Dr. Joanne Spetz, Director, Philip R. Lee Institute for Health Policy Studies at UCSF: Where Futuro Health Fits in the Workforce Training Landscape

Van Ton-Quinlivan

Hello, I’m Van Ton-Quinlivan, CEO of Futuro Health, welcoming you to WorkforceRx, where I interview leaders and innovators for insights into creating a future-ready workforce.

This is our 100th episode of the podcast, and we’ve tapped a very, very special member of the Futuro Health family for the occasion to share her uniquely informed insights into the nation’s healthcare workforce situation in general, and to tie together how Futuro Health fits into those efforts in meeting the growing demand for allied health workers because she is on our board of directors.

Dr. Joanne Spetz is director and presidential chair in healthcare financing at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco. She also directs the federally funded UCSF Health Workforce Research Center on long-term care, generating evidence to ensure an adequate workforce to provide care to individuals with long-term care needs across their lifespan.

In addition, Joanne is an internationally known expert on the nursing workforce. Her research focus includes the economics of the healthcare workforce, organization of healthcare services, and quality of healthcare.

Thanks very much for joining us today, Joanne, and being our 100th podcast guest.

Dr. Joanne Spetz

My pleasure. Thank you for inviting me to do this.

Van

Well, let’s set the stage for our conversation by learning about what professions have the biggest shortages in healthcare right now from a national perspective.

Joanne

That’s a great question. We don’t have a lot of data that give us a firm sense about which professions have the biggest shortages, so my answer to that depends a bit on just what I’m hearing on the street, as it were, and also my knowledge of what the national data do tell us.

We continue to hear problems about every occupation in the long-term care space. Everybody who is working in that space had a lot of challenges during the pandemic, but it’s also an industry that has always had challenges with shortages. That would include your nursing assistants, many of whom are certified; it includes your home health and personal care aides who bring a lot of skills to their jobs, but often have very low pay; and it also includes the licensed nurses who work in long-term care — that’s both your licensed practical and vocational nurses and also the registered nurses. I think part of the challenge for long-term care is that licensed nurses are also in high demand in hospitals, and hospitals tend to have deeper pockets and the ability to pay a higher wage.

We also hear a lot less about a lot of the other occupations that are smaller, but for which shortages seem to emerge very significantly and regionally. Anybody with technician after their name would fall into that bin….laboratory techs, radiology techs, physical therapy techs, and assistants. These are people who are in roles where they have training requirements and training is necessary. A single employer might have only one or two, maybe three, but man, when they can’t find that one or two or three, it shuts down their services.

Those are harder professions to track, but end up being really impactful when there is a shortfall, which tends to be very regional. You’ll have like a community college shut down a program and all of a sudden, none of the healthcare systems can find enough lab techs and then you have a crisis before you know it. So, those kinds of occupations, I think are an ongoing challenge.

Van

That is a great overview, Joanne. And if you could remind for our listeners, what are the mega trends that are affecting healthcare shortages or just general labor shortages?

Joanne

Well, in the big picture, the aging of the population is a big factor. It turns out that the Baby Boom cohort is retiring just as they all need their knee replacements, and so we have more demand for health services with an older population. At the same time, that big Baby Boom cohort is retiring and taking a lot of expertise and knowledge out with them, regardless of what field they’re in.

People who are in that cohort who’ve been working as personal care aides have rich experience in being fantastic personal care aides and that’s going out with them. That goes all the way through the physicians that are retiring in that cohort. So the straight out aging is a factor.

Related to that is the increasing demand for care for people who are older, which is an underlying factor for long-term care. I think long-term care also struggles because the United States does not have a long-term care financing system. If you follow the money, you can certainly see that Medicare provides a lot of services and supports for an older population. The Affordable Care Act expanded health insurance to a very broad swath of this country, and Medicaid continues to be a really key program for people with lower incomes, but none of these programs really have comprehensive long-term care insurance.

