of the Family Practice Fellowship Program found that four years after it ended 65 percent of the graduates held medical school appointments and more than 90 percent, including those not affiliated with a medical school, spent some of their time teaching

When the Foundation began its philanthropic efforts, it recognized that if health care were to be made accessible to underserved populations, health professionals other than physicians would have to be trained to deliver primary care. As a result, it began supporting the training of nurse practitioners and physician assistants in the early 1970s, a time when both fields were in their infancy. Initially, grants were made to a number of demonstration programs. The Utah Valley Hospital in Provo, for example, received funds to establish a network of rural clinics that would be staffed by nurse practitioners backed up by physicians who flew in every week. At the same time, the Foundation supported several pilot programs to train physician assistants.

Acceptance of nurse practitioners did not come easily. (Physician assistants were less threatening to people, since their profession grew out of efforts within the medical profession, and they worked directly under the supervision of doctors.) Many people in the medical community saw nurse practitioners as unqualified upstarts eager to encroach on the territory of physicians. To placate these concerns and give credibility to advanced-degree primary care nursing, the Foundation adopted two approaches to bring nurse-practitioner training into the mainstream of graduate nursing education. In the mid-1970s, it awarded ad hoc grants to six nursing schools to establish primary care training for nurse practitioners at the master's degree level. Next, it initiated a Nurse Faculty Fellowship Program to develop a core of nursing educators who would be able to train nurse practitioners at the master's level. Between 1977 and 1982, ninety-nine fellows--the pioneers in a movement that led to the acceptance of nurse-practitioner training as an integral part of graduate nursing education--completed the program.

Before the Foundation established its successful nursing programs, it provided funds to The Johns Hopkins University in 1973 to establish a school of health services that would train a new class of health professional--similar in some ways to physician assistants--called health associates. These newly minted professionals were to be the model for the delivery of primary care services at a time when the debut of national health insurance seemed imminent. However, the school closed after only four classes had graduated.

This was the Foundation's most visible workforce failure: an admittedly high-risk idea that, if successful, might have had a major impact on the delivery of health services. In retrospect, it may have been unrealistic to expect a medical school whose reputation depended on training specialists to throw its support behind an approach to health care that would rely on people who were not physicians. Moreover, the timing for such a program was simply not right. National health insurance was not enacted in the 1970s, and the huge infusions of federal money to train physician assistants and other health professionals as part of health care reform never materialized. Within the university, the new school had little political leverage. Given these factors, it is not surprising that when the university suffered a budget crisis in the seventies and the Foundation's funding also ended, Johns Hopkins decided not to commit any more of its scarce resources to the school.

With this exception, the Foundation's early nurse practitioner and physician assistant programs have been among its more successful undertakings. Its funding helped establish these two fields as viable career options at a time when the idea of such programs was under attack. The Foundation decided to withdraw its support for these programs in the late 1970s, after Congress began earmarking money to train nurse practitioners, physician assistants, and generalist physicians. The Foundation reasoned that once the models it had helped develop were adopted by the federal government, it should move on to new endeavors. Although nurse practitioners and physician assistants still faced formidable legal, political, and financial obstacles, for twelve years beginning in 1982 the Foundation did not develop any new national programs directed toward these health professionals.

Another field that attracted the early attention of the Foundation was dentistry. The Program for Training Dentists in the Care of Handicapped Patients, 1974-1979, led to the inclusion of dentistry for handicapped patients in the standard dental school curriculum. The Dental Research Scholars Program aimed at developing a cadre of dental faculty members knowledgeable in health care services and administration. It awarded two-year postdoctoral fellowships for research in dental health services. The Foundation did not fund any new national workforce programs for dentists after 1982, although it did provide partial support for an Institute of Medicine study on the future of dental education and continued to provide ad hoc grants to the dental profession.

The Foundation also has sought to improve the American health care climate by developing health professionals--primarily physicians--who understand health services, the social sciences, and health policy making, and who could become leaders in their home institutions, professional societies, and state and federal government. To train these leaders, the Foundation established two fellowship programs.

