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The introduction of computers, the expansion of health insurance coverage through employers and government programs, and the increased use of personal health information have created a demand for a new breed of qualified medical record and health information personnel. The health information management workforce, which is entrusted with accurately coding, maintaining, storing, managing, analyzing, and disseminating all personal health information created from health care encounters, is reportedly in short supply. Given the complexity in defining and enumerating the profession, it is challenging to determine if such a shortage exists. There is a lack of uniformity across scope of practice, job titles, educational paths, and credentials. We report selected findings from a study of the health information management profession in North Carolina illustrating the methodologic problems encountered when measuring the supply and demand of this workforce. A case is made that greater standardization across these multiple facets of the profession would be beneficial to the workforce, and we offer recommendations on how this could be accomplished. [ABSTRACT FROM AUTHOR]

Despite a growing awareness that primary care is essential to an accessible, equitable, high-quality, cost-effective health care system, family medicine research remains woefully underdeveloped. The increased focus of both state and federal policy makers on primary care payment and care delivery models presents an opportunity for family medicine to redefine itself as an academically rigorous discipline at the forefront of generating evidence that improves patient care and population health while reducing costs. In a critical review of the literature, we identified five themes-leadership, funding, resources, team science, and departmental culture-that are integral to family medicine departments seeking to grow and expand their research capacity., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Hospital nurse practitioner (NP) turnover is costly and complex., Purpose: Provide a pre-COVID-19 pandemic baseline of hospital NP turnover., Methods: A secondary analysis of NSSRN18 data on 6,558 (67,863 weighted) NPs employed in hospitals on 12/31/2017. We describe rates of turnover, intention to leave, and reasons for leaving or staying. Using multivariate logistic regression, we examine the association between individual and organizational characteristics and turnover. Survey weights and jackknife standard errors were applied to analyses., Discussion: Approximately 10% of NPs left their job the following year, and 53% of NPs that remained considered leaving at some point. The top reasons cited for leaving or staying were largely organizational factors. Regression analysis revealed not practicing to one's fullest scope, lower income, lack team-based care, and non-white race were associated with an increased likelihood to leave., Conclusion: We find several modifiable factors associated with hospital NP turnover that can be used to tailor recruitment and retention strategies., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Total Medicaid funds invested in graduate medical education (GME) increased from $3.78 billion in 2009 to $7.39 billion in 2022. States have flexibility in designing Medicaid GME payments to address population health needs. This study assessed states' impetus for using Medicaid funds for GME, structure of state Medicaid payments, composition and charge of advisory bodies that guide these investments, and degree of transparency and accountability to track whether Medicaid GME investments achieved desired workforce outcomes., Method: Structured interviews were conducted in 2015 to 2016 and 2020 to 2021 with subject matter experts representing 10 states. Interview transcripts were analyzed and coded in 6 thematic areas: impetus for using Medicaid funds, the structure of state Medicaid payments, the composition of advisory bodies, the degree of transparency of Medicaid investments, accountability of Medicaid investments, and challenges and changes., Results: States used Medicaid GME funding to address maldistribution of physicians by geography, setting, and specialty, respond to population growth and undergraduate medical education expansion, offset potential loss of teaching health center program funds, and launch new programs and sustain existing ones. States leveraged Medicaid funding by modifying state plan amendments and redesigning funding formulas to meet specific health workforce needs. Many states had advisory bodies to educate legislators, reach consensus on workforce needs, recommend how to disburse funds, and navigate competing stakeholder interests. States identified a need for improved data and analytic systems to understand workforce needs and monitor the outcomes of GME investments. Determining which accountability measures to use and implementing metrics were challenges., Conclusions: States have much to learn from each other about strategies to best leverage Medicaid funds to develop and sustain residency programs to meet population health needs. Learning collaboratives should be developed to provide a forum for states to share best practices and strategies for overcoming challenges., (Copyright © 2024 the Association of American Medical Colleges.)

Background: Critical care nurse shortages and burnout have spurred interest in the adequacy of nursing supply in the United States. Nurses can move between clinical areas without  additional education or licensure., Purpose: To identify transitions that critical care nurses make into non-critical care areas, and examine the prevalence and characteristics associated with those transitions., Methods: Secondary analysis of state licensure data from 2001-2013., Discussion: More than 75% of nurses (n = 8,408) left critical care in the state, with 44% making clinical area transitions within 5 years. Critical care nurses transitioned into emergency, peri-operative, and cardiology areas. Those observed in recession years were less likely to make transitions; female and nurses with masters/doctorate degrees were more likely., Conclusion: This study used state workforce data to examine transitions out of critical care nursing. Findings can inform policies to retain and recruit nurses back into critical care, especially during public health crises., (Published by Elsevier Inc.)