So, as people have long-term care needs, they maybe can get some of that covered by Medicaid if their incomes are low enough and they don’t really have much in the way of assets, but for everybody else, they’ve got to figure out how they’re going to pay for it out of their savings, out of their family’s money.  And even if you’re on Medicaid, Medicaid payment rates tend to be quite low because of the cost of running the program for states. So, that means long-term care really struggles with having enough revenue to do the kind of hiring and pay the kind of wages that I think a lot of employers in that space would like to see.

For younger workers, we’re still seeing some of the fallout from the pandemic when workers that were close to retirement may have chosen to retire rather than risk their own exposure to a new virus for which we had no vaccine and had very little understanding about how to treat it and prevent severe illness. We know, of course, a lot more now, but if you remember what it felt like in the summer of 2020, it was really terrifying and so there were a lot of healthcare workers who were kind of close to retirement who said, “I’m done. I’m gonna retire now. I’m not gonna wait a year or two.” A lot of people shifted around their priorities in their work, I think, during that period. They became more interested in working remotely or having more flexible schedules or ensuring they had more time with their families.

We also had some geographic mobility, where some urban areas lost population, some rural areas gained population and we’re still seeing all of that shake out. But the latest numbers I’ve been seeing suggest that most of the labor markets, in terms of supply, have recovered and the educational system has largely recovered as well, because in addition to early retirements we saw a lot of education programs have to take hiatus and have to take breaks, especially if they were offering in-person education.

Van

Well, Joanne, I’d like to pull on one of the threads that you talked about in terms of our long-term care coverage in the US not being comprehensive, and therefore the expense of providing the care is likely to be internalized by the family. Not many Americans have that type of financial cushion. What does comprehensive long-term care look like in a country that does it well? Would you know?

Joanne

Ooh, that’s a great question. I was just in a meeting the other day where there was some discussion about long-term care systems in a lot of the Scandinavian countries, which are often held up as an exemplar. They really take an overall social care approach to long-term care. There’s a recognition that long-term care is not just medical care, it is not just helping people recover after a surgery and sending them home. Long-term care involves a range of expertise that includes social care. It includes helping people have conversations that may be difficult, but are essential to what matters the most to them and thinking about how to attain that.

The US healthcare system is very focused on medical care and our long-term care sector is not coordinated, shall we say. So, there’s really that lack of navigation and personalized supports and that’s where there is a lot of opportunity for making improvements in thinking about that care navigation, about community health workers, social work and various types of fields in that space that can help really think about the whole person’s needs and how to attain them.

A great example that I have heard some of our clinical colleagues talk about is where you might have a patient who has a new cancer diagnosis and the immediate thing that you should do, of course, is refer that person to oncology. And oncology often will move straight into fairly aggressive treatment, which often makes sense and may be the right thing to do. But if you’re dealing with an older person who might be frail, they might say, if they were asked, “I am willing to take the risk of holding off my treatment because I want to feel really good when my granddaughter gets married next month. Please delay my treatment so I’m at optimal energy to go enjoy this really important family event.”

That conversation can be a hard one to have. The reality is while physicians are trained to do it, the time that they have available isn’t there. And that’s where I start turning to, well, could they have a social worker with them or a community health worker or a peer navigator or  some type of professional who has training?

I think other countries honestly do this better than we do.  Japan also was pointed to as a country where there is more of a sense of social care and addressing loneliness, addressing isolation, and trying to really think holistically about engaging older people in society as a whole in optimal ways that are not necessarily like, we’re always going to treat you aggressively with medical care.

Van

Thank you for sharing those exemplars from the Scandinavian countries and Japan. Now, you had mentioned that education providers have largely recovered from the pandemic days.

What have you seen as exemplars for making training less expensive and easier to access for some of these skillsets that you’re talking about, whether it’s nursing assistants, home health aides, or licensed roles like LPNs and RNs?

