By: Sheldon M. Retchin, MD, MSPH, vice president for health sciences, Virginia Commonwealth University, and chief executive officer, VCU Health System, and Alan Dow, MD, MSHA, assistant vice president of health sciences for interprofessional education and collaborative care, assistant dean of medical education, and associate professor of medicine, Department of Internal Medicine, Virginia Commonwealth University
In the last several years, numerous controversies from the Affordable Care Act (ACA) have coated the health care landscape with uncertainty. Partisan viewpoints and judicial decisions have left states grappling with whether and how to expand coverage. More recently, technical flaws in the rollout of the health exchanges have left the public and policymakers wondering whether appropriate mechanisms for implementation are in place.
Overshadowed by the hullabaloo surrounding the ACA is the substantive issue of whether the nation’s health care workforce is adequate to accommodate its coverage expansion goals. With 40 million potential new beneficiaries under the ACA, existing health care labor shortages will only worsen as health reform is fully implemented. And yet, not enough is known about the unmet needs of the uninsured to predict the number or type of health professionals needed and how to structure health care delivery to meet these needs.
In the December issue of Academic Medicine, we describe our 13-year experience with the Virginia Coordinated Care (VCC) to model the additional workforce that might be required with the coverage expansion from the ACA. The VCC uses the infrastructure of a Medicaid HMO to manage the care for approximately 30,000 uninsured. The punchline? The data reveal that one size does not fit all. For instance, more than half of VCC individuals use only episodic care, and never visit a primary care physician. Moreover, while these individuals are provided access to primary care through the program, they continue to seek care for non-urgent, episodic problems in emergency departments. In addition to being expensive, this pattern does not support preventive care that could avert or delay future illness. After all, the emergency room is an abysmal setting for vaccination, screening, and health counseling. Therefore, policymakers may need other approaches to promote the health of newly covered beneficiaries.
Like those with insurance, costs among the uninsured are concentrated in a disproportionately small number of individuals with complex chronic illnesses. Thus, about 20 percent of the VCC population account for approximately 70 percent of the total cost. However, since we have struggled to effectively and efficiently manage complex care for insured super-utilizers, exporting the same ineffective model to the uninsured would be folly. With this subpopulation, we have an opportunity to create new models of care, whereby these complex patients can be triaged to interdisciplinary teams specifically trained and structured to care for patients with multiple chronic illnesses.
Regardless of the controversy of the moment, the ACA represents the most profound coverage expansion in almost half a century. And yet, for the full spectrum of care with the uninsured, there are clearly workforce challenges. Whether it involves steering newly covered individuals to primary care for health promotion and disease prevention, or managing chronic illnesses with a multidisciplinary team, the workforce model needs a makeover. Clearly, imposing the current delivery system from the insured onto the care of the newly insured would squander this chance to transform health care. In the end, both sides may even agree on that.