Established by the Commonwealth Fund and the Carnegie Corporation in 1969, the Clinical Scholars Program was taken over and expanded by The Robert Wood Johnson Foundation shortly after the Foundation became a national philanthropy. This program, which continues to flourish, gives young physicians who are committed to clinical careers the opportunity to acquire skills and knowledge in areas such as epidemiology, economics, law, biostatistics, management, ethics, and anthropology. Currently, thirty-four scholars (eight of whom are funded by the Department of Veterans Affairs) are chosen annually to spend two years studying and conducting research at one of seven leading academic medical centers. Outside evaluators have praised the program as "a national treasure"⁵ and "exceptionally influential."⁶ Many of its more than seven hundred graduates have become leaders in academic institutions, managed health care programs, and government agencies.

The second program, begun in 1973 and still in operation, is the Health Policy Fellowships Program. Every year, it gives six outstanding midcareer health professionals an in-depth look at the federal health policy process. The fellowships begin with a three-month orientation in Washington, D.C., followed by a nine-month placement in the office of a senator, representative, or senior member of an executive department.

In the 1980s, the federal government turned away from the role it had played since the 1930s in addressing the nation's social problems. Rising health care costs became a national concern; the maldistribution of the health care workforce worsened, particularly as more young physicians chose careers in medical specialties. During this period, the Foundation solidified its commitment to training minority health professionals, developed national programs to strengthen the nursing profession, and established a new

fellowship program for health care finance (Figure 2.2).

The Foundation has allocated more than $100 million to date to minority health professionals. Although this commitment began with its very first program--medical school scholarships for women, students from rural areas, and minorities--it was in the mid-1980s that the Foundation launched its first national initiatives to bring more minorities into the health professions. What the Foundation hopes to achieve is increased access: if everyone is to have access to medical care, there must be more minority health professionals, for studies show that they choose careers in primary care, serve other minorities, and provide care to poor patients to a greater degree than nonminority physicians. African Americans, Mexican Americans, Native Americans, and mainland Puerto Ricans make up 22 percent of the United States population, but only a small proportion of the health care workforce.

In addition to its early scholarship programs for needy minority medical students, the Foundation addressed the fact that many minority applicants had not been adequately prepared to enter medical school. Many of these students had not taken the right premed courses and had not been adequately prepared for the Medical College Admission Test (MCAT); as a result, they could not compete successfully for admission with other college students. To overcome these disadvantages, the Foundation supported a wide variety of enrichment programs for minority college students in the 1970s and early 1980s.

In 1985, a report issued by the Educational Testing Service found that summer programs increased the chances that minority students would be accepted into medical school. The Foundation combined its various enrichment programs into one national program, the Minority Medical Education Program, which continues today. Guided by a mentor, students learn about medical care and research, take courses in math and science, and are counseled in practical matters such as how to complete a medical school application and improve their interview skills. Currently, eight academic medical centers participate, each providing a six-week summer program for approximately 125 minority college students. An in-house evaluation found that the summer enrichment program doubles a student's chances of being admitted to a medical school.⁷

Even highly qualified and well-prepared minority students have been hesitant to apply to medical schools that did not have minority faculty members who could ease the difficulties that minority students sometimes encounter. So the Minority Medical Faculty Development Program was developed to increase the number of full-time minority faculty members in nonminority medical schools. Begun in 1984, this program helps promising junior faculty members who are committed to academic careers move up the academic ladder by offering them four-year postdoctoral research fellowships. Research can be in the biomedical, clinical, or health services area. Initially, eight fellows a year were appointed; this number was increased to twelve in 1991. A recent evaluation concluded that the program played a pivotal role in developing the potential for advancement of its program graduates who have remained in academic medicine.⁸

The Foundation also supported faculty development at the nation's traditionally black medical colleges. The bulk of Foundation support has gone to Meharry Medical College in Nashville, Tennessee, primarily to strengthen its faculty.

During the 1980s, the Foundation launched a number of programs to improve the training of nurses and to alleviate a critical nursing shortage. The first of these was the Clinical Nurse Scholars Program, which addressed a serious problem of hospital nursing: college-trained nurses did not have the practical experience needed to provide adequate patient care. The Foundation designed a program, patterned on the Clinical Scholars Program, to prepare a cadre of nursing school faculty for careers combining clinical practice, research, and management. These clinical nurse scholars would provide a base of notable and credible faculty members who would be capable of bridging the gap between nursing education, with its focus on research, and nursing practice, with its focus on patient care and management.