Joanne

Well, you know, I feel like I have to say this, but part of the reason I agreed to be on the board of Futuro Health is that it’s creating a model to really think about how do you do this at scale? And the deliberate decision-making of the core educational component for people through the Futuro Health programs is the Human Touch Healthcare modules of really thinking about core skills for people who are working in any healthcare profession or occupation…about being good navigators, understanding their ethical responsibilities, understanding enough about the system as a whole that they can really be the best providers that they can be for their clients.

I think also just in general, Futuro Health is one of a number of organizations that are really thoughtful about what components of education can be delivered remotely or delivered on a convenient schedule for the person pursuing the education and what modules really require the in-person component. Because for most of the health professions, you really do need to touch people at some point in your training. The simulation is not 100 % of what you need. You can go a long way with it, but it’s not everything.

I think a lot of the in-person programs may meet the needs of people who really have to have that in-person classroom experience to learn effectively. But for many people, they have learned how to learn through remote and self-directed platforms. Having them do their hands-on training after they’ve already had that baseline from a remote module can be really, really effective and enable the streamlining of the programs, making them more convenient for people who are pursuing education and still delivering a high quality of education.

There are some neat exemplars all the way from personal care aides and home care services all the way through nurse practitioner programs. New Mexico has a nurse practitioner program where a lot of the didactic education is online and then they bring all the students in physically for kind of a boot camp on, you know, let’s practice doing assessments live, let’s practice these skills in-person, and then they do their clinicals near where they live. Most of the students in that program are from remote and rural communities, so they don’t have a bricks and mortar program anywhere near them.

They get all their didactics in a modality that works for them but then they’re able to do their clinicals in-person with qualified mentorship and preceptorship locally. I just think they do a lovely job with a distance learning model of a program. Some distance programs I think have been really challenged to achieve high quality, but they’re clearly exemplars of how to do that.

Van

Your example is a great one in terms of explaining how the component parts add up to quality and a day one ready worker for the employers. Now, especially in healthcare, it’s never just once and done in terms of the training. What is the role of employers in supporting the upskilling of their workers?

Joanne

Yeah, you’re absolutely right. In these healthcare professions, just like many professions, you’re always learning and I think employers need to recognize that workers are going to come in and they almost always want to do better at their jobs. So, helping them develop their skills, get coaching and mentoring as they need it is very important.

Different employers also have very deliberate opportunities for people who want to pursue additional formal education. For many, many years, SEIU has worked with a lot of their employer partners, as an example, to help provide formal opportunities for their members to advance their certifications or their licensure and they’ve even done that even though the person attaining the next level of licensure has meant that they would no longer be a member of SEIU. They have supported programs to advance people into registered nursing licensure, knowing that those individuals would then become members of the California Nurses Association. It’s kind of a dedication to the growth of their workforce above their own interest in maintaining their membership. They view the individual’s growth as more important than just keeping their numbers, which is, I think, a really nice model.

Whether or not there is a union within an employer organization, there surely is a lot of wisdom that the workforce can provide about what they need. And so finding those worker representatives that may or may not be union representatives and saying, “Hey, we’re thinking that we need more medication aids or we need more people who are trained to work in the radiology department. What would you suggest for ways that we could make that happen?” I think workers have a lot of great guidance to provide employers about what they need as well as about what kind of continuing education they need if they want to stay in the job they’re in now. If you’re a medical assistant, what else would you like to learn to be a better medical assistant? I think workers will answer those questions if they’re asked, and it’s really important for employers to be asking.

Van

We’re now in a bit of a reflective mood as we hit the 100th episode mark and start our fifth year as an organization. So — wearing your hat both as a scholar and a Futuro Health board member — I’d love your advice on what Futuro Health should continue to do more of as we think about expanding our impact.

Joanne

That’s a great question. Futuro Health has built so much in a relatively quick period of time, which I think was some of the vision of recognizing that the need for more healthcare workers is rising so rapidly that we don’t have a lot of time to sit and ponder.  Futuro Health has been doing a lot of testing, revising, experimenting, and so on to recognize and find different pinch points in the system. You know, to what extent is having people go through Human Touch Healthcare making a difference? I think the answer to that has been looking at your own data. Yes, that’s important. And then, okay, what can we do to help make sure that people’s hands-on training is more effective?