Health disparities between rural and urban areas are widening at a time when urban health care systems are increasingly buying rural hospitals to gain market share. New payment models, shifting from fee-for-service to value-based care, are gaining traction, creating incentives for health care systems to manage the social risk factors that increase health care utilization and costs. Health system consolidation and value-based care are increasingly linking the success of urban health care systems to rural communities. Yet, despite the natural ecosystem rural communities provide for interprofessional learning and collaborative practice, many academic health centers (AHCs) have not invested in building team-based models of practice in rural areas. With responsibility for training the future health workforce and major investments in research infrastructure and educational capacity, AHCs are uniquely positioned to develop interprofessional practice and training opportunities in rural areas and evaluate the cost savings and quality outcomes associated with team-based care models. To accomplish this work, AHCs will need to develop academic-community partnerships that include networks of providers and practices, non-AHC educational organizations, and community-based agencies. In this commentary, the authors highlight 3 examples of academic-community partnerships that developed and implemented interprofessional practice and education models and were designed around specific patient populations with measurable outcomes: North Carolina's Asheville Project, the Boise Interprofessional Academic Patient Aligned Care model, and the Interprofessional Care Access Network framework. These innovative models demonstrate the importance of academic-community partnerships to build teams that address social needs, improve health outcomes, and lower costs. They also highlight the need for more rigorous reporting on the components of the academic-community partnerships involved, the different types of health workers deployed, and the design of the interprofessional training and practice models implemented., (Copyright © 2022 by the Association of American Medical Colleges.)

Evidence shows that those living in rural communities experience consistently worse health outcomes than their urban and suburban counterparts. One proven strategy to address this disparity is to increase the physician supply in rural areas through graduate medical education (GME) training. However, rural hospitals have faced challenges developing training programs in these underserved areas, largely due to inadequate federal funding for rural GME. The Consolidated Appropriations Act of 2021 (CAA) contains multiple provisions that seek to address disparities in Medicare funding for rural GME, including funding for an increase in rural GME positions or "slots" (Section 126), expansion of rural training opportunities (Section 127), and relief for hospitals that have very low resident payments and/or caps (Section 131). In this Invited Commentary, the authors describe historical factors that have impeded the growth of training programs in rural areas, summarize the implications of each CAA provision for rural GME, and provide guidance for institutions seeking to avail themselves of the opportunities presented by the CAA. These policy changes create new opportunities for rural hospitals and partnering urban medical centers to bolster rural GME training, and consequently the physician workforce in underserved communities., (Copyright © 2022 by the Association of American Medical Colleges.)

Advanced practice providers comprise an increasing percentage of the health care and primary care workforce. This paper evaluates the weighted contribution of advanced practice providers to the primary care workforce in well-served and underserved counties across North Carolina using age- and sex-adjusted population measures of access., (©2022 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Background: North Carolina, as a state with a significant Black population and fast-growing Hispanic population, serves as bellwether of demographic changes nationally and the challenges facing the nation to recruit and retain a general surgery workforce that mirrors the population., Methods: Annual licensure data from the North Carolina Medical Board were analyzed between 2004 and 2019. Physicians self-reporting a specialty of abdominal surgery, critical care surgery, colon and rectal surgery, general surgery, trauma surgery, proctology, and surgical oncology were categorized as general surgeons., Results: Female surgeons made the most gains from 2004, at just 8% of the workforce in 2004 to 26% of the workforce in 2019. Over the same period, Black surgeons increased from just 5% to 6% of the workforce, with those gains largely represented by Black female surgeons. Almost half of North Carolina's Black physicians are aged 46 and 55 and will be nearing retirement in the coming decade. Nearly two-thirds (64%) of Hispanic general surgeons were 45 or younger, and one-third of these young surgeons were international medical graduates., Conclusion: Although the general surgery workforce in North Carolina is slowly diversifying, growth in the Black surgeon workforce has stagnated in the last 15 years at levels much lower than their representation in the population. More research is needed on the individual and life course phenomena that drive this underrepresentation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background Over the past 40 years, the physician supply of North Carolina (NC) grew faster than the total population. However, the distribution of physicians between urban and rural areas increased, with many more physicians in urban areas. In rural counties, access to care and health disparities remain concerning. As a result, the medical school implemented pipeline programs to recruit more rural students. This study investigates the results of these recruitment efforts. Methodology Descriptive analyses were conducted to compare the number and percentage of rural and urban students from NC who applied, interviewed, and were accepted to the University of North Carolina's School of Medicine (UNC SOM). The likely pool of rural applicants was based on the number of college-educated 18-34-year-olds by county. Results Roughly 10.9% of NC's population of college-educated 18-34-year-olds live in rural counties. Between 2017 and 2019, 9.3% (n = 225) of UNC SOM applicants were from a rural county. An increase of just 14 additional rural applicants annually would bring the proportion of rural UNC SOM applicants in alignment with the potential applicant pool in rural NC counties. Conclusions Our model of analysis successfully calculated the impact of recruitment efforts to achieve proportional parity in the medical school class with the rural population of the state.   Addressing rural physician workforce needs will require multiple strategies that affect different parts of the medical education and healthcare systems, including boosting college completion rates in rural areas. This model of analysis can also be applied to other pipeline programs to document the success of the recruitment efforts., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Beck Dallaghan et al.)