As the program was originally designed, nine midcareer fellows were to be chosen every year to conduct clinical or health sciences research. The first nurse scholars were selected in 1982. As it developed, however, the program shifted direction and became a basic research fellowship program for postdoctoral students. This led the Foundation to reconsider the program, and to end it three years earlier than planned. The last group of fellows completed its studies in 1991.

The 1980s witnessed a severe shortage of nurses; a commission established by the Secretary of Health and Human Services characterized this shortage as "real, widespread, and of significant magnitude."⁹ In response, the Foundation funded three new national programs. The first, Strengthening Hospital Nursing: A Program to Improve Patient Care, was a six-year, $26.8 million effort begun in 1989. Funded jointly with the Pew Charitable Trusts, the program attempted to make hospital nursing a more attractive career choice by restructuring medical and support services around the nursing staff. More than a thousand hospitals and consortiums submitted applications, eighty of which received planning grants, and twenty of which were awarded five-year implementation grants.

The two other programs--the Nursing Services Manpower Development Program, begun in 1989, and Ladders in Nursing Careers, begun in 1993--aimed at increasing the number of nurses by attracting and supporting disadvantaged students and health care workers who wanted to pursue nursing careers. The seven Nursing Services Manpower Program grantees adopted approaches ranging from counseling minority seventh graders to setting up a cooperative recruitment program among nursing schools to attract minority students. Under the Ladders in Nursing Careers Program, grants were awarded to nine hospital associations to help employees, especially nurses' aides, overcome financial, educational, and other barriers to becoming nurses.

For a variety of reasons, the Foundation has not succeeded in developing a coherent and consistent approach to its nursing programs. Some of the reasons have to do with the characteristics of nursing: the gulf between the academic focus of nursing education and the clinical focus of its practice; three distinct entry levels (diploma, associate degree, and baccalaureate degree) leading to what many employers consider the same job; the lack of agreement about nurses' roles and the skills nurses need to fill their roles; and the recurring scarcity and surplus of nurses.¹⁰

Other reasons have their roots in the Foundation's approach. Perhaps reflecting the bias of an organization whose three presidents have been internists from academic medical institutions, the Foundation single-mindedly pursued its goal of training primary care physicians. In contrast, its nursing programs addressed short-term labor crises rather than long-term needs; supported activities with diffuse, conflicting, or unclear objectives; and lacked follow-through. The Clinical Nurse Scholars Program was probably terminated prematurely; although it had veered from its original objectives, it might have been redesigned to overcome its problems.¹¹ The Strengthening Hospital Nursing program had unclear and perhaps unrealistic objectives. Not only did it focus exclusively on process but its twin goals--one having to do with reorganizing hospital care around nursing, the other having to do with improving patient care--were not necessarily compatible. (In addition, it had the misfortune to begin just as many hospitals were laying off nurses in a wave of downsizing.) Similarly, the objectives of the Nursing Services Manpower Training and Ladders in Nursing Careers programs were overly broad: on the one hand they were supposed to increase the supply of nurses, and on the other they were supposed to attract minorities to nursing careers.

As health care evolved in the 1980s from the fee-for-service care offered by nonprofit institutions to managed care provided by for-profit entities, and as cost became a public policy issue, it became increasingly clear that health care finance was the key to understanding the system--and perhaps to reforming it. It became equally clear that the number of people who could claim expertise in this complex field was limited. In 1985, the Foundation began its Program for Faculty Fellowships in Health Care Finance. It offered thirty-month fellowships to six faculty members a year. An evaluation found that even though the program changed the lives of many of its fellows, its target audience was unclear; for example, it was not clear whether the purpose was to increase the knowledge of professors of health care finance, introduce health policy faculty to financing issues, or train professors of finance in health policy issues. Concern was also raised about the narrowness of an approach that trained faculty in health care financing apart from overall health policy. The program ended in 1994.

The early 1990s were characterized by concern about escalating health care costs, President Clinton's failed attempt to reform the system, and the growth of for-profit managed care. Within the Foundation, a new board chairman took office in 1989,

a new president in 1990. These appointments led to a refocusing of the Foundation's workforce programs: renewed emphasis on educating primary care physicians, reinvigorated efforts to train other health care professionals, and concentration on entire systems of health care rather than individual components. At the same time, the Foundation reasserted its commitment to minorities and opened its fellowship programs to a wider group of recipients (Figure 2.3).