What can we do to help make sure that people’s job placements and first jobs are satisfying to everybody involved? I think that that transition from the education into the workplace is probably proving to be challenging for Futuro Health and for everybody else in the healthcare system that is trying to do recruitment at scale. How do you recruit people and bring them into a cultural environment of the workplace? Every organization has a different culture. How do you mentor them? How do you support them?

I think Futuro Health has opportunities, perhaps, to continue to think about are there mentorship relationships that the various learners can develop within their cohorts so that they can continue to be in touch with each other to support each other? They are, in many cases learning together in a group and those can become their kind of peer life coaches, as it were.

We’ve seen this in leadership development programs that I’ve been connected with and those programs often think about any healthcare worker as a potential leader. Those leader cohorts come together repeatedly and just become each other’s life support for the rest of their careers. It’s lovely. And so I think there may be some opportunities there, especially for these allied health occupations, where again, a hospital might have three or four or a radiology lab might have three or four techs, but it’s a small cohort. So can those workers continue to be supporting each other and connected to each other for their lifelong career development and partnership, and give each other career opportunities and hear about vacancies and share them and all the other things that workers do together?

Van

That’s a great example of how we can facilitate the persistence of all of our graduates to stay in healthcare, right? The peer support and the peer mentoring. Great idea. Out of curiosity, what does the field of labor economics bring to these questions of healthcare shortages and talent supply issues?

Joanne

That’s a great question. You know, the field of labor economics is really centered around looking at the kind of underlying economic forces that lead workers to decide whether they’re going to work, where they’re going to work, and how they’re going to work and on the demand side, to have employers decide how many workers they think they need and how many they can afford and what the trade-offs are in their different employment decisions. The worker side, I think, is particularly complex because if I were an organization projecting a need for another twenty new radiology techs over the next five years, I might simply say that means I need to train four a year for the next five years to get my twenty. I might then say, hey Futuro Health, can you train twenty people over five years for me?

Well, what I just ignored in that math was those workers have other choices. Those workers can decide they want to work part-time. They might decide to go work for a competitor. They might decide that they’ll make more money working at the Verizon store as a sales representative and not work in the field at all after I trained them. And so what are the factors that lead people to decide to supply their labor into a specific setting? That’s the supply side of the market.

I think some of the questions that we’ve already talked about — how do you retain workers, what makes them want to stay in the job —  those factors do include things like, what is the pay and what are the benefits? What is the cultural environment? One of the things that labor economics research also tells us is that people are sometimes willing to give up some of their salary if they have other benefits of the job, such as my supervisor is really nice and supportive. You know, I think many of us would be willing to give up a little bit of pay to have a nice supervisor versus to have a mean and nasty supervisor.

On the demand side, of course, it kind of goes the other way. The more that an employer feels like they need to pay or invest in their workforce, the harder it is for them to hire at scale. They need to make trade-offs. The more that employers are facing wage inflation because they’re competing against other employers for a limited labor market, the harder it is to hire people. And those costs get passed on to somebody, which really is all of us that are paying for healthcare, whether it’s through our insurance or whether we’re paying out of pocket.

So, I might describe it as ‘follow the money’ and money is not the only thing that people make decisions about. People are making decisions about their overall total wellbeing, and the field of economics recognizes that.

Van

That helps us understand what the field of labor economics is, so thank you for that description. I’d love to hear what are some of the current projects that you are working on these days and what are you interested in studying?

Joanne

Well, I’ve got three major areas of work, one of which is a series of reports and different products from surveys that we did with support from the California Health Care Foundation of nurse practitioners and midwives in California. That’s been a lot of fun because it’s a workforce that we don’t know a lot about, but is of growing importance.