Context: Preventive medicine physicians work at the intersection of clinical medicine and public health. A previous report on the state of the preventive medicine workforce in 2000 revealed an ongoing decline in preventive medicine physicians and residents, but there have been few updates since., Objective: The purpose of this study was to describe trends in both the number of board-certified preventive medicine physicians and those physicians who self-designate preventive medicine as a primary or secondary specialty and examine the age, gender distribution, and geographic distribution of this workforce., Design: Analysis of the supply of preventive medicine physicians using data derived from board certification files of the American Board of Preventive Medicine and self-designation data from the American Medical Association Masterfile., Setting: The 50 US states and District of Columbia., Participants: Board-certified and self-designated preventive medicine physicians in the United States., Main Outcome Measures: Number, demographics, and location of preventive medicine physicians in United States., Results: From 1999 to 2018, the total number of physicians board certified in preventive medicine increased from 6091 to 9270; the number of self-identified preventive medicine physicians has generally decreased since 2000, with a leveling off in the past 4 years matching the trend of preventive medicine physicians per 100 000 population; there is a recent increase in women in the specialty; the practice locations of preventive medicine physicians do not match the US population in rural or micropolitan areas; and the average age of preventive medicine physicians is increasing., Conclusions: The number of preventive medicine physicians is not likely to match population needs in the United States in the near term and beyond. Assessing the preventive medicine physician workforce in the United States is complicated by difficulties in defining the specialty and because less than half of self-designated preventive medicine physicians hold a board certification in the specialty., Competing Interests: The authors have no other conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Integrated health care is utilized in primary care clinics to meet patients' physical, behavioral, and social needs. Current methods to collect and evaluate the effectiveness of integrated care require refinement. Using informatics and electronic health records (EHR) to distill large amounts of clinical data may help researchers measure the impact of integrated care more efficiently. This exploratory pilot study aimed to (a) determine the feasibility of using EHR documentation to identify behavioral health and social care components of integrated care, using social work as a use case, and (b) develop a lexicon to inform future research using natural language processing., Method: Study steps included development of a preliminary lexicon of behavioral health and social care interventions to address basic needs, creation of an abstraction guide, identification of appropriate EHR notes, manual chart abstraction, revision of the lexicon, and synthesis of findings., Results: Notes (N = 647) were analyzed from a random sample of 60 patients. Notes documented behavioral health and social care components of care but were difficult to identify due to inconsistencies in note location and titling. Although the interventions were not described in detail, the outcomes of screening, referral, and brief treatment were included. The integrated care team frequently used EHR to share information and communicate., Discussion: Opportunities and challenges to using EHR data were identified and need to be addressed to better understand the behavioral health and social care interventions in integrated care. To best leverage EHR data, future research must determine how to document and extract pertinent information about integrated team-based interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Medical assistants (MAs) are a flexible and low-cost resource for primary care practices and their roles are swiftly transforming. We surveyed MAs and family physicians in primary care practices in North Carolina to assess concordance in their perspectives about MA roles, training, and confidence in performing activities related to visit planning; direct patient care; documentation; patient education, coaching or counseling; quality improvement; population health and communication. For most activities, we did not find evidence of role confusion between MAs and physicians, physician resistance to delegate tasks to properly trained MAs, or MA reluctance to pursue training to take on new roles. Three areas emerged where the gap between the potential and actual implementation of MA role transformation could be narrowed-population health and panel management; patient education, coaching, and counseling; and scribing. Closing these gaps will become increasingly important as our health care system moves toward value-based models of care.

The health workforce has been greatly affected by COVID-19. In this commentary, we describe the articles included in this health workforce research supplement and how the issues raised by the authors relate to the COVID-19 pandemic and rapidly changing health care environment.

