Paula Nickelson, Director of the Missouri Department of Health and Senior Services: The Long and Short Game of Addressing Workforce Shortages

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health.

State departments of health play a huge role in America’s healthcare system, with responsibility for community and public health, licensure, public policy, and much, much more. Given their critical function in the system, I’m happy today to welcome Paula Nickelson, the Director of the Missouri Department of Health and Senior Services, so we can get a state-level view of the workforce issues and other challenges they are confronting.

Paula assumed her current role in 2022 after spending twenty-four years at that agency focused on maternal child health, chronic disease prevention, and emergency preparedness amongst many of the most important issues in the country.

She also serves as the regional director for the Association of State and Territorial Health Officials with oversight of Iowa, Kansas, Missouri, and Nebraska – wow – so we’re looking forward to tapping into her broad knowledge of healthcare across the country.

Thanks very much for joining us today, Paula.

Paula Nickelson: Thank you, Van. Very happy to be here.

Van: So, let’s get started by having you help us understand the scope and span of agencies such as yours. How would you add to that brief description that I had made, Paula?

Paula: So, our agency has three authorities. We are the State Health Authority, we’re the State Healthcare Regulatory Authority, and we’re the State Aging Authority. Public health authorities across the nation are organized differently. Some sit within what we would typically call a super agency that might have the Mental Health Authority, might have the Medicaid Authority as well. We also have the Environmental Health Authority. We do have some environmental health components, but also some of that rests in our Department of Natural Resources.

In Missouri, our Mental Health Authority and our Medicaid Authority are two separate agencies, so it’s really incumbent upon us in Missouri to work very closely across Medicaid, public health, and mental health.

Van: You mentioned, frankly, a very wide breadth and depth of authorities. How do state agencies interrelate with the federal government, and what are the pain points of that relationship?

Paula: Let me just speak a little bit to the ways in which we interface. For instance, on the regulatory side, we basically serve as a subcontractor to CMS, the Centers for Medicaid and Medicare Services, conducting surveys according to their guidelines on their behalf for hospitals, for long-term care, home health, hospice, laboratories.  We are funded through CMS to do that work. A pain point in that respect, specifically, is that because CMS is in the federal budget, they’ve been operating under a continuing resolution, so we’ve not seen any increases in salaries for our staff or increased staff since 2015. So, those are pain points in particular in that regard.

On the public health side, we typically work most closely with Centers for Disease Control and Prevention. Certainly a lot of our funding comes through them and our relationship with them is very much a partnering relationship. Sometimes it’s a cooperative agreement with regard to the funding flow, but very much a technical assistance relationship and a partnering relationship with CDC.

From the aging perspective, a lot of that funding comes through Medicaid, but is also guided by CMS and so that funding flows through CMS. So again, in terms of funding, the pain points are what happens with the federal budget, et cetera.

Van: You mentioned your own workforce pain point, tied to the fact that there had been no salary increases since 2015 — wow — so, you have your unique workforce pains. Tell us about the workforce shortages that are affecting the healthcare sector and how they impact Missouri and especially your rural communities.

Paula: Sure. So, like every other state, you can’t name a title in public health in healthcare or in behavioral health, in oral health, that hasn’t experienced a shortage. I do feel like we’ve been pretty proactive in Missouri to be intentional in the way that we’re going about workforce development and to be very clear-eyed about it. When people speak with me about the future of workforce supply and how we’re approaching it, I always am careful to say this is a long-term strategy. I would estimate it will probably be twenty years before we really begin to bend the curve — hopefully, we can flatten it a little bit — but to really bend the curve, because much of the workforce shortage that we encounter, for instance, in nursing or in physician workforce, require very long-term strategies. We’re looking at issues with nursing clinical faculty, with clinical faculty for physicians, with residencies for physicians that take a very long time to impact the real trajectory there.

But when I say that we have been, I believe, clear-eyed and intentional in our work, we began in late fall of 2021 with a very broad-based — probably three dozen or so organizations across the state — coming together to talk about our issues in public health, healthcare, behavioral health, and oral health, workforces. That resulted in twenty-four recommendations to the governor in July of 2022. Just last month, we published our progress report on those recommendations.

I’m happy to say a number of them are well into implementation. But early on, it was wanting to ‘boil the ocean.’ We knew we had shortages in everything, and we felt that we needed to address everything.  We realized that our state legislature wasn’t going to be able to devote resources in that regard, so we wanted to get really strategic about which positions and which titles might have long-term impact in the immediate, and which ones we wanted to address in the immediate.

So, for instance, we knew we were having difficulties with long-term care having adequate Certified Nursing Assistants and that was impacting our hospitals being able to discharge in an appropriate time frame. So, we put funding and resources into CNA training and resources. We knew that we had a long-term issue with nursing, and so we put some additional resources into allowing our schools of nursing to say what were their local and regional pain points, what did they need to do in order to change that, and our Board of Nursing puts out contracts to our schools of nursing.