In particular, we surveyed licensed midwives who are direct-entry midwives who do not have a registered nursing background. That’s a very small but growing workforce that can play a big role in advancing health equity and because it doesn’t require registered nursing education to begin with, there are opportunities for more streamlined pathways for people to become midwives through that path. It’s a very rigorous education, but doesn’t have that like, ‘first you become an RN and then you go work as an RN and then you go back for a master’s path.’ In California right now we have no Licensed Midwife education programs, so there’s a lot of opportunity there, too.

I’ve been continuing to do work for the California Board of Registered Nursing, surveying California RNs. The 2024 survey data collection just ended shortly before the holidays and we just got our data set back from our data entry vendor so we’re now merging the data and getting it all cleaned and set up so we can learn about what registered nurses tell us about their experiences as of late 2024.

And then the last batch of stuff has been all related to the dementia care workforce. I’m part of a project called the National Dementia Workforce Study that was funded by the National Institute on Aging. It is an $81million investment from NIA that we are doing with the University of Michigan. Dr. Donovan Maust at Michigan and I are the leads of this giant thing where we are surveying clinicians and we are also surveying staff in nursing homes, assisted living facilities, and home care agencies.

We’re focusing this first year on the home care aides and certified nursing assistants…kind of the direct care workers who are doing a lot of the hands-on care — plus the licensed practical and vocational nurses and the registered nurses and we’re asking them about their knowledge and training in dementia care, their overall work environment, their occupational safety, their attitudes and underlying perceptions of caring for people with dementia, any experiences of racism and sexism on the job, violence in the workplace. My gosh, there’s a lot of questions!

A lot of the data will be linked into patient-level data, so not only can we study the workforce, but we can also learn more about how the workforce is driving quality of care for people living with dementia. We’re just in our first wave of data collection and it has been a really fast and furious project because our charge was to try to get all these surveys in the field in the first year. Super busy, but really exciting. It’s gonna be a rich new data source and we’re not being paid to actually analyze the data. We’re getting paid to create this data resource and then we’re putting it out there in the world for the research community to use. I think there’s going to be a tremendous amount of knowledge that comes out of this data resource that builds over time.

Van

We so appreciate your leadership and sponsorship of all these important projects. Let me just give you a final moment to give us any comments about the future of care.

Joanne

Ooh, you know…I think as I’ve said, the aging of the population is something that we all need to be paying attention to. We clearly have increasing concerns about the costs of healthcare. You know, healthcare in the United States is a lot more expensive than anywhere else in the world, even more that a lot of countries that have better health outcomes and better health equity than we do. So, we’ve got a lot of room to think about how can we do what we’re doing more efficiently.?

I think that a lot of that comes down to thinking broadly and holistically about the care of populations, really focusing on the broader allied health workforce that supports the healthcare system and how we can better navigate individuals through a really complicated system. There’s just a lot of opportunity there and organizations like Futuro Health play a really important role because they recognize that there is a broad group of healthcare workers that need new, at-scale, creative ways to develop and deliver their education and their human capital skills to help them find jobs and help meet employers’ needs for this broad, diverse workforce.

And those skills can make such a big difference. A really good medical assistant, for example, helps the patient navigate, it gives them a point of contact, it can help alleviate the stress on the clinician by knowing that they have a partner in their medical assistant. Sometimes patients tell medical assistants things that they wouldn’t tell the clinician, so the medical assistant is also a part of the overall healthcare team’s eyes and ears.

So, I think organizations that are really building the broader workforce in healthcare play a really big role in the overall transformation of our system to focus on value and being more attentive to what matters to the people receiving care and how to deliver that care in ways that are affordable and high quality.

Van

Well, thank you for your call to action and all the insights that you shared today. We so appreciate your national and international leadership, Joanne, and especially that you spend the time to be in service of Futuro Health and serve on our board. So thank you, thank you, thank you.

Joanne

Well, thank you so much for inviting me to speak with you about this. Usually in our board meetings, we are focused on the business of making Futuro Health a better organization, so it’s really a treat to get to have more of a conversation with you.

Van

I’m Van Ton-Quinlivan of Futuro Health. Thanks for checking out this episode of  WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.