BACKGROUND In the early months of the COVID-19 pandemic, health care decision-makers in North Carolina needed information about the available health workforce in order to conduct workforce surge planning and to anticipate concerns about professional or geographic workforce shortages. METHOD Descriptive and cartographic analyses were conducted using licensure data held by the North Carolina Health Professions Data System to assess the supply of respiratory therapists, nurses, and critical care physicians in North Carolina. Licensure data were merged with population data and numbers of intensive care unit (ICU) beds drawn from the Centers for Medicare and Medicaid Services (CMS) Healthcare Cost Report Information System (HCRIS). RESULTS The pandemic highlighted how critical data infrastructure is to public health infrastructure. Respiratory therapists and acute care, emergency, and critical care nurses were diffused broadly throughout the state, with higher concentrations in urban areas. Critical care physicians were primarily based in areas with academic health centers. LIMITATIONS Data were unavailable to capture the rapid changes in supply due to clinicians reentering or exiting the workforce. County-level analyses did not reflect individual, facility-level supply, which was needed to plan organizational responses. CONCLUSIONS Health care decision-makers in North Carolina were able to access information about the supply of clinicians critical to caring for COVID-19 patients due to the state's long-standing investments in health workforce data infrastructure. Ability to respond was made easier due to strong working relationships between the University of North Carolina at Chapel Hill Cecil G. Sheps Center for Health Services Research, the North Carolina Area Health Education Centers Program, the health professional licensure boards, and state government health care agencies., (©2021 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Background: Previous studies reported that primary care nurse practitioners working in primary care settings may earn less than those working in specialty care settings. However, few studies have examined why such wage difference exists., Purpose: This study used human capital theory to determine the degree to which the wage differences between dingsPCNPs working in primary care versus specialty care settings is driven by the differences in PCNPs' characteristics. Feasible generalized least squares regression was used to examine the wage differences for PCNPs working in primary care and specialty care settings., Methods: A cross-sectional, secondary data analysis was conducted using the restricted file of 2012 National Sample Survey of Nurse Practitioners., Findings: Oaxaca-Blinder decomposition technique was used to explore the factors contributing to wage differences.The results suggested that hourly wages of PCNPs working in primary care settings were, on average, 7.1% lower than PCNPs working in specialty care settings, holding PCNPs' socio-demographic, human capital, and employment characteristics constant. Approximately 4% of this wage difference was explained by PCNPs' characteristics; but 96% of these differences were due to unexplained factors., Discussion: A large, unexplained wage difference exists between PCNPs working in primary care and specialty care settings., (Copyright © 2018. Published by Elsevier Inc.)