We’re very fortunate in that we have seven medical schools in Missouri, which is really unusual for a state of our population, but we knew that of our roughly 1,100 medical students graduating, we only had residency slots for about two-thirds of those and so in order for us to get ahead of that, we needed to create additional residency slots. We’ve begun that process. We just recently closed out an application period for existing residency programs to increase their slots, and are now in the process of looking at what a long-term state strategy is to assure that we’re maximizing Medicare funding in that regard.

That’s just three examples — there are a number of other examples — but we’re trying to be very strategic in how we align, not only with existing funding streams, but then also with our Office of Workforce Development and those workforce strategies.

Van: Paula, I’m curious, what tips would you have, given your intentionality, for other states and state agency leaders like yourselves?

Paula:  We have taken advantage of every opportunity that we are aware of to educate ourselves. So, examples of that are working with the National Governors Association on a health care policy learning community in active discussion with other states about how they have worked together. Often I find in other states, their health authority or their mental health authority aren’t really hooked in with the office of workforce development and understand, you know, what levers they can help pull in that regard.

Another opportunity we took advantage of was some HHS leadership work with the National Academy of State Health Policy, NASHP. There’s been planning with them for a forum coming up in just a couple of weeks with virtually all of the federal funders that feed into workforce and fund healthcare and behavioral health. So, I think being involved in those national level conversations to the extent that you can.

Number two, taking advantage of every opportunity to talk with other states about what they’re doing, how they’ve structured it. It may not be an exact fit for your state, but just learning from their examples.

And then thirdly, understanding within the state who all is involved in the work, because what we are finding within our state is virtually everybody has a workforce initiative. Let’s make sure that we’re not duplicating, let’s make sure that that we’re thinking, you know, cross-disciplinary, just to really be talking broadly across everyone who’s interested in the work.

Van: And are you finding that your higher education institutions are leaning in to the work that you need, and as well, are employers — the providers for example — leaning in with you?

Nickelson: I think that’s one of the advantages of being involved with our Office of Workforce Development. In Missouri, our higher education institutions and the Office of Workforce Development are in the same department, and so that allows us to enhance those conversations. I do think sometimes there is a schism, you know, between what higher ed is moving towards and what employers need. I do think that as a state health authority, we have the opportunity to help bridge that conversation sometimes between the employers and higher education.

Van: So, if you had a wish list for public policies that would enable the goals that you have for workforce, what would they be? Tell us about the current policy landscape in Missouri relative to workforce shortages, and do you have any wishes in terms of policy changes?

Paula: Oh, I have a long wish list.

Van: (laughs)

Paula: (laughs) I’m not sure we have that much time, but, you know, I would really ask federal policy makers to reexamine existing programs and criteria for programs in light of the workforce situation that we are in. For instance, I’m aware of a very dynamic physician in Missouri, a fairly new graduate, who opened a small rural residency program and is working additionally as a physician in that hospital. And yet, when she goes to apply for a loan, she takes a lesser loan amount because she is, quote, not a full time physician and that’s just a disincentive to anything any of us want to do. So, take a look at those pieces.

In that same vein, I would really encourage CMS to take a look at how GME — Graduate Medical Education — is structured.  I think that it’s been a long time since we have looked at how caps are applied on existing residency programs and why they occur. Because if you have a successful residency program, why would you cap them after five years and that’s all that they can ever get from a Medicare reimbursement? Why wouldn’t we optimize those existing programs and offer them additional Medicare reimbursement? I also think that the cap on what we will pay for residents needs to be revisited. I think it probably has not kept up with inflation. So, I would suggest those sorts of things.

There’s also the area of value based payments. In visiting recently with a primary care provider whose clinic is moving toward value-based payments, they told me that they’re finding the intent to align with value-based payment and reimbursement isn’t really changing how they practice within the clinic. This particular physician described it as a ‘gentle rollout’ of value-based payment in that they’re receiving a scorecard to show them where they are with their visits, and yet their daily practice doesn’t change. They still have 15 minutes per patient. And so, we really have to align intent and conceptual structure around reimbursement with how practice occurs from a realistic and pragmatic perspective.

Then, I would say, speaking as a public health professional, perhaps my biggest wish is that we as a society begin to think differently about how we provide care. In Missouri, we are advancing a model for public health — it’s entitled Foundational Public Health Services — it’s a national model and we “Missouri-ized” it a few years ago for ourselves. But in Missouri, in the twenty-four years I’ve been here, we have either been the poorest per capita or the next poorest per capita state in how we fund public health. We’re now at $7 per capita. We will never change our health indicators in a positive way, nor will we get out of the escalating spiral of acute care costs and long-term care costs, until we invest in public health and prevention and I believe that’s true across the nation. There are some states that invest at a rate that allows them to really impact their indicators, but largely within the nation, we just are not investing in public health and prevention in a way that allows people to really get healthy and allows our health care systems to thrive.

Van: Well, we’re going to get back into this discussion of public health in a second. But I wanted to ask you, you’ve talked about doctors, you’ve talked about nurses…what about the allied health area? What are you facing in terms of allied health workforce issues?

Paula: We certainly do have those shortages as well, certainly in OTs, PTs and respiratory therapists. I will also just tell you a personal reflection. You were asking about how higher ed supports employers. I am always supportive of lifelong learning. I think higher education is helpful, but I also think that in this scenario, that sometimes the push toward PhD-level therapists, for instance, doesn’t necessarily help our employment situation and indeed may not drive better patient care. So, I would really encourage our academic organizations to think about that in relation to our current workforce as well.