In the early 1990s, as part of a $100 million strategy to improve access to basic health care, the Foundation launched a second cluster of programs to bring primary care into the mainstream of academic medicine and to attract more medical students to general medicine. The goal was no less than to change the thrust and the focus of medical education. Unlike the programs of the 1970s, which added more generalists to the pool of physicians without reducing the number of specialists, these programs sought more fundamental change: shifting the balance between generalists and specialists.

Under the Generalist Physician Initiative, the Foundation gave grants to medical schools that made a commitment to training generalist physicians and to increasing the proportion of generalists to specialists they graduated. Working in collaboration with state agencies, HMOs, and other partners, the grantees devised strategies aimed at four critical points in medical education: admissions, undergraduate medical curriculum, residency, and entry into practice. Beginning in 1991, the Foundation awarded planning grants to eighteen medical schools and consortiums, followed by six-year awards to fourteen of them to carry out the programs they had designed. The initiative stimulated a number of innovative partnerships and served as a model for New York and Pennsylvania to develop their own grant programs to increase the supply of primary care physicians.

A parallel program, the Generalist Physician Faculty Scholars Program, started in 1993, aimed at increasing the prestige and credibility of generalist faculty members at medical schools. Recognizing that published research is the key to respect and seniority in academia, the program awarded four-year research grants to up to fifteen junior faculty members annually.

In lieu of evaluating each of its programs to encourage generalist medicine, and to place its efforts in a larger context, the Foundation funded the Generalist Provider Research Initiative, a five-year program also begun in 1993. Awards were made to carry out research on issues such as how to increase the number of physicians entering the three generalist fields, reduce the number of specialists, and attract more physicians to underserved areas.

Until the managed care revolution changed the way that professionals viewed health care, American medical students looked askance at careers in general medicine. The percentage of medical students selecting one of the three generalist fields--general internal medicine, general pediatrics, and family practice--as their first choice dropped from 36 percent in 1982 to less than 17 percent in 1991 and 1992. But the need for primary care physicians by managed care organizations appears to have reversed that trend. In 1993, the percentage of medical students making one of the general medicine fields their first choice rose to 19 percent; it has continued to rise, reaching 35 percent in 1996.

The extent to which The Robert Wood Johnson Foundation programs contributed to the changed environment is hard to determine. While market forces no doubt played a dominant role, they were augmented and reinforced by the Foundation's efforts. At the least, through its programs and a phenomenon known as the brochure effect,^* the Foundation's long commitment helped validate the idea of training generalists, made medical school faculty and administrators more receptive to primary care, and prepared medical schools to teach general medicine.

Beyond its work with medical schools in training primary care physicians, the Foundation took steps to educate other health professionals who might practice in underserved areas. Unlike the programs of the 1970s, these initiatives involved health care systems: state agencies, HMOs, community organizations, professional schools, and the like. The Partnerships for Training Program, started in 1996, required institutions in a region--universities, HMOs, state agencies, employers--to collaborate in the use of nontraditional techniques such as distance learning to train nurse practitioners, certified nurse midwives, and physician assistants in their home communities. Since these health professionals are being educated in the underserved communities where they live, they are expected to practice in those communities when their training is completed.

The 1990s also saw an expansion of the training of minority health care professionals. In part because of the Foundation's Minority Medical Education Program, academically qualified minority students had a good chance of being admitted to medical school. But the number of minority students is small relative to their proportion in the population. To reach a far wider pool at an earlier point in their lives, the Association of American Medical Colleges (AAMC) began Project 3000 by 2000 in 1991. This program tries to attract and prepare high school students for medical careers. The goal of the AAMC is to more than double--from thirteen hundred to three thousand--the number of underrepresented minority students entering medical school by the year 2000.

In 1994, with Foundation support, the project expanded to include other health professionals. Working in partnerships with colleges, school systems, and communities, ten academic centers offer enrichment courses, collaborate in creating magnet health sciences programs in high schools, provide mentors, and strengthen the science skills of elementary and secondary teachers. As mentioned earlier, the Foundation also is attempting to increase the number of minority nurses through two other programs: the Nursing Services Manpower and the Ladders in Nursing Careers programs.