Objective: To identify predictors of therapist use (any use, continuity of care, timing of care) in the acute care hospital and community (home or outpatient) for patients discharged home after stroke., Design: Retrospective cohort analysis of Medicare claims (2010-2013) linked to hospital-level and county-level data., Setting: Acute care hospital and community., Participants: Patients (N=23,413) who survived the first 30 days at home after being discharged from an acute care hospital after stroke., Interventions: Not applicable., Main Outcome Measures: Physical and occupational therapist use in acute care and community settings; continuity of care across the inpatient and home or the inpatient and outpatient settings; and early therapist use in the home or outpatient setting. Multivariate logistic and multinomial logistic regression analyses were conducted to identify hospital-level, county-level, and sociodemographic characteristics associated with therapist use, continuity, and timing, controlling for clinical characteristics., Results: Seventy-eight percent of patients received therapy in the acute care hospital, but only 40.8% received care in the first 30 days after discharge. Hospital nurse staffing was positively associated with inpatient and outpatient therapist use and continuity of care across settings. Primary care provider supply was associated with inpatient and outpatient therapist use, continuity of care, and early therapist care in the home and outpatient setting. Therapist supply was associated with continuity of care and early therapist use in the community. There was consistent evidence of sociodemographic disparities in therapist use., Conclusions: Therapist use after stroke varies in the community and for specific sociodemographic subgroups and may be underused. Inpatient nurse staffing levels and primary care provider supply were the most consistent predictors of therapist use, continuity of care, and early therapist use., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Social workers are increasingly being deployed in integrated medical and behavioral healthcare settings but information about the roles they fill in these settings is not well understood. This study sought to identify the functions that social workers perform in integrated settings and identify where they acquired the necessary skills to perform them., Methods: Master of social work students (n=21) and their field supervisors (n=21) who were part of a Health Resources and Services Administration-funded program to train and expand the behavioral health workforce in integrated settings were asked how often they engaged in 28 functions, where they learned to perform those functions, and the degree to which their roles overlapped with others on the healthcare team., Results: The most frequent functions included employing cultural competency, documenting in the electronic health record, addressing patient social determinants of health, and participating in team-based care. Respondents were least likely to engage in case conferences; use Screening, Brief Intervention and Referral to Treatment; use stepped care to determine necessary level of treatment; conduct functional assessments of daily living skills; use behavioral activation; and use problem-solving therapy. A total of 80% of respondents reported that their roles occasionally, often, very often, or always overlapped with others on the healthcare team. Students reported learning the majority of skills (76%) in their Master of Social Work programs. Supervisors attributed the majority (65%) of their skill development to on-the-job training., Conclusions: Study findings suggest the need to redesign education, regulatory, and payment to better support the deployment of social workers in integrated care settings., Supplement Information: This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services., (Copyright © 2018 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine whether receipt of therapy and number and timing of therapy visits decreased hospital readmission risk in stroke survivors discharged home., Design: Retrospective cohort analysis of Medicare claims (2010-2013)., Setting: Acute care hospital and community., Participants: Patients hospitalized for stroke who were discharged home and survived the first 30 days (N=23,413; mean age ± SD, 77.6±7.5y)., Interventions: Physical and occupational therapist use in the home and/or outpatient setting in the first 30 days after discharge (any use, number of visits, and days to first visit)., Main Outcome Measures: Hospital readmission 30 to 60 days after discharge. Covariates included demographic characteristics, proxy variables for functional status, hospitalization characteristics, comorbidities, and prior health care use. Multivariate logistic regression analyses were conducted to examine the relation between therapist use and readmission., Results: During the first 30 days after discharge, 31% of patients saw a therapist in the home, 11% saw a therapist in an outpatient setting, and 59% did not see a therapist. Relative to patients who had no therapist contact, those who saw an outpatient therapist were less likely to be readmitted to the hospital (odds ratio, 0.73; 95% confidence interval, 0.59-0.90). Although the point estimates did not reach statistical significance, there was some suggestion that the greater the number of therapist visits in the home and the sooner the visits started, the lower the risk of hospital readmission., Conclusions: After controlling for observable demographic-, clinical-, and health-related differences, we found that individuals who received outpatient therapy in the first 30 days after discharge home after stroke were less likely to be readmitted to the hospital in the subsequent 30 days, relative to those who received no therapy., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: In 2015, the Institute of Medicine's Committee for Assessing Progress on Implementing the Future of Nursing recommendations noted that little progress has been made in building the data infrastructure needed to support nursing workforce policy., Purpose: This article outlines a case study from North Carolina to demonstrate the value of collecting, analyzing, and disseminating state-level workforce data., Methods: Data were derived from licensure renewal information gathered by the North Carolina Board of Nursing and housed at the North Carolina Health Professions Data System at the University of North Carolina at Chapel Hill., Discussion: State-level licensure data can be used to inform discussions about access to care, evaluate progress on increasing the number of baccalaureate nurses, monitor how well the ethnic and racial diversity in the nursing workforce match the population, and investigate the educational and career trajectories of licensed practical nurses and registered nurses., Conclusion: At the core of the IOM's recommendations is an assumption that we will be able to measure progress toward a "Future of Nursing" in which 80% of the nursing workforce has a BSN or higher, the racial and ethnic diversity of the workforce matches that of the population, and nurses currently employed in the workforce are increasing their education levels through lifelong learning. Without data, we will not know how fast we are reaching these goals or even when we have attained them. This article provides concrete examples of how a state can use licensure data to inform nursing workforce policy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To describe the future supply and demand for pediatric surgeons using a physician supply model to determine what the future supply of pediatric surgeons will be over the next decade and a half and to compare that projected supply with potential indicators of demand and the growth of other subspecialties., Background: Anticipating the supply of physicians and surgeons in the future has met with varying levels of success. However, there remains a need to anticipate supply given the rapid growth of specialty and subspecialty fellowships. This analysis is intended to support decision making on the size of future fellowships in pediatric surgery., Methods: The model used in the study is an adaptation of the FutureDocs physician supply and need tool developed to anticipate future supply and need for all physician specialties. Data from national inventories of physicians by specialty, age, sex, activity, and location are combined with data from residency and fellowship programs and accrediting bodies in an agent-based or microsimulation projection model that considers movement into and among specialties. Exits from practice and the geographic distribution of physician and the patient population are also included in the model. Three scenarios for the annual entry into pediatric surgery fellowships (28, 34, and 56) are modeled and their effects on supply through 2030 are presented., Results: The FutureDocs model predicts a very rapid growth of the supply of surgeons who treat pediatric patients-including general pediatric surgeon and focused subspecialties. The supply of all pediatric surgeons will grow relatively rapidly through 2030 under current conditions. That growth is much faster than the rate of growth of the pediatric population. The volume of complex surgical cases will likely match this population growth rate meaning there will be many more surgeons trained for those procedures. The current entry rate into pediatric surgery fellowships (34 per year) will result in a slowing of growth after 2025, a rate of 56 will generate a continued growth through 2030 with a likely plateau after 2035., Conclusions: The rate of entry into pediatric surgery will continue to exceed population growth through 2030 under two likely scenarios. The very rapid anticipated growth in focused pediatric subspecialties will likely prove challenging to surgeons wishing to maintain their skills with complex cases as a larger and more diverse group of surgeons will also seek to care for many of the conditions and patients which the general pediatric surgeons and general surgeons now see. This means controlling the numbers of pediatric surgery fellowships in a way that recognizes problems with distribution, the volume of cases available to maintain proficiency, and the dynamics of retirement and shifts into other specialty practice.