Van: So, going back to your wish of more emphasis on public health and prevention, what is the workforce that would be deployed to do that type of work?

Paula: You know, that’s one of the issues is that we don’t have a national workforce analysis of public health. In Missouri, we are contracting with the University of Missouri-Columbia to conduct a minimum data set similar to what HRSA’s minimum data set work in the past has been around nursing and other healthcare entities. Nothing like that exists for public health, so we don’t have comparable data, for instance, across public health nurses, across epidemiologists, laboratorians, et cetera. That’s part of the workforce.

But I also think part of the public health workforce is the evolving use of community health workers and how they will be paid, how they assist making connections and addressing social determinants of health, and then certainly other providers, not so much in public health, but in the healthcare arena, such as doulas.

Van: In Missouri, is there already a reimbursement process for the CHWs, the community health workers?

Paula: There is not. Actually, just this morning I was speaking with our Medicaid director, and the Medicaid agency certainly shares our interest in assuring that that is a reimbursable activity. Most of them are paid via grant. Our department has been active in training and certifying so we know we have 400-ish trained and certified around the state. Once we crack the reimbursement issue, we will be well placed to deploy that workforce more exuberantly.

Van: Talk to us about the data skills that have shifted in public health nowadays.

Paula: It is definitely an expanding landscape for sure. I think those of us who have been in public health saw it pretty clearly before COVID, but COVID laid it bare for the public that we didn’t have healthcare data and we didn’t have public health data, A, that was even visible across the public health system, and it certainly wasn’t integrated with the healthcare data.

So, there’s a lot of work occurring. CDC has a pretty robust public health data strategy that they are moving forward with, with milestones in the next couple of years. Public health entities are looking at what is the relationship, and what should the relationship be going forward, with public health data with the advent of healthcare entities sharing data under TEFCA. So, I think in the next ten years, we’re going to see just a virtual explosion of what that looks like.

From a public health perspective in Missouri, for instance, we’re not even in the century with our infectious disease surveillance platform, or our vital records platform. So, we’ve been very intentional in using some of the funding that came in through COVID to bring ourselves into the century in that regard with the purchase and deployment of new infectious disease surveillance platform and a new vital records platform that allows us to bring all vital records together.  We literally had, I think, seven systems of vital records across the state and a variety of statutes that governed those particular years of vital records. So, it really is going to be very advantageous for us going forward to have used that one time funding in that regard.

Van: Another intentional act. Congratulations on doing that hard work on the system side.

Paula: Thank you, Van.

Van: Paula, we often read headlines in the papers about care facilities in rural areas shutting down from lack of workers. I’m wondering how the rural hospitals and how the rural providers are faring in Missouri.

Paula: I was looking at that data just recently. We and our hospital association recognize that about half of our hospitals — and I think we’re right at 169 licensed hospitals in Missouri right now — about half of them are underwater. Most of those are our rural facilities. We have had a number of closures in the past five years or so, and are really, like many states, beginning to see some pretty significant maternal healthcare deserts in particular.

I’m very pleased and very optimistic with a new TORCH program which is a pilot of six rural hospitals overseen by our Medicaid authority. Our legislature funded the pilot beginning this past year to not pay those rural hospitals for sick care, but instead to pay them to address social determinants of health. We’re really excited about that model, because we think that’s a more sustainable funding model for many of our rural hospitals, and then it also helps us move that needle in Missouri toward prevention and public health. And if indeed it shows the outcomes as we hope and anticipate, then we’ll begin to bring on more.

But we continue to have that conversation — with Medicaid, with ourselves as a state health authority, with our hospital partners — about what does rural healthcare look like going into the Future and I think it probably is very different than what it is now. We are worried that, you know, hospitals closing tends then to decrease the entire healthcare footprint — primary care, urgent care, etc. — available in those communities and we want to be proactive in designing what that looks like going forward.

Van: Well, TORCH sounds like an exemplar for rural health and rural care, so thank you for sharing that.

Paula, I’ve learned so much. You’ve shared so many examples of what would be good practices, intentional practices, as well as policies that could be of help to the care of individuals within your state, but also could be deployed across states, so thank you for that.

I’d love to close by just asking you for your thoughts on the future of care. What do you see?

Paula: You know, I’m definitely a glass half full type of individual. I do think that the future is going to be a little rocky in the coming years with the workforce issues that we have, with the reimbursement concerns. I’ve heard individuals speculate about the number of hospitals that might close over the coming years, so I do think it’s going to take some pretty fierce advocacy. I do think it’s going to take our society moving more toward a public health and a prevention mindset, certainly as we see that growing aging population that typically requires more health care.

But, I think we’re pretty smart people. I think that we can crack this nut together and I think that the future, in the long run, looks very optimistic.

Van: Well, there you have it. I know our audience has so appreciated your time, Paula. Thank you very much for being with us today.

Paula: Thank you, Van.

Van: I’m Van Ton-Quinlivan with 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.