Responding to changes in the health care system, in the 1990s the Foundation expanded the eligibility requirements for people who might become fellows. At mid-decade, amid concerns that bright junior members of social science faculties were not drawn to health policy research and that senior investigators were not receiving sufficient support, the Foundation initiated two new fellowship programs. Under the Scholars in Health Policy Research Program, which started in 1993, twelve two-year postdoctoral fellowships are awarded annually to promising young economists, political scientists, and sociologists. The Investigator Awards in Health Policy Research, which began in 1994, broadens the pool of health policy researchers even further: applicants may come from any discipline. The program provides salary support for ten outstanding young researchers or eminent senior scholars for up to three years.

From its very earliest days, the Foundation had a vision of a health care system that would be available to all Americans. As a result, it funded a multitude of programs to improve the health care workforce in the belief that this would result in more available care. Some, such as the Clinical Scholars Program, succeeded spectacularly. Others, such as the bold attempt to establish a new class of health associates at Johns Hopkins, failed utterly.

Where the Foundation worked with academic medicine, it has been successful. Through its programs with academic medical centers, it has been a major force in developing the field of general internal medicine, in introducing primary care into the medical school curriculum and residency training, and in making medical education more relevant. Perhaps more important than the specific programs it funded, the Foundation served as what one commentator called "a moral compass."¹² It pursued its vision of primary care as the key to health services, even when the idea seemed hopelessly unfashionable.

The Foundation showed similar determination in fostering a core of physicians to assume positions of leadership in the health care field. The Clinical Scholars Program, now nearly a quarter of a century old, is considered to be its flagship program, boasting a large constituency within the Foundation, among the program directors at the schools that train the fellows, and in academic medicine generally. The Foundation has also stayed the course in preparing minority students for medical school and training minority medical faculty.

When it came to nonphysician health professionals, however, the Foundation showed little of the same clear vision and steely devotion that characterized its programs for improving the physician workforce. After taking the lead in developing nurse practitioners and physician assistants as viable professions, it pulled back

support in the early 1980s. Its nursing programs have lacked coherence and long-term perspective. The flow of money speaks loudly here: national programs to train physicians consumed 70 percent of the Foundation's workforce budget, leaving 30 percent for training all other health professionals (Figure 2.4).

Perhaps reflecting its comfort with academic medical institutions, the Foundation was slow to recognize that the shift in health care from the medical community to corporations and business concerns presented an opportunity to offer training to individuals from disciplines such as economics, management, and law that are not normally associated with health care.

As the twenty-first century approaches, the question is how the nation's workforce programs will respond to a health care system that was barely envisioned in the relatively recent past. Twenty-some years ago, "health maintenance organization" was a concept known to only a smattering of academicians, policy wonks, and health professionals. Now most people with medical needs enter the world of managed care, where large conglomerates buy and sell health services, generalist physicians serve as gatekeepers, and the bottom line is paramount. Government can no longer be counted on to ensure that services are provided for the neediest citizens, and federal subsidies for graduate medical education are threatened. With the graying of the population, more chronic care is provided in homes and outpatient facilities. At the same time, the amount of acute care in hospitals is declining as these services are delivered on an outpatient basis. Advances in communications technology are changing the way information is transmitted and received.

This is the context in which workforce programs intended for the early twenty-first century operate. The content of the programs depends on how these factors are addressed. While it is premature to draw definitive conclusions from recently initiated programs, the Foundation's cumulative experience over nearly a quarter of a century suggests four principles that can serve as guidelines for the development of future workforce programs.

Investments in people provide great returns to the health care field. To date, the Foundation has already devoted nearly half of its workforce funds to fellowships and faculty development awards (Table 2.1).

Although these are expensive (each clinical scholar and health policy fellow costs the Foundation more than $100,000 a year¹³), often invisible to trustees and staff, and difficult to evaluate (how much credit, for example, does a fellowship contribute to an individual's success later in life?), they are a productive investment. They give talented individuals the freedom to take risks and enter careers that the market is not yet willing to support.

What's more, there is a professional advantage in being awarded an esteemed fellowship. Such a plum often leads to enhanced career opportunities and to greater influence on the institutions where fellows work, the professional societies to which they belong, and health policy in general. It may be that the Foundation has had more effect on academic medicine and the public policy process indirectly through its fellows and scholars than directly through its institutional support.