Objective: To outline a methodology for allocating graduate medical education (GME) training positions based on data from a workforce projection model., Data Sources: Demand for visits is derived from the Medical Expenditure Panel Survey and Census data. Physician supply, retirements, and geographic mobility are estimated using concatenated AMA Masterfiles and ABMS certification data. The number and specialization behaviors of residents are derived from the AAMC's GMETrack survey., Design: We show how the methodology could be used to allocate 3,000 new GME slots over 5 years-15,000 total positions-by state and specialty to address workforce shortages in 2026., Extraction Methods: We use the model to identify shortages for 19 types of health care services provided by 35 specialties in 50 states., Principal Findings: The new GME slots are allocated to nearly all specialties, but nine states and the District of Columbia do not receive any new positions., Conclusions: This analysis illustrates an objective, evidence-based methodology for allocating GME positions that could be used as the starting point for discussions about GME expansion or redistribution., (© Health Research and Educational Trust.)

Objective: To understand factors affecting specialty heterogeneity in physician migration., Data Sources/study Setting: Physicians in the 2009 American Medical Association Masterfile data were matched to those in the 2013 file. Office locations were geocoded in both years to one of 293 areas of the country. Estimated utilization, calculated for each specialty, was used as the primary predictor of migration. Physician characteristics (e.g., specialty, age, sex) were obtained from the 2009 file. Area characteristics and other factors influencing physician migration (e.g., rurality, presence of teaching hospital) were obtained from various sources., Study Design: We modeled physician location decisions as a two-part process: First, the physician decides whether to move. Second, conditional on moving, a conditional logit model estimates the probability a physician moved to a particular area. Separate models were estimated by specialty and whether the physician was a resident., Principal Findings: Results differed between specialties and according to whether the physician was a resident in 2009, indicating heterogeneity in responsiveness to policies. Physician migration was higher between geographically proximate states with higher utilization for that specialty., Conclusions: Models can be used to estimate specialty-specific migration patterns for more accurate workforce modeling, including simulations to model the effect of policy changes., (© Health Research and Educational Trust.)

Physician workforce projections often include scenarios that forecast physician shortages under different assumptions about the deployment of physician assistants (PAs) and nurse practitioners (NPs). These scenarios generally assume that PAs and NPs are an interchangeable resource and that their specialty distributions do not change over time. This study investigated changes in PA and NP specialty distribution in North Carolina between 1997 and 2013. The data show that over the study period, PAs and NPs practiced in a wide range of specialties, but each profession had a specific pattern. The proportion of PAs-but not NPs-reporting practice in primary care dropped significantly. PAs were more likely than NPs to report practice in urgent care, emergency medicine, and surgical subspecialties. Physician workforce models need to account for the different and changing specialization trends of NPs and PAs.

Health care in the United States is likely to change more in the next 10 years than in any previous decade. However, changes in the workforce needed to support new care delivery and payment models will likely be slower and less dramatic. In this issue of the NCMJ, experts from education, practice, and policy reflect on the "state of the state" and what the future holds for multiple health professional groups. They write from a broad range of perspectives and disciplines, but all point toward the need for change-change in the way we educate, deploy, and recruit health professionals. The rapid pace of health system change in North Carolina means that the road map is being redrawn as we drive, but some general routes are evident. In this issue brief we suggest that, to make the workforce more effective, we need to broaden our definition of who is in the health workforce; focus on retooling and retraining the existing workforce; shift from training workers in acute settings to training them in community-based settings; and increase accountability in the system so that public funds spent on the health professions produce the workforce needed to meet the state's health care needs. North Carolina has arguably the best health workforce data system in the country; it has historically provided the data needed to inform policy change, but adequate and ongoing financial support for that system needs to be assured., (©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Inspired by the Affordable Care Act and health care payment models that reward value over volume, health care delivery systems are redefining the work of the health professionals they employ. Existing workers are taking on new roles, new types of health professionals are emerging, and the health workforce is shifting from practicing in higher-cost acute settings to lower-cost community settings, including patients' homes. The authors believe that although the pace of health system transformation has accelerated, a shortage of workers trained to function in the new models of care is hampering progress. In this Perspective, they argue that urgent attention must be paid to retraining the 18 million workers already employed in the system who will actually implement system change.Their view is shaped by work they have conducted in helping practices transform care, by extensive consultations with stakeholders attempting to understand the workforce implications of health system redesign, and by a thorough review of the peer-reviewed and gray literature. Through this work, the authors have become increasingly convinced that academic health centers (AHCs)-organizations at the forefront of innovations in health care delivery and health workforce training-are uniquely situated to proactively lead efforts to retrain the existing workforce. They recommend a set of specific actions (i.e., discovering and disseminating best practices; developing new partnerships; focusing on systems engineering approaches; planning for sustainability; and revising credentialing, accreditation, and continuing education) that AHC leaders can undertake to develop a more coherent workforce development strategy that supports practice transformation.

There is growing consensus that the health care workforce in the United States needs to be reconfigured to meet the needs of a health care system that is being rapidly and permanently redesigned. Accountable care organizations and patient-centered medical homes, for instance, will greatly alter the mix of caregivers needed and create new roles for existing health care workers. The focus of health system innovation, however, has largely been on reorganizing care delivery processes, reengineering workflows, and adopting electronic technology to improve outcomes. Little attention has been paid to training workers to adapt to these systems and deliver patient care in ever more coordinated systems, such as integrated health care networks that harmonize primary care with acute inpatient and postacute long-term care. This article highlights how neither regulatory policies nor market forces are keeping up with a rapidly changing delivery system and argues that training and education should be connected more closely to the actual delivery of care.

Objective: To develop a projection model to forecast the head count and full-time equivalent supply of surgeons by age, sex, and specialty in the United States from 2009 to 2028., Summary Background Data: The search for the optimal number and specialty mix of surgeons to care for the United States population has taken on increased urgency under health care reform. Expanded insurance coverage and an aging population will increase demand for surgical and other medical services. Accurate forecasts of surgical service capacity are crucial to inform the federal government, training institutions, professional associations, and others charged with improving access to health care., Methods: The study uses a dynamic stock and flow model that simulates future changes in numbers and specialty type by factoring in changes in surgeon demographics and policy factors., Results: : Forecasts show that overall surgeon supply will decrease 18% during the period form 2009 to 2028 with declines in all specialties except colorectal, pediatric, neurological surgery, and vascular surgery. Model simulations suggest that none of the proposed changes to increase graduate medical education currently under consideration will be sufficient to offset declines., Conclusions: The length of time it takes to train surgeons, the anticipated decrease in hours worked by surgeons in younger generations, and the potential decreases in graduate medical education funding suggest that there may be an insufficient surgeon workforce to meet population needs. Existing maldistribution patterns are likely to be exacerbated, leading to delayed or lost access to time-sensitive surgical procedures, particularly in rural areas.

Nurses are the single largest component of North Carolina's health workforce, and nursing jobs are an essential driver of the state's economic recovery. We propose 5 recommendations for creating a nursing workforce system that, if implemented, would position the state to meet the future health care needs of North Carolinians.

Although the funding and organization of the health care systems in the United States and England are quite different, there are striking similarities in the allied health workforce planning challenges facing the two countries. This paper identifies some common issues facing workforce policy-makers in both countries and suggests key next steps to enhance workforce research and planning in both countries, including the creation of a national minimum data set for allied health professions.

Objective: To examine variation in the practice patterns of individual general surgeons and how they differ between rural and urban areas of North Carolina., Summary of Background Data: Traditional physician supply analyses often rely on "head counts" and do not take into account how physicians' practice patterns differ. Practice characteristics including the volume and the breadth of services that a physician provides may be especially important in understanding the supply and distribution of specialists, such as general surgeons., Methods: Cross-sectional study using physician licensure data linked with administrative records on all inpatient hospital discharges and all surgeries performed at freestanding ambulatory surgery centers in North Carolina in 2004., Results: Total procedure volumes varied widely (interquartile range: 356-700). The average general surgeon in a rural county performed 54 different procedures at least once during the year, compared to 59 in counties with small urban areas and 62 in metropolitan counties. The 10 procedures that a general surgeon performed most frequently accounted for 72% of that surgeon's total annual procedures in rural counties, 67% in counties with small urban areas, and 66% in metropolitan counties. These rural metropolitan differences were smaller after controlling for secondary specialty and other surgeon characteristics., Conclusions: There was significant variation in the volume and scope of procedures that North Carolina general surgeons performed in the year. Many general surgeons in metropolitan areas performed an array of procedures that was broader than those in rural areas.