As professionals other than physicians play a greater role in health care, fellowship programs should be broadened to include people from a wide range of disciplines. The Foundation's fellowship programs during the 1970s and 1980s reflected the dominance of physicians in the health care system. During these years, the Foundation invested heavily in training physicians, particularly internists. It made a smaller but still substantial investment in nursing and dental fellows.¹⁴ Of the programs initiated in those decades, only the health policy fellowships (which, in practice, have been awarded mainly to physicians) and the faculty fellowships in health care finance were open to a broader range of disciplines.

In the 1990s, the role of business executives, economists, lawyers, and other nonphysicians in shaping health policy has expanded, while the dominance of physicians has diminished. Whatever one might think of this trend, it does offer an opportunity to broaden the network of people who receive fellowships, and indeed, recent Foundation programs have opened up fellowships to individuals from nonmedical, nonnursing disciplines. In light of this change, and in recognition of the changes in the health care sector, it is time to explore an increased focus on training professionals who can play important roles but do not come from disciplines traditionally associated with health care.

With the rapid and dramatic changes in health services, workforce programs should involve total systems of health care rather than focusing on specific components such as medical centers. In the 1970s, the power to affect health care lay substantially with academic medicine. This led The Robert Wood Johnson Foundation to concentrate its resources in medical centers. Since then, health care has changed dramatically. New organizations--HMOs, health centers, hospital and health care networks, and state agencies--have joined academic medical centers in shaping the careers of health professionals.

Any institution that strives to influence the supply and distribution of health professionals must design programs to work with these organizations. Currently, three programs support consortiums of health providers and training institutions: the Generalist Physician Initiative, Practice Sights, and Partnerships for Training. Systemwide and cross-cutting approaches that move beyond academic medicine in the training and placement of health professionals are the logical way to respond to and influence an increasingly complex health care system.

To increase access to health care requires emphasizing more equitable distribution, as well as an increased supply, of health professionals. Even with increased numbers of generalist and minority physicians, nurse practitioners, and physician assistants, the scarcity of health professionals in underserved areas remains critical, and in the current economic and political climate this is likely to worsen. So far, nobody has found the key, if one exists, to overcoming the barriers that discourage health professionals from serving inner city and rural communities. Although it may be, as some commentators have argued, that nothing short of an expanded National Health Service Corps will resolve the problem,¹⁵ the Foundation has made some limited attempts to encourage physicians to practice in underserved areas.

In the 1970s and 1980s, the Foundation addressed the distribution of health professionals as a peripheral part of programs designed to restructure health care delivery, for example, by establishing networks of rural physicians and group practices allied with community hospitals. In the mid-1990s, the Foundation began to address some of the structural and social factors that discourage health care professionals from practicing in rural areas and inner cities: the poor reimbursement, the isolation, and the lack of social amenities and professional opportunities for a spouse that keep health care professionals, no matter how well trained, from serving in rural areas. Practice Sights, a five-year program begun in 1993, focuses directly on reducing such barriers. It requires participating health care systems--such as state agencies, academic institutions, and HMOs--to work together. Under this program, health care systems have set up loan forgiveness programs, provided technical assistance in practice management, worked to increase reimbursement rates, and offered other incentives to attract health professionals to inner city and rural practices. A second program, Reach Out, is discussed in Chapter One; in the present context we note how it builds on the medical profession's tradition of community service.

Investments in training the health care workforce are necessary, but not sufficient, to increase access by underserved populations to basic health care. As the creation of such programs as Practice Sights and Reach Out suggests, it is important to address the inequitable distribution of health professionals directly.

The lessons of the past twenty-four years are both simple and complex. They are simple in demonstrating that an unwavering commitment to improving the health care workforce is required to effect change, or to prepare for it when change comes about for other reasons. The lessons are complex insofar as any single foundation's resources can have only a limited impact in a health care system that is rapidly changing and has many more key players than it did even five years ago.

The challenge for the future is to develop workforce programs that further a vision of universal access within the context of an evolving American health care system where business rather than social values predominate, where incentives to avoid serving sick and vulnerable populations are inherent, and where power has shifted out of the hands of medicine. How institutions, including The Robert Wood Johnson Foundation, meet this challenge will determine the course of health care in the United States.

*The brochure effect is a well-recognized phenomenon that is difficult to quantify, by which the announcement of a national program calls attention to a priority area of the Foundation, and institutions that are not currently receiving grants then move in the direction of the national program. [Return to Article]