The debate over the status of the physician workforce seems to be concluded. It now is clear that a shortage of physicians exists and is likely to worsen. In retrospect it seems obvious that a static annual production of physicians, coupled with a population growth of 25 million persons each decade, would result in a progressively lower physician to population ratio. Moreover, Cooper has demonstrated convincingly that the robust economy of the past 50 years correlates with demand for physician services. The aging physician workforce is an additional problem: one third of physicians are over 55 years of age, and the population over the age of 65 years is expected to double by 2030. Signs of a physician and surgeon shortage are becoming apparent. The largest organization of physicians in the world (119,000 members), the American College of Physicians, published a white paper in 2006 titled, "The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care" [37]. The American College of Surgeons, the largest organization of surgeons, has published an article on access to emergency surgery [38], and the Institute of Medicine of the National Academies of Science has published a book on the future of emergency care (Fig. 10). The reports document diminished involvement and availability of emergency care by general surgeons, neurologic surgeons, orthopedists, hand surgeons, plastic surgeons, and others. The emergency room has become the primary care physician after 5 PM for much of the population. A survey done by the Commonwealth Fund revealed that less than half of primary care practices have an on-call arrangement for after-hours care. Other evidence of evolving shortage are reports of long wait times for appointments, the hospitalist movement, and others. The policies for the future should move beyond dispute over whether or not a shortage exists. The immediate need is for the United States, as a society, to commit to workforce self sufficiency in health care. The reliance on international graduates for more than 25% of the nation's physicians is a transnational problem. Reliance on IMGs, nurses and other health professions for the United States workforce is an issue of international distributive justice. Wealthy, developed countries, such as the United States, should be able to educate sufficient health professionals without relying on a less fortunate country's educated health workers. The 2000 Report of the Chair of the AAMC, the accrediting agency for United States and Canadian medical schools through the LCME, recommended expansion of medical school class sizes and expansion of medical schools [41]. For the past 25 years, the AAMC has supported a no-growth policy and the goal that 50% of USMGs be primary care physicians. In 2003, the AAMC developed a workforce center,-led by Edward Salsberg. The workforce center has provided valuable data and monitoring of the evolving workforce graduating from medical and and osteopathic schools in the United States. The NRMP, also managed by the AAMC, has begun useful studies analyzing the specialty choices of the more than 20,000 participants in the Match each year. The AAMC workforce policy was altered in 2006, and a 12-point policy statement was issued (see http://aamc.workforceposition.pdf). Three of the 12 points reflected significant change from past positions. They are a call for a 30% increase in physicians graduated by United States allopathic medical schools and an increase in residency positions now limited by the BBA of 1997. The recommendation that students make personal specialty choices reversed the prior recommendation that a majority of students enter primary care practice.

Drawing from the results of an empirical study, we discuss the strengths and challenges of Area Health Education Centers in three domains-mission, programs, and organization--and highlight their implications for Academic Health Science Center leaders.

Context: Passage of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) has created interest in how the legislation will affect access to prescription drugs among rural beneficiaries. Policy attention has focused to a much lesser degree on the implications of the MMA for the financial viability of rural pharmacies., Purpose: This article presents descriptive information on mail-order prescriptions, volume, and payer type of retail prescriptions in rural vs urban areas. Together, these data provide a baseline for evaluating how implementation of the MMA may affect the financial viability of rural independent pharmacies., Methods: Projections of prescriptions dispensed from retail and mail-order pharmacies in 2002 for the total US and a sample of 17 states were obtained from IMS Health., Findings: The volume of mail-order prescriptions is small. Rural providers prescribed fewer retail and mail-order prescriptions per person, but more units per person. Rural areas have a higher percentage of prescriptions paid for by cash (18% vs 13%) and Medicaid (16% vs 10%) and a lower percentage of third-party payers than urban areas. Significant variation in volume and payer type exists between states., Conclusions: Rural, independent pharmacies may be negatively affected by MMA implementation as business shifts from cash to third-party reimbursement. The high degree of variation between states also has potentially important implications for the implementation of Prescription Drug Plan regions under MMA.

This article describes the process used by the Consortium for Spinal Cord Medicine to develop evidence-based clinical practice guidelines for managing and treating individuals with spinal cord injury and provides important information on lessons learned and the potential problems to avoid. Issues to consider during the guideline development process include topic selection and explication, methods for selecting the panel chair and panel members, the writing of recommendations and supporting scientific rationales, peer-reviewing guidelines, and the process for disseminating, implementing, and evaluating guidelines. The applicability, advantages, and disadvantages of available evidence and guideline recommendation grading systems and issues arising from the lack of scientific evidence supporting particular recommendations are also discussed.